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 http://www.archive.org/details/surgeryofheadnecOOIane 
 
THE SURGERY 
 
 OF THE 
 
 HEAD AND NECK 
 
 BY 
 
 LEVI COOPER LANE, 
 
 A. M., M. D. (Berol.), M. R. C S. ENG., LL.D., PROFESSOR OF 
 SURGERY IN COOPER MEDICAL COLLEGE, 
 SAN FRANCISCO 
 
 Second edition 
 
 PHILADELPHIA, 
 P. BLAKISTON, SON & COMPANY, 
 
 IOI2 WALNUT STREET, 
 
- - L 
 
 EnttTPfl acfonliiiy; to act of Congress in the year 1890 
 
 BY 
 
 LEVI COOPER LANE, A. M.. 31. I). 
 
 In the office of the Librarian of Congress, at Washington, D. C. 
 All rights reserved. 
 
It has been the custom of authors in separating from their 
 
 books to say a parting word to them; this, by some, has been a 
 
 dedication to a father, brother or friend, and in one case to the 
 
 Author of Nature. Horace warns his of coming abuse and final 
 
 neglect; Martial hints to his scroll that it may serve the base 
 
 use of wrapping fish, or the worse one of becoming a flaming 
 
 festoon to illuminate and torture the criminal; but Ovid, more 
 
 ambitious and hopeful, announced in advance the salutations of 
 
 immortality with which the coming years would greet his Meta- 
 
 morpljoses; but the medical writer of to-day, warned by the 
 
 fortune of his cotemporaries, may prudently contract the horizon 
 
 of his expectation, and reckon on but a brief life for his book. 
 
 He who thinks otherwise, reckons ill with Futurity. Thus 
 
 warned, with limited hope, should a few years of existence be 
 
 granted to the following pages, the writer's expectations will he 
 
 fully realized. 
 
 Levi Cooper Lane. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 SURGERY OF THE SCALP. 
 SURGICAL ANATOMY OF THE SCALP. 
 
 CHAPTEE II. 
 
 GENERAL CLASSIFICATION OF THE 
 AFFECTIONS OF THE SCALP, FOL- 
 LOWED BY A CONSIDERATION 
 OF INFLAMMATION AND OTHER 
 MATTERS WITHIN THE SPHERE 
 OF GENERAL SURGICAL PA- 
 THOLOGY. 
 
 u 
 
 CHAPTER III. 
 
 "WOUNDS OF THE SCALP. 
 
 Incised 51 
 
 Lacerated 60 
 
 Contusion of the scalp 65 
 
 Gunshot wounds 72 
 
 Scalp and skull 76 
 
 Treatment 78 
 
 Gangrene 82 
 
 Ulceration 85 
 
 Hypertrophy 88 
 
 Atrophy 89 
 
 Tumors 89 
 
 Warts 91 
 
 Cystoma 93 
 
 Lipoma 99 
 
 Angioma 103 
 
 Vascular growths 114 
 
 Infantile sanguineous tumor . . . 119 
 
 Pigment marks 120 
 
 Malignant growths 121 
 
 Epithelioma 131 
 
 Treatment 135 
 
 Carcinoma 139 
 
 Treatment IM 
 
 Pneumatocephalus 145 
 
 Pericranium and its affections. . . 147 
 
 Wounds 147 
 
 Cranial Periostitis 148 
 
 CHAPTER IV 
 
 CRANIUM. 
 
 Traumatic lesions of the cranium . 
 Incised Wounds " " 
 
 PAGE 
 
 PAGE Fracture of the Cranium 159 
 
 7 Treatment 166 
 
 7 Gunshot wounds of the cranium. . 172 
 
 Treatment 179 
 
 Trephination 185 
 
 CHAPTER V. 
 
 MENINGES OF THE BRAIN. 
 
 Surgical affections of the membranes 
 
 of the hrain 209 
 
 External pachymeningitis of 
 
 puerperal origin 215 
 
 Tumors of the dura mater . . 216 
 
 Epithelioma 218 
 
 Osteoma 218 
 
 Psammoma . 219 
 
 Parasitic tumors 219 
 
 Constitutional tumors .... 219 
 
 Tubercle 220 
 
 Syphiloma 220 
 
 Etfects of meningeal tumors . 220 
 Treatment of meningeal tumors 221 
 Concussion of the brain . . . 223 
 
 Diagnosis 230 
 
 Prognosis 231 
 
 Treatment 232 
 
 Compression of the brain . . . 234 
 
 Diagnosis 238 
 
 Prognosis 239 
 
 Treatment 240 
 
 General consideration of 
 the conditions which fa- 
 vor or contraindicate 
 
 trephining 242 
 
 Contusion of the brain . . . . 245 
 
 Prognosis 247 
 
 Treatment 248 
 
 •CHAPTEE VI. 
 
 Encephalitis, or Inflammation 
 
 OF THE brain 250 
 
 Causes 250 
 
 Symptoms 252 
 
 Diagnosis 255 
 
 Treatment 257 
 
 Tumors 261 
 
 Syphiloma 262 
 
 Symptoms of intra-cranial tu- 
 
 153 "^mor 263 
 
 157 Treatment 26T 
 
 (V) 
 
VI 
 
 CONTKNTS. 
 
 PA<:e 
 Meningocele iind eiieepluilocele 270 
 
 Treatment 272 
 
 Hj'dioeephalus 272 
 
 Treatnienl 275 
 
 3Iicroccphalus 278 
 
 CHAPTEE VII. 
 
 Surgery ok thk External Ear.. 285 
 Defects and affections of the ex- 
 ternal ear 288 
 
 Wounds of the external ear. . 290 
 
 Treatment 291 
 
 Othaematonia 291 
 
 Treatment 293 
 
 Adherent pinna 296 
 
 Eents, fissures, and other de- 
 fects in which there is a loss 
 
 of structure 297 
 
 Affections of the auditory canal 298 
 Treatment ....'... 299 
 Occlusion of the auditory canal 300 
 Polypus in the auditory canal. 301 
 Occlusion of the canal by ceru- 
 men or foreign bodies. . . . 301 
 H.emorrhage from the auditory 
 
 passage 306 
 
 Mastoid cavity 308 
 
 Emphysema — pneumatocepha- 
 
 lus." 311 
 
 Treatment 312 
 
 CHAPTEE VIII. 
 
 Surgery of the Frontal Eegion 315 
 
 Erontal region 315 
 
 Acne 315 
 
 Treatment 315 
 
 Frontal sinus 318 
 
 Trephining, how done over 
 frontal sinus 323 
 
 CHAPTEE IX. 
 
 No!<E AND Nasal Passages . . . 325 
 
 Defects 327 
 
 Injury 328 
 
 Fracture of the nas^l bones. . 329 
 
 Treatment 330 
 
 Growths affecting the external 
 
 surface of the nose. .... 33-i 
 
 Angioma 336 
 
 ''Treatment 337 
 
 Lupus 338 
 
 Treatment 339 
 
 Lupus rodens, or rodent ulcer. 341 
 
 Treatment 342 
 
 Nostrils and Their Diseases . 343 
 
 Narrowness 343 
 
 Deflection of the nasal septum. 340 
 
 Treatment 347 
 
 Purulent Tumor 34« 
 
 Treatment 349 
 
 Necrosis of the osseous septum. 351 
 
 PAGE 
 
 Obstruction of the nasal passages 351 
 Kasal polypus 352 
 
 Symptoms 353 
 
 Treatment 355 
 
 Fibrous polypus 360 
 
 Treatment 364 
 
 Hypertrophy of the nasal mu- 
 cous membrane 370 
 
 Bleeding from the nose. . . . 371 
 
 Treatment 376 
 
 Foreign bodies in the nasal 
 
 passages 381 
 
 Pai'asites in the nasal passages. 382 
 Ozicna, or nasal catarrh . . . 383 
 
 Treatment 385 
 
 CHAPTEE X. 
 
 Maxillary Sinus, or Antrum 
 
 OF Highmore 391 
 
 Abscess of the maxillary siiuis. 393 
 
 Treatment 395 
 
 Fistula of the antrum .... 396 
 
 Treatment 379 
 
 Cysts in the antrum 397 
 
 Treatment 398 
 
 Tumor of the maxillary sinus . 398 
 Perforation of the nasal septum 400 
 Nasal deformity and means em- 
 ployed for its relief. .... 402 
 
 Ehinoplasty 406 
 
 Partial nasal repair 420 
 
 Alar margin defect of . . . , 421 
 Defects from the loss of the side 
 of the nose, including the 
 alar margin 421 
 
 CHAPTEE XI. 
 
 The Elements of Plastic Sur- 
 gery- 427 
 
 The first method, or that of 
 immediate adduction. . . . 430 
 
 The second method 433 
 
 The third method 441 
 
 Other methods 445 
 
 Thiersch's method of cutaneous 
 transplantation 449 
 
 CHAPTEE XII. 
 
 Surgical Affections of the 
 
 Eyebrows and Eyelids . . . 455 
 
 Eyebrow 455 
 
 Eyelid 459 
 
 Wounds of the eyelids .... 468 
 
 Erysipelas 467 
 
 Burns 468 
 
 Emphysema 469 
 
 CHAPTER XIII. 
 
 Diseases of the Eyelid .... 471 
 
 Hordeolum, acne ciliaris, or .sty 471 
 
 Treatment 471 
 
CONTENTS. 
 
 vn 
 
 PAGE 
 
 'Chalazion, otherwise known as 
 tarsal, gelatinous or fibrous 
 tumor of the eyelid .... 471 
 
 Treatment 472 
 
 Palpebral deformities .... 473 
 
 Treatment 473 
 
 Ankyloblepharon, blepharophi- 
 mosis, or narrowness of the 
 
 palpebral opening 475 
 
 Treatment 475 
 
 Symblepharon, or bulbo-palpe- 
 
 bral union 476 
 
 Treatment 477 
 
 Ectropion 478 
 
 Entropion 486 
 
 Congenital deformity of the 
 
 eyelid 489 
 
 Treatment 489 
 
 Epicanthus 490 
 
 Treatment 491 
 
 Blepharoplasty 491 
 
 Tumors arising from the orbital 
 
 wall 494 
 
 Treatment 495 
 
 Tumors originating within the 
 
 orbit 496 
 
 I^oreign bodies in the eye. . . 500 
 Treatment 501 
 
 CHAPTEE XIY. 
 
 Surgery of the Malar and Par- 
 
 OTIBEAN KeGIONS OF THE EaCE 503 
 
 Wounds of the cheek and side 
 
 of the face 504 
 
 Scrofulous ulcer 508 
 
 Treatment 509 
 
 Parotidean region of the face . 509 
 Inflammatory affections of the 
 parotid gland: parotitis . . 513 
 
 Treatment 514 
 
 Parotidean growths 515 
 
 -Salivary concretion 516 
 
 Treatment 517 
 
 Benign tumors 517 
 
 Angioma 517 
 
 Treatment 518 
 
 Malignant growths of the par- 
 otid gland 521 
 
 Epithelioma 522 
 
 Carcinoma 523 
 
 Treatment of malignant tumors 
 
 of the parotis 523 
 
 Parotidean fistula 528 
 
 CHAPTEPv XY. 
 
 Maxilla Stjperior 533 
 
 Fracture ......... 533 
 
 Eesection of the upper jaw . . 536 
 
 CHAPTEE XVI. PAGE 
 
 Mouth and Oral Cavity. . . . 544 
 
 Lips 544 
 
 Treatment of partial or com- 
 plete atresia of the mouth. . 548 
 
 Macrostoma 550 
 
 Treatment 552 
 
 Deviation of the oral opening . 552 
 
 Labial hypertrophy 553 
 
 Treatment 553 
 
 Labial ectropion 554 
 
 Hare-lip, cleft-lip, labium lep- 
 
 orinum 555 
 
 Operation 566 
 
 Operation on uncomplicated 
 double hare-lip 575 
 
 CHAPTEE XVII. 
 
 Labial Growths 585 
 
 Treatment 586 
 
 Labial cystoma 589 
 
 Labial cancer 590 
 
 Commencement and course 591 
 
 Diagnosis 596 
 
 Prognosis 597 
 
 Statistics of labial cancer . 598 
 
 Treatment 599 
 
 CHAPTEE XVIII. 
 
 Tongue 607 
 
 Surgical anatomy 607 
 
 Deformities 609 
 
 Lingual prolapsus, with hyper- 
 trophy 610 
 
 Treatment 611 
 
 Ankyglossa, or tongue-tie . . 613 
 Glossitis, or inflammation of the 
 
 tongue 615 
 
 Treatment 617 
 
 Abscess of the tongue .... 618 
 
 Ulceration of the tongue . . . 618 
 
 Treatment 620 
 
 Growths of the tongue .... 622 
 
 Treatment 623 
 
 Cystic growths 624 
 
 Fibroma of the tongue .... 626 
 Malignant growths of the 
 
 tongue . . " 626 
 
 "Wounds of the tongue .... 643 
 Foreign bodies lodged in the 
 
 tongue 644 
 
 Roof of the oral cavity . . . . 644 
 Inflammation of the palatal 
 
 structures 647 
 
 Treatment ..... 648 
 
 Wounds of the palate .... 649 
 
 Tumors arising from the palate 650 
 
 Aneurism 650 
 
 Malformations of the soft and 
 hard palate; acquired or con- 
 genital 652 
 
 Treatment 653 
 
vm 
 
 COXTKNTS. 
 
 FAliE 
 
 Palatal adhesion ti56 
 
 Destruction of the uviihi iiiul 
 soft palate 657 
 
 CHAPTER XIX. 
 
 Palatal Cleft or Division- , . 659 
 
 Treatment 663 
 
 Stapliyl<irrai)hy 665 
 
 Uranoplasty 677 
 
 CHAPTER XX. 
 
 Tonsil 686 
 
 Surgical anatomy 686 
 
 Tonsillitis 688 
 
 Treatment . . ..... 694 
 
 Hypertrophy of the tonsil. . . 6117 
 
 Treatment 700 
 
 Tonsillotomy, amygdalotomy, 
 
 or excision of the tonsils. . . 701 
 
 Tonsillar tumors 710 
 
 Treatment 711 
 
 CHAPTER XXI. 
 
 Pharynx 713 
 
 Abscess of the pharynx. . . . 713 
 
 Treatment 716 
 
 Ulceration of the pharynx . . 719 
 
 Treatment ....... 720 
 
 Pharyngeal tumors 721 
 
 Foreign bodies in the pliarynx, 723 
 
 CHAPTER XXII. 
 
 • Sublingual Region 725 
 
 Ranula 727 
 
 CHAPTER XXIII. 
 
 Maxilla Inferior 732 
 
 Surgical anatomy 732 
 
 Congenital deformity .... 733 
 Alveolar periostitis, gingivitis, 
 
 and dental abscess 7?>3 
 
 Treatment 734 
 
 Dental fistula 734 
 
 Treatment 7-36 
 
 "Wisdom teeth 736 
 
 Necrosis of the lower jaw . . . 738 
 
 Prognosis 741 
 
 Treatment 741 
 
 Phosphorus-necrosis 743 
 
 Treatment 746 
 
 Growths in the maxilla inferior. 748 
 
 Maxillo dental cystic tumors. . 748 
 
 Treatment. ". 752 
 
 Odontoma 752 
 
 Treatment 753 
 
 Fibroma 754 
 
 Epulis 755 
 
 Treatment 757 
 
 Malignant growths 758 
 
 PAGE 
 
 Carcinoma 758 
 
 Treatment TOO 
 
 Ancliylosis of the maxilla in- 
 ferior . . 764 
 
 Treatment 765 
 
 Luxation of the maxilla inferior 770 
 
 Treatment 773 
 
 Fracture of the lower jaw, 
 
 Treatment 775 
 
 CHAPTER XXIV. 
 Facial Neuralgia 783 
 
 CHAPTER XXV. 
 
 Neck 800 
 
 Surgical Anatomy 800 
 
 Torticollis. . . . ' 804 
 
 Treatment 808 
 
 CHAPTER XXVI. 
 
 Congenital Clefts or Fistul.e 
 
 IN THE Neck 810 
 
 Treatnaent 822 
 
 Thyroid Gland, and its Affec- 
 tions 823 
 
 Surgical anatomy 823 
 
 Goitre .... 625 
 
 Treatment. 834 
 
 Medical 835 
 
 Surgical 838 
 
 Exophthalmic goitre 847 
 
 jMalignantdisea.se of the thvroid 
 
 gland * .849 
 
 Wounds of the thyroid gland . 850 
 
 Thyroiditis 851 
 
 Phlegmon and abscess of the 
 
 neck 853 
 
 Treatment 858 
 
 Drainage 860' 
 
 CHAPTER XXVII. 
 
 Tu.MORS OF THE Neck 864 
 
 Treatment 867 
 
 Lymphangioma 867 
 
 Angioma 869 
 
 Treatment 870 
 
 Blood-cysts 871 
 
 Treatment 873 
 
 Solid growths of the neck. . . 873 
 Sarcoma of the cervical glands. 874 
 ^lalignant lymphoma .... 877 
 Treatment of cervical glandu- 
 lar tumors 880 
 
 Carbuncle, anthrax 893 
 
 Diagnosis 895 
 
 Prognosis 896 
 
 Treatment. ... .896 
 
 Malignant pustule 900 
 
 Pathological changes pre- 
 sent after death .... 902 
 Treatment 902 
 
' CONTEXTS. * IX 
 
 CHAPTER XXA'III. , page 
 
 PAGE Malignant growths in the 
 
 WocxDS OF THE Xeck 905 pharj'ns and. cesophagus . . 992 
 
 Treatment 915 Wounds of the cesophagus . . 998 
 
 Fracture of the h void bone... 922 TPvAcnEOTOMY or Bkoxchotomy..1000 
 
 Treatment / 923 
 
 Fracture of the larynx. ... 923 CHAPTEE XXXII. 
 
 Symptoms 924 t 
 
 Treatment 9'>4 Lartxgotomt 1069 
 
 Strangulation, hanging. .' ' ' 925 Operation of laryngotomv. . . 1075 
 
 Hanging . . .\ . . . 929 Intubation 1078 
 
 Artificial respiration . . . 935 „„ x-rr-r-x. -w^ttt 
 
 Insufflation. 935 CHAPTEE XXXIII. 
 
 Aspiration 938 Extiepatiox of the Laktstx or 
 
 Drowning. ... . . 946 Opekatioxof Laetxgectomy,1086 
 
 ± oreign bodies m the air ' 
 
 P^'^^S*^* ^-5^ CHAPTEE XXXI Y. 
 
 (2;2;^P'pj;p^ XXIX Vessels oe the. Xeck 1056 
 
 Atfections of the carotid artery.1098 
 
 CEsoPHAGrs 959 Ligation of the primitive 
 
 Congenital defects of the cesoph- carotid 1101 
 
 agus 961 Ligation of both primitive 
 
 Stricture of the oesophagus.' . 963 carotids 1120 
 
 Spasm 971 Ligation of the external carotid 
 
 Treatment ....... 974 artery 1120 
 
 Subclavian artery 1127 
 
 PTT A -PTVT> vv V Ligation of the external jugu- 
 
 CHAPIEK XXX. lar ^ein 1131 
 
 FOREIGX Bodies ix the Pharyxx Wounds of the internal jugular 
 
 AXD (Esophagtis 982 ^ ™^ i i V " /./ ■ ^^^ \ 
 
 Congenital defects of the spinal col- 
 
 . umn (spina bifida) 1139 
 
 CHAPTEE XXXI. Treatment 1141 
 
 Pharyngeal axd (Esophageal ^tt » -Drr-17-D -k-^^^ 
 
 Neoplasms 989 CHAPiEK XXXV. 
 
 Treatment 990 Luxatiox or the Certical Yer- 
 
 Warts, cysts and polypoid tebr^ 1144 
 
 growths in the cesophagus . 991 Fracture of the vertebrae,. . . 1150 
 
LIST OF ILLUSTRATIONS. 
 
 .-fIG. PAGE 
 
 1. Lobes of the Brain Original 192 
 
 2. Osteoplastic Method of Trephining — 206 
 
 3. Martino's Method of Lessening the Pinna . — 289 
 
 4. Plastic Method of Celsus . . \ Otto Weber 410 
 
 - -r.1 • 1 j^- -r> 1 \ Dictionaire Encyclopedique^ .,„ 
 
 ■a. Khmoplastic Procedure | des Sciences Medicales T^'^ 
 
 6. Alquie's Khinoplastic Method " 413 
 
 7. Talicotian Method of Khinoplasty — 419 
 
 8. Plastic Surgery— the Circle — 429 
 
 9. The Semicircle — 429 
 
 10. The Ellipse — 429 
 
 11. The Oval — 420 
 
 12.- The Triangle of Equal Sides — . 429 
 
 13. " " with Two Equal Sides .... — 429 
 
 14. The Eectangle — 429 
 
 15. The Parallelogram — 429 
 
 16. The Khomboid — 429 
 
 17. Khomboid Slightly Lengthened — 430 
 
 18. Khomboid Much Elongated — 430 
 
 19. The Lozenge — 430 
 
 20. The Sector — 430 
 
 21. Closure of Circle — 430 
 
 22. " " Parallelogram — 431 
 
 23. " '* Equilateral Triangle — 431 
 
 24. " " Khomboid Space; Ellipse and Oval — 431 
 
 25. Triangle with Opening in Base — 432 
 
 26. " " Closure " « — 432 
 
 27. Two Parallelograms Resting on Same Base . — 434 
 
 28. " " Closing Defect .... — 434 
 
 29. One Method of Closing Triangular Defect . . — 435 
 
 30. Sutural Line Kemaining after Closure ... — 435 
 
 31. Burow's Plan of Closure ... — 435 
 
 32. Sutural Lines after Closure by Burow's Plan — 436 
 
 33. " " of Two Triangles . . ... — 436 
 
 34. Two Triangles Exsected — 436 
 
 35. Closing Triangular Defect by Curvilinear 
 
 Extension — 437 
 
 36. Plan of Closure of Lozenge-shaped Defect . — 437 
 
 37. Sutural Lines after Closure of Lozenge-shaped 
 
 Defect — ^ 487 
 
 ■38. Plan of Closing a Parallelogram — ....'... 438 
 
 39. Line of Suture after Closure of a Quadrangu- 
 
 lar Defect — 438 
 
 40. Plan of Closing a Quadrangular Defect . . — 438 
 
 41. Sutural Lines after Closure of Quadrangular 
 
 Defect — 438 
 
 42. Another Plan of Closing Quadrangular Defect — 439 
 
 43. Sutural Line Remaining after Closure of Space 
 
 Indicated in Figure 42 — 439 
 
 .44. Closure of Rectangular Defect — 439 
 
 45. Lateral Closure of a Kectano;le — 439 
 
 46. Method of Closing a Circular Defect .... — 440 
 
 (xij 
 
Xii LIST OF ILLUSTKATIUNS. 
 
 FIG. 
 
 PAGE 
 
 47. Appearance after Closure of Circular Defect . — 440 
 
 48. Closure of the Circular Defect — -l-H 
 
 49. Sutural Lines after Closure of Circle .... — 4^1 
 
 50. Method of Closing Semicircular Defect ... — 441 
 
 51. Closure of Triangle — 442 
 
 52 " " Second Plan. — 442 
 
 53. " " Third Plan — 442 
 
 54. Plan of Closing a Quadrangle : — 442 
 
 55. Closure of Oval Space — 443 
 
 56. Sutural Line after Closure of an Oval Defect — 448 
 
 57. Plan of Closing a Semicircular Space ... — 443 
 
 58. Sutural Line after Closure of Semicircular 
 
 Defect — 443 
 
 59. Another Plan of Closing a Semicircular De- 
 
 fect — 443 
 
 60. Closure of a Semicircular Space — 444 
 
 61. Dietlenbach's Method of Operating for Eelief 
 
 of Palpebral Eversion — 480 
 
 62. Von Amnion's Plan of Operating in Ectropion — 480 
 
 63. Syzmanowsky's Method of Operating in En- 
 
 tropion — 481 
 
 64. Sutural Line llemaining after Sj-zmanowsky's 
 
 Operation — 481 
 
 65. Bonnet's Plan for Eversion of Eyelid . ... — 482 
 
 66. T. Wharton Jones' Operation for Belief of 
 
 Ectropion — 483 
 
 67. Guerins Method for Kelief of Eversion of 
 
 Lower Eyelid — 483 
 
 68. Denonvilliers' Plan of Elevating Outer Angle 
 
 of the Eye — 484 
 
 69. Dieflfenbach's Plan for Correcting Ectropion . — 485 
 
 70. Plan of Anagnostakis for Kelief of Entropion — 489 
 
 71. Sutural Line after Operation of Anagnostakis — 489 
 
 72. Epicanthus of the Eye ". . . . — 490 
 
 73. Hasner's Plan of Kemoving Neoplastic Disease — 492 
 
 74. Burow's Method <>f Kemoving a Portion of 
 
 Lower Eyelid .... — 493 
 
 75. Plates, Showing Development of Fa?tal Head From Von Amnion . . . 55*5 
 
 76. Graefe's Plan in Treatment of Hare-lip ... — 567 
 
 77. " " Modified by Bruns From Weber 567 
 
 78. Sedillot's Plan in Hare-lip — 568 
 
 79. Result in S^dillofs Plan — 568 
 
 80. Metliod Employed by Mirault, Henri, and 
 
 Malgaigne — -309 
 
 81. Result of Method Employed by Mirault, 
 
 Henri, and Malgaigne — 509 
 
 82. Mirault's Method — 569 
 
 83. Result of Mirault's Method — 569 
 
 84. SMillot's Plan for Closure of Breach in Lower 
 
 Lip — 602 
 
 85. Result of Closure by SediUot's Method . . . From Emmert .... 002 
 
 86. Interdental Gag OrUjinal (541 
 
 87. Davies-Colley's Uranoplastic Procedure . . . — 683 
 
 88. Appearance after Closure According to Plan 
 
 of Davies-Colley T . . . . — 684 
 
 89. Enormous Maxillary Fibroma Baucltot 754 
 
 90. Luxation of Inferior Maxilla — 772 
 
 91. Apparatus of Bonnet for Correcting Torticollis — 815 
 
 92. Transfixor Used in Enucleation of Goitre . . Original 843 
 
 93. A Sarcomatous Tumor " «75 
 
 ^. T, T> 1 1 * J rr ( Dlctlonalre Fncyclopec/ir/ue} ooi 
 
 94. Enormous Pedunculated Tumor | des Sciences mdLalei } ^^^ 
 
 95. Marshall Hall's Method of Artificial Respira- 
 
 tion From Holmes^ Surgery . 939 
 
LIST OF ILLUSTRATIONS. 
 
 XllI 
 
 FIG. 
 
 96. Howard's Method of Artificial Kespiration 
 
 97. Silvester's Method of Artificial Eespiration 
 
 98. Instrument Used in Opening (Esophagus . 
 
 99. Mathieu's (Esophageal Forceps 
 
 100. Canula . 
 
 101. Blunt Retractor — 
 
 102. " Dissector — 
 
 103. Canula of Usual Form — 
 
 104. " with Inner Tube "Withdrawn . ... — 
 
 105. O'Dwyer's Instruments for Intubation ... — 
 
 106. Gussenbauer's Artificial Larynx From Schuller 1094 
 
 107. Complete Antero-posterior Luxation of Spine From Albey^t 1145 
 
 108. Bilateral Luxation of Spine . '' 1145 
 
 109. Complete Fracture of Vertebral Column . . " 1152 
 
 110. Fracture of a Vertebra " . . ' . 1152 
 
 PAGE 
 
 From Holmes' Surgery 940 
 
 " .941 
 
 Vaca Berlinghiera . . . 978 
 
 — 986 
 
 From Schuller 1006 
 
 — • 1041 
 
 — 1041 
 
 — 1043 
 
 — 1043 
 
 — 1081 
 
INTRODUCTION. 
 
 Bacteriology, Antisepsis, Asepsis. 
 
 The following work was commenced soon after the birtn of 
 Bacteriology, and the subject matter of that science, thougii 
 tacitly accepted, demands further mention than has been given 
 to it in the following pages. To meet this want, a brief consider- 
 ation of this new-born science will herewith follow. 
 
 One of the first to teach that many diseases are caused by a 
 fungoid agent was Dr. J. K. Mitchell of Philadelphia. Dr. 
 Mitchell, in a course of lectures heard by the author in 1850, 
 with great fervor taught the doctrine that cholera, yellow fever, 
 and other contagious or infectious diseases, originate from a 
 portable microscopic entity. Many proofs of this doctrine were 
 presented by Mitchell, and the belief expressed that it would be 
 fully verified in the future. In 1858 Pasteur announced his 
 doctrine that fermentation and putrefaction are produced by 
 microscopic agents of which tlie germinal elements are in the 
 surrounding air. One of the pioneer lectures on these subjects 
 delivered in the French Institute was listened to by the writer. 
 The words uttered then by Pasteur were pregnant with more 
 import than he or his audience wei'e aware of: they were the 
 magical utterances which heralded the birth of a new science — 
 Bacteriology. In this early work one of the chief objects aimed 
 at by the French savant was to disprove the doctrine of spon- 
 taneous generation, and to prove that every living entity, whether 
 a microbe or a macrobe, owes its origin to a preexistent one. 
 
 In his studies of fermentation and putrefaction Pasteur deter- 
 mined that fermentation has its specific ferment, consisting of 
 living cells; he also discovered that putrefaction is induced by 
 an organized minute agent; and that the causal agents of fer- 
 mentation and putrefaction are universally present in the air, or 
 contiguous bodies. 
 
 These microscopic entities were named by Sedillot microbes, 
 and this name was satisfactory to those who claimed that they 
 were animalcules, and who named them microzoa; and the name 
 microbe was acceptable also to the opposite party, who classed 
 these entities with plants, and named them microphytes. 
 
 Through the studies of Cohn, de Barry, Nsegeli, and others 
 
 (XV) 
 
Xvi IXTRODUrTIOX. 
 
 it has been established that these microscopic agents belong to 
 the lowest orders of plants. 
 
 Tiie new field of !-cieiUific research oi)ened by Pasteur was 
 quickly entered by Davaiue, Koch, Sternberg, and many others ; 
 and from the united labors of these investigators have sprung 
 the germ theory of the origin of many diseases, the knowledge 
 that many diseases may be successfully combated by inoculation, 
 and from the discoveries of these men conjoined with those of 
 Lister, Aseptic Surgery has been born and developed. 
 
 This work took a practical turn in 18G0, when Pasteur 
 discovered the micro-organism which destroys the silkworm. 
 Anthrax or splenic fever which is so fatal to cattle, and the 
 cholera of swine and chickens, were soon found to de})end upon 
 a portable parasite. And those morbific entities being discovered, 
 the .scientist next suggested remedies against them. 
 
 The morbific agents of disease in.man are chiefly microjdiytic 
 in nature; a few are animalcular or protozoic. In the class of 
 microphytes are included Bacteria, wliich arc so named because 
 many of them are rod-shaped. 
 
 Cohn divided bacteria into four classes, viz., those of globular 
 form, of tlie form of short rod.s, of the form of longer rods, and 
 tlio.se of spiral shape. The first class is now named Cocci, the 
 second ;ind third. Bacilli, and the fourth class. Spirilla. Another 
 classilic-ation of bacteria, founded on their method of reproduc- 
 tion, is into two groups, viz., those reproduced from endospores, 
 and those from arthrospores. The triple cla.ssification, founded 
 on the form of the Bacteria, is the one usually adopted, and a 
 diagram showing these forms is here presented. 
 
 FiGL'UK 1. a cocci; 6 bacilli; c spirilla. 
 
 The surgeon in his work is only concerned with the coccus 
 or round, and the bacillus or rod-shaped bacteria. 
 
 Cocci appear in isolation, in regular groups, or in irregular 
 masses. When they exist singly and separate, the cocci are 
 named monococci; when in pairs, they are named di[)lococci, and 
 when four are grouped together, they are denominated tetracocci; 
 and when they are linked together, chain-like, they are named 
 strei>tococci. When the cocci are aggregated in irregular masses, 
 they are designated by the term zoogloea; and when in clusters, 
 they are named staphylococci. A mass of cocci inclosed in a 
 capsule is named ascococci. 
 
BACTERIOLOGY, ANTISEPSIS, ASEPSIS. xvii 
 
 Bacterial organisms are cells which have an average diam- 
 eter of one-thousandth of a millimeter. The cell consists of a 
 wall within which is a homogeneous or granular protoplasmic 
 material. The cell is ordinarily colorless. From contact with 
 water the cell wall may hecome gelatinoid; and in this condition 
 the cells may cohere in chain form, or aggregate in the irregular 
 masses named zoogloca. 
 
 The ]nost of bacteria are capable of locomotion, in which 
 they are seen to rapidly move in the containing fluid from place 
 to place, in a very irregular manner. Other bacteria, instead of 
 progression exhibit vibratory movements, dependent on molecular 
 movement of the cellular content. Rod-shaped bacilli are some- 
 times provided with cilia-like appendages, which are attached to 
 the ends or sides, and these appendages, like fins, may aid in 
 propulsion. They may also aid the microphyte in getting its 
 nutriment. 
 
 Bacteria placed in proper conditions have the endowment of 
 rapid multiplication; and reproduction may occur by segmenta- 
 tion or sporulation. Reproduction of the coccus by segmentation, 
 in four different stages, is shown in Figure 2. And segmentation 
 
 Figure 2. Divibion ot coccus. (After Mace.) 
 of a bacillus, in its five successive stages, is shown in Figure 3. 
 
 Figure 3. Division of a bacillus. (After Mace.) 
 
 Instead of development by simple division, bacterial repro- 
 duction may occur by means of spores, which correspond to the 
 seeds of ferns. Most bacilli grow by njeans of spores. There 
 are two ways in which the growth by spores may occur : in one, 
 the embryo appears within the mother-cell; and this mode of 
 reproduction is named endosporous; and in a second wa}^ the 
 offspring appears as an appendage to the mother; and this mode 
 is named arthrosporous. These modes of development, which 
 are also respectively named endogenous and exogenous, are 
 shown in Figure 4 on page xviii. 
 
 If sporulation be intra-cellular, the spore may appear at any 
 point within its progenitor. It begins as one or several granules 
 within the parental protoplasm ; and this, enlarging and acquir- 
 
XVIU 
 
 INTKODUCTION. 
 
 ^03Cii^# 
 
 i'lciUKE 4. buowiiig growth 
 within and outside of the parent 
 (After de Barry.) 
 
 cell 
 
 iiig a capsule, liually encroaches on the wall of the parent, when 
 the latter is opened, and the spore escapes. 
 
 The mode of development by arthrosporous (budding) growth 
 lias not been very definitely made out: in iacl, some bacleriol- 
 ogists deny that it occurs. 
 
 Bacteria have tiie endowment of great reproductive activity. 
 It has boon calculated that a single cholera bacillus, of which 
 
 the reproduction is by segmenta- 
 tion, can produce sixteen million 
 descendants in one hour. A fluid 
 or senii-fluid medium, which con- 
 tains tiie proper nutrient elements 
 for bacteria, together with warmth, 
 constitutes the ground and envi- 
 ronment necessary for the rapid 
 develoj)ment of bacteria. 
 
 The bacterial spore possesses 
 great inherent vitality; it will live 
 in conditions which are destructive 
 to all other forms of life. Many are 
 only <lestroyed after an exposure of 
 several hours in dry jiir heated to 
 140 degrees centigrade. Fully-develo[)ed bacteria {ire destroyed 
 at a much lower gi-ade of heat than that re(|uired for destruction 
 of their spores, bi a course upon Biology given by Professor 
 Huxley, attended by the writer, the former showed that if milk 
 or water and cheese containing bacteiia be heated to (iO degrees 
 centigrade, the parasites were destroyed; but if the heat be some- 
 what increased, the bacteria reappeared; when, however, the heat 
 was raised to 110 degrees, there was no reappearance of the 
 parasites. The writer thinks it probable that the more advanced 
 microscopy of to-dny would fail to verify those phenomena ob- 
 served a quarter of a century ago. 
 
 Botli bacteria and their spores successfully resist chemical 
 and physical agents which are fatal to all other forms of animal 
 and plant life. 
 
 There are many varieties of bacteria; and each one maintains 
 its form and properties through countless generations. They are 
 incapable of miscigenation and the development of hybrid forms. 
 Most bacteria thrive best when they can obtain a free supply of 
 oxygen from the air; and these are named aerobic. Others only 
 grow when air is absent, and they are destroyed by free oxygon; 
 and these are designated as anaerobic. Tlie bacillus of tetanus is 
 anaerobic. A third class tlnive in aii-, and also where air is 
 absent; and these are named facultative bacteria. The micro- 
 
BACTERIOLOGY, ANTISEPIS, ASEPSIS. xix 
 
 organisms, the causes of disease in man, belong to the class of 
 facultative bacteria. Some bacteria only live in the dead bodies 
 of organized beings; and these are named sap ropliytes; and they 
 live at a low temperature, 
 
 A high or low temperature arrests the growth of certain 
 microbes; and growtli is resumed at an intermediate degree of 
 iieat. Some require nearl}' a constant heat, as the bacillus of 
 tuberculosis. Other species can withstand liigh heat and extreme 
 cold; and these may be frozen and then restored to life by 
 warmth. Hence cold merely retards bacterial life; but it may 
 be extinguished by a high grade of lieat. Moist heat is more 
 destructive tlian dry heat. Boiling water will destroy all micro- 
 organisms which do not develop by spores. Electricity retards 
 the growth of bacteria; and sunlight is destructive to them, 
 especially to the bacilli of tuberculosis. 
 
 For development, bacteria require a soil from which they can 
 obtain suitable nutrient material, and also an environment of 
 warmth and moisture. Some demand an albuminous nutriment, 
 others a compound of carbohydrates; and all require hydrogen, 
 oxygen, nitrogen, carbon, lime, and potassium. 
 
 The tissues of man and animals often become the nutrient 
 soil for bacteria. The man in perfect health, whose tissues are 
 in perfect integrity, is usually proof against bacterial attack; but. 
 if his vital power be diminished by traumatism or other morbific 
 agency, then he becomes a prey to micro-organisms, which exist 
 in his cuticular or mucous teguments, or in earth, air, water, 
 or in organisms, living or dead, around him. And persons 
 in apparent health differ in respect to susceptibility to bacterial 
 disease. 
 
 Many bacteria are causal agents of fermentation, and if 
 fermentation is attended by the production of ill-smelling gases, 
 the process is named putrefaction. 
 
 Bacteria have physical properties, among which the following 
 may be mentioned: A few have the power to form pigmentary 
 matter, either in themselves or in material which they set free. 
 The blue color, sometimes seen in pus, arises from a bacterial 
 pigment. Some bacteria give a phosphorescent appearance to 
 the structure which contains them. Some yield an odor which 
 may be agreeable or disagreeable. Bacteria, like man, take in 
 oxygen and nutrient material, which they assimilate, and their 
 brief life is crowded with activity, in which are produced 
 ptomaines, toxins, toxalbumens, and antitoxins. 
 
 A ptomaine is an inanimate septic substance, which arises 
 in dead animal or vegetable matter. It is a metamorphic ma- 
 terial in a state of mutation; and from being found in the 
 
XX INTRODUCTION. 
 
 putrefying animal body, and yielding an alkaloid reaction, it is 
 named a cadaveric alkaloid. Some ]>tomaines are ])oisonous, 
 others are harmless. Some are the analogues of vegetal^Ie alka- 
 loids, viz., of atropine, nicotine, morphine, strychnine, etc. Many 
 ptomaines, when introduced into the animal body, have the 
 same effect as do their bacterial progenitors. 
 
 A second agent which originates directly or indirectly from 
 bacteria, is the toxin. This is thought to be set free from the 
 bodies of degenerating microbes; or in the changes which bac- 
 teria induce in the tissues, toxins may be generated. Some of 
 these, as the tetanus-toxin, are intensely poisonous, and are 
 rapidly absorbed. Bacteria generate and excrete another sub- 
 stance, akin to a ferment, which, acting on the cells of the con- 
 taining tissue, produces a substance named toxalbumen, which 
 may act on the body as a poison. This may be produced in the 
 laboratory; it gives the reactions of albumen, and is not alkaline. 
 
 Another important product of bacteria is that which is named 
 antitoxin. The origin of antitoxins has not been settled beyond 
 question; possibly instead of arising from bacteria, antitoxins 
 may originate in the cells of the body in which the bacteria 
 are lodged. Should the origin be in the parasite, then bacteria 
 have the double endowment of producing poisons and their 
 counter-poisons. 
 
 The toxins and antitoxins are procured in isolation by the 
 filtration of bacterial cultures: Thus, to obtain the toxins, a 
 culture containing them is placed in a cylinder of porcelain, 
 kaolin or asbestos, when the toxin containing serum will j)a.ss 
 through the wall, while the bacteria will remain in the scrum. 
 The .serum which has transuded is next treated with chemical 
 agents, and the toxin is thus obtained. The antitoxins are 
 procured by filtering through a specially-constructed filter the 
 serum of animals which liave been rendered immune. 
 
 By immunity is meant that the body of man or an animal is 
 insusceptible to disease; and the immunity may exi.st in reference 
 to more than one disease. An exemplification of immunity, long 
 known, is that furnished by vaccine virus against variola. The 
 bacteriologist has furnished an immunizing agent against diph- 
 theria, hydrophobia, tetanus, glanders, anthrax, and })neumonia; 
 and such agent may act in a two-fold manner, viz., preventively, 
 it may render the subject immune, or proof against the disease. 
 or if he l)e already affected with the disease, the latter may be 
 rendered milder by the immunizing agent. And such treatinent 
 is named orrhotherapy. or serum-therapy. The enthu.siastic 
 claims made for serum -therapy, for establishment. re(iuire to be 
 
BACTERIOLOGY, ANTISEPSIS, ASEPSIS. XXI 
 
 tested by time, severe examination, skepticism and cool obser- 
 vation. 
 
 Immunity may naturally exist in man against disease com- 
 mon to animals; and the converse is true of animals in respect 
 to human disease. Artificial immunity may be acquired by 
 man and animals, in several ways; it may be produced by inocu- 
 lation with an attenuated virus, of which a familiar example is 
 vaccine virus. Immunizing inoculation is done with a sterilized 
 culture in which the toxic bacteria have been destroyed. And 
 similar work has been done by the intravenous injection of 
 highly attenuated virulent cultures. 
 
 The serum of normal blood is antagonistic to bacteria; and 
 when the latter are injected into the vessels of a living animal, 
 the germs soon disappear; or rather, they become stranded in 
 certain viscera, as the liver and spleen, where they die, disin- 
 tegrate, and vanish. 
 
 The power to destroy bacteria is, according to certain author- 
 ities, possessed by white blood-cells, connective-tissue cells, mucous 
 cells, endothetial cells, and glandular cells. This doctrine 
 was announced by MetschnikofF, and has been accepted by a 
 number of pathologists, and strongly op])Osed by others. 
 MetschnikofF taught that when bacteria are admitted into the 
 living body, there soon ensues a struggle between them and 
 the bodily cells before mentioned; and that the victory is to the 
 stronger party. The leading defendants of the body are the 
 leucocytes, which receive into their interior the microbic entities 
 and destroy them, the process being similar to that which occurs 
 when a larger animal swallows and ends the life of a smaller one. 
 If, on the contrary, the bacteria be superior in force and energy, 
 the victory is theirs. This hostile action between living cells 
 and bacteria is named phagocytosis; and the devouring cells are 
 named pliagocyie.s. From the writer's study of this matter he 
 infers that the living cells have had their day of phagocytic 
 victories, and that this honor will hereafter belong rather to 
 the serum than to the cells of the blood. 
 
 Since the announcement by Davaine and Koch of the discov- 
 eries which they liave made in the field of bacteria, a multitude 
 of investigators have entered it and brought to light a great 
 number of microbic agents. A part of these do not interest us, 
 since they have no morbific action on man and animals; another 
 portion, however, do concern both the physician and the surgeon, 
 since they have been demonstrated to be the causal agents of 
 disease in man. Morbific bacteria are named pathogenic organ- 
 isms. An enumeration and brief notice of the leading patho- 
 genic bacteria will herewith follow: — 
 
xxii introdt'ctiox. 
 
 Bacili.is Tuberculosis. 
 
 The bacillus of tuberculosis was discovered, cultivated, and 
 demonstrated by Koch to be an inseparable accompaniment of 
 tubercular disease; and he proclaimed it in 1882 to be the causal 
 agent of tuberculosis. It does not j)Ossess the ])Ower of motion, 
 it is one of the smallest of tlie microbic organisms, its volume 
 being equal to one-fourth of that of a rod blood-cell. It is rod- 
 shaped, or bacillary in form; and sometimes it is curved in 
 form. They are occasionally found in groups of two, so disposed 
 as to form an acute angle. It thrives well on blood-serum, at a 
 temperature of 100 degrees, Fahrenheit. It can be grown in 
 other media. It has been obtained through culture in branched 
 and club-shaped forms. Bovine tubercle-bacilli are much smaller 
 than the tubercle-bacilli originating in man. 
 
 Tubercular disease in animals and man arises from this 
 bacterium. Tubercle-bacilli are the causal agents in man of 
 pulmonary tuberculosis, and of tubercular disease, whether 
 seated in the osseous or soft structures of the body. Disease 
 formerly designated scrofula owes its origin to this agent. The 
 tubercle-bacillus is found in tissues the seat of lupus. 
 
 Koch has ])repared a lymph from tubercular matter, which 
 is known under the name of tuberculin. This lymph, for a time, 
 was believed to be a cure for tuberculosis; this hope has not been 
 realized, yet the experience had with tuberculin has led to the 
 discovery of a derivative from it, known as oxtuberculin, which 
 experience has shown to be a valuable remedy against some forms 
 of tuberculosis. 
 
 The animal body is infected with tubercular disease through 
 the breathing of air, or use of food, containing the bacilli of 
 tuberculosis. 
 
 Bacillus of Anthrax. 
 
 Prior to the era of bacteriology, the causal agent of splenic 
 fever or malignant pustule, now usually named anthrax, was 
 investigated by Davaine, in France. In later years, the knowl- 
 edge of anthrax has been greatly advanced by the researches of 
 Pasteur and Koch. The anthracic bacteria are shaped like rods, 
 which liave broadened ends, and in their dimensions they equal 
 red blood corpuscles. They thrive readily in different culture- 
 media, and ])roduce spores which have great vitality. In 
 animals which have died from anthrax, the blood and abdominal 
 viscera are found infected with bacilli. If tlie elements of the 
 di.sease are inhaled they cause pneumonia. It occurs as a local 
 disease in men whose occupation briuirs them in contact with 
 animals which have died from anthracic disease. The disease 
 
PYOGENIC BACTERIA. XXIll 
 
 commences as a local gangrene of the infected surface, and 
 spreading rapidly and without limitation it soon destroys life. 
 Sometimes the writer lias stayed the disease and rescued the 
 patient by thermal cauterization and the local use of bromine. 
 This treatment, to be of avail, must be resorted to early. 
 Animals have been rendered immune through inoculation with 
 an attenuated culture of the antliracic bacilli. Through his 
 immunizing work, Pasteur has enabled tlie herdsman to save 
 his flocks, which formerly perished with anthrax. 
 
 Streptococcus Erysipelatis. 
 
 This bacterium, discovered b}^ Fehleisen, presents itself in the 
 form of a coccus, or of articulated cocci. It was discovered in 
 the lymphatics of tissue affectcl with erysipelas. This is 
 believed to be the causal agent of puerperal fever. It has been 
 found in scarlatina, variola, and cerebro-spinal meningitis. 
 This microbe formerly abounded in tlie foul air of septic hospi- 
 tals, and it was the cnuseof the constant prevalence of erysipelas; 
 but under the improved sanitary conditions of the present day, 
 this disease seldom occurs. It may, however, be readily gener- 
 ated if, in a suppurating wound, the generated pus is prevented 
 from escaping. And the exanthema having commenced, it 
 spreads cutaneously and subcutaneously ; and its march is not 
 alone centrally, corresponding to the lymph current, but it 
 extends quite as rapidly peripherally. 
 
 Pyogenic Bacteria. 
 
 Several bacterial fornis precede and accompany suppuration 
 as causal agents. About the time that Fehleisen discovered the 
 coccus which is the cause of erysipelas, Kosenbach discovered a 
 bacterium of identical form, which he named streptococcus 
 pyogenes, and which is generally found in suppurating struc- 
 tures. In fact, the streptococcus of Fehleisen is believed to be 
 the same as that discovered by Rosenbach. Another microphyie 
 discovered by Rosenbach, and named by him staphylococcus 
 pyogenes aureus, is more generally accepted as the immediate 
 cause of suppuration. This bacterium is nearly always found in 
 pus; it is found also in soil and water. The staphylococcus 
 occurs in clustered groups, which are never united in chain-form. 
 They are motionless, develop in moderate temperature, and are 
 anaerobic, that is, they can exist and grow without air. If a 
 culture of it be injected into a serous cavity of a rabbit, life is 
 quickly destroyed ; but if the material be injected subcutaneously, 
 the action is limited to the formation of an abscess. Instead of 
 presenting a yellow hue this staphylococcus, or those cognate to 
 it, may be white or of lemon color. 
 
xxiv INTRODUCTION. 
 
 Through the action of chemical or pliysical agency on living 
 tissue, its life may be tlestroyed and a material produced which 
 has the appearance of i)us. But such pus has not the property 
 of propagation; and it may be named sterile or barren, since it 
 is not inoculable, and cultures can not be grown from it; in fine, 
 it lacks tlie pus-germ. Pus capable of reproduction, transi)lanta- 
 tion, and dissemination originates from a bacterial organism of 
 coccus, streptococcus or staphylococcus form. Wiien the causal 
 agent is in staphylococcus form tlie suppurative action is local- 
 ized, but if the action is migratory, it is due to streptococci. 
 
 The action of pyogenic bacteria consists in the destruction of 
 the component cells of living ti-^sne; and this destructive action 
 takes place most rapidly in tissue known as inflammatory 
 neoplasm, granulative or embryonic tissue, and also in tissue of 
 which the vitaHty has been impaired by traumatism or other 
 depressing agency. The excreta from these microbes perform 
 the part of ferments or solvents, and thus they })revent coagula- 
 tion which often furnishes a barrier against purulent infection. 
 The surgeon, in asepticising the surface on which he operates, 
 and who afterwards j)rotects the part with aseptic dressing, 
 guards against suppuration. The dermal tegument of the body 
 when in com[)lete integrity, and the intact mucous membranes 
 are effectual barriers against the entrance of pyogenic bacteria. 
 
 Bacillus Pyocyaneus. 
 
 . Pus sometimes has a blue color, arising from the presence of 
 a bacterium known by the name of bacillus pyocyaneus. This 
 bacillus is rod-shaped with rounded ends. It develops in the air 
 at ordinary temperature. This bacillus thrives rapidly, and it 
 soon imparts a blue color to the dressing of a suppurating 
 wound which contains the coloring microbe. Chlorinated water 
 is destructive to it, and is one of the best disinfectants for its 
 extermination. If the pyocyanic pus be mixed with chloroform, 
 the pigment is precipitated in crystalline form. Blue or colored 
 pus is not more infective than ordinary i)us. 
 
 Malignant (Edema. 
 
 A number of years ago, Pirogofif described a suppurative 
 l)rocess wdiich he named purulent or malignant (edema. Its 
 leading characteristic is rapid diffusion and destruction of the 
 invaded structures, especially of the subcutaneous tissues. The 
 causal agent of this disease was discf>vered by Pasteur, and 
 named by ])im septic vibrio. This microphyte was found later 
 by Koch, and described by him as a bacillus of rod-shape. It 
 is motile and grows rapidly, when excluded from the air. It has 
 
BACILLUS OF DIPHTHERIA. XXV 
 
 been found in soil. Parts the site of malignant oedema are 
 tensely swollen, and the overlying skin has a glistening appear- 
 ance. Incisions should be made which permit the escape of 
 albuminoid serum, and lessen tension. And the affected part 
 should be dressed with carbolized gauze. 
 
 Bacillus of Tetanus. 
 
 The causal microphyte of tetanus has been especially investi- 
 gated by the Japanese bacteriologist Kitasato, who has isolated 
 and made a culture of tlie bacillus of tetanus. In form it is a 
 slender rod, in the tenninal end of which a spore is developed, 
 through which tliis microbe is* propagated. It develops very 
 slowl}', and only when all oxygen is excluded. It can grow in 
 hydrogen. It has slight power of motion, and grows in a tem- 
 perature corresponding to that of the human body. A culture 
 has been prepared from this bacterium, which, injected into 
 animals, produced true tetanus, in which the tetanic spasms 
 started from the point which was inoculated. An antitoxin, or 
 rather an antitetanic remed}^ has been prepared by Tizzoni from 
 the serum of animals which had been rendered immune by 
 inoculation with a sterilized culture of the tetanic microphyte. 
 This has been used in tlie treatment of patients affected with 
 lockjaw, and some seem thus to have been cured. Further trial, 
 however, is necessary to establish the efficiency of this plan of 
 treatment. 
 
 Bacillus of Diphtheria. 
 
 This bacillus, discovered by Klebs and Loffier, is in the form 
 of a slightly curved rod, of which the ends are swollen. This 
 bacterium is variable in shape, and in normal form it is only 
 found in diphtheritic membrane. It has no movement; and its 
 growth is favored by a current of air. A culture of this bacillus 
 develops diphtheria at the site of inoculation, and it can produce 
 general paralysis. A toxin is developed from the diphtheritic 
 bacillus which was isolated by Roux, which is extremely 
 poisonous, and speedily destroys the life of an animal inoculated 
 with it 
 
 Behring, from the blood of animals which had been rendered 
 immune, obtained an antitoxin which is antagonistic to the 
 diphtheritic virus. The serum of the horse, which has been 
 immunized by a, series of diphtheritic inoculations, is used as the 
 antitoxic remedy, both proph^dactically and curatively, in the 
 treatment of diphtheria. This serum has no influence on the 
 bacilli, but it neutralizes the toxic material which is generated 
 bv the bacilli. 
 
XXvi T\TK<^DrOTTON. 
 
 GONOCOCCUS OK B.VCTEltlUM Ol' GoNORKHCEA. 
 
 The causal agent of gonorrhoea is a coccus that is triangular 
 in form, and usually two cocci are seen united hv their bases. 
 Several pairs are often found clustered together. ^ It is not motile. 
 This germ abounds in the pus of gonorrlioeal ophtiialmia. The 
 gonorrlucal microbe is found in the fluid of gleet so long as the 
 disease is contagious. 
 
 In the lochial and blenorrhceal discliarges of the female, 
 bacteria exist which are similar in form to the gonococcus; yet 
 when these bacteria are subjected to the known tests of differen- 
 tiation they are found to differ from the gonococcus found in the 
 pus of gonorrhoea. 
 
 Bacillus of Glanders. 
 
 This bacillus presents the form of a slender rod, of which the 
 ends are rounded. It appears single and not in groups, and is 
 developed by spores. It is not motile, and when dried it retains 
 its vitality for a long time amidst the straw of a stable, in 
 which a horse infected with glanders has been housed. It easily 
 infects the mucous membrane of the nose of the horse, or a 
 wound in the skin of man. As yet, no remedy against glanders 
 
 is known. 
 
 Bacillus Coli Communis. 
 
 Bacteria are found in the intestinal canal, and of these an 
 important one is the bacillus coli communis, which is found in 
 the bowel and itecal content. It is in the shape of a short rod 
 which is slow in its movements. The normal mucous membrane 
 of the intestine seems to prevent the migration of this microbe 
 into the neighboring peritoneal cavity, but when the mucous 
 membrane loses its integrity, the bacillus becomes a virulent 
 morbific agent. And this morbid action is more intense if the 
 lesion be in the ileum than in the jegunum or colon. In case of 
 intestinal obstruction, this bacillus is thought to be the causal 
 agent of the trouble which arises. The surgeon is able to render 
 aseptic the skin and the accessible mucous membranes, but as 
 the small intestine is beyond his reach, he can only imperfectly 
 disinfect its interior. For this disinfection Nussbaum admin- 
 istered chlorate of potash. The writer would give cam))hor water, 
 cinnamon water or a decoction of capsicunj. It is not improbable 
 that the bile which is constantly being poured into the intestine 
 may limit bacterial development. 
 
 Actinomycosis. 
 
 Actinomyco.sis is an infectious disease occuring primarily in 
 the ox and hog, and from these animals the affection may be 
 
ACTINOMYCOSIS. XXVI 1 
 
 communicated to man. It may attack the mouth, jaws, tonsils, 
 alimentary canal, lungs, and skin. It arises oftenest in the jaws 
 of animals, and the starting point in them is usually a decayed 
 tooth. Men who have tlie care of such diseased animals are 
 sometimes infected with actinomycosis. The inoculation may 
 occur in the mucous membrane of the mouth, or in the skin. 
 It begins as a circumscribed, nodular induration, which finally 
 suppurates and the pus contains small yellow grains the size of 
 a pin's head, and visible to tlie eye. When one of these granules 
 is flattened and examined microscopically, it will be found to 
 contain star-shaped figures. From the center of these actinoid 
 bodies proceed club-like branches, and the arrangement of these 
 branches is often such tliat the figure resembles a rosette. This 
 fungoid parasite belongs to the family of hypomycetes or 
 molds. It is believed to develop by means of spores. It 
 should be treated by excision, cauterization, and administration 
 of large doses of iodide of potassium. 
 
 After this brief description of the chief bacteriological 
 agencies which are recognized as the causal entities of certain 
 surgical affections, the subject of Antisepsis and Asepsis will be 
 considered, by which the surgeon can prevent the admission of 
 bacteria into the field of his opei'ative work, or can render those 
 inert which exist there. Should the means known as antiseptic 
 and aseptic be omitted, then a condition named sepsis arises in 
 the wounded structures. This is due to the development of 
 bacteria and the action of tlieir toxic derivatives on the tissues 
 exposed to them. In the subject of such morbid action, there 
 are increase of temperature, accelerated heat, coated tongue, and 
 diminution of the normal secretions. The patient is physically 
 ill at ease. 
 
 The doctrine of antisepsis and its application in the treat- 
 ment of wounds originated with Joseph Lister, about 1870. 
 Lister believed that wuunds w-ere infected through contact with 
 air which contained pathogenic germs. And Jiis early treatment 
 consisted in disinfecting the air in the field of his operation. 
 And this was done by generating an antiseptic spray or cloud, 
 in which both surgeon and ])atient were enveloped. This 
 method was in vogue for a period ; but it was abandoned when 
 it was determined that the air contains very few pathogenic 
 microbes; and the few which are thence derived may be 
 destroyed by phagocytosis, or rendered inert by the cells of the 
 living tissues. Lister's dressing of wounds was complex, and 
 consisted, in the main, of several layers of gauze which were 
 permeated with carbolic acid. Between this and the wound was 
 interposed a layer of specially prepared oiled silk, which was 
 
XXVlll INTRODUCTION 
 
 named "protective." The Listeriaii method was rapidly adoi)ted 
 by the younger generation of surgeons; but numerous modifica- 
 tions of it soon appeared, promineut among which was the 
 abandonment of the spray in which Lister did liis early opera- 
 tions. Instead of carbolic acid, salicylic acid, and boracic acid 
 were employed to impregnate the material used for dressing. 
 Chloride of zinc in solution was likewise used. Sternberg 
 deserves great credit for what he has done in the development of 
 Bacteriology; he tested the germicidal power of the various 
 antiseptic agents, and found that corro.sive sublimate is remark- 
 able for its anti-bacterial properties. As the result of the investiga- 
 tions of Sternberg and others, corrosive sublimate has come into 
 general use in both aseptic and antiseptic surgery. It is used in 
 dilution varying in strength from a solution of one part in one 
 thousand parts of water to one in ten thousand parts of water; 
 the usual dilution is that of one in two thousand. 
 
 In operative work done antisepticall}', the surgeon disinfects 
 the part to be operated on, also his hands and instruments; and 
 this disinfection is done with a carbolized, sublimated, or other 
 antiseptic solution. It was the custom, in the early days of 
 antisepsis, to flush the wound with the antiseptic solution; but 
 the antisepticijui has modified this part of his work, and instead 
 of active chemical solutions, he uses sterilized water for flushing 
 the wound. In thus doing, the operator avoids the irritation of 
 the wounded j^arts wliicli results from the application of carbolic 
 acid, corrosive sublimate or other chemical irritant. 
 
 A few surgeons in operating closely follow the antiseptic 
 metliod as first ]>ursued by its author; more deviate widely from 
 it, and have adopted a procedure known as tlie aseptic. Asepsis 
 is the offspring of antisepsis. Asepsis is Listerism simplified. In 
 aseptic work, germicidal chemicals are withheld from the wounded 
 structure. 
 
 To do an operation asepticall}^ the surgeon's hands should be 
 absolutely clean, his operating dress clean through sterilization, 
 his instrnments purified, the surface to be operated on must be 
 purified from bacteria and their derivative toxins. And finally, 
 the work being done, a dressing must be applied which will 
 exclude every infective agency. 
 
 To cleanse the hands and forearms let them be scrubbed well 
 with Castile or green soap and water, which has been sterilized by 
 boiling. A brush which has been sterilized by immersion in 
 chloroform, alcohol, or turj)entine must be used on the nails, 
 fingers, and hands. The hands should then be rubbed with 
 alcohol, and, lastly, immersed in a solution of sublimate. An- 
 other plan, after the hands have been cleansed with soap and 
 water, is to immerse them in a solution of permanganate of 
 potash, then to decolorize them in a solution of oxalic acid, and 
 to conclude by immersing them in a solution of sublimate. 
 Another plan is to take equal parts of chloride of lime and 
 carbonate of soda, and having made a paste of them to rub tliis 
 
ACTINOMYCOSIS. XXIX 
 
 on the bauds which have been cleansed with soap and water, 
 and to conclude by washing this off with sterilized water. The 
 writer's plan is to scrub the hands well with soap and water, 
 and then to rub them well with pure alcohol, or instead of 
 alcohol, chloroform may be used as the final application to the 
 hands. 
 
 The operator should wear a rubber apron to protect his dress, 
 and over this a sterilized linen or cotton gown sliould be worn. 
 Instruments can be purified by inclosure in an oven or closed 
 vessel, which is heated to a high temperature. The steel of 
 instruments, however, is softened or changed by a high heat; 
 hence other methods of sterilization have been introduced. 
 That of Schimmelbusch is often used, which consist in immers- 
 ing them in a strong solution of bicarbonate of soda, and boiling 
 them in this for fifteen minutes. Another plan is to immerse the 
 instruments in a four per cent solution of carbolic acid, and 
 afterwards w^ash them in sterilized water. And during the 
 operation the instruments may remain immersed in a twenty- 
 five per cent solution of alcohol. 
 
 The skin, especiall}' the hair and sebaceous follicles, are the 
 special habitats of bacteria, hence dermal purification is a most 
 important prcliminarv to an operation. And the first step in 
 this is a general bath, in which the patient's body is cleansed 
 with soap ai)d water. The part to be operated on is to be shaven, 
 and then turpentine rubbed on it, and the work to conclude by 
 diligently washing with soap and water. And if the pleural or 
 ]-)eritoneal cavity is to be opened, besides the disinfection men- 
 tioned, a soap poultice may be worn for twelve hours prior to the 
 contemplated operation. The part to be operated on should be 
 surrounded with sterilized sheets. 
 
 The material for ligating vessels may be of silk or catgut. 
 Silk can be sterilized by boiling it in water, or by prolonged 
 immersion in alcohol. Catgut is sterilized in several ways: this 
 may be done by boiling in alcohol, or by prolonged immersion 
 in an alcoholic solution of corrosive sublimate, viz., one of sub- 
 limate to five hundred of alcohol, and afterwards the thread is to 
 be retained in alcohol. Some prepare it by treatment with 
 formalin, and others with cnmol. Catgut may he hardened, and 
 rendered less absorbable by boiling in a dilute solution of chromic 
 acid in carbolized water. 
 
 Silk-worm gut is used for external sutural closure. It is 
 disinfected by prolonged immersion in ether, and it should be 
 preserved in alcohol. 
 
 Silver wire, or copper wire well plated or gilded, may be 
 used for suture. Wire can be purified by immersion in boil- 
 ing water, an-l it is best closed by twisting instead of tying. 
 Unlike silk or catgut, metallic suture does not swell or enlarge 
 in the tissues. 
 
 If the dermal lips of the wound be too far asunder for sutural 
 approximation, then the wounded surface should be closed by 
 
XXX INTHODrCTION. 
 
 the dermo-epidermal grafts of Thiersch as described elsewhere in 
 this book. 
 
 The wouud may or may not be drained according to its 
 condition: if the raw cavity be well cleansed, and there be no 
 probability of etfnsion of blood, serum, or of infected excrementi- 
 tial matter, then complete closure may be done. In case ihe 
 wound be infected, or blood or scrum will probably be effused 
 into it, then drainage should be established b}' sterilized catgut, 
 rubber tubing, or iodoform, or other aseptic gauze. 
 
 The sutural closure being completed, the remaining seam may 
 be painted with the compound tincture of benzoin. This agent 
 is especially useful where the operation is done on a mucous 
 surface, or on the skin near the mouth, nostrils, or eyes, whence 
 excreta can flow and come in contact with the wound. Tincture 
 of benzoin quickly forms an imi)ermeable varnish, which acts 
 both occlusivel}' and antiseptically. 
 
 The wound is next to be covered with several layers of 
 sterilized gauze, and an outer layer of absorbent cotton. Cotton 
 in some unknown way, insures against the penetration of 
 bacteria ; and owing to this property of cotton, Guerin obtained 
 excellent results, as the writer was witness of, from the use of 
 cotton wadding as a dressing of compound fractures. 
 
 The sterilized gauze may be prepared from cheese-cloth, 
 tarletan, or other meshed cloth, by boiling it in a solution of 
 soda, and afterwards saturating it with a berated or sublimated 
 solution ; and after this preparation, it may be preserved, moist 
 or drv, in a closed vessel. A gauze that is in common use, is one 
 which, after being sterilized by boiling or steam, is saturated with 
 iodoform. 
 
 After the wound has been dressed with gauze, the latter may 
 be covered with absorbent cotton, and the whole fixed in place by 
 a retaining bandage. 
 
 The wound dressed in the way described may remain undis- 
 turbed for a week or more, provided there be no rise of the 
 patient's temperature, and then, on the removal of the dressing, 
 the wound will be found healed. Such are the results which are 
 obtainable in a surgical operation which has been executed 
 without fault or lapse in all the details of asepsis. Should 
 the wound, however, not have this satisfactory termination, of 
 which the surgeon would have a foretoken in the rise of tempera- 
 ture, then the dressing should be removed, and such corrective 
 measures taken as the conditions indicate. 
 
CHAPTER I. 
 
 SURGERY OF THE SCALP. 
 
 Hippocrates fully appreciated the gravity of affections of the 
 head, and especially, of the wounds of the head. Several chapters 
 of the works under his name which have reached us are devoted 
 to wounds of the cranium, and create in the reader admiration 
 of the progress and knowledge which had then been reached in 
 this direction. In several editions of the divine old max, as 
 Hippocrates is often reverentl}'' named, this famous sentence 
 occurs: "Nullum vulnus capitis contemnenduvi est; " or, as our tongue 
 would have it, " Xo wound of the head is to be viewed as a trifling 
 matter." If, as Littre thinks, this phrase is an interpolation by 
 some later transcriber, yet there is so much practical wisdom 
 couched in it that, rather than expunge, we should be grateful 
 for the interpolation, for the practitionCT of surgery can have 
 no more valuable rule for his faithful observance and constant 
 guidance than that every wound of the head should receive 
 careful and thoughtful treatment. With this prefatory prelude, 
 we will proceed to a brief study of the surgical anatomy of the 
 scalp, necessary to a proper understanding of the diseases and 
 injuries to which the scalp is subject. 
 
 surgical anatomy of the scalp. 
 
 Some knowledge of the parts that enter into the structure of 
 the scalp is necessary to enable one to intelligently study morbid 
 and traumatic conditions which occur here. As component 
 elements of the minuter species, one finds squamous or flat 
 epithelial cells, connective ti.ssue and adipose cells, and muscular, 
 fibrous, nervous, vascular, and lymphatic structures. Each of these 
 components, whether cellular or structural, performs an important 
 part in the attendant phenomena of the wounds of the scalp, 
 especially the epithelial and connective tissue cells and the 
 vessels. The scalp is divisible into stratified aggregated struc- 
 tures of larger order than the preceding ones mentioned. Com- 
 
 (7) 
 
S Sl'KGKRY OF TIIK SCAI.I'. 
 
 mencing outwards and i)assing inwards, tliese layers rest on each 
 other in the following order, the cutaneo-adipose, the aponeurotic, 
 and the periosteal. The outer one is constituted of the derm 
 and fatty couch, and is especially important, since from it proceeds 
 the hair, and in it are contained, also, the sebaceous and sudo- 
 riferous glands and the vessels. 
 
 This first layer is especially conspicuous as the ground in 
 which the hair grows. In it the hair roots are planted, reaching 
 often quite through the derm, and thou resting on the .subjacent 
 fatty couch. This fatty layer, it may be renuirked, is so closely 
 adherent to the derm that it requires a forced dissection to 
 separate the two. The fat is lodged in ovoidal compartments, 
 the wall-like partitions being composed of dense fibrous tissue. 
 It can only be removed from the skin by careful scraping, where 
 the under surface of the derm will present a figured appearance. 
 The roots do not penetrate vertically, but obliquely, so that the 
 hairs, as a rule, tend to lie flatwise, with shafts diverging from, 
 and roots converging towards, the so-called crown, or posterior 
 fontanel, of the skull. This cutaneo-adipose layer increases in 
 thickness as one passes from before backwards. With advancing 
 years, the hair on the upper part of the scalp, through atrophy 
 of the blastema, wheyce tlie individual hair grows, gradually 
 falls. At the same time this portion of the scalp becomes atten- 
 uated through the vanishing of the adeps contained in the 
 outer stratum. This senile attenuation has a bearing in surgical 
 work. The traversing scalpel creaky as it goes, and demands 
 greater efifort to open its path than is the case in the structures 
 of the younger subject. 
 
 The cutaneo-adipose layer is remarkable for its richness in 
 vessels, which are found here in greater multitude than on any 
 other part of the surface of the body, excei:)t that of the surface 
 of the ends of the toes and fingers; and, as on the ends of the 
 fingers, the vessels in the skin of the scalp lie ver}^ superficial. 
 As Tillaux has specially pointed out, the vessels of the scalp lie 
 in the skin and fatty stratum, and not beneath it, as is the 
 arrangement elsewhere: for the usual anatomical disposition is 
 that vessels near the periphery lie in the subcutaneous fascia. 
 In the scalp, however, they are quite external to this structure. 
 
 In the cutaneo-adipose layer are numerous sebaceous and 
 sudoriferous glands. The occlusion of the outlets of the sebaceous 
 glands gives rise to the atheromatous or sebaceous cysts often 
 found in the scalp. 
 
SURGICAL ANATOMY OF THE SCALP. 9 
 
 The second important stratum is the so-called aponeurosis 
 or musculo-fibrous layer, which, like an arched bridge, rests on 
 the cranial vault, from before backwards. In the frontal and 
 parietal regions it is reenforced by muscular fibres, the whole of 
 these forming the occipito-fron talis muscle. From its firm, dense, 
 and protective character arose the name galea capitis, or helmet 
 of the head. In the lateral regions of the head this aponeurosis 
 becomes attenuated to a layer of less thickness, corresponding 
 more to subcutaneous fascia elsewhere. 
 
 This aponeurosis of musculo-fibrous structure is so closely 
 adherent to the cutaneo-adipose layer outside that they can only 
 be separated by a forced dissection. From it spring the fibrous 
 partitions which separate and inclose the fat cellules, and then 
 fuse with the external derm. In its vascularity this stratum 
 presents, in an unusual degree, a numerical superiority of the 
 venules over their corresponding arterioles. The consequent 
 slackening of the circulation resulting from this disposition 
 throws some light on morbid conditions which occur here. This 
 musculo-fibrous stratum is closely adherent, as has been stated, 
 to the layer external to it, but is very loosely connected to the 
 periosteal stratum which lies inside of it, namely, there is an 
 interval between it and the subjacent stratum, occupied only by 
 loose connective tissue. The result is that the closely cohering 
 first and second layers are readily movable on the third or inner- 
 most stratum, and, due to such laxity, the outer portion of the 
 scalp can be moved backwards and forwards at will, by certain 
 persons. This space external to the periosteum is of such a 
 character that it is almost serous or bursal in structure, and it 
 furnishes ready lodgment for pus, extravasated blood, and oedem- 
 atous accumulations. As a consequence of the existence of 
 this space the scalping knife, as well as that of the necropsist, 
 can the more readily detach the scalp, and due to it the lacerated 
 wound, also, may reach great dimensions. 
 
 The third layer, which must be reckoned as the innermost 
 portion of the scalp, is the periosteum, named here, from its 
 position, the pericranium. This pericranial layer is thicker than 
 the periosteum elsewhere, and contains blood-vessels and nerves. 
 The unusual number of nerves renders the membrane sentient 
 and the seat of neuralgic trouble. The vascularity varies with 
 age, becoming more limited in advancing years, yet in the young 
 subject Hyrtl has found through injections that there is a direct 
 connection between the intra-cranial vessels of the dura mater 
 
10 SURGERY OF THE SCALP. 
 
 and the pericranium. Material injected into the middle menin- 
 geal artery traverses the cranial wall of the child, and appears 
 in the external periosteum. And in this way the encephalic en- 
 gorgement of the child finds a medium for partial escai)e. But 
 later in life osseous condensation obliterates these minute vessels. 
 And as this obliteration proceeds, death of the bone can more 
 readily occur. As a result of sucli vascularity, and the facility 
 for afflux and efflux of blood, cranial necrosis is rare in the young- 
 subject. 
 
 The pericranium is adherent to the sutures of the cranium, 
 and somewhat so to the frontal and parietal eminences; elsewhere 
 the connection is slight, so that the membrane can easily be 
 detached from the adjacent bone. The adherence of the peri- 
 cranium to the skull is closer and firmer than is the adhesion of 
 the pericranium to the overlying musculo-aponeurotic layer. 
 Hence in the wound made for trephining, unless these conditions 
 be well borne in mind, the uplifted flap will leave the periosteal 
 layer behind. 
 
 The arteries of the scalp are derived from the external carotid, 
 except those which are distributed to i»arts within the orbit, or 
 which emerge from this cavity, as the supra-orbital, frontal and 
 nasal, and also a few which traverse the cranial foramina: in all 
 these excepted cases they emanate from vessels within the cranium, 
 and chiefly from the internal carotid artery. 
 
 The arteries found in the scalp are the following: frontal, 
 supra-orbital, temporal, auricular and occipital. 
 
 The frontal, which furnishes blood to the pedunculated flap 
 taken from the forehead in rhinoplastic operations, done according 
 to the Indian method, lies from a quarter to a third of an inch 
 from the median line; hence, if the pedicle of the twisted flap have 
 a breadth of a half inch, it will certainly contain one of the frontal 
 arteries, and therefore its nutrition will be insured. 
 
 The temporal artery is the posterior one of the two branches 
 into which the external carotid divides, when it has ascended 
 into the upper part of the parotid gland. This division into the 
 temporal and internal maxillary branches occurs in front of the 
 tragus, and in the angle formed by the condyloid process of the 
 lower jaw and the zygoma of the tem|)oral bone. After rising 
 nearly an inch above the zygoma, the temporal becomes super- 
 ficial, and divides into two branches, the anterior and posterior 
 temporal arteries. These vessels., quite visible to the eye, become 
 tortuous with age. Just previous to the division of the primary 
 
SURGICAL AJSATOMY OF THE SCALP. 11 
 
 trunk, it gives off a branch named the deep or middle temporal, 
 which dips down through the superficial fascia to the bone, and 
 thence lying in a furrow on the squamous portion of the temporal 
 bone, it ascends nearly straight upwards towards the summit of 
 the skull; the course of this deep temporal artery corresponds 
 pretty nearly to a line drawn vertically upwards from the external 
 auditory meatus, as may be verified by one unwittingly opening 
 it, as once occurred to the author in lancing an abscess in 
 this region. In front of the middle temporal lies the posterior 
 superficial branch, which mounts upwards to near the summit of 
 the head. The anterior superficial branch is distributed to the 
 integument on the side of the forehead. The branches of the 
 temporal artery are often the subjects of wounds, and in former 
 times when arteriotomy was resorted to for disease of the eye, 
 these arteries were often attacked. The service of the lance here 
 has been superseded by that of the suction-cupping cylinder, and 
 other improved methods of the oculist. 
 
 Another artery deserving attention is the posterior auricular, 
 which in its origin lies under the edge of the parotid gland. It 
 soon reaches and lies in the sulcus between the pinna and the 
 mastoid portion of the temporal bone. Yet abscess, which often 
 appears here, lifts the vessel from its deep sub-aponeurotic site, so 
 that it becomes (as Tillaux says) interested in the lancing of such 
 abscess. From dissections made by the author, the vessel in the 
 normal state of the parts lies deep on the bone, so that in plastic 
 work done to reconstruct the adjacent part of the ear, a flap may 
 be uplifted without risk of wounding the posterior auricular 
 vessel. 
 
 The disposition and situation of the lymphatic vessels and 
 glands of the scalp merit more attention than is commonly given 
 them. These vessels, from their minuteness and want of color, 
 often pass unnoticed, or are mistaken by the dissector for con- 
 nective tissue. As channels for the metastatic transmission of 
 septic or infectious material, these parts are of extreme importance. 
 The glands, when swollen, point unmistakably backward to some 
 infected point along the course of their different vessels, and then 
 become important aids in diagnosis. 
 
 The lymphatics commence by a close network of fine vessels 
 along the median or sagittal plane of the scalp. This capillary 
 network, discoverable by injection in the young child, lies very 
 superficial in the skin. From it depart toward each side groups 
 of vessels, which, according to their destination, may be named 
 
12 SURGERY OF THE SCALP. 
 
 frontal, parietal, and occipital lymphatics. These vessels (juickly 
 abandon their superficial situation, and penetrate so deeply into 
 the skin that, unlike what occurs elsewhere, when they become 
 inflamed they cannot be seen as red lines. 
 
 The frontal, or anterior series, passes downwards and back- 
 wards and enters two or three glands which lie in or on the parotis, 
 near to the condyle of the lower jaw. Lymphatics of the parot- 
 idean region enter these glands; hence swelling of the glands, 
 though it may point to disease on tlie forehead, might also indi- 
 cate disease or lesion on the side of the face or eyelids. These 
 glands have also connection with others which lie below, near 
 the angle of the lower jaw. 
 
 The second, or parietal group of lymphatics are of larger 
 volume than the frontal, pursuing a downward course, almost 
 straight in direction, to two or three glands which lie on the origin 
 of the sterno-cleido-mastoid muscle, over the mastoid process; 
 and from these glands efferent lymphatics proceed to the super- 
 ficial and deep cervical glands. 
 
 The third group named, occipital, pass downwards and back- 
 wards to the occipital glands, one or two in number, which lie on 
 the origin of tiie trapezius muscle. 
 
 The parietal and occipital lymphatics so interlace and inter- 
 communicate that they may be regarded almost as one system. 
 In consequence of such inosculation, it is probable that when one 
 or more branches become obstructed, their contents may find 
 escape through contiguous branches. 
 
 Tlie glands wliich as a broken chaplet clasp the posterior 
 part of the head near its base, are so often affected in secondary 
 syphilis that Ricord proposes to feel, in the back of the neck, the 
 pulse of the syphilitic subject. More properly, however, these 
 glands are like signs which point back and indicate the course of 
 the afferent lymphatics. 
 
 The nerves of the scalp, functionally considered, are of three 
 kinds: Motor, from tlie facial, few in number; jnirely sensory, 
 from the fifth pair; and also those of mixed functions. Of these 
 three, the purely sensory nerves are those which require notice 
 here; for as these are the site of neuralgic pains, along with 
 others of their order, they sometimes become the subjects of 
 operation. 
 
 From the ophthalmic branch of the fifth pair proceeds, 
 within the orbit, the frontal nerve, which, lying close to the 
 upper wall of the orbit, escapes with a small artery through the 
 
SUHGICAL ANATOMY OF THE SCALP. 13 
 
 supra-orbital notch, and passes thence upwards on the forehead. 
 Within the orbit there are given off some small branches, an 
 important one of which is a small twig which penetrates and 
 ascends within the frontal bone, and it ends or escapes at the 
 frontal eminence ; this filament, escaping neurotomy or neurec- 
 tomy of the frontal nerve, explains the continuance of pain after 
 these operations. 
 
 After this preliminary consideration of the structures of the 
 scalp that especially fall within the province of surgery, we will 
 now proceed to a study of the surgical diseases of this region. 
 
CIIAPTEI'v IT. 
 
 GEXEKAL CLASSIFICATION OF THE AFFECTIONS OF THE SCALP, FOL- 
 LOWED BY A CONSIDERATION OF INFLAMMATION AND OTHER 
 MATTERS WITHIN THE SPHERE OF GENERAL SURGICAL PA- 
 THOLOGY. 
 
 The interminable variety of diseases, to which additions are 
 being made by the legitimate progress of medicine, and especially 
 by the ambition of those who are desirous of fame as contributors 
 to nomenclature, is perplexing to both teacher and learner. To 
 lessen tlie lalxn* of mastering such detail, considerate writers seek 
 to epitomize and to clearly generalize, and thus to lessen, as much 
 as possible, by mnemonic aids the tasks of their readers. With 
 such purpose the following categories and groups of disease which 
 are met within the cranial integuments are presented: — 
 
 1. Inflammation, traumatic or specific, as seen in erysipelas; 
 or in a furuncle, abscess, carbuncle, diffused phlegmon, or ulcer; 
 or in the more simple forms of skin disease, as acne, eczema, etc. 
 
 2. Gangrene, ulcers and fistula. 
 
 3. Syphilitic, scrofulous and tubercular disease in their local 
 manifestations. 
 
 4. Injuries, in which are comprised the various forms of 
 wounds, viz., incised and flap wounds; penetrating, lacerated and 
 contused wounds, wounds caused by gunshot and the diverse 
 missiles used in war. 
 
 5. Burns and inj ury from contact of acids and caustic alkalies. 
 G. Hypertrophy and atroph}'. 
 
 7. Tumors, benign and malignant. 
 
 8. Aneurism. 
 
 9. Arterio-venous enlargement and varix. 
 
 10. Oedema. 
 
 11. Emphysema. 
 
 12. Neuralgia. 
 
 It is the plan of this work to intermingle the subjects of 
 surgical anatomy, special and general surgery, in such a manner 
 (14) 
 
INFLAMMATION. 15 
 
 that each may add to the interest of the other; by following out 
 such a course it is hoped to maintain an enlivening variety of 
 matter, and thus, as far as possible, to avoid tedious monotony. 
 And though in following such a plan the rigidly scientific method 
 may be the loser, yet it is expected that the reader will be the 
 gainer. 
 
 If precedent be sought for such deviation, the waiter finds one 
 in the example of Joseph Hyrtl, in whose admirable work on 
 "Topographical Anatomy" one finds a violation of the prescribed 
 rules of treating this subject; yet Hyrtl's transgression, though 
 chastised by Grerman critics, has given medicine a work of which 
 each page interests the reader, and clings to his memory; should 
 these pages, though they violate wonted method, awaken a tithe 
 of such interest the writer's task will be well rewarded. 
 
 INFLAMMATION. 
 
 The subject of inflammation, which, as above mentioned, is 
 present in some of the affections of the scalp, demands an early 
 and important page. xA.nd this importance is augmented when 
 it is considered that this subject is shared equally by surgery and 
 internal medicine. It has engaged the study of a Billroth, a 
 Weber, a Chauvel in surgery quite as much as a John Simon 
 and Virchow in internal medicine. This list of names (in which 
 many others might have been included), represents some of the 
 best intellects which by their labors have advanced medicine in 
 modern times. The subject has become, as it were, a scientific 
 arena in which cultivated minds have worked ambitiously,, 
 hoping to win laurels by solving some difficult problem, or by 
 making some new discovery. Until within recent years, the 
 student of inflammation confi.ned his researches to the laboratory 
 of his brain. The modern investigator has chosen the inductive 
 method of vivisection ; and in this latter work, the frog, guinea 
 pig, pigeon, dog, and other animals have become important 
 coadjutors. 
 
 The Latin tongue, which long prior to our civilization 
 passed from the rude and concrete stage to the abstract, has left 
 us a treasure in the writings of Celsus; and to the lovers of classic 
 literature, no more charming work can be commended for study 
 than that of this old author. And, though it remains a matter of 
 controversy whether Celsus ever practiced medicine, yet every 
 one of his readers becomes quickly convinced of the practical 
 value of his teaching. Celsus has left us a definition of iuflam- 
 
16 AIM'KCTIOXS OK THE SUALP. 
 
 niation that is remarkul)lo for brevity, as well as wide range of 
 meaning. The four words of this definition, redness, swelling, Jteat, 
 and jmhi, have been named the Celsian (quadrangle ; and, altiiough 
 these corner stones were laid eighteen hundred years ago, they 
 endure until to-day; and on them the modern l)uilders yet build. 
 As proof of this, the following definitions of infiammation given 
 in recent times are presented. Says Otto Weber, an eminent 
 German student of surgical pathology, " Inflammation is a local 
 disturbance of nutrition caused by an irritant; this disturbance 
 commences with augmented formative action and is attended by 
 an increased afflux of nutritive material to the part, as well as by 
 increased disintegration." Strieker, another medical authority of 
 eminence, defines it to be "a wound, disturbance of circulation, 
 exudation of fluid and solid matter, disturbed nutrition, and new 
 growth." The author ventures to offer a kindred one: in inflam- 
 mation there is an increased afflux of blood or plasma to a part 
 as agents of ascending metamorphosis; also an increased efflux of 
 elements resulting from disintegration, as the result of retrograde 
 metamorphosis, the whole originating from a local irritant. Se'e, 
 a French writer, says that " inflammation consists of tumultuous 
 acts, nutritive and innutritive; it is an image of nutrition in which 
 equilibrium is broken." 
 
 According to Heurtaux, a diligent student of this subject, 
 inflammation is a disturbance of nutrition inducing a reversion 
 to the embryonic type of tissue, and a production of plastic 
 material, and sometimes of pus; the resulting lesions are transient 
 and leave no trace; or they are destructive; or they may aid in 
 the formation of connective tissue; of the eventualities here 
 enumerated, one or more may be absent. And this inconstancy 
 depends on the fact that the process may stop and retrograde. 
 
 Now if the leading points of these definitions be note,d, we 
 are able, by a slight interpretation, to discover in them that of 
 Celsus; we have a resemblance to a palimpsest, or old manu- 
 script, in which the first writer's text can be re-read througli the 
 lines of the second one. The modifications in nutrition which 
 inflammation induces in a part are the chief phenomena which 
 eighteen centuries have added to our knowledge. And even the 
 processes concerned in nutrition are so far from being clearly 
 known that the term itself is more a name than a thing clearly 
 understood. If to the Celsian definition we add the term modified 
 function then it becomes supplemented with about the only impor- 
 tant addition that modern research has given us. Our Celsian 
 
INFLAMMATION. 17 
 
 definition being thus completed, we will proceed now to an 
 elucidation of its component factors, and will begin with that of 
 rubor, or redness. 
 
 When a part of the body is irritated, the vessels which traverse 
 it momentarily contract and then they dilate and remain swollen ; 
 but if the part be non-vascular, as cartilaginous or corneal struc- 
 ture, then the contiguous or circumambient vessels undergo like 
 changes, the result in both cases being that the redness of the 
 parts is increased as soon as the second act, or swelling of the 
 vessels, has ensued. As causes of the consecutive contraction and 
 dilation of the vessels, investigators differ; one class invokes an 
 occult intervention on the part of the nerves; another class locates 
 the action exclusively in the muscular tunic of the capillaries, 
 which, for an instant, contract and then expand through exhaus- 
 tion. The only act usually visible is the widening, manifested 
 by the redness of the part. The tegument of the affected part 
 has some influence on the degree of redness; when thin, as in the 
 cuticle of the skin when attenuated, or in the covering of the 
 mucous membrane of the mouth, the redness is increased. But 
 when the epidermis is thick, as on the soles of the feet, then the 
 inflamed condition of the underlying structures may not be 
 apparent on the surface. Again, the presence of redness in a 
 part of the living or dead body may be due to physical causes; 
 for example, it may be dependent on gravitation or obstruction 
 to the escape of blood from the part, and thus the observer can be 
 misled. A notable example of this may be cited to serve as 
 a warning against falling into such error. Broussais, of the 
 Parisian school of medicine, distinguished for both frailty and 
 brilliancy of intellect, announced that he had discovered the 
 pathological key to many diseases in an inflammation of the 
 coats of the stomach. This doctrine was founded on the fact that 
 he found in all the autopsies which he made or observed, redness 
 of the mucous lining of the stomach. The position of the portal 
 system of vessels, so intercalated between the vessels and arterial 
 capillaries of the systemic vessels as to permit congestion as the 
 cardiac force is lessening, was overlooked by this author, and this 
 theory, which led the medical world captive for a generation, like 
 the fallacy of Phrenology, in which Broussais likewise believed, 
 has vanished before the light of more careful observation. And 
 this example should warn the observer from asserting that an 
 inflammation exists when no other evidence of it is present than 
 that of redness. 
 
18 AFFECTIONS OF THE SCALP. 
 
 Swelling (tumor) results from the stasis or accumulation of 
 an unusual quantity of blood in the part, likewise from the 
 presence of leucocytes or white blood cells, which, through the 
 researches of Cohnheira and others, have been shown to emigrate 
 from the blood vessels into the adjoining tissues during the 
 inliammatory act; and, lastly, sliould the inflammation be pro- 
 longed, then the swelling is further increased by a development 
 of new cells which spring from the connecti-ve tissue and endo- 
 thelial elements composing the i)art. The density or laxit}' of 
 the tissue which is inflamed has a direct influence on the 
 amount of the swelling. In parts which are naturally lianl and 
 den.se, the swelling is often scarcely perceptible, but in those 
 which are loose and yielding, the swelling is much greater. 
 Examples of the latter are seen in the great swelling met with 
 in the scrotum, eyelids, and lips when these parts are inflamed. 
 The redness and swelling of parts tend to recede under the action 
 of the inherent elasticity of the parts. Inflammatory tumefaction 
 should not be confounded with oedema or dropsical swelling; in 
 the latter condition pressure readily displaces the accumulated 
 fluid. 
 
 Heat (calor) was viewed as so important an element in inflam- 
 mation by the early fathers in medicine that in both the Latin 
 and Greek tongues it gave name to the process. The heat and 
 redness of flame, and pain from too near approach to the latter, 
 were eminently suggestive of inflammation as manifested in 
 the human body. Yet the improved methods of modern times 
 em{)loyed to estimate heat in inflamed structures have, curiously 
 enough, led to discordant results. John Hunter, the earliest 
 student in the field, was the first to use the thermometer. In a 
 scrotum the seat of a hydrocele, though heat was created by 
 inflammation, yet the temperature found was less than that of 
 the blood of the body. Later, many others, and among them 
 Billroth, continued this investigation, and as long as the heat 
 was measured b}^ the thermometer, the results in the main 
 were negative. Subsequently the testing was done by means of 
 thermo-electric instruments, first by Becquerel and Breschet, 
 and afterwards by the Etiglish pathologist, John Simon. The 
 method used by Simon was to solder an iron and platina needle 
 together at one end and to thrust their divergent shafts into the 
 part to be examined. These needles were connected with a 
 copper wire which encircled an astatic polar needle or galvan- 
 ometer. By such an ingeniously contrived thermo-electric appa- 
 
' INFLAMMATION. 19 
 
 ratus the degree of heat of the part explored was accurately 
 measured by the deflection of the needle. The discordant results 
 obtained by the thermometer v/ere now rectified, and it was 
 clearly shown that the temperature of the inflamed parts is 
 greater than that of the blood of the body. Otto AVeber, who 
 <;arefully repeated the experiments of Simon, obtained the follow- 
 ino; results from the examination of inflamed and non-inflamed 
 parts, as well as of blood which is entering and departing from 
 inflamed structures: — 
 
 1. An inflamed part is warmer than the corresponding unin- 
 flamed part. 
 
 2. The arterial blood entering an inflamed part is less warm 
 than the inflamed part itself. 
 
 3. The venous blood departing from an inflamed part is less 
 warm than the inflamed part, yet it is warmer than the arterial 
 blood which is approaching. 
 
 4. The departing venous blood is warmer than the blood in 
 the veins of the corresponding non-inflahied part of the body. 
 
 Hence, it is demonstrated that there is heat produced in the 
 inflamed part; and the amount of this is probably considerably 
 more than can be accurately estimated, since the cooler arterial 
 blood which is constantly entering the part must reduce its tem- 
 perature. In connection with the heat of inflamed structures 
 when at the surface, Gierse has determined that^ heat is more 
 easily given off than from parts in normal state. This circum- 
 stance makes the observer exaggerate the temperature of the 
 part which he is examining; and when this is combined with the 
 additional fact that the patient's sensation over-estimates the lieat, 
 we have an explanation of the unanimity of the old observers 
 that there is an increase of heat. 
 
 The heat generated in an inflamed part is constantly being 
 dispersed through the effluent venous blood and added to the 
 general temperature of the body; and in this way we can account, 
 to some extent, for the general rise of heat in one whose body is 
 the site of some inflammation. The locally inflamed part must 
 not be considered as the entire source of heat in inflammatory 
 fever; the generally increased temperature must be accounted 
 for chiefly as the result of dead elements of disintegrated tissue 
 entering the general circulation. And having entered the blood 
 these functionless elements become the subjects, as well as the 
 promoters, of chemical change in which heat is generated. 
 
 The three properties of inflammation which liave been con- 
 
20 AFFECTIONS OF THE SCALP. 
 
 sidered are of an objective nature, susceptible of verification; 
 pain (dolor), the next one to be considered, is njore of a subjective 
 character, and escapes tiie usual tests of observation. The 
 instrument, which might be named an odynomorneter, which can 
 detect and measure pain, lias not been invented. But science is 
 continually adding to our knowledge and extending our foresight; 
 and art is ever enlarging our power and sphere of action;* with 
 these faithful and fearless guides, it may yet be possible to pene- 
 trate the inmost recesses of life, and with scale and indicating 
 pendulum, to measure sensation in its various phases. And 
 until such metrical device has been invented, there can be no 
 quantitative estimate of the pain Avhich is present in an inflamed 
 part. And, though so intangible that it eludes the scrutiny of the 
 five senses of the observer, yet it is manifest enough to the 
 unfortunate subject of it, by whom it is announced by interjec- 
 tions or sounds recognized by any ear, for pain phrases itself in a 
 universal language which needs not to be learned. 
 
 Pain is not an unerring sign of inflammation, since it may be 
 present from an abnormal accumulation of blood in a part which 
 is not inflamed. The degree of pain in an inflamed part depends 
 on several conditions; the chief of these is an ample supply of 
 sensory nerves of either the part affected, or of the parts contigu- 
 ous to the latter. 
 
 The immediate cause of pain lies in changes which may be 
 induced in nerves by pressure, mechanical lesion, structural dis- 
 integration, or cell growth either in the nerve or its sheatli. In 
 very many cases the pain present is due to swelling and the 
 resultant pressure on the nerves. An unyielding texture of the 
 affected structure intensifies pain. As illustrations may be cited 
 the violent pain in a whitlow, in the fang of a diseased tooth, 
 and in the case of an inflamed nerve traversing an unyielding 
 osseous foramen or canal. 
 
 By means of propagation through reflex routes pain may be 
 felt quite beyond the primarily affected part. Examples of this 
 occur in the hand, in which an affected filament of the median or 
 ulnar nerve may awaken pain in the whole hand and arm; and 
 an affected branch of the trifacial nerve may awaken pain in 
 other parts of the face which are supplied by the nerve. Inat- 
 tention to this circumstance has led to errors in diagnosis. 
 For instance, disease in the kidney or bladder may be denoted 
 
 ■*Comptes "Positive Philosophy," article "Biology. 
 
INFLAMMATION. 21 
 
 only by pain about the external outlet of the urethra, and not 
 unfrequently pain in the knee (as yet ill explained) has diverted 
 the attention of the physician and misled him in regard to the 
 true seat of the disease in the hip joint. And through the inter- 
 lacing and intercommunication of the radical fibers of nerves in 
 their centers of origin, pain awakened in one part of the periphery, 
 as on the neck or arm, may be felt at some distant point in the 
 lower part of the trunk. 
 
 These examples of pain, which tax the anatomist to explain 
 them, find their analogue in these cases in which the pain, instead 
 of reappearing as sensation, awakens motion. Thus an inflamed 
 cornea causes spasmodic closure of the lids; inflammation of the 
 mucous membrane of the pharynx and larynx awakens muscular 
 movements of these parts; urethral inflammation may induce 
 contraction of the sphincters of the bladder, and consequent 
 retention of urine; inflammation of encephalic structure can 
 cause the muscles to contract which are concerned in vomiting; 
 and lastly, an inflamed peritoneum is primarily indicated by 
 retching and vomiting. 
 
 Antecedent to the appearance of pain, there may be detected 
 by cautious palpation increased sensitiveness of the part in which 
 the inflammation is developing; this condition sometimes assists 
 in the discovery of approaching disease which is deep seated; yet 
 for its detection there is required a touch which has become 
 erudite by much experience and careful training, for if by rough 
 manipulation we rudely question the parts, the latter on their 
 part may return us a rude and misleading answer, for violent 
 pressure may awaken pain in parts where it does not really exist. 
 
 Though pain is commonly a prominent feature of inflamma- 
 tion, yet it may be absent in palsied parts which are inflamed. 
 And such inflamed part through strangulation or pressure may 
 become gangrenous without the patient's knowledge; as examples 
 of this, which should awaken prudent foresight on the part of 
 the surgeon, are decubital sloughs which occur through lesions 
 of the spinal cord, or from luxation or fracture of the spine. 
 And in an inflamed part, especially in structures which are 
 oedematous, the element of pressure may be so excessive that it 
 finally extinguishes sensation; and this, too, is a timely warning 
 that death of the part is impending. 
 
 Inflammation is the peculiar prerogative of living tissue; 
 whether these be lax or dense, highly vascular or non-vascular, 
 abounding in or destitute of nerves, all living parts whatsoever 
 
22 AFFECTIONS OF TlIK .sCALr. 
 
 may become iiillained. Earliest youth and extreme old age have 
 no iniimiiiity from it. But many circumstances, and among 
 these ai"e comj)rised those just enumerated, niodify and stamp it 
 with s})ecial characteristics. For example, it may bo so mild as 
 to run its course quite unperceived, or it may be so violent in its 
 action that it soon extinguishes the life of its subject; and between 
 these exist many intermediate varieties. As a general grouping 
 founded on these facts, we have acute, subacute, and chronic inflam- 
 mations. 
 
 If the phenomena which precede, accompany, and follow an 
 inliainmation, be studied in their logical connection as an artic- 
 ulated series of actions, there will always be found a causal 
 agency from which the inflammation originated, and which 
 determines the grade and intensity as indicated by the foregoing 
 division. The old writers, Van Helmoiit and Staid, familiar, per- 
 haps, with the elFects of a penetrating thorn, named such cause a 
 spina, or thorn; the writers of recent time name it an irritant; and 
 the initial stage as that of irritation. This causal agency may be 
 classified under the headings of mechanical, physical, chemical, 
 and toxic, the toxic being closely cognate to the chemical. Ex- 
 amples of the mechanical are wounds due to violence from some 
 instrument; an instance of physical cause is the burn; one from 
 chemical agency is that from a concentrated acid or alkali ; and, 
 lastly, toxic action is represented by the so-called poison, which 
 acts probably in some undetermined chemical way, dependent 
 probably on the respective molecular composition of the agent 
 and the structure acted on. 
 
 In their descriptions of inflammation, writers mention a species 
 which they name idiopathic; this occurs oftenest in works on 
 internal medicine. The term idiopathic is a Avord coined to veil 
 ignorance; such ignorance, however, were better acknowledged 
 than concealed by the subterfuge of obscure verbiage. Every 
 effect or result is linked to some antecedent causal agency. In 
 medicine, as in other branches of knowledge, words sometimes 
 acquire too much importance and become the counterfeit expo- 
 nents of what are fancied to be facts. Thus paraphrased an idio- 
 pathic or causeless inflammation cannot rationally be conceived 
 of. The class of idiopathic diseases is constantly lessening before 
 the advancing tide of observant investigation. 
 
 Another agency claimed as causal is ascribed to certain para- 
 sites discoverable only by the microscope; there are many varie- 
 ties of. these microphytes, or microbes, as some name them; the 
 
IXFLAMMATIOX. 23 
 
 one, however, which has received the greatest credit as an agent 
 of inflammation is the genus bacterium, whicli has lent its name 
 to a new section of medicine, viz., Bacteriology. The work which 
 has been done in this field, and what has been written on the 
 subject, constitute one of tlie most brilliant chapters in modern 
 medical science. Tlie agent of disease which had so long eluded 
 detection, now seems, in many cases, to be discovered. The san- 
 guine minded are sure of this; the prudent, with certain 
 reservations, accept it; the cautious are hopeful that it is so, and 
 before full acceptance of it, are waiting for further confirmation. 
 Another class of men, however, who are valuable as aids in the 
 search for truth in this, that they earnestly work as irrepressible 
 contestants, are the skeptics. This class, whose minds find more 
 pleasure in contemplating the vibrating scales of doubt than in 
 accepting established truths, is found here on the side of denial. 
 Skepticism finds an ally in age, whose stereotyped immutabilitv 
 scoff's at any new thing. The writer has fully accepted this new 
 doctrine. The evidences in favor of its truthfulness have so accu- 
 mulated that it can no longer be rejected, except by those who, 
 Cato-likc, are onl}- happy when steering against the opinion of 
 their fellows. The writer wull not attempt to explain how the 
 microbe awakens an imflammation, nor will he deny that instead 
 of being the antecedent it may finally be demonstrated to be the 
 concomitant, or even the subsequent of inflammation; still the 
 two entities are indissolubly conhected. 
 
 Pathology has traversed four stages of development. Among 
 the ancients it existed in the most rudimentary state. As proof 
 of this may be cited Celsus, who was unfriendly to the examina- 
 tion of the dead body. He believed that the changes produced 
 by death are such that no true idea could be learned from the 
 examination of dead bodies of their real condition in life. It was 
 only wuth A^esalius that an epoch of accuracy began. Vesalius 
 won for himself the title of Reformer in Anatomy, because he cor- 
 rected the inaccuracies of Galen, who is said to have studied the 
 subject wholly from the dissection of monkeys — a statement with 
 difficulty credited by any student of Galen. Accurate knowledge 
 of the form, site, and aspect of the parts composing the human 
 body made it possible to discover and discriminate the changes 
 produced by disease ; and the labors of Vesalius completing this 
 work, mark the initial era of Pathology. 
 
 The second important epoch of advance in this matter w^as 
 ushered in by Bichat. Amidst the excitement of the French 
 
24 AFFECTIONS OF THE SCALP. 
 
 Revolution, "which gave the world so much that was good and 
 bad, this remarkable genius appeared, and at the early age of 
 thirty-one years, wlien most men have scarcely learned to 
 think maturely, Bichat gave to the world his wonderful works on 
 "The Tissues" and on "Life and Death." His researches led ob- 
 servation, which had hitherto only contemplated the rude macro- 
 scopical aspects left by disease in the structures of the dead body, 
 to a study of the minuter changes and perversions whicli disease 
 impresses on the component tissues. Bichat's classification of tis- 
 sues, though inaccurate in points, was a positive advance in 
 knowledge, and was the pioneer work in constructing the way along 
 which others were enabled to march to the final site of refuge of 
 disease, which lies within the sphere of the infinitely little,* 
 which the microscope has opened to us. 
 
 To this interesting field a number of eminent investigators 
 was attracted in Germany, France and England. Among these 
 investigators were Yirchow, Henle, Hasse, Cornil, Waller and 
 Wharton Jones. The pathologist was engrossed in the study of 
 cell-life, cell-form and cell-change; for in this field, really so 
 narrow, but which became so broad under the microscope, lay 
 a great number of treasures awaiting disclosure. The leader in 
 this work was Rudolf Virchow, whose discoveries were so numer- 
 ous and important that they have added a new section to med- 
 icine, viz., Cellular Pathology. 
 
 The pages of this work are *less poetical than those of the 
 genius who wrote "La Vie et la Mort," yet those of the former 
 constantly delight and instruct, as the writer depicts the eventful 
 acts of the cell in its nutritive and innutritive changes, in the 
 phenomena of life and death. 
 
 The tracing of the ever-changing life of the cell from its birth 
 to its death, in health and disease, has rendered equal service to 
 both surgery and internal medicine; in surgery it has illustrated 
 the inflammatory processes awakened by the wound or other irri- 
 tant; it has revealed the initial conditions of Ijoth benign and 
 malignant tumors, placing those conditions under the observer's 
 eye, as it were, at the very moment of their conception; and finally, 
 this investigation of the cell has wrested from nutrition much 
 of its mystery. Such has been the service which Virchow has 
 rendered to medical science; and as Bichat has been immortalized 
 by a prominent place among the figures which emblazon the 
 
 *P!iscal, '-Les Pensecs. 
 
IXFLA.MMATIOX. 25 
 
 frontispiece of the Pantheon, so when death closes the door of 
 envy, Virchow will liave perhaps a more conspicuous place 
 among those whom grateful posterity will honor with enduring 
 remembrance. 
 
 The fourth, and probably the final stage of advance in the 
 search for the factor of disease, is to the concomitant entity so 
 often found associated with the cell, viz., the microbe before men- 
 tioned; this is now thought to be the solving term in the expla- 
 nation of morbid action. Passionate controversy on this subject 
 has scarcely yet arrived at the period when a dispassionate review 
 can be made. The pioneer work in this field of the truly 
 infinitely little was done by Pasteur in his researches on fer- 
 mentation and putrefaction. The writer heard Pasteur read 
 some of his papers on these subjects at the French Institute in 
 1860, and confesses that he foresaw c[uite as little their bearing 
 on the future of medicine and surgery as probably did Pasteur 
 himself. These observations then announced by Pasteur were 
 the first lines in the volume of '"Bacteriology,"' which has since 
 been given to the world; and at this time engrosses so much 
 attention. The microphyte in its various forms and diverse hab- 
 itats has become the object of study on the part of both ama- 
 teurs as well as earnest students, and many species have been 
 assigned special places as Eetiological agents of disease. And 
 what is yet more important, the thing which has been assigned 
 the part of causal agency, may, it seems under certain manage- 
 ment, furnish immunity against the disease which it originates. 
 And when this hope is realized, which Bacteriology is promising 
 in several directions, the accomplished task will remain a supreme 
 benefaction to humanity. 
 
 In recent pathological inA^estigation there has been a tendency 
 to overlook past methods, and to underrate past acquisitions; the 
 bacterium with a special fascination has so nearly engrossed all 
 inquiry, that the cell, the tissue, and the crude anatomical masses, 
 have been almost neglected. This is an error, and it were well if 
 more attention were given to the appearances of parts revealed 
 by necropsy, such as engrossed the attention of Morgagni and 
 Hunter, and in the pursuit of which they made many additions 
 to our knowledge. The knowledge gathered by these men 
 through work done in the cheerless dead-house is lasting, and 
 will bear comparison with the best work done with the micro- 
 scope. And the cell also, recently nearly overlooked, or divested 
 
 3 
 
2G AFFECTIOXS OF THE SCALP. 
 
 of inucli of its former importance, should be porniitted to return 
 from partial exile to its former place. 
 
 After this pathological excursion, we will resume the narrative 
 of inflammation, and in so doing will consider some of its results. 
 The most important of these is the rai)id a2)})earance of a number 
 of cell-like elements. Some of these elements have a defniite form 
 or outline; others are irregular in shape, and some again are dis- 
 similar in size, and are wholly irregular in form. Those of regular 
 outline are nsually round, oval, or elongated in figure; the round 
 or round-like form is the predominant one; deviations from this 
 are probably due to pressure. These forms are only discernible 
 by the aid of a microscope, and, when examined with this instru- 
 ment, these cells, or corpuscles, as the}'' sometimes are named, 
 are seen to have one or more dark points, named nuclei, as occu- 
 pants of the cell. A })ortion of these corpuscles are white blood 
 cells which have forsaken their containing capillaries b}' escaping 
 through interstices in their walls. .Vnother })(n"tion originates 
 from preexistent elements composing the inflamed tissues. The 
 two modes of origin here mentioned have been verified by actual 
 observjition. Cohnheim has seen the white cells in the act of 
 traversing the walls of the minute vessels in their passage towards 
 the inflamed tissue; and this may be named development by cell 
 immigration. And on the other hand Otto Weber and Billroth 
 have seen cells in different stages of development arising from 
 inflamed structures; and this develoj^ment has been named, 
 according to the stage of growth in which the corpuscles are 
 observed, nucleation and cellulation, nucleation being the initial 
 period, while cellulation represents a more advanced stage of 
 development. 
 
 The cellular elements mentioned, both the formless and the 
 definitely sha[)en, are similar in appearance to those which com- 
 pose the embryonic being in its early stages of growth, and are 
 named by histologists, especially by Charcot and others of the 
 French school, embryonic elements. When such elements be- 
 come organized, the resultant tissue in its inchoate stage is named 
 embryonic or granular tissue. Charcot and Hanvier have formu- 
 lated as the result of their observations of the action of inflamma- 
 tion that it tends to reduce tlie affected structure to its primordial 
 embryonic stage. The transformation is the same whether the 
 inflammation has attacked the organs of the thorax, abdomen, or 
 surface of the body. 
 
 The future destiny of these simple granular elements depends 
 
inflammation; events. 27 
 
 on tlie grade, slowness or vehemence, and special character of the 
 inflammation which generated them. 
 
 The inflammatory process may be constructive or destructive 
 in its course; constructive in this, that lost structures, to a limited 
 extent, may he reproduced similar to the original one. This is 
 true of vessels, nerves, and, in a slight degree, of muscular tissue; 
 the new-formed vessels seem to be offshoots from contiguous 
 vessels, and the nerves appear to arise from the extension of 
 preexisting nerve filaments. Again, the process may be destruc- 
 tive in its action, and then the cellular and granular elements 
 remaining in their nascent or embryonic state die before tliey 
 reach the stage of organization; or, if they reach organization, 
 this is of a very rudimentary character. Examples of destructive 
 action are seen in diptheritis and the rapidly perishing products 
 of hospital gangrene. The explanation of such early death of 
 the newly-produced elements is that the development of cells has 
 outstripped the growth of vessels. The cells die through lack of 
 nutritious material, and in their death they involve the underly- 
 ing adjacent capillaries. In military phrase, the army is lost 
 through leaving its commissariat too far behind. Recent investi- 
 gation makes it very probable that certain forms of bacteria are 
 active adjuvants in the work of destruction. 
 
 Through changes which occur in the future destiny of the 
 cellular and granular elements which have been produced in the 
 inflamed tissues, inflammation may have the following endings 
 or events: — 
 
 1, Dispersion immediate or retarded. — In a case of immediate 
 dispersion, the inflammation is transient in duration; the redness 
 and swelling quickly disappear, and the elemental products, few 
 in number, are soon removed from the affected part. Or, instead 
 of being immediate, the dispersion may be retarded and take 
 place at a somewhat later period, and in both cases the inflam- 
 mation is so completely innocuous in action, and the restoration to 
 normal type is so entire, that hardly any vestige remains of what 
 has occurred. It should be mentioned that this ending is known 
 also by the name discussion; it is often seen in slight wounds, 
 and not unfrequently in larger ones, through the improved 
 methods which have recently been introduced in the treatment of 
 wounds. Certain anatomical conditions favor such ending; for 
 example, an ample supply of blood-vessels, and especially of lym- 
 phatics, favors this rapid or immediate restitution to integrity. 
 
28 AFFECTIONS OF TIIR SCALP. 
 
 2. Condensation. — Inflammation may end in condensation or 
 hardening of the alFected part, and this event may present itself 
 in two forms, which are the opposites of each other, viz., enlarge- 
 ment, or hypertrophy, or in diminution, called also atrophy. In 
 the condition of enlargement, the swelling depends on increased 
 afflux of blood to the dilated capillaries, and likewise on the 
 increased number of cells and granules which appear in an 
 inflamed tissue. Here the conditions are such as to offer an 
 obstruction to the escape of both fluid and solid contents. Con- 
 secutive to such enlargement, a diminution of volume may occur 
 through escape of the fluid contents from the part, and contrac- 
 tion of the remaining solid elements. The actual state in both 
 enlargement and diminution is induration of the structure; and 
 the induration is especially present in the case of atrophic or 
 diminished volume. 
 
 3. Adhesion. — Inflammation has, as a frequent event, adhesion 
 of the affected structures; such adhesion is seen in the lessened 
 mobility of subcutaneous parts; thus muscles may become bound 
 together in such a way that their separate, individual movements 
 are interfered with, and consequently, their function is lost or 
 impaired. Such adhesion may occur between tendons and their 
 containing canals, and thus the movements of the hands and 
 fingers are imjiaired and hampered. Vessels also may become 
 adherent to adjacent parts, their caliber may be diminished, and 
 thus the supply of blood to parts be lessened. Such adhesion or 
 close tethering of vessels to adjacent structures near to luxated 
 joints favors atrophy, and exposes the vessels to danger of rup- 
 ture in the work done to reduce the luxation, especially in cases in 
 which reduction has long been delayed. Through adhesion of other 
 tubular canals to the parts inclosing them, or through coherence of 
 folded sections of their walls, their permeability may be impaired 
 through lessening of caliber; hence stricture originates from pre- 
 vious inflammatory action. This is seen in the urethra, in the 
 alimentary canal, and in other tube-like passages. Adhesion 
 arises in inflamed serous membranes and produces agglutination 
 and fusion together of the opposite surfaces; thus the serous sur- 
 face of the lung may become attached to the costal pleura, and 
 the pleural cavity be partly or wholly obliterated. The heart 
 may thus contract attachment to the pericardium. Within the 
 abdomen, under the action of peritonitis, the serous surfaces of 
 the intestinal coils may cohere, and the peristaltic mobility of the 
 
inflammation; events. 29 
 
 intestine be fatally interfered with. On the otlier hand, adhesion 
 sometimes becomes eminently conservative in its action; thus a per- 
 forated bowel through adhesion of parts around has been prevented 
 from pouring its contents into the abdominal cavity. Also, in case 
 of abscess about the coecum, or in the spleen, or liver, through 
 adhesion of the wall of the abscess with the abdominal wall, a 
 way is prepared by which the pus may safely escape externally. 
 I have seen a gall bladder laden with many calculi thus get rid 
 of its deleterious burden, many months being occupied in the 
 work. Alongside of these cases in which adhesion acts preserv- 
 atively, may be cited a few others in which its result is deleterious. 
 An instance of this kind is the palpebral space, which, through 
 adhesion of the lid to the globe of the eye, may be almost oblit- 
 erated, and the motions of the parts greatly obstructed. Also, 
 inflammatory action within the mouth can cause union of the 
 cheek to the inferior maxilla, so that the action of the jaw is 
 hampered, and mastication rendered difiicult. The phimosed 
 prepuce may become adherent to the glans so that the two become 
 ona continuous structure. Also in case of burns in which the 
 parts have been denuded of dermal integument, such parts readily 
 cohere, if their raw surfaces remain in contact; the webbing of 
 fingers after a burn is a familiar example. The art of the sur- 
 geon is severely taxed in preventing adhesion in the cases 
 referred to, and where it has already occurred, the task is 3^et 
 more difficult to restore the parts to normal condition. 
 
 4. Suppuration. — The event most familiar to both the pro- 
 fessional and the non-professional eye, is suppuration. In this 
 eventual phase of inflammation there presents itself a remarkable 
 product, technically called pus. The layman, from whose early 
 experience and primitive contact with rude nature the nude 
 germs of all language originated, has adopted as symbol to denote 
 this thing the most important word in his forcible vocabulary, 
 viz., matter. 
 
 To the unaided eye, pus is semi-fluid; it is of a white or yel- 
 lowish cream-like color; to the touch it yields the slimy feel of 
 mucus, and tested by the sense of smell, its odor varies according 
 to its source, or the part of the body in which it has arisen. It 
 was deemed by Hunter to be a secretion from the tissues, and, 
 like a secretion, it is composed of corpuscles of varying form 
 floating in liquid. In this it is analogous to milk, saliva, mucus, 
 and other secretions, for in them one has varying form-elements 
 
30 AFFECTIONS OF TIIK SCAI.l'. 
 
 suspended in a su[)arablc fluid. It may l)e compared to an 
 imperfect enuilsion, in wliicli the suspended iiuiterials tend to 
 sink downwards wlien loft in repose, for if pus be allowed to 
 remain quiescent for a time, such a ])recipitation of the solid 
 elements does occur. The thickness of the deposited stratum 
 varies in different cases, and depends on the nature of the struc- 
 tures whence it emanates; also, the age of the pus has an influence 
 on its density. For example, when the pus has long been pent 
 up in a cavity of which the containing walls favor absorption, 
 then the liquid contents will be found to have disappeared, and 
 a solid cheese-like content only remains. Instances of this are 
 seen in the chronic abscess, and so complete is the solidification 
 sometimes, that there is only found a fossilized cretaceous mass. 
 Where the containing w^all is unfavorable to absorption, as in the 
 pleura that has become dense and thickened through chronic 
 inflammation, then the purulent content may remain liquid for 
 an indefinite period. Such pus in which the corpuscular elements 
 are in lessened amount, and tlie containing fluid is in excess, is 
 that derived from an ulcerated surface of long standing; the 
 product here is closely allied to serum; it is almost transparent. 
 A similar pus is derived from the chronic fistula, from a surface 
 covered with exuberant granulations, and from an eye the sur- 
 faces of which are the site of a chronic inflammation. This 
 species of pus, characterized by its barrenness in form-elements, 
 when emanating from a mucous surface, is with difficulty dis- 
 tinguished from the normal mucus produced by the surface. 
 Examples of this are the catarrhal sequelae which attend chronic 
 inflammationof the various mucous membranes, and particularly 
 that of the urethra. The interminable sero-purulent discharges 
 from such affected surface often remain, despite tlie best efforts 
 made for their relief. 
 
 Having considered the qualities of pus, primary and acquired, 
 w^hicli unaided vision perceives, we will next consider what the 
 microscope reveals. 
 
 If a drop of recently-formed pus be placed in the field of a 
 microscope which magnifies five hundred times, it will be seen to 
 consist of a fluid in which form-elements are floating. The fluid 
 portion nearly resembles water. The solid content consists of 
 bodies of varying figure; many have a rounded outline, and are 
 opaque, or, at least, they are dark in a])pearance. If water be 
 added, then these bodies become more transparent, and the trans- 
 parency is further increased, if acetic acid be added. This clear- 
 
IXFLAMMATIOX; EVEXTS. 31 
 
 ing up is due to the reagent clearing up the granular content of 
 the corpuscle, and then one or more nuclei are brought to view. 
 This body, which we will name the pus-corpuscle, when magni- 
 fied five hundred times will be about two lines in diameter. In 
 its appearance and behavior under the different tests to which 
 the microscope subjects it, it is identical with the white blood- 
 cell. Besides these rounded bodies there are other elements less 
 regular in form, indeed, many are shaj^eless. 
 
 The rounded corpuscles when derived from recent pus present 
 certain remarkable phenomena, which indicate that thev are 
 possessed of vitality. For example, in many, one sees movements 
 of the molecules within the corpuscles, also from its surface one 
 sees that processes are projected outwards, and at another point, 
 retraction takes place. The motions are such as enable the cor- 
 puscle to change its place, and are the same as those manifested 
 by the Amceba, a minute organism familiar to the naturalist. 
 This faculty of motion enables the pus-corpuscle to move from 
 one place to another, and as the normal tissues of the bodv 
 abound with numerous lymph-passages and spaces between the 
 elements of connective tissue, it is easily conceivable that pus 
 when external may pass inwards, or when inclosed, that it may 
 penetrate surrounding parts. 
 
 The number of pus-corpuscles present is very variable. In 
 some specimens the containing serum greatly predominates. 
 Also the number of cells endowed with mobility mav be small, 
 or quite absent; for example, none are found in pus which is old. 
 In pus which is the product of gangrenous tissue few or no regu- 
 lar corpuscles can be found, and the elements which are seen 
 present no movement. 
 
 Besides pus of light or yellow color, examples have been seen 
 in which it was of a blue color. This hue has been referred to 
 the presence of vibriones; others again, claim that the color is due 
 to some compound of iron. Pe'trequin says that it is caused bv 
 the sulphuret of iron. The writer has seen a case in which the 
 pus was of a purplish color with a faint trace of blue. Such dis- 
 colored pus (whether blue or purp)lish) has no ill import so far 
 as observed in the writer's experience; though a lurid omen to the 
 patient, yet it does not interfere with the healing of his wound. 
 It is probable that it sometimes arises from a chemical change 
 in some ingredient in the bandage through contact with pus. 
 Other hues of pus have been seen: black in that derived from 
 bone; j^ellow in the jaundiced patient, and red when it contains 
 hgemetine, or an admixture of Idood. 
 
32 AFFECTIONS OF THE SCALP; SUPPURATION. 
 
 The pus-corpuscle has the power of incorporating in itself 
 foreign material in molecular form, thus carmine, blood, bile, and 
 other material of a color that can contrast with the content of the 
 pus-corpuscle become incorporated with the latter. The conclu- 
 sion arrived at from these facts is that the corpuscle is not a true 
 cell, it has no containing wall, its component molecules are held 
 together by an attraction akin to that which holds together the 
 constituent })arts of the living body. The thoughtful student of 
 animal life and plant life finds many examples of such cohesive 
 force. No more remarkable instance can be cited than that of 
 the fixation of the tendon in a bone; though seemingly a union 
 of the simplest order, yet the parts are almost inseparable. And 
 so an attractive affinity holds together, arranged in a spheroidal 
 form, the constituent elements of the pus corpuscle with an 
 amount of force which permits of motion. 
 
 The law of biological development tliat every cell refers its 
 maternity to a preceding one, finds no exception in the origin of 
 the pus corpuscle; each one arises from a kindred element in the 
 inflamed tissues. As before said, one of the later acts of inflam- 
 mation is the production of a substance similar to that constitut- 
 ing the embryo, and hence named embryonic tissue. Nature 
 here, as in her other acts which have the purpose of continuing 
 species, makes provision with a liberal hand; the elements of 
 repair are furnished in excess, and those not needed are cast off, 
 and in effluent fluid they are carried outside of the organism, and 
 share the fate of other excreta. Or, dropping the figurative for 
 pathological terms, pus is the direct product of an inflamed tissue; 
 the elemental forms contained in it are the offspring of similar 
 elements in the generating structure, and in an open or closed 
 wound, they are nearly identical with those which repair the 
 breach. Every normal structure can generate pus, and the same 
 law applies to every abnormal growth; carcinoma, sarcoma, lipoma, 
 fibroma, chondroma, etc., can each produce a pus of which the 
 elements correspond to those of the maternal structure. And in 
 the case of a tumor of which the development is rapid, as in the 
 encephaloid growth, if a breach be made in the surface of the 
 same, there will be an unusually abundant production of pus. 
 Here the work of organization does not keep pace with that of 
 cell-production, and the unemployed portion of the latter appears 
 as purulent material. In the newly-organized structure numer- 
 ous fragile vessels appear as the predominant component; ftom 
 these vessels emanate the fluid in which the corpuscles float. 
 
ULCERATION. 33 
 
 This fluid may very properly be named serum, since it is similar 
 to the serum of the blood. 
 
 Pus, then, is so nearly allied to the structure generating it 
 that Boerhaave but slightly erred when he named it dissolved 
 tissue. In composition it is nearly allied to blood which a French 
 physiologist has named flowing flesh (chair coulante). Blood is 
 one of the most costly products of the animal organism; and the 
 near kindred of pus to blood gives the former almost equal rank. 
 Its production on a large scale is an exhausting drain on the 
 vital resources. The exhausting action from a profuse suppura- 
 tion is nearly equal to that of hemorrhage. An important thing 
 to be borne in mind is, that besides the loss to the organism 
 incurred through chronic suppuration, it induces disease in parts 
 often remote from the aff'ected part; thus a joint or bone the seat 
 of long-continued suppuration causes renal, splenic, hepatic, or 
 intestinal degeneration of amyloid type; and the life of the sub- 
 ject may thus be imperiled through innutrition. 
 
 When pus is imprisoned, or has only imperfect outlet for 
 escape, its elements undergo disintegration ; and pus thus changed 
 is capable of being partly absorbed; certainly, the pus-serum, 
 molecular elements, and bacterial forms may be absorbed and 
 become intermingled with the blood. Virchow denies that pus 
 corpuscles enter the body except through open veins; the lessened 
 volume of retained pus clearly shows that partial absorption of it 
 is possible. And the absorbed purulent elements through chem- 
 ical action cause fever; and, probably, through traversing or 
 lodging in the kidneys, cause renal disease. The conclusion here 
 come to is justified by the results of experiments made on ani- 
 mals, in which pus has been injected into the blood vessels. 
 
 5. Ulceration. — Another result of inflammation occasionally 
 seen is ulceration. This is present in an open, unhealing wound. 
 Similar conditions often exist in the boundary of an abscess, 
 which tends to enlarge rather than remain in fixed limits. It is 
 also present in a modified form in purulent infiltration, where 
 pus disseminates itself, and breaks down tissues contiguous to it; 
 in this instance, the inflammation present is of an acute and 
 highly active character, but in the others cited it is of a subacute 
 or mild character. An analagous process is seen in the malig- 
 nant growth which has opened, and whence pus-like fluid is 
 eliminated. Ulceration on an enormous scale is often present in 
 the mammary cancer in its last stages. In the several cases of 
 
34 AFFECTIONS OF THE SCALP; ILCKKATIOX. 
 
 ulceration cited, there is a slow breaking down of tissues, whether 
 these be normal or neoplastic. And if the conditions present be 
 studied and briefly defined, ulceration is found to be molccvJar 
 structural disintegration combined with suppuration. It occurs on 
 the skin, on the mucous membranes, in the serous surface of the 
 joints, in glands, muscles, and even in bones, in which it is named 
 caries, the rule being that structures which suppurate also read- 
 ily become the site of ulceration. Ulceration proceeds more rap- 
 idly in lax parts than in those which are solid or hard. 
 
 The causes of ulceration are general and local. 
 
 The general cause, which may also be named predisposirig, 
 lies in some peculiarity or constitutional tendency of the subject. 
 Scrofula, tuberculosis, scorbutus, and. syphilis, each in its way, 
 favors ulceration in its victim, and each modifies and gives an 
 imjDress to the ulcer arising, so that from an inspection of the 
 local breach one gets diagnostic proof of the constitutional tend- 
 ency of the subject. There may also be a predisposition less 
 general than the cases just given; for example, a diseased condi- 
 tion of an artery through calcification of its coats, may so impair 
 nutrition in the part to which it is distributed, that ulceration 
 on a large scale may there occur. Illustrations of this liave been 
 seen in the leg, arm, and other extensive districts of the body. 
 Also, interruption of the normal routes of circulation through 
 amputation, furnishes a condition favoring ulceration in the 
 stump, especially, if the latter is the offspring of poor mechanical 
 work. And cognate to the instances here cited are those of lost 
 or impaired inneuvation, as seen in the palsied limbs of the hemi- 
 plegic subject from fracture of the spinal cord. Here a slight 
 injury, or even continued pressure, can awaken a low form of 
 inflammation ending in ulceration of the affected parts. 
 
 A general predisposition to ulceration exists in persons who 
 have been the subjects of exposure, hunger, and overwork, through 
 which the blood has been impoverished and the strength of the 
 body greatly reduced. Examples of the kind the author had an 
 opportunity of seeing, some years ago, in Costa Kica among the 
 soldiers who had followed the Filibuster General AValker, in his 
 attempted conquest of Nicaragua. After his defeat, a number of 
 these soldiers were left for a time in the country in great destitu- 
 tion. They were emaciated, anaemic, bronzed in complexion, and, 
 as prisoners, living on the smallest pittance which would sustain 
 life. Many of them had wounds, caused in most cases, not by 
 bullet or sabre, but by thorns which had torn the skin in their 
 
ULCERATION. 35 
 
 march through the ahiiost impassable forests of the tropics. The 
 trailing vines which cling to shrub or tree are armed, as a rule, 
 with sharp thorns; a prick from these, slightly wounding the skin 
 of these men, had caused ulcers of a remarkable character. The 
 surface of these was occupied b}" a pouting fungoid substance of 
 a dirty yellowish color; and from this a discolored watery fluid 
 was exuding. This spongy ulcerating mass, often some inches in 
 breadth, rose considerably above the surrounding skin. It was 
 painless, and resembled the pale exuberant masses which spring 
 from an open encephaloid tumor. These cases showed how, 
 under unusual circumstances, ulceration may deviate from its 
 usual course; in fact, the ulcers might easily have been mistaken 
 for malignant growths. 
 
 Ulceration can also arise from local causes, many of which 
 permit of a mechanical interpretation. It may also j^roceed from 
 some irritant of chemical or animal origin. Cases w-hich can be 
 explained mechanically are ulcers in the lower limbs. The veins 
 here, during standing, are greatly swollen, and the blood in these 
 tubes, in accordance with the law of hydrostatics, transmits its 
 weight to the parts on and against which it rests. And pressure 
 is increased by further widening of the vessels. The continued 
 pressure lowers nutrition until ulceration commences, and the 
 ulcer is only healed by treatment adapted to lessen or counteract 
 the pressure. 
 
 Chemical agents which abstract w^ater from the tissues, or 
 which coagulate their albuminoid content, disturb the nutrition 
 of parts and may cause ulceration. And this property when duly 
 managed and regulated is often utilized for curative* purposes by 
 the physician and surgeon. 
 
 Ulceration may be caused by contact of some animal poison. 
 Instances of this are seen in glanders and in the action of ser- 
 pents' poison. And akin to this are the ecthymatous ulcers 
 sometimes seen by the surgeon as the embarrassing attendant on 
 some wound or operation, especially in operations on the neck of 
 the scrofulous subject. The discharge from such ulcers infects 
 the skin around, in which appear minute vesicular eruptions, 
 which soon enlarge, pass into a purulent state, and then open, 
 and the affected part remains as an extending ulcer, unless 
 arrested by some local remedy. 
 
 Scars, from their low vital endowment, are disposed w^hen 
 wounded, or even slightly irritated, to inflame and ulcerate. 
 The inherent quality of cicatricial tissue to contract, may proceed 
 
36 AFFECTIONS OF THE SCALP; MORTIFICATION. 
 
 to such an extent that from a sHglit cause a rupture of surface 
 occurs in it, which remains as an unliealing ulcer; examples of 
 this are seen in the scars from large burns. 
 
 Where the skin rests on a prominent ridge or crest of bone, 
 and from the absence of subjacent soft structure it is the subject 
 of pressure from within and exposed to violence from without, 
 there we have a strong local predisposition to ulceration, and 
 ulcers occurring at such points are very intractable to treatment. 
 
 6. Mortification. — The final and most fatal event which 
 can proceed from inflammation is mortification or death of 
 the affected structure. Gangrene, mortification and sphacekis, 
 names nearly synonymous, are used to designate dissolution or 
 death of tissue. Tliough some writers attempt differentiation of 
 the early, advanced, or ending stages of the process by these sev- 
 eral terras, yet their efforts to do so seem only to have obscured 
 the subject. The English and American writers, as a rule, have 
 preferred the terms gangrene and mortification, the latter having 
 precedence; the French writers use the term gangrene. 
 
 Says John Hunter, "Inflammation often produces mortifica- 
 tion or death in the part inflamed. This commonly takes place 
 in old people that are very much debilitated, and chiefly in the 
 lower extremities." And from Hunter to the present period 
 most English and American writers, in treating of inflammation, 
 mention mortification as one of its terminations. 
 
 Mortification presents itself in two forms, moist and dry. In 
 the moist species the dead structure is saturated with ichorous 
 fluid; this fluid consists of decomposed blood intermingled with 
 the detritus of dead tissue. This humid form, as it is sometimes 
 named, is seen in cases in which the death of the structure was 
 rapid and had been preceded by swelling and local congestion. 
 Examples of the moist form are seen in carbuncle, in the destruc- 
 tive action of the cattle poison, in the localized gangrene which 
 sometimes attacks the fingers and liand, in scrotal sloughing, in 
 the gangrenous form of syphilis and sloughing from erysipelas. A 
 bandage improperly applied has fatally strangulated a limb and 
 furnished a striking example of moist gangrene. In nearly all 
 of the cases cited, there is present some inflammatory action 
 through which there have been a profuse cell production and 
 exudation of fluid within the affected part; this newly introduced 
 material, by pressure on the vessels, interrupts circulation, when 
 death soon ensues. Nutrition is prevented by excess of plastic or 
 building material. The parts die surfeited by materials, which 
 
MORTIFICATION. 37 
 
 under more favorable conditions might have been valuable ele- 
 ments of repair. 
 
 The dry form, as Hunter says, occurs in the old and feeble, 
 and especially in those in whom the arteries are diseased through 
 atheroma or calcification; and hence the parts supplied by them 
 are imperfectly nourished. From its occurring chiefly in the 
 aged, this species is named senile gangrene; and in the old it 
 often commences from a slight injury of a toe. Contiguous to 
 the part in which the mortification has begun, there will be 
 found an abnormal condition of the structures; they are swollen, 
 painful, and of a dusky red color. And this unusual condition 
 seems to be an accompaniment of the advancing mortification, 
 and in reality, to be the result of it. The district of dead struc- 
 ture awakens a low grade of inflammation in the parts adjoining, 
 so that the gangrene is both cause and result of the inflammation. 
 Certain French writers claim that the arteries being inflamed are 
 the cause of senile gangrene. 
 
 In parts of Europe where rye is used as an article of food, 
 and where formerly care was not taken to isolate spurred rye 
 (ergot) from the sound grain, the rye flour thus adulterated 
 caused, in persons of all ages, a mortification similar to senile 
 gangrene. That ergot was the morbific cause was proven by 
 experiments on animals. The picture of the disease as left us by 
 eye-witnesses is deplorable; its subjects often made pilgrimages 
 to distant shrines, where they unsuccessfully sought relief for 
 their dying limbs, a relief which was found later at the shrine of 
 jEsculapius. Intelligent medicine here, as in many other cases, 
 plucked the mystery from the matter, found in food the cause of 
 ergotism, as this form of mortification is called, and the peasant 
 was taught to save his limbs by improving his bread. 
 
 There are many cases of mortification which arise from 
 mechanical closure of the nutrient vessels by means of emboli or 
 plugging clots. Instead of inflammation, thrombosis and embol- 
 ism, as demonstratively shown by the studies of Virchow, must 
 be regarded as the causal agency. In this way a small district, 
 or an entire limb, may, by deprivation of circulating blood, 
 quickly die from inanition. 
 
 Having considered the several terminations of inflammation, 
 viz., resolution, adhesion, suppuration, ulceration, and mortifica- 
 tion, there remain to be noticed certain anomalous endings which 
 sometimes follow inflammation so closely that they must be con- 
 sidered as products of it. Under this head the simplest forms 
 
38 AFFI'X'TIONS OF THK SCALP; ERYSIPELAS. 
 
 wiiich can be cited are the fibroid and keloid growths, whicli are 
 often merel\" transfbnned scars, the product of a recent inflam- 
 mation. And finally must be mentioned cases of carcinoma, in 
 which, though the origin is recondite and obscure, still experience 
 fully justifies the conclusion that tliere often exists the relation of 
 cause and effect between inflammation and carcinoma. Examples 
 confirmatory of this statement are familiar to those occupied with 
 the treatment of malignant growths. It is seen in the malignant 
 growths which arise in the mammary gland, the lip, the tongue, 
 throat, and points of the alimentary canal, which are the sites of 
 frequent irritation or slight inflammatory action. 
 
 Erysipelas. — After this review of the phenomena of inflamma- 
 Lion, which was necessary for a proper comprehension of what 
 follows, we return again to our original subject, and resume the 
 study of the surgical diseases of the scalp. A form of inflamma- 
 tory action fre(|uently seen here is erysipelas, which we will now 
 proceed to consider. 
 
 The name is from the Greek, and respecting its origin the 
 etymologists disagree. One class claims that it is derived from 
 erueiri, to draw, and jtelas, the skin; but a more probable deriva- 
 tion is from eruthros, red, and pelas, skin, literally meaning red 
 skin. The disease is mentioned by Hippocrates in his book on 
 "Epidemics," and he seeks for the cause of erysipelas in some 
 state or constitution of the air, viz., at the beginning of spring, 
 erysipelas arises from some accidental cause in very ordinary 
 lesions and slight wounds, no matter where they may be located, 
 and particularly in persons who are above sixty years of age, and 
 the wound is in the head. In some cases the disease arises when 
 treatment has been neglected, and in others it appears during 
 some treatment. In the majority of cases, the disease ends in 
 suppuration, and the muscles, tendons, and bones are destroyed 
 on a large scale. The fluid which escapes does not resemble pus, 
 but it is an ichor-like fluid. 
 
 Celsus states that in what the Greeks named erysipelas, there 
 is "inflammation, redness, ulceration, and pain." "And this, 
 which is named erysipelas, not only supervenes on a wound, but 
 it can originate without a wound, and in each case it is very 
 dangerous, especially, if it attack the neck or head." Celsus 
 associates it with cancer and gangrene. 
 
 From the statements of Hippocrates and Celsus, it is clear 
 that the ancients had observed a causal connection between 
 wounds and erysipelas. That the connection was obscure and 
 
ERYSIPELAS. 39 
 
 involved in mystery, is evident from the circumstance that, at an 
 early period, the disease was called sacer ignis, or the sacred fire. 
 Ceelius Aurelianus designated it by this name in his reference to 
 it as an accompaniment of diseases of the throat. 
 
 Though these ancient references to erysipelas are historically 
 interesting, yet they give us but vague notions of the affection, 
 for in many particulars an accurate description of it must be 
 sought for in the modern writer. 
 
 By erysipelas is meant a disease which manifests itself by 
 general as well as by local symptoms. The general or constitu- 
 tional manifestations are the initial ones. The first one is a 
 severe chill, in which the muscles tremble, the teeth chatter, the 
 entire body is irregularly shaken. Nausea, and finally vomiting 
 of bilious matter, supervene. The pulse is hastened and irregu- 
 lar in action. The mouth is dry, the tongue is coated, and there 
 is intense thirst. There is pain in the back, and a feeling of gen- 
 eral fatigue. The temperature of the body is elevated three or 
 four degrees. There is often delirium, usually of a mild char- 
 acter, sometimes amounting to merely a mental clouding. This 
 delirium is less during the day than at night, and is oftenest 
 present in erysipelas of the scalp. These general conditions con- 
 tinue from three to six hours, when a careful inspection of the 
 body will discover in some parts of the body a larger or smaller 
 district of redness in which coexist the additional characteristics 
 of inflammation, viz., heat, pain, and tumefaction. The heat is 
 sensible to the patient and the physician. The pain is slight, 
 still it is always present, and assists in the detection of the dis- 
 ease, especially in the scalp, before there are any visible mani- 
 festations of it. Pain can often be awakened by pressure on the 
 lymphatic glands, beneath or contiguous to the affected part; and 
 thus pressure awakening pain in the glands enables the physician 
 to herald the coming disease. Redness is modified by the nat- 
 ural tint of the skin; where this is very fair, the redness is more 
 conspicuous, but where the skin is dark, the redness may be 
 nearly absent. This is the case in the African and other colored 
 races. And on the scalp the dark pigment of the hair roots may 
 so disguise the surface that the hue of erysipelas can scarcely be 
 perceived. The swelling depends on the nature of the tissues; 
 where these are loose or lax, the swelling is greater; this is seen 
 in the scrotum and eyelids, which swell enormously when the 
 site of erysipelas. The swelling here is of the nature of oedema, 
 and is due to the transudation of serum from the swollen vessels. 
 
40 AFFECTIONS OF THE SCALP; ERYSIPELAS. 
 
 The enormous serous content present renders the part pale, rather 
 than red. 
 
 Erysipehis niuy remain stationary, and then it is named fixed; 
 and in tliis case the disease is confined to a limited part of 
 the body, and is the most favoraljle form with which we liave to 
 deal. In another form the affection spreads and occupies a more 
 extended surface, and from this circumstance it is named migrat- 
 ing. The affected part is always somewhat higher than the 
 adjacent sound surface; and the transition from the higher to the 
 lower surface is sudden and abrupt, so that it can readily be felt 
 by the observer, and tiiis bounding line or crest of the advancing 
 erysipelas wave is sinuous or serpiginous in direction. This ele- 
 vation of the affected parts may be taken as a measure of the 
 grade or intensity of the disease, for the disease presents itself in 
 varying degrees of violence from tliat which is mild to that which 
 is severe. Tlie mildest grade is limited to the superficial part of 
 the skin, being merely a simple dermatitis; while the more severe 
 form occupies the entire skin and subcutaneous structures; in the 
 latter form there is much more swelling than in the former. The 
 grade of violence is influenced by the constitutional characteris- 
 tics and hygienic surroundings of the patient. The author has 
 observed in the otherwise robust and health}'' child, that erysipe- 
 las, though migrating, assumes the form of a mild dermatitis, in 
 which, after the lapse of two or three days, the general health of 
 the patient is not seriously deranged. 
 
 The disease occasionally runs a very irregular course. After 
 migrating over a large surface, and the patient meanwhile being 
 pleased with the hope that he has reached the end of his disease, 
 the latter retraces its steps, and reoccupies the surface of regions 
 over which it has just passed. And this reappearance may occur 
 at isolated points, contemporaneously. In these acts of recurrence 
 the disease is less violent than its primary invasion; the pain, 
 swelling, and redness are less. In this recurrent form the disease 
 may last for a number of weeks. In one case seen by the author, 
 in which the disease attacked the head, and especially the region 
 about one ear, the aflfection lasted some months, recurring, and 
 again recurring a number of times. And in the latter part of the 
 course, the patient suffered so little that he yielded with reluc- 
 tance to hospital discipline. In an ordinary case unmarked by 
 irregularities, the disease runs its course in a period varying from 
 ten to fifteen days; then the concurrent concomitants vanish, the 
 redness fades, the epidermis falls by piece-meal, and in parts cov- 
 
ERYSIPELAS. 41 
 
 ered by hair, the latter falls. The epidermal detaeliment is due 
 to a serous exudation in the meshes of the true skin; and Volk- 
 mann finds such exudation most abundant in the lower stratum 
 of the cutis. The hair may not fall in mild cases, yet in severe 
 ones it does, and this is caused, as Haight has shown, by the exu- 
 dation of serum between the roots of the hair and its containing 
 sheath. Again, where the disease attains to a high grade of 
 intensity, the exudation is so profuse that the epidermis is 
 uplifted by the fluid in a mariner resembling the action of a 
 vesicant. And in cases of the greatest severity, the disease for- 
 sakes its accustomed bounds, the inflammation then terminates 
 in extensive suppuration, which may be in isolated foci; or there 
 may be phlegmonous destruction, in which there may be struc- 
 tural death on a large scale. 
 
 From the earliest times, as already mentioned, erysipelas was 
 thought to have a dual origin, viz., from a wound often slight in 
 character, and from some epidemic influence or peculiar consti- 
 tution of the air. This notion of its connection with some 
 peculiar state of the air, which is held b}^ many cotemporaries, 
 originated with Hippocrates, who sought for the origin of many 
 diseases from some state of the atmosphere. The obscurity in 
 which the matter was veiled in the terms constitution and epi- 
 demic influence, was not materially lessened by the substitution 
 of miasm, by which the occult agency has been designated, espe- 
 cially by the French in modern times. But the miasmatic agent, 
 hitherto an intangible entity, has lately assumed more definite 
 shape in a microbe discovered and announced in 1884-85 by 
 Fehleisen, a German, and which, it is claimed, is the veritable 
 cause of erysipelas. 
 
 The parasitic origin of erysipelas announced in Germany, was 
 studied by Denuce, in Paris, in 1886. In nineteen cases of the 
 disease, Denuce found the erysipelas coccus of Fehleisen in the 
 diseased tissue subjected to examination; and besides this microbe, 
 Denuce found others in two cases. From the microbe of Feh- 
 leisen he made cultures with which he inoculated animals, viz., 
 dogs and rabbits, and erysipelas was developed in them. Denuce 
 did not try to inoculate in man, though Fehleisen did in seven 
 cases, and Janicke did it in one man. Where the erysipelas is phleg- 
 monous in character, besides the coccus mentioned, Denuce found 
 the staphlococcus aureus. The parasitic origin of erysipelas was 
 accepted by Verneuil and others in 1885. Verneuil thinks the 
 microbe retains its vitality, even if situated in the liair, ear pas- 
 
42 AFFECTIONS OF THE SCALP; ERYSIPELAS. 
 
 sages, mucous membrane of the nose, throat, or that of the bowels. 
 And situated at any of these points it readily enters a breach of 
 the surface and develojjs the disease. In this way, Verneuil 
 explains the disposition to relapse and recurrence after subsid- 
 ence of the disease. The microbe commonly remains in the tissue, 
 where it can be found for three or four days, 3'et this period may 
 be greater and reach even to fourteen days. 
 
 The parasitic origin of erysipelas explains the ready transition 
 of the disease from place to place, viz., the passage of the affection 
 from the skin to the mucous surfaces, and reversely. Thus it has 
 been seen to pass into the rectum and thence up to the colon, and 
 also to enter the urethra and travel to the bladder, and, finally, in 
 the puerperal patient it may attack the vagina and uterus. It 
 may pass from the pharynx to the middle ear, and from the 
 external ear it may migrate to the tympanum and there awaken 
 sounds subjectively. A physician once thus affected, told me 
 that he heard the "singing of a thousand grasshoppers." The 
 disease may j^ass from the eyelids to the bulb and there attack 
 the cornea and iris; it may detach the retina and induce atrophy 
 of the choroid tunic and optic nerve. In the days when .sepsis 
 trod quickly in the footsteps of the surgeon, I witnessed the 
 removal of a tumor from near the eye; an erysipelas supervened, 
 which attacked the structures of the adjacent eye, and, in a few 
 days, permanently destroyed vision. 
 
 Both Fehleisen and Denucd failed to find the microbe in the 
 capillaries, except in those of the lungs and kidneys. The kid- 
 neys eliminate the parasites through the urine, and these organs 
 may become diseased in this way. 
 
 This history of the .mode of migration of erysipelas, or its 
 irregularities in progress and regress, in which it marches and 
 counter-marches, strongly supports, even without the aid of the 
 micro.scope, the theory of microphytic origin; for the phenomena 
 are those which might be caused by the |»urposeless and erratic 
 movements of an independent organism. 
 
 Ponfick, in his studies of erysipelas in 1867, announced that 
 he found the inner lining of the blood vessels affected, and from 
 this originate the thrombi and emboli found in the vessels. 
 
 Few physicians and still fewer surgeons deny that the causal 
 agent requires a wound or breach through which it can gain 
 admission into the human organism. Accurate search rarely 
 fails to find such a breach, though sometimes it may be so minute 
 as to elude discovery. Certain sites and conditions of those sites 
 
ERYSIPELAS. 43 
 
 favor erysipelatous development, for example, it commences most 
 often at the angle of the mouth, angle of the nose, and angle of 
 the eye, also in the hair-covered scalp. At the corners of the 
 mouth, nose, and eye, a condition favoring development is that 
 at these transition points from derm to mucous membrane, lesion 
 from mechanical or chemical cause often occurs, and this may be 
 a mere fissure or slight abrasion. This is irritated and inflamed 
 by the decomposing detritus from the adjacent outlet. The con- 
 ditions of the scalp, studded as it is with glands and hair roots, 
 which are the centers of exuberant organization and disorganiza- 
 tion, are qualities favoring erysipelas. The virulent microbe 
 transplanted in any of the parts mentioned, finds ample field for 
 its nutrition and multiplication. 
 
 Wounds with certain peculiarities favor the evolution of ery- 
 sipelas; among sucli are wounds which have continued for some 
 time, and which are nearly healed. After an amputation in 
 which ligatures are left hanging from the wound, as was the 
 former custom, ery.sipelas sometimes appeared around the fistu- 
 lous opening. And the same is tlie case with the metallic suture 
 employed to secure union in pseudarthrosis, for in the wound 
 around the wire, if it be left projecting, the disease is wont to 
 appear in the recurrent form. AVounds made for plastic pur- 
 poses when nearly healed, and the site of slight suppuration, may 
 become attacked with the disease. The silken sutures used for 
 the closure of superficial wounds, if not removed early, often 
 become points of erysipelatous infection. Any small wound, 
 whether from suture or other traumatic cause, especially on the 
 head and face, which, while healing by suppuration, becomes 
 covered by a crust or scab impeding the exit of pus, is often the 
 starting point of erysipelas; and the early detachment of the scab 
 and careful removal of the pus will prevent the development. 
 And besides those of traumatic origin, any ulcerating wound, 
 whether of tubercular, scrofulous, syphilitic or vaccine origin, if the 
 exit of pus be prevented by dried pus, or an impervious dressing, 
 an erysipelas can easily arise there. And most favorable condi- 
 tions for the evolution of the disease exist in the scrofulous, tuber- 
 cular or syphilitic subject, in whom dead bone is being detached, 
 and where an existing outlet for the necrosed material is suddenly 
 closed. This is often seen in the necrosis of the frontal and nasal 
 bones in tertiary syphilis. 
 
 From the several cases cited the induction follows that erysip- 
 elas tends to appear at some wounded point in which an inflam- 
 
44 AFFKtTIONS OF TlIF SCAL]'; KIIYSIl'KLAS. 
 
 niatiou has not a free outlet for its pui'iileiit produet; and these 
 conditions arc more favorahle in a sninU, than in a hirge wound, 
 since the extent of tlio hitter guarantees tlie escape of ])us. 
 
 As a ruk', the diagnosis of erysi[)ehis is readily made; the 
 inei})ient chills, gastric derangement, increase of heat, dry tongue, 
 and intense tliirst, and redness commencing at some point and 
 traveling thence continuously, are unmistakable marks by which 
 erysipelas announces its presence. With these there is commonly 
 associated some trivial lesion, the point of departure of the dermal 
 affection; exceptionally the starting-point may be from the border 
 of some large open wound, in which the escaping purulent matter 
 drying prevents the escape of pus. The migratory tendency of 
 the redness distinguishes it from a counterfeit form of the disease, 
 in which redness due to a subjacent collection of pus is stationary, 
 and instead of ending at an aln'upt border, it fades insensibly 
 into the color of the surrounding parts. A neglect to note these 
 characteristicSt or ignorance of their significance, has led the 
 unwary practitioner to accept and treat a case for genuine ery- 
 sipelas, which was merely a counterfeit form of the disease. 
 
 The prognosis of erysipelas is favorable: few among the phy- 
 sicians of the younger generation have seen deaths from it, and 
 this arises from the improved hygienic conditions whicli surround 
 the sick, whether rich or poor, learned or unlearned, soldier or 
 civilian. But where the opposite conditions exist, as prevailed 
 in the boasted past, in which the j^atient was the subject of filth, 
 foul air, and vitiated food, then the disease assumes a graver 
 form; and instead of recovery with slight epidermal exfoliation, 
 the affected structures, particularly the subcutaneous tissues, are 
 destroyed on a large scale, and death often occurs from p)ya3mia, 
 or general exhaustion. And if regions be compared as to their 
 relative peril when the site of erysipelas, the danger is greatest 
 when the disease jienetrates deeply into the orbit; also when it 
 attacks the deeper structures of the throat; in such cases, despite 
 the best sanitary surroundings and ablest treatment, death com- 
 ]nonly claims the victim. 
 
 Trcabuent. — As erysipelas is a dual compound of general and 
 local morbid conditions, so the treatment must have two objects 
 in view; and hence the remedies used must embrace both general 
 and local means. Inasmuch as the local symptoms are more 
 conspicuous than the constitutional manifestations, so the former 
 have absorbed chief attention from both writer and physician ; 
 and this has proved of detriment to the patient. 
 
ERYSIPELAS. 45 
 
 The strength or weakness of the patient should he carefully 
 considered, and the treatment made to conform to the conditions 
 found. The weak subject should be sustained by nourishing 
 food, and by tonic and stimulant remedies. Meats and their 
 extracts, wines, and alcoholic stimulants are likewise indicated. 
 Where the debility is extreme, tea or coffee mingled with brandy 
 should be given. While the nutrition is thus being admitted 
 through the upper portion of the alimentar\^ canal, the lower part 
 must be relieved of its excremental accumulations by simple 
 enemata: but in the strong, in whom there is an amplitude or 
 excess of the vital forces, then the treatment may be more ener- 
 getic. 
 
 Some excellent surgical authorities, as Gosselin, in cases of 
 plethora, favor bleeding. The author would prefer indirect 
 depletion through the great excremental routes of the skin, 
 kidneys and bowels, through the use of sudorific, diuretic, and 
 purgative agents. As purgative. Dr. Rush's combination of cal- 
 omel and jalap, ten grains each, has no superior. And if there 
 is nausea and much gastric disturbance, an emetic of ipecacuanha 
 should be administered. Besides emptying the stomach of its 
 catarrhal content, the mechanical action of vomiting has been 
 proven by experience to combat the tendency to pysemic devel- 
 opment. To reduce the fever an antipyretic may be given; and 
 for this, for two days in succession, ten grains of quinine may be 
 given twice daily; this agent does double duty as antipyretic and 
 germicide. In tlie debilitated subject, quinine may be seconded 
 by some form of iron, -as the chloride or acetate, given in mini- 
 mum doses. The large doses sometimes thoughtlessly given, of 
 both iron and quinine, are a reckless perversion of medicine; and 
 whether in this or other kindred ailments, instead of opponents, 
 they become allies of disease. Tliey are like valueless freight 
 taken aboard of a vessel already well laden, which is on the eve 
 of a hazardous voyage. 
 
 The remedies which, from time to time, have been heralded 
 wit]] praise for the cure of tlie disease have accumulated to so 
 great a list that the inexperienced beginner in medicine is certain 
 that nothing wnll be easier than to cure a case of erysipelas. But 
 to his chagrin he soon discovers that the law in force, that num- 
 bers carry strength, does not hold true here ; and in time he learns 
 that the opposite canon obtains, viz., the multitude of medicines 
 advised is a certain exponent of their inefficiency and uncertainty. 
 An attempt to collect tlie local remedies in groups offers the fol- 
 lowino- classification : — 
 
4G AFFECTIONS OF THE SCALP; ERYSIPELAS. 
 
 1. T//O.SC WJiich Are Absoluteb/ Inert. — Among these may be 
 mentioned staivh, flour, the seeds of lycoj)odiuiH, also the bland 
 ointments, as Unguentum Cetacei, Ceratum simplex, Oleum 
 Amygdalae, Adeps, and, lastly, water. These remedies do not 
 limit the extension of the disease, yet they have considerable 
 virtue in allaying the itching and burning of the affected skin. 
 The desiccating powders mentioned are of less value than the 
 unguents. The hpdropathist claims much for his panacea lo- 
 cally used. The remedies of this list, though inert, have the 
 virtue of being harmless. 
 
 2. Agents Wlikh Constrict. — As such are collodion and the 
 properly adjusted constricting bandage. Collodion has been used 
 and praised by Brainard, Cooper, and other American surgeons. 
 Its constrictive power, when collodion is applied and let dry on 
 the affected parts and surfaces bounding the latter, lessens the 
 supply of blood to the part, and this combats the leading element 
 in the inflammation. This action reduces the erysipelas to a low 
 grade; and thus it controls, but it does not remove, the disease. 
 In a child the subject of the disease, though collodion was applied 
 by the author with watchful diligence, still the disease was only 
 ameliorated; and it ])assed from the head to the feet, and would 
 plainly have proceeded further had there been room for exten- 
 sion. The constricting bandage, where the parts admit of its use, 
 acts in a similar and more effectual manner than collodion; but, 
 like collodion, as every practical surgeon has witnessed, it lessens 
 but does not arrest the progress of the disease ; the eruption glides 
 onwards beneath the bandage. 
 
 3. Astrinr/ents. — Under this head may be mentioned alum, 
 acetate of lead, and the sulphate and chloride of iron. These 
 medicines when dissolved in water and applied to tlie affected 
 parts represent, in a slight degree, the part of mechanical con- 
 stringents, and in their action, lessen the afflux of blood. 
 According to the writer's experience, if these weapons be per- 
 mitted to re.st in their armory, the patient will suffer no loss; for 
 they exercise no curative action against erysipelas. 
 
 4. Disintegrants. — Examples of these are the preparations of 
 iodine and mercury, of which the action is to cause molecular 
 solution of tlie animal tissues. And the property of disintegra- 
 tion explains their beneficial action in other diseases. In the 
 medical niind hitherto no article of faith has been more firm!}- 
 rooted than that iodine is a remedy against erysipela.s. But an 
 
ERYSIPELAS. 47 
 
 extended series of trials in which iodine was tried and found to 
 have no remedial agency, led the author long ago to abandon 
 its use externally in erysipelas. It burns, irritates, vesicates, and 
 discolors the skin; meantime, the disease, undiminished by this 
 action, moves onwards. Mercury applied in the form of ointment 
 has no more efficacy than iodine, and brings along the additional 
 peril of salivating the patient. Hence the group of disintegrants 
 may well be dropped in the treatment of erysipelas. 
 
 5. Escharotics. — Of these the nitrate of silver has been much 
 used, applied in solution, or in full strength. The immediate 
 action is to form a superficial eschar on the skin. The observa- 
 tion that such action does not arrest the disease in the least 
 degree, soon led to the abandonment of nitrate of silver, especially 
 when it was found that the treatment entailed a discoloration of 
 the skin which lasted much longer than the disease. 
 
 6. Vesication. — Somewhat akin to escharotic treatment is that 
 by cantharidal vesication. When Dupuytren held reign in the 
 surgical world, his advocacy of blistering in erysipelas, rendered 
 the method generally popular. Blisters were directly applied on 
 the affected parts. But experience, than which nothing aids 
 more in the art of healing,* did not confirm what was proclaimed 
 of vesication; and to-day the blister is almost forgotten. 
 
 7. Scarification. — A new mode of treatment was announced a 
 few years ago by Schutzenberger of Strassburg, of a more heroic 
 character than most of those already mentioned ; this consists in 
 making slight scarifications of the affected surface. For this 
 purpose slight cuts parallel to each other are made with inter- 
 vening intervals of about a quarter of an inch. The surface is 
 slightly rubbed so as to promote the escape of blood from the 
 incisions; and this blood is to be spread over the surface and al- 
 lowed to dry as a slightly protective film. In this way the intro- 
 ducer of this treatment claims that the surface is covered, and the 
 inflammation lessened by the withdrawal of blood. Like other 
 plans of treatment, this one seems to have done more for its 
 inventor than for any one else; it has been abandoned except in 
 cases in which the inflammation assumes a high grade, and 
 destruction of the parts is threatened; in such, impending gan- 
 grene may be aA'-erted by emptying the capillaries in which the 
 blood has ceased to move. 
 
 * Celsus. 
 
48 AFFECTIONS OF THE SCALP; ERYSIPELAS. 
 
 8. Saperfidal Germicidal Treatment. — Agents for tliispui[»<)se are 
 tur[)entiiie, alcohol, carbolic acid, and others of the antiseptic 
 list, which has so increased during the last few years. Turpen- 
 tine has especially been praise<l by Llicke, who, having niixed it 
 with oil, covers the surface with it. Trials of this agent made 
 by the author have not given very satisfactory results. Its 
 disposition to spread and diffuse itself on the surface, renders its 
 use difficult near the eye, ear, nose, or mouth. But as these agents 
 only penetrate the surface very superficially, it is evident that as 
 germicides they can have but an imperfect action; to be effective 
 they must be used as described in the following paragraph: — 
 
 9. ParencJiymatous Germicidal Treatment. — Germicidal remedies 
 injected into the tissues in front of the advancing erysipelas will 
 arrest its progress. This has been verified by the author in two 
 cases, in one of which the agent used was a three per cent solution 
 of carbolic acid, and in the other the compound tincture of iodine 
 was employed. The work was done cautiously, only a small 
 quantity of the remedies being injected. The result obtained 
 w^as that in no case did the disease travel through the structures 
 thus treated. Yet through the intermediate uninjected portions 
 the disease iintrammeled continued its normal course. From the 
 experience of the writer he is convinced that where the disease is 
 limited to a small space, by the injection of some germicidal agent 
 around it at short distances, the disease might be effectually iso- 
 lated and extinguished. The amount to be injected, for example, 
 of the tincture of iodine, should be from one to two drops of the 
 ordinary Pravaz hypodermic syringe. If this amount ])e not 
 exceeded, then the injecting may be done at numerous points. 
 Thus done at an early stage the disease may be completely cir- 
 cumvallated and caused to expire through isolation. 
 
 Herewith is concluded an epitomized summary of the various 
 modes of treatment employed against erysipelas. Nearly all of 
 them bring some relief and ameliorate the patient's condition ; 
 but in none is the hope of a cure realized except by the subder- 
 mal method last given. But when the disease has already full 
 mastery of the field by having occupied a large surface, even this 
 plan could not safely be pursued; then we should select some 
 inert agent for local use, such as almond oil, simple cerate, or a 
 desiccating powder. Besides this, the general condition of the 
 patient must be attentively considered; and according as exuber- 
 ant strength or debility is present, or, as the old Methodists would 
 put it, according as constriction or laxity predominates, so should 
 the constitutional medication be shapen. 
 
CI-IAPTER III. 
 
 WOUNDS OF THE SCALP. 
 
 Wounds of the scalp next claim attention, but before consid- 
 ering them it is well to study the general characteristics of 
 wounds. The wound gave birth to surgery, of which the nascent 
 field was furnished by war. Where violence ran riot, and the 
 soil drank and became enriched with libations of human blood, 
 there grew the seminal germs of surgery close beside the equally 
 precious ones of civil and religious liberty. The growth was 
 slow, very slow, like all things, which, through inherent value, 
 endure. The observation of wounds, and some knowledge of 
 their treatment, antedate all written re'cord. Machaon and 
 Podalirius treated wounds before the deeds of olden times were 
 sung in epic verse, and Homeric hexameter, long before Hippoc- 
 rates, tells us that a pliysician is worth a legion of common men. 
 
 The ancients assigned a place to ^Esculapius among the 
 Olympian Celestials, thus giving medicine its representative in 
 the divine hierarchy, and this honor was probably assigned to 
 ^Esculapius on account of his treatment of wounds, for it was 
 only to these that his sons above mentioned gave attention. 
 Wounds and diseases held places widely asunder in the mind of 
 early antiquity. Diseases were then regarded as penal entities, 
 sent by some offended god on a mission of vengeance, and this 
 need not lessen our estimate of the intellect of olden times wlien 
 we recall wliat absolute ignorance then obtained in regard to tlie 
 cause and nature of maladies which were intrenched deep within 
 the invisible regions of the body. Coming from the unknown, 
 and going to the unknown after it had destroyed, or perliaps left 
 no footprint on its subject, disease easily became an object of awe 
 and religious fear, and for relief it was natural that the remedy 
 was sought in some appeasing sacrifice. In this matter the hand 
 of cunning priesthood is too plainly discernible. 
 
 The origin of the wound was involved in no such uncertainty; 
 its causal agency was plainly apparent, since it could l)e traced to 
 
 ( 49 ) 
 
50 WOUNDS OF THE SCALP. 
 
 mail himself, or to some violent natural force. The division of 
 the healing art into Surgery and Jnternal Medicine was most 
 natural, since such division was founded in the marked contrast 
 between the wound and disease, the one telling its own story 
 plainly, while the other concealed its story in mute mystery. 
 Bleeding and gaping, the leading features of the wound, were 
 manifest and unmistakable, and needed no interpreter; but inter- 
 nal disease, in order to be divested of its abstruse obscurity and 
 to have complete interpretation, required all past time and much 
 of the future. Disease in its recondite complexities has challenged 
 and exhausted the efforts of the best intellect; the wound is known 
 and comprehended by the unthinking child. Over twenty cen- 
 turies has been occupied in reaching a treatment of wounds which 
 is now nearly perfect. The day is yet remote when the same will 
 be reached in Internal Medicine. 
 
 John Hunter, in some i^hilosophic lines, seeks to present the 
 ditference between disease and wounds. His language, a model 
 of clearness and directness when he details his remarkable experi- 
 ments, becomes complex and obscure when he attempts to formu- 
 late princi}»les in deductive method; this is apparent when he 
 sa^'s: "I may observe tliat all alterations in the natural dis})Osi- 
 tions of a body are the result either of injury or disease, and that 
 all deviations from its natural actions arise from a new disposition 
 being formed. Injury is commonly simple; disease is more com- 
 plicated. The dispositions arising from these are of three kinds; 
 the first is the disposition of restoration in consequence of some 
 immediate mischief, and is the most simple. The second is the 
 disposition arising from necessity, as, for instance, that which 
 produces the action of thickening parts, of ulceration, etc. This 
 is a little more complicated than the former, as it may arise both 
 from accident and disease, and therefore becomes a compound of 
 the two. The third is the disposition in consequence of disease, 
 wdiich is more complicated than either, as diseases are infinite. 
 ... A disease is a wrong action of the living parts; the restora- 
 tion to health must first consist in stopping the diseased disposi- 
 tions and actions, and tlien in a retrograde motion towards 
 health. . . . The operations of restorations arise naturally 
 out of the accident itself, for when there is only a mechanical 
 alteration in the structure, tlie stimulus of imperfection taking 
 place immediately, calls forth the actions of restoration. But 
 this is contrary to what happens in disease, for disease is a dispo- 
 sition producing a wrong action, and it must continue this wrong 
 action till the disposition is stopped, or wears itself out." 
 
WOUNDS OF THE SCALP. 51 
 
 As a distinction between the two, the following is offered: 
 Disease involves a large part, or the whole of the body; a wound is 
 primarily local, and it may remain so, or it can become a starting 
 point for general diseased action. In both the wound and disease 
 there is a spontaneous effort towards restoration to previous integ- 
 rity; unaided nature will often accomplish this work, but that 
 desirable end is greatly insured by the cooperation of intelligent 
 art. Nature here may be compared to a blind workman, who 
 often needs a hand to guide him. With pain one often sees 
 in the retrospective history of medicine that the guiding hand 
 was also blind. 
 
 The modern definition of a wound is a solution of continuity, a 
 sonorous pedantic phrase to ears unaccustomed to it, but through 
 ■use it has lost much of that quality. Stripped of a part of its 
 Latin dress, with which classic language has invested it, the 
 wound might be more plainly defined to be a breach of structure 
 caused by some external violence; in a few exceptions the violence 
 may be caused by muscular action within the body. The wound 
 is open or closed according as the skin is ruptured or not. And 
 this condition of being open or closed figures greatly in the grav- 
 ity of the wound; in fact, its future destiny depends on this cir- 
 cumstance, the closed wound pursuing a painless course towards 
 recovery, unless, as sometimes occurs, the closed wound becomes 
 changed to an open one. 
 
 Wounds may be classified as incised, lacerated, contused, 
 punctured, and those caused by gunshot and other projected mis- 
 siles. The burn, though not classified among wounds, is nearly 
 allied to them; for modern physics reckons heat to be a form of 
 rapid motion in the thing heated. 
 
 Incised Wounds. — These are produced by the blow or contact 
 of some instrument having a sharp edge; and variety in wounds 
 is determined by the sharpness or bluntness of the cutting edge. 
 If the edge of a cutting instrument be examined microscopically, 
 it will be found to be notched or serrated; and under a highly 
 magnifying |)ower, it is very irregular; the edge of the sharpest 
 instrument appears to be unevenly notched. Now if the instru- 
 ment have a fine edge, the margins of the residting wound will 
 be sharply angular; but the margins are blunter and more irreg- 
 ular, according to the dullness of the instrument. These minute 
 points, though seemingly unimportant minutiae, are not so, since 
 they have a practical bearing on the healing of the wound. For 
 time is saved, pean lessened, and scarring diminished in propor- 
 
Ol: WolNDS OF TIIK SCAI.T. 
 
 tion to the sliarpncss of the instrument making the incision. 
 And especially is this the case when the wound assumes the cleft 
 or flap form; for such flap when only connected to the rest of the 
 bod}' by a small pedicle, lives or dies, according to the sharp- 
 ness or dullness of the instrument causing it. The thin, sharp 
 blade, free from foreign material, and moving rapidly, inflicts a 
 wound which, though on a large scale, soon heals. Such an in- 
 strument merely separates the tissues, and but slightly injures 
 their molecular integrity. No particles of structure destroyed 
 at the time, or afterwards dying, are present to interlere with 
 iiinnediate agglutination. Milton's fertile fancy had a concei»- 
 tion of such traumatic characteristics in wounds in these given 
 and received by the combatants in the celestial battle which he 
 has depicted. 
 
 The instrument of dull edge lacerates; and besides, fatally 
 injuring some elements, it displaces others, so that exact coapta- 
 tion of corresponding parts is impossible. But in cases in which 
 the wound has smooth surfaces, kindred or similar elements can 
 again be joined, and immediate healing secured. By her varying 
 action in these dilferent conditions, nature gives an intelligible 
 wink to the surgeon for guidance in his cutting operations; his 
 instruments should be as sharp as sharp can be, and when' used 
 they should move hastingly and thoughtfully, not rcstingly and 
 loiteringly in their work. Thus operating, the surgeon conforms to 
 the three rules of the classic trilogy, tufo, cifo etjucunde; his cunning- 
 knife almost efi'aces its own i^athway, or only insignificant stig- 
 mata remain to mark it The cry* of the bistoury as it traverses 
 the scalp announces a dull instrument rather than unusual den- 
 sity of structure. 
 
 The form and minute characteristics of wounds sometimes 
 become the matters of study in Forensic Medicine, inasmuch as 
 they have a bearing in criminal investigation in which it is 
 sought to determine whether the wound was self-inflicted, or done 
 b}' another's hand, or was the result of accident. In case of the 
 purely incised wound, its location and direction will usually 
 determine whether it was self-inflicted or not. But in case the 
 wound has irregular edges, the question sometimes arises, By what 
 instrument was it caused? was it a knife, club or missile? or did 
 it originate in a fall against a body having a sharp projection or 
 cutting border? A solution of these problems is frequently the 
 unenviable task of legal medicine. Few eyes see and few ears 
 
 " Richet. 
 
IXCISED WOUNDS. 53 
 
 hear all that they might, through discipline, learn to see and 
 hear. But an eye trained and skilled to detect exact outline, and, 
 if need be, aided by the microscope, will be able to satisfactorily 
 solve the problem here referred to. 
 
 The cardinal conditions which are present in structures the 
 site of an incised wo'und are opening, bleeding, and pain; as inflam- 
 mation is sketched by four lines, named the Celsian quadrangle, 
 so the gaping breach, the escaping blood, and the pain awakened, 
 represent wliat may be named the traumatic triangle. TJie sur- 
 geon's care in tlie treatment of the incised wound is comprised in 
 attention to each of these parts. 
 
 The opening is due to lesion of muscular tissue. Both striated 
 and non-striated muscular structure contracts when it is wounded; 
 and Iience, when severed, each part retracts and leaves an inter- 
 vening gap. This phenomenon of retraction is doubtless due 
 to reflex influence emanating from the lesion of peripheral 
 nerves. The central ending of nerves has been diligently studied; 
 who knows but that their peripheral terminations ma}' have quite 
 as important functions? Besides this, it is probable that the 
 containing tegument of the animal body is normalh/ in a state of 
 contracted tension. Thus change of volume of the parts con- 
 tained within is permitted. Valentin, the Swiss physiologist, by a 
 series of exj)erinient3 many years ago, determined this extensile 
 property of the animal tissues, and especially of the skin. Hyrtl 
 has made some similar ones with the peritoneum, in which the 
 resisting power and strength of this membrane were tested. 
 Farabeuf in his work on ligations and amputations has made 
 some valuable contributions on this subject. In the mechanical 
 calculations which should precede and accompany all operative 
 surgical work, the extensile and retractile property of the parts 
 operated on must be taken carefully into the account; ignorance 
 or neglect of this matt-er is a common cause of faulty result. 
 From inattention to the influence of these inherent properties of 
 the animal structures, a beautiful piece of plastic surgery has 
 often perished and proved a bitter disappointment to both patient 
 and operator. And in no case is neglect of the retractile property 
 of tissues attended with more unfortunate results tlian in the 
 work of amputation; thence can result the painful and conical 
 stump, an ill requital for the perils which the patient assumes. 
 At risk of life, a useless limb has been exchanged for a useless 
 fragment of one; and all this is due to the fact that the surgeon 
 forgot the sim23lest and most familiar fact of daily experience, 
 
54 WOUNDS OF THE SCALP. 
 
 viz., that the incised wound opens, its lips being pulled asunder 
 by tl>e inherent retractility of tlie tissues. And in tlie case of the 
 ilap wound, or where the subjacent connectin<^ tissue is so loose as 
 to easily permit displacement, then the flap or loosened structure, 
 as experiment and observation have verified, retracts one-third 
 its length. Retractility should also receive proper attention in 
 the work of closing open wounds which penetrate deeply. If the 
 closure be merely superficial, then there will remain underneatii 
 open spaces (dead room), in which traumatic excreta may be 
 imprisoned, act as poison, and delay the healing. 
 
 The second important result of an incised wound is haemor- 
 rhage, Avliich may be slight or profuse, according to the vessels 
 wliich are wounded. The vessels opened are arteries, veins, and 
 lymphatics. The lymph vessels require no surgical attention; 
 the arteries demand prompt and thoughtful care, and so do the 
 veins when those of large caliber are wounded. And here the 
 character of tlie cutting instrument performs an important part; 
 the sharper the edge the more profuse is the bleeding, but the dull 
 blade contuses the opened vessels, and thus arrest of hsemorrhage 
 is favored, for here partial torsion is caused. Tlie jetting of 
 arterial blood distinguishes it from the purling flow from the 
 wounded vein; the crimson blood from the artery distinguishes 
 it from the darker blood of the vein. But where the heart and 
 lungs are acting feebly, these differences are less, the arterial 
 blood scarcely bounds from the wound, and from imperfect pul- 
 monary action it is of dark hue. And though in checking 
 bleeding the wounded arteries should receive the first attention, 
 yet the wounded veins should not be neglected, since the blood 
 escaping proximally and peripherally from the vein can equal that 
 escaping onl}' proximally from the artery. The slow oozing of 
 venous blood may mislead as to the quantity lost. The expe- 
 rience of the practical surgeon soon teaches him not to neglect 
 such bleeding, for the vein doing its work at tortoise pace, often 
 outstrips the leaping artery in fatal hsemorrhage. 
 
 In several parts of the body, the direction of the incised 
 wound has an important bearing on the quantity of blood lost. 
 As a rule, vessels, and it may be added nerves too, lie in inter- 
 muscular interstices, and parallel to the adjacent muscles. This 
 is especially true in the limbs, in which the course of the muscles 
 and nerves corresponds to the long axis of the limbs. The most 
 of the vessels that lie in the superficial structures of the head and 
 neck lie in lines converging towards the summit. The conse- 
 
INCISED WOUNDS. £)0 
 
 quence of such anatomical disposition is that on the limbs and 
 head transverse cuts wound more vessels than do longitudinal 
 wounds. By utilizing these facts, long incisions may be made on 
 the limbs, and head, and neck, with but moderate loss of blood. 
 It is only from the practice of continually dissecting that this 
 guiding knowledge is retained; thus, £uid only thus, the scalpel 
 becomes an intelligent instrument and ceases to wander from con- 
 servative lines. 
 
 The side of the traumatic triangle which remains to be con- 
 sidered is pain. This depends on lesion of nerves wliich lie in 
 the track of the incising agent. The pain of the wound is most 
 acute in those parts which are abundantly supplied with nerves. 
 Examples are the labial and anal structures, those of the outlets 
 of the genito-urinary organs, the integument of the fingers and 
 toes, the mucous membrane of the nose and of the eyelids, and 
 the structure of the auditory meatus. In the parts enumerated, 
 incised or other wounds are very painful, even careless manipu- 
 lation in which no lesion is produced, causes pain. "Wounds in 
 the dorsal region of the trunk are less painful than those of the 
 anterior surface; in fact, every surgeon has frec|uently seen with 
 v/hat stoical composure extensive incised wounds on the back are 
 borne, for example, such as are made for the removal of fatty 
 tumors, in patients who decline an ansesthetic. As a rule, wounds 
 of the surface of the body are more painful than those made in 
 parts deep seated. In the evolution of the animal body, nature, 
 in her conservative work, has placed pain as a faithful sentry at 
 every outpost of the living organism, and where danger oftenest 
 menaces, this sentrj'-, though usually slumbering, is easily awak- 
 ened to duty. It has been found that transverse wounds in 
 dividing many vessels cause much bleeding; for like reason, 
 through the division of many nerve filaments, they cause much 
 pain. These facts maybe advantageously used in operating. In 
 the removal of tumors and similar work, if the first incision be 
 made on the proximal side nearest the heart, then subsequent 
 incisions will cause but slight hEemorrhage; thus proceeding the 
 surgeon economizes blood, and also pain, if the patient be con- 
 scious. 
 
 The incised wound, except when made by the surgeon's knife, 
 is less often seen in the scalp than in the extremities and trunk. 
 From the dense structure of the scalp favoring laceration with 
 abrupt edges, a wound similar to the incised one ma}" arise from 
 a fall, or blow of a blunt instrument. 
 
5() V\-()rXDS OF THE SCALP. 
 
 Preparatory t() the treatment of incised or other wounas of 
 the sealp, tlie usual custom (thougli not always necessary) is first 
 to remove the hair around, and if this be done by shaving, care 
 must afterwards be taken to wash oiY all fragments of hair; this 
 being done, attention must first be directed to controlling the 
 hemorrhage. This is accomplished in most cases by catching 
 and pinching, or by pinching and twisting the wounded vessel. 
 Both arteries and veins are to be treated in .this way, though as 
 a rule, the Avoundod veins here cease to bleed spontaneously. It 
 is often requisite to })atiently repeat the com})ressive pinching. 
 Where torsion must be combined with the pinching, then a slight 
 circumscribing incision must be made around the end of the 
 vessel so that it can be seized by the twisting instrument. The 
 common small forceps may be used for this work. Should this 
 modified torsion fail to arrest the bleeding, then the ligature in 
 some form must bo resorted to. The author prefers alcoholized 
 silk, made by immersing strong silken thread in a fifty per cent 
 solution of alcohol. A few hours of immersion serves to make 
 the silk free from irritating qualities. Retention in the diluted 
 alcohol will preserve the thread aseptic and ready for immediate 
 use. Immersion of the silk in a five }»er cent solution of carbolic 
 acid will serve the same purpose as alcohol, yet the carbolized 
 silk is more irritating. In the use of the ligature in the scalp, 
 the peculiar relation of the artery to the parts in wdiich it is 
 lodged, must be attended to. The vessel is so adherent to the 
 fibro-adipose structure, that when severed it can neitlier contract 
 nor retract, as is its wonted act when wounded. In a wound of 
 smooth surface the opened artery continues to bleed much longer 
 than a wounded vessel of similar calilx-r elsewhere would bleed. 
 And these anatomical conditions render accurate ligation very 
 difficult, and before it can be ligated, the artery must be made 
 accessible. This is done by isolating the vessel by slight incisions 
 made around it, whereupou the ligation can be done. Instead of 
 the ligature, Tillaux prefers compression to arrest the bleeding in 
 wounds of the scalp; this is to be done by means of a properly- 
 comi)ressing bandage. Doubtless a bandage applied by an expe- 
 rienced hand might do the work, yet such continuous jiressure 
 soon becomes irksome to the patient. 
 
 Another mode to check bleeding, which has often been suc- 
 cessfully employed by the writer, is that in which the efferent 
 vessel is tied in mass, or by what is known as percutaneous cir- 
 cumscription. For this purpose a well-curved needle, armed with 
 
INCISED WOUNDS. 57 
 
 a strong, aseptic, silken thread, is caused to traverse tlie tissues 
 and pass underneath the vessel; next, a small compress formed 
 of folded paper is laid over the vessel, and the circumscribing 
 thread is next tied tightly on the paper compress. This circum- 
 scribing ligature should be removed at the end of forty- eight 
 hours; if allowed to remain longer, it can cause supj)uration. 
 The thread should be removed with care lest the included vessel 
 be disturbed and caused to bleed. This circumscriptive compres- 
 sion is best adapted to controlling haemorrhage in wounds of the 
 temporal artery, and here it may be necessary to do it on both 
 the hither and distal sides of the wound. Besides these methods, 
 bleeding may be arrested coincidently with the work of closing 
 the wounded scalp. To do this, let the sutures so transfix the 
 lips of the wound near the vessel that when the sutures are tied, 
 they will compress and close the wound. In no structure is this 
 plan so readily followed as in the scalp, since the arteries there 
 lie in the skin. Where the vessels are situated deeper, this 
 method, to be successful, requires deep sutures, for superficial and 
 even deep sutures inaccurately used for this purpose would allow 
 the blood to escape within the tissues. Some years ago there was 
 reported a case of death from this cause. In the removal of an 
 angioma from the scalp of a child, though the wound was 
 closed, yet hsemorrhage continued subcutaneousl}^, the blood 
 entering the loose space between the scalp and the pericranium, 
 and was only arrested by the attachments of the occipito-frontalis 
 muscle. This can more readily occur in the child's scalp than 
 in that of the adult, since the former is less closely fastened to 
 the skull. 
 
 The hsemorrhage having been controlled, should there be much 
 pain, an anodyne may be given; as a rule, this will not be required, 
 yet should it be, then morphia in doses from a quarter to a third 
 of a grain may be given an adult every four hours until the pain 
 is relieved. 
 
 Before the closure of the wound, this must be carefully 
 cleansed; this work is done by irrigating with a continuous 
 stream of water which has been boiled. Another agent for irri- 
 gating is a solution of corrosive sublimate, viz., one part of the 
 salt to two thousand of water; or, in the absence of this, a twenty -five 
 per cent solution of alcohol may be used: All clots which loiter- 
 ingiy cling to the wound should be removed. 
 
 The work of cleansing being thus done, the wound is to be 
 closed, an d^ this may be effected by adhesive plaster, suture or by 
 
58 WOUNDS OF THE SCALP. 
 
 tying the unshaven hair across tlie wound. The old method of 
 shaving olf the hair for some distance around the wouncl, and 
 then approximating the lips by adhesive i)laster, may be charac- 
 terized as very unsurgical, and has become nearly obsolete. The 
 re-growing hair soon lifts the plaster so that it stands bridge-like 
 over the widening gap beneath. Until recent years the scalp 
 was intangible to the suture. For in the teaching and practice 
 of fifty years ago the suture was allowed no place in the treat- 
 ment of the wounds of the scalp. This doctrine was firmly 
 planted in the student's mind as a truism intended to remain 
 there undisturbed by question or criticism, and rightly, too, for 
 its violation was followed by certain punishment in the form of 
 an erysipelatous inflammation, ^yhich started at, and proceeded 
 from, the points of suture. A disease was thus awakened which 
 in gravitv far outweighed the simple wound of the scalp. For in 
 the olden days which antedate the antiseptic reformation, the 
 needle and its following thread often became instruments of viru- 
 lent inoculation. Infecting elements abound in the scalp. It is 
 an excellent lurking place for parasites; the civilized man has 
 eliminated those visible to his eye, but those of microscopic 
 minuteness are not so easily banished, for the epidermal and 
 furfuraceous elements, decomposing sebaceous matter and the 
 retained excreta of the hair follicles are admirable habitats for 
 morbific microphytes. The suturing needle opened the way and 
 the following thread drew and lodged these elements of disease 
 within the canal, where they multiplied. Some were probably 
 contained within the meshes of the thread, so that when the field 
 is viewed with the light of modern knowledge, it is a wonder that 
 erysipelas did not develop in every wound of the hair-clad scalp. 
 But since Lister has taught surgeons cleanliness and given them 
 germicidal w^eapons, the scalp tolerates the suture as well as other 
 parts. The old rule may be fearlessly disobeyed, or perhaps 
 expunged from the surgical code. But in doing so, both scalp 
 and suture must be freed from every species of infecting material. 
 The best suture is metallic, wliich may be of silver or of copper 
 which has been heavily plated or gilded. Copper wire, from its 
 strength and flexibility, is an excellent material for suture. This 
 wire should be washed in dilute alcohol; the sublimated solution 
 is unsuited, since it will tarnish the wire. Chloroform may be 
 used for the disinfection of the suture, as the author has verified 
 in his experience. A well-curved needle should be chosen, and 
 its flattened end not so sharp as to cut the fingers which use it. 
 
INCISED WOUNDS. 59 
 
 The wire passed an inch through the eye should be squarely bent 
 over the head of the needle, and so twisted as to form a uniform 
 thread. Thus arranged, the needle and wire can enter a quarter 
 of an inch from the edge of the wound, and pass through the 
 lower part of the fibro-adipose stratum and emerge at the same 
 distance from the wound on the other side. The wire may now 
 be cut with ordinary scissors, so that one end, an inch long, will 
 remain on each side of the wound. These ends may next be 
 united by twisting, and this twisting should be done, not over, 
 but on one side of the wound. The twisting may also be done 
 before the wire has been cut, and in this way the wire may be 
 used more economically. The work of suturing should be com- 
 menced at one end and proceed thence to the other. The stitches 
 should be about three-quarters of an inch asunder. And should 
 the coaptation be incomplete at any point, a superficial suture 
 may be introduced there. In some cases it is more convenient to 
 introduce the first stitch at the middle of the wound, and to pro- 
 ceed thence to each end. Where the parts have been well 
 cleansed, one need not shave the hair; but then care must be 
 taken not to include the hair in the lips of the wound. 
 
 The projecting ends of the metallic sutures should be bent 
 down; and to prevent their being entangled in the superjacent 
 dressing, the author advises to ensheath the ends in a piece of 
 drainage tube of small caliber. The closure being completed to 
 this stage, some dressing is next to be applied. A good one is 
 lint saturated with compound tincture of benzoin, known also 
 as Friar's balsam in former times, when the priest was the 
 minister of both religion and medicine to his people. By this 
 dressing the wound is hermetically occluded and excluded from 
 the air, with the result that it inflames in but a minimum degree, 
 and a union almost scarless is often obtained. At the end of two 
 days the metallic suture should be removed, and if there be some 
 retractile tension of the sutured parts, the removal may be post- 
 poned a day or two longer. In the withdrawal of the suture, 
 some care is required not to reopen the wound. The benzoated 
 lint must first be removed, by being uplifted from each side of 
 the wound, then the end of the wire being seized with forceps, it 
 is so drawn upon that it can be cut off in the part which had 
 been buried; then the divided suture is to be loosened at its other 
 point of emergence, and from this side, viz., the one opposite to 
 where it has been divided, traction is to be made, and thus the 
 wire is easily removed. During this work the parts adjacent 
 
(JO WOUNDS OF THK SCALl". 
 
 isliould be pressed on Avitli the fingers, so as to immobilize these 
 l>cirts and the uniting wound contained in them. The union will 
 now often be found complete; yet should there be seen any indi- 
 cations of suppuration, then vaseline (petroleum gelatum) con- 
 taining four per cent of carbolic acid, should be used as dressing; 
 thus an outlet will be furnished for any purulent material. If 
 proper care has been taken in the work, in most cases union will 
 be found complete at the first dressing when the sutures are 
 removed, viz., on the third or fourth day. The site of the wound 
 should afterwards be protected from violence or irregular move- 
 ment for a few days: otherwise it might be reopened. 
 
 Besides closure by wire, the work may also be done with cat- 
 gut suture, which has the advantage that it vanishes by absor])- 
 tion, and does not require extraction, as must be done with wire; 
 yet absorption sometimes occurs before firm union is estfiblished, 
 and then some gaping occurs. Catgut should be u.sed where 
 there is no tension of the parts. 
 
 Another method of closing wounds situated in the hairy scalp 
 is by means of the hair itself. The advantage of this plan is that 
 healing is accomplished without shaving the hair, and one avoids 
 the conspicuous mark resulting from such shaving. To close 
 the wound in this way, commence at one end of it by placing a 
 thread in or alongside of the wound, and then isolate a lock of 
 hair on each side and lay this over the thread across tiie wound. 
 Xext the locks held accurately are included in a half knot, each 
 lock is next to be tlirned back towards its own side, when the 
 two are to be held in place by completing the knot. Tlie work 
 is to be continued by a series of knotted loops, so as to wholh' 
 close the wound. The wound being thus united, the part should 
 be washed with undiluted alcohol, and then covered with dry 
 lint or cotton wadding. This plan of closing wounds was prac- 
 ticed by Dr. Garwood, formerly physician to the City and County 
 Hospital of San Francisco. The striking advantages of it are 
 that no sutures are used, and the tied liair may remain undis- 
 turljed until the healing of the wound is wholly completed; 
 and when this has occurred, then the threads may be cut and 
 removed, and scarcely any trace of the ju-evious injury will be 
 visible. 
 
 Lacerated Wounds. — Lacerated wounds of the scalp are next to 
 be considered. These injuries may originate in two ways: in the 
 one case, they may arise from blows from some blunt object; and 
 then, if the causal instrument be but slightly blunt, the wound 
 
LACERATED WOUNDS. 61 
 
 will resemble the incised wound before described. The lacerated 
 wound can arise in a second way by the subject falling with his 
 head obliquely against tlie ground, or some object having a blunt 
 surface. The edges of this wound are ragged, uneven, and often 
 very irregular. The wound may run in any direction; it may be 
 straight or curved, it may consist of a single breach, or have one 
 or more branches running from the main opening. Vessels are 
 opened, yet in such a way that, as a rule, they bleed but slightly; 
 for the violence in severing the vessels closes the latter either 
 completely or incompletely. 
 
 Lacerated wounds present themselves in two classes; in one, 
 there is no lateral detachment; in the other, there is lateral sepa- 
 ration of the soft parts, on one or both sides of the wound. In 
 the second form the separation may comprise the entire thick- 
 ness of the scalp, the pericraiuum being included; this is rarer 
 than the other form, in which the separation is through the 
 stratum of iax tissue Avhich has previously been described, as 
 connecting the pericranium to the superjacent structures. 
 
 The treatment of the lacerated wound without lateral detach- 
 ment, if the margins be even and untorn, is similar to that of the 
 incised wound. But if the edges be torn and crushed, they must 
 be trimmed off; that is, the breach is to be converted, as nearly 
 as possible, into the form of the incised wound, when it must be 
 treated similarly to the latter, by suture, or tying the hair across 
 it, as above described. 
 
 The cleansing of these wounds prior to closing them, should 
 be done with scrupulous care, more so, if possible, than in the 
 simply incised wound, since in the origin of the lacerated 
 wound some foreign matter is liable to be forced into, and 
 remain incorporated in, the structures. After closure has been 
 done by one of the plans mentioned, the further dressing may 
 be done with the compound tincture of benzoin or alcohol. An 
 agent recently brought into use, and of which the excellence has 
 been established by much experience, is iodoform. Iodoform 
 tends to maintain the parts aseptic; it is used pure, in the form 
 of a finely levigated powder, sprinkled over the wound and parts 
 immediately contiguous; the dressing is ended by complete 
 occlusion under cotton wadding. Since the above cases, as well 
 as all other forms of lacerated wounds, are unfavorably consti- 
 tuted for primary union, during healing they should be watched 
 lest pus form and, being retained, lead to ill consequences. 
 
 In the second group of lacerated wounds there is u|)Hfting of 
 
62 WOUNDS OF THE SCALP. 
 
 one or both sides of the soft parts, and this detachment may 
 indude the pericranium, tliough, as a rule, this is left intact. 
 The pericranium is oftener uplifted in the young subject, more 
 rarely in the adult or old subject. The detachment may be 
 slight, or it may be on a most extensive scale, so as to constitute 
 a large flap. Such flap at the time of injury may be so displaced 
 as to expose the subjacent skull. The flap when large bears 
 resemblance to one-half of a bivalve shell. 
 
 The lacerated wound of flat valve-shape is one of the injuries 
 of the scalp demanding serious attention; for careless or improper 
 treatment of it may perilously compromise, and even end the 
 patient's life. The dangers here referred to are seldom directly 
 from the wound, but more commonly they are secondary com- 
 plications, or results of it. 
 
 The lacerated wound with detachment of the scalp may, as 
 just stated, be on a large or small scale; the detachment may be 
 so slight as to demand no attention ; again, it may be so large as 
 to comprise a large portion of the scalp. Hyrtl mentions a case 
 in which the entire scalp was detached and left hanging by a 
 pedicle. As a rule, the anatomical conditions are such that there 
 exists no doubt about the maintenance of the vitality of the 
 uplifted part. The free and abundant vascular anastomosis 
 within the scalp is favorable to maintenance of its life. The 
 position of the pedicle or V)ase of the flap, and also the breadth of 
 the same, have an important bearing in this matter; a narrow 
 base of attachment is unfavorable; also, when the attachment is 
 downwards the chances of maintaining vitality are most favor- 
 able; but these chances are less when the foot stalk or base is 
 directed towards the summit of the cranium. 
 
 An effort should always be made to save the flap, no matter 
 how narrow its pedicle of attachment may be ; even if it should 
 be wholly detached, the surgeon should endeavor to save the part, 
 provided the patient be seen soon after the receipt of the injury. 
 In the restoration of the separated part to its original site, the 
 conditions for reunion are very favorable, so much so that an 
 attempt to save the part should be made, even though a consid- 
 erable time has elapsed since the d^etachment. 
 
 The preliminary and principal work, in the treatment of the 
 lacerated fla^) wound, is careful cleansing of the space or cavity 
 underneath it; and this is best done by irrigation with a dilute 
 alcoholic or sublimated solution, of the strength before given. 
 Continue this subcutaneous cleansing until all blood clots and 
 
WOUNDS OF THE SCALP. 63 
 
 other foreign ipiaterials are removed. A syringe may be used in 
 order to carry the cleansing fluid to the bottom of the sinuous 
 pockets. This work is often hastily or imperfecth^ done ; and, in 
 consequence, pus forms and prevents the reunion of the separated 
 parts; and, what is worse, it may, by burrowing, increase the detach- 
 ment of the scalp. Besides the removal of the clots, any hanging- 
 shreds which can be found should be removed by trimming or 
 twisting off, and if any bleeding follows this, arrest it by pinch- 
 ing or torsion. 
 
 The edges of the wound are now to be trimmed ; and this 
 should be so done that the opposite faces can be accuratel}^ fitted 
 to each other, when they are to be united by suture or tying of the 
 hair. In case the scalp be detached to a great extent, then the 
 parts after closure must be carefully watched, lest in the blind 
 pockets fluids may be poured out, and by their intervention pre- 
 vent union, or perhaps lead to suppuration. Should this danger 
 menace at the time of dressing, then one or more drainage tubes 
 should be introduced ; or should signs of such accumulation pre- 
 sent themselves later, then a counter-opening should be made 
 through the flap at such point as will insure the escape of the 
 liquid material. If, at the time the wound is dressed, external 
 pressure be judiciously made by means of a bandage, it would 
 tend to prevent such eff'usion of fluid. If pus presents itself in 
 the drainage tubes, or it collect after closure, then open and let 
 the cavity of the wound be cleansed daily by syringing it 
 with an antiseptic fluid. This, work should be done with a flex- 
 ible rubber syringe, and the fluid thrown in as gently as possible. 
 And since forcible injection is apt to separate the surfaces which 
 are uniting, hence, as soon as the fluid has been put in motion 
 through the instrument, the latter should be curved into the 
 shape of a siphon, when the fluid will move by atmospheric 
 pressure, and not in jets as occurs in simple syringing; and the 
 pressure in siphoning may be augmented by lifting the receiving 
 end of the syringe. This work may be done by means of an 
 irrigator, which may be made by fixing a rubber tube to an 
 opening in the vessel which contains the cleansing fluid. The 
 common rubber syringe with which propulsion is done by com- 
 pressing a bulb, may easily be converted into a siphon or irrigator. 
 Whatever way may be selected for cleansing the wound, the work 
 should be continued until all traces of pus disappear. Neglect 
 in this matter, through which pus is overlooked and allowed to 
 be retained, sometimes becomes the cause of erysipelas ; thus not 
 
G4 WOUNDS OF THE SCALP. 
 
 unfrequently, the genuine or niigniting Torni of thisatiectioii has 
 arisen, and as a complieation has been more serious than tlie 
 wound itself, A spurious form of the disease, simulating true 
 erysipelas, has occasionally been seen as the result of retained pus. 
 This spurious affection is indicated by a purplish or dark red hue 
 of the integument over and around the retained pus. If this pus 
 be early liberated by incising and washing out the pocket, then 
 the surgeon is pleased to find that his suspicions of commencing 
 erysipelas were erroneous, since the red flush soon vanishes. 
 
 Sometimes the flap remains attached to the adjacent scalp by 
 a very narrow pedicle; in such case one must try to save it; and 
 to do this, cleanse and trim off hanging shreds, and replace the 
 flap in its original site and fix there by sutures. These sutures 
 should be as few as will suffice to retain the flap in i)lace; too 
 many will interfere with the blood supply required to maintain 
 the flap alive. All tension and traction on it must be avoided, 
 especially so where the flap is scarcely large enough to fill the 
 breach. If an attempt be made to fill the opening by stretching 
 the flap, such traction has the effect of elongating and narrowing 
 the vessels in the pedicle, and thus greatly lessening the passage 
 of blood through them in accordance with the laws governing 
 the transmission of liquids through tubes of different caliber. For 
 example, if a tube be doubled in length, the quantity of fluid 
 passing through it will be diminished one-half; and if Avith the 
 elongation the diameter be diminished one-half, then tlie (piantity 
 of fluid sA'hich can pass through it in a given time will be reduced 
 to one-sixteenth part of that which would pass through the tube 
 before elongation and narrowing. This oflers an explanation of 
 the tendency to slough in parts which are subjected to traction in 
 the work of closing wounds; especially in wounds made by the 
 surgeon in operating. Severe lateral traction is often fatal to the 
 vitality of the part. Subjacent or eccentric pressure, which 
 stretches overlying structures, as well as extensive swelling from 
 any cause, may, in like manner, cause death through elongation 
 and narrowing of the nutrient vessels. 
 
 In the attempt made to revivify a flap, and thus to close the 
 wound with it, the bandage and dressing should be such as to 
 tiioroughly ])rotect it; and the dressing, which may consist of lint 
 and iodoform, should not be disturbed for two or three days; the 
 sutures also should not be removed for a much longer time; and 
 on the removal of the sutures, when wire has been used, it should 
 be done with care so as not to loo.sen the flap. It often happens 
 
CONTUSION OF THE SCALP. 65 
 
 that but a part of the flap is found alive, perhaps islets here and 
 there; these are valuable aids in closure. These living islets lie 
 in dead structure, which must be permitted to loosen and detach 
 itself. An effort to prematurely remove the sloughing tissue 
 always endangers the living points; and though there be a strong 
 temj^tation on the surgeon's part to aid Nature, yet as a rule she 
 will do better when left unassisted; for if these islets be once 
 loosened from the subjacent nutrient ground, they v/ill perish. 
 Even irrigation violently done may break their attachment. 
 Some two or three weeks' time will be required for the dead 
 structures to detach themselves; a few threads of fibrous tissue, 
 owing to their immunity from disintegration, often maintain the 
 connection much longer than the period here mentioned. The 
 detachment of the sloughs will be favored and perhaps hastened 
 by moist warmth. For this purpose cataplasms of ground flax- 
 seed or bark of the slippery elm were formerly used. An 
 objection to these agents is that they soon ferment, and hence 
 they require frequent renewal. Instead of these materials, soft 
 linen or cotton cloth, wet in aseptic water, may be used, the cloths 
 being covered with oil silk. If the water be made alkaline with 
 carbonate of soda or potash, the disintegration will proceed more 
 rapidly. This depends on the property which alkalies have of 
 dissolving the albuminoid compounds. After the complete 
 removal of the sloughs, the remaining wound should be dressed 
 with some bland ointment by which the raw surface will be 
 protected. The use of such ointment, though no better than 
 water, entails less attention; it need not be renewed so often. 
 For this purpose one may select Unguentum Cetacei, which, 
 smeared on lint, is applied to the wound, and need not be changed 
 oftener than twice a day. An excellent ointment, which the 
 writer has used, is made by adding enough prepared chalk to 
 Linimentum Calcis to convert the latter into an ointment. The 
 important quality of the ointment is that it should be unirritat- 
 ing. This mode of dressing should be continued until the healing 
 is completed; for this, some weeks' time is often required. 
 
 Contusion of the Scalp. — The contusion results from a blow 
 with some blunt object; or it may originate from a fall in which 
 the head strikes some blunt object or surface. Its causation is 
 similar to that of the lacerated wound. According to the degree 
 of violence, so the wound may vary from one of trivial degree to 
 one of extreme severity. The striking characteristic is swelling, 
 which occurs quickly after the receipt of the violence, and this 
 
66 WOUNDS OF THE .SCALP. 
 
 is due to lacerated vessels. In the contusion, even of mild grade, 
 there is a subcutaneous breacli of the structures, the more fragile 
 tissues suffering the most. In this lesion the vessels are crushed; 
 minute ones, and, in case of greater violence, large veins and 
 arteries, may be opened. Thence results effusion of blood into 
 the adjacent torn structures, causing swelling. The effusion of 
 blood is termed extravasation or ecchymosis. 
 
 The extravasated blood may be of ca[)illary, venous or arterial 
 origin. Capillary extravasation is that occurring in the mildest 
 form of contusion. The effused blood then permeates the allccted 
 tissues without definite limitation. The contused part is some- 
 what swollen, and to the toucli and scalpel it is denser than 
 normal tissue. The covering integument, at first normal, soon 
 becomes discolored; this discoloration, which originates in the 
 breaking up of the red cells and the dispersion of their coloring 
 matter, remains often after the other phenomena of the contusion 
 have vanished. This simple form of contusion (or bruise, in our 
 vernacular) is nearly painless; there is felt by the subject inerely 
 an unnatural tightness and tension in it. It requires but little 
 treatment; at the time of the injury, pressure will arrest most of 
 the effusion of blood and so prevent swelling. But if seen after 
 the contusion has reached its final limit of swelling, then tlie 
 recovery may be facilitated througli friction with some mildly 
 stimulating liniment, such as soap liniment or diluted Lini- 
 mentum Ammonite; still, if such cases of inild contusion be 
 committed solely to the fostering hand of Nature, restitution to 
 health will occur nearly as soon as where there has been surgical 
 intervention. 
 
 As the antithesis of the mild form is that where the violence 
 has been so great as to lead to immediate or later destruction of 
 the integument implicated; here the elementary tissues have been 
 so acted on by the casual violence that their component molecules 
 are so displaced or altered as to wholly lose their function; and 
 hence gangrene soon appears in the part. Such gangrene is 
 indicated by a livid discoloration. The treatment in this case is 
 to be directed to tlie separation of the dead structure and, after- 
 wards, to a closure of the remaining breach. If it be ap})arent 
 that oidy the outer stratum is destroyed, then the treatment will 
 consist in favoring the drying of this part; for this purpose paint 
 it witli the compound tincture of benzoin or tincture of iodine; 
 thus the dead part is converted into an occluding eschar similar 
 to a scab, beneath which the wound heals. The dried eschar 
 
CO.NTUSION OF THE SCALP. 67 
 
 should be let remain in place until it becomes loose and falls off. 
 But if the destruction extend through the whole thickness of the 
 scalp, then this desiccation cannot be obtained; tlie detachment 
 of the gangrenous part must be favored by moist warmth; the 
 warm alkaline water before mentioned may be used to accelerate 
 the separation of the slough. After the detachment, one of the 
 best dressings is that of water containing two per cent of alcohol, 
 applied by means of surgeon's lint. The processes of granulation 
 and repair are thus favored. Repair, however, ensues often very 
 slowly, due perhaps, as Hunter says, to the remoteness of the part 
 from the heart; the tardiness of repair is also due to the bony 
 substratum on which rest the soft parts ; for it is a matter of com- 
 mon observation that open w^ounds of large extent situated near tlie 
 surface of broad bones are slow to heal ; examples of this are seen 
 on the cranium, scapula, and the front of the tibia. The slowness 
 in cicatrizing over sach parts is due to the absence or paucity of 
 blood-supply from beneath; the material for repair must be derived 
 from tlio marginal, or surrounding vessels. In consequence of 
 this disposition, cicatrization may occur at normal rate in the 
 peripheral parts of the wound, while centrally, the process pro- 
 ceeds slowly or is at a standstill. After a long period the wound 
 ma}^ wholly heal; the remaining cicatrized surface is dry, hard, 
 immovable, gloss}^ and hairless. Its sensibility is perverted; it 
 may be almost destitute of feeling; or it may be the site of pain, 
 in consequence of compression of the nerves which have devel- 
 oped in the scar, or which have reached to it and been arrested 
 there by the hard texture of the cicatrix. Two such cases have 
 fallen under the writer's observation, in which extensive scars 
 had followed lacerated wounds of the scalp. The large scars 
 remaining after healing, especially in one case, were painful; or 
 at least, were the seat of disagreeable sensations, which the 
 patient could not clearly describe, yet they w^ere the source 
 of constant torment. It should, also, be remarked that the 
 patients, having such painful cicatrix, manifested some psychical 
 peculiarity bordering on insanity; and it was not improbable 
 that along with the injury of the scalp there also occurred slight 
 cerebral concussion, sufficient to cause change of mental character. 
 Since such patients localize their trouble in the scar, it is justi- 
 fiable to remove the latter, and replace it by sound structure bor- 
 rowed from the adjacent parts. As preliminary to such operative 
 work, one should examine and study the parts around in reference 
 to their capability of lending tissue for replacement; and in this 
 
08 WOUNDS OF THE Sf'ALP. 
 
 matter an important point is that the replacing tissues be easily 
 movable, so that the wound made in them can be closed. It 
 being decided where it is best to obtain the structure, one traces 
 off a portion somewhat greater in extent, if possible, than the 
 vacant place. Since this replacing flap must be twisted in order 
 to reach and occupy the breach, it should be so chosen and situ- 
 ated tiiat its base siiall be twisted as little as possible; and this is 
 accomplished by incising the flap from alongside of the vacant 
 breach. The breach must now be jn-epared b}" the removal of 
 the cicatrized structure; and if the surface is yet unhealed, then 
 the indolent granulations should be pared off*, and when bleeding 
 has ceased, the replacing flap should be brought into its destined 
 site; and having been pressed well against the subjacent surface, 
 the free end of the flap must be fastened to the contiguous border 
 by metallic sutures. Should the flap not readily reach to the 
 opposite border, still let it be fixed in i)lace bv an elongated 
 suture; and thus, if the flap be not brought in contact with the 
 adjacent margin, at least it is so fixed on the subjacent parts that 
 it becomes united to them. The wound left whence the flap was 
 uplifted must next be closed by lateral api>roximation; to do tliis 
 use metallic suture, inserted and passing a half inch from each 
 margin. When this amount of structure is included in the 
 suture, it will bear much traction witlioiit arresting the circulation 
 through it: and such suture will uiaintain apposition of the 
 margins until they have cohered. The wounded parts must be 
 dressed daily if suppuration appears; the best agent for dressing 
 is iodoform, which should be dusted freely over the surface. 
 
 In case the breach is so extensive that it cannot be wholly 
 covered in the manner just described, then' let the restoring 
 material be carried across the middle of the breach ; for, done in 
 this way, the remaining uncovered portions will be reduced to 
 minimum proportions in tlie subsequent healing process. 
 Througii this plastic procedure the painful scar is removed, the 
 breach partly or wholly covered and, through the growth of the 
 hair, the patient is relieved of an unsightly mark. Should the 
 operation fail to wholly close the breach by Jiair-covered flaps, 
 then the latter may be supplemented by cuticular flaps according 
 to the method lately introduced by Thiersch. 
 
 A form of contusion next to be considered is that in wliich 
 there is subjacent separation of a portion of the scalp, or injury 
 in which there has been lesion of structure without external 
 opening. In these cases vessels are supposed to be opened from 
 
COXTUSIOX OF THE SCALP. 69 
 
 which blood is extravasated into the subcutaneous breach ; and 
 this effused blood is the phenomenon which distinguishes this 
 form of contusion, and which claims chief attention in treatment. 
 The form of such wound is rounded, both in its free surface and 
 .its boundaries; and its content of blood may vary from a small 
 quantity to that of several ounces. The dimensions, though they 
 can be estimated with the eye, can be more accurately determined 
 through touch, by which the consistence of the swollen part is 
 learned. 
 
 The contusion with ecchymosis of blood is often seen on the 
 head of the new-born child; sometimes it is of very great size. 
 There are two kinds: one in which there is a distinct cavity 
 filled with blood; and a second form, in which the blood enters 
 and is disseminated through the tissues of a portion of the scalp. 
 In the first case there is a well-defined sac of blood, usually 
 liquid, and which has arisen from subcutaneous laceration and 
 loosening of the pericranium, in wdiich vessels are torn and their 
 blood poured into the sac-like cavity which has thus accidentally 
 arisen. This form of extravasation, named cephalhaematoma, in 
 the opinion of trustworthy students of parturition, arises from the 
 passage of the child's head through a rigid, unyielding os uteri, 
 which displaces and so slides the scalp on the cranium that the 
 vessels are torn and empty their blood into the loosened space. 
 That this is the way that such extravasation is created is proven 
 by the fact that it has been seen in births in which the foetus 
 presented by its feet or breech. The contained blood is dark, 
 grumous, and not coagulated. This tumor is often so large as to 
 deform the head of the child. The tumor is compressible, 
 slightly movable, and its liquid content evident to the touch. 
 As John Hunter mentions, the pulsation of a subjacent fontanel 
 may be transmitted to, and through, such tumor, and give the 
 semblance of an aneurism. Where an artery of some size has 
 been opened and communicates with the tumor, the case is very 
 analogous to a false aneurism; however, the pulsation in such 
 tumor usually soon disappears. The best treatment of such 
 tumor when small is slight compression, and should the blood 
 not disappear after some days, then a slight incision may be 
 made in the dependent part of the tumor, and the blood be 
 scjueezed out, and tlie wound closed under an iodoform dressing. 
 As a rule, however, non-interference is the safer plan, since, if the 
 tumor be opened, suppuration is apt to appear in the sac, and 
 then the healing becomes prolonged and tedious. The author 
 
70 WOUNDS OF THE SCALP. 
 
 has found that })aiiiting such tumor with the tincture of iodine 
 accelerates the absorption of its contents. As before said, an 
 accompaniment of the tumor is tliat the pericranium is often 
 detached to some extent; and where this detachment continues 
 long through the non-removal of the effused blood, then there, 
 arises a slight growth of bone which, wall like, marks the 
 former site of the ce])halhaematoma. This osteophyte or bone 
 growth is so slight in amount that it gives no trouble. 
 
 A second form of contusion, occurring in the foBtal scalp, 
 presents itself in those cases of cephalic presentation in which, 
 after the ru])ture of the membranes, the child's head is forced for 
 many hours against the uterine mouth; in this delayed deliver}^ 
 a portion of the scalp is pushed through and constricted, 
 cord-like, by the unyielding os uteri. The final result of such 
 constriction is that the blood is extravasated and disseminated 
 through the part, so that after birth there is present a large 
 tumor, well marked off from the adjacent scalp. This tumor, 
 slightly elastic and compressible, differs in consistence from the 
 preceding form, in which the content was grumous blood; for 
 though the swelling is due to effused blood, yet tlie latter is not 
 contained in a sac or common cavity. This more solid form of 
 contusion of the foetal scalp is seen in the majority of new-born 
 infants as an inevitable incident of birth, yet it is seldom suffi- 
 ciently grave to demand attention; on the contrary, however, the 
 lesion is sometimes so severe that the vitality of the part is nearly 
 or quite destroyed, and then suppuration or sloughing follows. 
 Where conditions are present which portend this, an attempt 
 must be made to prevent such ill events. For this |)urpose gentle 
 friction should be daily made over the part; or, as Hunter teaches, 
 "the best stimulus is pressure, which if urged beyond the point 
 of ease, sets the absorbents of the part to work." Such pressure 
 may be made by means of an elastic bandage, but it should be 
 slight, lest the absorbing vessels be occluded or retarded in their 
 work. As a general rule, however, the contusions met with in 
 the scalp of tli^ new-born rarely demand any treatment; the 
 superabundant forces stored up in the nursling are adequate to 
 the vanquishing of most of the accidents which accompany its 
 birth. 
 
 Besides the wounds in the infant just described, contusion with 
 concealed extravasation of blood is met Avith in subjects of any 
 age, as the result of violence. In similar contusion met with in 
 other parts of the body, the ecchymosed blood is partly or wholly 
 
COXTUSTOX OF THE SCALP. • 1 1 
 
 clotted; yet in such injury in the scalp, the effused blood, similar 
 to what occurs in the child, does not coagulate, but remains 
 semi-fluid or grumous in character. The coagulation of blood, 
 according to Hunter, is due to its being alive; and non-coagulation, 
 to the blood being dead. Bruecke refers fluidity to some influence 
 emanating from the coats of the containing vessels; while 
 Richardson referred the fluidity of the blood to ammonia, which 
 he claims is present in the circulating blood. Richardson received 
 a premium for the solution of a problem yet unsolved. Hunter 
 was probably not far from tlie truth; since, as he observed, such 
 licjuid blood is often attended by inflammation aud suppuration, 
 such as might arise from a foreign body. 
 
 Another important fact to be noted in connection with such 
 injury is that it often deceives the touch, and is mistaken for a 
 fracture with depression of bone. The deception arises from the 
 sinking of the part under pressure, and from the hardened tissues 
 which, as an abrupt wall, surround and separate the ecchymosed 
 blood from the adjacent parts. The careful observer learns to 
 distinguish sucli contusion from depressed fracture by the 
 circumstance that the bounding margin in fracture is more 
 sharply defined than in mere contusion; and in the latter the 
 boundary is inclined toward the cavity. To avoid error, in some 
 cases, much tactile experience is demanded. In the case of 
 fracture the causal violence is greater than in uncomplicated 
 contusion, and the patient's condition is sucli, in most cases, that 
 some grave injury may be inferred; but in contusion there is 
 rarely any enduring encephalic complication; if anyj;hing, it is 
 merely a transient concussion of the brain. 
 
 Where the effused blood is small in quantity, no special 
 treatment is required ; slight compression of the part is sufficient; 
 such compression is especially indicated on the forehead, where 
 it has appeared to the writer that the effused blood coagulates 
 and becomes organized oftener than in the hairy scalp; and in 
 such case, though the clot be somewhat reduced in amount by 
 compression, yet as a rule, some of it remains as a discernible 
 deformity. As just said, in slight cases little or no treatment is 
 needed, but if a large amount of blood be effused, and which 
 remains liquid, then it is proper to consider this as a foreign body 
 which should be removed. This work of removal should be 
 done with much care; and for this purpose, first cleanse the part 
 carefully, and then, at some point best situated for the evacuation, 
 make a valvular incision and, having forced out the blood 
 
tJ. WOrXDS OF THI-: SCALP. 
 
 close the wound made with iodoform dressing. In forcing out 
 the blood, let tliis bo so done as not to disturb tiie torn vessels and 
 cause new bleeding in the cavity. If tlie blood removed has 
 become putrid, a suppuration is sure to arise, and then it is 
 necessary to open the cavity freely, scrape off and cleanse its 
 walls, dust these with iodoform and close again; thus doing, it is 
 sometimes possible to obtain healing with but slight suppuration. 
 
 A matter of importance to the patient in the several cases of 
 contusion considered, is whether the hair Avill be lost over the site 
 of injury; in nearly all cases he can be assured that no such loss 
 will occur; only where there has been suppuration and destruction 
 of tissue is tliere loss of hair in the part. 
 
 Occasionally the coagulated blood remains and becomes the 
 starting-point of a fibrous growth; such growth is oftenest seen 
 on the forehead, and may so interfere with the head-dress as to 
 require attention. A contusion may occlude the outlet of seba- 
 ceous glands, which are numerous in tlie scalp, and thence an 
 atheromatous tumor can arise. Again, w'here tlio content is 
 non-coagulated blood, the containing cavity may remain and 
 be trap.sformed into a cyst. Such cyst rarely attains to great 
 dimensions; and hence will not require surgical interference 
 unless it interfere with tlie subject's dress; in that case it may be 
 removed. The same advice may be given in regard to tlie fibrous 
 growtli mentioned above. If such benign development, wlietlier 
 fluid or solid, remain undisturbed, it will continue without pain, 
 or increase or decrease in volume, for an indefinite period. The 
 continued tranquillity of such formation is often disturbed by the 
 patient's solicitude and desire that his figure should conform to 
 that sketched by his vanity; and especially is the existence of 
 such develoiDment menaced by the knife of some new recruit to 
 tlie ranks of surgery; and though the removal is an easy matter, 
 the recovery is not always so; for through some untoward 
 circumstance, the healing may be long and vexatious, and the 
 finality of an attempt to improve a feature may disappoint both 
 subject and surgeon. 
 
 Gunshot Wounds; General Remarks. — Human civilization often 
 boasts of its advancement, and with much satisfaction prides 
 itself on a near approacli towards perfection; yet when one 
 regards the sanfruinarv battle-fields of modern vears, on which 
 life was wantonly sacrificed, it is evident that many vestiges of 
 the worst barbarism of the untamed era of our race still remain. 
 And even should the optimistic hope be entertained that humanity 
 
GUXSHOT WOUXDS; GENERAL KEMAEKS. 73 
 
 will sometime reach a stage of reason in which w^ar shall cease its 
 deadly w^ork, yet it is more than probable that even in peace the 
 fatal firearm will continue in use as an agent with which the 
 human body will voluntarily or involuntarily be mutilated; and 
 hence that hereafter, as heretofore, gunshot wounds will constitute 
 an important chapter in surgery. The human body is vulnerable 
 to the missile projected by gunpowder, from the scalp to the sole 
 of the foot; among modern men there is no one wdio has acquired 
 immunity through armor or Stygian water ; a Charles the Tw^elfth, 
 if in range of a musket ball, falls a victim ; the sentry Destiny, 
 whom the king fancied to be his constant guardian, on one 
 occasion slumbered at his post, and the royal hero, as readily as 
 a pawn, was swept from the chessboard of battles, on which he 
 had played the intangible victor so many times. 
 
 The gunshot wound is caused by a missile discnarged by an 
 instrument known as a gun or firearm; of such instruments there 
 are many kinds, which vary in form and size from that which is 
 very small to that W'hich is of stupendous proportions, and 
 intermediately there are many gradations. Also, there is an 
 infinite variety of missiles corresponding to the projecting instru- 
 ment. The gun may have a smooth caliber, or the inner surface 
 may be rifled with spiral furrows; these furrows are designed to 
 impart a whirling movement to the ball, so that the latter, planet- 
 like, wdiile moving in its course, likewise revolves about its center. 
 Thus moving, the ball acquires a double endowment of doing 
 violence. Gunshot missiles vary in form, volume and in com- 
 ponent material. The form may be round, which was the only 
 one in use until recently; in modern times a ball of elongated 
 and oval form has been introduced. The best type of this is the 
 minie ball, which is egg-shapen. The ball of this shape acts 
 somewhat as a wedge, and thus by splitting the structure of the 
 body on which it strikes, it acts more destructively. The wedge- 
 like smaller end of such ball striking a long bone may split it 
 from end to end, but a ball of rounded form causes a more 
 localized fracture with numerous fragments. The conical ball 
 traversing rapidly the soft parts leaves a w^ound similar to an 
 incision, but the round one leaves a more circular track. As to 
 component material, the gunshot missile may be of lead, copper, or 
 somemixed metal; the leaden ball isthemost usual kind. Thegun 
 may be loaded with powder alone, and the violence done by the 
 firing will depend on the condition w^h ether the powder has been 
 rammed dowm or only lies loose in the gun barrel, for when forced 
 
74 WOUNDS OF THE SCALP. 
 
 well down, firing at short range may cause much violence; a charge 
 of powder fired at a short distance into the abdomen of a man 
 caused immediate death. Dupuytren, wlio saw the case, records 
 that a large opening was made through the abdominal wull, 
 the intestines were wounded and the wadding of the powder was 
 lodged in the abdominal cavity. Where no wadding is used, the 
 discharged powder, says Dupuytren, wounds the skin severely. 
 The suicide in his haste and desperation has sometimes, luckily 
 for his life, forgotten to place the ball in his weapon, and there 
 resulted only a severe powder wound of his face or mouth. 
 
 Besides the missile's form, its magnitude and velocity cooper- 
 ate as im})ortant fa-^tors in the amount and character of the 
 violence done by it. For example, if a small and a large ball 
 move with equal ]>ropulsive force at a long distance, the small 
 one will do much more injury than tiie large one; at a great 
 distance the small ball will penetrate, or even pass through a 
 human body, while the larger may fall as a spent ball on the 
 hither side of tlio target. Again, a ball moving at a slow rate of 
 motion injures more than one moving rapidly, and in case the 
 two sever tissues, the one moving rapidly makes its way rather 
 by cutting than by tearing; but the one moving slowly does so 
 by tearing rather than by cutting; in the former case, the wound 
 made resembles an incised one, while the latter resembles a 
 lacerated one. The Swiss government, in equipping its military 
 forces with guns which can do work of violence at a great dis- 
 tance, has utilized these facts; tlieir guns carry small balls. 
 
 John Hunter, who had opportunities for the study of gunshot 
 wounds while holding the position of staff-surgeon in the British 
 army, says that the wound produced by the bullet is a contused 
 one. He remarks that from "such contusion there is most 
 commonly a part of the solids surrounding the wound deadened, 
 as the projecting body (bullet) forced its way through the solids, 
 which (tissue) is afterwards thrown off in the form of a slough, 
 and which prevents such wounds from healing by the first 
 intention, from which circumstance the most of them must be 
 allowed to suppurate." Yet he observes that the amount of 
 contusion differs, the difference arising from the variety in the 
 velocity of the projectiles. Instead of the velocity, it is rather 
 the piomentum, which is a component of the velocity and tlie 
 weight of the missile, that figures in the work done by the missile; 
 for the weight of the ball has an important bearing on the injury 
 inflicted. To illustrate this, a large pistol ball impelled by a 
 
GUNSHOT WOUNDS OF THE SCALP AND SKULL. 75 
 
 small charge of powder and striking the trunk of a man would 
 cause him to fall, though the injury done to his body was only 
 slight, but with the same charge of powder a small ball would 
 penetrate and probably pass through the body; in the former 
 case the subject would be stunned and disabled for a short time, 
 while in the latter he might be killed. Those selling arms are 
 familiar with these facts, and advise their purchaser to buy this 
 or that piece according to the purpose intended. To such refine- 
 ment have the agents of destruction been brought! 
 
 Gunshot Wounds of the Scalp and Skull — The victim of a gun- 
 shot wound of the head is fortunate if the lesion is limited to 
 the scalp, but in the case of large balls, or the fragment of a 
 bomb causing the wound, then the injury commonly extends to 
 more important parts which are adjacent, viz., the cranium and 
 the encephalon. But where the injury has arisen from a small 
 ball which did not pass deeper than the structures of the scalp, 
 the wound, in nearly all cases, is an unimportant one. 
 
 The varieties in the form of the wound produced by a ball arc 
 here, as well as elsewdiere, the following: — • 
 
 1. An open wound caused by the missile merely impinging 
 against the surface in its passage and dividing the tissues to a 
 greater or smaller extent, and owing to the convex form of the 
 head, this wound must necessarily be short, seldom equaling, and 
 almost never exceeding, two inches in length. 
 
 2. The ball may enter and escape, the intermediate passage, 
 canal-like, lying beneath the surface. Such tubular wound, as a 
 rule, is not more than two inches long; an exception is where the 
 ball passes deeper, and striking the surface of the skull, it is 
 deflected from a straight course, and in this case the point of 
 emergence may be at any distance from that of entrance. 
 Though the ball has escaped from the canal, yet not unfrequently 
 it carries along with it and leaves some foreign material detached 
 from the head-dress or covering of the scalp. The walls of this 
 wound are in contact, so much so that fluid injected into one end 
 would with difficulty escape from the other end, especially if the 
 missile be small. 
 
 3. The ball may not escape, but remain imbedded in the scalp, 
 and then the ball lies at the bottom of a blind canal, and with 
 it may be detritus from the head-dress. Another species of blind 
 ending shot-canal is that in whicli the missile rebounds and 
 escapes where it entered; contact with the skull might cause such 
 rebound of the missile. 
 
76 WOUNDS OF THE SCALP. 
 
 4. Finally, there is a variety in which there is no external 
 wound, nevertheless, the structures underneath the skin are 
 severely, perhaps totally, killed; the integument nuiy also be 
 destroyed. Such injury on the head would necessarily involve 
 parts deeper than the scalp; the skull might be injured as well as 
 the brain itself. The explanation of the manner in which this 
 wound is ])roduced has been a matter of much study among those 
 who have studied gunsliot wounds. As no mark on the surface 
 remains to indicate the contact of the projectile, the wound has 
 been referred to the action of the suddenly displaced air, and 
 thence arose the name of windshot Another explanation offered 
 by Rust, quite the opposite of this, is that the ball passing near 
 the surface causes a vacuum towards which the structures are so 
 violently displaced as to wound them. Neither of these explana- 
 tions is deemed satisfactory. The one now accepted is that the 
 ball actually strikes the surface in a glancing way, and in so 
 doing communicates a part of its momentum to the parts which 
 thereby become wounded. 
 
 The projectile in its passage through the air describes a uni- 
 form curve in accordance with laws so unvarying and so well 
 known to the mathematician that the final end or stopping point 
 of the ball can be definitely estimated and determined. Yet in 
 the human body, constituted as it is of materials of such varying 
 consistence and density, the ball, striking some hard structure, is 
 caused to stray from its previous direction; and should such 
 impact be repeated, then the course of the ball is com2)osed of 
 broken lines, of which mathematics find no analogue in the sec- 
 tions of the cone, straight or curved line. The ball glancing 
 from point to point leaves a path vague, erratic and incalculable. 
 Thus it has followed the convex surface of the skull, and then 
 emerging has reentered the trunk and continued its wandering 
 there. A ball has struck tlie chest wall, and, without entering it, 
 has passed quite around the thorax, its path lying just under the 
 skin. And not alone has such wandering followed convex sur- 
 faces, it has followed concave ones; this has occurred within the 
 cranial and thoracic cavities; thus a bullet having entered the 
 thorax has confined its course to the inner surface of the ribs, and 
 left the adjacent lung intact. The deflection of a ball from a 
 straight course occurs when it passes from a rarer to a denser 
 medium; this is well illustrated on the water when a ball is 
 so projected as to bound from point to point (ricochet) on 
 the water. The varying structures of the human body do not 
 
GUXSHOT WOUNDS OF THE SCALP AND SKULL. 77 
 
 permit any regular rebounding as occurs in the ricochet of 
 the naval gunner; for the latter is so nearly master of it that he 
 can utilize it in his destructive work. In the human body, like 
 many things familiar to our observation of humanity, though it 
 may start straight, yet it may end very crookedly. 
 
 The form of the entrance opening and that of the exit, where 
 this exists, will here be considered. As a rule the edges of the 
 entrance opening are turned inwards; if, however, the ball were 
 moving with great sj^eed, then the edges might be cut so abruptly 
 as not to turn inwards. Where the ball does not emerge from 
 the body, its course often becomes a difficult problem to solve. 
 In such cases the position and direction in which the inverted 
 edges lie are indices of the direction in which the ball started. 
 Besides the eversion of the exit opening, it is larger than that of 
 the entrance, and this is caused by the missile carrying along 
 with it foreign material caught outside of the body; or such 
 enlarging material may be derived from the tissues through 
 which the missile passes; for the shot-canal, especially when the 
 ball moves with great speed, is not caused by misplacement alone 
 of the parts traversed, but the structures are likewise severed. 
 The opening of escape may also be enlarged, or rendered irregu- 
 lar, through the ball having been altered in its form, through 
 contact with some bone or tendon. From such contact the ball 
 might also be split and the fragments escape at different points; 
 or one fragment only escajDing, the exit point might be smaller 
 than that of the entrance. The entrance point may be distin- 
 guished sometimes by marks of powder; and such marks would 
 indicate, also, proximity of the discharging weapon. 
 
 From the facts and circumstances already detailed, the diag- 
 nosis of the gunshot wound can readily be made out in most 
 cases; in cases of obscurity the history of the accident will usually 
 remove any doubt from the mind of the diagnostician. 
 
 The prognosis of the gunshot wound will depend somewhat 
 on the extent of the injury, but more on the situation and nature 
 of the parts wounded; certain regions of the body may be trav- 
 ersed by a gunshot wound, and but slight injury occur to the 
 subject; should the ball leave foreign matter in its track, then the 
 wound becomes much more grave. But if parts necessary to life 
 are injured, the wound becomes a perilous one, the peril depend- 
 ing, in case the head and chest be the site, more on the foreign 
 matter carried into the tissues, than on the wound made in them. 
 In the abdomen, besides the foreign matter which the missile 
 
/b WOUNDS OF THi:* SCALP. 
 
 may introduce, a wound of the bowel may lead to tlie effusion of 
 intestinal content, and these invisible contingencies add greatly 
 to the wound; and though modern surgery would expose them 
 to sight by exploratory incision, yet, thus far, the danger of such 
 injury has only been but partially diminished. 
 
 The wanderings which the ball may indulge in, and the impos- 
 sibility often of deciding what structures have been wounded, 
 render it impossible in many cases to predetermine the final result 
 of a gunshot wound; so that when the ball has entered the head, 
 chest, or abdomen, the first few days, and sometimes the first few 
 hours, are pregnant with momentous issue to the unfortunate 
 victim. xVnd the prophetic art of the attending surgeon on such 
 occasion is often most successfully exercised if his prognostic 
 utterances are couched in the jihraseof the Delphic oracle, which 
 admits of opposite interpretations; for the medical seer when he 
 casts his prognostic horoscope very often descries no absolute 
 certainties; when, however, the lit-ld is limited to that of the 
 sim[)le gunshot wound of the scalp, there is rarely any occasion 
 for ominous foreboding, for recovery may always be expected. 
 
 Treatment. — In considering the treatment of gunshot wounds 
 of the scalp, we commence with tlie simplest form, viz., the open 
 shot canal, which is a furrow in the surface of the scalp. Tlie 
 depth of this may vary from that of a mere abrasion to a wound 
 involving the whole thickness of the parts, but in every case the 
 surgeon has the advantage of being able to inspect the wound, 
 whether it is smoothly cut or lacerated, and he also sees wliether 
 the surface is free or not from foreign impurities. If impurities 
 be present, they should be removed by irrigation with an anti- 
 septic fluid; and if the edges be irregularly torn or limljriated, 
 they should be rendered smooth by trimming. This work being 
 done, if the edges can be approximated by sutures without much 
 tension, this should be done; the part is next to be sprinkled with 
 iodoform, and lastly covered with lint. In this case the wound 
 has 1)een converted into a simple, incised one, and the healing 
 should be immediate and leave but a slight trace in the form of a 
 linear scar. In case the wound is so broad that it cannot thus be 
 closed, partial closure should be made, either by suture or by 
 tying the hair across the breach, as already described; and tlien 
 dress with iodoform and occluding lint; thus treated, the least 
 possible scarring will remain. 
 
 In the second form of wound, viz., tubular and open at both 
 ends, when it is superficial, the subjacent track will be indicated 
 
GUNSHOT WOUNDS OF THE SCALP AND SKULL. 79 
 
 by some discoloration of the skin; also, if pressure be made along 
 this track a crepitant or emphysematous sensation will often be 
 perceived, and becomes a diagnostic aid. Besides this, the nor- 
 mal consistence of the parts may be altered. If it be probable 
 that some foreign material has lodged in the canal, a careful 
 search should be made for the same with a bullet sound, and if 
 found, removed. The removal can be done by cutting down 
 directly on the body, but the work can be done j)referably in 
 most cases by means of forceps introduced through the opening 
 of the canal, viz., the end which is nearest the foreign object. 
 After this, the canal, if sufficiently permeable, should be cleansed 
 by injecting through it an antiseptic fluid. This injection must 
 not be done too violently, lest the fluid forsake the canal and be 
 forced into the adjacent tissues. This preliminary work being- 
 completed, the wounds are to be treated as any simple wound, 
 and the whole to be covered with lint and a retaining bandage. 
 The wounds will probabl}" C|uickly lieal, with only a slight serous 
 discharge from the concealed canal. If there b« indications of 
 hsemorrhage in the canal at the time of the dressing, it would be 
 improper in most cases to open the wound to find the opened 
 vessel, since the bleeding could be arrested by a compressive 
 bandage over the dressing. If later there occur signs of suppura- 
 tion in the canal, which would be indicated by circumscribed 
 swelling, the canal must Ije oj^ened, and having been cleansed, it 
 must be dressed daily with iodoform. 
 
 In the third or csecal form, in which the canal ends blindly, 
 at its bottom the missile may be expected to be found. In a case, 
 however, of a gunshot wound of the chest seen by the author, no 
 ball was found in the canal, and on examination it was discov- 
 ered that the coat, vest and outer shirt had been pierced, but the 
 undershirt was intact; the undershirt had escaped opening, and 
 been forced into a canal two inches long, and then the missile 
 had been dislodged by the retraction of the shirt. From this the 
 lesson is forcibly taught, always to examine the clothing care- 
 fully, both with the view of learning whether it has been pierced, 
 and if so, wdiether the ball has cut and carried with itself some of 
 the dress. As a rule, the ball will lie at the bottom of the canal, 
 and can be detected there by a sound; but if the wound will 
 admit the finger, the latter is the best detective both of the ball 
 or any adventitious matter. The ball having been removed, it 
 should be examined as to its form, since from changes in this 
 some information can be gained concerning injury which may 
 
80 WOUNDS OF THE SCALP. 
 
 have been done to the skull. P'rom studies of the change of the 
 bullet's form, Bousquet, in 1SS5, announced the following: "When 
 the point is flattened it denotes that the bullet struck and caused 
 a depression, or, along with depression, the bone is also broken. 
 When the bullet is depressed on one side and is cracked on the 
 opposite side, this indicates that the bone impinged on was not 
 broken. A lateral depression on the bullet means that the bone 
 was touched and only depressed." Instructed by these facts, it is 
 well to study any changes visible in a bullet which has been 
 extracted. The ball being removed, dress the wound according 
 to the methods alread}' described. 
 
 In cases in which the ball lies concealed, and there would be 
 great difiiculty in removing it, the better course is to let it remain. 
 Such practice, however, would not be proper where the ball lies 
 anywhere on the cranial vault, since its removal there is easily 
 effected; but when the missile is lodged in the structures at the 
 base of the cranium, the case is otherwise. For example, in the 
 occipital region, a ball might lie in the trapezius and complexus 
 muscles, and be so deeply buried that it Avould be extremely hard 
 to find it, and, if found, the attempt to remove it would cause 
 great laceration and injury to the tissues. Also, if buried in the 
 temporal fossa, the effort to extract the ball would be attended 
 with much violence; hence, in gunshot wounds in these regions, 
 non-interference is the better plan for the patient; yet it is too 
 rarely followed, since the surgeon finds it difficult to withstand 
 the popular clamor that the ball must be found. Yielding to 
 such mischievous opportunity, the surgeon has too often forsaken 
 the line of duty and engaged in adventurous work which has 
 added little to his own reputation, and still less to the welfare of 
 his patient. The probe, led by a blind guide, has often wandered 
 far from the object of its search, and caused irreparable injury. 
 In some cases, the ball which lies at the bottom of a blind canal, 
 does as little harm in the body as it would outside of it. In all 
 such cases abstention is urgently indicated. When the ball is 
 allowed to remain in the tissues, if it be unaccompanied by any 
 foreign material, it does not awaken much reaction in the parts 
 contiguous; it is an aseptic agent which has been purified by its 
 passage through fire. No more innocent intruder could make 
 its ingress into the tissues of the body; its only offensive qualities 
 are its weight and the slight pressure which it makes on the parts 
 around. The resultant irritation awakens a formative action by 
 which a cicatricial capsule is thrown about the ball; especially, it 
 
GUNSHOT WOUXDS OF THE SCALP AND SKULL. 81 
 
 it be lodged in the muscular tissue; but in more yielding structure, 
 as the brain, the ball may sink by gravitation from its first place 
 of lodgment. The same has occurred in the loose structures of 
 the axilla. 
 
 The fourth form of gunshot wound, caused by the lateral or 
 glancing contact of a large ball, is often a grave injury, since the 
 parts thus wounded are often wholl}'' destroyed; and, when on the 
 scalp, the cranium may also be fractured. Such fracture con- 
 joined to the lesion of the soft parts, is extremely perilous to life. 
 Where the bone is probably not injured, as may be inferred where 
 depression and crepitus are absent, then the treatment is directed 
 to the use of means calculated to save or restore the life of the 
 injured soft parts. For this purpose, shave the part and apply to 
 it a paste composed of balsam of Peru and iodoform. This com- 
 pound, should the injured parts die, resists putrefaction and aids 
 in the disinfection and drying of the surface covered by the paste; 
 and thus if the injury does net involve the entire thickness of the 
 scalp, the outer desiccated layer acts the part of a scab, under 
 which healing occurs. Such healing, however, is slow, and would 
 rarely complete itself under the protective slough; and, therefore, it 
 is better that the latter be removed, and the remaining injured 
 surface treated as an open wound. If, however, at the first exam- 
 ination of such injury the surgeon is convinced that the parts are 
 wholly killed, then any attempt to restore their vitality would be 
 irrational; it is better to use means which would promote detach- 
 ment of the dead structures; and for this use moist warmth, by 
 means of cataplasms covered with oiled silk. And if ten per cent 
 of alcohol be added to the liquid, and enough of carbonate of soda 
 or potash to render it highly alkaline, then the maceration will 
 be best effected. After the dead tissues have been removed, the 
 remaining wound should be protected by moist dressings; and if 
 the granulative action be tardy, a slightly stimulating dressing 
 should be used, viz., a five per cent solution of alcohol. In case 
 the surface to heal is so large that it cannot readily close by cica- 
 trization, then the surgeon should lend assistance by some of the 
 plastic artifices at his command; for this, adjacent tissue may be 
 utilized, either by complete or incomplete approximation of oppo- 
 site margins, or by taking a flap from the contiguous parts and 
 placing it across the breach. Should these methods be impracti- 
 cable, then the work of closure might be accomplished by means 
 of skin-grafting; such grafting material may be procured from 
 the subject, his friends, or from corpora viliora, as the frog or 
 
82 WOUNDS OF THE SCALP. 
 
 dog: the dog, it is said, has repaired liis master's scarred and 
 hairless scalp with hair-covered derm. Transplanting grafts 
 from the sheep has been advised, and, in fact, trial of the 
 same has been reported; yet it is not probable that the api)endage 
 inseparable from such grafting would be satisfactory to many 
 heads, though, as a humorous journalist once })ut it, it niiglit be 
 the "best thing that many heads could be put to." In tliis work 
 of skin-grafting, where there has been loss of the entire thickness 
 of the scalp, the anremic condition of the surface to be repaired 
 will be more apt to entail failure than success; should, however, 
 the pericranium be intact, the peculiarly disposed vascularity of 
 this membrane would insure the life of the grafts; for tlie numeri- 
 cal superiority of the veins over the arteries would favor conges- 
 tion and insure an abundant supply of blood; and hence the 
 l)resence or absence of the pericranium has no small bearing on 
 the question of repair by the method of grafting. Instead of 
 using the entire derm, Thiersch's epidermal grafts might be used. 
 Gangreyie. — Gangrene or mortification of the structures of the 
 scalp is seldom or never seen as a primary phenomenon; a fact 
 due to the abundant supply of blood to these parts; in this 
 respect the head contrasts with the inferior extremities, so often 
 the seat of mortification. Besides the abundant su[)ply of blood 
 to the scalp, its position is unfavorable to stasis or congestion, 
 which, in many cases, may be viewed as the proximate factor in 
 tiie causation of gangrene: the crowded vessels in the lower 
 limbs exert no inconsiderable pressure on the parts which they 
 traverse, and the paradoxical condition is present of starvation 
 in the presence of excessive nutrition; but in the scalp the 
 forces of the heart, assisted by gravitation, avert stagnation of 
 blood; and as result, if the structures on the head die, it is 
 from actual antemia due to some mechanical agency. As exam- 
 ple of such case may be cited concussion, in which the vio- 
 lence done has immediately deprived the scalp of its vitality, 
 and those in which the part has been rendered anaimic through 
 pressure. The cases arising from sudden violence have been 
 sufficiently considered.; but as examples arising from lack of 
 blood, may be cited those cases in which the patient, the sub- 
 ject of some debilitating disease, rests the head in one position 
 for a long period ; thus a patient in the later stages of typhoid 
 fever has been found to have death of the scalp on the back of 
 the head on which he has lain for a number of weeks. This 
 tendency to death from pressure in any adynamic disease of long 
 
GANGRENE. bd 
 
 duration, should be borne in mind, and suitable means used to 
 avert it. As means to avoid such gangrene, let the head rest on 
 an air-cushion, and besides having its position changed from time 
 to time, let the exposed part be bathed with alcohol containing 
 corrosive sublimate, in the proportion of one in a thousand. If, 
 notwithstanding this, the part dies, then the detachment of the 
 gangrenous structures should be favored by moist warmth, and 
 the ulterior management of the case should conform to advice 
 before given. 
 
 Again, fatal anaemia of the parts may be induced by the 
 careless use of the ice-bladder, the use of which is so much in 
 vogue in the treatment of injuries of the head. To avoid such 
 ill results, the heavy fragments of ice should not be used, but 
 instead, ice which has been finely crushed; or, if it could be 
 obtained, snow might be used; and between the containing 
 bladder and the head, a layer of flannel should be interposed; 
 thus the" excessive action of the cold will be prevented. 
 
 Gangrene of the scalp may arise from the subcutaneous 
 ravages of phlegmonous erysipelas; thus from the suppuration in 
 the lax tissue of the interspace beneath the scalp, the confined 
 pus may burrow, and in its diffusive march, destroy the nutrient 
 vessels of the overlying parts, and cause the death of parts so 
 deprived of blood. Such mortification will not be uniform, but 
 islands of dead tissue will be found interspersed in sections of 
 living structure. The detachment of the sound from the 
 unsound parts in such cases is very tedious. It need hardly be 
 remarked that such cases are rarer now than formerly; yet the 
 aseptic doctrine, like all great truths, will sometimes fall short of 
 realization; and suppuration and erysipelas will continue, as 
 hitherto, to occupy some portion of the domain of pathology. 
 
 In the cases of concealed suppuration mentioned, the sloughing 
 may be lessened, or prevented, by incisions made early, so as to 
 allow free escape of the pus. In making these incisions the vessels 
 should be studiously avoided, for if cut, the consequent bleeding 
 will almost defeat the purposes of the opening; if an artery by 
 mischance should be opened, the vessels should be ligated. If 
 such cuts be made in lines radiating from the summit towards 
 the base of the head, then the risk of wounding vessels will be 
 much lessened. Through the incisions made, the suppurating 
 cavity should be washed out, and the dressing completed by the 
 introduction of iodoform into the recesses of the cavity; thus 
 doing, suppuration is lessened and healing is promoted; but, if 
 
84 WOUNDS OF THE SCALP. 
 
 some structure is lost through gangrene, the case should be dealt 
 with as heretofore detailed. 
 
 Remotely cognate to the subject just treated of are fistula and 
 ulceration. 
 
 A fistula, technically considered, is a tubular ulcer; that is, a 
 canal of which one or both extremities open on the surface, and 
 the walls of which are lined with indolent granulative tissue. A 
 sero-purulent fluid normally escapes from such a canal; and the 
 latter is occasionally so situated that some excrementitial matter 
 also escapes through it. The leadi^ig characteristic of tl)e fistula 
 is tliat it is non-healing; in some regions of the body the fistula 
 is an unending source of inconvenience to its possessor. It does 
 not heal because the materials which traverse it, separate the 
 canal; in some cases, also, the healing is prevented by the 
 frequent movement of the structures in which the fistula lies; 
 but this latter condition does not exist in the case of fistula in the 
 scalp, and hence in the treatment of fistula in that region, the 
 immobility is favorable to healing. 
 
 Fistula of the scalp mav arise from a phlegmonous inflam- 
 mation, in which there occurs a latent burrowing in, or beneiitli, 
 the structures of the scalp; the lost structure is not whollj 
 restored, and one or more narrow ])assages femain. Fistula 
 may remain as the sequel of scrofulous or syphilitic disease, 
 in which the ulceration penetrates and traverses the structures, 
 and leaves unhealing passages beneath the surface. And this 
 condition is oftenest found where the bone is aftected, and being 
 in a carious or necrosed state, acts as a foreign body at the bottoin 
 of, or along the track of, the fistula. And, lastly, a fistula has 
 arisen from the lodgment within the tissues of a gunshot missile; 
 or any other foreign object penetrating and remaining in the 
 scalp may leave an unhealing fistulous canal. 
 
 From the diversified causation of fistula in the scalp (and the 
 same is the case wherever it may be found), some diagnostic 
 acumen must be exercised to determine the origin of it; whether 
 it be from phlegmon, scrofula, syphilis, a bullet, or other foreign 
 body, will generally clearly appear from the history of the case. 
 Besides, the sound is an aid which should not be neglected; and 
 though it may not reveal the origin, it may reveal some important 
 conditions of the fistula; thus, the presence or absence of a foreign 
 body may be determined, and especially, whether the subjacent 
 bone is implicated. To distinguish, however, between dead bone 
 and a foreign bodv is not alwavs easilv done. And even contact 
 
ULCERATION. 85 
 
 ■with the rough surface of sound bone has often misled the searcher. 
 Dense fibrous or tendinous tissue has likewise often deceived the 
 prober; great experience is requisite to guard one from error in 
 arriving at a correct diagnosis in such cases. 
 
 The treatment of fistula, as may be inferred from what has 
 preceded, may be wholly local in character, or both local and 
 constitutional. Where the trouble is purely local, as from a 
 foreign body, then the canal must be freely opened and the body 
 removed; and this done, the track of the canal must be scraped 
 or curretted, until it has been freed of its granulative investment, 
 and the work concluded by dressing with iodoform and means 
 before given. If, however, the disease depend on cranial caries 
 or necrosis, then the affected bone must be wholl}^ removed by 
 gouge and chisel, and the further treatment correspond to that of 
 simple fistula; and if thus treated the wound will close rapidly. 
 But if foreign matter be inadvertently overlooked, or some 
 diseased bone be left, the wound may close, but reopen again in 
 a short time; in such a case, repeat, and do the work more 
 thoroughly; especially, if the causal agency be diseased bone, 
 must the removal of this be thorough; the excising chisel or 
 forceps must only cease work when the instrument has passed 
 into the contiguous sound bone; stopping short of this has often 
 been followed by a return of the fistula. 
 
 Should some constitutional disease coexist, and which must 
 be reckoned as the cause of the fistula, then appropriate- treatment 
 must be directed to the general disease; sucli causal disease is 
 commonly scrofula or sj^philis; and as the fistula present will be 
 the same in each case, the diagnosis of the causal affection must 
 be definitely made out before appropriate treatment can be pre- 
 scribed. Soon after the constitutional treatment has commenced, 
 the fistula should be operated on and treated in the manner 
 ■detailed in the preceding paragraph. 
 
 Ulceration. — By ulceration is meant that condition present 
 in a part from which the skin or mucous membrane has been 
 removed, and which remains as an open wound, with little or no 
 tendency to heal. Such wound, called an ulcer, is usually 
 bounded by a border regular in outline, and which is elevated 
 above the ulcerated surface. This surface is constituted of imper- 
 fectly formed granulative tissue, which has been before referred 
 to as embryonic tissue; and from this surface is thrown off a thin, 
 pus-like fluid. The discharged fluid contains a few pus-cells 
 along with elements of irregular form, which have, in part, arisen 
 
80 WOUNDS OF THE SCALP. 
 
 from broken-down, decomposed pus cells. Some of the formless 
 elements arise from tlie death and detachment of minute portions 
 of tiie ulcerated tissue. Ulcers vary in color from red to a pale 
 hue; this depends on their greater or lesser vascularity. Their 
 limiting margins also differ in different cases; these may be steep 
 and high, the margins may be inverted, and this indicates that 
 the inverted edge is undetermined by the ulcer; and this state is 
 one unfavorable to healing. When an ulcer is near bone, a dis- 
 eased condition of the bone ma}-^ be the origin of the ulceration. 
 Contiguous vessels, muscles, and nerves may also become affected. 
 The immediate cause of ulceration is a disturbance of the 
 vascular structures of the affected part; the venules, arterioles, and 
 lymph-vessels are in an abnormal state, the blood does not come 
 to, and go from, an ulcerated part, as it does in healthy structures. 
 The function of the lymphatics is likewise interfered with; and 
 this impediment to the movement of the blood and lymph exists 
 both under an<l around the ulcerated structure. In order that 
 the nutrition of a part be duly maintained, the nutrient material 
 must be supplied to it at regular intervals, and be under a certain 
 amount of pressure from the action of the heart; hence in the 
 process of maintenance of the tissues, several factors occur; and 
 without this regulated action and concurrence, the vital process 
 ceases and death results; and when this death is on a large scale 
 the event is gangrene, but when small particles or molecules only 
 die, it is ulceration; death in the first ca.se is macroscoi)ic, and in 
 the second it is microscopic. In gangrene the obstruction to 
 nutrition is primarily in the large vessels; but in ulceration the 
 impediment is in the capillaries. Gangrene involves both the 
 superficial and the deeper structures; the action of ulceration is 
 limited to the superficial ones. Ulceration does its work in 
 detail; gangrene does it in mass; the former runs a more chronic 
 cour.se than gangrene does. The favorite site of the ulcer is on 
 the inferior extremities, though not infrequently it occurs in the 
 scalp. 
 
 Similar to fistula, ulceration in the scalp may be associated 
 with, or be dependent on, scrofulous or syphilitic disease. The 
 products of these diseases interfering with the nutrition of the 
 parts adjacent, often cause atrophy or even death in these parts; 
 thus the tubercular product of .scrofula and the gumma of syphilis 
 act destructively on parts adjoining. The nature of this accom- 
 panying disease must be accurately determined, since the treat- 
 ment of scrofula would be very inappropriate for syphilis, and 
 
ULCER ATIOX. 87 
 
 vice versa, since the mercurial course so proper in syphilis 
 would be detrimental in scrofula. Hence it is evident that in 
 the treatment of ulcer on the scalp, as well as elsewhere, the 
 varied causation must be studied. 
 
 When the ulcer is the result of loss of integument from 
 uncomplicated traumatism, then local means may suffice for 
 cure. The surface of the ulcer should be carefully noted, and if 
 it be clad with exuberant granulations, these should be reduced 
 by an escharotic. For this an excellent agent is the sulphate of 
 zinc, which must be applied in crystal form. To do this, cover 
 the part to be acted on with a stratum a half line deep of the 
 crystals of the salt, cover these with dry lint and allow them to 
 remain undisturbed for twenty-four hours: the surface will then 
 be found quite charred to a depth equal to the thickness of the 
 stratum of the salt that was used. This dead surface is to be 
 removed by means of a macerating cataplasm. Three or four 
 days will be required to separate the destroyed structure. The 
 surface tlms cleared off will heal rapidly, the cicatrization pro- 
 ceeding towards the center from the peripheral border. If skin 
 grafting be resorted to at this period, and a few grafts be placed 
 here and thereon the raw surface, the healing will proceed much 
 more rapidly than if allowed to proceed wholly from, the circum- 
 ference of the ulcer; or healing might be further hastened by cov- 
 ering the surface with epidermal grafts. The healing will also 
 be promoted by the local use of a ten per cent solution of alcohol. 
 The secret of success in the treatment of ulcers as well as that of 
 many other diseases, local or general, is not to persevere too long- 
 in the use of any one method. Nature is whimsical and requires 
 to be catered to by variety, and hence when one method ceases or 
 fails to do what is wished of it, some other means must be resorted 
 to. Change of plan often accomplishes what pertinaceous conti- 
 nuity is impotent to effect. 
 
 As a local application to the ulcer, iodoform may act well for 
 a time. A better remedy than this is the sub-iodide of bismuth. 
 This agent was announced in 1876 as an antiseptic agent. Dr. 
 Reynolds and others reported good results from its use; its expen- 
 siveness is an objection .to it. This remedy may be employed 
 alone or combined with calomel or salicylic acid; for use, it is to 
 besprinkled once daily over the ulcerated surface, and the whole 
 to be protected by a covering of adhesive plaster. If the ulcer is 
 so situated as to render the use of the plaster difficult, then it may 
 be covered with lint or a simple bandage. The author has often 
 
8b AFFECTIONS OF THE SCALP, 
 
 seen an ulcerated surface speedily take on a healthy character, 
 and cicatrization to commence under this management. 
 
 Should the prime causal factor be a constitutional disease, as 
 before stated, this should be accurately determined and receive 
 appropriate treatment. As topical means, one of the most effect- 
 ive is calomel combined with mor[)hia, in case the patient has 
 constitutional syphilis. The following is a recipe which, used 
 locally, has acted well: — 
 
 \\. Hydrargyri Chloridi Mitis .^1 
 
 Morphinae Sulphatis gr. j 
 
 Misce. 
 
 A portion of such a powder .should be sprinkled over the ulcer 
 once daily, and the part then covered with the cotton wadding. 
 Meantime the patient, if feeble, should take internally the iodide 
 of potassium in combination with the tincture of Peruvian bark. 
 Should the patient, however, be a strong subject, then he may 
 take a combination of mercury and iodine; and for this purpose 
 the protiodide of mercury may be given. As additional local 
 remedies may be mentioned the balsam of Peru and the com- 
 pound tincture of benzoin; these remedies applied to ulcerated 
 surfaces stimulate and promote healing. The fluid extract of 
 ergot may also be used with benefit. 
 
 Hypeiirophy. — The scalp is sometimes the site of abnormal 
 thickening; and this hypertrophy may embrace a large extent of 
 the scalp, or it may be of limited extent. Such increase of 
 structure is the result of some prior derangement or disease of the 
 part. The most usual cause is a chronic erysipelatous inflamma- 
 tion of a recurrent or continuous form. In such state, the affected 
 structures, being constantly swollen with blood, receive an undue 
 quantity of formative material, and the result is growth of the part 
 beyond normal limits. Such thickened structure is painless, and 
 except tliat it slightly deforms the head, it is the cause of no 
 inconvenience to its possessor; and should this trouble be of 
 sufficient moment to cause the subject to seek treatment, the best 
 results may be obtained from compression with collodion, and 
 also from the topical use of iodine. And these remedies may be 
 used in combination, viz., first painting with tincture of iodine 
 and then cover the painted surface with collodion; thus the 
 absorbent action of the iodine and compression act conjointly. 
 But if the hypertrophy be so great as to demand more active 
 measures, then the knife may be resorted to; and wedge-shaped 
 portions having been excised, the wounds must be closed with 
 
ATROPHY. 89 
 
 sutures. It is seldom, however, that a recourse to cutting will be 
 needed, or even any other treatment, since, after a lapse of time, a 
 diminution of the structure may confidently be anticipated. For 
 it is a rule that the bodily form, however modified by circum- 
 stance or contingency, tends to revert to the original model. 
 Careful of the products of her work during uncounted years, 
 Nature jealously guards them; her maternal watchfulness is ever 
 diligent in their maintenance in permanent constancy in form 
 and type, unperverted and unchanged; and if changed, as a rule, 
 this is for the better. The tendency to the elimination of the 
 hybrid or compound form in the domain of plant life finds its 
 analogue in animal life; the products of cicatrization and hyper- 
 trophy often slowly vanish and leave but slight traces of their 
 existence, and such, in most cases, is the final event of hypertrophy 
 of the scalp when due to simple multiplication of the normal 
 constituent elements. 
 
 Atrophy. — An opposite condition to that just considered is 
 atrophy of the scalp, in which it is the subject of attenuation, of 
 which there are varying grades from extreme thinness to that 
 which is scarcely perceptible. This condition arises from imper- 
 fect nutrition of the part, and in the male is often associated with 
 baldness; and the two are, doubtless, promoted by the irrational 
 head-dress which obstructs the circulation of blood in the part, 
 and of the air on its outside. The thinness of the scalp is like- 
 wise associated with attenuation of the adjacent cranial wall. In 
 atrophy of the scalp the normal mobility of the part is limited, 
 or quite lost; and the part so affected is dense, tense, and appar- 
 ently bloodless. The innervation of the part is impaired, and in 
 every respect its vitality is lessened. Such tissue, when wounded, 
 is slow to heal; and, on this account, the surgeon should avoid it 
 with his knife; especially so when it is the site of atheromatous 
 or sebaceous tissue, not unfrequently seen on the head of old 
 persons. Such atrophy is irremediable, and only exceptionally 
 does it cause any inconvenience. 
 
 Tumors. — By the word "tumor" was meant, primarily, enlarge- 
 ment or swelling; including this idea, the word has acquired in 
 pathology the additional meaning of a structure superadded to 
 some part of the body, and the superadded structure may resemble 
 and be nearly identical with the tissues in which it is contained, 
 or from which it arises; or the tissues which compose it, and the 
 course which the tumor takes in its development, may present 
 
 radical and striking differences from the parent structure, whence 
 7 
 
90 AFFECTIONS OF THE SCALP. 
 
 the tumor originates. In the former case, the tumor may continue 
 as a harmless appendage for an indefinite period, and in many 
 cases causing its subject little or no inconvenience; if there be any- 
 trouble, this is due to the pressure of the tumor on adjacent parts, 
 and also to the deformity which it causes. The other form, in 
 which the tumor consists of normal elements which are abnor- 
 mally compounded, unlike the former type, sooner or later 
 becomes a source of incalculable trouble. This species, like any 
 organized being, has a definite life; it starts from an humble, 
 usually unnoticed origin, thence grows to such size that the parts 
 on which it rests are unable to furnish it with sufficient material 
 for its maintenance; it then dies, and fatally involves in its death 
 tlie parts about it. Such tumor, like an ingrate, finally ruins the 
 organic household into which, inadvertently or unknowingly, it 
 has been adopted. From their action and course, the former 
 group is named benignant or benign, while the second group is 
 named malignant. 
 
 In tlie scalp almost all forms of tumors occur, both benign 
 and malignant; yet in our treatment of the subject we will only 
 consider those of greatest frequency. 
 
 Tumors originate from the preexistent constituents of the 
 parent tissue, or that in which their growth is situated. In tlie 
 scalp one finds as component elements the following: epidermal 
 scales, epithelial cells, muscle of the striated and non-striated 
 species, connective, fatty and fibrous tissue, and nervous, vascular 
 and glandular structures. Though seemingly simple, the scalp 
 is a complex compound and reducible to the proximate elements 
 enumerated; and in any tumor growing in it, it will be found 
 that one element is the sole or predominating constituent, and 
 hence the tumor, elementarily and histologically considered, is 
 simple in character; and this is true of both the benign and 
 malignant. 
 
 The benign type is represented by the fibroma, cystoma, 
 lipoma, and angioma; the representatives of the malignant type 
 are sarcoma, epithelioma, and carcinoma. 
 
 The fibroma is seldom seen in the scalp except in the form of 
 warts; these, however, contain so many elements besides fibrous 
 tissue that, structurally considered, they can only be viewed as 
 remotely cognate to the fibroma, which, in its simple form, is 
 composed of fibrous tissue. For the pure fibroma the scalp does 
 not furnish the conditions favorable for its development; space 
 for growth is absent The nearest representation to it which the 
 
WARTS. 91 
 
 author has seen is the fibro-adipose tumor, in which the fibrous 
 tissue is the chief constituent. Such tumor occurs on the sides of 
 the head, where the scalp is thickened by the addition of fatty, 
 muscular and tendinous structure. The starting point is gener- 
 ally a scar resulting from a severe contusion or open wound. 
 And then in the work of repair the production of granulative 
 tissue is continued beyond what is needed for restitution to normal 
 form; and in the new growth, adipose elements are incorporated 
 or entangled, since from the nature of its development, such 
 growth is not definitely separated from contiguous parts, and the 
 tumor passes insensibly into, and is intermingled with, neigh- 
 boring structures. Such growth is elevated above the parts 
 around, and thus it becomes a slight deformity through inter- 
 rupting the even surface of the head. From its poverty in 
 nervous structure there is obtuseness of sensibility, if such 
 structure be pricked or wounded in anyway; and yet through 
 encroachment or pressure on peripheral nerves, it may become 
 the source of pain; a neuralgia or sensation of uneasiness may 
 thus be awakened, and cause no inconsiderable trouble to the 
 patient, so much so that the surgeon's knife may be invoked 
 for relief. And should the growth be painless, it should be 
 regarded with some suspicion, as it can alter its type and become 
 malignant; in this way sarcoma and carcinoma have originated. 
 Hence, an additional motive for the removal of such fibroma. 
 For this excision, let the tumor be circumscribed by a cut of such 
 figure as to admit of the readiest closure of the wound; and this 
 may be elliptical or triangular, for the wound in either of these 
 forms remaining after the removal of a tumor of moderate 
 dimensions can be closed by direct sliding or approximation of 
 the opposite edges; this should be done with deep metallic 
 sutures, which should be allowed to remain in place for not less 
 than eight days. The wound should be washed with alcohol and 
 then dressed with iodoform and cotton wadding. A cure can 
 thus be accomplished in from ten to fourteen days. 
 
 Warts. — The wart is well known as a miniature growth origi- 
 nating in a hypertrophy of the papillary layers of the cutis of the 
 hands; the primary cause is probably some continued local 
 irritant, such as the hands are the subjects of, and also the feet 
 of the barefoot boy ; in the latter, the feet being as much exposed 
 to injury as are his hands, one finds in him warts as often on the 
 feet as the hands. The Avart requires a free supply of blood,, 
 both for its origin and subsequent maintenance; and to this is 
 
92 AFFECTIONS OF THE SCALP. 
 
 due the occasional occurrence of warts in the scalp. The wart 
 here is concealed in the hair, and is a source of inconvenience in 
 dressing the head, since in this work it is easily wounded; and 
 from this cause, as from being an unsightly object when visible, 
 its removal is commonly demanded. Tliis may be done by 
 escharotics or by excision. The escharotic may be applied 
 externally, or injected into the wart. Numerous agents may be 
 used for this purpose ; among the best is nitric, sulphuric, car- 
 bolic, or chromic acid. Where the wart is small, the local use of 
 any of these W'ill accomplish the gradual destruction of the 
 growth ; yet the remedy will require to be applied a number of 
 times, since each application destroys but a small portion of the 
 wart. Sulphuric acid is l>est applied in the form of a paste made 
 by mixing the acid with powdered charcoal ; with this mixture 
 cover the wart and let it dry, when an adherent crust is formed, 
 which will fall off in a few days, carrying a small portion of the 
 wart with it. Instead of the external use of these acids, each one 
 may be used by inserting or thrusting a drop of the agent into 
 the wart. To do this, trim a piece of oak or hickory wood into a 
 small, sharp point, and, having saturated the point with nitric or 
 chromic acid, thrust this through the base of the wart. The 
 escharotic thus introduced will interrupt the circulation, and 
 thus cause gradual atrophy or immediate death of the wart. 
 Another method used by the author to destroy Avarts is to trans- 
 fix and cauterize it with a long needle or pin such as is used in 
 the twisted suture in harelip. For this pur})Ose take a long cork 
 and thrust the pin through it near one end, so that the other part 
 of the cork may be used as a holder. Having thrust the needle 
 well through the cork, next insert its point in the base of the 
 wart, and then witii a small lamp's flame heat the needle on the 
 side of the cork nearest the holder; in this way the nutrient 
 vessel of the wart can be closed and the wart caused to die and 
 fall off. And finally, by the hypodermic method, an escharotic 
 agent can be intfoduced into the base of the wart, and its 
 destruction effected; the corrosion of the instrument renders this 
 plan unsatisfactory. 
 
 The wart can be very successfully destroyed b}' directly ex- 
 cising it; for this work small curved scissors may be employed. 
 To remove the wart in this way, let it be transfixed with a tenac- 
 ulum so introduced as to lie parallel to, and in the same direction 
 as, the cut to be made; the tenaculum is next lifted up so as to 
 elevate the wart above the parts around, when the cutting can 
 
CYSTOMA. 93 
 
 readily be done with the scissors. This excision will be followed 
 by considerable bleeding, which, if troublesome, may be con- 
 trolled by some styptic; for example, by alum applied in solid 
 form; and where the bleeding is not great, it is better to allow it 
 to cease spontaneously, as thus a clot is formed, beneath which 
 healing occurs rapidly and faultlessly, and more conveniently 
 than by any other method, since no dressing is needed; for the 
 encrusted blood forms a protective covering on the wound. This 
 plan of healing under coagulated blood may be adopted in many 
 minor operations on the head and face, and has the advantage 
 of leaving only a slight scar. Such scar differs from that result- 
 ing from granulation, in which granulative closure is tedious and 
 often leaves a scar, which is unsightly from its unevenness and 
 elevation above the parts which surround it. 
 
 Cystoma. — The next form of growth to be considered is the 
 cystoma, the generic name of a large class of benign tumors, of 
 which the leading characteristics are that they possess a well 
 formed and clearly defined boundary or wall ; and they have a 
 content which differs wholly from the containing wall. The 
 containing wall may be indistinguishably fused with the adjacent 
 parts, or it may differ wholly from them and be easily separable 
 from them. This sac, or cyst, as it is ordinarily named, is 
 usually wholly closed, though in a certain class one can, by 
 inspection, often detect an opening in it. In constitution the 
 wall consists of closely woven and compressed areolar or fibrous 
 tissue. In some cases a thin filamentous wall lies between the 
 content and the main wall. The main wall receives a supply of 
 blood through one or more vessels which enter it ; in some cases 
 the vessels are so small that they are hardly distinguishable b}^ 
 the eye. The arrangement of the arteries and veins is such as 
 to retard rather than hasten the circulation of the blood ; and 
 thus growth is favored. 
 
 The material contained in the cyst may be synovia, mucus, 
 serum, sebum, dermoid material, or blood; and such cysts are 
 named respectively, synovial, mucous, serous, sebaceous, dermoid 
 and blood-cysts. In the case of most cysts their origin can be 
 found in the retention of some secretion or excretion, which in 
 some way does not have free escape through its natural outlet. 
 The species of cysts found in the, scalp are the serous, sebaceous, 
 dermoid, and blood-cyst ; for anatomical reasons, the synovial 
 and mucous cysts do not occur here. 
 
 The cyst of purely serous content is infrequent in the scal|) ; 
 
94 AFFECTIONS OF THE SCAL1>. 
 
 and ill most cases it arises from extravasation of blood into the 
 tissues, by wliich a cavity is formed in which principally blood 
 is lodged ; the tissues immediately adjacent undergo a change of 
 structure ; by condensation a wall is formed ; meantime, the 
 blood is absorbed and replaced by serous content. In otlier situa- 
 tions, as in the case of the scrotal hydrocele, the reverse may 
 occur ; serum may be the original content, yet through enlarge- 
 ment and rupture of vessels in the wall, blood may be mingled 
 with the serum. Besides this, the serum may contain other 
 organic material, such as detritus cast off from the wall, and also 
 material may be precipitated from the serum itself, so that a 
 purely serous content no longer exists, but instead, a turbid 
 heterogeneous fluid. 
 
 The serous cyst in tiie scalp might be confounded with the 
 dermoid ; yet the briefer existence of the former, and the history 
 of some accident, as a contusion, w'ould indicate that the tumor 
 was a serous and not a dermoid cyst. The dermoid tumor is 
 nearly always found over or near the supra-orbital ridge, espe- 
 cially the outer part of this ridge. The serous cyst, if it is found 
 in there, lies more superficial ; the dermoid growtii reaches 
 deeper downwards, and from its subjacent attachment to the 
 periosteum it admits of but little lateral movement. The serous 
 cyst may increase in its volume, wdiile the dermoid remains con- 
 stant, neither diminishing nor increasing in size. 
 
 Unless the serous cyst be so located on the head as to be a 
 visible deformity, it need not be interfered with ; but should its 
 removal be desirable, tliis may be done by compression, the 
 external use of an absorbent, or, finally, the work may be done 
 more radically by excision. 
 
 Simple com})ressioii by means of a bandage or adhesive plaster, 
 continued for a time, has caused such tumor to vanish; and the 
 same has been done by frequently painting with the tincture of 
 iodine; and a more effective agent of this kind is iodized collodion 
 prepared as follows: — 
 
 Iji. lodini puri gr. vi 
 
 Potassii lodidi gr- xij 
 
 Collodii §i 
 
 Misce. 
 
 This is to be applied in the same way as the tincture of iodine. 
 A. strong solution of muriate of ammonia, viz., fifteen per cent, 
 or the pure powder of tliis salt, may be used. A cure may like- 
 
CYSTOMA. 95 
 
 wise be obtained by injecting into the sack tincture of iodine 
 diluted with two parts of water. Such a solution having been 
 injected is allowed to flow out again. When done in this manner 
 the cyst soon refills, and then absorption slowly ensues, finally 
 ending in the cure of the cyst. Should an injection fail to cure, 
 the work may be repeated after a few weeks. Lastly, the tumor 
 may be extirpated by making a straight incision through the 
 overlying integument, and then having dissected out the sac, 
 treat the case as a simple wound. 
 
 Of all the kinds of cysts which occur in the scalp, that of the 
 sebaceous species is the most frequent. This has its origin in tlie 
 sebaceous glands, of which one or two are contiguous to, and open 
 into, each hair follicle, and have the function of furnishing an 
 oil-like matter to the hair. The precarious destiny of the hair 
 exposes its glandular satellite to frequent disturbance and acci- 
 dent; in the falling or plucking out of the hair, the outlet of the 
 gland may become closed, and still the production of sebaceous 
 material continues. The result is distension of the glandular 
 cavity beyond its natural capacity; and thus distended it crowds 
 on neighboring glands and involves these in its morbid condition. 
 The final end is a cavity of greater or less capacity filled with 
 abnormal sebaceous material, which, in its changed condition, 
 approaches more nearly to the character of a solid substance than 
 a licjuid. Of the three elementary constituents of oil, viz., oleine, 
 margarine, and stearine, the latter is the predominant one in the 
 content of the sebaceous cyst. When the tumor has existed long, 
 there will be found a countless number of crystals of cholesterin 
 in the content. Also, irregular masses of calcareous matter are 
 likewise present in the old cyst. In fact, the content having 
 lost its hold on organic life, the processes of inorganized nature 
 assume mastery, and, under the action of crystallization and cal- 
 cification, the content becomes a lifeless fossil. The sebaceous 
 cyst presents a well-formed containing wall of wliitish or grayish 
 color; and in this sac a small orifice or outlet can often be 
 detected, which continues through the integument; and through 
 this opening the content can be forced out — a procedure which 
 Sir A. Cooper recommends as a method of curing such cysts. 
 Between the proper wall of the cyst and that formed by conden- 
 sation of the tissues in which the cyst is imbedded, there exists 
 a thin stratum of filamentous or areolar tissue, which contains 
 the nutrient vessels prior to their terminating in the proper cyst- 
 wall. This intermediate layer is of such tenacity that it is liable 
 to escape the attention of the operating surgeon. 
 
96 AFFECTIONS OF THE SCALP. 
 
 The sebaceous cyst is known among German writers as the 
 atheromatous cyst, from the resemblance of the content to mate- 
 rial found in the semi-calcified tunic of the artery which is the 
 site of senile or fatty degeneration. 
 
 The sebaceous cyst, in the primary period of its growth, is so 
 small that for a time it escapes observation; it can, however, grow 
 to great dimensions; and in the same scalp one finds sometimes a 
 number in different grades of development, viz., from the size of 
 a pea to that of a volume two or three inches in diameter. As the 
 tumor augments in size, the overlying integument becomes 
 thinner, and if this be the site of hair, the latter falls. 
 
 From pressure or violence of any kind, the cyst may inflame 
 and then its content becomes darker in color and approaches 
 more nearly to a liquid in consistence; and such inflamed cyst 
 tends to open and discharge an ill-smelling, ichorous material; 
 this consists chiefly of the sebaceous content which has under- 
 gone putrefactive change. If unaided by art, such opened cyst 
 can continue discharging for several weeks or even months; for, 
 though the content may soon escape, yet the proper cyst wall 
 only slowly disintegrates, and during the time that it is breaking 
 down it probably continues its perverted excretory action, thus 
 becoming a persistent source of a discharge that is most offensive 
 in character. And besides the offensiveness of the discharged 
 material, the latter, not unfrequently, through its acrid nature 
 attacks the structures with which it comes in contact and awak- 
 ens an erysipelatous inflammation, which in its march may 
 involve the scalp and face. This possible event in the course of 
 a sebaceous cyst should be borne in mind, and when it seems 
 impending, such unfavorable event should be forestalled by proper 
 treatment. 
 
 The sebaceous cyst occurs in those who have reached the 
 middle period of life, probably from the fact that the hair then 
 begins to fall, and as a result the hair follicles become obstructed. 
 The commencing baldness renders the growth conspicuous and 
 especially offensive to its possessor. From its volume, and espe- 
 cially when multiple, this cyst may interfere with the head-dress, 
 and on this account the surgeon's assistance is occasionally sought. 
 
 For the reasons given, and to rid the patient of a deformity, 
 the removal of a sebaceous cyst is a proper procedure unless the 
 patient be very old; in all cases advanced age is a most serious 
 contraindication to surgical interference, and especially is this 
 so in the region of the scalp, wdiere advancing years induce 
 
CYSTOMA. 97 
 
 attenuation and degeneration of the tissues. In the ante-lysterian 
 period, ere surgery had opened its eyes to the perils of sepsis, 
 when operations were often done by the careless surgeon with 
 instruments whose hilts and blades bore the microscopic remains 
 of a score or two of operations, then the old man who submitted 
 to the removal of a sebaceous cyst in his scalp, did so at the risk 
 of his life. The writer recalls the case of an old man in whom 
 the desire to be rid of such a deformity was paid for with his life. 
 After these words of caution, intended to emphasize the impor- 
 tance of careful action in the removal of the sebaceous cyst, and 
 to give the matter a place in major rather than in minor surgery, 
 we will consider the ways in which the removal may best be 
 done; and as methods, two have been recommended and prac- 
 ticed, viz., one in which there is injection of some agent which 
 will induce atrophy of the cyst, and in the other there is imme- 
 diate extirpation of the tumor with the knife. The absorbent 
 or atrophic plan was announced by a European surgeon a few 
 years ago. The medicinal agent employed was a strong solution 
 of tartar emetic; in this way it was claimed that the sac was 
 caused to atrophy, and that the sebaceous content was reduced to 
 a calcified fossil. It is probable that this could be done, but after- 
 wards the patient would not be entirely relieved, since an irreg- 
 ular nodule would remain and disfigure the scalp. This treat- 
 ment is not advised by the author, and it is only mentioned here 
 as a plan which might be tried in those knife-shy patients to 
 whom nature has denied the endowment of courage. The 
 proper treatment of the sebaceous cyst is to remove it with the 
 scalpel. As preliminary to this is a careful preparation of the 
 part to be operated on, which may be done with soap and w^ater; 
 and when these have been well used, alcohol should be poured 
 over the part. To remove the large cyst a portion of the wall 
 should be excised; this excised portion should be elliptical in 
 outline, and should be removed as the first act in the work. As 
 this part of the investing dermal wall is thin, the operator runs 
 the risk in his dissection of opening the underlying wall of the 
 cyst, which is likewise attenuated; in fact, it is often so thin and 
 tense that a slight pressure suffices to rupture it; and should it 
 be opened, the remainder of the removal becomes much more 
 difficult; in fact, from the collapse of the cyst there is danger 
 that some fragment of the wall may be left, and this will insure 
 a regrowth of the tumor. The integument covering the lateral 
 portions of the cyst is next to be uplifted on each side, and 
 
98 AFFECTIOXS OF THE SCALP. 
 
 retracted by means of blunt liooks or suitable retractors; thus 
 held, the dissection can be continued until the tumor is uplifted and 
 separated from its subjacent attachments. The elliptical portion 
 of integument, uhich is removed in the case the cyst is large, 
 must not be too large, lest the gap made will be so great that it 
 cannot be easily closed. And should the operator fear that he 
 cannot estimate correctly the portion to be excised, this work had 
 better be deferred until the cyst has been removed, when such 
 amount of the lateral valve-like flaps can be removed as will 
 permit of ])erfect coaptation of the opposite edges of the divided 
 integument. Should the error be committed of excising more 
 than the superfluous j)ortion, then the wound can only be imper- 
 fectly closed, on account of the absence of elasticity in the over- 
 lying wall; for the elastic or extensile property of the integu- 
 ment which covers a large sebaceous cyst is gradually extin- 
 guished by the constant pressure of the underlying growth; it 
 cannot be elongated by drawing on it, nor does it retract or 
 shorten to any great extent after the removal of the cyst; so that, 
 where a large amount of the superfluous wall has been left, this 
 remains afterwards for a long time, and perhaps always, as an 
 irregularity in the surface. In the work of removal, tlie vascular 
 fllamentous stratum which lies next to the cyst must be carefullv 
 removed; and if any vessels bo opened, the bleeding from them 
 should be arrested by torsion ; it is seldom that ligation is 
 demanded. Should torsion be insufflcient, then exposure to the 
 air for a few minutes will suffice to contract the vessels and check 
 bleeding. After washing the wound with dilute alcohol, sprinkle 
 with iodoform and then cover with lint; also wet with dilute 
 alcohol. In case the tumor be a small one, as soon as the cyst 
 has been removed, the covering integument falls into and closes 
 the vacant space; the closure is so complete that no pressure, 
 suture, or tying of the hair is required. But where the tumor is 
 a large one and the remaining valve-like flaps do not readily 
 close the breach, tlien this should be accomplished by the aid of 
 sutures; one or two will be sufficient; as a rule, however, no arti- 
 ficial aid will be needed, as the parts will, without aid, properly 
 adjust themselves. 
 
 The case will occasionally offer itself for treatment in which 
 the cyst has, through violence in some form, been opened, and 
 remains as the source of a constant foul discharge; and such 
 discharge often awakens an erysipelatous inflammation which 
 may be perilous to life. Operative interference is here urgently 
 
lipo:ma. 99 
 
 demanded, even though the erysipelas has commenced ; the cyst 
 must be freely opened and its contents removed with the curette. 
 To check the erysipelas, inject into the infected structure a five 
 per cent solution of carbolic acid. This injection should espe- 
 cially be done in parts where the disease is advancing. The 
 wound should then be dressed with alcohol and iodoform. In- 
 stead of carbolic acid, tincture of iodine may be injected into the 
 infected parts; as this must be done at several points, but a drop 
 or two should be inserted at each point. The recession and van- 
 ishing of the redness of the affected structure is strikingly mani- 
 fest soon after the injection. But where the neighboring parts 
 are yet intact around the opened sebaceous cyst, the recovery 
 under proper treatment is usually unimpeded and rapid. 
 
 In cases of multiple cysts, one need not hesitate to remove a 
 number at once, especially where they are of small volume. In 
 this work, if the patient possesses a fair share of courage, the 
 work may be done without an ana?sthetic, since the cutting 
 through the overlying integument causes but islight pain. AVhere 
 a number of cysts exist, however careful the operator may be in 
 his work, some minute ones will probably not be found, and 
 these, continuing to grow, will at some future time demand 
 attention. 
 
 As a rule the sebaceous cyst is met with only in the adult of 
 mature age; exceptionally, however, it may occur at a much 
 earlier age. In fact, there is sometimes seen a peculiarity of 
 constitution which may be denominated a sebaceous diathesis, in 
 which a great number of these cysts appear; and these are not 
 confined to the scalp, but they are found on the trunk, and espe- 
 cially on the limbs. The author has seen instances of the kind 
 in which there were a great number of such tumors, of different 
 sizes, on different parts of the body; yet they were the most 
 numerous on the scalp. ISTone of the tumors reached a great 
 size; and several of them contained semi-fluid content which 
 had, presumably, arisen from some violence to the cysts. In such 
 a case, in which the cysts are so numerous, prudence would dictate 
 abstention rather than surgical interference; and such interfer- 
 ence, if decided on, should be limited to the removal of such 
 tumors as give inconvenience to the subject; or to those which, 
 through liquefaction, threaten to rupture. 
 
 Lipoma. — The lipoma is a tumor of which the predominant 
 constituent is fatty tissue; and this may be modified by the 
 addition of fibrous or vascular tissue; and thence arise the three 
 forms of pure lipoma, fibro-lipoma and angio-lipoma. 
 
100 AFFECTIONS OF THE SCALP. 
 
 Like the sebaceous cyst, the lipoma usually has a proper wall 
 which closely invests the fatty tissue; through condensation 
 of the structures which contain the tumor, another wall is formed; 
 and these two walls are separated by a thin structure of web-like 
 tissue in which the nutrient vessels lie previous to their distribu- 
 tion to the lipoma. And this is the usual disposition of the parts 
 in the three classes mentioned, viz., in the pure, fibrous, and vas- 
 cular lipoma; but there is a form of lij)oma in Avhich the tumor 
 is not so separated from the parts around; in fact, it is so fused 
 with the contiguous fatty structures that it cannot be distin- 
 guished from them; this form, named diffuse lipoma, is embar- 
 rassing to the operator, since he is puzzled to decide to what point 
 the work of removal should reach ; a part may easily be left from 
 which the growth readily reappears. 
 
 Though the lipoma is so easily recognized in most cases, yet 
 its diagnosis is not always an easy matter; indeed, there are few 
 surgeons who have not been guilty of the error of mistaking a 
 lipoma for an abscess, or an abscess for a lipoma. Such mistake is 
 commonly due to inadvertance or haste, and might be avoided 
 by attending to 'the following points: The lipoma in most cases 
 can be laterally displaced, and as this is done, the covering skin 
 will be retracted so as to ])resent a quilted or figured surface; the 
 lipoma appears tethered to the integument at certain j)oints, so 
 that if the skin be nioved over the tumor, the former is depressed 
 in regular lines. The abscess is more firmly imbedded in the 
 structures, and cannot be so readily moved as the lipoma. There 
 are, however, cases in which the lipoma and abscess are so nearly 
 alike that they cannot be infallibly distinguished except by the 
 use of the exi)loring needle of large caliber. A few drops of the 
 pus of an abscess differ materially from the adipose matter which 
 is withdrawn from a lipoma. 
 
 The lipoma when found on the head is oftenest in that part of 
 the scalp which is adjacent to, and emerges into, the skin on the 
 back of the neck. Yet the author has seen and removed this tumor 
 from the region of the frontal tuberosity; in one case, the content 
 was purely adipose; in others it was fibro-adipose. It is oftener 
 seen in the strong and muscular subject and, from the author's 
 observation, oftener in the male of short neck; and, in conse- 
 quence of the peculiar conformation of the neck, the tumor may, 
 for a time, escape observation. In this location the lipoma is 
 often of a fibrous type, and is so hard and firm in consequence as 
 to resemble a fibroma. Though situated under the occipital 
 
LIPOMA. 101 
 
 portion of the scalp, this fibro-lipoma extends downwards on the 
 neck, so that often it is quite as much an occupant of the neck as 
 of the head ; and the fibrous character of the tumor is also shared 
 by the normal adipose structures situated here. 
 
 The lipoma of the head, similar to that in other parts of the 
 body, is painless ; so that its removal when undertaken is mainly 
 done to gratify the patient, viz., to relieve him of a prominence 
 which deforms the person and interferes with the dress. In its 
 usual site on the occipital cervical region, it may attain such a 
 volume that it interferes with the collar of the shirt, and causes 
 tightness and an unpleasant constriction; and from the pressure 
 of the dress the tumor is forced inwards, reaching, as the author 
 has seen, quite down to the upper cervical vertebra. For these 
 reasons the extirpation is undertaken, and should be done before 
 the growth has become very voluminous. The work is done in 
 a manner similar to that pursued in removing the sebaceous cyst; 
 yet it will not be required to excise any of the covering integu- 
 ment, since the superfluous portion of this will afterwards vanish 
 through spontaneous contraction. From the pressure to which 
 the tumor has been subjected by the patient's dress, it will be 
 found closely attached to the integument and subjacent parts; 
 besides, the tumor is often of the diffused species, that is, its 
 actual boundaries are indistinguishable. For these reasons the 
 lipoma here located, in its removal, radically differs from that in 
 other parts of the body; for in other situations the extirpation of 
 the lipoma may be reckoned the easiest feat of the surgeon's 
 knife, since, through one simple incision, the work of enucleation 
 can be rapidly done. But in the case under consideration, the 
 work is one of tedious dissection. 
 
 After a deep vertical incision through the thick and dense 
 skin, the work of separation is to be continued until the lateral 
 limits of the growth have been reached; thence the work is to 
 be continued downwards and underneath until the lipoma is 
 freed from the parts in which it lies imbedded. Usually one 
 or more nutrient arteries will be found deep seated, entering 
 the tumor, and which must be ligated ; if this precaution 
 be omitted, troublesome bleeding from the wound will occur, 
 which, despite the closure and compression of the wound, will 
 continue; hence these vessels should always be ligated or closed 
 by torsion, and thus the operator will be saved the trouble of 
 subsequently reopening the wound, and hunting for the vessels 
 amidst difficulties which were not present in the primary work 
 
102 AFFECnoNS OF THE SCALP. 
 
 of removal. Hence, a cardinal rule to be observed is to seek ond 
 tie all vessels as soon as tliey are opened. Even those of minute 
 caliber should be controlled, either by torsion or tying, since they 
 are certain to recommence bleeding, if neglected. The attempt 
 to prevent sucli haMuorrhage by the use of a deep suture has, 
 doubtless, disappointed many an operator. 
 
 The bleeding being controlled, the surface of the wound may be 
 sprinkled with finely levigated iodoform. This done, the wound 
 must be closed, and this should be done by means of a long curved 
 needle; for this one can emplo}'' a handled needle, with its eye near 
 the point, such as is used for the closure of the torn perineum. 
 This instrument entering a half inch from the margin on one side, 
 is to be passed down beneath the floor of the wound, and then to 
 ascend and emerge at a like distance from tlie edge, and the point 
 of emergence of the suture should be as nearly as possible opposite 
 to that of entrance, in order that the apposition of the sides shall 
 correspond to their normal position and situation before they were 
 opened. But if the wound have much depth, as it may have in 
 the robust subject, then there may be dithculty in obtaining 
 exact apposition of the wound's walls. Where these conditions 
 are present, by a plan used by the author, better coaptation can 
 be gotten than is obtained by the common suture; this, which 
 may be named the figure-of-eight suture, is to be introduced as 
 follows: A needle of semicircular curve is to be threaded with 
 aseptic silken thread, or flexible wire, and, being introduced into 
 one wall of the wound at the middle point of its depth, the needle 
 is carried downwards beneatli the wound, and let emerge at tlie 
 corresponding middle point of the opposite side; from this point 
 tlie needle is carried and made to enter the point of commence- 
 ment, and brought thence through the remainder of the wall, 
 emerging through the skin a short distance from the edge of the 
 opening; next the remaining loose end of the thread is to be 
 armed with a needle and carried across and caused to pass through 
 the remaining unincluded portion of the wall of the wound. 
 The work thus described in words, like all descriptions of mechan- 
 ical work, is not very clear, as Hippocrates remarks in his 
 description of mechanism for dressing fractures; yet it is readily 
 comprehended when it is stated that when closed the suture 
 represents a figure of eight, of which the deeper portion is first 
 introduced. When such a suture is closed, it cannot fiiil to bring 
 the walls of the wound into apposition throughout their entire 
 extent; no space is left in which blood or other material can 
 
ANGIOMA. 103 
 
 collect — a condition most necessary to obtain speedy nnion. 
 This suture does not cramp the included structures into a circular 
 form as the usual suture does. And it can be removed as readily 
 when its work is done as the usual suture. The use of this suture, 
 it need scarcely be mentioned, is applicable in the scalp only in 
 the inferior part of the occipital region, since elsewhere the 
 structures are not thick enough to demand its use. 
 
 Angioma.. — By this term is meant a tumor of which the pre- 
 dominant constituent is vascular tissue; and these vessels are of 
 different thickness, viz., they may vary from that of minute 
 caliber, so small as to be unseen by the unaided eye, to that of 
 vessels of considerable caliber. The angioma is capable of be- 
 coming turgid; and this property of temporarily swelling has 
 given the angioma a place among the erectile structures of the 
 body; yet it differs materially from those structures of which 
 erection is a normal and physiological action; the turgid state 
 occasionally occurring in the angioma is an accidental condition 
 dependent on the circumstance, that blood under some movement 
 of the body is forced from the heart towards the periphery; and 
 this action is, in most cases, some phase of expiration, as in the 
 acts of coughing, crying, screaming, and straining, acts in which 
 the blood is forced towards the periphery and temporarily 
 retained there. Hence these structures are not properly erectile, 
 but through some contingency they become swollen. The prop- 
 erty mentioned is often connected with the growth of the 
 angioma. The angioma may consist of fine capillaries, or of large 
 vessels which are remarkable for their involved and contorted 
 disposition; and these vessels present irregular dilatation, which 
 are called caverns; hence the two species of angioma have been 
 respectively named capillary and cavernous. 
 
 The capillary angioma may vary in size from a mere point to 
 that of a large surface; and it may be superficial or penetrate 
 deeply. The caliber of the constituent vessels have an influence 
 on these conditions. The most superficial variety is the red-wine 
 mark, which arises from a dilatation and multiplication of the 
 outermost dermal capillaries. Between the superficial species and 
 the cavernous angioma, in which the vessels are dilated into 
 irregular sacs, there are numerous gradations; as the develop- 
 ment reaches inwards, the vessels are found more dilated and of 
 greater caliber; the vessels reach such dimensions in the caver- 
 nous species that the pulsating arteries impart an impulse to the 
 hand akin to that of an aneurism. AVhen constituted of larger 
 
104 AFFECTIONS OF THE SCALP. 
 
 vessels, the intervascular tissue increases in amount so that the 
 normal volume of the affected part is more or less hypertrophied. 
 
 The color of the angioma varies from the bright red hue of 
 the superficial wine-color mark, to that which does not differ from 
 the normal hue of the skin. The color of the deep-seated species 
 is often blue, and has given rise to the opinion that such growth 
 is composed chiefly of veins; if, however, such angioma be pricked, 
 the blood which oozes thence will be found to be bright red and 
 plainly of arterial character. The color, though varying, is of 
 valuable diagnostic import; yet this sign is not infallible, since 
 the cyst of liquid content may also contain blood, which, permeat- 
 ing the wall of the cyst, gives the semblance of an angioma. The 
 ordinary angioma is usually painless, and the subject would be 
 unconscious of its presence if he did not see or touch it; this, how- 
 ever, is not always true, since the angioma may cause much dis- 
 comfort, and even acute pain, when it is large and presses on 
 nerves. 
 
 The history of an angioma is usually an indefinite one; as a 
 rule it is coeval with birth, having originated in embryonic life; 
 yet there area few exceptions to congenital origin. When congeni- 
 tal, its origin has been associated with some error in the develop- 
 ment of the primordial segments of the early embryo; others, 
 discarding this theory, refer the origin of the angioma to some 
 accidentoccurring in intra-uterineor post-uterine life. Angiomata 
 having arisen often follow divergent lines in their subsequent 
 course; one retains its i)rimitive form and character without much 
 change; another grows slowly or very rapidly, and, having reached 
 certain dimensions, ceases to grow and, later, it may increase in 
 size. The tumor, when it follows a course of unlimited growth, 
 may press on and destroy bones, muscles, nerves, etc.; in fact, 
 destroy or render the affected part wholly functionless. And 
 finally, in another class of cases of congenital origin, during 
 infantile growth, it sometimes fortunately occurs that the angi- 
 omatous structure atrophies, and, finally, nearly or entirely disap- 
 pears; this desirable event is seen now and then in the superfi- 
 cial dermal form; the infant loses the deformity, greatly to the 
 delight of the mother, who suspects that she is guilty of marking 
 her child. The belief in such origin is deeply rooted in the popu- 
 lar mind, in which so many errors planted in the past have taken 
 fast hold; to pluck thence the present one, which lives in the 
 name nseims mafernvs, or mother's mark, will demand a long 
 period in future time. And the prospect of its eradication is 
 
ANGIOMA. 105 
 
 narrowed, when the fact is recalled that this error is shared by 
 some minds otherwise noble in our profession. The author 
 heard a clinical lecture some years ago in which a famous Euro- 
 pean surgeon c[uite failed to show his disbelief in regard to 
 maternal agency in the causation of dermal angioma; indeed, 
 the cases which he enumerated, in which these stigmata might be 
 referred to the fear, fright, or fancy of the mother, were so pointed 
 that it was clear that the would-be skeptic was a partial believer. 
 The speaker forgot to call the attention of his hearers to the host 
 of uncounted exceptions in this field, w^here "millions miss for one 
 that hits." Beliefs of the kind here cited are often so fondly 
 nursed, especially by the great multitude that finds it awkward 
 and irksome to think outside of wonted lines, that he who would 
 eliminate them is seldom complacently listened to. 
 
 The marked characteristics of angioma, especially that of 
 purely dermal site, is its want of circumscription; no definite 
 boundary isolates it from adjacent parts, and the lack of such 
 limiting bounds favors its extension into contiguous parts; there 
 are, however, exceptions to this diffusion, viz., the growth may 
 be capsulated so as to resemble a cyst. In these exceptional cases 
 the containing wall is closely adherent to the vascular structure; 
 in fact, it cannot, without violent dissection, be separated from the 
 vascular structure; on the contrary, this quasi cyst is loosely con- 
 nected to the parts which contain it, since there only intervenes 
 between the two a loose, filamentous tissue. 
 
 As has been stated, the angioma can spontaneously vanish 
 and leave no trace of its previous existence; besides this most 
 desirable ending, other changes may occur which deserve mention. 
 For example, in one of these, from structural changes which 
 occur in the angioma, the supply of blood may be interrupted 
 and the remaining spaces or vacuoles in the tumor remain, and 
 the separating partitions vanishing, there finally is left a common 
 cavity, similar to a serous cyst. A deviation from this form is 
 that in which the liquid content of the cavity is absorbed, and 
 there only remains some solid material. These altered forms of 
 angioma have resulted from some of the modes of treatment 
 resorted to for the cure of the'tumor. 
 
 The diagnosis of the dermal angioma is easily made where the 
 growth is superficial; its congenital origin, red hue, temperature 
 above that of the parts around, and capability of becoming turgid 
 from an expiratory or straining effort of the child, are marks 
 
 which clearly distinguish such growth from other abnormal 
 
 • 8 
 
106 AFFECTIONS OF THE SCALP. 
 
 developments. When more deeply seated, the livid color, tur- 
 gescence, and warmth are characteristic features; and should tliere 
 be doubt as to its nature, the rapid bleeding that would follow a 
 prick or slight incision, would clearly indicate an angioma. 
 
 From numerical observation it has been found that the dermal 
 angioma is found on the head much oftener than elsewhere, viz., 
 two-thirds of the cases observed were on the head. Some occur 
 on the hairy scalp, yet the larger number have their site on the 
 forehead and face. 
 
 The surgeon's aid is often invoked for the relief of the angi- 
 oma; especially, when it is congenital, there is usually an urgent 
 desire on the part of the infant's parent to have the marring part 
 removed. And even the adult who has inertly and complacently 
 borne, for years, a red, purple, or wine mark, some day may be 
 seized with an irresistible impulse to be freed of his deformity, his 
 chief reason perhaps being that he desires to "look like his 
 friends." Such an impulse once awakened is similar to all 
 ungratified whims, it never vanishes until its purpose has been 
 realized. 
 
 In most cases the dermal angioma is painless; and its re- 
 moval is only desired in order to be rid of a disfiguring mark; 
 and, as this is the principal thing sought, the surgeon's task is 
 surrounded with unusual difficulties; for in no way can such 
 work be accomplished without leaving some cicatricial evidence 
 of what has been done; some scar must inevitably remain ; and 
 this often becomes to the patient quite as offensive as was the 
 angioma; but as the latter has vanished from view, it is quickly 
 forgotten, while the cicatrix remains and becomes an ever-during, 
 hated object. The footsteps of time are constantly changing the 
 human face; and, though they may obliterate some of the un- 
 sightliness of a cicatrix, yet the latter can never be wholly 
 effaced ; and in it, as in an ind'elible inscrpition, the imperfec- 
 tions of the surgeon's art ever legibly appear. 
 
 Instead of commencing his work at once, the prudent surgeon 
 will premise his treatment with certain 23reliminaries intended 
 to prepare the patient's mind, or that of the friends, for the future 
 condition of the part ojx'rated on; tlie scarring which must result 
 from the operation must be heralded in emphatic terms; and 
 should this be strongly deprecated by the patient, then it is far 
 better that no operative procedure be attempted than that the 
 surgeon should plant in the patient's heart a feeling of unend- 
 ing resentment against him. In cases involving life, such pre- 
 
ANGIOMA, 107 
 
 cautionary policy and prophylactic conservatism on the part of 
 thp surgeon should be allowed no place in his action ; but in the 
 case under consideration, in which the patient's life, comfort, and 
 ease are not interested, and the removal of the deformity will not 
 remove a pain, nor add one day of life, and where the proposed 
 work is one of "complacency," then to such prudential considera- 
 tion prominent place should be given. The clear-minded Celsus 
 duly estimated such discretion where he refers to the hesitancy 
 of the physician to adopt treatment of doubtful result in a 
 " splendid personage." 
 
 The patient having consented to accept the results of scarring, 
 which may never vanish from sight, the surgeon proceeds to 
 select one of the many methods which may be chosen for the 
 removal of an angioma; the principal ones of these methods are 
 excision, ligation, cauterization (actual and potential), the induc- 
 tion of coagulation of the blood of the growth, destruction by 
 vaccination, and induction of atrophy by compression. 
 
 Of the methods mentioned, the author has a decided prefer- 
 ence for excision, based on an extended use of the same; yet the 
 beginner may be wanting in some of the requisites needed to do 
 the work in this way. The peril in this method is from the loss 
 of blood ; to lessen this loss, the excision must be done rapidly 
 and the vessels secured quickly — work which is best done by one 
 who has had ample discipline in operative work. The advan- 
 tages which the method of excision has are that it reduces 
 scarring to the minimum amount; and it reduces the period of 
 healing to its shortest limits. To operate by excision one must 
 have two assistants, and, as instruments, scalpel, curved needles 
 armed with wire, scissors, haemostatic forceps, and silk ligature. 
 The silk ligature is rarely needed, yet it should be at hand. To 
 one assistant should be committed the important task of making- 
 compression around the part to be removed, and also on the 
 carotid artery which furnishes blood to the tumor; for the latter 
 compression, a third assistant may be required. Inattention to 
 these means of preventing the loss of blood has been the cause 
 of death in several recorded cases. The temporary compression 
 of the carotid artery is an important precaution, where the growth 
 is unilateral in site, as thus the bleeding may be controlled in a 
 great measure. 
 
 The cutting may be done quickly or slowly ; in the first way 
 the growth is removed as rapidly as possible, the vessels being 
 secured after the removal ; but in the second way, the vessels are 
 
108 AFFECTIONS OF THE SCALP. 
 
 secured as they are divided. As Petit advised, the line of incision 
 should be in the boundary between the sound and the affected struc- 
 tures; done thus, the haemorrhage will be reduced to the smallest 
 amount. AVhere the angioma is of small dimensions, it may be 
 easily and safely removed by the rapid plan ; when thus done, 
 the assistant who is compressing the parts around, lessens the 
 wound by sliding its borders towards each other; and when thus 
 approximated, tlie edges, through the aid of the sutures, can be 
 brought quite together, provided the angioma is of small extent. 
 The sutures should be introduced so as to include the vessels, 
 and thus the bleeding is controlled. In introducing the suture, 
 the needle must avoid the vessels; and if these be tranfixed, 
 which will be revealed by blood escaping from the wounds made 
 by the needle, then the needle should be withdrawn and passed 
 at another point. A suture transfixing a vessel not only causes 
 bleeding externally, but it may do so internally, beneath the 
 scalp. Haemorrhage under the scalp may occur where an edge 
 containing a vessel is infolded, and such bleeding, being con- 
 cealed, may be so great as to be dangerous. This concealed 
 bleeding may occur in operating in other parts of the body in 
 which wounds are closed externally, while vessels are left open, 
 and bleeding continues in the wound beneath. In such cases the 
 blood continues escaping and fills every recess of the wound ; 
 and the clotting blood, wedge-like, thus insinuates itself between 
 the opposite walls of the wound or cavity, and prevents healing. 
 And in the wound caused by removing the angioma from the 
 child's scalp, such concealed haemorrhage is very perilous, since 
 in the loose interspace between the nericranium and the hairy scalp 
 the blood has room to collect in large amount; enough, in fact, 
 to cause death, as occurred in a case reported some years ago. 
 In this unfortunate case the angioma was excised from the 
 frontal region, the wound closed by suture, yet the blood con- 
 tinued to flow unperceived, until the infant perished, when it was 
 discovered that an immense quantity of blood was imprisoned in 
 the space referred to. Hence in excising the angioma from the 
 scalp, the operator should neglect no precaution to avoid both 
 seen and unseen haemorrhage. 
 
 If the angioma be of large extent, then the slow method of 
 dividing section by section is the safer plan; then the vessels can 
 be ligated as soon as they are severed. Another method is by 
 percutaneous transfixion, in which one so circumscribes the 
 vessels beyond the line of cutting that the incision can be made 
 
ANGIOMA. 109 
 
 in nearly bloodless tissue. This hgemostatic precaution being 
 taken, the excision is next to be done, and the vessels ligated as 
 they are opened. Or should the provisional circumscription be 
 so complete as to quite control any bleeding from the wounded 
 vessels, then the ligation of the latter may be dispensed with, 
 and the circumscribing ligatures be left in site for three days, 
 when they can be removed. Meantime, an attempt should be 
 made to close the wound as nearly as possible. This is best done 
 by metallic sutures which are introduced a little distance from 
 the margin," so that some traction can be made with them. 
 Where the breach made is very extensive, and the closure by 
 direct apposition is impossible, then the work may be done 
 plastically by dissecting up flaps from the contiguous scalp, and 
 turning these into the opening ; thus complete closure can some- 
 times be accomplished ; or if it be not complete, then the small 
 spaces left uncovered will soon heal by cicatrization. 
 
 The infantile angioma has been removed by ligation; and the 
 work can be done in sections; or the growth may be tied in one 
 mass. If ligation be attempted, the plan of doing this in mass is 
 the better one; for when done in sections, some of the structure 
 may not be included, and through this the vitality of the growth 
 may be maintained, and thus a failure result. Ligation in mass 
 is best done subcutaneously. To do this, let a well-curved needle 
 armed with a strong silken thread enter at some point on the 
 border of the angioma, and, passing some distance under the skin, 
 emerge at another point in the border of the growth; let the 
 needle reenter and emerge again; and thus let the work proceed 
 until the needle has passed quite around the growth, and emerge 
 at the first point of entrance. When it is thus done, the silken 
 thread will have encircled the tumor, and the two ends of the 
 ligature having been tied firmly together, the growth will be cut 
 off from its supply of blood, and die from strangulation. The 
 cord should be so tied that it can be retied as soon as it loosens. 
 This method has been successfully used by the author, yet there 
 is an objection to it in this, that it is attended by suppuration, 
 and, there being no free outlet for the pus, it may have a septic 
 action. Yet in a large erectile tumor in an infant's face, the 
 author obtained a satisfactory result; the scarring was not un- 
 sightly, since the skin remained intact except where the needle 
 wounded the parts. Where the tying is done in sections, the skin 
 being included, the skin must necessarily die, and thus the scar- 
 ring is greater than when the work is done by subcutaneous 
 
110 AFFECTIONS OF THE SCALP. 
 
 circumscription. The plan of ligating by means of a ligature 
 thrown around transfixing needles has been tried; this method 
 is less effectual than the other modes of ligation which have been 
 described. Also, temporary ligation, in which the ligature is 
 removed after a couple of days, has not given satisfactory results; 
 for the part that has thus been deprived of blood is rapidly 
 resuscitated after the removal of the ligature. 
 
 Cauterization, actual and potential, has been employed for the 
 removal of angioma. AVhen the growth is superficial, it may be 
 removed by touching it with a cauterizing iron t^hat has been 
 heated only to brown heat; at such a temperature the work can 
 be done without breaking the surface acted on. Sucli a heat will 
 coagulate the albuminoid content of the blood, and thus an 
 im})ortant step is taken towards lessening the nutrition of the 
 angioma. This cauterization should be repeated once in forty- 
 eight hours; and if persevered in, a superficial angioma may 
 thus be removed. A degree of heat sufficient to do the work can 
 be obtained by immersing the cauterizing iron in boiling water. 
 But in case the growth be thicker and approach to the cavernous 
 tyi)e, then superficial cauterization will l)e insufficient; in sucli 
 case the work can be done by means of a needle at red heat, that 
 is inserted into the tumor. This can be done in the manner 
 described for the destruction of warts, in which a long needle 
 having been made to penetrate, the latter is afterwards heated to 
 a red heat. The needle must be made to enter different parts of 
 the growth at intervals of a quarter of an inch ; thus done, the 
 clotted blood interrupts the circulation, and, checking the nutri- 
 tion of the growth, the latter is caused to atrophy. In the 
 author's essays with this plan he found that there was less danger 
 of wholly destroying the growth by excessive heat than he appre- 
 hended; even though the angiomatous structure was pierced and 
 burned at many points, yet it soon regained its vitality, so that it 
 became necessary to repeat the cauterization two or three times, 
 at intervals of a week or two. Done in this manner, the skin is 
 not destroyed, but the subjacent vascular structure atrophies, and 
 the affected part gradually approaches the type of the contiguous 
 sound parts; some months, however, will be needed to finally 
 complete this reduction. Besides the plans described, the cauter- 
 ization may be done by means of the thermal cautery; for this a 
 special apparatus is required, while for the method above described, 
 some simple means may easily be contrived. 
 
 The dermal angioma may be removed by the potential cautery. 
 
AXGIOilA. Ill 
 
 For this purpose, when the growth is superficial, nitric acid may 
 be used ; to do this, let a glass rod be dipped into the fuming acid 
 and applied to the surface of the angioma. This repeated daily 
 for a number of times, by coagulating the blood in the superficial 
 vessels, ends in causing atrophy of the vascular growth. It is 
 only in cases in which the growth is very superficial that this 
 plan is successful. This treatment was much employed by 
 Langenbeck, yet in trials of it by the author, the results have 
 not been satisfactory. It might, however, be tried in cases in 
 which the angioma is merely superficial; but when the growth 
 comprises the entire thickness of the skin, then cauterization done 
 potentially rec[uires a more active agent than nitric acid; as such 
 are chloride of zinc and caustic potash; arsenic, also, has been 
 used, yet its poisonous property renders its use unsafe. To use 
 chloride of zinc, let the following mixture of it be made: — 
 
 ^. Zinci Chloridi. 
 
 Farinse aa 3i 
 
 Misce. 
 
 This moistened into a paste may be spread over the 
 growth, when it hardens into a crust-like coat. In this way 
 a stratum of the angioma is destroyed, and, after a few days, 
 it will fall off as a dry eschar. After this detachment, the 
 escharotic paste may be applied again, and this work may be 
 repeated until the growth is wholly removed. This is one of the 
 safest plans of potential cauterization ; yet the work is painful 
 and tedious. The work, however, may be more rapidly done by 
 means of potassa fusa; but the caustic potash is too violent in 
 action if used in its pure state, and, hence, it should be employed 
 in a dilute form ; for this it may be mixed with an equal part of 
 Pulvis Radicis Sanguinariee, or with an equal part of calcined 
 magnesia. The use of the latter compound is original with the 
 author, and his experience justifies him in recommending its use. 
 The latter compound is a white powder, and, for use, must be 
 moistened and spread in small amount over the angioma. This 
 acts more destructively than the chloride of zinc, and hence 
 caution is required not to apply too large a quantity. A few 
 hours after the application, the structures underneath are black 
 and lifeless; and the dead eschar must be detached by poulticing, 
 which must be continued for some days, to complete the detach- 
 ment. The caustic potash may also be used mixed with an equal 
 portion of Pulvis Sanguinarise; and the action from this has 
 
112 AFFECTIONS OF TIIK SCALP. 
 
 seemed to the writer to be more severe than that composed oi 
 caustic potnsli and magnesia. Instead of the external use of the 
 potential caustics, they may be used interstitially; both tlie 
 chloride of zinc and potassa fusa may thus be employed. The 
 chloride of zinc, with wheaten flour made into a paste, can be cut 
 into arrow-shaped portions, and these, hardened by heat, can be 
 inserted into the openings made into the growth, and, being left 
 there, they do their work of destruction. The caustic potash 
 mixed with one of the ingredients mentioned, may be introduced 
 into the angioma through the canula of a trocar after the stilet 
 has been withdrawn; thus cylinders of the escharotic may be 
 passed into the angioma, at different points, and in this way the 
 growth may be destroyed. A serious oljjcction to the method of 
 destruction by the potential cautery is tlie destruction of the skin, 
 and the deforming scar which afterwards remains. 
 
 The angioma may be removed by injecting into it some agent 
 which will induce coagulation of blood, and as a consequence so 
 impair tlie nutrition of the growth as to cause its atrophy and 
 disappearance. Agents employed to accomplish this work are 
 ergotine, the tincture of iodine and astringent solutions, as that 
 of the chloride or sulphate of iron, alum, and the strong decoction 
 of oak bark. Considerable trial has been made of this method, 
 yet the results obtained have not been such as to awaken much 
 enthusiasm on the part of those who have employed it. The best 
 results have followed the injection of tincture of iodine and 
 ergotine. The coagulating fluid is to be introduced b}" means of 
 a hypodermic syringe, which is caused to penetrate at different 
 jwints, and not more than two or three drops are to be injected at 
 each point. The ergotine used and praised by Langenbeck is 
 objectionable on account of the pain it produces. The solution 
 of the salts of iron used by injection may arrest and prevent 
 further growtli in the angioma, yet the most serious objection to 
 these agents is that the iron remains incorporated with the tissue 
 of the angioma, giving the same a black color, so that the work 
 ends by giving the patient a black mark in place of the previous 
 red one. The tincture of iodine is free from the objections which 
 can be urged against the otlier agents mentioned; and if the 
 treatment by subcutaneous injection be decided on, this agent 
 may be selected as the best one. In cases in which the angioma 
 contains large vessels, pressure should be kept up for a time 
 around the angioma, so as to retain the clotted material in the 
 tumor, and thus prevent its escape into the general circulation; 
 
ANGIOMA. 113 
 
 and thus proceeding one avoids the embolic closure of vessels 
 elsewhere. As final injunction to those who may adopt this 
 treatment, let the tincture of iodine be used, and the injection 
 only be done with minimum amounts of the tincture, and repeated 
 a number of times, at intervals of two days; and should reaction 
 indicating suppuration appear, then the treatment should be 
 suspended until the reaction has disappeared, and resumed again 
 at longer intervals. 
 
 The angioma may be cured by vaccination in a subject who 
 has never been vaccinated. This is done by introducing the 
 virus at different points of the growth; and this is not an easy 
 thing to do, since the wounds made for the insertion of the virus 
 bleed so freely that the latter is washed away. Hence the plan 
 has been successfully tried of vesicating the surface with can- 
 tharides, and then placing over the denuded part lint saturated 
 with vaccine virus. Or threads saturated with the material may 
 be passed seton-like through the growth. It may also be done by 
 slightly scarifying, and then placing the liquified virus on the 
 slight wounds. The work of inoculation might be done with a 
 hypodermic syringe. Vaccination done in this way takes a 
 j)eculiar course. After the common period of incubation the 
 vaccine vesicles open and ulcerate; the ulcerating process dipping 
 inwards, as well as extending laterally, so that each vaccinated 
 point becomes a large open wound. In an angioma seated on the 
 chest the author saw, from vaccinating, an ulcer several inches in 
 diameter, and which was accompanied by so much destruction of 
 tissue that for a time the infant's life seemed imperiled. The 
 action deviated wholly from the normal cycle of vaccinia; the 
 ulceration continued for a number of weeks; and, what was 
 remarkable, it appeared to follow, attack and break down the 
 abnormal vascular structure, and to leave the normal tissues 
 unacted on. After a tedious period of ulceration, cicatrization 
 ensues and continues until the wounded surface is closed by a 
 white scar. In this way an angioma of superficial character may 
 be safely destroyed, but where it is of great extent and penetrates 
 deej)ly, its removal had better be tried by some other means. An 
 objection to this method is that, after the surface is healed, it 
 retains the characteristic marks of the vaccine scar. A plan 
 cognate to this is that by pustulation, which may be done by the 
 application of croton oil or tartarized antimony. The pustules 
 produced by tartarized antimony have a striking resemblance to 
 those produced by the vaccine virus. 
 
114 AFFECTIONS OF THE SCALP. 
 
 And, lastly, the angioma may be retarded in its growth by 
 compression continuously applied for a long time; and in this 
 work the surgeon should bear in mind that the angioma often 
 continues to grow until the subject's body has attained its final 
 term of development. It is stated tliat infantile angioma has 
 been cured by compression maintained by the mother's hand; 
 it is j)robable that the successful continuance of such a task could 
 only be maintained by maternal affection. Compression, indi- 
 rectly used, has been obtained by astringents used locally; cures 
 thus obtained have oeen announced. As a substitute for the 
 mild action of an astringent, the contractile action of collodion 
 might be used. For this, the best quality of collodion should be 
 employed; and of this a thick coating should be applied on and 
 around the afifected structure. The long continuance of this 
 might induce atrophic regression of the vascular structure. 
 Fingers, even the mothers, may tire; the action of astringents 
 may prove impotent; and collodion through its ethereal ingredient 
 must irritate and cause pain; hence, if compression be selected 
 for the cure of the angioma, some mechanical way of accomplishing 
 it should be used. Such com})ression may be made by means of 
 a pad similar to that of a truss; to the truss straps may be 
 attached made of leather or of India rubber, and such straps are 
 to be carried around the head and fastened by buckles, so as to 
 remain in place and exert a continued pressure. As already 
 5aid, this compression must be continued an indefinitely long- 
 period to accomplish its purpose. 
 
 Vascular Growths.— Besides the growths which arise from 
 abnormal development of the capillaries, which have been 
 described as very frequently occurring in the scalp, there are seen 
 there tumors in which the leading constituents are vessels of 
 larger caliber; and such tumor may consist of veins alone, or 
 veins and arteries may unite in the formation, or the growtli ma}'- 
 be wholly arterial. 
 
 From the position of the veins of the scalp, in which the force 
 of gravitation is slight or absent, venous dilatation, occurring so 
 often in the lower part of the body, is rarely seen in the head. 
 And where such widening, named phlebectasis, is found in the 
 scalp, it is a result of congenital enlargement, in which the veins 
 are primordially dilated; and, in some cases, this irregular 
 development continues after birth, until an extensive portion of 
 the scalp becomes affected. The overlying skin becomes atten- 
 uated and livid in hue, and the affected structure when opened 
 
VASCULAR GROWTHS. 115 
 
 to view seems intrenched with irregular channels, on the walls of 
 which the pigmentary matter of the blood is usually found 
 deposited. Ordinarily such venous growth is painless, and, having 
 reached a certain volume, it ceases to grow. The hair, in part or 
 in whole, falls from the affected structure. 
 
 Not unfrequently, along with the venous dilatation, the 
 arteries undergo a similar change, the condition then being 
 named arterio-venous aneurism. This form resembles simple 
 phlebectasis, yet in such growth there may be felt the vibratile 
 thrill of the widened arteries; and rising and falling movement 
 of the superjacent surface is also visible; and if touched it will be 
 found warmer than parts adjoining. In a case of this vascular 
 growth seen by the author, the greater portion of the scalp was 
 affected. The man who was the subject of this growth was over 
 fifty years of age; it had existed many years. The vascular 
 development seemed to be greater in the deeper portion of the 
 scalp, and as accurately as could be estimated by palpation, it 
 was an inch in depth. This increased thickness was not wholly 
 due to the vessels, but depended on growth of the tissues which 
 lay around the vessels. This development had arisen from the 
 irritation caused by the pressure of the encroaching vessels. This 
 growth, commencing near the summit of the head, reached down- 
 wards on one side of the forehead; the structures of one pinna 
 were affected. This growth was not painful, yet it was the sight 
 of a vibratile movement and a buzzing sound which was very 
 annoying to the patient; and, for relief from this constant sound, 
 the man sought surgical aid. The growth was too extensive to 
 admit of removal; in fact, any of the known methods for the care 
 of such a morbid development are too perilous to life, and should 
 not be advised unless the growth has become such a burden to 
 the patient that he is willing to risk his life in the effort to find 
 relief; and in that event a recourse might be had to arterial liga- 
 tion. The supply of blood might be cut off by tying the external 
 carotid arteries. The ligation of these vessels, though mechani- 
 cally difficult, is not a severe assault on the patient; and it should 
 be tried in preference to excision, or parenchymiatous injection of 
 some agent to cause coagulation. The ligation of one carotid 
 would be insufficient, since through the remaining untied artery 
 the blood would soon reach and fill the growth. Instead of liga- 
 tion, an attempt to relieve might be made by direct compression 
 of the affected structure; in this way the growth might be pre- 
 vented from further development; and, besides this action, if the 
 
110 AFFECTIONS OF THE SCALP. 
 
 growth had reached such dimensions as to seriously tinnoy the 
 possessor by its buzzing fremitus, then the latter might be lessened 
 b}' a properly adjusted compress. Pressure should not be too great, 
 lest it might cause abrasion of surface, and thus cause haemor- 
 rhage. 
 
 Aneurism occurs in the vessels of the scalp; but before consid- 
 ering it, a brief consideration of the subject of aneurism should 
 precede. The medical etymologist finds difficulty in discovering 
 the origin of the term; the author thinks he finds traces of it in 
 the Greek preposition ana, meaning up or upwards, and eurys, an 
 adjective meaning wide; and the name thus constructed signifies 
 an upward widening. An aneurism is a hollow tumor of irreg- 
 ularly rounded outline, which arises from an artery into which 
 the cavity of the tumor opens, and which is filled with blood in 
 irregular motion. The walls of the tumor are continuous with 
 those of the artery w^hence it springs; and when these walls are 
 complete, one finds in them the three tunics which constitute the 
 walls of the artery; or some of the tunics may be wanting. Hence 
 arises the classification of true and false aneurism; in the wall of 
 the true class no tunic is wanting, but in the false, called also 
 the mixed form, the w^all may be composed only of the external 
 arterial coat; or the external and middle tunic may have been 
 ruptured, and then, in this rare form, only the innermost tunic 
 will be found, forming the wall of the aneurism. The wall of the 
 aneurism has been the matter of discussion; some claim that with 
 careful dissection all three tunics may always be discovered, and 
 that their continuation with the normal tunics of the artery can 
 be traced out. 
 
 In another form akin to the false species, the wall has no 
 direct anatomical connection with the Avail of the vessel; and 
 since it arises from an injury in which the vessel is opened, such 
 aneurism is named traumatic. An essential condition here is 
 that the artery be surrounded by soft parts, into which the blood, 
 escaping from the torn vessel, forces itself and forms a hollow 
 cavity. In time, around such cavity there is formed an irregu- 
 larly organized wall, which prevents the further diffusion of the 
 blood into the neighboring structures. In case the rupture is in 
 a vessel which lies in a cavity, where it is not walled in by other 
 structures, then a fatal haemorrhage can ensue; such has been 
 seen in the thorax and abdomen. 
 
 True and false aneurism may be conjoined; namely, one aris- 
 ing from an artery and contained in the distended tunics of the 
 
VASCULAR GROWTHS. 117 
 
 vessel may burst, and form a hollow in the parts adjacent, and 
 the latter form a containing wall. 
 
 The connection of, and communication of the aneurism with, 
 the supporting artery, may be termed its pedicle or base, and the 
 form and extent of this base have an important bearing on the 
 course of the aneurism. When an aneurism has ceased to enlarge, 
 there is a tendency to spontaneous occlusion of its cavity. This 
 occlusion occurs through the agency of the cellular, fibrinous, and 
 albuminous constituents of the blood, which in solid form are 
 deposited on the wall of the cavity, so that this wall slowly thick- 
 ens at the expense of the inner cavity. This deposition is from 
 the blood, which is stagnant or in torpid motion, and the stagna- 
 tion or tardy movement is favored by the narrowness of the open- 
 ing in the aneurism. The materials thus precipitated become 
 organized and are stratified, so that the superadded structure is 
 separable into layers. This is tinged .with the pigment of the 
 blood. The formation of this material depends on a due amount 
 of blood which enters the aneurismal cavity, and, tardily moving 
 there, again escapes into the onwardly moving current of blood. 
 Spontaneous rupture seldom or never occurs, where the tumor is 
 inclosed by other structures; and bursting there occurring would 
 be from some violence. Nevertheless the pulsatile movement, or 
 action of an aneurism, on neighboring parts, tends to attenuate 
 the latter. Bone thus becomes eroded or softened, and disappears 
 similar to a rock over which the watery tide constantly ebbs and 
 flows. 
 
 As stated, there is a tendency in every aneurism to become 
 occluded through concentric growth or thickening of its walls; 
 this work is tardy and uncertain of its aim, so that in case the 
 tumor lies external, or is accessible, the surgeon's aid is invoked. 
 
 To favor and accelerate the deposition of the occluding material 
 two methods are prominently in use, — ligation and compression. 
 Ligation, introduced by John Hunter for the cure of popliteal 
 aneurism, has been resorted to for the cure of aneurism elsewhere. 
 There are different plans of ligating. It may be done between 
 the heart and the tumor, or on the distal side of the tumor. 
 Hunter's method was to tie at some distance from the aneurism 
 on the cardiac side. Anel and others advised to ligate on the 
 cardiac side close to the tumor. Aneurism may be cured by each 
 of these plans, though that of Hunter is more commonly prac- 
 ticed. An exceptional method is the ligation of the artery 
 beyond the tumor, known as Brasdor's operation; and a modifi- 
 
118 AFFECTIONS OF THE SCALP. 
 
 cation of this method is the tying of the two branches into ^Yhich 
 the vessel bifurcates beyond the aneurism; and this method is 
 named from its introducers, the operation of Brasdor and Ward- 
 rop. Ligation beyond tlie aneurism has been chiefly done on the 
 carotid and subclavian arteries. 
 
 Aneurism has been cured by compression made on the afferent 
 vessel, on the cardiac side of the tumor; and this compression 
 may be done close to the tumor or at a distance from it. Again, 
 the work lias been successfully done by pressure made directly on 
 the aneurismal tumor. Such compression may be done with the 
 human hand, or it may be done by means of an instrument. 
 
 And finally, a method of cure known as tliat of Anthyllus, is 
 that in which the aneurismal tumor is opened, cleaned of its 
 clots, and the entering and emerging portions of the artery are 
 ligated. This niethod is only applicable to aneurism seated on 
 small vessels, and usually such as have arisen from tiie rupture 
 of the vessel, that is, in traumatic aneurism. It would be wholly 
 inapplicable for the cure of an aneurism arising from a large 
 artery. A plan cognate to this has recently been practiced, 
 viz., to tie the artery on each side of the aneurysmal tumor, 
 and then dissect out the latter. 
 
 The arteries of the scalp are of diminutive caliber, and are 
 rarely the site of aneurism; and when this occurs it is commonly 
 of traumatic origin; sucli aneurism is met with in the frontal and 
 temporal regions of the head. The usual cause is a penetrating 
 wound or violence on the part through a fall, blow or moving 
 missile. The dense structures in which the vessel lies imbedded 
 prevents the aneurism from attaining a large volume. 
 
 Aneurism seated in the scalp tends to spontaneous occlusion; 
 yet this mode of ending is slow of accomplishment. Hence it is 
 better to hasten tiiis desired event by the selection of some of the 
 means previously described. Direct compression should first be 
 tried, since it causes no scar and is bloodless — conditions always 
 agreeable to the patient. For this purpose let a compressing pad 
 be constructed of yielding material, such as soft leather or India 
 rubber, and let this be placed on the tumor and be fastened there 
 by retaining straps. By such an appliance continued compres- 
 sion may be made on the tumor; enougli of force must be used 
 to flatten the tumor and arrest the pulsatile movement in the 
 latter. The author has seen a traumatic aneurism of the frontal 
 artery thus compres-sed, and a cure effected after a few weeks' 
 continuance of the treatment. Should this fail, the tumor might 
 
INFANTILE SANGUINEOUS TUMOR. 119 
 
 be opened and the vessel tied on each side; this method would 
 surely cure, but also scar the patient. 
 
 Infantile Sanguineous Tumor. — The newborn child usually 
 presents a swelling of greater or less extent on the parietal region 
 of the head. This tumor or tumefaction is caused by the violence 
 to which the head is subjected during its passage from the uterus 
 through the pelvic outlet. It is commonly located on the upper 
 and posterior part of the head, which corresponds to the posterior 
 portion of the right parietal bone. There are two forms; in one, 
 the blood is diffused through the soft tissues by simple extrava- 
 sation ; the capillaries are dilated or burst; the greater part of the 
 swelling is due to effused blood, since mere swelling of the capil- 
 laries cannot account for the greatly increased volume of the 
 part. In another form there is a collection of blood which rests 
 on the cranium, and is separated from the parts around by an 
 imperfectly formed wall. The infiltrated form, first mentioned, 
 is due to the jDrotracted delivery ; the head having partly pro- 
 truded through the os uteri remains there for some time, while 
 the surrounding uterine neck grasps the retained head like a 
 strangulating band. The form of this tumor is that of a non- 
 pedunculated growth, which is soft and slightly elastic. During 
 the progress of labor this protrusion can be felt, and also observed 
 to elongate during the time of the uterine expulsive acts, and its 
 volume is increased proportionately to the length of the labor, 
 the causal mechanism being in the firm and resistant collum 
 uteri, which, during the pains of labor, catches and holds the 
 dependent portion of the scalp, and ties off, as it were, a portion 
 of blood from the general circulation. 
 
 This vascular tumefaction seldom requires attention; if any- 
 thing be done, it may be limited to protecting the part with 
 cotton wadding, and the application of camphorated liniment. 
 Sometimes, however, the quantity of effused blood is too great 
 to be absorbed, and the result is suppuration, in which there is 
 formed an ichorous fluid, which is required to be liberated by 
 an incision of the overlying skin. There should not be haste to 
 do this, since unaided nature, usually, can effect a cure. 
 
 In the second form, in which there is a collection of dark, 
 grumous, uncoagulated blood, absorption of this fluid sometimes 
 occurs; yet in many cases the fluid remains, and the containing 
 parts show by their heat that there is inflammation tending to 
 breaking down and opening of the cavity. In such condition 
 the cavity should be opened, and after the blood has been evacu- 
 
120 AFFECTIONS oF THE SCALP. 
 
 ated, the containing space should be washed out with an alcoholic 
 or sublimated solution. In lieu of this an emulsion of iodoform 
 might be injected. In the em])tying of such cavit}', care must 
 be taken not to press violently on it, as there is danger of re- 
 opening the afferent vessels; if this should be done, the cavity 
 would quickly refill. This has occurred in the author's practice. 
 After the evacuation and wasliing out of the cavity, slight pres- 
 sure with a compress of cotton wadding should be fixed over the 
 cavity; thus closure is promoted. Nevertheless, it is rare that 
 one evacuation suffices; the cavity partly refilling will probably 
 demand reopening once or twice again, before a cure is efiected. 
 And, despite these precautionary measures, su})puration may 
 occur and entail a tedious recovery. 
 
 Pigment Marks. — The chapter on benign tumors of the scalp 
 would he incomplete without considering pigmentary marks of 
 congenital origin, which are of occasional occurrence. Such 
 marks are dark or black in color, and are commonly accom- 
 panied by increased thickness of the affected part; and, if covered 
 with hair, the latter is luxuriant in growth and sometimes of 
 intense blackness. Such growth may occupy a large surface, 
 even to the extent of three or four inches. The author has met 
 with two examples which were seated on the anterior portion of 
 the cranial vault, and extended from the coronal suture forwards 
 to the eyebrow, on one side. This coloring of Ethiopian black- 
 ness w^as congenital in each case. The limit between the normal 
 and abnormal parts was clearly defined; and in one case the 
 hair was several times the length of that on the unaffected por- 
 tion of the head. Such pigmentation does not appear inclined 
 to spread beyond the limits it has at birth. The affected structure 
 is not erectile; nor on section does it seem very vascular. It is 
 probable that such growth originates from a capillary angioma 
 wdiicli has undergone retrograde transformtion. 
 
 This pigmented growth is a serious inheritance to a newborn 
 child, since it fatally disfigures the head, especially when it 
 reaches down on the forehead. The author, though familiar 
 with infantile deformity, carries in memory pictures of the two 
 cases mentioned, traced with unusual vividness; and especially 
 does he recall the parental ap})eal for surgical aid, even though 
 such aid in removing the mark should remove tiie infant. In 
 the cases mentioned life was saved, though extensive excision 
 was done. To do this properly, the cutting must reach quite 
 through the scalp; and the operator must be sure that his inci- 
 
MALIGNANT GROWTHS. 121 
 
 sion reaches beyond the affected structure; for a small marginal 
 portion left will remain as a black seam on the border of the 
 cicatrix. In this work divided vessels must be seized and ligated. 
 Partial closure of the wound should be attempted, even though 
 the breach made be a large one; by lateral displacement the 
 wound may be materially lessened in extent, an-d opposite bor- 
 ders may thus be made to coalesce. Wire and catgut sutures 
 must be used for the closure. The wire sutures niust be so placed 
 as to fix the parts and relieve them from tension, while those of 
 catgut must effect accurate union. Heemorrhage being controlled, 
 and the part being sprinkled with iodoform, it is to be covered 
 deeply with lint which has been saturated with the compound 
 tincture of benzoin, and held by adhesive strips, which surround 
 the head. Such a dressing may remain in place for a week, or 
 longer, should there be no discharge; and afterwards changed as 
 occasion may demand. In this work of excision, should hair, 
 cither of the scalp or the brow, be removed, the cicatrix will 
 afterwards remain bald. In case of an eyebrow, this should be 
 announced to the parents beforehand, since no art will supple- 
 ment the loss. 
 
 Malignant Growths. — The author will next consider malignant 
 growths which occur in the scalp. 
 
 AVhence the malignant growth arises, to what extent spon- 
 taneous evolution, traumatism and indeterminate contingency 
 figure as elements of causation, how far the tendencies of 
 ancestry, distant or proximate, as transmitted heredity, may 
 influence such growth, whether cell or microphyte may be the 
 primary causal agent, are c[uestions which have been asked, 
 and will continue to be asked, until this department of Pathol- 
 ogy has reached a stage of unquestionable fact, far, very far, 
 from where the writer now finds it. Though much is known 
 here, probably much more remains unknown. The best work 
 in this field will be done by those who combine in themselves 
 the theoretical pathologist and the practical clinician; those 
 in whom the exuberances of theory will be lopped off or 
 corrected by observation and study of the thing as it exists 
 in nature. And, though such students of nature labor ear- 
 nestly and diligently, yet the line of progress only slowly 
 approaches, and rarely reaches the line of truth; and it finds an 
 analogue in mathematical lines, as the inclining sides of the 
 oblique parallelogram, which, though indefinitely prolonged, ever 
 draw nearer, vet never touch each other. Illustrations of how 
 
Vl'l AFFECTIONS OF THE SCALP. 
 
 much labor, reaching through many generations, is needed to 
 phick up error which has taken deep root in tiie human mind, 
 may be seen in the example of how long the notion lived that 
 inorganic nature was constituted of four elements, — earth, air, fire, 
 and water, — and an analogue is also seen in the long shadow 
 of error which "was projected over the field of medicine by the 
 doctrine of the four elements which were thought to constitute 
 organic beings, viz., blood, phlegm, bile, and atrabile; and from 
 these elements the old pathologist derived phlegmon, dropsy 
 (oedema), erysipelas, scirrhus, and the family of tumors. Atra- 
 bile was the element whence sprang all preternatural growths. 
 Medical science bowed its head to tliis idol, moulded into such 
 enduring form by the hands of Hippocrates and Galen. These 
 old notions, formulated so neatly and become sacred through 
 traditional preservation, were parted with reluctantly. Yet the 
 eighteenth century gave medicine many heretics, who renounced 
 many of the old doctrines, who read facts as they are recorded in 
 the tissues, sound and unsound, rather than their misinterpreta- 
 tions as treasured up in the parchment-bound tomes of antiquity; 
 and none plucked up more weeds of error, and planted more 
 truths in their stead, than John Hunter. And into this field, hith- 
 erto so little trodden by the foot of patient research, the nine- 
 teenth century has sent a host of diligent workers, among the 
 most famous of which may be mentioned Paget, Virchow, Wal- 
 deyer, Cornil, and Ranvier. From the numerous facts which 
 have been brought to light by these students of abnormal growth, 
 a few M'ill be presented to the reader concerning sarcoma and 
 epithelioma, forms of malignant growth met with in the scalp. 
 Sarcoma, literally flesh tumor, has had a changeable history, 
 as soon becomes apparent when one attempts to study the liter- 
 ature upon this subject, and tries to form a clear notion of what 
 is meant by this term. After mucli errant search for exact knowl- 
 edge, in which the student is often lost or puzzled by vague 
 descriptions of tissues seemingly very different, the fact is finally 
 grasped that the various elements of the animal body are held in 
 union by a web, which, from its office, is named connective tissue; 
 through this the peculiar elements, Avliich distinguisli the derm, 
 muscles, bones, glands and otlier organs of the body, are held 
 together, and the special structures individualized; and, finally, 
 it has been observed that this connecting structure is the starting 
 point of a large group of malignant growths. To the growth 
 which originates from connective tissue the name sarcoma is 
 
MALIGNANT GROWTHS. 123 
 
 applied; and as connective tissue abound everywhere, hence 
 arises the regional universality of sarcoma. And if the writer 
 has not erred in his observation, besides the connective tissue, 
 the parenchymatous elements which the latter unites, may 
 exceptionally be the starting-point of sarcomatous development. 
 Nay, more, the epithelial elements may stray from normal line 
 and contribute to sarcomatous formation. And such deviation 
 finds a parallel in the license sometimes taken by epithelioma, 
 since, in the latter, cells of connective-tissue origin sometimes occur. 
 In the healing of wounds, both concealed and open, repair is 
 accomplished through the medium of cells which originate partly 
 from the adjacent connective tissue, and partly from colorless 
 blood-cells, which have escaped from the contiguous vessels. 
 This reparative material, having reached the limits which cor- 
 respond to normal form, ceases to grow, and, as it does so, the 
 component elements are transformed into fibrous tissue. When 
 the sarcoma is studied in reference to its cellular constituents, it 
 is found to be singularly similar in composition to the structure 
 that repairs the wound. Both structures present us with the 
 same nucleated round cells, regularly arranged around vessels 
 which traverse the developing structure. The similarity, so 
 marked in the early stages of the two structures, vanishes at a 
 later period; the one becomes on the surface of the body a scar, 
 hard, fibrous and non-vascular. The sarcoma may undergo a 
 similar change, yet, as a rule, it is stamped by the jDermanency 
 of its round cell-form; hence the name of the round-celled 
 sarcoma. But these cells, similar to those of granulated tissue, 
 do sometimes undergo a species of development or transforma- 
 tion; the cells become organized into a tissue of fusiform or doubly 
 conoidal fibers; and this species is named the fusiform or spindle- 
 celled sarcoma. The round cells and spindle-shaped cells are, 
 usually, found combined with some growth. The student of the 
 microscope will soon learn here, as he has already learned in his 
 study of other structures, that there are many deviations from 
 the leading or typical forms; that though there are many 
 approaches towards roundness of cell form, yet there are few cells 
 which are perfectly round; and, likewise, that the schematic 
 spindle-cell, so familiar to the eye in plates, is a rarity in nature, 
 which, delighting, here as elsewhere, in freedom, spurns uniform- 
 ity and revels in variety. Exact type, definite rule, and measured 
 division of parts, are valuable aids in the acquisition of knowl- 
 edge, and they further mental discipline; yet these artifices are 
 
124 AFFECTIONS OF THE SCALP 
 
 unknown to nature, a fact wliich the experienced student soon 
 learns to his regret, and for which he must make due allowance 
 everywhere, and nowhere more than in the tield of Pathology. 
 The minute components of pathological structures must he viewed 
 again and again with untiring patience before order appears and 
 confusion vanishes; thus working, the typical at length asserts its 
 presence and predominance, and the non-typical and amorphous 
 are lost sight of. Having reached such a stage of proficiency, 
 one readily descries and distinguishes the round cells of the 
 .sarcoma, many of which through pressure or manipulation have 
 become irregularly polygonal or elliptically elongated. Also, 
 along with these rounded forms may be often seen figures of 
 shuttle-form, or similar in shape to the oat-grain; these are the 
 spindle or fusiform cells. One or the other of these cell-forms 
 jiredominating assigns the sarcoma to the round-celled or fusiform 
 species. In the latter there has been an effort at organization in 
 the transformation of the round embryonic cells into the long 
 forms simulating fibers; such a tumor is indurated and is fascicu- 
 lated in texture. 
 
 A third form of this tumor, which has been particularly 
 described by Sir James Paget, is that known as the giant-celled 
 sarcoma, this name being given on account of the enormous size 
 of the constituent cells. The giant-cells, when carefully exam- 
 ined, are seen to be compound forms, that is, cells in which a 
 number of nucleated round cells are packed in, and held together 
 by, a common containing envelope. A similar giant-cell has 
 been found in the syphilitic gummy tumor and in exuberant 
 granulation. As a cell of this -character is a normal constituent 
 of fetal marrow, it has been designated the myeloid cell. 
 
 In the three forms of sarcoma described, the component cells 
 lie in contact, or are exceptionally separated by an amorphous 
 intercellular substance. 
 
 In the development of tlie sarcoma, along with the production 
 of cells, there is also a vascular growth; vessels of minute capil- 
 lary form are developed in the tumor. And these vessels are 
 more numerous in proportion as the sarcoma is more closely allied 
 to the embryonic type, that is, to the round-cell species. There 
 is a similarity between the vessels of granulative and sarcoma- 
 tous tissue; yet the vessels in the granulation are more highly 
 organized than in the sarcoma; in the latter they are of a very 
 rudimentary form, and are easily ruptured. Hence, from slight 
 violence the vessels of the sarcoma may be torn and blood eftused 
 
MALIGNANT GROWTHS. 125 
 
 into the tissue. The constituent cells lie in immediate contact 
 with the vessels, in this respect differing from the vascular 
 arrangement of carcinoma, in which the vessels are separated 
 from the characteristic carcinomatous cells by a layer of tissue. 
 
 The sarcoma viewed niacroscopically presents itself in differ- 
 ent species or varieties; thus we have forms of it which are 
 named encephaloid, fasciculated, ossified, and myeloid. 
 
 Encephaloid sarcoma is constituted of round cells and vessels; 
 in structure it is very analogous to that of the early embryo, viz., 
 a compound of very rudimentary cells grouj)ed around minute 
 vessels. The cells and vessels grow rapidly, and sooner or later 
 the cell growth outstrips the vascular growth; and then the cells 
 which are most distant from the vessels perish from defective nutri- 
 tive supply; and if this be within the growth, a collection of semi- 
 liquid material appears, which in composition may be compared 
 to ill-formed pus; and if such disintegration occurs near the sur- 
 face of the tumor, then the integument of the latter may open 
 and an unhealing ulcer result. With such characteristics, the 
 encephaloid sarcoma is entitled to a place among malignant 
 growths of a highly destructive tendency. 
 
 The fasciculated form of sarcoma is one in which there are 
 efforts at organization; the most of the round cells are converted 
 into imperfect fibers; and these are disposed in an irregularly 
 lamellated order, so that when an opening is made in the surface, 
 and the tumor torn open, the torn surface presents a stratified 
 appearance. This species is less vascular tlian the encephaloid 
 sarcoma; it grows less rapidly, and as it does not reach such 
 dimensions as the encephaloid species, its presence may be toler- 
 ated a much longer time. The fasciculated variety is often found 
 in connection with muscular tissue; and the stratified form of the 
 muscle may be regarded as the prototypal model, according to 
 which is developed its abnormal correlate, the fasciculated 
 sarcoma. 
 
 The ossifying or osteal form is seen in the sarcoma which 
 originates from periosteum or bone. And, exceptionally, the 
 bony tissue is developed within the sarcomatous tumor which is 
 not contiguous to bone, especially in sarcoma that is of the typi- 
 cally fasciculated species. When it occurs in the growth not 
 adjacent to bone, the origin of the osteal tissue cannot be so 
 readily accounted for as when found in a growth having con- 
 nection with some bone of the skeleton; in the latter case there 
 can be traced propagation by continuity. The bony tissue in the 
 
120 AFFECTIONS OF THE SCALP. 
 
 isolated sarcoma is produced similarly to that of the upper half 
 of the foetal cranium, in which the bones grow directly from 
 fibrous structure, without the intermediate cartilaginous stage 
 which occurs in the growth of the bones at the base of the skull; 
 and this latter, as the hlstologist knows, is the normal mode of 
 development of the other bones of the body; consequently the 
 bone in sarcoma is not without a physiological analogue. The 
 partially ossified sarcoma has a long course; the slow growth of 
 such tumor gives long security to the integument covering it; its 
 firm and resistant texture enables it to withstand violence which 
 would disintegrate the encephaloid tumor; nevertheless, its malig- 
 nant character is incontestable, being shown in the frequency of 
 recurrence after the removal of such tumor. 
 
 The fourth species of sarcoma is the myeloid, which is con- 
 stituted mainly of the giant-cells already mentioned; besides, 
 there are intermingled with these the embryonic cells, a compo- 
 sition similar to that which is revealed by the microscope in fcetal 
 marrow. This species is situated always adjacent to or in bone 
 tissue, and originates from the medullary tissue of the bone; 
 starting from the marrow, it grows at the ex})ense of the bone. 
 In this tumor either the small or the giant cell may predominate 
 in development; and when the small cells are the leading pro- 
 ductive factors, then the tumor has a rapid course, and soon 
 attains large dimensions; but when the giant cell is the predomi- 
 nating element, then the growth is tardy, and the life of the 
 tumor is a long one. The myeloid sarcoma occurs oftenest in the 
 head, especially in the maxillary bones; but it appears also in 
 the long bones, especially in the tibia and femur, oftenest in the 
 head of the tibia. It has a tendency to undergo a vascular 
 transformation; and in that event, the development of vessels 
 may proceed to such extent that the pulsatile movement of the 
 tumor is perceptible to the touch. When the tumor has under- 
 gone this structural change, it is liable to be mistaken for an 
 aneurism. This mistake may be made when the tumor is seated 
 on the leg or thigh, and is in proximity to the vessels of the limb. 
 But if remote from vessels, the case can at once be decided to be 
 one of vascular myeloid sarcoma. 
 
 Writers disagree concerning the degree of malignancy of this 
 form of sarcoma. Gross estimates that it passes from its primary 
 seat and becomes constitutional in one -eighth of the cases; other 
 surgeons have seen generalization less frequently; and after 
 removal of the myeloid sarcoma, they have seldom seen recur- 
 rence. 
 
MALIGNANT GROWTHS. , 127 
 
 There have been described other forms of sarcoma; these, 
 however, are histologically so cognate to some of the former above 
 described, that a description of them here may be omitted, 
 excejDt the species known as melanotic, of which the malignant 
 nature commends its study to the surgeon. 
 
 The melanotic sarcoma, as its name implies, is dark or black 
 in color, and owes its hue to the deposition of granulated pigment 
 in the component cells. The minute components of this dark 
 material are fusiform or rounded in form; and the remaining 
 constituent cells of the tumor are either round or fusiform in 
 shape, that is, similar to those of the normal sarcoma; as a rule, 
 the si)indle-cells exceed the round ones in number, so much so 
 that the tumor is usually fasciculated in structure. The pig- 
 ment is not due to an accidental effusion of blood into the growth, 
 but it is formed in the sarcomatous cells, first around the nuclei, 
 and then it enters the nuclei, and finally appears in every part of 
 the cell. 
 
 The melanotic sarcoma is soft in consistence; and it appears 
 especially in the eye, and in the dermal and muscular tissues; 
 and in its work of generalization and destruction, it stands in the 
 front rank of malignant growths. 
 
 The above description contains in an epitomized form the 
 prominent points in the history of sarcoma; in more elaborate de- 
 tail the subject may be found in the voluminous chapters wdiicli 
 surgical writers have devoted to the matter. It must be acknowl- 
 edged, however, that the grouping of the different species together 
 is arbitrary, and that the relationship between them is a con- 
 strained one. The incongruity of placing together things so 
 diverse has led some writers to drop the name sarcoma, and to 
 apply to these tumors the name of fibro-plastic growths. Though 
 there is something rational in this proposal, yet the term sarcoma, 
 stripped as it now is of the irrelevancies which surrounded it in 
 the older writers' minds, has so firm a place in surgical Pathology 
 that it seems proper to leave it undisturbed as a prominent sec- 
 tion of malignant new growths. 
 
 When compared with epithelial cancer, sarcoma was formerly 
 deemed peculiar to youth and early adult life, while the advent 
 of the former was referred to more advanced years; the bloom of 
 youth was associated with sarcoma, while carcinoma and epithe- 
 lioma were deemed the evils of wasted age; though this, in a meas- 
 ure, be true, yet a wider observation of sarcoma has shown that 
 its advent may be in both 3^outli and age, though it occurs oftener 
 in the young. 
 
128 AFFECTIONS OF THE s^CAET. 
 
 When sarcoma and carcinoma are compared in reference to 
 curability, the former has advantages over the latter; for after 
 pro})er surgical treatment the patient of sarcoma is less apt to 
 have a recurrence of the disease; and sliould there be a recur- 
 rence, the sarcoma reappears with less violent character than is 
 the case when carcinoma recurs after removal. If carcinoma 
 reappears after excision, abstention from interference, as a rule, 
 is wisdom; but if removed sarcoma reappears, there is a fair pros- 
 pect that benefit will be reaped from another operation. 
 
 In the treatment of sarcoma, constitutional treatment has 
 proved of little avail; however, in this field internal medication 
 has not had a fair trial. The author has hope that the future con- 
 tains some happy surprises, and that some day will witness the 
 discovery of remedies which will check the growth of, and finally 
 extinguish, the malignant tumor. Man with his innumerable 
 ailments is, doubtless, surrounded by countless remedies, the 
 most of which as yet are unknown; a condition of things des- 
 tined to change when greater progress has been made in the 
 knowledge of materia medica. And there is ground for encour- 
 agement when one recalls what has been done elsewhere in the 
 therapeutic field. 
 
 To turn attention for a moment to what has been done in 
 recent years, nothing can strike the medical mind with more 
 gratifying effect than the story of coal tar, whence chemistry has 
 extracted so many remedial agents. Who knows but that in 
 some material now deemed useless, a remedy against the malig- 
 nant growth may be found? Perhaps the agent which is destined 
 to replace the present destructive treatment of the malignant 
 neoplasm is to be found in the field of botany, and that some 
 simple plant not even adorned with flowers, is elaborating the 
 organic compound which can accomplish the great work, and is 
 only waiting the advent of the fortunate one who shall discover 
 it. In the innumerable family of plants the author has no doul)t 
 but that such a boon exists, and which, when found, as a gift to 
 suffering humanity must take rank alongside of the discovery of 
 ansesthetics. Though as yet such remedy exists only in enthu- 
 siastic hope, yet the unfortunate victim of malignant tumor is 
 not without some aid from internal medication; for it has been 
 learned by observation that, though certain therapeutic agents 
 do not directly possess a resolvent action, yet they are able to 
 retard growth; as such may be mentioned mercury, iodine, and 
 arsenic. Mercury is more active when combined with iodine, in 
 
MALIGNANT GROWTHS. 129 
 
 the form of the protioclide or deutiodide of mercury. Of the pro- 
 tiodide, a half grain may he given three times a day. And in 
 such amount it can be given for a number of weeks; meantime, 
 its action should be carefully watched, and should symptoms of 
 phyalism supervene, as may be found in the weak and cachectic, 
 then the remedy should be temporarily suspended. Arsenic may 
 also be tried, and in the form of Fowler's solution of the arsenite 
 of potash, five drops may be given three times a day; and this 
 dose should be increased in amount, one drop daily, until as 
 large a dose is reached as the patient can tolerate. From the 
 well-known jjroperty of arsenic of acting on tlie skin, it is proba- 
 ble that it will act more efficiently on the dermal sarcomatous 
 tumor. And, again, as its effect is only obtained after prolonged 
 administration, it is presumable that its beneficial action is bet- 
 ter suited to tumors of slow growth. 
 . Besides the use of these remedies taken into the alimentary 
 canal, they may be employed parenchymatously, that is by direct 
 injection into the tumor; thus one may employ Fowler's solu- 
 tion, or a solution of mercury and iodine known as the iodohy- 
 drargyrate of potassium; of either of the solutions mentioned there 
 may be injected with a hypodermic syringe from four to eight 
 drops daily; the best action is gotten by injecting not more than 
 two drojDS at one point, for if more be thrown in, the resulting 
 irritation is apt to be so severe as to cause suppuration. In this 
 work a syringe with very fine point should be emploj^ed, and 
 care should be taken that the point should be shar^) and clean. 
 Besides the solutions mentioned, one may use ergotine or the 
 tincture of iodine; the latter is the preferable agent. The surgeon 
 should be careful to insert the syringe point into a new place for 
 each injection. Also, the point should pierce to different depths 
 in order to bring the solution into all portions of the tumor. 
 And should suppuration be excited, the work of injection should 
 be suspended for some time, and when resumed again, it should 
 be at a point as distant as possible from the site of recent selection. 
 The author urges a persevering trial in this method of hypodermic 
 treatment of the sarcoma; if only a retardation of growth is 
 accomplished, this is a valuable gain. 
 
 Should the means detailed fail to effect a cure, then a resort 
 must be had to the radical methods of cauterization or excision. 
 To accomplish anything with caustics, the most potent ones 
 must be chosen, as the chloride of zinc or potassa fusa, preferably 
 the latter. To use this, the surface of the tumor, if not opened, 
 
130 AFFECTIONS OF THP: SCALP. 
 
 should be abraided, since the epiderm offers some barriers to the 
 action of the escharotic. When the surface is opened, then a wall 
 of adhesive plaster should be built around the part, so as to pre- 
 vent the destruction of the adjacent sound parts. The caustic 
 [•otash should be mixed with an equal part of Pulvis Radicis 
 Sanguinariie, and of this a layer equal to a line in depth should 
 be placed on the tumor, and retained there by a covering of lint 
 and adhesive plaster. This amount used will destroy much 
 more than a line's depth of the growth. The destroyed part 
 must be detached by means of moist warmth. Proceeding in 
 this manner, successive strata may be destroyed until the tumor 
 is destroyed. A serious obstacle in the way of this work is the 
 peril of opening vessels, which may bleed; and hence where 
 large vessels underlie the tumor, the escharotic must be used 
 with caution or wholly omitted. This plan always causes a 
 large wound, which will be tedious in closing. In the patient, 
 however, whose shyness of cutting quite excludes the scalpel, 
 this method may be tried; and if the tumor be small and readily 
 accessible, with no adjacent vessels which niay be imperiled, 
 there is a reasonable hope of thus eradicating the tumor. 
 
 The use of the knife, as a rule, is a much surer and speedier 
 method, and by it the patient will be spared much pain of which 
 he is the victim when escliarotics are used. The great misfor- 
 tune of most patients is, however, that blatant charlatanism has 
 implanted in their minds the belief that the cancer quack (or 
 quackess) possesses for his relief some means of cure unknown to 
 the rest of the world. This false notion has such a hold in the 
 popular mind that intelligent medicine tlius far has availed 
 little towards its removal. The eti'orts of our profession to pro- 
 tect the public from the cancer-harpy are misconstrued; and 
 hence medical legislation has accomplished but little; the vermin, 
 against whom its acts are directed, continue to tiirive and pursue 
 their work of villainous imposture. 
 
 If the victim of the sarcomatous growth escapes the pitfalls of 
 charlatanism, and coniides his life to conscientious medicine, 
 then the latter may choose for treatment between the escharotics 
 detailed, or the use of the knife. In cases in which the growth is 
 sui)erficial, the escharotic })lan should be preferred, especially 
 when an extensive surface is the site of the disease; but when the 
 tumor admits of circumscription and ready removal with the 
 scalpel, then the latter should bo used. And on the scalp, where 
 Ave are supposing the growth to be situated, then the work should 
 
EPITHELIOMA. 131 
 
 be SO done as to avoid conspicuous scarring. The work then 
 done must conform to those already given for the extirj^ation of 
 benign neoplasms on the head. The form of the wound should, 
 as far as possible, be so made that the breach can be closed, or if 
 not closed, reduced to the smallest size. 
 
 Epithelioma. — This growth until recent times was 'ill under- 
 stood, and, like sarcoma, it received different names from those 
 who wrote concerning it; thus, among the old writers, one finds 
 the terms noli me tangere, cancerous ulcer, rodent ulcer, cutaneous 
 cancer, etc., names which plainly meant the same thing. The use 
 of the microscope, which introduced more precision in our knowl- 
 edge of sound and morbid tissues, though it threw light on the struc- 
 ture indicated by these names, yet it did not lessen the nomen- 
 clature of the subject; for example, such names as the following 
 have been introduced: false cancer, bastard cancer, cancroid, 
 epithelial cancer, and epithelioma; and there is appropriateness 
 in the latter name, when the fact is recalled that the histological 
 components of the growth are epithelial cells. 
 
 Epithelioma consists of an infiltration into the tissues of the 
 affected part of epithelial elements which resemble the cells on 
 the surface of the skin, or mucous membranes. The growth 
 beo'ins as an insig-nificant elevation of the surface, on which the 
 normal covering is thickened; yet finally, as the growth increases, 
 the surface opens, and continues open as an unhealing ulcer. 
 The covering of the epithelioma before opening is comj)osed of 
 numerous strata of cells, which individuall}^ have a marked 
 resemblance to cells investing the adjacent unaffected parts; on 
 the face or scalp tliey are similar to the normal epidermal cells. 
 In the progress of the growth, the cellular elements grow both 
 outwards and inwards; and it is in the encroachment of these 
 cells on the subjacent structures, sinking into and infiltrating 
 these structures, that we have the distinguishing characteristics of 
 the epithelioma. 
 
 The cells are small when compared with those of carcinoma; 
 they are nucleated and lie in layers or spheroidal masses which 
 can be squeezed from the affected structure. These rounded 
 masses when placed in water, though they may swell, do not dis- 
 solve or readily break down, but swim as separate particles. In 
 consequence of the form of the follicles or depressions in the 
 structures in which these cellular masses lie, the cells are often 
 arranged in a rounded or imbricated manner; and if these be 
 divided in a certain direction, the appearance under the micro- 
 
132 AFFKCTIONS OF THE SCALP. 
 
 scope is that of a bird's nest, or a fl(n'al whorl. As this wliorl-like 
 form is common to the normal (]e[)ressions of the skin and mucous 
 membrane, care must be taken not to confound the normal with 
 the abnormal forms. The youtliful microscopist often finds bird's 
 nests, which are normal structures of nature and contain no 
 element of disease. 
 
 Epithelioma commences on the surface and may be designated 
 a superficial disease; yet, as it spreads on the surface, it finally 
 penetrates inwards, and then causes extensive destruction of the 
 tissues. The ulcerated field which is produced is irregular or 
 winding in its boundary, and uneven or nodulated in its surface. 
 From such a wound there is discharged a thin viscid fluid which 
 is neither ])us nor pure serum, yet it is similar to the latter. This 
 open surface is of a reddish gray color; it has no tendency to 
 granulate; and if wounded it does not bleed freely, thus differing 
 from granulative tissue. If this diseased structure be examined, 
 by the touch, it will be characterized b}^ induration; both the 
 floor and border are unnaturally hard. Before opening and 
 afterwards, the affected part is coherent, so that it can readily be 
 taken between the fingers, and moved on the parts on which it 
 rests. This mobility is an important characteristic of epithelioma ; 
 and when duly estimated it will aid the surgeon in distinguishing 
 this lesion from a chronic ulcer. 
 
 In its primary stage there are three forms in which epithe- 
 lioma presents itself: papillary, nodulated, and squamous. 
 
 In the papillary mode of origin, the disease begins by the 
 enlargement of one or more cutaneous jjapilla?; as the papilla 
 enlarges, it becomes ensheathed in a coat of epithelial material. 
 If the growth commence by one papilla, others soon appear 
 around this one; these have a red or grayish color, and around 
 the affected part, there may be observed dilated capillaries. This 
 form is seen oftenest on the back of the hand and the lower lip. 
 
 The second primary mode of appearance, somewliat cognate 
 to the preceding, is in the form of a tuber or nodule; and this 
 enlargement may vary from the size of a small pea to that of a 
 walnut, the greater form arising from the enlargement of a 
 smaller one, or from the fusion of two or more smaller ones. 
 This growth is usually irregular on its surface; and hence the des- 
 ignation of lobulated epithelioma, by which it isoften distinguished. 
 In such a nodule one finds sudoriparous and sebaceous glands; 
 the latter are tiie most conspicuous; in fact, they furnish a cliar- 
 acteristic of the nodulated epithelioma; for if the structure be 
 
EPITHELIOMA. 133 
 
 pressed, from the clefts on its surface there may be forced out 
 particles of sebaceous material, mingled with epithelial detritus. 
 This growth as a rule is sessile on the part whence it arises, and, 
 exceptionally, it is pedunculated. The author has seen a case in 
 which around the original nodule smaller ones were present, 
 separated by small spaces of the unaffected structure. 
 
 In the third or scpiamous variety, the first sign of the 
 epithelioma is a small gray or dark-colored scale, a line or less in 
 diameter, and which seems as if set in a casing of sound epidermal 
 structure. This scale can be detached ; and the patient, as a rule, 
 falls into the unfortunate habit of loosening and detaching it with 
 his finger nail. This constant irritation of the part promotes the 
 development of the disease, and is entitled to the name of a 
 causal factor. 
 
 The papillary species occur oftenest around the mouth, 
 especially in the lower lip. The nodulated form is less common, 
 and has, as special site, mucous and semi-mucous surfaces of the 
 genitalia. The squamous form is so closely allied to lupus that 
 ihey may be regarded as akin or, possibly, identical structures. 
 This form appears on the cheeks, nose, forehead and temporal 
 region. It may occur on the scalp which has become denuded 
 of hair. Depressed dermal vitality disposes to its origin and 
 subsequent development. The initial scale consists of altered 
 epidermal material; and by its adherence, it becomes a local 
 irritant of the part, and interferes with nutrition at that jDoint. 
 This form develops and grows slowly, and, as a rule, it penetrates 
 but little beneath the surface; its growth is principally through 
 peripheral extension, the morbid work being limited to the skin; 
 exceptionally, the superficial epithelioma may change its type, 
 and, having become carcinomatous in character, it then penetrates 
 inwards and attacks indifferently any tissue which may be in its 
 way. Thus the author has seen skin, adeps, muscle and bone 
 desiroyed by an epithelioma, whicli, having begun as a simple 
 squamoas afi'ection of the skin of the cheek, penetrated to and 
 attacked the superior maxilla. The patient attributed his affec- 
 tion to the mischievous habit which he had acquired of constantly 
 detaching a scab from the malar region of the face. 
 
 A distinguishing characteristic of epithelial cancer is that it 
 continues a purely local disease for a long time. In many cases 
 the affection does not attack the glands; glandular affection 
 occurs oftenest when the epithelioma is seated on the lower lip, 
 parotidean and genital regions. Secondary or glandular infection 
 
134 VFP^KCTIONS OF THE SCALP. 
 
 from epithelioma seated on the hp or cheek occurs in glands sit- 
 uated near the submaxillary gland. Such infected gland gradu- 
 ally enlarges, and, for a time, it is freely movable; later, the gland 
 contracts adhesions to the parts around it, and while thus mova- 
 ble, the removal of the gland may not be followed by a reappear- 
 ance of the disease. But if the gland is fastened to the parts 
 around so that it cannot be easily enucleated, then the removal 
 affords no guaranty against an early recurrence. 
 
 For a period during the enlargement of the gland, its struc- 
 ture presents a uniform consistence; and this consistence is less 
 hrm than that of those parts which have undergone induration 
 through the advancing disease. The gland will continue to 
 enlarge until it has reached a volume of an inch or more in 
 diameter; then it softens in the center, and opens at some point 
 of its surface; and this opening continues through the overlying 
 j)arts until it pierces through the skin. Through the opening 
 thus formed, there is discharged a semi-liquid material composed 
 of the disintegrated gland and serum; this is not pus, but an 
 emulsion of softened glandular material and serum. This stage 
 of secondary metastatic development having been reached, the 
 disease progresses rapidly; the parts contiguous to the disinte- 
 grating gland become hardened, and afterwards break down. 
 The affected part is then swollen, and presents a number of 
 ragged openings, from which there is a constant discharge of the 
 emulsified material mentioned, often tinged with blood. Where 
 the glands of the neck have become secondarily affected, and the 
 structures break down, not unfrequently the blood-vessels are 
 opened and luemorrhage ensues: death has often thus occurred at 
 a period much earlier in the disease than otherwise would have 
 happened. 
 
 The course of the disea-se on the skin is always slow; on the 
 semi-mucous surfaces it is more rapid; ami on the mucous sur- 
 faces the disease, in its progress and evolution, is still more s[)eedy 
 in its course. 
 
 Besides the implication of glands contiguous or near, in rare 
 instances, the disease appears in some remote organ or part of the 
 body; thus cancer of the liver or stomach may follow an epithe- 
 lioma on the head. 
 
 This growth is oftenest seen in those who have passed the 
 vital meridian: namely, in those who are over forty years of age. 
 Sex is an important factor; the growth occurs much oftener in 
 men than in women; the male is three times more liable to 
 
EPITHELIOMA. 135 
 
 epithelioma than the female. This probably depends on the fact 
 that the disease originates usually in the skin, which, in the male, 
 is more exposed to injury than that of the female. Likewise, the 
 greater abundance of epithelial elements at certain points in the 
 skin of the male, may render his skin a more fertile field for the 
 origin of epithelioma. The lack of cleanliness among the poor 
 is assigned as a reason for the more frequent appearance of 
 the disease among that class, and the greater want of cleanliness 
 in the male, explains the more frequent occurrence of the disease 
 among men. 
 
 The opinion has been expressed by a few writers who have 
 studied the causation of epithelioma, that it originates from a 
 microphyte. A reason urged for this is that the growth oftenest 
 commences where there is a lesion or breach favorable to the 
 implantation and preservation of such jDarasite. As yet, however, 
 such an agent has not been discovered, and the suggestion that 
 this disease is of a parasitic nature is as yet a speculative deduc- 
 tion based on the tendency of modern Pathology to find, or think 
 to find, in the microphyte the universal cause of disease. 
 
 Treatment. — This is best done by external or surgical means, 
 though within the last few years an attempt has been made to 
 cure it by the employment of internal remedies. For this pur- 
 pose the chlorate of potassium has been praised ; cures are 
 claimed to have been obtained by this remedy. For this pur- 
 pose commence with small doses, as for example, five grain 
 three times daily, and increase the amount until as much as as 
 half drachm is taken within twenty-four hours. In case the 
 growth has opened, and an ulcerated surface is present, then a 
 solution may be made of the salt, and applied externally by 
 means of lint. To accomplish anything with this treatment, it 
 must be continued for a long time. The author has made trial 
 of this plan of treatment, but with only doubtful results. But 
 since a doubtful treatment is more satisfactory to the patient 
 than forlorn expectance, hence, in cases in which the disease is 
 so situated as to be inaccessible to external treatment, this 
 remedy might be used. Another remedy which deserves 
 trial is arsenic. As this remedy has been demonstrated to 
 have a curative action in squamous disease of the skin, from 
 analogy, a beneficial action from it miglit be expected in epithe- 
 lioma of the squamous species. Fowler's solution is the best 
 form for use: commence with three drops of this, three times 
 daily, and increase the dose one drop each day, until the stom- 
 
13G AFFECTIONS OF TH K SCALP. 
 
 ach will not tolerate a larger amount; tlieu gradually lessen 
 the amount until a small dose is reached. Thus by ascent 
 and descent in the quantity given, a large amount of arsenic 
 can be safely administered. This agent may be used where 
 the disease is inaccessible to local means; also, it may be given 
 in cases in w^hich an operation has been performed, as a 
 jtrophylactic against recurrence. Chrysophanic acid, whicii has 
 recently gained much celebrity as a remedy against skin disease, 
 might be tried in epithelioma; for this purpose it may be used 
 externally. As it has recently been given internally in psoriasis, 
 so it might be given in a similar manner in epithelioma; for this 
 purpose, very small doses should be used, since the strength of 
 the medicine has not been definitely determined. 
 
 A more direct way of using these agents of internal medica- 
 tion would be through liypodermic injection; in this Avay the 
 author has tried Fowler's solution; also the solution of ihe 
 muriate of lime, which is a useful agent, when given internally, 
 against neoplasms. To use these remedies, the syringe point is 
 to be introduced into the growth at several points, and not more 
 than two drops injected at each point; a larger amount might 
 cause local death and breaking down of the tissues, and thus 
 defeat the purpose of inducing atro})liic change of the morbid 
 tissue. The author has made trial of several agents in the 
 manner mentioned, and, from the results gotten, he gives the 
 preference to the arsenical solution. The hypodermic treat- 
 ment of ei)ithelioma is a field which invites further trial, and 
 it gives promise of furnishing weapons against this disease, 
 especially in cases which have been operated on, and in wliicli 
 there has been recurrence in such form that an operation is not 
 practicable. 
 
 Tiiough considerable has been said in favor of medication, 
 internal and hypodermic, yet the practice and observation of the 
 author have taught him that of all the means of treatment, the 
 knife or, its equivalent, the scissors, is the most eff'ective one. The 
 fear of, or j^opular prejudice against, the use of the surgeon's instru- 
 ment, has caused the loss of manv a life. This fear, planted by 
 the charlatan's hand; has been carefully cultivated by him, for it 
 is in this section of disease that the conscienceless montebank 
 plies his villainous craft, and reaps his richest harvest. The 
 result is that often when the patient applies to the surgeon, the 
 disease has made such advances under the torturing methods of 
 the charlatan, that the latter is forced to cease his caustic mutila- 
 
EPITHELIOMA. 137 
 
 tion; and, at the same time, there is left to the surgeon no oppor- 
 tunity of using the scalpel, for the disease, in such a case, has so 
 intrenched itself in the patient's body that it holds equal posses- 
 sion with life itself. In such unfortunate position, the surgeon 
 usually errs in operative interference, and he does better if he 
 limits his work to internal and hypodermic medication. 
 
 Should, however, the patient shun the snares in which he is 
 so often entrapped by charlatanism, and consult the surgeon 
 at an early period, then the growth should be removed with 
 knife or scissors. As an important preliminary to the work of 
 excision, the implicated surface must be carefully looked at, and 
 the extent of the affected structures be determined, as nearly as 
 possible, with the unaided eye. In the act of looking, it is seldom 
 that the eye is permitted or made to see all that it is possible to 
 see. In the work of vision, the eye falls into the habit of over- 
 looking much that lies within the field of vision; in fact, this is 
 requisite to the conservation of sight; for, if the eye were forced 
 to continually give close attention to all that lies before it, the 
 task would be painful, indeed, it would soon become intolerable, 
 and the overtaxed organ would soon be overpowered and no 
 longer able to act. This conservative act of inattentive vision, 
 so needful for healthful function, soon becomes our wonted habit, 
 and must be studiously avoided when it is necessary to study all 
 the features, lines and external appearances of an object. Sight 
 must be so employed as not only to take in the superficial exten- 
 sion of what is observed, but with equal thoroughness, the eye 
 should penetrate and seize, in the logical meaning of the word, 
 the intension of what is seen. 
 
 In the study of a surface, the site of an epithelioma, aided as 
 well as unaided vision should cooperate in the work. To aid the 
 eye a hand microscope of slightly magnifying jDower should be 
 used;, thus enlarged papillse are discovered, which otherwise 
 would have escaped detection. Vision in these ways having 
 made its best search, the finger must next do its duty in the way 
 of examining tactilely the surface, and also be made to explore the 
 structure beneath the surface. The surface must be lightly taken 
 between the fingers, and any abnormal hardness must be noted. 
 Such hardness is discovered by comj)aring the density of the 
 adjacent sound parts with those afiected; thus the gradual tran- 
 sition from normal to abnormal structure may be found. At the 
 time that the local conditions are thus being studied, the adjacent 
 glands should be examined, and anv inclination to enlargement 
 10 
 
138 AFFECTIONS OF THE SCALP. 
 
 in them carefully noted; for such enlargement means that the 
 alfection has outlived its local period of development, and has 
 already made one great stride towards generalization. 
 
 The extent of surface and structure involved in the growth 
 having been accurately determined, the operator should mark 
 the boundaries with a tinting pencil; or, what is better, tliis 
 tracing can be done with a pencil of nitrate of silver, a few 
 hours before the cutting is to be done. The work of preliminary 
 tracing is one of great importance, and though it may obstruct 
 the manual freedom of the operator, and render his work some- 
 what tedious, yet the patient is a great gainer thereby. The 
 laurels won by celerity are too often dimmed by an early recur- 
 rence ; it is here, as often occurs elsewhere, that the painstaking 
 plodder is the final victor. As before said, a tinted line, pre- 
 viously traced, must serve as a path to the knife, and the work 
 to be effective must be done early. Then the sacrifice of the 
 tissues is so small that the wound can usually be closed, espe- 
 cially where the tissues can be slidden, or laterally displaced. The 
 cut edges then should be perpendicular; or if they be made 
 slopingly, then tlie two should be so cut that they will rest on 
 each other in accurate coaptation, so that when the sutures are 
 introduced the closure will be complete, and no gaps or interlying 
 vacuoles will be left to delay healing. Thus done, early healing 
 without scarring will be obtained ; yet scarring must be reckoned 
 as a subordinate incident in the removal of an epithelioma, for 
 the removal must be complete and uns})aring of tissue. 
 
 After the excision of the affected structures, the cut surfaces 
 of the latter must be carefully examined, in order to ascertain 
 whether the cutting has been done through sound tissue; the 
 examination can be more readily made on this than on the 
 bleeding surface of the parts whence the growth has been 
 removed. The excised part being washed, it can easily be seen 
 whether the entirety of the growth has been removed ; if it has 
 been completely done, then close the wound, or dress it open, as 
 the conditions permit. But if there be found suspicious tissue in 
 the removed part, then the cutting must extend further, until 
 thoroughly sound tissue has been reached. As before directed, 
 the nearest lymphatic glands should be carefully palpated, and 
 if evidences of disease are found in tliem, the operation must be 
 directed to these structures; each enlarged gland must be re- 
 moved. At an early period the glands can be easily enucleated; 
 but later, they contract adhesion to the contiguous parts, and the 
 
CARCIXOMA. 139 
 
 extirpation is a more tedious task. When, such adhesion is 
 found, along with the gland, some of the surrounding adherent 
 tissue should also be excised. Such fixation with adherence of 
 the glands is always of ominous portent; and in such case, to 
 guard against recurrence, the parts suspected of infection should 
 be unsparingly sacrificed. And even these precautions are 
 usually unavailing, for adjacent glandular implication means 
 general infection. In such cases internal medication with arsenic 
 should be rigorously pursued; thus the patient, if not cured, is, 
 at least, solaced with hope of relief. 
 
 Where the growth lies externally and is so situated that com- 
 plete excision is impossible, then among the means of attacking 
 it is the use of destructive escharotics, viz., the potential or actual 
 cautery; of the former, one of the most effective is a compound 
 of potassa fusa already spoken of In this way deep sections of 
 the growth can successfully be removed. The ascertained virtue 
 of arsenic in cutaneous disease would point to its probable utilit}^ 
 used as a caustic, in dermal epithelioma. For this purpose an 
 excellent compound is that consisting of equal parts of arsenious 
 acid and cinnabar. This trustworthy escharotic, however, must 
 be applied cautiously, lest it act as a poison; hence, but limited 
 sections of surface should be successively attacked. When the 
 disease lies in a mucous surface, then heat in the form of the 
 galvanic cautery or ferrum candens may be used. 
 
 Carcinoma. — Carcinoma and cancer, equivalent names, derived 
 respectively from the Greek and Latin tongues, have reference to 
 the form of the diseased part, or to the appearance of the vessels 
 which lie like radii diverging from the part; more probably, 
 however, the name has reference to the firm hold with which 
 this growth clings to its unfortunate subject. With Celsus the 
 name cancer was applied to mortification or death of the soft 
 parts, a meaning far remote from the modern signification of the 
 word. A term cognate to cancer is scirrhus, which has reference 
 to the induration commonly found in cancerous structures. For 
 a century or more the term cancer has been used to denote malig- 
 nant growths of a destructive tendency. This term was vaguely 
 and indefinitely used until the beginning of this century, when 
 •Bichat carried the study of disease from the crude mass to the 
 constituent tissues of diseased parts. Bichat classified morbid 
 changes of structure under two heads: general alteration or 
 change, and particular alteration or change. According to him, 
 the affections in which general alteration is seen are inflamma- 
 tion and scirrhus. 
 
140 AFFECTIONS OF TIIK SCALP, 
 
 That the name cancer was obscurely used is shown in John 
 Hunter's remark that the diseases wliich are chissified as cancer- 
 ous are dilferent in appearance and probably differ in their 
 nature. Yet Hunter left these differences unexplained. 
 
 Early in the nineteenth century the notion was held, that, in 
 the malignant growth, elements exist which cannot be found 
 elsewhere in tlie normal or unaffected ])arts, and thus a broad 
 distinction was established between the benign and malignant 
 growths. And thonee arose tlio classification of hoteroloo-ous and 
 homologous tumors, as synonymous with malignant and benign. 
 The peculiar element of cancer was particularly isolated by 
 Cruveilliier, who, in cutting a cancerous tumor and scjueezing it, 
 obtained the heterologous elements in the expressed fluid. This 
 fluid examined microscopically presents small bodies, some of 
 which are definitely formed, and others shapeless or irregular. 
 This fluid, or emulsion, as it might be named, can not be 
 derived from a benign growth. Thus an advance was made 
 in the knowledge of cancer; and further, cancerous tissue was 
 found to consist of an areolar, mesh-like, or connective frame- 
 work; and this framework contained the fluid in wliich were 
 discovered cells of a peculiar form, which were nametl cancer- 
 cells. These cells, according to Lebcrt, Broca and others, have 
 peculiar characteristics, differing fi-oni any other cells found 
 among the component elements of the body, and which, when 
 seen, justify the observer in declaring that they are of malignant 
 nature; and, from not occurring in normal tissue, such cells are 
 named heterologous. After further study of the subject, Lebert 
 has been forced to admit that, from the observation of the cell 
 alone, one is not justified in declaring that it is of cancerous 
 origin. But if the tissue containing tlie cells be given, then a 
 microscopic inspection of its structure will enable the observer to 
 declare that tlie case is, or is not, one of cancer. 
 
 Virchow, who has studied the cellular components of tumors, 
 asserts that there is no cell peculiar to, or characteristic of, cancer; 
 in fact, that the cancer cell should not be named heterologous 
 or heteromor])hous, since it is identical with other normal cells. 
 Virchow pronounces the cell of cancer identical with cells con- 
 stituting epithelium; and where a difference from epithelial 
 cells occurs in cancerous structure, it is due to some accidental cir- 
 cumstance in the growth of the cell. Virchow finds that cancer- 
 ous structure consists of a stroma of new-formed tissue, originat- 
 ing from preexisting connective tissue, which is arranged in an 
 
CARCINOMA. 141 
 
 areolar or sponge-like form ; and the minute spaces or vacuoles 
 in this stroma are filled with a cream-like emulsion, the succus 
 cancri; and an examination of this fluid reveals cells which 
 are similar to normal epithelial cells. This cancerous tissue 
 resembles that of epithelioma, the difference being that in the 
 latter there is no new-formed connective tissue stromj^. 
 
 According to the foregoing opinion of Virchow, and which is 
 concurred in by others, there is no specific cell which can be 
 declared cancerous, since the cell which is found in cancer occurs 
 also in normal tissue; it is sometimes absent in the structure of 
 tumors which are certainly cancerous, and it can occur in tumors 
 which are neither scirrhoid nor encephaloid in type. 
 
 As there is no cell peculiar to cancer, so there is no single or 
 isolated pathological form which can be pronounced to be typical 
 of cancer; in fact, under the head of malignant growths, there ex- 
 ists a great variety of tumors which have some analogies with each 
 other, yet, also, offer many points of unlikeness, and these points 
 of unlikeness are so numerous that Robin has proposed to drop 
 the name of cancer, and to study each individual growth sepa- 
 rately. Though this might be justifiable, yet it would greatly 
 embarrass both student and practitioner in their respective tasks 
 
 It being, then, impossible to formulate a definition of cancer 
 founded on its microscopical appearances and anatomical form, 
 a resort has next been had to the clinical history or course which 
 the tumor follows from its commencement to its final ending. 
 Such a history, ^briefly traced, runs somewhat as follows: Cancer 
 begins as hardened tissue, at first of small or insignificant vol- 
 ume, for a long time painless, and, hence, for a time unobserved; 
 it grows continuously, and when it attains some size, it may cause 
 some inconvenience or pains of a shooting character; its bounda- 
 ries are rarely uniform or regular; it ma}^ arise in every structure 
 of the body, yet it oftener originates in glandular structures, and 
 oftener in those which lie near the external surface of the body, 
 the disease seeming to prefer as site, parts which are the scene of 
 much functional activity, or those which are in incessant vibra- 
 tion between inaction and action ; the tumor, by increase of vol- 
 ume, encroaches on, and finally destroys, parts around and over 
 it, and its development is only impeded, and at length arrested, 
 through an insufficient supply of nutrient material on one side, 
 and through the escape and loss of the same through the opening 
 or ulcerated breach which finally appears in the tumor. The 
 patient nearly always refers to some local injury of the part 
 
142 AFKECTIOX;? OK THE SCALP. 
 
 wliicli was tlie starting point of the cancer, and the connection 
 between such lesion and the growth is so clearly traceable that 
 it is safe to conclude that some traumatic agency is, if not always, 
 at least usually, the exciting cause of cancer. The last act in this 
 eventful history, Avhen the growth is unrestrained in its develop- 
 ment, is ajways death, which is preceded by infection of the 
 contiguous glands, and, afterwards, the disease appears in the 
 more remote parts of tlie body. This generalization seems to 
 take place through the medium of the lymphatics and blood 
 vessels. 
 
 As has been stated, in the microscopic study of cancer, two 
 leading constituents have been found, viz., the areolar framework 
 and the so-called cancer cells contained in this framework. In 
 any given cancerous growth these two constituents may exist in 
 very different proportions; the framework can be greatly in 
 excess, and so can the cellular elements. In the former case, the 
 growth is remarkable for its hard and firm structure, and this 
 form is named scirrhus. Where the cellular elements are the 
 chief constituent, then the tumor is named encephaloid. This 
 name is derived from the resemblance of the structure to the sub- 
 stance of the brain; and, as Avill be recalled, this name, for similar 
 reasons, is used to designate a species of sarcoma. 
 
 The scirrhous and the encephaloid types were the ones which 
 first attracted the attention of the early observers. The error 
 existed for a long time of considering scirrhus as the j^rimary 
 form, and encephaloid cancer as the direct derivative from the 
 former, through, some powers of softening, for which no satisfac- 
 tory explanation could be offered. It soon became apparent that 
 they were separate species, being distinctly different structures 
 from their earliest commencement ; their histories having nothing 
 in common, except that each one ended in the death of the 
 patient. Scirrhus, however, develops slowly, and presents, later 
 in its course, signs of regressive action, or an effort at healing in 
 the oldest portions of the tumor; that is, both stroma and con- 
 tained cells seem to have reached their maturity, and are found 
 in a stage of degeneration and decay. And to this is due the 
 scar-like depression often found over this form of cancer; and 
 when the disease is limited to the skin in the lenticular form, 
 such retraction explains the irregularity of surface. The enceph- 
 aloid type is soft and commonly of a uniform rounded outline. 
 It is soft, so much so that it has often been mistaken for a lipoma, 
 or a collection of pus. It is of very rapid development, especially 
 
. CARCINOMA. 143 
 
 where it has recurred after an operation. Tliis type examined 
 microscopically is found to consist of an areolar stroma and cells; 
 the cells are the j^i'edominant constituent; and to the small 
 amount of stroma is due the characteristic softness of this kind 
 of cancer. Glandular infection also follows this, yet the tumor 
 may attain considerable dimensions before the glands are impli- 
 cated. As to the primary point of commencement, encephaloid 
 cancer begins oftenest in the testicle; according to Paget's obser- 
 vation, it is found there in one-third of the cases of cancerous 
 testicle. This organ, as the author has seen in three cases, may 
 be attacked in early childhood. It attacks also, not unfrequently, 
 the bones. It is remarkable for the rapidity of its fatal march. 
 
 Though carcinoma is constituted mainly of the constituents 
 mentioned, yet other elements may be added, and give a special 
 character to the tumor; and to this is due the great confusion 
 among writers who have written on the subject of cancer; and it 
 was on this account that Robin and others proposed to relegate 
 the term cancer to the historic past, and to describe separately 
 each form of malignant disease: to extricate himself from the 
 difficulties of such a method, Robin was forced to adopt some 
 generic name: he chose that of epithelioma; and thus his 
 would-be improvement in nomenclature amounted to no more 
 than a substitution of terms. Through the addition of pigmen- 
 tary material to the two fundamental elements of carcinoma, 
 melanotic cancer arises. And by the addition of colloid or 
 gelatinous matter, there arises a peculiar form named colloid 
 cancer, which has been a puzzle to the pathologist; and, as yet, 
 the origin of this jelly-like material is a subject of investigation. 
 To say that it arises from a liquefaction of the solid components 
 of the growth, throws darkness rather than light over the prob- 
 lem. In another form of cancer there is found cartilaginous 
 material, and which may be in such quantity as to conceal the 
 true nature of the growth for a time. Beside the malignant car- 
 tilaginous tumor there is one which is benign, and which has 
 neither tendency to ulceration nor generalization; this form is 
 hard and has a tendency to ossify, while the malignant species is 
 softer, and tends to change to a semi-liquid or pulp-like material. 
 This soft chondroid form of cancer tends to generalization, and 
 is very malignant. In another form of tumor, to the dual pri- 
 mary components, elements of bone may be added, and thus a 
 tumor of extreme hardness is formed, to which the name of oste- 
 oid cancer is applied. Thus besides the two typical forms of 
 
144 AFFECTIONS OF THE SCALP. 
 
 scirrhous and eiicephaloid cancer, through superadded elements 
 four other forms have arisen, bearing the names melanotic, col- 
 loid, clioudroid and osteoid cancer, the name being derived froni 
 the new element which has been added. 
 
 Besides the forms of carcinoma which have been mentioned, 
 the disease may appear in the site whence a benign growtli has 
 been removed. Again, a growth has forsaken its simpler type of 
 an epithelioma or sarcoma and appeared as a species of cancer. 
 To attempt an explanation of such transmutation in the present 
 state of our knowledge would be fruitless. 
 
 Cancer is of infrequent occurrence on the seal]); still it does 
 occur here; one of the worst cases of the disease ever seen by the 
 author was in the scalp. This was concealed by the patient for 
 a long time. Commencing as a small nodule, the disease of 
 encephaloid type developed into a tumor of large volume; this 
 attacked the cranium, finally destroying almost the entirety of 
 one i^arietal bone, and extensively exposed one hemisphere of 
 the brain. The brain was never attacked, and for a long time 
 the mind remained unimpaired; later, mental perversion ap- 
 peared in which there was a slight excitation of the faculties, 
 similar to the excitement from wine. This extensive destruction 
 of the soft parts and cranial wall was attended by only a small 
 degree of pain. During the last few weeks, the chief complaint 
 of the patient was from fatigue. Meantime, the hopes of recover}'' 
 were cherished by her, and plans for the future made by the 
 j)atient, though an extensive surface of one hemisphere lay 
 exposed to view. In this case, there is probability that a cure 
 could have been effected had an early operation been done; for 
 the history showed that, for a long period, the disease existed as a 
 small wartdike nodule, which, for a time, was concealed by so 
 dressing the hair as to cover the growth. 
 
 Treatment. — Cancer may be treated by internal means, by top- 
 ical applications, and by means which slowly destroy or at once 
 directly remove, the part. 
 
 Internal medication has been industriously pursued; and, at 
 different periods, the much-sought-for agent has been announced 
 as actually discovered. A reference to the old books on JNIateria 
 Medica will present the reader, under the head of Anodynes and 
 Narcotics, a number of agents for which there was claimed a cur- 
 ative agency against cancer; conspicuous among these are aconite, 
 conium, stramonium and hyoscyamus. These agents have failed 
 to do that which was claimed for them. In the use of these med- 
 
PXEUMATOCEPHALUS. 145 
 
 icaiits, as well as of others, it is probable that a satisfactory trial 
 has not been made of them: they have been administered too 
 late, in insufficient amount, or for too brief a time. As the 
 disease is sometimes met when it has reached a stage that forbids 
 operative interference, when the case of the ph^^sician is limited 
 to work in which but little result can be expected, and what he 
 attempts is with the view that aliquid fecisse videatur: then these 
 remedies may be retried, and besides those mentioned, a trial 
 should be made of arsenic and iodine. And if the tumor is 
 opened through ulceration, then some of these remedies may be 
 used topically. 
 
 Treatment by cauterization, actual and potential, has fre- 
 quently been tried; and if it be decided to make use of some of 
 these methods, then the work may be done in accordance with 
 plans which have been described in the treatment of sarcoma 
 and epithelioma. Though these methods deserve mention and 
 occasional trial, yet of all plans of treatment, a resort to excision, 
 in which the knife is used early and radically, promises the best 
 results; and the manner of doing such excision has been generally 
 indicated in a preceding section in which the writer described 
 the treatment of sarcoma. 
 
 Instead of assuming the exuberant growth presented in the 
 case just mentioned, cancerous disease when seated in the scalp 
 commonly approaches to epithelioma in type. For besides the 
 six varieties of carcinoma which have been cited, there are others; 
 and among the latter are those which so closely resemble epithe- 
 lioma that it is difficult to establish a clear distinction. Nature, 
 in the domain of both normal and abnormal products, is often a 
 fugitive from both law and rule; she has infinite resources 
 whereby she can indulge in continuous variation. The surgeon, 
 as well as the practitioner of medicine, daily meets proof of what 
 is here stated, and must take due account of them if he attain 
 success in his practical work. The one who uses well his eyes 
 and remembers what he sees, even though he has not fathomed 
 the utmost depths of Pathology, often becomes successful in the 
 p/actice of his art. 
 
 Pneumatocephalus. — Beneath the anterior and posterior por- 
 tions of the scalp there sometimes occurs a singular tumor, of 
 which the content is 'air. Thomas, of Tours, a pioneer in the 
 observation of this development, was struck by its sonorous char- 
 acter. This tumor when seated behind, over the mastoid region, 
 receives its air from the mastoid cells or antrum, of which the 
 
14G AFFECTION'S oF TIIF SCALP. 
 
 outer wall from congenital defect, or eroding disease, is open, and 
 permits the air, received from the middle ear, to escape beneatli 
 the scalp; and this air finds isolated lodgment there. It does not 
 insinuate itself irregularly in the structure of the scalp, as is seen 
 in empliN'sema, in which air has escaped from the air-passages 
 and diffused itself in the adjacent or overlying soft parts. The 
 air, in tne case under consideration, is contained in a common 
 cavity. Besides in the mastoid region, such air tumor has been 
 observed on the forehead, where air is derived from, and com- 
 municates with, the frontal sinus, which, congenitally or acci- 
 dentally, lias been opened and permitted the air from the nasal 
 passage to enter and remain. Such emphysematous tumor has 
 received the name of pneumatocephalus. An explanation offered 
 of the commencement of such tumor is that in violent expulsive 
 efforts from tlie lungs, when the mouth and nostrils are closed, 
 or partly closed, the compressed air escapes from the nasal passages 
 through the middle ear and unclosed mastoid antrum beneath the 
 covering scalp; or should there be an imperfection in the outer wall 
 of the frontal sinus, the air may find escape there, and the result 
 be a pneumatocephalous development, lying on the corresponding 
 side of the forehead. A diagnostic sign in each case would be 
 that the tumor could be reduced in volume by pressure, viz., its 
 air content could be forced from it, and the tumor thus made to 
 vanish. And to further verify the true nature of the tumor, a 
 testing puncture might be made with a hj'podermic syringe. 
 
 This air tumor, if let alone, would never endanger the pa- 
 tient's life. It is simply an annoyance to him through its conspic- 
 uous volume, or, perhaps, it may interfere with the dress of the 
 head. Should treatment be decided on, two ways are open, viz., 
 a simply conservative one, and a radical one. As conservative 
 treatment, there niay be made simple compression over the tumor 
 by means of a pad, which is retained in site by means of straps 
 and buckles. Or a more radical plan would be to lay oi)en the 
 cavity and dissect off its parietal surfaces, so that the walls, so 
 denuded, might be brought together in such a way that by their 
 coalescence the cavity would be occluded, and no space be left in 
 which air might • collect. For some time afterward, pressure 
 should be made over the part, so as to guard against a recurrence 
 of the tumor. This case, however, like inany others, is one in 
 which the prudent surgeon would rarely interfere, since such 
 interference is not free from peril. It can readily be seen that 
 inflammatory action mio;ht th3re be awakened in the mastoid 
 
PXEUMATOCEPHALUS; PEEICRANIUM. 147 
 
 cells in case of a pneumatocele over that region; and once appear- 
 ing there, the inflammation might readily enter the cranial 
 cavity and attack the encephalon. Hence surgical effort should 
 be limited to simple compression, as above mentioned. Should 
 the prurigo secandi tonnent the young, or the conscienceless old 
 surgeon, he maybe assured that this is an ill field for such adven- 
 ture; too near intrusion is forbidden to the household of life situ- 
 ated close by; the mariner does not carelessly trifle with the 
 wooden wall which distinguishes (separates) him from death. 
 
 Pericranium and Its Affections. — The lowermost layer of the^ 
 scalp is the pericranium, or periosteum of the cranium, which is 
 rather a dependence of the subjacent bone than of the overlying 
 scalp. This structure, closely allied to periosteal tissue elsewhere 
 has already been briefly referred to. Though loosely adherent to 
 the skull except where it is inserted into the sutures, yet the 
 •attachment is sufficiently intimate between this membrane and 
 the skull to permit of disease or lesion being often shared in com- 
 mon by them. And the same applies to the soft parts which lie 
 exterior to the pericranium. Yet it is the site of isolated injury 
 and disease, which we now proceed to consider. 
 
 Wounds. — Deep wounds of the scalp necessarily iniplicate the 
 pericranium; the treatment of such does not differ from that 
 already detailed. But especial care should be taken to cover the 
 bone, for exposure of bone to the air, or prolonged contact of the 
 same with the detritus or excreta of a wound, ends in death of 
 the bone so exposed; and such necrosis greatly prolongs the 
 time of healing, since weeks and even months are required to 
 complete the exfoliation of the dead surface, so that the part can 
 close. The attempt to shorten this time may be made through 
 erasion or exsection of the necrosing bone; yet such attempt is 
 usually fruitless, since the surgeon's instrument will never follow 
 the line which nature selects for the line of detachment. Indeed, 
 the exsecting chisel in the author's hand has seemingly prolonged 
 the time of healing, since the new surface made, sometimes, 
 exfoliated. To remedy necrosis, then, in case of a wound expos- 
 ing the skull, after scrupulous antisepsis, close the wound so as to 
 cover the bone. 
 
 There may be an unopened wound consisting of simple detach- 
 ment of the pericranium from the skull; and such separation 
 may be so slight as to be insignificant, or it may be very exten- 
 sive; in the latter case there might occur some effusion of blood 
 beneath the pericranium. Yet such effusion would not equal 
 
148 AFFKCTIONS OF THE SCALP. 
 
 that which can occur in the space of lax tissue just outside of the 
 pericranium; liii-morrhage here can be excessive, while that 
 beneath the pericranium is of limited amount. It could only be 
 in large rjuantity in a case in which the pericranium was torn so 
 that an intercommunication was established between the space 
 beneath with that outside of the pericraniun). In such cases a 
 mild, conservative treatment is indicated; only where the blood 
 is effused in excessive quantity would it be proper to evacuate it. 
 Simple compression, if properly anil patiently employed, will 
 di.ssipate the blood. 
 
 The mo.st frequent affection of cranial periosteum is inflam- 
 mation, which may be local or general; and this may be of an 
 acute or chronic type. Local as well as general periostitis may 
 be the sequent of some affection of the overlying scalp. For exam- 
 ple, it may arise from an abscess, ulcer, or wound; it is frequently 
 of syphilitic origin. Scrofula and rheumatism are occasiona4 
 causes of it 
 
 From whatever cause the periostitis arises, the usual con- 
 ditions of inflammation are present; of these the most important 
 is proliferation, or cell-growth, in the affected structure. Thence 
 ihere is thickening. This cell growth may be absorbed, and then 
 the membrane returns to its normal condition. Or the new cel- 
 lular elements may undergo organization and become added to 
 the periosteum, and cause permanent thickening. Such an 
 event is rarely a source of trouble to the patient. Another event 
 is osteal growth, in which the new material is converted into 
 bone. Such bony growth appears in laminated, spinous, or irreg- 
 ular form; and it is attached to the external plate of the cranium, 
 and remains as a permanent addition to the same. Such devel- 
 opment is named an osteophyte or bone growth; the term exostosis 
 is also applicable to it. It is seldom so large as to become a 
 source of trouble; and it could only become so when it arises as a 
 sharp spine, or thorn-like process pricking the parts which rest 
 on it. In fijit or laminated form it would be wholly witliout 
 action on the superjacent parts. Where the growth is of sharp 
 spine form, then it should be excised, as it became necessary in a 
 case .seen by the author in which the offending growth was situ- 
 ated on the upper and lateral part of the occipital bone. After 
 exposing the growth it was exsected, and the wound treated as a 
 simple one. The complete healing was tedious. 
 
 Periostitis may assume on the cranium, as elsewhere, a differ- 
 ent form. The inflammatorv action in some cases is confined 
 
CRANIAL PERIOSTITIS. 149 
 
 chiefly to the outer structures of the pericranium; but in others 
 it chiefly attacks the deeper layer; and the course will difl'er in 
 the two cases; for if the inflammation is chiefly in the deeper 
 texture of the periosteum, then its march will be trammeled by 
 the sutural adhesions. On the outer face there is no such limita- 
 tion; the disease spreads rapidl}^ over a larger part of the pericra- 
 nium. This diffuse periostitis quickly ends in suppuration; the 
 pus formed rapidly diffuses itself beneath or ujDon the pericranium. 
 When outside, the diffusion may be so extensive that a large part 
 of the overlying scalp may be uplifted by purulent fluid. 
 
 In the early stage of periostitis, the most efficient agent to 
 check the inflammation is iodine. The action of this agent is 
 obtained when it is applied externally, in tlie form of the tincture 
 or ointment of iodine. The iodide of potassium may likewise be 
 given, in dose of ten grains, three times daily. By this treatment, 
 both in local and general pericranitis, suppuration may be averted, 
 or greatly limited. But when pus has formed, it should be 
 evacuated by one or more incisions; several openings will be 
 required when the pus is widely diffused. And through the 
 openings there made, an antiseptic fluid should be freely injected. 
 This may be a sublimated solution, or iodized solution, or one of 
 chloride of sodium. Along with the pus, fllamentous shreds of 
 dead tissue will also be detached and discharged. If such shreds 
 are not fully detached, violent traction should not be made on 
 them, since such pulling may open vessels which may bleed and 
 retard the healing. The work of opening should be done early, 
 since then the destruction of tissue is lessened. In the worst 
 cases of diffuse suppuration, sections of the scalp die; and then, 
 after recovery, some deformity will remain. When the pus lies 
 for a time in contact with the outer face of the skull, some necrosis 
 ensues, and the healing will be retarded. In such cases the outer 
 surface of the bone, dying, is slowly detached from the adjacent 
 sound bone; and the detachment of such bone is best confided to 
 nature. 
 
 A frequent form of disease of the pericranium is gummy 
 periostitis. Syphilis announces and records its possession of the 
 subject by various eruptions on the skin, clearly visible and legi- 
 ble by the eye; these eruptions, called syphilides, differ much from 
 each other in nature and appearance. But subcutaneously, the 
 disease has but one leading characteristic, viz., a neoplastic pro- 
 duction, the so-called gummy growth. Or, put figuratively, the 
 syphilitic pathological tree is rich in fruit of various hue and 
 
150 AFFECTIONS OF THE SCALP. . 
 
 form; if we should select a characteristic specimen of these prod- 
 ucts, it would be the gummy growth. The other rashes have 
 their non-syphilitic analogues; but the gomrae, or gumma, is an 
 isolated original, without correlate, kinsman, or analogues in the 
 pathological household. The ])ericranial gomme appears in two 
 forms, the circumscribed and the diffused. 
 
 The circumscribe|l gummy growth commences in tlie deeper 
 surface of the periosteum, and thence developing and growing 
 in conical form, it presses on the subjacent bone and causes 
 absorption of its tissues; one has here, on a small scale, })rogress- 
 ive osseous rarefaction. The gummy structure, when of limited 
 volume, undergoes the fatty change, and, later, it is absorbed. If 
 of larger volume, the growth might sup})urate and open exter- 
 nally. This disappearance by absorption is the usual event; and 
 the process is then named by Virchow syphilitic dry caries. The 
 site of such vanished gomme is indicated by an irregular, bony 
 growth, in the form of minute plates or spine-like points, which 
 circumvallate the depression in the bone. 
 
 The gummy growth can develop in diffuse form; it primarily 
 commences then, in and beneath the periosteum, as a soft ge- 
 latinous structure, which soon appears as a pulpy layer of a 
 whitish hue. Beneath this the bone undergoes rarefaction; and 
 in the spaces opened in the bone the gummy material likewise 
 develops in nodular or conical shape. These masses of gummy 
 material are traversed by minute blood-vessels which remain 
 permeable. The gummy matter is thus distinguished from 
 tubercular material, in which no vessels are found. This diffused 
 form of gummy periostitis may recede, and absorption of the 
 new material occur; and then osteophytic growths remain to 
 mark the surface. Or the mass can suppurate, open and be elim- 
 inated. The pus thence evacuated is viscid, and resembles acacia 
 gum in solution. 
 
 The treatment in such cases should be topical and general. 
 The local application of iodine acts most satisfactorily in perios- 
 titis arising from any cause, but in no case does it act so benefi- 
 cially as when the case is syphilitic. Applied either in the form of 
 ointjnent or tincture, it acts as a resolvent of the new growth. 
 That such action does occur has been proved by direct observa- 
 tion with the microscope of living tissue, to which iodine had 
 been applied. If the tincture of iodine be used, then, from time 
 to time, the dried epidermal crust must be removed, else such 
 material soon becomes an impenetrable obstacle to the action of 
 
PERICRANIUM AND ITS AFFECTIONS. 151 
 
 the remedy; and, on this account, the ointment acts better. This 
 local treatment must be long persevered in, in order to obtain the 
 full action. Meantime antisyphilitic remedies should be taken 
 internally; these should consist of a combination of mercury and 
 iodine. Sj^philitic pericranitis whether limited or diffused, treated 
 early, in the manner mentioned, will be made to recede and 
 vanish in most cases. If the disease is not thus checked, but 
 proceeds to suppuration, the condition becomes graver; for the 
 suppurative action is rarely limited to the soft structures, but also 
 attacks the adjacent external plate of the skull and causes death 
 o5 the same; in fact, a limited portion of the entire thickness of 
 the cranial wall may then die and be detached. And though 
 such breach, both in the scalp and skull, is repaired by fibrous 
 tissues, yet the site of the disease is permanently impaired, espe- 
 cially the bone, which will never be restored to its normal integ- 
 rity. When the entire wall is thus perforated, it is probable that 
 there is likewise similar disease of the dura mater lying under- 
 neath, that is, both intracranial and extracranial gummy develop- 
 ment. 
 
CHAPTER lY. 
 
 CRANIUM. 
 
 Having concluded the surgical studies of the scalp, we will take 
 up the cranium, premising with some general remarks in regard 
 to the form, structure, and general characteristics of the skull. 
 The form of the cranium is that of an ovoid, of which the larger 
 end is directed backwards; in a few cases, the anterior and pos- 
 terior ends are similar in extent and form. The transverse and 
 antero-posterior diameters may be nearly equal in the brachy- 
 cephalic skull; or the antero-posterior diameter may be much the 
 greater, and the form is named the dolicho-cephalic skull. The 
 anterior and posterior laces may be rounded or approach to a 
 quadrangular form. The vault of the skull may be flatly 
 rounded; or it may have a ridge-like elevation in the median 
 line from before backwards. 
 
 The rounded contour of the vault of the cranium is exchanged 
 below for a more irregular and flattened form; the surface below 
 is more broken and abruptly interrupted than is the upper one. 
 Tiie inner surface of the skull is more uneven and interrupted 
 than the external one; this applies especially to the base, where 
 anteriorly, the orbital wings of the s[)henoid, and behind, the 
 petrous portions of the temporal bones, abruptly break the surface 
 and form topographical boundaries of the parts contained there. 
 
 Structurally, crania differ greatly; some are much thicker 
 than others; this is a national characteristic, as well as an indi- 
 vidual peculiarity. From a limited range of observation, the 
 author ventures to decide; that those who labor with their heads 
 have thinner skulls than those who labor with their hands. In 
 two instances, of unusual intellect, the tenuity of the cranium, 
 as revealed by necropsy, was remarkable. 
 
 The cranial vault and base differ greatly in regard to inter- 
 ruption of structure through canals and direct openings. Such 
 interruption is wholly exceptional in the upper half of the 
 cranium. 
 
 ( 152) 
 
TRAUMATIC LESIONS OF THE CRANIUM. 153 
 
 These varieties of conformation, surface, and of thickness at 
 points, or in totality, have a direct bearing on, or relation to, 
 the capacity of the skull to resist violence; one skull may suc- 
 cessfully resist violence which another could not withstand. 
 
 The power to resist is influenced by the sutures, or possibly 
 is due to the inter-sutural material. As is known, the bones of 
 the foetal head are but imperfectly developed, and are united by 
 sutures which are also incomplete. This disposition permits of 
 the safe transit of the foetal head through the pelvic passage; 
 without such arrangement, in most cases the child's life would 
 be lost. And the continuance of the sutures for many years, also 
 acts protectively. The natural fusion of the cranial bones com- 
 mences at from forty to fifty years of age; and this process, called 
 synostosis, continues through many years, being, in the majority 
 of cases, only ended when the subject has reached seventy or 
 eighty years of age. After this synostosal fusion, the skull has 
 the appearance as if cast in one piece, and it is much more fragile 
 than it is prior to such fusion. This is demonstrated by taking 
 two dried skulls, one of a young subject and another of an old one, 
 and allowing them to fall the distance of four feet upon a stone 
 pavement; the skull of the young subject will rebound almost to 
 the starting point, and not be broken; but the other skull will 
 break, and as it does so it yields the sound of a broken kettle. 
 Besides the vanishing of the sutures, the lessened amount of the 
 organic constituents of the bone may probably account for the 
 increased fragility of the bones of the aged skull. 
 
 In early foetal life the skull is a simple fibrous capsule; in the 
 subsequent course of development, cartilage replaces this fibrous 
 structure in the lower part and base; and, later, this ossifies. On 
 the contrary, the parts constituting the vault directly undergo 
 ossification without an intermediate stage of cartilage. And this 
 may account for the tardiness of repair which occurs after fracture 
 of the vault and sides of the skull; months are required for recov- 
 ery after such injury, and even then the work is imperfectly done. 
 Fibrous tissue, and not bone, is the medium of union between 
 fragments of the fractured cranium. And also the portion of 
 bone removed by the trephine usually remains absent; and unless 
 the excised portion be replaced with certain precautionary prepa- 
 rations, the breach, in future, will only be replaced by fibrous 
 tissue. 
 
 Traumatic Lesions of the Cranium. — The cranium may be the 
 subject of contusion, penetrating wound, incised wound and 
 fracture. 11 
 
154 ('KANIUNf. 
 
 Contusion liere originates from direct viOience; ana it may be 
 limited to a small surface, or a considerable extent of bone may 
 thus be implicated. The diagnosis of such injury is diiiicult, in 
 fact, impossible, when the overlying scalp has not been opened; 
 and in such a case the contusion nmst be inferred from the sub- 
 sequent action of the injured bone. Tiie contusion consists in a 
 derangement, or limited displacement, of the constituents compos- 
 ing the bone. The lesional work does violence to the minute 
 vessels contained in the bone, and the circulation of blood 
 being disturbed in the bone, the nutritive processes of the latter 
 are altered and interfered with. And according to the nature 
 and extent of the local nutritive disturbances, so the subsequent 
 character of the lesion will take shape. For example, if the 
 injury is a slight one, restoration to perfect integrity will ensue 
 after a few weeks. But if the violence has been greater, then 
 acute inflammation of the bone will occur, and, as a result, there 
 may remain subsequently, at the place, an increase of osseous 
 structure; and this increased thickness may be jjermanent. And, 
 finally, the molecular injury may be so great that restitution to 
 the former state is impossible; there occurs then necrosis of the 
 injured part, with final exfoliation and detachment of a layer of 
 bone. In the several instances cited, the contiguous periosteum 
 participated in the alterations; and in case of necrosis, the j^erios- 
 teum will inflame and suppurate, so that it will be necessary to 
 incise the membrane and set free the contained pus. 
 
 The penetrating wound of the cranium may be caused by a 
 round instrument similar to an awl; or it may be caused by a 
 sharp blade; or the injuring instrument may be angular, as a 
 spike or a nail. If the instrument be small, then the resulting 
 lesion may consist of a simple displacement of tiie substance of 
 the bone; and when the injuring agent is removed, the wound 
 closes partially or incompletely, so that a fine probe could not 
 j)ass through it. This closure is due to the inherent elasticity of 
 the bone. Such penetrating wound may pass partially or com- 
 pletely through the thickness of the skull; the partially piercing 
 wound is not a dangerous one, while that which passes through 
 the cranial wall may in two ways be dangerous; it may fracture 
 and detach a fragment from the inner plate of the skull; and, 
 secondly, it may pass still deeper and wound the encei)halon. 
 The detached fragment of the internal surface of the skull 
 becomes an element of intense peril. The pulsatile motions of 
 the adjacent brain would cause such piece of bone to become a 
 
TRAUMATIC LESIONS OF THE CRANIUM. 155 
 
 constant source of irritation; tliere are no conditions present 
 wliicli favor or allow of the fragment becoming encysted. The 
 final end would be the formation of a pus cavity, which might 
 attain great dimensions and cause extensive destruction of the 
 brain. The true condition in such a case might not be suspected 
 in the commencement, since, for a time, no symptoms would 
 manifest it, but when suppuration occurs, this would be indicated 
 by impairment of some function of the brain. Another occasional 
 complication of such penetrating wound is that the injuring 
 instrument may break, and a fragment of it remain in the wound. 
 Such fragment may protrude beyond the inner wall, and, remain- 
 ing there, become a violent irritant of the brain; to do so, the 
 broken point must pierce through and beyond the dura mater. 
 
 Among such penetrating wounds of the skull may be included 
 those which enter the orbit, and, having pierced the soft parts, 
 they perforate the bony wall of the orbit at some point, and enter 
 the cranial cavity. Such a wound has been caused by a piece of 
 wire, a sharp fragment of hard wood, an umbrella staff, the 
 point of a saber, etc. An infant of the royal family of France was 
 killed by a needle which was thrust through the orbit into the 
 brain. And Henry the Second, of the house of Valois, was killed 
 in a tournament by a fragment of a lance entering his brain 
 through the orbit. He was treated by Ambrose Pare, with the 
 great anatomist Vesalius as consultant, both princes in medicine. 
 The execution of four criminals sentenced to death was hastened, 
 so that their heads might serve for experimental work to aid in 
 discovering the broken lance point; yet in vain, for the wounded 
 man died on the eleventh day. 
 
 From what has been said of the penetrating wound of the 
 skull, it is manifest that, though the lesion may be minute in its 
 proportions, yet in its fatal consequences it may equal in fatality 
 wounds of much greater magnitude. The author has knowledge 
 of what seemed to be an insignificant injury of this class, in which 
 the small blade of a knife was forced through the occipital bone, 
 and, breaking off, the point remained. For some days the man 
 suffered no inconvenience, then cerebral inflammation developed, 
 which soon ended the victim's life. The necropsy revealed the 
 broken point of the knife fixed in the skull and slightly penetrat- 
 ing the surface of tlie brain. Similar cases, of which examples 
 abound in surgery, illustrate the importance of the early recogni- 
 tion of and careful treatment of these wounds, and furnish veri- 
 fication of the Hippocratic aphorism that no wound of the head 
 should be carelessly treated. 
 
l.JG CRANIUM. 
 
 In the treatment of tlie penetrating wound of the skull a car- 
 dinal rule should be that tlie surgeon see and examine the in- 
 strument which caused the injury. Thus one may decide whether 
 a fragment has been left in the wound ; also, whether the entering 
 object was clean or unclean. Anotiier rule is that, where the 
 wound in the scalp is a slight one wliich does not permit a 
 view of the injured skull, and there be a suspicion that the pen- 
 etrating agent has been broken, then the track of the wound 
 should be laid open, and the cranial wound inspected: and should 
 it he probable that a fragment remains concealed in the wounded 
 bone an opening should at once be made, and the case treated 
 as will presently be explained. Though there remain a broken 
 fragment of the instrument, or a piece of the inner plate be 
 detached, yet for a few days probably, no symptom will indicate 
 this; for intra-cranial reaction from any cause is only slowly 
 aroused; and when once awakened, surgical intervention is often 
 too late. Hence the urgent need of an early determination of the 
 conditions. If it be evident, or even probable, that a fragment 
 of the penetrating object has l)een left in the wound, then if it 
 cannot be seized and extracted, the crown of a small trephine 
 must inclose the wound, and a small section of bone, including 
 the object, be removed. If the j^enetrating object be not wholly 
 buried in the bone, then with a proper instrument it should be 
 seized and extracted. Or if it be visible and yet so buried that it 
 cannot be grasped, then the bone adjacent may be removed with a 
 chisel, so that the body can be grasped; for the removal in tliese 
 ways would be less hazardous to the patient than if the work be 
 done with the trephine. If, however, some days have elapsed, 
 and symptoms of encephalic irritation are appearing, then tlie 
 tre])hine should be used, and, if pus be found, the part should be 
 careful!}^ cleansed, sprinkled with iodoform, and so dressed as 
 to })ermit of free drainage. The patient's head should rest in 
 such a position that any material, excreted by the wound, shall 
 spontaneously escape. The details for this work will be more 
 fully given under the head of Trephination. 
 
 In case the penetrating agent has entered the orbit and there 
 be signs that it has passed through the orbital foramen or sphe- 
 noidal fissure, or has pierced the thin, bony septum which at cer- 
 tain points separates the eye from the brain, then such wound 
 becomes a matter of the gravest consideration to the surgeon. 
 Should there be a visual or motor disturbance of the eye, such 
 lact would be of diagno.stic assistance. Should the causal agent 
 
INCISED WOUXDS OF THE CRANIUM. 157 
 
 have left a fragment behind, then its extraction must be at- 
 tempted; and even if the eye must be injured in the work, still 
 it must be done. It is probable, however, that where the object 
 has penetrated the supra-orbital plate, by an incision made 
 either below the lid or through its base, the roof of the orbit can 
 be reached, explored, and a foreign body found and removed. 
 
 Incised Wounds of the Cranium. — The incised wound of the 
 skull necessarily includes the scalp. Such wounds occur in 
 many grades, from slight to ver\" extensive. The wound may 
 merely attack the surface of the bone, or the latter may be 
 divided through its entire thickness. The bone may be wounded 
 perpendicularly or obliquely. AVhere the bone has been wholly 
 divided, the adjacent brain may be wounded also. AVounds 
 which are superficial, both the perpendicular and the oblique, 
 are seldom dangerous to the patient. Far more grave are those 
 which penetrate through the cranial wall. AVhen the wound 
 passes through the wall, the inner plate being pierced, a frag- 
 ment may be wholly detached, or remain adherent ; in each case 
 the complication is a dangerous one. 
 
 The most important class of incised cranial wounds is that in 
 which the cutting has been done obliquely, so that the wound 
 assumes a flap-like form ; and the bone which has been wounded 
 may be completely sliced off, or it may be only incompletely 
 separated from the remaining skull. AVhen not entirely sepa- 
 rated, the flap has a hinge-like pedicle, so that the wound may 
 be opened and closed. When the flap has been wholly severed, its 
 thickness will be a measure of the injury to the brain; such in- 
 jury may vary from a simple exposure of the dura mater to one 
 in which a section of the brain has been sliced off. An incom- 
 pletely severed osseous flap may become entirely separated 
 through fracture. The sharpness or bluntness of the incising 
 blade will have an influence on the surface of the wound; frac- 
 ture of the border of the divided bone arises from a blunt instru- 
 ment. 
 
 The treatment of the incised cranial wound, in case the latter 
 be superficial, is simple: it may be limited to antiseptic cleansing 
 of the wound in the scalp, and closure by suture, or tying the 
 hair so as to accurately unite the edges of the wound. In case of 
 a perpendicular wound that has pierced through the wall, one 
 must carefully examine with a fine probe for fragments of the 
 fragile inner plate. Such fragment is so often present that, 
 though it cannot be found in this exploratory search, yet it is 
 
158 CJtANlLM. 
 
 better to omit nothing in this search; and though it would add 
 to the existing wound, still it would be better to convert this into 
 a less perilous one by using a small trepliine over the suspected 
 point, and extracting the detached or partly detaclied fragment. 
 If this exploration seem premature, or pushed beyond the line of 
 caution, it may be answered that if it be delayed until encephalic 
 symptoms plead for interference, such interference will almost 
 certainly prove to be too late. But if the exploration be done 
 just after the receipt of the wound, it adds but little to the 
 primary wound; but if done later, it seldom does more than to 
 arouse to action and intensify the latent inflammation. In this 
 work conservative judgment and vigilant promptness should 
 have full participation; promptness in action should, liowever, 
 lead. 
 
 In case of cleft or iiap-wounds of the cranium, in regard to 
 the manner of treatment, surgeons have not been in accord: where 
 the bone flap is still adherent to the cranium, the usual rule is to 
 remove splinters or fragments of bone, hair and other foreign 
 matter that may be in the wound, and then replace the bone, and 
 close the wound in the scalp. Sucli wound should afterwards be 
 attentively observed; and should signs of encephalic trouble 
 arise, the wound must be reopened and a free outlet made for 
 subsequent drainage. But in those cases in which the section of 
 bone has been wholly separated from the rest of the cranium, and 
 yet the scalp wound is incomplete, viz., the severed bone is covered 
 by integument which is adherent to the rest of the scalp, then tlie 
 course of treatment has been a matter of sharp controversy among 
 military surgeons. The plan of Pare was to replace such a flap, 
 and endeavor to obtain reunion of the bone. Fallopius and 
 cotemporaries of Pare opposed this plan; they advised to remove 
 the bone and close the wound by the remaining flap. The latter 
 has been the plan pursued by most surgeons, and the results have 
 been more satisfactory than where an attempt has been made to 
 save the bone; since, not unfrecjuently, such bone has died, so 
 that it afterwards became necessary to reoijen the w^ound and 
 remove the necrosing bone. Guthrie, a famous English authority, 
 counsels to examine such flap, and if the bone is extensively sep- 
 arated from the rest of the flap, then it should be removed; but 
 if it lias unfractured edges and is well adherent to the tegumen- 
 tary flap, then the bone should be retained and an attempt be 
 made to reunite it; by this plan, wdiich is commonly successful, 
 the integrity of the cranium will be restored. Tlie po.sition of 
 
FK.ACTURE OF THE CRANIUM. 159 
 
 the foot-stalk of such flap must have considerable bearing on the 
 life or death of the bone adherent to it; when the pedicle lies 
 peripherally, the bone will be less apt to survive the violence 
 than when the pedicle is directed towards the heart, since in the 
 latter the supply of blood will be better. The smoothness or 
 roughness of the incised surfaces will favor or oppose reunion. 
 Unless the position of the pedicle and the nature of the cut 
 surfaces be very favorable for reunion, it woujd be safer to sacri- 
 fice the detached section of bone; the bone then should be 
 cautiously dissected from the tegumentary flap, care being taken 
 to preserve the periosteum. If the work be thus done, one might 
 hope that some bone would be formed beneath the retained peri- 
 osteum, similarly to what occurs in the rhinoplastic operation, in 
 which the periosteum is preserved with the flap taken from the 
 forehead, as was practiced by Langenbeck. 
 
 Fracture of the Cranium,. — This is one of the oldest chapters in 
 the history of surgery, and in many respects was as well described 
 four hundred years before our era as it can be done to-day; for 
 in Hippocrates one finds that which the modern writer, in the 
 main, repeats. The cranium, in which nature has stored the most 
 precious portion of the human organism, is frequently broken by 
 accidental violence, or by that which is intentionally inflicted by 
 man on himself or on his fellow. 
 
 The skull may be broken by direct or indirect violence; the 
 former is by far the more frequent. Examples of fractures 
 through direct violence are those in which a club, missile, or 
 some falling body strikes the head and breaks the cranial wall. 
 Again, the cranium may be fractured by a fall from a height, 
 through railway accident, or the overturning of a carriage. 
 Fracture from indirect cause is where the violence is transmitted 
 from some more remote point to which the force was primarily 
 communicated; such force may be first communicated to the 
 crown of the head, the face, especially the chin, or to the feet. 
 
 There are varying grades of fracture, viz., fissure, stellate, or 
 fracture in star form, fracture with depression, and communicated 
 fracture with or without depression. The cranium may be broken 
 in more than one place at the same time. The wall may be 
 incompletely fractured, in which the outer plate only is broken, 
 or the inner plate may be cracked wdiile the outer one remains 
 intact. Also, there may be inequality between the fragments of 
 the inner and the outer plate; as a rule, the outer fragment is the 
 larger one; yet the outer one may be small and the inner one 
 
160 CRANIUM, 
 
 much greater in magnitude. The fracture of the skull may be 
 the only injury, since it may exist while the scalp, dura mater 
 and brain are injured. Or the scalp may be openly wounded 
 over the cranial fracture; or the skull may be broken along with 
 lesion of the dura mater and brain, while tlie overlying scalp is 
 unopened. Each of the fractures enumerated are dangerous, and 
 not unfrequently end the life of the patient, though tlie danger 
 is far from being directly proportionate to the extent of tlie frac- 
 ture; for a slight fissure has destroyed life, while a great fracture 
 in which a large breach has been made in the wall through loss 
 of bone, has not killed the subject, as might have been appre- 
 hended. Hence, accurate certainty in prognosis cannot be 
 attained in these injuries; though extent and range of experience 
 may aid the surgeon, he can never infallibly foretell the ultimate 
 events of a fractured skull, and even though life be retained, yet 
 often the nijury leaves an indelible defect in the mentality of the 
 victim. 
 
 As has been said before, there is a small class of cranial frac- 
 tures in which the causal violence strikes the body at some point 
 other than tliat which is the site of fracture; thus a blow on the 
 summit of the head, on the chin, or a fall on the feet, knees, or 
 ischia.may cause fracture at tlie base of the skull. This fracture 
 has been the subject of much controversy. It was once tauglit 
 that when the point of first impact was the head, the violence 
 traveled from the point of primary contact to the" bone which was 
 broken, without lesion of the intermediate structures. More 
 accurate observation has rendered this uncertain, and, especially, 
 experiments made on the cadaver have rendered it doubtful. 
 Aran, in 1S44, published the results he obtained from a series of 
 experiments; he concludes that "a fracture never occurs at the 
 base of the skull without there being likewise a fracture at the 
 point which was first struck, A fracture of the vault of the 
 cranium may travel by radiation to the base; even the sutures do 
 not oppose the passage of the radiating fracture; tlie line of frac- 
 ture takes the shortest course; that is, it follows tlie curve of the 
 shortest radius." This, though nearly correct, is not wholly so, 
 since both by experiments made on the dead body, as well as 
 through necropsy of those who had died from cranial fracture, 
 such isolated injury has been found at the base of the skull. 
 Hence the old surgeons were right in their doctrine of independ- 
 ent fracture at the cranial base from transmitted or indirect force, 
 though it is much more rare than they thought; we are, therefore, 
 
FRACTURE OF THE CRANIUM. 161 
 
 not justified in erasing from the page of surgery, as some would 
 do, the word contre-coup, the French term by wliich the injury is 
 commonly designated by tl:ie English writer; or counter-fracture, 
 as the name becomes when anglicized. 
 
 The symptoms of fracture are of two kinds, physical and 
 rational. The physical signs are those which reveal themselves 
 to the sight and touch of the surgeon. When the scalp is entirely 
 opened, and the skull can be felt and seen, then the character 
 and extent of the injury can readily be learned, especially wdiere 
 the breach is an extensive one; by palpation and inspection, it 
 can then be learned whether there be depression of bone, and 
 whether there are fragments in large or comminuted form. The 
 most valuable knowledge obtained by this inspection is whether 
 there is anything escaping through the opened cranial wall. For 
 example, if cerebral matter be seen exuding, this indicates that 
 the inclosing membranes and the brain have been penetrated ; 
 or if a serous fluid only is escaping, tliis denotes, probably, an 
 isolated injury of the dura mater, and that the fluid escaping is 
 the cerebro-spinal liquid. Thus, when the bone is exposed, the 
 extent and gravity of the injury doiie can be accurately estimated. 
 The case, however, in which sight and touch may err, is where 
 the fracture is a simple fissure. A suture has been mistaken for 
 such fissure, and this is more apt to occur in regions which are 
 the occasional site of abnormal suture. For example, in a small 
 percentage of cases, the sagittal suture is continued through the 
 frontal bone; and, as a rare anomaly, there may be a transverse 
 suture dividing the occipital bone into two portions. Saucerotte 
 mentions one instance of the latter in a clergyman, who, after a 
 fall on his occiput, was on the eve of being trephined, yet one of 
 the consultants claimed that the supposed fracture was a suture: 
 the patient was rescued from the trephine, and in his gratitude 
 willed his skull to the surgeon who prevented the operation. As 
 errors have been made on this side, so it can be conceived that 
 they might be made in mistaking a fissure for a suture. For 
 instance, in the old subject's skull, a suture that has been closed 
 might be reopened in fissured form. In former times, when the 
 trephine was the inseparable follower of the fissured fracture, the 
 diagnostic determination of the latter was pushed to the verge of 
 pedantic refinement. Some staining material, as ink, was poured 
 on the suspected point; a rasp-like instrument was next used, 
 and the surface removed; if there was a fissure this was discov- 
 ered by traces of the ink which had penetrated. Since the use 
 
1G-! CKANIUM. 
 
 of the trephine has ceased to be a fashion, and this instrument 
 has been restricted to exceptional employment, such adventurous 
 method of diagnostic exploration, as that referred to, has ceased. 
 
 Formerly, where a cranial fracture was suspected, and tlie 
 scalp was unopened, the practice obtained of opening the soft 
 parts, so that the bone suspected of injury, could be seen. This 
 practice is now wisely limited to those cases in which the 
 patient's symptoms indicate internal injury of the head, whicli 
 demands surgical interference; in the absence of such indication, 
 the conversion of a subcutaneous fracture into an open one would 
 be a wanton meddlesomeness deserving of strong reprehension. 
 
 A partial breach of the scalp, caused by some direct violence, 
 has been mistaken for a fracture with depression; and only 
 through some tactile experience can such error be avoided. In 
 such injury of the scalp, the finger sinks into what seems mani- 
 festly to be a sunken condition of the bone. There will, however 
 be found a quick transition from the apparent depression in the 
 bone, to the normal structure of the scalp. The finger rests in a 
 hollow arising from a partial breach of the scalp, and the broken 
 tissues, somewhat abruptly bounding and walling the sunken 
 point, are indurated. In such pseudo-depression tlie bounding 
 wall is more rounded and less resistant than is the case in cranial 
 fracture with depression of the bone. 
 
 The old surgeons had a number of odd signs w^hich they 
 valued as indications of fracture; for examjDle, the pain that was 
 awakened at the site of fracture when the patient crushed some 
 hard object between the molar teeth ; or when a handkerchief 
 was seized between the teeth and this was jerked, pain was felt at 
 the place of fracture. Or if the patient was unconscious, and 
 moved his hand to some part of the head, this was thought to 
 signify fracture at the point touched by the patient. These signs 
 have lost their former value; in fact, but little importance is now 
 attached to them. 
 
 When some time has elapsed since the injury was received, 
 continued swelling or cedema over the site of it has been 
 thought significant of subjacent fracture. Or if the bone is open 
 to view, its condition, even if unfractured, is suggestive ; for if 
 dry, gray or yellow, encephalic lesion may be inferred ; subjacent 
 pus may be suspected. 
 
 When the fracture is seated in the lower part or base of the 
 skull, though some of the conditions above described are present 
 yet it has peculiarities and cliaracteristics which require some 
 
FRACTURE OF THE CRANIUM. 163 
 
 further description. Such fracture may be from direct or indi- 
 rect violence. In that from direct force the fracture may be with, 
 or without, an opening through the external soft parts. Tlie 
 causal agency is oftenest some missile or projectile. As the base 
 of the skull is nearly inaccessible to sight and touch, exploration 
 of injury there is much more difficult than when it is in the 
 cranial vault. And even when in the borders of the base, the 
 thickness of the overlying soft parts interferes with accurate pal- 
 pation. Tlie sterno-cleido mastoid, splenius and complexus 
 muscles both protect and pretty effectually hide the bones 
 beneath them. 
 
 From indirect violence or transmitted force, as before men- 
 tioned, the irregular structure composing the base of the skull 
 may be broken. Such fracture would be indicated especially bv 
 functional disturbance of adjacent parts. Thus nerves and blood 
 vessels may be compressed or torn, and, in case of the nerves, the 
 result would be the abolition or perversion of their normal office; 
 thus might arise disturbance of motion and common and special 
 sensation. There is some interruption of the media or routes of 
 intercommunication between the head and the trunk and limbs. 
 
 Fracture occurring at some point of the base of the cranium 
 may be indicated by ecchymosis, htemorrhage, efl'usion of serous 
 fluid, or crushed cerebral matter. 
 
 If the fracture be located behind, there may be ecchymosis of 
 blood, visible through the skin, in the inferior occipital region, 
 and especially behind the ear. Or if the fracture be in the 
 anterior structures of the base, then the ecchj^mosis may appear 
 in the eye, or in the pharynx. In all these cases, the ecchymosis 
 does not instantly appear; it only does so after the lapse of a 
 brief time; the blood, having penetrated the tissue from within, 
 gradually travels thence and finally appears at the surface. Such 
 ecchymosis should not unreservedly be depended on as furnish- 
 ing certain evidence of fracture. The author has seen cases in 
 which ecchymosis was present, where he was convinced that no 
 fracture existed, but that the effused blood was from superficial 
 vascular lesion due to violent concussion. This is frequently the 
 case where the effusion is sub-conjunctival. 
 
 Hcemorrhage from the ear, nose and pharynx, denotes lesion 
 of blood vessels caused by fracture of bone adjacent to the site of 
 the escape of blood. From the ear, it would imply that some por- 
 tion of the temporal bone had been broken, but if this symptom 
 be too implicitly followed, it mav mislead; for bleeding from the 
 
1G4 CRANIUM. 
 
 ear has been seen, several times, by the author where tlie injury 
 was not deeper than the external auditory canal. Bleeding from 
 the ear may be caused by rupture of the typaiium, by lesion of 
 the auditory canal, by fracture of the adjacent mastoid process, 
 and it can arise from other injuries of the head in which the skull 
 is not broken. Where there is fracture of the base, there may be 
 only tire appearance of specks of blood in the external outlet 
 and lobule of the ear. In other cases, the blood slowly trickles 
 from the auditory meatus, or it may flow in a constant stream; 
 and in tlio latter cases an artery, or sinus, has been opened 
 coincidently with a fracture of the skull. 
 
 The blood may escape from the nose and moutli tlirough 
 fracture of the base; and there may likewise be simultaneous 
 issuing of blood from the nose, mouth and ear, due to frncture of 
 the base; still it must be remembered that such ha3morrliage may 
 arise from otlier causes than cranial fracture. 
 
 The escape of serous liquid from the ear and nose indicates 
 fracture; that from the ear denotes fracture of tlie petrous portion 
 of the temporal bone. It may have been preceded or accompa- 
 nied by haemorrhage; it is of more diagnostic certainty when 
 unaccompanied by bleeding. The fluid, for a time, was thought 
 to be from tlie internal ear that had been opened; it is now known 
 to be the cerebro-spinal fluid, since it has been shown to be 
 chemically identical with the latter. Large quantities of this 
 fluid have sometimes been lost. The same fluid may escape from 
 the nose; then the sphenoid bone is the site of fracture. The 
 flow of this serous fluid may continue for hours, or even days. 
 When it appears some hours after the injury, and there has 
 been antecedent hemorrhage, and the escape of the liquid is 
 variable in amount, then it is more equivocal, and must be 
 reckoned as a certain sign of fracture. 
 
 Observations made in regard to the temperature of the subjects 
 of cranial fracture have revealed the following facts: During the 
 period of shock and depression which immediately follows severe 
 cranial injury, the heat of the body sinks below the normal rate, 
 viz., to 97° Fahr. or even lower; then there is a moderate rise, 
 which, not unfrequently,is followed by a depression of temperature, 
 which continues for some days. The increase of temperature 
 depends on the lesion of the encephalic structures, rather than on 
 that of the cranial wall, and rise of temperature, gradual or 
 abrupt, denotes morbid action of the parts outside of or within the 
 skull; abscess or erysipelas in the scalp would thus be indicated ; 
 
FEACTUEE OF THE CRANIUM. 165 
 
 and so meningitis, encephalitis and intracranial abscess might 
 reveal themselves by increased heat. Such augmented tempera- 
 ture might arise from both intra-cranial and extra-cranial morbid 
 action, and, hence, in erysipelas or abscess of the scalp, one would 
 not be justified in referring the rise of temperature wholly to 
 these extra-cranial conditions. In his study of the fractures of 
 the base of the skull, Battle has met with a few cases in which a 
 few hours after the receipt of the injury, the temperature rose to 
 the enormous extent of ten degrees above the normal rate; he 
 says that such great increase of heat portends a fatal termination, 
 and is due to severe contusion of the brain. 
 
 The functional disturbance in cases of cranial fracture depends 
 on the amount of injury done to the brain. The violence seems 
 often to expend itself in the fracture, and, in such favorable 
 condition, the encephalon being intact, the fracture becomes a 
 lesion of no great importance. In such a case, the fracture may 
 be looked upon as a conservative evejit, in which the injury ends. 
 If the violence had not thus been expended or used, it would have 
 passed inward into the cranial cavity, and done its work in the 
 graver work of cerebral concussion. And thus, not rarely, is seen 
 the paradox that a patient, who has fracture of the skull, is much 
 less injured than one whose cranium was not broken; the former 
 may rise and walk, and declare himself but slightly injured, 
 while the latter, having concussion of the brain, lies unconscious, 
 and is most seriously injured. 
 
 The region of the skull fractured has an important bearing 
 on the gravity and danger of the injury. Fracture in the ante- 
 rior half of the cranial vault is less dangerous than in the posterior 
 half. From the author's experience, a fracture in the region of 
 the forehead is better tolerated than elsewhere; cases have been 
 seen in which the frontal bone had been broken most extensively, 
 and, though fragments were lost and cerebral matter escaped, 
 still the patients recovered. A fracture in the occipital region is 
 more dangerous than when seated anteriorly; yet, in both cases, 
 the character and conditions of the fracture determine the 
 amount of danger which it brings to the patient. An open 
 fracture in which the integument has been torn, the bone broken 
 into two or more pieces, and these pieces have been removed, is oc- 
 casionally folio wed by recovery,in any portion of the cranial vault; 
 while a fracture on a much smaller scale, in which no bone has 
 been lost, more often ends unfavorably. For in the former case,in 
 which the fracture is open, the surgeon is able to dress the wound 
 
IGG CUANIUM. 
 
 more conformably to the con<litions which favor liealing; osseous 
 fragment.^ can be removed, bleeding arrested, and the margins of 
 the broken bone can be restored to normal site ; work that cannot 
 easily be done in a smaller fracture. 
 
 A fracture in any part of the base of the skull is more hazar- 
 dous to life than one in the cranial vault; for the reason that 
 more important parts of the ence})halon are thereby imjjeri led; 
 danger increases as the medulla oblongata is approached. In an 
 exhaustive study of fractures of the base of the skull, published 
 in 1890 by W. H. Battle, of London, this writer has collected 
 fifty -four cases which ended fatally; in nearly two-thirds of the 
 cases the cause of death, as revealed by necropsy, was from 
 cerebral contusion with laceration and haemorrhage. Death 
 occurred in from one hour to fourteen days; the most died within 
 three days after the injury. 
 
 Though the danger from these injuries may be estinjated with 
 a fair degree of probability, yet the keenest prognostic acumen 
 often errs, since the seemingly trivial fracture may destroy life, 
 while a breach a hundred-fold greater has often defeated fatal 
 predictions by ending in recovery; the latter error escapes crit- 
 icism; since all is well that ends well. 
 
 A fracture of the cranial bones is less perfectly repaired than 
 elsewhere; though the broken bone be but thin in extent, and is 
 invested externally and internally by a periosteum, still there is 
 a very limited amount of callus produced; so that union is accom- 
 plished chiefly through the medium of fibrous tissue. The oi)po- 
 site fractured borders are connected, similar to a cranial suture, 
 by a thin la}- er of non-vascular fibrous tissue. 
 
 Treatment. — Since fracture of the skull presents itself in vary- 
 ing degrees of severity, so the treatment must vary in character; 
 and as the ence})halic complication is far more important than 
 the injury of the cranial wall, so the former must ever be kept 
 prominently in view; in fact, it must claim the principal share 
 of attention. At present, only the fracture will be considered, as 
 a special section will be devoted to injuries of the brain. 
 
 The treatment of cranial fracture has been the subject of 
 sharp controvers}'^; methods long held in reverence have been 
 rejdaced by those quite opposite to former ones. For centuries 
 trephination, as a shadow, was the inseparable sequent of a frac- 
 ture of the skull; even in case of the minutest fissure, this instru- 
 ment was used, and, in the exploratory work done with it, the 
 cranial injury was increased many times. Such instrumental 
 
FRACTURE OF THE CRANIUM, 167 
 
 interference is now seldom resorted to; and by its present con- 
 servatism, surgery has removed a trammel with which nature 
 formerly had to contend in the work of restoration. 
 
 In a simply fissured fracture, or one in which there is slight 
 depression without symptoms of cerebral disturbance, the treat- 
 ment is exceedingly simple; the patient, or rather his head, should 
 be placed at rest; the ear and eye should cease their work; in 
 fact, the door of all the senses should be closed against external 
 impressions. These precautions, even though the brain has been 
 spared any injury, will not harm; and if the organ has received 
 a latent lesion, such precautions may prevent further develop- 
 ment. If the alimentary canal was laden with materials at the 
 time of the accident, these should be removed by a proper cathar- 
 tic. Fortunately much of this material is often gotten rid of by 
 spontaneous vomiting. This vomiting, probably called into 
 action through the pneumogastric nerve and the sympathetic 
 nervous chain which connect the head and stomach, usually 
 ceases as soon as the stomach is emptied. 
 
 Along with these matters of general management, the injury 
 of the head demands some local treatment. If there be a breach 
 in the scalp, this must be dressed by one of the methods before 
 described, best adapted to it. And if there be no open breach, 
 the management of the wound will be limited to a topical appli- 
 cation; and for this, cold in some form has general sanction. This 
 may be applied in the form of a compress saturated with cold 
 water, or broken ice or snow, in an India rubber bag, may be 
 placed over the injured part. As ice and snow may freeze, and 
 have done so when indiscreetly used, there should be interposed 
 between the containing sack and head a piece of cloth, woolen or 
 cotton. If a compress merely wet with water be used, such com- 
 press is best made from some porous or wide-meshed material; 
 mosquito netting, of which several thicknesses are folded together, 
 serves the purpose well. Such a compress wrung out of cold 
 water will retain the cold and moisture for some time; and there 
 will be little inconvenience from the water escaping, as occurs 
 when the compress is made of closer texture. Cold with moisture 
 is more agreeable than dry cold. 
 
 In regard to the topical use of cold in the treatment of 
 wounded parts of the head, when the matter is studied, there is 
 some difficulty in understanding how the cold can act bene- 
 ficially. For the immediate effect will be to contract the vessels 
 which are cooled, and thus lessen the quantity of blood which 
 
108 CRANIUM. 
 
 enters the arteries, and cold will also empty the veins; the result of 
 this must necessarily be to increase the amount of blood con- 
 tained in the structures around and beneath. Only where the 
 scalp is thin can the action of cold reach into the underlying 
 bone; but when the covering structures arc thick, then the blood 
 would merely be collected in greater quantity in the underlying- 
 cranial wall. Hence it is probable that in most cases, the local 
 use of cold to the head is hyperiennc, rather than amemic, in its 
 action on the injured bone. And, further, in those regions which 
 are the site of the emissaries of Santorini, or canals of intercom- 
 munication between the extra-cranial and intra-cranial structures, 
 the effect of cold is to cause the blood to flow from the cooled 
 scalp into the skull, and there cause a local hyperaem.ia; in fact, 
 the cold in such case does quite the opposite of what it is intended 
 to do. Emissaries of Santorini exist in the lower margin of the 
 forehead and in the parietal bones; hence cold applied over these 
 regions causes an atflux of blood into the skull. And though the 
 author has, in accordance with common usage and authorit}', 
 advised the local use of cold in these injuries of the head, yet it is 
 equivocal whether local cold here, as well as elsewhere, is actually 
 beneficial. The subjective experience of the patient often influ- 
 ences or directs the treatment; the wounded part being benumbed 
 by cold loses its sensibility, and this fiict probably first led to the 
 use of cold. A {)ossible benefit from cold is conceivable where the 
 blood in the seal]), being cooled, traverses the wall and lowers 
 the temperature within the skull; but here, as not unfrequently 
 occurs elsewhere, the medical writer who is seeking to give truths, 
 pauses in embarrassment and must ask his reader to await until 
 Theory and Experience, becoming more intimately acquainted, 
 shall unite in a common task of reconciling and adjusting con- 
 tradictory and incoherent facts. 
 
 In case both scalp and cranium have been opened and there 
 be no depression, then, after removing fragments, the margins of 
 the broken bone should l>e carefully attended to, viz., if there be 
 depression, the edges should be lifted into proper position. 
 Besides being restored to position, broken edges should be trimmed 
 w'ith extreme care and rendered perfectly smooth. If this pre- 
 caution be neglected, tlie adjacent encephalon, moving under the 
 influx and efflux of blood, will be brought in contact with, and 
 irritated by, any sharp j)oint impinging against it. And, though 
 this irritation be slight and produce but little present trouble, 
 yet, after the part has healed, the overhanging osseous promonto- 
 
FRACTURE OF THE CRAXIUM. 169 
 
 ries may increase in thickness and become an enduring source of 
 irritation; thus epilepsy has been caused, and continued until the 
 causal agent was removed. In one instance seen by the author, 
 from the osteophytic irregularities of a fracture of the vault, sup- 
 puration arose, with opening of the old wound, and prolapsus of 
 the brain, from which death ensued in a few weeks. 
 
 Healing, as before said, even in fissural fracture, is through 
 the medium of fibrous tissue; and where, from the loss of bone, 
 the broken edges are not in contact, then the interljdng breach is 
 closed by fibrous material. This tissue is analogous to that com- 
 posing cicatricial structure closing a breach on the surface of the 
 body. And this is true in all varieties of open wounds of the 
 cranium, whether merely bone lias been removed, or, in addi- 
 tion to this, whether the meninges have been opened and partially 
 destroyed: and, likewise, where there has been loss of bone, mem- 
 brane and cerebral substance; in each of these conditions of 
 wound, the healing is through the medium of granulations, which 
 finally become converted into normal cicatricial structure. And 
 this reparative material does not completely fill the breach; there 
 is afterwards left a depression, arising from the contraction and 
 sinking of the new-formed material; and a consequence of this is 
 that the adjacent brain is disturbed in situation and form. As 
 a result, there sometimes remains functional impairment; and 
 this is more especially so in the young subject, in whom the parts 
 have not attained the dimensions of adult life. Such maimed 
 heads are often the victims of epileptic or other encei^halic disease. 
 
 The treatment of cranial fracture in which the bone is 
 depressed has been the subject of shifting change. Formerh' the 
 trephine always found work to do in such injury, and a surgeon, 
 who would have neglected to perforate tlie sunken wall in such 
 case, would have been deemed guilty.of great carelessness towards 
 his patient. The opposition to trephination, which is one of the 
 conspicuous events in the history of modern surgery, has quite 
 reversed the management of such injury, so much so that he, who 
 would invariably trephine in cases of depressed cranial fracture, 
 would be pronounced guilty of wanton temerity. In the annals 
 of medicine similar examples are met in which the pendulum of 
 opinion, swinging to and fro between adverse doctrines, through 
 the zeal of the contestants has been made to move too far in each 
 direction; but as the pendulum committed to the constant force 
 of gravitation soon resumes its normal arc, so the controlling 
 power of truth is ever adjusting medical opinion to its own stand- 
 12 
 
17v) ( r.ANir.M. 
 
 art.]. The author is of the opinion that the sweeping renuncia- 
 tion of the trephine is an error in practice; still lie would not 
 adopt the medium way, as the compromiser is wont, between the 
 old practices, since the middle line, instead of being the safest, is 
 too narrow for occupancy and action. Ex})erionce permits and 
 indicates the use of the trephine in cases of fracture in which 
 there is extensive depression of the cranial wall. For such de- 
 pression, if unrelieved, must hamj)er the brain in its functions. 
 Of these multifarious functions, that of motor innervation is one 
 of which the site has been definitely located in the surface of the 
 brain; the others have doubtless their special sites, and await for 
 the exploring hand of vivisection to discover and indicate them. 
 Tiie encroachment of a depressed cranial wall must interfere with 
 any such subjacent center, impairing its nutrition and, partly or 
 completely, annulling its function. In the plastic period of youth, 
 the changes in the wall occurring through growth, may finally 
 compensate or efface the ill form; but where the cranium has 
 attained its complete form, such depression must be more detri- 
 mental in its action, since, if unrelieved, the deformity will be 
 permanent. 
 
 Guided by these principles, the author would use the trephine 
 and uplift the bone in every case in which there is an extensive 
 depression of the cranial wall. For this purpose, with precau- 
 tionary asepsis, a small opening shall be made in the center of 
 the depressed bone, and the latter carefully uplifted with an ele- 
 vator. This, in the young subject, can easily be done, but in the 
 old, the work of elevating is more difficult; and, in the latter, there 
 may have occurred an isolated fracture of the inner plate, so that 
 a fragment must be removed; and in such case the patient will 
 afterwards bo indebted to the trephine for saving his life. In 
 the work of elevating, care must be u.sed not to injure the inner 
 surface of the bone, as well as the adjacent dura mater. This 
 method of practice the author would })ursue in every case of ex- 
 tensive dei)ression of the cranial wall, which, if unrelieved, must 
 entail a future deformity of the inner and outer surfaces of the 
 skull.* 
 
 The treatment which has been detailed is only applicable to 
 fractures in the superior and lateral parts of the cranium; but if 
 the injury be in the base, its inaccessibility will place it out of the 
 reach of any direct surgical treatment. The character of such 
 fracture, owing to the injured part being invisible, can only be 
 inferred; and here the surgical management is restricted in its 
 
FRACTURE OP THE CRANIUM. 171 
 
 Sphere of action and has only occasional opportunities for indirect 
 intervention. For example, where there is a profuse escape of the 
 cerebro-spinal fluid from the ear or nose, resulting from injur}^ of 
 the petrous part of the temporal bone or the body of the sphen- 
 oid, then an attempt should be made to arrest the discharge. 
 This should be tried by plugging or tamponing the outlet of the 
 fluid; if this be from the ear, the meatus should be plugged with 
 lint saturated with some astringent, such as a solution of gallic 
 acid, alumen, or some salt of zinc or iron. Or if the fluid should 
 escape from the anterior or j)Osterior openings of the nostrils, 
 indicating the escape of fluid through the sphenoid bone, or pos- 
 sibly through the Eustachian tube from the tympanic cavity, 
 then an effort should be made to arrest this by tamponing the 
 nostrils before and behind by means of astringent lint. If the 
 fluid be thus arrested for a day or two, then it is possible that 
 the breach in the base of the skull might become closed, and 
 further escape of fluid be prevented. When the escape is from 
 the ear, as a co-adjuvant to plugging, one might first inject an 
 astringent solution into the auditory canal, and, perhaps, thus 
 directly plug the fissure in the petrous bone. Where the serous 
 discharge is small in quantity, and has its probable origin in 
 serum expressed from clotted blood, or is derived only from the 
 internal ear, then no treatment is required, as it will cease spon- 
 taneously. 
 
 If, instead of serum, the escaping fluid be blood, then its arrest 
 is more urgently demanded, since the amount lost may be so 
 great as to destroy life. An astringent solution should be injected 
 into the ear, if the blood issue thence, and afterwards, the meatus 
 should be carefully plugged. In this way a clot will be formed 
 which will extend into the open vessel and, possibly, occlude the 
 rent in it, until healing occurs. Or if the bleeding be from the 
 nose, then the nostrils in front, and the choanse behind should be 
 tamponed with lint saturated with some astringent. The astrin- 
 gent solution, if not antiseptic, should be rendered so by the addi- 
 tion of corrosive sublimate, viz., one in three thousand. By these 
 means severe hsemorrhage from the ear or nose due to cranial 
 fracture, might be controlled. The tampon should be renewed 
 and a new one substituted from time to time. Instead of the 
 astringents mentioned, the tincture of iodine may be used, and the 
 tamponing material saturated with it; the same may be used in 
 the auditory canal before the latter is plugged up. The tincture 
 of iodine coag-ulates the albumen in the blood, in a manner simi- 
 
172 CKANIUM. 
 
 lar to an astringent, and it has a less corrosive action on the 
 parts with which it is in contact. Such clot, probably, after par- 
 tial absorption, undergoes organization and may aid in closing 
 the fissure or cleft in the broken bone. 
 
 After recovery from a fracture at the base of the skull, it is 
 probable that the patient will be maimed in some way; there 
 may remain complete or ])artial deafness; and with this there 
 may be unilateral facial palsy. And so there may be lesion of one 
 or more of the first six pairs of nerv'^es, which have exit through 
 the base. Thus, besides deafness mentioned, the sense of smell, 
 sight, common sensation of the face, and the muscular movements 
 of tlie eye may be interfered with. And such peripheral lesion 
 would point with certainty to the site of fracture. Recovery from 
 sucli sensory or motor lesion could not be facilitated by any pro- 
 cedure now known to surgery. Tlio patient might be consoled 
 with the slight and delusive hope that in time the parts might 
 accommodate themselves to the pressure; or tliat if the pressure 
 were due to a coagulum, tiiis might be absorbed; and to favor 
 such absorption, some aid might be derived from large doses of 
 the iodide of potassium. 
 
 GUNSHOT WOUNDS OF THE CRANIUM. 
 
 Tlie history of fracture of the skull which precedes will con- 
 clude with an additional chapter devoted to gunshot wounds; the 
 individuality of these injuries entitles them to a special consider- 
 ation. 
 
 Missiles propelled by some explosive compound, of which gun- 
 powder is the most common one, are in infinite variety; as tliey 
 vary in form, volume, and velocity of movement, so the violence 
 done by them differs. The difference in lesion varies from the 
 slight marring caused by grains of powder, to that arising from 
 an exploding bomb, or shot of large surface and great weight; 
 from a superficial deformity to an instant destruction of the victim; 
 and of these varying forms, wounds caused by missiles of small 
 size chiefly engage the attention of the civil surgeon. On the 
 battle-field, wounds from -large projectiles are seen ; in civil life 
 the missile from the pistol or rifle is the usual agent of sucli wound; 
 and wounds inflicted by these weapons upon tlie skull are the 
 ordinary ones requiring the surgeon's care; those from larger guns 
 and explosive projectiles are more rare, and, as a rule, are speedily 
 fatal. 
 
 Gunshot wounds made on the cadaver are equal in severity to 
 
GUXSHOT WOUXDS OF THE CKAXIUM. 173 
 
 those made on the Kving body. Accuracy in shooting is rarely 
 attained with the revolver; and even though the instrument be 
 rested, yet the mark is often missed. A shot fired from this 
 weapon at a distance of forty inches, leaves no marks of powder; 
 but at the distance of sixteen inches, stains are made by the 
 powder. At the distance of seventy-five feet, small shot pene- 
 trates but slightly; but at the distance of five feet and a half, the 
 shot penetrates, yet no marks are made by the powder. The exit 
 opening is greater than the entrance point. At the distance of 
 five feet, small shot does more violence than a bullet fired through 
 the same distance. 
 
 Stains of different character are produced by different kinds 
 of powder. Fine powder leaves but little marking or burning; 
 powder which contains much sulphur is more violent in its 
 action. 
 
 The gunshot wound of the cranium presents itself in two lead- 
 ing forms; in the one class the scalp is not opened, the injury to 
 the cranial wall being wholly subcutaneous; but in the second 
 class, along with the osseous wound, there is also a lesion of the 
 scalp. Experimental work illustrating the action of the gunshot 
 projectile on the human body has been done and reported upon 
 by several surgical writers. On the cranial gunshot wound, one 
 of the ablest and most trustworthy rej^orts has been made 03^ 
 Teevan; later, reference will be made to the same. In 1875 
 Crespi and Tazon published some general observations in tliis 
 field, of which the subjoined is a summary. The ball or projectile 
 from oblique or glancing contact with the head may cause no 
 external wound, yet produce a fracture of the cranial wall; and 
 this fracture may be very extensive and even destroy life, though 
 the seal J) is unopened. Such wound can only arise from a large 
 ball; a smaller one will wound the scalp, and if it pass deeper 
 than the latter, it will also wound the skull. As wounds of the 
 wall, which then arise, diverse forms present themselves, of which 
 we will mention the following leading ones : — 
 
 1. The ball may penetrate the scalp, and at the same time 
 carry the clothing with it which it does not penetrate, and, hav- 
 ing reached the skull, it may rebound and be withdrawn with the 
 clothing; in such a case the bone is only superficially injured. 
 Or without any intermediate clothing, the missile, having been 
 spent or lost its speed, enters the uncovered scalp, impinges on 
 the bone and then rebounds through the same wound. 
 
 2. The missile may enter the scalp, and, having channeled a 
 
1/4- CKANILM. 
 
 slight furrow in the surface of the skull, it stops and remains 
 buried in the scalp; or it may escape from the scalp at some i)oint 
 near by. The open canal, then formed, will lie partially in the 
 cranial wall, and the gravity of the injury will then depend on 
 the depth of the furrow in the wall. The furrow may be deep 
 enough to fracture and detach a fragment from the inner plate; 
 and such shot-wound, though it does not directly pierce the wall, 
 yet it is more perilous, iierliai».s, than one which pierces quite 
 through the wall; for the loose fragment of irregular form may 
 act more deleteriously than would tlie ball itself. 
 
 3. The ball may enter the cranium, and, having })ursued a 
 straight route, it may lodge within the brain, or at the opposite 
 wall of the skull wliich remains uninjured; or instead of passing 
 straight into the brain, it may be deflected by the dura mater and 
 pursue a curved line along the inner surface of the skull, and 
 lodge in contact with the skull, without having opened the men- 
 ingeal envelope of the brain. 
 
 4. The ball may fracture and pass through the cranial wall, 
 and, having traversed the brain in a straight direction, it may 
 break and pass through the opposite wall of the skull; in this 
 form tliere is a straight shot-canal tlirough the head. It is pos- 
 sil)le in this last case, that the missile having passed through the 
 second wall may lodge beneath the scalp; and there would then 
 remain a blind canal, with a ball at the bottom of it. 
 
 To sum up, the cranial sliot M^ound may present itself in one 
 of the following forms: wound by simple contact, in the form of 
 a furrow, a blind canal, or in the form of a complete canal Dass- 
 ing through the head. 
 
 The diagnosis is commonly easily made, since the history of 
 the case, in which a firearm was used by the patient or some one 
 else, clearly reveals the causal agency of the wound. In deter- 
 mining the fact, one may be assisted by the presence of marks 
 about the wound in the integument; also, the form of the wound 
 can aid. The extent, direction, depth and character of the wound 
 must be learned by the use of the probing sound. The sound 
 judiciously used, carries, as it were, both an eye and a finger into 
 the wounded structures, so that the searcher learns the condition 
 of the injured parts. 
 
 Nearly connected with the diagnosis are the openings which the 
 ball makes in entering and escaping from the wounded parts. The 
 form of the ball and speed with which it is moving determine the 
 character of these openings; also, the 'distance which the ball has 
 
GUXSHOT WOUNDS OF THE CEAXIUM. 175 
 
 traveled before striking, influences the form of tlie wound. 
 Simon of Darmstadt, in 1850, made a series of experiments on 
 this subject; his work consisted in shooting at animals and 
 masses of flesh at short and long range. He found that, at short 
 distance, a ball, moving with great velocity, formed openings at 
 its entrance and exit whicli were exactly alike. In case the ball 
 is moving less rapidly, then, at its entrance, it cuts out a section of 
 the wounded structure equal to the size of the missile. This was 
 demonstrated by catching the material that was cut by the ball 
 on paper properly placed. And in this case, the margins of the 
 entrance point are contused, ecchymosed, and the edges are 
 inverted; meantime, the exit opening is less round than that of 
 entrance; besides it is torn and everted. But if the ball traversed 
 the part obliquely, these diagnostic differences are less marked; 
 and if clothing surround the part which is pierced obliquely, then 
 the entrance through the clothing will be round, with loss of 
 structure, while the exit point will be triangular, or slit-like. 
 After healing the entrance point is round and depressed, while 
 that of the outlet will present a scar uplifted and slit-like in 
 form. 
 
 Simon found that, in the soft parts, the exit opening ma}' be 
 larger than that of entrance, when fragments of bone have been 
 detached and are carried along with the ball; the same is the 
 case when the ball has been flattened and enlarged in surface by 
 contact with a bone. 
 
 The diagnosis of the entrance and exit openings, left by a ball 
 in traversing the cranial wall, has been greatly aided by the 
 experiments of Teevan of London, which will long remain as a 
 model of excellence amidst the vast array of experimental work, 
 which has been done to illustrate the character of violence done 
 by the gun-powder missile on the human body. 
 
 In these experiments, made in 1864, Teevan found that, by 
 firing from a short distance straight at a skull, the entrance 
 through the outer plate of the cranial wall will corre.spond to 
 the size of the ball, and the fracture will be smooth and without 
 fissure or splinter; but the opening through the inner plate will 
 be larger than the one tlirough the outer one, and the orifice 
 will be smooth and not fissured. If the ball be fired through the 
 foramen magnum, then those conditions will be reversed; the 
 outer plate will have a larger orifice than tne inner one. The 
 plate first impinged on and broken, shows the exact form of the 
 traversing ball. 
 
170 CRANIUM. 
 
 The form of the ball has its influence; a larger exit orifice is 
 made by a round ball than by a conical one; the round ball 
 produces a round 0})ening, while the conical one makes a conical 
 or elliptical one. 
 
 A ball, fired from a barrel of smooth bore, loses much more 
 of its speed, in traversing a body, th^n does one which has been 
 fired from a rifled barrel. 
 
 In traversing the skin, the inversion and eversion of the 
 openings correspond to the direction pursued by the ball. 
 
 If a round ball be fired obliquely against the skull, it glances 
 off; but if the ball be conical, it will nearly always enter the 
 skull; and having been flattened by the impact, it will cause more 
 violence than if fired perpendicularly. 
 
 If the skull be pierced by something other than a ball, vio- 
 lence, similar in character, is done. For example, if it be caused 
 by a nail or the edge of an axe, then the opening in the outer 
 plate will represent the entering object, while the inner plate will 
 be opened more extensively. 
 
 In firing through two boards, which are near each other, the 
 exit opening was larger than that of entrance, due to the ball 
 having carried along w'ith itself particles of wood, which increased 
 its volume. 
 
 The experiments of firing at the skull were varied in several 
 ways. For example, the firing was done from the inside, and 
 through the wall where one lamella had been removed by tre- 
 phining, and the conclusion arrived at was that the missile, in 
 traversing one lamella, carries particles with it, which enlarge its 
 volume, so that, when it passes through the next lamella or wall 
 it opens a larger orifice. 
 
 The foregoing points, concerning the entrance and exit open- 
 ings of the missile and the changes in form which it undergoes, 
 are important subjects, which closely concern the student of 
 Forensic Medicine; for the determination of the agent or person, 
 who inflicts the wound, ma}' depend on the peculiarities and 
 forms of the wound which hq,ve here been detailed; and thus 
 might be unraveled the facts whether the wound was self-caused, 
 or made by the hand of an assailant. 
 
 A careful search should be made to discern whether the ball has 
 passed through .some article of the dress of the patient, and carried 
 and lodged fragments of the same in the wound; hence clothing, 
 which may have been traversed, should be inspected, and, if it be 
 presumable that such fragments remain in the shot-canal, an 
 
GUNSHOT WOUNDS OF THE CRANIUM. 177 
 
 endeavor should be made to extract the same; for such foreign 
 matter acts much more deleteriously than the ball itself 
 
 In regard to the danger and fatality of wounds of the cranium, 
 there is ample material to draw correct conclusions from, fur- 
 nished by the surgical reports of the Northern army, during the 
 War of the Rebellion, in the United States. These statistics cost 
 an immense amount of labor, as well as the life of the compiler, 
 Dr. Otis, who fell a victim to overwork. From these voluminous 
 records, the following facts are extracted. Of gunshot wounds of 
 the cranium without depression, there were 2,911 cases; of these, 
 there died 1,826, that is, 64.6 per cent. There were 364 cases in 
 which there was depression, and, of these, there died 129, that is, 
 35.8 per cent. From this, it singularly appears that depression 
 acted conservatively in gunshot wounds of the skull. The only 
 explanation which can be offered of these facts, so contradictory 
 to what inexperience would have predicted, is that the violence 
 done in the latter series of figures was less than that done in the 
 former series. 
 
 Since the era of antiseptics, the mortality of all injuries of the 
 cranium, including also gunshot wounds, has undergone a mate- 
 rial revision. According to Estlander, the Finnish surgeon, who 
 has studied the subject, before 1870, the mortality of wounds, in 
 wliicli the skull is laid bare, was twenty -four per cent; but since 
 1870, under antiseptic management, the number of deaths has 
 been reduced to one and one-half per cent. Prior to 1870, the 
 mortality, in cases in M'hich the scalp has been opened and the 
 cranium fractured, was near sixty-seven per cent; but since that 
 time, five- sixths of such cases recover. But where the fracture is 
 in the base of the skull, that is, cases in which the antiseptic 
 treatment is not applicable, the mortality now is the same as 
 formerly. 
 
 In 1879, a series of figures was collected by Gurlt, bearing on 
 the fatality of wounds in which a foreign body enters the cranium, 
 and which shows that, of three hundred and sixteen cases, one 
 hundred and sixty recovered, and one hundred and fifty-six died. 
 In one hundred and six of the cases, the body was extracted, and 
 of these, thirty-four, or about one-third, died; while in two hun- 
 dred and ten cases, in which no effort was made to extract the 
 body, one hundred and twenty-two died, that is, somewhat more 
 than one-half. 
 
 In the history of gunshot wounds of the cranium, Fritz finds 
 that more recoveries liave occurred in cases in which there has 
 
178 ci:amlm. 
 
 been but little or no surgical interference. The young subject, 
 with such injury, is more ni)t to recover than the old person. He 
 finds that cranial injury becomes more perilous as it invades the 
 sides and base of the skull. 
 
 Cranial gunshot wounds are least dangerous when i)roduced 
 by small balls. Klister, in 1882, reported cases in which small 
 balls entered the cranium; the wound in the seal]) was enlarged 
 and osseous fragments removed, but the ball was not extracted. 
 The cases recovered. Bergmann advises not to open the wound, 
 nor remove osseous fragments, but to treat such as simple wounds. 
 Langenbeck treated five cases of cranial gunshot wounds, in which 
 a small ball had entered the skull. These cases recovered with- 
 out any active treatment. Bardeleben also reports cases, in which 
 there was recovery, witliout removal of the ball which had entered 
 the skull. 
 
 Balls of large volume have frequently entered the cranial 
 cavity and penetrated the brain without causing death; as a rule, 
 liowever, in such cases there has occurred some impairment of 
 the subject's intellect, or lesion of sensation or motion. Where a 
 ball remains, the most favorable event that can ensue is that it 
 become encysted, that is, that it become inclosed and held in 
 its new position by firm material which is similar to cicatricial 
 tissue. Such a ball may remain innocuous for an indefinite 
 period. A much more unfavorable event is that in which the 
 ball forsakes the site in which it is lodged; and when this 
 occurs in the soft substance of the brain, the ball may sink 
 directly downwards, or in that direction in which it meets with 
 the least resistance. Thus gravitating, the ball may travel w'holly 
 away from its |)riniary place of lodgment: and in its migration 
 it injures the parts witli which it comes into contact, and, thus, 
 the gravity of the pi'imary wound is much increased. Such 
 migration may occur immediately, or it may ensue at a much 
 later period; and in the latter case, the ball quits the encysting 
 structures by which it had previousl}' been held in place. From 
 these facts, it is apparent that when a ball has lodged in the cra- 
 nial cavity, it becomes an enduring element of danger, which will 
 ever afterwards menace the life of the patient; and though such 
 body has remained for a long time without giving trouble, yet 
 there is no certainty that it will continue to do so; and, hence, the 
 rule to be observed in all cases, in which the ball is large, is to 
 attempt to extract it when this can be done without greatly add- 
 inef to the wound alreadv existing. 
 
GUNSHOT WOUNDS OF THE CRANIUM. 179 
 
 Treatment. — As the extent and gravity of cranial wounds vary, 
 so their treatment must differ. 
 
 In the first class of wounds in which the projectile or ball has 
 not opened the scalp, and still, from glancing impact, the cranium 
 has been fractured, the extent of the fracture can only be infer- 
 entially determined through palpation and the condition of the 
 patient. Since, frequently, the fracture is on a large scale, and 
 consists of a number of fragments which are loose, in such cases 
 these fragments can be pressed inwards or moved by palpation, 
 and the gravity of the injury fairly estimated. Besides, the state 
 of the patient, as respects mentality, sensation and motion, 
 aj^proximately indicates the anjount of injury which he has 
 received ; and this is often so great that any active surgical inter- 
 ference, instead of benefiting the patient, would rather disturb 
 the quiet which should be the privilege of the dying man. 
 Where there is great depression and other symptoms denoting 
 serious if not fatal lesion of the brain, then the primary care of 
 the wounded person should be limited to giving him a stimulant, 
 and the use of means designed to restore and maintain the tem- 
 perature of the body. Should the patient, however, rally and 
 present signs that his case is not hopeless, then attention should 
 be turned to his injury. If there be marked depression of bone, 
 or a fragment, perhaps, has been displaced beneath another, or 
 forced under the undepressed margin of the adjacent wall, then 
 the broken bones should be exposed by incision, and the depressed 
 part uplifted. Likewise, through such incision any fragments 
 which are found to be quite detached from the periosteum and 
 dura mater, should be removed; for such loose pieces of bone 
 would act as foreign bodies and prevent recovery. But if a frag- 
 ment has sufiicient attachment to adjacent parts to insure its 
 vitality, then it should not be removed. After the removal oi 
 loose fragments, and the elevation of the depressed cranial wall, 
 the wound made should be closed by suture except at a depend- 
 ent point, where a drainage tube is inserted and allowed to 
 remain for some days, for the escape of fluid detritus from tlie 
 wound. Such wound should be covered by a protective compress 
 of lint which has been saturated with a dilute alcoholic solution; 
 and this should be retained cold by a light overlying ice-bag. 
 And should signs of cerebral trouble appear, these should be 
 combated b}^ means described under the head of meningitis and 
 encephalitis. 
 
 In the second group of wounds, in which the missile opens the 
 
180 CKAXIIM. 
 
 scalp, we will first notice the simplest form, in which the ball 
 merely comes in contact with the cranium and communicates 
 but slight violence to the bone. The injury then will differ 
 according as the ball merely grazes the surface in passing or, 
 having exhausted its motion, it lodges as a spent ball against the 
 wall. In the first case, the injury done will be confined wholly, 
 or nearly so, to the soft parts; and tlien the treatment would be 
 a simple matter, being similar to that of an incision or simple 
 breach of the scalp. And so in the second case, in which the 
 ball is an inert missile lodged against the wall, the treatment 
 would be limited to that of a slight wound of the scalp; but as 
 the full extent of tiie violence done is a matter of uncertain con- 
 jecture, the case should be thoughtfully watched; and should 
 other symptoms arise, the latter should receive approi)riate atten- 
 tion. Where severe internal complications appear, and sliow 
 that the gravity of the injury was not fully estimated, then it will 
 probably become necessary to use the trephine. 
 
 In the wound of the next grade, in which the passing ball 
 has touched and broken the surface of the cranium, then the 
 wound should be examined, and the detached or partly detached 
 fragments sliould be removed; and the further treatment of the 
 wound should be similar to that before detailed for injury of the 
 scalp. As in the case of simple contact, the amount of internal 
 injury done is not always known, so, in tlie case of the superficial 
 furrowed wound of the wall, there may be injury to the subjacent 
 dura mater; and the evidence of this will only appear at a later 
 time. Hence the need of heedful attention to any indication that 
 may point towards intra-cranial complication; such complication 
 would probably arise from' a fracture of the vitreous plate; the 
 loosened piece of bone, deprived of nutrition, would die and act 
 as a foreign body of uneven surfaces. In such a case, trephining 
 would furnish the only means of relief, and, the earlier this were 
 done, the greater would be the relief to the patient. 
 
 In the next form of gunshot wound, in which there is but one 
 opening, the missile may carry along with itself fragments of 
 clothing, hair, minute portions of the scalp and one or more 
 fragments of bone. As a rule, the ball will Ije found within the 
 skull; yet, as Guthrie, an eminent Englisli authority in military 
 surgery, remarks, this is not always so. The ball may strike the 
 cranium and fracture and force inwards a fragment of the wall^ 
 and yet the projectile may rebound and not enter the skull. In 
 such case the finger or sound can pass into the track of the wound. 
 
GUNSHOT WOUNDS OF THE CRANIUM. 181 
 
 and, finding a piece of bone nearly the size of the ball, this frag- 
 ment can easily be mistaken for the ball; such a condition would 
 greatly embarrass diagnosis, since, though the fragment of bone 
 is removed, the surgeon could not be sure that the ball was not 
 lodged somewhere in the head. 
 
 As the instances are very rare in which the ball rebounds from 
 the breach that it makes, hence no pains should be spared in a 
 diligent search for, and the extraction of, the missile when found. 
 The hope that the ball may, when not removed, become encysted, 
 and in such state remain inert and harmless, is doubted by Bill- 
 roth, who, in 1870, announced a contrary opinion. He claims 
 that from the irregular and battered shape which the ball often 
 acquires, it is apt to induce suppuration. From its impact with 
 the bone, the ball becomes roughened in form, and sometimes 
 split into two parts. The striking of the ball against a bone can 
 also cause inflammation of the latter. Billroth saw cases in which 
 round balls caused suppuration, due, he thinks, to laceration of 
 the tissue by the heavy body; and had the ball been smaller and 
 lighter, probably no suppuration would have arisen. 
 
 As the ball usually carries along with itself and leaves behind, 
 either in or at the side of its track, pieces of clothing and frag- 
 ments of bone, the first work of extraction should be directed to 
 the removal of these bodies; for their presence would be quite as 
 detrimental to the encephalic structures as the ball itself ^For 
 the removal of these foreign matters, Betz invented a sound 
 which terminated in a hook-like end, which must be short, not 
 more than a line long; such a sound may be made of silver, 
 attenuated at one end, and bent there at right angles. The 
 advantages claimed for such a sound are that, without making 
 any incision, the fragments can be caught, even if they lie trans- 
 versely, and thus much more easily removed than can be done 
 with forceps. In the absence of this instrument, one similar to it 
 might be extemporized, viz., a long silver probe, bent at one end. 
 The extraction might also be accomplished with a pair of long, 
 narrow-bladed forceps, similar to those used in operations on the 
 eye. 
 
 The ball, when lodged inside of the skull, penetrates deeper 
 than the foreign materials just mentioned; and as it has insufii- 
 cient momentum to bear it through the head, its lessened speed 
 permits of deflection; and then, wandering from a straight direc- 
 tion, its detection becomes difficult. For this work various sounds 
 have been devised; such an instrument may be wholly of metal 
 
182 (RAXIIM. 
 
 or gutta porclia, modelod somewhat after tlie form of a iiretliral 
 sound; ami this is improved, if the sound be armed with a point 
 of metal, ivory or })orcelain. The sound with ivory or porcelain 
 point was invented by Xelaton, and enabled him to discern, by the 
 trace of lead left on the sound, the bullet in Garibaldi's ankle. 
 Instead of this, the author, in a case of cranial gunshot wound, 
 used a probe extemporized on the spot from a piece of white pine 
 wood. This wood, as readily as porcelain, can receive and bring- 
 back a trace of the leaden ball. The work of finding the missile 
 is often no easy feat, even for the most experienced hand. xVlso, 
 without ])i'evious training and thoughtful management of the 
 searching sound, not only will the ball not be discovered, but 
 injury will be added to that already existing. Injudicious or 
 careless manipulation may carry the probe beyond the ball, and 
 thus the wound is made deeper; or the ball may be pushed 
 onward into the brain, and thus the shot canal can be extended. 
 The fruitless efforts, made by distinguished military surgeons, to 
 discover the bullet in the ankle of (Jaribaldi, fully illustrate the 
 difficulties attendant on probing for a bullet. The art attained 
 by experience, and tlie secret possessed by him who successfully 
 probes, consists of slowness and gentleness combined with thought- 
 ful tact in the use of the sound. 
 
 Considering the difficulty that is experienced in discovering 
 the ball, it is evident that there would be a special advantage in 
 having an instrument in which were combined both probe and 
 extractor; such an instrument is presented in some of the models 
 of bullet forceps which have been jn-oduced by the untiring hand 
 of invention; the desire to present something new, and the emu- 
 lation to outstrip predecessors, have furnished here, as in other 
 sections of surgery in which instruments are needed, a multitude 
 of specimens. One of the best forceps for finding and at once 
 removing the bullet, is one having sharp-toothed blades, of which 
 each, when detached, resembles a tenaculum. The handles are 
 long, and the joint, by which they are riveted and locked together, 
 is placed at a considerable distance from the points which seize; 
 this distance from the joints permits of the points being widely 
 separated, so that a much larger body can be grasped than could 
 be done if the joint were near the end. When the ball has been 
 touched with the instrument, the booklets of the latter can be 
 made to fix themselves in the missile; and, as withdrawal is done, 
 the Ijall is movable in the mouth of the forceps, and so adapts 
 itself to the canal that the removal is more readily done than if 
 
GUNSHOT WOUNDS OF THE CRANIUM. 1S3 
 
 the ball were firmly grasped. This instrument, armed as it is 
 witli firm-liolding tentacles, may be used also for the extraction 
 of fragments of clothing and other materials lodged in or beside 
 the canal. In this work of removing foreign bodies, the author 
 will repeat the warning hitherto given, to spare the encephalic 
 structures. 
 
 After this work has been done, the edges of the breach in the 
 cranium should be carefully inspected, and if there be depression, 
 this can readily be rectified. Also, the edges of the opening 
 should be observed, and if fragments be found there, they should 
 be removed. As the ball in passing through the wall fractures 
 the inner plate more than the outer one, hanging, or loose frag- 
 ments which have originated from the inner plate should be 
 removed. This work can only be done where the opening is 
 large, and admits of inspection with the eye. The bone frag- 
 ments, bullet and other foreign material having been extracted, 
 attention must also be given to the wounded soft parts. Cerebral 
 matter oozing from the wound should be cleansed away by a 
 small stream of aseptic water allowed to flow over the part; shreds 
 of the wounded dura mater must be trimmed off, so that a sound 
 edge will remain; and if there be grains of powder lodged in the 
 wound traversing the scalp, the powder-stained edges of the 
 wound must be trimmed off. The time spent in these tedious 
 minutse will be regained manifold in the accelerated healing 
 which such care assures. If, however, the wound is a clean, 
 smooth one, and there be no pendent fragments, then its margins 
 must be left intact; and the surgeon will proceed to the external 
 dressing. As preliminary to this, the part should be cleansed 
 with a carbolated or a sublimated solution. Arrived at this 
 point, the surgeon must select his course of treatment from the 
 different ones which have been advised. The nihilistic tendency, 
 which is seeking to overthrow the idols long venerated in the 
 domain of internal medicine, has its advocates also in the surgi- 
 cal management of the gunshot wound. For example, Passavant, 
 in 1871, teaches that the best method of treating such wounds is 
 that heralded by Bartscher and Burow, in which the wounds are 
 left open with little or no dressing. The author does not counsel 
 such a Fabian course, believing, as he does, that total inaction is 
 as baneful as excessive interference, since nature, like man him- 
 self, is ill tolerant of studied neglect. Roser, in the management 
 of these wounds, while deprecating complicated dressing, would 
 still do something; he would not sound, irrigate or inject; he only 
 
184 CHANir.M. 
 
 dresses the exLenial wound witli carbolizcd gauze; in this 
 simple Avay lie finds that the shut canal will often heal. Should, 
 however, the wound suppurate, he would open, dilate with lami- 
 naria and then introduce a tube for drainage. It is probable, how- 
 ever, that were more attention primarily given to the wound, 
 suppuration would be averted, or much reduced. 
 
 Rejecting then a nihilistic course, as well as one which is 
 nearly akin to it, the author would carefully note the condition 
 of each case, and. unless the hall had been so small that it had 
 fractured but slightly the cranial w^all, he would prejiare tiie 
 wound for the external dressing in the way that has been 
 detailed; he would sound, extract the missile and bony fragments; 
 and this completed, he would introduce a drainage tube of aver- 
 age calibre, so as to permit fluid excreta to escape : the external 
 wound should then be powdered with iodoform, and lastly, over 
 this should be placed a lint compress, maintained moist w^ith a 
 carbolated or sublimated solution. And to maintain the head 
 cool, an ice-bag should be used; or instead of this bag, the work 
 may be well done by means of a tubular helmet, through which 
 there is constantly circulating a current of cold water; by this 
 latter contrivance, the cold can be most equably distributed. In 
 large canals in wdiich the drainage is maintained through a tube, 
 the latter should he allowed to remain in place for several days; 
 too early removal has been the cause, here as elsewhere, of the 
 accumulation of scro-i)uruleiit matter, which imperatively de- 
 mands reoi^ening of the wound. In brief, it is seen that the 
 blind shot canal in the skull is to be treated, after it has been 
 freed from foreign material, in the same way as such a wound 
 should be elsewhere. 
 
 In the fourth class of gunshot wounds of the cranium, in wJiich 
 the canal has both entrance and outlet, the work of dressing will 
 be more simple than that of the blind canal. First of all, the 
 openings should be studied, and if that of exit be smaller than 
 the other, then, according to Demme, it is probable that the ball 
 has been broken, and a portion of it remains in the skull. Among 
 the students of military surgery there has been a contest whether 
 the leaden ball can melt through heat generated b}" impact with 
 bone, and there seems to be credible evidence that sucli fusion 
 does sometimes occur; thus the volume of the ball would be 
 diminished, and the molten material might then lodge on the 
 edge of the entrance. Meantime, the missile, lessened in volume, 
 would produce a smaller opening at its outlet. In the open canal, 
 
TREPANATION. 185 
 
 foreign material would probaijly lodge near the exit opening; 
 iience the search for such material should be more diligent at 
 that point. Demme likewise noted a difference in the liealing of 
 the two openings depending on the form of the ball; for example, 
 where the bullet is solid at its base, the outlet heals sooner than 
 the entrance, but if the base be hollow, then the exit opening does 
 not heal earlier. 
 
 After osseous fragments and other foreign matter liave been 
 removed, if there he dependent shreds, these should be excised ; 
 and then, if the openings are large enough to admit them, drain- 
 age tubes should be placed in each one, and retained there as long 
 as liquid excreta escape. This work being done, the dressing- 
 should be completed in the same manner as in the case of the 
 wound with a single opening. 
 
 Though the lesion just described is greater than that of the 
 blind canal, yet the fact that the missile has escaped from the 
 head, and probably left but little foreign material in its track, are 
 auspices more favorable for early and entire recovery than exist 
 in the case of the blind canal; and especially, if the ball in the 
 latter has not been discovered and removed; for such lodged ball 
 may, at any time, obey the law of gravity, and, sinking, encroach 
 on the vital nuclei in the lower part of the encephalon. 
 
 Trepanation. — In the treatment of injuries of the cranium, an 
 important operation has been reserved for a sjoecial chapter; this 
 is the use of an instrument by which the cranial wall is opened. 
 This operation was denoted anciently by the term trepanation, 
 and the instrument for doing it was named a trepan, which was 
 worked after the fashion of a carpenter's bit or wimble. The 
 more modern name for the operation is trephination, so called 
 from the trephine, with which the work is done; the trephine 
 resembles an auger or gimlet, and is worked similar to that im- 
 plement. The work done by both the trepan and trephine is 
 effected by a circular saw, in the form of a corona or crown, which 
 on one end is armed with teeth. These instruments are only 
 moditications of an instrument which was in common use in the 
 earliest recorded period of antiquity. The wars of olden times, 
 as well as of more recent ones, furnished ample material in inju- 
 ries of the head. Cases of compression of the brain from depres- 
 sion of a portion of the containing w^all must frequently have 
 occurred, and it is probable that the observation was early made 
 that the uplifting of such depressed bone was followed by relief 
 of the injured one; and hence the recourse to some instrument by 
 
ISG CRANIUM. 
 
 wliich the elevation could be done; thence the early origin of 
 such boring and elevating instruments. 
 
 In liis admirable work concerning injuries of the head, after 
 Hippocrates has described five species of cranial lesion, he 
 remarks that ''among these modes of lesion, those to which the 
 trepan must be applied are a contusion which is visible or invis- 
 ible, and a fracture that is visible or invisible." And then follows 
 the mention of a form of wound, in Greek named "hcdra,^' which 
 has so puzzled the Hellenists tliat Littr^, the most famous 
 translator of Hip[)0crates, instead of defining it, has retained the 
 original word, in his French version. The word evidently meant 
 a wound, or the site of a wouml. Continuing then the language of 
 Hippocrates, the following occurs: " Besides, if a v;oviiu\{Jiedra) has 
 been made in the bone by a missile, and there is a fracture and 
 contusion, or a contusion without fracture, the case demands the 
 trepan. But when tlie bone has been displaced from its natural 
 position and is depressed, then it is seldom that the trepan is 
 needed; the more the bone is depressed and broken, the less ireed 
 there is of trepanning. The wound {hedra) without fracture and 
 contusion, does not require this operation." These words, which 
 are the first existing lines in tlie long chapter since written on 
 the subject of trephination, are remarkable as prophetically con- 
 curring with subsequent experience. It is clear from the reference 
 to trepan, without describing the instrument, that the latter was 
 well known and in common use. Hippocrates, afterwards, often 
 refers to the operation, and carefully describes the cases in which 
 it should be employed. "It should not be done on a suture, but 
 to one side of it." The danger of injuring the meninges is spoken 
 of, and the caution given not to expose these too much. Also, in 
 the infant, the thinness of the wall is mentioned, and on that 
 account the work should be done with unusual care; and in 
 some cases it suffices to merely open with a very small trepan. 
 In the work of using the instrument, Hippocrates advises to 
 proceed with the section slowh^ wlien the bone is nearly sawn 
 through, so that the parts within the head may not be injured. 
 He coun.sels also to frequently withdraw the instrument and 
 plunge it in cold water, to cool it; for without this precaution, the 
 bone may be burned and caused to die. He tells how the work 
 should be done differently in different morbid conditions of the 
 bone; for example, if tlie bone be suppurating, there is danger of 
 sawing too rapidly. He likewise used as aid and precursor of the 
 trepan the rugina or rasp, in all cases in which the injury of the 
 
TREPANATION. 187 
 
 bone was not apparent; in such the surface of the bone was to be 
 rasped away, and the deeper osseous strata were to be tested within 
 and., if signs of deeper injury be revealed, then the trepan must 
 be resorted to. 
 
 Enough has been cited to prove the popularity of the trephine 
 the Hippocratic era of surgery. This popularity continued and is 
 mentioned and mildly censured by Celsus, who says that in every 
 injury of the cranial bones, the ancients proceeded at once to 
 instruments, by which the bone was excised. Instead of this 
 treatment, the more conservative Roman would first try local 
 remedies: "but if these fail and fever appear early after the 
 wound, and sleep be short and disturbed by tumultuous dreams, 
 and the wound remain open and moist, and glands swell in the 
 neck, and there be likewise a distaste for food, then one must 
 resort to the scalpel and the trephine." In the work of trephin- 
 ing, Celsus directed that it be done by one, two or three borings, 
 as the case may demand, and thus the bone lying between the 
 bored orifices, may be removed. The opinion and practice of 
 Hippocrates, however, maintained ascendency for many genera- 
 tions; and it is also probable that this practice prevailed for many 
 centuries before Hippocrates, for his work on injuries of the 
 head affords ample evidence that surgery in certain directions 
 was well advanced, though there remain no records of it. The 
 sanctity which attaches to the past, and that hesitates to abandon 
 lines of action which are evidently erroneous, had its share in 
 maintaining the use of the trepan in the middle ages, and trans- 
 mitting it as an enlarged legacy to modern times. The fortune 
 of trephining has been more lucky than that of the ligation of 
 vessels; the latter, though one of the most frequent needs to the 
 wounded man, stranded in the current of time for a thousand 
 years, while that of the trephine survived and attained a larger 
 sphere of action, with advancing time; the ligature was lost in 
 the morass of scholastic inertia in which human science lay 
 grounded for so many ages; the trepan, meantime, appears never 
 to have fallen into disuse. During the eighteenth century and 
 the first quarter of the present one, the trephine rose to a degree 
 of favor unknown in antiquity. In fact, the operation became 
 a fashion, and did its work, like the lancet, whether right or wrong, 
 without rebuke or censure. The absolute recklessness with which 
 this operation was done, and the instances in which a large por- 
 tion of the cranial vault was removed, justifies the satirical 
 remark of Sir A. Cooper, that "it is remarkable how much surgery 
 
188 CJtAXlLM. 
 
 it takes to kill a man." Survival after sucli multii)lc trepliiiiation 
 as one finds in the records of olden surgery, certainly demonstrates 
 that the operation is rarely a fatal one. 
 
 Among surgeons of modern, or comparatively modern times, 
 who have strongly advocated the trephine, are Petit, Pott, Sabatier 
 and Louvrier, These urge that the operation should be done as a 
 preventive measure; that by the timely use of the trephine, in 
 case of injury of the cranial wall, inflammatory action and other 
 accidents consequent on the fracture can be forestalled, and thus 
 prevented, or diminished. On the other hand, as strong opponents 
 of the operation, may be mentioned Sir A. Cooper, Brodie, Aber- 
 nethy, Desault, Langenbeck and Malgaigne. Alalgaigne was per- 
 haps the most determined opponent of trephining among modern 
 surgeons, and, by his writings, he tended to check the abuse, 
 and perhaps the legitimate use of the trejihine. Thus in words 
 often quoted he says: "In my conviction most deeply grounded, 
 all the doctrine concerning the compression of the brain from 
 wounds of the head, in which it is claimed that trephining is 
 demanded, seems to me to be a long and deplorable error, and 
 which even in our time is still pursuing its victims." This 
 denunciatory criticism was evoked by the illimitable use, or 
 rather abuse, of the instrument. Thus it is recorded that Stalpart 
 van der Weil trephined one patient twenty-seven times; the 
 Prince of Orange had seven openings made in his skull by the 
 trephine; and Fergusson tells the story of a surgeon, who, to 
 remove extravasated blood from the cranial cavity, continued to 
 use the instrument until he was told by the surrounding spec- 
 tators that the patient had been dead for some time. 
 
 More exact knowledge of the relations of the brain and the 
 cerebro-spinal fluid makes it evident that cerebral compression 
 can, to a considerable extent, be compensated b}' the outflow of 
 that fluid. And also, the observation has often been made that, 
 after very extensive depression or driving inwards of the cranial 
 wall, the abnormal condition did not cause cerebral trouble; or, 
 if such was present, the sunken wall was soon tolerated, and no 
 subsequent trouble w^as experienced from it. To this the writer 
 would answer that it is true that the forces of life have great tol- 
 erance, and often endure what they cannot escape from, yet it is 
 probable that, had their mute patience the power of language, 
 submission would often be accompanied by remonstrance. It is 
 certainly the duty of surgical art to rem.ove the necessity of such 
 tolerance, and to so clear the pathway that the forces of life can 
 move without clog or fetter. 
 
TREPANATION. 189 
 
 In a review of surgical literature from 1840 to 1850, one finds 
 that the advocates and op]3onents of trephination waged an indus- 
 trious controversy, and, as a partisan of the o^oeration, Spatli in 
 1844 decried the prevalent fashion of denouncing it. He claims 
 that many cases of cranial injury demand it, and formulates, as a 
 rule for guidance, that in all cases in which the functions of the 
 brain are interfered with, through irritation or pressure due to a 
 wound, one must trephine. Spath refers to the experience of E. 
 Walther, who, in one hundred and thirty-three cases of trephin- 
 ing, lost but thirteen patients, while in a series of twenty-seven 
 cases not trephined, which vfere similar in character to those 
 which were trephined, thirteen died. The teachings of Textor, a 
 German, discouraged trephining, while Cock, a surgeon of London, 
 was favorable to trephining, especially in cases of suspected 
 rupture of the middle meningeal artery; and, according to Cock, 
 the evidences of such rupture are deep coma, stertor, puffing 
 respiration, absence of muscular movement in the face, and 
 death-like immobility of the limbs; trephining should be done 
 when such symptoms are present. 
 
 In a discussion upon trephining in the Society of Surgery in 
 Paris, 1867, it was shown that the violent oj)position of Malgaigne 
 to the procedure had nearly remanded it to disuse in France; 
 Le Fort found that, from 1857 to 1866, but three reports of tre- 
 phining were recorded in the journals. In England, however the 
 operation remained in use, as hitherto; and there were reported 
 in that time one hundred and thirty-five cases, of which fifty 
 recovered, giving a mortality similar to that which occurred after 
 one hundred and seven operations done by surgeons in the 
 American war. 
 
 The eminent English authority, James Paget, 1870, laid down 
 the following indications for trephining: "In simple fracture in 
 which the scalp is unopened, and there is no depression of the 
 skull, nor symptoms of comj^ression of the brain, then trephining 
 should not be done. But if signs of compression be present, and 
 still there is no cranial depression, in such cases trephine, if the 
 site of fracture can be located. When there is depression of bone, 
 and there are signs of compression, if the subject be a young one, 
 do not trephine; and if the subject be old, even then the propri- 
 ety of trephining is doubtful." But an invariable rule laid down 
 by Paget is that "though the scalp be unbroken, and yet the skull 
 is depressed, and symptoms of compression are present, then tre- 
 phining should be done. Again, where the scalp is opened, and 
 
190 CRANIUM. 
 
 there is no cranial depression, nor symptom of compression, then 
 do not trephine. But if the bone is not depressed, and yet there 
 be present signs of compression, then one should trephine. In 
 the young where the bone is depressed and no compression exists 
 then do not trephine, but in such cases in the old it is proper to 
 trephine. In cases in which the scalp is opened, and compression 
 and depression both exist, then tre})hine." 
 
 The above rules seem correct guides, yet, as Hueter remarks, 
 "Pao-et should have defined more accurately what he implies by 
 compression." 
 
 Antiseptic surgery, here as elsewhere, has emboldened the sur- 
 geon to venture further in operative work. Leser, of Halle, in 
 1885 reported a series of thirty-six trephinations with four 
 deaths; in the fatal cases, the injury was very severe. He used 
 drainage tubes, which were brought in contact with the cerebral 
 substance, and the patients soon were permitted to walk around. 
 
 For many years the doctrine iield sway that tlie cerebrum 
 was insensible to irritants, whether meclianical, thermal or elec- 
 trical in nature. In 1800 the writer was a witness to experiments 
 made by Flourens, in Paris, by which this doctrine seemed most 
 certainly established. In terms of undisguised arrogance and 
 vehement pomp, tlie famous Secretary of the Institute enunciated 
 these doctrines with the strongest conviction that they were des- 
 tined to remain as immutable truths. Less than twenty years- 
 elapsed when this doctrine was proved erroneous by the 
 researches of Fritsch and Hitzig, in which they discovered that 
 the COTtex of the cerebrum is, at certain points, sensitive, and will 
 respond to an electrical irritant. These discoveries probably had 
 a germinal suggestion in the researches of Broca, who had found 
 that articulate speecli has its site of innervation in a frontal con- 
 volution of the brain. The discoveries of Fritsch and Hitzig, 
 that centers of innervation for movement of the leg and arm are 
 located in the cortex beneath the parietal bone, were soon after- 
 wards verified in France and England. In France, the subject 
 was studied by Vulpian; his experiments were witnessed by the 
 writer, in 1876. In England, controlling verification was furnished 
 by Ferrier, who experimented on monkeys; and from the simi- 
 larity between the simian and human brain, the deduction was 
 permissible that similar centers existed in the brain of man. In 
 the pathological field, the diligent hand of Charcot soon collected 
 a number of facts, which clearly demonstrated that there are 
 localized functional centers on the surface of the cerebrum. And 
 
TREPHIXATION. 191 
 
 soon the doctrine was corroborated and confirmed by many 
 observers, that there are definite and determinable foci on the 
 cerebral cortex of innervation of the organs of motion and of 
 special sensation. This discovery is the offspring of vivisection 
 so much decried by the half-educated sentimentalist, whose very 
 existence has, probably, been permitted by the work which he 
 decries. The discovery of cerebral functional localization is one 
 of the most important of the nineteenth century; it has brought 
 more light to the cerebral clinician ; it has added a new jewel to 
 the crown of the trephine; and this instrument, whicli lias had 
 so cliangeable a fortune in banisliment and recall, will not be 
 wrested again from the surgeon's hand. 
 
 Though a number of centres of innervation have been defi- 
 nitely located, yet those which specially concern the operative 
 surgeon, are those for the npper and lower extremities, and that 
 of Broca's lingual convolution; especially the former two. 
 
 The location of the centres for the limbs, according to Charcot 
 and Lucas Championniere, is in a zone comprising the superior 
 two-thirds of the ascending frontal and parietal convolutions, and 
 is contiguous to the fissure of Rolando. And these motor centres 
 are beneath the anterior half of the pai'ietal bone, in a space 
 which is a little over three inches in height and sonaewhat more 
 than one inch in breadth. 
 
 Since these central points are adjacent to the fisAire of Rolando, 
 the following is the rule of Championiere to locate this line: 
 First find the site of the anterior fontanel, by causing the subject 
 to look straight forwards; then draw a line from, one a\jditory 
 meatus to the other, and the summit of the curved line will cor- 
 respond to the fontanel. Next draw a line from the fontanel 
 backwards, two and a quarter inches; then draw from the external 
 angular process of the orbit, horizontally backwards, a line 
 nearly three inches long; now, from the posterior end of this 
 line, draw a line perpendicularly upwards one inch and a 
 quarter; between the upper end of this vertical line and the 
 posterior end of the first line, lies the fissure of Rolando. Though 
 this admeasurement will prove correct for many crania, yet 
 for some it will vary from accuracy ; for in the brachycephalic, 
 or broad head, and tlie dolichocephalic, or long head, the dis- 
 tance between the points above given cannot conform to any 
 fixed standard. In such cases of abnormal cranial form, to open 
 the wall over the motor centres, the trephine should be used in 
 front of the parietal eminence, within a vertical zone two inches 
 
192 
 
 CKANIUM, 
 
 broad, just anterior to that eminence. And tiiis work sliould be 
 done on the side oi)i)Ositeto that of tliealTeeted limbs. Tlie (hira 
 mater must be opened, and the causal agency removed, whether 
 this be a clot of blood, a collection of pu.s, or a neoplasm. If the 
 treidiining be done for the relief of apha.sia, then the operator 
 must seek the third frontal convolution by an opening lower and 
 more anterior than that which is made to find the motor centre 
 of the limbs. Should the point sought for not l)e discovered 
 within the vertical zone mentioned, another opening may be made 
 above or below the first one. 
 
 ''por(^i kohe 
 
 Occip 
 
 FiGiRE 1. Prepared under the directions of the author, in wliich the cere- 
 bral convolutions are designated, and the lingual and visual centres, and those 
 of the upper and lower extremities, are indicated. 
 
 The injury of the brain reveals itself in two classes of subjective 
 symptoms the opposite of each other, viz., those of excitation and 
 those of depression; or those in which excitation in one direction 
 and depression in another are present in the same case. The 
 indications for trephining may be present, arising from tlie.se 
 opposite conditions. 
 
 As has been shown, the operation of trephining has been the 
 subject of changing vicissitudes; an analysis of its history shows 
 that it has been resorted to, at different periods, for three pur- 
 poses: as an exploratory and diagnostic aid; as prophylactic or a 
 
TEEPHIXATIOX. 193 
 
 means of preveniing the development of trouble in the head; and 
 lastly, the trephine has been used as a curative agent. 
 
 As a means of determining the extent of a cranial injur}-, and 
 especially, to determine the existence of fracture and possible 
 detachment of the inner plate of the skull, trephining was recom- 
 mended by Sddillot and a few others. And, with the object of 
 discovering a suspected clot of blood, Sedillot would use the tre- 
 phine; thus, as a mere aid in diagnosis, and to enable the eye to 
 look through the cranial wall, tlie operation has been advocated; 
 and if one opening did not reveal the concealed trouble, then the 
 partisans of exploratory trephination would pursue their work, 
 in fact, continue the boring until the object of search was discov- 
 ered. The most remarkable instance in which this adventurous 
 work was pursued to the utmost limits of possibility is that of 
 Chabdon, which from the frecjuency of quotation has evidently 
 won in surgical history the prize of frequent mention. Chabdon 
 applied twenty-seven crowns of the trephine to the skull of his 
 patient, and had the rare fortune to find the clot of extravasated 
 blood, and, it is said, saved his patient. A pupil of Sedillot, who 
 resorted to this multifile trephination, was less fortunate; his 
 patient died. The innocuity of trephination has its limits; and, 
 though trephining is now done with fair immunity from danger, 
 yet the operation is not to be done for the purpose of merely per- 
 mitting intracranial insight; for the knowledge thus obtained 
 might be drawn more safely from the subjective and objective 
 symptoms of the patient. 
 
 Trephining was used as a preventive measure by Hippocrates; 
 in fact, it is probable that, inspired by his teaching, the use of the 
 instrument was oftener invoked by the old surgeons as a means 
 of prevention than as a means of cure. Among the modern 
 English surgeons. Pott w^as an enthusiastic ad /ocate of prophy- 
 lactic trephination, and somewhat later, Sddillot among the 
 French, besides using it as a means of diagnosis, employed it also 
 as a preventive measure. The cases in which the author would 
 use it preventively are the following: in all cases of stellate or 
 lineal fracture in which there is depression, or thrusting inwards, 
 of a portion of the wall; also w4iere a foreign body has entered, 
 and tlie entrance-opening is not large enough to permit the 
 extraction of the body, or the removal of fragments of bone 
 forced inwards. In the case of depression, through the uplifting 
 permitted by the opening made, the existing symptoms of com- 
 pression, sometimes present, will be relieved, and those of irrita- 
 
194 CRAXIUM. 
 
 tion destined to occur, will be anticipated, and probably prevented. 
 Thus the wound will be at once placed in conditions so favorable 
 for recovery that inflammation and suppuration will be avoided, 
 or retained in safe limits. The objection urged in the case of 
 fracture with depression, that the trepliine will add another 
 wound, is not valid, since the work done by means of the opening 
 made allows the surgeon to substitute a much less perilous wound 
 for the one that previously existed. The enlargement of an open- 
 ing as aid in tlie extraction of a penetrated missile or foreign 
 body, is a prophylactic measure sanctioned by all surgeons. But 
 there is more hesitation concerning the propriety of the ojieration 
 in cases of simple fracture without depression. To open the 
 skull at once in this case, with the thoughts of encountering 
 something which might be removed, would amount to mischiev- 
 ious meddling, and justify the sarcastic rebuke of Stromeyer, that 
 "he who would trephine such a cranial crack must have a crack 
 in his own head." 
 
 This early use of the trephine fails to receive support, in fact, 
 is condemned by the results of statisticians who have studied the 
 operation in long series of cases. For example, Bluhm, in 1S70, 
 collected 923 cases of trephination; when done primarily the 
 mortality was 55.26 percent; when done secondarily, the mor- 
 tality was 39.24 per cent; and when done at a late period, the 
 mortality was 40 per cent. These figures favor postjoonement of 
 the operation. 
 
 If general objection has been urged against trephining as a 
 diagnostic procedure, and opinion has varied in regard to operat- 
 ing as a preventive means, on the contrary, respecting trephin- 
 ing as a curative means in selected cases, opinion is not discord- 
 ant. From adventurous exploration the hand had better be 
 stayed, and in the field of expectant prevention hesitation should 
 have a frequent place; but in a third class of cases, the demand 
 for action is urgently imperative as a means of cure. 
 
 In the injuries of the head, there are those in which instru- 
 mental interference is demanded at once, or within a brief period 
 after the accident; and in such cases, there may be an opening 
 through the scalp, which exposes to view the entire extent of the 
 injury; for example, there maybe depression, fragments detached 
 and driven inwards, and accompanied by a foreign body. Or, 
 without an opening through the scalp, symptoms of irritation or 
 depression may point to concealed injury. In the former case, 
 the indications as to what is to be done, are apparent; the open- 
 
TREPHIXATIOX. 195 
 
 ing, if too small, is to be so enlarged that it will permit of the 
 removal of fragments, or a missile, or other disturbing agent. 
 But if the scalp be intact, and symptoms of grave intra-cranial 
 disturbance be present, then the integument should be opened 
 and the wall explored. If the wall be found intact, then the 
 surgeon's action must be shapen entirely by the subjective symp- 
 toms. If there should be present the phenomena of concussion, 
 in which the patient is in a state of coma, with normal respira- 
 tion and the muscles relaxed, then immediate trephining would 
 be ill-timed; it would be better to w.ait until the patient rallies 
 from the concussion. It should be remarked that coma here is 
 not deemed by all surgeons a contra-indication to trephining; the 
 more prudent, however, counsel delay. 
 
 But when in the commencement there exist symptoms of 
 compression in which the subjective phenomena are of the type 
 of depression in the form of monoplegia or more general motor 
 palsy, with or without partial convulsions concurring with coma, 
 and without or with a wound of the scalp, then it is proper to 
 trephine. Le Fort, a strong friend of the trephine, has formulated 
 the axiom : "When in doubt, one should act." 
 
 When the injury is such as to indicate the lesion of an intra- 
 cranial artery, and the symptoms, whether of exaltation or depres- 
 sion, point to the effusion of blood from the ruptured vessel, then 
 the immediate use of the trephine is explicitly indicated; if done 
 at once, an opportunity will be afforded of removing tlie clot 
 already formed, and to secure the vessel, so that further bleeding 
 will be prevented. 
 
 Velpeau urgently advises the use of the trephine in cases in 
 which blood has been effused between the dura mater and the 
 cranium; for in such patients the blood continues to escape, and 
 to push the dura mater more and more against the brain; and 
 then the subject is menaced with inflammation of the brain, 
 effusion into the arachnoid cavity, and softening of the cerebral 
 structure; in such a patient symptoms of compression will soon 
 appear, which will justify, in fact demand, early trephining. 
 This intra-cranial effusion of blood is caused by rupture of the 
 greater and lesser meningeal arteries, especially of the larger one. 
 And in case the injury is at the base near the entrance of the 
 arteries into the skull, then the blood will be poured out within 
 the dura mater; but if the injury is higher up, then the effusion 
 occurs exterior to the dura mater, and the latter membrane will 
 then be detached on a small or larg-e scale from the cranium. 
 
106 cRAXirM. 
 
 Sucli detachment is less in the infont than in the aduh, owing to 
 the firmer connection of tlie membrane to the bone, in the infant. 
 In the adult, Marchant has found that the separation can occur 
 from tlie lesser wings of the sphenoid to within nearly one inch 
 of the internal occipital protuberance; and it may reach to the 
 falx major cerebri above, and downwards to a horizontal line 
 which begins at the apophyses of Ingrassias and runs thence 
 backwards — no small space to extract clotted blood from, as the 
 author once verified. The higher up in the cranial wall the 
 injury is situated, the smaller the vessel will be, and the less will 
 be the amount of blood effused. 
 
 Kronlein, a German, in 1SS6, published his observations and 
 studies of lesion of the middle meningeal artery; he finds the 
 haemorrhage may be limited to a small spot, or it maybe diffused. 
 When the clot is isolated, its site may be temporo-parietal, lying 
 in the middle cranial fossa, or the clot may lie beneath the parie- 
 tal tuberosity, which Kronlein designates the parieto-occipital 
 site. A third location is the fronto-temporal, in which the blood 
 lies under tlie frontal protuberance. The clot in most of these 
 situations can be reached by trephining through the anterior 
 inferior angle of the parietal bone; through this oj>ening, the 
 diffused clot, as well as that in the temporo-parietal and fronto- 
 parietal sites, can be reached. And if no clot be found in either 
 of these sites, then an opening must be made beneath tlie parie- 
 tal eminence, and through this a clot in the parieto-occipital 
 situation can be reached. 
 
 In the cases cited, trephining done curatively is performed 
 immediately; in another small class of cases, the work may be 
 done late, or after the lapse of some days or weeks. For example, 
 if, after some time, symptoms of irritation or depression present 
 themselves, the operation may be done as a means of relief It is 
 confessed by all the advocates of trephining here, that it is diffi- 
 cult to distinguish the phenomena of encephalitis from those 
 which proceed from a local irritant which could be removed by 
 opening the cranium. The most enthusiastic [)artisans would do 
 the operation in ence})halitis of traumatic origin, with the hope 
 that the cause might be discovered and removed" by trephining. 
 As such cases almost always terminate fatally, the effort to avert 
 such an end is commendable, even tliough it should not be 
 crowned with success; for by such a course the patient suffers 
 no loss; his friends are consoled with the view that something is 
 being done for his rescue; and the surgeon has afterwards the 
 
TREPHINATION. . 197 
 
 satisfying reflection that lie did not stand supinely by, and let 
 his patient die. 
 
 And, lastly, the trephine may be used at a still more remote 
 period than the one mentioned. For example, there ma}^ arise, 
 months after the receipt of the injury, trouble of an irritated or 
 exalted character, such as convulsions and epileptic attacks. Or 
 the supervening affection may be of the adynamic or depressed 
 type, such as some form of palsy, aphasia, or some disturbance of 
 the functions of motion and sensation. Such trouble may arise 
 from a collection of pus, a clot of blood, a fragment of bone or a 
 foreign body. The scar of a healed wound can cause similar 
 morbid conditions. In such cases the trephine opens a way 
 through which the central causal agency can be reached and 
 removed. By this means it may be possible to cure or improve 
 the patient's condition by extracting a missile, excising a splinter- 
 like process of bone, excising scar-like tissues, or by opening a 
 pus cavity. 
 
 This instrument has been invoked as a not infrequent assist- 
 ant in the cure of epilepsy. It has been found that tiiis disease 
 can often be referred to some traumatic cause of the skull, to some 
 injury in which tlie cranial wall is deformed, and presses on and 
 alters the form of the brain. The wound of the skull may have 
 been slight, so insignificant as to have left no evidence of itself on 
 the outside; or it may have been an extensive wound in which 
 the wall has been broken and fragments lost. The epilepsy may 
 appear soon after the injury, yet, commonly, it supervenes at a 
 later jjeriod. This is especially so in cases of the open breach, in 
 which there is closure by cicatrization. From the author's obser- 
 vation, it is in the young subject that cranial injury most usually 
 becomes the exciting cause of epilepsy; in the child, he has 
 seen epilep.sy originate from a seemingly insignificant injury of 
 the head, in which there was merel}'' a slight depression of the 
 bone without fracture. The site of the injury was in the upper 
 part of the frontal bone, to the outside of and above the right 
 frontal tuberosity. The epileptic attacks occurred once or twice 
 daily, and were increasing in both violence and frequency. The 
 removal of a section of the wall from the part, which was reported 
 to be the site of an injury from a fall, cured the lad of his epilep- 
 tic disease. The bone which was removed showed signs of thick- 
 ening. After the removal of the bone, the inner plate was 
 removed to a small extent from the bony wall around the orifice. 
 This work was so done with chisel and forceps as to remove the 
 
198 CKANUM. 
 
 sharp edge of tlie bone, against which the brain rested in its 
 slight ascent into the opening made. Besides this inner beveling 
 done with forceps, similar to those used by dentists in the work of 
 dental exsection, there was excised an additional portion of the 
 wall, which was found to be thickened similarly to that portion 
 removed by the trephine. The remaining breach was elliptical 
 in outline. The cure was a permanent one, as verified by subse- 
 quent observation. The epilepsy in this case may be ascribed 
 to the continued irritation to wljich the brani was subjected by 
 the slight encroacliment of the thickened wall upon it. As the 
 antithesis in injury to this case was another in wliich the skull 
 was extensively broken over the motor tract of the cerebrum, 
 and fragments of the bone were removed. The membranes were 
 torn and cerebral matter was lost. The part healed with exten- 
 sive cicatrization, contraction and inversion of the surrounding 
 bone This boy recovered, and for some time wasin perfect health; 
 but after a few years, as he approached puberty, he became the 
 subject of epilepsy. The osteophytic growths from the margin 
 of the fractured bone evidently became the spines of irritation 
 which caused the convulsions. As no permission was granted 
 for trephining in this case, wliat the operation might have done 
 for relief remains unknown. In a third case the man was at the 
 middle of life, and his epilepsy was referable to an injury of the 
 .-kull received seven years before. The operation was done by 
 the writer, and furnished relief for a few months; the disease then 
 reappeared in violence, and at intervals, similar to the former 
 course of the disease. In a fourth case, a young man, who had 
 often been injured by falling from a horse, became the subject of 
 frequently recurring attacks of epilepsy; trephining over the left 
 motor tract with ligation of the left carotid artery effected a 
 cure. And a fifth man, the subject of epilepsy caused by a blow 
 without fracture of the left parietal bone, was cured by removing 
 a considerable section from the parietal bone. 
 
 In the three cases in which a cure w'as effected, the trephined 
 portions of bone showed merely a slight thickening of the cranial 
 wall ; there were no signs of depression. 
 
 In 1884, Walsham,an English surgeon, collected statistics in 
 reference to the results of trephination done for the cure of epi- 
 lepsy; of eighty-two cases in which it was done, twenty died and 
 forty-seven were relieved or cured; he concludes that these 
 results justify trephining in such cases. 
 
 In a species of ejiilepsy, in which but one-half of the body is 
 
TRErillXATIOX. 199 
 
 attacked with spasmodic contractions, trephination has been 
 resorted to with successful result. In this form of epileps}^ 
 described by Hughlings Jackson, and named after him Jackso- 
 nian, the disease depends on an affection of the cortex of the cere- 
 bral motor centre on the opposite side; and the trephine is 
 employed to remove a portion of the cranial wall overlying the 
 centre, thus permitting the removal of some of the cortex, by 
 which the centre is reduced to subsequent inactivity. 
 
 In cases of epilepsy in which the disease could be traced to 
 neither functional nor objective cause, trephining has been done 
 with the report of successful event. In the accidental contingen- 
 cies to which the developing head is exposed, it is conceivable 
 that some injury in these cases may have deformed the wall 
 which the trejjhine was able to modify to the benefit of the 
 patient. 
 
 Before proceeding to the use of the trephine, one should take 
 into account the anatomical character of the wall which is to be 
 bored through; also the relation of the wall to the sinuses or chan- 
 nels for venous blood, which lie near it. 
 
 The wall in different persons, as has been mentioned, is of 
 variable thickness; it may be only a line thick in cases of extreme 
 thinness; and then again, it may be a half-inch thick ; and this 
 can only be discovered as the work of boring is being done. 
 The operator must also consider the component parts of the wall, 
 viz., the external and internal plates and the intermediate diploe. 
 "When the wall is thin, there is but little or no diploetic structure; 
 and, as vessels exist in this which bleed when wounded, the 
 absence of blood in the bone-dust indicates that there is little or 
 no diploe, and, consequently, that the cranial wall is thin. The 
 diploetic vessels are largest near the foramina, which partly or 
 completely perforate the wall; these exist normally in the frontal, 
 parietal and mastoid regions. The bone-dust from the saw- 
 ing is commonly sufficient to arrest the bleeding from these 
 vessels when wounded, yet they may reopen and the escaping 
 blood may cause some trouble. A subjacent sinus is a contra- 
 indication to using the trephine directly over it; for instance, 
 the trephine should not enter over the superior longitudinal 
 sinus, viz., in that region corresponding to the median line of the 
 cranial vault, extending from the glabella to the external occipi- 
 tal protuberance. The superior longitudinal sinus lying there 
 increases in width as one passes backward ; at its posterior end it 
 is nearly a half inch wide. To remove the bone Iving over this. 
 
200 t-HANHM. 
 
 it is better to trephine on each side, and then remove with forceps 
 the bridge lying between the openings. And should it be needed 
 to trephine beliind the ear, as is sometimes done to give exit to 
 pus developing in connection with the auditory apparatus, then 
 the work must be done cautiously, so as to avoid the lateral sinus. 
 
 One would proceed with the greatest safety by first removing 
 the external plate, and then completing the work with the curved 
 chisel or gouge, worked without mallet, by the hand, alone ; and 
 if the work can not be done with one hand, then use as aid the 
 other hand. In 1847 this plan of trephining was announced by 
 Roux, wlio named it the method of trephining by evulsion. 
 He employed it to avoid the vessels, and thinks that tlius one 
 might open safely over the lateral sinus, as well as the other sin- 
 uses. Roux says that one can also open into the cranial cavity 
 above and below the petrous portion of the temporal bone, and 
 thus enter the cavity above and below the tentorium. 
 
 The ancients in trephining carefully avoided the sutures; the 
 counsel of Hippocrates preserved these lines intact for many cen- 
 turies after his time; and as Hippocrates, through his imperfect 
 anatomical knowledge, placed sutures in the skull where they do 
 not exist, hence the field of trephination had extensive limita- 
 tions. Some centuries later, Berenger di Carj)i crossed the for- 
 bidden sutural line, and, finding that no injury followed, the 
 suture has since been disregarded in trephining. 
 
 There are two forms of the instrument used for trephining; 
 and these have doubtless been modeled from implements to be 
 found in the shops of the smith and carpenter, the storehouses 
 whence have been drawn the most of the instruments used in 
 surgery. The one form of instrument is that W'hich has its 
 analogue in tlie carpenters' and joiners' bit and brace, and is pro- 
 pelled by a bow-like portion which lies between the handle and 
 the boring end. This is the form used by the French, and which 
 they name trepan. The second form of instrument is analogous 
 to an auger or gimlet; this is propelled by means of a handle 
 which is fastened at right angles to the upright staff that is 
 fastened to the boring end. Instruments with other attachments 
 for propulsion have been invented, yet their complexity renders 
 them less easily used than the two forms mentioned, which repre- 
 sent the two species of instrument wliicli have been used from 
 time immemorial. The gimlet-like instrument commonlv used 
 by the American and English surgeon is properly designated by 
 the name trephine, while the other is oftener called the trepan; 
 
TEEPHIXATIOX. 201 
 
 yet it should be observed that these distinctions are not always 
 observed by surgeons and surgical writers. 
 
 Whatever may be the mode of propulsion, the boring or cut- 
 ting end is similar in both trepan and trephine. This part is 
 named a corona or crown; it is cylindrical in form, armed with 
 teeth like a saw. These teeth, like those of saws, vary in form 
 and disposition. They are sometimes disposed with vertical 
 intervals between them which serve as spaces in which the bone- 
 dust collects as the sawing proceeds. This crown is often made 
 of poor steel, so that the teeth break readily, and the instrument 
 becomes useless. The trephine is, in fact, a circular saw, that 
 does its work in a horizontal plane, instead of a vertical one; and 
 the work may be done by continuous motion in one direction, or 
 the instrument may bore by half revolutions, each being the 
 reverse of the other in direction; the latter is the common mode 
 of propelling the trephine. The crown of the trephine rested 
 uneasily both on the head of the patient, as well as in the hands 
 of the surgeon, until it was provided with a central pin or pyra- 
 mid for fixation. This addition w^as made by Guy de Chauliac 
 and Bichat. The crown is so fastened to this pyramid that the 
 latter can be made to ascend or descend below the edge of the 
 crown; and wdien the descent is made, then the crown is fixed 
 and forced to follow the intended line of cutting, instead of slip- 
 ping from side to side. Another addition to the trephine is an 
 external guard, which can be fixed at any point, so as to permit 
 the crown to penetrate no deeper tlian is desired. From the 
 writer's experience this part, which was attached to thetrejDan by 
 Ambrose Pare, is more embarrassing than beneficial; depending 
 upon it, the operator is more apt to bore too deeply than if he 
 were to depend on his own hand and eye to measure the depth. 
 There are crowns of different sizes; that of average dimensions is 
 about half an inch in diameter; it may be much larger, as well 
 as much smaller. The crown, instead of being cylindrical, may 
 be conoidal in form, and the cutting end is the smaller portion. 
 The outer surface of this conoidal crown is provided wdtli cutting 
 ridges with intermediate furrow^s, the arrangement being such 
 that the crowm cuts as much with its outside as with its free edge. 
 Sometimes it becomes necessary to trephine where there 
 is a small opening which must be enlarged. In such a case 
 the. central pyramid for fixation can not be used, and one nnist 
 resort to another means to retain the instrument in the desired 
 place. This may be done bv first boring with the trephine 
 14 
 
20'J ciJANirM. 
 
 tliroiigli u piece of leather, or a thin iiiece of lliittencd wood, and 
 then i)lacing this over the point whicli is to be trei)hined: the 
 work being thus done the instrument cannot glide from its place. 
 
 The operation of trephining after the scalp has been shaven 
 and well cleansed, consists of three acts, viz., opening through the 
 skin, then perforating the skull; and a third act is the important 
 one of removing the clot growth, })us, missile or foreign body, 
 which is lodged within the cranium. 
 
 The skin, if covered with hair, should be well shaven, and 
 then well washed with dilute alcohol. The incision may be made 
 with a scalpel or convex Idaded bistoury. The form of this 
 incision may be linear, crucial, triangular, quadrangular, or the 
 arc of a circle. The crucial cut is the one usually reconnnended 
 and made; of all the forms it is tlie most inconvenient, since by 
 it four angular flaps are made, which must be drawn aside during 
 the second act; by any of the other incisions, except the linear, 
 there is but one flap. The semicircular flap is the one which the 
 author, from his experience, especially recommends; it is easily 
 held aside, and after the work is done, it is readily restored to its 
 place so that healing is promoted. The linear is rarely used, 
 since but a limited portion of skull can thus be laid bare. By 
 the semicircular cut the scalp is wounded less than by the crucial ; 
 in fact, the wound of the scalp by this mode amounts to but little 
 more than one-half of that produced by the crucial incision. 
 
 The primary semicircular cut is first made by fixing the scalp 
 by pressure with one hand, wdiile tlie other makes an incision 
 that extends at once to the cranium. The flap should be so con- 
 structed that its attachment or pedicle is directed towards the 
 summit of the head ; thus made the wound will be best situated 
 for the subsequent escape of materials that may l)e thrown ott' 
 from the wounded parts. The incision must reach to the bone, 
 so that the flap, including the periosteum, can be uplifted from 
 the bone. In thus preserving the periosteum, the possibility of 
 subsequent osseous repair is favored, and thus the bone which is 
 removed may, perchance, be replaced by a new growth of bone. 
 
 If the work be done in this way, it is probable that the breach 
 made would not be left so imperfectly closed as often occurs. 
 The flap thus incised can be elevated by means of a blunt dis- 
 sector, a thin chisel or the handle of a scalpel; and should any 
 vessels have been divided, these should be controlled by means 
 of torsion or ligation. 
 
 The .sawing through of the bone is next to be done. The tre- 
 
TREPHINATION. 203 
 
 phine crown must first be adjusted for its work by causing the 
 central pyramid to descend and project about one line beyond the 
 edge of the crown; also the external guard if present should be 
 fixed on the outside of the crown at a point corresponding to the 
 depth which it is designed to bore. When the instrument is 
 thus adjusted it is placed on the exposed skull, and by pressure 
 and rotation, the pyramid is made to descend until the crown 
 reaches the bone and its teeth so engage in the wall that a guid- 
 ing furrow is traced. At this stage, the instrument is withdrawn 
 and the pyramid is uplifted. Now the crown is to be placed in 
 the furrow that has been traced, and the work of sawing con- 
 tinued. The work must be done slowly, and the instrument so 
 held that it will do equal work on all sides. ■ It should be removed 
 from time to time, and dipped into a dilute solution (y^) of 
 corrosive sublimate, which will have the effect of rendering the 
 wounded bone aseptic, and also to wash the bone-dust from 
 the teeth of the crown. This immersion has the effect also, of 
 cooling the instrument. It was advised by Hippocrates during 
 trephining to occasionally withdraw the trephine and dip it into 
 cold water, for he taught, if this were not done, the bone would 
 be burnt by tlie boring crown. When the outer plate has been 
 severed and the diploe reached, blood will escape from the wound, 
 due to opening the diploetic veins. In the very old subject, in 
 whom the diploetic structure has disappeared, little or no signs of 
 blood will be perceived; and in such, as the wall is thin, there 
 is need of unusual care lest the dura mater be injured. During 
 the work of sawing, the instrument should occasionally be 
 removed, and the progress of the work be measured by the intro- 
 duction of a wire or find sound. It is seldom that the part tre- 
 phined is of uniform thickness; also the unequal pressure made 
 on the instrument, which is difiicult to avoid, causes the wall to 
 be sawn through earlier at one point than at another; and when 
 this is perceived, the sawing must be continued slowly and the 
 remaining portion carefully divided. 
 
 The case of trephining instruments contains also an extractor, 
 an elevator and a lenticular knife, which are used to finish the 
 work, when the boring has been done. When it is found that 
 the wall has been nearly perforated, which is perceived by the 
 slight mobility of the segment of bone included in the crown, 
 then the gimlet-like extractor may be bored into the piece to be 
 extracted, and, perhaps, in this way it can be removed. Or, in- 
 stead, a thin chisel can be fixed in the sawn piece, and made to 
 
204 CRAXUM. 
 
 act as a lever on. this, the edge of the sawn skull serving as a 
 fulcrum. By these artifices, tlie work can often be completed 
 more safely than could be done by sawing entirely through. 
 AVlien the sawn portion has been extracted, the edge of the open- 
 ing must be examined, and if fragments or spicula remain adher- 
 ent to it, these must be removed; the removal can be done with 
 forcej)S, the lenticular knife, or a round edged chisel. Again, it 
 often occurs that the opening nuide is insufficient for the purpose 
 for which it was intended, and then it is necessary to enlarge it. 
 The enlargement may be done by Roux's method of evulsion, 
 before described ; but if the wall be thick, this work is done witlj 
 difficulty in this way. The exposure of more surface is better 
 done by again trephining near the opening formed, on the side 
 towards which one wishes to enlarge. And if need be, a third 
 adjacent opening, and as many more as the case requires, can be 
 made, and afterwards, the small bridges of bone left between the 
 orifices can be exsected with bone forceps or chisel; and thus an 
 elongated portion of the surface of the encephalon is offered to 
 view; and through this the surgeon can conclude the ulterior 
 work of extraction, which is embraced in the third stage of tre- 
 phining. 
 
 There are but few cases in which there is required a larger 
 opening than that which is obtained by one boring; however, 
 an exceptionally large opening is sometimes required in the case 
 in which the meningeal artery has been ruptured; yet even here, 
 before enlargement of the opening is done, an attempt should be 
 made to remove the coagulum with a small scoop passed inwards 
 beneath the wall. This clot lies outside of tlie dura mater, unless 
 the meningeal artery should be ruptured near its entrance at the 
 foramen spinosura; then the blood might flow inside of the dura 
 mater within the arachnoid sack. In this case, the blood would 
 be hidden from view, and if its unusual site were not suspected, 
 then tlie surgeon would be perplexed to explain the cause of the 
 compression which must exist in such a case. Formerly, the 
 dura mater was never opened except in very extraordinary cases; 
 this rule is now often transgressed, in fact, so often that it has 
 nearly ceased to be a rule. To enlarge the field of cerebral 
 exploration, this membrane may be opened, and in the instance 
 here considered, when a clot is not found outside of the dura 
 mater, the latter should be opened, and the search prosecuted 
 towards the base. Such clot, whether inside of or outside of the 
 dura mater, should be removed ; yet aire should be taken not to 
 
TREPHINATION. 2C5 
 
 open the rent in the ^vessel which has furnished the blood. 
 Some claim that it is impossible to avoid this, and on that 
 account they would prefer leaving the patient to his fate 
 rather than subject him to an operation of which the results, at 
 best, could only be doubtful; they claim that the pressure on the 
 brain will soon be tolerated, and later, the blood will be removed 
 by absorption. It is, however, better to remove the coagulated 
 blood, since even should the material be absorbed, this would 
 occur slowly, and meantime cause derangement in the parts 
 which are pressed on ; and at best, a cyst-like cavity would remain 
 in the site of the clot. The functions of the brain are so impor- 
 tant that a grave perversion of them is a costly price to pay for 
 the continuance of life; a bold effort should be made to escape, 
 and to secure freedom from such fetters; risks are not only justi- 
 fiable to be taken, but they become a duty to both the patient and 
 his surgeon. If death is better than slavery of the body, how 
 much more so is possible death occurring in an attempt to escape 
 thralldom of sensation, motion and mentality, the noblest posses- 
 sions of individual life. The author would then trephine exhaust- 
 ively and sedulously remove the coagulum, and if there was 
 difficulty in arresting the bleeding from the ruptured vessel, by 
 pressure or ligation, then the external carotid artery should be 
 tied, which would surely insure immunity from further bleeding; 
 after such ligation the surgeon might prosecute the work of 
 extraction more freely; and, besides, the cavity might be irrigated 
 with an aseptic solution, so as to insure the entire removal of 
 the extravasated blood. In this way the brain would resume its 
 natural form and contour, and immediate recovery would probably 
 ensue. 
 
 If the trephining be done merely to elevate bone that has been 
 depressed by fracture, then the opening is usually made contigu- 
 ous to the sunken bone; even the edge of the latter might be 
 embraced in the opening. Sometimes the work has been done 
 on the depressed bone itself; yet the want of uniformity of 
 surface of the sunken bone renders it difficult to trephine there. 
 This work can usually be done through a single opening, when 
 the portion sawn has been removed, then the work of restoration 
 of the bone to its normal level can be accomplished by the aid of 
 the elevator or small lever that is inserted under the margin of 
 the depressed bone, and the latter lifted into position. In this 
 uplifting care must be used not to contuse the under surface of 
 the bone that is acted on. Another precaution to be taken is not 
 
200 CRANIUM. 
 
 to complete the fracture of the bone tliat is depressed. There is 
 less danger of this occurring in the young subject than in the old; 
 in the latter, fracture can easily happen. If the uplifted bone be 
 yet covered by the periosteum, it is probable that its vitality will 
 be maintained, even though it be marginally detached. 
 
 In the operation of trephining two important innovations 
 have lately been introduced, differing radically from the former 
 metiiods. In one of these, instead of sacrificing the disk of bone 
 that has been excised, the latter is broken into small frag- 
 ments, which, being asepticized by a dilute sublimated solution, 
 are placed on the breach, and the wound in the scalp closed over 
 the opening. Another plan recommended is to asepticize the 
 disk and replace this entire on the trephined opening. Doing 
 thus, it is claimed that the breach in the wall will be repaired 
 and the continuity of bone restored. 
 
 In the second method, the work is an osteo-plastic procedure, 
 in which the sawn segment is left attached at one end or side by 
 a small pedicle, so that it can be uplifted like a trap door, and 
 when the door has served its purpose, it can be lowered to nor- 
 mal site, and thus the continuity of the cranial wall can be })re- 
 served. To do the work in this way, a special saw is employed 
 by which the wall is only partially divided, the division except 
 the pedicle being completed by means of the chisel, mallet and 
 elevator. This method is illustrated in figure 2. 
 
 Figure 2, showing the osteo-plastic method of trephinin 
 
 Professor Linn has recently suggested, as material for reclosing 
 the opening, decalcified bone, and Frankel has proi)0.sed the use 
 of celluloid. 
 
 The writer has had no experience in closing the trephined 
 opening by any of the methods mentioned, yet the osteo-plastic 
 method appears rational and is wortli}^ of trial; that of closure 
 by osseous fragments is more equivocal and should be limited to 
 employment in the young subject. 
 
 In the mind of the laity many half truths have lived for a 
 
TREPHINATION. 207 
 
 long time before they developed into whole truths; the methods 
 of replacement just mentioned have such a correlate in the popu- 
 lar mind, and are answers to the question which every surgeon 
 has heard. Are you going to close the skull with a gold or silver 
 plate? 
 
 The work having been done, which was the purpose of the 
 trephining, viz., the removal of a foreign body, clot, pus or tumor, 
 the further treatment of the wound will vary according to the 
 condition of the parts operated on. If they are entirely sound, 
 as they must be when a blood-clot has been extracted, then after 
 cleansing the parts well, the wound can be closed by means of 
 two or more catgut sutures. In case the parts have been lacer- 
 ated by the penetration of a foreign body, then the torn shreds of 
 the meninges should be excised, and the wound should not be 
 completely closed; an opening should be left for drainage through 
 a fenestrated tube of medium caliber. If the work has been the 
 removal of a cerebral tumor, then there should also be made 
 provision for the free escape of excreta from the injured parts. 
 And such a passage should be maintained open for a considera- 
 ble period of time. And if the operation be done to evacuate pus, 
 then a drainage tube should be inserted in the cavity, and 
 through the tube the cavity should be cleansed daily. The 
 patient should so lie as to favor the continuous escape of the 
 excreted fluid. And the drain of outlet should be so placed and 
 inclined as to favor escape. It is rare that there is closure by 
 immediate union; even in the case in which the trephining has 
 been done to relieve epilepsy, immediate union is rare, and, 
 though it may occur, yet the wound sometimes reopens and a 
 sero-purulent fluid is discharged, often, for weeks. Besides this, 
 the absence of healing is sometimes caused by a fragment of 
 bone which detaches itself from the wounded wall. Yet these 
 cases of delayed healing will occur less frequently if the surgeon 
 follows closely the best methods of treating wounds. 
 
CIIAITKU V 
 
 MENINGES OF 'II I i-: lUtAIN. 
 
 When the membranes of the brain are viewed by the surgeon 
 in reference to tiieir anatomical structure and disposition for 
 practical considerations, the three normal meninges may be 
 reduced to two, for the arachnoid is connected to and shared by 
 the other two; and thus viewed, we liave the dura mater, with 
 an inner serous lining, and the pia mater, with an outer serous 
 lining. The dura mater, a fibro-serous structure, bears some 
 resemblance to an articular capsule. Galen, in his epode, as he 
 names it, on the utility of parts, in which, as a neplus ultra tele- 
 ologist, lie continually unveils the purposes of creative wisdom, 
 teaches that the brain has three protective ramparts, viz., the 
 cranium, the most solid of all; then the dura mater, firm and 
 resistant but less so than the cranial wall; and, lastly, on the 
 inmost side, is the pia mater, less firm than the dura mater; and 
 Galen thinks that these are so disposed that each membrane, in 
 its turn, lessens the shock of impact against the part which is 
 next adjacent; and so at last, the solid skull is prevented from 
 injuring the brain which may be carried against it by any vio- 
 lence. 
 
 Henle, the greatest anatomist in modern times, as Galen 
 was in antiquity, finds a protective agent in the arachnoidean 
 and subarachnoidean fluid. This liquid, about two ounces in 
 quantity, rests on the outside of the brain, and besides leveling 
 the inequalities on the surface of the brain, it is interposed as a 
 thin film between the organ and the cranial wall covered by the 
 dura mater. The prophylactic agencies mentioned are powerless 
 against violent injury; they are only efficient against mild shocks, 
 such as may arise from brisk or sudden movements of the head. 
 
 Besides its protective agency, the dura mater performs other 
 
 offices in the animal economy; it is the periosteal investment of 
 
 the inner surface of the skull ; yet, different from other periosteum, 
 
 there resides in it but little bone-producing power; and this is 
 
 (208) 
 
AFFEGTiO^'S OF THE MEMBKAXES OF THE BRAIN. 209 
 
 contrary to that which might have been expected, since it is more 
 vascular than normal periosteum. A third office of this mem- 
 brane is to receive the blood from the brain in the sinuses or res- 
 ervoir-like channels which lie in it. The blood is brought bv 
 veins from the subjacent brain, and emptied into the sinuses, and 
 the course of the blood in these veins is opposite to that in the 
 sinuses: the seeming effects of which would appear to be to 
 retard tlie outward passage of the blood, and thus to avert sudden 
 cerebral anaemia, wliich might otherwise occur. 
 
 The veins that convey the blood from the brain to the sinuses 
 in the dura mater are valveless and remarkable for their fragility: 
 conditions which favor the easy passage of blood as well as their 
 rupture and effusion of blood. 
 
 To the dura mater the function of producing bone has been 
 generally denied by anatomists: and hence the explanation of the 
 fact that where portions of the wall of the skull have been 
 removed by the trephine, or by accident, the breach remains 
 afterwards unfilled by bone. From study of tljis matter by 
 Ballon, of Strassburg, in 1864, it is probable that if more effort 
 were made to preserve the integrity of the dura mater, there 
 might be a reproduction of bone; in such cases Ballon refers to 
 experiments which have been made by Oilier and Flourens, in 
 which these men have proven that the outer surface of the dura 
 mater can generate bone. From an examination of the speci- 
 mens in the medical museum of Strassburg, Ballon is convinced 
 that the dura mater can generate bone, both from its outer and 
 its inner surface. This writer thinks that the serous epithelial 
 lining of the inner surface of the dura mater must be unfavorable 
 to the production of bone. And, furthermore, were bone devel- 
 oped in the inner surface, it could serve no physiological purpose; 
 and, further, that its position then would endanger the contiguous 
 cortical surface of the brain. 
 
 SURGICAL AFFECTIONS OF THE MEMBRAXES OF THE BRAIX. 
 
 The meninges of the brain in their diseases and derange- 
 ments offer a common field to surgeons and physicians, the 
 greater share falling probably to Internal Medicine. 
 
 Inflammation of the dura mater, though pertaining rather to 
 the province of the physician, finds, also, a place in the works of 
 modern surgery. It has received the name of pachymeningitis; 
 also of scleromeningitis ; though the latter is the more appropriate, 
 yet the former name is the more usual one. Pachymeningitis 
 
21U MKMiniANKS OF TIIK BRAIN. 
 
 may be caused by a wound, or external violence. A peculiar 
 form of it is that which can originate from excessive and pro- 
 longed alcoholism. 
 
 If violence injures the cranial wall in its entire thickness, 
 the dura mater must share in the lesion. The membrane may be 
 contused, torn, or a portion of its structure may 1)0 lost. 
 
 The treatment of such injury must necessarily be comprised 
 in the general management of the wound of the head of which 
 it is but a part. Similar to the course recommended in the treat- 
 ment of the scalp, it should be the aim to preserve all that is 
 possible of the membrane, since, similar to the skin or mucous 
 membrane, when a portion of the dura mater is lost, it cannot 
 be restored again. The tissue of rejiair is at best but cicatricial 
 structure, which here, as eLsewhere, contracts, compresses, and 
 changes somewhat the form of the parts with which it is contigu- 
 ous. Here the rule must be to save some torn shreds of the dura 
 mater, if it is probable that the}^ wnll< retain their vitality. As 
 the membrane is vascular, and if wounded at certain points, 
 hemorrhage must result, hence such opened vessel when acces- 
 sible must be ligated; or if that be not possible, for example 
 where the vessel lies partly imbedded in the bone as well as in 
 the dura mater, then the torn vessel may be closed by plugging 
 it with a small piece of sponge. Asepticised white wax might 
 be used as closing material. The small mass of occluding mate- 
 rial would afterward remain as harmless matter. 
 
 The dura mater can be injured by blows on the skull in 
 which the latter is not fractured, and still the subjacent mem- 
 brane is contused, and possibly detached from the wall. The 
 result of such injury may be the opening of a blood vessel, 
 and the effusion of blood between the membrane and the 
 skull. Such effused blood may disappear mostly by absorption, 
 yet the result will be a prolonged irritation of the part, and, as a 
 consequence, a thickening of the membrane, and, sometimes, a 
 production of bone. The osseous growth can be merely a thin 
 plate on the outer surface of the dura mater, or it may be a spine- 
 like development, which by its presence may maintain a local 
 irritation of the adjacent surface of the brain. Such an irritant 
 might become the cause of epilepsy. Again, a large clot of blood 
 might not be wholly absorbed, the solid elements of the coagulum 
 remaining, and deforming the surface against which the brain 
 rests. Nature, in her efforts to restore parts to their normal form, 
 is in most cases competent to remove, or compensate the results 
 
AFFECTIONS OF THE MEMBRANES OF THE BRAIN. 211 
 
 of, the injuries just considered. Still, in the study of the diseases 
 of the brain and nervous system in their protean forms, a possi- 
 ble origin from some lesion of the species mentioned should be 
 borne in mind; and as means of relief, should there be a localized 
 guide, exploratory trephination might be resorted to. 
 
 The observation was made some years ago that inflammation 
 of the dura mater may originate from the prolonged use of alco- 
 holic drinks. In such cases the inner face of the membrane is 
 principally affected. Among those authorities who have particu- 
 larly studied this disease may be mentioned the names of Grie- 
 singer, Lancereaux, Virchow, and Vulpian. Griesinger, in 1862, 
 wrote on the subject from the observation of eight cases. In most 
 of the cases there were headache, narrowness of the pupil, somno- 
 lence, and, in a few cases, palsy. But where effusion of blood 
 occurred, the attendant symptoms were more obscure and compli- 
 cated; for after such hemorrhage, there ma}' be convulsions, anaes- 
 thesia, and idiocy, as the result of cerebral changes. He found 
 the disease usually in' drunkards who were over fifty years of 
 age. The patient may recover, and then there will remain pig- 
 mentary traces of the preexistent hemorrhage. 
 
 In 1863 Lancereaux published his studies and observations, 
 and he is the leading authority on the subject. He assigns a 
 varied causation for 2)achymeningitis, viz., that it may arise from 
 alcoholism, traumatism, rheumatism, erysipelas, cancer, tubercu- 
 losis, scrofula, and rachitis. Old age and infancy are predispos- 
 ing agencies. Continued encephalic congestion caused by the 
 excessive use of spirituous drinks seems to have been the most 
 frequent cause. And that alcohol can act thus has been demon- 
 strated by Kremia.nsky and Neumann in experiments on dogs, 
 which were given large amounts of alcohol. In these animals it 
 was found that the administration of alcohol for the period of 
 four weeks, caused an inflammation of the dura mater. 
 
 The prominent condition present in the disease is, in some 
 cases, a neoplastic formation rich in blood-vessels remarkable for 
 the thinness and fragility of their walls. In other cases there is 
 found clotted blood, as well as membranous structure. 
 
 From a study of the pathological conditions, which have been 
 revealed by necropsies of fatal cases of pachymeningitis, it has 
 been found that there results from the inflammation a connective 
 tissue growth on the inner face of the dura mater. The usual 
 site of this is beneath the cranial vault, and is near the falx 
 major cerebri. The structure developed is analogous to that of 
 
•_'12 MKMr.RANES OF THE BRAIN. 
 
 ordinary graiiulativo tissue- it is extremely vascuiar. Tlie fragile 
 nature of these vessels disposes them to rupture and effusion of 
 blood. The effusion, if small in quantity, may remain pent up, 
 or inclosed in the new growth; but if it be larger in amount, 
 then, after a time, a fine membrane is developed over it, which 
 some observers think is a continuation of the adjacent arachnoid. 
 There niay be a large amount of blood poured out at once, or 
 there may occur successive ruptures, so that coagula of ditlcrent 
 ages may be found. Possibly, these a]>oj)lectic effusions of blood 
 may originate in spontaneous rupture of the vessels; it is more 
 probable, however, that the vessels are opened through transmitted 
 violence. The growth, in such near proximity to the cortex oi' 
 the brain in which the motor centres lie, must induce some func- 
 tional disturbances of these centres, and hence the patient will be 
 liable to other injury from stumbling, fall, or some kindred acci- 
 dent. And for similar reasons, the a})Oj)lectic effusion having 
 occurred once, predisposes to other attacks. And in this work it 
 is clear that alcoholism is no mean adjuvant, both in causing 
 meningeal congestion, and in toppling the patient to the ground. 
 
 Pachymeningitis presents, according to its stage, different sub- 
 jective symptoms, viz., irritation and depression. In its early 
 period the symptoms are that of irritation and excitation; and 
 this stage, which may be long or brief, corresponds to the period 
 when the neoplasm is developing. In this stage tlicre is often a 
 headache excruciating in character: such cephalalgia when 
 unaccompanied by fever, and yet is continued for a long time, 
 according to Abercrombie, indicates inflammation of the dura 
 mater. The pain is located in the region of the new growth. 
 There is also vertigo, with ringing of the ears, disturbed sleep, 
 and nightmare. Sometimes there is a sensation of a floating 
 wave in the head. The power of speech is interfered with in 
 some instances. A symptom observed by Griesingeron which ho 
 lays much stress, is myosis, or narrowing of the pupils. The irri- 
 tative period is of variable duration, viz., for only a few weeks, 
 or it may continue for months. 
 
 The second period, viz., that of depression, is noted for the 
 general adynamic character of the morbid phenomena })resent. 
 It may appear suddenly, or its advent can be so gradual that it 
 is unpercei ved. The ai)Oi)lectic effusions can occur consecutively 
 and in such slight amount that the brain tolerates them, and 
 scarcely any depression is present. This rupture of the vessels 
 and the pouring out of the blood causes sharp pain. Such pain 
 
AFFECTIONS OF THE MEMBRANES OF THE BRAIN. 213 
 
 arises from the sensory function of the dura mater, which the 
 author has seen demonstrated many times hy Flourens, who first 
 discovered this property of the dura mater; the great vivisection- 
 ist never referred to this addition to physiology without a visible 
 display of vanity. The more recent observation of Vulpian 
 that there are developed nerve fibers in the vascular neoplasm, 
 furnishes an explanation of the pain felt when the growth rup- 
 tures. This stage is characterized by the somnolence wliich attends 
 it; the patient often sleeps for twenty-four or thirty hours. And 
 when he awakes there is still drowsiness present. During this 
 stage the pupil remains narrowed, as in the first period; but, dif- 
 ferent from the first stage, when rupture has occurred, the pupil 
 of the eye on the side of the rupture is more contracted than on 
 the other side. When awakened the patient still complains of 
 headache. The pulse is slow and irregular. And there is per- 
 ceived still the same sensation of something floating in the head 
 which was complained of early in the disease. The symptoms 
 described are those arising from a diff'used or extended clot, occu- 
 pying a considerable space of the cerebral cortex; in another 
 class the clotted blood occupies a limited extent of surface. In 
 the diffused form the symptoms of depression reveal themselves 
 in palsy affecting a large portion of the body. Yet certain parts 
 may be less palsied than others. There may be comj)lete hemi- 
 plegia of one-half of the body, and incomplete paralysis of the 
 other side; this would indicate a clot on each side, one being 
 larger than the other. Again, if the clot be definitely localized, 
 then the palsy will be less diffused in its manifestation, viz., a 
 certain part of the body will be affected. And in all cases the 
 paralysis produced is less permanent and more incomplete than 
 that which arises from an intra-cerebral effusion of blood. 
 
 Pachymeningitis has been seen in the infant; the neoplasm 
 pursues the same course as in the adult; the vessels burst and a 
 clot of blood is formed on the subjacent surface of the brain; 
 more frequently, however, the growth resulting from the 'inflam- 
 mation does not burst, but there is merely a serous effusion. 
 Such disease in the infant falls more often to the care of the 
 physician than to the surgeon. 
 
 The hemorrhagic effusion from pachymeningitis limits its 
 action chiefly to a perversion of motion; the sensory function of 
 parts is rarely affected by it. The morbid manifestations have, 
 as a rule, occurred on the side opposite to the apoplectic effusion; 
 still there have been noted exceptions to this observed by A'^irchow 
 
214 MK.MI'.IIANKS 1)1-' THK I'.JiAIX. 
 
 ;ui<l Wood; the paralysis and clot were on tlie same side of the 
 body. 
 
 Pachymeningitis when it reaches the hemorrhagic or dej)ressed 
 stage, nearly always destroys life. Still in the necropsies which 
 have been made in fatal cases, not unfrequently there have been 
 fonnd conditions of the parts which indicate that there had 
 occurred a rupture, from which the parts were in process of 
 recovery; through absorption an old clot had been nearly removed; 
 there remained only pigmentary remnants. Such a favoraljle 
 event is too rare to materially change the inauspicious prognosis 
 usually coupled with this disease. 
 
 Treatment. — This may be medical or surgical. Along with 
 the removal of any discoverable causal agency, as remedial means, 
 one may give intestinal and renal derivatives. As a purge, 
 calomel is one of the best. And to act both as diuretic and 
 absorbent, there may be given the iodide of potassium. For the 
 same purpose, the arseniate of soda is advised by Charcot. Local 
 derivatives, as irritants and pustulating agents, may be tried. 
 
 Inasmuch as the means which have been mentioned have 
 proved unavailing, and have scarcely cured, the question arises. 
 Is this not a field wdiere surgery may intervene and extend to the 
 patient a more helpful hand than internal medication has thus 
 far offered? As the trephine lias pioneered the way by which 
 cerebral tumors may be reached, so it may open the way by 
 which an equally intractable malady may be directly reached 
 and directly combated. The attack by means of remedies given 
 internally is like that of besiegers, desultory and indirect, and 
 like them the surgeon would act more rationally by opening a 
 breach through the wall, even though it be at greater peril; for 
 thus he could meet the eneniy hand to hand. Perhaps it 
 might be urged that the s\'mptomatic evidences of the pachymen- 
 ingitis are too obscure to justify a resort to the trephine. The 
 .symptoms are not more obscure than are those presented in the 
 case of the intracranial tumor. One would not be justified in 
 trephining before the second stage of the disease, in which the 
 condition of the patient indicated rupture of the new vascular 
 growth: viz., motor disturbances, general or localized, according 
 as the effusion was spread out over an extensive surface or con- 
 fined to a limited point of the cortex. The localizing of such a 
 clot can be done more surely than in most cases of tumor. The 
 neoplasm, and consequently a coagulum arising from its rupture, 
 must alwavs be on one side of the cranial vault. Hence should 
 
EXTERNAL PACHYMEXINGITIS OF PUERPERAL ORIGIN. 215 
 
 this be one of those anomalous cases in whicli the clot and palsy 
 are on the same side, the trephining could readily be repeated 
 on the opposite side. 
 
 As trustworthy indications for operating, besides a continuous 
 cephalagia, would be a persistent narrowness of the pupils, and a 
 slow pulse. And some corroborative evidence might be furnished 
 by the history of the case. The opening should be made with a 
 large trephine through the parietal bone, just outside of the lon- 
 gitudinal sinus. As soon as the dura mater is reached, its condi- 
 tion might confirm the diagnosis, yet whether this be so or not, 
 an opening should be made, and the clot, if discovered, should 
 be removed. For this, a sf)oon-shaj)ed curette may be used. 
 Should no coagulation be found, in a patient in whom there 
 were strongly marked signs of effusion, then one would be justi- 
 fied in operating on the ojDposite side; and should nothing be 
 found there, still the surgeon w^ould have the satisfaction of hav- 
 ing neglected notliing for the relief of the patient. 
 
 External Pachymeningitis of Puerperal Origin. — A singular 
 form of inflammation of the dura mater, of which observations 
 Avere jDublished by Rokitansky in 1838, is one associated with the 
 puerperal female. The inflammatory action seems to confine its 
 action to the outer surface of the membrane. This morbid process 
 has been observed in every period of the puerperal subject, from 
 the third month on to the close of gestation. Instead of tlie 
 vascular growth, which from other causes we have seen occurring 
 on the inner face of the dura mater, in this form, the neoplastic 
 formation tends to ossification on the outside of the membrane. 
 It has been observed in different stages of development, from a 
 soft gelatinous material, to one in whicli the latter has become 
 organized into cartilaginous, and finally into osseous material. 
 It is evident that the dura mater when inflamed acquires a 
 duplicate faculty: viz., on its inner side it can develop a vascular 
 structure, while on its external face, it can discharge the oflEice of 
 a periosteum, in jDroducing bone. How the puerperal condition 
 can arouse this osteo-genetic action is unknown; perhaps it may 
 be caused by the displacement of the blood towards the upper 
 part of the body through the encroachment of the developing 
 uterus on the abdominal cavity. 
 
 The new growth of bone appears along the regions adjacent to 
 the sagittal and coronal sutures ; it is especially abundant along 
 the course of the middle meningeal artery. In some cases the 
 growth is so extensive as to occupy the entire inner surface of the 
 
210 MKMIIKANES OF THK IJKAIX. 
 
 cranial vault. A remarkable feature of this osseous product is 
 that it is separated from the inner plate of tiie skull by a diploctic 
 structure. It is also found sometimes stratilied, tlie different 
 layers corresponding to and denoting a pregnancy. This osseous 
 growth varies in tliickness in different skulls from the thinnest 
 lamella to a layer one line in thickness. There has been observed, 
 in some cases, a similar growth of bone on the outside of the skull 
 corresponding in site to that on the inside. These osteophytic 
 enostoses and exostoses are singularly interesting, from the fact 
 that they are the chronicles of pregnancy, the child recording its 
 foetal life in the enduring tablets of the maternal cranium. If 
 nature in her structural handiwork had shifted to the side of 
 paternity this recording tablet, she would have shown a fairer 
 division of labor connected with the continuation of our species. 
 
 As clinical conditions of the puerperal state referable to the 
 encroachments of tliese osteophites on the brain are the headache 
 and vomiting which so often aiiect the pregnant woman; condi- 
 tioiis dependent more on local congestion than on cerebral conges- 
 tion; in fact, the growth of bone is too gradual in its formation, 
 and too limited in amount, to cause compression of tlie adjacent 
 brain. In those days when the lancet did not contract rust 
 through disuse, the contributions of blood which the puerperal 
 woman was accustomed to make, doubtless, in reducing the 
 amount of blood, lessened or wholly j^revented the amount of this 
 osseous formation, in removing the materials for its formation. 
 
 As treatment which miglit be pursued against this osseous 
 deposit, the most rational one would be absorbents; iodine in 
 some form, and likewise mercury, might be employed. For this 
 purpose, the iodide of potassium may be administered internally; 
 externally, the tincture of iodine might be painted over the 
 regions in which the bony material is deposited. Ji. solution of 
 the biniodide of mercury might be given internally. The 
 author, however, would say that it is rare that it would be justi- 
 fiable to interfere witli the puerperal condition by way of the 
 plans of treatment here referred to; only in cases of violent 
 continuous cephalalgia in phlethoric subjects, would it be 
 prudent to abstract blood, and check the neoplastic tendency by 
 the use of iodine externally and internally. 
 
 Tumors of the Dura Mater. — It is rare that the dura mater is 
 the site of tumors, whether benign or malignant. It is true that 
 it is not infrequently penetrated or encroached on by growths 
 which, originating on the scalp, grow inwards, or which, arising 
 
TUMORS OF THE DURA MATER. 217 
 
 from the brain itself, grow outwards and involve the meninges; 
 jet the cases are much rarer in which the prime starting point 
 is from the membranes. Nevertheless, in recent times, since 
 Pathology as a science has become more accurate, frequent 
 instances in which tumors have originated in the meninges have 
 been noted. 
 
 Meningeal tumors differ in respect to their points of origin, 
 their mode of development, their structure, and the symptoms to 
 which they give origin. In regard to their classification there 
 exists much discord among the pathologists; the leading generic 
 names formerly were cancer and fungus of the dura mater. From 
 these the sarcoma was afterwards separated; and from the latter, 
 Robin detached the epithelioma, which, he claims, arises from the 
 arachnoid membrane, while the sarcoma, consisting of fibro-plastic 
 elements, originates in the dura mater. Others, as Virchow, deny 
 that any of these tumors are of the nature of epithelioma. 
 
 From a study of these growths Jaccoud and Labadie-Lagrave 
 have classed them under three general divisions: (1) Accidental, 
 (2) Parasitic, and (3) Constitutional. 
 
 Those of the accidental class may be composed of elements 
 similar to those whence they spring; or the}' may consist of 
 elements different from the structures whence they arise. Subdi- 
 visions of this group are fibroma, sarcoma, epithelioma, myxoma 
 lipoma, chondroma, osteoma, and calcareous concretions. 
 
 The fibroma has its representative in the Pacchionian corpuscles, 
 which are revealed to the necropsist in almost every case of 
 autojDsy on an adult. Besides these, there is a form, after vascu- 
 lar, which springs up on the inner face of the dura mater, beneath 
 the arachnoid. The fibers of these tumors are arranged concen- 
 trically; it is round or oval in form, and may vary from the size 
 of a pea to that of an orange. 
 
 The sarcoma occurs in the dura mater in a form designated 
 angiolithic (Ranvier). This form consists of attenuated fibers, 
 traversed by vessels which are varicosed ; or its component ele- 
 ments may contain also sand-like material, similar to what occurs 
 in the choroid plexus. This sand-containing growth is named by 
 Yirchow, psammoma. Gintrac, who has studied these meningeal 
 tumors, finds that sarcoma occurs oftener in the membranes than 
 in the brain itself. Of thirty-two sarcomata collected by him, 
 nineteen were seated in the dura mater, and most commonly 
 such tumor is seated at the base, and there presses on the chiasm 
 of the optic nerves. The tumor often grows towards the skull, 
 and it may perforate the latter and appear on the outside. 
 15 
 
218 MEMBRANES OF THE BRAIN. 
 
 Epithelioma. — Some discord exists among pathologists concern- 
 ing the question of epitliehoma of the meninges of tlie brain; its 
 existence is denied by some. It is clear that the growths whicli 
 have been so classified do not conform histologically to what is 
 commonly recognized as epithelioma. But, adopting the opinions 
 of Cornil and Ranvier, there are two varieties of the growth, 
 pearly or nacreous, and the papillary. Tlie first species has a 
 thin covering; it is vaguely fibrillated, and its content is disposed 
 in concentric layers. When this structure, which is of irregular 
 form, is examined it is found to consist of epidermal cells which 
 have undergone fatty degeneration. Both the content and its 
 outer coat contain no vessels. In the second form, the tumor is 
 constituted of papillDe, and covered by a coat of epithelial cells. 
 Again, tumors have been observed here which were composed of 
 strata of pavement-celled epithelium. 
 
 The myxoma has seldom been seen arising from the meninges; 
 it is found oftener in the brain itself It is composed of mucous 
 tissue, of which the constituent cells are large, pale, fusiform, and 
 often anastomose. The myxoma is oftenest found on the con- 
 vexity of the hemispheres. 
 
 The lipoma has been often observed arising from the meninges; 
 more rarely it has been found in the brain. As Parrot observes, 
 it is hard to explain the presence of fatty tumors in the brain 
 when one remembers that there is no fatty matter in the brain, or 
 in its membranes. Yet Parrot found a lipoma arising from the 
 pia mater of a child. This growth was three inches long and a 
 third of an inch thick. It was yellow in color, and proved to be 
 fatty matter when analyzed. The lipoma has been seen arising 
 from the meninges by Virchow, Home, and Meckel ; still it is not 
 of common occurrence. 
 
 The chondroma can arise from the inside of the skull; also 
 from the meninges. Like the lipoma it rarely occurs. Accord- 
 ing to Gintrac, this tumor has been found usually in young sub- 
 jects. 
 
 Osteoma. — Besides the osteoma of puerperal origin hitherto 
 mentioned, the dura mater is the site of osseous formations, which 
 may appear at any point; the membrane seems to undergo ossi- 
 fication; thus the tentorium has been seen almost wholly con- 
 verted into bone. Again, the dura mater, where it lines the 
 vault of the cranium, may become almost wholly ossified. Osse- 
 ous growths may appear also in the cerebral falx. The osteoma 
 may also appear on the arachnoid membrane; here lamella) oi 
 
CONSTITUTIONAL TUMORS. 219 
 
 bone have been found, armed on their inner surface with stalac- 
 tite-like processes. The arachnoidean osteoma is oftenest situated 
 over the convex surface of the brain, and especially on the ante- 
 rior lobes. The meningeal osteoma occurs independently of age, 
 since it is often found in the young; even at birth it has been 
 seen. 
 
 Psammoma. — Calcareous growths have been fou-nd in the men- 
 inges, and the formation as described by Virchow may appear in 
 two forms; in one, the growth in cylindrical, sj^inous or globular 
 form, is closely connected with, and ensheathed as it were in, con- 
 nective tissue; but in the other species the sand-like material 
 lies loose in the structure, and can easily be detached. Such con- 
 cretion can attain considerable dimensions. Bergmann has seen 
 one as large as a walnut. The tumor is hard, smooth, and of a 
 reddish white hue. The action which such tumor can have on 
 the brain depends on its situation; its influence is greatest when 
 it lies at the base, where the superincumbent brain is caused to 
 atrophy. Or functional disturbance of nerves can be caused by 
 such pressure. 
 
 Parasitic Tumors. — Of this class of meningeal tumors there are 
 two species: the cysticercus and the echinococcus. 
 
 The cysticercus occurs in the pia mater. Nineteen cases have 
 been collected by Gintrac. The vesicular growth arising from 
 this parasite may attain the volume of a pigeon's egg. The 
 tumor finally undergoes a fatty change; and in this detritus there 
 are found fragments of the parasite. 
 
 The cyst from the echinococcus is usually more voluminous 
 than that of the cysticercus; and there are seldom found more 
 than two or three cysts. The containing wall is fibrillated in 
 structure, and contains vessels. This cyst in the cranium may be 
 coincident with similar ones in the body. The author has seen 
 an instance of echinococcus cyst on the convex surface of the 
 brain. The tumor was somewhat larger than a cherry. 
 
 Constitutional Tumors. — Carcinoma occurs more rarely in the 
 membranes than in the brain itself. When of meningeal origin, 
 it can attain large dimensions, even some inches in diameter, 
 and then it perforates the adjacent cranium. This growth, when 
 it originates from the membranes,, is commonly single, but if it 
 appears there secondarily, then there may be several growths. 
 Unless the growth appears externally, it does not soften or ulcer- 
 ate; it may even undergo regressive changes and become smaller 
 The stroma may become invested with calcareous deposits. 
 
220 MEMBRANES OF THE P.RAIN. 
 
 Tubercle. — Isolated tubercular deposit is sometimes found on 
 the meninges; there are usually several found, and such growth 
 may reach the volume of a cherry. When there are many, they 
 are small in size. As an exceptional case, the growth sometimes, 
 through the fusion of several separate masses, has become as 
 large as an egg. The tubercular growth is yellow, with a tinge 
 of green. The content is caseous in character. If such a growth 
 be split open, the central portion will be found hard, opaque, and 
 dryer than the cortical portion; the latter is semi-transparent, 
 and is traversed by reddish lines, the remnants of vessels. And 
 thus this tubercular growth can be distinguished from the sar- 
 comatous growth, in which vessels enter and remain permeable. 
 Wagner wisely remarks that the tubercular growth may be con- 
 founded with the syphiloma, since the two, when they have 
 undergone the caseous degeneration, are quite similar. 
 
 Si/pJiUoma. — This product of syphilis, commonly named the 
 gummy growth, can appear in diffuse or collected form; as a rule, 
 the gummy material presents itself as a circumscribed, well- 
 defined tumor. Its site may be in the meninges alone, or it may 
 be seated in the cortical substance of the brain. This growth is 
 never encysted, but, at its limiting boundaries, it passes insensibly 
 into the parts around. Though it may attain some dimensions, 
 it never reaches the colossal volume which it does in the lungs 
 and liver, in which the gummy tumor can become as large as an 
 orange. 
 
 When examined microscopically, the syphiloma is found com- 
 posed of cells and nuclei; the cells lie centrally, wliile the nuclei 
 occupy the peripheral portion of the tumor. The cells are 
 similar to those of the white blood corpuscles, with a single 
 nucleus; and these are imbedded in a network of connective tissue, 
 so that the whole presents an areolar structure with cells filling 
 the interspaces. At a late stage the cells and nuclei undergo a 
 fatty change, similar to that of many neoplasms. 
 
 Tlie Effects of Meningeal Tumors. — The meningeal tumors have, 
 as common effect, encroachment upon, and reduction of, the intra- 
 cranial cavity, and from such encroachment they produce dis- 
 turbances, which can be placed under two heads: atropliy and 
 turgescence of the neighboring tissues. The result of atrophy of 
 the structure of the brain is to compensate, in some degree, the 
 encroachment of the enlarging growth. The other effect of the 
 meningeal tumor, viz., turgescence of the parts impinged on, adds 
 to the trouble, and this may be present in different forms; for 
 
TREATMENT OF MENINGEAL TUMORS. 221 
 
 example, the growth may cause inflammation, congestion, oedema 
 or hemorrhage, in the contiguous parts. The effect of the 
 inflammation, even though it be mild, is to cause softening of 
 the part acted on. The effect of oedema and congestion is vari- 
 able, as the conditions themselves are variable; and hence the 
 clinical symptoms must be variable. Hydrocephalus, and oblit- 
 eration of the encephalic veins and sinuses, can result from such 
 tumor. The nature of the tumor has a strong bearing on the 
 condition of the adjacent structures; for example, certain growths 
 are inert, and act passively through encroachment and compres- 
 sion; such, as a rule, are the accidental tumors. Other tumors 
 are active in their efforts, such, for instance, as cancer; these 
 modify deeply, and often fatall}^, the tissues which surround them. 
 Tumors which compress the cranial nerves induce in these a 
 fatty degeneration which often extends to the peripheral branches 
 of the nerves. The results of such compression are easily seen 
 and estimated by the ophthalmoscope, when the optic nerve is 
 compressed. 
 
 Treatment of the Meningeal Tumors. — A few of these tumors 
 may be treated by internal medication; especially, one may hope 
 to do something in this way in case the growth is of syphilitic 
 origin. When concomitant syphilitic disease is present justifying 
 the diagnosis of syphiloma in the meninges, then the patient 
 should be subjected to a thorough course of antisyphilitic reme- 
 dies; for a month, at least, he should take the protiodide of 
 mercury in doses of a half grain, three times a day. When this 
 has been done, the iodide of potassium should be given and con- 
 tinued for some montlis. In this way grave subjective phenomena 
 have been caused to disappear, within the author's observation; 
 perversion of mental energy and motor function has been caused 
 to disappear, and the seemingly hopeless invalid, within four 
 months, has been restored to health. Even in case the tumor be 
 carcinoma or sarcoma, the well-proven properties of iodine and 
 mercury to disintegrate tissue, justify and encourage their employ- 
 ment, certainly for a period of six or eight weeks. 
 
 But where inward medication fails, or has no indication for 
 its use, then the question of surgical interference arises. The 
 experience of modern times justifies or permits work upon 
 ground which was once forbidden; and especially is this true of 
 the interior of the head, where surgical daring, Prometheus-like, 
 has scaled the hitherto untrodden heights and brought thence 
 to man the empyrean boon of relief of disease, which heretofore 
 
222 MEMHUANKS OF THE liKAIX. 
 
 seemed securely and iini)regnably entrenched within the cranial 
 walls. It is well that this adventurous daring shouhl not arouse 
 a cohort of greater ills, wiiich sometimes do follow the returning 
 steps of the bold surgeon. 
 
 As said, iu a few cases of meningeal tumor, surgical interven- 
 tion is proper. Namely, the trephine may be used, and through 
 an opening in the skull the neoplasm may be sought for, and 
 if found it can then be extracted and the patient thus given an 
 opportunity of recovery. Trephination should only be resorted 
 to in those casesin which the diagnostic signs indicateconclusively, 
 or with probability, tlie site of the neoplasm; and an additional con- 
 dition must necessarily be that this site is accessible and can be 
 opened without wounding vessels or veins which traverse the 
 wall. As trustworthy indications of the existence of a growth 
 would first be a continuous pain at one point of the liead; and, 
 secondly, perverted sensation and motion located peripherally, if 
 their anatomical channels converged to tlie same .source, might 
 almost conclusively denote the location of the tumor. How 
 much relief might be obtained would depend on the nature of 
 the tumor; if it should fortunately prove to be a fibroma, a 
 lipoma, a tuberculous mass, or a calcareous concretion, then one 
 might expect that permanent recovery might follow the removal. 
 But, on the contrary, if the growth were of a malignant nature, 
 as sarcoma or a carcinoma, then the operation could only be fol- 
 lowed by failure. But even in this unfortunate condition, the 
 impossibility of making matters worse would grant unusual 
 liberty to the surgeon. The surgeon and physician sometimes 
 meet cases in which life is a burden and death a favor to the 
 unfortunate subject ; examples of such are incurable diseases 
 which are coupled with continuous pain and a perversion of the 
 functions of one or more of the organs through which life is 
 maintained; and under this head no more apposite example can 
 be cited than the intracranial growth, which by its volume inter- 
 feres with the office of the brain. 
 
 .Justified by the diagnosis of such conditions, the trephine 
 should be applied over the probable location of the growth, and 
 an ample section be uplifted. As soon as the dura mater has 
 been ojtened to view, its color, tension, and upheaval would indi- 
 cate whether there were a neoplasm underneath; or if the tumor 
 had perforated the meninges, it would at once be evident to the 
 eye. If the tumor were concealed, those membranes must be 
 opened and the neoplasm enucleated, or excised from the parts 
 
CONCUSSION OF THE BRAIN. 223 
 
 with which it is connected; that is, the work of removal will be 
 done as the conditions suggest or permit. Stereotyped rules for 
 guidance in such operative procedures cannot be formulated; 
 ordinary mechanical ability best finds a method for itself. Inas- 
 much as in such operations the integrity of the parts must 
 sometimes be disturbed greatly, hence immediate closure would 
 rarely be advisable. After the tumor has been removed, the 
 torn shreds or ragged edges of the membranes must be cut off, 
 and the wound cleansed antiseptically, sprinkled with iodoform 
 and then, a drainage tube being properly placed, the external 
 Avound can be closed by suture, except at the point where the 
 drain lies. 
 
 The structure next in order, as we pass from above downwards, 
 is the brain, of which the affections falling within the domain of 
 surgery will now be considered. 
 
 Concussion of the Brain. — During tlie last fifty years the sub- 
 ject of concussion, or commotion, as the Germans and derivative 
 Latin writers term it, has been the matter of careful study, obser- 
 vation and experimental research. It is caused by some external 
 violence which communicates vibration, oscillation or minute 
 movement to the anatomical elements of the parts acted on. In the 
 causation all observers agree ; but what occurs in the constituent 
 elements of the parts affected cannot be said to be as yet satisfac- 
 torily settled. All parts of the body may be the subject of such 
 action: bones, muscles, nerves, viscera; and some assert that the 
 blood itself may be the subject of concussion. The study of the 
 effects of concussion has been devoted chiefly to the brain ; yet it 
 seems certain that the same cause would be followed by like effects, 
 no diff'erence Avhat part of the body should be the site, and hence 
 that one common definition might be given of concussion founded 
 on physical and physiological laws. In a classic article on this 
 subject by Verneuil the able French surgeon and writer, after 
 revealing to the reader the difficulties which perplexed him in 
 his task, Verneuil offers us the following definition of concus- 
 sion : "It is a series of phenomena occurring more or less 
 suddenly which result from a mechanical shaking (jarring move- 
 ment) of the anatomical elements, tissues and organs, character- 
 ized by a temporary excitation or depression of the properties, 
 offices or uses of the parts which are shaken; and as a result there 
 are caused anatomical changes similar to those which are nor- 
 mally seen in the successive phases of functional activity and 
 functional repose." This definition is the embodiment of what 
 
22^ THE IJJIAIX. 
 
 its author has derived from his own observation and that of 
 others; and especially from tlie results which others have obtained 
 in experiments on animals. 
 
 In the milder grades of concussion in the animal, the question 
 has been whether there is any appreciable lesion to be discerned 
 in tiie part subjected to experiment; the most admit that such 
 lesion cannot be discovered; and since in man, in case of concus- 
 sion of the brain, tlie subject soon recovers, hence there is no 
 opportunity of searching for the evidence of such lesion. For, as 
 Verneuil savs, we derive our elements of the diagnosis of anv 
 disease from three sources : to wit, the causation, the symptoms 
 arising, and thirdly from the direct inspection of the part affected. 
 But in case of cerebral concussion one or more of these sources of 
 information is often wanting. The inspection of the injured part 
 is wholly denied to the surgeon; the extent of the violence done 
 can often only be vaguely and imperfectly estimated; and not 
 unfrequently it is wholly unknown, as where the patient is found 
 unconscious or unable to explain how he was injured; and finally 
 the remaining source of knowledge, viz., the symptoms, are often 
 far from being clear and well defined. 
 
 Concussion, as wall presently be more fully detailed, may be 
 said to present itself in three grades, wdiich we will designate the 
 mild, severe and fatal. The second, which offers symptoms 
 sufficiently durable to admit of deliberate consideration, presents 
 as marked condition a depression of the cardio-pulmonary func- 
 tions, in which pulse and breathing are slow and feeble; temper- 
 ature is lowered as a result of the preceding; the functions of the 
 sensory and motor nerves are temporarily aljolished; the patient 
 neither moves nor feels. The mental faculty is, for a time, 
 reduced to a nullity; the patient is not conscious of existence, and 
 in all this the animal for a time has lost his distinguishing 
 characteristic, and lies at the verge of plant life. 
 
 Many explanations of these conditions have been offered, as 
 will be seen from a brief review of the literature which during 
 the last fifty years has been written on the matter. 
 
 In 1842 Haworth wrote on concussion of the brain, and 
 claimed that the violence impinging on one side of the skull car- 
 ried the brain against the opj^osite wall, and thence, rebounding, 
 a vacuum succeeded, in which blood and gas collected, the phe- 
 nomena being similar to those of contre-coup. Haworth thinks 
 that a vacuum is also formed in the brain in those who ascend 
 great heights, and thus he would explain the cerebral trouble 
 
CONCUSSION OF THE BEAIX. . 225 
 
 sometimes present in such cases, Tliis explanation of the phe- 
 nomena arising from concussion could only be applicable in those 
 cases which had arisen from great violence, in which the patient 
 dies at once from the violence done to the brain; and in such 
 cases the organ is lessened in its volume, and into the empty 
 space thence arising, blood escapes from the lacerated vessels. 
 The filling of the space with blood is therefore a secondary effect 
 of the injury. 
 
 In 1852 there were reports on concussion of the brain by 
 Fano, Chassaignac and Haas; the former two find that where 
 death has immediately followed a blow on the head, then there 
 will be found effusion of blood around the pons Varolii; but if 
 death occurs later, then in the cerebral structure there will be 
 found disseminated small clots of blood, which these writers 
 attribute to cerebral contusion. Fano and Chassaignac deny 
 that concussion can injure without leaving some signs of violence: 
 one always can find egchymosis, or marks of cerebral injury. 
 Haas, however, thinks that there can be concussion with or with- 
 out ecchymosis. In each there is sopor with unconsciousness. 
 If it be simple concussion, then these conditions may soon dis- 
 appear, but if blood be effused, then these symptons may con- 
 tinue and even increase in intensity. 
 
 Continuing his studies in 1853, Fano combats the notion that 
 in concussion there is no perceptible material change in the 
 cerebral structure; but he claims that there will be found effusion 
 of blood near the base of the brain. Fano, Chassaignac and 
 Lawson have found in the brain small points of effused blood, 
 not larger than millet seeds. In mild cases, Eisenmann thinks 
 there is a shock which acts reflexively through the vaso-motor 
 filaments on the capillaries, and produces a stasis of blood in the 
 latter. And in more severe cases the stasis may be carried to 
 the extent of rupturing the vessels. The order of the phenom- 
 ena is as follows: The shock is first propagated from the vibrating 
 bones to the nerves, and thence a recurrent, reflex action in and 
 through the nerves; next stasis, and sometimes rupture of the 
 vessels, and occasionally structural softening. 
 
 Paget, writing on cerebral concussion in 1863, made three 
 stages of it. In the first stage unconsciousness occurs, and this 
 may vanish, and the patient recover. In the third stage the 
 violence is greater, and the condition may be sthenic or asthenic 
 in character. The asthenic symptoms occur early, viz., within a 
 day or two. The sthenic symptoms occur after a longer period, 
 
22(> THE iniAix. 
 
 viz., after ten or eleven days. Between the first and third, or 
 inflammatory stage, Paget 2)hices a second one, in which there 
 is ahnost a total absence of morbid signs. After surgical opera- 
 tions, for example, an amputation, Paget finds that similar condi^ 
 tions may arise, viz., one of excitement and one of depression. 
 Paget estmates the chances of recovery to be very slight after 
 severe concussion of the brain. In such cases not jnoro than one 
 in twenty got well. 
 
 Alquie, in Paris, made some experiments in 1805 on concus- 
 sion, and concludes from them that tlirough the injury caused, 
 the functions of the brain are more or loss interfered with, and, 
 further, he believes that concussion and contusion do not differ 
 much from each other in their respective actions. The lesion 
 produced by slight concussion is so slight that it eludes the closest 
 search with the eye. Its mechanism is not that of vibration, but 
 of a blow that came and vveut at once. The causal violence carries 
 the brain forwards in (xne direction, viz., that of the causal violence. 
 Alqui^ concludes that concussion "and contusion are convertible 
 terms. Local and diffused concussion cannot be distinguished 
 from each other in their action. The phenomena resulting from 
 severe concussion are vertigo, fainting, weakness, drowsiness, and 
 coma. The cerebral trouble caused may apj^ear in remissions 
 and exacerbation. From concussion one or many functions of 
 the head, or parts dependent on it, may be impaired or annulled, 
 and this disturbance may be brief or long lasting. Concussion 
 in its action resembles grave mental disease. 
 
 In his treatment Alquie' is in accord with Paget. Collapse 
 and depression demand stimulants; active reaction denjands 
 an opposite course. 
 
 Beck, of Freiburg, in 1865, referred the effects of cerebral con- 
 cussion to violence transmitted to the medulla oblongata, and to 
 lesion of thecentres which preside over the functions of the heart 
 and lungs. Pie finds as common causal agency a blow with a 
 blunt instrument. 
 
 Witkowsky, in 1877, made some experiments on animals, in 
 which the head was struck with a hammer, and the pressure of 
 the blood in the carotid arteries was noted in the meantime. 
 The immediate effect was increase of blood pressure in these ves- 
 sels. The increase commenced immediately after the injury, and 
 reached its highest degree in from twenty to fifty seconds, and 
 continued for from one to two minutes. This increased pressure 
 followed both slight and more severe concussion. It was after- 
 
CONCUSSIOX OF THE BRAIN. 227 
 
 wards succeeded by a slight descent of pressure below the normal 
 st^lndard. The pulse, as a rule, was not changed. 
 
 In cases in which the skull had. been trephined so that the 
 brain could be seen after removing sections of the dura mater, 
 it was found that the strokes caused a perceptible contraction of 
 the vessels of the dura mater. This continued for a moment or 
 two, and then a slight reaction followed. Witkowsky decided 
 that those alterations in the blood pressure were not due to the 
 oscillations from concussion, but were the consequences of direct 
 action on the nerve matter. Though Witkowsky offers this state- 
 ment designed to explain the conditions present, yet it is proba- 
 ble that few readers can comprehend it. 
 
 Duret, of Paris, in 1877, made experiments on animals, in 
 which he studied the effects of concussion on the brain. The 
 violence done to heads of animals was produced by blows on the 
 skull and also by violently injecting fluid into the cranial cavity 
 through a trephined opening. He, finds the leading results of 
 concussion to be slowness of the pulse and respiration; and, find- 
 ing au absence of all lesion in the cerebral liemispheres, he sought 
 for injury in the medulla oblongata. In the experiment in 
 which water was violently injected into the skull, the fluid in 
 the lateral ventricles was caused to pass downwards through 
 the middle ventricle and the canal of Sylvius to the fourth 
 ventricle. In its passage through the canal, the fluid caused 
 laceration of the walls of the narrow passage. In another exper- 
 iment the skull was trephined above, and the posterier ligament 
 connecting the axis and atlas was exposed when pressure was 
 made through the trephined opening above; then an impulse 
 could be perceived below from the descent of the fluid into the 
 spinal canal. 
 
 Direct experiments were done chiefly by the injection of water 
 into the cranial cavity. This fluid was forcibly thrown against 
 the surface of the brain beneath the dura mater. It is evident 
 that the action of such violence differs from that caused by a 
 blow. It is not so instantaneous, the violence progressing from a 
 slight grade to a higher one ; and only when the fluid reaches a 
 certain amount could it displace the intra-ventricular fluid. 
 Such action must differ from that in which the violence impinges 
 on the outside of the skull, and thence travels onwards to the 
 less resistant cerebral matter. Hence the results of Duret's exper- 
 iments may be deemed rather an approximation to, than an 
 actual reproduction of, the action of concussion from direct 
 violence. 
 
228 THE KRAIX. 
 
 Ill 1878 Duret continued his researches on this subject, and 
 divides the shock of concussion into three classes, viz , central, 
 bulbar and medullary, according as one of these structures is 
 most involved. In the case of a blow, the passage of the fluid 
 downward acts most severely on the bulb. 
 
 Duret divides the action of concussion into two periods; in the 
 first period there is a spasmodic and a paralytic stage, in which 
 there are coma and depression. In the second period, there are 
 congestion and inflammation. The site of the blow has an influ- 
 ence on the morbid phenomena; for when the forehead receives 
 the blow, the pons and bulb are the most affected; but when the 
 side of the head is the site of the violence, then the other hemis- 
 phere is more affected. 
 
 After this review of the subject of concussion, if the facts which 
 have been drawn from so many quarters be condensed and con- 
 clusions be drawn from them, the following may be offered as an 
 epitomized summary of the changes which are induced tempora- 
 rily or continuously in the brain from concussion. In the mildest 
 grade there is a brief diminution of the blood pressure in the part; 
 its tension is temporarily lowered. As the result of this there is 
 mental disturbance; the cells and the cortex of the brain, on whose 
 normal condition the evolution of thought in some unknown way 
 depends, are deprived, for a few moments, of their accustomed 
 supply of nutrient material; the result is a brief perversion of 
 intellect; memory is lost; the power to recognize surrounding 
 objects is weakened or lost. As a personal illustration of this, 
 from a fall from a carriage, the author once suffered temporary 
 concussion of the brain; though he arose at once to his feet, on a 
 street with which he was very familiar, yet, for a minute, all 
 appeared to him as if he were in a strange city, and that picture 
 registered on memory ^^et remains as an enduring scene of mental 
 imagery. And though there was knowledge of what had occurred, 
 and thought enough to search the head for fracture, yet the 
 subject of the injury possessed no accurate knowledge of his sur- 
 roundings. The author would attribute those conditions to a 
 temporar}' disturbance of the circulation on the surface of the 
 brain. 
 
 If the violence be somewhat greater than that here supposed, 
 then, to the disturbance of blood pressure, there is superadded a 
 disturbance of the cellular constituents composing the surface of 
 the brain. A jostling or dis])lacement of the molecular elements 
 of those cells, even though it be microscopically minute, must 
 
CONCUSSION OF THE BRAIN. 229 
 
 suffice to induce functional derangement. In such condition the 
 patient lies unconscious to all that is around him; lie breathes 
 naturally; the pulse is commonly somewhat weakened and regu- 
 lar; the temperature is not increased, and sometimes is less than 
 normal; the pupil is neither dilated nor contracted, and reacts 
 somewhat to light. The patient may remain for hours, a day, or 
 even a week in this condition, in which he is neither awake nor 
 asleep; he is so nearly asleep that his condition is often taken for 
 sleep. But it differs from sleep in tliis that the eyeballs do not 
 occup}^ the upturned divergent position they have in healthy sleep; 
 they are often in motion beneath the closed lids. There is an 
 absence of snoring in the breathing; in fact, the patient breathes 
 as one who is partl}^ asleep, rather than as one who is really so. 
 For the Jack of a name, we will designate it the sleep of concus- 
 sion. 
 
 In the grades of concussion just mentioned, its action is chiefly 
 manifested in obtundingor temporarily suspending the functions 
 oftliemind; but if the intensity of the causal violence be still 
 greater, then, besides the abolition of the thinking faculty, the 
 cardio-pulmonary functions are disturbed, dependent, doubtless, 
 on lesion of the centres at the base of the brain, wdiicli preside 
 over these functions; lesions which were represented by the 
 lacerations in that region observed by Duret. The pulse is soft 
 and often irregularly hastened. The breathing is similarly 
 affected; regular may alternate with irregular breathing, and so 
 may slowness with acceleration. And these disturbances of the 
 actions of the heart and lungs conjoined to unconsciousness, may 
 remain for days and even weeks, and. then consciousness may 
 reappear suddenly, the patient arousing, as from a sleep, wath a 
 gradual disappearance of the other abnormal conditions. Such 
 an injury of the head as here described often results from a fall, 
 from a carriage or horse; it sometimes occurs in accidents 
 from climbing. In such accidents the weight of the body, 
 multiplied by the velocity acquired at the final moment of strik- 
 ing the ground, represents a high degree of violence, especially 
 where the surface fallen on is a hard one. In such cases, when 
 severe, there is a contusion of a limited surface of the brain, and 
 thence results localized or isolated palsy of some part of the body. 
 Or, as the author has observed, there may be partial hemiplegia 
 of the arm and leg, and not unfrequently one limb is more 
 affected than the other. And, at the same time, there may be 
 restlessness of the limbs on the unparalyzed side. 
 
230 THE BR A IX. 
 
 Ill a still higher grade of concussion, the functions of life are 
 permanently suspended, either at once, or death ensues in a few 
 minutes after the receipt of the violence. Such fatal result has 
 given the opportunity of necropsy, in which the condition of the 
 brain could be suspected. Yet, singularly enough, there is far 
 from agreement among observers in respect to these conditions, 
 .some asserting that the brain did not fill the skull; others have 
 found the contrary state. Of the first condition there is a notable 
 instance on record, an observation made and reported b}' Littre 
 over a century ago. This case, cited by nearly all writers on con- 
 cussion, was that of a criminal, who, to escape punishment, ran 
 and struck his head so violenth' against the wall of his prison that 
 he fell dead. The desperate energy displayed in the fatal act has 
 had no small share in retaining the fact in history. , In the 
 necroj)sy of the case reported by Littre, the cerebral matter was 
 found broken down, and to lack much of filling the cranial cavity; 
 that is, a vacuum was found in the upper part of the skull. There 
 have been reported a few other cases in which there was found a 
 slight open space above the brain, in those who have died from 
 cerebral concussion. There has* been reported an effacement of 
 the natural irregularities of the cortex of the brain. However, 
 other observers contend that both the empty space as well as the 
 alleged leveling of surface, is not present in the unopened cranium, 
 but is caused by the escape of blood from vessels which are 
 divided in opening the cranial cavit^^ Notwithstanding these 
 discordant utterances, the predominant weight of observation is 
 on the side of those who assert that there is some lessening of 
 volume as well as effacement of the cortical irregularities of the 
 brain. Besides these evidences of violence, the cerebral matter 
 on being cut presents minute ecchymoses of blood, due to rupture 
 of minute vessels. And it is probable that such rupture, in less 
 extent, occurs in concussion of a milder grade. 
 
 Diagnosis. — Tlie diagnosis of cerebral concussion is an easy 
 matter in cases in which there is a history of violence acting on 
 the head. Yet, in the absence of such history, the problem of 
 diagnosis becomes, sometimes, difficult, since it must be wholly 
 solved by the symptoms present; then the pulse, breathing, pupil, 
 and color of the face give valuable information ; stertor and 
 narrowed pupil point to poisoning with opium; the fumes of 
 spirits in the breath point to alcoholic excess. An instance of 
 the latter kind came under the notice of the author: a man who 
 was found prostrate by the side of the street was the object of 
 
CONCUSSION OF THE BRAIN. 231 
 
 puzzling study to soine physicians, when the coachman of one of 
 the doctors solved the matter by saying that he would give a half 
 dollar to be as sick as the man was. 
 
 There are cases in which the work of diagnosis is much embar- 
 rassed b}^ the lesion not being a simple one of concussion; there 
 may be conjoined to it contusion and compression, especially 
 compression, which would greatly modify or change the usual 
 symptoms of a case of concussion; in fact, concussion and com- 
 pression present in a case would naturally interact and influence 
 the symptorns of each other; and in such case the surgeon would 
 find it extremely difficult, perhaps impossible, to determine all 
 the conditions present; in such embarrassment, the most promi- 
 nent symptom should receive attention and indicate the proper 
 treatment. In the following chapter devoted to the consideration 
 of compression of the brain, there will be presented the symptoms 
 by which concussion and compression of the brain may be dif- 
 ferentiated. 
 
 Prognosis. — From what has preceded, it is clear that the prog- 
 nosis of concussion of the brain must depend on the grade of the 
 injur}'. In the grades of slight severity a recovery may certainly 
 be anticipated at an early period. But in the severe forms the 
 prospect is more unfavorable; the patient may remain in an 
 unconscious, half-dead state for weeks, and afterward slowly 
 recover; or from his half-dead condition he may lapse into actual 
 death. Also it is to be observed that after some concussion, 
 though the patient may live, yet not unfrequently there remains 
 some vestige or memento of the injury in the form of perverted 
 motion, sensation or impaired mentality. From the observation 
 of Griesinger and other alienists it has been found that the men- 
 tal character often undergoes some change in those who have 
 been the subjects of severe cerebral concussion. The memory, as 
 has been observed by the writer, may be weakened or altered in 
 some way; the recollection of proper names, of specific nouns 
 and adjectives may be partly or wholly lost; from the framework 
 of language may be plucked the most of its exuberant apjDcndages, 
 and the whole be reduced to a meager skeleton of generic headings 
 and categories. Besides this the character of the individual may 
 be slightly or greatly modified. The hitherto well-controlled 
 temper may become vehement and rash; the patient has out- 
 bursts of anger, and may become the actor of lawless deeds. He 
 becomes distrustful of those around him. These changes may 
 be plainly manifest, or they may be so slight as onl}^ to be per- 
 
232 THE BRAIX. 
 
 ceptible to the subject's intimate friends. And whatever character 
 these changes may assume, they will probabl}^ remain permanent, 
 inasmuch as they depend on structural change, which will con- 
 tinue unchanged. In modern times when crime seeks for its 
 defense that its subject cannot control his action, and consequently 
 that he is not responsible for liis offenses, the matter of concussion 
 has assumed a special importance in Forensic Medicine. As the 
 concu.ssion of the spinal column from railway accident on account 
 of real or assumed injury, seeks reparation from the pocket of the 
 owning corporation, so the transgressor of laws often claims 
 immunity on the ground that at some time previously he has been 
 injured in his head, and as concussion leaves no tangible or visible 
 mark, hence it conveniently serves the purpose of such subterfuge 
 Treatment of Concussion of the Brain. — Since there are two 
 totalh' different states in which the patient of concussion may be, 
 namely, depression or excitation, so the treatment must be shapen 
 as one or the other condition exists. As a rule, the first effect of 
 concussion is to induce depression and exhaustion of the vital 
 forces; and this condition must be met and counteracted by 
 stimulants and excitants. The patient is often so prostrated that 
 the reflex act of swallowing can only be imperfectly performed, 
 a fact which renders it difficult to administer remedies by the 
 mouth. If, while the muscles of deglutition are in a partly 
 palsied .state, liquid medicine be given by the mouth, the most of 
 it will probably pass into the trachea, and add to the patient's 
 perilous condition by partly asph vxiating him. In fact, the same 
 precaution is required here as must be exercised in administering 
 matters to a person moribund or near death; the wine or other 
 thing thus given, as the writer has witnessed, can strangle and 
 immediatelj' end life. Hence, wlien the patient is greatly pros- 
 trated by depression, and cannot readily swallow, fumes of 
 ammonia should be applied to the nose; also tickling the nostrils 
 will often arouse the patient. Stimulants, as brandy and warm 
 w'ater, and black coffee, may be injected into the rectum. Hot 
 applications should be placed over the prrecordia, and the surface 
 of the body should be well rubbed so as to promote the move- 
 ment of the blood. In case of extreme prostration, syncope may 
 be avoided, or rather life awakened by lowering the head so that 
 the heart may be aided by gravitation in carrying the blood to 
 the brain. After the patient has been sufficiently resuscitated to 
 swallow, then remedies may be given by the mouth. The admin- 
 istration of stimulants must be limited to the period of depression; 
 
'concussion of the brain. 233 
 
 afterwards the treatment must look to controlling the inflamma- 
 tory symptoms which usually present themselves after a few days; 
 the stage of excitement is ushered in about the eighth, ninth, 
 or tenth day after the receipt of the injur3\ Should the patient 
 be plethoric, then bleeding from the arm should be done; not less 
 than a pint of blood should be drawn. The signal advantages 
 of such depletion have been verified by the writer in several 
 instances. If the subject be very robust, as much as thirty ounces 
 can be safely withdrawn; thus inflammatory action, through the 
 absence of material for its maintenance, is subdued and retained 
 within tolerable limits. Depletion might be done by means of 
 leeching; yet withdrawal of blood from an open vein is more 
 effectual. 
 
 A valuable adjuvant in this antiphlogistic treatment is ice, 
 which should be applied to the patient's head as soon as he 
 merges from the primary stage of depression. The ice well 
 crushed should be applied to the head in an India rubber bag; 
 and this should not be heavy, lest it cause sloughing on the sub- 
 jacerit scalp. The head should be maintained in an elevated 
 position, so as to favor the descent of the blood through the veins 
 towards the heart. All constriction of the neck should be 
 avoided. As a faithful ally in this work of derivation of the 
 blood from the head is warmth applied to the lower extremities; 
 for this, hot water contained in bottles or a rubber sack, may be 
 used. As there is danger of freezing the scalp, so there is of 
 burning the feet, unless the warmth be carefully used. 
 
 As internal treatment there should be given a purge; and for 
 this none is better than calomel and jalap, ten grains of each. 
 Besides this, to restrain or prevent the development of inflamma- 
 tion, there should be administered iodide of potassium, in doses 
 of ten grains, repeated every four hours, for the adult. If the 
 patient be a child of four or five years of age, the dose should 
 amount to three grains, repeated three or four times daily. And 
 should there be the usual restless somnolence, this must be con- 
 trolled by bromide of potassium, of which an amount equal to 
 that of the iodide of potassium should be given. By the use of 
 this internal medication, the author has repeatedly seen the sub 
 jects of severe concussion pass safely through the inflammatory 
 stage; the temperature was retained in low limits. 
 
 There should be mentioned a mode of treatment formerly 
 much used in cases of severe cerebral concussion: this was vesi- 
 cation of the scalp. To do this, flrst let the hair be shaven off, 
 16 
 
234 THK BRAIN. 
 
 and then the whole covered with Eiiiphistrum Cantharidis. This 
 does not act entirely as an ordinary blister; only a small amount 
 of serum is drawn out, but instead, there will form a coating of 
 libro-albuminoid material over the scalp, tenacious and adherent. 
 This vesication was a iavorite of Dupuytren; and it is claimed 
 that good results followed its use. Yet when one considers the 
 slight anatomical connection between the scalp and tli'. enceph- 
 alon, it is difficult to conceive how this external blister can act 
 on the parts within the cranium. 
 
 Frequently, two or three months are required for entire recov- 
 ery of the patient so that he can resume his usual occupation, 
 and for a yet longer period, limitation in exercise of body and 
 mind should be enjoined. 
 
 Compressiou of the Brain. — By compression of the brain is 
 meant an abnormal condition arising from pressure acting from 
 without inwards on the brain, or the compressive agency may lie 
 within the organ. In the first case, the force acting centripetally 
 may be caused by a portion of the cranial wall being pressed 
 inwards ; or from blood that is extravasated between the cranial 
 wall and the dura mater, or between the dura mater and the 
 cortex of the brain. Centripetal compression may also arise 
 from a neoplasm springing from the dura mater, skull wall or 
 scalp, which tumor and its development lessen the containing 
 cavity and crowd against the brain. A subdural abscess may 
 attain such dimensions that it can give rise to compression. A 
 foreign body having entered the cranial cavity, and occupying a 
 subdural position, may cause compression. Again compression 
 can arise from an ettusion of blood within the brain ; from an 
 abscess located there; from an intra-cerebral growth; from a 
 foreign body that has penetrated the brain; and lastly, a not 
 infrequent cause of compression is the swelling of the brain 
 through congestion or inflammatory action. 
 
 The encephalic content is constituted of cerebral and cere- 
 bellar matter, of nerves, vessels and cerebro-spinal fluid. 
 
 The material comprising the cerebrum and cerebellum con- 
 sists chiefly of water; the aqueous contents make up more than 
 three-fourths of the whole; in this it resembles blood, of which 
 water forms nearly four-fifths;* thus intercommunication and 
 interchange of organic elements are provided for and happily 
 facilitated A large part of this water is closely associated with 
 the cerebral and cerebellar elements; a portion of it is the cerebro- 
 *Moleschott's Kreislauf des Lebens. 
 
COIMPRESSION OF THE BRAIN. 235 
 
 spinal fluid, which has no connection with the structure of the 
 brain. 
 
 As is w^ell known, water is incompressible within limits which 
 can be tolerated by organized beings ; hence, a compressing force 
 acting on the brain does its injury by displacement; the fluid 
 content is forced from the organic structure, and the latter is 
 altered in its position and form. Should the compression come 
 on slowly, then the cerebro-spinal liquid will be forced from the 
 cranium, and the encroachilient be compensated; this happens 
 in cases in which there is a gradual outpouring of blood from 
 the rupture of a vessel. But if the compressive force in its 
 entirety acts instantaneously, then the rapid retreat of the fluids 
 before the violence must injure the fragile structures through 
 which the fluids are forced; and thus a slight or grave lesion 
 results, proportional to the degree of violence. 
 
 To verify the effects of compression on the brain, experiments 
 have been made on animals; this has been done in two ways: by 
 the injection of water into the cranial cavity, and by directly 
 pressing on the brain when the latter is exposed by trephining. 
 The action of pressure when made directly on the brain has thus 
 been observed in animals; and its effects on voluntarj'- motion, 
 respiration, pulse, and the pupil of the eye have been found to 
 correspond to conditions arising in the human subject of cerebral 
 compression. Some fallacy, however, may be mingled in these 
 deductions from vivisection, since the violence which causes 
 compression in man may be associated with concussion and con- 
 tusion of the brain. 
 
 The following are the effects of uncomplicated compression 
 as observed in the animals experimented on by Leyden, in 1866. 
 The experiments w^ere made by first trephining the animal's 
 skull, and measuring by means of a dynamometer the amount of 
 pressure which was applied. By pressure of a mild degree, pain 
 was caused through the action on the dura mater. When greater 
 force was used, there was produced a loss of consciousness, with 
 coma; and, along with these conditions, in some cases there were 
 spasmodic contractions of the muscles; and when the pressure 
 was still greater, epileptiform convulsions occurred. In all 
 grades of pressure the pupils were acted on; these were widened, 
 yet not equally so on both sides. The pulse was altered according 
 to the grade of pressure; in the commencement of compression, 
 the pulse was rendered slower, but as the pressure was increased, 
 the pulse suddenly changed, and from being slow it became 
 rapid. These changes were referred by Leyden to action on the 
 
230 THE r.KAlN. 
 
 vagus nerve. Respiration in the beginning was irregular and 
 sometimes liurried, and later intermittent; during coma the 
 breathing became slow and stertorous; and later it became irreg- 
 ular and intermittent with long pauses. Vomiting rarely 
 occurred. Death was caused by paralysis of the respiratory 
 nervous centre. The heart continued to beat for some minutes 
 after the respiration had ceased. The action of compression of 
 the animal's brain corresponds closely to that which has been 
 observed in man. In the milder degrees of pressure there are 
 conditions perceptible in the human subject which cannot be 
 recognized in the animal ; for example, disturbances of the special 
 senses and of the mind can be noted in man. 
 
 In the experimental w^ork on the animal, conditions of exci- 
 tation and depression were induced, and these conditions vary 
 according as the compression is made gradually or suddenly; for 
 if made suddenly there is no preceding period of excitation, since 
 that of depression is ushered in at once; but if the force is applied 
 slowlv, then there is an antecedent period of excitement. And 
 sometimes the conditions of excitation and depression are com- 
 mingled, since some parts of the brain are pressed on much 
 more than others. Pus slowly forming may first be indicated 
 by excitation, which is followed later by depression; and the 
 same is the case in which a tumor slowly grows, for here obtuse 
 intellect, .somnolence, palsy and finally coma and stertor apj)ear ; 
 3'et only at a late period. 
 
 Hutchinson and Bryant, prominent surgeons of London, have 
 written on compression from observations of it in surgical prac- 
 tice. Bryant, in writing on injuries of the brain, in 18G0, says 
 that when symptoms of compression immediately follow a blow 
 with a blunt body, there is probably injury of the base of the 
 brain through contre-coup, and this injury and its effects cannot 
 be reached by the trephine. The trephine, however, is especially 
 useful in cases in which a fragment of bone has been forced into 
 the skull and caused compression. Also, w^iere compression has 
 supervened slowly afterthe injury, it indicates rupture of a vessel, 
 and here if the vessel can be reached, trephining may bo done. 
 
 In 1868 Hutchinson writing on compression, as deductions 
 from many cases observed that compression is sometimes 
 suspected where it does not exist; and again it may exist without 
 any indicative symptoms. Compression can originate from the 
 effusion of blood between the dura mater and the skull; and 
 unless this is soon relieved by operating, death ensues. The 
 
COMPRESSION OF THE BRAIN. 2^7 
 
 cases here referred to are those in which some meningeal artery- 
 is ruptured; and it may be suspected wliere the patient has 
 remained well for a time after the accident, and then signs of 
 compression have suddenly appeared. From an effusion of blood 
 on one side, the pupil of the eye on the same side is widened; and 
 meantime on the opposite side of the body the arm and the leg 
 can be palsied. Compression can occur from injury of the cere- 
 bral structure; the blood then escapes from the wounded part 
 underneath the dura mater, and when the vessels torn are small, 
 the compression may appear slowly. Compression can arise from 
 pus which is formed inside or outside of the dura mater. When 
 the pus is external to the dura mater, it may proceed from dis- 
 eased bone or from an injury of the bone; and finally compres- 
 sion can arise from an abscess within the brain. 
 
 Hutchinson thinks that compression rarely arises from 
 depressed bone, and though it may be requisite to elevate the 
 bone, this is done rather to prevent inflammation than to relieve 
 compression. 
 
 After this general review of the causes and effects of compres- 
 sion of the brain, the following, derived in part from the author's 
 own observations, may be subjoined. Compression, the effect of 
 violence acting on the head, in most cases results from the effu- 
 sion of blood, which presses on the surface of the brain. Excep- 
 tionally it is caused by a portion of the cranial wall which has 
 been broken and forced upon or into the brain. The patient is 
 unconscious, one or both pupils are dilated; the dilatation is often 
 unequal. The breathing is slow, measured, slightly snoring and 
 often stertorous, with intervals between the respirations, similar 
 to that occurring in narcotic poisoning. This breathing is char- 
 acterized by the peculiarity that the inspiratory act is the one 
 which is especially prolonged, while that of expiration remains 
 almost normal in its duration. The interval between the breaths 
 is long in proportion to the severity of the comj)ression. The 
 pulse is much changed from normal; it is slower and fuller, con- 
 ditions which denote that the heart has undergone some change 
 in its mode of action. The heart, in the uniformity of its work, 
 has assumed the character of a machine ; the pulse wave is pro- 
 pelled with the uniform motion of the piston of a slowly moving 
 engine. It is a movement stately, measured, and rhythmical. 
 The hardness or softness of the pulse will depend on the force 
 ■which the heart is capable of exerting, and this again is some- 
 what dependent on the strength or weakness of the subject. 
 
'^38 Till-: IIKAIN. 
 
 The pulse is so peculiar that it niiglit be named the pulse of com- 
 pression. The temperature may remain normal, but if the agent 
 of compression develops an inflammation, as not unfrequently is 
 the case, then the lieat of the body is increased, and may rise to 
 a high grade of temperature. 
 
 Dingnosis. — The foregoing symptoms present themselves in a 
 case of compression uncomplicated with concussion or contusion 
 of the brain; yet in nearly all cases one or the other, or both of 
 these conditions are present, and thus it is difficult to determine 
 the true nature of the case, unless one of the conditions greatly 
 predominates. The confusing condition most commonly present 
 is concussion, by which the pulse, respiration, and motor power 
 are greatly weakened. And again when time enough has elapsed 
 for irritation or inflammatory symptoms to arise, then the facies 
 of tlie disease is changed, and the symptoms above described are 
 essentially altered. From these facts it is evident that the diag- 
 nostic problem in such injury sometimes baffles solution, and 
 thence has arisen the discrepancy among surgeons who have 
 written on the subject of cerebral compression. 
 
 As aids, however, to the diagnostician in the case of perplex- 
 ity which oftenest presents itself, viz., to distinguish concussion 
 and com^jression from each other, the following collateral pictures 
 may assist in their comparison and differentiation. 
 
 In a case of slight concussion there is some mental disturb- 
 ance coupled with general muscular weakness. The action of 
 the heart and lungs is debilitated, and, as result, the pulse and 
 breathing are weak and slow, and the temperature is not 
 increased, and sometimes it is slightly lowered. If the concussion 
 be more severe, the patient is nearly or wholly unconscious, the 
 heart and lungs act feebly; no snoring ; the pupils are equally 
 dilated; there is a universal reduction of the vital powers, and 
 reflex action remains, though in limited degree; and the eyes 
 move torpidly and aimlessly in their sockets; and the urine 
 escapes passively. In a still higher degree of concussion the 
 universal depression is still greater. The patient lies as if in 
 deep syncope, with cold skin, inaudible breathing, and impercep- 
 tible pulse; in fine, in a moribund state. 
 
 Compression does not occur in such varying forms of gradu- 
 ated intensity as concussion presents. The patient lies in the 
 position of deepest sleep, sleep in which he often loudly snores, 
 and the lips and cheeks move as they do in the act of smoking the 
 pipe. The tongue lapses towards the pharynx, and increases the 
 
COMPRESSIOX OF THE BRAIN. 239 
 
 difficulty of breatliing. The patient makes no voluntary move- 
 juent, nor can reflex action be excited; the pulse is slow, full, and 
 for a time regular; later, the pulse becomes irregular. The pupils 
 are wide, and often one is more dilated than the other, and the 
 urine dribbles after the bladder becomes distended. 
 
 As just stated, compres.sion, contusion, and concussion of the 
 brain are often combined in the same patient, and then the case 
 may be represented by a symbol of the initial letters CCC, and 
 as the accent or emphasis is on an}^ one of the letters, or on two 
 of them, so the character of the conditions present will be modi- 
 fied and shapen ; and if two of the injuries be equally severe, 
 then will the diagnosis be intricate, and the indications for treat- 
 ment obscure. 
 
 Prognosis. — The prognosis of this injury is one in which cau- 
 tion dictates many reservations. For cause and effect seem here 
 sometimes to have lost their ivonted relations, since not unfre- 
 quently a slight injury may eventuate disastrously and a grave 
 one may proceed rapidly to recovery, thus verifying the Hippo- 
 cratic axiom that no cephalic injury is to be underestimated. 
 
 It has often been observed that the symptoms in cerebral com- 
 pression may gradually subside; for example, this can happen 
 where the cause is extravasated blood which is absorbed; also, 
 when the compression is caused by a depressed bone to which the 
 brain seems gradually to accommodate itself. Such tolerance 
 may be brought about by the retirement of some of the fluid con- 
 tents of the brain, viz., of blood and the cerebro-spinal fluid. 
 Besides, it has been observed that where pressure is maintained 
 for a long time on a portion of brain, this, similar to any part 
 that is long jDressed upon, atrophies or lessens in volume. Hence 
 the tolerance of pressure is acquired through permanent struc- 
 tural impairment, a fact which should be considered in progno- 
 sis. In cases in which compression is caused by a neoplasm, or 
 through an accumulation of pus, then the prognosis is entirely 
 inauspicious. Improvement can only be gained through some 
 perilous surgical procedure. 
 
 The prognosis is most favorable in cases in which compression 
 has instantly arisen from a depression of bone. It is less favor- 
 able in cases in which compression has come on some minutes 
 or a short time after the injury, for in such patients a rupture of 
 a blood-vessel may be suspected, and a subsequent effusion of 
 blood. There is a third class of cases, in winch the symptoms of 
 compression only supervene some days after the injury, and in 
 
240 THE BRAIN, 
 
 which it is due to the swelling of the brain through inflamma- 
 tory action. In such cases, besides the afflux of blood, there 
 occurs also an emigration of cells from the vessels into the 
 adjacent tissues; and perhaps there is also a cell j^roliferation. 
 Through these several agencies, the volume of the brain is 
 enlarged and crowded against the unyielding cranial wall, and 
 thus compression arises, of which the prognosis is very unfa- 
 vorable. 
 
 Treatment. — In the treatment of compression, the question 
 of operative interference is one which has been agitated and 
 discussed by surgeons, and at different periods interference or 
 non-interference has predominated. This matter is a part of the 
 history of the trephine, and has been considered in a preceding 
 section, in wdiich this operation was treated of. The treatment 
 is most properly considered under different headings. 
 
 First, in the case in which compression is produced by a 
 smaller or larger portion of the cranial wall that has been forced 
 inwards and crowded on the adjacent brain: though the brain 
 may tolerate this violence, and finally, as it were, forget the intru- 
 sion, yet this is a case in which the trephine should be employed. 
 The effect of trephining will be to place the encephalic structures 
 in such condition that the blood will circulate normally, and 
 thus a proper balance is restored between the defect at one point 
 and the excess at another one; ansemia and hyperasmia both 
 give place to equal diffusion of blood. And if the brain moves, 
 as some contend, with the influx and efflux of the blood, then an 
 operation is indicated to remove the encroaching portion of the 
 wall, which must interfere with the normal influent movement. 
 The onerative work to be done will consist of trephining a small 
 orifice, through which the elevator can be passed, and the wall 
 uplifted and restored to its original position and level. When 
 the depression has been great, after it has been elevated theri- 
 sometimes remains a hollow space for a time; especially is this 
 so where the depression has existed so long that the inherent 
 elasticity of the structures has been partly extinguished. As, in 
 such a case, there would be a tendency of the blood to exude and 
 fill the vacant space, there should be provided drainage for the 
 effused fluid, for a day or two; a drainage tube should be allowed 
 to remain as long as there is any escape of fluid. The stage of 
 inflammation, which is impending in every such injury, should 
 be forestalled, curtailed, and, if possible, prevented by rigid anti- 
 phlogistic treatment. The ice-bag should be at once placed about 
 
COMPRESSION OF THE BRAIX. 241 
 
 the head. The head should be somewhat uplifted, warmth 
 applied to the feet, and the patient have perfect rest of mind and 
 sense. If the subject be plethoric and have an ample endowment 
 of physical strength, then he must be bled from the arm; not less 
 than twenty ounces of blood should be withdrawn. xVs internal 
 medicine, cathartics should be given in the commencement; also 
 iodide of potassium, combined withthebromide of potassium, should 
 immediately be commenced with, and continued for some weeks. 
 The submuriateof mercury, once in so much favor as a controller 
 of cerebral inflammation, should not be forgotten ; the disrepute 
 into wdiich it has fallen in recent years is unmerited; the spectre 
 of ptyalism which hovers in the popular mind as an objection to 
 the use of mercurials, will be conjured away, if the remedy be 
 administered wuth properly w^atchful precautions. Tlie calomel 
 ma}^ be given in doses of a half grain every four hours; and 
 should signs of its specific effect appeaT in an increased flow of 
 saliva, and swelling of the alveolar integument, then the remedv 
 should be suspended for a few days. Another remedy, whicli 
 rarely disappoints in its action, is the protiodide of mercury, w'hicli 
 may be given in doses of a half grain three times a day. 
 
 The anticipated benefits of treatment in cases of cerebral 
 compression from depressed bone are often not realized, since the 
 injury is frequently associated with concussion or contusion, 
 especially with the latter. The in-pressed bone can hardly fail to 
 bruise the underlying brain, and hence the antiphlogistic reme- 
 dies mentioned should have early and vigorous use; and they 
 must be continued for not less than four weeks, and the adniinis- 
 tration should be continued much longer in cases in which motor, 
 sensory, or mental disturbance points to organic lesion. 
 
 The next form of compression, of which the treatment is now 
 to be considered, is that arising from effusion of blood from one or 
 many ruptured vessels. The indication of such ruptures will be 
 that the compression supervenes gradually; for its complete appear- 
 ance, minutes or even an hour or more of time maybe required; if 
 it appears cjuickly, a vessel of considerable calibre must have been 
 opened. As treatment where such vascular rupture is suspected, 
 the bold prophylactic measure of ligating the vessel, which supplies 
 the blood for ecchymosis, has been recommended; thus, it has 
 been proposed to tie the external carotid ta check bleeding from 
 the meningeal arteries, and, as a more radical procedure, in 1863, 
 Furneaux Jordan recommended the ligation of the common 
 carotid artery; for, if this be done, effusion of blood from rupture 
 
'242 THK I'.KAIN. 
 
 of the middle lueningeal artery or of a branch of tlie iiilernal 
 carotid, would be coutroUed. This ligation would control the 
 tendency to intlamination of the injured brain. According to 
 Jordan, the results of ecchymosis of blood from the ruptured 
 meningeal artery are hemiplegia, snoring, whifHng of air from 
 the side of the mouth on the affected side; the pu})il is insensible 
 to liirht. and control of the rectum and bladder is lost; as soon as 
 these symptoms appear, one should, according to Jordan, tie the 
 carotid on the side opi)Osite to the hemiplegia. And the author 
 will add to this advice to bleed the patient freel}'. Without this 
 precaution, the tension with which the blood is carried to the 
 brain through the remaining carotid is abnormally great, and 
 must cause disturbance of nutrition; the abstraction of blood 
 would lessen such disturbance. 
 
 A question next to be determined is whether there are indica- 
 tions present which demand or justify the use of the trephine. 
 The mass of surgical authority favors the use of the trephine; for 
 none deny that the presence of a large clot of blood must be 
 detrimental to the brain, and most agree that its removal is 
 necessary. The opponent of trephination claims, however, that 
 the work will be done by absorption. It may be conceded tliat 
 this is partially possible, yet not wholly so; some remnant of the 
 coagulum will remain as inert material, and, by its presence, will 
 act the part of a foreign body which has become encysted. 
 During the period of absorption the brain adjacent to the clot 
 will be rendered ansemic, and must iindergo some atrophic 
 change; hence, it is manifest that the expectant method of non- 
 interference has its disadvantages. 
 
 General Consideration of the Conditions wJiicJi favor or contra- 
 indicate Trephining. — A few years ago, Leon Le Fort, and, still 
 more recently, Laugier have made an exhaustive study of the 
 hterature of cerebral injury, and each has endeavored to point 
 out the indications for the use of the trephine. 
 
 Le Fort groups together the symptoms which can arise from 
 lesion of the brain in three general classes, as follows: (1) Coma, 
 insensibility, and stupor, that is often associated with stertor, 
 which commence with and continue after the accident. (2) Fever, 
 agitation, delirium, pains in the head, and epileptiform convul- 
 sions. (3) Hemiplegia with or without slight convulsions. When 
 the first group of symptoms is present, and if the coma be deep, 
 and there is a total loss of muscular power, then it is better not 
 to operate; or if this be done, one should wait until the cerebral 
 
COMPRESSIOX OF TPIE BRAIX. 243 
 
 depression has abated or subsided. Trephining in such cases has 
 been followed by a mortality of twenty-five per cent. The second 
 class of symptoms is indicative of a limited lesion of the brain, 
 and of a limited or general inflammation of the organ; there is 
 no satisfactory indication for trephining in such cases, and when 
 the operation has been done, it has seemed to provoke or increase 
 the inflammation. Should the convulsions occur immediately 
 after the injury, then, as probable signs of some compression, they 
 would justify the use of the trephine; yet if the convulsions occur 
 at a later period, they indicate an inflammation which has arisen 
 around a contusion of the organ; and trephining has resulted 
 disastrously in such condition, viz., the mortality was ninety-four 
 per cent. Finally hemiplegia, isolated or associated with spasms 
 which are limited to the palsied limbs, is deemed a sign of com- 
 pression, and an indication for trephining. This compression 
 can arise from a depressed bone, yet it arises more commonlv 
 from an ecchymosis of blood. 
 
 To sum the subject up briefly, Le Fort says that there are 
 three orders of morbid phenojnena which result from blows and 
 other injuries of the head and which govern the use of the tre- 
 phine, viz., coma, convulsions, and hemiplegia. In coma, the rule 
 is to wait; in convulsions, one should never, or almost never, 
 trephine; but in hemiplegia, without or with limited spasms, the 
 indication is to trephine, and to do this at an early period. And 
 if the morbid conditions only occur secondarih^, and there is the 
 presumption that, with the effusion of blood, there is a fracture, 
 then one should operate. And, finally, as an apothegmatic rule 
 of guidance in conditions of uncertainty, Le Fort lays down the 
 follow'ing: In all cases where doubt exists one should act. 
 
 Tangier discusses the points for and against trephining in 
 those cases in which there is evidence or presumption of an 
 ecchymosis of blood. He finds that almost all agree that the 
 unilateral palsy is on the side opposite to ecchymosis; yet, before 
 the trephine is used, there must be found some local injury which 
 can serve as a guide for the point of opening the skull ; in such 
 cases, nearly all authority is unfavorable to operating. Van 
 Swieten alone advises to open guidelessly the parietal region, 
 since the leading vessels run beneath the parietal bone. Again, 
 the local injury and the hemiplegia are exceptionally on the 
 same side of the body, and, though a probable explanation of this 
 is that there has been a rupture by contre-coup, yet there is too 
 much uncertainty as to the site to justifv one in trephining ; in 
 
244 THE BRAIN. 
 
 such cases the operation is not justiiiable. But when the local 
 injury coiTes})onds to a sinus of the <lura mater, or to the middle 
 meningeal artery, and the palsy is on the opposite side, then one 
 may trephine at the site of injury. Again, when the causal 
 injury is an open wound, yet too small to permit the effusing 
 blood to escape, then some counsel to introduce a wedge of dry 
 wood between the fragments, and thus to forcibly enlarge the o{)en- 
 ing; a much better ])lan would be to use the trephine and make 
 an opening at once. 
 
 Fr()m the facts and opinions which have been presented there 
 may be derived, as })ractical rule Ibr guidance, to use the tre})hine 
 in all cases in which there is unilateral l)alsy resulting from 
 blood ecchymosed into, or upon the brain. The removal of the 
 clot is especially indicated when aphasia is conjoined to the 
 hemiplegia. The removal of the clot is not always an easy matter, 
 even though it be reached; sometimes it is spread out over so 
 large a surface that much of the clot is inaccessible. And, again, 
 (hough it be removable through localized isolation, yet the clot 
 may soon reform through the continuance of the bleeding, and 
 thus the surgeon will be frustrated in the object of his work. In 
 the former case, in which there is a widespread coagulum, besides 
 the scoop, the syringe might boused, and a weak sublimated solu- 
 tion should be used for washing out the blood. Due precaution 
 should be used in this injection not to detach the dura mater 
 around the injury. And in tlie case in which the clot reforms, 
 the external carotid artery, or the common trunk, may be tied; 
 and thus both bleeding and inflammation will be controlled. In 
 these operations the wound should be subsequently carefully 
 drained; and if there be disintegrating clotted blood escaping, 
 the exit of this should be favored b\^ ablution, which will be 
 most safely done by the use of fluid })asscd through a siphon, or 
 irrigator held at short distance. 
 
 Compression, as before stated, can arise from a neoplasm, or 
 from an accumulation of ])us within the cranium. The recent 
 advances in tlie knowledge of cerebral localization before referred 
 to, have added much to the accuracy in the location of pus, or a 
 neoplasm in the brain; the peripheral disturbance in limb, 
 muscle, or sense, serves to determine with much definiteness the 
 site of the encephalic disturbance, enough so, at least, to prevent 
 the use of a half score or more of tre[>liine crowns, as was the 
 wont of old, to discover the disturbing agent within the cranium. 
 It must be confessed, however, that much is yet to be learned; 
 
CONTUSION OF THE BRAIN. 245 
 
 niid that, as in our earth large polar and equatorial regions are 
 3''et terra incognita, so in the cranial sphere there is much that is 
 unknown, and, from its nature, it is destined to remain so. 
 
 When the location of a tumor can be determined, which from 
 its volume is causing compression, the indication is clear that if 
 the anatomical conditions are such as will permit the removal of 
 the growth, the attempt should be made to do so; should the 
 neoplasm, however, be intrenched in some anatomically inap- 
 proachable site, then the patient must be committed to his fate. 
 
 And similar principles should serve for the guidance of the 
 surgeon in reference to the use of the trephine for the liberation 
 and escape of pus from the cranial cavity. The operator here 
 has generally the advantage of a local sign which will serve as a 
 guide for his perforation; the pericranium overlying the puru- 
 lent collection wdll be found loosely adherent to, or perhaj)s 
 detached from, the skull. The skull itself will present some devi- 
 ation from the normal appearance. A similar alteration in the 
 appearance of the bone has been observed in cases in which there 
 was subjacent ecchymosis of blood. This has been noted by 
 several English surgeons. After the wall has been opened, some- 
 times the pus is not at once found; it may be beneath the mem- 
 branes, or within the brain itself. Such subjacent pus is denoted 
 by alteration in the hue and texture of the covering membrane. 
 And, further, when the pus lies in the brain, the overlying 
 stratum of cerebral matter is motionless; the pulsating move- 
 ment that is present in the normal healthy brain is absent. 
 With such signs for guidance, Dupuytren plunged his bistoury 
 into the overlying brain, and discovered pus; the story of this 
 case is universally quoted in surgical literature, and has since 
 had a following In practice. 
 
 If pus be found, provision must be made for its ready dis- 
 charge; viz., after opening and carefully w^ashing out the pus 
 cavity, a drainage tube should be inserted, and through this daily 
 ablution should be made with a sublimated solution. 
 
 Contusion of the Brain. — It is only within comparatively recent 
 years that contusion of the brain has been carefully studied, and 
 this study has been embarrassed by the circumstance that, nearly 
 always, there are associated with the effects of contusion also 
 those arising from concussion or compression ; in fact, it is diffi- 
 cult for contusion to occur without there being also some concus- 
 sion. 
 
 As causes of contusion may be cited various kinds of violence 
 
246 ' THE BR.vrx. 
 
 acting directly or indirectly on the cranium. The violence may 
 drive the wall inwards for an instant, and tiicn it may return as 
 (juickly to normal form again; that is, through tiie ordinary 
 action of elasticity, of which, as early stated in this work, the 
 skull has ample endowment. Through such momentary impres- 
 sion the adjacent encephalic structures, viz., tlie membranes and 
 the underlying brain, are bruised to a limited extent. Such 
 lesion, according to the degree of violence, may act only on the 
 cellular cortex, or, besides this, the injury may reach into the 
 subjacent fibri Hated matter. 
 
 Again, contusion may result from violence in which the 
 cranial wall is fractured, and the fragments, or fractured edges of 
 bone, are driven against and bruise the underlying soft structures. 
 In this form of contusion there may he an open wound through 
 which the substance of the injured ])rain may exude, and the 
 conditions are such that the wounded parts may be somewhat 
 open to inspection with the eye. 
 
 There may be contusion affecting the cerebellum as well as 
 the cerebrum; yet the latter, from its larger volume and greater 
 surface, is more frequently injured. There may be single or 
 multiple points of contusion. And when the violence has acted 
 by contre-coup, it is probable that the primary point of impact 
 is likewise contused as much or more than the one opposite to it. 
 
 The conditions found where the brain has been contused are 
 the following: A few drops of effused blood lie in softened 
 cerebral substance, wdiich is easily distinguished from the sur- 
 rounding unaffected cerebral substance. Tlie softening is njostly 
 superficial, or it may reach into tlie white matter of the brain. 
 There may l)e several points of softened structure. The softening 
 is such that the atfected material can l)e washed away with a fine 
 stream of flowing water. Wlien the softened matter is washed 
 away, there remain slight hollows or depressions of violet or 
 slate-colored tint. Sometimes the arachnoid and i)ia mater are 
 found torn. After some days in the course of the disease, pus 
 forms and spreads out over the adjacent surface of the brain. 
 
 In all fractures of the skull, whether concealed or open through 
 a wound of the scalp, contusion of the brain is to be feared; 
 the agent whicii caused the fracture, may penetrate deeply enough 
 to bruise the brain; and when the brain remains depressed, it 
 hastens tlie disorganization of the contused structure. 
 
 To Dupuytren is due the credit of having first observed and 
 described contusion of the brain; and according to him the 
 
COXTUSIOX OF THE BEAIX. 247 
 
 symptoms arising from the injury do not appear until the 
 fourth, fifth or sixth day after the action of tlie causal violence; 
 and the symptoms thus appearing are those of inflammation of 
 the brain and its membranes; for example, there occur chills, 
 fever, delirium, muscular contraction and spasms on one side of 
 the body, provided the lesion is unilateral; later there are com- 
 pression and complete pals}^ of one side, and in most of the cases, 
 the patient dies. Dupuytren states that persons so wounded often 
 walked to the hospital, and after their reception there, for a few 
 days they exhibited no grave symptoms; then suddenly the con- 
 ditions mentioned were ushered in. Sanson claims that there are 
 evidences of contusion from the commencement of the injury. 
 Such symptoms are the contraction of one lid, and the narrowing 
 of a pupil, spasmodic movement of the lips and of one or more 
 muscles of the face; besides there is a difficulty of pronouncing 
 some words, with headache, and a general agitation of the body. 
 These symptoms are at first without fever; but after four or five 
 days, fever arises. Laugier, however, has seen contusion in 
 which, as is asserted by Dupuytren, there were no antecedent 
 symptons during the first few days. 
 
 Boinet, in 184S, on the subject of cerebral contusion, announced 
 that the following conditions are present: There is strong con- 
 traction of the limbs, general agitation of the body, unconscious- 
 ness and stertorous breathing. In mild cases there is contraction 
 of one e_yelid, narrowing of one pupil and inability to pronounce 
 certain words. There is also pain in the side of the head which 
 is injured. These signs of contusion appear at once, or within a 
 short time after the receipt of the injury. The symptoms of 
 contusion are often concealed by those of concussion and com- 
 pression. 
 
 Prognosis. — The chances of recover}^ in a case of severe contu- 
 sion of the brain depend on whether there is associated with it an 
 open wound or not; an opening to the contused structure is a 
 condition greatly favorable to recovery, since the structural ele- 
 ments which are destroyed can escape. Cases have been treated 
 by the writer in which the skull was fractured, a fragment of bone 
 detached so that there was a free opening to the cerebral structure, 
 which was severely contused and lacerated, and yet, despite the 
 severe wound and considerable loss of cerebral matter, through 
 the open state of the wound, the patient made his escape from a 
 contusion of the brain that surely would liave destroyed his life 
 had the wound been a closed one. If the contusion be a severe 
 
248 THE BRAIN. 
 
 one involving the death of a small tract of the surface of the brain, 
 tlien suppuration must result. Such pus must continue to increase 
 in amount, and, necessarily, have a disastrous termination; only 
 in mild cases of contusion, iu which the mere surface of the brain 
 is injured, is it conceivable that the injured elements can be 
 absorbed, and the patient recover; but such absorption and 
 resolution are impossible where there is extensive contusion with 
 unopened cranial wall. Though cures in such cases have fre- 
 quently been proclaimed, yet, as Laugier remarks, where is the 
 evidence that the brain was severely contused? The unopened 
 skull conceals the true conditions; the peripheral manifestations 
 probably gave an exaggerated report of the intra-cranial injury; 
 and what was deemed a severe contusion, was probably only a 
 slight vertical bruise. In fact, the surgeon has been misled by 
 the absence of peripheral manifestations which are usually pres- 
 ent; a few cases have been seen which ended fatally, in which 
 the necro[)sy revealed some cerebral contusion in which the 
 peripheral manifestations had been wholly wanting. It may be 
 predicted that cases will end in death, in which there has been 
 severe contusion of the brain, in which the injury has penetrated 
 deeply, and the skull was not opened; and the escape from death 
 can only occur through an opening made either by the causal 
 injury or the surgeon's trephine. But in superficial contusion, 
 recovery may, with a fair degree of certainty, be predicted. 
 
 Treatment. — Since the efiects of contusion do not reveal tlj em- 
 selves immediately, there is an interval in which preventive or 
 proph3dactic measures may be used; among such njeasures, one 
 of the best in the plethoric suljject is bleeding, done with the 
 lance from the arm, or with leeches from the temples or regions 
 lying over the emissaries of Santorini or trans-cranial foramina. 
 Boinet, to whom reference has been made, recommends that the 
 patient should be leeched behind the ears. The head should be 
 covered with an ice-bag, and the patient should be restricted to 
 low diet, and the bowels well emptied. In this way the develop- 
 ment of inflammatory symptoms may be prevented. Still, if the 
 contusion be severe, and has penetrated deeply, these primitive 
 measures will fail to accomplish this purpose; chills, fever, 
 increase of heat, and the general sym})tom3 of encephalitis, will 
 appear about the fifth or sixth day, and portend great peril to 
 the patient's life. Should these symptoms increase in gravity, 
 then, at an early period, taking a lesson from the favorable course 
 which is often seen where the wound is an open one, the surgeon 
 
CONTUSION OF THE BRAIN. 249 
 
 would be justified in using the trephine and making an opening 
 to the contused structure, which is probably in process of suppu- 
 ration. For this object, a small opening will suffice, and when 
 made, the membranes if closed should be incised, and a free exit 
 provided for pus and other disintegrating material; thus doing, 
 the surgeon would open a door for the escape of a patient who, 
 otherwise, was certainly destined to die. 
 
 1 / 
 
CHAPTEIl VI. 
 
 ENCEPHALITIS, OR INFLAMMATION OF THE BRAIN. 
 
 Pure inflaujination of the brain is a morbid process which is 
 first concerned with the interstitial structure; next, the vessels 
 become accessorily, or secondarily, aflected. In paralysis in which 
 there is found change in the cells and their nuclei, the condition 
 is not an inflammatory one, and hence it is claimed that a 
 parenchymatous inflammation, in which all the elements of the 
 brain are involved, docs not exist. Though, in nosological 
 nomenclature, the terms encephalitis, cerebritis, and cerebral and 
 cerebellar inflammation, are in use, yet it must be admitted that a 
 purelv isolated inflammation of the cerebrum or cerebellum can- 
 not exist; the investing membranes must, also, be involved in an 
 inflammation ; hence the name meningo-encephalitis is often used 
 to designate the disease; and when the development and cause 
 of tlie disease are studied, since the membranes, especially the })ia 
 mater, are the first to be affected, the most rational name for the 
 disease must be one in which there is reference to all the 
 structures implicated in the inflammation. 
 
 Causes. — The chief causes are traumatic, in which the brain is 
 directly injured. Examples of these are falls upon the head, or 
 blows on the head; and in each case the cranium may or may not 
 be broken. When there is no fracture, the inflammation can arise 
 from both contusion and concussion; it can be caused by com- 
 pression in which the in-driven wall injures the part against 
 which it presses. Or the wall may be broken into fragments, of 
 which cneormore pieces wound and inflame the brain. In open 
 wounds of the scalp coexisting with comminition of the bone, 
 fragments of the latter can be forced into the brain, and soon 
 awaken* an inflammation, which, local at first, soon involves 
 adjacent parts. 
 
 A frequent cause is caries of bone forming a part of, or 
 adjacent to, the cranial cavity; the bones most liable to such dis- 
 ease are those forming the upper and deeper portions of the 
 ( 250 ) 
 
CAUSES OF INFLAMMATION OF THE BEAIN. 251 
 
 nasal fossae, and also the mastoid and ^petrous portions of the 
 temporal bone. According to Toynbee, the location of the dis- 
 ease in the auditory region determines the point of attack upon 
 the brain; namely, when the external auditory canal is affected 
 the disease is more apt to pass to the cerebellum. Affection of 
 the tympanum oftener awakens cerebritis, while if the caries 
 be located in the labyrinth the inflammation oftenest passes to 
 the medulla oblongata. Other observers have met with frequent 
 exceptions to the rules of Toynbee here stated. 
 
 According to the researches of Hayem, the inflammatory 
 process pursues the same course in the structures of the brain as 
 it does elsewhere. There is a proliferation of the constituent 
 cells, and a structural development of which the component 
 element is the embryonic or granulative cell. The terminations 
 are similar to those of inflammation elsewhere, viz., suppura- 
 tion or granulative tissue, which may end iu a cicatrix. Or the 
 process may recede through the vanishing of the hypergemia 
 and dispersion of the new bone-cells. 
 
 Encephalitis, when it assumes the hyperplastic form, may be 
 diffused or circumscribed in character. The diffused form may 
 involve a large part of the brain. This form is often seen in 
 infants, and then does not fall within the domain of the surgeon. 
 In the circumscribed form the hyperplastic product is limited 
 to a small space. This form of the disease has rarely been seen. 
 
 The suppurative event of encephalitis may appear in three' 
 different forms, namely, purulent infiltration, abscess with infiltra- 
 tion of the adjacent structure, and, thirdly, circumscribed abscess. 
 
 It is seldom that one has an opportunity of observing in 
 man's brain the condition of the parts which precedes the forma- 
 tion of pus; the most that is known has been'' learned from 
 experiments that have been made on aninjals. If the brain of 
 an animal be locally irritated, there will be observed a multipli- 
 cation of cells, which spring from the stroma, named here neu- 
 roglia, of the brain. This cell growth is preceded first by a tume- 
 faction of the cells of the wounded stroma. A similar action 
 occurs in tlie constituent cells of the walls of the vessels. As 
 the process advances, the new cells are infiltrated into the inter- 
 cellular substance. Nucleated cells appear free or detached, and 
 these are pus-cells. As occurs on the surface of the body in an 
 inflamed structure, so here we have an exuberant development 
 of cells, the most of which, not being organized, aid in the gen- 
 eration of pus; and these cells arise in part from the neuroglia, 
 and in part through emigration from the vessels. 
 
252 KNCKI'IIA LITIS, OK INFLAMMATION OF THE BRAIN. 
 
 When tlio event is abscess, this is situated most frequently in 
 the white matter of the brain, and it is found oftenest in the 
 cereljrum. tstill abscess has been found in the cerebellum, also 
 in the pituitary body, and in the medulla oblongata. The 
 abscess may be multiple or single. When multiple the volume 
 is smaller than where but one exists. At first the containing 
 wall is irregular and softened ; later, a cyst-like wall is formed. 
 The abscess may remain (luiescent without change for a long 
 time, or it may burst into an adjacent ventricle, or open on the 
 surface of the brain; and in this change of site it can awaken 
 an inflammation in the parts with which it comes in contact. 
 An unusual event of such abscess is that it may ulcerate through 
 the cranial wall and appear under the scalp. Such pus has 
 opened into the aural cavity. In case the abscess becomes 
 encysted, some months are needed for the formation of a firm 
 containing wall. The pus cavity may contract through change 
 in its contents. The })us does not putrefy or acquire an ill odor 
 unless it comes in contact with the air. 
 
 Symptoms. — Inflammation here, as elsewhere, changes with- 
 out abolishing the functions of the afiected structures. And as 
 the result of an increased supply of blood, tlie earliest change is 
 functional exaltation; and as the inflammation exists in vary- 
 ing grades of intensity, so there are variations of excitation, from 
 that wdiich is scarcely apparent to that which is an entire })er- 
 version of the functions of the part. To formulate a description 
 which will comprise the different phases of functional perversion 
 is difficult, if not impo.ssible; and this could hardly be other- 
 wise when we consider the diversity o£ causation. For example, 
 the presence of the inflammatory tract, or the continuance of the 
 primarily exciting cause, will determine oedema or congestion 
 in the parts contiguous; a serous eff'usion into the ventricles may 
 thus arise; thence various shades of functional disturbance arise, 
 which become mingled with those previously existing. 
 
 An antecedent, or milder stage, usually precedes the full 
 development of encephalitis. In this period, which ma}^ be 
 called that of congestion, the patient is disturbed with obstinate 
 headache, vertigo, giddiness, and sometimes difficulty of speech ; 
 often the pupils are of unequal size; the face is alternately red 
 or pale; sometimes there are spasmodic, jerking movements of 
 the muscles of the limbs, face, and eyes; sometimes contractions 
 and strabismus; there may likewise be disturbance of general 
 sensation. The patient may have the feeling of formication and 
 heaviness on one side of the bodv. 
 
SYMPTOMS OF INFLAMMATION OF THE BRAIX. 253 
 
 The symptoms mentioned gradually augment iu intensity, 
 and the disease soon appears in its full proportions. In a few 
 exceptional cases the disease assumes the form of apoplexy, the 
 patient losing entire consciousness; yet usually some conscious- 
 ness remains, and the patient is capable of being aroused. The 
 relaxation of the body is incomplete, and the limbs do not 
 remain wholly motionless and passive. Instead of passive 
 relaxation of the limbs there is often present in them some rigid- 
 ity. In fact, such stiffness is one of the most common accom- 
 paniments of encephalitis. This rigid state, called contracture, 
 may be limited to a small number of muscles, or it may occupy 
 one-half of the bod}'. Contracture may appear primarily, or it 
 may be preceded or accompanied by convulsions, and in these 
 cases the medulla oblongata is probably implicated in the inflam- 
 mation. The convulsive action may recur rhythmically, or it may 
 assume an unmeasured action similar to chorea. Paralysis may 
 affect both sides of the body; and so may contracture. Palsy is 
 seldom seen at the beginning of encephalitis. 
 
 The disturbances of intellect present endless variety. There 
 may be only a slight exaltation, or delirium in its wildest and 
 most acute form may be among the earliest manifestations of 
 encephalitis. The mind may be tormented by illusions, in 
 which the normal sensory impressions are wrongly interpreted. 
 There may be hallucinations of sight, hearing, and taste. Faces 
 and objects well known are not recognized, and familiar things 
 are transformed into demons and other objects of fear. The ear 
 may hear sounds which are wholly imagined; familiar sounds 
 may be transformed into those which are humorously unnatural, 
 wildly incongruous and monstrous. There are deceptions of taste. 
 The patient may spit from his mouth what he conceives to be 
 some foul or unnatural material. And the sense of smell, also, 
 may convey false messages; that is, the eye, ear, nose, and tongue 
 may carry false reports from their respective quarters. In short, 
 the unfortunate subject has lost all natural relation to his sur- 
 roundings, or, summed up briefly, the acts of mentality of the 
 subject are those of misinterpretation or falsification; and the 
 conditions in some way or another are similar to those which 
 the alienist would name insanity. 
 
 There is an increase of heat in the commencement of enceph- 
 alitis; the heat rarely rises above 103° Fahr. The pulse is fre- 
 quent, and is sometimes unequal and irregular. One of the 
 earliest and most constant symjjtoms of commencing encephalitis 
 
254 ENCEPHALITIS, OR INFLAMMATION OF THE BRAIN. 
 
 is nausea and vomiting; the patient, at first, vomits any materi- 
 als which may have been recently swallowed ; then in limited 
 quantity gastric mucus is expelled, and soon afterwards bile is 
 vomited. This is often vomited in such large amount that it is 
 probable there is some connection between the encephalic inflam- 
 mation and the generation of bile. This constant vomiting has 
 a tendency to augment the congestion in the head and to promote 
 the development of the disease there. The emptying of the upper 
 part of the alimentary canal, by lessening the content there, 
 becomes the cause of the constipation, which is a constant 
 accompaniment. There is also retention of urine; the inaction 
 of the bowels and bladder may be due to contracture of the })arts, 
 as some authors have suggested; the writer, however, thinks 
 fsecal and uiinary retention is rather referable to the patient's 
 mental perversion, in which he forgets to obey the summons of 
 functions of wdiich the accomplishment in normal health depends 
 on active volition. 
 
 The primary period of encephalitis, of which the leading 
 features are excitation and increased action, is succeeded in a few 
 days by depression. The excitable and acutely active mind 
 becomes obtuse and torpid; vision becomes dull, and the eye is 
 no longer annoyed by brilliant light; the ear scarcely heeds 
 sounds and is no longer disturbed by those which previously 
 pained it; and so the other senses have become obtunded, and all 
 have fallen asleep, as it were, at tlie portals where they previously 
 received messages for the mind. 
 
 In this stage the patient soon falls into stupor; there is both 
 retention and incontinence of urine; that is, the palsied bladder 
 overflows and, instead of the excessive and violent movement of 
 the muscles which required force of nurses to prevent the patient 
 from injuring himself, he becomes partly or wholly palsied; the 
 temperature soon rises to the highest abnormal limits; the eyes 
 and face are suffused with redness approaching to a cj^anotic tint. 
 The pulse becomes small and irregular; the breathing lapses into 
 irregularity, and sometimes it is temporarily suspended. The 
 symptoms named precede and indicate an early fatal termina- 
 tion. 
 
 The duration of the disease varies greatly, and this depends 
 on whether or not the disease implicates the portions of the brain 
 which are speciall}^ the centres concerned in the maintenance of 
 animal life; such centres are found in a limited region at the 
 base of the brain, and particularly include the medulla oblongata. 
 
DIAGNOSIS OF INFLAMMATION OF THE BRAIN. 255 
 
 Life may continue for weeks, as the author lias witnessed several 
 times, when the inflammation is chiefly limited to the anterior, 
 posterior or lateral portions of the brain. On the other hand, 
 the disease may run a rapid course, death occurring within a few 
 days. Encephalitis may have a uniform course; or remissions of 
 intensity and moderation may alternate with each other ; also 
 symptoms of depression and exaltation may be concerned, due to 
 gradual involvement of parts adjacent to the j^rimary focus of 
 inflammation, and then the disease proceeds in such a manner 
 that the inflammation does its destructive work at the site of 
 commencement; meanwhile, in contiguous parts it is in process of 
 early evolution. In this condition there may coexist palsy of 
 some muscles and spasmodic movement of others; or, as the 
 author has seen, there may be irregular motion in one-half of the 
 body, while the opposite side lies in passive hemiplegia; one nupil 
 may be contracted while the other is dilated. 
 
 The disease sometimes has a chronic development, and then 
 its changes are only apparent when some days, or perhaps weeks, 
 have elapsed; in such a case the patient emaciates; there is occa- 
 sional nausea, and food is ill tolerated; life may continue thus 
 for months, and an autopsy finally reveals those changes in the 
 brain which are produced by encephalitis; probably one or more 
 foci of pus may be discovered, and elsewhere on the brain cicatri- 
 cial changes may be found ; since here, as in almost ever}^ case of 
 morbid action which continues for some time, a close inspection 
 of the part afl"ected reveals the fact that there has been an attempt 
 at repair, and which is often complete, so far as a limited portion 
 of the affected 2:)art is concerned. 
 
 Encephalitis arising from a traumatic cause, or from disease 
 of some portion of the cranial wall, remains isolated for a time; 
 finally pus is developed, though so latently that it may not 
 be suspected, if it does not involve some part of which the func- 
 tional impairment is apparent; yet such unsuspected pus after a 
 long period of latency may burst its containing walls and pass 
 into the lateral ventricles; and such event is heralded by convul- 
 sions, from which the patient sinks into a coma, which may be 
 terminated by a sudden or a lingering death. 
 
 Diagnosis. — There is some resemblance between encephalitis 
 and the conditions which accompany rupture of a vessel and 
 softening of structure. Yet in encephalitis there aj:e signs of con- 
 gestion early in the disease which are absent in the other two 
 conditions. There is always an augmentation of temperature in 
 
256 ENXEI'IIALITIS, OH INFLAMMATION OF TIIF BRAIN. 
 
 an inflamed brain, but in case of vascular rupture and softening, 
 the temperature does not rise, but it may sink to less than nor- 
 mal. Contracture is more frequent in encei)halitis, and it often 
 persists for some time; it is less frequent after rupture of a vessel. 
 In encephalitis there is a constant progress from bad to worse, 
 but in case of softening and vascular rujiture, there often occurs 
 at an early period an amendment in the symptoms; tolerance of 
 the condition is frequently seen. "When the inflammation is 
 purely meningeal, the temperature rises high, and the functional 
 disturbances are marked by more acuteness and intensity than 
 is the case in simple encephalitis. 
 
 Pus, the result of an encephalitis, can become encysted and 
 then remaiu inert, and exert, for an indefinite time, almost no 
 action on the brain ; and even then, should it suddenly burst and 
 cause apoplectic symptoms, the true nature of the condition could 
 not be diagnosticated, since such, apoplectic attack might result 
 from a tumor encroaching on the brain. That it is pus might be 
 inferred from the antecedents, viz., if there had been an otic caries, 
 or one about the orbit or nose, then there would be satisfactory 
 proof that pus, and not a neoplasm, is the causal agency. 
 
 As a brief summary of the diagnostic signs of encephalitis, the 
 following may be oftered: Temperature abnormally increased; 
 acceleration and irregular pulse; pupils contracted or dilated 
 according to the stage of the disease; twitching, spasm or contrac- 
 tion of the muscles, and perversion or alteration of mentality. 
 
 From the author's observation, inflammation of the brain occurs 
 much oftener in the male tlian in the female, and in the latter the 
 writer has seen cerebral and hysterical trouble so commingled that 
 it was impossible to arrive at absolute definiteness in the diagnosis. 
 In a young female who was the subject of hysteria, he saw enceph- 
 alitis suddenly develop, and the hysterical symptoms continued 
 so prominent that the real nature of the disease was not suspected 
 until it had nearly reached its fatal termination. And in a 
 second case, which originated in mastoid caries, the young woman 
 sank into fatal coma before the nature of the disease was appre- 
 hended. Hence, to the conspectus of symptoms just presented 
 should be added the precautionary mention, when the subject is 
 a young woman, that encephalitis may be masked, obscurely 
 veiled by, or commingled with, hysteria. In such a patient, 
 elevated temperature would indicate the cerebral inflammation. 
 
 Prognosis infausta, or an inauspicious prediction, may be 
 given ill respect to most cases of inflammation of the brain; the 
 
TREATMENT OF IXFLAMMATIOX OF THE BRAIN. 257 
 
 inaccessibility of the parts, and the important offices which they 
 perform in the maintenance of animal life, have long since, even 
 with the layman, caused this inflammation to be regarded as a 
 ]natter of the greatest peril. Death, as a rule, is the end, and 
 should the case not terminate in death, recovery is sometimes 
 not a blessing to tlie patient, since tliere may remain some per- 
 version of intellect, of the power of motion, or of special and 
 general sensation. Of these contingent sequences the most dis- 
 astrous is the partial or complete loss of intellect wdiich encepha- 
 litis may entail. The individual ma}^ afterwards remain 
 changed both in his reason and in his emotional nature; and 
 the possibility of such change remaining as an entailment ren- 
 ders life of little value to the patient. 
 
 Treatment. — Encephalitis may end by resolution, in which 
 there is complete recovery, the effused or newly formed material 
 being wholl}^ removed by absorption; or the disease may end by 
 absorption of some of the material effused or formed. The 
 structures of the eucephalon then remain somewhat changed from 
 their normal condition. There are alterations slight or extensive, 
 through cellular neoplasm ; and, thirdly, the new formed or 
 effused material may die, a condition fatal to the patient in 
 nearly all cases, unless relief be furnished by the surgeon. Of 
 these three endings the first is the desirable one, and treatment 
 to accomplish this should be diligently pursued. The elements 
 which inaintain the inflammation and, when morbidly changed, 
 become instrumental in destroying the patient's life, are prima- 
 rily derived from the blood. 
 
 The indications of treatment are to secure resolution, if pos- 
 sible, and, failing in this, to avoid the fatal ending by j^romoting 
 and obtaining partial absorption of the material which, if unre- 
 moved, destroys life. These indications are fulfilled by lessen- 
 ing the supply of blood to the brain. The patient should be 
 Ijled early, freely, and to the utmost limit of tolerance, and this 
 abstraction of blood should be done with the lancet, and not by 
 leeching or cupping. A A^ein in the arm should be opened, and 
 while blood is flowing the pulse in the other one should be 
 observed, and the flow should continue until the pulse becomes 
 attenuated and feeble. In this work the patient should have the 
 head elevated, so that if signs of approaching faintness appear, 
 the head can be lowered and syncope averted. 
 
 The amount of blood to be drawn is better measured, as just 
 said, by the impression on the pulse than by the amount drawn. 
 
258 ENCErnAi.iTis, ok inflammation of the bkain. 
 
 Yet, as a general rule in the rol)Ust subject of full habit the 
 withdrawal at one bleeding of from thirty to forty ounces is 
 safely borne. If this is followed by lowering of temperature, 
 and the subsidence or disappearance of the general symptoms 
 of exaltation, then it will not be necessary to resort to depletion 
 again, since there is a fair probability that the inflammation 
 has been overcome, and that recovery through resolution will 
 ensue; if not entire resolution, at least dispersion of so niucli of 
 the new-formed material that the remainder will be tolerated. 
 But if the depletion is found not to have accomplished this, it 
 must be repeated, and a quantity of blood again removed until 
 an impression is made on the heart. As collateral aids in com- 
 bating encephalitis are cathartics, sudorifics and diaphoretics. 
 As a purgative calomel will act well; so, also, the saline a})erients 
 which in their action abstract fluid from the intestinal wall. As 
 a diuretic and alterative the iodide of potassium acts effectively. 
 To act on the skin pilocorpin in small doses may be used; full 
 doses of this wonderful agent depress the heart too much. 
 This is avoided if the pilocarpinbe given in doses of one-eighth of 
 a grain, repeated every eight hours. The author, in accepting 
 this internal medication as an ally, will say that it is but dust in 
 the balance when weighed against venesection. Internal rem- 
 edies may be likened to arrows discharged over the wall of a 
 besieged enemy, which fall aimlessly. But venesection acts as 
 does the besieger, who deprives the enemy of his means of su.ste- 
 nance, and in so doing soon conquers him. 
 
 But this treatment may fail of its purpose. The inflammation 
 then ends in suppuration; pus is developed as the flnal event of 
 the encephalitis, a not unfrequent ending of the disease, wdiether 
 of traumatic or other origin. 
 
 If pus develops as the result of a traumatic encephalitis (the 
 form which is here being considered), the purulent matter may 
 be situated between the skull and the dura mater, between the 
 dura mater and the brain, or it may be lodged in the viscus. 
 The pus may be collected within a circumscribing wall, in which 
 there seems to have been an effort on the part of nature to isolate 
 the morbid matter and protect the adjacent brain from it. Or 
 the purulent fluid may be diff'used and widespread as a thin 
 stratum, the morbid material traveling in the directions in which 
 it meets the least obstruction. The pus in this latter form is 
 found between the dura mater and the brain, probably because 
 this situation is more favorable for diffusion. The anatomical 
 conditions here are unsuited to adhesion and occlusion. 
 
TREATMENT OF INFLAMMATION OF THE BRAIN. 259 
 
 Pus situated between the skull and dura mater is, from its site, 
 necessarily small in amount. It is commonly but imperfectly 
 circumscribed. The color is greenish, and the bone over it has a 
 similar tint and presents the first signs of necrosis, and if the 
 case has continued long, the bone is slightly eroded. Between 
 the dura mater and the brain the pus is yellowish, and is closely 
 adherent to the membranes subjacent. But if the purulent 
 matter be developed in the substance of the brain, such collection 
 is circumscribed, and may be in large or small amount, and has 
 the characteristics of an abscess. Such abscess, which may be 
 designated cerebral or cerebellar, according to its site, has been 
 seen in all parts of the brain; and when in the cerebrum it may 
 occupy one or both hemispheres; and in this situation the pus 
 often bursts into the lateral ventricles. The amount has been 
 so great as to convert one hemisphere into a capsular envelope; 
 or it may occupy the upper part of one or both hemispheres, and 
 have a portion of the cranial vault as its covering. 
 
 As stated before, the desirable ending of traumatic encepha- 
 litis is resolution complete, or nearly so, of the products of inflam- 
 mation. The worst event is suppuration, since recovery is impos- 
 sible without evacuation of the dead material, and, though this 
 may be done by the hand of nature, yet this is rare. Art may 
 essay to do it, and some progress has been made in this direction 
 since modern surgery has claimed the interior of the skull as a 
 field for legitimate work. Such cases unaided have recovered 
 by the pus finding an outlet through an opening formed by the 
 fracture, or the material may be near some naturally perforated 
 portion of the cranial wall, and there find egress. Thus through 
 an opening occupied by an emissary of Santorini, in the parietal, 
 frontal or temporal region, pus may find a path for emergence. 
 Again, such pus lying near the base of the skull, as the result of 
 counter blow, may be so imprisoned that neither surgical art 
 with its daring nor nature with her resources can find a way of 
 escape. 
 
 The presence of pus may be suspected where, despite the 
 active antiphlogistic treatment above detailed, outward symp- 
 toms still continue; where there remains perversion, either in 
 the form of exaltation or depression of intellect, motion or sen- 
 sation. Symptoms of depression are the more usual, viz., mental 
 torpor. Muscular paresis or j)alsy, or anaesthesia, or parsesthesia 
 of some organ of the body, points to central trouble, probably 
 from pressure due to a collection of j^us. A significant symptom 
 is a rigor and continued high temperature. 
 
260 l:n'ci:i'ha LITIS, uii inflammation of the kkai::. 
 
 If these symptons, one or ull, are })re.seiit, the presence of i)us 
 may be inferred with sutticient probaJjihty to justify the use of 
 the trephine or some procedure by which the material may be 
 evacuated, and here two classes of cases present themselves : one 
 in which the causal agency has been a fracture, and another in 
 which llie causal violence did not break the bone. 
 
 Where a fracture exists and is of such a character as to expose 
 the dura mater, tlie condition of the latter may clearly point to 
 the existence of pus near by; thus a brown, ashy or semi-necrosed 
 appearance denotes lowered or vanishing vitality, and tlio |»roba- 
 bility of pus near by, and warrants, if the foregoing general 
 symptoms be present, the opening of the dura mater, and if 
 purulent matter does not lie contiguous, the cortical layer of 
 the brain should be explored by means of a small trocar; and if 
 pus be thus detected, the overlying structure must bo freely 
 opened, and the dead material washed out by gentle irrigation; 
 and this irrigation may be repeated until pus no longer appears. 
 
 In the second case in which fracture is absent, and yet the 
 general symptoms point to localized purulent material, an effort 
 must be made to discover and evacuate it. For this purpose at 
 the site of injury the scalp should be incised and the bono 
 examined. As intra-cranial extravasation of blood when next 
 to the wall reveals itself by alterations in the pericranial lining, 
 so changes occur in this membrane when pus lies directly under 
 the intermediate wall; for example, if the pericranium be dis- 
 colored or is detached from the bone, then, beneath such site, 
 pus is probably located. Also, along with looseness of membrane 
 there will be discoloration of the bone itself; the latter will be 
 brown instead of a pinkish hue; such bone will be in the first 
 stage of necrosis. In such conditions of the cranial wall and its 
 investing membrane, the trephine should be used, and a free 
 opening made; and should pus then not be in view, an incision 
 should be made into the cortical stratum of the brain; and if 
 pus be discovered, the treatment should be similar to that pur- 
 sued in the case of an opening made by fracture. Also should 
 there be a fissuj'e in the wall without other visiljle changes, the 
 trephine should be used at that point. 
 
 There is another class of cases in which the surgeon is nearly 
 or quite without guide; here there is no lesion or change discov- 
 erable in tlie soft parts, and the cranial wall jiresents no abnormal 
 appearance; in such there is no guide for the localization of the 
 pus except that the patient received a severe blow at some point 
 
TUMORS. 261 
 
 of his skull, and subsequently symptoms of suppuration have 
 J) resented themselves. In this case, though the pericranium and 
 skull be found intact, yet in the existing state the surgeon should 
 resort to a procedure similar to acupuncture exploration. For 
 this purpose a small incision is first to be made through the 
 scalp ; then an opening is made through the bone by means of a 
 small drill; through this canal a small trocar can be passed, and 
 the pus, if present, is thus detached. Should nothing be found 
 when the dura mater is pierced, then the instrument should be 
 passed into tlie superficial or even deeper structure of the brain. 
 Should no purulent material be found at the point first chosen, 
 then another aperture should be drilled near by, and then another, 
 until pus has been discovered, or the search for it proved fruit- 
 less. If the pus be thus located, then a larger opening should be 
 made with the trephine, and the work of emptying and irrigat- 
 ing be done, in the manner before described. If the exploratory 
 procedure here described be done with aseptic precautions, should 
 one fail to find pus, the injury to the parts will not be a serious 
 one. 
 
 Tumors. — When the brain is studied in its earliest stage of 
 development, it is found, according to the observation of embry- 
 ologists, to originate in the epiblastic layer of the embryo. In 
 accordance with such derivation one might expect that neoplasms 
 originating here would conform in type to those originating in 
 the cutaneous tissue; and, hence, an epithelial neoplasm might 
 be inferred to have its origin here. In the great changes which 
 this epiblastic structure passes through to become brain, the latter 
 seems to inherit in a slight degree the tendencies to neoplastic 
 perversion which are prevalent in the surface of the body. 
 
 Tumors of both the malignant and benign type are found in 
 the encephalon. As examples of the malignant type there 
 develop here, carcinoma, sarcoma and glioma. These growths, 
 when they originate in the brain, proceed oftenest from the 
 cortical structure. 
 
 Carcinoma may have its primary origin in the surface of the 
 brain, in the dura mater, or it may arise from the inner face of 
 the skull, and the growth, springing froin any of these sites, 
 generally develops centrally and excentrically. It may attain a 
 great size. 
 
 Sarcoma occurs more rarely than carcinoma; in its mode of 
 growth it is similar to cancer. 
 
 Glioma may be characterized as less heterotopic or foreign, in 
 
262 ENCEPTiALrns, or inflammation of the bkain. 
 
 its site liere, tliun cancer or sarcoma; for its stroma is analogous 
 to the skeleton tissue of (he brain. It consists of a thin Aveb-like 
 tissue iu which the constituent cells are contained, and the 
 whole is remarkable for its softness and fragility; an<l, owing to 
 this want of firm union of its elements, the glioma is subject to 
 rupture and effusion of blood. Glioma sometimes contains fusi- 
 form cells, and then the growth is called glio-sarcoma. 
 
 The benign growth is rarely met with in the cranial cavity. 
 Examples of this are the psammoma, the lipoma, and the angioma 
 and dermoid growth. 
 
 The psammoma arises almost always from the dura niater. 
 It is constituted of particles of sand connected together by lilms 
 of connective tissue. The tumor resembles a mulberry in its 
 surface, and may attain the dimensions of a small walnut. 
 
 The li})oma is rare here; yet it has been found at sites where 
 there is normally a small amount of adipose tissue. Such sites 
 are the optic chiasm, the pons A''arolii and the raphe of the 
 corpus callosum. 
 
 Ansfioma is found in the cranial cavity; it does not ])resent 
 itself in a form that would demand, or be suitable for, intra- 
 cranial intervention. Should surgical treatment be required, the 
 better plan would be to ligate the common carotid supplying 
 blood to the tumor. 
 
 A case of dermoid tumor situated in the anterior portion of 
 the brain was discovered in a necropsy made in one of the hospi- 
 tals of San Francisco. Hair and other components of the 
 dermoid tumor were found. 
 
 Syphiloma. — The syphilitic or gummy tumor appears within 
 the cranium as the product of constitutional syphilis. This 
 growth may arise from the dura mater, pia mater and the struc- 
 ture of the brain. 
 
 Secondary syphilis may appear either on the outer or tlie 
 inner surface of the dura mater. When on the external side it 
 appears as a slow inflammatory process, whence there is a growth 
 of bone, an osteoma of small or large extent. But the syphiloma 
 proper arises from the inner face of the membrane and grows 
 toward the brain, and may attain dimensions varying from that 
 of a filbert nut to that of a walnut. Such growth may encroach 
 on a vessel and then, obstructing the flow of blood, it may cause 
 softening or atrophy of a limited region of the brain. Or it may 
 encroach on a nerve in its course, or it may lessen the diameter 
 of a foramen, and in each case the function of the nerve is altered 
 
SYMPTOMS OF IXTRA-CKAXIAL TUMOR. 263 
 
 or abolished. The growth may arise from the pia mater, and 
 produce troubles similar to those just mentioned. And finally, 
 the gummy tumor may originate in tlie tissue of the brain itself 
 
 The syphiloma is of a grayish red color, and, on section, its 
 interior presents yellowish spots; these have originated in caseous 
 change of the growth. AVhen in the brain the growth is often 
 surrounded by a layer of translucent, colloid material. The 
 growth may become casefied, a*nd is then fragile; or it may 
 become dense and resistant in structure, and become surrounded 
 by a cyst-like membrane. 
 
 The gummy growth is most often found at the base of the 
 brain, generally contiguous to the sella turcica, and then by 
 jjressure on the optic nerve, or on the motor nerves of the eye, 
 such growth is the occasion of some phase of impairment of the 
 visual apparatus. Besides being an agent of compression, the 
 growth awakens inflammatory action, and thus localized paresis 
 and excitation may coexist. 
 
 A growth having some analogy to the syphiloma is one in 
 which the constituent material is tubercular matter; in situation, 
 aspect and form the two are similar. Yet the external manifesta- 
 tions which accompany such growths are entirely different, for in 
 the one case, the rashes of s^^philis are present; in the other, the 
 symptoms of tuberculosis present themselves in some other part 
 of the bod}'; and the tubercular bacillus may be found. 
 
 Osteoma and chondroma may develop from the inner surface 
 of the cranium and cause trouble through pressure on the brain 
 or encroachment on nerves arising from it. Exceptionally, the 
 osteoma has been seen to spring from the inner face of the dura 
 mater, also from the surface of the brain itself. 
 
 Parasitic growths occur within the cranial cavit}-; the content, 
 then, may be cysticerci or the echinococci. The cysticercus cyst 
 may be situated in the central or superficial parts of the brain; it 
 occurs oftenest in the convolutions. Such cyst, in multiple form, 
 is found also in other parts of the body. The echinococcus cyst 
 is f jund in or on the hemispheres, commonly but one or two in 
 number. The parasitic cyst can attain the volume of a pigeon's 
 egg. These cystic growths may cease to grow and their jDarasitic 
 inhabitants die, and the content undergo fatty metamorphosis. 
 
 Symvptoms of Intra- cranial Tumor. — The location of an intra- 
 cranial tumor is a pathological problem which is often extremely 
 difficult of solution; in fact, large tumors have existed without 
 having been suspected, and were only discovered by necropsy. 
 
20-1 EN'CKrilA LITIS, ()U INFI.AMMATIdN OF TIIK I5RAIX. 
 
 And this may occur for the reason that certain enceplialic struc- 
 tures are liighly tolerant of invasion, whether this be from a 
 growth, efiused blood, or an abscess; such tolerance is possessed 
 by tlie white structure in the commissures, and in the interior of 
 tlie hemispheres. Tumors located at the base of the skull are 
 distinguished from those arising at the sides or summit of the 
 brain through causing functional disturljance of some of the 
 nerves which arise from the base. Where indications of basial 
 tumor are present, and yet there is no peripheral index of exact 
 location, then among the possible sites which maybe suspected 
 is one near the body of tlie sphenoid bone, since the structures 
 reposing on its intra-cranial, as well as its pharyngeal surface, in 
 their primary development undergo great moi-i)hological trans- 
 formation; and if located here the tumor would lie beyond the 
 surgeon's reach. Tlie writer is pleased to state that with the 
 light which has been furnished by the recent revision of the 
 chapters of neurology, the surgeon, aided by the physician, can 
 often locate the intra-cranial tumor, and, if it be anatomically 
 accessible, he is able to penetrate to and to remove it. 
 
 A general character of neoplasms of any type whatsoever, 
 located in the skull, is slow and irregular growth, and sudden or 
 })aroxysmal appearance of the morbid phenomena produced by 
 the growth. Such irregularity in morbid movement is referred 
 to the appearance and disappearance of local congestion. In 
 some instances the volume of the growth may lessen, as has 
 occurred with the syphiloma. 
 
 The intra-cranial tumor is the cause of functional trouble aris- 
 ing from lesion or disturbance of the parts primarily compressed 
 or acted on; ixUo from disturbance of parts adjoining; and, lastly, 
 functional alteration in peripheral structures. This functional 
 disturbance appears in different forms; examples of it are spas- 
 modic contractions, convulsion, augmented sensation, delirium, 
 febrile reaction, localized palsy and coma. These SNanptoms are 
 classifiable under two heads: excitation from increased supply of 
 blood, and depression from anoemia due to compression caused by 
 the growth. These phenomena usually occur in the order here 
 described; yet there are many exceptions; symptoms of excita- 
 tion and depression may be commingled, here due, probably, to 
 multiple development; a large growth may compress parts, while 
 another is in its initial period of evolution ; and a single large 
 tumor may compress subjacently and adjacently; it may cause 
 an alilux of blood, and thus spasmodic contraction and par- 
 alysis may coexist in adjacent peripheral parts. 
 
SYMPTOMS OF INTRA-CEANIAL TUMOR 265 
 
 The s^niiptoms caused by intra-cranial tumor are not exactly 
 alike in any two cases ; the resemblances are only general. The 
 most common symptom is headache, which may be diffused over 
 tlie whole head, or it may be local, and when confined to the occip- 
 ital region the lesion is probably cerebellar. It may be so acute 
 as to awaken cries of anguish when intensified by sound, light, 
 movement or vomiting. As a great part of the structure of the 
 brain is insensible, the cephalalgic pain must be referred to lesion 
 of the dura mater, of the crura and the pons Varolii. In such 
 condition the patient is restless, peevish and easily awakened to 
 anger; it is with difficulty that he sleeps and, when he does so, he 
 is disturbed by frightful dreams. 
 
 Another common symptom is vertigo, arising from changes 
 in the position of the body, in which the head is raised or lowered. 
 In such vertigo the patient imagines that objects about him are 
 whirling around him; or when lying on his bed, as in a case seen 
 by the author, the subject fears that he wall fall upwards, and to 
 avoid doing so, he clings violently to his bed. In walking, the 
 patient may suddenly become worse, and he may fall or be forced 
 to support himself against a wall or other object. 
 
 Singular sensations are felt in the head; the patient fancies it 
 will burst or that it is filled with fluid that moves; one patient 
 had the feeling that his head was filled with bran. 
 
 These symptoms are usually concurrent with impaired intel- 
 lect ; if an intelligent patient, he observes that he thinks more 
 slowdy and with more difficulty than he formerly did; the atten- 
 tion can scarcely be fixed; facts committed to memory are incor- 
 rectly recalled ; for example, the multiplication table or prose or 
 verse once learned is inaccurately recalled. This clouded condi- 
 tion gradually merges into indistinct twilight of intellect, and this 
 again into total mental darkness; oblivion, in which the subject 
 divested of any psychical endowment lies in a torpid condition, 
 with rectal and vesical incontinence. 
 
 Another symptom of such tumor is vomiting, which occurs 
 when the stomach is full, and if empty, there is retching ; assum- 
 ing the erect position may arouse such action, which subsides 
 when the subject is recumbent. Such is the case when the tumor 
 presses on the cerebellum or the crura cerebelli. 
 
 Encephalic tumor at an early stage may cause epileptiform 
 convulsions, which may come on instantaneously and cause the 
 patient to fall. These attacks may recur often, and soon end 
 life. Such convulsions appearing in the adult without other 
 assignable cause should awaken the suspicion of tumor. 
 IS 
 
2G0 KXCEIMIALITIS, Oil INFLAMMATION' OF TIIK F.KAIN. 
 
 Limited contracture and localized bypersesthesia, continued 
 or recurrent, are symptomatic of encephalic tumor. The most 
 unerring indication, however, is disturbed function of cranial 
 nerves, especially when tliis is associated with hemiplegia. 
 Physiological exploration, which in recent years has been so 
 diligent in its work, has discovered that the cranial nerves have 
 a cerebral as well as a nuclear origin. The nuclear origin is 
 from a nucleus situated in the floor of the fourth ventricle, or in 
 the pons Varolii. In this respect these nerves are so similar 
 that a description of the facial nerve will serve for the history 
 of the whole. Primarily, it may be stated that this nerve may 
 be palsied by })ressure on the same side as the palsy is; or this 
 pressure may be on the side opposite to that of tiie palsy, as 
 herewith is explained. 
 
 The facial nerve, having entered thebulb of the cord, proceeds 
 to a nucleus located on the surface of the fourth ventricle where 
 the bulb is just entering the pons; above and beyond the nucleus 
 a radicle in the form of a band passes upwards into the brain. 
 As is known, a tumor pressing on some part of a hemispliere 
 causes hemiplegia on the side of the body opposite to the com- 
 pressed hemisphere; and meanwhile the cerebral branch of the 
 facial nerve may be so implicated that there will be palsy of the 
 face on the same side as the general hemiplegia. But a tumor 
 acting on the facial nerve beyond its nucleus, causes palsy on the 
 .same side as that on which the pressure is made. Thence it 
 results that wlien multiple tumor exists there may be hemiplegia 
 on one side and facial palsy on tiie other. It has been found that 
 pressure on the cerebral radicle of the facial causes much less 
 palsy than when the pressure is on the nerve near or beyond the 
 nucleus; and such limited facial palsy concurring with a hemi- 
 plegia would indicate that the site of the tumor is in the cerebral 
 or superior portion of the .skull; but a facial palsy on the side 
 opposite a hemiplegia might denote multiple tumor, one above, 
 and one near the base of the skull pressing on the facial, and 
 which is situated on the same side as the tumor above. 
 
 Several cranial nerves are often implicated at the same time, 
 and as each has .a nuclear origin, the resultant paralysis will 
 obey tlie laws just mentioned as obtaining in the case of the 
 facial. Vision is often disturbed b\'' an intra-cranial tumor, and 
 such a symptom would be perceived by the patient at an early 
 stage. A tumor acting on the tubercula qiiadrigemina may 
 cause partial or entire blindness. Pressure on the cerebellum 
 
TREATMENT OF INTRA-CEAXIAL TUMOR. 267 
 
 causes feeble vision ; for this no explanation lias been given. 
 The auditory nerve may be acted on, yet impaired hearing is 
 seldom thus caused ; more often there is awakened some sub- 
 jective sensation, such as ringing, roaring, buzzing, etc. The 
 sense of smell is seldom disturbed by an intra-cranial growth. 
 
 In some cases the encephalic tuuior does not impair the 
 nutrition of the patient; he may even improve in flesh. On the 
 contrary, should there be nausea, vomiting and other depress- 
 ing conditions, the subject may become emaciated. If the tumor 
 be cancerous in nature, then the usually attendant cachexy may 
 soon appear, and greatly reduce the patient's body. 
 
 The tumor may perforate the cranial wall, and then it usually 
 makes its appearance through one of the natural openings of 
 the skull, as at the orbit, or the upper part of the nasal fossae; 
 or it may perforate the wall and uplift the scalp. Such perforat- 
 ing tumor may be hard or soft. The protruding portion mny 
 pulsate with the pulse, and sometimes it rises with expiration. 
 If pressed on, coma may result. The appearance of tlie tumor 
 through the cranial wall is attended by diminution of compres- 
 sion and, lience, an amelioration of the symptoms caused by 
 compression. 
 
 The course of intra-cranial tumor is usually of long duration, 
 and it is characterized by remissions, accessions, and exaggera- 
 tions of the symptoms ; a course in which there is an absence of 
 uniformity. Death comes in many cases from palsy of the 
 medulla oblongata. 
 
 The prognosis is extremely unfavorable; the greater number 
 of intra-cranial tumors end fatally; the exception is where the 
 tumor is of syphilitic origin. Tumor from this cause, in its 
 early stage, if not curable, at least is controllable. The can- 
 cerous and aneurysmal tumors destroy life; yet the time in which 
 the tumor does its fatal work depends greatly on its site. The 
 rule concerning this is that growths located in the upper part of 
 the cranial cavity are tolerated much longer than those in the 
 base. A tumor pressing on the medulla oblongata, or the pons 
 Varolii, does its fatal work swiftly. The prognosis of the syphi- 
 litic tumor, if the case be seen early, is favorable; but if the 
 syphiloma be allowed to develop without treatment, it encroaches 
 on and occasions lesions of the contiguous parts, which sometimes 
 are irreparable. 
 
 Treatment. — Until recently the intra-cranial tumor was com- 
 bated chiefly by internal medication, and this treatment was 
 
268 ENCEPHALITIS, OR IXFI.AMMATION" OF THE BRAIN'. 
 
 limited to remedies which merely relieved syra[)toms, and 
 mainly that of pain. Pain was controlled by the use of opium 
 and other narcotics. Treatment which aimed at a cure or 
 removal of the cause was only pursued with hope wliere the 
 growth originated from constitutional s^'phihs. 
 
 To relieve the headache morphia in a third of a grain doses 
 should be given and repeated every six hours, or in larger doses 
 if the dose mentioned does not give relief. The alkaloid of 
 hyoscyamus may be used, viz., one-sixtieth of a grain of hyos- 
 cyamine may be injected hypodermically; thus sleep may be 
 obtained when morphia fails. Atropine in similar amount may 
 be used hypodermically. Aconite may be used ; the fluid extract 
 may be used externally, or an ointment or solution of the alka- 
 loid aconitine. A weak solution of the cyanide of potassium 
 may be used externally over the focal point of pain. The head- 
 ache may be palliated by tlie local use of ice. As anodyne rem- 
 edies these maybe administered : the bromide of potassium and 
 the tincture of gelsemium. 
 
 As mentioned before, the only hope of curing by internal med- 
 ication is where the tumor is the product of syphilis. Here the 
 administration of the protiodide of mercury, one-half grain three 
 times daily, will not only arrest the development of a syphiloma, 
 but favor its absorption. With this agent the writer has obtained 
 the most satisfactory results; intellect on the verge of imbecility 
 has been restored to normal state; a staggering walk has been 
 changed to a steady gait, and vertigo relieved. Tlie remedy, 
 however, must be commenced as early as the cephalic sj^mptoms 
 manifest themselves. For the same purpose Hydrargyrum 
 cyanuretum may be used with benefit. To use this, prepare a 
 solution as follows : — 
 
 R. Aqua? 51 
 
 Hydrargyri cyanureti gr x 
 
 Misce. 
 
 Inject this nypodermically, commencing with five drops, 
 and increase the dose to ten drops. Ten drops, the maximum 
 dose, will contain about one-sixth of a grain of the salt. This 
 compound of mercury has been found by the writer to act more 
 efficiently than any other. The gummy nodule in iritis is sure 
 to literally melt away before this treatment, and in case the tumor 
 be cancerous this treatment promises some relief in retarding 
 growth. The writer has verified that this is so in cancerous 
 growths seated on the surface of the body. 
 
TKEATMEXT OF INTRA- CRAXIAL TUMOR. 269 
 
 As known, within the last few years, surgery, emboldened by 
 the success attained by the antiseptic method, has invaded regions 
 liitherto untouched by instrument; the cranial cavity is fearlessly 
 laid open, and disease once impregnably entrenched there, is 
 exposed, attacked, and sometimes removed; it must be said with 
 some reserve, sometimes, since surgical aggression here has more 
 often been attended by defeat than success. Yet, when the fatal 
 character of the intra-cranial neoplasm is considered, great risk 
 in the adventure is justifiable; and should failure, coupled even 
 with the death of the patient, be the result, it may be reckoned 
 as a gain to the sufferer; for what human being would not prefer 
 death to life coupled with dementia? 
 
 The rule of procedure should be to first determine whether 
 the growth is so located as to be accessible; namely, if at the 
 summit or the sides of the brain, it can be reached b}'- means of 
 the trephine, saw, chisel and mallet. Or, as a preliminary, the 
 wall may be opened by the exploratory drill mentioned before, 
 and a small section of the subjacent soft part withdrawn and 
 examined microscopically. Guides to location are to be found in 
 the affection of speech, motion and sensation. By means of the 
 saw, sections of the wall may be uplifted on a large scale; and the 
 dura mater being opened, the surface of the brain can be seen, 
 and a neoplasm discovered, can be removed; and the growth 
 being extracted, the uplifted osseous bridge can be lowered to its 
 former site. Should the growth be a cyst, or benign in nature, it 
 would be possible to thus cure the patient. Where the growth 
 lie^ in contact with the base of the skull, that is, springs from the 
 inferior surface of the brain, conservation would pronounce the 
 word inaccessible. This warning, however, is quite uu heeded by 
 the gens audax omnia perpeti; for example, by such as announce 
 that they think operations for the removal of tumors from the 
 base of the brain are feasible ; such daring characterized a special- 
 ist in cerebral surgery, whom the writer heard say that he 
 believed it possible to so open the skull and lift up the brain as 
 to catch a view of the foramen magnum. The reader may ask, 
 Did he mean this of the living subject? The well-known ineffi- 
 ciency of medicine against these growths in nearly all cases, has 
 lured on the surgeon's hand, and encouraged and emboldened 
 work here which elsewhere should not be permitted. For death 
 is a cheap price with which to purchase exemption from helpless 
 palsy and hopeless amentia. 
 
 The operative course advised by Horsley, Macewen, Keen, 
 
'2,0 EXrKI'HALITIS, OK INFLAMMATION OF TIIK BRAIN. 
 
 Laiiphearaiid others to be pursued in the removal of a ineuingeal, 
 cerebral or cerebeHar growth is to select the part towards which 
 the diagnostic indices point convergingly, and there to remove, 
 by means of the trc[)iiine, saw and chisel, enough of the cranial 
 wall to reach and uncover the tumor; and, liaving exposed the 
 arowth and determined the connections, the surgeon continues 
 with the removal, at which w^ork vessels must be avoided or 
 ligated if they be opened. Macewen fearlessly attacks the dural 
 sinuses; and finally the wound made in the scalp and dura 
 mater must be closed by sutures, a drainage tube inserted, and 
 the part covered with aseptic lint, and retained cold by a thin 
 ice-bag. By the perseverance of the treatment here briefly indi- 
 cated, an occasional patient may be cured ; the majority, however, 
 will })robably fall by the Avayside. 
 
 Meningocele and Enccphaloccle. — By meningocele is implied a 
 l)rotrusion, hernia-like, of the encephalic membi'anes through an 
 opening in the wall of the cranium; and the content of such 
 tumor is cerebro-spinal fluid; but if the content be cerebral or 
 cerebellar, then the tumor is named encephalocele. 
 
 Some surgical authorities, for instance, St. Germain, deny the 
 existence of unconi])licated meningocele; on tlie contrary, others, 
 as Spring, as determinedly contend for its existence. 
 
 Encephalocele may appear congenitally; more rarely, it is 
 acquired; a few examples of the latter have been seen, in which 
 some defect of the cranial wall, due usually to a wound, permitted 
 the esca})e of the adjacent meninges, along with a [)ortiou of 
 brain. Such hernial protrusion has appeared where a portion of 
 the containing wall lias been removed; the membranes with fluid 
 and a portion of brain have protruded, and afterwards the pro- 
 truded brain receded and the patient recovered. 
 
 More often the case is congenital, and from its containing a 
 portion of brain along with the meninges which cover this, it is 
 ])roperly named meningo-encephalocele. The site of such tumor 
 may be frontal, orbital, occipital and basial. 
 
 The frontal tumor is rarely seated wholly in the os frontis; 
 more often it appears between the frontal and nasal bones. 
 
 The orbital variety presents itself behind the eyeball, near 
 the lachrymal bone, through the sphenoidal fissure, or at the 
 spheno-maxillary fissure. 
 
 When occipital in site, it may contain the posterior cerebral 
 lobes, or the cerebellar lobes; or the tumor can contain both 
 cerebral and cerebellar lobes. 
 
MEXIXGOCELE AXD EXCEPHALOCELE. 271- 
 
 AVhen basial in location, the tumor may traverse the ethmoid 
 bone, the body of the sphenoid, or it may traverse the temporal 
 wings of the sphenoid bone. 
 
 The meningo-encephalocele is composed of the following con- 
 stituents: There is a cutaneous wall, in which the skin is thin and 
 the hair partly or wholly disappears. This may inflame and 
 open. Beneath this lie the aponeurotic structures in attenuated 
 form, thicker in the occipital variety than in others. The next 
 structure is the dura mater, which may present an irregular sur- 
 face, stretched and uneven, from elevations and depressions. 
 This membrane may contain a section of 'a sinus. The arach- 
 noid membrane that is protruded, continues its serous secretion, 
 wdnch may be so large in quantity as to form a cyst-like structure. 
 The prolapsed portion of brain mav be altered in character; and 
 if it be a part containing a ventricle, the latter may be much dis- 
 tended. 
 
 Spring and others think the primary cause is encephalic 
 dropsy; and the part is protruded through some abnormal or 
 accidental opening in the wall. Others refer encephalocele to 
 hypertrophy pf the brain. The tumor is sometimes transparent, 
 and its content can be caused to fluctuate. AVhen the protruded 
 part contains a ventricle, the latter may be swollen with fluid; 
 and a layer of fluid exist between the cerebral structures and the 
 meningeal wall. 
 
 This tumor has commonly a disastrous course, and the life of 
 the subject usually ends in a few j^ears, and this depends on the 
 fact that the tumor continuing. to grow, morbid changes in the 
 nerve centres are induced, which soon destroy life; such patients 
 have reached the age of from seventeen to fifty-five years; yet 
 thej^ usually die much earlier. 
 
 Encephalocele has been mistaken for a benign tumor, and an 
 operation on such encephalic growth done inadvertently, has 
 caused death. A distinguishing characteristic is that such tumor 
 may be reduced in volume by compression, yet the pressure 
 causes coma, nausea, convulsions, etc. It need scarcely be 
 remembered that diagnostic verification by such pressure must 
 be done with much care. 
 
 The prognosis is, in all cases, inauspicious; and more so in 
 proportion as the tumor is larger in volume; when small as a 
 walnut, possibly a cure might be obtained ; but when of enormous 
 size, in which the volume of the tumor almost equals the remain- 
 der of the head, an early fatal ending is the only possible event. 
 
272 KXCErHALITIS, OR INFLAMMATION OF THE DRAIN. 
 
 The latter cases, which fall Avithiii the domain of Teratology, 
 shouhl not be interfered with, but left to the care of nature, whose 
 liand having illy molded them, soon finds a way to remove them. 
 
 Treatment. — As stated, it is only when the tumor is of moder- 
 ate dimensions that it becomes a proper subject for surgical 
 treatment; and this may consist of one of the following plans: 
 Simple aspiration, aspiration combined with compression, com- 
 pression alone, ligation, or excision. Aspiration is the simplest 
 and safest of the several plans here enumerated; and if it be 
 often repeated, possibly a cure might be accomplished by it if the 
 tumor be a small one.* The plan is rendered more effective if 
 along with the aspiration there be combined comjDression; for this 
 purpose a compress may be maintained over the part by means of 
 an elastic band or bandage, or a truss-like appliance may be em- 
 ployed, or the treatment might consist of simple compression of 
 the tumor maintained by one of the plans just mentioned. The 
 tumor has been removed by ligation, by wdiich it is tied tightlv 
 around its base, and the part beyond being strangulated, dies and 
 is detached. And, lastly, the removal has been done by excision 
 of the protruded part. 
 
 Therej^ort of the results obtained by these several methods of 
 treatment is unsatisfactory ; a majority of the cases died. In view 
 of this, the writer would hesitate to choose any of these plans, and 
 were he called to treat a case, his course would be as follows: 
 After making an incision by which the protruded parts could be 
 inspected, let the prolapsed bruin be restored to place and the 
 wound be so closed as to retain the brain in its normal site. To aid 
 ill this work, a compress should afterwards be retained over the 
 part; such pressure should be maintained both during the time 
 of healing, as well as some time afterwards. 
 
 Hydrocephalus. — In early embryonic age the cephalic terminal 
 protuberance is a simple capsule of water; the watery content is 
 gradually displaced and replaced by parts constituting the 
 normal brain; and remnants of these primordial water-cavity 
 are the ventricles of the brain. From disturbed equilibrium 
 of the forces contained in development, the M-atery content 
 may acquire the ascendent, and the morbid condition called 
 hydrocephalus, or better named hydrencephalus, results. The 
 causal agency which disturbs the balance of normal develop- 
 ment is tliought to be an inflammation. As it is sometimes 
 coincident with tubercular heredity, the causation is referred to 
 tubercular affection of the cephalic membranes. As the fluid is 
 
HYDROCEPHALUS. 273 
 
 formed v\-ichin the residual cavities or ventricles of the brain, it 
 may also be designated ventricular dropsy. The disease usually 
 is congenital, dating from an early period of intra-uterine life; 
 yet it may commence and develop after the birth of the child. 
 Hydrocephalus developing in utero may attain a great size, so. 
 that the child cannot be born without lessening the volume of 
 the head; in such cases, if the head does not spontaneously burst 
 during labor, the accoucheur is often compelled to tap the head 
 and thus reduce it to a smaller volume. 
 
 Writers on this subject have mentioned numerous causes which 
 may predispose to the disease; among these are the following: 
 Great age of the child's parents, their abuse of alcoholic drinks, 
 excessive sexual indulgence, compression of the abdomen during 
 gestation, and compression of the child's head during delivery; 
 these things mentioned have probably but little influence in 
 originating hydrocephalus; more probable causes are disturbance 
 of the circulation in the foetal head, for example, some agenc}- 
 which prevents the read}'' escape of the venous blood, and, as a 
 consequence, the serous formation predominates, and arrests the 
 normal evolution of the brain. Where cretinism is endemic, 
 hydrocephalus appears in the offspring as the alternating disease. 
 In a cretin family several successive children have had the dis- 
 ease. Transmitted syphilis has probably been a frequent causal 
 factor, the gummy growth awakening an inflammation in the 
 membranes; or such growth may impede the return of blood 
 along the venous routes. 
 
 The Cjuantity of the hydrocephalic fluid A'aries according to 
 whether it is formed before or after the ossification of the cranial 
 bones; before the completion of ossification the quantity may 
 become very great, amounting sometimes to over twenty pounds 
 of fluid; but the quantity is small, if it be formed after the bones 
 are ossified. Examples of enormous hydrocephalic enlargement 
 are to be found in pathological museums; in the collection of 
 crania made by Eetzius, at Stockholm, the writer saw a specimen 
 of marvelous dimensions, greatly excelling anything of the kind 
 seen elsewhere. The fluid content of such head is remarkable for 
 the small amount of solid content; this content, albuminoid in 
 character, amounts only to one or two pai;ts in a thousand. 
 
 The ventricular cavities of the brain in the hydrocephalic 
 subject are found enlarged; the dividing walls between these 
 cavities are attenuated, and sometimes torn so that they become 
 one common space; thus the lateral ventricles may present 
 
'27-i KNTKI'lIAI-ITIS, OR I N FL.V M>r ATK )N Ol' 'I'lII') liRAIX. 
 
 one sinylo cuvily. The covering of the lateral ventricles may 
 atrophy until, linally, they assume the form of a cystic cavity: 
 the upper thin wall of this being ru2)turc(l, the flattened rem- 
 nants of the liemispheres entirely differ from normal form, and, 
 on their lovolod upper surface, one finds no trace of the third 
 ventricle; the striated bodies are also compressed into flattened 
 shape. The deformed cerebral matter is liistologically changed. 
 
 Sometimes the development is limited toone-half of the head; 
 as a rule, however, the entire head is involved, and then the 
 enlargement is principally in the frontal and occipital regions. 
 The forehead, in height and breadth, is such as would have 
 delighted the eye of a Gall or Spurzheim, whose ignorance of 
 anatomy w^ould have j:)ermitted tliem to mistake water for brain. 
 The exces.sive growth of the frontal bone encroaches on tlie orbit 
 so that the supra-orbital arches are pre.ssed downwards, the pal- 
 pebral slits are narrowed and the eyelids are rendered ocdematous. 
 The temporal fossae are effaced. The face is strikingly small when 
 compared with the overlying head; and though it is natural in 
 form and outline, the countenance of the child is remarkable for 
 the utter effacement from it of all the lines of ordinary intelligence; 
 the usual mental light belonging there has been extinguished, so 
 that though the pathologist's eye may be delighted in the morbid 
 and atypical which are present, yet the parent scarcely finds inter- 
 est in the picture of his demented ofFsj)i'ing. The bones of the 
 skull, especially those of the cranial vault, become thin until 
 they are as flexible as parchment and are separated by large 
 interspaces; ])ut if the subject survives for some years, ossific 
 centres appear in these spaces, and develo])ing as "Wormian ossi- 
 cles, they finally complete the osseous case. The auditory meat- 
 uses are shallow from the crowding outwards of the middle ear. 
 
 Hydrocephalus is often associated with other deformities, 
 such as spina bifida and harelip, each referable to a common 
 cause, viz., arrested and ill-directed development. 
 
 The child may be born with the head apparentl}^ normal, and 
 soon after birth, the head enlarging, es})ecially in the frontal 
 region, gives signs of hydrocephalic change. And, later, the 
 child shows dullness of intellect; the nutritive functions are illy 
 accomplished; the gust;,itive sense is impaired or lost, since the 
 child swallows with equal indifference ill-tasting matters or 
 proper food. The arms and legs are retarded in their growth and 
 are moved sluggishly or awkwardly, or they may l)e the subjects 
 of spasm or contracture. Should the patient learn to walk, the 
 
TREATMENT OF HYDROCEPHALUS. 275 
 
 gait will be hesitating and uncertain. Sometimes there are 
 epileptiform or jerking movements of the limbs. The eyes do 
 not act in unison, but often move divergently. Vision and the 
 other special senses are impaired, "^ as might be inferred from 
 the morbid changes in the brain. 
 
 The disease is ordinarily chronic in its course, which may be 
 varied by sudden exacerbations; from paresis of the limbs the 
 subject may be forced to lie in bed; and epileptiform attacks may 
 supervene. Or should the dropsical fluid cease to form, the sub- 
 ject mav so far improve in general condition that he may live 
 for many years, though he remains the subject of arrested or 
 obtunded intellect. In the worst cases, the fluid continues to 
 augment until it bursts the wall, and then it may pa.ss into the 
 tissues; or it may rupture the integument and escape externally. 
 It has escaped through the nose. Where the fluid has thus 
 found exit, recovery from the disease has been reported. The 
 most unfavorable cases seem to have been those in which the 
 cranium did not continue to enlarge, yet the fluid continuing to 
 augment caused atrophy of the brain. 
 
 Treatment. — The disease has been combated by internal medi- 
 cation; as remedies used have been calomel, iodide of potassium, 
 nitrate of potash,- cantharides, acetate of potash, digitalis, and 
 turpentine; also by cathartics which act as derivatives on the 
 bowels. Mercurial ointment has been apjDlied to the shaven scalp. 
 All impediments to the free return of blood from the cranial 
 cavity should be removed. An attempt has been made to pro- 
 mote absorption of the fluid by compression of the skull; thus 
 strips of adhesive plaster may be so used as to form a cap which 
 will maintain con.stant pressure on the head. Roux in 1859 
 announced the cure of a case by the aid of compression con- 
 tinued by means of adhesive plaster; this was applied at first 
 tightly, and later, loosely. All the methods of treatment enumer- 
 ated have failed to cure the disease, though they may have 
 retarded its progress. If the writer were to select a plan of 
 treatment from those mentioned, the most rational would seem 
 to be that by compression; and for this he would use, instead of 
 adhesive strips, a rubber bandage, so applied as to maintain 
 slight and uniform pressure on the head. Such compression 
 should be commenced in the early stage and continued for a long 
 period. Such peripheral pressure would counteract secretion and 
 promote absorption. The general health of the child should be 
 diligently maintained. 
 
27G EN'CErir.VI.rTIS, ok I^•FLA^[^rATIO^' OF THE lUlAIX. 
 
 As mild operaiive measure, mat of capillary drainage might 
 be resorted to. For this procedure, lirst cleanse the scalp with 
 an alcoholic or sublimated solution: and then, having made a 
 small incision at a point where the fluid could readily be reached, 
 and wliere vessels would not be endangered, introduce through 
 this incision a tube of fine calibre, and cover this with borated 
 or sublimated absorbent hnt; and thus an outlet for the slow 
 escape of the fluid is furnished, and provision is made against in- 
 flammation of the structures within the cranium. By this means, 
 tlie slowly escaping fluid becomes an ally of absorption; the 
 minute vessels which are the agents of absorption are thus 
 relieved of pressure, and their functional activity is promoted. 
 As an ally to this capillary withdrawal, compression with the 
 rubber bandage may be made. This treatment, to be successful, 
 should be continued for some weeks; and then, if the disease is 
 not controlled, the procedure may be repeated at another point. 
 
 The treatment, however, which is oftenest pursued is that of 
 tapping; this method, though far from being always successful, 
 has so often been followed by success as to entitle it to commen- 
 dation. According to West, who has collected fifty-five cases 
 treated by tapping, forty died and fifteen were cured; and tliis 
 was in the days of infectant surgery. 
 
 Tapping, which is best done by the method of aspiration, 
 should not be resorted to in cases in which there is but a small 
 amount of fluid; nor in those in whicli the amount of fluid is 
 stationary, or is becoming less in quantity. Nor should it be 
 done in cases in which the head is enormously enlarged, and 
 where there are grave defects elsewhere in the body. It would 
 be improper where the subject has become idiotic and will con- 
 tinue so. The cases in which it is indicated and proper are 
 those subjects of hydrocephalus who are well nourished and 
 otherwise in good health, and in whom conservative methods, as 
 compression and capillary tapping, have failed to cure. The pro- 
 cedure whicli has been followed b}^ the best results is that in 
 which the fluid has been drawn off at intervals, in moderate 
 amount, and after each tapping the head has been compressed. 
 
 The operation i§ most safely done by aspirating; yet a small 
 trocar will answer for the purpose, if care be taken not to allow 
 air to enter. The proper site is where fluctuation is evident, and 
 the wall to be penetrated is thin. Such sites are at the lateral 
 angles of the anterior or posterior fontanelle, wliere neither 
 venous sinus nor meningeal artery will be imperiled. A small 
 
TREATMENT OF HYDROCEPHALUS. 277 
 
 instrument should be used, and having displaced the skin, the 
 trocar is to be forced towards the middle of the lateral ventricle, 
 from a quarter to a half inch in depth. The fluid should not be 
 removed in such amounts as to permit the walls to fall together; 
 only enough should be withdrawn to remove tension and swell- 
 ing. If the content be entirely withdrawn, then the unsupported 
 walls sink in a distorted manner, ilfter the withdrawal of the 
 fluid, the wound should be closed with adhesive plaster, and the 
 walls compressed by a rubber bandage, or adhesive strips. In 
 cases which have been cured the quantity of water, which has 
 been withdrawn, has been from one and a half to three ounces; 
 and when the fluid reformed, it was withdrawn again. 
 
 As before stated, this plan of treatment has been so rarely 
 successful that some surgeons have abandoned its use. Among 
 those who sanction its use ma}^ be cited Bruns and Malgaigne, 
 who have formulated the conditions in which it should be resorted 
 to. According to Bruns it should only be done in cases in which 
 the fontanelles and sutures are widely open, the cranial bones 
 are freely movable, and the child, behig well nourished and not 
 paralyzed, possesses a physical and mental development corre- 
 sponding to its age; and, finally, that the hydrocephalus is con- 
 tinually augmenting. Malgaigne would only operate wdien the 
 child is less than three or four months of age, and the disease 
 seems stationary; exceptionally, however, he would do it if the 
 child were over four months old, and the disease was manifestly 
 progressing and threatened to destroy the child's life. 
 
 As a modification of the mode of tapping above described, 
 Langenbeck, in 1850, did the work through the orbit. He thrust 
 the trocar beneath the upper lid, and thus reached and entered 
 the anterior horn of the lateral ventricle; thus the venous sinuses 
 and the meningeal artery are avoided, wdrich are endangered 
 when tapping is done through the coronal suture or the anterior 
 fontanelle. Through the wound left in the orbit the fluid continues 
 to drain away. Langenbeck would evacuate from three to six 
 ounces, according to the volume of fluid j^resent. 
 
 There are cases in wdiicli the enormous accumulation of fluid 
 has so separated the bones of the skull and enlarged the cavity 
 that, though the fluid were removed and did not reform, the con- 
 ditions of the head would not permit the continuance of life. 
 Some years ago the idea suggested itself to the author, and has 
 probably done so to others, that the unoccupied space might be 
 lessened by removing a portion of the cranial wall. The toler- 
 
278 ENCEPHALITIS, OK INFLAMMATION OF THE BRAIN. 
 
 aiice of the iionual skull of the removal of sections of the wall, 
 and the impunity with which the hydrocephalic skull can be 
 pierced in tapping, justify the belief that portions of the latter 
 might safely be exsectcd. A few years since the writer proposed 
 such an operation to the parents of a hydrocephalic child; and 
 it was on the eve of being done when the mother interrupted the 
 matter by her decision that she would rather have her child con- 
 tinue an imbecile than incur any risk of losing its life. Doubtless, 
 however, such an operation, if it has not already been tried, will 
 erelong be done, and, the writer predicts, with successful event. 
 
 As before stated, liydrocephalus developing in ntero may 
 render delivering of the foetus impossible, unless the volume of 
 the head be reduced; in such cases, when the condition is dis- 
 covered, as soon as the uterine mouth is sufficiently dilated, a 
 trocar is to be plunged into the lateral portion of a fontanelle, 
 and the fluid evacuated. Ill these cases the child seldom sur- 
 vives birth more than a few hours; exceptions, however, have 
 occurred in which the child survived for some time. 
 
 • This di.sease has been treated by a combination of tapping, 
 injecting tincture of iodine, and compression. The writer has 
 recently treated a case in this way; the infant's head, which was 
 enormously distended, was relieved of a large portion of its 
 contents, when there was injected a twelve per cent aqueous 
 solution of the compound tincture of iodine. This being intro- 
 duced, the head was strapped with adhesive strips so as to main- 
 tain compression. Despite this course the fluid soon returned and 
 filled the cavity. The treatment was repeated, with the same 
 result, and the case, uncured, returned to its home in the country. 
 The curative results obtained by injection of iodine into other 
 serous cavities, as tJje pleural and peritoneal, encourage further 
 trial of this means in the treatment of hydrocephalu.s. 
 
 MicroceplialiLS. — It is a fact of common observation that a dimin- 
 ution of the yolume of the cerebrum, such as is witnessed in con- 
 genital hydrocephalus, is accompanied by mental imbecility; as 
 the bodies of such children grow, their intellect does not develop 
 correspondingly. The microcephalic head at birth usually 
 presents closure of the sutures; the regions of the fontanelles 
 are also found completely ossified; the pulsatile fountain no longer 
 exists, for its site is occupied by solid bone, and, in some cases, 
 the osseous formation has proceeded so far that the sites of the 
 fontanelles are elevated above the contiguous wall of the skull. 
 It is clear that in such microcephalous head osteo-genesis has 
 
MICROCEPHALUS. 279 
 
 proceeded more rapidly than is tlie case in the normal skull. The 
 skull, then, at birth is a solid bone case, and it and the contained 
 brain are abnormally small. In such an infant it is easily 
 observed that the ordinary signs of developing intellect are absent; 
 the child is not observant, or but little so, of what is occurrino- 
 around it. Objects brought before its eyes are scarcely looked 
 at; and if the object be moved away, the eyes do not follow it. 
 Accurate fixation of the eyes is absent, and the two eyes do not 
 cooperate in the act; in fact, there is a condition of mental torpor 
 which marks the subject as idiotic, or but slightly removed from 
 idiocy. 
 
 In another class of cases, in which there has occurred intra- 
 uterine closure of the sutures and fontanelles, there is not present 
 the condition of torpor or inertia just described. The infant, as it 
 grows, is often abnormally quick in its motions; it is attracted 
 by sounds, and fixes its eyes accurately and quickly on objects: 
 it makes purposive and well-coordinated movements with its 
 hands and feet, smiles, and is pleased with the caresses and 
 attentions of its nurse; still, the child presents none of the com- 
 mon signs of infantile mind; it is in a stage of mental imbecility, 
 from which it does not emerge as its body grows. 
 
 To relieve such unfortunates, the aid of surgery has been 
 invoked, and the procedure which is resorted to is to reopen the 
 closed skull, and, having removed sections of bone, to provide 
 open spaces which will permit the encephalon to develop. By 
 the operation, it is sought to place the infant's head somewhat in 
 the condition of a normally formed infantile head. 
 
 The first work in this new section of cerebral surgery was done 
 by the author in May, 1888, and the idea did not originate with 
 him, but in the mind of a mother who had the misfortune to 
 have such an infant. This child was born with complete closure 
 of the cranial bones, and in a few months after birth it betrayed 
 signs of mental defect. The mother referred its condition to 
 the closure of the skull, and she was so sure that this was so, 
 that she wrote to me from her home in the country, and asked 
 me if there was any means of relieving this by an operation. 
 In her graphic language she said: '' My child's brain is locked 
 up, and can you not unlock it?" The author advised her to 
 bring the child to him, which she did. The infant, then fifteen 
 months old, was well nourished and perfect in every respect, 
 except that it was markedly microcephalic, and evinced but few 
 signs of mentality. The fontanelles and sutures were firmly ossi- 
 
280 ENCEPHALITIS, OR INFLAMMATION' OF THE BRAIN. 
 
 fieJ; the site of the anterior fontanelle was somewhat convex. 
 The child had free use of its limbs, and could make purposive 
 movements with them. In view of the hopeless state of the 
 cliild, it was decided to operate on it, and, in the mother's lan- 
 guage, make an effort to "unlock its brain," and this work was 
 done as follows: An incision was made in the median line of 
 the liairy scalp from the summit of the forehead to somewhat 
 beyond the posterior fontanelle; the skin with the periosteum 
 was uplifted and dissected laterally, so as to expose an oblong 
 section of the skull over an inch in width and some inches in 
 length. At the posterior end of this space two openings were 
 made with a small trephine, through which a blunt dissecting 
 instrument could be passed, and the dura mater separated from 
 the bone. This detachment was done between the openings and 
 also for a short distance in front of each orifice. la the space 
 provided by this separation one blade of a pair of blunt scissors 
 was passed, and the bridge of bone divided which separated the 
 trephined openings; also in front of each 0[)ening a similar 
 division of the bone was made anteriorly for nearly an inch in 
 distance. There remained, then, a portion of bone attached in 
 front, lying over the longitudinal sinus. With the blunt dissector, 
 it was then found an easy matter to separate this bridge of inter- 
 mediate bone from the underlying sinus, and, when detached, it 
 was uplifted and cut off. 
 
 Proceeding in this way, by lateral division and detachment of 
 another section of bone, the work was done without difficulty, in 
 which an oblong section of bone, an inch wide, reaching from 
 the posterior to the anterior fontanelle inclusive, was excised. 
 There was found no difficulty in detaching the bone from the 
 longitudinal sinus by the use of the blunt dissector cautiously 
 mani}»ulated. 8ome small drops of blood oozed from the sinus 
 through the opening of minute vessels, which passed from the 
 cranial wuU to the sinus. Besides the longitudinal section of 
 bone removed, tliere was exsected a portion transversely, corre- 
 sponding to the site of the coronal suture. This transver.se sec- 
 tion on each side extended one inch beyond the border of the 
 longitudinal one, and was a half inch broad; the vacant space 
 left after the bone was exsected was cruciform. 
 
 The work of exsection being completed, the Avound was 
 dusted with iodoform and closed by sutures, and the whole cov- 
 ered by aseptic lint. During this operation the anaesthetic acted 
 badly; the child was greatly depressed, cyanosed, and was nearly 
 
MICROCEPHALUS. 281 
 
 lost from this cause; it was only by persevering efforts that the 
 child was resuscitated, and, though rescued, it never fully rallied 
 from the anaesthetic. 
 
 The anaesthesia was induced by a mixture of chloroform, 
 ether and alcohol. The child lived nearly forty-eight hours 
 after the operation, and death resulted rather from the ill action 
 of the aneesthetic than from the operation. This operation was 
 the first work done, as far as the writer knew, in craniectomy 
 performed for relief of mental imbecility due to microcephalus 
 and premature closure of the sutures and fontanelles; and the 
 originating thought which led to the work was awakened in a 
 mother's mind by her love for her unfortunate offspring. 
 
 Since this operation, which was not published at the time, 
 craniectomy for the relief of mental arrest due to 'microcephalus 
 has been proposed and done by Lannelongue over twenty times; 
 it has also been done by Keen, of Philadelphia, and others. 
 Though time enough has not elapsed to show to what extent it 
 may be beneficial, yet the reports on the subject are favorable, 
 especially those of Lannelongue. Unfortunately, every new 
 procedure in surgery has the fault of awakening undue expecta- 
 tions in those who originate it, and this one may share the fate 
 of many others which have failed to accomplish for subsequent 
 operators what has been announced by those whose vision was 
 obscured by the bias of paternity. It is scarcely probable that a 
 brain which has been primarily molded according to a micro- 
 cephalic type can afterwards be much changed, for such brain is 
 as perfect in all the detail of parts as is a normal brain. These 
 parts are lacking in volume; there is not present the field of suf- 
 ficient amplitude for the growth of the precious germs of intel- 
 lect; the latter consequently develop as dwarfs. And it scarcely 
 seems probable, though the containing rampart be enlarged, 
 that this can have a material influence on the cerebral content. 
 A larger bowl held before a flowing stream will not enlarge the 
 stream; so it may be predicted that craniectomy, done in the best 
 manner which can be devised, will afford but temporary or lim- 
 ited relief for the unfortunate subjects of mental imbecility. The 
 plan, which was sketched by the predetermining hand of organ- 
 izing Nature, must necessarily remain as primarily traced; the 
 attempt, however, to rectify or improve such imperfect sketch is 
 permissible, if not laudable. 
 
 A few weeks prior to writing these lines, the author was con- 
 sulted in reference to an infant whose head could scarcelv be des- 
 19 
 
282 KXCKIMIALITIS, oli IXFLANrM ATION OF THE BRAIN. 
 
 igiiated microcephalous, yet the sutures and fontanelles were 
 closed at birth and there were signs of mental inbecility or vacu- 
 ity, and, as in the former case, the parents asked to have some- 
 thing done for the assistance of their child. They liad been told 
 that some oi)eration, for relief in such cases, had been done abroad, 
 and thev wished an attempt made in the case of their child. 
 The child was normal in other respects, j'^et it had ceased to 
 observe what was passing around it, and remained, for the most 
 of the time, in a condition of listless torpor. 
 
 The operation was done somewhat differently from tiie former 
 case. The infant, aged five months, was placed under the influ- 
 ence of the mixed ancesthetic previously mentioned, wliicli acted 
 well in every respect. An antero posterior incision, over the left 
 parietal bone, was made connecting and reaching somewhat beyond 
 the anterior and posterior fontanelles; this cut reached to the bone, 
 and was followed by bilateral uplifting of the scalp and pericra- 
 nium for over an inch on each side of the lateral inci.sion. Next^ 
 a small opening was trephined through the bone near the poste- 
 rior end of the bared surface, and, through this, one blade of a 
 pair of scissors was passed, and an oblong section of bone was cut 
 out from behind, forwards. This was a half inch wide and over 
 two inches long. The work of dividing the bone was always pre- 
 ceded by the separation of the dura mater from the bone; in 
 this way the scissors did not catch or injure the dura mater. 
 Tins oblong section was not excised in one piece, but in fragments 
 about three-quarters of an inch long. A similar oblong section 
 was excised from the right side, through a longitudinal cut in the 
 scalp. These sections of bone were removed so as to leave an 
 interjacent bridge of bone lying over the longitudinal sinus ; this 
 bridge was an inch and a quarter in breadth. There was next 
 excised a portion from this interlying bridge, corresponding to 
 the anterior fontanelle; the exsection resembling an H. The 
 removal of the lateral portions of boJie was accompanied by but 
 little hemorrhage, since tlie endings of the middle meningeal 
 arteries were so small that almost no Ijlood escaped from them. 
 
 Besides the work of osseous exsection here described, the blunt 
 dissecter was passed in between the remaining bone and the dura 
 mater, and the latter was separated to the extent of an inch and 
 a half beneath the remaining fragmentary parietal bones. The 
 wounds made were cleansed by a twenty-five per cent solution of 
 alcohol, which had been warmed to the temperature of the l)0(ly; 
 thus, in its contact with the dura mater, the cleansing fluid did 
 
MICEOCEPHALUS. 283 
 
 not cool the part and render ansemic the brain underneath. In 
 the operation done three years previously, this precaution was 
 neglected, and this cause should, perhaps, be added to the ill-acting 
 anaesthetic, to explain the syncopated state into which the cliild 
 lapsed during the operation, and remained so afterwards. The 
 wounds closed by silken sutures, in the second case, were covered 
 with lint, moist with the alcoholic lotion, and they healed most 
 rapidly; only where the bone was removed from the region of 
 the anterior fontanelle, did a slight degree of suppuration occur; 
 the healing was complete within ten days. The skin was slightly 
 depressed over the site of the bone which had been removed, and, 
 at the position of the anterior fontanelle, there was the pulsatile 
 movement which characterizes the infantile fontanelle in the 
 normal head. Little or no movement was perceptible in the 
 region where the oblong exsection had been done. 
 
 The most remarkable thing in this operation was tne slight 
 impression which it made on the child; the temperature hardly 
 ever rose above the normal one; food was taken and digested as 
 usual, and there was no nausea or vomiting, as is usually seen as 
 the accompaniment of injury of the head. 
 
 The ameliorating result of the operation was more than was 
 expected; there was a visible improvement of the infant's mental 
 condition; the condition of apathetic inertia and vacuity of intel- 
 lect, which previously stamped the child as destined to idiocy, 
 were changed somewhat; the child, during the period of healing, 
 commenced to look at wliat was passing around it; it would fol- 
 low a moving object with its eyes, which it did not do before the 
 operation, but whether the improvement will continue, time will 
 prove. The results already obtained fully justify further effort 
 in this newly-opened section of operative surgery, and here, as in 
 other departments of surgical work, discretion should beused in the 
 selection of proper subjects for the work. Subjects of microceph- 
 alus in whom other incurable facial deformity exists, as is some- 
 times seen, should be discarded. Also, cases of teratological 
 monsters, in whose construction nature has forgotten lier sublime 
 dexterity and, in her embryonic sketch, has abandoned those 
 archetypal lines with whicli we are so familiar in the ordinary 
 infant, should be eliminated from the list selected for crani- 
 ectomy. 
 
 In many cases, it is easy to foresee that the ojoeration will be 
 sought by unfortunate parents wlio would prefer to lose the life 
 of their imbecile waif, rather than preserve it. However desirable 
 
284 ENCEPHALITIS, Oil INFLAMMATION OF TlIF 1!KAIN. 
 
 death may bo in this ease, as Avell as in others which fall within 
 the physician's and surgeon's observation (and desirable it indeed 
 is), yet our profession has no such power; the right to take life is 
 only delegated to another profession, whose code, formulated from 
 precedent and old usage, grants authority to take the life of him 
 who has taken life. If such a right or power can be exercised 
 towards the murderer, why not towards him whose life has become 
 a curse to its possessor? When Mirabeau was suffering inexpres- 
 sible agony from a mortal disease, and he begged Cabanis, the 
 celebrated physician, to give him an euthanasic nepenthe, the 
 friend replied that sucli an act was not permitted. The great 
 statesman rebuked the refusal by saying: "If my dog were suffer- 
 ing and going to die, you would not iiesitate to do something 
 which would end his misery, and in so doing you would say that 
 you were doing a favor, a blessing; am I not better tlian my dog? 
 can you not do as much for me?" Cabanis had all the endow- 
 ments of the tender-hearted physician, as was manifested in his 
 endeavors to prove that death by the guillotine was a painless 
 one, in a work written to solace those who had friends who died 
 by that instrument in the Frencli Revolution; yet, in answer to 
 the suffering statesman, he said: "The world lias not yet reached 
 that stage of civilization." 
 
CHAPTER VII. 
 
 SURGERY OF THE EXTERNAL EAR. 
 
 The auditory apparatus is claimed by the specialist in the 
 treatineiit of disease or disorder seated in any portion of the 
 apparatus; the general surgeon, however, has not wholly aban- 
 doned this region. His services are often invoked in affection of 
 the external ear, in which are embraced the pinna, or external 
 ear, and the auditory canal; his work commonly lies outside of 
 the tympanic membrane, and to this section of the subject the 
 present chapter will be confined. As preliminary knowledge, 
 necessary to a correct understanding of the subjects to be treated, 
 the writer premises a brief survey of some of the anatomical 
 characteristics of the structures comprising the pinna and meatus. 
 
 The external ear is movable, and at the same time it is so 
 strongly attached to the head that one, grasping the ears, can lift 
 the entire bod3^ 
 
 The ear presents a multitude of forms, and may vary in size 
 so that the smallest, as well as the largest, becomes an element of 
 deformity in the subjects figure. The condition of the middle 
 ear seems, sometimes, to be indicated by the conditions of the 
 pinna; for if this be verj' flat, dry parchment like, angular, and with 
 a dwarfed lobule, there may be inferred to coexist sclerous otitis. 
 Whether the imperfectly formed ear corresponds with an imper- 
 fect brain, and whether the assertion of Joux be justified by facts, 
 viz., "Show me your ear and I will tell you who you are, and 
 what you are," we wdll leave for the otoscopist and psychologist to 
 determine. The supporting framework of the pinna, instead of 
 being bone, as is elsewhere found, is of cartilage, and this is lined 
 by skin which adheres closely to the cartilage, except on the 
 posterior side, and to this close adherence is due the peculiarity 
 of form which characterizes the abscess, hsematoma and cyst 
 sometimes occurring here; but on the posterior side, the skin is 
 loosely adherent, and this condition permits the swelling which 
 is seen in erysipelas, seated here. The lobule, from its pendent 
 
 (285) 
 
28G SURGERY OF THE EXTERNAL EAR. 
 
 j)Osition, retains its form and site witliout the intervention of the 
 cartilage which maintains the form of the rest of the outer ear, 
 and this absence of cartilage enables the surgeon to solve a plastic 
 problem, in case of defect here, more readily than elsewhere in 
 the ear; defect in the cartilage-bearing portion maybe restored 
 from parts adjacent, j'et from the absence of the cartilaginous 
 framework, such plastic work rarely retains its proper form, and, 
 to counteract this in some degree, much ingenuity is needed. 
 
 The external auditory meatus, more properly named a ca- 
 nal, is the continuation of the external ear to the tympanic 
 membrane. This passage is very short in the new-born child; 
 in the adult it varies in length, and among those who have 
 stated itslenorth there is but slight accord. Buchanan savs it is 
 from an inch and a quarter to an inch and a half long; accord- 
 ing to Comparetti its length is nine lines, while Tillaux makes 
 its length vary from nine and a half lines to fourteen and a half 
 lines. Its breadth varies also greatly, and the outline of the 
 transverse section varies from a nearly circular figure to almost an 
 elliptical form. Its long axis reaches from behind forwards, and 
 from without inwards, and these directions correspond with those 
 of the petrous portion of the temporal bone. The auditory 
 canal is not straight, but is curved, so that a longitudinal section 
 of the pa.ssage is convex above and concave beneath; that is, the 
 canal at its middle is curved upwards. As a result of this curv- 
 ing, if one introduce a straight speculum which fills the canal, it 
 will strike the upper wall in its inmost third and awaken pain. 
 Such pain may be avoided b}^ pulling the pinna directh' upwards, 
 as thus the canal is somewhat straightened. 
 
 The walls of the canal are composed of cartilage and bone. 
 The outer part is constituted of cartilage; the inner portion for 
 more than one-half its extent is of bone. The bony wall forms 
 a very obtuse angle with the tympanic membrane above; below, 
 it forms a correspondingly acute angle. The ceruminous glands 
 are seated chiefly in the skin which lies on the cartilage. 
 
 The superior, posterior, inferior and anterior walls of the 
 canal may, from their external relations, be respectively named 
 the cranial, mastoid, parotidean and temporo-maxillary walls. 
 The cranial wall is so thin here that a wound or disease in the 
 canal may easily traverse the bone and affect the contiguous 
 dura mater. Indirect violence having ])rimary impact on the 
 chin can reach the brain through this wall and produce cerebral 
 concussion. Those whose brutal profession is to deal blows on 
 
SURGERY OF THE EXTERNAL EAR. 287 
 
 the bodies of their fellows are well aware that violence applied 
 here is most certain of its intended effect, for a blow from a weak 
 man administered to a powerful man's chin will fell the victim 
 to the ship's deck, which, as the writer has been a witness of, 
 was once no infrequent scene of such violence. 
 
 The posterior w^all is contiguous to the mastoid process, and 
 caries of this latter bone, as seen in the scrofulous subject, may 
 lead to suppuration of the soft parts and discharge of pus into 
 the canal. A more frequent and a graver trouble, which is seen 
 here, is where a deep-seated inflammation commences in the 
 periosteum lining the osseous portion of the canal, and extend- 
 ing outwards and backwards, appears in the mastoidean region; 
 this will be treated of more fully in another section. 
 
 The inferior wall lies in contact with the parotid gland, so 
 that swelling in this gland may partiall}'- or wholly occlude the 
 external meatus; the parotidean growth is a frequent cause of 
 such closure. Thus, as the author has seen, unilateral deafness 
 may arise from the develojDment of a malignant growth in front 
 of the ear, though the deeper portions of the organ remain 
 unaffected. By an extirpation of the growth in such a case 
 hearing in the ear was restored. The close contact of the parotid 
 gland and ear explains the tinnitus and pain in the ear present 
 in parotitis. 
 
 The temporo-maxillary or anterior wall is in contact with the 
 temporo-maxillary articulations, and this proximity is the cause 
 of the pain which is caused by masticating when the anterior 
 wall' is inflamed. 
 
 After birth the auditory canal becomes deeper, and the tym- 
 panic wall changes its position as the cranium is developed. 
 This change in position is as follows: At birth the membrane is 
 elevated but slightly above the plane of the horizon; the mem- 
 brane makes with that plane an angle of ten degrees. As the 
 child grows, the membrane rises towards the vertical plane, and 
 ends normally, in making with the horizon an angle of forty -five 
 degrees. In the cretin and non-developed head, the tympanic 
 membrane occupies the position of that of the infant; hence, 
 according to the anthropologist, this angle is an index of the 
 grade of intellect; so that, if this be true, wath the quadrant one 
 might measure the height of the sun of reason and the latitude 
 of the understanding. This matter concerns the surgeon less 
 than the fact that this disposition of the membrana tympani ren- 
 ders the upper wall of the auditory canal shorter than the lower 
 
288 SURGERY OF THE EXTERNAL EAR. 
 
 one; and the inclined membrane is thus made to form a recess 
 on tlie lower wall, in which small foreign bodies may lodge. 
 Drawing the pinna upwards tends to lessen this recess, and to 
 bring what may Le lodged there into view. 
 
 Dcfccta and Affcci ions of the External Ear. — Congenital defects 
 are met with in the pinna and auditory canal. The pinna may 
 be wholly or partially wanting. When wanting, if one palpates 
 the site, as tlie author has verified, there may often befelt traces of 
 cartilage buried beneath the surface; and in one case portions of 
 the cartilage cropped out and were visible above the surface. In 
 two instances of such defect the meatus was closed, and so effec- 
 tually that it was difficult to precisely locate its proper site. In 
 these two cases the writer attempted by a plastic operation to 
 remedy the condition. The buried cartilage was uncovered, and, 
 along with a portion of integument, it was so uplifted as to present 
 the appearance of an ear. Unfortunately for satisfactory form 
 and aspect the cartilage found was very imperfect. The opera- 
 tive procedure consisted in first marking off a portion of skin in 
 outline similar to an ear, yet longer; next was incised and 
 dissected up the skin until the site of the cartilage was approached; 
 then the knife was carried deeper, so as to include and pass 
 beneath the cartilage at two or more points. In this way the 
 material for the new aural formation may be prepared, wdien the 
 uplifted integument is to be infolded about the cartilage, and 
 fixed in place by fine metallic sutures. Along with this work an 
 attempt must be made to open the closed canal, and this is easily 
 done if the passage be merely closed by an external operculum, 
 for the meatus is restored by crucially incising the covering, and 
 then, having seized each hanging portion, cut it off, so as to fully 
 restore the outlet. And, to render and preserve the orifice per- 
 manently patent, tlie hanging flap of the divided operculum 
 may be dissected up at its attached base, and thus a small cuta- 
 neous covering be made and sutured to the wounded circumfer- 
 ence. Thus, in such congenital closure, the opening may be 
 restored, but if the occluding material reach inwards still deeper, 
 an effort should be made to restore the opening; but if the 
 canal should be found occluded, or rather obliterated, throughout 
 its entire length, then the operation must fail in its purposes. 
 
 A duplicate auditory canal has been seen by Velpeau ; along- 
 side of the normal one there was an abnormal canal which pene- 
 trated to the mastoid process. In such a case the surgeon's inter- 
 ference would not benecessarv. 
 
AFFECTIONS OF THE EXTERNAL EAR. 
 
 289 
 
 A singular anomaly was seen by Birkett, in wliicli there were 
 two pinnse on one side; the surplus one was removed by a sim- 
 ple operation. 
 
 Congenital cleft or fissure in the external ear has been seen; 
 Schwabach, who has given study to the matter, refers the origin 
 of such fissure to the embryonic bronchial cleft, which, not 
 properly closing, leaves a fissure. Such fissure has been observed 
 by Paget and Urbant-Schitsch. In several cases the defect was 
 transmitted from parents. 
 
 From diminution, as well as excess of volume, the pinna 
 may be deformed. Besides being too small, the ear may be ill- 
 formed; such dwarfed auricle might possibly receive some plastic 
 aid, yet, in such effort, the surgeon should not try to do too much, 
 lest he make that which is bad still worse. 
 
 In case of excess of volume, in which the parts are in proper 
 proportion, the surgeon has intervened with advantage. In 
 
 Figure 3. Illustrating Martino's method of lessening the pinna; tlie section 
 ac being removed, the closure is seen in the figure at the right. 
 
 such ear enlarged to deformity, the work may be done as was 
 done by Martino, who removed a cuneiform section from the 
 middle third of the pinna (as shown in Figure 3). Such a sec- 
 tion should traverse the concha, ending near the meatus, and 
 should embrace as much of the convex border of the ear as is 
 requisite to reduce the part to better shape. The opposite borders 
 of the remaining gap must be accurately brought together, and 
 retained so by fine metallic sutures, which should remain in place 
 for not less than two weeks. The part should be immobilized by 
 aseptic lint placed between the ear and the head, as well as on 
 the ear; the whole to be permanently fixed by adhesive plaster 
 encircling that side of the head. In this way, the wounded parts 
 
290 8rK(ii;i;v of tiih kxtkuxal ear. 
 
 woulil unite; and if accurately coaptated, the remaining scar 
 would nitt be an unsightly one. Wounded cartilage does lieal, 
 despite the contrary opinion which was taught by the medical 
 writers of antiquity. 
 
 Wounds of the External Ear. — The external ear may be the 
 subject of a piercing, incising or contusing wound. 
 
 A penetrating or piercing wound here will readily close, if 
 placed in proper conditions of cleanliness, and covered by an 
 occlusive dressing. 
 
 An incised wound may form a flap, or the detachment of a 
 portion of the ear may be complete. When there has been no 
 loss of structure, the wound, if one of even surface, should be 
 closed by means of metallic sutures, immobilized and covered 
 by an aseptic dressing. In the use of sutures, these should be so 
 introduced as to maintain complete coaptation and adjustment 
 of the wounded surface; thus done, the reunion will be secured, 
 and deforming surface or outline, avoided. The sutures must be 
 removed so as not to disturb the united parts; and this should 
 not be done until a week has elapsed since the sutures were 
 inserted; and even a longer time must elapse if the union seems 
 yet incomplete. Delay in the removal is more necessary here 
 than elsewhere, since the unsupported position of the ear, differ- 
 ing from other structures which have subjacent support, renders 
 a wound in the ear more apt to be reopened than is the case 
 elsewhere. In case the injury be a compound of incision and 
 contusion, then the contused structure must be removed by sharp- 
 edged scissors, before sutures are introduced. And this trimming 
 should be so done that the oppo.site faces can be congruently fitted 
 to each other. If this precautionary preparation be neglected, 
 then the wounded parts may unite imperfectly, with, perhaps, 
 one or more perforating gaps through the ear. 
 
 In case there be detachment of a portion of the pinna, then it 
 has been repeatedly demonstrated that the separated part can be 
 made to reunite again: examples, even of the reunion of the 
 entire ear after its detachment have been seen. A noted instance 
 of this kind is that of Prynne, a member of the English Parlia- 
 ment, who, on account of some writings then adjudged libelous, 
 was condemned to have his ears cutoff; though this was over two 
 centuries ago, yet surgical art in this field, from repeated oppor- 
 tunities, had reached such proficiency that the excised ears were 
 .successfully restored to their places again. The rebuke of muti- 
 lation failed of its effect. After three years his pen repeated its 
 
OTPI/EMATOMA. 291 
 
 offense, and Prynne was again condemned to have his ears cut 
 off; the cruel work was repeated by the baihff ; yet surgery was 
 denied the privilege of another trial of replacing the parts, 
 since this time the ears were confiscated. As the era has fortu- 
 nately passed in which the conscience, private judgment, and 
 religious opinions of men are controlled by the lash, pillory, 
 stocks and mutilating instruments, surgery has less opportunity 
 of testing its resources in tbis field of restoration, than in the 
 much- vaunted "good old times." Accidental injury, however, 
 does sometimes furnish an opportunity for work in this line, as 
 shown by the monograph in 1870, of Berenger-Ferraud, in which 
 there is a collection of cases of restoration, in which there had 
 been partial or complete detachment of a portion of the ear. In 
 one case told by Manni, the ear had been cut off for hours, and 
 carried in the man's pocket; this ear, properly replaced by sutures, 
 reunited without any necrosis of cartilage; in this respect diflPer- 
 ing from a detached finger, from which when restored, the bone 
 is apt to die and be thrown out. Berenger-Ferraud hints that 
 there may be some benefit for a short time elapsing, between the 
 cutting off of the ear and its restoration ; for thus done, there is 
 time for the bleeding to cease, and no intervening blood prevents 
 adhesion. 
 
 To restore a detached portion of the ear, coaptate accurately 
 by the aid of metallic sutures, immobilize the part, retain the 
 patient in recumbence, apply moderate warmth without mois- 
 ture and let the dressing remain unchanged for three or four 
 days. 
 
 Erysipelas not unfrequently appears on the pinna; and it 
 may arise here primarily, or the disease may appear first in the 
 scalp or face, and emigrate then to the ear. It may run an acute 
 course, or it may be chronic in duration; and in the latter case, 
 it may appear, vanish, and then reappear on the same site. 
 This chronic form can end in shriveling and contraction of the 
 pinna, thus causing marked deformity. In its acute form the 
 disease usually enters the meatus, and passing inwards it causes 
 tinnitus. 
 
 Treatmeiit. — Mercurial or iodine ointment, or one containing 
 quinine, two grains to the ounce, may be used locally. 
 
 Othsematoma. — Since the othematoma is sometimes, if not al- 
 ways, of traumatic origin, it is proper to consider the subject here. 
 The name othsematoma or hgematoma of the ear was applied by 
 Weiss, of Coblitz, to a soft fluctuating tumor which suddenly 
 
202 SUROEKY OF TIIK KXTKKXA I, KAM. 
 
 appears on the pinna. It has also been named auricular ery- 
 sipelas, blood-cyst of the ear, and shriveled ear. It occurs most 
 fre(|uently in tlie insane. This tumor, which usually appears on 
 the outer face of tlie ear, within depressions bounded by the 
 helix and antihelix, may attain such dimensions as to interfere 
 with liearinir; and in the bcirinnintr, it is somewhat iiainful, and 
 soon inaiiifests symptoms of inflammniion in Ijcing hot, red and 
 swollen. 
 
 Tliere have been assigned two modes of origin of this tumor: 
 in one it is claimed that it originates from a constitutional or 
 general cause; and in the other, it is contended that the tumor 
 is the result of local injury. Hasse, who has seen six cases, 
 espouses the latter opinion; he thinks that it is caused by pull- 
 ing the ear, or by frequent blows on the part. From such vio- 
 lence the lining of the cartilage can be cracked, or so injured 
 that the blood can insinuate itself into the fissure and uplift the 
 lining membrane. Such violence might be done by the patient 
 himself. Tlie tumor has oftenest been seen in the inmates of 
 asylums for the insane; and hence the origin of an otha3matonia 
 has been discussed in courts of law, at whose bar the managers of 
 such institutions have been arraigned under accusation of cruelty 
 to the inmates in their charge. On such occasion the question has 
 been mooted whether the subject may not have caused tlie vio 
 lence himself by striking his head against some object. 
 
 That the tumor may be caused by violence, voluntarily or 
 otherwise inflicted, is shown by the fact that it has often been 
 seen among the knights of the arena whose ears are the subject 
 of many blows; and in such it occurs oftener in the left ear. 
 This tumor was not unknown to the ancients; and the artist 
 who chiseled the ears of Hercules, and those of Castor and Pollux, 
 has delineated those famous athletes of the mythic age as bearing 
 ears deformed by this affection. 
 
 Others, again, contend against a traumatic origin; this opin- 
 ion is espoused by Ludwig Meyer and Virchow. Meyer, in 1865, 
 in an essay on this subject, claims that othiematoma arises from a 
 chondroraatous degeneration of the aural cartilage, wliich is suc- 
 ceeded by the vascular development in the part so changed. He 
 finds three kinds of alteration in the cartilage, the hyaline and 
 fibrillar degeneration, and the formation of hollow spaces in the 
 cartilage. Virchow, likewise, though admitting that the tumor 
 may have a traumatic origin, still claims that it can arise from 
 changes which primarily occurred in the cartilage itself, and 
 
OTHEMATOMA. 293 
 
 which were afterwards followed by the vascular etfusion. Perti- 
 nent to this matter is an interesting observation made by Brown- 
 Sequard, that from injuries of the restiform columns of the 
 medulla oblongata in the guinea pig, there soon appeared vascu- 
 lar effusion in the animal's ears, consequent, he thinks, on the 
 iinpairment of nutrition produced by the injury to the cord. 
 The author of this work suggests that it is possible that the ani- 
 mal, in his wounded condition, injured himself. 
 
 As summary then of the causation which has been assigned 
 to ex2:)lain the origin of othsematoma are the following agencies: 
 from local violence of the part frequently repeated, from troubles 
 of general nutrition; and, thirdly, from a disturbance of the local 
 nutrition of the ear. 
 
 When the othsematoma is slight and multiple in site, it resem- 
 bles somewhat erysipelas, differing, however, from the latter in 
 being a fluctuating tumor, and nearly always seated on the 
 external face of the ear. It may slowly grow until the tumor 
 occupies the entire outer face of the pinna. The tumor may 
 also penetrate through the ear, and then it communicates with, 
 or forms, a tumor on the inner face of the pinna, looking towards 
 the scalp. The content, though clotted, is liquid in its centre. 
 
 The othsematoma presents a .varied course; sometimes it 
 vanishes through absorptive dispersion of its contents; it can 
 inflame, suppurate and open, and disappear in this way; or the 
 tumor may remain an indefinite period, and, as it is then pain- 
 less, it is chiefly objectionable from the deformity which it causes. 
 
 When the tumor disapj)ears through spontaneous absorption, 
 or, through suppuration and evacuation of content, it entails 
 some change in the form of the pinna; the affected part shrivels, 
 and the concha is deformed through contraction. The final 
 deformity, in the main, is one of shriveling; and this, as above 
 stated, has not been forgotten by the ancient sculptor. 
 
 Treatment. — In the early stage, inflammatory action should be 
 controlled, and absorption promoted; for the former, lead water, 
 and for the latter, some compound of iodine may be topically 
 used. If reduction is not accomplished by these measures, then 
 the knife may be used; and through proper incisions, the blood 
 may be forced out, and tincture of iodine, or iodoform, introduced 
 into the emptied spaces. As the blood soon refills the cavity, 
 other means have been resorted to for relief: viz., there may be 
 passed a seton through the tumor, which is allowed to remain 
 there perriaanently. In this way it is claimed that the blood finds 
 
2t>4 SURGERY OK Til I! KXTKJiNAI, K.VR. 
 
 escape as soon as it forms, and the cavity gradually closes. 
 Wilde treated tiie tumor by freely incisino- it, emptying- the con- 
 tents and tilling the cavity with lint. 
 
 The sebaceous cyst occurs on the ear, oftener on the outer 
 surface. Such cyst commonly remains of diminutive size, though 
 it may become as large as an olive. It is treated by incision and 
 removal of the sebaceous material by compression or curetting. 
 The spoon-shaped end of the grooved director is a convenient 
 instrument for scooping out the contents in most cases. Akin to 
 the sebaceous cyst is the chalky concretion sometimes found here. 
 Tlie Engli.sh writers associate this with a gouty diathesis. Such 
 material may l)e removed by curetting. 
 
 The fiijroid tumor occurs iii the pinna; its origin may be 
 spontaneous, or it may arise from some i)revious injury. The 
 usual site is the lobule, where it has ari.sen from the irritation 
 excited by an ear-ring. Such growth can attain the size of a 
 small cherry. It may partake of the nature of keloid structure, 
 and then it is the site of an itching sensation. Such growth 
 being in the female and an offense to her eye as well as to the 
 eyes of others, its removal is urgently solicited b}'' the patient. 
 This is done by extirpation, which should be done from the 
 inner surface of the lobule;. and in the work two points must 
 be observed : one, to remove the tibromatous structure in its 
 entirety, and the other to preserve the skin and remove as little 
 as possible of tlie lobule; and these rules are so much in conflict 
 with each other, that it often occurs that the work is not thor- 
 oughh' done, and sooner or later there is a recurrence of the 
 growth, as has happened in the writer's experience. Should 
 there be a return, another removal may be more succe.ssful. 
 
 Malignant growths appear in the external ear; carcinoma, 
 sarcoma and epithelioma are found here. Such growth may 
 have its original site here, or it may invade the ear as an immi- 
 grant from some adjacent part. Epithelioma is oftener seen 
 than the other forms of malignant growth just mentioned. It 
 commences usually in the folded border of the pinna, or in the 
 prominent portion of the antihelix. Owing to the defective 
 vascularity of the peripheral portions of the pinna, the epithe- 
 lial cell-growth makes but slight progress before ulceration 
 ensues; in the central portions of the concha, the growth is 
 greater, and proceeds to such an extent that, as in a case treated 
 by the writer, it occluded tlie meatus, and deafened the patient 
 on that side. Carcinoma is more rare here; in fact, thfe structure 
 
OTH.EMATOMA. 295 
 
 of the ear is but little favorable to the development of this type 
 of malignant growtli; still, Sedillot and Duplay have observed 
 cases in which carcinoma rapidly destroyed the external ear, and 
 attached and destroyed the subjacent bone. The pinna is his- 
 tologically ill adapted for the development of sarcoma, and the 
 writer has seen no example of it there. 
 
 Malignant neoplasm seated in the ear should be attacked 
 early and radically; if thus treated, the case can be cured, as has 
 often been verified. If, however, the disease has made such 
 progress that it has appeared in the adjacent glands, which are 
 connected with the part by lymph-vessels, then recurrence is 
 almost inevitable, though radical means be used. If the disease 
 have an isolated site, this should be so circumscribed as to surely 
 include the affected structure. And the excision should be done 
 in such a figure that the wound may be closed and leave no 
 conspicuous gap or deformity in the ear. This is only possible 
 when the affected part is limited in extent; for example, when 
 it is on the border of the ear, and the excision can be done 
 triangularly. Bat if a great portion of the ear be the site, then 
 a large portion of the pinna must be excised; if, however, a 
 part of the circumference can be saved and attached to a portion 
 of the concha, then the deformity will be much less than if the 
 entire ear be excised. In a case operated on by the author, in 
 which the concha and entrance of the canal were the site of 
 epithelioma, the affected parts were removed, including the derm 
 for an inch around the meatus, Avhich was likewise implicated; 
 there was left remaining the upper fourth of the pinna, along 
 with the greater portion of the helix, which was not affected. 
 The part which remained was falciform, being broader above 
 and gradually tapering to a sharp point behind and below; the 
 posterior cutaneous face of this was removed, and the part then 
 fixed by metallic sutures to the dermal edge of the raw surface 
 which remained behind tlie meatus after the excision of the 
 affected structure. The parotidean sulcus behind and below the 
 ear, from which affected structure had been removed, was next 
 covered by a flap, which being uplifted from over the upper fifth 
 of the sterno-cleido-mastoid muscle was turned across the large 
 raw gap. By the work thus done the wounded surface was in a 
 great degree covered, and the portion of the ear which remained, 
 though less than one-fourth of the original part, was so utilized 
 as to greatly lessen the deformity. In healing, the meatus 
 tended to close cicatricially, yet this was prevented by the 
 
296 SURGERY OF THK EXTKRXAL EAR. 
 
 insertion of a rubber tube. There was no recurrence in this case. 
 
 The ]>inna is sometimes the site of a lupoid ulceration, cog- 
 nate in feature and behavior to eiiiihelial cancer, and, like the 
 latter, it occurs oftenest in the aged subject. It would seem to 
 ai)i)eai' most frerjuently in persons in whom the skin is dry and 
 the site of freckles and other pigmentary marking. In the senile 
 period of general lapsing vitality, this structure, which is rendered 
 especially non-resistant by its pe ipheral situation, becomes the 
 favorite site of lupoid development. Histogenetic weakness, the 
 result of such condition, favors the development of both cell or 
 microphyte to w^hich the causal agency of this disease is attributed. 
 
 For the extirpation of the disease, the curette and escharotic 
 are oftener resorted to than the knife. Tlie diseased structure 
 should be scraped off and the raw breach opened should be 
 cauterized with potassafusa, or it may be covered with a paste of 
 sulphuric acid and charcoal; such paste is allowed to dr}^ and 
 remain in place until an eschar is detached. Or a paste composed 
 of salicylic acid and liquid carbolic acid may be u.^ed and left in 
 place until the resulting eschar drops off. Multiple lupoid points 
 may thus be treated at the same time. 
 
 Adherent Pinna. — Adherence or fusion of the pinna with the 
 adjacent surface of the head appearing congenitally has received 
 sufficient mention; the acquired form will next be considered. 
 
 From burns, eczematous ulceration, and from the surgeon's 
 instrument the adjacent and opposite surfaces of the ear and scalp 
 may be denuded, and if brought in continuous contact, the sur- 
 faces will cohere. Improper head-dress of the infant has caused 
 it, viz., one by which the ears are forced against the head. 
 
 This condition of coherence is not easy to completely remove; 
 though detachment be done, and separation maintained by some 
 intervening material, still there will occur reunion in the deep- 
 est part of the normal sulcus. To oppose such union, a flap of 
 cutis from the contiguous sound structure may be lifted up, and 
 twisted in and sutured to the floor of the sulcus. In this way 
 the deeper part of the normal interval Avill be maintained open, 
 and when this is done, the remainder of the work is easily accom- 
 plished; for if parts unite beyond, it suffices to simply separate 
 them and maintain the surfaces apart by some intervening lint. 
 The process here is similar to that done for the separation of 
 webbed fingers. Skin grafting might be resorted to for the same 
 purpose; and then the grafting might be done on one or both 
 surfaces. 
 
RENTS, FISSURES AND OTHER DEFECTS. 297 
 
 Rents, Fissures and other Defect in which there is loss of struc- 
 ture. — The simplest case of this kind, and not unfrequently seen, 
 is tliat in which the lobule has been torn by the ear-ring. 
 Such rent occurs oftener from accident, by which the ring is torn 
 out, or from continuous ulceration from the ring, a rent arises. 
 In all such cases restoration to normal form, or at least fair relief 
 from deformity, is obtained by paring the edges evenly and 
 uniting them by means of metallic wire; such wire must be verv 
 fine. 
 
 Sometimes a surgeon is consulted in reference to the repair of 
 a larger or smaller loss of structure of the ear. Such loss may be 
 in the marginal or in the central portion of the pinna, or in the 
 lobules. The material for restoration is to be taken from the 
 dermal integument, which is most conveniently situated, and this 
 should always be selected, by preference, from a part where the 
 subsequent scar will not be visible; and ia accordance with this, 
 the material behind the ear is best suited for replacement. 
 
 The difficulty encountered in this plastic work is the retention 
 of form. Since the cutaneous material used for restoration con- 
 tains no cartilage when it is transplanted to the border of the ear, 
 it soon shrivels, and if this be at the upper border, the latter soon 
 shrinks down into a shapeless figure. To avoid this, the cartilage 
 already remaining may be utilized; to do this a strip-like section 
 may be cut with nutrient connection at one end, while the free 
 portion is lifted and placed arch-like on the border. Into the 
 open space thus left, a flap of skin, uj^lifted from behind, is 
 inserted, and fixed by sutures. In this work the epidermal side 
 of the flap should look outwards. The vascularity of the flap 
 will aid in maintaining alive tlie newly formed cartilaginous 
 border. After three weeks the flap can be cut asunder at its base, 
 or it might be left unsevered, since its site is quite concealed. 
 In operative work of this character, the author has verified the 
 advantage of thus using the existing cartilage for constructing a 
 border. 
 
 If such expedient in the technical work of restoration be omit- 
 ted, though the ear be well repaired, the added material will soon 
 shrivel and the operation be a disappointment. In an attempt 
 by the writer to restore a large breach in the upper half of tlie 
 ear, caused by the bite of a beast in form similar to the patient, 
 the primarily well-restored section afterwards shrank to unsatis- 
 factory form; and thus a double lesson was taught: the limita- 
 tions of plastic repair, and the inestimable value of cartilage in 
 20 
 
208 SUKGEKY OF THE KXTEKXAL EAIl. 
 
 the arcliitecture of the ear. In case tlie defect be central tl»e 
 repair is less difficult, since if the peripheral framework of the 
 ear remains, the newly-added material will be retained in its 
 central position. And in such a case the restoration is done by 
 trimming tlie margin of the opening and uplifting a flap and 
 adjusting it to the breach, with its epidermal surface looking 
 outwards. 
 
 If the defect in the ear be from a lost lobulus, the work of 
 repair can be satisfactorily done by uplifting a flap with attach- 
 ment below. This flap should be so broad that it may be folded 
 together and thus present a skin-covered surface on all sides; and 
 the whole should be broader and thicker than the part which it 
 is to replace, since it will afterwards diminish in size. 
 
 Affections of the Auditory Canal. — Inflammatory action may 
 arise in tlie surface of the canal, originating in the glandular 
 structure wliich abounds there; such inflammation may be 
 limited to a small point, viz., a sebaceous or ceruminous gland 
 may be the origin, and thence a diminutive abscess can arise. 
 Such abscess, tliough i)ainful, is not a serious trouble. As appli- 
 cation, tliere may be used camphorated oil, or almond or olive 
 oil. Also warm carbolized water should occasionally be poured 
 (not injected) into the passage, so as to remove any material 
 which may be emptied into the passage. The suppuration will 
 be hastened and the pain lessened by placing over the ear a 
 poultice of hops to which laudanum has been added. By such 
 management, the ordinary aural abscess is satisfactorily treated. 
 It has, however, a tendencj'' to recur; the first one often having 
 several successors. 
 
 Besides the circumscribed glandular inflammation just men- 
 tioned, there is another form of a much graver nature, which has 
 been studied by Tillaux. According to him, the inflammation 
 commences in the periosteum which lines the deeper portion of 
 the canal, and travels inwards, and follows the periosteum that 
 covers the mastoid process behind the ear. Pus forming, o^^ens 
 into the canal, but much of it remains confined underneath the 
 thick structures which cover the mastoid process; and from this 
 fact Tillaux names the purulent collection, mastoid abscess. It is 
 probable that instead of originating as Tillaux thinks, in the 
 periosteum, it commences in the deep glandular structure of the 
 canal, and thence penetrates to the periosteum, and |)ursues its 
 course backwards, and being pent up beneath the dense and 
 inelastic structures there, it causes excruciating pain, as the 
 
AFFECTIONS OF THE AUDITORY CANAL. 299 
 
 writer has seen in two cases of the kind. The protracted contact 
 of .the pus with the surface of the bone, tends to destroy the 
 latter, and, as result, there may occur necrosis of the surface of 
 the mastoid bone, and penetration of pus into the mastoid cells. 
 
 Treatment.— As soon as this osteo-periosteal inflammation of 
 the deeper portion of the auditory canal is diagnosed, which may 
 be done through the swelling and the acute and widespread 
 pain about the ear, Tillaux counsels to locate the pain by 
 examination with an aural speculum, and to freely iucise through 
 the swollen wall of the canal to the bone; thus proceeding, the 
 inflammation may be checked, and prevented from extending 
 further. Such prophylactic incision can rarely be made early 
 enough to arrest the inflammation at its primary site of appear- 
 ance; as a rule, the surgeon is only consulted after the disease 
 has extended its sphere, and has appeared behind the ear. At 
 this stage it must likewise be met by a free incision by which 
 the swollen structure will be divided to the bone, and free escape 
 provided for the pus. As Tillaux w^arns, such division of the 
 parts endangers the posterior auricular artery, which normally 
 lies in the bottom of the furrow between the ear and the wall of 
 the head. Dissections made by the writer of this region have 
 shown that this location is not unvarying. The vessel is some- 
 times of diminutive calibre. If opened by the incision, the firm 
 and resistant tissues in which the vessel lies, renders it diflicult 
 to tie or twist it; and hence, as Tillaux directs, if it be opened, it 
 is better to seize the divided structure in which the artery lies in 
 its entirety with a pair of compressing forcejDs, and let the latter 
 remain in place for some hours. A plan which the author has 
 pursued is to make a vertical cut, somewhat behind the site of 
 the vessel, reaching to the bone. Then with a chisel or blunt 
 dissector, dissect the soft j)arts from the bones towards the ear. 
 In this way a free outlet is made for the escape of pus, and if the 
 dissecting chisel be kept in contact with the bone underneath 
 the periosteum, the artery will be uplifted witli the soft parts, and 
 will not be opened. 
 
 After this incision has been made, the parts which are the 
 seat of suppuration, should be washed out with an alcoholic 
 sublimated solution; and such injected fluid will commonly 
 escape through the meatus by an opening in the wall of the 
 canal, through which the pus, unaided, has established an outlet 
 for itself; an outlet, however, too small to give free vent to the 
 material. The connectien between this opening in the canal and 
 
oOO SUKGEKY OF TlIK KXTKKXAL EAR. 
 
 the purulent collection beliind the ear, often eludes detection 
 until thus verilied by injecting fluid from the incision. The 
 relief which is allbrded by the treatment here indicated is imme- 
 diate; the excruciating agony in which the patient writhed, 
 vanished in a few minutes. The wound made must be kept open 
 for some days by means of lint and a drainage tube, and the 
 whole covered with lint saturated with an aseptic solution. And 
 if the dressing be warm, it will be more agreeable to the patient 
 than if it be maintained cold. If this osteo-peri osteal inflamma- 
 tion be treated early in the way here detailed, the middle ear 
 will escape implication; but if it be allowed to pursue its course 
 untrammeled, it can enter the tympanic cavity and pass thence 
 into the mastoid antrum; and in this form it attains such 
 intensity that it passes from the aural apparatus through the 
 intervening wall to the cranial cavity, and there becomes the 
 cause of fatal disease; hence the lesson taught of early and 
 thorough surgical intervention in such cases of osteo-peri osteal 
 inflammation. 
 
 Ocdimon of the Auditory Canal. — The canal may be closed by 
 growths adjacent, which coming in contact with the canal, finally 
 close it; in such case the removal of the growth must be done to 
 restore the opening. 
 
 The meatus has been closed by the violent use of nitrate of 
 silver, by whicli granulations were caused to grow and become 
 organized, and occlude the orifice. Weintrach, of Vienna, 
 described such cases in 1870, in which the closure had thus been 
 intentionally done to induce deafness for the purpose of avoiding 
 military duty. In these cases a little patriotism might be pre- 
 scribed as a prophylactic against such mutilation. 
 
 The meatus may be closed by an os.seous growth developing 
 there and finally occluding the canal. In 1879, Delstanche (fils) 
 of Brussels, wrote an essay on such exostosis, of which he collected 
 twenty-five cases. 
 
 Delstanche finds that this growth can appear both before and 
 after the ossification of the ear is complete. As causes assigned 
 are heredity, and spontaneous or traumatic inflammation; also 
 primary or secondary inflammation of the })eriosteum and bone. 
 The growth occurs in all parts of the canal, yet it is oftenest 
 noted on the posterior wall. Symptoms of such growth are 
 deafness and subjective auditor}' sensations; likewise, the feeling 
 of pressure and vertigo; all of which is duo to closure of the 
 meatus. 
 
OCCLUSIOX OF THE AUDITORY CAXAL. 30l 
 
 The treatment is surgical in cljaracter and consists in the 
 occasional introduction of dilating sounds, and tents of laminaria. 
 One may also bore through the exostosis and chisel it off; or the 
 removal may be attempted by means of the galvano-cautery, or 
 electrolysis. In one case Delstauche removed the bone by boring 
 a part of the way; and he then softened the remaining wall with 
 chloride of zinc, and thus removed the whole of it. Some 
 months were occupied in the work, yet finally the bone was 
 entirely removed, and hearing perfectly restored. 
 
 Polypus in the Auditory Canal. — A polypoid growth may arise 
 from the wall of the canal, from the outer face of the tynjpanic 
 membrane, or from the wall of the tympanum itself; the first 
 site is very rare; the third is unusual, while the polyp springing 
 from themembrana tympani is the one commonly seen. These 
 growths are highly vascular, as a rule, and bleed when their 
 surface is broken; a fact to be borne in mind when their extir- 
 pation is undertaken. Methods which have been pursued for 
 their removal are excision with small curved scissors, cutting off 
 by means of a snare-like wire, and plucking out by means of 
 small forceps. Excision is rarely practiced, while removal by 
 means of a snare devised by Wilde, or by forceps, are the methods 
 in common use. Simpler cases of aural polypus may be treated 
 by the surgeon; since the work of removal is easily done by 
 carefully seizing the growth with forceps, and detaching it by 
 traction and slight torsion. But cases which are deeply seated, or 
 present other complication, are more properly committed to the 
 aurist, whose special training has given him dexterity in manip- 
 ulation of forceps or snare in the auditory canal. 
 
 The syphiloma has been seen in the auditory canal ; its nature 
 would be indicated by symptoms of secondary syphilis in other 
 parts of the body. Gruber, in his study of syphilis of the audi- 
 tory apparatus, finds that the disease more often attacks the 
 deeper than the superficial aural structures. In all such cases 
 the constitutional remedies against the disease should be admin- 
 istered. 
 
 Occlusion of the Canal by Cerumen or Foreign Bodies. — Cerumen, 
 the normal secretion of glands seated on the cartilaginous or 
 outer portion of the auditory canal, may accumulate to such 
 amount as to close the canal. Though the ceruminous matter is 
 generated in the outer two-thirds of the passage, yet when found 
 in large amount, it is always situated in the deeper part of the 
 canal in close proximity to, or in contact with, the tympanic 
 
uU2 yURGKRV OF THK KXTKRXAL EAR. 
 
 lUL'Uibraiie. A large mass may exist and not be suspected; and 
 it is only when tlie closure is comi»lete that the ear is deafened a 
 small crevice of open passage to the membrana tympani sufiices 
 for the purpose of normal hearing; let the closure become com- 
 plete from matter added to the mass, or let the walls of the pas- 
 sage swell from some cause, and at once the power of hearing in 
 that ear is suspended. Ceruminous occlusion of the ear passage 
 occurs only in the adult; the cliild frequently supplements his 
 exemption by closing the canal with some foreign body just 
 suited, as the child thinks, to stop the ear. 
 
 The history of the case as told by the patient, often enables 
 the surgeon to suspect the nature of the trouble before he has 
 examined the ear; by the aid of tlie speculum, or by looking 
 into the ear, when the pinna has been drawn upwards, the dark 
 mass of cerumen is seen. This may be removed by means of a 
 minute tenaculum, which, being hooked into the outer face, the 
 mass is drawn out. As there is danger in thus proceeding, of 
 forcing the matter against the tympanic membrane, a preferable 
 method is to inject a stream of tepid water into tlie open portion 
 of the canal; thus doing, if the current of water be continued for 
 several minutes, the mass will be loosened and will float out. 
 The water should not be thrown in with too much violence; for 
 by such imprudent work the membrana tympani has been in- 
 jured. If the impacted material still remains immovable despite 
 the syringing, then an effort should be made to dissolve it by 
 pouring into the passage an alkaline solution; for this, lime 
 water or a weak solution of carbonate of potash may be used. 
 The solvent power of the solution will be increased by the addi- 
 tion of glycerine. 
 
 In persons in whom there is a disposition to frequent recur- 
 rence of ceruminous impaction, the trouble may depend on an 
 abnormal activity of the producing glands, and an attempt 
 should be made in such cases to counteract the tendency; for this 
 purpose, an alterative remedy should be locally applied. We 
 may select one of the following recipes, and apply it in the 
 canal with a camel-hair brush, making the application once in 
 two days: — 
 
 H. Tinctura? lodi Comi)Osita? 3ss 
 
 Glycerini six 
 
 Misce. 
 
 1^. Olei AmygdaliL' Expressi gss 
 
 Olei Cadini gj 
 
 Misce. 
 
OCCLUSION OF THE AUDITORY CANAL. 303 
 
 I^. Unguenti Hydrargyri Nitratis 3ss 
 
 Petrolati 5ss 
 
 Misce. 
 li. Extracti Ergotse Fluid i. 
 
 Ichthyol aa 31 
 
 Glycerin! gx 
 
 Misce. 
 
 1^. Chrysarobini g^- iij 
 
 Petrolati oss 
 
 Misce. 
 
 The topical use of one of these comjiounds, applied once to 
 the passage in two days, with irrigation to the canal with warm 
 water on the intervening days, would act alteratively on the 
 glands, and lessen their abnormal activity. 
 
 Foreign Bodies in the Auditory Canal. — The canal of the outer 
 ear is a site of lodgment of small foreign bodies, which enter 
 usually by accident in the adult; but children, inspired by the 
 instinct of curiosity and the desire to explore the passage, push 
 small bodies into it ; examples of such foreign bodies are beads, 
 peas, beans, leaden shot, pebbles, grains of wheat, in fact, any 
 small object with which the child is accustomed to amuse itself. 
 Among adults such accident occurs oftenest with those who 
 handle hay or grain; the grain of oats, the beard (arista) of 
 wheat, oats or barley, and fragments of straw are not unfre- 
 quently found in the ear ; and remaining there, may cause much 
 pain. The adult, commonly a male, may be quite ignorant of 
 the cause of the trouble of his ear, for which he seeks advice, and 
 he is astonished when the body is removed and shown him. 
 
 In both the child and adult, the foreign body is first intro- 
 duced into the outer portion of the canal; and situated there, it 
 is readily removed by the surgeon; yet usually before he has 
 been consulted, through inadvertence or mismanagement, the 
 body has been thrust to the bottom of the canal. 
 
 Various methods of extracting foreign bodies from the outer 
 canal of the ear were known and practiced by the Latin physi- 
 cians, as is evident from the following chapter of Celsus: "Now 
 and then something is accustomed to fall into the ear, such as a 
 pebble or some living thing. If a flea has entered, there should 
 be introduced into the ear a little wool; and if the flea enters 
 this, the wool and insect are to be withdrawn together. If this 
 has not succeeded, or there be some other small animal in the 
 ear, a probe wrapped in woolis to be dipped into some resinous 
 
304 SURGERY OF THE EXTERNAL EAR. 
 
 or very glutinous material (and for this a terebinthinate sub- 
 stance is the best); and the probe thus armed is to be introduced 
 into the ear and twisted around; thus the object will be cauglit and 
 removed. But if the object be something inanimate, then it is to 
 be drawn out with an ear probe, or by means of a curved hook; 
 and if the extraction cannot thus be done, the removal may be 
 done by means of resinous matter, as before mentioned. Agents 
 wliicli provoke sneezing being used, may force out the body; 
 also, water thrown into the ear with an aural syringe may force 
 out the object. Or a table with wings adhering to each side may 
 l)e placed in position, and the patient tied to the table, with 
 liis head lying on one of the wings, and the affected ear turned 
 downwards; while the subject lies thus, let the wing which is at 
 the feet be violently struck; thus there is concussion of the ear 
 and what is contained in it drops out." The surgery of modern 
 times gives many rules for the removal of bodies from the ear, 
 the suggestions to which may be found in these lines of Celsus. 
 
 Should the patient be a child, the facility and security of the 
 work will be promoted by first administering an ancesthetic. 
 And before commencing the work of extraction, it should first be 
 certainly determined that a foreign body is in the ear; and this 
 can be done by the aid of a speculum and direct or reflected 
 light. When the object is once seen, there is no risk of a fruit- 
 less search for something, as has occurred when sucli precaution 
 was neglected. 
 
 Before resorting to instruments, the Celsian plan of concussion 
 should be tried ; for this, place the head horizontally, with the 
 ear directed downwards; then by gravitation the body may fall 
 out; and to aid this, the head may be shaken. 
 
 As instruments used for this work are a common syringe, a 
 minute curette, and a small tenaculum, similar to that used in 
 ophthalmic surgery. 
 
 In almost all cases, the injection of water into the passage will 
 dislodge a body lodged there ; this painless and simple method 
 should be tried in the child, in preference to any other; for, in 
 this way, without even a resort to an ana}sthetic, the object can 
 be removed, especially if this be of inorganic material, which 
 cannot enlarge by moisture. As has previously been intimated, 
 the syringe should be used cautiously; the violent force of water 
 against the membrana tympani has caused fainting, which 
 might be perilous if the patient be under the influence of an an- 
 aesthetic: likewise, as the author has known, the violent action of 
 
FOREIGN BODIES IN THE AUDITORY CANAL. 305 
 
 the v/ater can wound the membrane itself. If the body be a seed 
 or grain which swells in germinating, then it may become so 
 wedged in between the walls that the removal is very difficult. 
 If the injection of waterfalls to remove the body, other means 
 must be tried. Itard, a writer on this subject, advises to let the 
 seed sprout, and then extract by means of the projecting roots; 
 he has omitted to state whether he had tried his plan; his advice 
 is probably an awkward attempt at witticism. To remove an 
 impacted se^d, ansesthetize, if a child, and then through a bivalve 
 speculum, insert a tenaculum in the body and extract. If an 
 attempt be made with a curette, pass this along the upper wall 
 and insinuate it above and behind the upper end of the object. 
 This is facilitated by the obtuse angle which the upper wall 
 makes with the membrana tympani. 
 
 In the adult the object, according to the writer's experience, 
 is oftenest a bearded grain of oats, or the beard from the barley 
 or wheat spike, or a fragment of straw, and such object is often 
 held in place by becoming entangled in cerumen. As a rule the 
 object can easily be seized with a pair of forceps and withdrawn; 
 failing thus, one can resort to the syringe. In both adult and 
 child, if there have been failure to remove by the methods given, 
 the receiving end of a rubber syringe, which would fill the 
 meatus, might be introduced and a vacuum formed by which 
 suction could be made on the body, and the same possibly with- 
 drawn. 
 
 In the work of removing objects from the auditory passage, 
 the careless or ill-adroit hand has often forced the body against 
 the tympanic membrane and perforated it, or otherwise injured 
 its delicate structure. Also the continued contact of the intruded 
 body can open the membrane; and in such case the body may 
 enter the cavity of the tympanum. In this condition, especially 
 if the body be still lodged in the canal, the method mentioned 
 by Celsus of inducing sneezing might be resorted to, thus the air, 
 being forced backwards through the Eustachian tube, might 
 dislodge the object. Or sneezing being induced and the mouth 
 and nose being closed, as directed by Paul of ^gina, the object 
 might be sneezed out through the ear. This old writer says, if 
 one has not succeeded otherwise, let an errhine be placed in the 
 nose, and then close the mouth and nose. Thus it is evident 
 that in Celsus, one has a part of, and in Paul of ^gina, the 
 whole of the procedure of Valsalva, of forcing air through the 
 Eustachian tube. 
 
306 SI KllKRY OF THE EXTERNAL EAK. 
 
 Sliould one fail to remove the body by the methods described, 
 the pUiii advised by Paul of .Egiiia might be resorted to, viz., 
 to partly detach the pinna posteriorly, and thus form a shorter 
 road to the body. This is approved by the anatomist Ilyrtl, 
 tlie aurist Troltsch, and the surgeon Tillaux. To do this Tillaux 
 counsels to incise posteriorly and su[)eriorly, in the furrow 
 between the ear and tlie head, keeping close to the mastoid 
 bone. By this incision the canal is opened at the junction of the 
 cartilaginous and osseous portions. Though one has not short- 
 ened the passage much, yet a more direct view of the object is 
 thus obtained. Some advantage may result from the haem- 
 orrhage from the cut, as thus the inflammation caused by the 
 body is combated. 
 
 In case the body has penetrated the middle ear, as a means of 
 removal it has been proposed to open the mastoid process, and 
 thence forcing air or water into the tympanum exi)el the body. 
 It is scarcely probable that this adventurous method will be 
 tried. 
 
 HiTinorrhage from tJie Auditory Passage. — When blood flows 
 from the ear after the head has been the subject of violence, as 
 from a blow or a fall, it is a matter of importance to determine 
 the origin of tha blood: is its source extra-cranial or intra- 
 cranial; or does it issue from parts both inside and outside of the 
 cranium? If its source be from inside of the head through a 
 fissure from fracture, the injury is one which menaces life; yet if 
 the source be external, the injury is an unimportant one, and it 
 then can arise from injury of one or more of the following 
 structures. Violence that is first received on the chin may be 
 transmitted along the lower jaw to the anterior wall of the auditory 
 canal, and rupturing the lining of the bone, can cause bleeding. 
 The violence may also reach and act on the tym})anic membrane; 
 this membrane contains, both in its outer and inner surface, 
 arterioles, derived chiefly from the internal maxillary artery, and 
 in the membrane the}'' lie alongside of the handle of the malleus. 
 From a rupture of these vessels as observed by Tillaux and 
 Duplay, a considerable bleeding can originate. Also from a 
 rupture of the mucous lining of the walls of the tympanum 
 haemorrhage can arise. And finally from fracture of the mastoid 
 portion of the temporal bone l)lood may pass into the tvmpanum 
 and escape through its membrane if that be torn ; or if the 
 membrane be intact, the blood may flow into the tliroat through 
 the Eustacliian tube. Le Bail, Duplay and others have made a 
 
HAEMORRHAGE FROM THE AUDITORY PASSAGE. 307 
 
 careful study of these points, and have shown that after injury of 
 the head, bleeding from the ear may proceed from some of the 
 superficial sources here enumerated. It must however be men- 
 tioned that though it arise thus superficially, the bleeding may 
 arise from a fracture of the cranium at or near its base; thus a 
 fracture of the petrous bone may open the carotid artery, and 
 violent bleeding take place into the middle ear; such injury 
 would be perilous, and would probably soon be followed by grave 
 encephalic trouble; yet if the haemorrhage originated superficially, 
 it would soon cease, and be accompanied by no symptom indi- 
 cating danger. 
 
 In fracture of the base of the skull in which the petrous 
 part of the temporal is broken, though primarily there may be 
 an escape of blood, yet this may soon cease, and instead, a serous 
 fluid may continue to flow from the ear ; the origin of the serum- 
 like fluid has been a matter of discussion. 
 
 This discharge of fluid resembling serum has been carefully 
 studied by Laugier, and his observations have been confirmed by 
 Nelaton, Chassaignac, Guthrie and others. The fluid is at first 
 stained with blood, yet later it becomes nearly colorless, and may 
 vary in amount from an ounce to as much as two pints. A similar 
 escape of fluid has been observed from the nose in injury of the 
 cranium. The hearing may remain intact while such fluid is 
 escaping. 
 
 Some five theories have been ofiered to explain this discharge. 
 It has been claimed that it originates from the internal ear, and 
 is the liquid of Cotunnius; the enormous quantity often seen 
 disproves this opinion, and especially so when the escape is from 
 the nose, as often occurs. Laugier erred in referring the source 
 to a clot of blood lodged between the meninges and the adjacent 
 bone, whence the serous content escaped; and this was again dis- 
 proven by the small volume of such clot, and the absence of 
 compression, which such coagulum must cause: and the analysis 
 of the fluid made by Chatin, which revealed a great difference 
 between the composition of this fluid and the serum of the blood, 
 quite disproved the notion that such fluid is derived from a clot. 
 And a similar objection can be urged against the opinion of 
 Chassaignac that the fluid is from veins of which the walls have 
 been thinned by stretching or tearing. Guthrie believed the 
 source of the fluid to be the arachnoid membrane. The true 
 source of this fluid is the liquor cerebro-spinalis; the arachnoidean 
 cavity containing this is opened at a dependent point, where 
 
308 SURGERY OF THK EXTERNAL EAR. 
 
 the auditory nerve enters tlie internal auditory meatus, and 
 thence tlirough a fissure it may reach the middle ear. Besides 
 this route ingeniously traced out l)y IVrard, it is probable that 
 the thin bony roof of the tympanic cavity might be fractured and 
 the fluid find egress there. 
 
 Concerning the intra-cranial source of such fluid, there can be 
 no such doubt as is often the case concerning blood escaping from 
 the ear, since in respect to the former there is no other fluid with 
 which it could be confounded. 
 
 Mastoid Cavity. — The cellular antrum of the mastoid portion 
 of the temporal bone is an important appendage to the middle ear, 
 which in recent times has become one of the added fields of sur- 
 gical occupation: or it may more properly be said, a section which 
 having once been abandoned, has been reclaimed; for, as early 
 as 1770, Ja.sser opened the mastoid antrum, so as to have a .shorter 
 road to the tympanum, through which injections could be made 
 to remove obstruction in the Eustachian tube: and, at the same 
 period, it appears to have been done to obtain a more direct open- 
 ing into the tympanum than the Eustachian tube, in case of 
 deafness from closure of the latter; and with this object the 
 mastoid cells were opened by Jasser, in the case of Just Berger, 
 the royal Danish physician; but as the operation caused his 
 death, the procedure was quickly abandoned, and for more than 
 half a century afterwards, there are recorded but three cases in 
 which the operation was done. In 1847 Dieffenbach speaks of 
 trej)hining the mastoid process as an operation which has been 
 abandoned, and he says that it should be stricken from the list of 
 surgical operations. About 18G0, however, the operation was 
 resumed again; and, due to the efforts of Schwartze, Pean. Buck, 
 Schede and otliers, it has been given a merited and an enduring 
 place in operative surgery. 
 
 Some anatomical description should be jjremised of the bony 
 structure in which the mastoid cells are lodged. 
 
 Externally, the cells are bounded by a wall of bone which 
 se[)arates them from the skin, and the thickness of this wall 
 varies from one to three lines; and according to Huschke this 
 difference is not dependent on age,sex,or the volume of the mastoid 
 process. Tillaux, however, finds it dependent on age, and that 
 in the old person, it may be reduced to extreme thickness. The 
 inner wall, a thin glass-like plate, has close relations with the 
 lateral sinus; relations which luive been fatally learned by the 
 indiscreet trephine; for through this wall venules pass to the 
 
MASTOID CAVITY, 309 
 
 sinus, along which disease may travel from the affected cells, 
 and cause phlebitis and thrombus. The sinus lies on the 
 inner face of the mastoid process, and nearest to its anterior 
 border. (Tillaux.) 
 
 In front, the mastoid cells are separated from the auditory 
 canal by a layer of compact tissue, and the relations witli the 
 canal and tympanum are such that pus can escape from the 
 antrum into the auditory canal without entering the tyrnj^anum; 
 and conversely, pus developed in the canal can pass through this 
 anterior wall into the mastoid antrum, and thence travel into tlie 
 cranium. 
 
 With these topographical conditions, as Tillaux has pointed 
 out, pus in the mastoid region may have the following situa- 
 tions: pus may originate on the outer wall of the mastoid cells 
 and afterwards traverse the wall and appear inside. In a second 
 form, the pus may pass from the tympanum into the cells. Or 
 the pus from one of these sources may penetrate the inner wall 
 and attack the encephalic structures: hence, as to site, the pus 
 may be extra-mastoicl, intra-mastoid or intra-cranial. 
 
 Whatever situation the purulent collection may occupy, the 
 proper treatment is to make a free opening through which the 
 pus can be evacuated; and for this work the services of the 
 general surgeon will sometimes be invoked. The indication is 
 urgent and imperative; for if the diseased material once traverses 
 the thin plate which separates it from the brain, the patient's life 
 is often lost. All those operated on, however, do not recover: 
 Poinsot has made a collection of ninety-one cases in which the 
 mastoid bone was opened for the liberation of pus; of these fifteen 
 died and seventy-one were cured. These figures justify the oper- 
 ation, even though some of the cases might have recovered with- 
 out surgical intervention. Still non-interference is unwise, for 
 nature, possessed as she is of unlimited time for her work, too 
 often appears too tardily on the scene with relief; the lethal work 
 of disease has been completed through the pus seeking an intra- 
 cranial route rather than an extra-cranial outlet. 
 
 The work of opening the mastoid cells has been done with 
 the gouge, the drill, the trephine, and the chisel and mallet; the 
 gouge, chisel and mallet are the best; though in cases in which the 
 wall is very thin, the opening might be made with any species of 
 cutting instrument. 
 
 The operators, though in accord in reference to carefully 
 shunning the lateral sinus, do not agree in reference to the point 
 
310 SURGERY OF THE EXTERNAL EAR. 
 
 cit whic'li tliiscan best l)e done. Ilyrtl directs to open tlie exter- 
 nal face of the mastoid process, and not to open heliind this, 
 though the latter structure is properly the mastoid portion of 
 the temporal bone. This is directly the contrary of the advice of 
 Tillaux, who says that the lateral sinus corresponds in the cranium 
 to the anterior border of the mastoid process. Poinsot, who has 
 written extensively on this subject, counsels to do the work by 
 first making a crucial cut through the soft parts; namely, a 
 vertical cut over two inches long, is to begin at the temporal 
 ridge, and thence downwards; tliis is to lie about a half inch 
 behind the concha. The vertical incision is to be intersected by 
 a horizontal cut which lies on a level with the superior wall of 
 the auditory canal. In this work a branch of the ])Osterior 
 auricular arterj' may V)e severed and require torsion or ligation. 
 At the point of intersection of the two cuts, according to 
 Desarenes, one finds near the posterior root of tlie zygomatic 
 process, a slight depression in tlie bone, which, he thinks, is the 
 proper point for opening the wall. Should, however, there be 
 discovered a disease point in the wall elsewhere, this, of course, 
 should be selected for the opening. But wdiatever site may be 
 selected, the orifice made should have a direction inwards, for- 
 wards, and slightly upwards, a direction parallel with the audi- 
 tory canal. The opening must be made with care, especially as 
 one reaches the inner wall. With whatever instrument it is done, 
 the outlet must bo sufficient for the free escape of the purulent 
 matter: and this eidargement of the opening is readily done with 
 small exsecting forceps, of which a good one may be found among 
 forceps used in dentistry. Since the cells, the site of suppuration, 
 do not intercommunicate freely, these should be broken down so 
 that tlie part can be perfectly evacuated. The cavity thus 
 opened must be irrigated daily with some aseptic fluid; carbol- 
 ized or alcoholized water may be used. During tlie period of 
 separation, a drainage tube must be retained in the opening. A 
 number of weeks, or even months, maybe required to complete 
 the cure. The wound, during the period that it is kept open, is 
 the site of an exuberant granulative growth, which must be 
 repressed by potential cauterization. Nevertheless, after the 
 closure, a iibrous neoplasm may a[)pear on the site of the previous 
 wound: a neoplasm resemljling keloid and ver}^ difficult to 
 remove; for, as the writer has verified in a case treated by him, 
 despite radical removal by the knife, like a keloid growth, the 
 neoplasm soon reappeared. In sucli a case non-intervention would 
 
EMPHYSEMA IN MASTOID REGION. 311 
 
 be the better course, especially as the post-auricular site of such 
 growth conceals it from view. 
 
 Ill the scrofulous child suppurative action of lymphatic 
 glands seated on the mastoid process may implicate the latter, 
 and terminate in necrosis of a large part, or of the entirety of the 
 mastoid process. The author has seen instances of this: in one, 
 the entire process became necrosed and was removed. The hear- 
 ing was not affected; but there remained a slight degree of torti-« 
 collis. 
 
 The mastoid process has been fractured by a bullet; such a 
 case was seen by Dupuytren. The sterno-cleido-mastoid being 
 inserted into this bone would tend to displace the fragment down- 
 wards; acting similarly to the triceps extensor cubiti, or quadri- 
 ceps extensor cruris in fracture respectively of the olecranon and 
 patella. There would be, after such displacement, much diffi- 
 culty in maintaining coaptation of the parts. A bandage, as 
 suggested by Hyrtl, would not accomplish the purpose. A plan 
 which might succeed would be myotomy done near the upper 
 end of the muscle. A more certain means of maintaining union 
 would be by metallic ligature. This could be used here more 
 easily than in the case of fractured olecranon and patella, in which 
 it has been employed; in the former fracture,' there is no joint 
 which would be endangered, like that of the elbow or knee. For 
 metallic suture, first drill a canal from above downwards, which 
 beginning above in the mastoid process shall traverse a section 
 of this bone, and be continued longitudinally through the frag- 
 ment below; through this canal, a wire may be passed by which 
 coaptation can be effected, and union secured: treatment analo- 
 gous to that sometimes pursued in cases of ununited fracture. 
 
 Emphysema, called also Pnemnatocephalus, situated in the mas- 
 toid region. — The external wall of the mastoid portion of the 
 temporal bone is often extremely thin, as has been pointed out by 
 Hyrtl; and to an opening through this is due the occasional 
 appearance of a collection of air beneath the scalp, which is 
 similar to a gaseous accumulation in the soft parts elsewhere, 
 and has been named here pnemnatocephalus, and also pneumat- 
 ocele. 
 
 Though air may escape from the mastoid antrum in conse- 
 quence of a fracture of the wall, and insinuate itself beneath the 
 scalp, yet pneumatocephalus proper is that form of trouble in 
 which a tumor containing air has appeared without any antece- 
 dent fracture. In such case, through a weak point, or an opening 
 
312 SURGERY OF THE EXTKRXAL EAR. 
 
 in the outer wall, existing congenitally, the air is forced from the 
 throat into the niicUlle ear, and thence into the mastoid antrum; 
 ' and through the defect in the mastoid wall the air appears 
 beneath the soft parts. For this to occur, strong expiratory effort 
 is required, as in coughing, sneezing, and blowing the nose. 
 
 Costes of Bourdeaux, in 1859, seems to have first observed 
 pneumatocephalus; in 1865, Tliomas of Tours described it as a 
 .tumor of irregular surface, situated behind the ear, and which, 
 by pressure, is reducible, and can thus be caused to disappear. 
 As it disappears, the escaping air can be heard in the ear, and 
 perceived passing into the throat. A similar collection of air 
 can appear on the frontal region, arising from fracture or defect 
 in the outer wall of the frontal sinus. By far the greater number 
 of cases of pneumatocele which have been recorded were situated 
 in the mastoid region. In all these cases, the tumor occui)ied 
 only the upper portion of the mastoid bone, and extended thence 
 upwards towards the summit of the cranium. 
 
 Besides deforming the head by its volume, the pneumatocele 
 becomes a source of inconvenience to its possessor through the 
 whistling sound which arises from the escaping air wdien the 
 patient rests his head on the affected side. The variable volume 
 of the tumor, its temporary' disappearance under compression, 
 and the roaring or whistling sound which arises from pressure, 
 are symptoms which denote the character of the tumor. 
 
 Treatment — As the tumor tends to advance rather than to 
 recede in volume, an attempt should be made to obliterate it: as 
 methods to effect this, the following have been tried: compression, 
 seton, incision, and the injection of iodine. Compression is 
 similar to all other means in medicine which cannot harm, yet 
 are incapable of doing much good; jjueuraatocephalus has been 
 relieved, but not cured, by pressure. Adhesion must be obtained 
 between the bone and the uplifted scali>, else the air will enter 
 and refill the cavity. Some inflammatory action must be awak- 
 ened. The seton has been tried; but here, as in other cases, the 
 irritation excited is too limited. To do the work more thoroughly 
 the cavity has been laid open by a free incision, with the view of 
 obliteration through suppuration and granulative action. The 
 work thus done was too thoroughly done; a case thus treated 
 ended fatally, through the inflammatory action extending tlirough 
 the cranial wall, and causing meningo-encephalitis. Hence 
 incision is perilous and, as a safer method, recourse has been had 
 to injections of the tincture of iodine; in this way pneumato- 
 cephalus has been successfully treated. 
 
EMPHYSEMA IN MASTOID REGION. 313 
 
 111 the concluding section to this chapter on the surgical 
 affections of the ear, the writer will refer to a class of cases in 
 which suppurative action beginning in the tympanic cavity, or 
 mastoid cells, has passed into the cranial cavity. Such pus in 
 its intra-cranial immigration might pass upwards and appear in 
 front of the petrous portion of the temporal bone; or it might 
 appear external to or contiguous to the lateral sinus ; or it might 
 travel behind the lateral sinus, and affect the cerebellar portion 
 of the brain ; that is, pus forming in the middle ear might enter 
 the middle cranial fossa, and involve the contiguous cerebrum 
 with its membranes; or it might appear in the posterior fossa 
 and involve structures beneath the tentorium. Pus in these 
 positions,, if in large amount, would cause symptoms of cerebral 
 compression: there would be mental unconsciousness, coma, a 
 slow full pulse and probably dilatation of the pupils. With 
 such symptoms, if trephining the mastoid process did not detect 
 pus, one would be justified in pursuing the search further, viz., 
 to seek for pus inside of the skull, by opening the wall. For this 
 purpose, lay bare the skull above the mastoid bone, and apply a 
 trephine above the superior root of the zygomatic process, viz., 
 above that ridge which is continuous with the temporal ridge. 
 An opening could be safely made here ; and through such 
 fenestra one could examine and determine the condition of 
 structures which lie in the petroso-squamous interspace; and 
 also the search might be continued inwards over the roof of the 
 tympanum, through which disease sometimes passes into the 
 skull. Such explorations can readily be done by detaching and 
 uplifting the membranes with a blunt dissector. Should no pus 
 be found, and yet the membranes present signs of disease, an 
 opening should be made in the latter, through which, if pus be 
 discovered, an outlet will be provided through which the con- 
 cealed material can escape. If the search for purulent material 
 prove fruitless at this point in the squamous portion of the 
 temporal bone, then an opening should be made through the 
 suture which separates the mastoid from the occipital bone; here 
 there would be some risk of injuring the lateral sinus. By such 
 exploratory trephination, intra-cranial pus whether of tympanic 
 or mastoid origin might be found, and an outlet for it furnished. 
 If pus be found, the site of it should be antiseptically irrigated, 
 and free drainage be provided through a tube, and downward 
 lateral position of the head. In this unusual manner of proceed- 
 ing some opportunity would be offered to the patient of saving 
 21 
 
314 SURGERY OF THE EXTERNAL KAK. 
 
 his life, wliich, without surgical interference, would certainly be 
 lost. 
 
 In former days, when penetration of the cranial wall and 
 search for disease were forbidden or neglected, the writer recalls 
 fatal cases in which the procedure here advised would have 
 offered the patient a chance to escape from death. Some work in 
 this, but little trodden, field has .successfully been done by Mac- 
 Ewen : work original and of great interest, and reflecting high 
 credit on its author. Under his guidance, no one need hereafter 
 dread the dural sinuses. 
 
CHAPTER Vlir. 
 
 SUKGERY OP THE FRONTAL REGION. 
 
 Frontal Region. — The frontal region, bounded above and 
 laterally by the hair, and below by the occular cavities and the 
 nasal region, is the seat of a number of surgical affections, and 
 these, proceeding from without inwards, are located in the skin, 
 the periosteum, and the bone. 
 
 In the skin during the evolution of puberty, and continuing 
 a few years afterwards, the sebaceous glands are often the site of 
 abnormal activity, in the form of acnaceous eru]:)tion. Sebaceous 
 acne bears a resemblance to the atheromatous cyst; the former is 
 a miniature model of the latter; and the opening which maybe 
 found in each, is of similar size. Acne, though occurring on the 
 cheeks, is especially conspicuous on the forehead, and from tlie 
 unsightly appearance which it gives the forehead, it becomes a 
 source of sorrow to its youthful possessors: a sorrow that the mir- 
 ror multiplies; and though time will eventually relieve him of 
 his anguish, yet that method of relief is too tardy for youth; so 
 that physician, surgeon, and specialist are often appealed to. 
 
 Treatment. — A simple means of relief, and sometimes cure of 
 this affection, is the use of strongly alkaline soap, such as is often 
 manufactured in the farmhouse. An article similar to this is a 
 species of soap sold by the cliemist under the name of German 
 green soap. Let either of these articles be rubbed well on the 
 affected parts at night; and on the following morning let this be 
 washed off. A repetition of this application a few times often 
 removes the acnaceous points. Another remedy that may be 
 employed for the same purpose is corrosive sublimate in an emul- 
 sion of sweet almonds, viz., in the proportion of two grains of the 
 sublimate to an ounce of the emulsion; this should be applied 
 twice a day. A third remedy is an ointment of calomel, viz., five 
 grains of the submuriate of mercury to an ounce of spermaceti 
 ointment, applied twice daily. These local remedies are preferable 
 
 (315) . • 
 
31G SURGERY OF THE FRONTAL REGION. 
 
 to the methods, sometimes adopted, of pressing out tlie hardened 
 sebum, or of splitting the cup-shaped cavity and expressing the 
 contents. 
 
 The frontal integument is the site of benign and malignant 
 growths; the latter class is so rarely seen here that our attention 
 will be limited to a consideration only of the benign neoplasm. 
 
 The verrucose or warty growth seldom appears on the frontal 
 integument; yet it may do so, and is then most frequently where 
 the hairless skin meets the scalp ; and the site there may inter- 
 fere with the head-dress. The removal of- such growth is best 
 done by means of a circumscribing incision, which, to be effectual, 
 must reach quite through the derm. If the gap made be large, 
 it should be closed by a suture. 
 
 Lipoma frequently occurs in the integument of the frontal 
 region, and is usually of the fibrous species, in which fibrous 
 tissue is the predominant element of the growth. The most 
 ordinary site of this growth is on the frontal tuberosity, and its 
 origin there is probably due to the long-continued pressure of the 
 hat, or some article of head-dress. It is oftener seen in the male, 
 doubtless referable to the weight and pressure of the hat on the 
 upper part of the forehead. If such growth attains a volume 
 which interferes with the dress of the head, it should be removed. 
 For this i:)urpose an incision, directed horizontally or vertically, 
 should be made through the skin to the growth, and when this is 
 reached, it is to be uplifted with a tenaculum and dissected from 
 the under surface of the skin, to which it is closely adherent. And 
 this detachment is tedious, owing to the close adherence of the 
 skin to the tumor, which in flattened form, due to pressure, is 
 intimately joined to the skin; in fact, this adherence to, and fusion 
 with, the skin is the distinguishing characteristic of the frontal 
 fibro-lipoma. The connecting bands of adhesion must be patiently 
 cut asunder with scissors or scalpel; for it cannot be rapidly 
 lifted out of its recess, as one does with the normal lipoma. The 
 irregular wound made by such dissection does not heal rapidly, 
 as a rule, and will require much care in dressing to avoid an 
 unsightly scar. Since the site of this scar is such as to render it 
 conspicuous, the operator must study to lessen and conceal it as 
 much as possible, and to do this the line of incision should be in 
 one of tiie wrinkles or furrows which often exist in the frontal 
 tegument; and since the vertical or horizontal furrows may pre- 
 dominate in depth, the deeper one should be chosen for the incis- 
 ion; usually this can best be done horizontally. 
 
FRONTAL REGION. 317 
 
 The angioma often occurs congenitally in the frontal region ; 
 and the vascular growth presents itself in various forms; there 
 may be only a miniature point, or it may embrace a large space ; 
 it may be definitely bounded, or, without clear limit, it may vanish 
 insensibly in the adjacent structure. It may be venous in struc- 
 ture, or arterial and venous elements may be intermingled. It 
 may be situated only in the surface of the skin, in the form of the 
 so-called wine-mark; or it may occupy the papillary structure 
 of the derm, or it may extend quite through the skin. Varicose 
 dilatation seldom occurs here. Appearing as a speck in the new- 
 born child, it may soon grow, and, in a few months, spread over 
 a large surface. Within eight months more than half of the 
 frontal region was occupied by the vascular growth, in a case 
 seen by the writer. Again, having attained wide dimension, it 
 may cease to grow, and may even recede and vanish. 
 
 For further description of the angioma and of the means 
 employed for its extinction, the reader is referred to a previous 
 chapter of this work, in which this subject has been fully con- 
 sidered. 
 
 The frontal wall of the cranium is the occasional site of 
 exostosis; and this may spring from the outer plate, or from the 
 diploetic structure. Such osseous growth has been found most 
 frequently at the site of the frontal tuberosities, or near the junc- 
 tion of the frontal, ethmoid and superior maxillary bones; and 
 in this latter situation the osteal growth can encroach on the 
 orbit. Such growth demands surgical aid, both to free its pos- 
 sessor of deformity, and of obstructioi^^to the subject's head-dress. 
 
 The exostosis, here as elsewhere, must be excised from its parent 
 bone; and to guard against re-growth, the excision must include 
 the external plate of the cranial wall, and should reach slightly 
 beyond the growth. If the section made be a smooth one, the 
 wound will heal quickly, with but slight scarring. 
 
 The secondary manifestations of syphilis seem to have .a 
 preference for the frontal region as field for their development. 
 In the dermal structures Venus displays the elements of her 
 varying coronal chaplet in the diverse forms of rashes which, 
 enumerated in climacteric order, are maculated, papular, squa- 
 mous, vesicular and pustular. After these eruptions have taken 
 possession of the surface, the disease, like a Messalina, in orderly 
 disorder revels in riot, and seeks ground for further occupancy 
 in the deeper structures, in the form of the syphiloma or 
 gummatous tumor. The gummatous growth develops within 
 
318 SURGERY OF THE FRONTAL REGION. 
 
 the derm, tlie pericranium, the bony wall, and then, if followed, 
 it may be found in the dura mater and brain. 
 
 The superficial syphilides, if tlie patient receive early and 
 proper treatment, will vanish and leave no trace; but neglected 
 until the pustules have destroyed the surface and ended in ulcer- 
 ation, then, though the disease be controlled by treatment, 
 enduring vestiges of it will remain. 
 
 The gummy growth in its site can be limited to the derm; 
 oftener it arises from the periosteum, and implicates the wall of 
 the skull. In each situation it may, under proper local and con- 
 stitutional treatment, disappear by absorption, and leave only 
 slight marks of its previous existence: viz., such fortunate ending 
 is often obtained by the topical use of iodine, and the internal 
 administration of mercury and iodine. In many cases, however, 
 the gummy growth ends by caseous and sup|>urative change; and 
 then, if the soft parts are the site, they become the site of chronic 
 ulceration, of which the healing is tedious. But in those cases 
 in which the gummata arise from the periosteum, or still deeper 
 from the diploetic structure of the frontal bone, then extensive 
 caries may be the event, in which the outer plate, or the entire 
 thickness of the wall, may be destroyed. When the gummata 
 occupy large districts of the bone, these growths in their regressive 
 change may, by depriving the osseous tissue of its nutrition, 
 cause death of separate sections; or a large mass of the vertical 
 portion of the os frontis may become necrosed. Caries or death 
 of small sections of the osseous structure is oftenest seen in the 
 supra-orbital ridges; the txternal portion of those ridges is a 
 frequent site of syphilitic caries. Whether the necrosis be on a 
 large or a small scale, the dead structure must be removed; also 
 the affected bone bordering the necrosed portion must be excised. 
 This rule is specially incumbent when the caries is in the form 
 of a fistula, in w^hich form it often penetrates the entire wall. If 
 such fistula be merely curetted, it will not close, but caries will 
 soon reappear in the sides around. Where large portions of bone 
 are necrosed, they should be removed through incisions made in 
 the soft parts; and, at the same time, marginal portions which 
 are diseased should be excised. And the operator should ever 
 bear in mind that this local excision is but plucking leaves from 
 the tree, which also must be attacked by collateral constitutional 
 treatment, plied rapidly, persistently and thoughtfully. 
 
 Frontal Sinus. — The frontal bone is the site of two hollow 
 spaces, which are situated above the root of the nose, and each one 
 
FRONTAL SIXUS. 319 
 
 lies respectively over the inner portion of the orbit. Similar to 
 a monstrous diploetic cell, they are situated between the inner 
 and outer plates of the cranial wall. These spaces, filled with air, 
 communicate b}^ means of an infundibuliform opening with the 
 middle nasal meatus. They are absent in childhood, and only 
 begin to appear when the subject is over ten years of age, and at 
 eighteen years these cavities have nearly reached full develop- 
 ment. Their appearance is, in some measure, coincident with 
 puberty; yet in a few subjects they never develop, and when 
 present, they vary much as to dimension, being, in some cases, 
 very diminutive. If a section be made of a skull, in which the 
 sinuses are of normal dimensions, the space will be found to be 
 pyramidal, the base resting on the partition which sej^arates the 
 two, and the apex lying over the external orbital j^rocess. One 
 is usuall}'' larger than the other, and the separating portion does 
 not lie in the median line. Each sinus will contain, on an aver- 
 age, a half drachm of water. They are lined by a mucous mem- 
 brane, which is white, smooth, thin and non-vascular, thus differ- 
 ing from the mucous membrane which lines the nasal passages, 
 which is much tlncker, very vascular, and studded with glands, 
 which do not exist in the lining of the sinus. This mucous 
 membrane has a ciliated epithelium, is provided with nervous 
 filaments, and its deeper stratum readily ossifies. 
 
 This larger air cavity is tlie subject of accidental injury and 
 disease. Fracture has here occurred; likewise, gunshot wound. 
 In case of fracture, the outer plate alone may be broken, and 
 forced into the sinus, either as depressed bone, with attachment of 
 the fragment to the bone adjacent, or the fragment maybe quite 
 detached and lie loose in the hollow space. And, lastly, from some 
 penetrating object, as a piece of broken glass pottery, or a pointed 
 object, both walls may be broken. The error has been made 
 of mistaking fracture of the outer wall, accompanied by depres- 
 sion, for fracture which implicated both outer and inner plates; 
 for in the former, similar to what is seen in the latter, blood, 
 tissue or pus may rise and sink in the cavity, and such motion may 
 be wrongly referred to encephalic movement, while it is merely 
 caused by the action of the air in the nasal passages. A French 
 surgeon records such a mistake made in the diagnosis of an 
 injury made in this region. If the probe failed to determine the 
 extent of the injury, light on its nature might be gotten by letting 
 the patient breathe through his nose, or suspend the breath for a 
 few seconds; in either act the fluid lodged in the sinus would 
 remain quiescent. 
 
320 SURGERY OF THE FRONTAL REGION. 
 
 A simple fracture with only depression of the bone, without 
 opening throu<;li the skin, if not a signal deformity, sliould be left 
 to the care of nature; should, liowever, the deformity be striking, 
 by drilling a small opening, the bone might be restored to its natural 
 place. If, with an open wound; the bone has been broken and a 
 fragment lies loose in the sinus, this must be removed, through 
 the existing opening if this is possible, or if this be too small, 
 enlarge it. In such injury, unusual care should be given to secure 
 occlusion by means of aseptic dressing, lest exposure of the 
 fractured bone should permit the broken margins to die, and thus 
 a tedious healing result. 
 
 The frontal sinus has been opened by gunshot injury, and the 
 missile has lodged and remained for a long time in the cavity, 
 and if the missile were so impacted as to be motionless, it might 
 be left there; the anxiety of the patient would seldom be content 
 with such inert conservatism. The ball could be removed by 
 an opening made with the trephine. The missile, in a reported 
 case, escaped through the nose. 
 
 Larvse of insects, in botii man and animals, have entered the 
 sinuses from the nose, and have developed there. Di.slodgment 
 of such intruders has been effected by arsenical vapors; it is 
 probable that the fumes of tobacco would be an equally efficient 
 as well as a much safer agent to be used, and to many patients it 
 would not be repulsive. 
 
 Blumenbach mentions a case of a curious intruder into the 
 frontal sinus, viz., a many footed insect named scolopendra elec- 
 trica, which, safely housed, tortured its bearer for over a year. 
 Osteoma originating in the frontal sinus was the matter of 
 research by Dolbeau, in 1871. He says that the osseous growth 
 proceeds from the mucous lining, and, hence, that it is easily 
 removed when the front wall of the sinus is opened; in fact, that 
 such osteoma can be lifted from the cavity of the sinus as readily 
 as a stone can be removed from the bladder to which an opening 
 has been incised. Richet asserts that the removal is more diffi- 
 cult; he cites cases in which it was necessary to chisel the growth 
 from the bony wall of the sinus. 
 
 The lining of the sinuses is the site of an excretion which, from 
 morbid change of the generating membrane, may become muco- 
 purulent. As long as the outlet into the middle nasal meatus 
 remains open, this material would have free outlet; but should 
 the funnel-shaped orifice become occluded, then this content 
 would be retained, and induce disease in the containing wall; 
 
FRONTAL SINUS. 321 
 
 and, if unrelieved, the continued increase of the muco-pus, by 
 pressure, would reopen the normal outlet, or pierce the front wall 
 of the sinus. The pent-up material, from the author's observa- 
 tion, singularly and fortunately enough, spares the posterior thin 
 wall, and causes caries of some point in the anterior wall, which 
 finally opens and allows the content to escape. 
 
 Before the appearance of pus through the nose or the anterior 
 wall of the sinus, it would be difficult to determine its presence 
 there, and the only trustworthy means of doing so would be to 
 make an opening into the cavity; and this could be done through 
 the nose, or, more directly, by drilling a small opening through 
 the anterior wall; the latter would be the preferable way, since 
 afterwards through such opening a flexible probe or silver wire 
 could be introduced and carried to the lower angle of the sinus, 
 and the occluded outlet opened. And even a drainage tube 
 might be carried from the sinus into the nose, and be tied and 
 retained in place for what time would be requisite for the recov- 
 ery of the cavity. To hold the tube in place, a thread should be 
 fixed to its U23per end, and at its point of attachment so enlarged 
 by a knot as to i^revent the tube from escaping unless considera- 
 ble traction be made on it. This thread will lie alongside of the 
 tube in the middle nasal meatus. Through this tube the sinus 
 can daily be washed out with some antiseptic fluid; meantime, 
 any fluid excreted there can readil}?- escape. And when the 
 escaping material denotes a return to health, the tube can be 
 withdrawn by making traction on it and the thread at the same 
 time. It is probable that the tube would have to be retained in 
 place for three months at least, before the sinus would be restored 
 to healthy condition. 
 
 When, however, the case comes into the surgeon's hands after 
 the sinus has opened entirely, and there is a fistulous opening 
 where muco-pus opened, then another course of treatment will 
 be demanded. In such a patient, the anterior wall of the sinus 
 will be found in a carious or semi-necrosed state: a condition 
 most unfavorable to healing. Five cases of the kind have been 
 seen and treated by the writer: the sinus had an opening piercing 
 the anterior wall. In one of the cases, the orifice was beneath the 
 superciliary arch, where the orbital plate ends in the vertical 
 portion of the os frontis; in three others, the opening was 
 slightly higher than the point here mentioned; and in a fifth 
 one, the orifice into the sinus was near the middle point of the 
 anterior wall of the sinus. In the patients here mentioned, who 
 
322 SURGERY OF THE FRONTAL REGION, 
 
 were all adult men, the following were the causal agencies: ir. 
 one, the affection of the sinus was the sequel of measles, con- 
 tracted after puberty; in one it was from constitutional syphilis; 
 in a third, the cause was traumatic, in which the bone had been 
 fractured with an open wound of the soft parts: in a fourth it 
 was traceable to scrofula, and in a fifth man it was doubtful 
 whether it had syphilitic or scrofulous paternity. 
 
 In the four cases which originated in constitutional disease, 
 deep-seated pain of a neuralgic character had preceded the open- 
 ing of the sinus for a long period. 
 
 In the patient, in whom the sinus was opened by fracture due 
 to violence, there was a persistent trial of various means to effect 
 a cure: injections of iodine and other stimulating agents were 
 used topically with the object of restoring the inner wall to a 
 sound condition. In this way the discharge was temjjoraril}' 
 arrested; yet this soon reappeared. Curetting the cavity was 
 also ineffective. The man retained his diseased sinus for over a 
 year, when he died from a chronic diarrhoea, which seemed to 
 have no connection with his local trouble. A necropsy was 
 made, from which it was apparent that the local treatment which 
 had been pursued, had fallen far short of restoring the diseased 
 wall to integrity. In fact, when the anatomical conditions pres- 
 ent are considered, it is seen that they are wholly unsuited to 
 effecting a cure: the breach in the wall cannot bridge over with 
 osseous structure. And even if such closure were possible by 
 dermal covering, and though the usual outlet of the sinus were 
 reopened, it is probable that the latter would become occluded 
 again, and tlie pent-up excreta would force a passage through 
 the point which had been closed. These facts, and the failure to 
 accomplish anything satisfactory by conservative topical treat- 
 ment, convinced the writer that the proper way to treat such 
 cases is excision of the anterior wall and total obliteration of the 
 sinus. In this way four cases have been treated with successful 
 result by the writer. To perform this osseous exsection, the soft 
 parts covering the anterior wall should be carefully uplifted by 
 means of a long-horizontal and a short-vertical incision ; tlie verti- 
 cal cut should end over the inner angle of the eye. Next, by 
 means of a pair of forceps, which is used by the dentist for alveolar 
 excision, the removal is done by inserting one blade of tlie forceps 
 into the cavity, and excising a portion of the border of the outer 
 wall. This work of excision by piecemeal can l)e continued in 
 all directions, until the whole of the necrosing wall is removed. 
 
TREPHINING OVER THE FRONTAL SINUS. 323 
 
 As remarked before, the inner wall of the frontal sinus is found 
 but slightly affected in these cases; and whatever abnormal 
 structure is discovered there, can be scraped off with a curette. 
 The wound is now to be sprinkled with iodoform, closed by suture, 
 with provision made for temporary drainage; this latter can be 
 removed in the fourth day. There will be recovery in from three 
 to four weeks. This speedy healing is in marked contrast with 
 the long and tiresome efforts which are often made in such dis- 
 ease to obtain a cure by conservative means, which end in failure. 
 In the case which had arisen from an exanthematous affection, 
 the writer ran through the list of topical means, including curet- 
 ting, with the only result to see the suppurative action soon 
 reappear. After tliis radical excision (the first case in which 
 it was tried) both patient and operator were surprised to see the 
 part entirely healed at the end of twenty days. 
 
 The question is asked: Does this exsection not leave a formida- 
 ble scar and change of form? This, in fact, is a serious objection 
 to the procedure ; a permanent cicatrix with depression of surface 
 remains. But the patient is cured; he is freed from the pus- 
 exuding orifice which hitherto disfigured his forehead; and he is 
 delivered from the necessity of spending some time daily in 
 cleansing this diseased point. Before the operation is done, how- 
 ever, the patient should have these points placed clearly before 
 him, and as he elects, so should the surgeon proceed. In all 
 operations which are done for cosmetic purposes, and which do 
 not concern the life, but the convenience of the patient, the option 
 of the latter, unbiased by persuasion, should guide the operator; 
 the latter should scrupulously withhold his hand from giving 
 that artful touch to the scales, which, too often unperceived, turns 
 them from impartial poise. In all such cases, an excellent rule 
 is to let "even-handed justice present the chalice" to the operator; 
 and if he would willingly accept it, the patient will not err in 
 commending it to his own lips. 
 
 Trephining, how done over the Frontal Sinus. — As site for enter- 
 ing the cranial cavity the region of the frontal sinus is never 
 chosen; sometimes, however, it becomes necessary to trephine 
 there, and then the operation requires some modification. If the 
 same instrument be continued through the outer and the inner 
 plates, when the boring crown reaches the inner plate, it will 
 become entangled with the mucous lining of that plate, and uplift 
 and tear this structure in an irregular manner. To avoid this, 
 Boyer advises to use a larger crown to perforate the outer plate 
 and a smaller one to cpen the inner one. 
 
324 SURGERY OF THE FKOXTAl. REGION. 
 
 Schillbach, of Jena, in ISGO, advised to trephine through the 
 outer j>late, as liad previously been done by Reid, for the removal 
 of neoplasms which arise in the sinus, or which, originating in the 
 nose, extend into the frontal sinus; and such operation maybe 
 required for the removal of a foreign body that has lodged there. 
 In such cases, Schillbach counsels to expose the bone by a hori- 
 zontal and vertical cut over the inner angle of the eye. The 
 opening is to be made at the junction of the nasal bone with the 
 frontal bone. If need be, some bone may be exsected. In three 
 cases, trephining was done in this way. After the trephining has 
 accomplished its purpose, the communication witli the nose 
 should be established, and the opened integument closed hy 
 suture. 
 
CHAPTER IX. 
 
 NOSE AND NASAL PASSAGES. 
 
 The nose, as the portal through which objects of smell are 
 admitted, and by which in respiration air should enter, has recently 
 been abandoned to the specialist; still many of its affections fall 
 within the sphere of general surgery; and prior to studying these 
 affections, it is proper to consider some points in the anatomical 
 structure of the nasal apparatus. 
 
 In its central and promontory-like position the nose is favor- 
 ably situated to receive violence, and avert in some degree its 
 effects from the eyes and front of the cranium. The visible 
 prominent portion is composed anteriorly of cartilage, and pos- 
 teriorly of bone; a disposition likewise protective in nature. The 
 prominent external portion presents a root, dorsum, tip or lobule, 
 sides, wings, septum, and openings of the nostrils. And each of 
 these may vary in outline, figure or volume ; such variety being 
 characteristic of race. And each of these parts of the nose may, 
 through injury or disease, deviate so much from normal type as 
 to become the subject of surgical treatment. 
 
 The dermal integument at the root of the nose is thin, smooth 
 and easily moved on the subjacent bone; but below, where it lies 
 on the cartilage, it is closely adherent to the latter, and is thick: 
 hence, the integument at the root of the nose is suited for plastic 
 purposes, since it admits of displacement; while that covering 
 the cartilaginous portion is ill suited for such purposes. The skin 
 of the nose has a rich vascular endowment; this condition adds 
 to its vitality and favors the rapid healing of wounds here : even 
 if a portion be partially or wholly detached. This vascular 
 quality favors hypertrophy. The skin of the nose is the site of 
 sebaceous glands, of which the distribution is irregular: viz., few 
 glands exist on the dorsum, while they are more numerous on 
 the sides, and most abundant on the wings of the nose : hence, 
 the more frequent derangement, or disease, of the glands in the 
 latter sites. The subcutaneous tissue is thin and loose over the 
 
 ( 325 ) 
 
32G . SOHE AND NASAL PASSAGES. 
 
 nasal bones; but on the cartilages it is thick and closely adherent 
 to the skin. 
 
 The muscles of the nose, greater in name than in material, 
 puzzle the anatomist to clearly demonstrate them, since they are 
 dwarfed to inconspicuous vestiges, except the pyramidalis no.se, 
 whicii, reaching from the root of the nose upwards, is concerned 
 in rhinoplasty, when restoring material is taken from the frontal 
 region. If this muscle be included in the twisted flap, the hitter 
 is lessened by contraction of the muscular element. 
 
 Tiie osteo-cartilaginous framework maintains the nose in its 
 prominent form; and from disease or injury of it, sunken nose 
 can result. The osseous portion consists of the nasal bones, and 
 a partition composed of the vomer and the perpendicular plate of 
 the ethmoid. The nasal bones, arch-like, have great strength, 
 enabling them to resist external violence; but the partition, whicli 
 is less strong, is screened from injury by the protective vault 
 above; in fact, it adds to the strength of the latter. The carti- 
 laginous portion is movable, and, according to the statement of 
 anatomists, cannot be broken, though surgeons have reported 
 such fracture. 
 
 The external skin passes into the nares, and as it penetrates 
 inwards, attiie entrance it contains strong, sliort hairs; but as it 
 reaches farther inwards, it loses its dermal character, and assumes 
 the character of mucous membrane: yet, as mucous membrane, 
 a portion of it is imperfect in excretory function; but tliis is 
 compensated by fluid which is poured into the nasal passages on 
 every side from the adjacent sinuses, viz., maxillary, sphenoidal 
 and frontal. 
 
 ]Mucli of the surface of the nasal fossie is lined by a mucous 
 membrane of a peculiar character, named the pituitary or Schnei 
 derian membrane. The Schneiderian membrane is thicker than 
 ordinary jnucous membrane; this thickness is such that itlessen.s 
 the space of the fossie, and tends to lessen the calibre of the 
 orifices which open into the cavity. It is thick and resistant 
 where it lines the floor of the nares, as well as where it invests the 
 basilar process of tlie occipital bone; but on the turbinated bones 
 it is soft and .pulpy. This membrane is composed of two layers: 
 a deep one that adheres to the bones and cartilages, and is fibrous 
 in structure ; and a superficial one which lies on the jDreceding is 
 soft and very vascular; and above, where the olfactive nerve enters, 
 this superficial stratum is clad by ciliated epithelium. Mucous 
 glands lie in the pituitary membrane. 
 
DEFECTS. 327 
 
 The nasal cavity is divided into a right and left passage by 
 the vertical partition ; and these passages are bounded by an 
 internal, external, superior and inferior wall. The inner wall, 
 usually regular, may be irregular from deflection or deviation of 
 the vertical septum; the outer wall is in the highest degree irregu- 
 lar in surface, owing to the scroll-like form of the turbinated 
 bones which are attached to it and constitute a part of the wall. 
 The upper wall is narrow, and, according to Richet, it measures 
 from one inch and three-quarters to two inches in length. The 
 lower wall, or floor, measured from the anterior nasal spine to the 
 posterior one, is shorter than the upper one. 
 
 Behind the nasal passage lies a space, which, as the frequent 
 site of neoplasm, should be studied by the surgeon. Though it 
 may be represented as having six sides, yet two of these are open, 
 viz., the anterior, which opens into the posterior nares, and the 
 inferior one, which is only closed when the soft palatal veil is 
 uplifted, as occurs in swallowing. The other four sides, which 
 are bounded by walls, are the superior, posterior and lateral. 
 The superior wall, bounded by the occipital basilar process, forms, 
 with the posterior wall, an angle of one hundred and thirty 
 degrees; and if the head be turned backwards, the angle becomes 
 greater, so that the two surfaces are nearly continuous. This dis- 
 position is utilized when it is necessary to pass a tube or sound 
 through the nostrils into the pharynx; such instrument passes 
 without interruption. The posterior wall corresponds to the atlas 
 and axis; it is two-thirds of an inch high. The lateral walls are 
 adjacent to the carotid artery, the internal jugular vein, the vagus, 
 hypoglossal and the sympathetic nerves. On this wall opens the 
 Eustachian tube, at a point on a level with the prolongation of 
 the inferior turbinated bone. 
 
 The nasal fossae are divided, on each side, into three passages 
 by the turbinated bones; these passages are known as the superior, 
 middle and inferior meatuses. The middle meatus, into which 
 open the outlets from the frontal and maxillary sinuses, and the 
 lower meatus, into which the lachrymal canal ends, are the two 
 passages with which the surgeon is mainly concerned. 
 
 Defects. — The nose is the site of defect, which may be congeni- 
 tal or acquired; it may also be the site of injury and disease. 
 
 As congenital defect, a case of absence of the nose has been 
 seen by Maisonneuve : instead of a nose there only existed a plane 
 surface pierced by two openings. This is the only instance of 
 such defect that the writer finds on record. An attempt was 
 
328 XOSK AND NASAL l'ASSA(iKS. 
 
 made by Maisoimeuve to improve the appearance of the part by 
 hfting up a bridgc-Hke fold of skin, provided with a median nar- 
 row portion, whicli being turned inwards, served as a septum or 
 division of the subjacent space. As there was no cartilage to 
 maintain the form, it is probable that, like many examples of 
 restoration of parts by the plastic surgeon, the restored i)art is 
 fairer in description than in actuality. 
 
 Asthereverse of thedefect mentioned, cases have been observed 
 in which nature was too generous in her gifts to the new-born: 
 the infant appeared with a double nose. Also, the new-born has 
 had a nose whicli was much too great in volume. Duplicate form 
 would puzzle, if not baffle, surgical effort; more, however, could 
 be done where there was merely excess of volume; yet even here 
 there should not be haste to intervene. For the infant's nose, 
 which is always shapeless at birth, through the plastic molding 
 of evolution undergoes singular changes, changes by which feature 
 is acquired which is absent in the new-born; for at birth infantile 
 noses are all alike: featureless, expressionless; feature, expres- 
 sion, and character, if an old writer,* be credited, appearing in 
 the changes which growth brings. Hence, in view of the im- 
 provement in form which time may bring to the abnormally 
 large nose of the infant, intervention should not be premature, 
 lest nature be thwarted in her reparative effort. Should, how- 
 ever, the infantile nose have such excessive proportions that 
 time instead of retrenching will add to them, then some of the 
 excess may be removed by cuneiform excisions so situated and 
 directed that when closed by sutures, the remaining part will 
 conform to normal form. 
 
 The entrance of the nostrils of tlje new-born may be abnor- 
 mally narrow; such narrowness, for its relief, does not demand 
 operative interference; care is chiefly to bo directed to })reventing 
 the nose from becoming still narrower, as occurs where there is 
 ulcerative disease. To oppose closure, tamponing plugs should be 
 introduced from time to time. 
 
 Injury. — The nose may be the site of incised, lacerated, and 
 contused wounds, with or without fracture, and there may be 
 fracture without lesion of the investing integument. 
 
 The incised wound occurring from accident, or intentionally 
 made by the surgeon's knife, is not infrequent. Such wound, 
 owing to the vascularit}' of the derm here, bleeds freely; and for 
 
 "^Xoscitur ex nam. 
 
FRACTURE OF THE NASAL BONES. 329 
 
 the same reason, heals readily. This is true of both incised and 
 contused wounds. And even where a portion of the nose has 
 been cut off, the detached part can often be reunited. Beranger- 
 Ferraud has made research in this field, and finds sixty-five cases 
 on record in which the detached portion of the nose was success- 
 fully restored to its place. Martin and Hoffacker have collected 
 a number of similar cases. According to Galen, even though the 
 fragment has been separated from the remainder of the nose for 
 from twenty to sixty hours, yet an attempt should be made to 
 save it, since recovery has been obtained in such cases. In 
 attempting reunion of such fragment, the clots of blood should 
 be carefully washed from it, as well as from the surface to which 
 the former is to be restored. The bleeding must be thoroughly 
 staunched, even though it be necessary to tie a vessel. The raw 
 surface being thoroughly cleansed with alcoholized or sublimated 
 water, the fragment must be fixed securely in position by means 
 of metallic suture, or by the twisted suture. Warm, moist dress- 
 ing should be applied over the part. Cold dressings, used by some, 
 are improper, since the cold must contract the parts and impede 
 the cell-growth requisite for healing. The replaced fragment 
 often remains cold and pale for some time; in fact, for hours it 
 may have a cadaveric hue. Holmes Coote observed an alterna- 
 tion from paleness to redness, and from redness to paleness, and 
 these changes of color continued for two or three days. These 
 facts encourage the surgeon to j^ersevere in his endeavors to save 
 the detached part, in such wounds of the nose, and not to aban- 
 don his efforts until the fragment is surely dead. 
 
 Fracture of the Nasal Bones. — The external osseous fabric of 
 the nose, though having great power of resistance, is not unfre- 
 quently fractured, Hippocrates deemed this injury sufficiently 
 important to devote several chapters to it. Celsus, likewise, 
 wrote a chapter on the same subject. These writers also describe 
 fracture of the nasal cartilages, which is denied by modern 
 surgeons. The classification of Celsus is fracture of parts in 
 front, and lateral fracture. A brief classification, in which the 
 principal attendant conditions are included, is that of lateral 
 fracture, which may be unilateral or bilateral ; subcutaneous or 
 open; and fracture with or without displacement of the broken 
 bone. 
 
 Fracture of the nasal bones is from violence, of which the 
 impact may be directly in front, or on one or both sides; thus one 
 or both nasal bones can be broken. The adjacent nasal process 
 22 
 
330 NOSE AND NASAL PASSAGES. 
 
 of tlie superior maxillary bone, in severe fracture, may also be 
 broken without a wound in the soft parts, or tliere niny be a 
 breach in the mucous membrane, or derm, or in both. As a rule, 
 the external surface is not wounded; the inner or mucous lining- 
 is commonly injured, and, as a result, there is bleeding. This 
 luiemorrhage is ordinarily small in amount; yet a case is recorded 
 in which the patient bled to death from nasal fracture. 
 
 In fracture limited to one side of the nose, tlie broken nasal 
 bone is usually depressed. Or if botii bones be fractured by vio- 
 lence received directly in front, the dorsum is driven backwards, 
 and the nose is flattened or sunken. Again, wiiere the violence 
 has been received on one side, the nose may be deflected or driven 
 wholly to one side, and it will then be inclined towards one cheek. 
 In any of tliese cases, the change of position and alteration of 
 form would clearly indicate the nature of the injury; the surgeon's 
 eye, rather than his touch, would make the diagnosis, for crepitus, 
 which is present in fracture of bones elsewhere, can scarcely be 
 detected in this injury. The injury is not always limited to the 
 nose, for if the violence is not exhausted in the fracture of the 
 nasal bones, it will pass to the ethmoid bone and do further vio- 
 lence by either fracturing this bone, as once claimed, or it will 
 cause concussion of the brain. Hyrtl has experimented on the 
 cadaver by striking and breaking the nasal bones, and yet in no 
 case did he find that the ethmoid bone had been broken; the 
 cribriform plate of that bone is so strong, he thinks, that it can 
 resist fracture in such cases, and, hence, in most if not in all cases, 
 the cerebral injury present is due to concussion. 
 
 Treatment. — The treatment consists of two acts: the restoration 
 of the broken bone to natural site, and the maintenance of this 
 position by proper dressing. 
 
 To restore to normal position the broken, deviated and 
 depressed nasal bone, or bones, a finger, or something similar to 
 it, must be passed into the nose beneath the displaced bone, when 
 the latter is to be lifted and restored to its place. As the surgeon's 
 finger is commonly too large to enter the nostril, hence some 
 smaller instrument must be used, and for this purpose the grooved 
 sound, which always should have a place in the pocket case, may 
 be used. The round end of the male or female catheter can be 
 used for the same i>urpose. Whatever is employed must have a 
 smooth surface that will not wound the mucous membrane. 
 "With the instrument which is used to restore the fragments to 
 site, the surgeon's fingers inust carefully cooperate, and the work 
 
FRACTURE OF THE XASAL BOXES. 331 
 
 of uplifting and molding be continued until the nose regains its 
 natural figure. When the fracture is bilateral, which is usually 
 the case, then the modeling must be done in each nostril; and, if 
 the nasalbones be not displaced directly backwards, one bone is usu- 
 ally depressed and the other uplifted; in such state the modeling 
 consists in pressing one side inwards, and uplifting the other. 
 And as there is concurrent deviation of the septum, this is likewise 
 to be restored to vertical position. If this lateral deflection be 
 overlooked, the calibre of the nostrils would be altered: a condition 
 which might interfere with normal respiration and olfaction; 
 especially with the latter, since, for the- accomplishment of smell- 
 ing, it seems necessary that the current of inspired air should be 
 compressed. Hence, in the endeavor to restore the broken bones 
 to site, the septum should have as much attention as the contain- 
 ing walls of the nose. 
 
 After the restitution of the broken nose to form, means must 
 be employed to prevent the part from becoming misshapen 
 through displacement of the bones; such displacement, it is true, 
 cannot arise from muscular action, as occurs in the case of 
 fracture elsewhere; yet the prominent and exposed site of the 
 nose renders it necessary to guard the parts against derangement. 
 In antiquity we learn from Hippocrates that many forms of 
 contentive appliances were used to retain the broken nose in 
 proper position; says he: "Many errors are committed by piiysi- 
 cians who without judgment admire beautiful bandages, and who 
 especially pride themselves on such appliance for use; for this, 
 bandages of the most varied forins are used ; bandages containing 
 compresses, and in rhomboidal form, so disposed as to present 
 diversified intervals and islets. As has been said, those who pique 
 themselves upon thoughtless mechanical display, are pleased to 
 meet a fractured nose, so as to apply their bandage to it. Then 
 for a day or two the physician struts in delight of his work, and 
 the bandaged patient is also delighted; the latter soon gets 
 annoyed with and is tired of his dressing; but for the phj^si- 
 cian it was enough to have shown that he knew hov/ to apply 
 remarkable bandages. Such a bandage defeats its purpose; for if 
 the nose has been flattened by the fracture, such bandage will 
 render it more sunken." Celsus counsels to maintain the broken 
 nose in position by the aid of an adhesive band, wliich, fastened 
 to the nose, is to be attached to the head behind the ears. Both 
 he and Hippocrates advise to support the fragments b}' means of 
 plugs introduced in the nostrils. But Hippocrates, after his 
 
332 NOSE AND NASAL PASSAGES. 
 
 satirical dismissal of the complex bandages then used as retentive 
 dressing, says that uo coutentive api)aratus is equal to the index 
 finger of the patient, if the latter be attentive and constant. 
 These should be applied, one on each side, and retained until the 
 cure; and if the patient does not do this, the soft fingers of a 
 child or woman may be used instead. "Men, though they 
 would be rid of deformity at any price, will not give care 
 and attention for their relief, unless they suffer, or are in dread 
 of death." Both Hippocrates and Celsus direct that sustaining 
 plugs of soft material be inserted and permitted to remain in the 
 nose, until the bones heal; such obturator was made by Hippoc- 
 rates of whatever soft material was at hand; and he used a 
 portion of a .sheep's lung, yet he preferred a plug made of Cartha- 
 ginian leather. 
 
 These ancient methods, as detailed by Hippocrates and Celsus, 
 contain the fundamental elements of treatment as pursued by 
 the modern surgeon. After the parts displaced by fracture have 
 been restored to normal site, they must be retained so by obtu- 
 rating plugs or tubes, which are in.serted and should remain 
 in the nostrils. 
 
 The obturating supports may be made of almost any material 
 whicli can be molded into cylindrical shape; a convenient article 
 is a portion of a cotton roller. This should be rolled into a hard 
 cylinder about two inches in length, and of sufficient thickness 
 to entirely fill the nasal passage; in the bilateral fracture, two of 
 these are needed. The plug should be saturated with an alco- 
 holic solution, and then smeared with vaseline, and, thus pre- 
 pared, it must be inserted its full length. In the young subject, 
 and where the nose is small, a shorter plug should be used. 
 As the outer layer of the obturator may be displaced in its 
 introduction, it is well to first wrap a fine thread around it 
 several times; and nothing is better for this than the thread 
 which can be detached from the end of a common roller. The 
 little cylinders when once placed can be retained in position by 
 a strip of rubber adhesive plaster, carried acro.ss the nostrils and 
 fastened to the upper part of the cheek. These plugs should be 
 withdrawn and replaced by new ones, as often as every second or 
 third day; if this is not done, they soon become offensive through 
 the .septic matter with which they become impregnated. Instead 
 of this solid obturator, a hollow one may be employed. This has 
 the advantage that the patient is able to breathe through the 
 nose instead of through the mouth, as he is compelled to do 
 
FRACTURE OF THE NASAL BONES. 333 
 
 when the nostrils are wholly occluded. Such hollow plug might 
 be made of a section of a quill, which, if too small, could be 
 enlarged by wrapping about it adhesive plaster or a strip of 
 cotton, or linen cloth. Such hollow obturator might be con- 
 structed of India rubber or metal; but as each case demands a 
 tube of different dimensions, hence the surgeon will find it most 
 convenient to extemporize one, adopting one of the plans before 
 mentioned. 
 
 When the nose has been restored to form, and remains in 
 shape by means of the internal supports, nothing more is required 
 than to apply to the part cold water dressing. It is rare, how- 
 ever, that the internal support alone suffices; to prevent the 
 tendency to deviation to one side which is often present, 
 lateral support is required. Also, where the injuring violence 
 has depressed one nasal bone, and elevated the other, then, a 
 compressive support should be applied on the uplifted side, so 
 placed as to maintain slight pressure backwards. Also, if the 
 uplifted bone has been broken into two or more fragments, then 
 such lateral compress is required to maintain the broken parts in 
 level position; the neglect of this precaution has resulted in an 
 irregular form, unsatisfactory to surgeon, and as much so to the 
 patient. 
 
 This external dressing may consist of two small rollers, of 
 length equal to the nose, covered with adhesive plaster, with the 
 adhesive face turned outwards; and these adhering compressive 
 rollers are to be placed on each side of the nose, and retained 
 there by transverse strips of plaster. The adhesive rollers should 
 be of equal size in case merely lateral support and protection of 
 the injured nose is required; but in those cases in which one side 
 is too much elevated, and must be repressed, then one roller 
 should rest against and press on this side; while a thicker roller 
 must be placed alongside of the bone that has been sunken, and 
 held there by the crossing adhesive strips; thus closed, the 
 uplifted side will be maintained at a proper level, and the side 
 which tends to sink will be protected from pressure. Under 
 such treatment the fractured nose will heal in a period of three 
 weeks, in the adult, and in a less time in the child. 
 
 Fracture of the nasal bones is, in rare cases, associated with an 
 open wound of the soft parts which cover them; and such 
 wound, as a rule, is of lacerated and contused species. Such a 
 complication is certain to entail an unsightly scar; and, besides, 
 it demands a slight deviation from the treatment already described 
 
334 NOSE AND NASAL PASSAGES. 
 
 for subcutaneous fracture; for after the fractured bones have been 
 restored to position, and provision made for their fixation by 
 plugs in tlic nostrils, attention must be given to the external 
 wound. If there be hajuiorrhage, this is to be controlled by 
 torsion; and, that failing, the ligature should be ap})liod. Con- 
 tused and fringe-like margin should be trimmed off; thus the 
 wound is converted into one of the incised type, and lifnling with 
 slight scarring is favored. Should there be unevenness of sur- 
 face of the broken bones, this should be corrected by digital 
 molding. To correct gaping, and to fix the edges of the wound, 
 fine metallic sutures should be used; and these should be so 
 introduced as to effect accurate coaptation of the edges. Lint 
 saturated with alcoholized water may be used as an external 
 dressing. If a fragment of bone tends to rise and form an 
 uneven surface, this must be corrected by pressure over the 
 dressing, maintained by a bandage transversely applied. Such 
 dressing must be examined daily, in order to see whether the 
 bones remain in place. After three days, the metallic sutures 
 may be removed, and fixation continued by means of strips of 
 India rubber plaster beneath the alcoholized dressing. By such 
 management and daily observation of the wound, a satisfactory 
 cure of both bones and soft parts can be secured. 
 
 Growihs affecthig the external surface of the Nose. — The outer 
 integument of the nose may be the site of neoplasms, benign and 
 malignant. The benign growths oftenest seen here are simple 
 hypertrophy and angioma; of the malignant species lu])us is 
 often seen here; a less frequent development is epithelial cancer. 
 
 Hypertrophy of the lobule or lower end of the nose occurs, 
 in those who have passed the meridian of life, and who have 
 been the subjects of acne rosacea. It is occasionally seen in the 
 female, who, as is known, is sometimes affected with this acnaceous 
 affection: yet in the majority of cases of nasal hypertrophy, the 
 deformity is met with in the male. 
 
 This growth involves both the skin and the subcutaneous 
 tissue; the glandular, vascular, and epithelial elements of the 
 skin are greatly increased in volume. This structural augmen- 
 tation is greatest in the lobule; yet it occurs also in the wings 
 and septum of the nose; and, in the worst cases, the entire nose 
 is monstrously enlarged. Hyrtl refers to instances of the kind 
 in which the part attained such dimensions that it reached to the 
 chin, and interfered with breathing, eating, direct vision and 
 kissing. For suggestive reasons the osculatory functions would 
 
GROWTHS AFFECTIXG- THE XOSE. 335 
 
 seldom be interfered with. The hvpertrophr then may affect 
 partially, or totally, the nose; or it may appear in the form of an 
 isolated growth, of which there may be one or several on the 
 nose. Such tumor consists of an irregular aggregation of small 
 lobulated masses; and it may be pedunculated or sessile. The 
 growth is conspicuous for its red or purplish color ; it is tubercu- 
 iated or uneven in surface, and is in a high degree unsightly and 
 deforming: in the male, to whom facial beauty is often a serious 
 detriment, the enormous nose may be tolerated; but in the female 
 the deformity is such as to extinguish whatever attractive lines 
 her face may possess, and even to force her to social retirement. 
 
 The development of this hypertrophy is promoted by what- 
 ever induces congestion of the face, for example, the use and 
 abuse of spirituous drinks. Such congestion is, at first, active in 
 character; later, the dilated vessels remain permanently widened 
 and constantly filled with blood. Cases, however, have been seen 
 by the writer which were not referable to irregular regimen, and 
 which, presenting no remarkable enlargement of the vessels, the 
 growth was pale instead of florid or purple. The patient, how- 
 ever, should be advised to abstain from articles of drink and food 
 which cause facial hypersemia. Tlie subject of nasal hypertrophy 
 rarely appeals for surgical aid until the growth is so advanced 
 that some radical treatment is necessary to relieve the deformity: 
 some procedure which will at once remove the excessive structure, 
 or which will promote its atrophy. As means which might 
 arrest growth and lessen the existing volume, the tincture of 
 iodine, fluid extract of ergot or ergotine, and Fowler's solution 
 of arsenic, may be employed hypodermically; from two to four 
 drops of one of these agents may be injected into the enlarged 
 structure once in two days. If inflammatory action is awakened, 
 the injection should not be repeated until this has wholly sub- 
 sided. For if the part be much irritated, suppuration would be 
 caused, and destruction of a portion of the structure would ensue; 
 thus, though the hypertrophy would be reduced, an unsightly 
 irregularity of surface would result. The fluid extract of ergot 
 used externally will reduce the growth. 
 
 As the acnaceous disease which usually causes the hypertrojjhy 
 has been plied by remedies which were chiefly remarkable for 
 their number and ineffectiveness, the patient is probably ready 
 to accept treatment which will at once remove the disease: and 
 hence he will prefer, or at all events he will not decline, a resort 
 to the knife. The hypertrophied mass should be reduced by 
 
336 NOSE AND NASAL PASSAGES. 
 
 multiple cuneiform excision: enough being removed to reduce 
 the nose to normal form. Inasmuch as it is difficult to know 
 how much should be taken away, it is better to operate twice: the 
 first time doing most of the work, and later finishing it: thus, 
 cautiously proceeding, there would be little danger of rendering 
 the nose too small. Tlie long axes of the wedge-shaped sections 
 should, as a rule, correspond witli the long axis of tho nose; as 
 exception to this may, perhaps, be a section removed transversely 
 from the tip of the nose, in cases in which the no.se remains too long 
 after tlie longitudinal exsections. From the enlarged septum, a 
 longitudinal exsection should be cut, and this should reach in 
 deep enough to provide an ample opening for the nostrils. The 
 remaining wounds must be accurately closed by fine metallic 
 sutures, which should remain in site for one week. The writer 
 has learned from experience in such cases that accurate closure 
 of the wounds is no easy matter where several broad excisions 
 have been made, and hence, to avoid such difficulty, the portions 
 excised should not be broad, and each gap should be closed as it 
 is made. In thus proceeding, the amount of tension caused by 
 closing the wounds will appear, and allowance for the same can 
 be made. The scars which remain after healing are not conspicu- 
 ous, owing to the vascularity of the structure. 
 
 Instead of total enlargement of the nose, a portion of it may 
 be the site of hypertrophy, and this may be so isolated as to 
 resemble a pedunculated growth. In such isolated hypertrophy, 
 whetlier sessile or pedunculated, the procedure of removal would 
 be much simpler than in the condition of total hypertrophy. 
 The part should be extirpated by an oblong circumscribing cut, 
 which would wholly include the affected part. The resulting 
 wound, from its elliptical outline, would be easily closed, and the 
 remaining scar would be linear in direction. 
 
 Angioma. — The nose is a frequent site of angioma. This 
 growth nearly always dates from foetal life. And every grade of 
 it is seen, from the merest superficial speck, to a vascular growth 
 which occupies the entire thickness of the nasal wall. When 
 seated superficially, which maybe limited or cover a large sur- 
 face, the nose is of normal size. But when it extends througli 
 the greater part, or the whole of the wall, the affected part is 
 enlarged. And if this deep-seated species occupy the tip of the 
 nose, the part is developed much beyond the remainder of the 
 nose, and imparts to the figure of the infant a ludicrous appear- 
 ance. As tlie venous element is the predominant constituent, 
 
AXGIOMA. 337 
 
 instead of the red hue as seen in the superficial species, this 
 deep-seated variety presents a bluish or cyanosed hue. 
 
 Treatment. — This vascular development can be removed by 
 subcutaneous ligation, or by partial or total excision. Since sub- 
 cutaneous ligation leaves but few scars, it may be tried, though it 
 is less certain to accomplish the purpose than the knife. To do 
 it, a needle armed with a strong thread is made to enter and 
 emerge at short intervals, around the border of the angioma, 
 until it emerges at the point of entrance; there the two ends of 
 the thread lying in the first opening made can be firmly tied. 
 Care must be used not to overdo this work of concealed circum- 
 scription, lest sloughing be caused. The writer, however, has 
 employed this procedure in an angioma, which occupied the 
 entire nose: and his experience would indicate that it is not an 
 easy matter to wholly arrest the supply of blood to such struc- 
 ture: for the atrophic action induced was insufficient, and it was 
 necessary to repeat the ligation. It is probable that the needle, 
 reentering after emerging, left portions of the periphery unin- 
 cluded. After the work is thus done, the part should be dressed 
 with carbolized vaseline. The case should be kept under close 
 observation, and should it appear that the blood suppl}^ has been 
 wholly cut off, as would be denoted by a continued cyanosed 
 color, then the ligature should be divided, so that the constriction 
 will be lessened; and, if need be, the thread is to be removed. 
 On the contrary, should it be apparent that the constriction is 
 insufficient to effect the purpose, then the ligature must be tied 
 tighter. From what has been said, it is clear that the work 
 should be kept under close observation; and the ligature is finall}' 
 to be removed when it has become loose. 
 
 Should the method of concealed circumscription fail to ac- 
 complish the extinction of the angioma, a resort to the knife 
 should be had, in which the procedure before mentioned used in 
 removing hypertrophy should be followed; cuneiform sections of 
 the vascular growth should be excised, and the wounds made, 
 accurately coaptated by suture. Yet even this23lan, as tlie writer 
 has experienced, may not effect a cure: the remaining vascular 
 structure may awaken to new action, and the unsightly growth 
 reappear. In such case the last refuge of the patient is substitu- 
 tion of normal tissue instead of the vascular, by rhinoplastic 
 means. The material for replacement may be obtained from the 
 frontal or malar regions: preferably from the cheek adjacent, 
 when the vascular structure does not occupy the entirety of the 
 
338 NOSK AND NASAL PASSAGES. 
 
 nose. To operate thus, the angiomatous structure should be first 
 excised, and the haemorrhage carefully arrested: and for this, fine 
 ligatures may be used. Next, from the cheek contiguous, lift up 
 a flap, somewhat larger than the breach to be filled, and fix the 
 same in place by sutures. This replacing flap should be so 
 planned as to have its pedicle near the breach to be filled: and 
 this may be accomplished by having the pedicle situated near the 
 wing of the nose, and the body of the flap directed towards the 
 malar bone. In proceeding thus, the wound on the cheek can be 
 so closed as to somewhat support the flap, and to leave a scar on 
 the cheek nearly coinciding wdth a natural furrow of the cheek. 
 
 Li(jnis. — "Writers are nearly in harmony in makingtwo species, 
 or rather grades, of the disease: viz., lupus ulcerans and lupus 
 rodens; and in whichever form it appears, the disease has a 
 selective preference for the nose and cheek adjacent, for its 
 development. 
 
 Bacteriological researches prosecuted b}' Koch.Neisser, Demme' 
 and others have determined that there is a close kindred between 
 lupus and tuberculosis. Koch obtained cultures from the two 
 diseases which were identical in character and action. As the 
 result of these investigations, the modern pathologist seems justi- 
 fied in naming lupus a tuberculosis of the skin. 
 
 Lupus ulcerans may commenceon the dorsum, point or wing 
 of the nose. It maybe situated on the skin or the mucous mem- 
 brane, or simultaneously on both these surfaces. 
 
 The disease begins on the surface as minute pa[)ules, which 
 enlarge and fusing become larger; and in this latter form they 
 are crowned with a thick epidermal covering. The summits of 
 these nodular eruptions pass rapidly through a vesicular or serous 
 stage and become pustules. If the summit of these be removed, 
 there escapes a sero-purulent fluid, which, drying, the partis cov- 
 ered with a brownish crust. If this crust be removed, there 
 remains an ulcer-like surface, which bleeds when touched, and 
 Ijecomes the site of fungoid granulations. This denuded surface 
 is, at first, level with, or perhaps higher than the adjacent skin. 
 The bounding skin, though red, is not indurated. Later, the 
 disease penetrates inwards, and in time destroys the skin; and 
 even the cartilage and bones may be attacked. This ulcerative 
 process tends to move laterally, more than inwards, so that, as a 
 rule, the supporting framework of the nose is not destroyed; and 
 what is remarkable, the disease, like a fire on the prairie, dies 
 out behind, while it proceeds onwards in its destructive work. 
 
LUPUS. 339 
 
 The scar covering the healed portion is thin, and, for a time, per- 
 mits the subjacent red structures beneath to be seen ; later, the 
 cicatrix thickens and contracts so as to deform the part. And, 
 though healed, there is a tendency in the disease to reappear in 
 parts in which it has previously existed ; and this recurrence is 
 probable where there remain abnormal hardness and redness, 
 and the cicatrix is streaked with fine vessels. 
 
 It is sometimes a question to determine whether the disease is 
 one of lupous or syphilitic ulceration, especially so in a patient 
 of syphilitic antecedents; yet the form of the ulcer in the two 
 diseases is quite different: viz., the syphilitic ulcer has margins 
 clear cut, steep, well-defined, and the adjacent skin stands higher 
 than the denuded part; while lupus has no definite boundaries, 
 the point where the disease ends being hardly distinguishable; 
 and the subject of it is young, in many cases not having reached 
 puberty; hence early youth and ill bounded ulcers would prove 
 the case to be lupous in character. 
 
 Treatment. — Seven months prior to the time when these lines 
 were written, the world believed itself in possession of a cure for 
 tuburculosis whether that disease be in lung, joint, skin, or 
 mucous membrane; and the discoverer of that cure, Robert Koch, 
 was lifted to a position of popular eminence, by the professional 
 and popular press, loftier tlmn that ever attained b}^ any 
 writer, and, it may be added, by anyone within the ranks of 
 medicine. For a few weeks, the radiant personality of this 
 physician as the first star in the firmament of fame, was the sub- 
 ject of reverent admiration of all eyes, and his name was hourly 
 spoken by every tongue of the civilized world. Yet this great 
 medical scientist, who had already secured by his bacteriological 
 discoveries an enduring place for his name on the page of future 
 medicine, committed the error of announcing as fact that which, 
 though probable, had not been fully demonstrated ; tuberculin, 
 the remedy announced against pulmonary tuberculosis, after a 
 test by trial and careful use, disappointed the hopes which had 
 been awakened: so that to-day the clamors of fame which 
 recently deafened the ear of Koch have subsided into expiring 
 echoes; and have almost been replaced by the remonstrating 
 murmurs of public disapjDointment. 
 
 Inasmuch as ulcerating lupus is cognate to tuberculosis, the 
 remed}'' of Koch was tried against it also; and the trials made 
 seem to indicate that tuberculin may arrest or even extinguish 
 this form of lupus. This inoculation, however, demands so many 
 
340 NOSE AND NASAL PASSAGES. 
 
 precautionary guards, lest the reaction caused by it should injure 
 the ])atient, that it is not probable tliat it will ever become a ]iop- 
 ular remedy for the treatment of lupus. 
 
 The treatment of simple ulcerating lupus should be both gen- 
 eral and local. General remedies should be given to combat the 
 scrofulous diathesis which is present; cod-liver oil, iron, bark, 
 and the phosphate of lime should be administered. The prepa- 
 rations of iodine and arsenic may also be given. A nutritive 
 diet should likewise be used. 
 
 As topical means to combat the local destructive ulceration, a 
 number of agents may be selected from the list of escharotics. 
 In the initial stage, ere the disease has invaded the deeper layers 
 of the skin, the author has found much benefit from tlie nitrate 
 of silver; let this, in small cylinder form ground to a point, be 
 thrust into the affected structure,until this is thoroughly destroyed. 
 If the disease has advanced further, and involves tlie deeper 
 tissue, then a more active escharotic should be used; and yet too 
 much destruction must be avoided, for the caustic action should 
 not penetrate through the nasal wall. As agents which will not 
 act severely, one may emyjloy a paste of charcoal and sulphuric 
 acid, of which a layer may be smeared over the affected surface, 
 after the latter has been curetted. Or a paste made by mixing 
 three parts of powdered Radix Sanguinariaj Canadensis w^ith one 
 part of potassa fusa; or one made by saturating salicylic acid 
 with creosote, or with concentrated carbolic acid, may be applied 
 on the curetted surface. Or, as liquid application, one may use 
 nitric acid, carbolic acid, or the acid nitrate of mercury. Finally, 
 the diseased part might be superficially cauterized witli the 
 ferrum candens. 
 
 From his experience with all the destructive agents mentioned, 
 the writer would counsel the use of the mixture of Sanguinaria 
 and potassa fusa, or of that of carbolic acid and salicylic acid; a 
 paste from one of these, applied, destroys the diseased tissues to 
 a slight depth, and forms a crust w^hich, scab-like, adheres for 
 some days and then falls, leaving a surface which heals. As 
 dressing to the part, after the eschar is detached, one may use 
 citrine ointment, diluted with an equal part of adej^s; or anoint- 
 ment containing five grains of biniodide of mercury to the ounce, 
 will promote closure of the wound. In the selection, use and 
 retention of the topical remedy in place on tlie nose, one must 
 bear in mind the intractability of cliildhood, in which the dis- 
 ease often occurs, and take precautions accordingly. 
 
LUPUS RODENS, OR RODENT ULCER. 341 
 
 Lupus Rodens, or Rodent Ulcer. — This disease is closely allied 
 to epithelial cancer. It is probably a severer form of ulcerating 
 lupus. It is cancerous in its appearance, cancerous in its march, 
 and cancerous in its destruction of parts. Like cancer, it nearly 
 always is seen in those who have reached or passed beyond fifty 
 years of age. Unlike cancer, it is seen in those who are otherwise 
 in perfect health; and it rarely implicates the lymphatic glands. 
 
 Rodent ulcer appears on the nose at some point of the skin 
 which is not bordering on mucous membrane, and is oftener an 
 immigrant than an. aboriginal production; for it occurs more 
 frequently on the eyelids and cheeks, and then it passes to the 
 nose; and yet exceptionally, the disease may travel from the nose 
 to the structures contiguous. It commonly begins as an isolated 
 tubercle; in rare instances, other tubercles arise around the first 
 one. The tubercle, whether single or multiple, does not undergo 
 pustular change, but its summit opens fissure-like; this opening 
 being often due to the action of the patient's own nails. From 
 his observation, the writer is certain that the initial tubercle 
 would remain for a long period a harmless growth if it were not 
 stimulated to further development by incessant irritation. Many 
 examples of such irritation will suggest themselves to the experi- 
 enced physician; there is one, however, to which reference may 
 be made, and this is the ill custom into which the majority of 
 persons fall of touching, handling, rubbing and scratching an}' 
 irregular point on the surface of the face. And such habit once 
 established, is nearly incorrigible; when thought is absent, the 
 hand without voluntary guidance seeks the forbidden part, and a 
 nail detaches the epidermal covering. A patient, with such rodent 
 ulcer, stated that, despite the sternest efforts of self-discipline, he 
 found, when attention was withdrawn, that his finger would 
 resume its forbidden task ; and only after the rodent ulcer had 
 attained a dangerous foothold on his face, and fear became a 
 diligent ally of his eff'orts, did the patient break his ill habit. 
 
 Finally, the initial point of the disease begins to ulcerate; 
 and as the ulcer advances, the new growth, in the form of dense, 
 hard tissue, a];)pears around and underneath the eroding breach. 
 The neoplasm with its following ulcer attacks the skin, subcu- 
 taneous fascia, and is not arrested by the bones which occur in 
 its pathway; they, too, are destroyed. Thus the nasal bones have 
 vanished, and the destroying disease continued its course of ruin, 
 until it has reached the cranial base, which, also, it perforated 
 and attacked the brain. The patient, whose face finally becomes 
 
342 NOSE AND NASAL PASSAGES. 
 
 indescribably hideous, often enjoys, otherwise, excellent health; 
 and the lymphatic glands, of which the afferent absorbent vessels 
 lie in the track of the ulceration, do not enlarge. As a rule, the 
 patient has but little pain, were it not for his apprehensions of 
 the future. 
 
 The picture which has been traced of rodent ulcer clearly 
 distinguishes it from the more simple form of ulcerating lupus 
 and syphilitic ulceration; the mild lupoid ulcer is in the young- 
 subject, and its margins are not so hard, nor so uplifted, as are 
 those of rodent ulcer; and the syphilitic ulcer is distinguished 
 by being contagious and, also, more rapid in its course. 
 
 The course of rodent ulcer, as here given, is that which one 
 finds described by the English authorities; and though such a 
 form is sometimes seen, there is evidently a much milder species 
 which is more frequently seen. In this milder species the dis- 
 ease appears as an isolated tubercle; this tubercle finally becomes 
 covered with a dry crust-like eschar. Other tubercles appear 
 as does the first, the whole forming a confluent mass, whicli 
 becomes, like the primary point, invested with a hard brown or 
 black epidermal crust. When this crust is detached, specks of 
 pus and bleeding points appear. 
 
 Treatment. — Inasmuch as the severer form of rodent ulcer is 
 fatall}^ destructive of the part on which it is situated, and, if its 
 course is not arrested, ends in frightful deformity and final death 
 of the patient, it is clear that the treatment which promises the 
 speediest extinction of the disease should be resorted to; and as 
 such means are the knife and the actual and potential cautery. 
 With the knife the work can be done, care being taken that the 
 line of excision be well in the sound tissue. The writer's experi- 
 ence has forced him to regard excision as uncertain, and less to 
 be depended on than the cautery. And what the knife (ferrum) 
 cannot cure, the Hippocratic aphorism tells us fre can cure. 
 The ferrum candens, if properly used, does its work effectively, 
 yet it has the disadvantage of leaving a contracting, shriveled 
 and scarred surface: a species of tissue which is arid and sterile 
 ground, ill suited for the reception of a transplanted rhino- 
 plastic flap. For the reasons mentioned, the surgeon will do 
 better to employ potential cauterization in preference to the 
 actual heat, and, as agent for this, good results will be gotten 
 by applying the paste composed of potassa fusa and Sanguinaria. 
 This should be used immediately after beinj; prepared ; and only 
 a thin layer of the agent should be applied; and even then, the 
 
NOSTRILS AND THEIR DISEASES. 343 
 
 destructive action may extend through tlie nasal wall. A 
 minute breach thus made might be neglected, yet a large one 
 should be repaired by transplanting upon it sound tissue. For 
 the treatment of the milder form of rodent ulcer, to which refer- 
 ence has been made, a less active cauterization will suffice; then 
 one may use the paste of charcoal and sulphuric acid, or that 
 made of creosote and salicylic acid. Tt is sometimes necessary 
 to repeat the use of the escharotic, reattacking the disease when 
 it reappears. 
 
 Carcinoma of the epithelial species may appear originally on 
 the nose, or by transition from neighboring parts, viz., from the 
 cheek or lip. In its initial appearance and subsequent develop- 
 ment the disease closely resembles rodent ulcer; the cancerous 
 disease, however, differs in this respect, that it first appears on 
 the transitional integument which lies between the derm and 
 mucous membrane, viz., on the border of the nostrils. Thence the 
 disease proceeds laterally rather than centrally, and, hence, the 
 title of cutaneous cancer is sometimes used to designate it. This 
 cutaneous cancer sooner or later manifests itself by adjacent 
 metastasis in the neighboring lymphatic glands. 
 
 Cancer, here as elsewhere, has a fatal destiny; yet, akin to the 
 fire, which begins as a spark, and is then easily extinguished, 
 yet later a brigade of firemen can hardly arrest it, so this carci- 
 noma, in its infantile stage as an isolated fissured tubercle or 
 wart, can easily be eradicated; but if the destruction be permitted 
 to proceed until it has poured into the numerous adjacent lym- 
 phatic streams its fertile germinal elements, then surgery with 
 all its arms usually suffers defeat. A treatment, similar to that 
 indicated to be used against rodent ulcer, should be resorted to. 
 The part must be well curetted and then cauterized with one of 
 the escharotic compounds above named; and should, unfortu- 
 nately, there have been so much delay that there is already 
 infection of the neighboring glands, these should also be removed ; 
 such removal being donelesswith the hope of a cure than of staying 
 the disease, and giving the semblance of doing something; ut 
 aliquid fecissevideamur, as Hyrtl says. 
 
 NOSTRILS AND THEIR DISEASES. 
 
 Narrowness. — The entrance of the nostrils may be abnormally 
 narrow or entirely closed; and these maybe congenital conditions 
 or they may be subsequently acquired. 
 
 The unshapen nose of the infant often presents nostrils too 
 
344 NOSE AND NASAL PASSAGES. 
 
 ntirrow at their entrance for free breathing; usually, in the course 
 of development, this imperfection is rectified. In infancy and 
 childhood narrowness may be acquired through some inflamma- 
 tory or ulcerative disease, situated in the nostrils, which, in the 
 process of repair, constricts the nasal orifices. Examples of such 
 disease are scrofulous inflammation and eruptive cutaneous affec- 
 tions, as variola, impetigo, rubeola and scarlatina. The scrofu- 
 lous child often presents a nostril denuded of its mucous coating; 
 likewise, rubeola and scarlatina may act in a similar way; the 
 result being as the surface heals, cicatricial contraction and nar- 
 rowing of the outlet of the nostrils; and this narrowness may 
 extend some distance into the nasal passages. In these cases, 
 during the period of repair of such denuded or ulcerated surface, 
 the tendency to constriction should be resisted by the introduc- 
 tion of obturating plugs which will retain the nostrils of proper 
 calibre. Such obturator should be tubular or hollow; yet, in the 
 want of these, the solid form may be used. For this ])urpose the 
 writer has found a section of a drainage tube to do the work sat- 
 isfactorily. Such tube should be somewhat larger than the 
 nostril, so that it must be comj)ressed before it will enter; and 
 when thus placed, the elastic walls of the tube exercise continu- 
 ous pressure on the walls of the nostril, and not only prevent 
 closure but even enlarge the opening. During this dilating 
 treatment, the affected surface of the nostrils should daily be 
 smeared with some alterative ointment; for this, one may use a 
 dilute mercurial ointment; or an excellent application is an 
 ointment made of iodoform and cod liver oil; also an efficient 
 compound for this purpose consists of fifteen grains of the sub- 
 iodide of bismuth to an ounce of vaseline. 
 
 If the contraction be great, the method of dilating just men- 
 tioned will be insufficient, and a resort to the knife becomes 
 necessary. In such cases, in 1840, Schmitt announced a plan as 
 follows: the opening is to be enlarged by removing sections from 
 the nostrils, and then tannin is to be applied to the wound, and, 
 later, nitrate of silver. This plan has the objection that a raw 
 surface is left, which, in cicatrizing, contracts, and the opened 
 nostril is again lessened in calibre. A better plan, as the writer 
 has found, is to preserve the dermo-mucous membrane, and after- 
 wards use this for covering the wound made. To do this, first lift 
 up a flap and excise structure, in shape and amount sufficient to 
 enlarge the orifice, and then fix by suture the flap that had been 
 formed. The structure is best removed from where the nostril 
 
NOSTRILS AND THEIR DISEASES. 345 
 
 joins the posterior wall, that is, from the posterior part of the 
 outlet of the nostril; thus done, the opening will be elongated 
 antero-posteriorly. This procedure would be unsuited for cases 
 in which the narrowing is due to cicatricial contraction; in such, 
 the opening should be enlarged by excising sections of the orifice, 
 and patency maintained by dilating obturators. 
 
 In case of total atresia of the nostrils, whether congenital or 
 acquired, the imperforate condition may only be superficial, as a 
 membranous operculum; or the occluding structure may extend 
 some distance into the nostril. In such condition the occluding 
 material will require to be excised, and the passage retained open 
 by an obturating tube, which must be used for a long period. In 
 this operative work, if it be possible to cover a portion of the 
 wounded surface with dermal investment, the restored nostril 
 will be more apt to remain permanently open; especially so 
 where, the occlusion being deep, a deep and extensive excision of 
 the parts must be made. 
 
 In the plastic operation of restoring closed nostrils, Velpeau 
 and Jobert utilized the outer wall by paring and folding it 
 inwards upon itself. This method is attended with the incon- 
 venience that the border would be abnormally thick, and the 
 septum would prominently protrude; and were the latter removed, 
 the nose would attract attention by its shortness. 
 
 The sub-se[)tum or inferior portion of the partition between 
 the nostrils is sometimes so pendent, or reaches downwards so far 
 beyond the other portions of the nose, that it is a conspicuous 
 deformity. According to Blumenbach's observations, the Hebrew 
 race is distinguished by prominence of the nasal septum. Cases 
 may occur in which the surgeon's knife may be asked to retrench 
 the superfluous structure. Such was the case in the patient men- 
 tioned by Blandin in whom the prominence of the sejjtum was 
 such that it became an insuperable obstacle to getting a wife; the 
 writer would add that a few cases have been seen by him in which 
 subjects of such deformity were more fortunate than was the 
 patient of Blandin, since they found escape from their enthrall- 
 ment through the magic of coined metals. 
 
 Such deformity should be removed by an operation done so 
 nearly within the nostrils that but slight marks of the cutting 
 will afterwards be visible. To do this, the author's plan is to let 
 the pendent dermal portion of the partition be separated from its 
 posterior attachment, and be dissected so as to hang suspended 
 from the tip of the nose ; next a section sufficiently large must be 
 23 
 
34G NOSE AND NASAL 1' ASS AGES. 
 
 excised from the cartilaginous partition above so that when the 
 pendent flap is restored to place, it will not project, but conform 
 to normal type. The coaptation should be accurately made, and 
 the part retained in position by fine metallic sutures, which 
 should not be removed before one week, that is, when union is 
 assured. 
 
 Chassaignac reports operations for the relief of prominent 
 septum, in which he proceeded somewhat similarly, yet instead 
 of excising a section of the septum in its entire thickness, after 
 uplifting the mucous membrane, he pared the remaining parti- 
 tion laterally, and, thus attenuated, he forced it into position, and 
 then replaced on this the flap-like mucous portion which had 
 been uplifted from the septum. The mode of operating before 
 described is preferable to this one, since the surplus structure is 
 wholly renewed, and the septum is at once restored to normal 
 
 Deflection of the Nasal Septum. — Some deviation of the septum 
 is, in many cases, congenital, and, as a consequence, one nasal 
 passage is rendered larger than the other. In the adult, equality 
 of the space of the nasal passages is rarely found; yet, in most 
 cases, the difference is so slight that the subject of it is so little 
 inconvenienced by it that he is not aware of his condition, since 
 he breathes readily through each side of his nose. Not unfre- 
 quently, however, the deviation being congenital, or, having com- 
 menced in childhood as the consequence of some accident, con- 
 tinues to increase until it nearly or quite occludes one nasal 
 passage. Tliis deflection may be situated deep in the nose, and 
 is then unseen unless the nose be turned upwards; it may then 
 be discovered to involve the deeper portion of the cartilaginous 
 septum, and perhaps, likewise, the bony septum Or, instead of 
 this deep location, the deflection may be in the outer cartilaginous 
 portion, and may project from the nostril so as to become a con- 
 spicuous deformity, in the shape of a red pouting mass. This 
 protruding structure, more commonly occurring in the boy, is 
 usually mistaken by his parents for a neoplasm; and a similar, 
 though less excusable, error is sometimes committed by the med- 
 ical attendant. And such error is apt to arise in cases in which 
 the deflected part, hitherto unseen, has suddenly appeared, due to 
 tumefaction from irritation or inflammatory cause. 
 
 The diagnosis of the deflected septum, whether the deviation 
 be high up in the nose, or situated at the outlet, is readily made 
 if one examines the two nostrils. The convex portion is lined by 
 
DEFLECTION OF THE NASAL SEPTUM. 347 
 
 mucous membrane which is continued upon the parts adjacent, 
 and in the other nostril, corresponding to the deviated part, one 
 finds the partition hollow from inflection; such inflection of 
 the septum will always be found on the side of the larger nostril. 
 It cannot be a nasal polyp, since this does not arise from the 
 septum. A case resembling deflection is one in which theie is 
 isolated tumefaction on one side -of the septum due to a smtll 
 abscess or heematoma situated there, or to a swelling from local- 
 ized inflammation of the mucous membrane; yet, iu cases of 
 abscess, hsematoma, or localized inflammation on one side, incui- 
 vation of the other side of the partition would rarely be present 
 
 The consequence of such deflection is partial or complete 
 closure of the affected nostril ; in such nostril the nasal excreta 
 would be retained unless they escaped posteriorly. Such occlusion, 
 according to Moleschott, favors the development of the nasal 
 polypus. And should the unaffected nostril become obstructed, 
 the patient would be forced to breathe through the mouth. For 
 these reasons, surgical interference in such condition is not only 
 justifiable, but necessary. 
 
 Treatment. — The rectitude of the partition may be accomplished 
 in several ways. An attempt dias been made to do this by first 
 crowding the deviated part into proper position, and retention 
 there by means of a tampon introduced into the nostril. This 
 plan, the writer has found by experience, is tedious, painful and 
 unsatisfactory; for, though the deformity be thus rectified, it 
 tends to recur. Another procedure similar to that of Chassaignac 
 already mentioned, is that in which the mucous membrane cover- 
 ing the convexity is uplifted flap-like, and the subjacent cartilage 
 is trimmed off so that the partition can be forced into position, 
 and the flap returned to its place and held there by a plug in the 
 nostril. The fault of this plan is that the continued compression 
 may cause death and sloughing of the part pressed on, and an 
 opening through the septum will remain. Another plan which 
 has given the writer satisfactory result is to make a long oblique 
 incision through the deviated part, so that the latter can be recti- 
 fied ; and when this is done, the two faces of the obliquely divided 
 septum will slide on each other, and then a retaining plug being 
 introduced, the wounded facets may unite. In this sliding, if a 
 wounded part should be displaced upon sound tissue, then the 
 latter must be trimmed off, so that union can occur. By another 
 method, which was proposed by Adams, a star-shaped cut was 
 made through the septum by means of a specially devised knife; 
 
348 NOSE AND NASAL PASSAGES. 
 
 thus divided, the part is to be brought into position and retained 
 so by ivory plates retained temporarily in the nostrils. 
 
 Jurasz, of Berlin, writing in 1682, on this subject, finds that such 
 deviation is commonly situated in the posterior two-thirds of the 
 cartilaginous portion of the septum. If situated in the anterior 
 third, Jurasz would remove the prominent part by excision; but, 
 to correct deviation which is more deeply seated, he uses forceps 
 constructed after the model of obstetrical forceps, one blade of 
 which is to be introduced into one nostril and the other into the 
 other, and the blades are then to be locked and compression to be 
 made by means of a screw that passes through the handles. This 
 instrument is to remain in place for three days, and then the 
 rectitude is to be maintained by means of the ivory plates of Adams. 
 A more radical procedure l)as been practiced recently, viz., to 
 excise the deflected portion of the septum, thus forming a })erma- 
 nent opening through the partition; such an opening, though 
 causing no functional disturbance, has the objection of leaving a 
 lasting defect. Excision, if done, should be partial and limited 
 to the removal of the outer prominent portion of the septum, 
 which, sometimes, protrudes through the nostril, and occasionally 
 is accompanied by but little deflection of the deeper portion of 
 the septum; in such cases (which are those which oftenest ask 
 surgical aid) the mucous membrane should be uplifted flap-like, 
 wath attachment above, the cartilage then excised, and the flap 
 restored to place and fixed there by suture. 
 
 The septum is the occasional site of what is named purulent 
 tumor by Beaussenat, by whom the disease was first described in 
 1SG5. Such tumor consists of a collection of ])urulent matter, 
 situated on the cartilage of the septum, underneath the mucous 
 membrane. As there is not room for the mass, it swells out the 
 nasal wings and protrudes from the nares. Such a tumor forms 
 on both sides of the septum, and ends by perforating the latter, 
 after which the two intercommunicate. The purulent content is 
 mingled with blood. This affection commences as a swelling that 
 is red and dry; meantime, the outer wall of the nose may be 
 slightly affected. As accompaniments of this swelling are pain 
 in the head, lachrymation and intolerance of light. The swelling 
 finally becomes so great that the nostrils are nearly or quite closed, 
 and breathing through them is very difficult. 
 
 The cause of this swelling is often a traumatic one in which 
 there has been a contusion or fracture of the nasal skeleton; it 
 may, likewise, arise from a coryza, or from some exanthematous 
 
DEFLECTION OF THE NASAL SEPTUM. 349 
 
 affection, as rubeola, scarlatina, or variola, and, lastly, it may 
 proceed from a scrofulous dyscrasy of the subject. 
 
 These tumors are polypoid in appearance, still they can be 
 distinguished from the polyp in this that they are redder and 
 always spring from the nasal septum, and are near the anterior 
 outlet; a true polypus is situated deeper, is of whiter hue, and 
 springs from some part of the outer wall. There commonly coex- 
 ist two purulent tumors which inter-communicate through the 
 nasal septum. 
 
 Treatment. — Such tumor should be opened and its contents 
 evacuated; and if this be done early in an acute case a speedy 
 cure may be obtained; yet, if the case is neglected, or becomes 
 chronic, there may be entailed atrophy of the cartilage or a per- 
 foration of the septum. 
 
 Besides this j^urulent tumor, Beaussenat describes a collection 
 of blood (hse-matoma) beneath the mucous membrane of the 
 septum, which is caused by a wound or blow. This swelling 
 when large can obstruct respiration. As proper treatment of 
 such hsematoma,- it should be opened, emptied and the wound 
 brushed with the tincture of iodine. 
 
 Sir A. Cooper has described a fungous tumor of the nose, 
 resembling polyp. The writer has seen a similar form, which 
 springs from the septum, is unilateral, and nearly or quite 
 occludes the nostril. The patients were chiefly children, though 
 exceptionally it was seen in the adult. Such fungous swelling 
 may be treated by scarification or astringent applications. In 
 the adult, free scarification, in which the part is divided by a 
 number of incisions which reach through the swollen tissue to 
 the cartilage, is the speediest mode of cure: cicatricial contraction 
 is thus induced, which speedily lessens the swollen part. In the 
 child, M'hich is less amenable to operative treatment than the 
 adult, topical means can be used for reducing the swollen part, 
 and as proper agents astringents may be employed; and of these 
 one of the most effective is tannin, A mixture, compounded of 
 glycerine saturated with tannin, may be applied to the part, 
 once or twice daily, on a pledget of absorbent lint; and this 
 may be used as adjuvant treatment where scarification has been 
 done; and in any case, this astringent application, to be effective, 
 must be continued for a number of weeks. 
 
 The nasal septum is the frequent site of ulceration; and this 
 is nearly always confined to one side, and is situated in the 
 lower third of the partition, just inside of the movable or der- 
 
350 NOSE AND NASAL PASSAGES. 
 
 mal extension of the septum. As predisposing cause, there may 
 be syphiHs, scrofuhi or some obscure cachectic condition of the 
 patient In such subjects, the nasal excreta collect on the septuuL 
 as hard, dry and adherent crusts, and their removal often 
 causes some abrasion of the mucous surface; such is the man- 
 ner in which a slight lesion arises and, having commenced, 
 enlarges and becomes permanent through continued irritation. 
 And as an indolent ulcer elsewhere has but slight tendency to 
 either recede or advance, so, in this location, it may remain with lit- 
 tle change, for an indefinite period, as a denuded point of the 
 mucous surface, covered by a thin crust; yet, exceptionally, it 
 may penetrate deeper and perforate the septum. 
 
 This little ulcer is most unfavorably situated for healing, 
 and hence it often remains as a tiresome annoyance to both 
 patient and physician, for an indefinite period. For the ulcer- 
 ated tissue soon becomes tolerant of the local remedy used, and 
 ceases to respond to its action; and hence the remedy must 
 soon be exchanged for another; and the more frequently the 
 remedies are changed, the sooner will a cure 'be obtained. As 
 means which may be tried are the compound tincture of benzoin, 
 and ointments composed of thirty grains of iodoform or subio- 
 dide of bismuth to one ounce of vaseline. Ointments of tannin 
 and of the salts of mercury may be tried ; and, as before indicated, 
 these several remedies may be successively used for a short time, 
 and then again repeated. The most difficult cases to treat suc- 
 cessfully are those in which the ulceration has made a breach 
 through the septum, and the destructive process continues slowly 
 enlarging the opening. Should local remedies not arrest the 
 ulceration, the thermal cautery should be tried; and thus, the 
 surface being destroyed in which there is jirobably lodged some 
 parasite or other agency which maintains ulceration, healing 
 may take place in the sound structure which remains. Some- 
 times, in spite of the most careful management, such ulcer 
 remains stationary, and is a source of anxiety to the patient lest 
 the destruction of the partition may proceed so far as to permit 
 the nasal dorsum to sink. When it commences in the anterior 
 part of the cartilaginous portion of the septum, this ulcerative 
 disease never entails the sunken nose, unless it arises from 
 syphilis, through which the osseous portion of the septum being 
 also attacked dies and is finally ejected. In these cases of ulcer 
 of the septum, with whatever constitutional disease the ulcer 
 
NECROSIS OF THE OSSEOUS SEPTUM. 351 
 
 may be associated, the latter should be appropriately treated, for, 
 if a military simile be permitted, it would be folly to arrest the 
 individual skirmishers who advance in front, while the main 
 force of the enemy lurks in immunity behind. 
 
 Necrosis of the Osseous Septum. — The vomer and the perpendic- 
 ular plate of the ethmoid, which together form the bony parti- 
 tion between the nares, are the subjects of disease. This disease 
 is, in most cases, of syphilitic origin, and, in the form of gum- 
 matous deposit, this usually appears in the soft parts which line 
 the bone. This disease, in its course in the soft parts, often 
 deprives the bone of its vascular supply so that it dies, and this is 
 sometimes on so large a scale that the entire bony partition 
 becomes the site of necrosis. As a rule, this necrosis is only 
 partial, portions of the bone from time to time dying, and are 
 detached; and for the complete destruction of the bony septum, 
 often a period of one or more years is required. Besides con- 
 stitutional treatment, there should be directed to the part topical 
 remedies, which will act curatively, and likewise deodorize. As 
 curative agents solutions of iodine and mercury should be applied; 
 an excellent mixture is one composed of equal parts of tincture 
 of iodine and the tincture of nut-galls. To deodorize, one may 
 use the compound tincture of benzoin, or the following: — 
 
 I^. Potassii Permanganitis oij 
 
 Aquae Menthse Piperitse ox 
 
 Misce. 
 
 Irrigation with a solution of chloride of sodium may be prac- 
 ticed. In spite of the best directed efforts of treatment, the 
 bone usually dies, and fragments, becoming detached, must be 
 removed. The patient should be foretold of his coming mis- 
 fortune, viz., that the dorsum of the nose will probably sink and 
 render him the subject of unsightly deformity; thus notified, his 
 impending evil will fall less severely on the victim. 
 
 Obstruction of the Nasal Passages. — Golding Bird, who has 
 studied the causes of nasal obstruction, finds that these may vary, 
 and, according to symptoms, may be classified as follows: 1. 
 "Where there is no discharge from the nostrils, and no change 
 occurs during alterations of the atmosphere, the obstruction may 
 then arise from necrosis, sarcoma, enchondroma, deflection of the 
 septum and thickening of the inferior turbinated bone. 2. In 
 obstruction from a mucous polyp, there is a discharge from the 
 nose; and the condition is worse in bad weather. 3. In long- 
 
352 NOSE AND NASAL PASSAGES. 
 
 continued nasal discharge from the posterior nares of mucous or 
 purulent content, the obstruction may be from an adenoid growth" 
 in the posterior part of the passage. 4. Tliere may be a chronic 
 nasal obstruction situated anteriorly, attended by a continuous 
 muco-purulent discharge from an oziena of local or constitutional 
 origin. 
 
 Nasal Polypus. — Among these causes of obstruction of the nos- 
 trils, the most common is that produced by a growth named poly- 
 pus: an ill name, since this tumor is rarely many-footed and 
 many-branched: characteristics which the name implies. 
 
 Two forms of nasal polypus are met with, to wit, the mucous 
 and the fibrous or fibro-cartilaginous. Hippocrates says that the 
 polypus, when it arises in the nose, originates from phlegm, 
 gives obliquity to tlie nose and disturbs breathing. The brief 
 and erroneous pathology here given, which finds the origin of the 
 polypus in phlegm or mucus, has reference to the easily mastered 
 pathology of the ancients, in which four elements, viz., blood, 
 phlegm, bile and atrabile served for the compounding and evolu- 
 tion of all organic structures of the animal body. Through the 
 cribriform plate of the ethmoid bone, the old physicians thought 
 the phlegm was decanted from the brain into the nose. But 
 Virchow, Billroth, Paget, and the microscope have disturbed 
 these felicitous simplicities of the olden times and given us 
 knowledge nearer the truth. Microscoj)ically the mucous polyp 
 is found to consist of a mesh of delicate fibres, analogous to con- 
 nective tissue; and in its meshes one finds a liquid or semi-liquid 
 material in which are seen elements round, oval and fusiform. 
 According to Billroth, there are contained h^q^ertrophied mucous 
 glands in clusters in the polypus: and from these enlarged glands 
 vesicles or C3^sts may arise. The polypus will be denser or softer 
 according as the fibrous constituents or the mucous substance 
 predominates. Its serous content and the lack of vascularity 
 render the nasal polyp translucent. When its form has not been 
 altered by compression, the polypus has a singular resemblance 
 to an oyster. Its figure may be changed by pressure of contigu- 
 ous parts. There may be a single one, or several; and when 
 multiple they lie at diff"erent distances from the anterior outlet of 
 the nose: so that when occupying that outlet, if one be removed, 
 another one comes into view. 
 
 The mucous polypus may arise from every part of the nasal 
 passages except from the septum; it ma}'' arise also from the frontal 
 sinus, or the ethmoidal cells, and pass thence into the nose. The 
 
NASAL POLYPUS. 353 
 
 most usual origin is from the mucous membrane covering the 
 superior and middle turbinated bones, as well as from the remain- 
 ing mucous membrane of the meatuses bounded by these bones. 
 The polyp may attain such dimension that there is no longer any 
 room for it in the passages; it may then pass backwards or forwards, 
 and appear in the pharynx, or protrude from the nose upon the 
 upper lip. By inspiratory and expiratory effort, the polyp can be 
 drawn inwards, or forced outwards: and this mobility is due to the 
 j)olypus being pedunculated. Yet exceptionally, the polypus 
 may be sessile, and then it is less movable. The soft plastic 
 structure of the mucous polyp does not allow it to compress the 
 adjacent parts to the extent of injuring them ; the nose may be 
 more rotund on the affected side, yet rarely has the mucous 
 membrane been found ulcerated; and never have the bones been 
 seen diseased, as occurs from the fibrous polyp, or malignant 
 growth ; and hence the mucous polypus is not regarded as a seri- 
 ous matter, by either physician or layman. 
 
 Symptoms. — The presence of a mucous polypus in the nasal 
 passage, as soon as it assumes some dimensions, is announced by a 
 heaviness and fullness in the affected side of the nose; there is 
 sneezing and a constant mucous discharge from the part. The pa- 
 tient thinks he is "taking a cold ;" and his medical adviser is often 
 similarly misled ; and this error may originate in the circumstance 
 that the trouble has become worse, seemingly, from some atmos- 
 pheric change. The eye of the affected side is often red and tears 
 flow from it. One of the most notable sj/mptoms is a change in 
 the voice; this is nasal in tone. The voice sounds as if in some 
 way it were mufEed. The complete obstruction of one side of 
 the nose, or of both passages, where the growth is bilateral, com- 
 pels the patient to breathe through the mouth instead of through 
 the nose. He sleeps ill, being awakened by his own snoring. 
 When the growth is unilateral, if the unoccupied nostril be 
 closed, the patient finds that he can not breatlie through the 
 affected side. The sense of smell, and even that of taste, are 
 impaired. The patient imagines that his nose is swollen, or is 
 filled by some foreign material; and he is continually endeavor- 
 ing to liberate the nostril of its contents; and these efforts instead 
 of affording relief, only aggravate his condition by increasing 
 the congestion. The frequent irritation of the swollen part 
 occasionally provokes bleeding. This condition has often lasted 
 for a long period, the patient being ignorant of his true condition 
 and referring his trouble to "catarrh," which, in modern times, 
 
354 NOSE AND NASAL PASSAGES. 
 
 has been added to the category of aihnents of the layman, and 
 made to phiy an important part in his ills and expenses. 
 
 The effects of tlie polypus are so nearly analogous to those 
 which may be caused by deflection, or suppurative tumor, of the 
 septum, that error in diagnosis has arisen from careless examina- 
 tion, or want of knowledge on the part of the medical attendant 
 from whom advice is sought. ^ The polypus is readily distin- 
 guished from disease, located in the septum, by color and site; 
 the mucous polypus is of pale hue and is located in some part of 
 the outer wall; it never grows from the septum ; disease or deflec- 
 tion in the septum is of reddish color, and its investing covering 
 is continuous with the mucous lining of the septum. A not 
 infrequent error in diagnosis is in mistaking a swollen condition 
 of the membrane lining the inferior and middle turbinated bones, 
 for a polypoid growth. Xot unfrequently from congestion of the 
 nasal passages the blood gathers in the pituitary membrane, and 
 then the latter may hang pendent from the lower margin of the 
 turbinated bone; and the pendulous structure can readily be 
 moved laterally, if touched, with a probe. The rhinologist, whose 
 field of work is bounded by the four walls of tlie nasal passage, 
 easily recognizes the condition present through the intense vascu- 
 larity of tlie aff"ected structure and its blood-red color and mobility, 
 provided it does not wholly fill the nostril. 
 
 As important aids in seeing and determining the situation of 
 the growth are the nasal speculum and direct or reflected illumi- 
 nation. Light of the sun or from a lamp can easily be reflected 
 into the nasal passage by means of the common ophthalmoscopic 
 mirror. In the most of cases, however, when the patient applies 
 for relief, the growth has attained such dimensions that it can 
 readily be seen if the nose be so uplifted as to bring th^ -massage 
 within the range of the eye. 
 
 As symptoms and characteristics which distinguish the mucous 
 polypus from the fibrous and other growths in the nasal passages, 
 Durham gives the following: The pale color, the semi-transparence, 
 the elastic softness, the slowness of its course, the absence of 
 haemorrhage, the continuance of good health, are symptoms which 
 distinguish the simple mucous polypus from that of fibrous 
 nature, of which the color is more or less red, and light cannot 
 traverse it; and the fibrous growth has a dense and resistant 
 structure, and one which is not affected by atmospheric changes. 
 Tlje fibrous polyp also grows rapidly, and is often attended by 
 epistaxis. And if the growth be malignant, it is distinguished 
 
NASAL POLYPUS. 355 
 
 "by pain, opaqueness, hardness and immobility. It bleeds easily 
 if touched, and the discharge from it is fetid. Again, from the 
 mucous polypus, the osseous or cartilaginous tumor is distin- 
 guished by the hardness and immobility of the latter. 
 
 The mucous polypus, though wholly benign in character, is 
 exceedingly troublesome from its endowment of rapid reproduc- 
 tion, and this reproduction is usually not from the site whence 
 the polyp has been extracted, but recurrence is from the develop- 
 ment of scions, or other polypi, which spring up alongside of 
 preexisting polypi. Hence, not unfrequently he who is once the 
 subject of mucous polypus remains always a victim of this fertile 
 growth. The writer, however, has known exceptions to this, in 
 which thorough removal, done by extraction with forceps, was 
 not followed by a return of the disease. 
 
 Treatment. — The nasal polypus was well known to the an- 
 cients; both Hippocrates and Celsus have chapters devoted to 
 the treatment of this growth. In Hippocrates one finds all the 
 elements of treatment which are used in modern surgery, or, if 
 not wholly the same as methods now used, yet sufficiently sim- 
 ilar to have suggested them. To remove the polypus which is 
 soft, and which is forced out and again withdrawn in expiration 
 and inspiration, Hippocrates directs to first cut a round section 
 from a sponge that will fill the nostril, and then tie to this four 
 pieces of Egyptian cord, each a cubit long, which are knotted 
 together at the other end; next attach these cords to a metallic 
 rod (wire), and carry them through the nose until they are seen 
 behind in the mouth; then seize the cords, and, supporting the 
 uvula by means of a forked bone, the cords are pulled upon 
 until the polypus is extracted. Arrest the bleeding by means of 
 lint carried in with the rod; and finally dress with a mixture 
 containing copper. 
 
 When the polypus resembles flesh, and is hard to the touch, 
 Hippocrates advises to pass a canula to the tumor, and, through 
 this, cauterize the growth with the hot iron three or four times; 
 treat the wound with black hellebore, and, later, with the com- 
 pound of copper. 
 
 In a third manner, the polypus may be removed by means of 
 a cord made from a tendon or nerve, which is tied into a loop at 
 one end. Carry the other end of this cord through the nose into 
 the throat by means of a fenestrated rod; the looped end of the 
 cord, at the entrance of the nose, is next to be carried around the 
 polypus by means of a forked sound, and, when the growth is 
 
350 NOSE AND NASAL TASSAGES, 
 
 thus caught, the cord in the back of the mouth is to be seized 
 and pulled upon until the polypus is withdrawn. During the 
 traction support the soft palate with the forked bone, as was done 
 in extracting the polypus by means of cord and attached sponge. 
 
 A fourth Hippocratic procedure was as follows : There are 
 cases in which the polypus appears to be flesh, yet when it is 
 touched it resounds like a stone; when the condition is thus, 
 open the nostril with a knife and, having cleared out the nose, 
 cauterize the part. Afterwards, close the w^ound with suture, and 
 treat the former with an ointment, and subsequently with a mix- 
 ture of copper, and, finally, complete the cure wath lead. In case 
 the nasal growth be cancerous, it is necessary to burn it, and 
 afterwards, apply hellebore; and conclude the treatment with 
 copper and lead. 
 
 These extracts from Hippocrates embody the essential ele- 
 ments of the treatment of nasal growths among the moderns. 
 
 Celsus briefly gives the knowledge of the Roman physicians 
 on this subject as follows: The polypus, sometimes white and some- 
 times reddish in color, adheres to the bones of the nose, and may 
 appear in front or behind where the breath descends from the nose 
 to the fauces; and in the latter position it may grow so large that 
 it becomes visible behind the uvula; and when the south or east 
 wand blows, it causes strangulation. It may be hard or soft ; the 
 hard species obstructs the breath more than the soft, and widens 
 the nostrils, and is of the nature of carcinoma, and should be 
 let alone. The soft species is to be cured by the knife; mean- 
 time it may be reduced by a compound of lead, lime, and other 
 ingredients. To remove this grow^th use the spatha (a spoon- 
 shaped instrument similar to a curette); but use diligent care in 
 the removal not to wound the cartilage, since this heals with 
 difficulty. When the polypus is detached, remove it with a 
 hook-shaped instrument. The subsequent management is sim- 
 ilar to that taught by Hippocrates. 
 
 The treatment of the mucous polypus as now pursued may be 
 placed under the heads of non-operative and operative. 
 
 As non-operative means are medicinal agents which possess 
 astringent and, in some degree, escharotic properties. One of 
 the best for this purpose is tannin, which may be used, when 
 finely powered, as a snuff". Powdered Sanguinaria may be used 
 in the same way. A solution of alum, of sulphate of zinc, or 
 one of the chloride or subsulphate of iron may be used; yet of 
 the agents mentioned tannin is the best, since it has none of the 
 
NASAL POLYPUS. 357 
 
 objectionable qualities which may be urged against one or more 
 of the others. These agents arrest the growth of the polypus, yet 
 do not remove it; and to be effective they must be continued for 
 along period. 
 
 As operative means may be enumerated excision, extraction, 
 or plucking out, ligature or snare, and cauterization: methods, as 
 before seen, employed by Hippocrates and Celsus. 
 
 Before resorting to any of these methods, the location and 
 site of origin of the mucous polyp must be accurately deter- 
 mined; and this may be done by means of a speculum con- 
 structed of metal or India rubber, and which may be used equally 
 well in examining both the auditory and the nasal passages. 
 This instrument may be bivalvular, with handles by which it is 
 held in the hand; or, as a cylinder, it retains its place when 
 inserted into the passage. With one of these instruments, by 
 means of direct or reflected light (the latter is better), the poly- 
 pus may be seen, and its situation and the volume of the growth 
 estimated. As aid in this search, a probe may be used, with 
 which the pendulous growth can be moved, and the fact deter- 
 mined whether the polypus is single or multiple. These circum- 
 stances being learned, one next selects a method for the removal 
 of the polypus. 
 
 The Celsian method by excision was done by the Latin phy- 
 sicians by means of a species of spatula, probably spoon-shaped, 
 with which tlie growth, being detached, was afterwards drawn 
 out by the aid of a hook. A modification of excision was prac- 
 ticed by Dr. Gross, who used his finger-nail for detaching the 
 polypus, when the latter was thrust into the throat. The plan 
 of excision, or better named curetting, may be reserved for cases 
 in which, after the body of the growth has been plucked off, 
 there remain peduncular fragments. When the location of these 
 can be seen, they may be scraped off by a curette. 
 
 Excision, or the modification of it mentioned, is rarely used ; 
 removal by plucking off or joulling out is more commonly prac- 
 ticed. Removal in this way, though fiercely decried by special- 
 ists, will remain as a usual method of getting rid of tlje nasal 
 polypus. It is, doubtless, often abused, yet this should n^t forbid 
 its use. The abuse consists in trying to remove what is not 
 clearly seen, and in doing the work solely by traction; no attempt 
 should be made at removal unless the polypus is clearly seen and 
 located. And this may usually be done with the unaided eye, 
 if the other nostril be closed and the patient then force air out 
 
358 NOSE AND NASAL PASSAGES. 
 
 through the affected side; thus the growth is brought into view. 
 It should, however, have been remarked that in few cases will 
 this strategem be needed, since commonly, when the patient 
 applies to the surgeon, the polypus is plainly seen when the sub- 
 ject's nose is uplifted. 
 
 For the extraction of the polypus, special kinds of forceps have 
 been invented ; these instruments, as a rule, have curved blades 
 which are serrated and fenestrated. The writer prefers a forceps 
 with straight blades, the rivet or lock of which will correspond 
 to the outlet of the nostrils, when the instrument is intro- 
 duced into the nose. The blades should be flat, well fenestrated, 
 and broader than that of the instrument commonly used for 
 extraction. With such forceps, standing where he can work with 
 facility and not obstruct the light, the operator closes the sound 
 nostril b}' pressure, and directs the patient to force the air out 
 through the affected side ; as this expiration is being done, the 
 surgeon having already introduced the forceps to the growth 
 with opened blades, and the pol3''pus being carried into the grasp 
 of the blades, they are closed. Done in this way, the polyp is 
 caught without random groping for it, as is done by the inexpert 
 operator; and being caught, the surgeon extracts by first twisting 
 and then making traction. The twisting, to be effective, must be 
 continued until the torsion has reached the pedicle; then if trac- 
 tion be made, the detachment will probabl3^be at the peduncular 
 insertion of the polypus; and occurring there, there will be but 
 little or no bleeding, since the vessels of the pedicle have been 
 subjected to torsion. Should the growth not be entirely removed, 
 an effort should be made to extract the fragment remaining, 
 provided there be not much haemorrhage; if there be bleeding so 
 as to conceal the interior of the passage, then further work should 
 be deferred until the morrow or a later day. With straight-bladed 
 forceps, there is but little danger of injuring the contiguous vas- 
 cular wall; often but a few drops of blood appear; and if the 
 operator be experienced and adroit in manipulation, and the 
 patient be docile, no blood at all may follow the extraction. The 
 haemorrhage, on account of which the method of extraction is so 
 violently decried, is usually due to an awkward hand, impatience 
 to complete the work at one sitting, and forceps which instead of 
 being straight are so curved that in torsion they necessarily 
 wound the contiguous membrane. The writer has seen this 
 traction done so dexterously by the adroit hand of Verneuil that 
 no bleeding occurred. 
 
NASAL POLYPUS. 359 
 
 A third method of removal is that done by means of metallic 
 ligature in the form of a snare. This method, advocated by 
 Duplay, and now practiced by the specialist of nasal disease, is 
 done by means of an instrument modeled after the polypotome, 
 invented by Wilde for removal of the aural polypus. This con- 
 sists of a wire folded into the form of a loop, which is passed 
 along the handle through canulated openings which partially 
 conceal the wire. By light reflected from a frontal mirror, the 
 growth is located and the noose having been thrown around the 
 polypus, and carried, if possible, to its attachment, the wire snare 
 is tightened, and the growth thus severed. By this means those 
 mucous polyps which are deep-seated, and inaccessible to the 
 forceps, may be removed with little or no haemorrhage. Though 
 some traction can be made with this instrument, the work of 
 removal is rather done by section of the tumor; and done thus, 
 there must remain a portion of the pedicle, when an early recur- 
 rence of the original polypus is inevitable. But when done by 
 extraction, the pedicle is commonly eradicated, often with a frag- 
 ment of the turbinated bone; conditions which insure against 
 re-growth of the original polyp, and-, perhaps, of scions that are 
 near it. Hence removal with the snare, winch was advised by 
 Hippocrates in a reversed manner from before bacicwards, will 
 not wholly supersede that by traction and torsion done by means 
 of properly shaped forceps. 
 
 Another method of treatment is that of cauterization, poten- 
 tial or actual. Potential escharotics have been employed, but their 
 use is nearly abandoned. Thudicum, known for his writings on 
 the treatment of nasal affections, employs the thermal cautery to 
 excise the polypus. He passes the loop of the thermal cautery 
 around the growth, and effects the division by heat. The advan- 
 tage claimed for this method is that it is free from pain and causes 
 no bleeding. The statement by Thudicum that one polypus was 
 removed by fifty-five sections, and in another the thermal loop 
 was introduced thirty-three times, shows that the excision thus 
 is tedious, and that the operator, to be proficient, must have long 
 training of the hand. 
 
 There was recommended in 1862 by Fredericq, a treatment of 
 the mucous polyp, by which he claimed to cure without an opera- 
 tion. For this purpose he employed the acid chromate of potash, 
 applied to the growth. In this way twenty cases were cured. 
 The remedy was used in the form of a concentrated solution 
 applied on lint to the polypus. In case the remedy caused too 
 much irritation, its use was temporarily suspended. 
 
360 NOSE AND NASAL PASSAGES. 
 
 After the removal of the mucous polypus, treatment may be 
 pursued that will retard the return of the growth. For this the 
 author has used with advantage Radix Sanguinariaj canadensis, 
 and tannin. These agents, singly or combined in equal parts, 
 should be used as snuff. This must be used for months, and the 
 snuffing done several times a da}'. As the powder accumulates 
 in the nasal passages, these should be cleansed daily by irrigating 
 them with a current of warm water. This irrigation is done by 
 utilizing the ])hysiological fact discovered by Weber, that when 
 a stream of water is carried by douche, or injected into one nasal 
 passage, and tlic patient, meantime, breathers througli the mouth, 
 the current of water, after reacliing the choanie returns tlirough 
 the otlier passage, escaping in front. The contact of the ihiid 
 with tlie upper surface of the pendulous palate, awakens reflex 
 action, probably through the filaments of the glosso-pharyngeal 
 nerve, and causes muscular contraction, similar to what occurs in 
 normal deglutition. By utilizing this action, the nasal passages 
 may be effectually cleansed, and also medicated fluids can be 
 brought into contact with the entire inner surface, for disinfec- 
 tion or other purposes. 
 
 Fibrous Polypus. — The fibrous polypus or neoplasm is much 
 more formidable than tlie mucous polypus just treated of. These 
 tumors, according to their site, are named nasal, naso-frontal, 
 naso-maxillary and naso-pharyngeal. The usual form is the 
 naso-pharyngeal, which, though occupying a naso-pharyngcal 
 location, may exce])tionally originate outside of this region, and 
 yet, by growth, appear there. Nelaton and others claim that these 
 tumors always spring from the basilar process and body of the 
 sphenoid bone. Exceptions to this have been observed, viz., tliat 
 the tumor may arise from the sphenoidal pterygoid processes, and 
 front face of the superior cervical vertebrae. Tliis discrepancy in 
 respect to tlie point of origin has originated, as Bryant has sliown, 
 from the fact that the tumor may have more than one site of 
 attachment, the secondary ones having arisen from the circum- 
 stance that the growth, as it develops, may come in contact with 
 other adjacent points, and contract adhesions to them; and thus 
 the growth will appear to have more than one point of origin. 
 Tlie fibrous polypus primarily arises from the })eriosteum, start- 
 ing beneath the mucous membrane, and, as it develops, it 
 carries the mucous membrane before it, wdiicli often becomes 
 thickened and resistant. In structure this tumor is firm, hard, 
 and sometimes has a hardness approaching that of cartilage. 
 
FIBROUS POLYPUS. 361 
 
 Unlike the mucous polyp, tliis one is inelastic and opaque. It is 
 usually red in color, dark or lustrous in appearance; yet when it 
 is removed, its color is gray or whitish. In three cases seen by 
 the writer, the growths had this whitish or cartilaginous appear- 
 ance before detachment; and the structure was not very vascular, 
 as seems to be the rule in most cases. One surgeon found an 
 artery, as large as the ulnar, on the base of the tumor. 
 
 Histologically, the chief constituent is fibrous tissue; and the 
 tumor, or section, presents to the naked eye a fasciculated aspect. 
 The fascicles are arranged, at points, concentrically; and if 
 examined carefully, they will be seen to converge towards the 
 j)edicle or point of attachment. The microscope usually reveals 
 only the elements of fibrous tissue; sometimes, however, the 
 fibrous constituents have a fusiform appearance, in which there 
 is an apjDroach, in form, to that of the doubly conical nucleated 
 cell of sarcoma; and this form is closely allied to the malignant 
 connective tissue growths; and, similar to these, such tumors com- 
 monly return after removal. Some claim, as Boyer, that the 
 naso-pharyngeal growth can lose its benign character and 
 become transformed into a malignant tumor; a more rational 
 conclusion, however, is that such growths are primarily malig- 
 nant, and, in- their development, violate none of the canons of 
 pathology. 
 
 The fibrous tumor has •been seen incrusted with calcareous 
 matter which may penetrate some distance into the growth. 
 Such chalky formation might Ije precipitated from the normal 
 nasal secretions. 
 
 The growth of basilar origin is free to expand in any direc- 
 tion; but soon, from contact of the lateral walls, its development 
 is directed antero-posteriorly, since the tumor meets no obstruc- 
 tion in these directions. Perhaps one nostril alone is occupied, 
 and then the septum, inasmuch as it can offer but slight 
 resistance, yields, and is forced into the other passage. The 
 tumor coming in contact with adjacent parts becomes adherent 
 to them. If the growth is not interfered with, the outstretching 
 processes of it may extend forwards and appear at the anterior 
 nares, and forcing the lateral walls asunder, enlarge and deform 
 the nose. Or, the tumor may enter the maxillary sinus, and 
 thence proceeding outwards, uplift and change the form of the 
 cheek. Again, it may develop towards the eye, and, uplifting 
 the floor of the orbit, encroach on the eye, and force the globe 
 from its socket, and, producing exophthalmic deformitv, finally 
 24 
 
362 NOSE AND NASAL PASSAGES. 
 
 impair, if not destroy, vision. And in this situation a process 
 having ]>enetrated the frontal sinus may seem to have originated 
 there. Tlie tumor in its development may pass in a direction 
 entailing yet more fatal consequences, viz., it may penetrate, 
 through erosion of the base of the skull, into the intra-cranial 
 cavity, and fatally compress the brain. In all tlieso directions, 
 whatever osseous structures the tumor may encounter in its 
 march, the bone is gradually' absorbed. 
 
 As results caused by the tumor from obstruction of the nasal 
 passages, and from encroachment on parts whicli are contiguous, 
 the following may be enumerated : obstruction of respiration, 
 which may be limited at first to one nostril, and later, to both 
 nasal passages; encroachment upon, and occupancy of, one or both 
 frontal sinuses, and tlien if tlie volume become enormous, there 
 is upheaval of one or both cheeks; closure of tlie lachrymal 
 canal, and, as result, unilateral or bilateral epiphora; encroach- 
 ment on tlie orbital cavity, with displacement of the globe of the 
 eye, forwards, or laterally; penetration into the cranial cavity 
 through the base of the skull, and as nerves are met, there will 
 arise impairment of their individual functions; thus the trifacial, 
 ocular motor, optic or olfactive nerves may have their functions 
 impaired or annulled. And, finally, should the growth enter the 
 cranial cavity, though there may be tolerance of the pressure for 
 a long period, finally, signs of encephalic compression will 
 appear. When the tumor develo[)s in the choanse and entrance 
 of the pharynx, difficulty of deglutition arises, and is a source of 
 mucli discomfort. In the pharyngeal istlimus in which the paths 
 of air and food cross each other, there must be no impediment to 
 either; and the presence of a naso-pharyngeal growth introduces 
 confusion in the nicel}^ balanced acts of reflex automatism seated 
 there. 
 
 In the early period of development of this growth, the symp- 
 toms present are often mistaken by both patient and physician 
 for a cold or a catarrh (as the popular phrase now has it); yet, at 
 this initial stage, the frequently recurring epistaxis should 
 awaken suspicion of a growth in the nasal passages; and one 
 which is of fibrous and not of mucous structure. 
 
 The naso-pharyngeal fibroma almost always occurs in the male 
 subject; in only a few cases has it been observed in the female. 
 Probably, some structural or anatomical reason exists for this 
 immunity of the female; 3^et none has been offered. Perhaps 
 nature, who has been so unfair in the allotment of tasks and 
 
FIBROUS POLYPUS, 363 
 
 burdens between the two sexes, has not erred in this instance, in 
 placing the load on the stronger shoulders. 
 
 ' This growth is seen oftenest in the young, viz., between the 
 ages of twelve and twenty years. Of one hundred and sixty-four 
 cases collected by Durham, one hundred and twenty-two had not 
 passed the twentieth year of life. And in this period of exu- 
 berant growth, fibroma or enchondroma may develop in contigu- 
 ous regions; of this the author has seen the following example : 
 A purely fibromatous tumor, as large as a. pigeon's egg, developed 
 in the zygomatic fossa near to the pharynx. Through an incision 
 within the buccol cavity, this tumor was reached and extracted, 
 without leaving any external mark of the work done. A few 
 months afterwards, there was discovered a naso-pharyngeal 
 fibroma, which doubtless had coexisted with the tumor that had 
 been removed. 
 
 In the diagnosis of the nature of the growth, a matter of the 
 utmost importance to the patient is to decide whether the tumor 
 is or is not malignant; and as signs that it is cancerous, are the 
 following: The growth is in a subject who has passed the middle 
 period of life, and it develops rapidly, and is accompanied by 
 keen shooting pains; and the glands adjacent swell. Tlie can- 
 cerous tumor is soft, friable and ulcerates at an early period, and 
 the subject soon presents the ashy hue, and the poor health char- 
 acteristic of the cancerous cachexy. In contrast with this, the 
 nasal fibroma occurs in the young, is hard in structure, does not 
 ulcerate and grows slowly. A fragment placed under the micro- 
 scope would assist in determining the true character. 
 
 Yet the nasal fibroma is not a harmless invader; when it 
 reaches large dimensions, it causes frequent epistaxis which 
 slowly weakens the patient; and through pressure, it causes pain.. 
 Such tumor protruding into the pharynx can cause suffocation; 
 so much so that Gosselin proposes for the tumor the name of 
 suffocating polypus. Sudden death has arisen from asphyxia 
 thus arising. 
 
 Cases, however, have been seen in which the naso-pharyngeal 
 fibroma has become gangrenous, and thus the patient has been 
 liberated from his disease without medical or surgical treatment. 
 And analogous to growths whose appearance and development 
 are limited to a certain period of life, it is not improbable that 
 this nasal growth, having attained certain limits, may, possibly, 
 cease to grow. Yet these fortunate events are so seldom seen 
 that one can scarcely hope for their realization; absolute extinc- 
 
364 NOSE AND NASAL PASSAGES. 
 
 tion is rarely seen; and recurrence is the rule unless the site of 
 origin is also radically destroyed ; and this leads to a considera- 
 tion of the means of treatment. 
 
 Treatment. — The tumor must be attacked operatively; and the 
 operation done may be simple or palliative; or it may be radical 
 or curative; and, as the latter embraces subsidiary work by which 
 the tumor may be reached, it is named complex or compound. 
 
 The simpler operation, in which the work is limited to the 
 mere removal of the growth, without any attempt to destroy the 
 site of origin, may be one of the subjoined methods: excision, 
 extraction, ligation, detachment by scraping or curetting, and 
 division or destruction of the part by cauterization. 
 
 Excision may be done by means of scissors or knife; it is clear, 
 however, that the almost inaccessible situation of the growth will 
 interfere with the use of these instruments, with any great degree 
 of accurate efifect; in the majority of cases, the work, at best, can 
 only be blindly done. Another objection to excision is the danger 
 from haemorrhage; for, as before stated, these tumors are very 
 vascular, and to divide such structure, where the vessel could not 
 be reached, must cause severe, if not dangerous, haemorrhage. If 
 this method be pursued, the operator should be prepared to intro- 
 duce, at once, a styptic tami)on, and such a one is best made of 
 sponge saturated with a strong solution of tannin, alum or a salt 
 of iron. 80 many risks, however, surround this procedure, that 
 it is rarely put into practice. 
 
 Extraction is much to be preferrea to excision, for relief from 
 this tumor. For this purpose, strong forceps, such as are used in 
 extracting vesical calculus, should be used. The extraction is 
 done from the pharynx; in the exceptional cases in which the 
 tumor can be reached anteriorly, the removal might be done from 
 in front through the nostrils. If done from behind, the forceps 
 should have a curve similar to that of one form of forceps used 
 in lithotomy; for, thus shaped, the instrument can be introduced 
 through the pharynx into the choanse, and the growth there seized. 
 The detachment should be accomplished b}" traction combined 
 with twisting. The work of torsion will be done with difhculty, 
 if the tumor be impacted in the posterior nares, or have processes 
 reaching into the adjacent sinuses. The torsion will act on the 
 footstalk, and close the vessels contained in it. The difficulty of 
 reaching the growth, of getting a firm hold of it, and of severing 
 by pulling and twisting the strong structure of the tumor, are 
 serious defects to this method of removal; yet, if the growth is 
 
FIBROUS POLYPUS. 365 
 
 pedunculated, or has a small attachment, then this method, as 
 a palliative procedure, is one of the best which can be used. It 
 is best adapted to those cases in which the tumor having sprung 
 from the overhanging basilar process, hangs in the pharynx; in 
 such condition the tumor might possibly be so completely ex- 
 tracted that it would not recur. ' 
 
 A third method of removal is by ligature, which has been 
 done in two ways, viz., one in which the ligature acts slowly, and 
 the other in which the section done is immediate. 
 
 The ligature of slow action may consist of silken thread or 
 wire. The work of throwing the ligature around the base of the 
 tumor is difficult, since the operator works in a space into which 
 he cannot see, and hence the casting of the strangulating loop 
 around the growth is done at random; work in which "millions 
 miss for one that hits." And when the noose has been adjusted, if 
 the cord is silken, the formidable difficulty arises of securely 
 tightening it by a knot. For this reason a strangulating loop of 
 wire is better, since this can be closed by twisting, and can after- 
 wards be made tighter by twisting it one or two turns more, if 
 additional constriction be needed. The objections to this method 
 are the difficulties that attend its use; and after the tying, the 
 slow detachment is attended by the passage of foul materials into 
 the pharynx, which, being swallowed, or entering the lungs, 
 become a source of disease. These objections have caused this 
 method to be nearly abandoned. 
 
 Immediate or instant ligation, by which the tumor is detached 
 at once, is preferable to the slow mode described. The detach- 
 ment may be done by the linear ecraseur, or the loop of the 
 galvano-cautery. The same obstacles are met here in adjusting 
 the loop as in the slow method, and the division will more prob- 
 ably be made through the body of the tumor, than through its 
 base; and, hence, it often becomes necessary to repeat the opera- 
 tion on the remaining peduncular portion. It is probable that 
 division with the linear ecraseur would be more effective than if 
 made by means of the galvano-cautery. The thermal method, 
 however, seems to be preferred by the nasal specialist. 
 
 A fourth method is that in which the tumor is removed by 
 piecemeal detachment: a procedure which may be accomplished 
 by scooping, scraping, curetting, or plucking off fragments. The 
 uterine curette, or a chisel-edged instrument, may be used in this 
 work. The work of such fragmentary disintegration is necessarih^ 
 slow and attended by considerable loss of blood. The difficulty 
 
366 NOSE AND NASAL PASSAGES. 
 
 or impossibility of wholly removing the growth, is an objection 
 which can be urged against this one as against all the other 
 methods which have been enumerated. 
 
 All the procedures mentioned, inasmuch as they leave the 
 site of the tumor uninjured, are imperfect, incomplete and unsat- 
 isfactory to both patient and operator; f(^r in the trilogistic ruloi 
 of safely, speedily and happily, the operator has chief pride in the 
 middle term cifo; and as to the patient, his chief purpose with 
 his physician is to be speedily and thoroughly cured; and hence 
 a treatment which promises but transient relief, or a scries of 
 recurrent operations, will surely be rejected by him if anything 
 better can be offered. And this introduces a consideration of 
 those methods which, though radical, severe and deforming in 
 character, yet insure a cure to the patient. 
 
 The obstacle to a cure in the methods before mentioned is the 
 impossibility of reaching and destroying the peduncular ground 
 whence the tumor springs; and to do this, some pioneer work is 
 needed to open a road to the tumor and its site. For this j^ur- 
 pose a subsidiary operation, sometimes of considerable extent, 
 is needed. Such preliminary work may be done in three direc- 
 tions, and according to the route taken in this particular work, so 
 the method may be named the nasal, tlie facial and the palatine; 
 and of these, different operators have offered modifieations. So 
 numerous are the latter, that a monograph devoted to this sub- 
 ject and published in French about 1870, contained some score of 
 diagrams, each representing some surgeon's preliminary section 
 to reach the tumor. 
 
 As varieties of the nasal method, the following merit notice: 
 In 1866, CoUis made a vertical cut alongside of the nose until 
 he reached the nasal bone and nasal process of the superior max- 
 illary bone; these bones were next sawn through, when the 
 base and side of the nose were uplifted and the whole external 
 nose was deflected to one side, so that the interior cavity of the 
 nose was exposed to view, and a growth there could be removed. 
 Verneuil advises to open the cartilaginous portion of the nose in 
 the median line, and, if need be, continue this through the nasal 
 bone, and if further opening be necessary, to resect these bones. 
 Verneuil lays down the rule, that the opening suffices, if the 
 finger can enter through the orifice made. Oilier proposes a 
 horse-shoe cut, the branches of which lie on the sides of the nose, 
 and are united over the root of the nose. The nasal bones are 
 next cut through, and also the septum is divided, when the nose 
 
FIBROUS POLYPUS. 367 
 
 is lifted from its site and turned downwards, so that a free open- 
 ing is made to tlie naso-pliaryngeal cavity. Langenbeck per- 
 formed a similar operation, but tbe horse-shoe was reversed; be 
 severed tbe soft parts and divided the nose, so that the nose, with 
 upward attachment remaining, could be turned upwards. After 
 tbe removal, by either tbe method of OHieror of Langenbeck, the 
 nose is restored to its normal site and retained there by sutures. 
 
 These methods are especially suited to the cases in wdiich the 
 tumor lies in tbe nasal passages, and is not impacted in the cav- 
 ity, viz., in tbose in wdiich the nasal bones and adjacent portion 
 of the superior maxillary bone are forced forwards.- The way 
 towards the basilar site of implantation is both opened and 
 shortened; and one is enabled to directly attack the greater por- 
 tion of the growth. And in case processes of it cannot be re- 
 moved, it has been found that such portions may atrophy, and 
 cease to be troublesome, if the central mass of the tumo^ has been 
 removed. Besides, if it be necessarj' to enter the maxillary sinus, 
 this nasal route oflFers a free passage. And the pterj^go-masillary 
 fossa is penetrable by the same route. 
 
 x\s before stated, after extraction of the tumor, which will be 
 considered later, it is usual to repair the breaches made by the 
 preliminary operation: and in case a portion of the nasal wall 
 has been destroyed, this is to be repaired by some of the proced- 
 ures which will be detailed under the head of rhinoplasty. The 
 breach, however, is not always closed; in cases in which the 
 removal is imperfect, or an early recurrence is anticipated, the plan 
 has been j)ursued of leaving the breach unclosed, through which 
 the cavity could be inspected from time to time, and an attack 
 on the tumor be renew^ed, in case of its regrowth. Such opening 
 must be closed by strips of over-bridging adhesive plaster; and 
 at a later period, when the growth is found to be extinct, then 
 permanent closure by some plastic procedure may be resorted to 
 
 Tbe facial method of operating will next be considered. In 
 this method the preliminary w^ork of pioneering consists in pre 
 paring a route through the superior maxillary bone : and various 
 modes of doing this have been proposed, or carried into effect. 
 
 Tbe entire removal of the maxilla superior, which w'as first 
 done by Syme, though it offers ample facility for removing the 
 tumor, yet the patient remains deformed beyond rescue: tbe eye 
 sinks downwards, and may be lost ; the tears escape continuously. 
 Such total ablation interferes v^'ith mastication, deglutition and 
 voice. Hence, to avoid tbese defects in form and function, a 
 
368 .>OSE AND NASAL PASSAGES. 
 
 partial exsection of the up}ier jaw has been done: a procedure in 
 which the orbital and palatal portions of the bone are preserved. 
 But it has been found thattliis method deforms tlie face severely, 
 and, withal, the way thus opened to the tumor is too narrow to 
 permit its removal. 
 
 The next modification of tlie facial method is that of tempo- 
 rary resection, in which a portion of tlie maxilla superior is 
 excised, yet so retained in connection with the soft parts that it 
 can afterwards be restored to site, and reunited. This has been 
 done in several ways. Dezanneau thus temporarily resected and 
 afterwards replaced the lower half of the jaw, with successful 
 results. Other attempts seem to have been less fortunate: the 
 teeth and fragments of the resected portion were lost. The 
 resection was next done on the anterior ftice of the bone by 
 Langenbeck, Esmarch, Trelat and others. Langenbeck resected 
 the front face of the bone, and reflected the osteo-cutaneous flap 
 inwards, while Boeckel reversed the work by reflecting the flan 
 outwards. The removal of the tumor seems to have been easily 
 done by these ways ; and the uplifted flaj), afterwards being 
 replaced, readhered to its former site. 
 
 The writer proposes as a way of doing this work, to combine 
 the nasal and facial methods; for this, make a longitudinal cut 
 along the affected side of the nose, its entire length; saw through 
 the nasal bone thus exposed, and let this be a portion of the 
 cutaneo-osseous flap, which by suitable sawings is to be uplifted 
 from the front of the maxilla superior. The next incisions must 
 traverse the upper jaw transversely: one just above the alveolar 
 process, and the other must lie below the infra-orbital border: 
 thus done, the nasal and maxillary incisions form three sides of 
 a rectangle, which is open towards the ear; operating tlms, the 
 orbit and the buccal cavity will not be infringed on, and a satis- 
 factory route will be opened to the growth. 
 
 These facial operations, however well and conservatively they 
 are done, mu.st deform the ftice by large scars. To avoid this^ 
 the palatal method may be resorted to. The attempt to reach 
 the growtli through the palatal way was first done, by Manne of 
 Avignon, in 1747, who divided the soft palate. Dieffenbach 
 operated in a similar manner, yet his incision did not divide the 
 soft palate wholly; the posterior margin was left intact. This 
 opening being found too small by Maisonneuve and Nelaton, the 
 latter enlarged it by extending the incision into the o.sseous 
 palatal vault. Yet even the large opening which is thus made 
 
FIBROUS POLYPUS. 369 
 
 is sometimes insufficient to permit of the easy removal of a large 
 tumor: in such case, the removal is done by fragmentary disin- 
 tegration, and may be attended by severe haemorrhage. The 
 chief defect of this method is that the palatal vault is so injured 
 by the perforation made that it cannot be repaired, or but im- 
 perfectly. This breach in the roof of the mouth is a source of 
 much inconvenience to the patient, since in eating, the food can 
 pass into, and remain in, the nasal passages. The attempts to close 
 such breach, when the latter is large, have usually failed. 
 
 The three methods which have been considered have had 
 strong partisans in those who originated them: it remains to 
 consider which one should be chosen. The ruin made of the 
 palatine vault, usually irreparable, the deformity and functional 
 impairment entailed by the facial method, are serious objections 
 to these two plans of operating: the nasal method is less objec- 
 tionable, and is the one commonly selected. Tillaux, guided by 
 his accurate anatomical knowledge, says that the nasal route is 
 the most rational and direct way to reach the point of implanta- 
 tion of the naso-pharyngeal tumor. But should the removal of 
 the tumor, through fixation of its processes, be impracticable in 
 this way, his second j) reference would be for the palatal route. 
 
 The route being opened to the tumor, there are several ways 
 by which the removal can be accomplished: and of these, the 
 most simple is that by traction combined with torsion, in case the 
 volume of the tumor is small enough to permit the work being 
 thus done. The haemorrhage which follows the removal of these 
 tumors, and which, in several recorded cases, has ended fatally, 
 demands the most serious attention of the operator; and as opera- 
 tive means which give greater security in this direction, are the 
 procedures of linear ecrasement, the galvano-cautery and the 
 simple thermal cautery. And of these methods the division by 
 heat has proven safer than that of linear crushing.. The pedun- 
 culated portion of the tumor being included in the looped wire 
 of the galvano-cautery, the detachment can thus be done with 
 but slight loss of blood. In most cases the section could be made 
 conveniently with the knife point of the thermal cauter3^ 
 
 The removal has likewise been done by means of the poten- 
 tial cautery; for this arrow-shaped points prepared from a mix- 
 ture of chloride of zinc and wheaten flour, should be thrust into 
 the tumor. This plan is less practicable than that of the actual 
 cautery, and there is tlie danger inseparable from it that some 
 of the caustic material will escape into the throat, and pass to the 
 
370 NOSE AND NASAL PASSAGES. 
 
 stomach or lungs. A patient treated thus died, and the operator 
 reported that the caustic agent was not "foreign" to the death. 
 
 In many cases, after the removal of the tumor, the road that 
 has b^eu opened to reach it has been left open for some time, in 
 order that tlie operation shouhl be repeated if there be recurrence. 
 
 The nasal fossse are the site of malignant growths, of which 
 the type most often seen is epithelioma: tlie sarcoma has been 
 observed. These tumors apjiear at all periods of life. They are 
 found so adherent to the bones that it becomes diflicult to decide 
 whetlier the growth originated from the bone, or the structures 
 covering the bone. 
 
 The malignant neoi)lasra may s})ring from any portion of the 
 inner surface of the nasal cavity; it develops rapidly, soon reach- 
 ing the ulcerative stage, and bleeds when the surface is scratched 
 or broken. Durham finds that the veil of the palate is red, 
 tliickened, and distended. The special origin of the naso- 
 pharyngeal fibroma, its advent in the youthful subject, and its 
 slow development, distinguisli this growth from the malignant 
 growth. It is true that each type is recurrent, yet recurrence of 
 the malignant tumor is soon concurrent with that form of viti- 
 ated health named the cancerous cachexy. 
 
 Tlie concealed site of the malignant tumor in the nasal fossae 
 lets it develop for a time unperceived: this circumstance, and tiie 
 difficulty of radically removing the tumor in its labyrinthian 
 retreat, render the prognosis of sucli growth eminently unfa- 
 voral)le. 
 
 The treatment described for the removal of the naso- 
 pharyngeal growth is pro[)er for any form of malignant disease 
 located here. The site of origin must be destroyed; otherwise 
 the removal would be a temporizing culture of the growth. 
 The osseous ground must be removed; hence, after an opening has 
 been made to the tumor by the excising chisel, and the growth 
 completely removed, extinction is best insured by attacking the 
 osseous site by thermal cauterization. 
 
 Hypertrophy of the Nasal Mucous Membrane. — The mucous 
 membrane of the nose may become thickened to an extent which 
 may interfere with respiration. And as the growth depends on 
 development and widening of the vessels of the membrane, the 
 condition may properly be named vascular hypertropliy. This 
 thickening of the membrane occurs especially on tlie inferior 
 and middle turbinated bones; yet when prominently present on 
 these bones, the remaining mucous membrane is likewise affected, 
 
BLEEDING FROM THE NOSE. 371 
 
 viz., that of the septum and floor of the passages. The hyper- 
 trophied membrane hangs pendulous from the turbinated bones, 
 and has been mistaken for a polypoid growth. Such pendulous 
 structure, however, differs from the mucous polypi in being sessile 
 or directly attached to the margin of the bone, instead of being 
 pedunculated, and it is of a dark red color, this color indicating 
 that the venules are mainly concerned in the formation, and not 
 the muciparous glands, as is the case in the mucous polypus. 
 
 Besides interference with respiration, this hypertrophied for- 
 mation seems often to be the causal agent of asthma, through 
 reflex excitation. For these reasons the surgeon's aid is some- 
 times appealed to, for the removal or repression of such hyper- 
 trophy. This may be accomplished in two ways, viz., scarifica- 
 tion and cauterization. The procedure of scarification is adapted 
 to cases in which the subject is plethoric, and to wdiom the loss 
 of blood will not be detrimental. To do this use a sharj)-edged 
 scalpel, and make rapid, shallow incisions at various points in 
 the swollen membrane. The result will be, for a few minutes, a 
 free bleeding. This escape of blood will lessen the volume of the 
 structure, and the bleeding will cease spontaneously in a few 
 minutes. The loss of blood will be lessened if cold water be 
 applied to the bleeding surface. There will result from the 
 ■wounds made a gradual contraction and lessening of volume, 
 due to the contraction of the cicatrizing structure. This contrac- 
 tion can also be accomplished l)y the thermal cautery, with which 
 the surface may be burnt at numerous points. The division of 
 the surface by means of the scalpel can be done more readily 
 and easily, and the lesion made can be measured better with the 
 hand wdien holding a knife than the long handle of the 
 thermal cautery. As topical means which will favor the com- 
 pletion of the cure, tannin, or a solution of a mineral astringent, 
 may afterwards be applied for some weeks. 
 
 Bleeding from the iVbse.— Nasal bleeding was observed by Hip- 
 pocrates, who makes frequent mention of it; he named it hsem- 
 orrhage, a term which has acquired a much broader signification, 
 viz., to indicate bleeding from any source. Several names have 
 since been applied to it, all of which have fallen into disuse 
 except the term epistaxis, invented by Vogel and Pinel. 
 Traced to its Hellenic origin, this word means "falling drop by 
 drop." This name, formal and pedantic as it is, has crowded 
 out better ones, and obtained an enduring place in nomenclature. 
 
 Bleeding from the nose was given high diagnostic meaning 
 
372 NOSK AND NASAL PASSAGES. 
 
 by Hippocrates, Celsus, and other ancient writers, an importance 
 wliicli the moderns have failed to verify. 
 
 Blood to the interior of the nose comes through the common 
 carotid artery, and is finally received through branches of the 
 external and internal carotid arteries: the final branches of supply 
 being the ethmoidal and the spheno-palatine arterioles. 
 
 The greater part of the blood comes through the spheno- 
 palatine, a branch of tlie internal maxillary. The recurrent 
 blood traverses venules, which accompany the arteries, and a part 
 of it returns directly to the heart, while a 2:)ortion returns indi- 
 rectly through an intra-cranial route. As a result of such ana- 
 tomical arrangement, when there is congestion in the district 
 supplied by the internal maxillary artery, the mucous membrane 
 of the nose will participate in the same, and the same is true 
 when there is hypersemia of the district supplied b}^ the internal 
 carotid artery. 
 
 Haemorrhage from the nose would seem to herald its coming 
 by certain local signs; as such have been noticed unusual redness 
 of the mucous membrane, a feeling of tension, heat and itching 
 in the nose, fullness and redness of face, and suffusion of the 
 eyes. As further concomitants there may be ringing of the ears 
 and vertigo. The pulse is hard and full, and the extremities 
 may be cold. Also, signs in remote portions of the body have 
 been observed; a remarkable instance is glandular swellings. 
 
 The advent of the bleeding is peculiar, for, in most cases, the 
 stream of blood breaks forth from the nostril as if it had been 
 pent up and merely awaited an outlet for escape. It escapes 
 through the anterior or posterior nares, according as the head is 
 inclined. It may escape from one nostril alone or from both, 
 more usually from one alone. After the blood has started, it 
 may flow slowly or rapidly, according to the character of the 
 source. If the point of origin be well behind in the foss?e, or, 
 even if it be situated forwards, and the patient be reclining as in 
 sleep, then the l^lood will not be seen, but it wilL[)ass backwards 
 into the throat. During sleep such blood has slowly passed from 
 the throat and been swallowed; and afterwards, the blood being 
 vomited, the source of it has been thought to be the stomach. 
 This imperceptible passage of the blood to the stomach is due to 
 the fact that, in the dorsal recumbent position, if fluid be dropped 
 into the nostrils, it w^ill enter the pharynx and descend to the 
 stomacli without any effort being made to swallow. And as 
 Hyrtl observes, nutritive material may thus be given in cases of 
 
BLEEDING FEOM THE XOSE. 373 
 
 trismus, tetanus, or in which the patient cannot or will not open 
 the mouth; the precaution to be taken is that the fluid be intro- 
 duced drop by drop. Or the blood may collect in the throat, 
 and some of it passing into the windpipe may cause coughing 
 and ejection of blood, which has been mistaken for pulmonary 
 haemorrhage. 
 
 The amount of blood which may thus be lost may vary from 
 a few drops to amounts which fall within the incredible and fab- 
 ulous: thus in the Actes de Leipzig, a case is recorded in which 
 a man lost seventy-five pounds of blood in two days. Such a 
 statement is more suited for a page of Munchausen than for a 
 work on medicine. The large quantities sometimes seen are gen- 
 erally augmented by the addition of other excreta. 
 
 Usually, after the haemorrhage has continued for sometime, it 
 is arrested by a clot of blood closing the nostrils; but as soon 
 as the patient clears his nostrils, which the interference of breath- 
 ing leads him to do, the bleeding returns. The bleeding may 
 recur several times during the same day, or once daily for a period; 
 and this daily return may be at the same hour, or at a different 
 one; and when appearing periodically, it has been cured by 
 quinine. 
 
 The amount lost may be so great as to become dangerous to 
 life; death has thus arisen from s3aicope; as a rule, however, the 
 patient nearly faints, and rallies again if the head be lowered. 
 As before remarked, the blood may escape down the throat, and 
 enough blood be swallowed to endanger life; such bleeding can 
 be discovered if the pharynx be examined; and besides, when a 
 considerable Cjuantity has entered the stomach, the fact is revealed 
 by vomiting, since the blood coagulating acts as an emetic. 
 
 Adopting the classification of the varieties of epistaxis as given 
 by Jaccoud, we have the following: 1. Traumatic, or from ulcera- 
 tion. 2. Bleeding from a morbid condition of the vessels. 3. 
 From a mechanical cause, which may be active or passive. 
 4. From an adynamic condition of the patient. 
 
 1. Bleeding from a wound of the nose is often seen in the 
 child from falls on the nose, in which the nasal bones may be 
 broken, or merely the mucous membrane. Bleeding may be 
 from violence, in which the patient in falling strikes on his head 
 or other portion of the body, and is the subject of severe concus- 
 sion. Fracture through contre-coup implicating the ethmoid or 
 sphenoid bone, has been revealed by haemorrhage in the pharynx 
 and posterior nares, the blood then escaping from the nose. An 
 
374 NOSE AND NASAL PASSAGES. 
 
 ulceration of the mucous membrane from any cause may open a 
 vessel and cause bleeding. A growth in the nasul fossjc is often 
 indicated by bleeding. 
 
 2. Bleeding from the nose is seen in the subjects of haemophilia; 
 viz., in those who have a constitutional tendency to bleed; in 
 such subjects, luemorrhage occurs from the most trivial wound of 
 surface, so trivial often as to be indeterminable. This hajmor- 
 rhagic tendency is referred by Virchow to vascular narrowing 
 due to fatty change of the walls of the vessels. It is probable tliat 
 defective coagulability of the blood has a causal agency. Such 
 unfortunate subjects oftenest bleed from the mucous membrane, 
 and especially from that of the nose. 
 
 3. Bleeding may arise in what may be designated a mechani- 
 cal way, through active or passive congestion. As examples of 
 active congestion are those caused by violent expiratory efforts, 
 exposure to great heat or to great cold, and breathing a highly 
 rarified atmosphere. Thus during the march of the French 
 army in Russia, wdien exposed to cold, as well as during an 
 African campaign when exposed to heat, nasal liaanorrhage was 
 a common occurrence among the soldiers. And the blood often 
 bursts from the nasal mucous membrane at great elevations where 
 the atmospheric pressure is much lessened; often witnessed in 
 passengers who pass over one of the Peruvian railroads, built over 
 a summit of the Andes. 
 
 This active congestive epistaxis is seen in the haemorrhage 
 which sometimes replaces the menstrual flow of the female; also 
 in that supplementing the flux from haemorrhoids. As is known, 
 ha3morrhage vicarious of menstruation may occur from the 
 rectum, lungs or nose; in a large list of such cases, Pueeh found 
 that in eighteen cases the haemorrhage was from the nose. Such 
 vicarious haemorrhage announces itself at its approach in the 
 female by a sensation dull, heavy and sometimes lancinating in 
 the nasal region; there is present the general lassitude which 
 heralds the advent of the menses. But when the epistaxis com- 
 mences, these local and general symptoms vanish. The amount 
 of blood which is lost equals that which escapes in normal men- 
 struation; yet, in a few exceptional cases, the quantity has been 
 excessive and imperiled the woman's life. 
 
 Nasal luemorrhage may result from cerebral congestion, also 
 from closure of the superior longitudinal sinus. It has occurred 
 in cases of leucaemia; one was observed by the writer in which, 
 despite all efforts to control the bleeding, the young subject died. 
 
BLEEDING FROM THE XOSE. 375 
 
 In leucsemic hsemorrhage, Jaccoud finds the cause in obstruction 
 of tlie capillaries by leucocytes. 
 
 Nasal bleeding accompanies hepatic disease. It is a common 
 accompaniment of icterus, of which it may be the initial herald, 
 as well as the subsequent attendant. The loss of blood adds to 
 the gravity and fatalit3''of the disease. Nasal bleeding, according 
 to Monneret, is present in cirrhosis; also in hepatic congestion. 
 The bleeding in these cases has been referred to a vitiated change 
 of the blood. 
 
 Nasal haemorrhage occurs in disease of the spleen, in which 
 the blood has been morbidly altered. 
 
 Cardiac disease in which the circulation is accomplished with 
 difficulty, is attended by epistaxis, especially in the latter stages. 
 The same has been observed in renal disease by Bright, Graves, 
 Raver, Virchow and Braun. It is often present in acute Bright's 
 disease. Ursemic poisoning may be accompanied by nasal haem- 
 orrhage. 
 
 Disease obstructing the pulmonar}^ circulation may cause 
 bleeding from the nose. 
 
 4. In the fourth class of nasal hgemorrhage, Jaccoud finds the 
 cause in an alteration of the blood, and from the accompanying 
 debility he names the cases adynamic epistaxis. There is pres- 
 ent, as chief causal agency, diminution of the fibrin, and a dissolu- 
 tion of the blood-cells. In many cases which he calls pseudo- 
 hsemorrhage, it is not blood but colored serum which exudes 
 from the mucous surfaces. Yet there may escape blood in such 
 cases, and its escape may be referred to an alteration in the walls 
 of the vessels, or to impaired vaso-motor innervation leading to 
 vascular rupture. 
 
 Haemorrhage of this character may be a prodromal attendant 
 of fevers and of exanthematous aff'ections. As is well known, 
 epistaxis, as pointed out by J. K. Mitchell, is one of the most 
 trustworthy indications of an approaching typhoid fever. Also, 
 a nasal bleeding is a common precursor of scarlatina and rubeola; 
 and where these diseases appear in their malignant form, in which 
 the eruption presents itself as a dark purple redness, there is a 
 frequent or continuous hsemorrhage from the nose. And the 
 same is the case in variola, when it appears in a malignant pur- 
 pural type. Malarial fever, when long continued, may induce a 
 cachexy in which there is frequent bleeding from the nose; and 
 such bleeding is characterized as pernicious haemorrhage. 
 
 In the cancerous cachexj^ there is often nasal hemorrhage. 
 
SJO NOSE AND NASAL PASSAGES. 
 
 Also ill the ill conditions of the blood jiresent in scurvy, chlorosis, 
 purpura luemorrhagica, and kindred cachexies, nasal htemorrhage 
 is a frequent accompaniment. 
 
 Nasal luemorrhage of the class here mentioned, becomes of 
 diagnostic importance in indicating the approach of disease; and 
 in many of the instances cited, it is of prognostic value as indic- 
 ative of grave and obstinate disease, which sometimes is incura- 
 ble, inasmuch as the affection depends on disintegration or 
 morbid changes in the blood-cells. 
 
 Treatment. — The diversity of causation which lias been pre- 
 sented, frequently connected with conditions the opposite of each 
 other, indicates that tlie treatment must vary, and that thought 
 and discretion must be used in the selection of curative means. 
 
 In cases in which the cause is traumatic, for example, as is 
 often seen in the child from a blow or fall, tlie bleeding soon 
 ceases spontaneously; and its cessation may be promoted by cold 
 water applied to tlie part. And in the robust and plethoric 
 youth, who is reaching the adult period, when the structural 
 development and sanguification should be in mutual equipoise? 
 it sometimes occurs that the production of blood exceeds the 
 demands of the economy; in such case the surplus blood may be 
 rejected through the nose; and such bleeding, as a physiological 
 aid, should, as a rule, not be interfered with. Exceptions, how- 
 ever, are sometimes met with, when the nasal bleeding is so pro- 
 fuse as to demand treatment; for though such haemorrhage does 
 not directly menace life, yet it may impair the health for a long 
 time. In such subjects, an essential point in the treatment is 
 that the patient should rest and avoid effort which causes afEux 
 of blood to the Iiead. When the bleeding appears, cold water 
 may be snuffed up, or injected into the nostrils. Should this not 
 suffice, a mineral astringent may be added to the water that is 
 injected: and for this purpose, alum, in the proportion of fifteen 
 grains to the ounce of water, may be employed. 
 
 As in the youth who has excessive sanguine endowment, so in 
 the adult of middle life, the nasal ha3niorrljage may be salutary: 
 the turgid vessels of plethora find through the nose a convenient 
 outlet: and interference in such cases has met with a severe 
 rebuke to the physician, and brought disaster to the patient: for 
 the sudden arrest of the blood has, in more than one recorded case; 
 caused a rupture of a cerebral vessel, with death from apoplexy 
 or half death from hemiplegia. An attention to the resistance 
 and tension of the pulse preserit in such cases should serve as a 
 
BLEEDING FROM THE XOSE. 377 
 
 monition to depletion, if nature does not take the work in her 
 own hand; and such conditions of tension should certainly guard 
 against arresting the nasal bleeding. 
 
 It would be unwise to arrest epistaxis which is the initial 
 symptom of a fever, or exanthematous affection. Yet in a scrofu- 
 lous, scorbutic, cancerous, purpural, or leucsemic cachexy, the 
 bleeding must be arrested. 
 
 AVhen the nasal hsemorrhage is vicarious or supplementary of 
 the menstrual flux, it should not be disturbed, unless the loss of 
 blood be excessive; then it must be controlled. 
 
 Should the bleeding recur periodically, then it should be 
 treated with quinine, provided there be no existent plethora 
 contra-indicating the arrest. 
 
 In renal disease of chronic albuminuric or glycosuric species, 
 nasal heemorrhage should be repressed. But in acute ura^mic 
 intoxication a nasal haemorrhage would be salutary, and should 
 not be checked : indeed, if it be scanty, it should be supplemented 
 by a free depletion from the arm; tlius, as the writer has verified, 
 eclamptic convulsions may be arrested, and, without doubt, the 
 life of the patient saved. 
 
 The methods of arresting nasal haemorrhage are the following: 
 The topical application of cold water, styptics in solution or in 
 substance, cauterization of the bleeding point, when that can be 
 found, tamponing the nostrils before and behind, or throughout 
 their entire length, compression of the carotid artery, lifting the 
 arm upwards, and, finally, the erect position of the entire body. 
 
 The slow irrigation of the bleeding nostril with cold water 
 often suffices to arrest the hgemorrhage: this may be done by 
 means of an irrigating apparatus suspended above the head from 
 which the water is conducted through a tube into the affected 
 l^assage. Or the water can readily be pumped into the nose with 
 an elastic tubular syringe. The cold fluid should be carried into 
 the affected nostril; or into one, and then into the other, in case 
 of bleeding from both sides. The discovery of Weber, already 
 referred to in this work, that a fluid thrown into one nostril will 
 pass to the choanse and return by the other nostril, is utilized in 
 this irrigation. 
 
 Beside simple cold water, the irrigating fluid may be made 
 more effective if there be added to it alum or subsulphate of iron, 
 in the proportion of fifteen grains to the ounce of water. Or the 
 astringent and styptic material may be used in the form of a 
 powder, which is to be snuffed into the nostrils. For this purpose 
 25 
 
378 NOSE AND NASAL J'ASSAGES. 
 
 alum or the iron salt mentioned, or sulphate of zinc, or acetate of 
 lead, or tannin in pulverized form, may be snuffed into the 
 nostril, and, coming in contact with the bleeding jwint, there will 
 be formed a clot of blood which will temporarily, or permanently, 
 arrest the lia3morrhage. As a styptic for this purpose, tannin is 
 the best, since it exerts no corrosive action on the mucous mem- 
 brane, as do alum and the salts of iron. 
 
 From observations on epistaxis made b}'" Chiari in 1883, he 
 found that the bleeding originates, in most cases, from the septum, 
 and that an inspection will reveal a bleeding point there: or if 
 not found there, it will be in the floor of the passages. Dr. 
 Simrock, a specialist in Xew York, has also found that the bleed- 
 ing point is usually on the septum, and in most cases this is near 
 the outlet. These specialists advise to arrest the bleeding by 
 cauterization of this point: Simrock touches it with a Dencil of 
 nitrate of silver. 
 
 Should the methods mentioned fail to arrest the haemorrhage, 
 or should this be so profuse as to admit of no delay, then the 
 tampon may be employed. This may be done by completely 
 plugging the nostrils throughout their entire length : or the 
 closure may be done at the posterior and anterior outlets. As 
 material for the tampon, sponge of fine texture can be used • also 
 surgeons' lint. 
 
 The closure through the entire length is best done by means 
 of a narrow strip of lint, several inches long, which has been 
 saturated with sonie astringent solution, as of alum or tannin. 
 With a probe or attenuated sound, one end of this strip is carried 
 into the posterior 2:)ortion of the passage, and enough is thrust in 
 to close the posterior outlet. The plugging is continued with the 
 remainder of the strip, until the nostril is entirely closed. And if 
 there be bleeding from both sides, the other passage must be 
 treated in the same manner. In this tamponing occlusion, the 
 work must be done gently: for if done too forcibly, the mucous 
 lining of the passages will be lacerated and subsequent bleeding 
 promoted. To completely close the rear of the nostril, the di- 
 mensions of the posterior opening must be known. This outlet 
 in the dried skull of the adult has the form of a ])arallelogram, 
 with short diameter from side to side: but in the living subject, 
 this outlet is lined by mucous membrane, and is an ellipse, of 
 wdiich the long diameter is nearly an inch in length, while the 
 short one is nearly a half inch long. Hence the occluding tam- 
 pon must have these dimensions. For this use, sponge of fine 
 
BLEEDING FROM THE NOSE. 379 
 
 texture answers well. To introduce this tamponing plug one 
 may use the canula of Bellocq, which is exhibited in the accom- 
 panying figure. This is an ingeniously contrived instrument, 
 
 Figure 4. Representing Bellocq's canula. 
 
 consisting of a canula in which there is concealed an elastic coil 
 resembling a section of a watch-spring. AVhen the canula is car- 
 ried through the nostril into the pharynx, the spring is thrust 
 out and projects forwards in the oral cavity, so that the tanipon- 
 ing plug can be drawn into the posterior opening and left there. 
 
 The surgeon may not have at hand Bellocq's canula; in fact, 
 other means may be devised to rej^lace it. For this purpose, a 
 wire folded on itself may be passed along the floor of the nostrils 
 and the end caught, and a piece of occluding sponge attached to 
 it; and thus the wire pulled on will draw the sponge into the 
 passage. The tampon must be drawn quite into the passage 
 Tlie other nostril may be plugged in a similar manner; and to 
 prevent the sponge escaping into the throat, a thread attached to 
 each one may be tied in front across the septum. Instead of a 
 wire, a convenient means of carrying a thread backwards along 
 the floor of the nostrils is a small soft catheter, or a piece of flex- 
 ible whalebone. When the posterior passage is occluded, the 
 anterior one is to be filled with occluding material. The blood 
 thus having no egress, clots at the bleeding point, and the hemor- 
 rhage is thus controlled. 
 
 If a comparison be drawn between the mode of continuous 
 plugging and that of only closing the anterior and posterior 
 nares, the former is preferable, for the following reasons : When 
 the entire passage is plugged, the tamponing material will prob- 
 ably come in contact with the bleeding point and directly close 
 it; but if merely the anterior and posterior nares be occluded, 
 then the blood accumulates in the included passage, and, clotting, 
 arrests the bleeding. But before coagulation occurs, a large 
 amount of blood is poured out, which seeks vent, and may pen- 
 etrate the sinuses connected with the nose. It has been seen to 
 pass through the lachrymal canal and appear in the corner of 
 the eye: and in a case thus treated by Crequy, after some hours 
 
380 NOSE AXD NASAL PASSAGES. 
 
 the blood escaped from the ear; and later the cheeks and eyelids 
 became swollen; and the condition became so perilous that the 
 tampon was removed, and a solution of a salt of iron was injected 
 into the nostrils, and thus a clot "was created which arrested the 
 htcmorrhage. Should the anterior and posterior plugging be 
 done in a case in wliicli the bleeding is so j^ersistent as in the 
 case of Cre'quy, tiien, after the posterior nares are occluded, a 
 styptic fluid injected in front might arrest the bleeding, or cer- 
 tainly insure control, if the anterior nares also be pklgged. 
 
 The author, in a case of terrible nasal haemorrhage in a leu- 
 csemic child, controlled the bleeding by carotid compression. And 
 this compression, which is best done digitally, need not be contin- 
 uous. Pressure made for ten or fifteen minutes usually suffices 
 to arrest the bleeding; and when the hsemorrhage reappears, the 
 pressure must be repeated. Such compression must be made on 
 the vessel where it lies alongside of the larynx, just prior to its 
 bifurcation: and to be efiective, the work must be done by an 
 instructed hand. The error often fallen into is, in prosing, to force 
 the artery inwards beneath the side of the larynx. When the 
 bleeding is arrested by tlie compression, the pressure may gradually 
 be lessened, and finally discontinued. Here, as in compression 
 to cure aneurism, the flow of the blood through the vessel should 
 not be entirely checked; enough should be permitted to pass to 
 form an occluding clot. 
 
 A simple method to arrest nasal bleeding is to lift and main- 
 tain the arm erect on the affected side. The manner in wliich 
 this acts may be explained as follows: The heart, to propel the 
 blood througli the vascular circuit, exerts a fixed amount of force: 
 now if one arm, and still more if botli arms, be uplifted, no small 
 amount of tliis energy will be used in moving and sustaining the 
 high column of blood in the erect limbs: and this ex[)enditure 
 will lessen the pressure in the nasal vessels, and tend to lessen or 
 arrest haemorrhage from the nose. 
 
 Thus a French surgeon narrates that during a campaign in 
 the north of Africa, a number of soldiers who were seized with 
 Aasal hsemorrhage from exposure to the tropical sun, were ordered 
 to lift up an arm, with the result that the bleeding was arrested. 
 
 X method akin to this is that of Bresger of Vienna, who in 
 1883 advised as a means to check nasal bleeding that the patient 
 stand erect ; such position would lessen pressure. 
 
 Foreign Bodies in the Nasal Passages. — Children to amuse 
 themselves, or to gratify a curiosity to explore the cavity of the 
 
FOREIGN BODIES IX THE NASAL PASSAGES 381 
 
 nose, thrust bodies into the nostrils, which remain and partially 
 obstruct the passage. Examples of such bodies often thus toyed 
 with are the seeds of apples and cherries, peas, beans, beads, peb- 
 bles and other small bodies used as playthings by the child. In 
 swallowing, fragments of food sometimes enter and lodge in the 
 posterior nares. This occurs in the adult; and, as a rule, intrud- 
 ing material is dislodged by coughing. 
 
 Foreign bodies may lodge in any portion of the cavities, yet 
 the most usual site is the inferior meatus, xlt first, it may pro- 
 duce but slight irritation; yet later the body becomes a nucleus 
 about which the nasal excreta collect, harden and enlarge the 
 body. If it be a seed which can germinate, it swells, and, as in 
 the case of the bean seen by Boyer, it can sprout. In his case, 
 the bean, having sent forth a dozen roots, was imbedded in a mass 
 of hardened matter, and had been mistaken for a polypus. Also 
 an inorganic body may become coated with hardened saline 
 material, until it reaches such dimensions as to crowd on and 
 irritate the adjacent walls. Such body is sponge-like and easily 
 broken, and sometimes presents irregularities of surface similar 
 to a mulberry calculus of the bladder. In other cases it has been 
 found of stone-like hardness. 
 
 Again, concretions of mineral matter in which no jDreexistent 
 nucleus can be discovered, occur in tlie nasal passages. This 
 body, named rhinolith, is a calcareous compound, and is composed 
 of carbonate and phosphate of lime. Its origin has been 
 referred to an inflamed condition of the pituitary membrane; 
 others refer it to an affection of the lachrymal gland. A gouty 
 diathesis has been assigned as a cause. Such petrifaction is an 
 occasional accompaniment of ozsena, in which disintegrated 
 nasal material forms crust-like concretions, which collect and 
 adhere to the irregular recesses of the nasal fossse. The rhinolith 
 may appear single or multiple. When divided by a saw, they 
 present concentric layers, or there may be a central cavity con- 
 taining fetid matter. 
 
 "When the rhinolith attains considerable size, it becomes a 
 constant irritant and causes swelling, and sometimes a sanious 
 or sanguinolent discharge. The condition is similar to that 
 caused by a foreign body which has lodged a long time in the 
 nasal fossee. The body can become embedded in the swollen 
 mucous membrane, so that the latter nearly covers the concretion. 
 About the site of it one finds masses of ill-smelling, cheese-like 
 matter. 
 
382 NOSE AND NASAL PASSAGES. 
 
 It is evident that both a rhinolitli, as well as a foreign body 
 lodged in the nose, can occasion great inconvenience in causing 
 foul breath and an intolerably offensive discharge. The irrita- 
 tion may extend to the eyes, and, besides conjunctival redness, 
 there may be flowing of tears. 
 
 Yet, despite these and other indications pointing to the pres- 
 ence of a foreign body in the nasal passages, from the neglect of 
 careful examination of the cavity, the condition has been mis- 
 taken for some more grave affection. More than once a severe 
 operation has been arrested midway, which would not have been 
 commenced had there previously been made a careful examina- 
 tion with speculum and probe. The writer was the intervener 
 once in a case in which the patient was saved from a painful 
 operation that was on the eve of being performed ; a probe 
 introduced found a movable foreign body, which, being removed, 
 proved to be a cherry-seed incrusted with calcareous matter. 
 Several cases are recorded in which the rhinolith was mistaken 
 for necrosed bone. 
 
 Such bodies are commonly easily removed by means of prop- 
 erly constructed forceps. Durham uses a pair of forceps of which 
 the blades can be separated and introduced singly, and then locked. 
 A forceps with small blades which are toothed answers the pur- 
 pose well. The precaution must be taken not to force the body 
 backwards into the pharynx, since it might drop into the wind- 
 pipe and cause strangulation. After the removal, the passage 
 should be irrigated for a time with some anti-septic fluid. 
 
 Parasites in the Nasal Po-s-sa^cs.— Frequently in the tropics, 
 and sometimes in the temperate zone, parasites have Ijeen known 
 to enter the nasal passages, and deposit larvae, which develop 
 there. This parasite is a species of insect, and from its habit is 
 named Lucilia hominivora. It probably lays its eggs in the 
 entrance of the nares; and the eggs are afterwards drawn 
 inwards by inspiratory efforts, and lodged in the deeper recesses 
 of the nose. As the in.sect develops, it causes a stinging or 
 boring pain, also epistaxis. If undisturbed, the insects continue 
 their ravages, in which the soft parts ulcerate, and tlie bones are 
 perforated. Later, the face is opened, and the disintegrated 
 structures teem witli moving worms. This hominivorous parasite 
 has been known to perforate the base of the skull, and, having 
 entered the cavity, caused death by meningitis. 
 
 As soon as such trouble is suspected, the enemy should be 
 vigorously attacked by local remedies. Among the most effi- 
 
OZ.EXA, OR XASAL CATARRH. 383 
 
 cieiit means at our control is turpentine, which is swiftly fatal to 
 insect life. In solution, or in its pure state, this agent should be 
 injected into the affected cavity. Other germicidal solutions may 
 be used; for example: chlorinated or sublimated solutions. 
 The fumes of tobacco, arsenic, or chloroform may also be used. The 
 frontal sinus has been trephined, and the germicidal solution 
 thrown through the opening into and through the nasal passages. 
 Ozsena, or Nasal Catarrh. — The essential idea implied by the 
 term ozpena is afoul odor; and since fetor of the breath is the 
 prominent characteristic of nasal catarrh, the terms ozsena and 
 nasal catarrh are equivalent terms. The European writers more 
 often use the name ozsena, while the American writers often er 
 employ the name nasal catarrh. The name ozsena will be used 
 by the writer, inasmuch as it more definitely specifies the most 
 offensive feature of the disease; catarrh, or descending discharge, 
 only occasionally offends the sight of others, while the foul breath 
 of the patient is an unending annoyance to those within its 
 reach. 
 
 Ozsena, then, may be defined to be a disease of the nose in 
 which there is a diseased condition of the inner surface of tlie 
 nasal passages, whence ill smelling matter is excreted; and this 
 material may be profuse in amount, or so small in quantity as 
 scarcely to be discoverable. And this difference in the amount 
 of tlie excretion led Hedenus, writing on the subject in 1861, to 
 make two species: one in which there is a discharge, and another 
 with no discharge; and the former may be of scrofulous, herpetic, 
 syphilitic or mercurial origin. 
 
 In 1863 Trousseau, writing on ozsena, finds that ill breath 
 may arise from causes outside of the nasal disease: it may arise 
 from the mouth, teeth, throat, disease in the oesophagus, and he 
 might have added, disease of the lungs. Some persons, again, 
 have ill smelling excretions, of which it is difficult to determine 
 the caase; and such cases are sometimes incurable. 
 
 To determine whether the fetor proceeds from the nose or the 
 mouth, Trousseau directs to alternately close the one and the 
 other; by thus doing the true source of the odor will be discov- 
 ered. An error might, how^ever, be made in cases in which fetid 
 matter has fallen into the choanse, or space which is common to 
 the mouth and nose. 
 
 Fortunate for the patient of ozsena, his fetid breath only dis- 
 turbs others ; and only by others is he reminded of his unfortu- 
 nate condition. A fetid odor may be generated by a healthy 
 
384 NOSE AND NASAL PASSAGES. 
 
 secretion when this remaius too long in contact with its generat- 
 ing surface. But if the surface is unhealthy, then the jnatter 
 excreted is offensive as soon as it is found. 
 
 Ozaena is commonly associated with some constitutional 
 cachexy ; such cachexy may be scrofula, scorbutus, tuberculosis 
 and syphilis; a scrofulous or syphilitic origin is oftenest met 
 with. It may be associated with some cutaneous disease, as lupus, 
 herpes; or an exanthema, as scarlatina, may be referred to as tlie 
 origin. 
 
 In the general constitutional disease, or the cutaneous causal 
 affection, the mucous membrane, as well as the subjacent osseous 
 and cartilaginous structures, become affected. Primarily, the 
 mucous membrane is swollen; and the localization of the dyscra.sy 
 here is favored by the numerous acinous glands seated in the 
 membrane. This swollen stage is nearly odorless, and succeeded 
 by an atrophic one in which the fetor is present. In the atropljic 
 condition the thick tenaceous secretion is retained and decomposes. 
 Also, if the profuse discharge from the hypertrophic form remains, 
 dries and adheres, crust-like, to the surface, a fetor may arise 
 from this desiccated matter. 
 
 According to Max Schaefer, of Bremen, scrofulous ozaena 
 occurs between the riinth and twelfth years of age, and begins 
 with a snuffling and nasal discharge. The membrane here is 
 swollen; but the atrophic form occurs in older persons. 
 
 At a medical congress in London, in 1881, oziena was the 
 subject of discussion. Frankel claimed that it is associated with 
 a chronic catarrh ; and there is atrophy of the mucous membrane 
 to a greater or less degree. The ill odor is from the stagnant 
 excreta. 
 
 Fournier, referring the origin of ozsena to syphilitic, dipli- 
 theritic, catarrhal or scrofulous disease, finds that it may be moist 
 or dry in character. 
 
 AVatson finds ozaena associated with lupus and chronic eczema. 
 
 Martin, of Paris, finds an ulcerative and a non-ulcerative 
 form ; in the latter the periosteum and bones do not become 
 affected; and he and Zaufal refer this species of ozjena to a 
 preternatural width of the nostrils. They claim that this width 
 of nostrils depends on a cessation of growth of the inferior turbi- 
 nated bones, in which the middle turbinated bone is also impli- 
 cated. In this malformed condition of the nose, atrophy with 
 catarrhal discharge ensues. 
 
 Hedenus saw cases of ozaena in which the fetid breath ap- 
 
OZiENA, OR NASAL CATARRH. 385 
 
 peared and continued only during the time of the menstrual flux. 
 
 Hence, as appears from the preceding, authors agree in opinion 
 thatozsena is dependent on some general or constitutional disease, 
 and that the nasal affection is only a local manifestation of the 
 same. This local trouble may be limited to a simple swelling of 
 the lining membrane, and, as a result of this hypersemic condi- 
 tion, the mucous glands become abnormally active; or the disease 
 may not thus be limited, but may reach to and attack the sub- 
 jacent bones. The osseous invasion may be caused by gumma- 
 tous or other neoplastic development, which interferes with the 
 proper vascular supply of the parts; or the nutrient supply can 
 be obstructed by embolic or thrombic closure of the minute 
 vessels. The dry atrophy of the membrane, before mentioned, 
 may be thus caused. Inveterate duration of the disease, and 
 rebellious obstinacy to resist treatment, characterize those cases in 
 which the turbinated bones and the septum have become affected. 
 And when this stage is reached, the sense of smell is greatly 
 impaired. The delicate structure of the terminal filaments of 
 the olfactory nerve are the subjects of lesion, which sometimes 
 proceeds to the partial loss or total extinction of the sense of 
 smell; and as this impairs thegustative sense, it results that the 
 subject of oz8ena becomes maimed, as to two of his important 
 special senses. Also, the bones when once lost are never restored; 
 hence ozsena, with necrosis of the interior bones, entails perma- 
 nent mutilation of the interior architecture of the nose; and, in 
 some cases, the collateral constitutional disease destroys the ex- 
 ternal skeleton of the organ, and ends in the sinking of the nasal 
 arch, and leaving one of the most offensive of disfiguring deform- 
 ities, viz., the saddle-seat nose. With these possible eventualities, 
 especially if the affection arise from constitutional disease, ozsena 
 demands earnest care on the part of the surgeon. 
 
 Treatment. — This will vary according to the stage to which the 
 disease has proceeded, as well as according to the character of the 
 causal constitutional disease : conditions demanding varied local 
 and general treatment. Where the ozsena has arisen from syph- 
 ilis, the patient should receive such varied care, viz., mercur}^ 
 and iodine, with a predominance of the latter; and, locally, the 
 parts should be treated with astringent and alterative compounds, 
 of which mention will presently be made. In all cases scrupulous 
 care must be used to remove the nasal excretions; and this may 
 be done by resorting to Weber's procedure, in which the fluid, 
 siphon-like, is caused to make the circuit of the nasal passages. 
 
386 NOSE AND NASAL PASSAGES. 
 
 And the fluid thus used should be warm water, to which is added 
 the agent designed to act topically. 
 
 If the oza?na occur in a tubercular or scrofulous subject, anti- 
 scrofulous remedies must be administered, viz., iodine and cod 
 liver oil. If the affection of the nasal surface is confined to the 
 mucous membrane, and consists of a swollen state of the same, 
 linear thermal cauterization should be resorted to. This may 
 be done with the wire loop of the galvano-cautery, which, for a 
 moment, is caused to touch in lines the affected surface ; or, in 
 absence of the thermal appliance, a simple one may be extem- 
 porized of a steel pin fixed on a cork for a handle, of which one 
 end, heated in a lamp, may do the w^ork of linear cauterization. 
 Thus fine linear sloughs are produced, and the heat, coagulating 
 the blood in the subjacent vessels, lessens the nutritive supply, 
 and thus reduction of structure is accomplished. In place of 
 fire, a potential caustic may be used, viz., with a pencil of nitrate 
 of silver, or of fused potassa; one may touch and destroy' small 
 sections of surface, and thus effect structural retrenchment. 
 
 As local treatment advised by different authorities, the follow- 
 ing may be cited: Hedenus used creosote both internally and 
 externally. Pulverized charcoal, to wliicli some aromatic is 
 added, as the oil of anise, bergamot, etc., may be used as a snuff. 
 Tincture of myrrh with infusion of bark may be used locally. 
 Where the local application caused too much discharge, Hedenus 
 added alum to it. As errhine remedies, Trousseau advises the 
 u.se of subnitrate of bismuth, chlorate of potash, and especially 
 the red precipitate of mercury. The nasal passage should be 
 prepared for the use of these remedies by previous irrigation. 
 As nasal injection. Trousseau uses a solution of nitrate of silver, 
 corrosive sublimate or sulphate of copper. As internal medica- 
 tion he uses iodine, cod liver oil and the preparations of arsenic. 
 Schaefer cleanses the passages with a syringe, and cauterizes 
 thickened .surfaces; and, for use by insufflation, he employs. the 
 following powder: — 
 
 1^. Argeiiti Xitratis gr. i ad x 
 
 Talci 9ijss 
 
 Mi see. 
 Or, 
 5t. Sodii Benzoatis gr. x 
 
 Talci gr. 50 
 
 Misce. 
 
OZ^NA, OR NASAL CATARRH. 387 
 
 Insufflation can also be done with boric acid, alum, or 
 iodoform. Frankel cauterizes with the hot iron. Fournier, as 
 local means, uses the decoction of althaea and that of poppies. 
 The crusts of concrete matter must be removed, and the surface 
 touched with nitrate of silver, carbolic acid or tincture of iodine- 
 In the dry form with constitutional cachexy, Fournier advises 
 arsenical baths, and he gives internally arsenic and the bicarbonate 
 of soda. In the moist constitutional form be uses sulphur baths 
 and internally iodine, iron and cod liver oil. He removes the 
 crusts and injects a two per cent solution of salicylate of sodium. 
 Fournier cauterizes the ulcerated surface with nitrate of silver. 
 The treatment must often be continued for a period of two years. 
 Relapses are frequent, so that treatment must often be resumed 
 again. AYatson uses iodoform bougies, and lets the patient snuff 
 bismuth in powder. Internally he administers iron, arsenic, cod 
 liver oil, iodine, copaiba and mineral acids. Gottstein, after 
 removing the crusts that form in chronic cases, introduces tam- 
 pons of cotton into the nostrils, and he limits his treatment 
 chiefly to this simple work. 
 
 As ozsena may, according to Zauful and Hartmann, arise from 
 too great width of the nostrils, it is probable that in such cases 
 relief might be obtained by lessening the entrance of the nares. 
 To do this, a wedge-shaped portion might be excised from the 
 posterior part of the nostril, viz., where the wall is continuous 
 with the upper lip. The wound thus made is to be closed by a 
 deep metallic suture. Such an operation, besides lessening the 
 orifice, would improve the form of the nose; it would overcome 
 in some degree the unsightly flaring of the part. 
 
 In the forms of ozsena mentioned the disease was limited to 
 the pituitary membrane; it may advance further, and attack the 
 bones of the nasal labyrinth, and this is not unfrequent in the 
 subject of tertiary syphilis. Also in patients of scrofula in whom 
 there is an element of congenital syphilis, there is often an affec- 
 tion of the nasal passages, which finally attacks the turbinated 
 bones and the septum. The concealed site of these bones permits 
 the affection to lurk in them for a long time before the full extent 
 of the disease is realized by the patient or suspected by the phy- 
 sician. The fetor from the necrosing structures finally announces 
 the nature and advanced stage of the disease. The course of 
 such a case, if its stages be enumerated in their consecutive 
 appearance, is primarily a congestion of the mucous membrane 
 which lines the nasal cavity; this congestion arises from the 
 
388 NOSE AND NASAL PASSAGES. 
 
 return of the blood being ini])cdecl by minute gummy or connec- 
 tive tissue growths, developed by constitutional disease. The 
 bone, deprived of a regular supply of aerated blood, dies, and the 
 investing membrane dies also at points, and this constitutes tiie 
 secondary or destructive stage. There is now concurrent necrosis 
 and ulceration. The tenuity of the bones is such that dentli of 
 surface involves death in totality. For the ulceration attacks 
 both sides of the paper-like bone, wlien the arrested or dis- 
 turbed circulation becomes inadequate to maintain vitality. 
 This process continuing, a large ])ortion of a turbinated bone, or 
 a section of the long partition, necroses, becomes loosened and 
 detached from the remaining parts, and, like a foreign body in 
 the passage, moves during the act of clearing the nostrils. The 
 necrosed bone when loosened a[)pears at the anterior or posterior 
 outlet, most frequently, at one nostril in front; and this period of 
 elimination, though it is the concluding stage of the worst form 
 of oziena, is often prolonged for an indelinite period: first, a por- 
 tion of the vomer, and, later, its entirety, are separated and thrown 
 out. Meantime the turbinated bones, one or all of them, and 
 the perpendicular plate of the ethmoid, die and are eliminated; 
 in brief, the architectural structure of the nose falls piece by piece 
 until there remains little else than the superior arch formed by 
 the nasal bones; and even these occasionally share in the ruin, 
 and, sinking, the patient's face is marred with the revolting deform- 
 ity of a sunken nose: a saddle-seat on which the fiend of impure 
 venery mounts and announces himself to every observer. 
 
 The treatment of this destructive form of ozEena, if wary, fore- 
 seeing and comprehensive, will, at an early period, apply the ax 
 at the root of the causal tree, in the form of remedies which will 
 arrest, if not extinguish, the constitutional cachexy. If, however, 
 the surgeon only sees the case at the second stage, when necrosis 
 has commenced, an effort must be made to stay or limit the 
 destruction of the bones. Nasal irrigation to remove the septic 
 excreta must be industriously done; and for this purpose alkaline 
 solutions should be used, viz., a .solution of carbonate of potassium, 
 in the j)roportion of five grains to the ounce; or Aqua calcis may 
 be used. A solution of chloride of sodium, or of borax, may be 
 used, yet the jiurely alkaline solutions, which as chemical agents 
 are solvents of albuminous or fibrinous matters, will be more 
 effective in dissolving and removing excreta which are cognate 
 to such material in composition. To chock osseous decay, irriga- 
 tion may be done with iodized .solutions; for example, iodide of 
 
OZ.EXA, OR XASAL CATARRH. 389 
 
 potassium in the proportion of half a drachm to an ounce of 
 water. Or a drachm of tincture of iodine to an ounce of water 
 might be injected into the nasal passage. In case the necrosis 
 has involved but a limited portion of bone, for instance, a section 
 of the vomer, the query arises: Should the dead portion be removed 
 at once, or should one delay until the sequestrum is wholly 
 detached? — a question not promptly to be answered, according 
 to the writer's experience. The observation of cases in which the 
 dead bone was removed early, and of others in which removal 
 was delayed, inclines the writer to advise late removal as the bet- 
 ter practice ; for in the work of extracting the dead bone before 
 its detachment, the adjacent bone, which is but slightly affected, 
 may be disturbed and its death favored. Hence the more con- 
 servative method is to wait until the sequestrum is freely mov- 
 able, and then remove it with a pair of forceps. If the osseous 
 fragment is too large to emerge from the nostril, as sometimes 
 is the case, then it should be divided with cutting forceps. 
 
 "When the osseous septum and the turbinated bones are lost, 
 there is no reparative power in the tissues which invest them to 
 repair the breach; the partial or complete destruction of the lin- 
 ing periosteum and the ulcerated and diseased state of the pit- 
 uitary membrane forbid any hope of such repair; the work of 
 devastation has permanently ruined the interior of the nose, and 
 with such ruin the sense of olfaction partially or comjdetely 
 vanishes. 
 
 If tlie necrosis should invade a nasal bone on its inferior sur- 
 face, the osseous destruction may proceed until tlie bone is per- 
 forated or is so weakened that it cannot maintain its position 
 longer; it sinks, and lets the overlying soft parts sink inwards. 
 This sinking may be on one side; or, both sides falling, the lobule 
 of the nose is tilted upwards, and the complete saddle-seat nose 
 is present. The deviation, both of side and point of nose, may 
 be greater towards one side. 
 
 If the patient be treated properly, constitutionally and locally, 
 the event here described may be averted; the weapons are mercury 
 internally and iodine internally and externally, with nasal irriga- 
 tion. Iodine, used locally, is the most efficient remedy. To use this 
 apply the tincture of iodine on the inside and iodine ointment 
 on the outside. Thus the minute gummatous and scrofulous 
 neoplasms which may exist in the mucous membrane, or the 
 inner or outer periosteal lining, will be caused to recede, and the 
 vitalilv of the bone n:iaintained. This absorbent, or better stvled 
 
390 NOSE AND NASAL PASSAGES. 
 
 conservative, action of iodine has been verified by the writer in a 
 few cases. If, however, through neglect of treatment, the necro- 
 sis be allowed to proceed, the dead hone is eliminated piecemeal, 
 rather than in entirety; so that portions of the nasal bones 
 remain, especially the articulating borders. Occasionally the 
 skin is perforated, and the sequestrum thus escapes, and a scar 
 results. In the majority of cases, however, the elimination of 
 the dead bone is on the inside tlirough a. breach in the ulcerated 
 mucous membrane; and the avoidance of a scar, which then 
 results, renders this mode of ending preferable to the other. 
 
 In operations on the face and mouth, in which blood may 
 pass into the nares and thence into the pharynx, Verneuil advises 
 as a preliminary to tampon the posterior nares by the aid of 
 Bellocq's cannla; after such ]>reliminary plugging, the patient can 
 be anaesthetized, and the operation more safely done. 
 
CHAPTER X. 
 
 MAXILLARY SINUS, OR ANTRUM OF HIGHMORE. 
 
 Of the three accessory cavities, which communicate with the 
 nasal fossse, the largest is the maxillary sinus, or antrum of 
 Highmore. This exists at birth, while the frontal sinus develops 
 post-natally. In the adult this large air-cell is prismoidal in 
 figure, and has four bounding walls. It may be compared to an 
 irregular triangular pyramid, the base of which, lies upwards, 
 and is formed by the floor of the orbit. This wall is traversed 
 from behind forwards by the continuation of the superior max- 
 illary nerve. Of the three vertical walls, the internal one 
 separates the antrum from the nasal fossse; a second or front 
 wall lies behind the cheek, and looks for\tards and outwards; the 
 remaining wall looks backwards and outwards. These three 
 upright walls converge from above downwards, so that the- inferior 
 floor is very small when compared with the upper one. 
 
 There are, as a rule, two openings from the middle meatus of 
 the nasal fossse into the maxillary sinus. Near the middle point 
 of this meatus exists, usually, an opening which leads directly 
 into the antrum; but more careful observation has found that 
 this orifice may be absent, or, at least, so occluded by mucous 
 membrane as to prevent the passage of fluids. But near the 
 anterior end of the middle meatus there lies the infundibuliform 
 opening of the frontal sinus into the nasal passage, and if the 
 outer wall of this funnel-shaped passage be examined, there will 
 be found an opening into the antrum ; so that if a fluid be injected 
 from the frontal sinus, some of it will pass into the antrum. 
 This normally duplicated communication between the nasal fossae 
 and the antrum gives additional security against the accumula- 
 tion of fluid material in the antrum. 
 
 As seen, there are three sides in which openings can be made, 
 and a communication established with the cavity of the antrum; 
 viz., through the inner wall, through the anterior one, and thirdly 
 through the underlying alveolar process. The opening through 
 
 (391) 
 
o02 MAXir.LARY SINUS, OR ANTRUM OF HIGHMORE. 
 
 (he inner wall would be difficult to make, and, when formed, 
 would be too indirect for use by the surgeon. An opening through 
 the alveolar process may be made through the site of a molar 
 tooth ; yet this rc(|uires tlie extraction and sacrifice of an important 
 tooth, viz., the second molar. As most patients Avould, like Don 
 Quixote, part with sucli a tooth as sadly as tlicy would with a near 
 friend, hence there are earnest objections to this site for an open- 
 ing into the antrum, and, besides, such opening is apt to remain 
 open. A third route by which tlie antrum can be entered is 
 through the anterior wall, which is thin, and, if opened, it can be 
 closed without difficulty. 
 
 We will next proceed to consider the surgical affections of the 
 antrum, and will connnence with fracture. 
 
 Fracture of the anterior wall is not an unfrequent occurrence, 
 and this may be subcutaneous or complicated with an open 
 wound. The thinness of the anterior wall, and its exposed posi- 
 tion in the face, render it lial)le to fracture. And within the 
 writer's observation a number of such cases have been observed, 
 in whicli the causal agency was a kick of a horse, or a blow with a 
 strong fist. If the violence be not great, then the soft parts are not 
 opened, but the wall of the maxillary sinus is broken and driven 
 inwards, and thus a depression is made in the face, below the eye, 
 and outside of the nose. And the depressed bone will remain in 
 its new position unless restored to place by surgical assist mce. 
 The rule has been, if an attempt was made to reduce to normal 
 form, to attempt this by an incision in the cheek, and through 
 this to elevate. As this must leave a prominent scar, the patient 
 has commonly jireferred to retain the sunken place in his cheek 
 rather than to exchange it for an unsightly cicatrix. In place of 
 this method, the author proposes a less deforming one, as follows: 
 In the cul-de-sac between the alveolar jirocess and the lip, make 
 an opening close to the bone until the canine fossa on the upper 
 jaw is reached, and, having exposed this, perforate the wall with 
 a small trephine, or a carved chisel, and through this opening 
 introduce an elevator and restore to normal position the sunken 
 wall; and, thus outlifted, the wall would remain in normal posi- 
 tion. The opening which the surgeon has made would soon 
 permanently close. 
 
 A more severe injury is that in whicli there is an open wound 
 to the fracture, and in such case, there may be a number of frag- 
 ments, some of which may lie in the antrum, and others may 
 hang to shreds of the torn soft parts; in fact, there are present 
 
ABSCESS OF THE MAXILLARY SINUS. 393 
 
 all the elements of a severe compound fracture. The treatment 
 here will commence with the removal of fragments which are 
 wholly separated from tlie soft parts, and the restoration to place 
 of fragments which are adherent to the lacerated soft parts. 
 Fragments, which are wholly loose and have no vascular connec- 
 tion remaining, should be removed, for if left, they would act as 
 foreign bodies, which would prevent healing of the wound. But 
 fragments of bone that are adherent to flaps of the torn cheek, 
 which will maintain the bone alive, must be preserved, since 
 their preservation will materially lessen the scarring consequent 
 on such open fracture. The irregular edges of these usually need 
 not be trimmed, but if they have a fringe-like border, which 
 floats in the fluid used for cleansing the wound, this edge should 
 be trimmed off, and the fragments or flaps should be restored to 
 site, and fixed by sutures, which should first connect opposite 
 angles or opposite free borders; and after this, suturing should 
 proceed towards the base of the flaps or beginning of the borders. 
 If thus united, the torn parts will lie in their natural position. 
 The wound should be dressed with lint moistened with an alco- 
 holic sublimated solution. The healing occurs rapidly, and often 
 with less scarring than was expected. 
 
 An occasional accompaniment of fractures of the walls of the 
 antrum is the passage of air into the adjacent soft ])arts of the 
 face. This may arise during an expiratory effort, in which, the 
 mouth and nose being closed, the air is forced into the wounded 
 soft parts. Such emphysema will be the cause of more mental 
 .than physical trouble to the patient; without treatment it will 
 vanish in a few days; probably much of it returns to the nasal 
 passages, through contraction of the containing soft parts. If 
 absorbed, as sometimes stated, would not its presence in the vessels 
 occasion serious trouble? 
 
 Gunshot missiles, as balls of medium calibre, have entered 
 and found permanent lodgment in the maxillary sinus; such 
 intruding body has been tolerated in this recess for an indefinite 
 period, causing but little or no inconvenience. As such missile, 
 if even slightly movable, must irritate the containing cavity, 
 its removal is indicated. This extraction can be done by detach- 
 ing the soft parts from the canine fossa, and trephining at that 
 point. 
 
 Abscess of the Maxillary Sinus. — The lining mucous membrane 
 of the antrum may become inflamed and pus or an ichorous fluid 
 be generated in the cavity. As exciting cause of the inflamma- 
 26 
 
394 MAXILLARY SINUS, OR ANTRUM OF HIGHMOKE. 
 
 tioii may be an eruptive disease, as scarlatina or other disease 
 accompanied by embolic processes. A frequent cause is dental 
 caries, in which the root of a tooth near the antrum becomes 
 affected. As is known, the roots of the first and second molar 
 teeth often j)enetrate into the antrum, and from such roots, if 
 carious, iniiannnation can pass to the mucous lining of the sinus. 
 Also, when such diseased molar is extracted, the floor of the cav- 
 ity may be opened, and through such opening, as Duplay has 
 pointed out, particles of food may pass and, lodging in the antrum, 
 cause inflammation and eventually pus in the cavitv. Also, the 
 continuity of the nasal mucous membrane with the lining of the 
 antrum, fonns a way by which disease in the nasal fossae travels 
 to the sinus; thus chronic catarrh and nasal polypi have led to 
 suppurative inflammation in the antrum. 
 
 Such pus being long retained in the antrum becomes thick, 
 caseous, and of foul odor, or it may be thin like serum. The 
 contact of this material with the containing wall causes disinte- 
 gration and necrosis, and the final result, in most cases, is tlie 
 perforation of the wall ; yet in some instances the wall, instead 
 of being attenuated, is thickened. 
 
 The primary symptoms of such inflammation is a dull, con- 
 tinuous or pulsating pain in the region of the cheek. The tears 
 flow, and finally there is a fullness and swelling of the corre- 
 sponding cheek. As tiie pus accumulates, the antrum is enlarged 
 through the yielding of the front or inner walls. Or the palatine 
 floor of the cavity may be forced downwards, or the floor of the 
 orbit uplifted. From such eccentric swelling, therefore, the 
 cheek, palatine vault, nasal passage, or eye may be encroached 
 upon, and functional disturbance be produced. Frequently, in- 
 stead of thus enlarging when the antrum becomes filled with 
 pus, the pressure reopens the passage into the middle meatus, 
 whereupon the material escapes into the nose, and presents itseli 
 in front or in the throat. If such escape through the natural 
 way does not appear, then the pus may perforate the attenuated 
 wall and form a fistula. Such fistula has formed through the 
 cheek below tlie eye, or through the canine fossa into the mouth, or 
 through the floor of the antrum. The fistula has passed directlj'' 
 into the oral cavity. It is especially troublesome and conspicu- 
 ous when situated in the cheek, and is most fortunately situated 
 when it passes through the alveolar process, or through the 
 canine fossa, emerging between tlie lip and the alveolar process. 
 In many cases the opening is so situated that the pus cannot 
 
ABSCESS OF THE MAXILLARY SINUS. 395 
 
 wholly escape, and a part remaining becomes extremely fetid; 
 and where the opening is through the inner wall, the case might 
 be mistaken for an affection of the nasal fossa. 
 
 Suppurative inflammation of the antrum is diflacult to diag- 
 nose in the beginning, for the reasons that the symptoms are 
 similar to those which attend disease in the roots of the teeth, 
 an abscess in the gingival tissue, or a facial neuralgia. The 
 purulent collection in the antrum will soon reveal itself by excen- 
 tric protrusion of one or more of the containing walls; and this 
 wall, when pressed on, yields with the crackling sound of parch- 
 ment. But to banish all doubt, a small trocar can be thrust 
 through the wall, and the pus brought to view. 
 
 Treatment. — It may happen that the pus may escape through 
 a perforation so situated that the entire content can escape, and 
 the sinus gradually return to its normal condition, and the out- 
 let of escape finally close. This occurs when the outlet is at the 
 most dependent portion of the cavity. Nature, unaided, seldom 
 opens at a point most favorable for recovery, viz., the perfora- 
 tion is oftenest somewhere above the floor of the antrum, and 
 consequently surgical aid is required. 
 
 When the choice of site for the opening is left to the option 
 of the surgeon, he may choose to open through the alveolar pro- 
 cess, or above this, through the lower part of the anterior wall in 
 the canine fossa. Most surgeons prefer to open through the 
 alveolar process; and they do this by sacrificing a tooth, if this 
 has not already been lost. The opening may be bored with a 
 drill through the alveolar depression of the first or second molar 
 tooth; the second molar is preferred. Should one of the molars 
 be carious, that one should be extracted. The writer greatly 
 prefers to open through the canine fossa, since when the work is 
 done there the opening can afterwards be closed. To operate 
 here incise upwards close to the canine fossa of the upper jaw; 
 then, having separated and elevated the detached soft parts, an. 
 opening is to be made with a small trephine or a curved chisel. 
 Through the opening thus formed the cavity is to be thoroughly 
 cleansed with water slightly acidulated with nitric or hydro- 
 chloric acid. The opening is to be maintained open by means of 
 a drainage tube, through which the cleansing irrigation can be 
 repeated daily. And, as fluid for this purpose, one may use a 
 solution of sulphate of zinc, five grains to the ounce; or one of 
 chloride of zinc, two grains to the ounce; or of alum, five 
 grains to the ounce. Should there be much fetor in the dis- 
 
396 MAXILLARY SINUS, OR ANTRUM <)U JIKillMORE. 
 
 charge, an antiseptic fluid should be used for the irrigation, and 
 then dihite chlorinated water, or a solution of chloride of lime, 
 or of permanganate of jiotash, of which one can use Condy's solu- 
 tion diluted, as follows: — ■ 
 
 li. Potassii Permanganatis 3! 
 
 Aquae 3x 
 
 Miscc. 
 
 Since some of these solutions are toxic in action if swallowed, 
 care must be taken in their use that the fluid does not escape 
 from the buccal cavity into the throat and be swallowed. Sucli 
 irrigating fluid can flow through the orifice in the inner wall of 
 the sinus, and thence pass into the pharynx; to prevent this lot 
 the patient's head be inclined forwards during the irrigation; and 
 then, if the fluid enters the nose, it will esca])e through the ante- 
 rior nares. To do this irrigation, an elastic tubular syringe may 
 be employed. This work, for a time, should be done by the sur- 
 geon; later, the patient can do it himself, with the occasional 
 supervision of his medical attendant. After the sinus has thus 
 been restored to a healthy state, the outlet may be allowed to 
 close, provided there exists an outlet into the nose, and if one does 
 not exist, one could be made from the middle meatus into the 
 sinus, by means of some sharp, perforating instrument, for exam- 
 ple, a blunt dissector or a small curved chisel. The inner wall 
 is fragile and can readily be fractured. Should the opening- 
 made, through the front wall for irrigating not close sponta- 
 neously, it can be done by trimming the borders of the opening 
 and uniting them by sutures. In case the sinus proves not to be 
 restored to health, as shown by the escape of fetid excreta from 
 the nose, then the opening in the canine fossa should be resorted 
 to, and the irrigation continued for a longer period. 
 
 FiMula of the Antrum. — From the purulent collection in the 
 sinus bursting through the anterior, superior or inferior wall, a 
 fistulous opening may form, which may remain an indefinite 
 time unless surgically relieved. According to its situation, this 
 fistula might heal spontaneously, or remain open; if it were in 
 the roof of the mouth, or were above the alveolar process within 
 the buccal cavity, the fistula might close after the sinus had 
 ceased to excrete diseased matter; but if the opening were througli 
 the cheek, or the floor of the orbit, then the fistula, without some 
 surgical aid, would be permanent. 
 
 The diagnosis of this fistula can readily be made when the 
 
CYSTS IN THE ANTRUM. 397 
 
 previous history of the disease has been considered, and all 
 obscurity vanishes if a probe be passed through the opening into ' 
 the cavity. Such diagnostic exploration being once made by an 
 English lady, the feather she used passed so deep into her face 
 that she became alarmed and feared she had entered her brain. 
 She consulted her physician, Nathaniel Highmore, who relieved 
 her fears by his explanation, and, publishing the case, he gained 
 for his name an undying place in Anatomy as the discoverer of 
 this sinus, though it l*ad previously been known to Galen. 
 
 Treatment. — If the fistula be situated so as to constantly draiji 
 the antrum, the treatment need only consist of simply irrigating 
 the sinus with an antiseptic fluid, which would accelerate the 
 healing. But if the fistula perforate the cheek or pass out beneath 
 the eye, then the task of closing and permanently healing it 
 becomes more difficult. The work will then commence by mak- 
 ing an opening through the canine fossa within the mouth; 
 afterwards enlarge the fistula, and, through the opening, remove 
 any dead structure which may exist in the bone, and then trim 
 the walls of the sinus and close accurately, with sutures. Cleans- 
 ing irrigation of the sinus must then be continued, until the 
 walls are restored to integrity; and then the provisional open- 
 ing may be permanently closed, provided the normal opening 
 through the inner wall is patent. The patency can be determined 
 by filling the sinus with fluid, when the latter will flow into the 
 nose, if there exist an outlet; and if no outlet exists, an artificial 
 one can be established. To do this, pass an instrument through 
 the opening made in the front wall, and bore through the inner 
 one near its middle point, and retain this open by means of a 
 drainage tube, passed from the outer to the inner wall. As soon 
 as the outlet into the nasal passages is permanently established, 
 then the intra-buccal w^ound of the soft parts on the canine fossa 
 can be closed by trimming its margins, and closing by sutures. 
 
 Where there is a collection of retained pus or ichor in the 
 sinus, instead of escaping by a small opening, a large portion of 
 a wall may become necrosed, and be detached and eliminated. 
 Such a case the author observed in a child eight years of age ; a 
 portion of the anterior wall was thrown off" through an ulcerative 
 breach in the cheek. The detachment of the bone w^as confided, 
 in this case, to nature, and the result was a sunken, permanent 
 scar. 
 
 Cysts in the Antrum. — The mucous glands of the lining wall of 
 the antrum have been studied by Giraldes, who finds that tlieir 
 
39S MAXILLARY SINUS, OR ANTRUM OF HIGIIMORE. 
 
 excretory ducts or outlets tend to closure and obliteration, and 
 thus the retained content forms a cyst through retention. Such 
 cysts of moderate volume, M'hich had not been suspected, are often 
 found in the antrum. The cyst may be so located as to occlude 
 the normal outlet of the antrum, and thus the cavity may be 
 filled with muco-serous content; or the fusion and growth of 
 several of these cysts can form a large one, filling the antrum. 
 Thus Giraldes explains the origin of what is sometimes erro- 
 neously named droi)sy of the antrum. The small cysts, seldom 
 exceeding the size of a pea, cause no inconvenience; a large one 
 may encroach on, and force outwards, the containing walls. 
 Such swelling can be discovered by everting the upper lip and 
 pressing on the front wall, wdien a crepitating, parchment-like 
 sound will be felt, as the attenuated wall yields under the finger. 
 The encroachment on the inferior wall may have worse conse- 
 quences; the palate may be depressed and the alveolar arch 
 widened, and the teeth caused to fall from their sockets; or from 
 upward crowding, exophthalmos may be produced. The lachry- 
 mal canal is, fortunately, rarely interfered with. To sum up, 
 then, as functional troubles from such cyst, there may be disturbed 
 mastication, respiration and vision; and exceptionally the walls 
 become thicker, and then they will not yield under pressure. 
 
 Treatment. — This consists in opening through the canine fossa, 
 and emptying the content; and to prevent re-formation of the 
 cyst, an iodized solution should be injected, from time to time, 
 into the cavity, tlirough the artificial opening. Should the 
 normal opening into the nasal passage be occluded, this must be 
 restored in the manner already described when treating of abscess 
 in the antrum. 
 
 Tumor of the Maxillary Sinus. — As neoplastic growths appear- 
 ing in the antrum are the mucous polypus, the enchondroma, 
 sarcoma, carcinoma and osteoma. 
 
 The mucous polyj), similar to that occurring in the nose, has 
 been seen in the antrum. Cartilaginous growths as well as the 
 more malignant forms of tumor have originated within this 
 cavity, and continued to grow until they crowded upon and dis- 
 placed tlie contaniing w'alls; and such displaced wall presses on 
 parts contiguous, and disturbs their function. This anterior pro- 
 trusion will disturb the contour of the cheek, and change facial 
 expression; if directed towards the roof of the sinus, the orbital 
 floor may be uplifted, the eye di.splaced, and double vision be 
 produced. Growth and pressure downwards will encroach on the 
 
TUMOR OF THE MAXILLARY SINUS. 399 
 
 bony palate and alveolar arch, and thence result destruction 
 of the teeth. Growth inwards towards the nasal passage will 
 crowd on the latter and impede breathing. The tumor does 
 not end its baleful march at mere functional disturbance; it 
 presses on the structures which it meets until it opens a way- 
 through them by ulcerative action; and thus the tumor presents 
 itself to view, in many cases. The pressure on branches of the 
 trifacial nerve, during this devastating march, causes severe and 
 agonizing pain. 
 
 The treatment must be directed to a radical and complete 
 extirpation of the growth as soon as its presence has been indi- 
 cated by some phase of the functional disturbance which has 
 been mentioned. And when suspected and not clearly indicated, 
 an intra-oral incision may be made through the canine fossa. 
 When discovered, the tumor, whether polypoid, enchondromatous 
 or cancerous, may be removed through the following incision: 
 Cut and separate the upper lip from the superior maxilla, and 
 then retract the separated soft parts from the jaw by a large 
 retractor; remove or uplift the front wall of the antrum, so that 
 its contents can be inspected, and extract the neoplasm which is 
 discovered. Should the incision mentioned not suffice for the 
 complete extraction, then it may be enlarged by another cut 
 extending vertically from the inner angle of the eye to and 
 through the upper lip. And should it be possible, this flap 
 should contain a portion of the front bony wall of the antrum, 
 which has been sawn through with an exsection saw. The 
 triangular flap, thus formed, can then be drawn outwards and 
 upwards, and thus a much larger field will be opened for 
 exsecting the contents of the antrum. In case the tumor be 
 found to be malignant, then the entire upper jaw must be 
 removed. But if the growth has previously been diagnosticated 
 to be of benign nature, then the front wall having been uplifted 
 along with the soft parts, after the growth has been removed,^ the 
 osteo-cutaneous flap can be replaced, and thus the form of the 
 cheek preserved. 
 
 Osteoma may originate within the maxillary sinus and attain 
 dimensions which may encroach on the parts contiguous, and 
 cause functional disturbance. An instance of the kind came 
 under the writer's observation. In the patient, a woman of twenty 
 years of age, a deformity of the right cheek and roof of the 
 mouth gradually appeared; also the right eye was shifting its 
 position upwards, and double vision was present. It was appar- 
 
4UU MAXILLAKV iSlNUS, OR ANTRUM OF IIIGIIMORE. 
 
 ent that tlie upi)er jaw was enlarging; and a growth within the 
 antrum was inspected, and an operation for its removal counseled. 
 To do this it was decided to do the work without external incision, 
 viz., by separating the iipper lip and cheek from the maxilla. 
 The loosened i)arts being retracted, a portion of the front wall 
 corres[)onding to the canine fossa was removed with the mallet 
 and chisel. It was found that the bone removed was very hard, 
 and that no vestige of an antrum existed. The excision of the 
 bone was continued b}^ means of chisel and mallet, until a large 
 portion of the upper jaw was excised, and a cavity left of larger 
 dimensions than the normal antrum. The osseous exsection 
 revealed the fact that the antrum was entirely obliterated, and 
 the enlarged maxilla consisted of bone of unusually dense nature; 
 the bone was of ivory-like hardness, and its removal was a task 
 of the most tedious and tiresome manual labor. The walls of 
 the jaw were left except a })art of the anterior one. Not much 
 bleeding occurred. One tooth was loosened in the work and was 
 removed. Some anaesthesia which existed prior to the operation 
 was not relieved by the exsection. The cavity made was filled 
 with alcoholized lint; and this treatment was continued for 
 many months, during w'.iich time fragments of bone detached 
 themselves from the surface which had been chiseled off. The 
 granulative tissue which appeared on the inner surface, later 
 became a tissue which resembled the normal lining of the 
 alveolar proce.s.ses. The extruded orbital, malar and palatal 
 walls gradually resumed normal position, until from the eye, 
 cheek, and roof of the mouth there vanished all aberration of 
 form; the right side of the face was not distinguishable from the 
 leftside; a condition different from what would have been the 
 case had the work been done through an external cut; and 
 certainly far different from tlie aspect which the patient would 
 have presented had the entire upper jaw been removed as had 
 been counseled to the patient by less conservative surgery. The 
 lapse of five years now gives immunity from recurrence in this 
 case; yet to observe the condition of the interior of the cavity, 
 the labio-alveolar incision was allowed to remain open. 
 
 In this osteomatous growth it was not determined whether 
 the tumor originated in the antrum, and grew eccentrically, or 
 whether it was a general hypertrophy of the maxilla superior, 
 in which the bone grew both centrally and eccentrically. 
 
 Perforation of the Nasal Septum. — The cartilaginous septum of 
 the nose is often the site of ulcerative action, which sometimes 
 
PERFORATION OF THE NASAL SEPTUM. 401 
 
 perforates the part and forms an opening of greater or less extent 
 between the nares. This ulceration is oftenest seen in the scrof- 
 ulous and syphilitic subject, yet it also occurs in subjects of other- 
 wise normal health. The point where the ulcer oftenest com- 
 mences is at the junction of the cartilage "u-ith the loAver part of 
 the partition. Where this muco-dermal border joins the carti- 
 lage above, the partition is thinner than elsewhere; and, from the 
 mobility of the parts here, this thin part might with some ana- 
 tomical license be named a joint of the nose. The mobile nature 
 of this structure predisposes it to lesion, and explains the frequent 
 commencement of ulcerative action at this point; and the breach 
 commencing here, its enlargement is promoted by the same 
 cause, and by the habit of the patient of industriously promoting 
 the extension of the ulceration bv often touching; and examinino- 
 it, and especially by the mischievous habit of often detaching 
 the encrusted scab which adheres to it. Under these influences 
 an insignificant initial lesion is enlarged and deepened until it 
 perforates the attenuated w^all. This ulcer extends upwards into 
 the adjacent cartilaginous septum; the cutaneous margin under- 
 neath does not ulcerate, or only in exceptional cases; and hence 
 the patient is spared the exposure of his ill, as would be the case 
 if the lower margin of the septum w^ere opened by ulceration. 
 The extension uj) wards, and immunit}^ of the sub-septum, depend 
 on the lower vitality of the cartilage. 
 
 From an extensive observation of such ulceration, the writer 
 has remarked that this otherwise trivial ailment is often the source 
 of much annoyance to its subject: his apprehensive fancy descries 
 in the future some mutilation of figure. This mutilation is rarely 
 realized, as the ulceration seldom reaches great limits; it is infre- 
 quent that an opening greater than that which would admit the 
 end of a finger, arises. Yet this small breach cannot be closed, 
 and to stay its enlargement is no easy task. The treatment is, in 
 the main, of topical character, though any concurrent cachexy 
 must be met with appropriate remedies. As a local means, is 
 the compound tincture of benzoin, applied daily with a camel 
 hair brush. Or an ointment of ammoniated mercury, viz: — 
 
 ^. Hydrargyri Ammoniati partes 10 
 
 Adipis partes 90 
 
 Misce. 
 
 Apply once daily after the removal of the crust. Also, an oint- 
 ment of quinine, in tlie proportion of ten grains to the ounce of 
 
402 MAXILLARY SINUS, OR ANTRUM OF IIIOHMORE. 
 
 vaseline. An ointment of calomel, in the proportion of six grains 
 to the ounce, acts well. The site of the ulcer, so located as to 
 receive and retain the excreta in their esca})e from the nasal fossa, 
 is so unfavorable to healing that often, despite attentive treat- 
 ment, the ulcer persists. As ultimate resort, the ferrum candens 
 or the thermal cautery may be used, and the ulcerated surface 
 slightly cauterized. 
 
 In cases which have come under treatment after the septum 
 is perforated, the best that can be hoped is a cure with an open- 
 ing between the iiares; though such condition is unsatisfactory 
 to the patient, yet he can be confidently assured that no func- 
 tional impairment can result from it as regards breathing, 
 smelling or S})eaking; these functions will be as perfect as before 
 the perforation; and as the defect is comi)letely hidden from 
 siirht, it is relieved from most of the odium which attaches to a 
 corporeal deformity. 
 
 Nasal Deformity and Means employed for its Relief — There may 
 be a deformity of the nose from excessive volume; likewise, from 
 abnormal shape of natural volume; and, lastly, deformity may 
 arise from defect in which a portion or the entirety of the exter- 
 nal nose is absent. 
 
 Deformity from excess of volume is rarely congenital; it is 
 oftener acquired. There is rarely excessive volume of the entire 
 nose; the hypertrophy usually affects the lobule, or lower half of 
 the nose. Reference, however, has already been made to this, as 
 well as to the means of relief by the excision of cuneiform sections 
 and closure by suture. By such method, excess of structure of 
 anv part of the external nose may be successfully corrected. In 
 thi.G retrenching excision, care must be used not to remove too 
 much; for a nose rendered too small offends the e^'e of both 
 observer and observed, quite as much as one of excessive pro- 
 portions. Also, if the proportions be asymmetrical, the effect 
 will be unsatisfactory. To avoid, therefore, error on the side of 
 excessive removal, the cuneiform excision should only be done 
 on a minimal scale; and, if need be, more structure could after- 
 wards be removed; but if the excision have been too freely done, 
 no subsequent work can efface or correct it. 
 
 It sometimes occurs that a nose which isnormal in the amount 
 of its component structure, is still so irregular in one or more of 
 its outlines that it is disagreeably conspicuous, and is a source of 
 no small vexation to its unlucky owner. As examples of such 
 ill form, the following may be enumerated: dorsal depression or 
 
NASAL DEFORMITY. 403 
 
 dorsal elevation of the nose; deviation of the lobule to one side; 
 deviation of the entire nose to one side; unusual prominence of 
 the sub-septum, or recession of the same. If any nose be care- 
 fully examined, a trace of one or more of the defects mentioned 
 may be found; and often this trace of ill shape, which, without an 
 effort on the part of the searcher to detect, would remain unob- 
 served, becomes so magnified in the eye of the subject that a 
 surgeon is consulted. The duty of the surgeon in such case is to 
 endeavor to convince his patient that his ill is unimportant, and 
 that the offending feature is seen by no one except himself. The 
 task of the consultant is not an easy one; for nothing is more 
 difficult than to expel from the human head a tormenting fancy 
 which has once been admitted there. Such fancy often eludes the 
 best directed weapons of reason. 
 
 In the cases of this class, the slighter the deformity, the greater 
 is th© difficulty of relieving it by operative means, for the opera- 
 tion usually only substitutes one ill feature for a new one; hence, 
 in such cases, the discreet surgeon will counsel non-interference, 
 a?nd pursue this policy even though the patient does not. But 
 where the deformity is such that it continually attracts observa- 
 tion, an attempt to correct it is justifiable; yet here as in all sur- 
 gical work which is done solely from cosmetic motive and pur- 
 pose, the patient must be forewarned that the best planned schemes 
 here often go awry; and also, that success often fails to bring 
 content, even as those who, dissatisfied with their lots, are allowed 
 to change them in accord with their praying; for many 
 are still unhappy; so that, as the Horatian Muse tells us, the 
 grantor, Jupiter, inflates his cheeks with rage, and declares that 
 in future he will not give so facile an ear to human prayers. 
 The surgeon, like Jupiter, who is persuaded to engage in cosmetic 
 work contrary to his judgment, sometimes regrets that he has 
 yielded to the suppliant. 
 
 A deforming condition, in which intervention may be per- 
 mitted, is that in which, from accident or other cause, the nose has 
 been deflected to one side, and the nasal passages are lessened by 
 being encroached upon. Restoration to form here has been 
 attempted by the writer by endeavoring to fracture the deviated 
 walls of the nose. The fracture of the nasal bones, though so 
 easily occurring through accident, is no easy task for the surgeon. 
 Should it be attempted, the work may be done by blows of a 
 mallet upon a plate of metal laid on the side of the nose, a piece 
 of lint meantime being interposed between the plate and the nose. 
 
404 MAXILLARY SINUS, OR ANTRUM OF HIGIIMORE. 
 
 To accomplish anything, violent blows must be struck: force 
 enough, in fact, to endanger the encephalic structures through 
 concussion. And though fracture may be thus caused, it will be 
 found of little aid, since the broken bones are so little movable 
 that form cannot be satisfactorily repaired. An effort to fracture 
 excentrically, that is, from the inside of the nose, might prove 
 more successful; to do this, first plug the nostrils posteriori}', and 
 then introduce a lever into each nostril, and, resting on a fulcrum, 
 pry against each side until the bony wall is loosened and mova- 
 ble. The work of reposition is completed by modeling the 
 loosened sides, and supporting them from beneath by tubular 
 supports. Even this method, as the author has verified, is 
 attended by difficulties, and the result obtained is far from satis- 
 factory. It is probable that the work might be done more satis- 
 factorily b}^ a preliminary division of the nasal bones. To do this, 
 after posterior occlusion of the nasal passages, from the inner face, 
 saw through each nasal bone near its lateral border. The deflected 
 nose being thus loosened at its sides, the deviated part might be 
 restored to approximately normal position, without any external 
 wound. 
 
 Tubular supports in the nose, aided by lateral compresses on 
 the outside, may be used to retain in site the restored part. And 
 should the osseous division mentioned be insufficient, additional 
 sawing might be done from the inside, also division of the tether- 
 ing bands could be done subcutaneously by means of a tenotome. 
 The princi})les here given may serve as guiding rules for improve- 
 ment of form, in cases of displacement or deviation of one of the 
 nasal bones. And in every case, the operator should bear in 
 mind that the calibre of the nasal passages must not be so 
 encroached upon as to interfere with respiration, and to avoid 
 this, |)atency must be maintained by large tubular supports dur- 
 ing treatment; the objective side must not overshadow, or cause 
 to be forgotten, the subjective one; for the ])atient will, erelong, 
 prize the faculty of free nasal breathing more than the form of 
 the nose. 
 
 xVnotlier minor defect of form whicii may solicit correction, 
 is unusual prominence of the sub-septum ; for when this depends 
 beyond the alse, the aspect is unsightl3^ The remedy for this 
 consists in excision of a })ortion of the contiguous cartilaginous 
 septum ; and then, having lifted the prominent part upwards, 
 fasten it by suture in the space formed. The excision of the car- 
 tilage can be done without severing the sub-septum, either from 
 
NASAL DEFORMITY. 405 
 
 the lip or the nasal lobule. Scrupulous care must be taken not 
 to remove too much of the septum, for by so doing, the lower border 
 of the sub-septum would be rendered concave, and an unsightly 
 feature created; the excision, then, should be done piecemeal, 
 until it is found that a sufficient amount has been removed to 
 repair the defect. 
 
 Again, the septum may, as a congenital or acquired defect, 
 not reach to the outlet, the alse and the lobule reaching beyond 
 it. This defect, when a congenital one, would rarely demand the 
 surgeon's aid; yet when the sub-septum has been destroyed by 
 disease, a reparative operation should be done. For this purpose 
 material from the upper lip can be used; and this may be taken 
 from the philtrum or middle of the lip; or a flap with pedicle 
 towards the septum, may be cut obliquely from the upper iip, as 
 done by Despres. If the upper lip were unusually high, it were 
 better to utilize material from the median part of the lip. For 
 this purpose, make an incision on each side of the median line 
 through the lip, so as to form a flap with upward pedicle, and 
 somewhat broader than the normal septum. Beneath the 
 lobule make a raw surface to which the replacing flap can be 
 attached; also, trim off the edge of the remaining septum. The 
 flap being twisted so that the epidermal face will look out- 
 wards it is fixed by sutures to its destined site. Thus done, if 
 the twisted pedicle be too large, after a month it can be given 
 a better form by slight incision; or to avoid this, the flap not 
 twisted may be lifted directly upwards; but to do this, the outer 
 surface must be pared off; in order to get a face which can unite 
 with the trimmed edge of the remaining septum. Besides, the 
 hair roots, if not removed, would occupy a very inconvenient 
 position in the male's lip. Should the lip be thick, the deeper 
 2)ortion might be used for repairing material. To do this, first 
 make a median vertical cut through one-third of the thickness of 
 the lip; from the bottom of this cut incise laterally, so that space 
 is gotten through which a flap can be formed from the deeper 
 portion of the lip. This flap is next to be lifted directly upwards 
 and fixed by suture. The mucous membrane which is thus ex- 
 posed in the new-formed sub-septum, at first conspicuous, will 
 finally acquire the appearance of ordinary derm. As the new 
 material lessens by contraction, due allowance for tliis must be 
 made in the work. By this latter mode of repair, there will be 
 less sacrifice of the labial structure. As before remarked, Despres 
 constructed the best sub-septum by means of an oblique flap, the 
 
40G MAXILLARY SINUS, Oil ANTRUM oK HIGIIMORK. 
 
 loose end of wliicli lies towards the left tingle of the mouth. This 
 must be twisted so that the dermal side will look outwards. 
 And, in all these metliods, the wounds created must be closed by 
 catgut suture. 
 
 Rhinoplasty. — By lihinoplasty is meant an operation in which 
 there is repaired or restored a j)ortion or the entirety of the 
 nose; and such operation may be required in cases in which the 
 following conditions are present: — 
 
 1. Partial or complete loss of the nose through some violence, 
 as a gunshot wound or other injury. Along with the nasal 
 injury, there may be loss or lesion of parts adjacent or subjacent, 
 and this accessory injury may be so great as to render any rhino- 
 plastic restoration difficult, or jjcrhaps impossible. 
 
 2. Constitutional disease, as syphilis, may destroy the nose, 
 and especially some malignant growth, as carcinoma or epitheli- 
 oma, frequently destroys a large jiortion of the nose. 
 
 3. A burn yet unhealed, or the cicatrix caused h\ a burn, or 
 by the destructive action of an acid or alkali, may demand repair 
 by a plastic i)rocedure. 
 
 4. The devastation of parts by the surgeon's knife in the 
 removal of malignant growths involving the nose, often demands 
 some reparative operation, and this may be done contemporane- 
 ously with the operation, or at a later ])eriod. 
 
 Before describing the procedure for repair required in the cases 
 enumerated, some general consideration of the subject of rhino- 
 plasty is proper. 
 
 The Sanscrit race, which early inhabited the valley of the 
 Ganges, along with the primal germs of language, gave to the 
 nations of the West some of the principles of medicine; in the 
 Ayur-Veda, a book on medicine, written by Susruta, there is 
 mention made of nose building. In the fifteenth century the 
 Latin race surpassing the rest of the world in enterprise, doubled 
 the Ca[)e of Good Hope; and it is probable that, as the art of 
 nose-repairing appeared at the same era in Italy, this knowledge 
 was transplanted there from the Orient. In the fifteenth cen- 
 turv Branca, a Sicilian surgeon, formed the nose from the skin 
 of the face. Branca's son went further: he formed the nose 
 from structure taken from the arm. In the sixteenth century, 
 Peter and Paul, sons of a family named Bojani, residing in 
 Calabria, also constructed the nose from the .'^kin taken from the 
 arm. And near this period Tagliacozza, j)rof(ssor of Anatomy at 
 Bologna, in Italy, wrote on this subject, and nt^nined so much 
 
RHINOPLASTY. 407 
 
 repute in re-formation of the lost nose that he was honored witli 
 the title of Xasifex, or nose-maker; and in Latin and Eugiisli 
 verse iiis handiwork was celebrated. In his "Hudibras," Butler 
 mentions the Talicotian art in blunt metre. Talicotius, as his 
 name is latinized, is thouo-ht to have reallv invented nothinp-, 
 and the charge against him remains unanswered, that he inten- 
 tionally and disingenuously aj)propriated to himself the work of 
 others. The Talicotian operation consisted in constructing the 
 nose from the skin of the arm, as had already been done by the 
 junior Branca: it is known as the Italian method. It consists of, 
 and might properly be named, nasal repair by transplantation. 
 And the transplanted material, in some of the earlier essays, 
 seems to have been taken from the body of another person: and 
 as the theology of that time essayed to dictate to science, and had 
 interpolated much material in the structure of science, it is no 
 wonder that they, whose minds had the crude mold of that time, 
 feared that the nose constructed of another man's flesh would 
 die when the original owner died. We are not, however, told 
 whether there was fear of the converse, to wit, that the nose 
 might outlive him on whom it was engrafted. 
 
 In the annals of surger}' one finds examples of immediate 
 transplantation of material from one human body to that of 
 another, for the repair of the defective nose. Unfortunately, 
 these accounts have often been derived from sources in which 
 the m^^thical and the authentic are too closely commingled for 
 credence; since writers then did not always confine themselves to 
 historical accuracy. An instance of this kind is the following: 
 Dutrochet reports the statement of his brother, who had been in 
 the East Indies, that a criminal who had been punished by cut- 
 ting off his nose, had his loss repaired with material taken from 
 the buttock of a slave. The thick integument had been jDre- 
 pared for transplantation by having been whipped severely. In 
 this way, the skin became surcharged with blood, and the irrita- 
 tion thus caused seemed to add to the vitality of the transplanted 
 part. The site to receive the excised skin was trimmed, so as to 
 render it raw, and fixation was effected by means of sutures. It 
 was so cut as to furnish material also for a septum. It is stated 
 that a good result was obtained. 
 
 Another example decidedly apocryplial is that told of an 
 Italian brigand, whose nose, in a nocturnal affray, had been cut 
 oflf. Whilst a surgeon was deliberating what he would do, the 
 brigand's confederates attacked a passer-by and cut off his nose, 
 
408 MAXILLARY SINUS, OK ANTRUM (>F IIICIIMOKK. 
 
 and })iaced the same on the face of their companion. This na.si- 
 ficial exploit, if credible, would exceed the most famous deeds of 
 Talicotius himself. A case cognate to this was that of a wealthy 
 Frenchman whose nose having been destroyed by lupus, the 
 proposal was made to his servant to give his nose to his master; 
 though a promised reward of many ducats accompanied the 
 request, yet the attempt was not made, as the servant valued his 
 nose more than a pocketful of ducats. 
 
 An authentic case of direct transplantation from one part of 
 the body to another, is tliat reported by Biinger, of Marburg. 
 The movable portion of the nose had been lost in a woman, aged 
 thirty-three, and fruitless endeavors had been made to repair the 
 loss from adjacent material of the face. Biinger decided to make 
 the experiment of transplantation of repairing material from a 
 remote part of the body. To do this, assisted by his colleague, 
 Ullmann, he whipped the anterior surface of the tliigli of his 
 patient, and excised from this an oval flap four inches long and 
 three inches wide, and applied this on the remaining jjortion of 
 the nose, which had been trimmed for the purpose; and the flnp 
 was fixed by sutures. The upper portion of this engrafted flap 
 lived ; the part which lived seemed to do so, not from the attached 
 edges, but from the subjacent surface, which was raw and rested 
 on a similar surface. There lived a sufficiency of the flap to 
 restore the greater part of the nose; the parts lacking wore sup- 
 plied by the adjacent cheek and lip. 
 
 Aside from these adventurous essays, in which direct trans- 
 plantation of tissue from a distant part may be done, the rhino- 
 plastic procedure as commonly practiced consists of two metliods, 
 one named the Indian, in wliicli the repairing material is taken 
 from the forehead or face; the other named the Italian, in wdiicli 
 the material of replacement is derived from the upper arm fore- 
 arm, or hand. 
 
 The Indian method consists in the appropriation of the dermal 
 surface of parts contiguous for the repair of partial or entire loss 
 of the nose; and the replacing material may be twisted semi- 
 circularly, or carried to its destined site by lateral sliding. This 
 plan of replacement is sometimes named the French method, 
 and, again, it is named the Celsian method; the latter name is 
 much more appropriate, since it is described by Celsus. In the 
 lines in which Celsus has described this w^ork, — lines in which 
 intense brevity merges into obscurity, — the student has the first 
 written description, spared by time, of surgical work done to 
 
BHINOPLASTY. 409 
 
 remove or conceal defects (curta) in tbe face. It is inferable that 
 the Roman race, which fearlessly conquered and held the world 
 in its martial grasp, had the weakness of quailing before facial 
 defect, and that, besides for glory, the Roman would suffer pain 
 for cosmetic purposes. Celsus has a chapter entitled "Defects in 
 the ears, lips, and nose; in what manner these may be closed and 
 cured;" the chapter opening with these words: "Defects occur in 
 these three parts, and if they be small in some part, they can be 
 cured; but if they are larger, they either do not admit of remedy, 
 or the result is such that the part is rendered less comely than 
 it was before." Since these lines were written, the truth which 
 they contain has often been verified by ill-devised and ill-done 
 work within the sphere of plastic surgery. 
 
 The manner of repairing a defect in the ear,' nose or lip is 
 stated by Celsus in the following words: "Reduce to a quadrate 
 figure that which is defective (curt); from the interior angles of 
 this figure incise transverse lines which may separate the nearer 
 structure from that which is beyond; then unite the parts together 
 which we have so loosened. But if the parts are not sufficiently 
 united, besides the incisions which we have made, we must add 
 two other incisions of crescentic shape, which are directed towards 
 the wound (already made), and in which the summit only of the 
 skin is separated; thus proceeding, it follows that what is drawn 
 upon easily 3'ields; and this must not be done with violence; 
 the traction must so be made that the parts easily follow, 
 and when they are abandoned to themselves, they recede but 
 little. Likewise, if the skin at one part is not entirely closed, it 
 renders the part ill-shapen. In the manner described, then, one 
 portion of such defect is to be incised, while the other portion 
 must be left intact. We shall not make traction on the following 
 parts, viz., the lower part of the ears, the middle of the nose, the 
 lower part of the nostrils, nor the angles of the mouth. But we 
 will seek, for replacing materials, on each side of the defect, in 
 the summit of the ears, in the middle of the nasal passages, or in 
 the middle of the lips. Defects are wont to be in two places : but 
 here the method of cure is the same as that mentioned. . . . 
 Then the lips of the wound must be united by sutures, the skin 
 being pressed together from each side. ... In the inner 
 incisions as well as in the crescentic ones, lint must be inserted, 
 in order that the growing flesh may fill the wound." 
 
 The latter portion of this extract from Celsus is obscure. To 
 describe mechanical work in one's vernacular tongue is a difficult 
 27 
 
410 
 
 MAXILLARY SINUS, OK ANTRUM OF JIKillMoKE. 
 
 task, and unless illustrated by diagrams, tlio best description is 
 vague, and scarcely comprehensible; and the obscurity of mean- 
 ing is still greater when the description is in a foreign tongue, or 
 a dead language. Yet the meaning of the first portion of the 
 Celsian citation is clear: he advises to convert the defect into a 
 four-sided figure, and then to elongate the incisions, and if the 
 sides cannot then be approximated, to make subsidiary incisions 
 at the side of the quadrangular space, so as to facilitate lateral 
 sliding. In fact, the Celsian method is the equivalent of the 
 Indian, with the addition of accessory cuts. A diagram of this 
 work is shown in Figure 5. The crescentic cuts, instead of hav- 
 
 a 
 
 
 a. 
 
 I 
 
 A 
 
 I 
 
 B 
 
 d 
 
 Figure 5. Showing the plastic method of Celsus (from Otto Weber); 
 a^ a b^ b shows the defect to be closed. 
 
 ing the points towards, may have them directed from the figure. 
 And the writer would suggest that instead of prolonging the 
 horizontal lines, as shown, it would be better to do this after the 
 sides were approximated, as much as possible, and then prolong 
 them above and below. 
 
 As indications or reasons for nasal restoration or repair, the 
 following may be offered: A face without the external nose is 
 eminently repulsive to the layman, and is even repugnant to the 
 medical man, though educational molding has so altered his taste 
 that he often finds interest in contemplating examples of mon- 
 strosity. And in such degraded countenance, instead of the 
 "human face divine," one is horrified with the sight of a figure 
 akin to that of a Medusa, a sight which inspires the beholder 
 with feelings of pity and disgust. Scljiller realized this when he 
 depicted his villain Roller with a deformed nose. If the subject 
 of calamity be one who is compelled to earn a livelihood by labor, 
 
itBIXOPLASTY. 411 
 
 he will find most doors closed against him ; so that life becomes 
 a burden to him. And such unfortunate has been known to tire 
 of his lot, and to yield to the impulse to drop the burdens of life 
 by suicide. Besides this the absence of the external nose, with 
 perhaps disease in the remaining fragments, and the accumula- 
 tion of sordes or septic excreta in the choanse, infect the patient's 
 breath with foul odor, so that both nose and eye of those about 
 the victim are constantly offended. The absence of the external 
 nose allows air laden with dust to pass unimpeded to the luno-s, 
 and to cause disease there. The warming function of the normal 
 nose is wanting, and hence the cold air directly enters the lungs. 
 The voice of the noseless face acquires a disagreeable tone. The 
 sense of smell is weakened, and perhaps. lost; and as the nose is an 
 intimate ally of the tongue, it happens that when smell is lost, taste 
 is much impaired. For perfect olfaction a complete nasal vesti- 
 bule is required. The current of air must transport the odorant 
 particles into the upper nasal chamber: a fact j)roven by Beclard, 
 who found that when the air is conducted into the lower part of 
 the nasal passages, any fragrant matters which it may contain 
 are not perceived. And in subjects in whom the nose was want- 
 ing, the power of olfaction was entirely lost. Hence, as seen, the 
 restoration of the lost nose is demanded, not only to overcome a 
 great deformity, but to aid in phonation, respiration, taste and 
 smell. 
 
 The restoration of the lost nose, as before mentioned, may be 
 from structure obtained from some other part of the dermal 
 surface of the body, which is directly transplanted; or this ma}^ 
 be from the arm or forehead, with temporary retention of the 
 pedicle, or the repairing material may be from the cheek on each 
 side, with permanent retention of the pedicle. The structure is 
 oftenest taken from the forehead. 
 
 In the selection of the repairing material, certain conditions 
 in the latter are demanded, viz., that it have an ample supply of 
 blood furnished through the pedicle, and that tlie material used 
 be sound in structure. As a rule, tissue which is j)artly or wliolly 
 cicatricial, should not be used; for such material will nearl}^ 
 always perish, and render the work a failure. The writer has 
 more than once heard the plaintive lament of some operator who 
 has met with a signal failure through using cicatricial tissue; the 
 whole had sloughed, and the previous deformity, instead of being 
 relieved, had been added to; and the- writer confesses to like 
 chagrin from having violated the rule which he is here enjoining. 
 
412 MAXILLARY SINUS, OR ANTRUM OF HIGHMORE. 
 
 The only license for such violation would be in cases in which 
 none other than cicatricial tissue existed, and the scar did not 
 reach through the structure to be transplanted, or had existed so 
 long that the part liad nearly regained its normal character. Only 
 in sucli conditions should one venture to transplant cicatricial 
 structure. It should have been stated tliat the slougliing of the 
 transposed cicatricial flap is but a part of the ill result; there 
 remains whence the flap was lifted an open ulcerating wound, 
 often destined to baffle all efforts at closure, for an interminable 
 period. Indeed, a disregard of this rule is similar in result to 
 that of violating a kindred injunction familiar to most readers, 
 viz., the rent is greater than before. 
 
 The part utilized must have an amjde supply of blood, and 
 hence the pedicle sliould contain a nutrient artery or arterioles, 
 and the flow of blood should not be impeded through this by 
 tension or pressure. The material on the forehead is favorably 
 situated in reference to blood supply through the frontal artery, 
 which, emerging from the orbit above the inner angle of the eye, 
 ascends vertically near the median line. An exact knowledge 
 of the site of this vessel wliere it escapes from the orbit is highly 
 important; as given by Ilyrtl, who is ever exact and trustworthy 
 ill his statements, each frontal artery lies from three to four lines 
 outside of the median line. Hence a pedicle of which one side 
 corresi)onds to the median line, of one-half inch breadth, will 
 include at least one of the arteries; and a breadth of over two- 
 thirds of an inch, including the median line, will contain both 
 vessels. The inclusion of both vessels might furnish too much 
 blood; for, according to Dieffenbach, the death of the flap may 
 be caused by excessive congestion of the part; in fact, he, perhaps 
 the greatest of plnstic ojierators, quite neglected the vascular 
 supply and made the pedicle so narrow that it could be readily 
 twisted. Rhinoplastic repair is oftenest done by material taken 
 from the forehead, and the modes of doing this will next be 
 considered. 
 
 The work will commence with the construction of a model, 
 to which tlie new nose is to conform in size and outline; such a 
 model might be taken from a nose on another face; yet it is 
 oftener made from wax, India rubber, or plaster of Paris. On 
 such model, adhesive plaster is s})read, and the outline thus 
 obtained. Or it might be made of leather, and afterwards this 
 must be coated with diachylon, or other adhesive material. In 
 the normal face the length of the nose is about equal to the 
 
RHINOPLASTY. 
 
 413 
 
 Figure 6. Exhibiting rhinoplastic procedui'e by means of a vertical flap 
 taken from the forehead (from ' 'Dictionaire Encyclopedique des Sciences Med- 
 icales! Dechambre et Lereboullet). 
 
 height of the forehead ; hence the guiding superficial model 
 should have that length. But as material for forming the sep- 
 tum will be required, hence the model must extend into the 
 hairy scalp for one inch, which should be shaven at that point. 
 In this work the contractile property of the skin when divided 
 must be remembered, and due allowance for the same be calcu- 
 lated. The experiments and observations of Farabeuf have 
 shown that this contractility in the case of amputation is equal 
 
 Figure 7. Showing Alquie's rhinoplastic method, in which an oblique flap 
 is taken from left side of the forehead. (Dictionaire Encyclopedique des Sci- 
 ences Medicales). 
 
414 MAXILLAKY SIXUS, OR ANTRUM OF HIGHMORE. 
 
 to one about one-third of the diameter of the limb which is 
 divided. Hence the frontal flap should be made at least one- 
 third longer and one-third broader than tlie nose which it is 
 designed to form. In the directly vertical flap, as shown in 
 Figure 6, unless the forehead were high, it would not be possible 
 to extend farther upwards without entering the hairy scalp; and 
 hence, as a free field in which ample range w^ould be permitted 
 to the operator, the plan of Alqui^ may be followed, viz., to con- 
 struct an oblique flap over one eye, with its free end directed 
 towards one of the temples, as is shown in Figure 7. To assist in 
 twisting the flap, one of the terminal incisions below should 
 extend further downwards than the other; the mode of doing 
 this will be understood by reference to Figure 7. 
 
 The retention of the periosteum along with the flap was done 
 by Langenbeck, wdth the hope that bone might thus be formed 
 beneath the transj^lanted flap, and that thus there maybe obtained 
 an osseous framework for the newly constructed nose. From the 
 reports of those who have thus operated, it does not appear that 
 this expectation has been realized. Others, laboring under as 
 great a fallacy, have not removed the periosteum, in order to 
 spare encephalic trouble which might result from the exposure 
 of the cranium. 
 
 The margins of the flap should not be cut perpendicularly, 
 but in such a way as to enlarge the surface of sutural attach- 
 ment; thus coaptation is facilitated, and subsequent vitality 
 favored. 
 
 Th-e nasal site is next to be prepared for reception of the flap. 
 All osseous and cartilaginous structures are to be carefully saved; 
 for upon the presence or absence of a su^jporting framework will 
 wholly depend the excellence of result in the work done: for if 
 the bone and cartilages are absent, the newly constructed nose 
 will be but a flattened bridge across the nasal breach ; but if there 
 is a sustaining skeleton on which to build, the newly formed part 
 will certainly resemble, if it does not represent, a nose. The mar- 
 gins of the part to be restored are to be trimmed in an oblique 
 direction, so as to present a surface which will correspond to the 
 broadened edges of the flap. The summits of the remaining 
 cartilage and bones must be paired so as to present a raw surface, 
 which may cohere to the under surface of the flap. 
 
 The Avork having advanced to this stage before adjusting the 
 flap to its site, the operator will wait until he has controlled all 
 bleeding; this done, he will next give the pedicle such a form 
 
KHIXOPLASTY. 
 
 415 
 
 that its torsion will be facilitated ; for, without such preparation, 
 the application of sutures on the side towards which the flap has 
 been twisted will be difficult, and the sutured margins will be 
 uneven, and become still more so when swelling occurs. To aid 
 in torsion, Lisfranc proposed to elongate downwards one of the 
 incisions. In the Indian method the incisions ended below at 
 points on a level with the eyebrows. Lisfranc advised to carry 
 the cut one-half inch farther downwards on the side towards 
 which the torsion is made. Labat and Langenbeck amended 
 this incision by carrying the cut downwards and towards the 
 other side. For example, if the torsion is to be towards the left 
 side, the left incision must reach downwards a half inch further 
 than the right one; and the left cut, besides being made longer, 
 is to be carried towards the right, until it reaches or has slightly 
 passed the median line. In this j^reliminary preparation for 
 easily twisting the flap, the vitality of the latter must be borne 
 in mind; and one of the frontal arteries must be retained intact 
 in the pedicle. The method of Alcj^uie, in which the flap is taken 
 from over one of the eyes, though the torsion might be reduced 
 from 180° to perhaps 120°, yet in its preparation the tw^o frontal 
 arteries w^ould be severed, and the upper third of the flap would 
 be cut off from any direct arterial supply, and hence its vitality 
 would be endangered. As seen, the problem of torsion of the 
 pedicle has been but imperfectly solved ; and this has led to the 
 attempt to use the flap without torsion, as will be seen hereafter. 
 
 In the methods of operating described, after the reversed (over- 
 turned) transposed flap had formed adhesions to its new site, it 
 w^as customary to divide the pedicle; and the result was that the 
 reformed nose contracted into a very unsatisfactory shape. To 
 avoid such shrinking, the endeavor has been made to dispense 
 with the section, and to so dispose of the pedicle at the primary 
 operation that it would be less prominent. To accomplish this, 
 Dieffenbach made a vertical incision at the root of the nose, and 
 placed the pedicle in this sulcus, and applied compression on the 
 parts so as to cause adherence. Blandin, to accomplish the same, 
 excised the surface of the skin, on which the pedicle is to lie. 
 But Velpeau excised the pedicle, converted it into a triangular 
 form and placed this in a sulcus which he had made, and retained 
 it there by sutures. The plan of Blandin or Dieflenbach is 
 preferable. 
 
 Instead of forming the sub-septum from frontal integument, 
 this may be constructed from the upper lip, as has been hereto- 
 fore described. 
 
41G MAXILLARY SINUS, OR ANTRUM OF HKiHMORE. 
 
 In case the septum is wanting, the transposed frontal flap 
 would rest as a flattened bridge across the nasal breach, and, at best, 
 be nothing more than a caricature of a nose. To improve the 
 condition in such a case, Verneuil has conceived the thought of 
 doing the work by means of a frontal flap, and two flaps taken, 
 one on eacli side of the nose. A frontal flap is to be modeled and 
 brought directly down on the breach without torsion; that is, the 
 bleeding surface is outside, and tlie epiderm directed inwards. 
 Then from each side a flap is to be uplifted, and the two are to 
 be drawn across the raw surface of the frontal flap, and fixed there 
 by sutures. In this way the wanting nose can be built up and 
 given a greater solidity than it would have from a single thick- 
 ness of transposed structure. The pedicle of the frontal portion 
 may be made narrower than where it is twisted. 
 
 In tliis work of nasal repair, which is done to render a face 
 less repulsive to otlier eyes, it must be ever remembered that the 
 subject has another interest in tlie matter, viz., that it may be 
 provided with nostrils through which he can breathe; and open- 
 ings for this must be maintained. For this purpose tubular 
 obturators must be placed in the new-formed nostrils, and retained 
 there for many months. Such tubular obturators may be formed 
 of silver, lead, aluminum or of India rubber. 
 
 Some facts should be mentioned in respect to tlie newly trans- 
 planted material. For a time, its temperature is lower than that 
 of the surrounding parts; for a short period it is pale, cold and 
 cadaver-like. In the transplanted structure, in regard to the 
 alternate ebbing and inflowing of blood, and the ascent and 
 descent of temperature, which are said to have continued for 
 many hours, tlie statements of Inmisch, Coote, and others are 
 examples of careless assertion rather than of accurate observa- 
 tion; for, as the writer has often witnessed, the circulation is soon 
 established in the part, and though it may be briefly cyanoscd, 
 yet the natural color returns early, and occasionally the part 
 becomes temporarily red and congested. Excessive congestion is 
 assigned by Dieff'enbach as the usual cause of death of the trans- 
 planted structure. And to avert sloughing, where the part 
 becomes passively surcharged with blood, Dieff'enbach scarifles 
 the swollen part and thus relieves the turgid condition. As to 
 the dressing of the part, authorities differ, some using warm, 
 others cold applications. The condition of the part should guide 
 in the matter; in the early stages, before the circulation has been 
 restored, this ought to be favored by warm dressings; but later, 
 
RHINOPLASTY. 417 
 
 when the congestive period appears, then the constrictive action 
 of cold dressings, or scarification, may be resorted to as means of 
 reduction. 
 
 Tlie sensation of the transported structure will be lessened and 
 perverted in character; for nerves have been severed, and those 
 left intact are altered in their position in reference to the surface 
 of the body, and the result is that, when the new nose is touched 
 or irritated, the sensation awakened is referred to the forehead. 
 And this error of place continues for a long period, and whether 
 it is finally dissipated by education and experience, the writer 
 has not been able to verify by observation. From the fact that 
 after amputation of limbs, a similar error of sensation exists, which 
 finally vanishes, it is inferable that a correction finally obtains in 
 case of the new formed nose. 
 
 The condition may exist in which the septum and nasal bones 
 are absent; such a state constitutes the highest grade of nasal 
 deformity; and what is quite as unfortunate, plastic surgery has 
 been able to offer the unhappy subject only slight relief; a 
 revolting deformity has, by the hand of rhinoplastic art, been 
 exchanged for an unsightly, repulsive substitute. The trans- 
 ported structure, lacking median and lateral support, lies flat over 
 the breach. The best that can be said of such a state is that it is 
 better than no nose. Perhaps, through combining the untwisted 
 frontal flap with lateral flaps from the cheek adjacent, the flattened 
 structure could be made more prominent; but the new struc- 
 ture would not be relieved of repulsive clumsiness. In such a case 
 in which there was a total lack of the parts which sustain the nose, 
 resulting from the misfortunes of misguided passion, the writer, 
 in 1864, operated as follows: A plate of gold was prepared, in the 
 form of a parallelogram, of dimensions sufficient to replace the 
 absent nasal bones. The plate was so thin that it could easily be 
 molded into an arched form. The site was prepared by trimming 
 the uneven margins and then lifting up the integument so as to 
 form lateral flaps, of which the anterior margins were equal to 
 the length of the nose which was to be formed. Such a flap was 
 dissected up from the subjacent parts on each side. Next, a frontal 
 flap was traced out and lifted from the bone. The plate of gold 
 was next put into its destined position, with its marginal sides un- 
 derneath the lateral flaps. The flap from the forehead was placed 
 without torsion on the plate and beneath the marginal flaps, 
 which covered with their raw surface a portion of the frontal 
 flap. No septum was formed, as it was deemed better to defer 
 
418 .MAXILJ.AKY SINUS, OR ANTRUM OF HIOHMORE. 
 
 this until tlie remaining work had been tested. When cicatriza- 
 tion had ended, the band of scar along the dorsum of the nose 
 did not present as ill an aspect as liad been feared. But the 
 patient, whose morale was below par, finally became impatient of 
 the pain caused by the contraction of the cicatrizing structure, 
 and after three months begged to have the metallic support 
 removed, which being done, the unsupported parts sank almost 
 to a level with the j^arts around. 
 
 The experience of this case showed that in a patient more 
 tolerant and docile to surgical management, with some modifica- 
 tion of the work, the ])lan here described might be employed to 
 advantage in those cases in which the osseous and cartilaginous 
 framework of the nose is absent. The frontal flap should have 
 been provided with material for forming a sub-septum; the mar- 
 gins should have been obliquely beveled on the dermal side, and 
 the flap turned by torsion; the beveled edges should then be 
 placed beneath the loosened margins on each side of the nose. 
 The frontal flap should be so large that it will require no addi- 
 tion to it from the contiguous structures of the cheeks. A pro- 
 cedure thus carried out would, in a great degree, avoid the pain 
 from contracting cicatrization. If nasal reconstruction were thus 
 done, the part would be provided with an enduring framework, 
 which w'ould defy change from time or disease; and, according 
 to the Twelve Tables of the old Roman law, which forbade the 
 cremation of gold which had been used to fasten the teeth, so 
 the gold used in nasal repair might at death be rescued and 
 made to do duty again by some conservative nasifex. 
 
 It is in order to next consider the method of nasal construction 
 in which the restoration is done w'ith material taken from the 
 arm, known as the Italian or Talicotian procedure. This method 
 appears to have been used particularly in those cases in which 
 the supporting framework of the nose had been lost. This opera- 
 tion, as done by the Italian surgeon Tagliacozzi, consisted of a 
 series of acts, which required from six to eight weeks for their 
 completion. 
 
 Taliacotius, as he latinizes his name, seems to have dreaded 
 that his material might die, and to avoid this he subjected the 
 part to be used to a preliminary preparation; during a consider- 
 able period he treated the skin over the biceps muscle with 
 rough friction and flagellation until the structure was hardened 
 and resembled that of the elbow. The integument being thus 
 altered until it no longer resembled the skin of the arm, the 
 
RHINOPLASTY. 
 
 419 
 
 operator seized and lifted up a fold of it with forceps, and cut 
 this so that there was formed a flap with free end directed 
 upwards, and pedicle attached some two inches above the cubital 
 flexure. This flap in its dimensions is double the size of the 
 future nose. The wound made behind the flap is closed by 
 sutures, and the bleeding surface of the flap in extended position 
 is covered with ointments, or material which will promote sup- 
 puration. Prior to the operation, during a few days, the arm is 
 to be trainee! to a position in which, the limb being uplifted and 
 the elbow fixed, the front surface of the upper arm is brought 
 near the nose and retained there. To maintain this tiresome 
 posture the patient must wear a hood-like head-dress, which is a 
 continuation of the outer coat of the chest. With such a dress 
 the arm, with the aid of attached straps and buckles, can be con- 
 
 FiGURE 8. Illustrating the Talicotian method of rhinoplasty. 
 
 fined in the position mehtioned. Such a position should be 
 maintained for not less than two days prior to the preparation of 
 the flap. The position, as well as the means of fixing the arm, is 
 seen in the annexed figure. The work of fixing the limb has 
 been done by means of adhesive plaster; this plan, however, is 
 less trustworthy. After the flap had suppurated, Tagliacozzi, 
 having trimmed the nasal breach, to which the former is to be 
 applied, next proceeded to apply a prepared model of the 
 intended nose to the flap, and trimmed from the latter the surplus 
 material, and fixed the flap to the nasal breach by marginal 
 sutures. The arm must still be maintained applied to the head, 
 and retained there by the contentive means described, for at least 
 twenty days. The flap thus adheres by its summit and borders 
 to tlie nasal site; the pedicle remains adherent to the arm. 
 
420 MAXILLARY SIMS, OK ANTRUM OF HIGHMORE. 
 
 After twenty days. Tagliacozzi divided with scissors the ped- 
 icle, which reached well down towards the mouth; from the lower 
 border of the flap-like structure, the operator next ])roceeds to 
 construct o[)enings for the naics, and also the sub-septum. To 
 form the nares, the skin is infolded, and the orilices are main- 
 tained open by tubes placed in them. 
 
 Griefe performed the Talicotian operation with some modifi- 
 cations; but instead of a flap from the humeral region, he took 
 the reparative material from the front of the forearm. Instead 
 of letting the uplifted flap pass through the suppurative stage, 
 he used it at once. A pasteboard model of the nose having been 
 prepared, this was laid on the forearm, and the flap incised, ele- 
 vated, and at once united to the recently trimmed surface of the 
 nasal site. The arm was maintained bound to the head for three 
 weeks, when the pedicle was severed, and a sub-septum and 
 nares coiL^^tructed. Griefe thus operated six times, with success- 
 ful result in five jiatients. It has been done by a few other sur- 
 geons; the result, as recorded, is satisfactory for a few weeks, but 
 some months later the i)art becomes less by atrophy, so that, by 
 its smallness, it contrasts with the remainder of the face. To 
 compensate the future diminution, the part should, at first, have 
 proportions abnormalh' large; and, as the brachial field of supply 
 is abundant, ample provision for shrinkage might readily be 
 made. 
 
 Talicotian rhinoplasty, or that done by the use of transplan- 
 tation of material from the arm, is in less favor than is the pro- 
 cedure in which pediculated flaps from parts contiguous are used; 
 yet the former may be used in cases in which the latter annot 
 be pursued. For exam})le, where the frontal derm is so scarred 
 that its vitality is lowered, or its surface is greatly disfigured, then 
 brachial transplantation is preferable. Again, the patient may 
 object to having an indelible mark set in his forehead, which, as 
 a telltale, would reveal his misfortunes;- here, again, material 
 from the arm might be employed for the re{)air. 
 
 Partial Nasal Repair. — Partial restoration of the nose may be 
 demanded in case of loss of the alar margin of the nostril, or of 
 the side of the nose including the alar margin, or of the tip or 
 lobule; and finally a sunken condition of saddle-seat shape may 
 solicit surgical aid. And the work of restoration may be required 
 on both sides or on one side only. 
 
 In each of these cases the material for closure is taken from a 
 surface that is contiguous, viz., from tlie forehead, nose itself, 
 
DEFECTS FROM LOSS OF SIDE OF NOSE. v 421 
 
 cheek, or upper lip. In fact, in the 'selection of the material for 
 replacement, the rule should be to take it where it is most readily 
 accessible, and where its employment will cause the least marring 
 of the patient's face. And these conditions are generally best 
 fulfilled by choosing material from intact derm, which may be 
 on the upper part of the nose, or from the adjacent cheek. 
 
 Alar Marginal Defect. — To repair this breach, after trimming 
 the margins of the defect, map out and uplift a pedicled flap from 
 the adjacent derm of the cheek; and as this replacing material 
 must be swung, or revolved, into its destined site, it should be so 
 situated that it can be moved into place through the shortest 
 circuit. If the flap be so placed that its free or distal border is 
 directed towards the outer angle of the eye, it can be shifted to 
 its intended site by passing through an arc of ninety degrees. 
 But if this border be directed towards the inner angle of the eye, 
 the movement of transposition will be done through an arc of 
 not more than forty-five degrees. And the same would be true 
 if the material be taken from the upper lip. It is better to take 
 the material from the inner portion of the cheek: that is, from 
 the derm alongside of the nose. This flap must exceed, in length 
 and breadth, the breach which it is to fill; and allowance should 
 be made of not less than two lines in each direction, for subse- 
 quent contraction. Should ample allowance for diminution not 
 be made, and the border rise above the normal level, the patient 
 will deem himself but imperfectly paid for his pains. The flap 
 with derm outside is placed in position and retained there by 
 metallic sutures, which should remain in place for a week at least. 
 It is seldom that an obturating tube is required. The wound 
 remaining in the cheek must also be carefully closed by metallic 
 sutures. In the closure of this wound the movable part of the 
 nose is usually deflected to that side by the traction made on it. 
 Such lateral deflection gradually v.anishes through the structures 
 of the cheek stretching or sliding towards the nose. 
 
 Defects from Loss of the Side of the Nose including the Alar Mar- 
 gin. — For the repair of this extensive breach, material in the form 
 of a pedicled flap, might be found in the contiguous cheek; and 
 in such case tlie technical steps, or acts, would be similar to those 
 above described for the repair of defective alar margin. If the 
 defect were not extensive, the repairing material might be ob- 
 tained from the upper part of the nose. 
 
 Denonvilliers repaired the breach by means of a triangular 
 flap which was attached at the root of the nose, and liad its 
 
422 MAXILLARY SINUS, OR ANTRUM OF HIGHMORE. 
 
 movable border lying on the cheek. Nelaton used for the purpose 
 a four-sided flap, of which the pedicle was also attached at the 
 root of tlie nose. In the work reported thus done, there was 
 subsequent retraction of the alar border. 
 
 In case the defect should be but a small opening through the 
 side of the nares, closure might be done by sliding or twisting a 
 small flap into the breach. Or the metliod wliich Celsus recom- 
 mends for the closure of openings in the ear might be adopted. 
 Celsus writes: "If the opening bo large, as is wont to be the case 
 in those wliose ears have borne weights greater than they could 
 bear, then one should make a long incision superiorly; and hav- 
 ing made the borders (of the opening) raw with a scalpel, then 
 close by suture; and over the wound a medicament must be 
 placed, whieli would cause union. The plan here indicated is 
 plainly to trim the borders of the defect and elongate this by 
 incising, so that the sides could be brought together. By sucli a 
 procedure, openings through the sides of the nose might be closed. 
 If closure could thus be done, less scarring would result than 
 would occur from repair through borrowed material. 
 
 In slight defect of the alar margin, Dieffenbach resorted to 
 the novel procedure of trimming off the wing on the opposite 
 side, so that the two sides would be of corresponding length. 
 Though the sides would thus be made symmetrical, yet the comi- 
 cal appearance which would be given the nose by such retrench- 
 ment, would be a great remove from cosmetic improvement; 
 some one compares such a nose to that of a cat. 
 
 Repair of nasal structure is sometimes demanded through 
 depression of the middle portion of the dorsal ridge in which 
 the part presents a saddle-seat incurvation. This may have, as 
 origin, a lesion in which a portion of the nose has been destroyed 
 by injury; the causal agency is far more frequently traceable to 
 a constitutional disease, such as scrofula or syphilis, in which the 
 nasal bones necrosing, the supporting skeleton of the nose is lost, 
 and the nose sinks at its middle. The lobular part, or lower 
 third, of the nose maintains its position in some cases, since its 
 cartilaginous supports remain intact; yet not unfrequently the 
 ulcerative disease reaches and attacks the cartilage, so that the 
 lobule sinks, and recedes into the upper portion: that is, the lob- 
 ular portion is received in the upper portion similnr to telescopic 
 ensheathing. This invaginated deformity is much more difficult 
 to rectify than tl)at in which the lobule is in its natural site, and 
 the means to be pursued in repair differ in the two cases. 
 
DEFECTS FROM LOSS OF SIDE OF XOSE. 423 
 
 Where the deformity has arisen from a wound in which a 
 section of the nasal dorsum was destroyed, and the remainder of 
 the nose is intact, then repairs might be done by means of 
 material obtained on the forehead, root of the nose, adjacent 
 cheek, or from the palm of the hand. When done by means of 
 a pedicled flap obtained from a contiguous surface, the work is 
 similar to that which has been described for restoration of the 
 entirety, or side of the nose. Should the contiguous material 
 not be suitable for the repair, then a procedure cognate to the 
 Taliacotian might be done, in which a flap is to be dissected from 
 the palm of the hand, and this being sutured to the trimmed 
 edges of the defect, the hand is to be fixed on the nose, and im- 
 movably held there by contentive appliance, in which the hand 
 is immobilized; and then the arm must be bound against a sup- 
 port placed between the limb and the side of the chest. 
 
 A small breach in the dorsum of the nose from traumatic 
 cause was rectified by Reid by means of flaps uplifted on each 
 side of the nose. Each flap was formed by means of two lateral 
 incisions, which were four-fifths of an inch apart at the base, and 
 two-fifths of an inch apart above. Next, through the nostril the 
 septum was cut from the structures above, so that the parts could 
 be lifted into proper position, in which they were retained by 
 means of pins. These pins are made to traverse plates of lead 
 laid on each side, so disposed as to maintain the nose in normal 
 form and position. Place tampons in the nostrils. 
 
 Diefl'enbacli, and after him Malgaigne, in cases in which the 
 osseous framework had been destroyed by scrofula or syphilis, so 
 loosened the nose from the face 6y incisions made at the sides 
 and underneath, that the movable parts can be molded into some- 
 thing like natural form. The work as done by Malgaigne is de- 
 scribed by him as follows: "The wings of the nose were separated 
 from the cheeks and upper lip; the loosened lower part was still 
 further detached by dissecting the soft j)arts from the nasal bones 
 at the root of the nose, as far as the frontal bones; also the upper 
 lip was detached from the apper jaw. After this work, the nose 
 could be raised and modeled into form, and retained so by long 
 pins which were passed transversely through the parts ; the heads 
 and points of the pins w^ere sheathed with corks. To still further 
 hold and retain the nose in place, adhesive strips and collodion 
 were used; and silver tubes were afterwards worn In the nostrils." 
 
 To restore form to a sunken nose, Konig in 1886 operated as 
 follows: A transverse cut was made across the lower part of the 
 
424 MAXILLARY SINUS, OR ANTRUM OF HIGHMORE. 
 
 nose; through tliis cut the nasal wings were dissected up and so 
 loosened tliat the nose could be reduced to something like the 
 normal form. Next a long flap of rectangular shape was formed 
 on the forehead, and was detached from the frontal bone along 
 with the periosteum and the outer layer of the bone. Thus there 
 was formed a cutaneous periosteo-osseous flap, which was turned 
 downwards with the dermal side inwards and the wounded sur- 
 face outwards. This flap is then slightly sutured to the adjacent 
 raw edges of the transverse wound previously made on the nose. 
 The next step was to form a similar flap of smaller size on the 
 right side of the forehead, which is to be turned downwards by 
 means of torsion, so that the raw surface will be directed inwards. 
 This flap is superposed on the other so that the raw surface may 
 cohere. Thus a long framework was obtained which afterwards 
 remained as solid material. Konig reconstructed four noses 
 according to the plan here described ; they had, however, the fault 
 of being too thick at the root: they were "too Grecian." that is, 
 the forehead passed into the no.'^e with too little incurvation at 
 the root of the nose. Yet this defect was capable of some improve- 
 ment afterwards. 
 
 We will next treat of those cases in which the surgeon is 
 compelled to remove a portion or the whole of the nose, on 
 account of some malignant disease. Should the extirpation be 
 followed by immediate repair, or should this be delayed to deter- 
 mine whether recurrence of the disease will ensue? Authority 
 differs here. Should tlie work of restoration be done at once, and 
 the disease return, it has been repeatedly observed that the 
 disease attacked the transplanted material. The proper rule of 
 guidance in such cases seems to be that if the growth can be 
 thoroughly removed, plastic repair should immediately be 
 attempted. Proof that the diseased structure has been wholly 
 removed would exist where the lines of excision had passed at 
 least four lines beyond all infiltrated or affected tissue. And, 
 further, should the disease return and invade the tissue used for 
 repair, the patient wouLl have had some advantage through tem- 
 porary suspension of both his disease and the deformity conse- 
 quent on its removal. Hence,in a i)atient whosenose is attacked 
 by sarcoma, epithelioma, and forms of cancer other than encej)h- 
 aloid and melanotic, the disease should be extirpated, and plastic 
 restoration at once be done, from the lateral structures if possible-, 
 and in absence of material there, seek it on the forehead or on 
 the arm. 
 
DEFECTS FROM LOSS OF SIDE OF NOSE. 425 
 
 There are cases in which it is impossible to repair the wanting 
 nose by any of the procedures practiced in rhinoplastic surgery; 
 or tlie performance of any such operation may not be advisable, 
 owing to the existence of some disease of the part which cannot 
 be eradicated, without too extensive destruction of the parts. 
 Examj)les of the former are those cases in which the face has 
 been nearly destroyed by violence; or the face of a patient in 
 which the field whence reparative material is obtained is occupied 
 by a cicatrix. An example of uncured or progressing disease, 
 forbidding rhinoplastic closure, is where lupus, rodent ulcer, 
 epithelioma or tertiary syphilis is laying waste or has destroyed 
 the deeper structures of the nose; a field where such invader 
 having intrenched himself tolerates no cooperative occupancy. 
 
 Prothetic appliance employed to conceal partial or complete 
 loss of the nose is first mentioned by Par^. Various materials 
 have been used for the construction of the artificial nose: namely, 
 it has been made of light w^ood, of gutta percha, vulcanized 
 rubber, of lead, tin, silver and aluminum. The art of the man- 
 ufacturer has been mainly occupied in devising that which will 
 deceive the eye of the beholder; that the false nose will be so 
 cunningly contrived that the falsity will not be revealed; a coun- 
 terfeit which W'ill impose for the genuine. To accomplish this, 
 attention must be directed to the form, color and retention of the 
 device in its destined site. 
 
 The form of the artificial nose is readily attained; and since 
 it would be difficult to select a type which would content all 
 eyes, hence some deviation in outline is tolerable. The hue or 
 tint of the skin is easily imitated, especially in a case in which 
 non-metallic material is employed; but if the material be silver 
 or aluminum, the metallic appearance cannot be disguised by 
 simply painting it; the object, however, can be attained, as 
 Charrierehas done, by first covering the metal with India rubber; 
 or the nose might be wholly constructed of this latter material. 
 The lightness of aluminum gives it an advantage over lead or 
 silver. An important need of such appliance is that it be held in 
 position, and, if possible, that this be done by means which escape 
 observation. If the entire nose be replaced, the substituted device 
 may be kept in place by the framework or bow of spectacles, or 
 the same can be attained by means of wire springs which may 
 pass laterally around the head; or the spring may ascend the 
 forehead, pass over the head, and rest claspingly on the back of 
 the head. This vertical attachment has the objection of being 
 28 
 
426 MAXILLARY SINUS, OR ANTRUM OF HIGHMORE. 
 
 constantly visible. It is, however, an effective mode of retentive 
 fixation; vet, for manifest reasons, the mode of retention by the 
 aid of spectacles is the more satisfactory one. 
 
 To procure a mould of the site to which the artificial part is to 
 be attached, first plug the nostrils and cover the eyes; lay over 
 the site some thin linen or cotton cloth, and again on this place 
 and mould to the adjacent parts a thickness of pasteboard of 
 nasal form ; now slightly lift the pasteboard, and while the 
 patient is leaning forward, pour beneath the pasteboard liquid 
 gypsum, which hardening forms an exact cast of the parts beiiind. 
 
 The fabricated nose has been held in position by being 
 attached to sponge which is pushed into the nostrils; the odor 
 that soon proceeds from the sponge will finally disgust lie patient 
 with such appliance. A more successful means of "fixation is by 
 means of some adhesive composition or cement; for this gum- 
 shellac may be employed. 
 
 Along with the loss of the nose there may coexist defect of the 
 lips and alveolar process of the upper jaw. In such cases, along 
 with the replacing nose there might be associated an obturator to 
 close the defect in the jaw. And the ingenuity of the artisan 
 might connect the nasal portion with the labial, alveolar or 
 palatal supplement. The connecting means may be wire so 
 placed as to be concealed; namely, from the inner or hidden 
 surface of the nasal portion, the wire might pass through the 
 maxillary breach and be joined to the part situated within the 
 mouth. 
 
 Cases again may occur in which a replacement of a portion 
 of the defect may be effected by some plastic procedure, in which 
 structure adjacent is utilized for the work of closure. 
 
CHAPTER XI. 
 
 THE ELEMENTS OV PLASTIC SURGERY. 
 
 Success in operative work within the domain of plastic sur- 
 gery is only to be reached by hiin who is familiar with certain 
 mechanical principles, and who is guided by these in planning as 
 well as in the execution of his work. To trust to the eye, and to 
 the inspiration of the moment, may answer for him who has had 
 much practical experience in such matter, yet for one who has 
 not had such discipline, trusting to the moment for lucky 
 guidance will usually end in an unsatisfactory result. As the 
 navigator who is compassless might reach a hundred ports 
 rather than the intended one, so the plastic surgeon relying on 
 fortunate chance and a mechanical eye must often stray far from 
 correct lines, A little geometry will add to the accuracy of 
 the scalpel in its tasks of plastic repair. Lines must be drawn in 
 accordance with premeditated study and plan, in order that any 
 degree of excellence shall mark the completed work; and in this, 
 due consideration must be given to the site, inch'nation and 
 outline of the part to be repaired. And, also, most attentive 
 study must be given to the selection of material for repair, viz., 
 where such material is most accessible, can best be spared, and, 
 above all, that its situation is such that it can readily be shifted, 
 or moved to its intended site. 
 
 In the consideration of rhinoplasty glimpses have been given 
 of the points here referred to; a more systematic elucidation of 
 them will now be presented. 
 
 A plastic operation may be defined to be a procedure by 
 which a breach of surface may be closed or repaired; or an 
 upheaved or irregular surface is replaced by a smooth one; or, 
 finally, plastic surgery has, as one of its most important offices, 
 the restoration of parts which are absent; for example, con- 
 genital defects, or which have been lost through some traumatic 
 
 agency. 
 
 (427) 
 
428 THE ELEMENTS OF PLASTIC SURGERY. 
 
 The work of repairing a defect may be done by one of the 
 following methods: (1) By adduction or sliding and partial or 
 complete approximation of surfaces which lie near each other; 
 (2) by adduction of parts which lie near each other, after detacli- 
 ment of the surface from structures beneath, with which it is 
 connected; other aids in such approximative sliding are sub- 
 sidiary lateral incisions; (3) by means of a replacing pedicled 
 flap which is shifted to its intended site by revolving it through 
 a semicircle, or an arc of the same; (4) by transplanting 
 pedunculated replacing material from the arm or hand of the 
 patient, or from the body of another individual. And as a 
 modification of this, the restoring material may be cut off, and 
 without sustaining pedicle be transplanted to its intended loca- 
 tion. The most of plastic surgery is done by one of the first 
 three methods. Where the defect is small, closure can usually 
 be effected by the first method; but where it is larger, there is 
 often needed some preliminary preparation of the surfaces which 
 are to be approximated. And finally, where the first and second 
 methods are unsuited to do the closure, a pedicled flap taken 
 from a surface which lies iiiore distant may be prepared, uplifted 
 and turned around into the defect. 
 
 In the first and second metliods, as subsidiary work to aid in 
 closure, the defect must be converted into a figure, the outline of 
 which will favor adductive closure. By the third method, it 
 matters not what outline the defect may have, the flap of replace- 
 ment must have a similar one. Hence the third method has 
 special advantages; and, besides, the fact that the pedunculated 
 flap may have any conceivable outline, it may be taken from a 
 surface in which closure can easily be made, and the resultant 
 scar will not be conspicuous. 
 
 As stated, in the first and second methods the border of the 
 defect must be converted into a figure of a shape that will favor 
 adductive approximation; and these figures are, in the main, 
 similar to those employed by the geometrician in the solution 
 of his theorems. Classified in the order in which they will be 
 presented to the reader, these figures are the circle, semicircle, 
 and other fractional portion of a circle, the ellipse and oval, the 
 triangle, the rectangle or parallelogram, the rhomboid and the 
 lozenge. These figures, diagramatically, are shown in the sub- 
 joined Figures 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 
 21, 
 
THE ELEMENTS OF PLASTIC SURGERY. 
 
 429 
 
 Figure 9. Showing the circle. Figure 10. Showing the semicircle. 
 
 Figure 11. Exhibiting 
 the ellipse. 
 
 Figure 12. Showing the oval. 
 
 Figure 13. Showing tri- Figure 14. Show- 
 angle of equal sides, ing triangle wnth 
 
 twQ equal sides. 
 
 Figure 15. Showing 
 the rectangle. 
 
 Figure 16. Representing a paral- 
 lelogram. 
 
 Figure 17. Exhibiting the rhomboid. 
 
430 
 
 THE ELEMENTS OF PLASTIC SURGERY. 
 
 Figure 18. Showing rhomboid slightly lengthened. 
 
 FiGiRE 19. Illustrating the rhomboid much enlongated. 
 
 Figure20. Showin>r 
 
 FiorKE21. Showing the sector. 
 
 The First Method, or that of immediate Adduction. — In this 
 method, of the figures here shown, the circle and the oblong rect- 
 angle can only be used when the surface of the defect is small. 
 In the case of the circle, the opposite sides, in order to meet, must 
 be carried at their middle point through half the diameter of 
 the circle; and this could only be done where the breach to be 
 closed is small; partial closure, however, could be effected, in 
 which the circle would be reduced to a smaller polygonal figure, 
 
 Ftgure 22. Showing closure of the circle. 
 
 as sliown ni Figure 22. In case of a rectangular defect, only in the 
 event of the surface being diminutive could the opposite sides be 
 approximated, and the lines of suture would be as shown 
 in Figure 23. 
 
THE FIRST METHOD. 
 
 43] 
 
 Figure 23. Showing closure of the parallelogram. 
 
 The oblong figure of the ellipse and oval renders them easier of 
 closure by sliding than is the case with the circle; the long sides 
 are to be apposed, and the result will be a straight line. 
 
 The closure of a triangular defect will depend on the figure of 
 the triangle; if this be one with two equal sides and with a nar- 
 row base, juxtaposition of the long sides is easily accomplished, 
 with the result of sutural lines resembling an inverted \. Should 
 the triangular defect be equilateral, then a large closure could 
 only be made in the direction of the angles, and the result would 
 be as shown in Figure 24, with a central space unclosed. A 
 
 Figure 24. Showing closure of the equilateral triangle. 
 
 rhomboidal defect will be more easily closed, proportionately to 
 the obliquity of its figure; for example, the same amount of 
 space in Figure 17, will not be so easily closed by suture as that 
 in Figures 18 and 19, of which the line of closure will be a long 
 
 i 1 
 
 ^ — I- 
 
 oval. 
 
 FiGUEE 25. Showing closure of a rhomboid space; also of the ellipse and 
 
 oblique line; for a defect of rhomboidal figure has the property 
 that as the obliquity augments the long sides approach nearer to 
 each other. A figure in the shape of a lozenge, which is similar 
 to two isosceles triangles applied base to base, can be closed by 
 direct sliding, provided the open surface is not large. 
 
432 THE ELEMENTS OF PLASTIC SURGERY. 
 
 A fit^jure which is compounded of, or derived from, the triangle 
 is that shown in Figure 26; and occasionally a dermal defect 
 
 Figure 26. Showing a triangle with Figure 27. Showing closure of this 
 
 opening in base. space. 
 
 may be converted into this form. This figure consists of a tri- 
 angle of two equal sides, with a small base in which there is a 
 reentrant or open angle. The space within the four sides repre- 
 sents the open defect, while the reentrant angle represents sound 
 tissue. A defect in such form can easily be closed by adductive 
 sliding. The point a can be pushed still further inwards, and 
 included in sutures which approximate the long sides. Such a 
 figure can readily be closed; the sutural line is shown in Figure 
 27. The solid structure in the base being carried upwards will 
 tend to support the structures above. This plan can be used to 
 correct ectropic eversion of the lip or eyelid. And in case the 
 defect is so constituted that structure can be preserved as a 
 reentrant angle in a figure which is otherwise circular, elliptical, 
 oval or rectangular, such entering angular or ovular material 
 will facilitate closure, and lessen sutural tension at one point. 
 
 In the first method of closure the displacement is done with- 
 out any detachment of the skin, which is moved from the under- 
 lying structures to which it is adherent; and but little sliding 
 can be done without subjecting the displaced integument to 
 strain or tension. The small vessels which maintain the nutri- 
 tion of the skin and which enter it from underneath and from 
 the contiguous derm, are stretched, and the amount of blood whict 
 passes through these vessels is greatly diminished, the result being 
 that the shifted skin is defectively nourished, and, consequently, 
 can easily die. The physical law obtains here that when a tul>e 
 is doubled in its length, there will flow through it but half the 
 amount of fluid which passed through it when it was of half the 
 length ; and if the tube be reduced to one-half of its previous 
 diameter, then the quantity of fluid which will flow through it 
 
THE SECOND METHOD. 433 
 
 will be sixteen times less than the quantity which passed before 
 any change was made in its calibre. It is evident that adductive 
 approximation, as has been described above, both elongates the 
 vessels of the displaced skin, and also diminishes the calibre of 
 the vessels; and the result is a diminished supply of blood, which 
 can easily reach a limit that can destroy the vitality of the skin. 
 And if the skin itself does not die, the degree of tension to which 
 the skin is subjected leads to its being cut by the sutures, and 
 thus the healing is delayed and scarring follows. And what is 
 more to be feared, when the sutures cut, they fail of their intended 
 purpose, viz., to immobilize the shifted surface and to counteract 
 retraction; for through the sutural cutting, the adducted parts are 
 permitted to retract, and this may endanger the work done, since 
 the approximated parts may fall asunder. Sucli result, which 
 often attends the work of the inexperienced, soon forcibly teaches 
 him that in closure by direct or immediate adduction, severe 
 straining and stretching must be avoided. 
 
 In the second method, to facilitate the mobility of the part 
 which is to be shifted, and thus by diminishing tension to favor 
 the vitality of the transposed structure, there must be done some 
 preliminary preparation. "When the defect has been given an 
 oval, elliptical, circular, triangular, quadrangular or rhomboidal 
 figure, to facilitate adductive approximation of the marginal 
 structure, the latter may be dissected from the subjacent parts. 
 In this dissection the subcutaneous fascia must be uplifted with 
 tlie skin; that is, the fascia and derm must be raised as one layer. 
 Sometimes the fascia is so thin that it is nearly indistinguishable, 
 and the derm seems to rest on the adipose layer without any 
 tissue being interposed. The derm, in such a case, though it 
 may be used, yet it is ill suited for plastic purpose; and when 
 it is used, a thin layer of adipose tissue should be detached along 
 with the derm. This subcutaneous detachment must not be too 
 extensive, lest in the hollow space created, blood may accumulate, 
 and delay or prevent healing. If the subscision should extend 
 farther than an inch, this trouble might arise. 
 
 Incisions subsidiary to shifting may be made through the 
 skin; and such incision may consist of cuts which are a continu- 
 ation of one or more sides of the figure into which the defect has 
 been converted; or it may consist of an incision made at a short 
 distance from the breach to be closed ; thus stretching is lessened, 
 and sliding facilitated. 
 
 These preparatory cuts, as adjuvants in closure, are mentioned 
 
434 
 
 THE ELEMENTS OF PLASTIC SURGERY. 
 
 by Celsus in the method which he describes for closure of a 
 qiiadranguUir defect. He advised to coiitinne laterally the upper 
 and lower lines of the four-sided defect; and if this does not 
 suffice for closure, then a crescentic cut, directed towards the 
 wound, is to be cut superficially through the skin. The Celsian 
 plan of closure has already been explained. The lateral or out- 
 side accessory incision is not to be closed, but is to be allowed to 
 heal by granulation; and this scar often left by the lateral cut 
 warns the surgeon that he should be chary of its use; it is better 
 to effect the sliding by subjacent detachment, of which the work 
 will remain unseen. The open lateral cut is best done in situa- 
 tions in which the resulting scar will remain invisible. Cases in 
 which it may be employed arc those in which large breaches have 
 been made in the surface, which it is desirable to close by a 
 tegumentary covering. And as the site of such operation is 
 often hidden by the subject's clothing, a scar from lateral sub- 
 sidiary incision becomes unimportant. 
 
 The second method consists, then, of closure by the aid of 
 accessory subscision, continuation of existing cuts and lateral 
 incision; and it may be used for the effacement of any breach 
 which has been converted into one of the forms before mentioned. 
 A few examples of its application will here follow. A triangular 
 defect may be treated as follow;:: — 
 
 Figure 28. Showing two parallelo- 
 grams resting on the same base c d. 
 
 Figure 29. Showing 
 result after closing defect 
 represented in Fig. 28. 
 
 If in Figure 28 a b d is the defect to be closed, let the side a 6 be 
 continued to e, and then an incision be carried from d to c, and 
 the quadrangular flap b d eche uplifted. The diagram if studied 
 will be composed of the parallelograms abed and be c d, which 
 are geometrically equal to each other, since they rest on the same 
 base, d c, and lie between the same parallel lines; hence the right 
 figure can be slidden and superposed on the left one, which it will 
 
THE SECOND METHOD. 
 
 435 
 
 fill; the sutural closure will then be that in which there only 
 remains a small open space, and this may perhaps be effaced, if 
 the sides h e and e c be subscised. 
 
 The material for closure can be taken on either side of the 
 defect; and thus the sutural scars and the small opening left may 
 be placed where they will be but slightly conspicuous. 
 
 EiGTJRE 30. Illustrating one method of closing a triangular defect. 
 
 -i h 
 
 </ 
 
 Figure 31". Showing the sutural line that remains after closure by unilateral 
 sliding. 
 
 Or if the triangle stands as in Figure 30, closure may be done 
 by subscising the derm a c d, and having drawn this to the left, 
 suture it to the side a h. The remaining sutural line will be as seen 
 in Figure 31. A defect in this method is that the surface beneath 
 the line h d will, for a time, be folded or uneven. This uneven- 
 ness will, in time, become less; yet, for a long period, the tense 
 
 Figure 32. Showing Burow's plan of closure. 
 
43G 
 
 THE ELEM^:^•T.S OF PLASTIC SURGERY. 
 
 condition of the structures above the line b d will contrast with 
 the loose state of the parts below the line. To give more uni- 
 formity to tlie surface, the ingenious conceit of Burow may be 
 utilized; this is done as follows: On the extended line bcxlet 
 
 FiGiRE 33. Showing sutural 
 lines after closure by Burow's 
 plan. 
 
 Figure 34. Showing sutural 
 lines remaining after exsection 
 of two triangles done according 
 to Burow's plan. 
 
 there be excised from the opposite side the triangle d ef; when 
 closure is made, the lines of suture will have the form here pre- 
 
 FiGCRE .3.5. In which two triangles are exsected to aid in closure of ah c. as 
 done by Burow. Closure is seen in Figure 34, 
 
 sented. Or the compensating subsidiary excision may be done, 
 as presented in Figure 35, in which the base line is extended 
 towards the left and the right; and these excisions need not be so 
 large as the one which it is sought to close. The sutural union 
 will present the appearance shown in Figure 34 A serious fault 
 in Burow's mode of closure is that it nvolves some sacrifice of 
 tegumentary structure; it also multijjlies scar-lines. Tegumen- 
 tary sacrifice cannot be made without detriment, derm once lost 
 is irrevocably gone; nature has no resource by which it can 
 be reproduced; and though plastic surgical art may close a 
 breach in the surface by the procedure which we are considering 
 
THE SECOND METHOD. 
 
 437 
 
 yet if, through destruction or sacrifice of structure, much strain 
 be left in tlie closed surface, such strain and tension will remain 
 as a lasting annoyance to the patient. It is a fact, that should 
 not be forgotten, that in the work of inclosure of the human 
 organism, the hand of nature furnished no surplus material in 
 the inclusive dermal and mucous teguments. In this furnishing, 
 nature gives nothing for waste. 
 
 Instead of closing the triangle by rectilineal extension of one 
 of its sides, the side may be prolonged as a curved line, towards 
 the right or left, and then the line of closure would be along the 
 line a b and b c d, as will appear if Figure 36 be studied. 
 
 "Figure 36. Showing the plan of closing a triangular defect by curvilinear 
 extension of base b c to d. 
 
 The work of closing the triangle by means of subsidiary 
 incision, subscision and excision may be employed to close the 
 lozenge ; for as this figure may be conceived as consisting of two 
 triangles resting on one base, as shown in Figure 37, the 
 
 Figure 37. Showing plan of closure of the lozenge-shaped defect. 
 
 ' ■ 1 J ^ ' H — f 
 
 Figure 38. Showing sutural lines after closure of the lozenge-ehaped defect. 
 
438 
 
 THE ELEMENTS OF PLASTIC SURGERY. 
 
 repair of such a defect can be done by closing each of their tri- 
 angles separately. The work is done by extending a central 
 bisecting line towards the right and the left; then by subscision 
 the right side is loosened, and the same is done on the left side; 
 tlie right flap is now to be drawn towards the left, and the left 
 one towards the riglit. Thus closure will be effected, since each 
 triangle has the same relation to its fellow as does the triangle of 
 Burow, which is excised to avoid an uneven surface. 
 
 dl^ 
 
 FiGrRE39. Showing the 
 plan of closing a parallelo- 
 gram by converting it into 
 two triangles. 
 
 Figure 40. Exhibiting 
 line of suture after closure 
 of a quadrangular defect 
 that has been divided into 
 two triangles. 
 
 A quadrangular defect can be closed by employing the prin- 
 ciples here given; viz., by the closure of the triangles into which 
 a rectangle or parallelogram can be divided. For example, let the 
 figure b ce dhe converted into two triangles as shown in Figure 
 39. Next extend the side d b to a, and the side c e to/, and then 
 dissect up the flaps ab c and d e f. These flaps can be drawn 
 towards each other, when the sutural line will be as shown in 
 Figure 40. The quadrangular defect may be closed in another 
 
 a 
 
 Figure 41. Showing a plan of 
 closing a quadrangular defect. 
 
 Figure 42. Exhibiting the sutural 
 lines remaining after closure of the 
 quadrangular defect, as indicated in 
 Figure 4i. 
 
THE SECOND METHOD. 
 
 439 
 
 I \ t 
 
 1-1- 
 
 4— t^ 
 
 -M- 
 
 Figure 43. Presenting another 
 plan of closing a quadrangular defect. 
 
 riGURK44. Showing sutural line 
 which remains after closure of a quad- 
 rangular space, as indicated in Figure 
 43. 
 
 way, as exhibited in Figure 41, in which the replacing material is 
 incised in the form of angular flaps; in this way the open paral- 
 lelogram ah G e can be closed by sliding upwards the right and 
 left flaps; meanwhile the adherent angular portion d f will aid 
 in supporting and retaining in site the uplifted lateral flaps. 
 This defect might also have been closed by incisions made as 
 shown in Figure 43, in which median flaps are uplifted at A and 
 B, and the lateral ones, C and D, are dissected up: thus a defect 
 of moderate dimensions may be closed; and the sutural lines will 
 appear as shown in Figure 44. The mechanical advantages 
 
 i ^ 
 
 Figure 45. Exhihitingclosureofa 
 rectangular defect by sliding an adja- 
 cent flap into it. An adjuvant cres- 
 centic incision is shown beneath. 
 
 Figure 46. In which is shown lat- 
 eral closure of a rectangle after re- 
 placement by a lateral flap. 
 
440 
 
 THE ELEMENTS OF PLASTIC SURGERY. 
 
 gained by this species of closure are that the median and lateral 
 flaps when fixed in position, mutually hold each other in place. 
 Another plan of closing a rectangular defect is shown in Figure 
 45, in which a lateral flap being uplifted and thrust into the 
 space and sutured there, the appearance will be as shown in 
 Figure 40, If in the construction of the flap one makes a semi- 
 circular incision beyond its pedicle, as shown in the figure, the 
 work of closure will be facilitated. 
 
 In the third method, in which a pedicled flap is traced out on 
 the contiguous surface, and then incised, uplifted, and revolved 
 into its destined site, closure of a shapeless or irregular defect 
 may be done, provided the closing material has corresponding 
 outlines; still, even here, the oj^erator will solve the problem of 
 closure more readily if he can convert his defect into a circular, 
 oval, triangular, or quadrilateral figure. In the preparation of 
 the repairing fla^j, since the pedicle is to be subjected to torsion, 
 provision against tension should be made by having the flap long- 
 enough; for traction and torsion, and the tension consequent 
 on these, can arrest the vitality of the shifted structure. Yet 
 this is readily avoided if the flap have ample proportions. 
 
 As has been mentioned in the third method of the plastic pro- 
 cedure, the replacing flap must be turned through the entirety or the 
 whole of a semicircle; and the surgeon should endeavor to ren- 
 der this arc as short as possible. The pedicle must be broad 
 enough to insure a sufficient supply of blood to the flap ; and to 
 guarantee this, the foot-stalk, when median frontal material is 
 used, should have a breadth of not less than two-thirds of an 
 inch. The component tissue of the flap must be sound and not 
 deteriorated hy cicatrix or other defect. 
 
 A few examples of the employment pf this mode will now be 
 presented with diagrammatic illustration. 
 
 Figure 47. Showing a method 
 of closing a circular defect. 
 
 FiGCEE 48. Exliibiti ng the 
 appearance after closure of a 
 circular defect by the use of 
 subjacent flaps. 
 
THE THIRD METHOD. 
 
 441 
 
 One plan of closing a circular defect by the use and circum- 
 duction of adjacent flaps is presented in Figure 47, and the 
 appearance after closure is seen in Figure 48. The unclosed 
 space d might be repaired by Thiersch's method of epidermal 
 grafts. 
 
 The circular defect can be closed by another method, as shown 
 in Figure 49. Let the flaps a h and c d be incised, loosened and 
 
 : A ; ? 
 
 L - -' 
 FiGPRE 49. Showing 
 closure of the circular de- 
 fect. 
 
 FiGUEE 50. Showing sutural lines 
 after closure of the circle. 
 
 turned, one upwards and one downwards, so as to occupy the 
 circle; the line of suture is shown in Figure 50, and if the work 
 be examined, it will be seen that the sutured flaps mutually hold 
 and maintain each otlier in place. After completion there will 
 remain an uncovered space at what a geographer would desig- 
 nate the upper and lower poles of the circle. 
 
 Figure 51. Showing method of closing a semicircular defect. 
 
 A semicircular space may be closed by uplifting the flaps a 
 and b, in Figure 51, and turning them into and attaching them to 
 the margin of the defect S C, The circle might have its com- 
 ponent semicircles closed in a similar way. The ov^l and ellip- 
 tical defect can be closed by the modes just presented for the 
 closure of the circle and semicircle. 
 
 The third method of plastic repair, in which the work is done 
 29 
 
442 
 
 THE ELEMENTS OF PLASTIC SURGERY. 
 
 by the circumduction of a pedicled flap of proper form to close 
 the defect, is applicable to the repair of the triangular and quad- 
 rangular space; for example, the triangle A, seen in Figure 52, 
 
 
 Figure 52. Showing closure 
 of triangle A by shifted flap. 
 
 Figure 53. Showing 
 closure of triangle B. 
 
 may be closed by a plan in which the flap c d is turned into the 
 space a b c. Or the flap a may be shifted into the space B, shown 
 in Figure 53; or tliis may be done by flaps taken from the right 
 and left sides, as in the triangle C, Figure 54, which may be closed 
 by the flaps a and b. 
 
 Figure 54. Showing closure of triangle C. 
 
 The quadrangle A may be closed by the quadrangular flap ch d, 
 which, being prepared, is to be revolved into the space A, as seen 
 in Figure 55. In thus closing, the angular portion of remaining 
 tissue represented by c gives a support to the shifted flap b, and 
 the surface will be closed except a small space lying at the right. 
 
 c/ 
 
 / 
 
 Figure 55. Showing a plan of closing a quadrangle A by the shifted flap chd' 
 
THE THIRD METHOD. 
 
 443 
 
 / X -J 
 
 FiGHRE 56. Showing closure of Figure 57. Representing the su- 
 
 an oval space. tural line after closure of an oval de- 
 
 fect. 
 
 P 
 
 An oval defect, as shown in Figure 56, may be covered by a 
 flap, which, being dissected up, is to be uplifted until the side d a 
 is brought in contact with the side d e, when the sutural closure 
 will be as shown in Figure 57, with a space remaining open at 
 X. A semicircular space, shown in Figure B, may be closed by 
 
 \> \ 
 
 Figure 58. Exhibiting a plan of closing a semicircular space B by lateral 
 flaps. 
 
 incising two flaps, a and b, at the sides, and turning these into 
 the breach, when the closure will be as shown in Figure 59. 
 
 / 
 
 Figure 59. Showing sutural line 
 after closure of a semicircular defect. 
 
 Figure 60. Showing another plan 
 of closing a semicircular defect by 
 means of a single flap. 
 
 The semicircular space C, shown in Figure 60, can be (jlosed by 
 a flap of similar shape, d, taken from the overlying surface- 
 Instead of one large replacing flap, two smaller ones might be. 
 formed on each side above, as shown in Figure 61. 
 
444 THE ELEMENTS OF PLASTIC SUKGEKY. 
 
 FiGCKE 61. Illustrating closure of a semicircular space A by means of two 
 flaps, a and b. 
 
 Having described tlie tliree methods of plastic repair by whicli 
 a breach of surface may be closed, and, in a measure, concealed, 
 if they be compared with each other, it will be found that the 
 first is applicable where the surface to be closed is small in extent; 
 the second is suited to cases in which the breach is larger, and 
 the third method may be resorted to in cases in which the open 
 breach is irregular or regular in outline, and the replacing flap 
 can be selected and taken from the surface near to, but not con- 
 tinuous with, the border of the breach. The second and third 
 methods add wounds to the one which it is sought to close. Yet 
 tlie additional wound, in the case of a flap that is revolved, can, 
 sometimes, be made where it will remain concealed or but slightlv 
 conspicuous. And as the flap is uplifted at a slight distance from 
 the open defect, the secondary wound can often be clo.sed; and 
 any tension caused bj'this adjacent closure will not influence the 
 wound into which the flap is turned. The transplanted flap 
 should consist of sound derm which can readily be shifted. 
 ^Muscular tissue is not adapted to such work, for it changes to 
 fibrous tissue, which, contracting or shriveling, deforms. A flap 
 clad with a thick mass of fatty tissue is unsuited as material for 
 repair; but in case none other is available, it may be used; and 
 then the entire thickness of the fatty couch, with the subjacent 
 fascia, should be used. If tlie derm be separated from'such adi- 
 pose couch, it is apt to die; also, if a thin structure of adeps be 
 retained with the derm, it ill performs the function of material 
 for re lacement, as the writer has often verified. The minute 
 lobules of adeps constituting the fatty couch are so disturbed in 
 their vitality when they are divided or split, that they contract 
 but imperfect adiiesions with otlier tissues. Dissolving adipose 
 material is a medium more suited for the separation than for the 
 union of wounded parts. The flap which has the best qualities 
 for plastic replacement is one of derm with a thin stratum of 
 fascia; and this will cohere to any structural compound of the 
 
OTHER METHODS. 445 
 
 body; for example, it will unite with periosteum, denuded bone, 
 or denuded cartilage, tendon, muscle, nerve and adipose structure. 
 Union to adipose structure is promoted, if the latter has a fascial 
 covering. 
 
 The transposed flap is influenced by the structure which 
 supports it ; if this be firm and immovable, for example, a flat 
 bone, the flap will contract adhesions to it, and undergo but 
 slight subsequent change; yet planted on an unstable muscle, the 
 flap will undergo displacement and deformity. 
 
 The work of final closure must be preceded ])y complete 
 staunching of all bleeding, especially when the work is done by 
 the flap method. No vessel must be left bleeding beneath the 
 newly planted tissue. Bleeding from the surface may be arrested 
 by irrigating with ice water; or, should a vessel of some calibre 
 continue to bleed, this may be closed by torsion. Ligatures 
 should not be used. Closure should be done by knotted suture 
 with fine aseptic silken thread. Fine wire may likewise be used; 
 this may be made of copper which has been gilded or plated; and 
 this may be either tied or twisted; and in whatever way closure 
 is effected, care must be taken that the cord or wire is not toO' 
 tightly drawn, for too tight closure pinches the patient and often 
 kills tbe included structure. 
 
 In case of lateral sliding, in which the parts are tightly 
 stretched in the approximative closure, the strain should be 
 relieved by tension -relieving sutures. Such sutures should be of 
 wire, and so introduced as to include from a half inch to one 
 inch of the structures which are to be united. These strain- 
 opposing' sutures need be but few in number; two or three will 
 suffice, and these should remain in place for not less than one 
 week; and even a longer time is sometimes necessary; for if these 
 supporting sutures be removed too early, the intermediate united 
 edges may tear asunder. 
 
 Besides the strain-oi^posing suture and that of simple closure, 
 as additional aids, one may resort, sometimes, to those species of 
 sutures familiarly called the mattrass, quill and pin, or twisted 
 suture. The mattrass suture can be used to bind down and fix 
 in position a section of a flap which tends to rise from the sub- 
 jacent surface. This suture, which should be of silk, is inserted 
 by means of a needle which is strongly curved; the thread 
 includes a small portion of the interior of the flap and the sup- 
 porting substratum. It is well to use this device of fixation 
 wherever the implanted flap is broad. The quill or brace suture 
 
446 THE ELEMENTS OF I'LASTIC SURGERY. 
 
 is advantageously used where the defect is an oblong breach, 
 having the long sides somewhat parallel with each other. The 
 brace or flattened rod of suitable length is to be passed through 
 the looped ends of doubled sutures on one side, and a similar one 
 laid on the opposite side of the defect is to be introduced between 
 the other ends of the sutures, and the free ends are then to be 
 drawn upon so as to close tlie breach; and when this is effected, 
 the free ends are to be tightly tied on the second brace. 
 
 In this way, in a piece of plastic work done on the cheek, the 
 writer has succeeded in closing a very wide Ijreach of surface. 
 Such suture must enter and emerge at a distance of not less than 
 a half inch from the borders of the defect. And should the su- 
 tures cut the included tissue, the threads may again be tied more 
 tightly. The Cjuill or brace suture is but a form of a tension- 
 relieving stitch. The pin or twisted suture may be used to sus- 
 tain and immobilize approximated edges, or a sliifted flap. An 
 objection to it is that, in the later act of removing it, the healing 
 parts may be disturbed or, possibly, torn asunder. The applica- 
 tion of these more unusual forms of suture should be as limited 
 as possible; they are complicated and demand experience for 
 their successful use. In nearly all cases, the simple knotted 
 suture will suffice. Surgical vork approaches nearest the line of 
 perfection when its component technical elements are of the greatest 
 simplicity. 
 
 Wlien plastic operations are done in the vicinity of natural 
 openings of the body, of which the edges and lining are lined 
 with mucous or semi-mucous membrane, it is necessary to restore 
 this mucous investment in order to maintain the calibre of the 
 opening and to prevent adherence of denuded surfaces. Such 
 natural openings are the lips and oral cavities, the eyelids, the 
 nostrils, the lining of the auditory meatus, the urinary meatus, 
 vagina and its outlet, and the anal opening of the rectum. To 
 counteract stricture, atresia and synechia, tlie denuded surface 
 should have an investment of mucous membrane or derm. If 
 the mucous membrane be used for this purpose, it must not be 
 too thin, but the sub-mucous tissue should be uplifted with the 
 membrane so as to insure the vitality of the transported structure. 
 Wlien the mucous membrane is closely adherent to the parts 
 which it lines, it cannot be used unless a stratum of subjacent 
 structure be uplifted with it; but in tlie cartilaginous portion of 
 the nose, the close adhesion of both derm and mucous membrane 
 to the cartilage renders it difhcult or impossible to utilize them. 
 
CARE OF THE WOUXDS. 447 
 
 The plastic work being com^^leted, an important duty yet 
 remains in which both patient and surgeon have a share; tliis 
 consists in protective care of tlie wounded parts; rest, most careful 
 rest, should be given to the part, for the hand of nature in adjust- 
 ing the delicate acts and processes of repair, tolerates no jostling 
 or disturbing movement. Another adjuvant, having great bear- 
 ing on this work, is that the patient should be in good health 
 when the work is done; for example, if in the face or mouth, no 
 plastic operation should be performed when the patient has a 
 cough; from this cause failure has attended work done by the 
 writer. The supervention of a diphtheritic attack rendered plastic 
 work null and void; and it would be difficult to 2:>rovide against 
 such misadventure. 
 
 Where the work has consisted of the simple juxtaposition of 
 opposite margins, after sutural closure, the remaining seam 
 should be dressed by coating it with compound tincture of 
 benzoin; and over this should be placed a layer of lint moistened 
 with diluted alcohol. And, as further protection of the part, 
 this lint should be retained in place by broad strips of rubber 
 adhesive plaster. As soon as the wouiid has united, the sutures 
 must be removed; if the suture remain too long in place, it will 
 leave a scar, viz., a white point, which will remain permanent; 
 hence where the suture merely maintains connection between 
 opposed borders, and the parts are not stretched, the suture may 
 be safely removed at the end of two days. An earlier removal, 
 advised by some surgeons, is not in accord with the writer's 
 experience. Should it be apparent that the stitches are irritating 
 the structures, and that suppuration impends, then there should 
 be no delay in removal. The tendency of the suture to irritate 
 will be lessened if the thread or wire used be duly proportioned 
 to the needle which carries it ; the thread or wire must not be too 
 large; for if this be so, and the suture exceeds the orifice through 
 which it passes, then it will press on and destroy the tissue 
 adjacent to it. And, again, the thread or wire must not be too 
 small for the orifice, the rule being that the carrying needle 
 should be slightly larger tlian the thread which it bears. 
 
 As a general rule for this work, a few sutures may be removed 
 near the end of the second day; on the third day, others can be 
 extracted, and, on the fourth, all may be removed except those 
 which were introduced to oppose and relieve strain. The cutting 
 and extraction of the sutures must be done with care; the cutting 
 must be done on one side, and as close to the surface as possible, 
 
448 THE ELEMENTS OF PLASTIC SURGERY. 
 
 after the suture has been slightly uplifted, so that the end to be 
 pulled througli shall have no dried excreta adherent to it, which, 
 catching in the sutnral canal, would cause tugging on the parts. 
 
 Should the united edges be torn slightly apart in the removal 
 of the sutures, as sometimes happens, then tlie blood which 
 exudes should be allowed to dry, and strips of Emplastrum 
 Ichthyocollse should be placed across the breach, so as to keep 
 the parts at rest, and insure their reunion. 
 
 After healing has occurred, there often remain some minor 
 defects in the parts operated on which require attention. In 
 turning the pedicled flap to its destined site, the pedicle is often 
 left in an irregular, twisted shape, which disfigures the surface. 
 After healing has advanced so far that the vitality of the flap is 
 guaranteed, even though the pedicle were severed, then any 
 irregular eminence or contorted edge can be removed, and the 
 surface rendered even. In this leveling work, the outer face of 
 the derm should be saved if possible and employed to cover any 
 wound which may be made. Again, in the union of margins by 
 sliding, if one side exceed the other in length, there will remain 
 a fold or two on the larger side. Such folds in time will gradu- 
 ally subside; they may also be lessened or prevented by one or 
 more cuneiform excisions from the larger side. Such excised 
 gap is to be closed by suture. Care must be used not to excise 
 too much. In fact, though such excision of surplus material is 
 generally practised, it is probable tiiat, if it were not done, 
 in time the unevenness would vanish through a process of 
 involution, in which the excess would become merged in the 
 common surface, and aid in relaxing the tension. In studies on 
 the best means of disposing of the sur])lus integument, which 
 remains after the removal of lipomata or other benign neoplasm, 
 Sir William Fergusson strongly urged to save the exuberant 
 derm which remained after the removal, on the ground that it 
 will afterwards become gradually incorporated in the surround- 
 ing integument. In the history of pla,stic surgery one fact has 
 repeatedly been verified, that there is an atrophic tendency in the 
 structures which have been operated on; in time they invariably 
 become lessened in volume; this has repeatedly been observed in 
 the new-formed nose of inordinate proportions. In all such 
 cases the new-formed channels which are opened for the vascular 
 supply of the part are usually inadequate for tiie continuance of 
 normal nutrition. Hence, in nearly all cases, the rule of guid- 
 ance should be that the retrenchment of seemingly surplus 
 
Thiersch's method of transplantation. 449 
 
 structures, instead of being done by the scalpel, should be 
 intrusted to the cautious care of nature, whose unostentatious 
 effort, if fair justice were done, would often be crowned with the 
 adornment of laurels which are awarded- to the surgeon's work. 
 
 As concluding lines of this chapter on plastic surgery, it 
 should be stated that, though much is essayed, and much is done 
 in this attractive field of art, yet the modest confession is due that 
 when a calm survey is made of the best results which can be 
 obtained, and the latter be compared with the unmarred human 
 form, the best plastic procedure can seldom furnish more than a 
 tolerable counterfeit of the excellent original. 
 
 Thiersch's Method of Cutaneous Trarisplantation. — Besides the 
 modes of repairing breaches in dermal continuity which have 
 been described, the work may be done by a procedure which is 
 designated grafting, or transplantation. Experience acquired in the 
 physiological and vivisective laboratory demonstrated the possi- 
 bility of removing small portions of the animal body and trans- 
 planting the detached tissue elsewhere in the body. 
 
 The utilization of the animal graft was early heralded by 
 Paul Bert, who announced that one day "those who are occupied 
 with morbid physiology would derive the most useful results 
 from it." Though grafting was essayed with many tissues of the 
 body, it was chiefly in the repair of defects of the dermal 
 structures that the first experiments were made. 
 
 To J. L. Reverdin, in 1869 and 1870, is due the honor of 
 using small epidermal grafts for the closure of a breach, especially 
 that due to an ulcer in the surface of the body. In the employ- 
 ment of his procedure, Reverdin had numerous collaborators 
 among the surgeons of France, Germany and England; so that 
 but a brief time elapsed before many reports were published 
 highly favorable to the process, popularly known as skin-grafting. 
 
 In the method of Reverdin, the operator seizes with fine- 
 toothed forceps the skin from which the graft is to be taken, 
 uplifts the surface, and with a pair of small curved scissors he 
 excises the uplifted point; the latter is then placed on the part to 
 be repaired, and pressed somewhat inwards, and allowed to 
 remain in its new site. From tlie islet of engrafted tissue lines 
 of new material shoot out horizontally, and seem to be attracted 
 by similar lines from neighboring grafts, the result being a great 
 increase in the activity of cicatricial closure of the raw surface. 
 
 The method of Reverdin underwent modifications in the 
 hands of other surgeons; in place of the thin cuticular section, 
 
450 THE ELEMENTS OF PLASTIC SURGERY. 
 
 much thicker ones were used for transplantation, until linally 
 those of the entire thickness of the derm were emj)loyed. 
 
 But by far the most important modification was that intro- 
 duced by Professor Thiersch, of Leipsig, who discovered that 
 epidermal grafts of almost indefinite length may be made to grow 
 on a raw surface. This discovery was published in 3887, tliough 
 Thierscli, it is said, had previously been studying the matter for 
 some years; and his discovery was made during researches under- 
 taken to solve the problem of the microscopic phenomena which 
 are present in the healing of wounds, and especially the disposi- 
 tion^ of the vessels in an ulcerated surface. 
 
 In a microscopic examination of the ground of a chronic 
 ulcer, Thiersch found that the capillaries in the upper and deeper 
 portions have a different arrangement, viz., those in the upper 
 stratum stand vertical, while the deeper capillaries are disposed 
 horizontally. The tissue supplied with vertical capillaries has 
 nearly lost the quality of further development; and before such a 
 surface is fitted for cicatricial closure, Thiersch found that it 
 required a preliminary preparation. 
 
 The Thiersch procedure, though first only used for the closure 
 of ulcerated surfaces, has now been extended to fresh wounds 
 involving any part of the surface of the body; and it matters but 
 little whether the wound be dermal, muscular, adipose or osse- 
 ous, the process has proved successful in all these sites. 
 
 Besides the repair of fresh wounds and ulcers- recent or chronic, 
 this method has been used and found a valuable aid in the treat- 
 ment of burns, contracted scars, syndactylia and all abnormally 
 coherent surfaces. 
 
 Though Thiersch was one of the first Germans who embraced 
 the antiseptic plan of treating wounds, yet in the work of skin- 
 grafting he did nc^t apply antiseptic agents to either the wound 
 to be closed or to the material of closure. Others, however, ni 
 the work do use antiseptics. Jungengel and Iliipscher, who 
 have written on the procedure, have applied to the wound, ulcer, 
 grafts and instruments, a two per cent solution of carbolic acid, or 
 a ToVo solution of sublimate. Thiersch used only a solution of 
 chloride of sodium, known as the physiological solution, which 
 contains six grains of the salt in one thousand grains of water. 
 
 The material for grafting is commonly taken from the subject 
 on whom the transplantation is to be done, yet it has been derived 
 from another person, also from the integument of amputated 
 limbs. For several reasons it is better to be taken from the per- 
 
Thiersch's method of transplantation 451 
 
 son on whom it is to be used ; and the sites from which it is most 
 easily excised are the front surface of the thigh and the extensor 
 side of the upper arm. 
 
 The surface furnishing the sections for grafting should be 
 carefully cleansed, and this is done by first washing it with soap 
 and water, then with a two per cent of carbolized water, and finish- 
 ing with a free use of the solution of chloride of sodium above 
 mentioned. 
 
 The surface to be closed requires some preliminary treatment. 
 In case of a breach the site of ulceration, the superficial struc- 
 ture should be removed; and Thiersch and others do this with a 
 sharp curette, but the author prefers to do this work by incision 
 with a long-bladed scalpel. The scalpel prepares a much 
 smoother ground than does the curette, however sharp this 
 instrument may be. If the ulcer have borders of irregular out- 
 line, these should be converted by incision into regular figure. 
 Closure is easy in a surface of oval form. 
 
 Besides the ulcer, fresh wounds, in which the skin has been 
 lost, are suited for closure by Thiersch's method. Such breach 
 must have a smooth ground. 
 
 If the surface to be closed is bleeding, care must be taken that 
 the blood has been staunched, and that all clots have been 
 removed; and for this purpose irrigation with the solution of 
 salt must be carefully done. 
 
 The thickness of the grafts is the subject of difi'erence among 
 operators. Thiersch advises that the graft include the epiderm, 
 papillary layer and a small section of the corium. Graser, Ever 
 busch and Hiibscher recommend the use of thinner sections, viz., 
 such as contain the cuticle and the summits of the papillae. The 
 thickness of the graft will vary according as it is broad or nar- 
 row; when broad, the central portion of the graft must be thick, 
 and contain at least the entire papillary layer of the derm. 
 
 The length of the sections for grafting must necessarily vary 
 according to the surface to be closed. Elongated breaches have 
 been closed by sections which were over a foot long. The longer 
 and broader the grafts are, the more expeditiously the work can 
 be completed. 
 
 For excising the grafts, a razor, or similar instrument, may be 
 used; the one most appropriate is a razor-like blade, of which 
 one side is plane and the other incurved. The microscopic stu- 
 dent of former years, who used a razor and not a microtome to 
 cut his sections, has acquired that use of the hand which makes 
 
452 THE ELEMENTS OF PLASTIC SURGERY. 
 
 him expert in excising the skin graft. The instrument, grasped 
 firmly, is to be brought in contact with the surface, and, being 
 held at a very acute angle to the latter, the work of cutting is 
 done by a rapid sawing movement. 
 
 The surface whence the graft is taken must be rendered tense; 
 and if this l^e the upper arm or thigh, tension of tlie skin is to 
 be made by an assistant grasping laterally the limb with both 
 hands and stretching the intervening space; and the operator 
 can aid also, if he slides the 'skin upwards or downwards from 
 the cutting instrument. 
 
 The excised grafts may be carried immediately to their 
 destined site; but if it is not convenient to complete the work at 
 once, the sections may be preserved for some hours in the saline 
 solution. If they are used immediately, they may be transferred 
 from the cutting blade by letting a small current of the saline 
 fluid trickle on the section, and float it from the end of theinstru- 
 ment to the surface to be closed. This transference can be aided 
 by using a probe. The graft tends to fold towards its incised 
 side, and, in placing it in position, this curling must be corrected 
 with the probe and index finger, so that the raw face of the graft 
 will lie directly on the surface that is to be closed. 
 
 Where more than one graft is to be used, the sections are to 
 be so placed that the margin of the second graft will slightly lie 
 on the edge of the first one, — the series lying like tiles on a roof. 
 Bv thus proceeding, no interstices will remain, and the surplus 
 margins will soon detach themselves. 
 
 The excision of the grafts may be done under anaesthesia, 
 provided the breach to be closed has arisen from operative work 
 in which the patient was ana'sthetized. Yet it is sometimes done 
 without anaesthesia, the patient then reporting that the sensa- 
 tion was similar to that of shaving with a dull razor. 
 
 The surface whence the grafts are cut soon heals under a.sep- 
 tic dressing; it remains discolored for a time, and in rare cases it 
 becomes the site of a keloid growth. 
 
 After the grafts are in position, they often become uplifted by 
 subjacent bleeding; and if this be considerable, the work will fail 
 unless the blood be removed and the grafts be properly placed 
 again. If the amount of blood beneath the grafts be slight, the 
 grafts may become ecchymosed, yet still retain their vitality, 
 and closure be accomplished. 
 
 As to the dressing of the transplanted surface, different modes 
 exist. To protect the grafts and retain them in place, strips of 
 
Thiersch's method of transplaxtatiox. 453 
 
 gutta percha tissue paper may be used. Such strips may also be 
 employed to transfer the grafts from a solution in which they 
 iiave been temporarily retained to the breach to be closed; and 
 when the grafts are thus placed, the carrying tissue paper may 
 be used as the protective covering; and as final dressing, dry or 
 moist aseptic gauze may be placed over the closed wound. 
 
 If it becomes necessary to frequently change the dressing, 
 gauze smeared with berated vaseline (xfo) is recommended for 
 the purpose. Yet usually dry dressing is employed; and then 
 the whole may consist of a layer of gutta percha paper on which 
 dry sublimated, borated or iodoform gauze is placed; and to im- 
 mobilize this an ordinary roller may be used. Some operators 
 have simplified the dressing by merely sprinkling iodoform over 
 the grafted surface; yet some retentive appliance is preferable, 
 since the grafts are easily displaced from their site. Should such 
 displacement occur from' tlie patient's movements, the grafts 
 should be restored to j^osition again. 
 
 In one week the grafts contract close adhesion to the subjacent 
 ground ; and two weeks after the grafting the healing is complete. 
 FoT two weeks after the healing a protective banda,ge should be 
 retained about the part. 
 
 The surface which has been closed with skin-grafts tends to 
 contract, and to rise: thus the site of the breach is lessened, and 
 if it be superficial, it may rise to a level with the surrounding 
 skin. In healing, the transplanted material becomes discolored 
 or slightly pigmented, so that it differs in hue from the neighbor- 
 ing skin. The transplanted surface is less smooth than normal 
 skin; and this unevenness is due to granulative elevations which 
 appear under the grafts during the i^rocess of healing. Slight 
 furrows are present along the lines of fusion of adjacent grafts. 
 
 The engrafted surface does not corresj)ond in color to the 
 adjacent skin; it is distinguished by an injected pigmentary 
 appearance; and this is a serious objection to the Thiersch method 
 in cases in which the cosmetic element must be taken into 
 account. But the j^lastic methods before described are free from 
 this objection, since the normal skin which is used for closure 
 nearly or quite retains its natural tint. A point strongly in 
 favor of the Thiersch procedure is that closure is very speedily 
 obtained; the work is accomplished within two weeks. The 
 other plastic procedures often require many weeks for complete 
 recovery. 
 
 Therefore, in conclusion of this subject, it may be said that. 
 
454 THE ELEMENTS OF PLASTIC SURtiERY. 
 
 though the Thiersch method lias seriously encroached on the 
 older plastic procedures, yet the latter, though less often resorted 
 to than formerly, must still continue to occupy a highly impor- 
 tant place in operative surgery. And this is particular!}- true 
 in operative work on the face; and es|)ecially in the repair of 
 breaciies made by excision around the eye, mouth and nose; for 
 here the experienced plastician, by studied plan, can often cover 
 or disguise unsightly lines left by the scalpel; or if this be denied, 
 then such lines may sometimes be so shifted as to be invisible. 
 By such work the plastician will win parental gratitude by re- 
 lieving the face of childhood of unsightly scars; and surgical art 
 will gratify age when it utilizes the latter's furrows for plastic 
 disguises. 
 
CHAPTER XII. 
 
 SURGICAL AFFECTIONS OF THE EYEBROWS AND EYELIDS. 
 
 Eyebrow. — The overhanging skeleton of the orbit above is em- 
 braced in what is designated the superciliary arch. The anterior 
 inferior edge of this arch, named the supra-orbital margin, is formed 
 by the union of the supra-orbital plate and the vertical portion of 
 the OS frontis: this margin ends so sharply that violence acting 
 on the soft parts which rest on the edge, can cause a lesion closely 
 resembling an incised wound; and to determine whether the 
 wound which lias arisen may have been caused by a cutting 
 instrument, or by the osseous margin through forcible impact on 
 it, has sometimes become a question difficult of decision. This 
 margin near its middle presents a notch or foramen, through 
 which passes the frontal nerve in its ascent towards the vertex of 
 the head. The outer end of the supra-orbital ridge terminates in 
 the external angular process, three-sided and prismoidal in form, 
 of which the thin edge is directed inwards, and separates the 
 orbit here from the temporal fossa. This prismoidal process by 
 its outer broad and strong face becomes a protective bulwark of 
 the eye; yet a missile or thin blade might readily pierce, from the 
 temporal side, the deeper thin edge of the process. 
 
 The soft parts which lie on tlie superciliary arch have a 
 resemblance to the hairy scalp; from without inwards lie the 
 derm containing hair, the muscular structure, a sub-muscular 
 layer of connective tissue, and the periosteum. To the dermal 
 layer containing hairs the name eyebrow is given, the inner, 
 middle and outer parts of which by the French writers are named 
 the head, body and tail of the brow. The hair on the head or 
 inner part of the brow lies pointing upwards; the remaining 
 hairs point obliquely outwards. The glabella or hairless space 
 between the brows ma}' be so encroached on by the hair that the 
 two brows are continuous across the space over the root of the 
 nose. Or the brow hairs may be so sparse as to deform the coun- 
 tenance. The surgeon may utilize the brow hair to mask scars 
 
 ( 455 ) 
 
456 AFFECTIONS OF THE EYEBROWS AND EYELIDS. 
 
 which are made in tlie removal of small tumors seated under or 
 near the superciliary derm. For this purpose, the brow should 
 first be shaven, the growth removed through a horizontal cut, 
 and the latter accurately closed by a temporary suture. Aseptic 
 precautions must be used against suppuration, for if the latter 
 occurs, hair roots will be destroyed, and, as result, both scar and 
 absent hair will stigmatize and avenge careless procedure. The 
 brow encroaching on the glabella renders the derm here unsuited 
 for transplantation on the side of the nose. 
 
 Three muscles unite in the formation of the muscular layer, 
 viz., the frontal slij) of the occipito-frontal, the corrugator and the 
 orbicular muscle. The commingled structure of these muscles 
 is so closely connected with the skin that only by forced dissection 
 can one separate the two: incision through the derm alone gapes 
 so little as not to require suture; yet if the muscular coat be 
 divided, sutural closure is necessary after shaving the hair. The 
 corrugator muscles fold the intervening derm vertically; and 
 incisions made here for any purpose, should lie in the infolded 
 lines. Of the three muscles here lying the orbicularis is outside, 
 the occipito-frontal intermediate, and the corrugator lies deei)est. 
 
 Beneath the muscular structure lies a loose cellular structure 
 which is continuous with the sub-aponeurotic layer of loose tissue 
 in the scalp. This loose couch allows the superjacent structures 
 to move freely over it. Here pus or blood may insinuate itself 
 and travel. 
 
 Beneath the layer of loose tissue lies the periosteum, which is 
 closely adherent to the frontal bone, and continues into the orbital 
 cavity, lining the supra-orbital plate; and with it fuse the palpe- 
 bral ligaments. 
 
 The soft structures of the brow have an ample sui)ply of blood: 
 externally, from the anterior temporal ; at their middle portion 
 the frontal artery reaches them through the supra-orbital foramen 
 ornotch; and internally, the supply is from the nasal branch of 
 the internal carotid. In consequence of its abundant supply of 
 blood the structure of the brow bleeds freely when it is cut; the 
 arrest of the hiemorrhage is best done by means of sutures or 
 circumscriptive ligature; the latter is best adaj)ted for the con- 
 trol of haemorrhage from the anterior temporal artery. 
 
 The vascularity of the brow favors swelling in case of contu- 
 sion or subcutaneous laceration. A clot thus forming may remain, 
 and, becoming organized, it can disfigure the part, since, besides 
 the induration which mav remain, the hair roots of the brow 
 
EYEBROW. 457 
 
 may be destroyed and a naked, swollen point remain; and hence, 
 though but an unimportant wound, such contusion should be 
 carefully treated by cold and compressive bandage. 
 
 The region of the eyebrow is seldom the site of origin of a 
 malignant growth; and though epithelioma may appear there, it 
 is rather as a secondary development than as a primary growth. 
 Cancer arising on the bulb of the eye or on the lids, in its pro- 
 gressive devastation, may invade and destroy the superjacent brow. 
 The treatment in such a case should be excision or cauterization, 
 and to be effective should be thorough and unsparing. 
 
 Of the forms of benign growths which appear here, the most 
 common are the atheromatous or sebaceous cyst, and the dermoid 
 cyst. The dermoid cyst is often seen beneath the outer end of 
 the brow, resting on the external angular process. Its frequent 
 appearance here is accounted for by the circumstance that in this 
 part of the head there exists in embryotic development a bran- 
 chial cleft, or gap between the primordial plates of the tempero- 
 frontal region. Through some inexplicable contingency, a point 
 of cutis becomes caught in this gap, and becomes covered beneath 
 the periosteum. The imprisoned dermal fragment contains the 
 elements of hair, sebaceous glands and other cuticular compo- 
 nents. These elements continue their development, and thence 
 arises the content of the tumor, consisting of hair, sebaceous 
 material and epidermal scales, the quantity of material and 
 volume of the cyst being probably j)roportional to the primary 
 fragment of included cutis. 
 
 This dermoid growth is soft and lies in a depression of the 
 bone, beneath the periosteum. Its situation beneath the perios- 
 teum renders the cyst nearly immovable. The cyst wall is dense 
 and strong. It is important to distinguish this growth from the se- 
 baceous cyst; the following characteristics distinguish the dermoid 
 cyst: it lies deep, cannot be moved laterally, and is depressible. 
 On the contrary, the sebaceous cyst lies less deep, can be caused 
 to slide laterally beneath the skin, and is of firmer consistence 
 than the dermoid growth. In a few cases which the writer has 
 observed, it was impossible to determine the nature of the tumor 
 until it was removed ; in one case, sebaceous content was found 
 where the differential diagnosis had indicated a dermoid cyst. 
 
 The treatment of each species is extirpation ; and this is more 
 
 strongly indicated in the sebaceous cyst than in the dermoid; for 
 
 the former tends to reach a larger volume than the latter, which 
 
 often remains of small size. The removal of the sebaceous 
 
 30 
 
458 AFFECTIONS OP THE EYEBROWS AND EYELIDS. 
 
 species is done here, as on the scalp, by a simple incision in the 
 long axis of the brow, through which the content is extracted; 
 and with this should also be removed the filmy structure of tis- 
 sue in Avhich the material is included. If tlie dermoid cyst is 
 small, and hence but slightly conspicuous, and has remained 
 without further growth for a long period, it is better not to inter- 
 fere with it. But if it be so large as to be unsightly, then it 
 should be removed; and the removal is still more imperative if 
 the tumor is growing. This extirpation is done through an 
 incision made in or below the longitudinal axis of the brow; 
 and this cut may sometimes be made, if the skin be drawn 
 upwards, in the eyelid near the supra-orbital margin; in this site 
 the resultant scar may lie in a natural sulcus of the surfoce. If 
 some tact be needed to open and remove without rupture the 
 content of a. sebaceous cyst, there is still more care required to 
 successfully extirpate the dermoid cyst. The entire cystic wall 
 must be removed ; a fragmentary portion of it left insures a 
 recurrence of the growth in a more complicated form; the cicatri- 
 cial tissue and adhesions will render another removal much more 
 difficult than the first one. Hence, through a horizontal free cut, 
 which has not opened the cyst, the latter must be dissected from 
 its connections. Since the cyst is adherent to the periosteum, 
 which is fused with the including sack, an incision to the bone, 
 circumscribing the growth, should be made, and then the cyst, 
 along with a periosteal segment, may be detached from the bone. 
 The wound should be closed by sutures, and a small drainage 
 tube or thread sliould be so placed in the middle of the wound 
 that any excreta may easily escape. In one case seen by the 
 writer, in which drainage had been badly done, final closure was 
 only secured by reopening the wound, curetting, and allowing the 
 part to heal from within outwards. Removal of the thread or 
 tube used should be done as soon as the excreta cease to appear. 
 The brow is sometimes the site of black pigmentation; and 
 with this discoloration there may be a grow^th of hair similar to 
 that of the hair of the scalp. Two instances of the kind, orig- 
 inating congenitally, have been seen by the writer. The skin 
 was of Nubian blackness. In each case the trouble was unilateral, 
 md, besides the brow, one side of the frontal integument was 
 implicated. The treatment consisted in each case in the removal 
 of the discolored tissue, and partial closure of the breach made, 
 by lateral sliding of the adjacent derm. As the children grew, 
 the immense scar became less in its dimensions, and the cica- 
 tricial tissue was free from pigmentation. 
 
EYELID. 459 
 
 Eyelid. — Anatomically, the eyelids consist of an upper and a 
 lower one; the upper descends so far that it may conceal too large 
 a gap made by iridectomy; also in cases in which the protective 
 action of the lower lid has been lost through loss of the lower 
 lid, the upper one when turned downwards can nearly cover the 
 globe. Each eyelid, near the osseous margin of the orbit, presents 
 a depression or sulcus; the superior one is deeper and is some- 
 times masked by an overhanging cuticular fold, especially in the 
 aged. 
 
 The free edges of the lids are named their ciliary borders, and 
 inclosure of the lids these borders are closely apposed, and do not 
 leave an intervening space for the passage of tears, as some have 
 taught. The lower border of the upper lid is slightly curved, 
 while that of the inferior is slightly concave. On the free margin 
 of the lids one can distinguish near the outer edge the insertion 
 of the eyelashes, of which there are from one hundred to one 
 hundred and fifty on each lid; and near the inner border there 
 are seen the openings of the Meibomian glands; and there is an 
 interstice between the cilia and the openings of the glands wide 
 enough for division with the knife of the free border into two 
 portions. About one-eighth of the free border towards the nose 
 is occupied by the lachrymal canaL At the junction of the 
 ciliary with the lachrymal portion of tlie free border is a small 
 opening which leads into the lachrymal canaL The angular 
 union of the free borders of the lids externally is nam^ed tlie 
 external canthus; the inner one is named tlie inner canthus. In 
 the inner canthus the conjunctiva and the cutis unite directly, 
 without depression. 
 
 The component strata of the eyelid, if enumerated from with- 
 out inwards, present themselves in the following order: the skin, 
 the orbicular muscle, layer of loose connective tissue, the tarsal 
 cartilage and ligament, fibro-tendinous layer and the conjunctiva. 
 
 The dermal layer is thin, pliant and easily moved; it contains 
 rudimentary hairs and sebaceous and sudoriferous glands. The 
 movement of the subjacent parts wrinkles this dermal surface; 
 the folds and depressions thus formed, from their frequent repro- 
 duction, become permanent features of the aged, and senility 
 when prompted with the desire of self-concealment, does not 
 forget those markings, yet is seldom successful in hiding the 
 footsteps which time imprints most deeply at the outer edge of 
 the eye. The mobile nature of the palpebral cutis is often util- 
 ized in surgical work in this region. This mobility may act 
 
460 AFFECTIONS OF THK EYEBROWS AND EYELIDS. 
 
 injuriously; for in the case of a wound near the eyelid, which is 
 followed by cicatricial contraction, the skin may be drawn upon 
 so as to displace it, and prevent the closure of the eye. 
 
 The palpebral orbicular muscle is a species of sphincter that 
 is concerned in the automatic act of wrinkling and closure of the 
 lids. It is a cutaneous muscle lying next to the skin. It is pale 
 in color, especially as it approaches the free borders of the lids; 
 and here the non-striated or involuntary muscular fibre is found. 
 The half of the muscle which lies on the lower lid is thicker and 
 stronger than the upper half, since the former, in the act of 
 closure, has more work to do. In closing, the edge of the lower 
 lid moves towards the inner angle; this inward movement, which 
 can be verified by a vertical line drawn on the united lids, 
 amounts to over a line in distance. Such movement serves the 
 purpose of carrying towards the inner angle tears, or particles of 
 foreign matter, lodged in the eye. The palpebral sphincter may 
 become the subject of continued or intermittent spasm, and become 
 a source of annoyance or pain. From contracture of the muscle, 
 a fold of skin may be drawn over the outer angle; and in the 
 little pouch, thus formed, irritating matter can collect and denude 
 the edge of the lid, and cause adhesion and shortening of the 
 angular commissure. In the aged the muscle becoming weak- 
 ened, the skin of the lid depends, that of the lower lid sinking 
 towards the cheek and causing an apparent tumefaction there; 
 this appearance is specially marked in the portrait of Dr. Frank- 
 lin taken in his old age. In the upper lid such pendent tegument 
 may fall within, and obstruct, the range of vision ; so much so 
 that the subject is compelled to lift the fold with his hand, in 
 order to obtain free vision ; but the screen may be retained in 
 place by a strip of adhesive plaster. 
 
 The muscularity of the lids is innervated by the motor oculi 
 and the facial nerve; the sphincter is moved by the latter, which, 
 in its transit from the parotidean region to the eye, lies beneath 
 the subcutaneous fascia; and thus this twig of the facial often 
 escapes the knife in superficial excisions made in this region. 
 But palsy of the nerve from division of it, or other cause, permits 
 the downward sliding of both skin and muscle in both lids, and 
 in the upper one, the dependent skin soon interferes with the due 
 admission of light. The subfascial site of the facial twig 
 referred to, which the author has verified by dissection, should not 
 lessen care in the use of the knife here; yet it allows the indul- 
 gence of the hope that when incision is done here, the nerve may 
 be spared. 
 
EYELID. . 461 
 
 Beneath the orbicular muscle there lies a layer of loose areolar 
 tissue, which, similar to one existing in the scalp, permits of the 
 free motion of the superjacent layer on the subjacent tarsal car- 
 tilage; and in this yielding space fluent materials, as blood and 
 serum, may diffuse themselves; and the supjDurative products of 
 phlegmonous inflammation may also travel here. Beneath the 
 lax structure of areolar tissue of the evelid lie the tarsal cartilap:e 
 and the tarsal ligament. The palpebral cartilages aid in main- 
 taining the curved form of the lids; that of the upper lid is much 
 the stronger one; it is crescenticin form and is comparable to a sec- 
 tion of an orange. The superior one measures about one-third of 
 an inch at the point of its greatest breadth. The lower cartilage 
 is quadrilateral in form. These two cartilages, at their outer 
 borders, become converted into a fibrous ligamentous structure, 
 which, for each cartilage, radiates towards the orbit where it is 
 inserted. This fibrous structure in the upper and lower lid is 
 named the palpebral ligament ; and the two, at the inner and 
 outer commissure, converge, and, uniting, form the inner and 
 outer palpebral tendons, which can readily be found and brought 
 respectively into relief, if the lids be drawn horizontally inwards 
 or outwards. The inner tendon is the greater one ; it is the tendon 
 of the orbicularis muscle as well as of the tarsal cartilages, and 
 should be known to the surgeon, since it lies across the lachry- 
 mal sack. 
 
 This fibro-cartilaginous framework of the lids may be better 
 understood when it is stated that the tarsal cartilages commenc- 
 ing at tlie border of the lid, after forming a supporting framework, 
 become changed into fibrous tissue, which at each end forms 
 rounded tendons; while between these lie intermediately the 
 tarsal ligaments, so that each lid is firmly connected by this 
 ligament to half the circumference of the orbit. AVhere the 
 cartilages lie, the lid is not easily bent or curved, but such flexion 
 can be made at the orbital border of the tarsal cartilage; and by 
 virtue of this disposition, the lids may be everted so as to expose 
 the inner surface. The eversion of the upper lid is more readily 
 done than is the case with the lower one. To effect this eversion, 
 seize the eyelashes, or lower margin of the lid, with one hand, 
 and with the other hand let some blunt instrument, as a silver 
 probe, or handle of a pencil, be fixed against the lid at the junc- 
 tion of the tarsal cartilage and its broad ligament; and pressure 
 being made there as the free border is pulled on, the lower half of 
 the lid is easily everted. Or the eversion can be effected without 
 
4G2 AFFECTIONS OF THE EYKliKOWS AND EYELIDS. 
 
 any instrument by catcliing the ciliary border with one hand, 
 and as tliis is pulled outwards, let a linger of the other hand 
 press backwards on the middle of the outer face of the lid; 
 iu "whatever way the work is done, the patient during the act 
 must direct his eye downwards. In fact, the junction of the 
 tarsal cartilage and the broad palpebral ligament of the upper 
 eyelid, serves in the eversion just described, the office of a joint. 
 The broad palpebral ligament permits the normal movements of 
 the lids; and when the latter are closed for many hours, a condi- 
 tion simulating anchylosis is felt by the sleeper on awakening. 
 
 The conjunctival mucous membrane that lines the inner face 
 of the lids, as well as a large zone of the bulb of the eye, forms a 
 blind recess or fossa between the lids and the globe of the eye. 
 The upper recess, or transition fold of the conjunctiva, is much 
 the deeper one, and demands the attention of the surgeon, as in 
 this hidden fold foreign bodies may lodge and remain undiscov- 
 ered. Also, a growth in the upper part of the orbit may here 
 make its primary appearance. The eversion of the upper lid 
 and turning the eye downwards greatly lessen the depth of the 
 upper fossa, and reveal anything which may exist there. Also, 
 by drawing the lower lid downwards when the globe is rolled 
 upwards, one will display the content of the lower conjunctival 
 fold. A neglect to carefully unfold and search to its bottom tlie 
 conjunctival fosste has permitted a foreign body to lie hidden 
 and continue its work of irritation, until a suppuration was 
 induced, which only ended with corneal destruction and loss of 
 vision. And should the lid be so swollen that it cannot easily be 
 everted, then the work should be preceded by local anajstliesia 
 with cocaine, or, what is more satisfactory if the case be a cliild, 
 general anaesthesia. 
 
 On the inner edge of the margin of the lids lie the outlets of 
 the Meibomian glands. These glands, akin in function to the 
 sebaceous, lie imbedded in the tarsal cartilages, much nearer to 
 the conjunctival face than to the dermal surface of the lid. 
 
 The bulbar conjunctiva can be easily moved on the eyeball; 
 the palpebral conjunctiva is more firmly adherent; the mobility 
 of the former may be utilized in o[)erative work on the eyeball. 
 
 The veins of the lids empty their blood partly into the facial 
 vessels and partly into the ophthalmic, which enters the cranium 
 and opens into the cavernous sinus: and through this venous 
 route, septic or infectious materials can travel and develop disease 
 within tlie skull. The lymphatics of the lids and the conjunctiva 
 
WOUNDS OF THE EYELIDS. 463 
 
 deliver their contents to the parotidean lymphatic glands; as re- 
 sult of such anatomical disposition, malignant disease of the 
 eyeball or lids may reveal itself by glandular swelling in the 
 parotid, the so-called parotidean bubo. Specific ocular disease 
 may have a similar distal manifestation. The lymphatics of the 
 inner angle of the eye pass to a gland situated on the masseter 
 muscle, sometimes named the facial gland. 
 
 In regard to the embryonic development of the eye it may 
 be briefly mentioned that, at the second month of uterine life, a 
 layer of the epiblastic la3'er passes over the eye, becoming the 
 conjunctiva. In the third month, another layer, in plicated 
 annular form, surrounds the eye, and gradually grows by concen- 
 tric development until it covers the eye. The edges of these 
 primitive lids fuse together and remain so until two months 
 before birth. The normal ty23e may be deviated from in this work 
 of fusion and separation. 
 
 Since the advent of the period when general surgery has been 
 differentiated by specialism, the treatment of the diseases of the 
 eye has fallen mainly to the hand of the oculist: nevertheless, 
 the eyelid has remained a field shared in common by the special- 
 ist and surgeon, the latter having the larger share when one 
 reckons the plastic operative work demanded by disease and 
 defect of the eyelid. 
 
 Wounds of the Eyelids. — The eyelids may be the site of any 
 species of wound; those occurring most often are the contused, 
 lacerated, incised and penetrating. 
 
 The protective bulwark of the superciliary arch usually 
 receives the violence which otherwise might impinge on and con- 
 tuse the eyelid. A contusion of the brow or of the cheek near by, 
 in its effects, often extends to the contiguous lids. The character- 
 istics of contusion, whether it arises directly or indirectly, are 
 swelling and diflPusion of extravasated blood. There are present 
 swelling from effused blood, and oedema due to obstruction of the 
 lymphatics through. diminution of their calibre by elongation or 
 lateral pressure. The ecchymosed blood finds space for its diffu- 
 sion immediately underneath the skin, and, especially, in the 
 distensible space between the muscular and fibro-cartilaginous 
 layers. A disagreeable concomitant attendant on this effusion of 
 blood is that the blood penetrates the skin and becomes visible on 
 the surface. The bluish, livid or blood-stained hue of the cutis, 
 though unfelt by the patient, annoys the latter far more than the 
 contusion itself. The sanguineous and serous effusion often swells 
 
464 AFFECTIONS OF THE EYEBROWS AND EYELIDS 
 
 the lid to such dimensions that it hangs as a motionless veil, 
 closing the eye, and wholly obstructing vision. And, what is 
 remarkable, the source of such efi'used blood may be ruptured 
 vessels situated at some distance, in the supra-orbital, temporal or 
 malar region; in the latter case the blood travels upwards. 
 
 Palpebral ecchymosis may be symptomatic of a more remote 
 injury: viz., it may arise from fracture at the base of the cranium, 
 in which the escaping blood travels through the sphenoidal fis- 
 sure, and appears iu the eyelids. And the distinction between 
 this form of ecchymosis and that which results from local injury 
 of the lid, is this, that blood proceeding from fracture of the 
 cranial base only presents itself some hours after the injury, 
 while in the other case the ecchymosis occurs immediately. 
 Hence, as seen, one may divide palpebral ecchymosis into two 
 species, primitive and consecutive. The tardy §.upervention ,of 
 the consecutive species indicates, very probably, an intra-cranial 
 injury perilous to the patient's life. Such symptomatic ecchy- 
 mosis occurs oftener in the lower than in the upper eyelid, since 
 the former lies more directly in the course of gravitation; on the 
 contrary, primitive ecchymosis appears equally in each lid. 
 
 In case of severe contusion of the lid, there may be a pouch- 
 like collection resembling a haematoma; such contusion is seen 
 in the prize-fighter; and the swelling may so obstruct his vision 
 that he is compelled to seek relief from the surgeon. 
 
 The contused wound is treated, in the early stage, by massage, 
 compression and cold application. After the effused blood has 
 been somewhat dissipated by cautious kneading, compression 
 should be made by means of compresses retained in place by a 
 bandage encircling the head, horizontally. And the part may 
 be maintained cold by moistening the compress with ice-water, 
 or a small bag of crushed ice may be laid over the part. The 
 cold must not be used to excess, lest the contused tissues, 
 enfeebled as they are by impaired supply of blood, should die. 
 Medicated solutions, which are elsewhere used to reduce swelling 
 from contusion, are inapplicable here, since they would come in 
 contact with and injure the eyeball. After three or four days, 
 when the active stage has passed, the absorption or dispersion of 
 the ecchymosed blood will be hastened by an exchange of cold 
 for warm applications; and for this, tepid water should be used, 
 applied by compresses. 
 
 If the lid be the site of a hfematoraa-like collection of blood, 
 as seen in the boxer's eye, the effused blood must be evacuated by 
 
WOUNDS OP THE EYELIDS. 465 
 
 an incision through the skin of the lid, made horizontally or 
 parallel with the fibers of the orbicular muscle. After the blood 
 is thus emptied, the lid is lessened in volume, and the lips of 
 the incision close without suturing. The livid stain which 
 remains for some time, as the result of palpebral contusion, is to 
 the patient the most disagreeable accompaniment of his con- 
 tusion, since nothing but the fingers of time can erase the stain, 
 and the work of erasure passes through one or more of the pris- 
 matic colors, viz., red, green and yellow. Nature uses leisure, 
 and her own convenience, for completing the task of obliteration. 
 If the patient be a female, to whom such discoloration is most 
 repugnant, a recourse may be had to the artful use of cosmetics, 
 or even to the use of counterfeiting pigments applied by means 
 of the painter's brush. 
 
 In case the sanguineous effusion be the consecutive result of 
 fracture of the base of the skull, it becomes a trustworthy proof 
 of such fracture; its treatment, however, is a thing of minor 
 importance, since the graver injury will absorb the surgeon's 
 attention. 
 
 Contusion of the lid is often associated with a lacerated 
 wound; and the presence of the latter will lessen the tumefaction. 
 Lacerated and contused wound here should be treated by trim- 
 ming the fringe-like edges, so as to change it, as nearly as 
 possible, to the form of an incised wound, and then close it by 
 sutures, and dress with cold compresses. 
 
 Incised wound of the lid, if superficial and parallel with the 
 fibres of the orbicular muscle, will often spontaneously close, and 
 heal without the aid of sutures; should there be gaping, sutural 
 closure must be resorted to by means of fine silken thread. And 
 in all cases in which the wound lies vertical, to prevent the 
 gaping usually then present, and displacement of the. edges, 
 sutures must be used. Should the incised wound divide the 
 broad ligament of the lid, then union must be effected by deep 
 stitches which will include the entire thickness of the lid, and 
 secure accurate union of the parts. Also, in case the levator 
 palpebrse superioris be severed, so that there is ptosis of the lid, 
 then accurate sutural coaptation is an imperative necessity; and 
 during the healing of the divided muscle, as also in the case of 
 the divided broad ligament, the lids must be closed and retained 
 at rest. 
 
 In case of wounds which involve the border of the lid, closure 
 must be so effected that no gap will subsequently remain; for a 
 
466 AFFECTIONS OF THK EYEBROW'S AND EYELIDS. 
 
 slight notch there is a deformity which attracts attention. To 
 shun this, a suture should be placed near the border, both on the 
 inner and outer face of the lid, but not on the border itself If 
 the suture include the border, the writer has seen that it is 
 certain to leave some trace of itself, as an indentation. 
 
 In case a wound implicates any portion of the tear-conducting 
 apparatus, great care is requisite to bring the parts into complete 
 coaptation; a neglect of this may consign the patient to perma- 
 nent epiphoral annoyance. A wound involving the border of the 
 lower lid near the inner cantlius, allowed to heal imperfectly, 
 may leave a gap through which the tears will escape on the cheek; 
 for such breach in the M'all of the " tear-lake" does not let the 
 tears rise to a level, in which they can be reached by the mouths 
 of the lachrymal canalicules. If the wound has not healed, close 
 it by sutures on the inside and outside; but*if healing has 
 occurred, then the edges of the gap must be trimmed, and united 
 by sutures, which should remain in site for a week. In trim- 
 ming the cicatrized border, more should be excised from the 
 conjunctival than from the dermal surface; thus done, the 
 tendency to ectropion which follows such closure will l)e some- 
 what corrected. Nevertheless, from the writer's experience, 
 despite the jiains taken there remained some eversion of the 
 border. 
 
 Penetrating wounds which are limited to the eyelids, seldom 
 occur; the wound generally passes beyond the lid, and injures 
 the globe of the eye; and in some cases the wounding instrument 
 or missile has penetrated still deeper, and, having passed through 
 the walls of the orbit, or the sphenoidal fissure, has entered the 
 cranial cavity, and wounded some encepjialic structure. Thus 
 the middle or anterior cerebral lobe, the ophthalmic vessels, the 
 internal carotid artery, or the optic nerve may be injured. An 
 unfortunate condition which attends such injury is that the mis- 
 sile may remain, or the causal instrument ma}' leave its point in 
 the dangerous site mentioned. Thus, a sharp fragment of wood, 
 a needle's point, a fragment of wire, or a bullet or fine shot, may 
 enter and lodge in the eyeV)all behind or outside of the bulb; or 
 such object may pass into the cranial cavity and produce grave 
 injury. Even though the traumatic agent l)e witlidrawn, if it 
 has entered the cranial cavity, it may have caused a tatal wound 
 of the brain. The history of surgical curiosities is embellished 
 with examples of the kind mentioned. 
 
 In the cases in which foreign bodies have entered and lodged 
 
ERYSIPELAS. 467 
 
 behind the eyeball, the wound on the lid has healed quickly ; 
 and this circumstance has deceived both patient and surgeon in 
 regard to the extent of the injury. The surgeon should endeavor 
 to discover the body and remove it. It should be mentioned that 
 instances have occurred in which the body has remained, become 
 encysted, and caused no inconvenience to the patient. 
 
 Erysipelas. — Erysipelas sometimes appears in the eyelid: 
 either primarily, when the disease commences usually in the 
 inner canthus; or the erysipelas beginning in the face or scalp, by 
 migration, attacks the lid. The lid swells greatly under the 
 action of erysipelatous inflammation ; and an unfortunate event, 
 which sometimes ensues, is suppuration. In cases seen by the 
 author, the disease has assumed the virulence of phlegmon and 
 caused destruction of a portion of the lid. The sloughing may 
 be limited to the derm and muscle. The treatment of erysipelas 
 here consists in the cautious use of the usual local remedies, care 
 being taken that nothing enters the eye which may injure it. 
 An ointment containing quinine, in the proportion of two grains 
 to an ounce of vaseline, may safely be used on the lid. Should 
 there be signs of suppurative action, haste should be made to 
 open and evacuate. Where the swelling is so great as to arrest 
 the blood supply and cause gangrenous destruction, this may be 
 averted by pricking the surface with a very sharp lance, so as to 
 give exit to the stagnant blood, and thus reduce the great tume- 
 faction, xlnd as a topical application, a decoction or cataplasm 
 of chamomile flowers may be used. 
 
 Acute abscess occasionally appears in the eyebrow and eyelid, 
 and takes a course similar to what is seen elsewhere. Chronic 
 abscess is also sometimes seen, and is often connected with some 
 morbid process in the tissues surrounding the bulb, or in the 
 bony wall of the orbit, or parts contiguous. And in such cases 
 the existence of the pus may reveal its presence by a swelling at 
 some point of the lid near the margin of the orbit. Though 
 such pus might arise from caries at any point of the wall, yet it 
 originates oftener in the upper portion of the orbit; and occa- 
 sionally, the disease begins in the frontal sinus, and, perforating 
 the supra-orbital plate, appears in the inner half of the upper 
 lid. In a case seen by the author arising from disease of this 
 sinus, the purulent collection had for its anterior wall a great 
 part of the upper lid; and on pressure it could be forced back 
 into the orbit, but caused the eyeball to prolapse downwards 
 and forwards. Such chronic abscess in its development causes 
 
468 AFFECTIONS OF THE EYEBROWS AND EYELIDS. 
 
 no pain, and, were it not for the swelling which it causes, it 
 would remain undiscovered. The purulent collection may remain 
 without increase of volume or other ciiange for an indefinite 
 time. 
 
 In the acute abscess it suffices to open and evacuate the con- 
 tents; but in the chronic form mere evacuation would soon be 
 followed by a reaccumulation of the content. Hence, to accom- 
 plish a cure, the cavity must be opened freely, and the point of 
 osseous disease must be searched for, found, and removed. And 
 to do this some exsection of the orbital wall will be neces- 
 sary; and the excision of bone must proceed to the extent of 
 wholly removing the diseased structure. If this removal is 
 imperfectly done, the purulent collection will soon reapjjear. 
 The origin of the intra-orbital abscess, as stated above, is some- 
 times from caries within the frontal sinus, whence pus arising 
 perforated the supra-orbital plate. When tlius arising, it is nec- 
 essary to freely open the sinus through its antero-inferior wall, 
 and remove whatever diseased structure is discovered; and to 
 make sure work, as before described, it may become necessary to 
 excise the entirety of the front wall of the sinus, and also a por- 
 tion of the inferior wall, in the way which elsewhere has been 
 described. 
 
 Burns. — The eyelid may be the site of burns, and these may 
 vary from the innocently mild to the destructively grave; that 
 is, there may be simple rubefaction, vesication, or the lid may be 
 partially or wholly destroyed. T])e causal agent may be flame, 
 boiling liquid, as water or oil, explosives, and molten metal. In 
 severer cases the burn of the lid is the less important lesion; the 
 graver one is the injury of the eyeball, which may be so burned 
 as to impair or totally destroy vision. 
 
 In mere rubefaction or vesication of the lid, the only treat- 
 ment necessary is the use of some mild local application. A 
 favorite remed}^ is Linimentum Calcis, applied on lint to the part. 
 And this may be applied to more severe burns. In place of this, 
 Unguentum Cetacei may be employed. 
 
 In cases in which the dermal surface is destroyed, as the part 
 recovers, the cicatrizing surface contracts and induces eversion of 
 the lid; an important part of treatment is to antagonize this tend- 
 ency. If mere vesication is present, the fibrinous coagulum 
 beneath the epiderm should not be disturbed, and thus it may 
 be possible to renew the normal cuticle. But if the derm be 
 wholly destroyed, then the regenerated surface will consist of con- 
 
EMPHYSEMA. ^ 469 
 
 tractile cicatricial tissue, with persistent tendency to shortening 
 and displacement. To counteract this something may be done, 
 if during the early stage of granulation the surface be covered 
 with cutaneo-epidermal grafts. And instead of minute, frag- 
 mentary grafts, the method of Thiersch might be resorted to, in 
 which large portions or patches of dermo-epidermal tegument 
 may be used for implantation on the raw surface. As far as 
 practicable, closure of the eye should be maintained during the 
 time of healing. Even though recovery of surface in normal 
 form may ensue, yet there usually exists a tendency to eversion 
 for some time. This may be counteracted somewhat by gentle mas- 
 sage and voluntary movements, in which the eye is alternately 
 widely opened and closed, motions which tend to maintain the 
 normal breadth of surface. In case healing has just occurred 
 and contraction is ensuing, the shortening may be lessened by a 
 few incisions in the surface, with closure of the lids, and their 
 fixation by means of adhesive strips placed vertically and hori- 
 zontally; thus disposed, the gaping incisions will be filled with 
 new material, and, as result, the surface will be broadened. 
 
 In the event of the burn having destroyed a portion of the 
 lid, or so everted it that the eye remains permanently open, 
 then some plastic procedure must be resorted to, of which a 
 description will appear elsewhere. 
 
 Emphysema. — The eyelids are sometimes the site of emphysema, 
 and the air in such case is infiltrated in the areolo-cellular spaces 
 of the lids. The cause of such infiltration of air is to be sought for 
 in a fracture of bones adjacent to the eye; such fracture may be of 
 the nasal bones, the ethmoid, the frontal, or the superior maxil- 
 lary bone, in which a cavity or sinus communicating with the 
 respiratory passage is opened; and when such lesion is present, 
 should the j^atient make a violent expiratory effort, as in the act 
 of blowing the nose, the violently compressed air may enter the 
 loose structure of the lids. The statement of the patient usually 
 is that, when he blew his nose, the lids suddenly swelled and 
 closed the eye. The entrance of the air is attended by a sudden 
 twinge of sharp pain. In some cases the air is forced backwards 
 between the bulb and the orbital wall, and extrudes the bulb for- 
 wards, causing, for a time, exophthalmus. The author once wit- 
 nessed the supervention of such emphysematous swelling of the 
 lids of one eye, and displacement of the eyeball, which occurred 
 during an operation in which a polypoid growth was being 
 removed from the nose. The patient being told to clear the nos- 
 
470 AFFECTIONS OF THE EYEBROWS AND EYELIDS. 
 
 trils the violent expiratory effort forced the air through the nasal 
 lachrymal canal into the lids of the right eye and tissues about 
 the bulb. The sudden closure of the eye, and the enormous dis- 
 tention of the lids, which prevented them from opening, equally 
 surprised both patient and surgeon. 
 
 Some difficulty has been met in distinguishing this infiltra- 
 tion of air from that in which the content is blood. The diag- 
 nosis can readily be made if one attends to the different origins 
 of the two: emphysematous swelling appears instantly as the 
 result of a violent effort through the nose, and the swollen part 
 is pale, and resonant on slight digital percussion or filliping with 
 the finger; effusion of blood occurs more tardily, the skin is 
 lividly discolored and yields no resonance on percussion. In 
 case of emphysema, if the part be pressed on, the displacement 
 of the air in the areolar spaces of the tissue reveals itself by a 
 sensible crepitation, in most cases. 
 
 Emphj'sema of the lids will disappear in a few days through 
 spontaneous absorption. In the case which the author saw, 
 the swollen parts were punctured, and the most of the air was 
 forced out through the openings made. A very important tiling 
 is that, for some days, the patient should make no strong expira- 
 tory effoio through the nose, lest air again be forced into the 
 palpebral tissues. 
 
CHAPTER XIII. 
 
 DISEASES OP THE EYELID. 
 
 Hordeolum, Acne Ciliaris or Sty. — Ciliary acne, or sty, as it is 
 commonly named in English, is an inflammation of the matrix 
 or follicle in which is imbedded an eyelash. It occurs oftener 
 in the upper lid. It may be single or multiple. It begins as a 
 slight swelling on the border of the lid, accompanied by slight 
 itching and discomfort at the point. The conjunctiva covering 
 and adjacent to the affected part is intensely red. The tumor 
 reaching the dimensions of a small wheat or barley grain (whence 
 its name), becomes filled with tenacious pus. Ciliary acne is 
 oftenest seen in the young scrofulous subject. In such person 
 the disease often recurs, and is often concurrent with conjunctival 
 and corneal disease. Besides the local inconvenience of the dis- 
 ease, it menaces, by its frec[uent recurrence, the ultimate destruc- 
 tion of the ciliary matrix, and, consequently, the loss of some 
 of the eyelashes, and a permanent deformity of the lid. Its 
 causation is probably referable to a microphyte. 
 
 Treatmerit. — The first thing to be done is the removal of the 
 eyelash which is lodged in the diseased follicle; the tenacious 
 pus should be scooped out with a small curette, and the edge of 
 the lid smeared with the following ointment: — 
 
 1^. 01. Jecoris Aselli gss 
 
 Ung. Hydr. Nitratis 3ss 
 
 Misce. 
 
 This ointment may be smeared on the outside of the eyelids, 
 near the roots of the eyelashes, as the patient is going to bed. 
 
 It must be borne in mind that constitutional remedies should 
 be given; as such the following maybe resorted to: bark, iron, 
 and arsenic, also sea-bathing has proved beneficial. 
 
 Chalazion, otherwise known as tarsal, gelatinous, or fibrinous 
 Tumor of the Eyelid. — The chalazion is a small, flatly rounded 
 tumor imbedded in the eyelid, and usually lies nearer the con- 
 junctival than the dermal surface. It occurs oftener in the 
 
 (471) 
 
472 DISEASES OF THE EYELID. 
 
 upper than in the lower lid, and is situated about midway 
 between the free and the attached border of the lid. 
 
 This tumor may develop more towards the inner or tlie outer 
 surface of the lid; in the former case there will be found a slight 
 prominence on the outside when the lid is lifted or everted from 
 the bulb; but if the tumor develop chiefly outwards, a small 
 rounded prominence will appear in the skin. There may coexist 
 two or more chalazia contiguous or near each other. Tlie growth 
 is usually painless, yet if it presses against and forces the con- 
 junctiva inwards, the latter will become inflamed, and is the 
 site of an itching sensation. 
 
 Pathologists usually refer the origin of this tumor to a degen- 
 eration of the Meibomian gland; others find the causation in a 
 degeneration of an isolated portion of the tarsal cartilage. It is 
 probable that the affection starts in a Meibomian gland, and 
 thence attacks the tarsal cartilage, in which the gland is lodged. 
 The development is slow, and the course of the tumor may 
 extend through a period of many months. When opened, a 
 cor tent of heterogeneous material is found: pus cells, red gelat- 
 inous matter, partly degenerated and partly calcified material. 
 If the suppurative elements predominate, and the tumor press 
 chiefly against the conjunctiva, the latter sometimes acutely 
 inflames, and opens, and permits the liquid content to escape; 
 and in this event, after the rupture of the inner wall, there pro- 
 trudes a small mass of fungous tissue. Though much of the 
 content thus escapes, nevertheless healing is very tedious; the 
 spongy extruded tissue will remain for a long time without much 
 change of volume, and by its presence there is caused some irri- 
 tation of the bulb. Instead of thus rupturing, the chalazion may 
 be the subject of regressive change, in which the softened tissue 
 is lessened by atrophy and absorption, so that there finally 
 remains a dry calcified concrement; and this simulates the ver- 
 itable hailstone, from which this tumor has taken name. This 
 encysted concretion may remain indefinitely without change or 
 causing functional disturbance. 
 
 Treatment. — The chalazion, when it has assumed the calcified 
 form, need not be interfered with, unless its volume is such as 
 to make it a conspicuous deformity; in such a case the hardened 
 material may be extracted through an incision in the conjunc- 
 tival surface, done when the lid is everted. 
 
 But if the tumor has not reached the concrete or cretaceous 
 form, its removal is indicated; and this should be done from the 
 
PALPEBRAL DEFORMITIES. 473 
 
 inner side. The lid must first be everted, so as to fully expose 
 the site of the growth. The bright redness of the conjunctiva 
 over the tumor will indicate the volume and limits of the latter. 
 A dimpled point often corresponds to the central part of the 
 growth. A tenaculum must be made to trans];)ierce the inner 
 wall of the tumor, and a circumscribing incision be made around 
 the tumor. Thus an oval section of the conjunctiva and tarsal 
 cartilage is excised. With a small curette, or Daviel spoon, the 
 remaining gelatinous or granulative material is to be carefully 
 removed, and the wall adjacent should be well plied with the 
 instrument, so that a thin stratum of the wall may be removed. 
 For if this precaution is neglected, there will be a recurrence of 
 the tumor after a few months. The treatment, as just described, 
 is the same should there coexist two or more chalazia. Also, in 
 case tlie growth has opened, and a pouting mass of soft tissue 
 protrudes, the remaining structure should be excised, for, if left 
 remaining, it would only tardily heal, to reopen again sooner or 
 later. In case the tumor has developed more outwards, and is so 
 adherent to the skin that it is difficult to wholly remove it from 
 the inside, then it can be done from the outside, through inci- 
 sion or excision, done parallel with the orbicular muscle ; such 
 external cut should lie in the fold which normally lies in the 
 outside of the lid; thus done, the scar will afterwards be invisible, 
 or, at most, insignificant. 
 
 Palpebral Deformities. — There are several varieties of deformity 
 which are met with in the lids, and these, in the main, are redu- 
 cible to two classes. In the first class the deformity arises from 
 too great breadth, or narrowness of the jDalpebral slit; and in the 
 second it consists of an inversion or an eversion of the lid. Also, 
 deformities of each class may coexist. 
 
 From excessive breadth of the palj^ebral slit the condition is 
 named lagophthalmos, or hare's eye; in this too large a surface 
 of the bulb is exposed. This stare usually depends on some 
 functional aberration of the muscularity of the lids, or it may 
 depend on a swelling, tumor or abscess of the structures adjacent 
 to the bulb of the eye. Protrusion of the bulb is sometimes an 
 attendant on goitrous tumor; and vivisective research here finds 
 the causation to be an irritation of the cervical sympathetic gan- 
 glia which supply innervation to the non-striated muscularity of 
 the eyelids. 
 
 Treatment. — When the stare is from intra-orbital swelling 
 tumor or abscess, this cause must be sought for, and treated as 
 81 
 
474 DISEASES OF THE EYELID. 
 
 the conditions indicate; pus should be evacuated through ihc must 
 dependent route, and a growth removed, if possible, without lesion 
 of the bulb. 
 
 But if the exposure of the bulb does not arise from the causes 
 just cited, but is dependent on imperfect closure of the lids, then 
 some relief may be gotten by shortening the slit at the outer 
 angle. This operation was originated by Walther, and consists 
 in removing at the outer canthus a small section from the upper 
 and lower lid. The part excised should be from one-fifth to one- 
 fourth of an inch long, and should be from half a line to a line 
 in depth. Care must bo taken to remove the bulbs of the eye- 
 lashes. The opposite raw margins are to be brought and 
 retained in union by two or three sutures; and over the wound 
 isinglass plaster and an occlusive bandage should be placed. 
 After this procedure, the outer commissure may be drawn 
 upwards in the movements of the bulb, and give an upward 
 aspect to the eye; to counteract this, Graefe has proposed to excise 
 a small triangle from the integument beyond the angle, accord- 
 ing to a plan practiced by Dieffenbach. To do this, trim only 
 the border of the lower lid, then excise from the temporal skin 
 near by a triangular portion of skin. The base of this inverted 
 triangle should be a continuation of the commissure, and the 
 apex should look downwards towards the outer i:»art of the 
 cheek. The freshened border of the lower lid is next drawn 
 outwards and attached to the base of the triangle by sutures. 
 The result of this work will be to draw the lower lid outwards, 
 and to uplift it, so the palpebral slit wall be lessened in its 
 surface. The wounds made must be closed by fine wire suture. 
 
 Should tlie lagophtbalmos depend on a goitrous tumor, this 
 should be removed. The writer's experience inclines him to 
 think that protrusion of the bnlb arises oftener from the paren- 
 chymatous than from the cystic form of goitre; the solid struc- 
 ture of the latter causes more disturbance of the innervation of 
 the eye. 
 
 From palsy of the lower lid, the lower portion of the bulb 
 may be exposed ; likewise, the tears may not be carried towards 
 the inner angle, but they escape over the lid upon the cheek. 
 The abnormally exposed portion of the bulb becomes irritated, 
 and the conjunctival vessels become congested, and give the eye 
 an unsightly appearance. In such cases a canthoplastic opera- 
 tion may be performed, in which the commissural borders of the 
 lids are pared and united by suture. Or, in place of this, the gap- 
 
ANKYLOBLEPHARON. 475 
 
 ing commissure may be closed by a strip of adhesive plaster 
 fixed to the pendent lid, and fastened in a vertical or oblique 
 direction. In this way the writer has known a patient to satis- 
 factorily correct the faulty position of his drooping eyelid. 
 
 Ankyloblepharon, Blepharophimosi^^, or Narrowness of the Palpe- 
 bral Opening. — Blepharophimosis may occur congenitally as the 
 result of a defective separation of the lids in the embryo; it may^ 
 as an anthropological characteristic, be the normal disposition of 
 the eyelids. In the Japanese and Chinese it is seen, and when 
 exaggerated it becomes a striking feature indicative of the Mon- 
 golian race. 
 
 It is frequently acquired, and the cause then is to be found in 
 some antecedent inflammatory condition; or it can arise from a 
 permanent spasmodic state of the orbicular muscle. The most 
 common cause is an inflammatory or ulcerative condition of the 
 lids, especially of the outer commissure, terminating in adhesion 
 of the raw surface, and a consequent lessening of the space 
 between the lids. Also a wound, especially that produced by a 
 burn in the adjacent temporal region, may, in tlie process of 
 cicatrization, cause outward traction of the commissure, and thus 
 produce narrowness of the palpebral slit. A lupoid ulcer on the 
 temple may act thus. 
 
 Blejoharophimosis is often complicated with adherence of the 
 lids to the bulb, and this complication renders successful treat- 
 ment much more difiicuh. 
 
 The narrowness of the palpebral slit, besides being a con- 
 spicuous deformity, may, when extensive, disturb the jjatient by 
 contracting the field of vision. Thus, when tlie eye is rolled 
 upwards, the upper lid may shut oif a part or the entirety of the 
 visual field, and similar interference may be caused by the lower 
 lid. 
 
 Treatment. — AVhen the closure depends on cicatricial adhesion, 
 the treatment will vary according to the character and extent of 
 the coalescence. Fractional marginal adhesion is overcome by 
 simply severing the united bands, and subsequent frequent move- 
 ment of the lids. At night the patient must occasionally be 
 awakened, otherwise the closed lids would soon cohere again. 
 
 But a diff'erent treatment is demanded where the narrowing 
 depends on complete closure of the outer commissure; mere sep- 
 aration of the united borders would be followed by reunion; to 
 prevent this, several plastic procedures have been resorted to. 
 The aim in this work is to cover the wounded borders with a 
 
470 DISEASES OF THK EYELID. 
 
 coating of skin or mucous membrane. The simplest plan is that 
 of Yon Amnion and Uicliet, wliich is as follows: The closed angle 
 is to be slit outwards; and this may be done with a bistoury, or 
 a pair of scissors, the incision being carried horizontally outwards 
 the distance of a fourth or third of an inch; and this cut must 
 include the entire thickness of the skin to the conjunctiva. The 
 cut should be straight. Some bleeding will ensue, which, however, 
 if it does not spontaneously cease, can be controlled by torsion. 
 The adjacent conjunctival membrane is now to be dissected up, 
 and attached by suture to the elongated connnissure, so as to give 
 to each raw edge a mucous coating, which will not permit reunion 
 of the wounded surfaces. It is well to preliminarih'- detach for 
 some minutes the conjunctiva which is to be used for covering 
 the wound, and thus permit it to retract as much as it tends to 
 do, before it is transplanted to the surface which it is destined to 
 cover; thus excessive tension will be avoided. The sutures 
 should be removed in about forty-eight hours. The result of 
 this operation is fairly satisfactory; however, it often occurs that 
 there remains some impediment to the inward motion of the 
 bulb; in such movement the conjunctiva is lifted at the outer 
 commissure into a slight ridge. In the operation described, Yon 
 Ammon pulled the conjunctiva outwards, and attached it directly 
 to the divided derm. Richet split the conjunctiva, and then 
 turned one part upwards and the other downwards, attaching 
 each by sutures to its adjacent border. Instead of lining the 
 wounded border with conjunctiva, Cusco inverts the skin, which 
 has been loosened somewhat from the incised border, and attaches 
 this to the conjunctiva by sutures. The last mode has the objec- 
 tion that it creates some deformity of surface. In whatever way 
 the commissure is elongated, for a few days the eye should be 
 closed, and a compress wet with water must be retained uoon 
 the wound. 
 
 SymUcpharon or Bulbo-palpehral Union. — In this condition of 
 the e^^e, the lid is adherent to the globe, and that adherence may 
 be partial or complete. Partial adhesion may affect one lid alone, 
 or both may be implicated. Such limited symblepharon maybe 
 direct in which the lid coheres to the bulb, or the connection may 
 be through the medium of a longer or shorter band. The jiros- 
 pect of treatment being successful is much greater when the 
 adliesion is by a band; but when the adhesion is immediate and 
 of large extent, the surgeon meets a problem which is extremely 
 difficult of solution. Functional impairment is great when the 
 
SYMBLEPHARON. 477 
 
 adhesion involves the most of the conjunctival covering of the 
 bulb; movement is then hampered, and the normal condition of 
 the tears being disturbed, they escape on the cheek. 
 
 Symblepharon is often caused by burns; hot water, steam, or 
 molten metal coming in contact with the conjunctiva can cause 
 a burn from which the mucous surface of the lid and bulb becom- 
 ing ulcerated, the parts cohere. Lead and other metals brought 
 by heat to fusion, during their use in the mechanical trades, by 
 careless handling or through explosive action, may be thrown 
 into the eye and lodge beneath the lids. Such lesion often leads 
 to adhesion of the lid to the bulb. Again, a chronic inflammation 
 arising from trachomatous affection may finally end in partial 
 or complete obliteration of the space between the lids and the 
 bulb. 
 
 Treatment. — When the adhesion is limited, and indirect, by 
 means of a band, the treatment consists in severing this band 
 close to the bulb, and also close to the lid, and then closing each 
 conjunctival wound by fine suture. These sutures should remain 
 in place until the wounds are securely closed. Again, if the 
 adhesion is direct, and limited, the lid should be dissected from 
 the bulb, and then the two wounds closed in the manner just 
 described. 
 
 In case the symblepharon is on a large scale, and either or 
 both lids are directly adherent to the globe, then the operator is 
 confronted with a task which has awakened the best efforts of 
 surgical invention. The object sought for is, after separation of 
 the parts, to obtain a covering for one or both of the surfaces 
 which will not readhere. 
 
 The earliest recorded method of operating was that of Fabri- 
 cius, who, two and a half centuries ago, sought to maintain the 
 separation of the parts by means of cicatricial tissue. This idea 
 was more recently pursued by Himly, who proceeded as follows: 
 A leaden thread was introduced through the connecting material 
 at its deepest portion, corresponding to the site of the transition 
 fold of the normal eye, that is, the bottom of the pocket formed 
 by the palpebral and bulbar conjunctiva. This thread of lead is 
 left in site until the pierced parts cicatrize around it. After an 
 opening has been established, surrounded by scar-tissue, the 
 remainder of the connecting structure is divided. The results of 
 this method were such as to encourage the endeavor to find a 
 better one. ■ 
 
 Arlt, Teale, Knapp and others have each announced and 
 
478 DISEASES OF THE EYELID. 
 
 published ways in which they have been successful in obtaining 
 separation. If the condition of tlio eye is such as to permit the 
 transplantation of a conjunctival flap into tlie bottom of the cul- 
 de-sac formed by the separation of the lid, then a successful result 
 can thus be obtained. Such shifted conjunctiva should be taken 
 from the bulb and have its pedicle, for vascular maintenance, near 
 the bottom of the new-made cul-de-sac; this flap is to be fastened 
 by small sutures. After this implantation the remainder of the 
 opposite raw surfaces must be kept asunder by means of gutta- 
 percha tissue; and in the absence of this, the silk tissue might be 
 interposed. Instead of the mucous tissue of the conjunctiva, 
 should it be impossible to obtain the latter, a slip of dermal tissue 
 from the lid or adjacent check .might be carried through a slit 
 made in the lid, and implanted in the bottom of the space formed 
 between the bulb and lid. Tlie operative i)rinciple involved in 
 these methods is that where synechial adhesion exists between 
 parts, whether of congenital or accidental origin, the surgeon, if 
 he hopes to obtain permanent separation, must cover the bottom 
 of the angle of divergence, which the opposite surfaces form, with 
 non-adherent tissue, viz., cicatricial, mucous or dermal. This is 
 the principle involved in the relief of palpebral adhesion, the 
 webbed finger, or the narrowed openings into the alimentary eanal. 
 And, if possible, kindred tissue should rejJace kindred tissue, viz., 
 derm should replace derm, and mucous membrane replace mucous 
 membrane. 
 
 The skin-graft, introduced by Reverdin as an aid in closing 
 raw or granulating surfaces, has found more extensive use than 
 its author foresaw. Conjunctival grafting has been resorted to 
 for relief in pal})ebral adhesion; and for tliis purpose, the con- 
 junctiva of tlie rabbit and dog has been transplanted to man's 
 eye. Thus AVolfe and De Wecker report successful operations. 
 The mucous membrane of man has been used, viz., that from the 
 mouth of the patient has been transferred to his eye to replace 
 deficient conjunctiva. "Where this transplantation has been done, 
 it has been noted that the transplanted grafts were absorbed after 
 they had served the end of separating the parts. 
 
 Ectropion. — Ectropion implies aversion or turning outwards; 
 and this condition is not unfrequently seen in the eyelid. It 
 occurs in the upper and lower lid ; yet oftener in the lower one. 
 
 The most common cause of palpebral eversion is a wound of 
 the surface of the lid, as from a burn, or some affection which 
 induces ulceration of the outer face of the lid. Also a wound of 
 
ECTEOPIOX. 479 
 
 the adjacent surface, which in liealing cicatrizes, contracts, and, 
 pulhng on the skin of the lid, displaces the free border of tlie lid 
 outwards; that is, the free border is drawn towards the attached 
 one and the lid is everted. Thus a burn on the lid, or on the 
 skin around the eye, may act. Affection of the bony wall which 
 surrounds the eye may end in inflection of surface, and become 
 the cause of one of the most obstinate forms of palpebral eversion. 
 "Where the cause of ectropion is a scar, it will be more complete in 
 proportion as the cicatrix lies at right angles to the long axis of 
 the lid; and it is greatest in such case, if one end of tlie scar is 
 attached to an adjacent bone. 
 
 There is a troublesome species of ectropion in which the derm 
 of the lid is the site of no disease or change, but the eversion is 
 produced by a reflex irritation originating in a diseased condition 
 of tlie cornea and bulbar conjunctiva; in the effort to close the 
 eye to exclude light, the orbicular muscle is violently contracted 
 so as to force the conjunctiva forwards, and cause it to be caught 
 between the lids, where it appears as a mass of red swollen tissue, 
 similar to what is presented by the mucous membrane in prepu- 
 tial paraphimosis. The spasmodic ectropion, as is evident, differs 
 widely from that of cicatricial origin; the former will disappear 
 under appropriate treatment of the disease of the eyeball, whicli 
 is the prime cause, while that caused by a scar is only removed 
 by some surgical procedure. 
 
 An accompaniment of eversion from cicatricial cause in its 
 w^orst form, is an elongation of the free border of the lid. Cica- 
 tricial ectropion is slow in its development, since it is only after 
 a long lapse of time that scar tissue reaches its final point of 
 contraction; and this precautionary fact must be remembered in 
 the selection of the time for operating, for the work should be 
 delayed until the vascular tissue has become transformed into 
 fibrous structure. 
 
 Two indications are present in palpebral eversion; first, to 
 cover the exposed bulb and thus protect the latter against irrita- 
 ting agencies; and, secondly, diffusion of the tears over the front 
 of the eyeball, and their conduction away by the natural channels 
 of escape. The procedure to be adopted will vary greatly, accord- 
 ing to the grade of the eversion. As a rule, the lower lid is the 
 one which oftener requires correction. The operations may be 
 classified as those done on the lid, and those done on the surface 
 adjacent to the eye, or a combination of the two. Some plastic 
 device involving transplantation or shifting of tissue is often 
 required. 
 
480 
 
 DISEASES OF THE EYELID, 
 
 A method in vogue among French surgeons is to unite tlie 
 two lids directly or indirectly. Tarsorrhaphy may be done 
 directly by trimming the opposite edges of the lids and then 
 uniting these by suture; and such sutural union maybe limited, 
 or done to such an extent as to -wholly close the eye. A serious 
 objection to this method is that in trimming the lids the follicles 
 of the eyelashes may be injured, so that when the patient is cured 
 he is left with a deformity. To avoid this, Mirault has proposed 
 to close the eye by lifting a V-shaped flap from one lid, and, 
 having made a vertical incision on the opposite orbital border, to 
 implant the apex of the V in this cut, so that when it has healed 
 in the new position, it will maintain closure of the lids. This 
 triangular flap is so disposed that its dermal face is turned towards 
 the dermal face of tlie lid across which it is carried. This way 
 of closing by means of a dermal bridge, or that in which the 
 borders are directly sutured, to be effective, must be continued for 
 several months. Ectropion is not always cured in the manner 
 here described; for after the liberation of the lids, eversion some- 
 times recurs. 
 
 To rectify ectropion, Graefe advises the following method: 
 An incision is to be made along the border of the everted lid 
 
 Figure 62. Showinsf Dieffenbach's Figure 63. Showing Von Am- 
 
 method of operating for the relief of mon's plan of operating in ectro- 
 palpebral eversion. pion. 
 
 from the outer commissure to near the punctum lachrymale; by 
 this cut the free border is split into an inner and an outer stratum. 
 A crescentic flap is next to be formed by cutting through the 
 dermal layer o*f the lid; this flap, which is convex towards the 
 attached border of the lid, is to be so detached from the subjacent 
 structure of the lid that the eversion of the latter can be corrected, 
 when the flap is to be fixed in its rectified site by sutures. 
 
 Palpebral eversion is corrected by Dieffenbach and Yon 
 Amnion, by o})erations resembling each other. Dieffenbach 
 
ECTROPION. 
 
 481 
 
 excised a portion of the commissural border of the lid which is 
 everted; then an equilateral triangle, with apex downwards and 
 base continuous with the commissure, is excised from the temple 
 adjacent. The sides of this triangle should not exceed one-third 
 of an inch. The trimmed border is next drawn outwards and 
 sutured to the base of the triangle; thus the lid is rectified by 
 lateral sliding. This method is shown in Figure 62. 
 
 Von Amnion's plan is to excise an elongated isosceles triangle, 
 of which the narrow base rests against the bulb within the com- 
 missure, as shown in Figure 63. The sutural closure of this 
 triangle will bring the everted lid or lids into normal place. The 
 twisted or hair-lip suture may be resorted to with advantage to 
 close and immobilize the parts. These two methods just 
 described, tend to shorten the border of the lid, which is too 
 long, as has before been remarked; this is specially so in Dieffen- 
 bach's plan, in which the outer portion of the border is excised. 
 
 Figure 64. Elucidating Szyma- Figure 65. Showing sutural line 
 
 nowskj^'s method of operating for that remains after Szymanowsky's 
 relief of entropion. operation. 
 
 An operation cognate to those just described is that of Szyma- 
 nowsky. This consists, as shown in figure 64, in the excision of a 
 triangular portion of derm from the temporal region, adjacent to 
 the commissure. Two sides of the excision start and diverge 
 outwards from the commissure; these divergent lines include a 
 small section of each lid, and are to be sutured to the third 
 or temporal line. The sutural closure, shown in Figure 65, has 
 had the effect of restoring the everted lids to normal position. 
 
 As before mentioned, tarsorrhaphy is much practiced by the 
 French surgeons; and the work is done by trimming each free 
 border so that, united by sutures, they will unite. The inner 
 edge of the free border is trimmed off, care being taken to spare 
 
482 
 
 DISEASES OF THE EYELID. 
 
 the bulbs of the eyelashes. The outlets of the Meibomian glands 
 must necessarily be interfered with in this work; yet their closure 
 does not seem to be followed by such trouble as might be aj)prc- 
 hended; no cyst by retention has followed such occlusion. Fine 
 silken thread is used for the sutures, which may be removed after 
 three or four days, when the union will be found quite complete. 
 Along with tliis closure, some work maybe required on the evert- 
 ing cicatricial structure; for example, the scar maybe divided 
 and become, by interstitial growth, somewhat elongated; also, 
 plastic operations on the lids are facilitated by this immobiliza- 
 tion. 
 
 The effort to overcome cicatricial e version by division of the 
 scar and filling the wound with lint, was an old method, which 
 theoretically would seem to promise much, but ])ut into practice 
 it has yielded so many disappointments that this plan of treat- 
 ment has been nearly abandoned. 
 
 Bonnet rectified the cicatrized eversion by making a horizon- 
 tal incision in the lid, as seen in Figure G6; then by lifting, if it 
 
 Figure 66. Showing Bonnet's plan of treating eversion of the eyelid. 
 
 were the lower, or drawing down if it were the upper lid, the 
 wound is converted into a lozenge-slia])ed figure; closure is now 
 done while the wound is thus shaped by liorizontal sutures. The 
 result will be to broaden the lid. 
 
 T. Wharton Jones rectifies the ectropion by making, as 
 shown in Figure 67, a flap, the pedicle of which is directed 
 towards the free margin of the lid. This triangular flap is 
 dissected up so that it liberates the lid, and, the fiajD being lifted 
 towards its attachment, the remaining open space is closed later- 
 ally by sutures. Thus done, the closed space becomes a prop to 
 the uplifted fia|) ; and the result is lengthening of the vertical span 
 of the lid. 
 
 Gudrin's method, slio-^n in Figure GS, is to make an incision 
 in the form of a W, and dissect up the lateral angular flaps; and, 
 
ECTKOPION. 
 
 483 
 
 having forced these towards the free border of the hd, they are 
 united together over the intervening angular point, which is left 
 remaining adherent. 
 
 The writer has employed in his practice several of the preced- 
 ing methods for the relief of ectropion ; yet the relief, wdiich was 
 
 Figure 67. Showing T. Wharton Jones' operation for the relief of ectro- 
 pion. Sutural closure is seen on the left side. 
 
 aimed at, was not always realized; in fact, the result was often 
 unsatisfactory. And, though at the time of the operation resti- 
 tution to normal position was secured, yet, after healing, the 
 former mal-position gradually reappeared; the wounds made in 
 cicatrizing, shortened the surface, and the previous deformity was 
 present again. The usual cause of this is that scar tissue caused 
 by a burn, or similar wound, being the constituent of the surface 
 which is operated on, the elements of inevitable recurrence are 
 
 Figure 68. Showing Guerin's method of operating for relief of eversion of 
 the lower lid. Sutural closure is seen on the right side. 
 
 present. These circumstances have led the writer to attempt 
 rectification of the everted lower lid by a plan differing from any 
 of those before described. His first operation was done in 1870, 
 as follows, upon a lower eyelid everted by a burn: First make 
 an incision through the lid a half inch long near its attached 
 
484 
 
 DISEASES OF THE EYELID. 
 
 border. Next between tliis opening and the free border a flap is 
 to be uplifted from the conjunctival side with its pedicle towards 
 the free border. Tliis flap should be a half inch broad, and 
 should be divested of its conjunctival covering; that is, it should 
 be raw on both sides. It contains tarsal cartilage and portions 
 of the divided Meibomian glands. The free end of this flap is to 
 be drawn into the horizontal slit first made, and retained there 
 by sutures placed on the outside, and traversing the derm of the 
 lid. The traction on this flap and its fixation in the cut tlirough 
 the lid, will correct the eversion if tliis be not very great; that is, 
 the method is most applicable to cases in which but a })art of the 
 lid is involved. But in cases in which the correction cannot be 
 whollv accomplished b3'this plan, still it may aid other accessory 
 plastic work. The advantage of utilizing this intra-palpebral 
 flap is til at it surely disposes of the unsightly mass of pouting 
 tissues which so disfigures the eye, and uses the same for a sup- 
 port of the lid. No trouble arises from the divided and shifted 
 Meibomian glands. The author has only resorted to this method 
 for the correction of eversion of the lower lid; it might, however, 
 be used in the upper lid. 
 
 There is sometimes seen a deformity of the eye, in which there 
 is a depression of the outer angle ; and this is associated with 
 some eversion of the lower lid. For relief in this case, Denon- 
 villiers has planned an ingenious operation, shown in Figure 
 69, styled an exchange of flaps. To do this, make an incision 
 
 FiGCRE 69. Showing Denonvilliers' plan of elevating the outer angle of the 
 eye. Closure is shown on tlie right. 
 
 above and below the eye, converging and meeting a few 
 lines beyond the outer commissure. From the inner end of the 
 upper incision, and from overthe middle of the brow, carr}'^ a curved 
 third incision downwards and outwards, ending on the temple. 
 Thus a flap is described, which is uplifted and carried down- 
 
ECTROPION, 485 
 
 wards and sutured below tbe eye. As this is done, the angular 
 flap beyond the commissure is carried upwards and occupies 
 some of the space left by the upper flap. A small space will be 
 left above the brow, which may be closed by stitches, or allowed 
 ,to cicatrize, and draw the brow upwards. 
 
 A scar causing the eversion of the lid may be of such a char- 
 acter that the work of correction can only be done by excising 
 the cicatrix and substituting in its stead healthy tissue borrowed 
 from the adjacent surface. This plastic work will be easily done 
 if the eyelashes still remain; then the operation (the steps of 
 which demand special planning in each case) will, in the main, 
 consist of excision of the scar tissue, and then, for the upper lid, 
 uplift a pedicled flap from the frontal or temporal region; or if 
 it be the lower lid, form the flap from the temporal or malar 
 derm, and then transpose and suture the flap in its new position. 
 If a portion of the free border of the lid be involved in the 
 scar, this may be excised and replaced by the transplanted flap. 
 As the flap will shorten, it should be longer than the remaining 
 border of the lid. If considerable allowance is not made for 
 such retraction, the new-formed border will be too short, as hap- 
 pened in a case operated on by the writer. 
 
 In some cases in which the scar is small, this may be excised, 
 leaving a triangular space, as shown in Figure 70 ; the closure 
 
 c 
 
 Figure 70. Showing a plan of DiefFenbach of correcting ectropion. 
 
 may then be effected according to the plan of Dieffenbach, in 
 which the incision a 6 is extended to the right and left, when the 
 adjacent derm a c and & c is to be uplifted, and the sides of the 
 triangle are to be united by suture; the efl'ect will be to force the 
 everted border upwards. Though in this way the position of the 
 lid can be improved, yet, as the writer has found, some pouting 
 of the border will remain. 
 
 A remarkable operation for the relief of cicatricial ectropion 
 
486 DISEASES OF THE EYELID. 
 
 was done by Wadswortb, of Boston, in 1876. After preparation 
 of tlie part to be operated on by removal of its surface, a flap 
 was taken from tlie arm and at once transplanted on tbe lid. 
 The flap thus transplanted was two and one-half inches long, 
 one and one-fourth inches broad, and one-half inch thicL 
 AVatlsworth found that the transplanted piece contracted greatly, 
 and he directs that due allowance for tliis be made. Tlie mate- 
 rial was retained in position by means of gold-beater's skin and 
 an overlying comj)ress. After the lapse of four months, the 
 result was satisfactory. 
 
 This plan of Wadswortb diflers from that of Thiersch, who 
 covers raw or granulating surface by material from the upper 
 structure of the skin, in which only the apices of the papillary 
 layer are included. 
 
 Entropion. — Entropion, or inversion of the lid, has a perni- 
 cious effect on the eye through the mechanical action of the free 
 borders of the lid and the eyelashes impinging against the bulb; 
 the eyelashes are the chief causes of the mischief. The general 
 causes of palpebral inversion may be classified under three 
 heads, viz., cicatricial shortening, spasm of the lid, and lessened 
 volume of the eyeball; the first and second causal agencies fre- 
 quently exist together. The upper lid is the one oftener affected. 
 Its superior, pendent position, and the larger tarsal cartilage con- 
 tained in the upper lid, give it an advantage over the lower one, 
 where the agencies of inversion are present. 
 
 Cicatricial inversion is seen in those cases in which trachoma- 
 tous disease of the inner surface of the lid has continued until 
 the affected structure becomes changed to scar-tissue. The har- 
 dened points which stand on the cicatrized surface irritate the 
 bulb, and, like foreign bodies, they produce spasmodic closure of 
 the lids. Meantime the ciliary portion of the orbicularis muscle 
 hypertrophies and contracts more violently. The continued irri- 
 tation of the eyelashes and of the border of the lid against the 
 cornea causes opacity of the latter, and finally ends in almost 
 complete loss of sight. Aside from trachomatous disease, any 
 cause, which constantly irritates the eyeball, may produce entro- 
 pion through continued spasmodic closure. In the cases men- 
 tioned, especiall}^ in those in which there is trachomatous cica- 
 trization, the tarsal cartilage softens and atrophies, so that it can 
 offer but slight resistance to the involution of the border of the 
 lid. 
 
 Again, entropion may arise from lessened volume of the eye- 
 
ENTROPION. 487 
 
 ball; this may appear as sequel of an inflammation of the eye; 
 it is not unfrequeutly seen in the aged as the effect of the atro- 
 phic changes resulting from senility. 
 
 Continued inversion of the lids ends in producing corneal 
 opacity, and a diversion of the tears from their normal channel, 
 and the latter, flowing on the face, irritate and excoriate tlie skin; 
 to avoid these serious troubles surgical aid is sometimes invoked. 
 
 The inverted lid may be attacked only on its outer surface, 
 or the operative procedure may involve the entire thickness of 
 the Hd. 
 
 Shortening of the outer surface and restoration ctf the lid to 
 normal position have been attempted by cauterization of the outer 
 surface; and this can be done by the actual or potential cau- 
 tery. This procedure, which dates from antiquity, is most safely 
 done by actual cauterization. This is best done with the wedge- 
 shaped point of the thermal cautery, which may be so applied as to 
 make a horizontal eschar in the middle portion of the lid; the 
 contraction resulting from this will correct the inversion. 
 
 Instead of this plan, portions of skin may be excised from 
 the outside of the lid; this excision is done by pinching up and 
 excising one or more folds of the skin, and then closing by 
 suture; or they may be allowed to heal by granulation. These 
 excisions are commonly made horizontally, yet one surgeon pre- 
 fers to. make them vertically. 
 
 ■The work of correction may also be made by means of liga- 
 tures passed through the derm and tied. In this way Gaillard 
 operated; his procedure consisted in passing threads vertically 
 through and underneath the derm, one near the inner angle and 
 another near the outer angle; these threads are to be tied so as to 
 include a section of the skin as well as the orbicularis muscle. 
 In each ligature there is included nearly an inch of vertical sur- 
 face. And a third ligature may be placed in the middle of the 
 lid, should the inner and outer ones be insufficient. These 
 tightly tied ligatures include, destroy, cause cicatrization, and 
 have the eff"ect of shortening the outer surface of the lid, and 
 thus eversion is efl'ected. 
 
 This method of treating entropion by ligatures may be advan- 
 tageously combined with Von Ammon's operation of cantho- 
 plasty, in which there is excised an elongated triangle from the 
 derm at the outer commissure, as before described in the treat- 
 ment of ectropion. 
 
 To overcome the spasm of the orbicularis muscle, often the 
 
488 DISEASES OF THE EYELID. 
 
 chief causal agency of entropion, tlie muscle may be divided, or 
 a small section of it may be excised. The fibers of the muscle 
 nearest the free border of the lid should be attacked; or the divi- 
 sion of the outer commissure may accomplish the same purpose. 
 Others have divided the orbicularis muscle subcutaneously to 
 control spasm of the latter. Instead of dividing the muscle, 
 otliers have divided the internal palpebral ligament, that is, they 
 have performed tenotom3\ 
 
 These operations have been limited to the dermal surface of 
 the lid or the orbicularis muscle : that i.-^, the tarsal cartilage is 
 neglected; and since this cartilage, through alteration of form and 
 structure, often figures as the chief cause of entropion, hence the 
 operations described often fail to permanently cure entropion. 
 In the worst cases the surgeon must attack the tarsal cartilage. 
 
 Sir Philip Crampton was one of the first to include the carti- 
 lage in the operation for relief of obstinate cases of entropion 
 dependent oa trachomatous cicatrization. His o^^eration con- 
 sists in making two vertical incisions a half inch long, one of 
 which is external to the punctum lachrymale, and the other near 
 the outer angle; the incision traverses the tarsal cartilage, so that 
 it becomes easy to evert the portion of the lid between the inci- 
 sions. Next, by means of a species of eye speculum, he retained 
 the lid everted for some days, until the wound healed. Reten- 
 tion of the lid ill eversion is better accomplished' by Guthrie's 
 plan, who, after making the vertical cuts, excises a horizontal 
 section from the surface of the outfolded lid, and then closes the 
 wound by suture, thus fixing the free border in eversion that 
 remained after the wound had healed. During the period of 
 healing, Guthrie holds the lid in suspension b}^ three ligatures» 
 which, being passed through the lid near the border, are to be 
 fastened on the forehead or cheek by adhesive strips. During 
 the time of healing the eye must be covered with lint coated 
 with a bland ointment, such as simple cerate or spermaceti oint- 
 ment. The method of Crampton, as modified by Guthrie, the 
 author has successfully emploj^ed in the treatment of trachoma- 
 tous inversion. In one case in which sight had been nearly lost 
 by corneal opacity, caused by friction of the eyelashes against the 
 bulb, this operation caused a restoration of average sight after a 
 few months. In this case the oblong dermal excision penetrated 
 the tarsal cartilage. 
 
 Since the time of Crampton and Guthrie, ophthalmic surgeons 
 in such cases of obstinate trachomatous entropion, have sought 
 
CONGENITAL DEFORMITY OF THE EYELIDS. 489 
 
 to correct the position of the lid by operations confined to the 
 cartilage. Thus Streatfield operated by making an incision a 
 couple of lines from the border through the skin and muscle to 
 the cartilage; and then from the latter a strip is to be excised; 
 and afterwards, the wound being sutured, the result is shortening 
 of the lid and e version of its border. Wells operates somewhat 
 similarly, excising a section of the skin, and a wedge-shaped 
 strip from the tarsal cartilage, with sutural closure. 
 
 In mild cases the operation of Anagnostakis may be tried; 
 this consists, as will be seen in Figures 71 and 72, in making an 
 
 -ef-of— 
 
 Figure 71. Showing the triangular Figure 72. Showing the sutural 
 
 excision made by Anagnostakis for line remaining after the operation of 
 the relief of entropion. Anagnostakis. 
 
 incision eight lines from the free border, parallel with the border; 
 then excise a triangular section of skin with apex towards the 
 border, and base on the first incision; dissect up the sides of the 
 triangle, and unite these by suture. Graefe operates similarly, yet 
 makes his incision near the free border, and his excised triangle 
 rests on this cut, and has its apex towards the brow. 
 
 Congenital Deformity of the Eyelid. — The lids may be absent, 
 or nearly so, and then the bulb is quite uncovered in its anterior 
 section. A condition quite the reverse of this may exist, viz., the 
 eye may be closed by coherence of the normally free borders. 
 
 Treatment. — Where the lids are absent, some plastic procedure 
 might be resorted to; to wit, flaps from the neighboring frontal, 
 temporal or facial derm, might be thrown over the uncovered 
 bulb, and thus the absent lid may be, in a manner, replaced. 
 
 In congenital ankyloblepharon, if there be no symblepharon, 
 relief might be obtained by separating the coherent lids. If 
 the eyelashes were absent, the operation would be assured, if the 
 dermal and conjunctival surfaces were united over each border. 
 
 Congenital coloboma, or cleft of the eyelid, has been seen ; it 
 is, however, very rare, only a small number of cases having been 
 seen. This cleft is triangular in outline, similar to that in hare- 
 lip, and in the most of cases observed, the cleft was in the upper 
 lid, viz., in ten of thirteen cases it was thus situated. In such 
 cases there is a breach in the tarsal cartilage, and there are no 
 eyelashes in the gap. The affected lid, at the site of opening, is 
 32 
 
490 
 
 DISEASES OF THE EYELID. 
 
 usually attached to the adjacent cornea. Such cleft is found in 
 the inner half of the lid, near the inner or greater angle of the 
 eye. 
 
 Many ingenious theories have been offered to explain the ori- 
 gin of the palpebral cleft; the most satisfactory explanation is that 
 it has arisen from an arrest of development, during the early period 
 of embryonic evolution. This theory is rendered still more 
 probable by the fact that such cleft is often concurrent with other 
 congenital defects: for example, hare-lip, palatal or facial cleft 
 may exist with palpebral cleft, in all of whicli the primal cause 
 is iion-closure of clefts or openings normally existing in the 
 embryo. 
 
 Tiie treatment of congenital cleft of the eyelid is similar to 
 that of hare-lip, provided the remaining portions of the lid will 
 permit their closure; then the borders must be pared and united 
 by metallic sutures. And should the lid be adherent to the bulb, 
 as is commonly the case, this must be detached. In the work of 
 closure, should the existing portions of the lid be so short that 
 their closure would cause too much tension, then subsidiary 
 lateral incisions must be made, which will permit of lateral 
 sliding. 
 
 EpicantJtus. — There is a rare deformity of the eye exliibited 
 in Figure 73 in which a fold of skin of crescentic form lies over 
 
 Figure 73. Showing the deformity known as epicanthus. 
 
 the inner angle; and this circumstance gave the name of epi- 
 canthus to the deformity. This cutaneous fold, starting from the 
 
BLEPHAROPLASTY, 491 
 
 inner end of the eyebrow, passes downwards on the side of the 
 root of the nose, and then passes across the angle, so as to have a 
 semilunar form with concavity looking outward. A hollow space 
 lies underneath. The effect of such a fold which is present in 
 the angle of each eye is to limit the field of sight of one eye, when 
 vision is directed laterally, since the pupil is carried partly or 
 entirely under the fold. These folds are movable, so that when 
 the skin on the root of the nose is pinched up and folded on itself, 
 the defect is made to vanish, yet it returns as soon as the skin is 
 liberated. 
 
 Epicanthus is often associated with some other ocular defect; 
 there m.ay coexist internal strabismus, defective action of the 
 upper lid, or smallness of the bulb. Epicanthus has likewise 
 been seen at the outer angle of the eye; and then it was asso- 
 ciated with other defects of the eye. The author has seen a well- 
 developed case of epicanthus at the inner angle of the eye, in 
 which there was no other defect of the eyes. The girl's parents 
 did not have the defect. 
 
 Epicanthus is often seen in the Mongolian race; and in them, 
 as well as in all thus deformed, the face is broad, abnormally flat, 
 and the nose is less prominent than usual. The new-born child, 
 in whom the nose is normally without character or shape, is often 
 accompanied by epicanthus in which the flattened root of the 
 nose slightly overhangs the inner angle of the eye. There may 
 be epicanthus in the congenitally scrofulous or syphilitic subject. 
 
 Treatment. — Only in very prominent cases of epicanthus is 
 interference necessary; should this be demanded, the work is best 
 done by removing a vertical section of the derm on the middle 
 of the nose, and then dressing by sutures. As this simple pro- 
 cedure would probably leave the parts too tense, and dispose to 
 an early reappearance of the deformity, it would be well to guard 
 against tension by incising the displaced derm horizontally, and 
 if need be vertically. 
 
 Blepharoplasty. — The eyelid may be lost in part, or in entirety, 
 by disease, injury or the surgeon's knife; the operative work done 
 for the purpose of repairing such loss is designated blepharo- 
 plasty. 
 
 Blepharoplasty may be done in two ways: (1), by uplifting a 
 flap and turning this into the defect; (2), closure by sliding. 
 
 The flap procedure is known as the method of Fricke ; 
 in this a flap is uplifted from the region of the forehead, 
 temple or cheek, and is shifted into the defect. Since the 
 
492 
 
 DISEASES OF THE EYELID. 
 
 skin when severed retracts, tlie flap must exceed in every 
 direction the space which it is to occupy; it should be two 
 or three times longer and broader than the defect. The axis 
 of the flap should make an acute angle with that of the defect, 
 so that torsion may be diminished. The margins of the flap 
 should be cut perpendicularly, so as to insure their vitality; and 
 its distal side should be from three to four lines longer than the 
 nearer side; thus torsion will be rendered more easy. 
 
 After moving the flap into its destined position, some sur- 
 geons apply sutures at once; otiiers use these later; and all 
 counsel to attach the free border of the flap to the subjacent con- 
 junctiva. After the work is done, the j)arts must be covered with 
 lint bearing some bland ointment; and both eyes should be 
 covered with a compressive bandage. 
 
 Probably a majority of the cases demanding these plastic 
 operations have arisen from excision, in which a portion of the 
 lid has been removed, in the extirpation of an epitheliomatous 
 affection of the lid. Such removal is oftcnest done at or near 
 the commissures. If this be at the inner angle, the lachrymal 
 sack may be interfered with; and tlien, besides repair of surface, 
 it may be required to remove the lachr3'mal gland. To restore 
 the angle is no easy task. A solution of the canthoplastic prob- 
 lem both at the angle of the mouth and eyelids has often baffled 
 
 Figure 74. Illustrating Hasner's plan of removing neoplastic disease seated 
 in the eyelids at the inner angle; the appearance after sutural closure is shown 
 at the right. 
 
 or puzzled the adroit surgical hand. A single flap with an open 
 or reentrant angle may be used ; or two flaps may be used. The 
 method with two flaps is the more usual one. Hasner thus filled 
 a large defect at the inner angle by means of an upper and 
 
BLEPHAROPLASTY. 
 
 493 
 
 lower flap, falciform in shape ; the beak-like end of one flap looks 
 outwards, while the other points inwards. These flaps form an 
 angle when folded together. 
 
 When the defect is triangular, and beneath or above the eye, 
 and its base occupies the greater part of the border of the lid, 
 the breach may be closed by means of a rhomboidal flap. 
 This is to be formed on the side of the defect: on the temple for 
 the upper lid, and on the cheek for the lower one. This rhom 
 boidal flap may be formed more or less obliquely, according as 
 circumstances demand. The wounds made can be closed by 
 suture. 
 
 The triangular defect below or underneath the eye may also 
 be closed by lateral sliding, after subjacent dissection of the 
 replacing derm. But as the contiguous surface will be wrinkled 
 in the act of closure, this can be obviated by the excision of a 
 triangle, according to Burow's method. This method has been 
 described in the chapter on Plastic Surgery, and is shown in 
 Figure 75. 
 
 
 Figure 75. Illustrating Burow's method of removing a portion of the 
 lower eyelid; also subsequent closure after excising a triangle from the temple; 
 the sutural closure of the wounds is shown at the right. 
 
 In the work of blepharoplasty there has been an attempt 
 made to transplant a flap with the semblance of eyelashes. 
 This has been done by so incising a flap that it should contain 
 on its margin some hairs of eyebrows. This ingenious conceit, 
 like many others, though laudable in purpose, would rarely 
 accomplish more than to mar an eyebrow, and form an unsightly 
 eyelash. The w^ork will be better done by him who, in the 
 probably near future, learns to transplant hair bulbs. 
 
 In case the lachrymal sack must be opened, and its wall so 
 
494 DISEASES OF THE EYELID. 
 
 destroyed tliat there will be an escape of tears afterwards, a 
 recourse may be had to removal of the lachrymal gland. It has 
 been found that the conjunctiva retains its moisture though this 
 gland be absent. Tiie moisture is maintained by the secretion 
 from ghmds which exist in the cul-de-sac, or concealed recess of 
 the conjunctiva. In fact, the secretion of tears is intermittent, 
 only occurring under the influence of emotion, or an irritation of 
 the membrane: for example, from a foreign body lodged in the 
 eye. These structural conditions i)ermit the eye to dispense 
 with the lachrymal gland, in case some defect in tlie tear- 
 conducting passage may demand the removal of the former. 
 
 The lachrymal gland was thus extirpated by the writer in a 
 case in which the lachrymal sack was destroyed in an operation 
 for the removal of a cancerous growth. The work was done by 
 extending the outer commissure by a horizontal slit; thus the 
 upper lid was uplifted in its outer half, and the gland extir- 
 pated. Instead of elongating the outer angle, the work may bo 
 done, as Tillaux advises, through an incision made horizontally 
 above the external angular process of the frontal bone; this cut 
 is made an inch long, through all the soft parts to the bone. 
 These parts, including the periosteum, are then to be reflected 
 downwards, following the bone into the orbit, until the gland is 
 reached. This lies between two layers of the periosteum, one of 
 which separates the gland from the bone, and the other layer 
 separates it from the conjunctiva. Through such a route the 
 gland can be reached and removed without entering the cavity 
 of the conjunctival pouch. It will facilitate the operator greatly 
 in this work if he precede his operation on the living subject by 
 one on the cadaver. To distinguish the structure of the gland 
 from adipose tissue is not so easy as the inexperienced might 
 suppose. Without occasional anatomical rehearsal, facts which 
 have been firmly fastened in memory become loosened and 
 obscure. The site and relation of parts, however firml}^ chained 
 in the mental field, gradually relax their tethering. These 
 conditions and limitations of our knowledge demand attention, 
 whenever the surgeon's scalpel essays an unfamiliar task. 
 
 Tumors Arising from the Orbital Wall. — The bon}- wall of the 
 orbit is the occasional site of tumors which demand curgical 
 intervention; as such may be mentioned the osteoma and the 
 myxoma. 
 
 Examples of the osteoma springing from the bony wall have 
 been observed, in which the growth, not being interfered with, 
 
TUMORS ARISING FROM THE ORBITAL WALL. 495 
 
 attained such size as to crowd on tlie eyeball and disturb or even 
 destroy vision. Such osseous growth ma}' spring from any por- 
 tion of the wall; or it inay arise from one of the adjacent fossae, 
 as the frontal or maxillary, and proceed thence towards the 
 orbital cavity. The growth may spring from the bone or from 
 its investing periosteum. In structure it may be similar to nor- 
 mal bone, or it may be of ivory hardness. The pedicle, when 
 sucli exists, has but little tendency to enlarge; the growth is 
 more eccentric, and may attain considerable dimensions; one 
 removed by Maisonneuve measured seven inches in circumfer- 
 ence. On section, the normal osseous tumor presents cartilagi- 
 nous content; but when it is of the eburnated or ivor}" species, it 
 is wholl}^ solid. This eburnated osseous tumor arises nearly 
 always from the ethmoid or frontal bone. "When divided by the 
 saw, it presents a stratified appearance. It is probable that the 
 ivory form differs only from normal osseous tumor in being 
 older; that is, it has become hardened by greater age. 
 
 The intra-orbital osteoma wdien seated deep may remain for 
 some time, without any visible indication of its existence, except 
 some pain in the eye; later, the bulb protrudes; signs of com- 
 pression on both vessels and nerves become then more manifest; 
 the eye is congested aiid painful, and as the tumor enlarges, it 
 forces the eye in a direction opposite to the site of the growth. 
 And this deviation aids in diagnosing the tumor's location. 
 
 Treatment. — The intra-orbital osseous tumor, w'hen of small 
 volume, and when it has ceased to grow, may be allowed to 
 remain; the removal of it would cause more disturbance to the 
 eye than the osteoma itself. It is seldom that it has this harm- 
 less character; for, continuing to grow, its encroachment on the 
 eye will finally prove fatal to that organ. Thus Textor saw^ and 
 operated on a case, in 1865, wdiich had reached the enormous 
 volume of a child's head; the tumor had crowded on and wholly 
 destroyed the eye. Textor removed this tumor by splitting it, 
 and extracting the fragments in sections. There remained a 
 great breach, opening into the nose, and antrum of the upper 
 ja-w. AVith hints from the disaster wdiich may result from per- 
 mitting such developing tumor to pursue its own course, it should 
 be removed early. And this is done by a horizontal incision 
 through the attached portion of the lid; or, instead of this, a route 
 may be made by slitting outw^ards the external commissure. By 
 one of these routes carried inwards alongside of the bony wall, 
 the growth can be reached and detached from the wall, by means 
 
496 DISEASES OF THE EYELID. 
 
 of ii chisel and mallet, or a gouge ; and if the growth be volumi- 
 nous, it should be divided with a resection saw or bone forceps. 
 The base or pedicle should be wholly removed, so as to prevent 
 recurrence. 
 
 A growth similar to the osteoma is the osseous cyst. An 
 example of this kind has fallen under the observation of the 
 writer. This was seated in the inner portion of the orbit, occupy- 
 ing a quadrant of the orbital margin. It was mistaken for a solid 
 osseous tumor until its true nature was revealed by the operation 
 undertaken for its removal. The tumor was found to have a 
 wall less than a line thick, and to be filled with a myxomatous 
 material, and more than a half ounce in amount. The cavity, in 
 which this was contained, reached upwards into the frontal bone, 
 and, internally, it occupied the right lateral mass of the ethmoid 
 bone. The lachrymal bone was uplifted and formed a part of 
 the wall of the tumor. A section of the right nasal bone was 
 likewise uplifted. The structure and connections of the tumor 
 were such that in its removal a breach was made into the contigu- 
 ous bones. The removal was done through a semilunar incision 
 with concavity looking outwards and somewhat downwards; and 
 the investing soft parts were carefully uplifted, and afterwards 
 reclosed, over the breach, by metallic sutures. Drainage was 
 maintained through a tube, of which the lower end pas.sed 
 through the right nasal passage, escaping through the nostril. 
 Through this tube the cavity of the wound was daily cleansed b\' 
 irrigation. The wound healed rapidly, and tlie skin, wdiich 
 closed it, did not sink so as to disfigure the boy's face. The tear 
 pa.ssage into the nose was wholly destroyed in the operation. 
 Yet the secretion found its way through the remaining canalic- 
 ulus into tlie breach which had been made. After a period of 
 two years there was no recurrence of this growth, though the 
 myxomatous nature of the neoplasm rendered it probable that 
 the operation would give but temporary relief 
 
 Tumors Originating within the Orbit. — Tumors benign as well 
 as malignant arise w^ithin the orbit. Of the benign species the 
 lipoma and fibroma occur here. 
 
 The lipoma has been observed here in a few cases; its more 
 frequent occurrence might have been suspected, when one takes 
 into account the adipose couch on which the globe of the eye 
 rests. Such growth when verified should be removed througli 
 an incision made in a properly selected site. A drainage tube 
 of small calibre should be introduced in most cases, and a com- 
 
TUMOES ORIGIXATIXG ^VITHIX THE ORBIT. 497 
 
 press saturated with cold water should be retained on the eye for 
 a few days. 
 
 The fibroma occurs as an orbital tumor, and, like the lipoma, 
 it is slow in its developmeut. It may become so large as to fill 
 the orbit and destroy the eye. It may likewise present eccentric 
 development, and penetrate the adjacent cavity of the nose, or 
 the frontal or maxillary sinus. This tumor arises from the 
 periosteal covering of the orbital wall; and, also, some claim, from 
 the fibrous sheath of the optic nerve. The treatment should be 
 similar to that of the lipoma, viz., removal with the knife. 
 
 Ryba, in 1853, described a wartlike growth arising from the 
 ocular conjunctiva, which was probably fibromatous in character. 
 Four cases were seen in man and two in the eyes of animals. 
 This growth was white, yellowish or reddish wdiite in hue, and 
 was covered with hairs of different lengths, color and size. Some 
 of the tumors which were examined were found to resemble 
 normal skin which produces hairs. And from this dermal 
 resemblance Ryba proposes as name for this tumor, conjunctival 
 dermoid tumor. Perhaps it may be a heterotopic production of 
 embryonic life, in which fragmentary segments of derm have 
 become displaced. 
 
 The proper treatment of this dermal fibroid is through extir- 
 pation; and, to prevent recurrence, there should be applied to 
 the site of the operation some astringent application, as the sul- 
 phate of copper, or nitrate of silver; likewise the tincture of 
 opium may be applied. 
 
 Sarcoma and epithelial and melanotic cancer have their origin 
 in the soft parts of the eye. 
 
 A form of sarcoma seen by several observers presents numer- 
 ous small cavernous spaces in its structure, and from this cir- 
 cumstance, it has been denominated cavernous fibroid. Accord- 
 ing to Virchow, it has its origin in the adipose tissue of the 
 orbit. It is usually seen in the young subject. Through 
 encroachment on the bulb, exophthalmos finally arises. It may 
 send prolongations into the adjacent cranial, nasal or maxillary 
 cavities, and, through pressure, cause functional disturbance in 
 these situations. This tumor rarely ulcerates, nor is it attended 
 by the cachexy of cancer. 
 
 The proper treatment is radical extirpation; yet the removal 
 is commonly followed by a regrowth of the tumor. Xelaton, 
 Pean and others report cases of sarcoma in the orbit, in which 
 there was recurrence, and repeated operations were done. The 
 
49S DISEASES OF THE EYKLID. 
 
 author has observed three cases, all in children, in whom there 
 was a recurrence, and repeated operations were done until death 
 occurred from exhaustion. In order that the removal should be 
 done as etfectually as possible, the work of the scal[)el should be 
 followed by that of the thermal cautery. The actual cautery can 
 scarcely be employed with safety where the eye is retained, lest 
 the latter be endangered; also, when heat is employed in the 
 upper part of the orbit, the thinness of the supra-orbital plate 
 should be remembered. 
 
 Epithelial cancer may commence in the lid; more frequently 
 it is an immigrant from contiguous structures which were pri- 
 marily attacked; and in the latter case, the most frequent site of 
 the growth is the derm of the adjacent side of the nose. The 
 writer has seen many cases in which the epithelioma appeared 
 secondarily in the eye; attacking then the lid, or entering the 
 commissure, the disease appeared on the conjunctiva. In several 
 cases the epithelioma began on the cheek and traveled thence 
 to the lower eyelid. In all these cases, the growtli commences 
 as a slight elevation of the surface, of rounded border, and con- 
 sists of a multiplication of the epithelial strata. This initial 
 growth has a whitish aspect, and, if the epidermal covering be 
 removed, the subjacent papillary layer will be seen to be prom- 
 inent. Such a growth commences to disintegrate at its central 
 point, and as this ulcer enlarges, the peripheral border advances. 
 It develops peripherally; and if near a palpebral commissure, 
 the advance is more rapid in tliat direction than elsewhere. 
 
 The treatment should be removal of the growth with the 
 knife, or its destruction by cauterization. If the knife be 
 resorted to, it should be used early and unsparingly. The 
 author has been taught by unfortunate experience that econo- 
 mizing the tissues for the purpose of avoiding a scar is certain 
 to be followed by a return of the epithelioma; and, to shun this, 
 if excision be resorted to, let it, besides including the affected 
 structure, pass three or four lines be3^ond into the sound surface. 
 
 Unfortunately, malignant disease does not limit itself to the 
 superficial species here described, and carcinoma of the most 
 intractable character, viz., melanotic cancer, frequently attacks 
 the eye. This growth occurs in childhood and youth, and is 
 seldom seen in mature or advanced age. Melanoma, as the dis- 
 ease is designated by the pathologist, has been the subject of 
 disagreement among those who have clinically studied this 
 growth; while many have pronounced it eminently malignant, 
 
TUMORS ORIGINATING WITHIN THE ORBIT. 499 
 
 others declare it curable by an operation; thus Pamard, in 1853, 
 finding that the disease did not recur after removal, decided that 
 it is not malignant ; on the contrary, Stoeber found that it 
 recurred, and reappeared metastatically in distant parts, viz., in 
 the liver. 
 
 Sichel, in 1856, in his study of melanoma seated in the orbit, 
 found that the disease commences in the fundus of the •eye; 
 thence it grows forwards, and finally pierces the anterior wall. 
 The melanotic material was found to be similar to that contained 
 in the choroid membrane, and in this matter were found carbon 
 and iron. 
 
 St. Lager and Hervier think that melanotic material arises 
 from an excessive production of the normal pigment of the body. 
 When the melanoma occurs in other parts of the body, these 
 writers find that it may be encysted or non-encysted; and in some 
 cases it may appear in liquid form; also in the form of a mem- 
 brane 
 
 The writer has seen a few cases of melanoma seated in tlie 
 eye; and all were in children. In its early stage, since it is then 
 painless, it may escape detection for a time; later, the eyeball 
 protrudes until, finally, the lids cannot be closed; and, at length, 
 the distended ball bursts at some point, and, through the rent, 
 there is forced out the gelatinous melanoid material character- 
 istic of the tumor. The site of the rupture is commonly in the 
 anterior portion of the sclerotic coat. When the disease has 
 reached this stage, its most remarkable feature is rapidity of 
 growth. Vision is lost at an early period. Like all rapidly 
 developing malignant growths, there is an absence of glandular 
 afi'ection. 
 
 Heyfelder and other surgical authorities, who have written on 
 the treatment of malignant disease of the eye, advise an early 
 removal of the affected part ; thus doing, Heyfelder thinks it pos- 
 sible to preserve the eye. This conservative action, the writer is 
 convinced, is rarely the proper one; he has never had to regret 
 too extensive excision; but pursuing the contrary method has, in 
 several cases, been followed by a recurrence which brought with 
 itself the necessity of a more wholesale sacrifice than primarily 
 would have been necessary. Whether a cell, liquid content, or a 
 microphyte be the factor of propagation, this agent soon finds 
 un.guspected lodgment in the contiguous structures, too often 
 beyond the line of excision. Hence, as a guiding rule in all 
 cases of malignant disease situated in the structures which lie 
 
500 DISEASES OF THE EYELID. 
 
 around the eye within tlie orbit, the bulb, including the intra- 
 orbital tissue, should be removed. And the same rule should be 
 followed if the case be melanotic cancer affecting the eyeball. 
 Enucleation, with retention of a portion or the entirety of the 
 •ocular muscles, so that an artificial eye may be worn, is nearly 
 always followed by a reappearance of the disease. This has been 
 verified several times in the author's practice. Excision conserv- 
 atively done was followed by recurrence, demanding a second, 
 and then a third, and a fourth operation, until nothing more 
 remained to remove. His experience leads the writer to formu- 
 late the rule that, wherever the ocular tissues have become the 
 seat of sarcomatous or carcinomatous disease, the knife should 
 only be stayed by the naked walls of the orbit. In work thus 
 done, the bare bony wall does not become necrosed, as might be 
 exi>ected, but it becomes covered with a cicatricial investment. 
 Should the bony wall be attacked, then the affected surface should 
 be removed with a chisel or gouge, and the remaining structure 
 be thermally cauterized. The cautery must not be applied to the 
 supra-orbital plate, lest the heat should injure the superjacent 
 cerebrum. The writer has known death to occur from such inad- 
 vertency. 
 
 Foreign Bodies in the Eije. — From the grave aff'ections of the 
 eye just considered, the writer passes by a pleasant transition to a 
 matter of minor moment; this is a foreign body which has acci- 
 dentally lodged on the surface of the eye, the removal of which 
 often calls forth an outburst of gratitude from the relieved patient. 
 The pain from this corpuscular object is greater when it is lodged 
 between the bulb and the lid than when it lies on the free surface. 
 The pain is very acute when the object has become imbedded in 
 the exposed portion of the cornea. A grain of sand or iron when 
 lodged in the eye, if rough in surface, as it usually is, is extremely 
 painful, and, owing to the insolubility of such object, it will con- 
 tinue to irritate until the object is removed. 
 
 Of all the objects which lodge in the eyeball, there is none 
 more perilous than the arista, or awn, of certain grains. This 
 awn, or beard, as it is familiarly called among farmers, is the 
 sharp projecting process in which ends the husk containing the 
 grain of barley, rye, wheat and oats. This little object, barbed 
 as it is laterally, when it becomes entangled in the conjunctival 
 structure, tends to penetrate and become faster in its hold. And 
 the danger is especially great when the awn has entered the 
 cul-de-sac of the conjunctiva, and has become concealed through 
 
FOREIGN BODIES IN THE EYE. 501 
 
 swelling of the conjunctival tissue. In such a case the move- 
 ment of the eyeball and the compression and motion of the lid 
 tend to bury the object and wholly conceal it. Thus situated, 
 the awn has led to suppuration and destruction of the cornea. 
 
 Treatment. — In the case of an object wdiich is of smooth 
 surface, the irritation awakened acts reflexly on the lachrymal 
 gland and causes profuse lachrymation, and the object may thus 
 be floated out of the eye. To aid in this washing out, the patient 
 should close his eyelids until the tears have collected under- 
 neath; then, suddenly opening the eye, the offender may be 
 borne away in escaping flood. Or with a little self-control, if 
 the eye be committed to its own unaided actions, the object may 
 be expelled spontaneously. 
 
 But if the object be a fragment of metal or a cinder or grain 
 of sand with sharp edges, and is partially embedded in the 
 corneal or conjunctival structure, then the removal demands 
 address and tact on the part of the surgeon. The first act will 
 be to prepare the eye for manipulation by applying to it a five 
 per cent solution of muriate of cocaine. Such a solution in ten 
 minutes deprives the eye of sensation, so that the bulb can be 
 touched, and no pain or unpleasant feeling is experienced by the 
 patient. The patient should also be told that the cocainized eye 
 wall, through the mydriatic action of the agent, be rendered 
 unfit, for a short time, for common vision; this will vanish in a 
 few hours. If not visible, the object must be searched for by 
 turning each lid outwards. The patient is rarely able to locate 
 the object correctly. To search, draw down the lower lid, while 
 the patient rolls the ball upwards. If not found there, evert the 
 upper lid by folding it on the proximal border of the tarsal 
 cartilage, or which may aptly be called the joint of the upper 
 lid. During upward eversion, the eye should be directed down- 
 wards, since thus the superior conjunctival pocket will be 
 unfolded, and its complete exploration is easily done. In the 
 majority of cases, the body will be found adherent to the pal- 
 pebral conjunctiva. The object is usually of gray or black hue, 
 thus contrasting with the red color of the deeply injected con- 
 junctiva. 
 
 AVhere the object is non-adherent and merely lies on the eye- 
 ball or the lid, it can readily be wiped off with a soft linen or 
 silken cloth; but if it has fixed itself in the corneal or con- 
 junctival structure, the removal is more difficult. In such a 
 case, if the particle be lodged in the bulb, it will be necessary to 
 
502 DISEASES OF THE EYELID. 
 
 fix this by means of forceps. The blades of the forceps should 
 be smooth and not serrated, since the latter, in tlieir clasp, 
 wound the structure. The cocainized bulb being thus caught 
 and held, the foreign body is to be detached with the needle- 
 pointed instrument used by the oculist for discission of the 
 cataractous lens. If the object be fixed in the cornea, the 
 detaching needle should be passed under one of its sides, and 
 then uplifted. In case the body be a })article of iron which 
 leaves a stain of rust on the cornea, this stain should be carefully 
 removed with the detaching-needle; since, if allowed to remain, 
 the iron rust may, like a salt of lead or silver, become afterwards 
 incorporated with tlie corneal tissue. After such manipula- 
 tion, the eye should be covered, for some hours, with a compress 
 wet in cold water. 
 
 In case the irritating body is not found, and is suspected to 
 be lodged in the bottom of the conjunctival pocket, that recess 
 must be diligently explored. Such search is often rewarded by 
 discovery of the irritating body. If the fatal awn of a member of 
 the Graminese be hidden there, its presence will soon be revealed 
 by tumefaction in the part, from local conjunctival inflammation; 
 and in the midst of the pouting swollen tissue, the object is buried. 
 Likewise, particles of exploded molten metal may enter, and 
 remain hidden in this conjunctival cul-de-sac. To aid in the 
 search, after eversion of the lid, the rounded end of a silver ])robe 
 may be used; thus metal is readily detected. I'he history of the 
 case must give some indication of the object to be sought for; 
 especially, if the eye has been injured by melted metal. Again, 
 if a child, whose sports expose him to the awned Graminea?, 
 becomes suddenly affected with tumefaction of one or both eye- 
 lids, a pretty accurate guess of the causal agent can be made; 
 and in such case the tumefied structure should be thoroughly 
 searched. 
 
 Tlie barbed sides of the awn favor advance and not return 
 of the object; and thus, after a time, it invariably buries itself, 
 and, if not found and extracted, it will later reveal itself in a 
 shred of gangrenous tissue, when the eye has been lost through 
 destruction of the cornea; to avert sucli a catastrophe, the sur- 
 geon must early fi.nd and remove the destructive agent. 
 
CHAPTER XIV. 
 
 SURGERY OF THE MALAR AND PAROTIDEAX REGIONS OF THE 
 
 FACE. 
 
 A LARGE portion of this region of the face in the male is cov- 
 ered with beard ; the surface thus invested varies in individuals. 
 Paucity of beard is a characteristic of the Mongolian race. The 
 subcutaneous adipose couch over the most of these regions is 
 closely adherent to the derm; this is especially true of the malar 
 region; and, owing to this fact, the derm here is not well suited 
 for operative plastic work. Commencing in front of the parotid 
 gland, contiguous to the parotidean duct, lies a layer of adeps, 
 which is augmented in mass in front of the masseter muscle; 
 and this adeps, lodged beneath the front border of the masseter, 
 loosel}' surrounds the terminal end of the parotidean duct. Ten- 
 sion of the duct is thus lessened, and the discharge of the 
 escaping saliva is not hampered by the varying volume of the 
 masseter in mastication. The muscles situated in these regions 
 may, when functionally considered, be divided into two classes. 
 In the one class concerned in mastication are the masseter and 
 buccinator; while the other group comprises muscles which, 
 besides lifting and depressing the lips, are mainly concerned in 
 emotional and other mental manifestations. These muscles con- 
 cerned in expression are imbedded in, and adherent to, the 
 subcutaneous adipose tissue, and they differ from most muscles 
 in having no sheaths within which they can glide; and, hence, 
 wounds severing these muscles, gape but little. If the surface of 
 the face be examined in the adult, and especially in the aged 
 subject, certain furrows will be found, which arise from the 
 action of underlying muscles. There are three series of such 
 furrows; the first series is situated on each side of the root of the 
 nose; a second series on each side of the wings of the nose, and 
 the third includes the angles of the mouth. Attention to the 
 site of these furrows is necessary in certain plastic procedures in 
 this region. Lines of incision following such normal furrows will 
 
 (503) 
 
504 MALAK AND PAROTIDKAN EEGIONS. 
 
 leave less conspicuous cicatrices. Thus the adroit plastician 
 hides the vestiges of his work in the footprints wliich time lias 
 left, or will leave, on the human face. 
 
 The supply of blood to this region is mainly derived from 
 the facial and the transverse facial branches of the external 
 carotid, and from the temporal arteries. The deeper structures be- 
 low the eye are supplied b}^ the infra-orbital artery; thus they get 
 their blood by a circuitous intra-cranial route from the internal 
 carotid. The variability of volume of the facial arter}^ should be 
 remembered; it often reaches tlie ala of the nose as a vessel of 
 moderate calibre; or it may be so attenuated on the side of the 
 face as scarcely to demand a ligature if it be opened. The 
 arteries of the face are remarkable for tlieir intercommunication; 
 they anastomose freely among themselves, and also with the 
 arteries of the opposite side. Hence, compression of the facial 
 artery, where it lies on the lower jaw, as is sometimes done to 
 control bleeding during operations on parts supplied by its 
 branches, controls the haemorrhage only imperfectly; torsion or 
 ligation should be done at the site of injury. 
 
 The facial region is traversed by the facial vein, which soon 
 acquires some magnitude; this vessel is found below the inner 
 angle of the eye and passes down from that point to the angle of 
 the lower jaw, where it turns inwards to meet and end in the inter- 
 nal jugular vein. The facial vein lies behind the facial artery; a 
 slight interval separates the two until they roach the anterior 
 inferior angle of the masseter muscle; here they lie close to each 
 other. In their transit on the face the artery and vein lie on the 
 buccinator, and beneath the zygomatic muscles. 
 
 The terminal branches of the facial nerve are distributed to 
 the muscles of the face; and if one or more of these branches be 
 severed, there will follow a corresponding palsy of the parts. 
 
 Wounds of the Clucek and Side of the Face. — The exposed situa- 
 tion of the cheek and the side of the face renders this region the 
 frequent site of injuries. Such lesions are, most frequently, 
 laceration and contusion, and the incised wound. The gunshot 
 wound has occasionally its site here; and, oftener than the pro- 
 jected missile, the powder leaves traces of its action on the 
 skin. 
 
 Contusion without laceration is frequent. In this injury the 
 tearing of the subcutaneous vessels pours out blood, whence 
 isolated swelling quickly occurs. The amount of the tumefac- 
 tion is a fair measure of the grade of violence. If the bruise 
 
WOUNDS OF CHEEK AND SIDE OP FACE. 505 
 
 be on the lower part of the cheek, the tumefaction will be 
 confined to that part; but if the injury be near the eye, the 
 effused blood quickly finds its way to the eyelids, which often 
 swell so as to close the eye. This frequent result of facial con- 
 tusion is one of its most disagreeable accompaniments; for the 
 "black eye," as it is called, socially banishes its owner for a few 
 days. Also the effused blood often leaves at the point where it is 
 poured out an induration and enlargement for a long period. 
 Hence, from the circumstances mentioned, the facial contusion is 
 sufficiently important to demand careful treatment. The objects 
 aimed at by the treatment should be to prevent the effusion of 
 blood, or, if effused, to favor its dispersion and absorption. If the 
 case be seen at its onset, the escape of blood into the tissues may 
 be impeded by methodical pressure made over the injured part. 
 For this a sheet of paper folded into a compress and laid on the 
 part and retained there for twenty hours, by means of broad 
 strips of adhesive plaster and a roller, will prevent further effu- 
 sion. But if the effusion has occurred, then dispersion can be 
 accomplished by massage or kneading the part; and in this work, 
 as far as is possible, the material should be forced from the ej^e- 
 lids. In the event of there being a considerable collection of 
 blood already effused, direct evacuation of this has sometimes 
 been done through an opening made through the skin; the 
 experience of any surgeon will pronounce against this way 
 of proceeding, since, despite aseptic precautions, suppurative 
 action often ensues and a tedious healing with scarring is the 
 result. Should, however, the effused blood be near the oral 
 cavity, an intra-buccal incision might be made through which 
 the blood could be evacuated. 
 
 In case the wound be a laceration with contusion, the effused 
 blood finding outlet does not require attention as in the j^receding 
 case ; but the torn wound must be treated wuth unusual care to 
 avoid a disfiguring mark ; and, for this purpose, the fringed 
 borders must be carefully trimmed off~- and the edges accurately 
 coaptated by fine catgut or metallic suture, after the wound has 
 been well washed with a sublimated alcoholic solution. The 
 wound should afterwards be covered with a compress, which must 
 constantly be retained moist with the same solution. Sometimes 
 the author has dressed with lint saturated with the compound 
 tincture of benzoin, wdiich is placed and retained on the part 
 with adhesive plaster. Thus union with slight scarring may 
 sometimes be obtained; yet there is more danger of failure from 
 33 
 
506 MALAR AND PAROTIDEAX REGIONS. 
 
 suppuration tliau if llie moist dressing just mentioned be used. 
 Under the benzoated application the sutures may remain longer 
 than the}'' should under the sublimated alcoholic dressing; in the 
 latter case the sutures, if metallic, should all, or nearly all, be 
 removed at the end of the second day. If catgut suture be used, 
 it rarely requires removal, since it usually disappears by absorp- 
 tion. When the dressing is frequently changed, there is the 
 advantage that the condition of the wound can be inspected; so 
 that if there be signs of suppurative action, as shown by redness 
 and swelling of the p[irt, tlien the lowest angle of the wound 
 should be opened, and the semi-purulent fluid allowed to escape; 
 and this escape will be favored by the moist compress; thus 
 watchfully treated, such a wound may heal almost as rapidly as 
 by first intention. 
 
 An open contused wound of the face may closely resemble an 
 incised one, viz., a wound over ctne of the bony prominences 
 which has been caused by a fall or an attack with a blunt object, 
 as a club or stone. The site of such wound may be the margin 
 of the orbit, the malar bone, the zygomatic arch, and the angle 
 or the margin of the lower jaw. The wounds of this class some- 
 times lie within the domain of forensic medicine; and their causal 
 agencies are favorite matters of controversy on the part of legal 
 counselors in their efforts to balance the scales of justice; efforts 
 which sometimes rather jostle than adjust the equipoise of these 
 scales. In such cases the surgical expert should be as blindly 
 impartial as Themis, before whom he stands. Should, however, 
 the expert become a partisan, he debases his science, and usually 
 reveals his false position by being drawn into contradictions, in 
 which disloyalty to truth surely entangles him. The treatment 
 of such wounds is similar to that of the incised class; in most 
 cases the edges should be trimmed, and union accomplished by 
 sutures. The moist aseptic dressing before mentioned should be 
 used; and if suppurative action impends, the sutures (or certainly 
 some of them) must at once be removed. 
 
 Incised wounds in the anterior portion of the face, as a rule, 
 gape less than wounds in other parts of the body. Bleeding is 
 not profuse unless the facial artery is severed. One or more fila- 
 ments of the facial nerve may be severed, and palsy of the 
 muscles which are supplied by the injured nerve may result; 
 thus an awkward expression of the face can originate. Such 
 might arise from a deep wound, running in a vertical direction, 
 that is, at right angles to the branches of the facial nerve. And 
 
WOUNDS OF CHEEK AND SIDE OF FACE. 507 
 
 this fact should be borne in mind in making incisions in this 
 region ; if possible these should lie in the horizontal and not in 
 the vertical plane of the face. 
 
 The incised wound here is to be treated in the same way as 
 elsewhere; bleeding should first be wholly arrested, and the mar- 
 gins of the wound accurately apposed and retained so by sutures. 
 Though all wounds here bleed freely in consequence of free vas- 
 cular inter-communication, yet, unless the facial artery be opened, 
 such hemorrhage usually ceases spontaneously if exposed to the 
 air for a few minutes. Should some arteriole continue to bleed 
 longer, the suture may commonly be so introduced as to arrest 
 the bleeding; to do this, the suture must pass beneath the open 
 vessel; if it pass above it, bleeding continues unseen and sepa- 
 rates the walls of the wound. Should the facial artery be 
 divided, it may be closed by ligature or torsion; the author pre- 
 fers the latter. The vessel should be caught at its end and 
 twisted three or four times around its axis. The dressing should 
 be the alcoholic sublimated compress. 
 
 In case of a gunshot wound, the missile, if lodged, should be 
 removed if it is accessible and extraction is practicable. The 
 removal of the bullet, if it will not entail additional violence, 
 should be attempted, for such removal delights the patient, 
 pleases his friends, lulls the public clamor usually present for the 
 extraction of the missile, and jDossibly facilitates the recovery of 
 the patient. The wound in the soft parts should be managed 
 similarly to that of an incised or lacerated wound, according as 
 it resembles one or the other. 
 
 A lacerated wound of the cheek, if the causal agency be vio- 
 lent, besides tearing the soft parts, may also fracture the subja- 
 cent bone. Such injury the writer has treated a number of times ; 
 in the most of cases the cause was a blow from a horse's hoof; in 
 one it was from the thrusting blow of the horn of a cow, and in 
 another, from the shaft of a rocket. The wound of both soft 
 parts and the bone is generally in the form of a stellate rent. 
 In the adult, pieces of bone wholly detached from the soft parts 
 may be found forced into the maxillary sinus; this is less often 
 in the child and when the antrum is but slightly developed. In 
 both the adult and the child, the osseous fragments are generally 
 found adherent to the flap-like soft parts. There is commonly 
 not much bleeding, and the pain is not violent; since the vio- 
 lence acts like the ecraseur in occluding the vessels, and by its 
 concussion deprives the sentient nerves of their sensibility, the 
 
508 MALAR AND PAROTIDEAX KKCilOXS. 
 
 liaemorrhage is seldom great, and tlie pain is small in i»ioportion 
 to the violence done. 
 
 The wounds of this class necessarily entail deformity, which, 
 in some instances, frightfully alters the patient's face. In the 
 wound seen by the author in which a cow's horn was thrust into 
 the cheek of a girl, the malar and superior maxillary bones were 
 fragmentarily broken. The cheek and lower eyelid were torn, 
 with the effect tliat the features on tliat side were blotted out 
 and replaced by radiating scars, and the eyelid, as a misshapen 
 mass, remained folded downwards. Some plastic work, done after 
 the wound had healed, somewhat improved the wretched figure 
 of the child. The wound caused by the rocket was of a yet more 
 severe character; the eyeball, the lower lid, and a portion of the 
 soft parts of the cheek were lacerated. The front face of the 
 superior maxilla was broken into several pieces. The wooden 
 shaft was left remaining in the wound, and, in the attempt to 
 extricate it by some non-medical hand, it was broken, and a por- 
 tion of it remained behind. The first surgical aid endeavored 
 to remove the part imbedded in the skeleton of the face, and this 
 was thought to be done until, the wound not healing, further 
 search discovered another fragment of wood. After this the 
 wound healed, leaving a fragmentary cheek. 
 
 The author would remark that in all similar wounds on the 
 face or elsewhere, caused by the penetration of a pointed frag- 
 ment of wood, in the act of extraction there is always a risk of 
 leaving a portion behind, especiall}' if the material be the red- 
 wood, so much in use on the Pacific Coast. If such fragment is 
 left, the time of healing will be indefinitely prolonged, and will 
 only terminate when the wound has been explored to its ultimate 
 recess, and the foreign bod}^ removed. 
 
 The region of the face here under consideration is seldom 
 the site of neoplastic development, except the superficial angioma, 
 which is a frequent occupant of the cheek. The treatment is 
 similar to that which has been heretofore explained. 
 
 Scrofulous Ulcer. — There ai:»pears here an obstinate form of 
 ulceration, which is analogous to tubercular disease. In some 
 cases seen by the writer this ulcer appeared as a single point; in 
 others, as multiple fjoints about the middle of the clieek, and 
 oftenest over the line of the duct of Steno. The affection first 
 appears as a soft tumefaction of the skin, and not exceeding a 
 line in breadth. This grows peripherally, but does not penetrate 
 deeper than the. skin. The outer portion of the affected part 
 
PAROTIDEAX REGION OF THE FACE. 509 
 
 becoming detached, there remains an ulcerated surface, which is 
 moistened by an adhesive, serum-like fluid. The affection may 
 appear at several separate points, which, pursuing the course 
 mentioned, may fuse together and occupy a large portion of the 
 cheek; or the ulceration may spread from a single center. Sim- 
 ilar to other ulcers, the affected surface may heal centrally while 
 it is spreading peripherally; healing, however, is rare, unless the 
 case be properly treated. 
 
 The tubercular or scrofulous diathesis obtains in the subjects 
 of this ulceration. 
 
 Treatment. — The cachexia present must be combated by appro- 
 priate means: iodine, arsenic, iron, proper food, and life in the 
 open air. If the local affection be yet limited to a small point, 
 it may be removed with the knife, and closure by suture be 
 effected; to accomplish this, however, scrupulously aseptic work 
 must be done, else the operation will be followed by a tediously 
 cicatrizing wound. And even despite such care, failure to obtain 
 immediate union so often occurs that the writer usually follows 
 another treatment. This plan was only arrived at after trials of 
 other methods ; these, in the main, consisted in first thoroughly 
 curetting the diseased surface, and then applying one of the fol- 
 lowing agents: iodoform, subiodide of bismuth, powdered rhu- 
 barb or ergot; under these local remedies, such a diseased surface 
 may heal, yet often it will not do so. A better method was 
 found to be to first curette the part thoroughly, cauterize the bor- 
 ders with the thermal cautery, and then, having washed with a 
 -20V0 solution of sublimate, let the part be covered with gutta 
 percha tissue paper. And tliis dressing, retained in place by 
 adhesive plaster, may remain unchanged until signs of suppura- 
 tion show themselves. At each dressing the surface should bo 
 washed with the dilute sublimated solution. Under this treat- 
 ment the author has succeeded in effecting the cure of an obsti- 
 nate example of the affection here referred to, which occupied a 
 large part of the right cheek. 
 
 As remarked, when the affection is limited, it may be treated 
 by excision, yet an objection to this plan is that occasionally, 
 instead of the resulting wound healing properly, there may 
 develop in its site a keloid scar, which will be difficult and some- 
 times imjDossible to eradicate. 
 
 Parotidean Region of the Face. — Of all the parts which lie 
 within the region of the face, none is more surgically important 
 than the parotidean district; hence, an accurate knowledge of 
 
510 MALAR AND TAROTIDEAX KKGIOXS. 
 
 tlie region is so necessary to the surgeon that the writer finds an 
 excuse for the extended section which here follows. 
 
 The parotidean boundaries vary in length as the head is 
 extended or flexed, and in breadth according to the movements 
 of the lower jaw. Its superficial limits are the following: above, 
 it is bounded by the auditory meatus and the temporo-maxillary 
 articulation; in front, by the posterior border of the maxilla 
 inferior; beiiind, by the anterior border of the sterno-cleido- 
 mastoid muscle and the mastoid process; and below by a band of 
 fibrous tissue, which is connected with the sterno-cleido-mastoid 
 muscle and the angle of the lower jaw. 
 
 If these bounds be viewed together, they form an oblong fig- 
 ure, of which the horizontal lines are much the shorter. 
 
 The gland is contained in a fascial envelope, of which the sides 
 originate and are arranged as follows: The aponeurotic or fascial 
 sheath of the sterno-cleido-mastoid muscle, after reaching the 
 anterior border and completely enclosing the muscle, divides into 
 an anterior and a posterior layer. Tiie anterior one passes in 
 front of the gland and fuses with the masseteric fascia. The 
 posterior stratum passes behind the gland, and forms a wall 
 between it and contiguous structures, and this partition is imper- 
 fect at the deepest part, where the gland lies near the wall of the 
 pharynx. This internal fascia is fastened to the styloid process, 
 and gives off processes which surround the muscles which are 
 attached to that process. The internal or deep la3"er of fascia, 
 after reaching the anterior border of the gland, fuses with the 
 anterior layer of fascia; and the united fascial structure passes 
 forwards and covers the masseter muscle. Between the sterno- 
 cleido-mastoid and the parotidean fascia there lies a mass of 
 tissue, trilateral in form, which may be the starting point of 
 fibromatous tumors Mdiich have no close connection with the 
 parotid gland. 
 
 If the fascial wall be examined in respect to its inferior por- 
 tion, it will be found complete and in relation with the fibrous 
 band which extends from the sterno-cleido-mastoid to the man- 
 dibular angle, and thus the wall here becomes strongly fortified. 
 But the superior part of the wall is incomplete where the gland 
 adjoins the cartilaginous portion of the external auditory canal. 
 The parotid gland, there, is completely isolated from the sur- 
 rounding structures by a closely fitting fascial wall, except at its 
 upper part, and at its internal or deepest part, where a process 
 like the end of a finger reaches through the containing fascia 
 
PAROTIDEAN REGION OP THE FACE. 511 
 
 above the styloid process and the internal carotid artery. Between 
 the deep portion of the gland and the wall of the pharynx lie 
 the following very important parts: the internal carotid artery, 
 the internal jugular vein, the pneumogastric nerve, the spinal 
 accessory, the glosso-pharyngeal, the hypoglossal, and the sympa- 
 thetic nerves, — parts so important that on their integrity depends 
 the continuance of life. The anterior border of the gland is 
 molded on the deep and superficial faces of the ramus of the jaw ; 
 the superficial portion is continued forwards on the masseter 
 muscle, and ends in the duct of Steno, its outlet. This anterior 
 process is sometimes named the accessory parotid. 
 
 The parotid and submaxillary glands, though analogous in 
 being racemiform glands, 3'et differ greatly in respect to their 
 fil)rous stroma; while that of the submaxillary is loose, that of 
 the parotid is compact, dense and resistant. And this unyield- 
 ing stroma interferes with swelling of the parotid, and renders 
 such swelling painful. 
 
 Two important structures traverse the parotid gland: the 
 facial nerve, which enters the deeper portion of the gland and 
 passes transversely through it and divides into branches, which 
 pass to the temple, cheek, and lower jaw; the other structure is 
 the external carotid artery, which, emerging from behind the 
 ramus of the jaw, at the union of the lower third with the mid- 
 dle third, enters the gland. This vessel enters the deep portion 
 of the gland and passes thence towards its surface ; that is, after 
 tlie artery enters the gland, it is continuall}^ becoming more 
 superficial. The external carotid, while it lies in the gland, divides 
 into the temporal and internal maxillary arteries; and these ter- 
 minal branches lie for a short distance in the upper part of the 
 parotid. The external jugular vein lies imbedded in the gland. 
 The external carotid is separated from the internal carotid and 
 the nerve, before mentioned, by the deep fascia, the styloid process 
 and the styloidean muscles; hence, in case of the tumor invad- 
 ing this site, the styloid process becomes a signal-head of warning 
 to the surgeon against penetrating deeper into this region, 
 bristling with anatomical perils. 
 
 The arteries mentioned, in their transit through the gland, 
 are closely adherent to the fibrous stroma of the gland; the ves- 
 sels lie in no loose sheath b}^ which they may be separated from 
 the gland, so that, to reach them, the parotidean structure must 
 be literally dug out or removed piecemeal. The facial nerve, on 
 the contrary, is so loosely attached to the structure which it trav- 
 
512 MALAR AND PAROTIDEAX RKfilOXS. 
 
 erses that it can be dissected out in the normal gland; if this, 
 however, is diseased, such dissection miglit be impossible. 
 
 An examination of the gland, proceeding from without 
 inwards, will meet successively the facial nerve, the external 
 jugular vein, the external carotid arter}^ and lymphatic glands; 
 the glands vary in number and position. 
 
 The anterior prolongation of the gland lies on the masseter 
 muscle, and sometimes reaches to its anterior border; this process, 
 as well as the duct which continues from it, lies between the two 
 fascial la3'ers before mentioned, which extends as far as the 
 point where the duct passes into the buccinator muscle. The 
 anterior prolongation of the gland lies in a line on the masseter 
 which is midway between the zygomatic arch and the lower bor- 
 der of the maxilla inferior. This prolongation of the gland is 
 accompanied by the transverse facial artery and branches of the 
 facial nerve. 
 
 The canal of outlet of the parotid gland, named the Steno- 
 nian or Stensonian duct, or the duct of Steno, lies deeper than 
 the normal subcutaneous fascia, and has an outer sheath formed 
 by a prolongation of the parotidean fascia; and within this outer 
 sheath there is another which surrounds the duct directly and 
 lies in contact with it. The parotidean excretory canal may be 
 divided into a masseteric and buccal portion, which lie respect- 
 ively on the masseter and buccinator muscles. 
 
 The masseteric portion appears as a white cord, a line and a 
 half in thickness; and from its beginning, though it is slightly 
 curved, it pursues its course forwards, until, reaching the ante- 
 rior border of the masseter, it is bent inwards, almost rectangu- 
 larly, and this sudden bend is an obstacle to the passage of a 
 sound into the canal. The canal, finally dropping its two fibrous 
 sheaths, curves suddenly inwards, and opens into the buccal cav- 
 ity opposite the first upper molar tooth. A cutaneous line drawn 
 from the aural tragus to the labial commissure overlies the parot- 
 idean duct (Tillaux). Hyrtl places the anterior end of the canal 
 somewhat higher; according to him tlje duct runs in a line 
 drawn from the tragus to the middle of the naso- labial sulcus. 
 No valves exi.st in the duct, yet the sudden infractions which 
 occur at two points are obstacles to the entrance of foreign mate- 
 rials. The canal is about sixteen lines long, and it opens into 
 the buccal cavity about sixteen lines behind the angle of the 
 mouth. 
 
 The excretory canals of the parotis and the submaxillary 
 
PAROTITIS. 513 
 
 gland differ in regard to their structure: that of the latter is soft 
 and analogous to that of a vein, while the parotidean duct is 
 much firmer, and has been compared to the teiise vas def- 
 erens. 
 
 Inflammatory Affections of the Parotid Gland: Parotitis. — The 
 leading constituent elements of the parotid gland are the fibrous 
 and the glandular; Tillaux claims, in opposition to most author- 
 ities, that inflammation of the gland begins in the fibrous ele- 
 ment; Virchow, on the contrary, teaches that the inflammator}^ 
 process begins in the glandular element, and extends thence to 
 the adjacent tissues. 
 
 Virchow, in 1859, claimed that the swelling is chiefly located 
 in the peri-glandular tissues, and the process is similar to that of 
 catarrhal pneumonia, prostatitis, and inflammation of the middle 
 ear. The inflamed glandular elements are red, and, in the com- 
 mencement, yield a thin catarrhal excretion; this excretion later 
 becomes purulent in nature. In the pus, one finds salivary cor- 
 puscles and pus-cells. In severe cases, the glandular elements 
 become disintegrated and mingled with the pus. Virchow found 
 portions of the gland thus destroyed, while the intermediate con- 
 nective stroma was not broken down. 
 
 The parotis has the same relation to the buccal mucous men: 
 brane as the prostate gland has to the genito-urinary mucous 
 membrane. 
 
 Pyaemia may result from such inflammation, and this may 
 be of the ichorrhgemic or of the embolic or metastatic form. 
 
 Virchow and Bamberger divide parotitis into three classes: — 
 
 1. Primary catarrh, which usually occurs epidemically; this 
 is limited to a simple catarrhal discharge, with no tendency to 
 suppuration or ulceration. 
 
 2. Secondary catarrh, in which pus and abscess appear, and 
 there is a coexistent oral or a|)hthous affection, or disease of the 
 middle ear. 
 
 3. A specific catarrh, almost always ending in an ichorous 
 discharge ; and this is commonly associated with some remote 
 ichorrhsemic or embolic metastasis. 
 
 Causes of parotitis are erythema or catarrh of the mouth ; and 
 the weather has an influence, as it appears oftenest in the cold 
 months of the year. 
 
 A single gland may be affected, yet both may be, and then 
 one usually precedes the other. 
 
 As events of parotitis are obstruction and swelling of the veins 
 
")14 MALAR AND PAROTIDEAN REGIONS. 
 
 of the temple and cheek, with oedema. The liead in general, and 
 the adjacent eye may suffer. From retarded movement of the 
 blood in the veins, coagulation can occur; and such clots may 
 decompose and become ichorous. Meantime, the contiguous 
 lymphatics and glands may become affected, and pus can form 
 in them. 
 
 Besides the constituent parts of the parotis, structures adja- 
 cent may become implicated: viz., the adjoining muscles, the 
 middle ear, and even the temporal bones and the subjacent dura 
 mater may become affected. And in the worst cases, the morbid 
 process passes through the meninges and attacks the brain. 
 
 The diffusion of the disease is by continuity and contiguity: 
 it may travel along nerve trunks, and in this way it may enter 
 the skull. Another route for intra-cranial invasion is along the 
 veins which traverse the inferior orbital fissure ; or tlie clotted 
 material may pass down through the jugular vein to the lieart. 
 Thus the inflamed parotis, ending in suppuration, may be the 
 source of morbific materials, which may awaken disease in the 
 brain, heart and other regions, near or remote. 
 
 There is an increase of temperature analogous to that which 
 accompanies inflammatory and suppurative action elsewhere, the 
 range of temperature being proportionate to the violence and 
 extent of these processes. 
 
 The a[ioneurotic envelope and the unyielding fibrous stroma 
 of the gland impede the flow of blood through the veins and 
 favor coagulation. The same constricting tissues tend to force 
 out pus which may form in the parotis. 
 
 ' Su}»purative parotitis usually falls within the domain of sur- 
 gery as a metastatic j)y8emic affection ; and often it is a secondary 
 event of a severe wound in some other part of the body ; its 
 appearance should excite grave apprehension. 
 
 Treatment. — From the facts presented, it is clear that suppura- 
 tive parotitis is an affection which may imperil and sometimes 
 destroy life; and, hence, its treatment should be prompt and ener- 
 getic ; the milder grades of parotitis, however, seldom demand 
 attention on the part of the surgeon. Where the evidences of pus 
 are presented, as denoted by local tumefaction, increased heat and 
 general rigor, an incision should be made so that the pus impris- 
 oned within the unyielding fascia may have free escape. Since 
 the most accurate anatomical knowledge cannot locate the vessels 
 and nerves of the gland with absolute accuracy, the opening 
 should be made in stich a manner as to give these structures the 
 
PAROTIDEAN GROWTHS. 515 
 
 greatest safety; and for this purpose, the incision with the scalpel 
 should not penetrate beyond the superficial fascia; and then the 
 opening should be continued by means of a blunt dissector, or a 
 small pair of dressing forceps, which, being thrust in, may be 
 opened and withdrawn as Hilton directs, so as to make a free 
 opening. Thus the pus may be reached, and any vessel or nerve 
 which might be met will be displaced, and not seriously injured. 
 As two or more separate pus-centers may coexist, each of these 
 may be opened in a similar manner. Thus, by prompt and early 
 action, the suppurative process may be arrested. The openings 
 made are slow in healing; a serum-like fluid may exude from 
 the wounds for a long period. This material contains saliva, 
 which is derived from the wounded glandular structure. If none 
 of the larger secondary ducts of the parotis be opened, the wounds 
 under proper treatment will finally heal. 
 
 Parotidean Growths. — The parotid gland, comj^licated as are its 
 structural constituents, is suited by nature to be tlie natal site of 
 numerous neoplasms ; every species of growth, from the simple 
 cyst to the gravest types of malignant tumor, occurs here; and, 
 beginning with the simplest, cystoma first offers itself for con- 
 sideration. 
 
 As varieties of cyst, the following have been observed here: 
 the sebaceous cyst, the simple serous cyst, the salivary cyst, and 
 cysts in which two or m.ore species are associated. 
 
 The cyst of sebaceous or atheromatous content occurs in this 
 region. It belongs rather to the derm than to the gland. It is 
 usually small, though the writer has removed one of rounded 
 form, of which the diameter exceeded two inches. Such sebaceous 
 tumor causes but little functional disturbance; as a deformity, 
 however, its removal is indicated. This may be done by a hori- 
 zontal or vertical cut through the skin and the filamentous cap- 
 sular envelope of the cyst. The only structures which might be 
 endangered in this enucleation are branches of the facial nerve. 
 But as these nerve filaments are beneath the fascial envelope of 
 the gland, which structure intervenes as a well-defined septum 
 between the cyst and the nerves, the latter could .only be wounded 
 through careless dissection. If the wall of the cyst be well exposed 
 through a horizontal cut, the growth can be enucleated from the 
 lateral and subjacent structures b}^ means of a blunt dissector. 
 And if the proper parotidean fascia be left intact, the branches of 
 the facial nerve will not be wounded. 
 
 The cyst of purely serous content has been observed in a few 
 
516 MALAR AND PAKOTIDEAN KECilOXS. 
 
 cases in the purotidean region. The contained iiuid has none of 
 the reactions of saliva. This cyst may be disposed ol" by excision ; 
 but before resorting to the knife, an effort to cure should be made 
 by injecting the cyst with the tincture of iodine. 
 
 A cyst similar to the one just mentioned, is that in which the 
 content is salivary; such a cyst, of small or large dimensions, may 
 arise from the retention of saliva in one of the ducts which con- 
 vey the secretion from a lobule of the parotis. This cyst resem- 
 bles that of purely serous character; yet the two can be distin- 
 guished from each other b}'' the fact that that of salivary content 
 yields the characteristic reaction of saliva, viz., it converts starch 
 into grape sugar. The salivar^^ cyst is diflicult to cure. Two 
 modes of treatment liave been advised; in one there is established 
 a communication between the cyst and the buccal cavity; in the 
 second plan there is an effort made to destroy the walls of the 
 cyst, and thus through suppuration to obliterate the cystic cavity. 
 Such destructive action with subsequent obliteration may, some- 
 times, be accomplished by cauterizing the cavity thermally or 
 potentially. As a potential escharotic, one might use the sulphate 
 of zinc, with which, in small crystalline form, the cystic cavity 
 may be filled. Thus the inner wall is destroyed and an action is 
 set up in the subjacent tissues which may end in obliteration of 
 the salivary cyst. 
 
 Salivary Concretion. — The calcareous salivary concretion named 
 sialolith, frequently observed in connection with the submaxillary 
 gland, has also been seen, though seldom, in the parotis. The 
 source of this calculus is the mineral constituent of the saliva; 
 and this consists, in the main, of phosphate and carbonate of 
 lime. IIow the initial nucleus begins, since it is not seen, has, 
 like vesical calculus, been rather a matter of conjecture than of 
 actual proof. 
 
 The sialolith has been a matter of study by Immisch, who in 
 his publication in 1861 classifies these concretions in those which 
 lie in the gland, and those occurring in the excretory canal of the 
 gland. As assignable cause of such formation, Immisch thinks 
 the starting j3oint may be a chronic inflammation in a duct, 
 whence arise elevations and depressions of the surface. In this 
 way the outflow of saliva is impeded and from the retained fluid 
 precipitation may occur. And the concrete material may close 
 the duct; or it may form in such a manner as to leave an open- 
 ing through which the saliva, which is scretod behind, may still 
 find escape. 
 
ANGIOMA. 617 
 
 A possible method in which the sialolith may form is about a 
 body which has penetrated and lodged in the gland. Possibly, 
 such foreign body might penetrate the common duct from the 
 buccal cavity. 
 
 The most usual site of such concretion is the duct of Wharton ; 
 it rarely forms in the duct of Steno, and most rarely, if ever, in 
 the sublingual duct. The facility of escape of the secretion from 
 the parotis and sublingual glands may account for the infrequency 
 of the sialolith in these glands. 
 
 The sialolith is seldom seen in the young; it has been seen 
 oftenest in those between thirty and forty years of age. It is 
 usually rounded or amygdaloid in form. 
 
 The sialolith may remain for a long time without causing 
 much disturbance; finally, by encroaching on parts contiguous, 
 it awakens inflammation, and finally pus is formed. If in the 
 common excretory canal, it can, by impeding the escape of saliva, 
 cause much more trouble than if lodged in the structure of the 
 parotis. 
 
 Since the tumefaction caused by the concretion might arise 
 from other growths, a differential diagnosis is best made by 
 means of a fine acupuncture needle. In a few cases recorded of 
 parotidean sialolith, the true nature of the affection has been 
 revealed by an opening occurring spontaneously, or made by the 
 surgeon, through the outer surface of the cheek, through which 
 the calculus could be seen or touched with a probe. 
 
 Treatment. — The calculus should be removed, and, to avoid a 
 salivary fistula, the opening, as a rule, should be made to the site 
 of the concretion on the inner side of the cheek. This may be 
 done by slitting up the buccal ending of the Stenonian duct, as 
 Manec has advised; or the opening may be made directly to the 
 calculus from the inside of the mouth. In the event of there 
 being an opening to the body from the outside, as not unfre- 
 quently is the case when the patient first comes under observa- 
 tion, this opening should be enlarged, and the calculus thus 
 extracted. From the report of cases treated in the latter way, it 
 would seem that no salivary fistula remained afterwards. 
 
 Benign Tumors. — The class of benign tumors is well represented 
 in the parotidean region; the angioma, lipoma, fibroma, adenoma 
 and chondroma occur in the parotidean region, each of these 
 arising from a normal anatomical element of the gland. 
 
 Angiovia. — The angioma here may be dermal in site and 
 present itself in different grades; and such dermal growth may 
 
518 MALAR AND PAKOTIDEAN KEGIOXS. 
 
 be treated in accordance with methods which have previously 
 been exphiined. 
 
 Angioma involving the structure of the parotis is a much 
 more formidable affection than tliat of dermal site. This form is 
 congenital, and at the birth of the child, it may be voluminous 
 and occupy the entire gland. Such tumor is cavernous in struc- 
 ture, yielding to pressure, and variable, somewhat, in volume, 
 viz., it has the character of erectile tissue, and is swollen during 
 expiratory efforts of the child. The overhanging skin, without 
 participating in the vascular growth, may show some widening 
 of its capillaries, and through the skin the bluish red color of the 
 subjacent vascular structure may be perceived. The growth 
 arises from abnormal develoi)ment of the normal veins and 
 arterioles; the veins in number and volume exceed greatly the 
 arterioles. These widened veins present cavern-like dilatations. 
 
 The author has treated three cases of [)arotidean angioma; 
 two were in children five and eight weeks of age, respectively, 
 and the third in an adult, in whom the affection was present at 
 birth, and, besides involving the parotid gland, it involved the 
 subcutaneous soft parts of the right cheek from the zygomatic 
 arch to the lower border of the maxilla inferior. This patient 
 had a frequently recurring spasmodic m.ovement of the facial 
 muscles on the affected side, a movement resembling that induced 
 in muscles by the Faradic electric current. The posterior por- 
 tion of the gland in the adult case was not affected, but in the 
 two infants the entire parotis was occupied by the growth. 
 Besides, in one infant, the vascular tumor reached below the 
 lower jaw, and embraced also the adjacent submaxillary gland. 
 In each case the angioma was a marked deformity, for which 
 relief was sought at the hands of the surgeon. 
 
 Treatment. — The treatment, most usually resorted to, has been 
 removal of the tumor by excision. In the adult seen by the 
 writer, there had been made an effort in infancy to obliterate the 
 structure by subcutaneous strangulation, which was done by 
 means of long needles, w^hich pierced the growth deeply, and 
 then the outer ends of the needles were included in twisted 
 suture. The result obtained was only a partial success; and the 
 portions wliich remained, developed so as to greatly deform that 
 side of the face. For relief of this, the patient was operated on 
 by the writer, as follows: A crescentic or rather a paraboloid cut 
 was made througli tVie skin, which, beginning at the malar bone, 
 extended towards the angle of the mouth, and thence passed 
 
ANGIOMA. 519 
 
 downwards and backwards to the lower edge of the maxilla 
 inferior, vertically beneath the point of beginning. This flap 
 being reflected and drawn well backwards, a large part of the 
 vascular growth was exposed. This was found to involve the 
 anterior portion of the parotis, and to extend along and beyond 
 the Stenonian duct almost to the angle of the mouth. The fatty 
 mass around the terminal end of the duct had undergone the 
 vascular transformation. The removal of the angiomatous 
 structure was done piecemeal ; this was the only way in which it 
 could be done, since the remaining cicatricial adhesions of the 
 former operation prevented any attempt at removal in mass. 
 The flap was closed, yet, owing to secondary haemorrhage, the 
 internal wound was tedious in healing. The face was much 
 improved in appearance; and the choreic movement, already 
 mentioned, of the risorius Santorini and zygomatic muscles of 
 the face on that side which had harassed the patient greatly, 
 disappeared after the operation. 
 
 In the two infants the treatment pursued was excision. In 
 one, a portion of the parotid gland and of the submaxillary 
 gland was extirpated. The result obtained was that the young 
 patient was delivered of the tumor, but there remained perma- 
 nent palsy of the muscles of the lower half of the face. Twenty 
 years afterwards, when the young woman was seen, it was gravely 
 questionable with the author whether the chagrin entailed by 
 the operation was not greater than that which would have arisen 
 from the unoperated tumor. In the second infant, under two 
 months of age, a large cuneiform section was excised from the 
 tumor, and the wound was closed by deeply including sutures. 
 This child surviA^ed the operation only a few days. Hence excis- 
 ion of the congenital parotidean angioma, advised by general 
 authority, from the results obtained by the author in the two 
 cases mentioned, was unsatisfactory. In such a case, subcutaneous 
 thermal cauterization might be essayed with the hope of better 
 results. This may be done by means of a long needle, which, 
 being inserted one-half its length, the external portion may be 
 heated by means of a spirit lamp in the manner already 
 described. This cauterization should be done in horizontal lines 
 so placed as to avoid the parotidean duct. If cauterization were 
 thus done, there would be less risk of injuring the branches of 
 the facial nerve. 
 
 Another plan of treatment which might be tried is continued 
 pressure maintained on the angiomatous tumor. For this pur- 
 
520 MALAR AND PAHOTIDKAX KlXilONS. 
 
 pose a disk of India rubber might be retained on the tumor by 
 means of an ehistic bandage. To accomplish much, such com- 
 pression should be continued for several montlis. 
 
 Lipoma in this region may be situated merely beneath the 
 skin, or it maybe imbedded in the ghmd. The only appro})riate 
 treatment is extirpation of tlie growth. 
 
 The fibroma occurs in the j)arotis; an example of this was 
 seen by tlie writer. In its extreme hardness, this growth resem- 
 bles carcinoma; the fibroma, however, may be distinguished 
 from carcinoma in this, that the latter continues to develop with- 
 out limit, while fibroma grows more slowly, and, liaving reached 
 a certain volume, it may not become larger. It is claimed that 
 fibroma under the influence of some inflammatory agency may 
 become malignant. The proper treatment of tlie parotidean 
 fibroma is removal through a horizontal incision. 
 
 The lymphatic glands, which lie on the parotis, or imbedded 
 in its structure, may inflame, suppurate and open through the 
 skin. A slowly healing sinus may thus arise. Such cases should 
 be treated by curetting tlie alfccted structure and dressing the 
 wound with an ointment of iodoform or of subiodide of bismuth. 
 
 Lymphatic glands, here situated in the scrofulous subject, may 
 enlarge and remain so without suppurating. The application of 
 iodized collodion often reduces such; if this fails, the glands may 
 be excised through a horizontal incision. In the lower portion 
 of the parotidean region such enlarged glands are often seated so 
 deep that, in their excision, the filament of the facial nerve which 
 passes behind, and close to, the mandibular angle may be injured, 
 unless the operator seeks for and isolates the nerve. If such 
 filament be injured, the lower lip and angle of the mouth will be 
 disturbed in their movements. 
 
 Enchondroma lias been observed in the parotis; and this may 
 be associated with fibroma; and it is probable that enchondroma 
 here is tlie offspring, or successor, of fibromatous structure. The 
 cartilaginous tumor may be removed through a horizontal cut. 
 
 Busch, in a study of the benign tumors which develop in the 
 parotis, finds that they most ordinarily appear in the inferior 
 part of the region, viz., in that which lies between the mastoid 
 process and the angle of the jaw. In this site the cartilaginous 
 tumor is oftenest found bound tightly down by the parotidean 
 fascia. Being thus tightly bound down by this dense fascial 
 stratum, as soon as the latter is opened, tlie tumor rises through 
 the gap made, so that enucleation is facilitated. 
 
MALIGNANT GROWTHS OF THE PAROTID GLAND. 521 
 
 Where the tumor is from the degeneration of one or more 
 lymphatic glands, it lies outside of the fascial covering of the 
 parotis; and in this site it is movable under the skin. 
 
 Busch finds that in partial removal of the parotis, the result- 
 ant palsy will depend on the part of the gland which is extirpated. 
 For example, in excising the lower portion, nervous filaments to 
 the neck will be severed; if the middle portion be excised, fila- 
 ments to the mouth will be injured; and, finally, if the upper 
 portion of the parotis be removed, the nervous filaments to the 
 eyelid will be cut. Allied to the benign growths described may 
 be mentioned the syphilitic affection of the lymphatic glands 
 here situated, which may become infected and swell in case of 
 primary chancrous ulcer having its site in the lips or mouth. 
 Care must be taken not to confound such disease with that which 
 might arise from tubercular disease. When the syphilitic nature 
 of the case has been diagnosticated, the treatment should be simi- 
 lar to that of constitutional syphilis. 
 
 In case ptyalism supervenes during mercurial treatment, the 
 parotid gland swells; and the accessory portion of the gland may 
 swell as a small isolated tumor in the cheek. Such tumefaction 
 would gradually vanish with the subsidence of the salivation. 
 
 Malignant Groivths of the Parotid Gland. — Sarcoma is a fre- 
 quent occupant of the parotidean region; and the growth pre- 
 sents itself here, as elsewhere, in its diversified form, viz., as 
 fasciculated, encephaloid, myxomatous and cystic sarcoma. 
 
 The most common form is the fasciculated type, which, appear- 
 ing in circumscribed form, is, at first, firm and solid in texture; 
 and later, as it attains larger volume, it is lobulated, softer and 
 rich in ve'ssels. The microscope reveals elongated and spindle- 
 shaped cells. And, imbedded in the same structure, one finds 
 proliferated or multiplied epithelial cells. Sarcoma, in its subtle 
 and shifting morphology, sometimes bafiies definite classification, 
 and escapes from the well-built bounds of the descriptive histolo- 
 gist. Thus, as just stated, sarcomatous structure is commingled 
 with degenerated epithelial elements, which are of the nature of 
 epithelioma ; also, cystic dilatations are often found in the sarcoma, 
 arising from the dilated cul-de-sacs of the initial glandular ducts. 
 The encephaloid species of sarcoma, constituted of round cells, 
 is soft in consistence, and develops rapidly, and often contains 
 dilated ducts and degenerated epithelium. Akin to encephaloid 
 sarcoma is the melanotic tumor, which has been seen here by 
 
 Weber. 
 
 34 
 
522 MALAR AND PAROTIDEAN REGIONS. 
 
 The cystic dilatations may contain material similar to lique- 
 fied gelatine; and a tumor thus formed is named myxomatous 
 sarcoma. This tliickened, jelly-like content is a i)roduct of the 
 glanduhir structure, that has wandered quite away from its pre- 
 destined function of secreting saliva. The cyst, containing 
 sarcoma, is nodulated in its form. 
 
 The sarcomatous parotidean tumor appears in the youthful 
 subject, or in those who have not reached the declining period of 
 life. It is so painless in its advent that it may liave attained 
 some size when it is accidentally discovered, as an eminence 
 causing irregularity of surface of tliat portion of the face. The 
 sarconja is not inclined to become generalized; and this character- 
 istic of isolated action renders the tumor a more [)r()per one for 
 extirpation than is the case in carcinoma. Leading authority 
 favors the removal of the sarcomatous neoplasnj ; and in the event 
 of there being a recurrence, a second or third operation has some- 
 times been successful in curing the patient. 
 
 Epithelioma, primarily arising in the parotis, has been the 
 matter of discussion among pathologists; some doubt whether 
 tliis growtli in pure form arises in the parotis. 0. Weber claims 
 the case to be epithelioma when the degenerated acini of the 
 gland have lost their limiting membrane, and the multiplied 
 epithelial cells encroach on the interstitial structure. 
 
 Delorme prefers the name epithelial adenoma for these 
 growths; and as anatomical characteristics Delorme enumerates 
 the following: in form it is spherical, ovoid, nodulated or regular 
 in outline; in consistence it is soft or elastic, and is definitely 
 separated from adjacent structures, and is rarely accompanied by 
 facial palsy. The tumor has commonly been observed in tlie 
 youthful subject. If ulceration occurs, the process is similar to 
 that seen in the non-malignant tumor. There is rarely glan- 
 dular infection, and the general health is seldom depressed. On 
 section the tumor presents a granular a.spect; and, if the jiart 
 be compressed, cylindrical bodies resembling vermicelli will be 
 forced from the incised surface. Under the niicroscoi»e a com- 
 plex structure ai)pears, in which fibrous, cartilaoinous and 
 myxomatous tissues are seen; also epithelial cells dispersed in 
 cylindrical or bird-nest form. 
 
 Epithelioina. — Epithelioma may commence primarily in the 
 parotis, or it may appear there secondarily, viz., in a lymphatic 
 gland, the disease appearing metastatically in the gland from an 
 epithelioma seated in the eye, the cheek, the lip or tlie mucous 
 
CARCINOMA. 523 
 
 membrane of the buccal or pharyngeal cavity. Also an epithe- 
 lioma, which has originated in the dermal glands overlying the 
 parotis, may penetrate through the skin and attack the gland. 
 
 Carcinoma. — Cancerous disease may appear in the hard and 
 soft forms, that is, as scirrhous and encephaloid cancer. The 
 disease may appear here as an aboriginal product; or it may 
 migrate to the parotis from a neighboring part where it first 
 appeared. 
 
 These two forms of carcinoma differ radically from each other 
 in structure. Scn-rhus is firm, of wood-like hardness, is intimately 
 adherent to the contiguous parotidean structure, and the boundary 
 between it and the unaffected glandular structure is scarcely 
 discoverable. On the contrary, the encephaloid growth has a 
 more definite boundary; it is both soft and elastic, and, examined 
 microscopically, encephaloid cancer presents a fibrous stroma, in 
 tlie meshes of which are found fluid and cells of variable form. 
 Both forms, besides implicating the gland, sooner or later be- 
 come adherent to the skin and cause puckering of surface, espe- 
 cially so in the case of the scirrhous form. These growths have 
 no tendency to limitation, but sooner or later invade and press on 
 adjacent parts; and in this way grave functional disturbance is 
 caused. Thus mastication is rendered difficult through pressure 
 on the muscles concerned in that act; also, thus may arise palsy 
 and pain in the region of the face. The growth may compress 
 vessels, or even penetrate them. The overlying skin is finally 
 perforated by ulceration, and exuberant and vascular granulations 
 protrude through the breach. The pus excreted is of foul odor. 
 In from six to twenty-four months the patient dies; and death 
 may arise from exhaustion induced by diffusion and migration 
 of the disease to important viscera, as the lungs or brain; also, 
 through ulceration, vessels may be opened and recurring haemor- 
 rhages ensue. Hence the prognosis of carcinoma of the j^arotis 
 is highly unfavorable. 
 
 Melanotic cancer has been observed here, and is remarkable 
 for its rapid progress, speedy recurrence after extirpation, and 
 early fatal termination. 
 
 Pile accessory parotid gland seated on the Stenonian duct has 
 been the site of neoj)lastic formations similar to those which 
 appear in the parotid gland itself. 
 
 Treatment of Malignant Tumors of the Parotis. — This treatment 
 has been the matter of sharp controversy, some espousing the 
 side of non-interference in case the tumor has attained large 
 
524 MALAR AND PAROTIDEAX KEdlONS. 
 
 dimensions and occupies a large part of the parotis; others, again, 
 ardently contend that the affected gland should be removed. 
 Topographical anatomists have taught that it is extremely diffi- 
 cult to remove the parotis in the cadaver; and they liave argued, 
 from this, the impossibility of such removal when the gland is 
 degenerated or changed through disease. Says Hyrtl: "It is well 
 known to the anatomist how difficult it is to dissect out the sound 
 parotis without leaving fragments of it behind; what is, then, to 
 be expected in the attempt when the parotis is dissected? Truly, 
 says one of the leading French authorities, the extirjmtion of the 
 diseased gland is an operation quite impossible." Allan Burns said, 
 in his "Surgical Anatomy of the Head and Neck," in 1811: "The 
 extirpation of the gland is quite out of the question; its imprac- 
 ticability is proved by reviewing the connections of the gland. 
 "Whoever has in situ injected the salivary duct with mercury', 
 and then, even when the gland is healthy, where it was free from 
 preternatural adhesions, and limited to its natural size, has tried 
 to cut it out, would be convinced, when he saw the mercury 
 running from the innumerable pores, that the gland extends into 
 recesses into which he could not trace it in the living body. . . . 
 On the dead subject I have attempted the extirpation of such 
 tumors, but, even there, have never succeeded in clearing fully 
 away the diseased substance." 
 
 Such teaching deterred many from operating; a few surgeons 
 disregarded the edict of the anatomist, and in 1841 Berard pub- 
 lished a work on the subject in which were reported fifty-two 
 extirpations of the parotid gland. Berard finds that the removal 
 of the parotis is not more perilous than other capital operations; 
 for of the fifty-two cases no one died during the operation; and 
 in only two or three cases did death supervene two or three days 
 afterwards. And he claims that it is no longer a question 
 whether the parotis can be extirpated, but rather whether the 
 disease can be entirely removed from the cavity occupied by tlie 
 diseased gland. Bruns has collected a much larger list of extir- 
 pations of the parotis, which shows that the operation is practi- 
 cable, and not especially perilous; wdiere death occurred it was 
 from some extrinsic comi)lication. 
 
 Extirpation of the })arotis endangers the external carotid 
 artery, the internal jugular vein and the facial nerve. Strangely 
 enough, some claim to have removed the gland and to have left 
 the artery and nerve intact. Malgaigne declared in 1858 that 
 the parotis can be removed without lesion of these parts. Burns 
 
CARCINOMA. 525 
 
 denies the possibility of this, and claims that such extirpation 
 has only been the removal of a conglobate gland, of which there 
 are two in connection with the parotis: one in the center of the 
 parotis near the division of the external carotid, and one division 
 underneath its lower lobe. In proof of this, he cites cases which 
 he saw operated on; and, in the discussion of the subject. Burns 
 gives glimpses of professional rivalry which animated both pen 
 and scalpel in his day. 
 
 To guard against hsemorrhage, the primitive carotid has been 
 tied, likewise the external carotid; or, instead of directly tying 
 the vessel, some have used a provisional ligature; that is, a cord 
 has been passed underneath the artery, and afterwards tied, if 
 the vessel was opened. Others have depended on compression 
 made by the hands of a competent assistant. Each of these plans 
 has had advocates of its superiority. The ligation of the external 
 carotid, and not the primary trunk, is the preferable plan ; and in 
 whichever way it is done, blood by reflux soon finds its way 
 through the ocular branches of the internal carotid into those of 
 the external carotid artery; but this vascular compensation occurs 
 sooner when the external and not the common carotid is ligated, 
 since the blood in the internal trunk is then subjected to more 
 pressure. In case the extirpation of the parotid be but partially 
 done, or if the growth be capsulated, and hence so isolated that 
 it may be removed without removing the gland itself, then the 
 hsemostasis may be accomplished by indirect compression, that is, 
 by pressure on the primitive trunk, or, better yet, by pressure at 
 the bifurcation of the common trunk. 
 
 The entire extirpation cannot be effected without lesion of the 
 external carotid, though some have asseverated to the contrary. 
 And the same is true of the facial nerve; its branches will be 
 severed, and the face palsied on that side. And of this condition, 
 to which the operation invariably consigns the patient, he should 
 be plainly foretold. The mouth will be drawn to the opposite 
 side; the emotional movements will be lost on the side operated 
 on; the movement of the corresponding eyelids is lost, so that the 
 eye will remain staringly open, and, as the result of such expo- 
 sure, the eyeball becomes congested and red through irritation, 
 and augments the patient's unsightly appearance. Such a picture 
 of the resultant condition should be traced before the patient by 
 him who will remove the parotid gland. 
 
 There is a general concurrence of opinion in regard to remov- 
 ing the malignant parotidean growth. So long as it is of moder« 
 
526 MALAR AND PAKOTIDEAN KKCIONS. 
 
 ate dimensions, as Weber advises, this sliould be done in cases in 
 Avhich the growtlv is a scirrhous tumor which can be detached 
 from the parts around it; and also in case it be an encephaloid 
 tumor which has not perforated the aponeurotic wall on the 
 side of the pharynx. But if the tumor has opened into the 
 pharynx, or has penetrated the internal jugular vein, or involves 
 the bones adjacent, the knife should be withheld. 
 
 Operation. — The instruments required for the operation are 
 scalpel, retractors, hemostatic forceps, blunt dissector, silk and 
 catgut thread, aneurysmal needle, bhmt scissors and materials for 
 sponging and for final dressing. 
 
 Various dermal incisions have been proposed for exposure of 
 the diseased parotis. Weber directs to open the skin, by an 
 incision parallel with the posterior border of the lower jaw; and, 
 should tliis not offer an ample field for the operation, this is to 
 be enlarged by a horizontal cut corresponding to the lower 
 border of the maxilla. The skin being dissected up so as to 
 expose the tumor, some, as Stromeyer and Liston, advise to open 
 the aponeurotic covering, and then to continue the work by 
 enucleation. Weber urgentl}^ opposes this plan, as well as that 
 of Roser, who removes a section from the diseased gland in order 
 to lessen its volume; but, retaining the fascial covering intact, 
 Weber prosecutes the dissection of detachment outside of this 
 capsule. When tlie external attachments are divided, then Weber 
 endeavors to get behind the tumor by uplifting the lower lobe, 
 and thence he continues the detachment upwards; thus the 
 external carotid is reached first in its proximal portion. Should 
 the adherence be so firm below that one cannot enter there, then 
 Weber would commence above, or at the sides, either in front or 
 behind; and thus the tumor is to be loosened and uplifted from 
 its deep connections. Tie vessels which are met, doubly, and 
 divide between the ligatures. Finish the deeper part of the 
 extirpation with care, and do not spoil, with undue haste, the 
 concluding steps of the work. Such, in brief, are the directions 
 for the total removal of the parotis given by Otto Weber, whose 
 diligent researches in surgical pathology and equally thoughtful 
 work as an operator, render him, in the opinion of the writer, 
 one of the most trustworthy guides who have appeared in this 
 century. Weber pronounces total extirpation of the parotis to be 
 one of the most delicate, subtle and beautiful surgical operations, 
 and which, with due care, can be done without much loss of 
 blood. 
 
CARCINOMA. 527 
 
 Delorme, in an elaborate exposition of the principles which 
 should govern in the extirpation of tumors involving the entire 
 parotis, makes three stages of the work: 1. Incision through the 
 skin, which may be done vertically, crescentically, crucially or 
 by an elliptical cut in which a portion of the skin is excised. 
 2. Detachment of the overlying derm. 3. Separation of the tumor 
 from its deeper connections; and in this act some dissect from 
 below, upwards; others from above, downwards; and others 
 again detach from the sides. Bdrard advises to first dissect up 
 the anterior border from the ramus of the jaw; then to loosen 
 the posterior border from the sterno-cleido-mastoid muscle. If 
 necessary, tie the external carotid, and do this as low down as 
 possible, since in this way it will not be necessary to tie the ves- 
 sels which arise beyond the ligature. Avoid, in the dissection, the 
 submaxillary gland, the facial artery, and, especially, the internal 
 jugular vein, which may be endangered in the deeper portion of 
 the detachment. Tie doubly the external jugular vein, and 
 divide between the ligatures. The scalpel must be dropped as 
 early as possible, and the work continued with the fingers or a 
 blunt dissector. 
 
 The writer, in the treatment of malignant neoplasm involving 
 the parotis, has several times removed the gland. The w^ork 
 has been done through a vertical cut through the skin corre- 
 sponding to the vertical axis of the gland; and to this was added 
 a short horizontal one in the line of the Stenonian duct, and to 
 control hsemorrhage, the external carotid w^as tied as the first act. 
 In the enucleation, the capsule of the gland should be included. 
 Veins, which are opened, should be ligated if torsion fails to con- 
 trol the bleeding. Care should be taken that no glandular frag- 
 ments be left behind, since salivary oozing from them would 
 prevent closure of the wound. In a patient of sarcoma of the 
 gland, operated on in the manner here briefly outlined, the writer 
 obtained complete union of the wounded structures in less than 
 two weeks. 
 
 Sometimes the tumor has developed independently of the 
 parotis, and, in its growth, it has pushed the gland bej'ond it, so 
 that the two are separate from each other; in such condition, 
 the growth may often be removed without ligation of the external 
 carotid artery, and without division of the branches of tlie facial 
 nerve. 
 
 In complete extirpation of the gland the following arteries 
 may be met in the dissection: the external carotid, the temporal, 
 
528 MALAR AND PAROTIDEAX REGIONS. 
 
 internal maxillary, transverse facial, posterior auricular, occipi- 
 tal, and numerous small branches distributed to tlie parotis. The 
 external jugular vein and its derivative confluents must be divided. 
 The former operators who removed the gland without first tying 
 the external carotid, were compelled to tie its several branches 
 just named; and the plan was to tie each doubly and divide 
 between the ligatures. And even though the external carotid be 
 tied, compensating reflux occurs so speedily tliat the writer has 
 found it necessary to tie some of tlie divided branches. 
 
 The operative incision should be closed by suture in its upper 
 portion ; the lower portion should be left open. The wound, which 
 is made, causes, for a time, difficulty of swallowing, so much so 
 that MacClellan was obliged to nourish his patient for a period 
 through a tube passed into the oesophagus. There have been 
 cases in which there temporarily occurred disturbance of hearing. 
 
 Cases have been reported in which secondary haemorrhage 
 occurred. In such an emergency the writer would use aseptic 
 sponge as a compress on the bleeding part. And the sponge 
 would do more effective work were it first saturated with dilute 
 alcohol, and sprinkled with tannin. Such haemostatic compres- 
 sion should be continued for from eight to twelve days; in such 
 time the opened vessels would become securely occluded with 
 clotted blood. 
 
 The facial palsy ma}^ be complete or incomplete; when it is 
 complete, in a few cases, the palsy of the face has afterwards 
 partly vanished; and this can only be explained by the supposi- 
 tion that certain branches of the nerve have not been severed. 
 
 Parotidean Fistula. — Parotidean fistula may arise from lesion 
 of the parotid gland, or of its excretory duct. 
 
 The fistula proceeding from the parotis is caused by a wound 
 or an abscess which, implicating the gland, severs one or more 
 of its component lobules. The wound causing it is not unfre- 
 quently produced by the surgeon himself in the course of opera- 
 tive work done in this region. The site of such fistula sliould 
 be taken into account, since it serves to distinguish the glandular 
 from the Stenonian fistula. Tlie glandular fistula may be situ- 
 ated above or behind the ear, in any point of the parotidean 
 sulcus. Or it may open on the cheek in front; and then the 
 cause is often an abscess which has opened remote from its 
 source, or which may have been seated in the accessory parotis. 
 And finally, the fistula may pass some distance under the skin, 
 and open through the skin more or less remote from the starting 
 point. 
 
PAROTIDEAN FISTULA, 529 
 
 The opening may be as fine as a hair, or so large that a large 
 sound can enter it; and this is generally in the center of granu- 
 lative tissue; and, commonly, the skin around is sound. 
 
 The diagnosis of such fistula is usually easily made, since, 
 during the act of mastication, the saliva flows from the orifice in 
 greater or less amount. Such fistula often closes spontaneously, in 
 this particular differing greatly from the Stenonian fistula, which 
 often taxes surgical art to its utmost to effect a cure. 
 
 Treatment. — A variety of methods have been resorted to to 
 obtain closure; these can be summarized under four heads: com- 
 pression, cauterization, suture, and suture with occlusion. 
 
 Cases have been cured by compression, maintained by lint 
 bound upon the opening. Compression of the entire parotis, 
 made with the view of causing atrophy of the gland, has been 
 practiced. As a single means of treatment, compression has 
 given unsatisfactory results; if used, it should be employed in 
 conjunction with cauterization or suture. 
 
 Cauterization by means of a finely pointed pencil of nitrate 
 of silver, or a wire which has been heated to red heat, may be 
 used. Or a. caustic solution, either alkaline or acid, may be 
 injected into the opening. 
 
 Suture has been used; for this purpose trim the edges of the 
 opening, and close by means of catgut or fine metallic suture. 
 The author has successfully employed the latter plan, combined 
 with occlusion of the sutured wound by means of collodion, 
 painted over the part. The operation was repeated three times 
 before success was obtained. Besides occlusion with collodion, 
 the work may be aided by compression on the parotis, by which 
 secretion of saliva will be diminished. Meantime, movements of 
 the mouth, tongue and lower jaw should be avoided, and nutri- 
 tion should be maintained by means of liquid food. 
 
 Stenonian fistula may arise from wounds which open the 
 duct; also from an abscess involving the duct. A rare cause 
 observed is a calculus, forming in the duct, which enlarges until 
 it perforates the walls of the canal. 
 
 The diagnosis of a Stenonian fistula is made without diffi- 
 culty; in fact, it too easily announces and declares itself by the 
 escape of saliva from the opening on the cheek. Though this 
 salivary trickling may be constant, yet it is greatly augmented 
 during the act of chewing food : and this fluid, trickling upon his 
 person, renders the patient offensive to himself, and an object of 
 nauseating disgust to those who are in his presence. The victim 
 
530 MALAR AND PAROTIDEAN KEGIOXS. 
 
 early and urgently seeks relief, and is surprised when told tliat 
 the repair of this insignificant breach in his face is one of the 
 most difficult feats in operative surgery; yet the patient is undis- 
 mayed by the troubles to which the proposed treatment will 
 subject liim ; for if unrelieved he will be forced to use some device 
 to catch his drivehng saliva. Morand says that a })atient of this 
 trouble, whom lie saw, was forced to use at his meals a barber's 
 basin. From a patient of Duphoenix there flowed, from such a 
 fistula, about four ounces in twenty minutes. The disuse of tlie 
 buccal end of the canal causes it to become very narrow; and this 
 impediment must sometimes be overcome in the treatment. 
 
 Inventive genius has been diligent in the searcli for means 
 to accomplish the cure of Stenonian fistula; and many expedients 
 devised seemed to have accomplished cures. 
 
 In a thesis on the subject of parotidean fistula, written, in 
 1868, by Mirza Abdal Vaherb de Gaffary, the numerous means 
 of treatment are reviewed; the following is a synopsis of the 
 methods: cauterization; com})ression made between the gland 
 and the fistula, or over the fistula, or on the gland itself; or 
 exsection of the fistula may be done, and the wound closed by 
 suture. The work can also be done by dilatation of the end of 
 the canal; -or a derivative canal may be made by means of a hot 
 wire, a silken cord, a canula or a trocar and a seton. Or two 
 canals may be formed by means of a leaden wire, or a common 
 cord. Cures have been effected by cauterization of the fistula; 
 likewise by injecting into it some stimulating fluid. The lead- 
 ing and trustworthy methods consist, in the main, in restor- 
 ing the calibre of the anterior portion of the canal, in case 
 that has been contracted, or of forming an opening from the 
 fistula directly through the check into the mouth. The forther 
 backwards the site of the fistula is, the more difficult is the cure. 
 Tillaux says that if the fistula be in the masseteric portion, the 
 cure is impossible, or nearly so; on the contrary, if seated in the 
 anterior or buccal portion, it is curable. And, as an opening in 
 the posterior portion might be mistaken for a fistula from the 
 glandular structure, as distinction between the two, Tillaux finds 
 that, in the glandular fistula, some saliva will still flow into the 
 buccal cavity, while in case of the main duct being openerl, the 
 whole of the fluid escapes on the cheek, and none into the mouth. 
 
 We will proceed to individualize in detail the methods which 
 have been successfully employed by different surgeons for the 
 cure of this fistula. 
 
PAROTIDEAX FISTULA. 531 
 
 Louis sought for the buccal end of the duct, and passed into 
 this a fine, fenestrated probe which carried a thread; the probe 
 and thread were carried through the anterior portion of the duct, 
 and brought thus through the fistula. The thread, being 
 detached frojii the probe, was left in the entire passage, and, to 
 maintain it in place, the end within the mouth was tied to that 
 on the cheek. In a day or two a larger thread was passed, 
 and this was repeated until the canal and fistula had been much 
 enlarged; this attained, the cord was cut off on the outside, and 
 then the buccal portion was drawn inwards, and the canal 
 allowed to close from the cheek inwards. This plan would be 
 impossible should there be closure or much narrowness of the 
 buccal j^ortion of the duct. As aid, injections may be made 
 through the anterior part of the canal. 
 
 A method superior to the one described is that invented by 
 Deguise in 1811. This consisted in passing a small trocar through 
 the fistula and forcing the instrument from before backwards; 
 through the canula Deguise ^^assed a leaden wire. Then, from 
 the same external orifice, the trocar was caused to traverse the 
 cheek from behind forwards, and the other end of the leaden 
 ware was carried through into the mouth, when the ends were 
 fastened inside. This method has served as the model of other 
 plans in which the original is somewhat modified. Instead of 
 leaden wire, that of silver or gold might be used, and, after the 
 wire is fastened inside of the mouth, the edges of the fistula may 
 be pared, and the external wound closed by suture. The looped 
 wire should be tightened, from time to time, so that it may grad- 
 ually cut through the included portion of the cheek. Silken 
 cord might be used instead of wire, or a small canula might be 
 passed in from the fistula and retained in the cheek, so as to per- 
 mit the saliva to enter the mouth after the outer opening is 
 sutured. 
 
 The treatment has been directed to the outer opening alone ; 
 the plans here used have been suture, cauterization and compres- 
 sion. 
 
 The edges of the fistula may be trimmed and then united by 
 suture, and this will be aided if covered by a thick coating of 
 collodion. A cure might thus be effected, provided the anterior 
 portion of the canal is yet patent; and should this be contracted, 
 it must be dilated by the use of appropriate sounds. 
 
 Closure has been attempted, yet rarely successfully, by cauter- 
 ization of the fistula by means of a pencil of nitrate of silver, or 
 the thermal cautery. 
 
532 MALAR AND I'AROTIDEAN RKGIONS. 
 
 Compression has been tried, and this may be applied on the 
 outer opening, so as to [)reveiit the escape of saliva; or the pres- 
 sure may be made on the gland, so as to check the secretion of 
 saliva. 
 
 Claude Bernard has found in vivisective experiment that, if 
 the salivary duct be tied and the secretion thus retained behind 
 the ligature, atrophy of the gland will ensue. Some have coun- 
 seled to utilize this fact in the cure of salivary fistula. The few 
 reports of trials of this plan do not encourage its repetition. 
 
 Viborg, after severing the duct in animals, reunited the ends 
 by suture; and as union occurred, he proposed direct suture as a 
 plan of curing Stenonian fistula. 
 
 The ingenious Langenbeck proposed to dissect up the poste- 
 rior end, and turn the same into the mouth through an opening 
 made inwards through the tissues. The objection to this plan is 
 that the end which has thus been shifted tends to retract, and 
 the buccal orifice becomes narrowed or closed. 
 
 Desault proposed to dry up the fountain by compression 
 maintained on the gland, so as to cause its atrophy. It is proba- 
 ble that the offspring of modern civilization would rebel against 
 such a painful plan of treatment. 
 
 Bonafont reports that he cured a salivary fistula in 1841 by 
 dissecting up the posterior part of the duct, and, having fastened 
 the end in a small canula, the latter was passed through the 
 cheek into the mouth, and retained there during the healing of 
 the outer fistula, which was closed by suture. In 1851, Balassa 
 reported a cure by a modification of the plan of Deguise, above 
 mentioned. In 18(31, Consolini cured a Stenonian fistula by pass- 
 ing a catgut thread through the anterior portion into the pos- 
 terior one, and retaining the thread in place until the outer 
 fistula healed. In 1882, Stokes, of Dublin, cured a case in a 
 similar way, yet, instead of catgut thread, he used a wire. 
 
 In conclusion, it is clear that there is no dearth of methods 
 from which the surgeon may make selection for the cure of parot- 
 idean or Stenonian fistula; and it is probable that by a dili- 
 gent prosecution of any one of them, a cure of the patient will be 
 attained. 
 
CHAPTER XV. 
 
 MAXILLA SUPERIOR. 
 
 Fracture. — Reference has already been made to fracture of 
 the upper jaw which existed coincidently with a lacerated wound 
 of the cheek; mention was also made of subcutaneous fracture of 
 the anterior wall, in which the latter is forced into the antrum; 
 there yet remains to be considered certain fractures of the maxilla 
 superior which involve the processes or the body of this bone. 
 
 The alveolar process may be broken, on a small scale, in the 
 act of extracting teeth ; yet the improved methods of dentistry, in 
 which the forceps has replaced the lever and key, have rendered 
 such fracture a more rare occurrence. The roots of the molar 
 teeth are sometimes disposed in such divergent position, or these 
 roots so embrace a portion of the process, that the teeth cannot 
 be extracted without causing some fracture of the process. And 
 this injury may consist merely of a small piece of bone broken 
 from the inner or outer wall of the alveolus; or the rent may 
 include a considerable portion of the alveolar process; or, finally, 
 it may involve the body of the jaw. 
 
 When a minute fragment of the alveolus is broken off, the 
 conditions are such that it usually dies, and, if not removed at 
 the time, it will sooner or later become separated by suppuration. 
 The condition is somewhat more grave and requires more atten- 
 tion when a portion of the process containing one or more teeth 
 is broken off. An injury of this kind is to be treated by restoring 
 the fragment to proper site, retaining it there, and maintaining 
 it in rest. The replacement is easily done; retention in site is 
 more difficult; this may sometimes be done by ligating the teeth 
 of the fragment to those outside of it by means of wire or silken 
 cord. Wire is more easily used, yet thread is less apt to injure 
 the teeth. If retention in place is thus impracticable, as is the 
 case in which a large portion of the process is broken, and by its 
 weight separates from the body, then a mold of gutta percha 
 should be applied to the part, and the lower jaw brought against 
 
 (533) 
 
53-4 MAXILLA SUPERIOR. 
 
 the upper one and held there by a bandage placed around the 
 head. Meantime the patient must be fed on liquid food. This 
 food may be introduced through a tube passed into the buccal cav- 
 ity , around and behind the molar teeth; or, if there be a breach in 
 the teeth of the lower jaw, the food may be introduced there. 
 During this closure of the teeth, the cavity of the mouth must be 
 rinsed out two or three times daily by injecting into it a weak 
 solution of borax: thus parasitical multiplication is averted, and 
 jnore rapid healing insured. Under this management speedy 
 eunion of the fracture ensues in from three to four weeks. 
 
 In case a portion of the body of the jaw is detached with the 
 alveolar process, then a similar plan of treatment is to be pur- 
 sued; special care, however, is to be taken that the displaced frag- 
 ment be accurately replaced and retained in normal site. After 
 the healing of the fractured alveolar process, should there remain 
 some inequality in the position of the teeth, this will commonly 
 disappear through the work of mastication, in which pressure on 
 the dependent part tends to force it into normal place. 
 
 The body of the maxilla superior is so situated that it is pro- 
 tected from the usual causes of violence which produce fracture 
 elsewhere in the body; and, excepting projectiles which also 
 wound the soft parts, the fracture of the upper jaw through 
 indirect or direct impact of force, is rare. 
 
 Fracture resulting from indirect violence has been studied by 
 Lelieribel, who finds that this bone is protected by three sets of 
 osseous columns, viz., the fronto-nasal in the median line, the 
 malar and the zygomatic at the sides, and lastly the pterygoid 
 processes, which support the bone behind. Violence is oftenest 
 transmitted to the upper jaw through the maxilla inferior; for 
 example: a blow on the chin may break the lower jaw; or, this 
 part escaping, the violence may travel to and break the upper 
 jaw. In a second way, when the lower jaw is fixed, violent force 
 acting on the summit of the head has been known to fracture 
 the maxilla superior. And in a third way, the bone may be 
 broken by the j)atient falling some distance and striking on the 
 chin. And, lastly, fracture has arisen from violence acting on 
 the malar bone, and driving this bone downwards and inwards. 
 
 Guerin, in experiments on the cadaver, found that a blow on 
 the face below the nose causes a horizontal fracture traversing 
 the maxilla below the malar bones; and the pterygoid ])rocesses 
 are likewise broken. In such case, if the finger be passed behind 
 the molar teeth and pressure be made on the pterygoid plate. 
 
FRACTURE. 535 
 
 tlie latter will be felt to move; or, if it is not moved, such, pres- 
 sure awakening pain is indicative of fracture; and the move- 
 ment mentioned and the pain awakened are pronounced by 
 Guerin to be trustworthy diagnostic signs of fracture of the upper 
 jaw. 
 
 In the cases of fracture resulting from indirect violence, the 
 diagnosis, as just seen, may be difficult to determine; on the con- 
 trary, cases occur in which the condition is clearly evident 
 through the displacement of the bone. The two bones may be 
 separated from each other, and one may be movable, and some- 
 what depressed below the other; or both of the maxillse, with- 
 out injury of their median synosteal suture, may be detached 
 from their upper, lateral and posterior connections, and may 
 hang loosely over the oral cavity. The writer has seen and 
 treated a case of the latter kind, which resulted from a cable-car 
 accident, and the violence was probably direct, as the cheeks 
 were greatly contused. There was no open wound. The max- 
 illse, as a common mass, were movable, and rested on the lower 
 jaw. There was serious encephalic injury, in which cerebral 
 concussion was prominent. 
 
 In fracture caused by direct or indirect violence, vascular 
 rupture must occur; and should the bones be displaced, this 
 rupture will be so extensive as to cause swelling and visible 
 ecchymosis. Such ecchymosis may be found in the roof of the 
 mouth, or in the tissues investing the base of the alveolar process. 
 Such swelling and blood marks aid in the determination of the 
 fracture, when there is no mobility. 
 
 Fracture of the upper jaw may have as ill consequences 
 obstruction or closure of the lachrymal canal, pressure on some 
 of the branches of the superior maxillary portion of the trifacial 
 nerve, and irregularity of the dental row through displacement of 
 the alveolar process. To avoid these results, which may amount 
 to grave annoyances, the surgeon in charge should accurately 
 restore the fractured part, or parts, to their normal site, and 
 afterwards retain them at rest until union has taken place. 
 Restoration to place may be done with the fingers and a blunt 
 instrument, such as a sound passed into the nostrils. That the 
 lachrymal canal is open will be shown by the tears passing 
 through their natural channel ; but if the canal be obstructed, 
 the tears will flow over the lower lid. Another rare accident is 
 the emphysematous infiltration of the tissues, due to air being 
 forced into them during strong expiratory effort through the 
 nasal passages. 
 
536 MAXILLA SUPERIOR. 
 
 Fracture of the maxilla superior is remarkable for the short 
 time required for healing, provided the i)arts be placed in proper 
 position, and thus immobilized. After coaptation, if alveolar 
 fracture demand it, let the teeth be encased in gutta percha, and 
 then, by a bandage, fix the lower jaw against tlie upper one, so 
 as to retain the latter in position. Meantime, during the four 
 weeks, which time is demanded for healing, let the patient be fed 
 in the manner already described. The appliance of retention 
 may be a gypsum cast; or straps with buckles may l)e placed 
 vertically, obliquely and horizontally, so as to maintain rest of 
 the broken bone. 
 
 Fracture from gunshot wound has often been observed by the 
 military surgeon; and in this era of social discord, in which the 
 worst as well as the best elements are evenly paired in the turmoil 
 of civilization, the civil surgeon is not an infrequent observer of 
 gunshot injuries; such injury, self-inflicted, may be the gunshot 
 wound in the mouth, which failing to kill, as was intended, the. 
 ball has shattered the upper jaw. Such projectile wound should 
 be treated in the same manner as gunsliot wounds in other |)arts 
 of the body; especial care, however, should be taken to save 
 fragments of the palatal orocess wliich are still adherent to the 
 soft parts. 
 
 Resection of the Upper Jaw. — Resection of the maxilla superior 
 may be partial or total in its extent; partial resection may con- 
 cern either the processes or a portion of the body; but in total 
 resection the entire bone or both maxillae may be extirpated. 
 Tn total resection the inferior turbinated bone is necessarily 
 removed, inasmuch as it articulates only with the upper jaw. 
 On the other hand, though resection is said to be total, yet, in 
 most cases in which it is done, fragments of the articulating 
 processes are left behind. 
 
 Resection is also done temporarily, in wliich a part of the 
 bone is loosened and uplifted in connection with the soft parts, 
 for the purpose of reaching growths situated in the antrum, the 
 nasal cavities or the naso-pharyngeal region; and after this pur- 
 pose is accomplished, the bone is replaced. 
 
 Resection is often done for the jiurpose of removing a 
 malignant neoplasm which implicates a part or the whole of 
 the bone; for the maxilla superior, like its close neighbor, the 
 parotis, is the germinal site of the various malignant growths; 
 and if these do not arise in it, they may reach it by extension. 
 Exceptionally, resection is required for the removal of benign 
 
RESECTION OF THE UPPER JAW. 537 
 
 tumors. These -anfortunate prerogatives belong to both the 
 uj^per and the lower jaw. 
 
 O. Weber has collected three hundred and seven cases of 
 tumors of the upper jaw, which he classifies under the following 
 heads: osteoma, thirty-two; vascular tumor, one; fibroma and 
 vascular fibroma, seventeen; sarcoma, eighty-four; enchondroma, 
 eight; cysts, twenty; mucous polypi, seven; carcinoma, one hun- 
 dred and thirty-three, and melanoma, five, Weber thinks that 
 some of the cases of carcinoma should have been placed under 
 the head of sarcoma, since he believes that nearly half of maxil- 
 lary tumors are sarcomatous in nature. 
 
 In case the disease requiring resection is limited to the palatal 
 or alveolar j^rocess, or is situated in a portion of the maxilla 
 superior, then partial resection is the proper operation to be done. 
 In such partial resection, the guiding rule should be to excise 
 enough of the bone so as to completely remove the disease; to 
 spare the parent bone and permit the early reappearance of the 
 disease would be ill economy. The excising knife or chisel should, 
 in its girdling cut, reach into the sound structure, and, in fact, 
 comj)rise a few lines of the latter inside of the line of excision; 
 only thus operating can a satisfactory result be obtained. 
 
 The resection of a portion or of the entire alveolar j^rocess is 
 done as follows : An incision is to be made between the cheek and 
 the jaw, in the bottom of the fossa between the two parts, and the 
 cheek is to be dissected from the jaw to a sufficient distance to 
 expose the outside of the bone which is to be divided. This 
 separation is best done, after the first cut is made with the scalpel, 
 by means of a chisel, with which the periosteum is uplifted. A 
 similar cut, and concentric with the first incision, is to be made on 
 the palatal side of the alveolar process. The vertical cuts are 
 now to be made through the bone, including the afiiected part. 
 To make these cuts, it is often necessary to extract one or more 
 teeth which stand in the line of the incision. Next a horizontal 
 cut uniting the vertical ones is to be made. This third cut com- 
 pletes the separation of the diseased part. The division of the 
 bone may be done with a resection saw, chisel and mallet, or 
 with large, strong-bladed forceps. If forceps be used, there 
 should be two pairs, one with straight blades for the vertical 
 cutting, and another curved pair to divide horizontally. The 
 chisel and mallet are favorite instruments of the French in 
 maxillary resection; the division, thus done, leaves a more irregu- 
 lar surface than if the removal be done with the resection saw. 
 35 
 
538 MAXILLA SUPERIOR. 
 
 This instrument witli its narrow blade can be used in any direc- 
 tion, and at any angle. The author has operated according to 
 each of the methods mentioiied, and gives his preference to the 
 saw, especially, if along with it, there be used a small trephine, 
 with which openings may be made at the point of union of tlie 
 vertical and horizontal lines of section; for the narrow-bladed 
 saw can be passed in such opening, and thence the sawing can be 
 done in both directions. 
 
 This alveolar resection can be done through the moutii, and 
 hence without external scar. Should the opening of tlie moutli 
 be too narrow, then more room could be gotten by extending the 
 angle of the mouth by means of a horizontal cut; and such a 
 cut would leave an inconspicuous scar. To assist in doing the 
 work through the mouth, the oral opening can be held open and 
 dilated and shifted from its site by means of large retractors. 
 
 A growth seated on the anterior surface of tlie superior 
 maxilla and limited to tliis face, may also be removed through 
 the mouth. To do this, incise through the labio-maxillary fossa, 
 and with a blunt dissector separate the structures of the cheek 
 from the maxilla; and this detachmen* ^.an be carried to the infra- 
 orbital margin. To aid in this dissection, the mouth may be 
 shifted upwards. In this wise the writer excised an osteomatous 
 growth already referred to, involving the front face of the 
 maxilla. 
 
 The total excision, or resection, as it is oftener named, of the 
 upper jaw has been the matter of emulous effort among operative 
 surgeons. Among those who have earned distinction in this 
 field are the names of Gensoul, Lizars, ISIichaux, Dieffenbach, 
 Heyfelder, Langenljeck and 0. Weber. A diagrammatic repre- 
 sentation of the lines of incision would present a face well 
 traversed with sections. If these lines be studied as to their 
 position and direction, one finds a frequent one to be a vertical 
 median line from the lower part of the forehead (glabella), along 
 the dorsum of the nose, through the upper lip into the mouth; 
 or, instead of in the median line of the nose, the incision may be 
 made vertically alongside of the nose to the mouth; in a third 
 method, the incision is made from the angle of the mouth, or 
 from some point of the border of the upper lip, upwards and 
 obliquely outwards. This oblique cut has been given various 
 positions on the cheek; and it may be straight or curved. 
 And, lastly, a horizontal cut may be made from the nose outwards, 
 close to the lower border of the orbit. 
 
RESECTION OF THE UPPER JAW. 539 
 
 In the pioneer work done by Gensoul and Lizars, the maxilla 
 was exposed by a quadrangular flap, which was made by two 
 vertical cuts, viz., one which was made alongside of the nose, 
 and another extended directly upwards from the angle of the 
 mouth. The lateral or outer cut, in this method, divided many 
 branches of the facial nerve as well as the duct of Stenson; and 
 thus the unfortunate patient remained with a palsied cheek and a 
 salivary fistula; conditions which, if not as fa:tal to life as the 
 growth which is to be removed, certainly render existence 
 scarcely tolerable. And to avoid these ill results, the outer 
 vertical cut was abandoned. 
 
 The following review of resection of the superior maxilla, 
 drawn from the published work of eminent authorities, will j^re- 
 sent in somewhat historic order the various methods which have 
 been pursued. 
 
 The quadrangular flap of Gensoul being abandoned, for the 
 reasons before given, DiefFenbach, in 1847, published thirty-two 
 operations in whicH the removal was done through a vertical cut 
 which passed from the inner angle of the eye to the mouth, and 
 which was aided by a horizontal cut beneath the eye; thus done, 
 the facial nerve was spared. 
 
 Michaux, in 1852, removed the superior maxilla to form a 
 way by which he could enter the posterior nares and remove 
 naso-pharyngeal growths; and, in his method, he discards the 
 removal of the malar bone as done by Gensoul, and exposes the 
 maxilla through a median incision which reaches from the lower 
 part of the forehead along the dorsum of the nose downwards: 
 into the mouth; and this may be aided by a horizontal cut 
 underneath the eye; and, if need be, a third cut may extend from 
 the outer angle of the eye to a point beneath the zygoma. As 
 far as the disease will permit, save the zygomatic, nasal and 
 palatal processes of the maxilla. To do bilateral maxillary 
 resection, Michaux counsels to use the long cut in the median 
 line of the face. He uses the chisel and mallet as more manage- 
 
 o 
 
 able instruments than the Listen forceps, or the chain-saw. 
 Michaux performed fifteen resections, of which seven died from 
 purulent infection. 
 
 Oscar Heyfelder, son of J. F. Heyfelder, in 1857 wrote on 
 maxillary resection : a work inspired by filial devotion, in which 
 the methods pursued by the father were compared with those of 
 other surgeons. The father, in 1852, was the first to perform 
 resection of both maxillse. This was done by two lateral cuts 
 
540 MAXILLA supp:rior. 
 
 extending on each side from the malar bone to tlie angle of 
 the mouth. The large Hap tlius formed, including the nose, was 
 dissected up and turned upwards. The malar bone, separated 
 ■''rom the upper jaw by the chain-saw, was preserved. And the 
 soft parts lining the palatal process were loosened and separated 
 as the last act of the detachment. As cuts, which may be used, the 
 Heyfelders employed a central median one and an oblique lat- 
 eral one; the latter, commencing at the angle of the mouth, may 
 run upwards and outwards, and terminate at the anterior, middle 
 or posterior part of the malar bone. As a rule, the maxilla, with 
 the tumor, can be removed through the oblique lateral cut; and 
 the advantages resulting from it are that tliere remains but one 
 scar; its disadvantages are that it must sever branches of the 
 facial nerve, and might divide the duct of Stenson. The maxilla 
 superior can also be exposed by an anterior lateral flap that lies 
 along the side of the nose; and to this, two horizontal incisions ma}' 
 be added, one underneath the 63^0, and one continued outwards 
 from the angle of the mouth; and thus a lar^e quadrangular flap 
 is so formed that the salivary duct and the facial nerve are spared. 
 This quadrangular flap is the one preferred by Heyfelder for 
 resection of the upper jaw. 
 
 In case partial resection is to be done, then Heyfelder advises 
 the incision of Kilchler, viz., a cut one and one-half inches long, 
 passing from the mouth upwards alongside of the nose. 
 
 Should it be needed to remove the lower jaw along with the 
 upper one, Heyfelder advises to do this through a cut made from 
 the forehead to the point of the chin; and another cut wliicli 
 jDasses along the lower margin of the maxilla inferior, and 
 upwards along the ramus. 
 
 In all these operations, Heyfelder advises to uplift and retain 
 the periosteum, when this is possible. When necessary, separate 
 the upper jaw through the median suture by which the two are 
 connected. Large forceps may be used to separate the maxilla 
 from the bones with which it is articulated ; in many cases, how- 
 ever, Heyfelder prefers the chain-saw, which he carries around 
 the part to be divided by the aid of a curved needle, which formed 
 three-fourths of a circle, of which the diameter was from four- 
 teen to sixteen lines. Such a needle attached to the chain can 
 be carried through the lachrymal canal into the nose. Bellocq's 
 canula may be used for passing the chain-saw. The posterior 
 articulation of the jaw with the sphenoid bone must be carefully 
 separated ; and this may be done with a chisel. After the detach- 
 
EESECTIOX OF THE UPPER JAW. 541 
 
 ment of the maxilla from the neighboring bones, as it is being 
 removed, divide the iufra-orbital nerve with scissors. Heyfelder 
 did not dress the wound for several hours. The labial cuts were 
 sutured, and no lint placed in the wounded cavity. Bleeding 
 was slight and did not occur secondarily. For two days, cold 
 dressings were used; then warm ones were applied. The patient 
 was fed with food injected into the oesophagus. Recovery was 
 most rapid, viz., in from two to three weeks. 
 
 Heyfelder published, in 1858, that, in a lisu of three hundred 
 and fifteen maxillary resections, there had been secondary bleed- . 
 ing in only five cases ; and this absence of haemorrhage he refers 
 to the fact that he did not plug up the wound. 
 
 Springer, in 1860, in a publication, offered some new sugges- 
 tions, partly his own, and partly those of others, on maxillary 
 resection; he advises to spare the palate and mucous membrane 
 as much as possible; also, to perform partial, instead of total, 
 resection in all cases where it is possible. The outer parts must 
 be sutured to the mucous membrane where the latter remains. 
 
 An example in whicli the incision was as limited as possible 
 was that of Butcher, in which the greater portion of the maxilla 
 superior was resected through a cut made from the mouth into 
 the nostril, and then, with one blade of a pair of strong forceps 
 in the mouth and the other in the nostril, the bone was divided 
 in the median line; and then, having extracted a tooth behind, 
 a similar lateral division of the bone was made at the side; thus 
 a portion of the jaw was removed. 
 
 In 1862, Liicke reported that B. Langenbeck had performed 
 two bilateral resections of the upper jaw witli no death; but of 
 eighteen unilateral resections two died, and of twenty-eight par- 
 tial resections one died. Death after removal of the jaw arose 
 from pus passing down to the lungs and causing pneumonia; and 
 to avert the swallowing of pus, Liicke advises to do the work, as 
 far as practicable, sub-periosteally. After total maxillary resection, 
 there occurred suppuration of the eye in a few cases, and this 
 was referred to destruction of the trifacial nerve; and as a means 
 to avoid such accident, Liicke directs to close the eye with adhe- 
 sive plaster. 
 
 To remove the upper jaw Langenbeck makes two incisions; 
 one of these commences on the glabella between the eyebrows, or 
 beneath the internal palpebral ligament ; thence the cutis carried 
 down to the wing of the nose, and, from the lower end of this 
 incision, another is carried upwards and outwards to the zygoma. 
 
542 ^r AXILLA SUPKRIOK. 
 
 By means of these incisions the soft i)arts are uplifted, and the 
 work can be done, to some extent, without entering the buccal 
 cavity. Langenbeck uses a fine saw to separate the jaw from its 
 surrounding osseous attachments, the saw being passed into 
 small crevices or openings. 
 
 Weber operated similarly to Langenbeck, viz., b}' means of a 
 vertical cut runnnig from beneath the inner angle of the eye to 
 the mouth; and this was aided by a horizontal cut under the eye, 
 in case it were necessary to remove a part or the whole of the 
 malar bone. If the periosteum be sound, it should be uplifted 
 with the soft parts and retained. Weber prefers to divide the 
 osseous attachments with the resection saw, which is used as fol- 
 lows: The saw is carried into the orljit under the uplifted peri- 
 osteum, and the bone divided thence to the opening of the nose; 
 or, the saw entering first, the nasal o])ening may be cut towards the 
 inner part of the orbit. The parts being uplifted outwards until 
 the saw can be i:»assed into the inferior orbital fissure, the 
 section, started in the inner or outer portion of this crevice, may 
 include and remove a fractional portion or the entirety of the 
 malar bone. The concluding act is to saw through the palatal 
 bone, in which, if possible, the soft part with the periosteum 
 should be preserved. In this sawing, the soft })arts should be 
 retracted from the cutting instrument with the fingers or 
 retractors. 
 
 Lehmann, in 1864, proposed in maxillary resection, of the 
 upper or lower jaw, to save the alveolar process and the teeth 
 contained in them. His plan is to detach and reflect from the 
 process the investing soft parts; next, saw through the base of 
 the alveolar process, so as to j^reserve as great a portion as the 
 conditions will permit. If the entire alveolar quadrant cannot 
 be saved, preserve a section of it. The teeth, thus saved, can 
 afterwards be used for mastication. New bone seemed to grow 
 on the portion of process thus saved. The teeth retained their 
 color and lustre. Kolliker teaches that the teeth depend for their 
 nutrition on the pulpa dentis and the contiguous tissue of the 
 alveolus, and Lehmann's observations confirmed this. Lehmann 
 claims for his method that, by it, the teeth, which are commonly 
 lost in the work of resection, may be saved. 
 
 As conclusion of the chapter on resection of the maxilla supe- 
 rior, it is appropriate to describe an operation akin to it, viz., 
 temporary resection of the upper jaw. In 1861 B. Langenbeck 
 wrote on osteoplasty, in which a bone is moved or shifted from its 
 
EESECTIOX OF THE UPPER JAW. 543 
 
 * 
 
 site, and afterwards replaced again; such an operation Laugen- 
 beck performed on the maxilla superior, to make a route by 
 which naso-pharyngeal growths could be reached and removed. 
 Michaux advocated the same procedure, clainaing that these 
 growths could only be successfully extirpated through the removal 
 of their periosteal attachments. Langenbeck was led to tem- 
 porary resection of the maxilla superior, by the good results which 
 followed temporary resection of the nasal bones to aid in the 
 removal of polypus. And to reach growths in the spheno-palatine 
 fossa, the sphenoidal sinus and the Eustachian tube, Langenbeck 
 found that the work may be done by temporarily shifting the 
 site of the body of the upper jaw. From a study of the facial 
 skeleton, Langenbeck conceived the design of detaching the 
 upper jaw from its place by sawing it through in certain direc- 
 tions, so that the body remained only connected by its nasal 
 process to the nasal and frontal bones. The jaw was sawn 
 through horizontally above the alveolar process, also verticallv 
 at the side. The vertical cut is placed so far laterally that it 
 includes the malar bone, and, when the sawing is done, the part 
 included is loosened and lifted upwards and inwards. After the 
 tumor has been removed, the shifted bone is to be replaced, and 
 if it does not remain in normal site, it should be retained there 
 by metallic sutures. 
 
 Demarquay announced in 1862 that, since 1851, he had prac- 
 ticed resection of the anterior face of the antrum and the nasal 
 process of the superior maxillary bone, for the purpose of reach- 
 ing growths in the nose, throat or antrum. To expose the part 
 to be resected, he makes a cut alongside of the nose down through 
 the lip: and a second cut is to be made horizontally from the 
 angle of the mouth to the masseter muscle; or the vertical cut 
 may be shorter and only reach from the ala of the nose to the 
 mouth, the horizontal one meanwhile being carried to the mas- 
 seter muscle. After such operation, Demarquay thinks that the 
 resected bone may be reproduced. 
 
 In concluding this chapter on resection of the maxilla supe- 
 rior, the writer will add that, from his operative experience, he 
 has learned that partial excision may be done through the mouth, 
 and that, for total unilateral removal, the work can also be done 
 by widening the mouth horizontally, through incising the bucci- 
 nator muscle. Such cut can afterwards be closed. Thus proceed- 
 ing, facial pals}^ will be avoided, and facial scarring and deform- 
 itv reduced to a minimum. 
 
CHAPTER XVI. 
 
 MOUTH AND ORAL CAVITY. 
 
 Lips. — The lips, which constitute the entrance to the buccal 
 cavity, may, within normal limits, vary much in shape and vol- 
 ume, and so the opening which the lips bound, commonly desig- 
 nated the mouth, may be small or large. The dimensions of 
 this opening, when large, give the surgeon an advantage when 
 he operates in the buccal cavity; on the contrary, the smallness 
 of the opening may be such that it requires widening by incision, 
 as a preliminary to intra-oral work. 
 
 The investing coverings of the internal and external surface 
 of the body meet on the lips; here one sees a transition from 
 mucous membrane to derm taking place so gradually that the 
 boundaries between the two are indeterminable. The mucous as 
 well as the dermo-mucous coat is normally of red color. This 
 hue varies in different subjects, and it may do so in the same 
 person at different times. In persons of the sanguine tempera- 
 ment, and in those addicted to spirituous potations, the lips are 
 strikingly red. In those who have lost much blood, and in the 
 leucfemic subject, the lips are pale. And the li^^s, which are 
 normally red, in the act of swooning, become pale; a condition 
 frequently supervening in those to whom an anaesthetic is being 
 given; such paleness then, as a faithful sentinel, announces 
 depressing nausea or commencing sj'ncope. The fading color of 
 the lips demands temporary suspension of the work, during a 
 surgical operation, and momentary attention to the condition of 
 the patient. Concealed htemorrhage is indicated by the colorless 
 lip: for example, when blood has escaped unseen down the 
 throat into the stomach, or in work done on tlie rectum the 
 blood has passed upwards into the bowel; and, lastly, such pale- 
 ness has given warning of intra-abdominal hfemorrhage which 
 had occurred unseen after a laparotomy. Therefore, attention to 
 the color of the lips must be among those matters which demand 
 care in the surgeon's work. Such paleness is the silent monitor 
 (544) 
 
LIPS. 545 
 
 of present or impending danger; if unheeded, the case in question 
 will probably afterwards stand in the fatal column of non-success, 
 and the cause of death be placed under the convenient heading 
 of shock. 
 
 Lying between the mucous and dermal coats of the lips, there 
 exist a small amount of adipose tissue, a circular muscle, a 
 glandular stratum, vessels, lymphatics and nerves. 
 
 The fatty tissue, different from what one sees elsewhere near 
 the surface of the body, does not occur as a sejjarate layer; the 
 derm and mucous membrane are closely adherent to the orbicular 
 muscle, and the adipose material is diffused through the muscle 
 in small rounded masses: and it does not augment in amount; 
 hence the lip, like the eyelid, does not increase in thickness 
 through adipose development. 
 
 The oj)enings of the eye, ear, nose and mouth contain muscu- 
 lar fibers; yet the openings of all except the mouth are main- 
 tained patent by a layer of cartilage in their walls; such stiffening 
 material is absent from the lips, which are distinguished by 
 their pliant mobility; and any surgical work, which lessens this 
 suppleness through interjection of cicatricial tissue into the muscle, 
 must trammel the functional activity of the lips. 
 
 The various facial muscles which converge towards the moutli 
 aid in the formation of the orbicular muscle, those from above 
 entering the lower segment, and those from below add fibres to 
 the upper segment, while the buccinator contributes fibres to both 
 segments; the arrangement being such that the mutually inter- 
 lacing bands support each other in the closure of the mouth. 
 The entrance and action of these comjoonent muscles at the 
 labial commissure give transverse elongation to the oral open- 
 ing, in opposition to the independent circular fibres, which form a 
 considerable part of the orbicularis; and these fibres retracting 
 cause a triangular gap when the lip is incised vertically. The or- 
 bicular muscle is closely and tightly bound to the skin by fibrous 
 tissue. In unilateral palsy of the face, the mouth is drawn 
 towards the unaffected side; and in bilateral palsy, as seen in the 
 apoplectic patient, the lips in breathing are passively drawn in 
 and out, as in the act of smoking the pipe. Also in the non- 
 palsied face, if from some cause there be greater power on one 
 side, the angle of the mouth will incline to that side, and give 
 an unnatural expression. In unilateral palsy, the depression of 
 the labial angle permits fluids, which are received in the buccal 
 cavity, to escape there, much to the patient's inconvenience. 
 
546 MOUTH AND ORAL CAVITY. 
 
 And a similar condition is induced when the muscular equipoise 
 of the two sides of the face is disturbed by some accidental lesion, 
 or, perha2)s, by the surgeon's knife. 
 
 A no less important structure tlian the muscular is that of 
 the glands, which lie between the mucous and nmseular coats. 
 These glands are in greater number in the upper than in the 
 lower lip, yet they are more voluminous in the lower lip. They 
 are surrounded by connective tissue, and the elements for suppu- 
 rative action are here present. 
 
 These glands, hard in texture, can be distinguished when the 
 lip is pressed between the thumb and finger; likewise, when a 
 section is made through the lip, as in the excision of epitheli- 
 oma, these glands crop out above the cut surface, and should not 
 be mistaken for diseased tissue. Should the uplifted glands ren- 
 der the surfaces uneven which are to be united, they should be 
 excised with scissors, or tlie ])oint of the scalpel. 
 
 The arteries of the lip are derived from the facial; they are 
 the superior and inferior coronaries and the inferior labial. These 
 vessels from the two sides inosculate. Their situation in the lip 
 is important to note: tlie superior and inferior coronaries lie in 
 the glandular structure, between the mucous and muscular strata; 
 and they are situated about midway between the attached and 
 the free borders of the lips. At the labial commissure, a thumb 
 and finger can grasp the edge of the mouth so as to include and 
 compress these arteries; or flat-bladed, clasping forceps can do 
 the same; such luemo.static clasps were used by Langenbeck 
 in his operations on tl)e lip. These vessels seldom demand 
 ligation, since the suture closing the wound can also include the 
 vessel; but since the coronary vessels lie just underneath the 
 mucous coat, the suture, to be effective, must transfix the entire 
 thickness of the lip. The inferior labial artery lies behind the 
 labio-mental sulcus; and it results that when a long vertical cut 
 is made through the lower lip, there is bleeding from both the 
 coronary and the inferior labial vessels. Likewise, where the 
 upper lip joins the septum of the nose, there is an arterial branch. 
 The labial veins may be disregarded in surgical work. 
 
 The lymphatic vessels pass to glands which lie above the 
 hyoid bone in the space bounded by the inferior maxillary arch. 
 The enlargement of these glands, in case of e^rithelioma of the 
 lips, is of great prognostic significance, and nearly always means 
 incurability. 
 
 The nerves are motor and sensory: the motor, derived from 
 
LIPS. 547 
 
 the facial nerve, is distributed to the orbicular muscle; the sen- 
 sory filaments of trigeminal source are numerous and are prin- 
 cipally sent to the mucous and glandular strata of the lips. 
 
 If one examines the site of the mouth in the incipient embryo, 
 the upper lip will be represented by three germinal buds or tuber- 
 cles, while the lower lip is indicated by two; in each lip these 
 germinal buds, developing, finally coalesce, and b}^ their fusion 
 they form the normal lip; such development and fusion nearly 
 always occur in the lower lip. The embryologist Coste, who 
 studied and described these rudimentary parts of the embryo, 
 named the middle one of the upper lip the incisive bud, since it 
 contains the germs of the incisor teeth; it likewise contains the 
 primary elements of the premaxillary section of the maxilla 
 superior. The origin of hare-lip has been referred to an arrest oi 
 the development of these primary components of the upper lip. 
 
 The mouth, or opening bounded by the lips, is an all-important 
 part to the new-born child, since it is the entrance to the canal 
 of nutrition ; and if the form of the lips is in some waj'- ab- 
 normal, the life of the infant is compromised. Such abnor- 
 mality may be present in the form of atresia or entire closure, 
 stenosis, wideness, deviation of the site of the mouth, adhesions, 
 labial hypertrophy, labial atrophy and hare-lip. 
 
 Atresia, or complete closure of the mouth, is rarely seen in the 
 new-born; while nature not unfrequently disregards her guiding 
 model in fashioning the rectal end of the alimentary canal, as 
 well as of the adjacent orifices, the oj^enings of the mouth, nose, 
 eyes and ears rarely apj)ear closed. The history of such cases, 
 as phenomenal rarities, is to be found in the annals of medicine, 
 especially in the olden time, when myth and fabulous statement 
 found place and credence along with truth. And, for this rea- 
 son, such cases occur much often er among the writers of the 
 eighteenth than of the nineteenth century; the winnowing hand 
 of criticism, the love of fact undebased with inaccurac}^ and the 
 restive intolerance of the unauthenticated and marvelous, which 
 characterize the present century, have greatly lessened the num- 
 ber of statements which levy the tribute of credulit\'. 
 
 Yet eliminating the untrue and improbable, a small number 
 of trustworthy observations of congenital oral atresia are found 
 recorded; and when studied they present themselves in two 
 classes: (1) Atresia, in which, not only the mouth, but the upper 
 extremity of the alimentary canal is wholly closed. This closure 
 coincides with other deformity; according to Craveilhier, it coin- 
 
548 MOUTH AND ORAL CAVITY. 
 
 cides with the teratological type of the cyclopeaii monster. (2) 
 111 the second form, the atresia is confined to the hibial orifice, 
 the cavitv of the mouth otherwise being perfect. Sucli closure 
 may be a coalescence of the entire thickness of the lips, or the 
 union may be tlirough the medium of a web-like film similar 
 to that seen in atresia ani. In the form in which oral closure 
 is associated with absence of the buccal and pharyngeal cavities, 
 the unfortunate infant is in a condition which defies legit- 
 imate surgery; concurrent conditions of ill form conspire to end 
 its existence before it would perish from hunger. But where the 
 atresia is of the web form just mentioned, then the operation is 
 of a simple nature, and consists in division of the occluding film; 
 to do this, let a tenaculum be fixed in the thin web, and the lat- 
 ter being lifted up, the little cone thus formed can be excised, 
 and thus a circular opening is obtained, through which one blade 
 of a pair of scissors can enter, and the oral orifice be reestablished. 
 The wound thus made is slight, yet, to maintain it fully patent, 
 some instrument of dilatation should daily be introduced; as such, 
 dressing forceps may be used, which, when withdrawn with open 
 blades, will dilate. 
 
 Incomplete or partial atresia of the mouth may appear con- 
 genitally, or it may arise later as the result of some lesion or dis- 
 ease; and such occlusion may vary from a small orifice to one 
 deviating but little from normal size. As a congenital condition, 
 the lips may be soldered direct!}^ together on each side, or they 
 may be united by means of a web-like film, there remaining a 
 small, median opening. The mouth may be narrowed by grad- 
 ual extension forwards of one or both commissures, through 
 ulcerative action and subsequent union of the raw borders; and 
 such ulcerative agency may arise from any cause wliich destroys 
 the mucous coat of the lips: viz., a traumatic lesion, or one from 
 fire, or an escharotic, as an acid or an alkali. And in cases in 
 which such injury to the lip has occurred, precaution should be 
 taken to prevent adherence of the parts; and this consists in 
 daily separating the adherent surfaces and interposing some 
 body which will maintain the parts asunder. This prophylactic 
 task, though industriously pursued, is rarely satisfactorily accom- 
 plished; the oral opening remains narrower than it was origi- 
 nally. 
 
 Treatment of Partial or Complete Atresia of the Mouth. — In cases 
 in which the atresia is partial, and there is an opening of small 
 dimensions, the condition has sometimes been allowed to remain 
 
ATRESIA OF THE MOUTH. 549 
 
 unoperated on; and then the patient has been fed through a 
 funnel and tube; or a beak-bearing cup has served the purpose; 
 or the nutrient fluid has been injected into the mouth with a 
 syringe. As a palliative procedure to maintain the small open- 
 ing patent, occasional dilatation may be made by means of a 
 sponge-tent, or other expanding agent. Such treatment would 
 rarely be continued long; its inconveniences would erelong 
 overcome the subject's reluctance to a more rational treatment, 
 in which one of the following operative plans may be adopted: 
 
 The united structures were 'simply divided with a knife by 
 Amussat, and separation maintained by means of lead foil ; this 
 plan was pursued by Boyer also; in spite of persistent efl'ort, the 
 cicatrizing force seems to have triumphed over that of the sur- 
 geon, and but slight improvement was thus obtained. 
 
 A better plan than the preceding was one which was sug- 
 gested by the custom of piercing j)arts of the body and establish- 
 ing a cicatrized foramen by means of a foreign bod}^; an example 
 of this is the introduction of a ring in the lobule of the ear. 
 Savagism, from which such mutilation originated, still affords 
 examples of a perforation of the cheek, similar to that which 
 the surgeon may use to restore the narrow mouth to normal size. 
 The Polynesian native, as well as the Indians in the valley of the 
 Amazon, pierce their cheeks and lips with pieces of bamboo or 
 wood, and retain the foreign body in site until scar tissue is 
 formed around it, and thus a permanent opening is established. 
 Such work ma}^ be imitated in the case of the narrow mouth; 
 and after the formation of such opening at the site of the desired 
 commissure, the part remaining between this and the small oral 
 opening may be severed. "Taking a lesson from the South Sea 
 savage, the surgeon may use as perforator a piece of bone, which, 
 having pierced the cheek, is allowed to remain in place until the 
 opening is permanently established, when, unlike the savage who 
 lets his remain in site as an ornament, the surgeon removes the 
 body and divides the remaining bridge. This method, named by 
 the French Botoc, from the Botocudos, a cheek-perforating tribe, 
 partakes too much of savagism for a place in scientific surgery, 
 and is better replaced by one of the following plans: — 
 
 Serre, of Montpellier, introduced an operation in which incis- 
 ions are made laterally and horizontally from the existing open- 
 ing, and then the mucous membrane and the derm are united by 
 silken sutures so closely applied as to completely close the 
 wounded parts. The work thus done is followed by healing, and 
 
550 MOUTH AND ORAL CAVITY. 
 
 a proper oral opening is secured to the patient. The writer 
 would suggest the use of the metallic instead of the silken suture 
 for closure of the wound. 
 
 A second ]»lan, which was originated by Dieffenbach, is the 
 immediate formation of commissures which are invested with 
 trans[)Osed mucous membrane, so that the constructed angle 
 remains as it is formed. To do this work, from the existing oral 
 opening incise laterally to the site of the desired commissure; 
 and, having cut through the skin, excise a small portion of the 
 thickness of the cheek, leaving only the mucous membrane intact 
 at the bottom of the sulcus. Next, from the unsevered mucous 
 memln-ane, so construct a flap that it can be folded outwards, and 
 joined by suture to the skin. In case the mucous membrane is 
 uusuited to form this commissural flap, then the adjacent derm 
 may be employed for this purpose. When the commit^sure is thus 
 formed, the skin and mucous membrane may be united over the 
 remaining wound of the divided cheek, tlius combining the 
 methods of Serre. and Dieffenbach. 
 
 In case the atresia has resulted from some cause which has 
 produced other deforming scars, these should be removed, 
 loosened or otherwise changed as the case demands ; and among 
 the means which can be used, that of subscision is one of the 
 best ; by means of a tenotome, introduced beneath the skin or 
 nmcous membrane, the contracted bands may be severed, and 
 irregularity of surface lessened. 
 
 3Iacrosfoma. — A condition, quite the o^jposite of the one 
 described, is that of extreme wideness, named macrostoma; this 
 is usually of congenital origin, though it can arise from acci- 
 dental lesion, or even the surgeon's knife. Congenital wide mouth 
 originates in an arrest, or standstill, in the work of commissural 
 fusion of the two lips in the development of the embryo. Sucli 
 defective form is often associated wath other abnormal conditions 
 of the infantile face. Or there may be cephalic deformity; and 
 these concomitant defects are usually of so serious a nature as to 
 destroy the subject's life. Should the infant have no other 
 deformity, this one would entail from birth the troublesome con- 
 dition of constant escape of saliva from the mouth; and at a later 
 period, during dentition, the teeth, lacking their usual wall-like 
 support, would tend to diverge outwards, and, cropping out 
 through the abnormal gap, they would become useless, and. 
 besides, add much to the unsightlincss of the i"ace. The abnor- 
 mally exposed mucous surfaces readily ulcerate, and add a con- 
 
MACROSTOMA. 551 
 
 tingent to the trouble. Besides this type of macrostoma there are 
 seen less grades of it ; these may be so near normal limits as to 
 demand no surgical attention; but if it is a marked deformity, 
 then surgical intervention is proper. Had the German princess, 
 who was nicknamed Taschenmaul, or pocket-mouth, had her mouth 
 reconstructed in infancy by the surgeon's hand, it is probable 
 that she would have been spared this ignoble sobriquet. 
 
 The writer has seen a case of unilateral macrostoma which 
 originated from mercurial ptyalism. This was not an infrequent 
 cause of oral and buccal devastation in the early part of this 
 century, when calomel, the "white eagle" of the old alchemists, 
 soared triumphantly through the domain of therapeutics, and, 
 not unfrequently, in its destructive swoops made prey of tooth, 
 jaw, lip and cheek. Accumulated experience has trained the 
 eagle, falcon-like, to abide in more purposive circlets. In the case 
 mentioned, the young man when an infant was so severely 
 ptyalized that a portion of his cheek, including the angle of the 
 mouth, sloughed and left a great breach in the wall of the buccal 
 cavity. The teeth which grew on that side diverged outwards 
 and stood more nearly horizontal than vertical. The saliva 
 constantly escaped. This breach, an inch and a half in height 
 and two and a half inches long, was closed by an operation in 
 which the protruding teeth were removed, the edges of the breach 
 made raw by free trimming, and then a large inferior flap was 
 constructed from the cutaneous and subcutaneous structures 
 which lay beneath the opening. As the uplifting of this flap left 
 a large gap on the upper part of the neck, to close this a pedicled 
 flap was raised from the loose derm near the clavicle, and fixed in 
 the place whence the first flap was taken. The open space, now 
 remaining above the clavicle, was closed by means of subcutaneous 
 detachment and lateral sliding of the adjacent derm. The flaps 
 healed by primary union, and the patient's appearance was 
 much improved. 
 
 Besides sloughing of the cheek from mercurial abuse, it niay 
 arise from noma, of which the writer once had the unfortunate 
 privilege of seeing a number of cases'; this was in a ward in an 
 emigrant hospital which had been set aside for children affected 
 with scarlatina and measles. The disease was of a virulent form, 
 and the ward was not ventilated. The noma began as a small 
 black point in the midst of the swollen and ashy pale cheek, and 
 soon extended until it occupied the surface corresponding to the 
 buccinator muscle. In nearly all these cases, death spared these 
 
552 MOUTH AND ORAL CAVITY. 
 
 unfortunates from impending deformity, and the essays of repar- 
 ative surgery. 
 
 Treatment. — The problem of lessening the mouth is an easier 
 one than that of enlarging it. The task consists in shifting the 
 commissure anteriorly. This can be accomplished by paring the 
 opposite margins and uniting the raw surfaces by metallic suture, 
 and then immobilizing the parts by an ap})ropriate bandage. The 
 work done in this way has the disadvantage that the commissure 
 is an acute and not obtuse angle. To remedy this, a flap of 
 mucous membrane may be uplifted from the border of the upper 
 lip, behind the site of the desired connnissure; this flap, a half 
 inch long, and with attachment forwards at the proposed com- 
 missure, is to be folded forwards, and sutured to the ]"aw surface 
 below. Thus an obtuse angle is formed. The remainder of the 
 wound is to be closed by sutures, and the jiarts rendei^ed motion- 
 less by a proper appliance. 
 
 Deviation of the Oral Opening. — There may be deviation of a 
 part of the wall of the month, or the entire oral opening may be 
 displaced. Thus from a burn on the cheek, or any cause destroy- 
 incr the structures near the angle of the mouth, the work of cicatri- 
 zation may attract, and displace the commissure towards the j)lace 
 of injury. In like manner, a single lip may be eccentrically 
 displaced by an adjacent cicatrix. And, on a more extensive 
 scale, a migrating lupus -has, in its cicatrizing march, drawn along 
 the mouth for a short distance. 
 
 Besides the causes enumerated, laljial deviation, extensive or 
 limited, may arise from osseous disease through which a portion 
 of the upper or lower jaw is destroyed. The author has seen 
 examples of each; in the greater numljer, however, the disease 
 was in the maxilla inferior, and in children. The loss of a 
 portion of the lower jaw through necrosis, and the dwarfed 
 development of the jaw, cause the chin to retreat, and the teeth of 
 the upper jaw to project forwards and slope outwards. And if 
 the necrosis be unilateral, the mouth will sink, and its angle be 
 deflected towards the affected side. In such cases the upper 
 incisors, through their ill position, become a striking deformity. 
 Such a mouth can be improved in form; and this improvement 
 will be greater if the subject be a child whose face is not wholly 
 developed. This work, commonly committed to the hands of the 
 dentist, is done by removing a canine or a bicuspid tooth on each 
 side, and then a compressive band including the incisor teeth is 
 fastened to the teeth behind. Tims the projecting teeth can be 
 
LABIAL HYPERTROPHY. 553 
 
 forced backwards into the space left by the extracted teeth. To 
 be effective, this compression should be continued for a year, or 
 even longer. In bad cases it may be necessary to extract two 
 teeth on each side. If the backward pressure be made with 
 too much force, in order to shorten the period of treatment, there 
 is the risk of injuring the nerves which supply the shifted 
 teeth; the latter, like other j^arts of the human body, will revolt 
 against a rapidly encroaching violence, which would be easily 
 tolerated if it approached gradually. Surgical art, as far as is 
 possible, should here copy the methods of nature, who hastens not, 
 and spurns all limitations of time in the accomplishment of her 
 work. 
 
 In cases in which correction of the deformity cannot be satis- 
 factorily effected in the manner above described, then, after the 
 removal of lateral teeth, the jaw can be partially divided on 
 each side, and the work of pressing backwards the protruded 
 portion can be done, as before pointed out. 
 
 Labial Hypertrophy. — Hypertrophy of the lip, consisting in a 
 thickening of the mucous membrane and of the submucous 
 structure, occurs as a rare deformity of the mouth. The upper 
 lip is more often the site of the enlargement; it does, however, 
 occur in the lower lip. This condition is named double lip, and 
 it has been given the more technical name of exstrophy. It 
 consists in an augmentation of the components of the mucous 
 membrane along the entire visible border of the lip. In the act 
 of smiling, this red and transversely striated structure, moistened 
 with the mucus, which its enlarged glands secrete, is rolled for- 
 wards, and gives the mouth a most disagreeable appearance. A 
 condition present, and probably having some causal agency, is 
 defective development of the derm which adjoins the lip. This 
 is said to exist congenitally; and afterwards, in growth, the 
 mucous structure outstrips the dermal. The infant, in protruding 
 its tongue against the lip, aids in the development. Irritation in 
 the form of slight abrasion, ulceration, or fissure, promotes the 
 growth. 
 
 Treatment. — Attempts have been made to remove this condi- 
 tion therapeutically; astringents have been applied for this 
 purpose, but with unsatisfactory result. The more rational treat- 
 ment is excision, which may be done by grasping horizontally a 
 fold of the redundant structure and excising this with scalpel or 
 scissors. A transfixing tenaculum may serve to uplift the part to 
 be removed. The writer once treated by thermal cauterization a 
 36 
 
554 MOUTH AND ORAL CAVITY. 
 
 case in which the upper and lower lips were the site of hypertro- 
 phy, the enlargement being mainly in the lower lip. These 
 greatly enlarged lips, with their gelatinous coating of inspissated 
 mucus, presented a most repulsive appearance. The derm was 
 not defective, as it usually is in the ordinary case of double lip. 
 The form was corrected by the use of the blade point of the 
 thermal cautery. The muciparous glands were much enlarged. 
 The wound made was allowed to heal, by granulation, and 
 the result was a reduction to something near normal form. In 
 such cases, the work of excision might be done with the knife 
 with less peril of exceeding the proper limit of retrenchment, and 
 after the surplus structure was removed, the wound could be 
 closed by sutures. 
 
 Labial Ectropion. — One or both lips may be everted through 
 ulceration or some lesion destroying the dermal surface near the 
 mouth. The most common cause is a burn arising from a flame, 
 exploding powder, or an acid or alkaline escharotic. The cicatriz- 
 ing surface shortens and draws the adjoining lip outwards and 
 fixes it in that position. The resulting deformity is great; for 
 example, in a case of a burn from flame which the writer saw, 
 the upper lip was drawn upwards to the septum of the nose, and 
 the lower lip was drawn down and fastened to the chin. And, 
 in another case, along with such labial distortion, the chin 
 was drawn down and held near the larynx. In such cases the 
 teeth exposed to the air are disfigured by incrustations and 
 inspissated secretions of the buccal cavity. The saliva trickles 
 uncontrolled from the mouth, and adds to the patient's unfortu- 
 nate condition. In eating, fluids escape, and the ingestion of 
 food is embarrassed, since the mouth cannot be closed, as is neces- 
 sary during ordinary deglutition. For relief from the wretched 
 plight in which such a patient finds himself, the surgeon's hand 
 is earnestly appealed to. 
 
 As means to correct labial eversion, one may resort to the 
 undulating incisions of Dieffenbach, the V-cut of Weber, or to the 
 incisions of Teale. 
 
 The undulating cut of Dieffenbach, best fitted for the upper 
 lip, is made on each side of the nose, as follows: The incisions 
 closely circumscribe the wings of the nose, and are continued 
 downwards convergently on the lip, and meet a short distance 
 above the margin of the lip; the incisions unite beneath the nasal 
 septum in one line, which is continued downwards into the 
 mouth; thus two flaps are formed which are drawn downwards 
 and united bv sutures. 
 
LABIUM LEPORINUM. 555 
 
 The method of Weber, of which he acknowledges the sugges- 
 tions from Wharton Jones, consisted in making a V-incision, 
 open towards the mouth, and wlaich includes tlie scar tissue that 
 pulls the lip outwards; the adjacent parts are detached, brought 
 into position, and retained so by sutures. Instead of opening 
 towards the oral opening, the writer suggests that tiie V-incisions 
 might converge towards the mouth, and then the lateral struc- 
 tures being loosened might be rectified in position, and fixed 
 thus by sutures to the sustaining and retaining angle of the V- 
 incision. In this work, should the mucous border be too promi- 
 nent, a horizontal section, oval in form, may be removed from it. 
 
 A third method by which the lip, everted and shortened in 
 height, can be improved in form, is that proposed by Teale, which 
 is as follows: For the lower lip, when ectropic, let there be made 
 two incisions downwards through its entire thickness; and these 
 cuts are at sucli a distance from each other as to include one-half 
 of the lip between them. Next, from the lower ends of each of 
 these cuts, an incision is to be made upwards and obliquely out- 
 wards, and end one inch beyond the labial commissure. Now 
 let the uj)per border of the intermediate portion be made raw by 
 trimming; and, finally, the lateral, detached flaps are to be drawn 
 inwards and fastened on and above the upright intermediate 
 portion. In this way the lip is rectified in position. 
 
 Hare-lip, Cleft-lip, Labium Leporinum. — Cleft-lip, or hare -lip, as 
 it is popularly named, is one of the most interesting subjects to 
 the operative surgeon ; he has an assured and undisputed posi- 
 tion here, since surgical art has no envious rival in the means 
 for the relief of this defect; and the surgeon's hand dan never be 
 superseded by that of the presumptuous charlatan. Nature, 
 whose unseen work is often usurped or stolen by cunning igno- 
 rance, is helpless here, and pleads for intelligent aid; and the 
 interesting myth invented to explain the incomplete model of 
 the cathedral at Cologne is here repeated; the envious fiend of 
 Ill-form seems to have snatched from the hand of nature the 
 archetypal design of her purposed structure; and nothing short 
 of a Saint Ursula typified in the wonder-doing hand of the 
 trained surgeon, can restore the lost sketch and bring back again 
 to normal form the marred face. To learn how nature may 
 wander from her wonted well-beaten path in her work of model- 
 ing the human face, some light is gotten by a study of the 
 metamorphic stages through which the embryonic face passes 
 in its primeval development. 
 
556 
 
 MOUTH AND ORAL CAVITY. 
 
 The changes of form which the embryo undergoes have been 
 carefully studied by Coste, His, Reichert, Thompson and others. 
 At the age of one month, the human embryo has the form of a 
 semi-circle or letter C; and the cej^halic end presents an enlarge- 
 ment corresponding to the future head. On the inner side of this 
 enlargement, transverse arches, named branchial or gill-arches, 
 are seen; and between these arches lie intermediate clefts, or 
 openings, as exhibited in Figure 76. A shows the head at one 
 
 o-~z 
 
 ^ S 
 
 Figure 76. Plates from Von Amraon showing development of the foetal 
 head. 
 
 month, and B exhibits a later stage when the frontal plate n, the 
 lower lip u and the eyes oo are appearing. ' The uppermost cleft 
 is the one to which the most interest attaches, since it occupies 
 the site of the future mouth ; and if the surroundings of this 
 fossa be observed, one finds that it has overhanging it a small 
 structural plate, named from its position the frontal lamella; on 
 the opposite side lies the part which corresponds to the inferior 
 maxilla, or lower boundary of the mouth. At the upper part of 
 the sides of the fossa are the germinal buds of the future upper 
 jaw, which are some distance apart; and as development pro- 
 ceeds, beneatli the frontal plate on each side exists a small 
 depression, bounded internally and externally by the nasal buds. 
 As growth continues, the lateral maxillary processes approach each 
 other; and the intermediate naso-frontal plate grows downwards, 
 and is named from its position the incisive plate. These parts, 
 in the normal face, continue to enlarge by growth, until the 
 incisive and lateral maxillary processes unite and close the 
 irregular gap, which overhangs the embryonic oral opening; the 
 fusion is so complete that in the normal adult all traces of the 
 primitive fissures have vanished. Reverting to the rudimentary 
 bars w^hich cross the inner face of the forming head, it is seen 
 that, at an early period, the upper one may be likened to a broken 
 arch, which is constituted of a middle and two lateral segments, 
 
LABIUM LEPORIXUM. 557 
 
 SO disposed that an upright cleft exists on each side. " Normally, 
 as said, these clefts vanish; abnormally, one of them continues, 
 and then an opening remains, which, if limited to the lip, consti- 
 tutes a single hare-lijD; or if the fissure extends deeper and more 
 posteriorly, then the case is one of labio-palatal cleft. The 
 defective development seems to be more concerned in retarded 
 growth of the intermediate plate; and if this part be followed in 
 its growth, it is found that there originate from it the frontal 
 bone, the nose, the vomer and the intermaxillary, named also the 
 incisive bone; and the retarded growth is principally in the 
 lateral faces of the intermaxillary bone and the lip in front of this 
 bone. 
 
 It was reserved for the inventive fancy of the chief of German 
 poets to catch the first glimpse of the doctrine that hare-lip is 
 the result of arrested development. Goethe, whose mind created 
 the imperishable imagery of Faust, revealed, as Virchow says, his 
 nobility in that he sought mental invigoration in the obser- 
 vation and study of material objects and material phenomena, 
 and found content in the "eternally true." Blumenbach, the con- 
 temporary of Goethe, whose museum of crania at Gottingen still 
 rivals any European collection, taught the same doctrine. 
 Meckel, Beclard and Geoffroy Saint Hilaire espoused the same doc- 
 trine. And the theory was elucidated and verified by the studies 
 of Coste, who found that the early forms of the embryo are in 
 accord with such theory. The conclusions arrived at from these 
 studies are, according to Sappey, that hare-lip is caused by an 
 arrest of development; that this arrest affects chiefly those parts 
 of which the development is tard}^; and that when the arrest is 
 present in other parts of the body, the deformity of the mouth 
 is usually the greatest; also the arrest appears simultaneously in 
 both the soft and hard structures; and finally, that such arrest 
 results from some natural cause, at present unknown. 
 
 Those who have been occupied in researches upon this subject 
 concede that causes other than arrested development may be 
 present, and cooperate or be the chief agent in the matter. 
 
 Among agencies which have been suggested as causes of hare- 
 lip, the following maybe mentioned: Heredity, in which some- 
 thing abnormal is impressed on the primordial germs, disease 
 affecting the foetus, maternal impressions acting on the foetus, 
 and mechanical causes, as adhesions of the foetus to its cord or 
 membranes. 
 
 That heredity has a bearing is shown by the fact, that in 
 
558 MOUTH AND ORAL CAVITY. 
 
 certain families liare-lip lias been transmitted through successive 
 generations; the anomaly in the first instance being due to the 
 law of variation, which is observed to particularize the form of 
 members of the same species. 
 
 Observation of the new-born has shown tliat intra-uterine 
 life has its diseases; and if some affection were to implicate the 
 region of the branchial arches and clefts, these parts might cease 
 their growth, and deformity result. The origin of hare-lip has 
 been referred to mechanical causation, in wliich some agent, as 
 the hand, cord, or other member or appendage of the embryo, 
 ma_y rest against the oral region and interfere with its proper 
 growth. 
 
 Popular opinion assigns to the mother's mind an important 
 agency in the causation of hare-lip. Dionis, Roux and Langen- 
 beck have given credence to such agenc}'. After an apologetic 
 prologue for the avowal of his belief, Roux says: "Since some 
 time, I admit the empire of the mother's mind upon her foetus; 
 and this power seems to be greater in prof)ortion as the foetus is 
 more removed from its complete term of development; I believe 
 that great mental shocks, and vivid impressions acting on the 
 pregnant woman, can probably cause naevi, and, especially, 
 striking deformities and freaks of nature; and such agency 
 might cause disturbance of nutrition, and change the order of 
 evolution, and development of the organs." In a clinical lecture 
 of B. Langenbeck, heard by the writer, the learned professor in a 
 manner half reluctant and apologetic, avowed his credence in 
 the influence of maternal impressions in producing deformity in 
 offspring; his remarks were a preface to an operation in a patient 
 of hare-lip; and a few cases within his own experience were 
 cited in proof of such agency. As counter evidence against 
 such agency, the author would state that, in an extended experi- 
 ence, he has met many women who, from some ill adventure, had 
 had ample reason to anticijiate such "mark" in their offspring, 
 but the latter, at birth, were free from any deformity; and, hence, 
 such agency lies within the domain of chance where "millions 
 miss for one that hits." 
 
 If such agency ever obtains, the impression could only be 
 made during the first few weeks of gestation; that is, during the 
 inceptive stage of development, while the miniature embryo lies 
 in contact with the uterine wall, and may be conceived to be in 
 contact with the ending of the uterine nerves; but, at a later 
 period, the separation of the embryo from the wall of the womb, 
 
LABIUM LEPORINUM. 559 
 
 and the intervention of tbe nerveless funis, preclude any com- 
 munication between the mother and foetus through the medium 
 of nerve roots. This fact may be offered as solace to expectant 
 mothers, who can be assured that after three months there exists 
 an impassable breach athwart which their imaginations cannot 
 wander to the detriment of their offspring, which is yet in plastic 
 state. 
 
 The causal agency of retardation of development has been 
 referred by some to the nerves of the foetus, yet most authorities 
 find the proximate agency in insufficient vascular supply of the 
 affected parts; with our present knowledge the more rational 
 theory is defective supply of blood. New development is natu- 
 rally the sequent of vascular growth; since the blood is the 
 pioneer agent of all organization. And in inadequate vascu- 
 larity may likewise be found the probable reason of the usual 
 occurrence of the hare-lip on the left side, instead of on the 
 right; and the defect finds its reciprocal correlate in right- 
 handedness, of which the most satisfactory explanation is that 
 of Hyrtl, viz., that there is more blood sent to the right side 
 than the left. 
 
 The supply of blood to the parts that become the site of hare- 
 lip is through the facial, transverse facial, the internal maxillary 
 branches of the external carotid artery and the infra-orbital 
 branch of the internal carotid artery. These branches are like 
 the ribs along which constructive material is carried to the 
 border of the leaf; and if the arteries are obstructed, the parts 
 supplied become dwarfed in the same way as the border of the 
 leaf is imperfect when its nutrient channels are obstructed. *In 
 what way the vessels of suj)ply may be obstructed has not yet 
 been determined ; the author will suggest that it may be explained 
 conjecturally by flexion and position of the developing embryo, 
 for example: Abnormal flexion of the arterial channels may 
 lessen the blood supply, and restrain growth. Also, from obliq- 
 uity of direction, in either the cephalic or podalic presentation 
 the blood-pressure may be unequally distributed, and the scales 
 of nutrition becoming unbalanced, there is an uneven or one- 
 sided distribution of constructive material. 
 
 Children occasionally present at birth, lips and roof of the 
 mouth marked as if they had recently recovered from an opera- 
 tion for the cure of cleft lip and palate; and such vestiges of 
 cicatrization are explained by the supposition that there has 
 been retarded closure of the fcetal clefts. Max Bartels, in 1873, 
 
560 MOUTH AND ORAL CAVITY. 
 
 published observations on the subject of closure of the hare-lip 
 in the uterus. In one case there was a scar of a cleft which had 
 healed on one side of the lip ; and, in a second child, there was a 
 scar on both the right and left sides of the lip, which seemed to 
 be remnants of healed clefts. Rcnnes, Dieudonne, Marjolin and 
 Desormeaux believe that such intra-uterine closure may occur. 
 Bruns thinks such labial scar is the mark remaining of a cleft 
 which extended through the palatal vault, upper jaw and lip. 
 The author has a case under observation, in which there is the 
 plain mark of a lately healed median cleft on the upper lip of an 
 infant, in which the burden of deformity is widespread, having 
 been laid in the arms, hands, fingers, legs and feet of the 
 unfortunate child. Probability is lent to this theory of late 
 closure by the fact that cases have been observed in which the 
 closure occurred after the birth of the child. The so-called intra- 
 uterine cicatrization is hereditary in certain families. It is 
 reported to have been seen in children, the offspring of parents 
 who were the subjects of hare-lip. Instead of closure having 
 occurred as here indicated, may not the appearance have arisen 
 from the parts having fused in an unnatural manner, in which 
 the supra oral tripartite components of the face met and fused 
 irregularly, nature here doing her work in the thoughtless way 
 of a surgeon who closes unevenly the lips of an incised wound, 
 or badly coaptates in the repair of a labial cleft? 
 
 A nearly forgotten theory of hare-lip is that, after the parts 
 have been normally formed, they, afterwards, through atrophy, 
 separate, and leave clefts; such a theory is irrational, and in 
 discord with tlie rules and method to which nature conforms in 
 the work of organization. 
 
 Hare-lip presents itself in several forms, wliicli may be clas- 
 sified as follows: — 
 
 1. Simple lateral hare-lip. 
 
 2. Simple lateral hare-lip with complications. 
 
 3. Uncomplicated double hare-lip. 
 
 4. Complicated double liare-lip. 
 
 5. Median hare-lip of the upper lip. 
 
 6. Median hare-lip of the lower lip. 
 
 1. Simple uncomplicated hare-lip is usually situated on the 
 left side : it consists of a cleft with separation of the borders, 
 having the form of an inverted Y. The borders have the red 
 lining of the normal lip; when the infant cries, the borders sep- 
 arate, and the gap becomes larger; and closure of the mouth 
 
LABIUM LEPOEIXUil. 561 
 
 brings the borders towards each other. This cleft in different 
 subjects varies in degree, from a minute gap in the border of the 
 lip to a breach which reaches from the border of the lip to the 
 lower border of the left nostril. 
 
 2. The simple cleft may present various complications, of 
 which the following may be mentioned: The opposite borders of 
 the cleft may be of unequal thickness; and in that case, the left 
 side is commonly thinner than the right one. In cases in which 
 there is claimed to have been retarded union, the united portion 
 is often thinner than the adjacent structure of the lip. In the 
 so-named retarded union, the closure may be yet more imperfect, 
 viz., there may be an angular opening at the nostril and at the 
 border of the lip, the apices of which are directed towards each 
 other, and are separated by a longer or shorter bridge of atten- 
 uated structure. Likewise, in the maxilla just behind, there may 
 be a depression denoting late union ; or perhaps there is irregular 
 closure of the lateral premaxillary suture. The labial hare-lip 
 may be coincident with palatal fissure, which may be minute or 
 of vast dimensions. A frequent complication of labial cleft is its 
 extension into the left nostril ; and then the nostril is much too 
 wide, and the left wing of the nose is inclined oblic|uely, and 
 adds to the deformity. 
 
 3. In the double uncomplicated harelip, there exist two clefts 
 of inverted Y-shajDe, separated by a triangular portion of the lip, 
 which lies over the incisor teeth. These two fissures, with the 
 intermediate angular portion of the lip, when Anewed together 
 present the appearance of an inverted M. The median remnant 
 may be regular or irregular in outline, and thinner or thicker 
 than the lateral boundaries of the defect. Palatal cleft is often 
 associated with the double cleft ; and in great variety of form, 
 this concurrent defect may complicate and increase the labial 
 deformity. AVhen palatal cleft exists, the premaxillary bone 
 may be lessened in volume, and occupy an abnormal position: 
 viz., the palatal gap on one side, or those on both sides, are formed 
 at the expense of the side or sides of the bone; in fact, the open 
 breach may c[uite occupy the premaxillary space; more often, 
 however, there exists a fragment of the bone; and then, as a con- 
 tinuation of the vomer, in smaller or greater volume it hangs 
 promontory-like, over the oral cavity; and if the subject has 
 reached adult age without being operated on, the protruded bone, 
 armed with teeth, becomes a revolting and most intolerable deform- 
 ity. No surgical ailment makes stronger appeals for operative 
 
562 MOUTH AND ORAL CAVITY. 
 
 aid; and in scarcely any deformity of the body can intelligent 
 skill make greater improvement than in this one. 
 
 Besides the usual forms of hare-lip before mentioned, there 
 remain to be referred to, certain unusual forms, placed in our 
 classification under heads three and four. 
 
 Bidalot, in 1867, wrote on rare and unusual forms of hare-lip; 
 he makes four groups of these rare cases : (1) Cleft of the upper 
 lip extending upwards to the lower eyelid, (2) Median cleft of 
 the upper lip. (3) Median cleft of the lower lip. (4) Horizontal 
 hare-lip. Michel saw an example of the first kind. In 1855, 
 Parise of Lille saw an infant in which there was a median cleft 
 in the lower lip ; the sides of the opening were lined with mucous 
 membrane and stood asunder as in normal hare-lip. The tongue 
 was bifid; also the lower jaw was cleft anteriorly, and the halves 
 united by fibrous tissue. The child lived but one month ; yet its 
 remarkable deformities assure it a lasting paragrapli in the 
 annals of surgery. 
 
 In 1870, Tr^lat reported a case of median cleft in the lower 
 lip, seen byoneRibell; this fissure extended down to the chin. 
 In 1879, Lannelongue reported two cases of congenital cleft of the 
 lower lip; in one case the fissure extended into the lower jaw, so 
 that the two halves were movable, one on the other. The child, 
 two and a half years old, had been operated on with but partial 
 closure of the cleft; the saliva escaped through the unclosed por- 
 tion. And, in another case, in a girl fourteen years old who had 
 club-foot, and hare-lip in the ujtper lip, tliere existed a transverse 
 fissure in the lower lip, a half incli long and two-fifths of an incli 
 deep; tliis fissure was beneath, and parallel with the border of 
 the lower lip; and was closed by an operation. 
 
 Morian, in 1886, writing on the irregularities which hare-lip 
 or facial clefts may present, finds three varieties: (1) The cleft 
 commencing as a hare-lip, ascends between the nose and the 
 cheek to the inner angle of the eye, and thence passes out through 
 the outer canthus, and extends upwards on the forehead. (2) 
 The cleft may commence more externally than the preceding 
 species, and ascending outside of the wing of the nose to the 
 inner canthus, it pursues the same course as the preceding one. 
 (3) The slit commences at the angle of the mouth and, ascending, 
 enters the palpebral slit. Other writers, as Blandin, Bitot and 
 Xicati, have written on median cleft of the upper lip. And if the 
 records of teratology were searched by some tireless compiler or 
 statistician, other examples of irregularity in labial cleft might 
 be found. 
 
LABIUM LEPOEIXUM. 563 
 
 Among the numerous agencies which are inimical to infantile 
 life, hare-lip deserves a prominent place; and this danger is 
 greater in proportion as the disease is more complicated. The 
 imperfect lip prevents the child from grasping the nipple ; and 
 swallowing is rendered difficult , since this function, to be easily 
 done, requires that the mouth be closed. Where the breach is 
 great, the infant breathes through its mouth ; and the air, not 
 warmed, as it normally is by passing through the nose, becomes 
 the causal agent of catarrhal and pulmonary trouble; thus, 
 between hampered nutrition and pulmonary affection, the chances 
 of life are materially lessened. Hence surgical relief of such 
 cases is early and urgently sought for by the infant's parents. By 
 the mother who has just escaped through the throes of labor, no 
 question is more earnestly asked than whether her child is per- 
 fect in form, and no more appalling words can fall on her ear 
 than the answer that it is deformed. Xo persuasion is required 
 to induce parents in such emergency to commit the unfortunate 
 one to the surgeon's hands; and the first C|uestion to determine 
 is: What is the proper period to operate on the child? and this 
 question has been answered differently by authorities who have 
 written on hare-lip. 
 
 ■ In a review of this matter published iu 1S42, the mass of 
 authority favored operating in the early months of infancy, viz., 
 about the end of the third month ; this was the time preferred by 
 Dupuytren, Houston and others; Godefroy operated at birth, yet 
 Dupuytren opposed operating at this time, since he thought the 
 parts are then too soft, and are more easily cut by the retaining 
 pins, than they are at a later period. Dubois the accoucheur, in 
 1845, in a communication to the Academy of Medicine, recom- 
 mended earh^ operations in strong and healthy infants. 
 
 Roux advocated doing the operation at birth: the reasons he 
 offered were the following: "The new-born infant is patient, 
 tractable, and without knowledge of what one is going to do, or 
 does do, on him; and he is without will or power to resist or 
 withdraw himself from what gives him pain : he has no knowl- 
 edge of pain, nor does he fear it ; and hence he is not agitated ; 
 nor does he make any movements which will interfere with the 
 operation and its results. The muscles at that time, including 
 those of the face, have but little power; those of the mouth 
 have no force beyond the function of suction ; hence one need not 
 fear brisk and violent movements of the lips and cheeks, nor 
 efforts of retraction which can cause tearing and separation of the 
 
564 MOUTH AND ORAL CAVITY. 
 
 united parts. Besides, the tissues which are operated on have 
 great vitaUty, and hence great })lasticity, and a tendency to heal: 
 and this tendency is greater 2)robably than at any other })erio(l of 
 life." These opinions of Dubois and Roux, for a time, had a great 
 following; but in 1S5G a number of unfortunate operations were 
 reported, and tended to alter o})inion on this subject. 
 
 Periat, in 18.37, in a thesis sought to settle the matter by col- 
 lecting a scries of cases wliich had been operated on at different 
 ages, and weighing the results in the scales of statistics. The 
 first series comprised fifty cases, consisting of thirteen of simple 
 form and thirty-seven of double hare-lip with complications; there 
 were three deaths, five failures and forty-two successes. The 
 operation was done at periods varying from the first to the 
 thirtieth day after birth. In a second series consisting of forty- 
 four cases, of which fourteen were simple and thirty complicated 
 hare-lip, there was one death, four failures and two secondary 
 reunions; consequently thirty-seven successes. These infants 
 were operated on at periods varying from two to twenty-four 
 months. A third series consisted of twenty-six cases, operated 
 on at ages varying from two to five years; of these one died, two 
 were failures, and two were secondary unions. Of these twenty- 
 six cases seven were simple and nineteen were complicated. In 
 a fourth series done at a late period, comprising forty-nine cases, 
 of which seventeen were simple and thirty-two complicated, there 
 was no death, and all the operations were successful. 
 
 The operations here enumerated amounted in all to one 
 hundred and sixty-nine, of w^hich one hundred and forty-nine 
 ended successfully, five died, ten were ftiilures and five were but 
 partially successful. The operations were done by leading sur- 
 geons of France; it is possible that these figures do ]iot represent 
 the whole of their operations. In statistical logic, fallacies often 
 lurk which are difficult to eliminate; that such fallacy does here 
 exist is evident when these figures are compared with others 
 which have been reported. In reflexions appended to a report 
 of ninety-eight operations for the case of hare-lip done by himself, 
 Eigenbrodt, in 1885, alludes ominously to the mortality which 
 attends the operation, Fritsch found that it was fifty per cent 
 in Zurich, and Herrmann reported that it was the same in 
 Breslau. And wliere hare-lip is double and complicated witli 
 palatal cleft, a still greater number die, viz., of sixty-eight cases, 
 sixt3'-five per cent died. Volkmann takes a j^et more gloomy 
 view of the results of operation for the cure of hare-lip with 
 
LABIUM LEPORINUM. 565 
 
 palatal complication ; he finds that such cases, if they do not die 
 at the time of the operation, generally do so within a year after- 
 wards. 
 
 These figures, which are probably correctly reported, differ so 
 greatly from those of Periat, that one must conclude that the 
 figures used by him did not fully represent the number of the 
 unfortunate cases which occurred. The writer, who has had an 
 extensive experience in the operation for hare-lip, thinks that the 
 figures of recovery of Periat, though too small, more nearly repre- 
 sent facts as observed in private practice, than do those of Eigen- 
 brodt, whose figures represent fatality in dispensary or hospital 
 practice. That so great a fatality as fifty per cent should have 
 attended the work of the skilled hand of the j)ainstaking German 
 surgeon, can only be accounted for by the supposition that the 
 cases after being operated on passed out of sight of the operator 
 into the hands of ignorant jjarents, who, too often, do not find 
 unalloyed evil in the death of such child. It has been the 
 writer's observation that the operation for hare-lip is very rarely 
 followed by death, if the surgeon carefully watches the case. And 
 if the author were to formulate a rule which should be religiously 
 observed, it is that the surgeon's attention should, by no means, 
 cease with the OiDcrative act, but that he should carefully watch 
 his patient afterwards; his obligations to surgical art and science 
 demand this; and his duties to a human being, wdiich has 
 intrusted its life to him, with a solemn and impressive emphasis 
 command this. 
 
 The question is usually put to the surgeon, whether he can restore 
 the cleft lip to normal form; in case of the simple uncomplicated 
 cleft, this may be answered affirmatively; and, likewise, that the 
 danger to the child's lip will be very slight. If it be a case of 
 double hare-lip complicated with other deformity, the result will 
 be less perfect, and there will be some risk of the child dying 
 from the operation. The defects, which may be left after the 
 operations, have been studied by Neudorfer in 1858, and are 
 classified by him as follow^s : (1) The edge of the lip may remain 
 lower on one side than on the other. (2) On the outside, though 
 union has been obtained, a vertical furrow may remain. (3) A 
 V-sha];)ed defect may remain at the site of union, and this defect 
 constitutes ninety per cent of all the defects resulting from hare- 
 lip operations. 
 
 In the writer's opinion, the defects mentioned may be referred 
 rather to the operator than the operation ; since by careful work 
 
566 MOUTH AND ORAL CAVITY. 
 
 and dexterity acquired through experience, the defects mentioned 
 may be avoided, or greatly lessened. From the author's observa- 
 tion, the most glaring and striking defect is that which remains 
 after operations on hare-lip, in which the cleft extends into one 
 or both nostrils, and the wings of the nose rest obliquely on the 
 face. This flaring nostril is oftener on tlie left side; and besides 
 the obliquity, the two sides of tlie nose are not syninietrical. To 
 correct such asymmetry and obliquity, and to erase the V from 
 the lower margin, are problems susceptible of fairly satisfactory 
 solution. The guiding rule or general principle involved in 
 the operation is to remove the margins of the cleft, and then unite 
 the opposite raw surfaces so that similar textures will be con- 
 joined; special pains being taken that the outer surface be levels 
 and hence free from irregularities. 
 
 Operation. — As instruments needed in the operation are the 
 following: scalpel, scissors, htemostatic clasps or forceps, a flat 
 piece of wood to be placed under the lip as it is incised, materials 
 for suture and adhesive stri2:is to immobilize the wounded parts. 
 
 In the early history of the operation, closure of the wounded 
 parts was effected by means of adhesive plaster and a variety of 
 cumbersome appliances; these have properly been consigned to 
 disuse, and the work of union is now universally accomplished 
 by suture of either the knotted or twisted species. -As to the 
 choice between these, authority is about equally divided. The 
 simple knotted suture is advised by the following surgeons: 
 Mirault, Guersant, Woakes, Boeckel, Giraldes and Hamilton. 
 The twisted suture, or that done by means of pins and thread, is 
 advised by Thierry, Ancelon, Langenbeck, Bruns and Tricot. 
 Thierry, to avoid the cutting of the skin which often occurs when 
 the twisted suture is used, closes the parts by means of a small 
 nut which is screwed on the transfixing pin; his plan is not fol- 
 lowed. To avoid this cutting, Tricot used an elastic thread 
 which he pa.ssed around the inserted ])ins. 
 
 A reserve or tension-relieving suture was used by Woakes,, 
 Boeckel and others. And this suture placed at some distance 
 from the border of the wound, was used by some surgeons along 
 with thin plates of metal, hard rubber, bone or ivory; the sutures 
 passed through apertures in these plates, so that, when tied or 
 closed, the sutures pressed on the plates, and not on the included 
 labial structures. Such protective supports were used by Denon- 
 viliers in 1856; he u.sed two, one on the in.side and one on the 
 outside, made of India rubber. After the threads traverse these 
 
LABIUM LEPOEIXUM. 567 
 
 plates, they are to be tied over a roller; and after twenty-four 
 hours, Denonviliers finds that union has taken place. 
 
 The ingenuity of surgery has been exerted to avoid the 
 V-shaped defect in the labial boraer at the site of closure. The 
 ways devised to accomplish this may be grouped in four classes: 
 (1) By introducing the pins in a direction tending to lengthen 
 the vertical span of the lips. (2) Marginal suture. (3) By a spe- 
 cial shape of the vertical wounds. (4) Flaps double or single cut 
 from the sides or side of the cleft; or a loop -form incision ma}^ 
 be used. 
 
 1. To depress the site of closure, the transfixing pin has been 
 caused to enter straighi;, and then to have its point rise, and then 
 afterwards to descend again; the effect intended is to force the 
 structure downward, and the action is similar to that of the 
 acupressure needle, which is so passed as to compress the subja- 
 cent ve.ssel. This plan is no longer used. 
 
 2. An attempt to depress the border has been tried by means 
 of a horizontal suture beneath the wound; this plan has acted as 
 ineffectually as the preceding one. 
 
 3. Better results have been attained by giving the vertical 
 wound such a form that the border or borders become elongated 
 when juxtaposed. For example, if one side of the cleft be 
 longer than the other, Dieffenbach trimmed the longer one by a 
 straight incision, while the shorter side was so trimmed as to 
 present a concave outline. The result would be, when the wound 
 was closed, to straighten, and hence to lengthen the concavely 
 wounded side. Tricot, in his dissertation on hare-lip, advises thi.? 
 mode of avoiding defect. And in case both borders of the cleft 
 be short, then each border may be trimmed with concavities fac- 
 ing each other, as shown in Figure 77; the effect of this would 
 
 Figure 77. Showing Graefe's plan FicrRE 78. Showing Giaefe's plan 
 
 of elongating the boideis b}' trim- as modified by Bruns. (From Weber.) 
 
 mills them ooucmvpIv. 
 
568 MOUTH AND ORAL CAVITY. 
 
 be to lengthen each border when the sides are exposed; thus 
 Graefe adv'ised the work to be done, in order to shun the V-defect. 
 In Figure 78 there is exhibited a nioditication of Grajfe's plan as 
 practiced by Bruns. 
 
 4. In plastic work done to remedy defects, it should be an 
 inviolate rule to sacriiice no structural material if this can be 
 utilized; and nowhere is this more imperatively necessary than 
 in the repair and reconstruction of labial and palatal cleft. 
 This rule applies preeminently in the solution of the problem to 
 avoid the Y-defect. For it is possible, through ingeniously 
 devised incisions, to retain the marginal structure of the cleft, 
 and to make it do the service of closing up the gap wdiich 
 otherwi.se would remain on the edge of the lip. In case the 
 cleft be single and does not extend up into the nostril, Sedillot, 
 Nelaton and Cl^mot make an incision which is so directed as to 
 circumscribe the summit and sides of the cleft in such a man- 
 ner that the uplifted edge is attached below on each side, and 
 resembles a loop or swinging bridge. "When this is closed, 
 instead of an underlying A^-gap, there will remain a slight prom- 
 inence, as shown in Figure 80. 
 
 \ 
 
 'V"' ' 
 
 Figure 79. Showing form of flap Figure 80. Result after partial 
 
 shaped like a swinging bridge, prac- closure, 
 ticed by Sedillot. 
 
 The same closure may be done b}' means of a flap formed on 
 each side, and which hangs at the base of the breach, as shown in 
 Figure 81. A correct idea of this is obtained by conceiving a 
 loop formed as above described, and then cutting out the 
 middle third of the loop. This method, or a modification of 
 it, was first suggested and practiced by Mirault of France; 
 and soon afterwards employed by Henri, Malgaigne, Langen- 
 
LABIUM LEPORIXUM. 
 
 569 
 
 FiGUKE 81. yiiowiug lateral pend- 
 ent flaps which were employed by 
 Mirault, Henri and Malgaigne. 
 
 Figure 82. Showing result when 
 flaps have been united, and surplus 
 material has been excised. 
 
 beck and others. The author early in his professional career 
 practiced a modification of this method, and believed at the 
 time that he had originated it; he learned later that his work 
 had, like that of many another inventor, been antedated by some- 
 one else; for, as history shows, many aloud-heralded invention or 
 discovery is but the " repetition of something which has gone 
 before. A wider range of knowledge would have mufHed the 
 herald's voice. Such prophylactic knowledge abounds in the 
 writings of Hippocrates. 
 
 FiGVEE 83. Showing 
 Mirault's method, 
 ing flap on the left side 
 
 Figure 84. Ee- 
 sult of work done as 
 shown in Figure 83 
 when closed. 
 
 Figure x. Showing the in- 
 cisions to be made for closure of 
 double hare-lip. 
 
 Mirault, in his method as shown in Figure 83, formed lateral 
 flaps which were attached to the base of the cleft. The mucous 
 membrane is trimmed off from one of these flaps, and retained 
 on the other. The breach is next closed b}'- sutures, and the flaps 
 so disposed that the one which retains its mucous membrane will 
 lie outermost. The pendent flaps being sutured in horizontal 
 position comoletelv close the cleft below. Malgaigne and Henri 
 37 
 
570 MOUTH AND OKAL TAVITY. 
 
 formed lateral hanging flaps, as shown in Figure 81 ; and these 
 flaps were united by their raw surfaces, and the surplus tissue 
 afterwards excised. 
 
 Wliichever of these modifications is chosen, the operator 
 will surely have enough material to fill the gap on the border; 
 in fact, there is more material than is needed, so that afterwards 
 a part must bo trimmed oft\ And should the surgeon desire to 
 change his phm, when lie has formed these flaps, he can easily 
 modify it so as to conform to the-^lan next to be described, viz., 
 that of the single flap. 
 
 The method of doing the work by means of a single flap to 
 avoid the V-gap is sometimes erroneously referred to Mirault; 
 still, to him surgery is indebted for the idea of swinging flaps, 
 dependent below with lateral attachment, for closure of the labial 
 cleft, and his idea suggested the modifications employed by sub- 
 sequent operators. Langenbeck used the single flap in some 
 cases; yet his plan is defective in this respect that he formed this 
 flap from the right side in the case of cleft on the left side. For 
 over a quarter of a century the writer has used the single flap in 
 closure of the simpler as well as of the complicated forms of hare- 
 lip. To do this in the best manner, if it be a cleft of the left side, 
 first remove tlie border on the riglit side by a vertical incision, 
 and, when this cut is near the lower border, let the knife continue 
 its work for at least two lines horizontally towards the right, and 
 finish by cutting tlie flap off. Thus a raw surface in L-sha4)e is 
 formed. And the horizontal part of the L should not terminate 
 acutely, but should have a blunt ending. In making this incisior 
 the section must be as perpendicular as possible to the surface of 
 the lip, and at its end below, it leaves a rectangular notch. Next, 
 from the left side, let a flap be formed which will hang from the 
 left border of the cleft by a pedicle which is a line, at least, in 
 thickness. This flap should commence at the apex of the cleft, 
 and be a continuation of the right incision, and, like the right 
 one, the left section must be perpendicular to the labial surface. 
 The hanging flap should now be brought across the base of tlie 
 cleft, and the raw sides of the same apposed; then it will com- 
 monly occur that the flap which has been formed will be too 
 long, and, if so, a part of the free end may be excised, but in this 
 excision care must be used not to shorten too much; also the flap 
 must end bluntly, so that it will fit and fill the notch on the 
 border. 
 
 After these preliminary statements, the writer will proceed to 
 
LABIUM LEPORINUM. 571 
 
 describe the proeedures to be pursued in the closure of hare-lip of 
 different grades, beginning with the most simple form, in which 
 tlie cleft does not reach to the nostril. The operator should first 
 examine whether the sides of the cleft are adherent to the upper 
 jaw, and, in most cases, such adherence will be found only on 
 one side. The child being anaesthetized for the operation, such 
 adhesion must be severed, and this may be done with scissors, 
 knife, or the blade of a thermal cautery. When the child is 
 feeble, or where" extensive division must be made, the thermal 
 blade is preferable, since in this way blood is spared. Sometimes 
 no abnormal adhesion exists, and still the operation will be 
 rendered much easier if the upper lip adjacent to the cleft be 
 freely separated from the upper jaw. If this be done with the 
 scalpel, as is commonly the case, less blood will be lost if the 
 labio-alveolar cul-de-sac of mucous membrane be divided close to 
 the jaw, and then the detachment be continued sub-periosteally, 
 with a blunt dissector. 
 
 The right side of the cleft should first be removed in the 
 manner above described, the incision beginning above and on 
 the left side of the summit of the cleft. Care must be taken that 
 this incision fully include the border at the vertex, and that no 
 dermal fragment be left which would interfere with union. And 
 this will best be done if the flap removed from the child's right 
 side pass over the vertex of the cleft and extend the distance of 
 two lines on the child's left side. This cutting is best done with 
 a scalpel of short blade and sharp point, and tlie cutting should 
 be done on a surface of wood which may be formed from a 
 shingle, and this wood should be three inches long and two 
 inches broad. Tlie work could not be done so well with scissors, 
 since the initial part of each section should commence at the 
 vertex by transfixion. Besides, incision with scissors tends to 
 leave inversion of the inner and outer surfaces of the divided 
 structure. While this cutting is being done, bleeding is to be 
 controlled by compression made at the labial angles by forceps or 
 the fingers of an assistant. 
 
 The wounded parts, as thus prepared, are next to be closed by 
 suture, and this is best done by the interrupted species in which 
 no transfixing pins are used. The best material for suture is 
 fine copper wire which has been well gilded, that is, covered with 
 gold. Such copper wire is stronger than that of silver of the 
 same thickness; it is so pliant that the ends can easily be united 
 by twisting or tying. Thread might be used, yet it irritates 
 
572 ^MOUTH AND ORAf, CAVITY. 
 
 more than metallic suture. lu most of the work clone, this tune 
 wire should be doubled, and if much tension is to be overcome, it 
 may be used triple or even cjuadruple. 
 
 For the sutural closure of a simple hare-lip, the author uses 
 four sutures; two of these are deep, in which the double wire is 
 used, and in two, single wire is used. The first deep suture 
 should be carried through the entire thickness of the lip, at the 
 lower part of the cleft, after the sides have been thoughtfully coap- 
 tated. The wire is carried through by means 'of a moderately 
 curved needle, which is so long that, when it has passed through 
 the two sides, its head will remain projecting beyond the entrance 
 point, and the point of the needle will project a half inch at least 
 after its emergence on the right side of the cleft. Such a needle 
 is much more easily used than a shorter one. Since the coronary 
 arterv lies near the mucous membrane, the needle nnist pierce 
 the entire thickness of the lip, so that the wire, when closed, will 
 circumscribe the vessel and prevent bleeding, which must occui- 
 if the wound be left open on the side of the mucous membrane. 
 Neglect of this has permitted the blood to flow unseen after the 
 operation has been completed; and to this cause may be referred 
 much of the mortality after this operation. The second deep 
 suture, likewise transfixing the entire thickness, is next to be 
 passed below the vertex of the cleft. These deep sutures should 
 enter and emerge at a distance of not less than a quarter of an 
 inch from the edge of the cleft. In case the labial material is 
 scant and there is much tension, it is well to let at least one of the 
 deep sutures enter and emerge a half inch from the edge of the 
 cleft. 
 
 A third suture is next to be introduced between the deep ones 
 and much more superficially; this suture, consisting of a single 
 wire, is to reduce the included surface to a level, and to maintain 
 it so during the subseciuent swelling of the parts. The fourth 
 suture, likewi.se of single wire, is to be introduced through the mid- 
 dle of the base of the swinging flap and then to pass through the 
 lower part of the right side of the cleft, and to emerge beyond the 
 anoular notch in which the flap's end is to fit. If this suture be 
 properly passed, it will hold tlie entirety of this flap in its 
 destined horizontal site, and the flap will completely fill the gap 
 which was wont to remain after the former methods of closure. 
 Should the fla}) be found to be too long, and by its pouting 
 downwards form too large a tuberculum, then enough should be 
 cut from the end to leave material which will form a normal 
 
LABIUM LEPORINU-M. 573 
 
 eminence at the middle of the lip. After the introduction of the 
 four sutures, sliould the wound gap or present an uneven surface 
 at some point, tlien another fine suture should be used. 
 
 The "writer closes the wire, not by tying, but by twisting the 
 ends together; and his custom is to cut short one end and leave 
 the other an inch or more in length. The wire should be closed 
 at one side of the wound, and never over it. It should not be 
 closed too tightly : merely enough to unite the sides of the wound; 
 more pressure will pinch and pain the child, and cause the wire 
 to cut. The long ends of the wire of the three upper sutures 
 should be laid horizontally, while the end of the one which fixes 
 the flap should be turned obliquely upwards. After the sutures 
 are in place, the line of the wound should be coated with the 
 compound tincture of benzoin, whicli forms a varnish-like cover- 
 ing which is impervious to the fluids of the mouth. The ends 
 of the wires are now to be covered with strips of adhesive plaster, 
 which, commencing below the lobule of the ear on one side, are 
 carried across the wound upwards on the cheek, to end above the 
 other ear. These strips may be three or four in number; and 
 when properl}'- placed, they alternatelv cross each other on the 
 wound. And, lastly, to maintain these crucially disposed strips, 
 one or more strips must be placed vertically, forming a loop 
 under the chin. In placing the first series of retaining strips, 
 the ends of the wires must be covered completely; and especiallv 
 the one that pierces the flap. 
 
 The adhesive strips have a tendency to slip down over the 
 edge of the lip; and to avoid this, they should be narrow and 
 placed well up towards the nose. These retaining and immo- 
 bilizing strips should consist of rubber plaster, which is insoluble 
 in, and impermeable to, saliva, milk or other fluid which may 
 come in contact with it. These strips applied in the manner 
 described, draw the adjacent parts towards the wound, and hence 
 they diminish the tension of the sutures. 
 
 After forty-eight hours the upper one of the deep sutures 
 should be removed; and this is done by dividing the crucial 
 strips on one side, so that the portion of them covering the 
 sutures may be uplifted, and then the long end of the upper 
 suture is to be seized and drawn on so that the wire can be cut 
 on the opposite side, close to the skin. The wire should be so 
 drawn on that, when it is severed, the cut end will sink back into 
 its orifice; now by pulling on the long free end, and at the same 
 time supporting the parts on each side, the suture is easily 
 
574 MOUTH AXD ORAL CAVITY. 
 
 drawn out. By lluis dividing the suture through a portion 
 wliich was buried, the end which is drawn on will have no 
 dried excreta on it, and will easilv forsake its canal. As soon 
 as the suture is removed, its track is re-covered "vvith the ad- 
 liesive strii)s sui)])orted by a new strip on each side. At the 
 end of three days, if union seems complete and firm, the lower 
 deep suture may be removed; and also the intermediate suture; 
 the work being done as in the removal of the preceding suture. 
 There now remains but one suture, viz., the marginal one, wdiich 
 may be removed on the fifth or sixth day, according as the 
 union seems solid. The supporting adhesive strips should 
 remain in place for at least one week after the operation has been 
 done. 
 
 Instead of the deep suture of wire here described, one may 
 use the twisted suture, in wddch the so-called hare-lip pin is used. 
 Tlie author has frequently employed this plan, and obtained sat- 
 isfactory results. It is used as follows: The cleft having been 
 trimmed and a swinging flap prepared as described, two pins are 
 to be introduced, occupying the sites directed for the deep wire 
 sutures. These pins should pass quite through the thickness of 
 the lip, so as to prevent hemorrhage. The next step is to twist 
 the silk thread around the inserted pins. The points of the pins 
 are finally to be cut off by means of a special instrument known 
 among mechanics as pliers; such an instrument cuts without 
 displacing the pin. And to prevent the heads and points of the 
 pins from cutting the surface beneath them, short strips of 
 adhesive plaster should be inserted between them and the skin. 
 The next step is to fix the swinging flap in its place by means of 
 a single wire suture. The long end of this suture is to be turned 
 upw^ards, and the whole to be covered by the rubber adhesive 
 strips before described. Should there be but little tension of the 
 parts, short strips placed horizontally will sufficiently immobil- 
 ize them. 
 
 In regard to the time when the pins should be removed, 
 opinion and practice vary; Langenbeck, for example, removed 
 them on the second day, but to prevent the closed parts from 
 rupturing, the thread wdiich surrounded the pins was allowed to 
 remain in place, having previously been fixed there by a coat of 
 collodion, applied at the time when the operation was done. 
 Other operators, again, remove one in forty-eight hours, and the 
 other at the end of the third day; or even a day or two later, in 
 cases in which separation of the Avound is feared. And here, as 
 
DOUBLE HARE-LIP. 575 
 
 in the case of the knotted suture, the unhealed wound should be 
 supported by protective strips of adhesive plaster. The act of 
 removing the pins requires care; the sides adjacent should be 
 supjDorted by the hands of an assistant, and he should be 
 instructed to support the parts gently, and not to press Yiolentl}^ 
 lest the tenderly united wound be caused to open. And similar 
 precaution should be used in the removal of the interrupted or 
 knotted suture. And should it happen that the wound is opened 
 in the extraction of the first pin or suture, then the remaining 
 one should be allowed to continue in place two or three days 
 longer, and the reopened wound closed by adhesive strips; thus 
 proceeding, the wound will re-heal in a da}^ or two. 
 
 Operation on Uncomplicated Double Hare-lip. — The operative 
 work of closing the double hare-lip of simple form is quite sim- 
 ilar to that, already described, which is done for the closure of 
 simple labial cleft; yet the operation is a more extended one, and 
 is more difficult. 
 
 In case the cleft is a broad one, the work should begin with 
 the formation of a flap on each side wdiicli will depend from the 
 border below, similar to the flaps which are made in Malgaigne's 
 operation before mentioned.* Next, the intervening V-shaped 
 part of the cleft is to be pared; and then the raw surfaces are to 
 be closed by two wire sutures which include the thickness of the 
 lip; or, instead of the interrupted suture, pins ma}^ be used for 
 closure. The closure of the lateral wounded border with the 
 median angular part is seldom satisfactorily done; the angular 
 part usually remains higher, and sits like a promontory between 
 the sides which are united to it. And where this has threatened 
 to remain a permanent deformit}', and disfigure the lip, the 
 writer in operating has preferred to wdioUy sacrifice the angular 
 part rather than to attempt to adjust the discordant promontory 
 to its surroundings. But if it be thought better to retain the 
 median part, then in closure the suture should pass through the 
 apex of the Y-portion, after the latter has been prepared and 
 drawn well downwards. If one partially separates this angular 
 median part from the upper jaw, and finds that it is so thick as 
 to rise above the lateral parts, it may be pared slightly under- 
 neath, so as to be on a level with the contiguous parts. The 
 two hanging flaps, which have been formed from the sides of the 
 breach, are next to be united by their raw surfaces, and surplus 
 material may then be cut from the end of these united flaps, so 
 that enough material will remain to fill the A"-shaped gap 
 
 *Seen in Fig. x on page 569. 
 
576 MOUTH AXD ORAL CAVITY. 
 
 which otherwise would remain. In this closure, the author uses 
 and recommends the metallic suture before described. Though 
 pins might be employed, the former plan has been found to act 
 more satisfactorily. In case of much tension, the wire cuts less, 
 and can be allowed to remain in place longer than pins. The 
 parts should be supported b}^ adhesive strips, and the sutures 
 should be extracted, successively, on the third, fourth and fifth 
 days; but the adhesive strips should remain a few days longer. 
 
 The double hare-lip may be complicated with fissure extend- 
 ing through the alveolar process and the palatal vault of the 
 roof of the mouth ; and such alveolar and i)alatal fissure may Ije 
 single, or it may be bilateral. 
 
 As previously explained, the osseous complication here men- 
 tioned arises from defective development of the primitive frontal 
 and maxillary processes of the embryo; and the part which emi- 
 nently figures in tlie present deformity is the median portion into 
 which tlie frontal plates are transformed. The anterior and 
 inferior end of this develops into the bone, variou.sly named 
 the incisive, intermaxillary or premaxillary bone; and in tiie 
 form of hare lip under consideration the premaxillary bone 
 may present every grade of growth between entire absence and 
 almost completed form. It may stand almost in row with the 
 broken alveolar arch on each side; or, it may be protruded for- 
 wards to such an extent that, instead of .standing vertical, it lies 
 horizontal. Also, the median V-shajDed fragment of the lip may 
 be of con-siderable size, or reduced to a mere vestige; and in these 
 particulars it resembles the premaxillary bone on which it rests. 
 The adjacent interrupted alveolar arch often presents irregular- 
 ities in this respect, that one portion of it stands higher than the 
 other; and something analogous to this sometimes appears in 
 uncomplicated double hare-lip, and even in simple hare-lip; for 
 frequently there appear traces of retailed closure of the bones; 
 and one side, oftener the right one, is protruded beyond the other, 
 so as to render the alveolar arch irregular. 
 
 Besides the extraordinary deformity with which complicated 
 double hare-lip stamps the child, the latter is menaced by a peril 
 5^et more grave in the interference with its nutrition; the function 
 of suction and swallowing becomes difficult, and sometimes 
 impossible in such an infant; and hence an operation here has a 
 double object, viz., to restore normal form and to aid alimentation. 
 The work to be done is a severe attack on the infant's vital 
 resources; and the question has been much disciLssed at what 
 
DOUBLE HARE-LIP. 577 
 
 time should the operation be done. The mass of authority 
 opposes early interference, and favors delay, until the child has 
 acquired greater strength, and has greater powers of resistance; 
 and this time is fixed at from three to six months, by some; others 
 would postpone operating until the child is four or five years old. 
 The majority of operators do the work of entire closure at one 
 time; others claim that the danger -to life is lessened if half of 
 the double cleft be closed at one time, and that closure be completed 
 at a later time. 
 
 The author's experience justifies him in advising an early 
 operation; for the new-born appears commonly in the threshold 
 of existence with an ample supply of reserve force to meet the 
 new conditions of life for the first few days; and as a consequence 
 the lungs and the alimentary canal, which must hereafter replace 
 the placenta, commence their functions leisurely. Through the 
 unclosed intercommunication between the right and left hearts, 
 venous blood, for a time, reaches the arteries, and, as a result, 
 general sensation is lessened and there is a tolerance of trauma- 
 tism in any form. Also, the exposure to cold air through the 
 labial breach, if closure be deferred, may induce bronchial and 
 j)ulmonary affection. Such are reasons which plead strongly for 
 an operation soon after birth, and have induced the writer 
 occasionally to operate during the first day of the child's life. 
 
 The child's life is imperiled by the large quantity of blood 
 which is usually lost at the time of the operation; also, by bleed- 
 ing which may continue after the work is done; and another 
 danger is the interference with respiration, which arises from the 
 closure of the nostrils, which is often temporarily done by the 
 operation; and such interference arises also through the closure 
 of the child's mouth which occurs during the inspiratory act. 
 The o^jeration greatly lessens the oral opening, so that when the 
 child draws in its breath the lips fall together, valve-like, and 
 entirely close the opening. The hsemorrhage arises from the 
 extensive surface which is wounded; also from the work which is 
 done in the disposal of the premaxillary bone. The writer has 
 found that some blood can be saved by using the thermal cauter}^ 
 to detach the sides and summit of the cleft from the upper jaw. 
 And other hgemostatic precautions will be mentioned when the 
 treatment of the premaxillary bone is considered. The breath- 
 ing must be watched by a nurse who will vigilantly discharge 
 the task of drawing down the chin or lower lip whenever the 
 mouth is closed. If this be neglected the automatic movements 
 
578 MOLTII AND ORAL CAVITY. 
 
 of inspiration and expiration will be repeated witliont the admis- 
 sion of air nntil the infant becomes e^'anosed tlirougli want of 
 oxygen. 
 
 In liare-lip with premaxillary complication, the best mode of 
 disposing of the premaxillary bone is a question which has 
 greatly occupied the attention of surgeons ; and as it is the first 
 act in the operative work, it will liere be considered. 
 
 In the early or developing period of the operation on tliis 
 complicated form of hare-lip, the older surgeons summarily dis- 
 posed of the difficulty by excising the premaxillary bone, and 
 then closed the labial breach in the same way as double hare-lip 
 without complication. And even in later periods this practice 
 was pursued. Volkmann, for example, was accustomed to sacri- 
 fice the bone. Yet this plan is obnoxious to the grave charge 
 that it lessens tlie arc of the upper jaw, and diminishes the 
 number of the teeth ; and in the end, the future face is thus given 
 a disagreeable shape. The nose sinks downwards and backwards, 
 and the middle portion of the maxilla superior has the appear- 
 ance as if it had been driven backwards; the normal rotundity 
 of this portion of the countenance is exchanged for flatness. 
 The shortened and Ijroken dental arch presents an unsightly, if 
 not repulsive, appearance when the mouth is opened. The 
 shortened antero-posterior diameter of the buccal cavity deterio- 
 rates the voice. These are valid reasons for preserving the pre- 
 maxillary bone; if, however, the labial defect cannot otherwise be 
 closed, the bone should be removed. This may be done in the 
 infant with a pair of scissors; yet, if the operation be done after 
 ossification, bone forceps will be needed for the division of the 
 nasal septum to which the bone is attached. Should much 
 bleeding follow the removal, this may be arrested by cauterizing 
 with tlie thermal cautery. 
 
 For retention and preservation of the premaxillary bone one 
 of the following methods may be chosen : (1) From the nasal sep- 
 tum close to the bone, Blandin excised a V-shaped portion, whereby 
 the septum could be shortened; the bone is then crowded back- 
 wards into the gap between the superior maxillary bones. Bruns 
 treats the premaxillary bone in a manner similar to Blandin's 
 method. As aid in this work, and to control ])iemorrhnge, a 
 strong thread passed through the partition before and behind 
 the excision may be tied, so as to aid in the closure and also to 
 prevent bleeding from the vessels opened in the excision. For 
 this purpose strong silver wire can be used more conveniently 
 
DOUBLE HARE-LIP. Oty 
 
 than silken thread, since tlie former can easily be twisted to any 
 degree of tightness, and the twisting can be repeated at a later 
 period if required. (2) Desault pushed the premaxillary bone 
 backwards into the opening between the maxillary bones. (3) 
 Butcher of Dublin first fractured the supporting sej)tum, and 
 then he forced the bone backwards. In the announcement of 
 his method of operating, Butcher claims originality for what 
 Hueter pronounces not new, but old work (and on this point the 
 writer would add that in such assumption Butcher held place 
 among a vast number of so-called discoverers and inventors), 
 (4) The mucous coating maj'' be separated on each side from the 
 unossified or ossified septum, and then, a section having been 
 excised from the latter, the bone is thrust back into the room 
 thus made for it, and a suture may be thrown around the wound 
 in the septum, if there be excessive bleeding. (5) Esmarch trims 
 the sides of the premaxillary bone, and then forces it into the 
 gap behind; he thus hopes to favor subsequent union of the raw 
 surface to the maxilla superior, for it has frequently been 
 observed that, although the bone be forced back into the gap, it 
 does not become adherent, but remains movable afterwards; and 
 in such case, the teeth would be functionally nearly valueless. 
 The objection to trimming the sides of the premaxillary bone is 
 that one or more dental germs might be injured. Of the plans 
 mentioned, the author advises that in which the mucous coating 
 is uplifted, and the intermediate structure cut out as far as 
 required, and then the bone is to be forced backwards. 
 
 Another complication of this form of hare-lip is the ill posi- 
 tion of the nasal wings, and the flaring, funnel-like form of the 
 nostrils, which results from such alar malposition. As means to 
 correct this, Blasius used a quill or brace suture, which is placed 
 on each side of the nose and included in sutures, which main- 
 tain compression. Bruns uses a loop of thread, which, suture- 
 like, including the alne and septum, corrects the obliquity of the 
 former. Again, the writer has found that this work may be done 
 by making raw the portion of the ala at its attachment to the 
 lip, also the adjacent side of the pedicle of the sub-septum; and 
 then uniting the raw surfaces by sutures, the form of the nostril 
 can be rectified or much improved. 
 
 The order in which this work should be done, after the child 
 has been anaesthetized, is first to place backwards the premax- 
 illary bone by one of the methods previously described, and then 
 to trim the margins of the cleft in the manner before given for 
 
580 MolTH AND ORAL CAVITY. 
 
 the treatment of uncomplicated double hare-lip. Two lateral 
 flaps should be formed, which are to be united, as they hang 
 pendent. The intermediate, angular, labial islet should be 
 trimmed and saved, if it can be ulili7,ed in the closure. The lip 
 should be detached from the jaw on each side, so as to facilitate 
 lateral sliding. If the material be scant, there will be much dif- 
 ficulty in a[)proximating and uniting tlie sides; and to k-s.sen 
 tension, Roux applied a bandage so as to include the united parts 
 and lessen tlieir tightness; and to accomplish the same, Heurte- 
 loup and Boeckel include the parts in a deep suture, which les- 
 sens the tension. Along with such suture, supporting adhesive 
 strips may be used, applied in the manner before described. 
 The nostrils are next to be rectified by means of lateral com- 
 presses, or the looped transfixing suture before referred to. The 
 work of closing the wounded parts is now to be completed by the 
 use of as many sutures as will effect coaptation. Metallic suture 
 should be employed in all this work, since it irritates less tlian 
 silk, and by twisting the wire, in place of tying it, any degree of 
 tension can be obtained which is desired. 
 
 The time wlien tlie sutures should be removed should be 
 longer after this operation than in any other case of liare-lip, 
 since there is danger of the parts tearing asunder, the rea.son of 
 this depending on two causes, viz., the thinness of the jjarts, and 
 the pressure of tlie premaxillary bone. In niany cases of com- 
 plicated double hare-lip the parts are atrophied and are not thick 
 enough to bear the strain of the sutures or the pressure of the 
 premaxillar}' bone, against which the lip? rest after the closure. 
 This tension, or rather distension, continue? after the sutures 
 have been removed, and although union of the two sides may 
 have been obtained, the pressure against them from behind con- 
 tinuing to act, they may finally separate completely or only j^nr- 
 tially. Partial union is much better than complete solution; in 
 the latter case the condition is worse than prior to the operation; 
 but when some union has been obtained it gives much aid in the 
 work afterwards undertaken to obtain complete union. 
 
 The question sometimes arises whether in case there has been 
 failure to get union, it is better to reoperate at once, or to delay 
 until the i)arts have healed and the inftnit has become stronger. 
 The experience of the writer is highly unfavorable to reoperating 
 at once, in case there has beoii failure to get union at the fiist 
 operation; though he has attempted this in a few ca.ses in which 
 such failure had occurred, in but one instance did the second" 
 
DOUBLE HARE-LIP. 681 
 
 operation end successfully. Hence, the writer would differ from 
 Sedillot, who advises to reoperate as soon as failure to obtain 
 union has occurred. According to the writer's experience, the 
 tissues which have recently been operated on and torn asunder 
 are abnormally fragile and are very apt to separate again should 
 they be reclosed; it is better to wait until the parts have become 
 solidified, as they will do if time be allowed for them to heal. 
 Not less than three months (and even six months is better) should 
 elapse before the next operation. If this course be pursued, the 
 chances of success after the second operation will be much 
 increased. 
 
 The writer would warn against the error sometimes committed 
 of prolonging the work by too much attention to the minute 
 details of the operation; leading operators, as Stokes and Hueter, 
 counsel expedition in the work. In hastening through the work, 
 and by obeying the second term of tuto, cito et jucunde, the oper- 
 ator will comply with and emphasize the first and third; that is, 
 celerity will contribute to safety and success. 
 
 After successful closure lias been thus obtained, some addi- 
 tional work is commonly required to overcome certain defects 
 which remain; and here, as in case of failure of the primary 
 operation, the temptation is great to do this immediately ; but as 
 delay was needed in the former case, so it is equally necessary in 
 this one; one should wait for three months at least, before using 
 the knife again. And should the defects be slight, it will often 
 occur that after a short period, they will become less conspicuous; 
 in fact, the appearance will become so much better that the 
 parents may decline any further operative amendment. 
 
 Surgical services are sometimes demanded in cases in which 
 an operation has been done some years before for the relief of 
 hare-lip, and in which the result obtained was unsatisfactory ; 
 and another operation is solicited. The remaining defect may 
 be a V-gap, uneven opposition of the two sides or the exposure of 
 too large a surface of raucous membrane; or an unsightly scar 
 records the imperfect work which has been done. Again, with- 
 out the scar being very conspicuous, it may contract lengthwise, 
 and thus uplift and evert the border of the lip. Besides these 
 labial irregularities, there may remain, after the operation, a flar- 
 ing obliquity of one nostril, which, if unrelieved, will remain as 
 an unsightly feature. In each of these conditions, a carefully 
 studied piece of surgical work will be rec[uired to efface or improve 
 the condition. And, desj^ite the most careful and intelligent 
 
582 MOUTH AND ORAL CAVITY. 
 
 attempt, the result obtained is often far from being a joy to the 
 patient; on the contrary, it is often a disappointment; for correc- 
 tion of tlio errors and jnissteps made by nature in her work of 
 molding the embryo, is far more easily done at the first operation, 
 than in cases in which nature's errors liave been intensified l)y 
 the blunders of unskilled art. Hence it is prudent to abridge 
 hope and limit promise in this secondary reparative work. 
 
 The most usual defect of those mentioned, requiring re{)air, is 
 that in which the V-gap is combined with an unsiglitly vertical 
 scar; the latter, by its paleness, contrasting with tlie adjacent nor- 
 mal skin. To correct this an operation may be done, consisting, 
 in tlie main, of three acts. By means of a horizontal cut, a 
 hanging loop-like bridge of tissue can be formed, from the border 
 of the lip, at the site of the V-gap. This incision must be made 
 in the horizontal plane and include enough tissue to retain its 
 vitality. Next tlie scar is to be excised by two vertical cuts 
 which closely include it; and these incisions sljould be continued 
 upwards on each side of the nose, at first, close to the ala; and 
 then each must diverge from tlie naso-labial sulcus laterally. 
 The upper portion of these incisions will be in the form of a Y, of 
 which the two upper branches should rapidly diverge as they 
 ascend; and, if need be, the lateral portions are to be dissected 
 from their subjacent attachment, wdiile the median upper por- 
 tion is to remain fixed in its site. Closure of the wounds is to 
 begin from above, and in doing this, the sides must be drawn 
 down and fixed to the intermediate portion by sutures, in 
 such a manner as to lengthen the sides and, consequently, the 
 height of the lip. To aid in this fixation, a transfixing pin 
 should be used, which will pass through the depressed sides and 
 the intermediate portion. Besides this twisted suture, one or 
 more knotted metallic ones should be used to complete the clo- 
 sure of the vertical wound. The horizontal swinoinir bridiie is 
 next to be folded on itself, and closed by a suture which will 
 fasten it, so folded, to the parts above. If these several cuts be 
 properly done, the lip will be vertically lengthened, and the V- 
 defect replaced by the normal tubercle. 
 
 In case the median gap is the only defect requiring removal, 
 then the filling up of this defect may be done by an incision of 
 V-form through the entire thickness of the lip, and stopping, on 
 each side, at least one line above the labial border ; and this may 
 be done in opposite ways. In one way the cut is shapen as an 
 inverted V, thus ^\; this incision allows the forcing downwards 
 
DOUBLE HARE-LIP. 583 
 
 of the angular portion included between the lateral cuts, and 
 the retention there of this part by proper sutures; thus done, 
 there is effacement of the gap; or it can be done in a manner 
 quite opposite to this, viz., with a cut of V form, in which tlie 
 inferior angle will reach nearly to the labial margin. Such a 
 cut will allow of tlie forcing downwards of the Y against the bor- 
 der, and its maintenance there by means of proper sutures. By 
 one of these ways, preferably by that of the ^v-^rm, the gap may 
 be filled. 
 
 The exposure of too broad a stripe of mucous membrane may 
 arise from the ill placing of the bridge which is used to fill the 
 median gap. And a defect, almost as striking, is where dermal tis- 
 sue occupies the normal site of mucous membrane. These defects 
 are difiicult of correction; their avoidance at the primary opera- 
 tion is an easier matter; here, as. elsewhere, the preventive ounce 
 far outweighs the corrective pound. As each case under this 
 head has its special characteristics, the procedures for correction 
 are so diverse that it is impossible to lay down special rules for 
 the work; the ingenuity of the surgeon, if he be fertile in expedi- 
 ents, will devise a plan suited to the individual case. And tlie 
 writer would say that the essays which he has made in this field, 
 though contenting the patient, have not been satisfactory to him- 
 self; indeed, the operation accomplished rather a change than 
 an effacement of the deformity; old lines of ugliness were super- 
 seded by new ones possibly less ugly. 
 
 A defect, sometimes arising from an operation on hare-lip, 
 is an eversion of the middle portion of the lip, and continued 
 exposure of the front teeth. To prevent such eversive retractile 
 action and consequent shortening, Soupart of Ghent, in 1859, 
 advised to cross the incision made by a second one, at right 
 angles to the first one. This plan is in conformity with a 
 principle which Soupart has verified, that a straight linear wound 
 will contract less if it be intersected by other cuts. In fact, Sou- 
 part asserts that he lengthened the short side of a labial cleft by 
 such intersecting incisions. The crossing cut need not pass 
 through the entire thickness of the lip. 
 
 In case, however, such vertical shortening with eversion of the 
 border is not corrected by a cross incision made horizontally or 
 obliquely, then, in the gaping space thus made by incision, a pedi- 
 cled flap, uplifted from the adjacent surface, may be turned 
 around and inserted in the opening made. The cut, into which 
 the insertion is made, sliould be deep, yet not pass through the 
 entire thickness of the lip. 
 
584 MOUTH AND ORAL CAVITY. 
 
 The last defect, for which corrective work may be demanded, 
 is that of wide nostril, oblique flaring wing, and sinking of the 
 end of the nose. The corrective work, here to be done, is to uplift 
 the ala nasi and bring it nearer to the sejitum. To accomplish 
 this, an excision of tlie tegumentary surface of the inferior outer 
 an<rle of the nostril is to be made, and then the ala is to be forced 
 inwards towards the septum, and retained there by metallic 
 suture. This work of rectification is seldom required on more 
 than one side, and this is commonly the left side. After the 
 operations for hare-lip, if the child can nurse it should be per- 
 mitted to do so; for if it be withdrawn from the breast until the 
 wounds heal, it sometimes forgets the act of seizing and holding 
 the nipple. It can readily nurse after the operation, provided 
 the nostrils are patent; but if these be closed, as sometimes 
 occurs, then the child must be nourished from a spoon, or other 
 means used in the nursery. And, as a severe assault is made on 
 the child by the operation, it is a matter of the utmost importance 
 that its nutrition should be well maintained. 
 
CHAPTER XVIi. 
 
 LABIAL GROWTHS. 
 
 The neoplastic developments which have location in the lips 
 will next be considered; and as the labial structure is a composite 
 of many elementary tissues, it is a favorable site for almost all 
 varieties of new growtli; and such neoplasm, according to 
 histologic origin, may be named vascular, follicular, epithelial or 
 of connective tissue type. 
 
 The statistician, who has collected long series of tumors, finds 
 that vascular growths occur oftenest in the head; Porta found, in 
 a series of .one hundred and fifty-one vascular tumors, that one 
 hundred and seven were seated on the head, eighty-nine of these 
 were situated on the face, and, of these, ten belonged to the labial 
 region. In a series of fifty-six, .collected by Lebert, twenty -six 
 were on the head; and seven of these were on the lips. The 
 upper and lower lips have equal share in furnishing site for the 
 vascular neoplasm. From the writer's observation, the growth 
 occurs much oftener in the female than in the male. Bouisson 
 reports the operation of ten cases, all of which were in females. 
 It may occur at the angle of the mouth, and then both lips are 
 implicated. 
 
 The labial angioma, analogous to that seen elsewhere, may 
 be superficial and confined to the surface; or the entire thickness 
 of the lip may be occupied by the growth, and between these 
 many gradations occur. Arterioles and venules concur in the 
 development of these growths; and, where the tumor involves 
 the deeper labial structure, it has the property of swelling. 
 This form is known as the erectile vascular growth; and, from the 
 fact that in this form dilated spaces are found which are filled 
 with blood, this species is sometimes denominated the cavernous 
 tumor. 
 
 The cavernous or erectile tumor is more frequent in the lip 
 than the superficial forms; it begins as a small point, as a rule, 
 and this may remain stationary, and afterwards rapidly grow, 
 38 (585) 
 
586 LABIAL GROWTHS. 
 
 extending into and involving the adjacent structure of the cheek. 
 It presents a livid bluish aspect, and enlarges during any expira- 
 tory effort of tlio patient. Tlie e})iderin conceals the color on the 
 side of the skin; and the livid hue is more apparent on the 
 internal side. 
 
 During infancy and youth the erectile angioma ma}^ continue 
 to grow until it reaches considerable dimensions; but in adult 
 life and in the aged, such growth is absent, or, at least, very slow. 
 And in a few cases the tumor has receded, and spontaneously 
 disappeared. Such fortunate event is so rare that it is prudent to 
 eliminate it from the problem of the prognosis of this growth. 
 
 This tumor is absolutely painless so long as the bounding 
 skin or mucous membrane remains intact; it is, liowever, not an 
 uufrequent occurrence that the external surface, through accident 
 or otherwise, becomes the site of abrasion or fissure; and such 
 opening permits the escape of blood from the broach; and thus 
 liaimorrhage may recur and debilitate the subject. Such luemor- 
 rhage can also originate from death and sloughing of the surface 
 of the growth, the condition, here, being similar to that seen in 
 ulceration arising from a varicosed condition of the lower extrem- 
 ities. This ulcerated condition of the angiomatous lip being a 
 source of continued irritation, there may result malignant disease, 
 similar to what occurs in the leg. And, in such a case, there is 
 a commingling of the elements of cancer and vascular growth. 
 Such disease, which has been observed by Bouisson, it is needless 
 to say, is far graver than normal angioma; the treatment of the 
 latter must vary from the former. 
 
 Another form of labial angioma is one which is limited in 
 volume, and situated on the mucous border. This is non-erectile, 
 constant in form, and is remarkable for its dark livid or purplish 
 hue, resembling in color an undried prune. In appearance it is 
 analogous to melanotic cancer; yet it is wholly benign. Tin's 
 growth occurs oftenest in the female's lij), and is a source of 
 trouble from its unsightliness. 
 
 As the form and appearance of the lip may, according to their 
 character, render the face attractive or repulsive, hence the 
 angiomatous development here becomes of far more importance 
 than it would if situated in other parts of the body; therefore 
 the removal of such deformity in the adult is urgently solicited; 
 and if in an infant, the diligence of affection is yet more importu- 
 nate in its demands for surgical aid. 
 
 Treatment. — Many means may be resorted to for the cure of 
 
LABIAL GROWTPIS. 587 
 
 labial angioma; a cardinal principle, which should guide in the 
 work, is to leave as small a scar as possible; were it done other- 
 wise, the patient would only exchange one ill for another. The 
 treatment, also, should vary according to the grade of the vascu- 
 lar growth. 
 
 In case the growth is of the most superficial species, in which 
 the affected structure, consisting of intercommunicating capillaries, 
 has been named telangiectasis, the most appropriate treatment is 
 cauterization by the actual or potential method. The simple 
 thermal cautery will accomplish the work ; but care must be used 
 not to destroy the surface too deeply; the metallic cautery should 
 be passed once or twice over the affected surface, and this should 
 be repeated after the destroyed surface is detached. The work 
 can also be done by means of fuming nitric acid, care being used 
 that the acid does not enter the mouth. 
 
 Should the vascular growth reach deeper, then attacking it 
 superficially will be insufficient. The most conservative plan 
 which then can be pursued is that of simple compression. Boyer 
 reports that he thus cured a labial vascular growth. To do this, 
 a strip of India rubber should intervene between the lip and 
 the teeth,and, on the outside, compression may then be main- 
 tained by an elastic bandage; or, to a head-dress, a compressive 
 appliance m.ight be attached anteriorly. As the intent of such 
 appliance is to lessen the blood supply to the lips, the work would 
 be materially aided by continued pressure maintained on the 
 facial arteries, where they lie on the maxilla inferior. 
 
 The labial angioma might be removed in the infant by 
 inoculation with vaccine virus ; a serious objection to this method 
 is that it entails the permanent marks which characterize the 
 vaccine scar. Another grave objection is the long period of 
 suppuration which it compels the patient to pass through. 
 
 Pustulation with tartar emetic will accomplish the same 
 regressive change in the vascular structure; and an ointment of 
 ipecacuanha acts similarly. 
 
 The tumor may be brought to a permanent standstill by 
 injecting into it some coagulating fluid, as a solution of a salt of 
 iron, or some vegetable astringent, as the tincture of nut-galls. In 
 this way the blood content may be coagulated and remain, as it 
 were, fossilized, an unchanging component of the labial structure. 
 Besides the peril that such fluid might overleap the boundaries 
 of the growth and enter the circulation, it is unsatisfactory in 
 another way, viz., that the mucous surface may remain uneven 
 
588 LABIAL (illOWTHS. 
 
 and discolored. Ileiu-e other methods are preferable to that of 
 coagulation. 
 
 Ainetlu)d whicli might be used is thermal cauterization, done 
 by means of needles, which, heated to red heat, are tlirust into 
 the angioma and retained there until they destroy a thin 
 stratum of structure contiguous to them. This plan should be 
 proceeded with slowly and repeated several times until the work 
 is completed. If the operator has had some experience in this 
 method, he will be able to thus satisfactorily remove or reduce 
 the vascular growth; but in his first essays he usually exceeds or 
 falls short of the proper measure. 
 
 Reduction may be done by transfixing the vascular structure 
 by pins, and then including the pins in constricting ligature, 
 the constriction to be maintained until the circulation is arrested. 
 
 By any of the methods mentioned, the angioma may be 
 reduced in volume and often cured; still, it not unfrequcntly 
 occurs that small sections of the growth remain, whence regrowth 
 may originate, and the angioma subsec[uently reappear. Hence 
 some certain and trustworthy plan is desirable; and this is found 
 in excision. By excision, the writer has frequently removed the 
 labial angioma, in which the growth occupied the whole, or the 
 greater part, of the thickness of the lip. The scalpel makes few 
 mistakes when wielded by the trained hand. Excision may be 
 done by sections, or the entire growth may be removed by a cir- 
 cumscribing incision. 
 
 In partial excision, cuneiform sections of the structure are to 
 be removed, and the intermediate w'edge-shaped sections of struc- 
 ture which remain are to be united by sutures. One, who has 
 not performed such cuneiform excision, should be warned not to 
 form gaps too near each other, else he will find difficulty in 
 effecting complete closure of the surface, for it is apparent that 
 the remaining triangular portions of structure cannot simulta- 
 neously be displaced in two directions; and to avoid error in 
 the closure, it is better to close each gap as soon as it is formed. 
 The experience of the writer in such excision and closure has 
 taught him that, if the work is done otherwise, it is difficult to 
 estimate correctl}" the amount which should be excised; but, done 
 as here indicated, besides satisfactory closure of the opened surfaces, 
 the loss of blood will also be reduced to the smallest amount. 
 
 Inasmuch as any portion of the remaining tumor may con- 
 tinue to grow, a more certain method is to completely excise 
 the vascular structure. In this work the entire thickness of the 
 
LABIAL CYSTOMA. 589 
 
 li23 should be excised; and this is practicable in cases in which 
 the growth is not of large volume; but if the greater portion of 
 the lip be involved, the treatment should be in accordance with 
 some one of the conservative plans which have hitherto been 
 explained. The question may be asked whether it would not be 
 more proper to spare the dermal side of the lip, provided the 
 angioma occupies cliieti}^ the opposite side; the objection is that, 
 thus done, there will be left a wound opening into the mouth. 
 Or, if an attempt be made to close the wound by a suture in the 
 inner side, the result wottld 1 le a pouting process on the outside, 
 which would continue as a lasting deformity. These are valid 
 reasons for sacrificing the entire thickness of the lip, and they 
 are further fortified by the facility which is given for accurate 
 closure of the wound when the work is thus done. 
 
 Total excision is best done when the scalpel follows the line 
 which separates the vascular from the normal structures. A 
 little observation and study will enable the operator to do this, 
 and excision, thus done, will cause but slight bleeding, for the 
 growth receives and returns its supply of blood through but few 
 arteries and veins. If, however, the incisions enter or traverse 
 the angiomatous structure, then there will be profuse bleeding 
 from the wound. It is rare that ligatures are required to check 
 the bleeding. The liEemorrhage can be reduced to a minimum 
 by torsion and careful apposition by sutures. 
 
 In case the growth is so extensive as to compel the operator 
 to enter tlie buccal wall, then the dermal side, if possible, should 
 not be opened, the removal being done wholly on the inside; and 
 in this work, should an extended recess or pocket be formed 
 between the mucous membrane and the outer wall, then the 
 cavity formed should be slit to its bottom, so that excreta or other 
 material may not find lodgment there. 
 
 Small, isolated angioma seated on the border of the lip, such 
 as the prune-colored species early mentioned, is best disposed of 
 by cuneiform excision done with scissors; and then, if a consid- 
 erable notch be formed, it may be closed by suture. 
 
 Labial Cystoma. — Cystic growth, commonly of small dimen- 
 sions, sometimes develops beneath the mucous surface of the lips. 
 Such growth is somewhat flattened in form, and rarely exceeds 
 the size of a pea in volume. The content resembles inspissated 
 mucus, and is viscid and gelatinous in character. The covering 
 wall is transparent and so thin that the character of the content 
 is distinguishable through it. If this wall be opened, the con- 
 
690 LABIAL GROWTHS. 
 
 tent escapes, and the cyst temporarily disappears; yet it soon 
 reforms and i)resents the same appearance as before. Besides 
 the small cysts here described, those of much larger volume have 
 been observed. And as these were multilocular in structure, they 
 probably arose from the fusion of two or more simple C3'sts. 
 
 Whether simple or compound, the labial cyst doubtless arises 
 from closure of one or more mucous follicles, and the retention 
 and accumulation of the secreted content. 
 
 Such cyst is painless, yet its presence is disagreeable, inasmuch 
 as the tip of the tongue falls into the habit of often visiting the 
 part, a fact which the writer can testify to from subjective knowl- 
 edge. And this becomes especially anno^'ing if the cyst is 
 large, as in the cases cited above; in fact, such development would 
 visibly deform the lip. 
 
 This follicular cyst is innocent in character, and free from 
 any malignant tendency; yet, as the lip is so often the site of 
 epithelial cancer, any growth in it awakens suspicion, is a 
 source of anxiety, and soon leads the possessor to seek medical 
 counsel. The physician or surgeon can quickly allay the 
 patient's fears by assurance of the harmlessness of the growth; 
 if, however, the patient has the misfortune to fall into the 
 clutches of the cancer quack, after a period of torture with 
 caustic applications, he finds himself cured, and his case is her- 
 alded among the laity as a case of cancer cured without tlie use 
 of the knife. 
 
 The proj^er treatment for this cystic growth is to insert a fine 
 tenaculum beneath it, and, having uplifted the cyst, excise with 
 curved scissors. Or the lip may be so compressed as to 2>usli the 
 growth outwards, when its removal with scissors alone is easih^ 
 done; in fact, in this way the writer, standing before a mirror, 
 removed such a C3^st from his lower lij), and his report on the 
 work is that it was less difficult than painful; and the lesson 
 derived from his experience w'as what, no doubt, many a reader 
 can bear witness to, that the most accurate knowledge of a dis- 
 ease is derived from being its subject; for while books furnish the 
 changing doctrines of disease, and clinical observation often 
 illustrates the same enigmatically, yet personal experience of 
 suffering stereotypes the same on the page of memory as knowl- 
 edge unembarrassed with doubtful theorv. 
 
 Labial Cancer. — The pathologist who divides the chapter of 
 cancer into four or five sections, may find representatives of these 
 different species in the labial region; but the infrequency of 
 
LABIAL CANCER. 591 
 
 encephaloid, cicatrizing, colloid and melanoid cancer on the lips, 
 renders a consideration of the latter unnecessary here. The form 
 commonly occurring in the lip is that which has received several 
 names, viz., local cancer, cancroid epithelial cancer or epithelioma. 
 The name of epithelioma was given it by Hannover, in 1852, and 
 this name is derived from the circumstance that the main con- 
 stituent of the growth is the epithelial element which forms the 
 outer investment of the lip; and so well is the name affixed to the 
 page of nomenclature, that the word is beginning to have a place 
 in the language of the learned layman. The name Cancroid had 
 its defender in Lebert, and after flourishing transiently, seems to 
 have run through youth and maturity and is now verging into 
 obsolete age, whence, if it follows the usual fate of words, it must 
 soon find its humble place in the glossary which is appended to 
 works on nomenclature. 
 
 Commencement and Course. — The labial epithelioma commences 
 by an augmentation of the epithelial investment of the lip, and 
 this, as a rule, is the lower lip ; the superposed strata are increased 
 in number, and the component cells are augmented in volume. 
 And this cellular development occurs initially on the border of 
 the lip where dermal and mucous epithelium meet. This aug- 
 mentation, at first slight, is jjlainly apparent later; and this may 
 be limited to a small space, or it may be spread along the border 
 until it attains an inch or more in extent, and then the middle 
 portion of the afi'ected border is the most elevated, unless it has 
 been lowered through ulcerative action. The affected part has a 
 whitish or grayish appearance. This altered condition may 
 remain with but slight change for a long period; the outer epi- 
 thelial stratum becoming desiccated and of dark color, is occa- 
 sionally detached, either by accident or the patient's finger, and- 
 then it is soon replaced by a thicker stratum. 
 
 Cases somewhat akin to those mentioned are those in which 
 the morbid growth is limited to a small surface; the epithelial 
 strata, forming a mold of two or more papillas, continues to grow 
 without limit, and thus a horn-like growth is jjroduced, which' 
 may attain dimensions of from a half inch to an inch in length. 
 Such a growth is formed of concentric strata, in the center of the 
 base of which is contained a process of the mucous structure 
 which is sensitive and vascular. The presence of sulphur, in 
 which the growth is rich, and the peculiar odor arising when it is 
 burned, show the identity of this growth with horn}' material, as 
 hair, nails, etc. Such growth may exist simultaneously with 
 
592 l.ABIAL GROWTHS. 
 
 adjacent epithelioma, and finally assume the malignant nature of 
 the contiguous epitheliomatous structure. 
 
 Instead of the epithelial development of the flattened or of 
 the horn-like species mentioned, an equally common if not 
 more frequent form, in which it makes its advent, is that of a 
 wart, or of a crack or fissure in the border of the lip. This 
 form is commonly in the middle third of the lip, and near or in 
 the median line of this portion. Whether in the form of a raw 
 tubercle, or a cleft in the border, there is a hardness of the 
 affected site, and this induration, alons: with increasiuir tliickness 
 of the lip, slowly enlarges its sphere until it occupies a greater or 
 less portion of the lip. If the initial ])oint be a fissure, sooner or 
 later the sides of this break down by ulceration; since the strata 
 of cells most remote from their nutrient source, through inanition, 
 perish, break down and are detaclied, there remains a raw 
 surface. And about the tuberculated site of ori2:in,from analogous 
 excessive cell growth, disintegration ensues. The advancing 
 malady in either case is like a cruel victor who both occupies and 
 destroys, and without rest pursues its march of devastation. The 
 cell product insinuates itself, by a species of substitution, into the 
 normal tissues, and ends by replacing the latter; a replacement 
 so complete that abnormal is substituted for normal tissue, and 
 the former, after a transient existence, dies, and there remains an 
 ulcerated breach. The morbid growth may extend along the 
 border of the lip horizontally; yet the infiltration proceeds rather 
 towards the base of the lip. This infiltration is not uniform, the 
 substitution being more complete at some points than at others; 
 hence sections of undestroyed structure may remain standing 
 alongside of the adjacent sections which have broken down; 
 thus, in time, there arises a very irregular surface; islets of but 
 slightly affected tissue border on ulcerated excavations. 
 
 If the epitheliomatous process be studied, it will be seen that 
 it consists in the development within normal tissue of a structure 
 of which the marked characteristics are rapid growth and short 
 life; after originating in some unexplained manner, it passes 
 through brief periods of youtji, maturity, age and dissolution. 
 If it be examined by incision in its mature state, it will be found 
 much harder in structure than the normal labial tissue; the 
 incised surface is marked by yellowish or greenish spots, and if 
 it be compressed, there will be forced out a paste-like fluid and 
 yellowish bodies. If the material thus extracted from the morbid 
 tissue 1)6 microscopically examined, it will be seen to be composed 
 
LABIAL CAXCER. 593 
 
 of epithelial cells, isolated or in groups, and those in groups may 
 have a concentric arrangement which they have retained from 
 their primitive molding around the papillae of the mucous mem- 
 brane. Elementary analysis discovers that the active agent in 
 this destructive transformation is the epithelial cell, and, along 
 with these cells, coexist bacterial microphytes, of which the 
 agency, whether causal or passively contingent, has not been 
 determined. 
 
 After the labial epithelioma has continued its work of ulcera- 
 tive destruction to the expiration of its lease of life, an examina- 
 tion will discover that the glands in the space within the inferior 
 maxillary arch become enlarged. When small, these glands are 
 easily movable; but later, they become adherent to the contigu- 
 ous structures, and finally the covering derm opens, and an ill- 
 formed pus is discharged. This pus is somewhat similar to the 
 material before mentioned, which can be squeezed from the 
 stroma of the mature epithelioma. In character the discharge is 
 similar to that which is yielded by a broken-down gummy 
 growth. The location of such enlarged glands is near the sub- 
 maxillary gland, and, as a rule, it is directly underneath the 
 affected portion of the lip; by some abnormal error, the affected 
 glands are exceptionally found an the opposite side; such aberrant 
 metastasis the author has now under his observation. If the 
 lymphatic glands, lying on the submaxillary salivary gland, indu- 
 rate, swell and open, the salivar}/- gland becomes infected, and 
 likewise ulcerates. The adjacent maxilla, when reached by the 
 advancing infiltration, becomes affected; the erosion may be 
 superficial, or so deep as to nearly divide the jaw and make its 
 fracture an easy matter. Or the ulcerative devastation may be 
 chiefly intra-buccal, and then the disease may burrow into the 
 wall of the cheek, or pass into the floor of the mouth, and dissect 
 up the tongue from its front connection to the floor of the mouth. 
 In its destructive migration, the epithelioma may cross the roots of 
 vessels, and, opening them, cause bleeding. From compression 
 or ulceration of the gustatory and hypoglossal nerves, there may 
 be loss of sensory and motor function of one side of the tongue. 
 The ulcerated breach in the lip permits the saliva to escape, and, 
 trickling down on the chin and falling on the dress, it renders 
 the patient intensely repulsive to others, and quite as much so to 
 himself. The ulcerated ga'p in the mouth interferes with respira- 
 tion and the taking of food. 
 
 Thus, as seen, the epithelioma, at first a microscopically small 
 
594 LABIAL (iROWTHS. 
 
 lesion, may widen its domain of destruction until it ends the life 
 of its victim; in its career it is akin to a spark of tire on a dress, 
 which a touch of a finger may extinguish, hut if once awakened 
 into a flame, a hundred hands can hardly rescue the unfortunate 
 one. 
 
 A remarkable circumstance in connection with labial epithe- 
 lioma is that, during its incipient period of development, the 
 slight lesion rarely awakens attention on the part of the })atient. 
 The trivial breach in his lip arouses no suspicion of its real 
 nature; and, as a rule, the subject is only awakened to his true 
 condition when the disease has well entrenched itself in the lip, 
 and has produced some destruction of tissue. 
 
 Causes. — The epithelial element of the lip is launched on its 
 aberrant course by some irritant which is continued in action 
 for a long period; such irritation may be caused by the irritating 
 action of the smoker's cigar or pipe-stem ; or the nail, tack or 
 other object which, the mechanic daily placing in his mouth, 
 presses on and bruises the lip; or the foul content of an uncleansed 
 mouth constantly coming in contact with an eroded surface of the 
 lip; or a crack or cleft in the border of the lip that is maintained 
 in a raw state by the action of the muscles which are constantly 
 moving the lips; or, finally, any occupation in which the mouth 
 is exposed to injury ; of which a rare example is the blowing of 
 food into the beaks of fowls which are subjected to forced feeding 
 to hasten their fattening, or rather fatty degeneration. An erosion 
 from any of the causes enumerated, often finds an efficient ally 
 in the irritant remedies which the patient applies to it ; and 
 a further efficient ally is the lingual manipulation with which 
 the eroded surface is continuously tormented. 
 
 To what extent smoking is a causal agency has been and 
 remains a subject of contest among surgical writers. As usual, 
 those who smoke are partisans for their favorite pleasure, and 
 offer numerous plans in defense of its harmlessness ; and an argu- 
 ment which tliey urge is that, while there are thousands of 
 smokers, there are but scattered units of those who become the 
 subjects of labial cancer. To this their opponents, among whom 
 the writer is included, reply that labial cancer occurs oftenest 
 among; men who smoke. And that units onlv of the thou-sands 
 of smokers become affected is in accord with the deportment of 
 many other diseases; though many are exposed to attack, yet 
 but a few become the subjects. There are doubtless constitutional 
 conditions, as yet undetermined, which dispose to the develop- 
 
LABIAL CANCER. 595 
 
 merit of malignant disease, whether in the form of epithelioma, 
 sarcoma or carcinoma ; in those with such predisponent endow- 
 ment, the continued irritation of the stump of the cigar which 
 often remains on the ground after its trunk has been consumed, 
 becomes the final causal excitant of epithelioma. The rough 
 stem of the clay pijje does the work more surely, since it has, as 
 co-workers, unclean mouth, unclean teeth and unclean lips. The 
 heat of the cigar and pipe overheats their point of contact, and 
 the drying saliva leaves its solid content on the lip; some irrita- 
 tion must thus be caused. The tobacco, as is known, contains 
 nicotine, a most active principle, whose toxic virulence is well 
 known to the pharmacologist. In the methods which are used 
 to prepare the tobacco for smoking or chewing, ingredients are 
 compounded with it which are said to set free ammonia as well 
 as the alkaloid nicotine, and thus the material is rendered more 
 acrid than it is in its natural state. Hence, in the act of smok- 
 ing, the lip is irritated by heat at a degree which almost burns 
 the surface; and. this is combined with the action of nicotine, 
 which evidentl}^ impairs and lowers the vitality of the part 
 which it penetrates. If a few drops of nicotine, introduced into 
 the throat of a bird, causes death, as has been found to be the 
 case, it certainly must have a depressing effect on the mucous 
 surface of the mouth. As this action may be exerted within 
 the buccal cavity, the smoker's cancer is not limited to his lip, 
 it develops quite as often at the sides of the base of the tongue, 
 and on the pharyngeal arch, at a point which receives the impulse 
 of the indrawn smoke. And finally, it may be stated that 
 women, rarely smokers, seldom have labial cancer. 
 
 Another point, strongl}^ in favor of the causal agency of tobacco, is 
 the greater frequency of labial epithelioma since the use of tobacco 
 has become more prevalent; this disease is one which now pre- 
 sents itself to the practicing surgeon oftener than any other form 
 of malignant disease; such frequency did not exist a century ago, 
 if one judge of the matter by the surgical works published at that 
 time: labial cancer was not spoken of as a frequent occurrence 
 by Boyer, Bell, Heister, Delpech, Richter and Richerand; but the 
 present prevalence of the disease is in direct ratio to the popular 
 use 6f tobacco; which has been advanced by fashion from an 
 occasional luxury to that of a necessity; and thus promoted, 
 tobacco will bafile the best efforts of the hygienist who seeks to 
 lessen or abolish its use. The "Counterblast against Tobacco" 
 written by a royal hand,* had as little effect in checking the use 
 
 *King Jatnes of England. 
 
596 I.AIUAL (JROWTHS. 
 
 of the i)laiit as docs the knowledge well diiTusod among people 
 that cancer may thus arise; and the principle here obtains that 
 man would rather add to the sum of his pleasures, even if the 
 added material must be taken from his life. In fact, the altruis- 
 tic virtue "which is so unseltisiily illustrated in hygienic medicine, 
 and which sacrifices itself for the sake of others, has slight extrin- 
 sic recompense. 
 
 Diagnosis. — The labial cancer during the initial period of its 
 evolution has strong analogy with the primary or secondary 
 lesion of syphilis. Chancre on the lip must originate from con- 
 tact with a syphilitic subject; it is seen oftener in the female, and 
 quite as frequently on the upper as on the lower lip. It may be 
 multi}>le, and it commences often on tlie outer edge of the border, 
 and, in its growth, it extends towards and on the denn, rather 
 than towards the mucous membrane. The secondary syphilitic 
 manifestation on the lips is oftencst on the lower lip.or at the labial 
 commissure; and in the latter site, it involves both the upper and 
 lower lip. This eruption is commonly in the form of the mucous 
 patch, which is pearl-colored, or it may be a slight ulceration ; 
 and this is near the angle of the mouth. Labial cancer, in any 
 of its forms, differs in appearance from the primary or secondary 
 manifestations of syphilis above mentioned: namely, tlie flat 
 form is slower in its march than the chancre or mucous patch; it 
 is surrounded by a dark crust, and a horn-like growth may spring 
 from it; manifestations unlike anything seen in the course of 
 syphilis. Tlie i)apillary epithelioma is drier than syphilitic con- 
 dyloma, and has more contiguous induration. Tlie nodular 
 branches which the epithelioma projects into the neighboring 
 structures are multi})le, while the gummy development is usually 
 single. The manifestations of syphilis are painless, or nearly so: 
 the labial cancer, when it reaches the period of ulceration, is 
 painful. Epithelioma confines its devastations to the structures 
 of the face, chin and front of the neck; syphilis has no tendency 
 to local isolation; it is ubiquitous in its secondary site; derm, 
 muscle, mucous structure, bone, brain, abdominal viscus, indis- 
 criminately share in the unenvied privilege of giving the consti- 
 tutional manifestations of syphilis a transient if not a permanent 
 abiding place. Syphilis is capable of elimination, and cure by 
 the use of mercury and iodine; these remedies will retard epithe- 
 lioma, as the author has verified in his practice; they will, how- 
 ever, not extinguish and cure epithelial cancer. The microscope 
 mav be used as a diagnostic aid ; a small section placed in the 
 
LABIAL CANCER. 597 
 
 objective field will discover the epithelial constitution of the 
 epithelioma; the cellular elements of the latter will sometimes 
 be found in the interior of the growth, where they arise, accord- 
 ing to Otto Weber, from the nuclear elements of the muscular 
 components of the lip; such a cellular structure will not be found 
 in tissue wliich has arisen from syphilitic action. 
 
 Tubercular disease may produce induration, swelling and 
 ulceration similar to that which arises from labial cancer. Such 
 tubercular disease appears as often in the upper as in the lower 
 lip. Tuberculosis, similar to syphilis, does not confine its morbid 
 action to so limited a portion of the organism as the lip; if found 
 there it will be found elsewhere; probably in a gland, in the 
 skin, in a joint, or a bone; but the localized site of epithelioma 
 distinguishes it from the multifarious site of syphilis. The sub- 
 ject of labial cancer, as a rule, has general good health ; except 
 ]iis lip, he is sound in body; the reverse usually obtains in 
 secondary syphilis, or in tuberculosis. 
 
 Prognosis. — The inevitable tendenc}^ and undeviating course 
 of labial epithelioma is to ever enlarge its sphere of destructive 
 action; to spread from the lip to parts near by; and by con- 
 tinued ulceration and ichorous suppuration to undermine the 
 patient's vital forces, and finally destroy his life. In the early 
 stage, the disease is easily curable by proper treatment; if 
 allowed to reach the adjacent glands, it is incurable. The poor 
 and penniless are oftener cured than the rich; since the former 
 are forced to depend on surgical aid which is furnished him by 
 the city or State; while the rich, having exhausted their intelli- 
 gence in the acquisition and maintenance of their fortunes, seem 
 to have none left for their guidance in medical matters. At 
 least, this has been the personal experience of the writer. Dives 
 is careful to choose a skilled engineer to construct an irrigating 
 canal, or pioneer the route for a proposed railroad; he would 
 scout the overtures of one who, with no knowledge of painting, 
 would offer to paint his portrait: he would look into and investi- 
 gate the qualifications of a surgeon for his domestic animals; 
 and yet such a one often submits his own disordered body for 
 treatment to one who is ignorant of both Anatomy and Pathol- 
 ogy. Often the author has been consulted by a patient whose 
 face had been laid waste by cancerous disease, which, at first of 
 minimum form, had been cultivated to its great dimensions by 
 the industrious hand of the ignorant charlatan; and through 
 ignorance or misguidance, such patient, once easily curable, was 
 doomed to a cruel death. 
 
508 LAIUAL (JHONVTIIS. 
 
 Statistics of Labial Cancer. — In 1887 Maiweg published observa- 
 tions made at the surgical clinic of Bonn on labial cancer. 
 These observations embraced four hundred cases, of which three 
 hun(h-ed and sixty-six were men, and thirty-four women; that 
 is, there were eiglit and live-tenths })er cent of females. In the 
 entire number there were twenty-two in which the disease was on 
 the upper lip, and one-half of these were females. In respect to 
 age, the most of the patients were between fifty-six and sixty-five 
 years. After seventy-live years, the disease is rarely observed. 
 The average time which the disease had existed when medical 
 aid was sought was two years. Of one hundred and eighty-two 
 persons operated on, one hundred and twenty-five remained free 
 from the disease; that is, the disease was cured in two-thirds of 
 the cases. 
 
 Worner of Tubingen has observed three hundred and five 
 cases of cancer of the lip. Of these cases ten ])er cent were 
 women; and three were seen who were under thirty years of age. 
 The subjects were nearly all of the laboring class. In sixteen of 
 the three hundred and five cases, the upper lip was the site of 
 the disease. Of two hundred and seventy-seven persons operated 
 on, one hundred and six remained well during a period of three 
 years in which they were observed. The mortality was five and 
 seventy-seven-hundredths per cent, and was from secondary com- 
 plication of the lungs. Melzer, in I80O, in a report of patients 
 received at the hospital of Laibach, states that every sixtieth one 
 was a case of labial cancer; he attributes the frequency of the 
 disease to the use of a pipe whicli was covered with copper. 
 
 From all the publications accessible to AVorner, there were 
 collected eight hundred and sixty-six cases of labial cancer, of 
 which ninety and four-tenths per cent were in males. The 
 upper lip was the site in five and six-tenths per cent of the 
 cases. Of those having the disease in the upper lip, the greater 
 number were females. The average mortalitv from the opera- 
 tion was seven percent; and the recoveries obtained by operating 
 were twenty -eight per cent. 
 
 The percentage of recoveries as here reported is strikingh' 
 small, and can only be accounted for on the ground that the 
 cases were well advanced when the operation was done; or else 
 the work was imperfectly done; probabh^ both of these agencies 
 .shared in the causation; since, from the writer's experience, 
 which has not Ijeen limited in this section of operative surgery, 
 it is a rare event that the patient is not cured, if extirpation be 
 
LABIAL CAXCER. o9y 
 
 thoroughly done at an early period. The patient, if seen and 
 operated on early, can be assured of permanent relief from his 
 affliction. 
 
 Treatment. — The patient requires two things from his surgeon: 
 viz., that the diseased portion of his lip be removed, and that the 
 continuity of the lip be so preserved, that it will, in some measure, 
 act the part of a retaining wall, which is an important function 
 of the normal lip. As a considerable portion of the lip is 
 sometimes sacrificed, a third operative act is often required, 
 viz., restoration of this retaining wall, by the procedure of 
 cheiloplasty. 
 
 Inasmuch as labial cancer is especially a disease of the lower 
 lip, the latter will usually be the site of the operative work. The 
 removal may be done by cauterization, potential or actual, or by 
 section made with knife or scissors. 
 
 The proximate relation of the lip to the buccal cavity, renders 
 it difficult, if not hazardous, to apply a destructive escharotic to 
 the lip; and should cauterization be resorted to, the thermal 
 method would be the preferable one; but the open breach which 
 must then remain, even though this be temporary, is a strong 
 objection against this mode of treatment. Excision, then, becomes 
 the method which is almost universally adopted, since the scissors 
 or scalpel do their work instantaneously; and the incision made 
 enables one to inspect the divided tissue; and if all the affected 
 structure has not been removed, one can remove another seg- 
 ment. The incisions may be so made as to as.sist in the 
 concluding operative act, viz., that of closing the breach made. 
 
 Excision, as stated, may be done with scissors or scalpel ; as a 
 rule, strong scissors, with curved blades, and sharp at the points, 
 do the work most easily. An aneesthetic should be used, if the 
 patient desires it; the writer, in many cases, has done the work, 
 in sesthesia, the patient choosing to show his powers of endurance 
 without further aid than his innate courage. Instead of a 
 general anesthetic, sensation might be suspended locally by 
 injecting into the lip a few drops of a four-per-cent solution of 
 muriate of cocaine. By this local ansesthesia, vomiting will be 
 avoided, and this risk of disturbing the work will be shunned; 
 but from the writer's observation it is rare that the injected 
 cocaine wholly annuls sensation ; the division of the cocainized 
 structure causes pain. 
 
 Only a small operation is required where there is a slight 
 erosion of the mucous border of tlie lip, and the removal can 
 
OOO J.AIUAI, (JKOWTIIS. 
 
 here be done by means of a su[)erHcial wedge-shaped excision, 
 in which the cutting is done antero-posteriorly or laterally, as 
 may be best suited to remove tlie affected part. The gap made 
 must be closed by one or more sutures, and the surface then 
 covered witli a coating of the tincture of benzoin. 
 
 If the disea.se involves a larger portion of the border of the 
 lip, and has perforated to some depth: for example, if the erosion 
 be a half inch or more on the labial edge, then a larger excision 
 must be done; and this should be of a triangular or quadrangular 
 form; the more usual one is tlie triangular one, in which a 
 wedge-shaped portion of structure is removed. Whether knife 
 or scissors be used, the incision should bo at least a half inch 
 beyond the affected tissue, within the sound structure. And to 
 be sure that this has been done, the excised portion should be 
 carefully examined; and then, if it be suspected that enough 
 has not been excised, more structure should be removed. This 
 cuneiform, mode of excision is a favorite with the operating sur- 
 geon, since it can be rapidly done, and the gap made can be 
 closed by direct apposition; if the gap is not great, the sides can 
 be brought together and retained so by suture. There is, how- 
 ever, the serious objection that structure is unneces.sarily sacri- 
 ficed in the lower part of the triangle; and further, the narrowing 
 of the excision as it passes from the labial border involves the 
 ri.sk of leaving behind germinal elements of the epithelioma; 
 and this will be greater the shorter the wedge is. A preferable 
 cut, then, is one of quadrangular form, of which the vertical 
 sides, commencing a half inch outside of the affected j)art, shall 
 extend from one to two inches beyond the labial border; these 
 vertical incisions are to be united by a horizontal one. To 
 restrain the bleeding, which follows either the triangular or quad- 
 rangular excision, compression of the coronary arteries should be 
 made, either with clasp forceps or with the fingers of an assist- 
 ant; the former are less in the way; the latter are more apt to be 
 at hand. 
 
 The quadrangular breach thus made in the lip may be closed 
 by one of several cheiloplastic procedures. ISince the object of 
 tiiese operations is to prevent deformity, the replacing material 
 should be selected where its removal will cause the least possible 
 scarring; and to accomplish this, the attempt has been made to 
 restore the removed structure by material taken from the arm. 
 Brachial restoring material was used by Graefe, Berg, Schuh, 
 Wutzer, and others; the result has only been partially satisfac- 
 
LABIAL CANCER. 601 
 
 tory; in Wutzer's case alone the attempt was in some degree 
 satisfactory. Such work is unsatisfactory in the color of the 
 derm which is transplanted, and in the shriveled or folded form 
 which the transplanted structure assumes. In Schuh's case the 
 brachial flap rolled up into an ill-shaped mass; in Wutzer's 
 operation the material was taken from the outside of the fore- 
 arm above the wrist; and this had the fa-ult of not being of the 
 same color as that of the adjoining face. For these reasons, the 
 operator should select material for restoration from the chin or 
 the side of the face, and as that from the chin leaves a less con- 
 spicuous mark, one should choose there, if possible, material for 
 restoration. 
 
 In case cuneiform excision be done in the lower lip, if the 
 portion removed does not exceed an inch in breadth, then direct 
 closure can be done; the oral opening will then be rendered 
 smaller; yet, in time, this condition is lessened through the 
 normal extensibility of the labial structure; nevertheless, the 
 narrowed mouth is a source of inconvenience, and where the 
 mouth will be rendered very small it is well to enlarge it. This 
 widening can be done by a horizontal incision carried laterally 
 from the labial commissure that is nearest the excision; and if 
 the excision occupy the median portion of the lip, then a hori- 
 zontal incision should be made at each angle of the mouth. To 
 prevent these lateral cuts from closing, on the lower margin of 
 each the mucous membrane and derm should be united by 
 sutures. To obtain this muco-dermal union, in making the 
 horizontal incision, a small mucous flap can be constructed on 
 the inside, which can afterwards be folded outwards over the raw 
 border; or a horizontal cuneiform excision from the cut border 
 would permit of a similar muco-dermal closure. It suffices to 
 make this closure in either the upper or the lower margin. 
 Where commissural elongation is made, the extension should 
 equal the breadth of the excised portion. 
 
 In directly closing the wound in the lower lip, either with or 
 without commissural elongation, there will be formed a fold on 
 the upper lip ; also the margin of the upper lip will project 
 beyond that of the lower lip; or, if the exceptional case occur 
 that the excision is done from the upper lip, then an analogous 
 folding or puckering will be formed in the lower lip. To correct 
 this, the plan of Burow may be followed, by which the surplus 
 fold is sacrificed by the excision of a triangle. Instead of losing 
 this tissue, the author would endeavor to save it by forming a 
 39 
 
002 
 
 I.AIUAL (JKOWTIIS. 
 
 pedicled flap from the sur})lus fukl, and then, having incised the 
 op])osite border, wlietlier this be tlie U2)per or lower lip, circum- 
 duct the Hap, and insert and fix this by suture in the gap formed 
 for it. Another plan, advised by Weber, is to elongate the com- 
 missure by an incision curving downwards towards the margin 
 of the lower jaw, if the disease be on the inferior lip. When this 
 incision is made, the lower portion of it may be sutured in such 
 a way as to remove much of the fold; and this is done by draw- 
 ing downwards the outer border, and sliding upwards the inner 
 border of the excision. 
 
 The cheiloi^lastic restoration is often done by means of ped- 
 icled fla])s taken from the adjacent surface. If the breach to be 
 filled be a quadrangular one in the lower lip, then the plan of 
 Sedillot may be resorted to, viz.: lateral flaps with upward base 
 near the angles of the mouth are uplifted and made to fill the 
 breach. This plan is shown in Figures 85 and 80. Or a plan 
 
 Figure 85. Showing Sedillot's 
 plan of forming flaps for closure of 
 quadrangular breach in the lower 
 lip. 
 
 Figure 86. In which is shown the 
 result of closure by Sedillot's method. 
 (From Emmert.) 
 
 the reverse of this has been resorted to by Bruns; here the flaps 
 have pedicles below, and their free sides are formed from the 
 cheeks. Tlie plan of Sedillot is the preferable one, since the scars 
 formed will be on the lower part of the face, where they are more 
 readily concealed. 
 
 The replacing flap, wlien it is brought into place by circum- 
 duction, can be given a form which will correspond to that of the 
 breach made in the excision of the epithelioma ; thus, it may 
 have a quadrangular, triangular, trapezoidal, ovoidal, or even 
 
LABIAL CANCER. 603 
 
 some nameless shape, provided it will thus fill the breach. 
 And in this work the operator must bear in mind the retractility 
 of the uplifted flap; an allowance should be made for a diminu- 
 tion of its surface; and this, when the material is abandoned, 
 should be equal to one-third of the replacing material. 
 
 The Celsian procedure is, sometimes, conveniently used to 
 close a quadrangular breach made in the lip; this consists in 
 elongating horizontally the basial cut, or that nearest the attach- 
 ment of tlie lip; thus lateral flaps are formed which can be jux- 
 taposed by lateral sliding. 
 
 Should the disease involve the angle of the mouth, then there 
 arises the problem of canthoplasty, which is a difficult one to 
 solve; one solution of it is the method pursued by Mackenzie, in 
 1851. This consists in forming a flap with a curved border on 
 the side of the chin; then split this horizontally, so that one 
 portion can form the lower, and the other the upper border of the 
 commissure. To prevent this angle from closing, a portion of 
 mucous membrane should be dissected up, wherever it is most 
 accessible, and sutured in the angular gap. 
 
 Instead of the plan described, an angle-bearing flap might be 
 uplifted from the side of the face, and so turned into the breach 
 that the angle contained in it would occupy the site of the 
 intended commissure. In this way a flap taken from the fore- 
 arm might be modeled and utilized, if material adjacent were 
 wanting. 
 
 In case the entire lower lip is removed by a crescentic incis- 
 ion, Weber advises to close the breach by means of two semi- 
 crescentic flaps formed below the breaches. One of these flaps is 
 to be uplifted and drawn across, so as to form the upper part of 
 a new-formed lip ; next, the remaining flap is to be elevated and 
 so fixed as to support the upper flap. These flaps are to be 
 retained in position by metallic sutures. After closure has been 
 done in this manner, there will remain an open space on the 
 chin. 
 
 In case there exist alternate sections of sound and diseased 
 tissue, AVeber removes the affected portion by triangular excisions, 
 the bases of which open towards the mouth. By this plan of 
 compound triangular excisions, a destroyed commissure can in 
 some measure be restored ; and it has another advantage, that it 
 shuns the needless sacrifice of unaffected structure. 
 
 The patient may present himself for treatment after the disease 
 has extended beyond the labial region; and by such extension 
 
604 LABIAL GROWTHS. 
 
 the disease may implicate the adjacent buccal wall, and even the 
 osseous structure of the lower or upper jaw; and simultaneously 
 with this, the lymphatic glands in the inferior maxillary arch, 
 and the upper part of the neck may be affected. According to 
 the writer's observation, if the epithelioma has attacked the 
 maxilla and appeared in the glands, an operation will be followed 
 by recurrence at no distant period. 
 
 If the disease involves the cheek, the affected part should be 
 excised by a circumscribing cut, and the opening i:)lastically 
 closed. Special care sliould be taken to avoid a salivary fistula 
 should the Stenonian duct be involved; and this may be done by 
 dissecting up the posterior portion of the severed duct and turn- 
 ing this directly into the buccal cavit3^ In this wise, the author 
 has successfully operated in a case in which the terminal part of 
 the duct was diseased. 
 
 If the lower jaw is involved, and the malignant disease has 
 penetrated to its central canal, then a portion of the body of the 
 jaw should be exsected ; and this is best done by a small saw by 
 which the opposite sawn faces can be so shaped and inclined that 
 tliey can bo apposed and united by metallic suture. In case the 
 bone be slightly affected on its surface, the entire thickness 
 need not be removed; still, the disease may have penetrated 
 beyond the surface, so that superficial removal of surface will 
 soon be followed by reappearance of tlie disease; in all such cases 
 the exsection should reach well into the bone: at least through 
 one-lialf its thickness. 
 
 At some period, early or remote, tlie disease passes beyond its 
 primary marginal site and commences a migration into structures 
 contiguous; that is, the neoplastic invader makes provision for a 
 successor in a new quarter, after it has consumed the structures 
 which it first attacked; and this secondary site is the structure 
 within the inferior maxillary arch and the anterior structures of 
 the neck; and the first points of metastatic appearance there are 
 the lymphatic glands which lie near the submaxillary gland. 
 The lymphatic vessels which convey the germinal elements of the 
 epithelioma seem to remain exempt from infection. The infected 
 glands are connnonly on the same side as the affected point of 
 the lip, and they are tlie ones wliicli become secondarily attacked 
 when the epithelioma appears at the root of the tongue or in the 
 arch of the pharynx. An exception to this rule of reappearance 
 was seen by the author in one case in which the glandular infec- 
 tion occurred on the oi)posite side of the neck. 
 
LABIAL CANCER. 605 
 
 The proximate relation of the lymphatic giands to tne sub- 
 maxillary gland exposes the latter to implication, so that finally 
 the submaxillary gland becomes also infected; and without much 
 swelling, tlie submaxillary gland finally ulcerates and a portion 
 of its structure is destroyed. 
 
 When labial epithelioma has advanced to the stage of glandu- 
 lar infection, in no instance has the writer seen the case perma- 
 nently cured, even though the affected lip be radically excised, 
 and the glands carefully removed; recurrence of the malady has 
 been the invariable fate of the victim. However, in such cases, 
 the operation is advisable, since the wound made will recover, 
 and the patient is cheered with the illusive hope that he is really 
 cured; an illusion which is sometimes unv/isely broken by the 
 surgeon revealing to the patient his own fears. The kindness of 
 the physician is nobly and laudably exerted when he promotes 
 the expectation of relief; he who would do otherwise is a 
 stranger to those sentiments of humanity which belong to the 
 morality of medicine. 
 
 In case the epithelioma has infiltrated the structures on the 
 chin, and the upper part of the neck, and the infected glands 
 have suppurated, the affected field of nodulated surface presents 
 a number of crateriform openings through which flocculent, case- 
 ous, fetid detritus is discharged; then a radical removal of the 
 disease is impossible, and any oj)erative procedure must be limited 
 to an essay to remove the diseased structure, and thus diminish 
 the foul discharge. This work is best done by the use of the 
 curette, care being taken to avoid the blood-vessels. And for 
 dressing a disinfectant may be applied; for example, a chlori- 
 nated solution, or one prepared from the permanganate of potash, 
 may be used. Such a one is Condy's solution containing two 
 drachms of the permanganate of potassium to two ounces of water, 
 which may be used in this strength, or diluted with an equal 
 quantity of water. 
 
 In the advanced stage of the disease in which the use of the 
 knife would be a fruitless adventure, the writer has endeavored 
 to retard the progress of the disease by the parenchymatous use 
 of remedies; and agents, which his experience sanctions the 
 emiDloyment of, are Fowler's solution of arsenic, the tincture of 
 iodine, the fluid extract of ergot, and the solution of the muriate 
 of lime. Of the agents here enumerated, the arsenical solution 
 seems to have acted the best. Should further opportunity offer 
 for this work, he would try the spirit of turpentine, which is one 
 
GOG LABIAL (iKOVVTHS. 
 
 of the most efficient germicides known. These remedies are 
 introduced by means of tlie common hypodermic syringe. To 
 do this work begin with the tincture of iodine, of which two or 
 three drops may be injected at six or eight points; some of these 
 points may be in the diseased structure, while others may be in 
 the parts which bound the growth. The amount injected shouhl 
 not be enough to cause death and sloughing of tissue. In this 
 procedure the tissues acquire tolerance to the agent injected, so 
 that after a day or two, tlie injection may be done at a greater 
 number of points. After the iodine has been used for a week, 
 tlie solution of muriated lime may be used similarly, and in the 
 same amount as the tincture of iodine was used. In the third 
 week, the arsenal solution may be similarly injected; and in the 
 fourth week the spirit of turpentine may be employed. And 
 should a fifth agent be tried, the writer would advise the trial of 
 stramonium, which as a topical application has retarded the 
 progress of malignant growths. For interstitial injection the 
 tincture of stramonium may be used. As here delineated, five 
 agents are to be injected successively, each one week, and then 
 the cycle to be resumed and repeated in the same order. . 
 
 The writer anticipates more than mere retardation of the epi- 
 thelioma by this plan; it is very probable that the trial of a 
 large number of medicinal agents would end in tlie discovery of 
 one wliich would act curatively. And the writer is pleased to 
 note that essays in this work are just now being made with 
 agents very remote from those hitherto known to the pharmacist, 
 viz., with antitoxin lymphs; and among those the germ of 
 erysipelas, as if to atone for the many lives it has destroyed, is 
 now lending its virus for the cure of the malignant neoplasm. 
 Such experimental work carried out in the cautious manner here 
 indicated, has a promising and inviting future. As Kepler 
 charted out the heavens with tentative diagrams with untiring 
 patience before he hit on those which proved his three immortal 
 laws, so the physician must patiently work who would find the 
 agent to vanquish and eliminate malignant disease; but once 
 discovered, the blessing will be as enduring as the laws of 
 Kepler. 
 
CHAPTER XVIII. 
 
 TOXGUE. 
 
 Surgical Anatomy. — The tongue completely fills the buccal 
 cavity when the lower jaw is fully uplifted, and the mouth is closed ; 
 this assertion made by a noted anatomist is not verified by the 
 inspection of the buccal cavity of one whose absent teeth permit 
 of its exploration ; and this extensive occupation of the cavity 
 when the mouth is shut, contrasts with the open space which is 
 present when the mouth is widely opened. 
 
 The striking characteristic of the tongue is its great mobility; 
 even the hyoid bone and the portion of the floor of the mouth to 
 which the tongue is fastened, are mobile and permit the tongue 
 in its movements to shift its points of attachment; this occurs 
 when the tongue is well protruded, or drawn forwards. This 
 lack of fixation permits the tongue to recede backwards, and so 
 occupy and occlude the pharynx as to obstruct the entrance of 
 air into the larynx. Beneath the anterior portion of the tongue 
 is a fold of mucous membrane named the frsenum lingua, 
 which, rising from the floor of the mouth, is attached to the free 
 portion of the tongue in the median line. This bridle-like fold 
 limits the forward movement of the tongue. 
 
 The marvelous mobility of the tongue arises from the dis- 
 position of the muscles; these are disposed in vertical, longi- 
 tudinal and transverse direction; the genio-hyo-glossi and the 
 hyoglossi act in a vertical plane; the linguales act in the antero- 
 posterior direction, and the transversus lingua muscle acts 
 transversely. 
 
 The lingual structure similar to that of the heart, contains 
 but little fibrous tissue; such tissue is found principally in a 
 central septum which, placed antero-posteriorly, vertically sepa- 
 rates the muscularity of the tongue into two lateral portions; 
 and from this fibrous portion arises the transverse lingual muscle. 
 This septum becomes much thinner as it proceeds forwards, and 
 finally vanishes in the anterior part of the tongue. There exists 
 
 (607) 
 
608 TONGUE. 
 
 a small amount of interstitial adipose tissue in the posterior half 
 of the tongue. 
 
 The tongue is the special organ of the gustatory sense; and 
 this is seated in the superior surface, in papillse of conical, filiform, 
 fungiform and calyciform or circuravallated form. The filiform 
 and conical papilla? are most numerous on the middle portion of 
 the dorsum ; the fungiform are most numerous at the point and 
 on the dorsum. 
 
 The most important to the surgeon of the lingual papillfe are 
 the circumvallated species, which lie on the hase of the tongue in 
 two lines, which converging, meet behind, and form an angle 
 which opens forwards. The papilla at the point of this angle 
 lies in a depression which is named the foramen coecum. The 
 circumvallated papillae are hidden from view so that their pos- 
 sessor rarely sees them, unless he makes some exploratory search 
 into his throat; and on seeing them he is frequently alarmed, 
 and, thinking that he has some growth appearing, he presents his 
 throat and fears to his phj'sician; and from the latter he should 
 learn that these eminences are the most important instruments 
 of taste, and are potent factors in the pleasures of the table. 
 
 The non-papillary portion is the site of numerous small 
 glands which empt}^ their excretion into small follicle-like 
 depressions. Glandules, deemed cognate to the sublingual gland, 
 lie along the border of the tongue. On each side, within the 
 structure of the stylo-glossi muscles, lie glandular masses, discov- 
 ered by E. H. Weber; and on the inferior surface near the point, 
 lie two glands, described by Blandin, and of which the excretory 
 ducts open on the fraenum. The posterior fourth of the tongue, 
 which lies between the calyciform papillae and the epiglottis, has 
 been found by Billroth and Kolliker to be the site of a lymphoid 
 tissue. In this ti.ssue glands and follicles are found. 
 
 The lingual arteries anastomose in the anterior portion of the 
 tongue; hence the oozing of blood, which occurs in section or 
 removal of one side of the tongue, though the corresponding 
 artery has been ligated. Besides the lingual, the sublingual, a 
 derivative of the facial artery, furnishes blood to the tongue; 
 thence some bleeding arises in removal of the tongue, though 
 both lioguals have been previou.sly tied. This bleeding, as the 
 writer has witnessed, is slight, and is readily controlled. 
 
 The lymph-vessels have been studied by Teichmann, who 
 finds them numerous and disposed in close net-form, in front of 
 the circumvallated glands, and these lymphatics are more super- 
 
DEFORMITIES. C09 
 
 ficial than the veins. As one passes backwards, the meshes 
 become wider, and the vessels of greater size. The lymphatics 
 situated in the posterior portion of the tongue and on its sides 
 converge to glands which lie in front of the internal jugular vein ; 
 those from the dorsal face of the tongue pass to glands near the 
 submaxillary gland. And, thirdly, the lymphatics from the 
 anterior part of the tongue pass to glands lying on the thyroid 
 gland. Cancer seated in the posterior part, the dorsal or superior 
 face, or in the anterior part of the tongue, will reappear in one of 
 the corresponding glandular sites here mentioned. 
 
 According to Cruveilheir, the tongue of the embryo begins 
 to appear in the median line of the floor of the mouth, in the 
 seventh week, as a minute bud or tubercle. 
 
 Deformities. — The tongue is the subject of numerous deviations 
 from normal form, which may be congenital or acquired ; they are 
 commonly congenital, in which, from some error in development, 
 the part wanders from its typical conformation ; for example, in 
 the new-born,'the tongue may be wanting; it may be bifid or it 
 may be too large; and when too large it may be so voluminous as 
 to be protruded from the mouth. The mobility of the tongue may 
 be hampered by adhesions which may be above, below or lateral. 
 
 Complete absence of the tongue has not been seen; such 
 absence has been merely partial, that is, there existed a stump 
 adherent to the floor of the mouth, and this may consist of two 
 or more parts. Loss of the greater part of the tongue has 
 arisen from accident; also, from the surgeon's knife. Such rudi- 
 mentary tongue, contrary to rational supposition, serves fairly 
 well as the instrument of speech; this ceases to be surprising 
 when an analysis is made of the mechanism of articulate speech: 
 since such examination discovers that, of the elementary sounds 
 which are formed by the vocal, organs, there are but four which 
 demand the action of the front portion of the tongue for their 
 formation, and these are d, t, ^/t,and /; it has been found that after 
 the removal of the tongue, all the other primary sounds may be 
 formed. In absence of the tongue, attempts have been made to 
 replace the organ; such an essay was made by Ambrose Pare, 
 though in a ruder way than has been done by the subsequent 
 instrument maker. Such artificial tongue has j^roved a failure. 
 
 The bifid tongue, which is a normal conformation in the 
 reptile, dromedary and certain birds, has occurred as a congen- 
 ital phenomenon in the human subject; the tongue is sometimes 
 given a bifid form in the removal of growths from the part. The 
 
010 T()N(;rK. 
 
 treatment of congenital bifid tongue consists in paring the 
 median edges and uniting by suture; inasmuch as many of the 
 cases of bifid tongue are in tlje infant in Aviiich many other 
 deformities coexist, the gravity of the latter is often such that the 
 lingual imperfections may be neglected: for tlie j)rudent surgeon 
 shoukl decline to become an ally of fatal teratology. 
 
 Lingual Prolaj^sus ivith Hypertrophy. — The tongue may be 
 enlarged beyond its typical proportions, and this may be coinci- 
 dent with birth, or appear subsequently. The abnormal devel- 
 opment concerns particularly the anterior free portion of the 
 tongue, and along with excessive volume, there is the disagreeable 
 accompaniment that the tongue is protruded from the mouth, 
 and in this position, l:)esides the repulsive appearance which it 
 gives to the infant, the tongue usualh' becomes painful through 
 ulceration. 
 
 Prolapsus of the tongue was mentioned by Galen, and occa- 
 sional mention of it occurs among inodern surgical writers; Del- 
 pech, Maisonneu ve, Clarke, Syme and Beauregard have described 
 it; nevertheless, the affection is a rare one; the writer has seen 
 but one case of it. It is seldom that it has been seen at birth; 
 still, the conditions are believed to exist then, which afterwards 
 lead to its development. As predisposing and causal conditions 
 are too great elevation of the larynx, abnormal length of the 
 tongue, pertussis, sucking the tongue, catching and compressing 
 it between the gums, and exaggerated suction of the nipple. 
 Symptoms which denote the development of lingual ])rolapsus 
 are, that the infant has its mouth constantly open, the saliva is 
 continually escaping, and the tongue is usually thick. 
 
 The writer had under observation, for a year, an infant which 
 was the subject of lingual prolapsus. At an early age, this infant 
 was in the habit of thrusting out its tongue and catching and 
 compressing it, at its middle portion, between the alveolar arches. 
 The result of such compression was gradual enlargement of tlie 
 tongue, and it was manifest that this development was promoted 
 by the turgid condition in which the tongue was maintained. 
 The child seemed to have pleasure in the act of thru.sting out and 
 compressing the tongue. The escape of saliva, which was con- 
 tinual, occurred because of the open mouth and the chewing 
 movements of the lower jaw. The autlior was convinced from 
 what he saw in this case, that the affection was the result of the 
 habit mentioned, into which the infant fell when a few weeks old ; 
 since at that early age, the infant's tongue was of normal volume 
 and was retained in its mouth. 
 
LINGUAL PROLAPSUS. Gil 
 
 The lingual prolapsus, commencing in the manner above 
 mentioned, advances until the enlarged part remains protruded 
 and the jaws cannot be closed. The exposed part of the tongue 
 has a violet color, and it is sometimes soft in consistence; at 
 others, it is indurated. The secretions of the mouth desiccate and 
 form crusts on the surface of the tongue. The deformed lingual 
 ]nass projecting from the mouth gives the subject's face a most 
 repulsive aspect. 
 
 The continual gaping of tlie mouth, and the dental alveoli 
 wanting the support of the labial structures, the teeth gradually 
 lose their position and incline towards a horizontal position. 
 The projected tongue also pulls on the pharyngeal arches and 
 displaces them, as well as the tonsils, forwards. The non-protruded 
 portion of the tongue remains nearly normal in volume. 
 
 The affection interferes wnth breathing, the taking of food, 
 and the cleansing of the mouth; hence emaciation and fetid 
 breath. 
 
 As may be inferred from what has j^receded, the primary 
 stage of prolapsus is soon followed by macroglossa or hypertrophy 
 of the tongue. The enlargement of the tongue is analogous 
 to elephantiasis; there is found a cavernous netw^ork of connect- 
 ive tissue filled with lymphoid fluid, and in this structure the 
 normal muscular fibres may be atrophied, normal or magnified 
 in form. And the subjacent lymphatic glands may be enlarged. 
 In 1853 reports appeared upon the pathology of hypertrophied 
 tongue; the opinion, hitherto held, that the enlargement depends 
 on enlargement of the muscular fibres was rejected by Virchow 
 and others, "who found only an augmented vascular development; 
 the arteries are much dilated, and the fibrous or connective 
 tissue is hypertrophied. Cystoid spaces are found, thought to be 
 connected with t\\e lymph-vessels. 
 
 Treatment. — The course to be pursued will depend on the stage 
 of the disease when the case first comes under observation. If 
 seen early, when tlie first signs of the affection are appearing in 
 the infant, then it is proper to make trial of means which may 
 prevent growth, and reduce that which has already occurred. 
 
 In the infant mentioned seen by the writer, the treatment 
 consisted in strewing the surface of the tongue with tannin, and 
 having forced the part into the mouth, it was retained so by 
 means of a properly applied bandage, and this was occasionally 
 aided by the nurse's hand. This child, which was a foundling, 
 finally passed out of sight. The observation made of this case 
 
G12 TONGUE. 
 
 was especially instructive, since it was evident that tbe prolapsus 
 and growth had origin in habit; for when the child was not 
 guarded, it thrust out its tongue and compressed it between the 
 jaws, and in the act it seemed to have extreme delight; such 
 satisfaction as accompanies every act which in the child has 
 grown into a habit, especially a forbidden habit. The treat- 
 ment pursued in this child produced but little effect. 
 
 Galen recommended the local use of the juice of lettuce, and 
 Louis claims to have cured a girl by this means. 
 
 Treatment by compression was employed by Le Blanc and 
 Van der Haar by means of a small linen sack or pocket into 
 which the tongue was thrust; eight cases were said thus to have 
 been cured. Fairlie Clarke, who has collected a series of cases 
 of this affection, reports cures by compression. Syme, in 1857, 
 is more favorable to compression than to operative means, and 
 only after the failure of compression Avould he operate. 
 
 Lingual prolapsus with hj'pertrophy has been treated opera- 
 tively in several ways, viz., b\'' ligature, galvano-cautery and 
 excision. 
 
 The ligature is advised by Maisonneuve, and others; it is, 
 however, extremely objectionable, since the ichor escaping from 
 the gangrenous jjortion may pass to the lungs, and cause gan- 
 grenous pneumonia. Besides, the removal by strangulation 
 leaves an irregular surface, and has sometimes been followed by 
 recurrence of the hypertrophy. 
 
 The method by thermal cautery is preferable to that by liga- 
 ture, since the remaining surface will be more regular in outline; 
 yet the cicatricial surface which will remain is not as good as 
 that which can be gotten by excision. 
 
 Excision has been practiced in three ways: in one the tongue 
 has been cut off transversely ; in a second method, a single cunei- 
 form exsection has been done; and in a third, a horizontal as 
 well as vertical wedge-form excision has been done. 
 
 The method of simply excising the prolapsing tongue by a 
 transverse cut is defective, since it leaves a broad, misshapen sur- 
 face of scar tissue uncovered by normal mucous membrane. 
 
 The plan by a single cuneiform excision is preferable to that 
 just mentioned, j'et is not equal to the third method, in which a 
 vertical and horizontal wedge-shaped section is removed: a plan 
 of operating introduced by Boyer. The result of Boyer's opera- 
 tion is to restore the tongue to normal volume, and to leave tlie 
 part which remains invested with its normal epithelial coating. 
 
AXKYLOGLOSSA. 613 
 
 To render the tongue accessible to the surgeon's knife in this 
 double excision, a strong thread should be passed through the 
 base of the tongue, posterior to the line of exsection, and tied so 
 as to form a loop, which an aid holding and making traction on, 
 the tongue can be drawn well out of the mouth. While the tongue 
 is thus held, the knife, with length sufficient to more than trav- 
 erse the breadth of the tongue, is inserted as far back as possible, 
 and by two incisions a wedge-shaped portion is horizontally 
 excised; then a vertical portion of like form is to be excised. In 
 this work enough must be removed to so reduce the tongue in 
 volume that it can be returned and retained in the mouth; and 
 to do this, it may be necessary to remove a large mass of structure. 
 In such an operation reported by AVutzer, he excised a mass of 
 structure which weighed over eight ounces. The hasmorrhage 
 which follows the excision has been reported as very considerable 
 in some cases, and was with difficulty controlled; to do so, AVutzer 
 was compelled to resort to circular circumscription, by which, a 
 portion of lingual structure was also included with the vessel 
 
 This double cuneiform excision has resulted well in nearly 
 all cases; Syme, however, lost a case, in which so much swelling 
 followed it that the patient died from asphyxia; against this 
 death, there are twenty-two recoveries reported. In some cases 
 the operation was not permanently successful; the hypertrophy 
 reappeared, and another operation became necessary. After such 
 recurrence, Humphry cured the patient by compression. 
 
 In 1853, Humphry wrote elaborately on macroglossa; he col- 
 lected twenty-seven cases in literature, of which seven were cured 
 by compression, seven by ligature and thirteen by excision. In 
 the early stages, Humphry recommends a trial of compression. 
 
 Ankyloglossa, or Tongue-tie. — The orator Cicero, in his work on 
 Divination, refers to tongue-tie when he asks: ''Where tongues 
 are so adherent that they cannot talk, may they not be liberated 
 by being cut with a scalpel?" 
 
 The tongue may be fastened to an adjacent wall on any of its 
 sides: thus it may be bound below, at its sides, or above. Lateral 
 and superior tongue-tie are phenomenally rare affections; sublin- 
 gual adhesion is a common occurrence, and often requires surgi- 
 cal aid. This subjacent fixation of the tongue is commonly due 
 to anterior extension of the normally present freenum. Ordina- 
 rily the frtenum is only about a line in its attachment; but if it be 
 much more than this, and especially if this band be short in its 
 vertical length, then the tongue will be hamj^ered in its move- 
 
014 ToxorE. 
 
 incuts. There is a popular notion that this restriction of the 
 tongue's movements will interi'ore with the child learning to talk; 
 such interference, however, is very slight. To discover the amount 
 of the suhlingual attachment, let the child's mouth he well opened, 
 Avlieu the end of the tongue can be uplifted with the finger, or the 
 handle of a spoon; commonly, the unusual manipulation frightens 
 the infant so that it screams, and, doing this, it fully exposes the 
 condition of the tongue. A little experience, however, will enable 
 the physician to determine the state of the tongue by merely insert- 
 ing two fingers under the tongue so as to include between them 
 the frcsnum. The treatment consists in dividing the extended 
 fraenum with a pair of blunt scissors; and this is most readily 
 done by "watching an opportunity when the part is well displayed 
 during the infant's crying; thus the author has frec^uently 
 divided the frpenum. The division is sometimes done by means 
 of a spatula with a fissure at one side, or a grooved dissector, which 
 has a furcated end. If such instrument be used, let the frajiium 
 be caught between its branches, and divided between the floor of 
 the mouth and the instrument. Instead of this plan, two fingers 
 may be used for uplifting and fixing the tongue. The bleeding 
 isslight, unless by careless work the floor of the mouth or the lower 
 surface of the tongue is wounded; and through such wounding, 
 haemorrhage can occur, which may demand control by compres- 
 sion, or applications of a styptic. 
 
 The child affected with congenital sy{)hilis, and being also the 
 subject of tongue-tie, should not be operated on. From unfortu- 
 nate experience in such a case, the writer desires to emphasize 
 this advice. In an infant several weeks old, in which there were 
 secondary lesions in the anal and genital region, the fnenum was 
 divided to liberate the tongue, which was bound down on the 
 floor of the mouth. A chancroid phagedenic ulceration was 
 developed, which extended to the adjacent mucous membrane of 
 the 'tongue and mouth, and this ulceration was only controlled 
 after months of anti-syphilitic treatment. 
 
 Instead of a thin fold of mucous membrane, the fr?enum may 
 be a thickened mass, in fact, a species of ranula, of solid instead 
 of cystic structure. Such a development seriously interferes with 
 the function of the tongue. The treatment practiced in such 
 cases has been to scarify or incise the enlarged structure. 
 
 The tongue may be adherent to the floor of the mouth by its 
 entire inferior surface; a condition which renders the organ- 
 unable to accomplish an}'- of its functions; and in the new-born. 
 
GLOSSITIS. 615 
 
 if unrelieved, it would cause death by starvation, since swallow- 
 ing of food would be nearly impossible; lastly, in the act of deglu- 
 tition the tongue could not recede and prevent the entrance of 
 food into the air passages. Such adherent tongue must be 
 detached from the floor of the mouth and reunion prevented by 
 frequent separation of the parts. 
 
 Lateral or gingival adherence of the tongue, m which the 
 part is attached to the surrounding maxillary wall, may arise 
 from noma, mercurial sloughing, or from destruction of the 
 mucous surface from any cause. It has been seen, though rarely, 
 in the new born. The treatment in such case would be to divide 
 the adherent parts, and maintain the liberation by sundering the 
 adhesions as often as they reformed, a task more easily advised 
 than accomplished in a case of extensive adhesion. 
 
 Lapie describes the rare condition of adherence of the tongue 
 to the palatal vault, in whicli the child was unable to nurse. 
 The treatment in such condition would be to separate the tongue 
 from the palatal roof by means of a spatula or blunt dissector, 
 and separation afterwards maintained by detaching points of 
 re-adherence. 
 
 Glossitis, or Inflammation of the Tongue. — The tongue may be 
 inflamed merely superficially, or the entire structure of the organ 
 may be affected. 
 
 Demme, who has made special study of the inflamed tongue, 
 gives the following classification of the superficial form: (1) Ca- 
 tarrhal, which may be caused by a local irritation, or by some 
 catarrhal affection of the alimentary canal; it is indicated by 
 hypersemia, thickening of the mucous membrane, and cell- 
 proliferation. (2) Exanthematous, an accompaniment of an 
 exanthema, and is papular or vesicular in nature. (3) Toxaemic 
 glossitis, which attends typhoid fever and pyaemia. (4) Croupal, 
 which is seen in croupous disease of the throat and air-passages. 
 (5) Dissecting glossitis, in which irregular ulcers appear on the 
 surface of the tongue. 
 
 Deep or profound glossitis is rarer than the forms just enu- 
 merated; there are two varieties of it, the phlegmonous and the 
 muscular; the phlegmonous commences in the sub-mucous and 
 inter-muscular tissue; but in the other variety, the muscular 
 fibres are the site of the disease. The deep form may end in 
 suppuration and death of tissue, or the event may be cell-growth 
 and the development of fibrous tissue. 
 
 Glossitis may be unilateral, or both sides may be affected; it 
 
616 TONGUE. 
 
 may also be diffused or circumscribed. It appears in acute or 
 chronic form. The epithelium may remain adherent, or it may 
 be detached, and in the latter case there is usually much pain. 
 
 If glossitis be studied in reference to its incipient symptoms, 
 four types of it may be distinguished: (1) It begins without any 
 general sym})tonis; (2) it may be preceded and accompanied by 
 rigor and fever; (3) it may be accompanied by affection of the 
 mucous coat of the stomach and bowels; (4) it may be attended 
 by concurrent pain in the jaws, teeth and throat. 
 
 In all cases of deep inflammation of the tongue, there are pain 
 and swelling, the swelling soon reaching a large volume; the 
 inflamed structure is red, tense and increased in heat, yet if the 
 tongue remains protruded, it becomes cool. If the tongue is com- 
 pressed within the mouth, its sensibility is lessened. In excep- 
 tional cases the tongue has been seen unusually white. 
 
 When pus forms, the tongue is altered in its form; it becomes 
 rounder, unless the pus is deep seated. Sometimes the pus 
 travels from the upper anterior part to the lower posterior part 
 of the tongue. The function of the tongue is impaired in its 
 office; the acts of chewing, talking and swallowing are tram- 
 meled. There is a feeling of tension and discomfort in the mas- 
 seter and temporal muscles, and in the joint of the lower jaw, 
 especially if one forcibly open the mouth. 
 
 From swelling, especially if this be in the back part of the 
 tongue, respiration may be so impeded that cyanosis results from 
 defective admission of air to the lungs. 
 
 From obstructed circulation, there may occur oedema in the 
 floor of the mouth, in the upper part of the neck, and in the 
 palate, throat and epiglottis. From the redema and swelling 
 cerebral congestion and apoplexy may result. 
 
 In the acute form there is high temperature, yet this is nearly 
 absent in the chronic form. 
 
 To epitomize the phenomena, then, of a case of glossitis of 
 the acute form vdiich is fully developed, the face is congested, 
 with oedema of the floor of the mouth, palate and throat; the 
 skin is cyanosed the expression of the face is that of extreme 
 anxiety; the tongue, as a swollen mass of violet hue, is protruded 
 from the mouth, and is dry; there is cerebral congestion and 
 mental stupor; the temperature is 104° or 105°; the pulse is 
 strong and rapid, the breathing difficult and anxious, and the 
 skin is hot and dry; speaking is trammeled, and there is little 
 saliva in the mouth; and signs of suppuration soon appear, 
 
GLOSSITIS. 617 
 
 unless a proper treatment early intervenes. The predominance 
 of the muscular structure in the tongue, almost to the exclusion 
 of other tissues, which elsewhere are so intimately associated 
 with the suppurative process, renders suppuration a rare event in 
 glossitis. 
 
 In 1856, Arnold saw a number of cases of glossitis in Wurtem- 
 berg, which seemed to arise from some epidemic influence, and, 
 in other districts, a similar epidemic influence prevailed. In those 
 cases the disease appeared to commence with a swollen point, 
 whence it extended and involved the entire tongue. The sub- 
 maxillary gland was involved in some of the patients, and sup- 
 puration occurred in the floor of the mouth. 
 
 The writer has observed two cases of glossitis of an extremely 
 malignant type. In one, the disease was preceded by erysipelas, 
 which traveled into the mouth, and attacked the tongue, which be- 
 came so swollen that breathing was interfered with; and the laryn- 
 geal and tracheal regions were so involved or swollen that the 
 patient perished through asphyxia. In a second case, the inflam- 
 mation involved the tongue, the floor of the mouth and the upper 
 anterior cervical region, and pus formed in these parts; though, 
 tracheotomy was done, death soon occurred from gangrenous 
 pneumonia. 
 
 Treatment. — From the observation of nineteen cases, Denime 
 claims that, nearly always, glossitis can be brought to a termina- 
 tion by resolution, that is, dispersion of the neoplastic elements; 
 and even where pus has formed, he claims that its absorption can 
 often be efiected. 
 
 In the early stage of the disease, the alimentary canal should 
 be emptied of its contents by saline cathartics, and astringent 
 washes should be used in the mouth; for this purpose a solution 
 of tannin, decoction of oak bark, or a solution of alum may be 
 used. Ice should be allowed to dissolve in the mouth, and thus 
 the oral cavity be maintained at a. low temperature. Ice may be 
 applied around the neck and throat. Should the disease still 
 persist, local bleeding should be resorted to; for this, leeches have 
 been used, yet a better plan is to scarify the surface of the tongue. 
 These incisions should be antero-posterior in direction, and 
 should penetrate so deeply as to cause free bleeding. As such 
 incisions quickly contract through lessening of the volume of 
 the tongue, it will be necessary to again repeat the incisions 
 after a few hours. A third remedy, of which the efiicacy has 
 been lauded by Demme, is the local use of the tincture of iodine. 
 This becomes more efficacious in the following combination : — 
 40 
 
618 TON'GUE. 
 
 li. Tr. lodinii Compos oi 
 
 Tr. Galhie 5i 
 
 Misce. 
 Let the tongue be painted with this every four hours. 
 
 In a case of glossitis which is developing rapidW, the disease 
 may be attacked simultaneously from several sides by the means 
 here detailed, viz.: by purging, cold, astringent gargles, scarifica- 
 tion, and tincture of galls and iodine; and by sucli vigorous man- 
 agement, the writer has seen the disease prom})tly controlled, and 
 within a short time the tongue was reduced to its normal vol- 
 ume. The incisions made soon heal and scarcel}'^ leave a scar. 
 
 Abscess of the Tongue. — A few cases of abscess within the body 
 of the tongue have been seen by the writer; and the pain which 
 had preceded the sui)puration was so slight that it scarcely 
 attracted tlje patient's attention. In the cases seen, tliere had 
 slowly appeard a swelling of the tongue, principally in the central 
 part of the organ, rendering this portion elevated and rotund in 
 form. The treatment, in such case, is to open the abscess by a 
 longitudinal incision, made as nearly as possible in the median 
 line of the tongue; such an incision wdll shun the blood-vessels, 
 or those which might be opened would not bleed much; for each 
 side of the tongue has its own system of circulation, and the 
 intercommunication between the two is only of a capillary char- 
 acter, except near the apex of the tongue. Through the opening 
 made, the purulent content can be forced out by digital compres- 
 sion made at the sides and beneatli the tongue; and since, in the 
 cases seen by the writer, the site of the pus was unilocular, such 
 compression, after reopening the cavity once or twice, sufficed to 
 cure the patients. 
 
 Ulceration of the Tongue. — The tongue may be the site of 
 ulceration; and viewed in reference to causation, the following 
 forms present themselves: mercurial, syphilitic, lupoid, scrofulous 
 or tubercular, aphthous and traumatic. 
 
 Since the era began of the more judicious administration of 
 mercury, dating from about the middle of the nineteenth cen- 
 tury, mercurial ulceration of the tongue is a rare event; the 
 aquila alba (calomel) of the old alchemists has been so domesti- 
 cated that its talons make fewer ravages in the oral cavity, than 
 was its wont in olden time; still, such cases are sometimes met 
 with, especially in the mercurial treatment of syphilis. This 
 condition is announced by a swollen, inflamed state of tlie alveo- 
 lar tissue, and redness of the borders of the tongue; soon the 
 
ULCERATION. 619 
 
 mucous membrane of these parts breaks down, and a raw surface 
 is left. Meantime, a peculiar fetor, termed mercurial or metallic, 
 proceeds from the affected parts; and there is a profuse flow of a 
 fluid consisting of saliva mingled with albuminous and epithe- 
 lial excreta. These phenomena, in a subject who is ushig mer- 
 cury in some form, are proofs that the remedy has exceeded its 
 intended action; in brief, that the patient is salivated. The 
 experienced eye will usually descry the coming ptyalism at a 
 period so early that it may be arrested before the aflected struc- 
 tures have suffered much injury: viz., the mercury must be 
 discontinued, the patient purged, a solution of borax be used for 
 cleansing and disinfecting the mouth, and a solution of alum, 
 viz., ten grains to the ounce, be applied to the gums, borders of 
 the tongue and the ulcerated portions of the cheeks. An excel- 
 lent gargle for the mouth is one composed of nine parts of water 
 to one of alcohol, or spirit of camphor. These detersive gargles 
 have done better service for the writer than the chlorinated 
 solutions which are often used ; for it has seemed probable that 
 the chlorine element in these compounds has increased the 
 activity of the causal factor, mercury. In case the borders of the 
 tongue and other affected surfaces are the site of ulceration which 
 is tardy in healing, then these parts should be lightly touched 
 with a finely pointed pencil of nitrate of silver; or a crystal of 
 alum may be used in the same manner. 
 
 Among the many secondary manifestations of syphilis, lin- 
 gual ulceration is of frequent occurrence; in its wandering vagaries 
 this destroyer does not omit the mucous membrane of the tongue; 
 the mucous patch, the characteristic ulcer, and the gummy 
 growth reveal a history which the tongue itself would fain deny. 
 The ulcer, here referred to, occurs on the margins of the tongue, 
 and most commonly on the middle portion of the sides. This 
 ulcer is superficial in its character; and as proof of its true nature, 
 there will coexist ulceration of a similar character in other parts 
 of the buccal cavity; also, an examination will reveal the exist- 
 ence of cutaneous syphilitic rashes. And this ubiquitous mani- 
 festation of mucous and dermal eruptions distinguishes clearly 
 this form of lingual ulcer from those of a diff'erent nature. 
 According to Paget's publication of 1858, the syphilitic ulcer is 
 more clearly bounded than the scrofulous, and is not preceded 
 by suppuration; it appears on the end or sides of the tongue; 
 and is in the form of oblique or star-like fissures ; or it has the 
 appearance of an erosion, of which the central part is the deepest. 
 
G20 TONGUE. 
 
 Further proof of its syphilitic nature is that it rapidly heals 
 under the u^se of iodide of potassium. 
 
 Treatment. — The lingual syphilitic ulcer can only be cured by 
 jjrolonged constitutional treatment: mercury and iodine, singly 
 or combined; and, cotemporaneously with this, some mild astrin- 
 gent, as a decoction of oak bark, may be applied, and this may 
 be alternated with a mineral astringent. During this course, the 
 patient, if he uses tobacco, must wholly drop its use: if he does 
 not do so, the tobacco will greatly retard the cure of the syphi- 
 litic eruptions in the oral cavity, of whatever form these may be. 
 
 Ulcer of the tongue of a lupoid nature is sometimes seen ; it 
 occurs oftenest on the edges of the tongue near the epiglottis 
 Lupus never appears on the tongue without already existing or 
 having previously existed on the face. It commences on the tongue 
 as small tubercles which soon break down and present a soft gran- 
 ulating base, which, healing, leaves star-like scars. The proper 
 treatment is energetic cauterization, which is best done by means 
 of the ferrum candens, or the thermal cautery. Along with this 
 topical treatment, the patient should be given cod liver oil and 
 Fowler's solution. 
 
 The tongue is not unfrequently the site of tubercular disease. 
 Weber, who saw and studied the tubercular ulcer of the tongue, 
 found that it occurs on the border of the latter, and is bounded 
 by irritable, irregular edges; and from the bottom of the ulcer, 
 granular, caseous, tubercle-like matter can be expressed. Cotem- 
 poraneous witli the lingual trouble, tubercular affection of the 
 lymphatic glands, ajjices of the lungs, epididymis or rectum may 
 exist. In cases of tubercular lingual ulceration, the writer has 
 seen similar affection in the anal and rectal region. In one 
 patient, besides the anal ulcers, the peri-rectal structures were 
 cribriform with fistulse. 
 
 The tubercular ulceration of tlie tongue has sometimes been 
 mistaken for cancer; and to avoid such error, experience and 
 discriminating judgment are requisite. The antecedent or cotem- 
 poraneous existence of tubercular disease elsewhere, will give 
 proof of the true nature of the disease. 
 
 Trelat, in 1870; described what he named phthisical ulcer of 
 the tongue as a forerunner of pulmonary tuberculosis. He finds 
 this disease of the tongue to begin from tubercle-like bodies in 
 the surface of the organ; from these develop ulcers with red 
 surface and ragged edges ; before opening, however, these tubercu- 
 lar eminences have a whitish aspect. Such eminences may be 
 
ULCERATION. 621 
 
 agminated or isolated. In the subject of such tubercular emi- 
 nences or ulcers, other manifestations of tuberculosis may often 
 be found. 
 
 Treatment. — Such ulcer will heal under the mildest treatment, 
 provided the nutrition of the patient be uplifted; along with a 
 rich, generous diet, the only local treatment needed is to maintain 
 cleanliness of the mouth by frequent abstersion with an aromatic 
 water, as mint, or cinnamon water, or chamomile tea; and if a 
 local remedy be used, let this be a weak solution of the sulphate 
 or chloride of zinc. As a gargle which wilL disinfect and facili- 
 tate healing, one composed of five grains of borax to an ounce of 
 water, may be used. By such management, tongues have been 
 saved to their owners which had been condemned to excision. 
 
 An aphthous ulceration of the tongue is not unfrequently 
 seen; this consists of a slightly hollow breach of surface, which 
 is coated with a thin layer of whitish gelatinous material, which 
 is closely adherent to the subjacent surface. This diphtheroid 
 structure requires a raw or wounded surface as a ground on which 
 it takes root; and it is doubtless associated with some- microphyte 
 as cause or a"lly. 
 
 The treatment of this form of lingual ulcer consists in fre- 
 quent washing of the mouth with some antiseptic fluid; for this 
 purpose one may use aqua picis lic|uid8e, a decoction of the leaves 
 of Eucalyptus globulus, or the bark of the wdiite oak.. And 
 should there be seen collateral gastric or intestinal derangement, 
 this also must have appropriate attention. 
 
 Traumatic ulcer may arise from any agency which causes a 
 breach of surface;, though there are many causes which fall 
 under this head,, the one of most usual occurrence is an irregular 
 face or edge of a sound or decayed tooth. Such cause, though 
 unsuspected by the patient, is often revealed by a careful ex- 
 ploration of the posterior teeth of the lower jaw. Such ulcer 
 has irregular outline, uneven surface, is often coated with an 
 aphthous formation, is extremely painful; and this pain is 
 maintained by the frequent movements of the tongue. As treat- 
 ment for this, the buccal cavity should be frequently cleansed 
 by an antiseptic solution selected from the list above given. And 
 to the ulcer itself let nitrate of silver be applied, sparingly, by a 
 rapid touch. 
 
 The various forms of lingual ulcer enumerated are accom- 
 panied by pain, which is continually awakened and intensified 
 by the movements of the tongue; and the normal action of the 
 
622 _ ToxfiuE. 
 
 tongue in taking food is so painful that the patient abstains from 
 food. To lessen this difiiculty, the food used should be fluid, or 
 so liquified that it can be swallowed without any preliminary 
 preparation in the mouth. An excellent diet for such patients 
 may consist of rice, milk, eggs and broth; ancl with this some 
 wine may be taken; and alter using food, the buccal cavity, and 
 teeth should be carefully cleansed; an act, indeed, which should 
 be done in every healthy mouth after the reception of food; for 
 thus doing the mouth would be purified, breath deodorized, teeth 
 preserved, and life probably prolonged. 
 
 The several formsof ulcers which have been treated of, though 
 they occur oftener in tlie tongue, yet they frequently are seen in 
 other parts of the wall of the buccal cavity; and, in these differ- 
 ent sites, such ulceration demands the same treatment as that 
 before explained for similar ulcer on the tongue. 
 
 Grouths of the Tongue. — Besides the aberration from normal 
 form and disease of tlie parenchyma of the tongue already 
 described, the organ is the occasional site of neoplastic growths, 
 both benign and malignant. The benign class contains the fol- 
 lowing species: vascular, cystic, lipomatous, fibromatous and 
 papillomatous. 
 
 The vascular species consist of two varieties, similar to those 
 found elsewhere: tlie superficial form, or telangiectasis, and that 
 which involves the deeper structure, or tlie entire thickness of 
 the tongue. 
 
 ■» Telangiectasis of the tongue is usually congenital and is often 
 so slight that it may remain unseen. It may be associated with 
 the deeper species, and then the whole thielvness of the tongue 
 can be implicated. Pure telangiectasis tends to lateral ratlier 
 than to deeper growth. Expiratory efforts tend to swell it and 
 increase its red color; compression or cold renders the surface 
 pale, and if it be .pricked, it bleeds easily, and perhaps profusely. 
 It may remain stationary for a long time and then suddenly 
 grow to much larger dimensions. ]Maisonneuve, who names this 
 form of vascular growth erectile arterial tumor, has observed 
 that it tends to cancerous degeneration. 
 
 The deeper form of vascular tumor, named by Maisonneuve 
 the erectile venous tumor, is sometimes congenital. In structure 
 it resembles the cavernous body of the penis. Compression easily 
 effaces it tem[)orarily, and the blood returns more tardily than 
 when the growth is arterial in structure. The writer has seen 
 two examples; in one the growth was at the border of the tongue; 
 
GROWTHS OF THE TONGUE. 623 
 
 iu the other it was situated in the median part of the dorsum of 
 tlie tongue. 
 
 It is seldom, that the vascular growtli of the tongue, whether 
 it be of the superficial or deep form, is a source of much incon- 
 venience; iu many cases it has existed without the subject of it 
 suspecting its existence; and where it is thus free from trouble, 
 the guiding rule must be abstention from surgical interference, 
 especially since the growth may spontaneously disappear, as was 
 observed by the accoucheur Dubois; and only in cases in which 
 it is annoying through its large size, or where from exposure of 
 the tongue to lesion, the subject is in danger of haemorrhage, 
 should relief be sought by some operative procedure. 
 
 Treatment. — As modes of treatment which have been employed 
 are cauterization, ligation, ecrasement and excision. Cauteriza- 
 tion may be done with the hot iron or heated portion of the 
 thermal cautery; the latter is the more convenient, since its action 
 can be more exactly gauged. Since extensive cauterization may 
 produce sloughs which might be followed by bleeding when they 
 are detached, hence the safer plan is to burn superficially and to 
 repeat the work as soon as the burnt surface has fallen off. 
 
 If the growth be of the erectile or cavernous type, cauteriza- 
 tion may be done interstitially, as Lallemand did in a case with 
 successful result; this is done by needles, which, being heated to 
 red heat, are thrust into the tumor at different points. 
 
 The tumor may be circumscribed by constricting ligature, 
 which introduced by means of a transfixing needle, is tightly 
 tied. This plan, though effectual in result, has the inconvenience 
 that from the gangrenous tissue, ichorous material continually 
 escapes and is swallowed, to the detriment of general nutrition. 
 Frequent ablution of the buccal cavity will, however, partially 
 counteract the ill results from such sloughing. 
 
 If the vascular structure is so situated that it can be isolated 
 by circumscriptive constriction, the linear ecraseur may be passed 
 around it and the removal be effected without peril of bleeding. 
 
 And a fourth method is excision of the affected part by means 
 of the thermal cautery, knife or scissors ; the method by scissors 
 the writer has employed in a case in which a venous vascular 
 growth was situated on the border of the tongue; after excising a 
 cuneiform section the breach was closed by a deep suture, which 
 remained in place for a number of days. 
 
 Should the vascular growth occupy one-half of the tongue, 
 the proper procedure would be ligation of the corresponding 
 
624 TONGUi:. 
 
 lingual artery; and if the vasculai' development occupy, on a lar^e 
 scale, both sides of the tongue, then the only procedure promis- 
 ing a successful result would be to tie both lingual arteries. 
 
 The tongue may be the site of aneurism, of the circumscribed 
 or diffused form. The strong pulsation perceptible in such 
 tumor, its compressibility and partial effacement by pressure, 
 and rebound when committed to itself; especially, if there be a 
 history of some injury of the tongue, would clearly indicate the 
 true nature of the affection. The pliant and yielding character 
 of the lingual tissues, conjoined to the mobility of the tongue, 
 favors the continued enlargement of such aneurismal tumor; and 
 hence the growth soon interferes with the function of the tongue. 
 The treatment which has been proposed is direct compression; 
 also, arterial ligation; compression of the tongue is, at best, an 
 ill-manageable procedure, and hence the better treatment would 
 be ligation of one or both of the lingual arteries. 
 
 Cystic Growths. — Four varieties of cysts have been observed on 
 the tongue: the serous, mucous, hydatid, dermoid and athero- 
 matous. 
 
 The serous cyst appears in all portions of the tongue; yet it 
 occurs oftenest in the base and the inferior face of the organ. It 
 would appear to commence from preexisting follicles, whih 
 closing, their content continues to be formed. This fluid ii 
 clear and water-like. AVhen the interior wall of such cyst is 
 examined, it will be found to be invested with an epithelium, 
 whence is excreted the serous content. This cyst appears as a 
 prominence uplifting the mucous ^membrane; and it rarely 
 becomes so large as to annoy the subject of it. When it occurs 
 underneath the tonsfue of the infant, it maA' interfere with seizino- 
 the nurse's nipple. 
 
 The mucous cyst originates in the glands with which the 
 tongue is jjrovided ; its walls are thicker than those of the serop.s 
 species, and its content is also thicker; it may resemble liquified 
 gelatine. 
 
 The serous and mucous cysts have a resemblance to x.m- 
 ranula; the former belong especially to the tongue, while ihe 
 ranula has sublingual site in the floor of the mouth. 
 
 The tongue, as an exceptional event, has been the site of a 
 hydatid cyst; the echiuococcus has been seen here; such cyst is 
 distinguishable from the serous species only through puncture 
 and examination of the content, in wliich the booklets of the 
 parasite will be discovered. 
 
CYSTIC GROWTHS. 625 
 
 The treatment of these several species of cystic tumor is much 
 the same: the entire wall should be uplifted with a tenaculum, 
 or toothed forceps, and excised so as to fully empty the contents; 
 and then the remaining cavity should be cauterized with nitrate 
 of silver; or what is j^et more effective, the work may be done 
 with the thermal cautery; thus the remainder of the wall will 
 be destroyed, and any secreting property it may possess, can be 
 destroyed. 
 
 The dermoid cyst, situated wholh" within the etructure of the 
 tongue, has rarely been seen; but such cyst has been met with 
 under the front of the tongue; thus Ozenne, in 1858, saw and 
 operated on a dermoid cyst, situated here, and which contained 
 hair and dermal cells. He collected twenty similar cases. The 
 operation should consist in opening freely the containing wall, 
 evacuating the dermoid content, and then, to hasten healing, the 
 wall of the cyst should be carefully dissected out. The athero- 
 matous cyst may have its site in the sublingual region, and in its 
 development, encroach on, and become buried in, the structure of 
 the tongue. The author has seen and successfully removed such 
 a cyst, which was as large as a hen's egg, and forced the tongue 
 upwards and backwards. After removal, drainage was made 
 through the floor of the mouth. 
 
 Lipoma has been observed in the tongue. In 1803, Mason of 
 London saw a case; also Maisonneuve saw and dissected such a 
 tumor; he states that its most usual site is in the posterior and 
 inferior part of the tongue; a situation that might be inferred 
 from the presence of fatty matter in this portion of the tongue. 
 This lipomatoiis growth may be pedunculated, sessile, or inter- 
 stitial in site. Cauchois, who saw a case in 1883, finds that its 
 site may be submucous, or inter-muscular. This fatty tumor is 
 soft, and it may yield a fluctuation similar to that of a cyst of 
 fluid content. It may attain considerable dimensions, and may 
 ulcerate at points, so as to embarrass the diagnosis. It has no 
 action on the lym]Dhatic vessels which are contiguous. 
 
 The lingual lipoma will never disappear spontaneously; the 
 proper treatment is extirpation ; this is readily done where the 
 growth is pedunculated; but if it be sessile, or inter-muscular, 
 then an opening must be made to it from the side at which it is 
 most accessible ; and such incision should be longitudinal, and 
 should be as near the median line as possible; thus vessels are 
 less exposed to injur}^ If the incision be deep, then it is well to 
 close with suture. Laugier in 1855 reported the removal of a 
 
G2G TONGUE. 
 
 lipoma from the tono-ue, wliicli was done b}'- making an incision 
 through the structures in which it was encapsulated, and then 
 simply enucleating the growth. There was no bleeding demand- 
 ing ligature. Laugier remarks that lipomatous growths are not 
 unusual in submucous tissue; and he thinks they are similar to 
 polypi in their origin. 
 
 Fibroma of tJte Tongue. — Growths consisting of connective or 
 fibrous tissue have been seen in the tongue; and they occur there 
 oftener than the lipoma. They seem to occur oftenest in the 
 border of the tongue, though Erichsen saw one on the inferior face 
 of the organ. As to relation with the tongue, they have been seen 
 pedunculated, sessile, or situated within the lingual structure. 
 Fairlie Clarke, of Ciiaring Cross Hospital, mentions such fibroma 
 as polypoid in character, and so situated as to embarrass or 
 obstruct swallowing. It is oftener single than multiple in its 
 appearance. The fibroma might be confounded with the lipoma ; 
 but since the treatment of the two is similar, such error in diag- 
 nosis would have no ill consequence ; a more unfortunate mis- 
 take, however, would be to excise a gummatous product under 
 the suspicion that it were a fibroma. Should there be a suspicion 
 that the growth is syphilitic, the true nature might be determined 
 by subjecting the patient to an iodo-mercurial treatment.' As the 
 fibroma continues to grow without limit, it filially reaches dimen- 
 sions which disturb the patient, so that surgical relief is solicited ; 
 and for this, extirpation is the only satisfactory procedure. If 
 pedicled, it may be removed after ligation of the footstalk ; if 
 sessile or interstitial, remove the growth by a circumscribing 
 cut, and close the wound by suture. 
 
 Malignant Growths of the Tongue. — If the literature of the lin- 
 gual neoplasm be studied, one finds that the chapter devoted 
 to the malignant genus has been gradually undergoing change; 
 formerly one found that writers recognized the existence here of 
 four species, scirrhous, encephaloid, melanotic and cancroid or epi- 
 theliomatous; to-day the generic tree, by most writers, is stripped 
 of three of its branches, and there remains but epithelioma as the 
 only type of malignant growth appearing in the tongue. Though 
 a few authorities contend that both epithelioma and carcinoma 
 may appear in the tongue, yet Paget, Hutchinson, Thiersch, Bill- 
 roth and Otto Weber find epithelioma to be the only form of 
 malignant tumor which attacks the tongue. And these authori- 
 ties claim that the only cases which they have met in which 
 carcinoma was present there, were those in which the disease 
 
MALIGNANT GROWTHS OF THE TONGUE. G27 
 
 had reached the tongue secondarily, after having commenced 
 primarily in contiguous structures. 
 
 As is taught by pathologists, the constituent element of the 
 epithelioma is the epithelial element, disposed in horizontal or 
 concentric layers superposed on each other. And such cells, 
 even in stratified arrangement, are sometimes found deep beneath 
 the surface, so deep, indeed, that Weber claims that they have 
 arisen from connective tissue elements; and the same is admitted, 
 though unwillingly, by Thiersch, whose theory only allows of the 
 origin of epitheliomatous cells from preexistent epithelial cells. 
 
 Epithelial cancer, according to its site or its situation in respect 
 to the surface of the tongue, may be grouped in two classes, viz., 
 excrescent and internal, and each of these may arise from a 
 papilla, wart, nsevus or a limited abrasion, which may be a 
 crack, fissure or a plain erosion. And these initial points of com- 
 mencement, if examined early, have no characteristics of epi- 
 thelioma. 
 
 If the unaffected lingual papilla be examined histologically, 
 the cells, which invest it, have an arrangement similar to that 
 possessed by all other normal papillse of the tongue; but when 
 the epitheliomatous change occurs, the papillae become radically 
 altered in their form; in fact, the papilla3 become crowded out of 
 existence by the invading strata or lines of multijDlying epithelial 
 cells. 
 
 In the excrescent papillary species the growth is outwards 
 rather than inwards; tuberculated, crested or wart-like promi- 
 nences, isolated or fused into an uplifted plateau, stand on a 
 hardened base. 
 
 In the internal form, besides growth outwards, there is 
 especially a development inwards of epithelioid cells, which 
 penetrate inwards between the muscular fibers, and along the 
 tissue which incloses the vessels and nerves. The invading new- 
 formed elements crowd on and destroy the muscular tissue, and 
 the walls of the lympliatics and of the blood-vessels. The cells 
 in this deeper situation are more prominent than those which 
 develop on the surface; the latter, from their remoteness from 
 nutrient supply, and especially from their exposed situation, are 
 being constantly detached, so that the uplifted structure presents 
 a raw surface, and this eccentric or superficial growth, in sessile 
 or in pedunculated site, rises often into crests resembling the 
 cock's comb, and is usually situated on the dorsal or anterior 
 face of the tongue, and less often near the epiglottis. It may also 
 
G28 TONGUE. 
 
 have a mulberry shape, of red tint, and bleeding when touched. 
 The lingual epithelioma of superficial site, occasionally attains 
 inunense proportions, too great to be retained in the buccal 
 cavity. 
 
 The penetrating species commences, according to the author's 
 observation, most usually on the side of the base of the tongue 
 near one of the ends of the V which tlie calyciform glands form 
 there; or, more definitely located, it begins in the sulcus between 
 tlie base of the tongue and the palato-glossus muscle, and extends 
 thence upwards on the base of the tongue, as well as laterally, on 
 the wall of the pharynx. This small ulcer always rests on a hard 
 base; it is bounded by irregularly notched or jagged edges, which 
 from being undermined, sink and are infolded. If this ulcerated 
 structure be compressed between the fingers, whitich or grayish 
 vermiform bodies are forced out, which, examined microscopicalh'. 
 are seen to be a conglomerate of epithelial cells. 
 
 The ulcerating process is unilateral and rarely crosses the 
 fibrous median septum of the tongue, and when situated posteri- 
 orly, in its lateral extension it finally attacks the alveolar process 
 of the lower jaw. Instead of this posterior site, it may appear on 
 the free border of the tongue anteriorly, and at or near the tip of 
 the organ. In two cases, the writer saw the epithelioma on the 
 free border, midway between the base and the tip of the tongue, 
 and in a third, the disease occupied the anterior border of the 
 tongue and extended backwards equally on each side, for the 
 distance of a half inch from the median line. 
 
 In both the deep and excrescent forms, the ulcerative process 
 finally reaches and opens blood-vessels, and thus haemorrhage, 
 slight or profuse, recurs and weakens the patient. The taking of 
 food into the mouth and its mastication are the source of so much 
 j)ain tliat the patient voluntarily abstains from food, and from 
 this cause he emaciates and loses strength. The decaying, ichor- 
 ous, fetid materials, Avhich are generated and detached from the 
 ulcerating surface, are partly swallowed, or they pass through the 
 windpipe to the lungs; in the former case, the material being 
 ab.sorbed vitiates the blood; in the lungs such materials are both 
 absorbed into the circulation, and act locally on the pulmonary 
 structure, causing an adynamic pneumonia. 
 
 The morbid agencies just enumerated, after some months, are 
 reenforced by the appearance of the disease in the lymphatic 
 glands, and this metastatic development corresponds, as a rule, 
 to the affected side of the tongue; only exceptionally does the 
 
MALIGNANT GROWTHS OF THE TONGUE. G29 
 
 metastasis appear on the opposite side. The gland or glands 
 which are infected, though swollen, are, for some time, very 
 movable; later, they become adherent to the adjacent tissues and, 
 finally, to the overlying skin, so that the whole is a conglomerated 
 mass of heterogeneous structures, in which glands, muscles, 
 vessels and nerves are almost indistinguishably fused together. 
 The glands initially infected are those which lie internal to the 
 angle of the lower jaw, and just behind or below the submaxillary 
 salivary gland. This fused conglomerated structure later becomes 
 very closely adherent to the skin, which is thickened and often 
 presents one or more folds with depressions. 
 
 There is but little pain in this morbid mass of secondary 
 infection. The swollen glands are painless, and this condition 
 diverts both patient's and physician's attention from these glands 
 until their presence is plainly declared by visible swelling. But 
 as the treatment and prognosis of lingual epithelioma are inti- 
 mately connected with the condition of these glands, the latter 
 should be carefully examined : an examination which demands 
 skilled tact and care in the early stage of the disease; the one 
 finger on the outside and one on inside of the lower jaw, should 
 include and explore the structures of the floor of the mouth, and 
 especiall}^ should the region around the submaxillary gland be 
 examined; thus an indurated gland can be discovered if present; 
 and should there' be doubt, the normal condition of the opposite 
 side will serve for corrective decision. 
 
 The mass of agglutinated tissues continuing to enlarge, 
 finally the central portion commences to soften, and at length 
 the skin is opened, and an ichorous fluid containing cheesy frag- 
 ments is discharged. This oj^ening is a small orifice at first, yet 
 it continues to enlarge until it becomes a free crater-like outlet, 
 which ever enlarges without any sign of healing. Should this 
 mass be removed before it opens, there will be found in it a cen- 
 tral cavity containing softened material; the outlines of the cavity 
 are irregularly notched and jagged, and of dark, livid color. 
 But when such cavity is allowed to open, though it discharges 
 freely the breaking-down material, yet this has no limiting effect 
 on the progress of the disease; the conglomerated mass contin- 
 ually incorporates into itself other tissues which are adjacent to 
 it: from the original side invaded, it j^asses to the other, and the 
 front upper portion of the neck is finally involved; and in this 
 enlarged field other openings may form. 
 
 Another form of metastatic invasion of the structures of the 
 
G30 TONGUE. 
 
 floor of the mouth and the upper part of the neck lias been seen, 
 in which there is little or no disposition to suppuration; there is 
 swelling and rapid infiltration of the parts mentioned ; the skin 
 remains white, and the affection has no definite borders. It is 
 accompanied by an oedema at the base of the tongue and entrance 
 of the larynx; and the cedematous swelling may quickly cause 
 death by occluding the glottis. The case here is allied to the 
 purulent (edema described by Pirogoff, since, after death, if the 
 aff'ccted tissues be 0[>ened with the knife, there escapes a sero- 
 purulent fluid, with which the swollen structures are saturated. 
 
 The course and duration of lingual cancer, if the disease be 
 allowed to run its natural course, will, according to Demarquay, 
 be completed within fourteen months, and this brief period may 
 yet be abbreviated, he says, if the disease be unwisely attacked; 
 for nearly all authorities report recurrence after operation. One 
 writer, however, Otto Just, presents figures much more favorable ; 
 he saj'S that recurrence only takes place in twenty-five per cent 
 of tlie cases. The author fully shares the opinion of Just, and 
 further believes that even more than seventy-five per cent of 
 patients could be saved if the disease were seen and treated in 
 its jn-imary stage by intelligent surgery. 
 
 Meddlesome ignorance too often monopolizes the precious 
 weeks, when proper treatment might rescue the patient from 
 death. Intelligent management can prolong life, though the 
 disease is not cured; for after operation the average duration of 
 life has been two years. The absence of glandular metastatic 
 infection adds much to the prospect of non-recurrence; in fact, 
 this may be regarded as almost a guaranty against return; 
 
 • In case of relapse, the epithelioma commonly reappears at or 
 near its primary site, or it may appear in the subjacent glands. 
 It has been observed that when the disease recurs, it grows at a 
 far more rapid rate than it did prior to the operation. 
 
 The causation of epithelial cancer of the tongue is unknown; 
 it is evident, however, that certain agencies do promote its evolu- 
 tion; as such may be cited calcareous incrustations on the inner 
 face of the teeth; sharp points or edges of the teeth, which may 
 continually wound the border of the tongue; and the habit of 
 thrusting the tongue into an interstice between teeth, or into the 
 hollow of a decayed tooth. The use of tobacco probably is a 
 causal agency, and this explains the far greater frequency of the 
 disease in the male than in the female, who seldom uses tobacco. 
 The fact that the man is less attentive to the cleanliness of his 
 
MALIGNANT GROWTHS OF THE TONGUE. 631 
 
 mouth than woman predisposes the former to epitheliomatous 
 affection, of ]iot only the tongue, but of the entire walls of 
 the buccal cavity. 
 
 Age has an important bearing in tlie development of epithe- 
 lioma of the tongue; the disease seldom appears under forty 
 years of age; it occurs oftenest between forty and seventy years 
 of age, yet there may be exceptions to this, since Billroth saw the 
 disease in a youth of eigliteen years of age. 
 
 Diagnosis. — The diagnosis of lingual epithelioma is of the 
 utmost importance, so that no error in treatment may be made; 
 and one unfortunate error, which has sometimes been made, is 
 that- of confounding syphilitic affection with cancerous disease of 
 the tongue. To avoid such misapprehension, the surgeon should 
 have a definite picture in his mind of the manner in which 
 sj'philis affects the tongue. 
 
 Syphilis may appear as the primary chancre on the tongue, 
 and then the appearances are similar to those of the disease 
 when it is primarily seated on the mucous membrane of the lips; 
 and to test the matter, if the chancrous lingual ulcer be cauter- 
 ized and treated with a mild astringent, the ulcer will heal; but 
 if it be cancerous, such mild local treatment will fail to heal the 
 lesion. A primary syphilitic sore may heal spontaneously; the 
 epithelial ulcer grows larger instead of less. 
 
 The secondary manifestations of S3q3hilis in the tongue, ac- 
 cording to one of the most competent authorities, Fournier, ma}'- 
 present themselves in one of the following forms: (1) Ulcerating 
 syphilide, or eruption; (2) non-ulcerating, gummy eruption; 
 (3) gummy growth within the tongue. 1. The ulcerating erup- 
 tions are small lenticular ulcers, wiiich are round when seated 
 on the dorsal surface, but when on the sides they are more 
 irregular in shape. They appear solitary, or in groups of 
 crescentic form; they are indurated and chronic in duration, and 
 when they are touched, or the tongue is moved, they are painful. 
 
 2. Non-ulcerating syphilitic eruptions of the tongue, named 
 also lingual sclerosis or plastic glossitis, present themselves in the 
 form of round and irregularly shaped nodules, which are situated 
 in, and rise somewhat above, the surface of the tongue. The 
 overlying mucous membrane is redder and smoother than tlje 
 normal coating, and it appears thickened and as if the pajnllas 
 had been removed from it. The entire surface of the tongue 
 may be the site of such syphilides, and then the teeth make 
 impressions on the sides of the tongue. 
 
(ju2 TOXULE. 
 
 3. Xoniuil gumma (better gummi) may develop in the mu- 
 cous membrane of the tongue or in the muscular tissue of the 
 organ. Gumma lies in or near the dorsum of the tongue, and 
 should it commence deeper, it grows towards the dorsal surface. 
 
 There are usually from one to four gummatous tumors in 
 the tongue; and they may be small, or so large as to protrude 
 the tongue from the mouth. It is diminutive when in the 
 mucous membrane; but when in the muscular tissue, it may 
 attain the dimensions of a walnut. Such gummatous growth 
 may ulcerate, and present a hollow cavity filled with gangrenous 
 structure; and this may remain open for years. The lingual 
 gumma is painless unless it opens; but when it opens, speaking, 
 chewing, swallowing and other acts in which the tongue is con- 
 cerned, are interfered with and cause pain. The saliva is 
 increased in quantity, and the breath becomes fetid. Taste is 
 unimpaired, and the glands rarely swell. This is Fournier's 
 description of the syphilitic eruptions of the tongue, which he 
 says may be confounded with lingual cancer; the latter, however, 
 appears in the old, while syphilitic eruptions appear oftener in 
 the 3'Oung and robust subject; cancer may be inherited, which 
 is rarely the case with lingual syphilitic manifestations. Cancer 
 retains its characteristics, though it becomes ulcerated on its sur- 
 face; and its base has a better defined induration than is the 
 case with the ulcerated gummy tumor. Cancer appears on one 
 side, while syphilis is bilateral in its development. Lingual 
 cancer is more spongy than the syphilitic growth; the former is 
 inclined to bleed, while the gummy growth is not. Cancer has 
 less steep edges than a gummy ulcer; the former granulates less, 
 and is not so covered with gangrenous tissue, and it has a more 
 fetid odor than the gummy ulcer. In the advanced period 
 of lingual cancer, the adjacent glands become implicated; this is 
 rarely the case in gummy ulcer. And the author will add that it 
 is rare that secondary syphilis has so isolated a location as the 
 tongue; if found there, it should manifest itself elsewhere. 
 
 Langenbeck in 1881 gave the following differentiating marks 
 between syphilitic gumma and lingual cancer. Gumma pre- 
 sents one or more rounded flattened tumors, on which the 
 mucous membrane appears smooth and shining; and the remain- 
 ing mucous membrane presents a warty, fissured aspect. Gumma 
 appears in the muscular structure of the tongue, and never in 
 the submucous tissue of the floor of the mouth. Multiple tumors 
 indicate syphilitic disease. Cancerous disease is more painful. 
 
MALIGNANT GROWTHS OF THE TONGUE. 633 
 
 iiiid it bleeds easily, ami soon passes to the floor of the mouth, 
 where gumma does not appear. Laiigenbeck observed cases 
 in which neglected s^-philitic disease of the tongue became 
 cancerous. 
 
 Demarcjuay observes that gummy tumor of the tongue is, at 
 first, round and hard, and, later, it softens at the center: condi- 
 tions not found in cancerous disease. 
 
 Boyer states that cancer attacks by preference the sides and 
 point of the tongue, while syphilis appears oftenest in the median 
 part and on the base of the tongue. 
 
 Treatment. — Epithelial cancer is, in its commencement, a 
 purely local disease; and in this stage, it is curable by appropri- 
 ate treatment ; but if the disease be allowed to progress and attack 
 the greater portion of the organ, and especially if the glands 
 beneath the floor of the mouth have become infected, then treat- 
 ment will aim rather at palliation than eradication of the dis- 
 ease. Where the disease already occupies all, or the greater part 
 of the tongue, non-interference should be the guiding rule ; in 
 such state, by an attempt to remove the disease, the surgeon's hand 
 would only stir the fire and widen the area of tiie flames. But 
 in all cases in which tlie disease is circumscribed to a portion of 
 the tongue that can be so operated on that the track of extirpa- 
 tion will be wholly within the sound tissues, then an operation 
 may be resorted to with a strong probability of curing the 
 patient. 
 
 To reach the tongue which is to be operated on, if one exam- 
 ines and compares the methods of work which have been done, 
 he finds that three routes have been used: through the floor of 
 the mouth, through the mouth itself, and, thirdly, through, the 
 lower part of the cheek. Xumerous methods have been proposed 
 and pursued in the work of extirpation; though multifarious, 
 these may be comprised in the following classes: cauterization, 
 potential and actual; ligation, moderate or gradual: excision by 
 the knife, scissors ecraseur or thermal cautery. One or more of 
 these methods finds illustration in the work which has been 
 done by eminent surgeons, whose procedures in somewhat 
 chronological order here follow: — 
 
 In 1842 Regnoli, to remove the tongue, made an incision 
 from the os hyoides to the symphysis of the chin ; and then a 
 second incision along the inner border of the inferior maxillary 
 arch; then through the two-flapped opening thus made, the 
 tongue was drawn down, and excised. In this way he removed 
 41 
 
634 ToxurE. 
 
 tlie tongue of a girl, who recoverecl so well from the operation 
 that she spoke clearly and (.listinctly. 
 
 In ISoO Nelaton found that division of the lower jaw through 
 the symphysis was an important aid in th'e operation of excising 
 the tongue; the jaw was divided by means of a chain-saw, and, 
 after the removal of the tongue, he reunited the halves of the jaw 
 by means of a ligature, which included the front teeth on each 
 side; the incisors and canine teeth were tied. Se'dillot, in a com- 
 parison of Nelaton's plan with that of Kegnoli, prefers the former, 
 since it renders more of the tongue accessible to the operator; he 
 thinks, however, that mere fixation of the sides by dental ligation 
 is an imi)erfect plan; and to more surely fix the parts, he would 
 so saw the sides that one would have a solid angle which might 
 be received in a hollow angle of the other end. 
 
 Near the same period, Syme operated in somewhat the same 
 manner as Nelaton, namely, he divided the lower jaw through 
 the symphysis, and English writers name this operation the 
 method of Syme. 
 
 In 1858, Demarquay operated in the following manner: a 
 vertical incision was made through the lower lip, when the lower 
 jaw was divided in the median line with the chain-saw^; the 
 tongue was excised with the ecraseur, and the divided bones 
 reunited by means of a gutta percha appliance; a complete 
 recovery was thus obtained. 
 
 Thiersch, in 1865, writing on lingual epithelioma, finds that 
 it commences oftener on the edges of the tongue than elsewhere. 
 And since the disease advances insidiously, undermining parts 
 which are sound, he prefers to do the work of removal with the 
 knife rather than with the thermal cautery or the ecraseur. As 
 a preliminary to the removal, he ties the lingual artery, which 
 he ligates near the os hyoides, fixing the latter with a tenaculum, 
 as aid in ligating. In one case, Thiersch tied the right and left 
 lingual arteries, and in another case, not finding the lingual, he 
 ligated the common carotid artery. 
 
 Nunneley, an English writer, in 3 866, from his experience in 
 five cases of cancer of the tongue, pronounces the operation of 
 removing the organ to be one void o^ peril. In three of the 
 cases, the disease did not return. He removed with the ecraseur. 
 To do this, Nunneley first thrust a curved needle between the 
 hyoid bone and the lower jaw, letting it merge under the tongue, 
 near the frtenum; by this n)eans the ecraseur was drawn into the 
 mouth, and over and behind the root of the tongue. To aid in 
 
MALIGNANT GROWTHS OF THE TONGUE. 635 
 
 applying the ecraseur, the tongue must be drawn well out of the 
 mouth. The division of the parts must be done slowly, so as to 
 insure the closure of the vessels. 
 
 Paget, to remove the tongue, first divides the genio-hyoid 
 muscles near their insertion in the maxilla inferior; through the 
 opening made, the tongue is drawn down, and then, an incision 
 being made around the tongue through the mucous membrane, 
 the loop of the Ecraseur is placed in this cut, and the division of 
 the organ is now completed. 
 
 Buchanan, as prej^aratory step, first divided the lower jaw in 
 the symphysis, according to the plan of Ne'laton and Syme; 
 and then, through this opening, he removed the tongue. 
 
 Gamgee, in 1868, removed the tongue by Regnoli's method, in 
 which he separated the muscles from the lower jaw on each side 
 as far back as the facial arteries ; and he is undecided whether 
 this plan is better than that of Syme, in which, as preliminary 
 step, the jaw is severed at the symphysis. He favors the previous 
 ligation of the lingual arteries. In 1868, Podrazky, of Vienna, 
 reported the extirpation of the tongue for epithelioma, in which, 
 as preparatory step, he tied both the lingual arteries; and he 
 claims that this was the first time that double ligation of these 
 vessels had been don^ at one time. 
 
 In 1871, Harrison, an English surgeon, to excise the tongue 
 affected with cancer, first divided the frsenum and the mucous 
 membrane around the tongue, so that the organ can be drawn 
 well forwards. Through a sublingual opening made, the loop 
 of the ecraseur is to be passed, and the tongue being included is 
 thus excised. 
 
 Billroth, in 1874, wrote on the removal of the tongue which 
 is affected with cancer. He directs special attention to the 
 cleansing of the mouth, and urges that more care be given to this 
 than is commonly done. Through an incision corresponding to 
 the boundaries of the floor of the mouth, the tongue is drawn 
 and cut off with scissors, and the vessels tied as they are opened. 
 The crescentic cut is next to be closed, except its lateral endings, 
 which are left open for drainage. 
 
 Menzel operated in a similar way, yet, as a preliminary, he 
 tied the lingual arteries, as advised by Czerny. 
 
 Axel Iversen, in 1874, wrote on the operation of removal of 
 the tongue partially, or in its totality. He opposes those meth- 
 ods which mutilate much by extensive cutting, viz., division of 
 the maxilla inferior. Though such mutilating operation be done 
 
636 TONGUE. 
 
 wliere thegrowtli is far advanced, it does not eradicate the disease: 
 the latter soon recurs. Iversen advises not to operate in cases in 
 wliich the disease has extended beyond the papilhc circunival- 
 latie. Where the affection has extended well backwards, he 
 prefers the metiiod of Heyfelder and Jjiger, viz., to reach the 
 growtli by an incision made through the cheek. Iversen oper- 
 ated on several cases, in Copenhagen, in wliicli lie modified 
 somewhat the cut of these operators, viz.: instead of incising 
 horizontally, outwards from the angle of the mouth, he did 
 this on a level with the teeth of the lower jaw. Tiiis cut curved 
 downwards, so that a convex flap was formed. Iversen claims, 
 as advantages for this incision, that it shuns branches of the facial 
 nerve, avoids the duct of Stenson, and does not injure that part 
 of the cheek in which the tendinous portion of the facial mus- 
 cles lie; and the wound made, having been closed by twisted 
 suture, heals by first intention. Iversen condemns the use of 
 the e'craseur for the excision as an instrument that is uncertain 
 and painful; but ho recommends the knife and the galvano- 
 cautery. He claims, likewise, that tlie ligation of tlie lingual 
 artery does not guarantee against lu^jmorrhage. He removes the 
 affected glands, which is easily done when they are not adherent 
 to the surrounding structures. 
 
 In 1881, Guillier, following the method of Verneuil, advises 
 thorough rertioval of the cancerous tongue and at an early 
 period; and should the glands have become affected, he counsels 
 their removal, as well as the removal of the structures which lie 
 between the tongue and the glands. Recurrence is rare in the 
 lingual stump; it occurs oftener in the sublingual tissues in the 
 floor of the mouth. To do this work radically, let an incision 
 be made through the floor of the mouth from one angle of the 
 lower jaw to the other; and this cut demands the ligation of the 
 two facial arteries. A double ligature should be placed on each 
 vessel, and the vessel then divided between the ligatures. Next, 
 let tlie tongue be drawn down through the crescentic cut and 
 divided with the thermal cautery. If the disease be unilateral, 
 remove only the affected half of the tongue, dividing antero- 
 posteriorly with the ^craseur. In case the palate and tonsil are 
 affected, divide the lower jaw through the symphysis. 
 
 Whitehead published in 1881 his method of operating: he 
 dissects the tongue from the floor of the mouth, and then divides 
 the organ near the epiglottis, tying vessels as they are di- 
 vided. 
 
MALIGNANT GROWTPIS OF THE TONGUE. 637 
 
 Berg, a kScandinavian, writing in 1881, finds that lingual can- 
 cer has a special tendency to travel antero-posteriorly; exception- 
 ally, it passes through the raphe: — facts to be remembered in 
 operations on the cancerous tongue. 
 
 In 1881, Wolfler describes the method of operating then pursued 
 by Billroth, who, within thirty months, had operated forty-five 
 times. He does not divide the lower jaw, nor make the sub- 
 mental flap as he once did, but now operates through the mouth; 
 thus septic pneumonia is warded off. He ties one or both of the 
 lingual arteries; and the cut for the ligation of the artery may 
 be enlarged and the diseased glands removed through it. He 
 divides the freenum and mucous membrane around the tongue, 
 so that the latter can be drawn well out of the mouth. Drainage 
 is made through the floor of the mouth. Wolfler states that the 
 secondary pulmonary afi'ection, which follows these operations on 
 the tongue, may be of a mild catarrhal character, which subsides 
 in a few days; or there may follow a severe pneumonia, from 
 which the patient may recover; yet, sometimes, death is thus 
 caused. The cause of pulmonary trouble, in all the forms, is 
 the swallowing of septic material, a part of which passes to the 
 lungs. 
 
 Langenbeck's plan is to divide the lower jaw, and then excise 
 the tongue with the thermal cautery. 
 
 The method of opei*ating by Baker, of St. Bartholomew's 
 hosiDital, is as follows: To hold and fix the tongue, a thread is 
 passed through each side of it a half inch from the median line; 
 and to loosen it, so as to allow of extension, the attachments of 
 the tongue are divided with scissors, the divisions being done 
 close to the lower jaw. If the disease be unilateral, the mucous 
 membrane is to be divided along the median line, and the two 
 halves separated with the finger; this done, remove the diseased 
 half of the tongue, and also any glands which may be affected. 
 The removal of the glands is most easily done through the floor 
 of the mouth by external excision. 
 
 Ivocher operates by first performing tracheotomy and plug- 
 ging the fauces; then an incision is to be made along the ante- 
 rior border of the sterno-cleido mastoid, and, from the middle of 
 the muscle, carry a second cut to the hyoid bone, and thence 
 along the digastric muscle to the symphysis of the jaw. The flap 
 described is reflected aside, and the facial artery and vein and 
 the lingual artery are then tied. The attachments of the tongue 
 are next to be severed, and the organ drawn through the opening 
 
038 TONGUE. 
 
 and divided with scissors or galvano-cauter3^ If the entire tongue 
 is excised, tie the remaining lingual artery. The canula must 
 remain in the trachea for some days, and the aseptic dressing be 
 removed from the fauces twice daily, and new ones placed there; 
 and at these dressings the patient must be fed. 
 
 In Volkmann's plan, if the tongue can be drawn out, the 
 diseased portion is excised, and the mucous membrane brought 
 over tiie wound, which is closed by sutures. Also, if a portion of 
 healthy tongue remains, this is turned around so as to form a 
 rounded end of the lingual .stump. But if the tongue be more 
 extensively affected, then let a thread be passed through it by 
 which traction can be made. An incision is then made down- 
 wards from the angle of the mouth; a canine tooth is extracted 
 and the jaw divided at this point; through the breach, thus made, 
 the tongue can be drawn out and excised. The cut surfaces are 
 now to be faced with mucous membrane and sutured; and the 
 jaw is to be sutured with wire. A drainage tube is to be placed 
 in the tonsillar fossa and carried out through the lateral wound. 
 The writer thinks that Volkmann's plan of dividing the lower 
 jaw should find few imitators. 
 
 Near this period, Hueter and Lesser report extirpation of the 
 tongue affected with epithelioma. Seven operations are reported, 
 in all of which the lingual artery was tied; and all recovered. 
 
 The operation of tying the lingual artery is now generally 
 practiced as a preliminary to extirpation of the tongue; and a 
 description of how this may be done is here given. 
 
 From his experience in this ligation, the author should state 
 that it may be easy or difficult, according to the conformation of 
 the .subject's neck; in those whose neck is long, and with scanty 
 adipose tissue, the artery is easily found; but where the neck is 
 short, thick and laden with a thick couch of fat, the operation 
 becomes extremely difficult ; and it is no wonder that one surgeon 
 was compelled to abandon the lingual, and ligate the carotid 
 artery. 
 
 Demarquay in 18G7 reported the ligation of the lingual artery 
 in eight cases; and in 1S68 he publislied a memoir on the sub- 
 ject. He claimed that the operation was not a difficult one to 
 one well versed in the anatomy of the parts. He says the opera- 
 tion was first suggested by Beclard and was first done l>y Mirault. 
 Besides, as a preliminarv to excision of the ton2:ne, tliis ligation 
 may be done to control bleeding in the wounds of the organ: and 
 in such cases the luemorrhaire has not returned after the ligation. 
 
MALIGNANT GROWTHS OF THE TONGUE. 639 
 
 Demarquay counsels this ligature to retard the growth in cases 
 ill which the cancer has advanced so far that it cannot be 
 removed. At the time he wrote his article the ligation had been 
 done by Mirault, Moore, Roux and Deguise. To reach the artery 
 Demarquay finds Blandin's plan to be the best ; this is done by an 
 incision made above the great cornu of the hyoid, and extending 
 from the anterior edge of the sterno-cleido-mastoid muscle to the 
 median line of the neck. If the neck be short, as soon as the 
 submaxillary gland is reached, open its capsule and let the 
 gland be pulled upwards. The digastric muscle and ninth nerve 
 are now brought into view; the artery lies in this field in a 
 triangle formed by the hyoid cornu below, the hypoglossal 
 nerve above, and the carotid artery behind ; the artery lies just 
 above the hyoid bone, and is displayed by a horizontal cut 
 through the fibres of the hyoglossus muscle, behind which the 
 vessel lies hidden. 
 
 Near the same time the lingual artery was tied by Hueter in 
 the operation of lingual excision. To find the artery, Hueter 
 incises horizontally above the hyoid bone, and, uplifting the skin, 
 there is displayed what he names the lingual triangle. This 
 triangle is bounded below by the two legs of the digastric muscle 
 and above by the hypoglossal nerve. The digastric portions are 
 the .sections of the digastric muscle which lie before and behind 
 the hyoid ^bone. The space included in the triangle does not 
 exceed a square centimetre in surface (a centimetre equals about 
 two-fifths of an inch in length). Hueter does not deem the 
 operation a dangerous one; on the contrary, Weichselbaum, who 
 has written on the subject, pronounces the operation dangerous. 
 When the disease occupies the middle portion of the tongue, 
 Weichselbaum advises to tie both lingual arteries, since accord- 
 ing to Hyrtl, the dorsal portions of the lingual arteries some- 
 times unite and form a single vessel in the median line. 
 
 Anatomists have found that the situation of the lingual artery 
 is not uniform in the first part of its course; exceptionally, 
 instead of lying above the hyoid bone, it may lie behind or 
 below it. If the artery is not discoverable, the ligation of the' 
 external carotid should be done. The lingual should be tied as 
 far backward as possible, since, done thus, no branches remain 
 through which the blood can enter the tongue. Should, however, 
 the vessel not be discoverable in this part of its course, or if from 
 inflammatory or cicatricial agglutination of the structures the 
 vessel is not accessible, then it may be sought for, more anteriorly. 
 
640 TONGUE. 
 
 In its anterior portion tlie vessel may bo found by making a 
 horizontal incision midway between the inferior margin of the 
 lower jaw and the hyoid bone. Tiie exposed submaxillary gland 
 must now be drawn upwards by a transfixing tenaculum; and 
 when this is done, tliere is offered to view the anterior leg of the 
 digMstric muscle, and above this the hypoglossal nerve; in the 
 space between these, and close beneath the hyoglossus muscle, lies 
 the lingual artery. To find the vessel, divide the hyoglossus 
 horizontally, and cause this cut to gap, and the artery will be 
 found. This search for the vessel will be facilitated if the surgeon 
 has recently dissected this region; for no matter how accurate his 
 anatomical knowledge may once have been, it is within the 
 experience of the writer that the sketches which have been copied 
 in the mind long ago, wander, in time, from the true picture in 
 nature; accurate correctness is only maintained by repeated 
 rehearsals on the cadaver. 
 
 As the linguist, who would retain intact a language which he 
 has learned, must, from time to time, rehearse his grammatical 
 rudiments, so the operative surgeon, to do the best work, must 
 ever and anon renew his early association with the cadavci". As 
 amnemonic guide wliicli represents the site of })arts which have 
 a close relation to the lingual artery, the one subjoined has been 
 constructed by the writer; in the posterior site of the vessel the 
 trilogram CAD represents the initial letters of cornu, artery and 
 digastric, in the order in which the structures stand from below 
 upwards; but anteriorl}^ after the artery has passed beneath the 
 posterior leg of the digastric, the symbol DAN represents the 
 series in which appear from below upwards, digastric muscle, artery 
 and ninth nerve; and the two syllables conjoined form the word 
 CADDAN. Such devices, as elusive artifices, amuse memory; 
 they become pebbles, which, dropped into the tub of the Danaids, 
 close some of the openings through which are wont to lapse so 
 many of the facts which we store there. 
 
 As conclusion of the subject of excision of the tongue for the 
 relief of ej)ithelionia located in the part, the writer will subjoin a 
 brief account of his method of doing the operation. The lingual 
 artery is to be tied on one or both sides, according as the tongue 
 is unilaterally or totally affected with the disease. An indispen- 
 sable aid in the operation is to have the lower jaw well depressed 
 and held so; and, for this purpose, the author has devised and had 
 constructed an interdental gag, which is exhibited in the adja- 
 cent illustration. This instrument when inserted has the ad van- 
 
MALIGNANT GROWTHS OF THE TONGUE. 
 
 641 
 
 Figure 87. Exhibiting an interdental gag devised by the writer, 
 structed by Dr. A. B. McKee.) 
 
 (Con- 
 
 tage that it does not encroach on the buccal cavity; and the 
 operator has untrammeled access to the tongue. The handle of 
 the inserted gag is held by an assistant who also clasps and 
 steadies the head. The tongue is next seized by strong clasp- 
 forceps and pulled aside so that its sublingual and palato- 
 pharyngeal connections can be brought into view and severed 
 with scissors. Thus liberated, the tongue can be pulled well for- 
 wards, when a circumscribing line is incised between the affected 
 and unaffected structures; and this line must lie within the sound 
 tissues. Through this guiding incision the excision can be 
 continued and completed. The part removed must be examined, 
 and should it appear that the disease has not been wholly 
 removed, the excision must be continued further. The line of 
 
042 TONGUE. 
 
 excision, if possible, should be bifid in form : that is, the stump 
 should be in two portions, which can be closed by sutures, and 
 thus the wound be closed, and the stump have a round end. 
 Thus done, the operation is almost bloodless. 
 
 The patient is to be sustained with liquid food. An impor- 
 tant part of the after-treatment is that the buccal cavity be often 
 cleansed of septic materials which tend to collect in it; and fur- 
 ther, let the cavity be frequently irrigated with mint-water, to 
 which five per cent of alcohol has been added. 
 
 The writer has performed the above operation thirteen times, 
 and eleven of the patients remain permanently cured; and their 
 power of speech is not greatly impaired. 
 
 In case the tongue cannot be removed, scrupulous attention 
 should be given to the palliative treatment; the patient's pain 
 should be reduced to a minimum by the use of narcotics. This is 
 an humble field of work in which there are no trophies to be won 
 by the surgeon's hand, yet for his heart there is ample field for the 
 exercise of his highest duty to his patient. The unfortunate victim 
 of cancer is too often ill cared for in the last days of his suffering; 
 yetno case appeals more earnestly for kind and unceasing care than 
 does his; and in this work the surgeon's hand should be the first 
 and the last. The slaves of the Aztec prince were slain to accom- 
 pany their dying chieftain, and to carry lamps which should guide 
 his feet through the dark vales of death : of kindred nature should 
 be the devotion of the medical and surgical attendant to him 
 whose days of agony linger seemingly interminable before they 
 reach the supreme hour. 
 
 In the list of anodynes which modern chemistry has so aug- 
 mented, no one exceeds o})ium and its comf)ounds in eflicac}'; 
 the patient should have morphia in doses increased correspond- 
 ingly, as tolerance of the remedy is developed; a quarter of a 
 grain should be commenced with, and this be increased to a half 
 grain, and finally a grain three times a day. Nutrient liquids 
 are to be used as food. And to lessen the pain of their ingestion, 
 the tongue should be cocainized; in fact, as a local anresthetic, 
 a five per cent solution of cocaine may be penciled on the raw 
 surface, from time to time. A ver}' efficient means of lessening 
 the pain is section of the sensory lingual nerve. In 1866 Colles, 
 of Dublin, advised the section of the gustatory branch of the 
 inferior maxillary nerve; and, as Hilton announced, the same 
 thing had previously been done by him. This section is done by 
 an incision which is a half inch behind the last molar tooth, and 
 
WOUKDS OF THE TONGUE. 643 
 
 three- fourths of an inch below. This cut is directed towards the 
 angle of the lower jaw, and must sever or detach the soft parts 
 from the bone. The relief, obtained thus, was great; but as the 
 pain returned finally, Colles thinks a portion of the nerve should 
 be removed. 
 
 WoufLcls of the Tongue. — The protected site of the tongue 
 screens it from injury; nevertheless, it is sometimes wounded, 
 being reached by some cutting, penetrating, contusing or burning 
 agent. The gunpowder missile may, also, wound the tongue. 
 
 According to the author's observation, the tongue is oftenest 
 wounded in the child from falls, in which the tongue, being 
 thrust between the teeth, is caught and bitten ; or the child 
 having some sharp-pointed object in its mouth, in falling, this 
 object is thrust into the tongue. From these agencies, longitu- 
 dinal, oblique or transvere cuts may originate ; and the wound 
 may be in the body or border of the tongue. In convulsions, 
 epileptic or tetanic, the tongue may be caught between the teeth 
 and severely bitten. And those who have care of such patients 
 should be directed to prevent such accident, by interposing some 
 object, as a knife handle, piece of rubber or other body, between 
 the teeth, so as to release the tongue, and, in some measure, pro- 
 tect it from injury. ' 
 
 The treatment of the open wound in the tongue does not 
 differ essentially from that of wounds in the dermal surface of 
 the body. The "wound must be accurately closed with sutures, 
 and, as far as possible, rest should be given to the part. To intro- 
 duce the sutures, the tongue must be drawn out by the aid of 
 clasp-forceps, and then the edges of the wound must be carefully 
 coaptated ; and since the muscles of the organ will move despite 
 its fixation, the adjustment of the wounded edges is not easily 
 done. Metallic suture is better here than silk; and, since the 
 tongue swelling buries the suture, and this remains hidden for 
 some time, the wire should be so cut that the end of it can 
 be found and caught, when the time arrives for the extraction of 
 the suture. If the tongue have been divided in its entire thick- 
 ness, deep sutures must be introduced. If the border be impli- 
 cated, the first suture must be placed there; thus proceeding, a 
 notch or marginal irregularity will be avoided. These sutures 
 must not be closed too tightly, lest they cut the included struc- 
 ture; and they must remain in place for a period of a week, or 
 even ten days. Too early removal of the sutures has led to 
 failure through reopening of the wound. During the time of 
 
(544 TONCiUK. 
 
 treatment, liquid or seini-liquicl food of bland eliaracter should 
 be given the patient. 
 
 In wounds of the tongue in which a part of the organ has 
 been detached, or is merely adherent by a mere fibre, an attempt 
 should be made to reunite and save the jtart. In 1870, Peltier 
 reported a few cases of the kind, which he had treated or had 
 observed in the practice of others. The results obtained were 
 very satisfactory; and he accounts for this on the ground that tlie 
 wounds are usually in children, in whom nutrition is in a high 
 grade of integrity. Also Beranger F^raud, in his dissertation on 
 the reunion of parts which have been severed from the body, 
 gives eleven cases of such reunion of parts detached from the 
 tongue. In sucli work of restitution in cases in which there has 
 been complete detachment, as well as in those in which the sep- 
 aration is incomplete, the raw surfaces should be well cleansed 
 before closure by suture. 
 
 Foreign Bodies Lodged in the Tongue. — As before remarked, the 
 protective ramparts around the tongue screen it from injurv so 
 that wounds of it are rare; for similar reasons, the lodgment of a 
 foreign body in the tongue is a yet rarer occurrence; nevertheless, 
 the annals of surgery present occasional records of such injury. 
 Examples of such are a bullet, a fragment of a tooth, fragment of 
 wood or a piece of a pipe-stem. 
 
 The famous case of Boyer is often repeated, in which a bullet 
 remained in the tongue for four years, when it was extracted by 
 him. In the extraction of teeth, a mal-adroit hand has left a 
 fragment of a molar in the tongue; such a case is reported by 
 Herbert. 
 
 In all cases of a foreign body lodged in the tongue, a well- 
 defined swelling occurs about the object, and if this be carefully 
 ius[)ected, there will be found a breach of tlie surface: an opening 
 through which a probe can be passed to the body; or, this wound 
 may heal and only a scar remain to indicate the point of entrance. 
 Such marks, with the patient's history of an injury, will aid in 
 the diagnosis; and besides this, more definite knowledge is gotten 
 by the insertion of a probe or needle, by which the body is felt. 
 
 The treatment of such injury is to fix the tongue with clasp- 
 forceps, and then make an incision through the surface of the 
 swelling, which will furnish the nearest approach to the body, 
 and after the extraction of the object, the wound will soon heal. 
 
 Roof of the Oral Cavifi/. — The roof of the oral cavity consists 
 of two portions, which differ in structure: the anterior part, which 
 
ROOF OF THE ORAL CAVITY. 645 
 
 is hard, fixed and motionless; the posterior one, which is soft 
 and movable, and hence is named the pendulous veil of the 
 palate. 
 
 The hard palate is a simple layer of bone which is lined on 
 each side by mucous membrane, and this membrane on the oral 
 side, is the one which specially demands our attention, since as a 
 passive agent it shares in some of the most complicated work 
 done by the surgeon in this region. The bony roof ends in, and 
 is bounded on the sides and front by, the alveolar process of the 
 upper jaw, and the space included between them is closely invested 
 by mucous and fibrous structure, which is continuous behind with 
 the pendulous veil of tlie palate. The roof of the mouth, in its 
 normal state, is a vaulted arch, and this arch, at its highest point 
 above the dental plane, is from a half inch to four-fifths of an 
 inch in height; yet Tillaux, who has given these figures, finds 
 numerous deviations from them; the arch may be low, and of 
 the slightly curved, Moorish type, or it may be high, resembling 
 then the Gothic form. In the usual form, the longitudinal and 
 transverse diameters of this vaulted space are of nearly the same 
 length; yet when the vault rises Gothic like, the transverse 
 diameter is lessened; but if the arch is lower, the space becomes 
 wider. 
 
 The mucous membrane of the palatal vault rests on a dense 
 stratum of fibrous tissue, and in this fibro-mucous structure 
 nerves, glands and vessels lie. The nerves belong mainly to the 
 sympathetic system, and descend from above through the ante- 
 rior and posterior palatine foramina. These nerves are derived 
 from the spheno-maxillarysympatheticganglion, whence branches 
 radiate in such multifarious directions as to puzzle or tire the knife 
 which seeks to trace them. These branches are distributed to the 
 internal ear, the tonsil, and the soft and hard palatal structures; 
 and the anterior branch traverses the naso-palatine foramen, and 
 finally reaches the anterior part of the palatal vault. The site of 
 the naso-palatine foramen is often indicated by a wart-like papilla. 
 There sometimes exists here a minute canal which traverses the 
 wall, and through which a fine wire maybe 2:»assed. Pressure on 
 the lower end of this canal acts on the naso-palatine filaments 
 which emerge there. It has been found that pressure on this 
 part of the palate wull arrest sneezing. And use was made of 
 this fact by Prochaska; those whom he had operated on for the 
 removal of cataract were instructed, when they felt the sense of 
 approaching sneezing, to press with the tliumb behind the 
 incisors and thus arrest the act. 
 
04(3 TONGUE. 
 
 Muciparous glands exist in the fibro-mucous glandular struc- 
 ture; these glands are especially numerous in the lateral portions 
 of the palatal roof, and to them is due the increased thickness of 
 the fibro-mucous palatal structure. These glands are similar to 
 the mucous glands of the lips. 
 
 The arteries are the posterior and anterior ])alatine, which 
 descend to the hard palatine through foramina of like name. 
 These vessels sup[)ly the nutrition of the osseous roof of the 
 mouth. Tillaux says that any lesion which separates the palatine 
 fibro-mucous structure from the overlying bone causes osseous 
 necrosis; evidently an error, for if it were so, many uranoplastic 
 operations would cause death of the bone; yet such necrosis is a 
 rare event. 
 
 It is important to study the site of these vessels. The poste- 
 rior palatine is a derivative of the external carotid through the 
 medium of the internal maxillary artery; it is one of the final 
 branches of the latter. The vessel descends through the posterior 
 palatine foramen, and emerges near to and at the side of the dens 
 sapiens. After its appearance here, the artery runs forwards 
 along the base of the alveolar process until it meets the anterior 
 palatine, with which it forms inosculation. In the course of the 
 posterior palatine along the side of the vault, the vessel lies in a 
 furrow, which, sometimes, is converted, by a covering of bone, into 
 a long canal; but, more frequently, the vessel lies in a shallow 
 furrow, or, at most, it is not more than half buried in the bone. 
 Branches are sent off on each side; the most of them, however, 
 pass inwards and forwards. According to Tillaux, the position 
 of the artery is such that it can be shunned by an incision cut 
 near the base of the alveolar process. The cut should be made thus 
 in the uranoplastic procedure; "for gangrene will never arise if 
 one preserve the posterior palatino artery in the flap." — (Tillaux.) 
 
 Though no muscular fibres are contained in the fibro-mucous 
 coat of the hard palate, yet wounds here gape, and, if a vessel be 
 opened, there will be much bleeding; and to check this the 
 actual cautery is the surest means. 
 
 Behind tlie hard palate lies the soft one, which in structure is 
 more complicated than the former. The antero-posterior diam- 
 eter of the palatal vault is normally about three inches; of this, 
 one-half belongs to the hard jialate and the remaining half to the 
 soft palate. The distance between the posterior border of the 
 soft palate and the posterior border of the pharjaix is a very 
 variable quantity. The uvula, or posterior portion of the soft 
 
INFLAMMATION OF THE 1'ALATAI. STKUCTURES. 647 
 
 palate, differs much in its length, and from disease it may 
 undergo enormous elongation. 
 
 The soft palate is lined above and below by mucous mem- 
 brane, and between these lie muscular, glandular and fibrous 
 structures. 
 
 From underneath, ascend and are fused in the soft palate the 
 palato-glossal and palato-phryngeal muscles, and its upper sur- 
 face receives the levator and tensor palati muscles. The tensor 
 palati has recently been deprived of some of the function which 
 was once attributed to it; instead of acting on the soft palate, as 
 formerly taught, it is now thought to pull on the lower wall of 
 the Eustachian tube, and aid in maintaining this patent. 
 
 The fibrous structure lies in the front portion of the soft pal- 
 ate, constituting its anterior third. This fibrous structure lies 
 between the hamular processes of the pterygoid plates, and is 
 fastened to, and is continuous with, the posterior border of the 
 long palate; and such is its firmness of structure that one may 
 readily be deceived respecting the posterior limits of the bone: 
 viz., he may suppose that the bone reaches farther backwards 
 than it really does. This fibrous portion may be designated the 
 tendinous origin of the so-named tensor palati muscles. In 
 the movements of the soft palate the fibrous layer does not 
 participate. 
 
 The glandular portion of the soft palate lies next to the 
 inferior mucous coat; though glands lie underneath the superior 
 mucous coating, yet those below are much more numerous, and 
 these glands are the starting point of the adenoid tumors which 
 sometimes arise from the palatal veil. 
 
 The vessels of the soft palate, which are named palatine, 
 are derived from the internal maxillary, the facial and the 
 external carotid; and as all the blood is originally received 
 through the external or common carotid arteries, tense pressure 
 on either of these will control haemorrhage from a wound of the 
 soft palate. 
 
 The lymphatic vessels proceed to glands which are situated 
 at the angle of the jaw. 
 
 Inflammation of the Palatal Structures. — The palatal vault is 
 the site of inflammatory processes, which may arise primarily 
 there; or such process arising in the adjacent dental and alveolar 
 structures may extend to the palate. Those which arise in the 
 alveolo-dental structures are usually tractable to treatment, and 
 do not leave much trace of their action. There is, however, 
 
648 TONGUE. 
 
 another class wliieli depends on some constitutional disease, and 
 often causes some destruction of both osseous and soft structure: 
 tiiese are scrofula and syphilis. Scrofula may develop Ijere a 
 localized inflammation, which runs a long course, and ultimately, 
 throufrh carious action or more extensive necrosis, destroys a 
 l)ortion of the bony vault. The disease probably commences in 
 tlie superior or inferior periosteal investment (often in the latter), 
 and it thence extends to the bone. The site of such periostitis and 
 .subsec|uent caries is commonly near the middle part of the pal- 
 atal vault, where the bone is thin, indeed, nearly transparent. 
 The syphilitic gumma appears in the same region, and may end 
 in perforation of the septum between the oral and nasal cavities. 
 The treatment of the cases comprised within these dyscrasic 
 classes is that employed against the constitutional disease: to 
 wit, anti-tubercular and anti-syphilitic remedies. The chief cura- 
 tive agent is iodine, which, in the form of tincture, should be 
 applied frequently to the affected point; and iodine in some form 
 should be given internally. Should the case be syphilitic, the 
 treatment should be iodp-mercurial, the details of which are 
 given elsewhere. The writer's experiencejustifies him in expect- 
 ing much from the local use of the compound tincture of iodine. 
 
 In the soft palate an inflammation may arise primarily, or it 
 may appear through propagation of an inflammation which began 
 in parts adjacent. The loose texture of the soft palate permits of 
 extensive swelling, in which the uvula is implicated. The swelling 
 is dependent on (edematous infiltration rather than on accumula- 
 tion of blood in the part. As functional disturbances from such 
 inflammation are cough and difficulty of swallowing. Dys- 
 phagia arises from the enlargement and from the partial loss of 
 the action of the muscles in the soft palate which are concerned 
 in deglutition; and as result, the choan;e being imperfectly closed, 
 food may enter the nostrils behind. The secretion of the mucous 
 glands is augmented and becomes more tenacious than normal, 
 lience arises cough or hawking to get rid of this disturbing 
 material. 
 
 Treatment. — If .seen earl}' the treatment should be rigidly anti- 
 inflammatory ; multiple scarification should be done in the swollen 
 structure; it should be painted with the following: — 
 
 T^. Tr. lodini C^omp. 
 
 Tr. Gal'iie aa li 
 
 Misce. 
 
AVOUNDS OF THE PALATE. 649 
 
 Fragments of ice should be used and the bowels well evacuated. 
 Treatment of this kind, commenced early and pursued diligently, 
 may arrest the affection; as a rule, however, it will proceed to 
 suppuration. The pus is rather in the form of diffused infiltra- 
 tion than in well-defined isolation from the containing struc- 
 tures. It may be discovered through the mucous membrane as 
 whitish streaks. The treatment is to open the affected structure 
 with properly directed incisions, viz., antero-posterior openings. 
 Such incisions allow the escape of existing pus; and they also 
 permit the escape of serum, with which the swollen structures are 
 surcharged. Extensive suppuration may destroy so much of the 
 palatal tissue that a perforation of the veil will afterwards 
 remain; this is rare; and the more usual result is an extensive 
 scar, which by its contraction renders the palate tense and 
 restricted in its motions. The orifice which remains may become 
 closed; yet the condition in which the part afterwards remains 
 is not wholly satisfactory, since the palate is left abnormally tense. 
 
 Wounds of the Palate. — However well the palatal structures may 
 be secured from injury by their position, still traumatic agency 
 may enter here, and implicate the soft or hard palate, or both. 
 
 The soft palate of the child is not unfrequently wounded by a 
 sharp-pointed object, often a toy, which, being held in the mouth, 
 is thrust backwards into the roof of the buccal cavity, by a fall 
 of the child on its face. Such injury tlie writer has seen caused 
 by a whistle, by which the soft palate was pierced by a flap-like 
 wound; and thus the wound may vary in form and situation. 
 One of the worst conditions is that in which the posterior border 
 of the veil is opened ; since the muscles on each side greatly widen 
 the gap thus made. "Whether the wound be a marginal cleft or 
 one which perforates the veil anteriorly, the pro^Der treatment is 
 to close the breach by metallic sutures, as early as possible; for 
 if thus done, the edges of the wound being raw, they readily 
 unite. One or two stitches will suffice. If the case be one of 
 flap-form, the edges should be accurately coaptated, and two or 
 more sutures introduced, so as to retain them in place. If 
 accurate union cannot be obtained, then the pendent, or unat- 
 tached border should be closely trimmed off'; and thus a fringe- 
 like scar is avoided. In case there has been a loss of structure in 
 the operative work of closure, it will be necessary to make lateral 
 incisions so as to permit disj^lacement inwards; of this further 
 details will be given hereafter. 
 
 The bony palate mav be injured bv causes similar to those 
 42 
 
650 iongll;. 
 
 above mentioned. Yet a greater degree of violence is required 
 to perforate this part. 8ucli perforation has arisen from violent 
 contact with some sharp-pointed object. The most frequent 
 causal agency, however, is the gunshot missile; a large portion of 
 the cases are contained in the records of military surgery; but 
 in the modern period of suicidal fashion, the pistol ball furnishes 
 no small quota of these wounds. In the statistics of military 
 wounds in the Crimean war, of two hundred and twenty wounds 
 of the fnce, there were nine perforations of the bony palate; and 
 in the war in Italy, Chenu reports that there were ten perfora- 
 tions of the palate in seventy-seven wounds of the face. In the 
 wound from a shot, there is usually other injury of the contigu- 
 ous parts; the ball in its passage may wound the cheek, jaw or 
 the base of the skull; and in the latter case, the missile may 
 wound the brain, and cause an injury of such gravity, that to 
 deal with the palatal wound would be idle work, akin to that of 
 dressing a fracture on a dying man. 
 
 In case the palatal bone is perforated, and fragments of bone 
 remain attached to the soft parts, the broken pieces should be 
 restored to normal site, and the flaps of muco-fibrous structure 
 should be retained in site by properly placed sutures. A large 
 flap ma}^ thus possibly be saved and aid in closing the breach 
 through the bone. Denuce has given the history of a case 
 which illustrates what may be done in closing such a wound. 
 Through a suicidal shot thefibro-mucous investment of the bonv 
 vault was detached and, as a large flap, was found hanging 
 in the mouth; this Denuce' uplifted and retained in site by 
 sutui'es, which were carried through the breacli and the nares, 
 and fastened on the cheek. A satisfactory result was obtained. 
 
 In brief, the immediate management of such a case is to 
 replace the osseous fragments and reattach by sutures the torn 
 shreds of the palatal veil ; subsequently, when the parts have 
 healed, some plastic procedure may be resorted to, to complete 
 the closure. At the primary dressing, however, an attempt at 
 com[)lete closure may be made, should this be permitted by the 
 conditions present. 
 
 Tumors Arisinr/ from the Palate. — Both the hard and the soft 
 palate are the occasional sites of tumors. 
 
 Aneurism. — The palatine artery, from pressure or direct trau- 
 matic cause, can become the site of an aneurism; in recent years 
 there have been recorded cases of such aneurism arising from 
 lesion due to the pressure of the dental palate. Such aneurism 
 
ANEURISM. 651 
 
 has been cured by tbe actual cautery; also by opeuing and 
 emptying the sack, after jDrevious ligation of the palatine artery 
 on the proximal and distal sides of the tumor: that is, by the old 
 method of Antyllus. Ligation of the external carotid artery 
 might also be done. 
 
 Pedunculated or polypoid growths have been seen on the soft 
 palate; they arise oftenest near the uvula from the posterior 
 border of the palatal veil. Tliese growths often are of such 
 diminutive size that they cause no disturbance ; but if thev 
 become large enough to interfere with the function of the part, 
 they should be excised. 
 
 Other growths have been observed here of cystoid character ; 
 such have been seen by Robin and others, and probably arise 
 from the closure of muciparous glands. Cystoid sacks contain- 
 ing petrified concretions have been mentioned by Parmentier, in 
 1856, as occurring here; the origin of these he finds in glandular 
 occlusion. Such cystic or cystlike tumors should be freely opened 
 and their contents evacuated by curetting. 
 
 Solid growths of non-malignant character arising from the 
 palatal roof of the mouth have been seen by Michon, Nelaton, 
 Langenbeck and others. Such tumor, as to its structure, mav be 
 chondroma, adenoma, fibroma or osteoma, according as the 
 cartilaginous, glandular, fibrous or osseous elements 2:)redominate 
 in the composition of the growth. 
 
 The adenomatous palatal tumor appears on the palatal veil, 
 where the glandular elements abound; but the chondroma or 
 fibroma springs from the structures of the bony vault, 
 
 Langenbeck, in 1859, saw a case of chondroma here in a 
 syphilitic subject who was twenty-seven years old. This tumor 
 had existed a number of years, and had grown to such a volume 
 that it filled the entire roof of the mouth. The growth was 
 easily removed. The writer in 1870 saw a palatal chondroma in 
 a young woman, which had been many years in its development, 
 and had attained such dimensions that it filled the entire palatal 
 concavity. It was convex above, or rather a mould of tlie roof of 
 the mouth; and below it was a smooth plane, on a level with the 
 crown of the teeth; and in length it extended from the incisors to 
 near the posterior border of the soft palate. This remarkable 
 tumor was nearly white in color, and was slightly movable, show- 
 ing that it had only a pedunculated connection with the palatal 
 vault. The tumor was removed by means of a thin-edged chisel 
 which was inserted between the front part of the growth and the 
 
{)0'2 TOXCIE. 
 
 alveolar process; the detaclimeiit was thus easily done, and the 
 attachment was discovered to be at the i)oint of union of the four 
 angles of tiie j»alatal process of the palatal and superior niaxillary 
 bones, viz.. at the spot where the problem can be solved of touch- 
 ing at once with the point of a needle five different bones, the 
 vomer being the fifth bone. The growth was probably due to 
 the exuberance of cartilaginous formative material, which may 
 be conceived to exist at such a point of convergence; the osteo- 
 genetic forces overstepped the lines at which their action is 
 usually limited; and the surplus of cartilage, the antecedent stage 
 of bone, was moliled into an enormous chondroma. What was 
 remarkable was that so large a development could have grown 
 from so small a pedicle. This tumor did not recur. A plan 
 of removal sometimes resorted to is that of cauterization; this, 
 liowever, is very painful, and the better i)lan is to directly 
 extirpate it; and if it is imbedded, the containing capsule should 
 be opened, and enucleation done. 
 
 Mi{formafioiis of the Soft and Hard Palate; Acquired or Congen- 
 ital. — Commencing posteriorly the uvula is first to be considered. 
 This terminal appendage of the pendulous palate is sometimes 
 seen consisting of two portions, which meet and fuse at the base; 
 the uvula has its cleft as well as the palate. This uvular divisitm 
 is probably the remnant of an embryonic cleft which has nearly 
 closed in utero ; or, viewed from another side, such division may 
 be the commencement of a palatal cleft which remained limited 
 to the uvula. Such deformity causes so little inconvenience that 
 its existence is often unknown to the patient. Should, however, 
 anv disturbance arise from it, it would be an easy task to pare 
 and unite the parts by suture. 
 
 The uvula may become the site of abnormal enlargement in 
 which there is thickening and elongation. And this may be a 
 congenital condition, or have arisen so imperceptibly that the 
 growth was unobserved. In such cases the abnormally long 
 uvula may cause disturbance through contact with the walls of 
 the pharynx, or the base of the tongue. This contact may 
 awaken a reflex movement and anno}^ the patient by cougiiing 
 and a constant effort to clear out the throat. A habitual cough 
 may thus originate and give suspicion of some organic disease of 
 the air-passages. In fact, it is claimed by a German writer that 
 such continued irritation may awaken pulmonary disease. 
 
 The uvula may become elongated temi)orarily,through inflam- 
 mation of the pharyngeal walls which implicates the soft palate. 
 
MALFORMATIONS OF THE PALATE. S53 
 
 Thus the uvula may become greatly lengthened and thickened, 
 and greatly distress the patient through cough and efforts to 
 expel what seems to be something foreign in the throat. The 
 thick, tenacious mucus excreted by the inflamed mucous follicles 
 is also an irritant. 
 
 Treatment. — The uninfiamed uvula which is abnormally long^ 
 should be shortened by excision. In this work some have 
 advised to remove the entire uvula; others recommend to pre- 
 serve a part of it. Smith, in the British Medical Journal, in 
 1872, wrote on this subject, and recalled and recommended the 
 method announced twelve years before by Jearsley, who counseled 
 to radically excise the part; for he claims that if a part be left, the 
 scar on the end of this will maintain an irritation. Smith advises 
 to remove with scissors, and to so cut that the remaining scar 
 will be directed backwards and upwards. Should much bleeding 
 follow, apply chloride of iron, and if this fails, ligate. Smith 
 excised his own uvula with the ecraseur, and found that the 
 operation w^as a painful one. An account is told of a patient 
 who did more than Smith; for the uvula of the former being 
 greatly elongated, he cut it off with his incisor teeth. The method 
 of Smith and that of his rival, though deserving worthy mention, 
 will have but few followers; the renown which Mucius Scaevola 
 has in history on account of the self-sacrifice of an arm is proof 
 of the rarity of such temper among men. 
 
 The entire extirpation, as counseled by Jearsley, is improper, 
 since the uvula has its function in deglutition; for it guarantees 
 the complete closure of the posterior nares, and thus insures 
 against entrance of fluids and solids, during swallowing, into the 
 nose. In one case in which the writer had excised the entire 
 uvula, the patient was so dissatisfied with her condition that an 
 attempt was made to restore the lost part. This was done by 
 short vertical incisions through the posterior border of the pendu- 
 lous palate, on each side of tlie normal site of the uvula. The 
 frequent movements of the soft palate retained the lateral cuts 
 patent, so tljat a short uvular stump was constructed. In other 
 cases in which the excision was close to the soft palate, the 
 patient complained of tension in the palate; he was dissatisfied 
 with his condition, and regretted the removal of his uvula. 
 Therefore, since the uvula has the function in deglutition above 
 mentioned, and probably has another in phonation, by which a 
 nasal sound in speech is lessened or avoided, the entire removal 
 of this appendage to the soft palate is an error; there should be 
 left a stump, at least, two lines long. 
 
654 TONGUE. 
 
 The excision of the uvula is best done with a pair of curved 
 scissors and long-handled clasp-forceps. The patient is to be so 
 placed that when the mouth is well opened, the structures of the 
 pharynx are brouglit well into view; tlie uvula is then seized 
 near its end with the forceps, which are to be clasped so that they 
 will not abandon their hold. The part is then to be drawn for- 
 wards in the median plane, and then to be excised so that the 
 section will be at right angles to the part and there will remain 
 a stump of wliich the sides are of equal length. The blades of 
 the scissors should be sharp, so that they will cut and not crush, 
 and, above all, will not let the uvula slip from them. The work 
 must be done at one stroke; if done by two strokes, the remaining 
 surface will be uneven; one side will probably be longer than 
 the other. Hence in removal of the uvula, no rule deserves closer 
 observation than that the excision should be done in one act. 
 
 If the uvula be enlongated tlirough inflammation, as is often 
 seen in pharyngitis, tonsillitis and sometimes in diphtheria, then 
 an attempt should be made to reduce its volume by scarification 
 and astringents. To scarify it, seize with clasp-forceps, and, with 
 a pointed bistoury or scalpel, make a number of vertical incis- 
 ions in the swollen tissue. As local application, a strong solution 
 of tannin or alum should be applied directly, or the same may 
 be used as a gargle when there is general pliaryngitis. Should 
 these means fail to return the uvula to normal proportions, then 
 it should be removed in the manner just described. 
 
 When the uvula has been excised, there is slight bleeding for 
 a few minutes; only exceptionally does this demand the attention 
 which will presently be considered. A mouthful or two of cold 
 water, as a rule, checks the bleeding. Within a week the wound 
 heals, and during this time the patient may be directed to rinse 
 his mouth and throat occasionally with a weak solution of borax 
 or chlorate of potash. 
 
 As stated, exceptionally, the excision of the uvula may be 
 followed by continued bleeding; two examples of this have been 
 seen by the writer; in one the uvula was not inflamed and was 
 removed to get rid of a troublesome irritation in the throat, 
 caused by contact of the part with the base of the toiigue. The 
 patient was anemic, feeble and sickly in appearance. The 
 removal of the uvula was followed by very slight bleeding, so 
 little, indeed, that at the time no attention was given to it, but on 
 the following day the man presented himself in my office and 
 stated that his "palate" was bleeding and had done so ever since 
 
MALFORMATIONS OF THE PALATE. GoO 
 
 the operation. On examination there was found to be a large 
 drop escaping from tiie wound as often as once in every two 
 seconds, and the blood was arterial. This hsemorrhage had 
 weakened the man, and it was necessary to resort to some haemo- 
 static procedure; the one chosen was ligation, which was done as 
 follows: The stump, which Iiad been left long enough to grasp 
 was seized with clasp-forceps, and then a silver wire was passed 
 around the stump above the forceps and twisted enough to check 
 the bleeding. The wire did not destroy the vitality of the small 
 portion of the stump which lay beyond it. This ligature was 
 allowed to remain in site for a week, when it was removed and no 
 more bleeding ensued. 
 
 Bleeding occurred in a second case, in which the writer removed 
 a uvula that was elongated, swollen and much inflamed. The 
 subject was a plethoric one with a marked apoplectic habit. Some 
 hours after the excision of this uvula the stump began to bleed, 
 and continued to do so, until the writer was called, who found 
 that there had been lost a considerable quantity of blood. The 
 short stump which had been left did not permit ligation in the 
 way in which it was done in the case just described. A circum- 
 scribing suture was passed by means of a needle through the 
 structures around the bleeding surface; thus the bleeding was 
 controlled, though some difficulty was met in doing the work: 
 a fact which the reader will be fully convinced of, should he be 
 forced to resort to either of the plans here mentioned, in an 
 impatient, indocile subject, and whose restiveness is increased by 
 the suspicions that his ills are due to an error or faulty work on 
 the part of his surgeon. 
 
 Hence, as seen, though excision of the uvula is usually one of 
 the minimum acts of minor surgery, it may, when haemorrhage 
 follows, rise to a place of no small importance in surgical hand- 
 work. And these exceptional cases are verifications of occasional 
 experience, that the minutest breach in the human organism 
 by a surgical instrument may be the opening prelude to an event- 
 ful drama. Even a simple suture may awaken a phlegmonous 
 or erysipelatous inflammation which may devastate a wide field 
 of the organism : ravages, however, possible of avoidance by 
 timely care. As the arrow aimed at the smallest mark must be 
 poised and directed with the greatest accuracy, so the minutest 
 acts of operative work should be planned, done and afterwards 
 cared for with scrupulous attention, and, especially, vigilance 
 should not remit in the after-attention. This precautionary 
 
656 TONGUE 
 
 precept finds apt illustration in llic two cases of bleeding from 
 excision of tlie uvula here cited. 
 
 Palatal Adhesion. — The soft palate may become adherent to 
 the phar\'ngeal wall above, so that the choanse or posterior open- 
 ing of the nasal passages can be occluded; and sucii occlusion 
 may be complete or incomplete. When it is incomplete, the 
 adhesion may be unilateral, bilateral or median; bilateral adhe- 
 sions are the most usual. 
 
 As causes which may induce palatal adhesion are the ulcera- 
 tions which may originate from syphilis, scrofula and lui)us. 
 Paul of Breslau has collected thirty cases of such adhesion, of 
 which twenty-six were due to syphilis; in tlie few cases seen by 
 the writer, the cause was scrofula. Total adhesion is rare, but 
 partial is not infrequent. 
 
 Such fixation of the soft palate causes interference with 
 breathing and swallowing. In case of complete closure, respira- 
 tion is greatly interfered with; the patient can only breathe 
 through the mouth, a condition which is not only disagreeable, 
 but it exposes the lungs to tlie action of cold air, which might 
 be tempered with warmth if it traversed the nasal passages. 
 Such total closure prevents the detachment and removal of the 
 excreta which tend to collect in the nasal passages; the expulsive 
 effort cannot be made by which such materials can be dislodged 
 and ex[)elled. Breatliing tlirough the mouth dries the tongue 
 and the mucous membrane lining the buccal cavity. The voice 
 is also soraewljat changed. 
 
 In case there remain some opening, these several impairments 
 of function are lessened in degree; the patient can probably 
 breathe through the nose, which to him is a great boon; for 
 patients, in whom the occluded nasal passages had been reopened, 
 have assured me that to breathe again tlirough the nostrils was 
 one of the greatest pleasures: an illustration of the great value 
 of a seemingly unimportant part of the body; but if once lost, 
 such part perforce reveals its importance. 
 
 Palatal adhesion impairing, as it does, voice, taste, smell, 
 swallowing and the power to clear the nostrils, demands surgical 
 attention; the choanse must be reopened. The work can be done 
 partly through the mouth, and partly through the inferior nasal 
 meatus. By the mouth one may enter, and with a blunt instru- 
 ment similar to a raspatory, the separation can be efiected. In 
 case the adherence be extensive, it will be easier to do some of the 
 work from above through the nose. For this purpose a blunt- 
 
DESTRUCTIOX OF THE UVULA AXD SOFT PALATE. 657 
 
 edged instrument with a handle curved similar to that of the 
 palatal arcli, may be passed into the nose and made to descend 
 down the wall of the pharynx, and separate the palatal structures. 
 In his student davs the writer saw a case in which durino- the 
 operation his preceptor, Dr. Cooper, cut a twig from a pear tree 
 which stood near the window, and having trimmed one end into 
 a blunt edge, this was carried along the floor of the nose until it 
 reached the posterior cul-de-sac, when, being thrust onwards, it 
 passed down the posterior pharyngeal wall, and soon appeared 
 in the throat; and by further work with the happily imj^rovised 
 instrument, the palatal structures were liberated from their attach- 
 ments. A piece of whalebone, similarly trimmed, might be used, 
 especially if it be softened in hot water, curved and allowed to 
 cool. No haemorrhage attends the w'ork. 
 
 The reestablishment of the occluded posterior nares will be 
 found a tedious procedure, and the subsequent maintenance of 
 permeability will be a yet more emijarrassing task; for, thouo-h 
 the passage be well opened, without subsequent precautions it 
 will Cjuickly reclose. The position of the parts renders it impos- 
 sible to invest the raw surface with a mucous coat, an indispen- 
 sable requisite to prevent reclosure; hence the wounded parts 
 must be maintained asunder until they cicatrize. To do this, 
 carry along the floor of the nostrils a cord, to the distal end of 
 which when seen in the fauces a plug of lint is fastened; thus 
 a temporary tampon can be placed in the choanse; and this 
 must be done daily for many w^eeks. Finally, if this plan be 
 patiently pursued, the part becomes invested with a cicatrized 
 surface; and since scar tissue tends to contract, the introduction 
 of the obturating plug must be continued for some time longer; 
 and at length it need be introduced only occasionally, until finally 
 the opening will remain permanent. The writer would suggest 
 that the j^atient would be more tolerant of the work, as well as 
 encouraged in its action, if the obturator were traversed by a tube 
 so that the air could pass through it in respiration. 
 
 Destruction of the Uvula and Soft Palate. — Sjq^ljilitic, scrofulous, 
 lupous and malignant disease, through destructive ulceration, may 
 destroy, partly or wholly, the uvula, as well as the soft palate. In 
 the unfortunate event that both these structures be totally 
 destroyed, it is probable that no operation which the surgeon 
 might perform could furnish relief; such cases would fall within 
 the province of the dental mechanician; and it is j^robable that 
 even his most ingenious device, though phonation, breathing and 
 
G.38 TONGUE. 
 
 smell might be aided thereby, would be found a poor substitute 
 for the lost parts, and be a disappointment to the patient; still, 
 such appliance is better than nothing, and probably better than 
 what could be gotten through the essays of tlie surgical plasti- 
 cian: the work of the latter might, however, find place where 
 the destruction had been incomplete. 
 
CHAPTER XIX. 
 
 PALATAL CLEFT OR DIVISION. 
 
 Palatal cleft may be congenital, or accidentally acquired. 
 Congenital cleft may involve both the soft and the hard palate; 
 or the division may be limited to one of these parts. And in 
 each of these cases the cleft presents varieties. Thus, in the soft 
 palate, there may be merely a division of the uvula; or the cleft 
 may extend into and end at any point in the median line of the 
 soft palate. Cleft of the soft palate occupies a median position. 
 
 In the bony palate the fissure may be unilateral, bilateral or 
 median in site ; and, in its extent, it may reach partly or whollv 
 through the osseous vault. There is fissure in which the cleft in 
 the hard palate extends partly, or wholly, through the soft palate; 
 and also a cleft may reach through the soft palate and penetrate 
 the osseous vault to a greater or less distance. 
 
 The unilateral osseous fissure is normally situated on the left 
 side; and when incomplete, it occurs in varying grades, from that 
 in which the alveolar process shows a slight depression, to that 
 in which the cleft reaches nearly through the vault. The uni- 
 lateral fissure begins in the portion of the alveolar process corre- 
 sponding to the interval between the outer incisor and the canine 
 tooth. And when the cleft is reduced to its minimum form, the 
 only traces of it may be a slight depression in the outer face of 
 the alveolar process; or it may be limited to imperfect form, or 
 mal-position of the two corresponding teeth. The unilateral 
 cleft, when it is extensive, is not confined to the side of the vault; 
 in the soft palate the breach occupies the median line. 
 
 The bilateral fissure may only implicate a part of the palatal 
 roof; or it may traverse the entire extent of the palatal structures. 
 In the bilateral cleft, which, from the osseous structures which it 
 divides, might be well named alveolo-palatal cleft, the united 
 fissures resemble the letter Y, between the anterior branches of 
 which lies the premaxillary bone. The premaxillary bone may 
 
 ( 659 ) 
 
OGO PALATAL (LEFT OR DIVISION. 
 
 be nearly complete, and then contain three or four teeth; or it 
 may be reduced to a rudimentary fragment; and finally, in the 
 worst cases, the bone may be wanting and the Y-gap then 
 assumes the sliape of a broad I. The double-fissured cleft may 
 be incomplete, posteriorly 
 
 As rarer complications, there may coexist a cleft in the bony 
 palate, and also one in tlie soft palate; and the two are separated 
 by a bridge of normal tissue. An osseous palatal cleft is usually 
 associated with labial cleft; and the extent and gravity of the one 
 lias its correlate in the extent and gravity of the other, arising 
 from similar causes; and the labial and palatal clefts often have 
 many points in common. 
 
 The cleft in the soft palate is of V-form with apex in front. 
 The base of the gap, when the parts are most widely separated, 
 nearly equals the breadth of the soft palate; and the author has 
 observed that the absence of tissue is often greater on one side 
 than on the other. The tissue composing the sides may be of 
 web-like thinness; or it may be of the usual thickness of the nor- 
 mal palatal reil ; conditions which have a bearing on the success 
 or failure of work undertaken for the closure of palatal cleft. 
 
 Besides the forms of cleft which have been described, there 
 has been observed one which has a median position, since it lies 
 in the anterior part of the sutural line of the superior maxilla. 
 This is a mild form of malformation, since it lies merely between 
 the middle incisor teeth and does not reach further back than 
 the anterior palatine foramen. This median fissure may be 
 associated with unilateral or bilateral cleft. 
 
 The osseous palatal cleft, whether it be long or short, may 
 varv much in its breadth ; thus the two sides maybe so near that 
 the mucous membrane of one side loosely touches that of the 
 other; or the intervening space may be a quarter of an inch or 
 more in breadth. The overlying nasal septum may overliang 
 the vacant space, not reaching fully to the level of the adjacent 
 palatal processes; or the septum may reach to and be attached to 
 one of the lateral palatal processes. 
 
 Besides palatal clefts which are acts of nature and are congen- 
 ital, there is another class which originates from disease, acci- 
 dental violence, or from the invasion of surgery itself. From 
 syphilitic or tuberculous disease, the soft and bony structures of 
 the palate may be the site of breach or opening; also, such dis- 
 ease in parts adjoining, may extend, attack and open the palatal 
 roof. The most frequent perforations from disease are those 
 
PALATAL CLEFT OR DIVISION. G61 
 
 caused by constitutional syphilis; a periosteal or subperiosteal 
 oummy growth, situated on the superior or inferior face of the 
 bony vault, may destro}^ and perforate the bone and soft parts : 
 and the resulting breach will be greater in proportion as it is 
 situated further backwards; for the palatal processes are so thick 
 in front that they are seldom perforated by syphilitic disease. 
 
 The soft and hard palate may be perforated through acci- 
 dental agency; and these clefts ma}^ vary as greatly in site and 
 character as pjossibilities are permitted within the scope of 
 chance; among such agencies may be mentioned the gunshot 
 missile, the thrust of a sharp-pointed object, etc.; the most frequent 
 is that in which the subject falls and thrusts such object through 
 the palatal structures. 
 
 Perforation can arise from neoplasms which, arising within 
 tlie nasal fossge or the maxillary sinus, at length come in contact 
 with, and finally pierce through, the palatal structures ; and in 
 this case the bony arch is oftener perforated than the soft palate; 
 for the latter wall yield and recede before the advancing growth; 
 and perforation can only occur in cases in which the tumor is 
 large, and the pressure has been long continued. 
 
 And finally, an opening may be made through the palatal 
 structures, both hard and soft, as a pioneering route b}^ which 
 tlie surgeon may reach growths which exist within the nasal 
 fossae. This operative route is seldom chosen, since the resultant 
 conditions are unfavorable to the successful closure of the 
 opening in the palatal structures; and as the cleft remaining 
 would entail much functional impairment, the surgeon, if possi- 
 ble, should avoid forming such breach. 
 
 Whetlier the palatal cleft be of ante-natal or subsequent 
 origin,, it is the source of much inconvenience to its possessor; 
 even in slight grades of palatal cleft this is true. Integrity of the 
 palatal structures is necessary for the proper accomplishment of 
 suction, for tlie retention of food in the buccal cavity in the act 
 of chewing, and thirdly, for well-regulated deglutition ; also a 
 perfectly formed palate is requisite for articulate speech and 
 modulated voice ; and its absence interferes with smell and 
 taste. 
 
 The interference with the act of suction seriously obstructs 
 the nutrition of the infant which is the subject of such mal- 
 formation ; in such an infant, the chances of living, or of reaching 
 physical maturity, are much lessened. And when food is to be 
 masticated, the escape of a portion of the aliment into the nasal 
 
GG2 palatal cleft or division. 
 
 passages causes much annoyance. And, conversely, the broken 
 partition between the buccal and liasal cavities permits the 
 escape into the latter of the nasal and catarrhal excreta, of "wliich 
 the absence of suction prevents the normal dislodgment and 
 elimination. Deglutition is faultily accomplished. Entrance 
 into both the nasal and the air-passages is but imperfectly guarded 
 against, and pulmonary affection might arise from nutrient 
 material which has lost its way. 
 
 The functional impairments cited are slight when compared 
 with those of phonation and articulation, for the patient has tlic 
 privilege of concealment in regard to the former defects, but in 
 resj^ect to his voice, every word he utters reveals his defect, and 
 tells the story of his malformation. Tlie hollow nasal tone of 
 his vowel sounds, and the ill molding and tripping utterance of 
 his palatal consonants, are more disagreeable to the subject's 
 ears than to those of his listener. That this is but a feeble 
 glimpse of the subjective side of cleft palate is more than con- 
 firmed by the appeals for relief on the part of victims of such 
 deformity. If the patient be an adult, as has been the case in 
 some treated by the writer, his api)eal for relief, though in words 
 deformed in tone, accent and articulation, is eloquent enough to 
 enlist in his behalf both the heart and hand of the surgeon. In 
 such a case, Roux, the pioneer surgeon in this work, has recorded 
 his experience in touching lines. 
 
 Before describing the means which may be used for the relief 
 of cleft palate, a brief reference will be made to the causation of 
 the deformity. The origin of congenital cleft palate, like that of 
 labial cleft, is referred to an imperfect development of the primi- 
 tive elements of the embryonic face. At the fifteenth day of 
 feetal life, as before stated, there are to be found three parts which 
 are destined to form the future face, viz., a superior or frontal 
 plate, and on each side of this a labial or mandibular plate; this 
 lateral plate or process is first single; later it divides into two 
 parts, of which the lower branch uniting with a similar portion 
 from the opposite side, becomes the lower jaw and the lower lip; 
 but the upper part of the lateral bifid 'plate, destined to form the 
 upper jaw, does not fuse with its opposite fellow. About the 
 twentieth day, there are seen two processes proceeding from 
 the frontal i)late, which, descending, form the incisive, or pre- 
 maxillary bones. And soon afterwards, there springs from the 
 frontal [)late a process which is the future vomer, or sej)tum 
 separating the nostrils; and this vertical process is met by two 
 
PALATAL CLEFT OR DIVISION. G6o 
 
 horizontal plates from the superior maxilla, wliicli become the 
 palatal plates, and separate the buccal from the nasal cavities. 
 Continuous posteriorly with these horizontal palatal processes, 
 there is developed the soft palatal veil. Soon afterwards, ossifi- 
 cation of the future upper jaw commences by four ossific centres: 
 one for the malar portion, one for the palatal, one for the 
 canine, and one or two for the incisive portion. Of these 
 four portions the incisive is tlie one which has been specially 
 observed, on account of its bearing on hare-lip and cleft palate; 
 this incisive portion uniting with its fellow of the opposite jaw, 
 there is formed the premaxillary, sometimes called the inter- 
 maxillary bone. This bone occupies the triangular space of 
 which the apex is at the anterior j)alatine foramen, and the base 
 forms the median section of the alveolar process. The origin of 
 cleft in these structures is thought to occur as follows: Let there 
 be an arrest of development of the canine piece and the inter- 
 maxillary bone, and unilateral fissure will result; and let there 
 be such arrest on each side, and bilateral cleft will arise. And, 
 again, let the development of the horizontal palatal processes be 
 checked, and a fissure will remain between these parts; and such 
 fissure may be a continuation of the anterior unilateral, or 
 bilateral fissure. 
 
 The causes which have been assigned for the arrest of devel- 
 opment of the palatal and alveolar structures lie rather in the 
 domain of plausible theory and conjecture, than within the 
 range of ascertained facts; they remain as problems to be solved 
 by the future teratologist. 
 
 As has been stated in respect to the labial cleft, so in the 
 case of the palatal cleft, it seems that the causes which led to 
 arrest of fusion may be suspended, and the parts may resume 
 their normal growth, and proceed to perfect development; that 
 is, a cleft that has formed in intra-uterine life may close before 
 birth. And continuing the comparison with the lip, as in the 
 latter a cleft may close after birth, so a palatal cleft may vanish 
 through late closure. Trelat saw a man in whom a congenital 
 palatal cleft had closed when he w^as twelve years of age. Yet 
 intra-uterine as well as post-natal spontaneous closure is a rare 
 event; and the hope of relief in this wise is so seldom realized, 
 that if it be indulged in by the parent and physician they may, 
 like (Esop's traveler, wait long on the river's bank expecting its 
 waters to run away. 
 
 Treatment. — The methods which may be resorted to for relief 
 
CG4 I'ALATAL CLEFT Oli DIVISION. 
 
 in cleft palate are mechanical and operative. The mechanical 
 method consists in ilie employment of an obturator by means of 
 which the opening is occluded. Such obturators, in manifold 
 forms, have been constructed b\' those who have given stud}'' to 
 this subject. The difficulty encountered in this work is in that 
 part of the device which is destined to maintain the obturator in 
 site. This has been attempted by wing-like or arm-like processes, 
 which pass into the superjacent nasal passages, and thus hold in 
 suspension the occluding part. Or the suspension may be done 
 by lateral springs which rest in the nasal passages. The fixation 
 may also bo effected by the aid of hooks and clasps, which are 
 attached to the teeth or alveolar processes. In case of a rounded 
 or oval brench, the closure has been accompli.shed by means of a 
 device similar to a double button, and which resembles the 
 modern sleeve-button. 
 
 These obturators are constructed of India rubber or gold; also, 
 for this purpo.'je aluminium might be used ; and this metal com- 
 mends itself by its lightness. An important requisite which 
 these contrivances should possess, is that they should be securely 
 fastened in their position, and thus the bearer secured from all 
 peril of swallowing them. The unending task of caring for 
 such device is a serious objection to it; hence, the aid of surgery 
 is often sought by the unfortunate subject of palatal cleft. 
 
 Inasmuch as the work of closing the breach in the soft and 
 in the osseous structures is different, it will be more convenient 
 to treat of each separatel}', and, thus proceeding, the closure of 
 cleft in the soft palate will first be considered. 
 
 The pioneer in the closure of cleft palate by operative means 
 was Roux, who performed his first operations in 1819, and he 
 thought, at the time, that he was the first one to do the operation; 
 this, however, was an error, since he had been preceded by the 
 elder Graefe, whose operation, though a failure, was done in 181G. 
 The method of Roux was the better one, and was so acknowl- 
 edged by Graefe. A further investigation of the subject has 
 brought to light the fact, that the operation of closing tlie soft 
 palate by suture w^as proposed to the French Academy in 1779 
 by Beziers. Priority here, as elsewhere, has proved a Protean 
 entity, a flitting fugitive, which, though sought and temporarily 
 possessed by rival claimants, has in the end escaped their grasp 
 and fled to other hands. Such emulation, however, should be 
 commended, since it is of generous source and is in.spired by 
 justice to give the palm to him who has earned it. Gold too 
 
STAPHYLOREAPHY. 665 
 
 often finds its way to tlie hand of him who has not earned it; 
 ilie curators, by which tlie field of science is vigilantly guarded, 
 do not permit such wrong; the earner is secured in his earnings, 
 often through the mutual aid of his competitors. 
 
 Staphylorraphy, which signifies sutural closure of the soft 
 palate, was a na;me invented and given by Roux to this opera- 
 tion. As a surgical procedure it is tedious, delicate, and for suc- 
 cessful termination, it demands some degree of experience: the 
 first essay of the operator is commonly a partial or complete 
 failure. 
 
 Before describing this operation, it is proper to advert to cer- 
 tain procedures in which closure has been attempted, and some- 
 times attained by plans which may be called non-operative. 
 Among these may be mentioned the plan of cauterization, wdiich 
 was practiced by Cloquet. Observing that contraction followed 
 burns, in 1855, Clocj^uet counseled to use this means for the clos- 
 ure of palatal and labial clefts in subjects who are unfit for 
 plastic operation. Cloquet does not cauterize the entire cleft but 
 only the angular end of the same: and this being repeated a 
 number of times, the efifect is similar to a number of sutures. In 
 this way, as early as 1826, Cloquet cured, by means of twenty 
 cauterizations, a palatal cleft which had arisen from constitu- 
 tional syphilis. Afterwards, in another case, in which the cleft, 
 having been closed by sutures, reopened, the opening was closed 
 by rej)eated cauterizations. In this manner, a palatal cleft of 
 traumatic origin was closed by Ndlaton. The objection to tins 
 method is that it requires so long a time; but the advantages 
 claimed for it by Cloquet are that it is attended by slight pain, 
 and the patient, during treatment, need not suspend his business. 
 To do the work, the galvanic cautery, the hot iron or the poten- 
 tial cautery may be used. Cloquet employed the nitrate of mer- 
 cury. Some years ago, this plan was used by the author to com- 
 plete closure in a case of cleft palate in which sutural closure had 
 been but partially successful; the ferrum candens was employed, 
 and the cauterization repeated a number of times, at intervals of 
 two or three days; thus proceeding, the breach was lessened but 
 not wholly closed. It is important in this work to cauterize onh^ 
 the angular end of the cleft. 
 
 Spessa, in 1844, announced that he had cured cleft palate by 
 simply paring the edges of the opening, and then repeating this 
 every fifteen or twenty days; and Spessa advises that the same 
 be done to close hare-lip or vesico-vaginal fistula. 
 43 
 
660 PALATAL CLEFT OR DIVISION. 
 
 Near the same time, Dieffenbacli advised to close small 
 clefts by applying to the margins of the breach the tincture of 
 cantharides; and this should be repeated as soon as the vesicated 
 surface has healed. Other surgeons report closure in this way; 
 and it seems that it was chiefly resorted to in cases in which an 
 operation to etfect closure had not been wholly successful. 
 
 Staphylorraphy is an operation for the closure of a palatal 
 cleft which is limited to the soft palate; and the work would be 
 of a very simple order, were it not for the almost unapproacha])le 
 site of the parts which are to be operated on. The operation, in 
 its simplest form, consists merely in trimming the opj)osite bor- 
 ders of the opening, and then coaptating and holding these 
 together by suitable sutures: surgical acts so simple, if the breach 
 were on the outside of the body, that they would not deserve 
 mention, much less would they merit a special name. But this 
 breach lies in the inmost recess of the alimentary vestibule, to 
 which light has not ready ingress; the fragmentary structures 
 are well supplied with sentient and motor nerves, so that when 
 touched on either their buccal or nasal side, they are thrown 
 into spasmodic contraction, which may be propagated downwards 
 to the stomach, and provoke vomiting; and finally, an almost 
 insuperable difficulty may be encountered in the scantiness of the 
 structures; too short, in fact, to form a complete bridge across the 
 gap. Hence, the energies of mechanical invention have been 
 stimulated to devise means to overcome these obstacles; and 
 among these aids may be mentioned gags, tongue depressors, 
 palatal supporters, specially contrived needles, needle-holders, 
 sutures, suture-clasps and sponge-holders. Myotomy and lat- 
 eral incisions have been made tributary allies in this surgical 
 work. 
 
 An important preliminary is to so discipline the jtalatal and 
 pharyngeal structures that they will yield quiet obedience to the 
 attacks made on them. The reflex sentinel who awakens these 
 parts to their destined automatic action, must be made to tempora- 
 rily sleep on his post; and this is done by so multiplying the 
 movements of the parts that they finally cease to act. This is 
 brought about by often touching the parts with some irritating 
 object. The adult may do this himself, but if the patient be a 
 child, the parent or nurse can do it. As instrument for this irri- 
 tation, two or three stiff feathers may be tied together, and the 
 plumed end employed; or the work can be done very successfully 
 with a small tooth-brush. If such preliminary training be dili- 
 
STAPHYLORRAPHY. 667 
 
 gently continued for a couple of days, the reflex movement will 
 be so subdued that it will not interfere with the operation. 
 ■Jb Though the cleft may quite divide the soft palate, yet some- 
 times there is an amplitude of tissue to quite close the gap, with- 
 out tension. In these cases, in the act of swallowing, the two 
 sides approach and touch each other. Such was the character of 
 a cleft in a young Canadian physician, who applied to Roux in 
 1819 for treatment of his real formation; the operation was a 
 successful one, and Roux added another name to surgical nomen- 
 clature by naming the work done, staphylorraphy. And it is in 
 cases of this character that the operation promises the best 
 results. 
 
 When should the closure of congenital palatal cleft be done? 
 A citation of the opinions given in answer to this question would 
 burden the reader with confusing differences; some would do the 
 operation when the child is a month old. Ehrmann operated* 
 when the child was five months of age; some would do it any 
 time during the first year of life ; Bihroth and Owen would oper- 
 ate when the child is three or four years old; Trelat operates 
 after the subject has reached puberty. Hence the surgeon 
 finds authority which sanctions the operation at any age. 
 The mortality which has followed the work done on young 
 infants shows that early operations are very fatal. The condi- 
 tion of the cliild's health should be considered quite as much as 
 its age. This rule was enjoined by Thos. Smith, who states that 
 in a series of fifty infants which were brought to him for opera- 
 tion, he selected not more than one in eight of the number. This 
 is an important rule to be observed, not only in the operation for 
 cleft palate, but in all other surgical operations on infants; the 
 feeble, sickl}^, emaciated and ill-nourished infant will generally 
 succumb to the surgeon's knife; to such should be accorded the 
 right which Dupuytren chose foi himself, when, in declining an 
 operation for empyema, he said that he " preferred to die by the 
 hand of God rather than by that of the surgeon." The child, 
 however, which is in robust health, will readily bear the opera- 
 tion, even though it be done in the early months of life, and this 
 vigorous health, rather than months or years, best indicates the 
 period suited for the operation. Staphylorraphy is extremely 
 difficult to do in the infant, in consequence of the small space in 
 which instruments must be used. 
 
 As instruments there are required a mouth -gag, a knife or scis- 
 sors for trimming, clasp-forceps to catch and hold the margins of 
 
668 I'ALATAL CLKFT OR DIVISION. 
 
 the cleft, sharp, strong, curved needles and a needle-holder, tine 
 gilded or plated copper wire for suture, small sponges and sponge- 
 holders, and ice water. 
 
 As gag or instrument to retain the mouth open, that of Smith 
 is most commonly used. This depresses the lower jaw and 
 tongue, and retains the mouth well open. It does, however, more 
 than this, it forces the tongue backwards; and this is a serious 
 defect of the instrument : so much so that in using it, the author 
 has been compelled to attach clasp-forceps to the tongue, and 
 thus draw the latter forwards during tlie work. And to avoid 
 this, the writer would use the interdental gag, which has already 
 been mentioned in the chapter treating of excision of the tongue. 
 The wedge-shaped portion of this gag has a hollow face above 
 and below, so that it can be inserted between the upper and lower 
 jaws, and thus the mouth is retained fully open. Anotlier simi- 
 • lar contrivance is one in which to the inserted wedge is fastened 
 a strap which ends in a short hook -shaped retractor; this adjusta- 
 ble strap is carried behind the head, and the retractor hooked in 
 the angle of the mouth. This instrument is self-holding; yet it 
 requires attention, lest the interdental portion slip and allow the 
 jaws to close. Simon of Prague, who recommends an early 
 operation in the child, sometimes used a mouth-dilator which is 
 always accessible, viz., the finger of an assistant, which, inserted 
 into the mouth, retained the latter open. The writer fears that 
 precept here was not illustrated b}'^ example. 
 
 A scalpel with short blade and a long handle, or long-handled 
 scissors, are needed to trim the edges of the cleft. The short 
 blade of the knife should have a straight edge, and end in a 
 sharp point. The scalpel is better than the bistoury. Some 
 operators prefer to trim with scissors, claiming that the raw 
 margin can thus be made straighter than with a knife. Long- 
 handled clasp-forceps must do the work of seizing and fixing the 
 free border in the work of trimming. Short, rounded needles, 
 with moderate curve, are needed to carry the sutural material; 
 also a needle-holder, to carry the armed needle. There are sev- 
 eral patterns of this instrument, and, in its stead, one may use 
 clasp-forceps to carry the needle. Instead of the needle and 
 holder, the two may be combined in one instrument, consisting 
 of a long handle and curved and shaped as a needle, with eye 
 near the point. The handle and needle portion are in one com- 
 mon piece; or the needle portion may be separable from the 
 handle-bearing part, so that it can be screwed on, and unscrewed, 
 
STAPHYLORRAPHY. 669 
 
 as required. Instead of this, a tubular needle is used by some 
 operators; this is hollowed through the handle and needle por- 
 tion, so that the sutural material can traverse it, and be protruded 
 to the extent which is needed. The hollow needle carries wire. 
 The objection to this instrument is tliat the needle portion must 
 be thicker than a common needle, to insure against breaking. 
 Langenbeck in 1860 announced that he used a long-handled 
 needle which w^as fashioned after the form of Bellocq's naso- 
 pharyngeal canula. The tubular portion had a sharp needle- 
 like end, which was passed through the edge of the pared margin, 
 when the contained spring was thrust out, and the thread 
 fastened to this and drawn through t^ie edge. With such an 
 instrument Langenbeck found that he could introduce the sutures 
 with great rapidity. A fault of the hollow needle is that it 
 makes an orifice much larger than the thread or wire which it 
 conveys; thus, cutting on the part of the suture is favored. 
 
 The material for suture may be wire, silk or horsehair. Silk 
 is less used than formerly. Though horsehair is highly advo- 
 cated b}'' those who have used it, yet it is not in general use. Silver 
 wire, or copper wire that has been coated with silver or gold, may 
 be employed. Leaden w^ire was used in the early palatal opera- 
 tions; it soon fell into disuse. The writer prefers gilded copper 
 wire, since it is stronger than pure silver wire, and hence, finer 
 thread of the former can be used. The difficulty in the use of 
 silk is to tie it closely, so as to hold the parts in contact. Tying 
 a knot in the bucco-pharyngeal recess is not easily done. But 
 the inserted wire may be closed by twisting the ends together; 
 and the final tightening may be done with clasp-forceps. Or the 
 wire may be closed by means of a wire twister; an instrument 
 with a figure-of-eight end. The sutural closure should not be too 
 tense, lest the included tissue be so constricted as to die; and then, 
 though union of the sides may be obtained, small openings will 
 be left at the site of the sutures, which will rec[uire some time to 
 heal. 
 
 If one examines the history of staphylorraphy, he will find 
 described many more instruments which have been devised and 
 used in the work; in fact, the writer has mentioned but a min- 
 imum of those W'hich have been invented; yet those here 
 described, when their use has become facile through experience, 
 will be found sufficient. The patient who has fasted for eight 
 hours must be placed in a recumbent position, with the shoulders 
 somewhat uplifted, and the face so turned backw'ards that when 
 
070 I'ALATAL CI.KFT OK DIVISION. 
 
 the mouth is dilated the hght will fall on the palatal roof. The 
 patient should be so placed that the light can enter at the side of 
 the operator, rather tluin from beliind. To illuminate the buccal 
 cavity, light, artificial or solar, may be reflected into the cavity 
 by a mirror proi)erly placed. 
 
 Children, and also adults, should be anassthetized ; only 
 exceptionally in the adult, who ])refers to be a witness of his 
 operation, may this rule be dispensed with. Yet there is not 
 unanimity of authority on this point. In 18G8, in the lioyal 
 Medico-Chirurgical Society this subject was discussed by the 
 members. Smith and Annandale advised anaesthesia; others 
 opposed it; Prescott Hevvett reported that he thus lost one case. 
 And the same occurred to Langenbeck, the patient dying from 
 the blood passing into the air-passages. And in another patient, 
 Langenbeck barely saved life by performing tracheotomy and 
 sucking out the blood that had escaped into the bronchi. Despite 
 these accidents, the custom is to ancesthetize the patient, and with 
 due care in spraying out tlie escaping l)lood with sponges which 
 have been dipped into iced water, the bleeding will be controlled, 
 and but little blood will escape downwards. 
 
 The mouth being retained open by the dilator, the surgeon 
 seizes the margin of the cleft on the patient's right side, near the 
 middle of the border, with clasp -forceps, and holding this in his 
 left hand, and having drawn so as to make the part tense, he 
 inserts the point of his angular knife near the forceps and then 
 trims off the entire border upwards and downwards from the 
 uvula to the summit of the cleft. And the same must next be 
 done on the remaining side. Particular care must be used to 
 trim the anterior angle, since a fragment of mucous membrane 
 remaining would obstruct the desired closure. The lateral trim- 
 ming should be done slopingly, one side inclining forwards and 
 the other backwards; thus done, broader and congruent marginal 
 faces are formed, adapted for union. After the marginal excision, 
 the remaining raw surface will broaden through the retraction of 
 the divided mucous membrane. Such retraction may be due to 
 the recoil of the mucous membrane which has been displaced 
 towards the median line, by the traction done with the clasp- 
 forceps. In place of grasping the margin of the cleft, the uvula 
 may be seized with forceps and the parts thus drawn in any 
 direction most convenient to do the trimming. Instead of grasp- 
 ing and fixing with forceps, Thiersch and Le Fort pass threads 
 through the parts of the- cleft uvula; and these threads may be 
 
STAPHYLOERAr^HY. 671 
 
 held by an assistant, and thus each side can be drawn on as is 
 needed in the work. 
 
 In tlie marginal trimming the operator must suspend his 
 work, every minute or two, to permit the assistant to sponge out 
 the blood. This is done with small sponges carried by special 
 holders or clasp-forceps, the sponges being cleansed and cooled 
 in iced water. Thus proceeding, there is no danger of much 
 blood entering the air-passages. Though these interruptions 
 prolong the operation, they secure against coughing and asphyxia. 
 The writer, who has seen palatal closure done by Sir William 
 Fergusson, was often an admiring observer of the tireless patience 
 of this veteran surgeon; not unfrequently, the operation occupied 
 a large part of the short afternoon of winter in London ; his 
 standing remark to his class was, "Those who wait to the end of 
 this operation deserve a premium." Yet it was this patient work 
 that enabled Fergusson in 1885 to record fifty-six operations with 
 but two failures. 
 
 In the case here supposed, in which tlie sides can easily be 
 united without lateral incisions, or division of the palatal mus- 
 cles, the operator next proceeds to the introduction of the sutures; 
 and, as already mentioned, these may be passed with a long- 
 handled needle, or with short curved needles, carried by a 
 holder. The operator will do well to learn each of these ways, 
 since one is sometimes more convenient than the otlier. To use 
 • the long-liandled needle, of which the eye is near its point, let 
 the wire enter the eye on the curved side of the needle; for if 
 thus inserted, after the needle has carried the wire through the 
 margin, the wire can be caught with a tenaculum, and withdrawn 
 from tlie needle. But if the wire be passed through from the 
 convex side, then its extraction from the needle will be much 
 more difficult, since after passing through the tissues, it will lie 
 on the side of the needle farthest from the operator. 
 
 The needles which are carried by a holder should be round 
 and of annealed metal; if more fragile needles are used, they may 
 break in being forced through the palatal structure. The wire 
 used should be at least two feet long, it should have a needle on 
 each end, and after being passed through the needle, the wire 
 should be so twisted that it cannot escape from the needle's eye 
 during the passage. Some practice is needed to grasp the needle 
 ■with the holder in such a way that the former can be made to 
 pass properly througli the margin; to do so, let the needle be 
 grasped so as to form an acute angle with the holder; and thus 
 
072 PALATAL CLEFT OR DIVISION. 
 
 held, let it be passed from the nasal side, and emerge on the 
 buccal face; and then the needle on the other end of the wire 
 must be passed through the oj)posite margin. The two needles 
 being removed, the ends of the wire are carried over the patient's 
 head, and temporarily twisted together. This first suture should 
 lie near the anterior angle of the cleft; and it is the most difficult 
 one to place. The remaining sutures are to be passed in a similar 
 manner, at intervals of a quarter of an incli, from the anterior 
 portion of the breach to its uvular ending; that is, the work 
 should proceed from before, backwards. Tliree or four sutures 
 are commonly sufficient to effect the closure of a cleft which 
 traverses the entire soft palate. The wires are next to be closed 
 in the order in which they were introduced from before back- 
 wards; the closure being best done with a wire twister. This 
 closure should fully coaptate the two sides, which, in the case 
 under consideration, contain material enough to unite without 
 tension. And the sutures being closed, tlie wire is to be severed, 
 and the ends of the suture bent to one side, so that they will lie 
 close in contact witli tlie wall above. If there be observed gai)ing 
 between the sutures, this may be closed by a more superficial 
 suture, which is inserted by means of a needle that is much 
 curved, and made to traverse and include both sides. 
 
 The operation being done, the patient should be placed in 
 bed and remain quiet for a few days. The food used should be 
 liquid, or such as can be swallowed with the least efibrt. The 
 buccal cavity should be cleansed every few hours; and for this 
 purpose mint- water may be employed; the patient if intelligent 
 may do this himself. No effort of gargling must be made. The 
 work of cleansing may be done by means of a syphon-like irri- 
 gator, by which a fine stream of fluid may be brought into the 
 various recesses of the buccal cavity. In ciiildren, irrigation is 
 the most convenient way of doing this work. Speech is to be 
 restricted to whispering; and this limited to the words, yes and no. 
 
 In respect to the time when the sutures should be removed, 
 authorities differ, the time given varying from four to ten days. 
 From the writer's experience, sutures should remain longer in the 
 child tlian in the adult; in adults, the removal can usually com- 
 mence on the fifth day, when every second one may be with- 
 drawn, the work beginning with the second one from the uvular 
 portion; the remaining sutures may be removed about the tenth 
 day. In children, the writer leaves some of the sutures a much 
 longer period ; and none should be removed before a week has 
 
STAPHYLOREAPHY. 673 
 
 elapsed. If the child be refractory, care must be taken lest, in 
 the act of withdrawal of the wire, some restive movement may 
 tear apart the united edges; but if a long time has elapsed, then 
 the union has probably become so firm that there is little peril of 
 separation. In a few instances, the writer has allowed some of 
 the sutures to remain in place for a month; in one case they 
 remained a still longer period. Sutures permitted to remain a 
 long time, should be cut short. Sutures which are thus allowed 
 to remain, by their presence excite some irritation, which lessens, 
 and tends to close the separated spaces. To remove the suture 
 seize it by the twisted portion, divide the wire on one side of the 
 twist, and then, drawing on the latter, the wire will easily be 
 withdrawn. 
 
 The sutural union as above described, suffices for all cases in 
 which there is an amplitude of tissue ; frequently, however, the 
 structures are so defective that, after being pared, they cannot be 
 juxtaposed; or, if it be possible to unite them, the parts are so 
 tense that the soft jDalate cannot perform its normal functians in 
 the acts of swallowing and speaking; for iu such tense state, in 
 deglutition, the materials can enter the choan«; and in speaking, 
 the tone of the voice is nasal in character. Hence, to lessen these 
 functional defects, certain collateral stej)s or procedures are some- 
 times resorted to; and these may precede, accompany or follow 
 the sutural closure. 
 
 To avoid or lessen tension, Sedillot, who has studied this 
 matter, finds tliat it has been done in one of the following ways: 
 
 1. Lateral incisions were made by Dieffenbach and Liston. 
 
 2. Mettauer, of Virginia, made four semilunar cuts, six lines long, 
 curved externally, on each side of the palatal opening. 3. "Warren 
 divided the anterior pharyngeal arches; others, however, divide 
 the posterior pillars. 4. Fergusson divided the muscles above 
 the soft palate, viz., he severed the levator and tensor palati 
 muscles, and this was done by a knee-shaped knife, which is 
 passed above the palatal veil, and caused to cut from above 
 downwards on each side; and when this is done, the soft palate 
 remains motionless. In this section, Fergusson left the surface of 
 the soft palate intact. Sedillot favors a combination of the 
 methods of Fergusson and AVarren ; after such section, one is 
 surprised at how much the existing breach is narrowed. Sddillot 
 advises that the division of the muscles precede the trimming of 
 the borders. 
 
 Smyly divided the muscles on the nasal side of the soft palate; 
 
674 PALATAL CLEFT OR DIVISION. 
 
 his method, announced in 1862, was to pass a long-handled knife 
 along the floor of the nostril, the blade resting at the hamular 
 process of the pterygoid i)late; then, while the finger presses up 
 the soft palate from below, the knife divides all the muscular 
 fibres which act on the soft palate. 
 
 Instead of severing the palatal muscles. Gay, in 1852, loosened 
 and dissected up the soft palate from the bony palate. 
 
 To quiet the palatal muscles. Pitha made an incision in the 
 soft palate itself; this he did by inserting the knife near the ham- 
 ular process, and cutting thence forwards and inwards, until he 
 reached the long arch. 
 
 Besides these adjuvant incisions of the arches, and division of 
 the palatal mu.scles, if sufficient laxity of parts is not obtained, 
 one may make lateral longitudinal incisions through the sides of 
 the soft palate, near the lateral attachment of the soft palate; such 
 incision was done by Sedillot,and many other 0})erators; and the 
 Avriter may add that it is his custom to make such lateral incis- 
 ions in nearly all cases. These cuts, one or two, may be made on 
 each side, and tliey may reach quite through the velum; or, as 
 Friedinger advises, these lateral cuts may reach but partially 
 through. To maintain these cuts open when they reach through 
 the velum, tiie writer and others have inserted in them plugs of 
 lint, which were allowed to remain in place for a few days. To 
 relieve tension, one or more of tlie plans mentioned may be 
 employed; but to correct the defects in phonation which are 
 often found to remain after the operation of staphylorraphy, 
 certain corrective procedures have been advised; but before 
 describing these, the nature and cause of the vocal defect should 
 be treated of. 
 
 According to the studies of Czermak in this field, speech of 
 normal sound demands a temporary closure or separation of the 
 nasal passages from the bucco-pharyngeal cavity; and this closure 
 is done by the soft palate. During the production of nearly all 
 the articulate sounds, the choante must be shut ; in the formation 
 only of the nasal sounds, m, n and no, must the choanse remain 
 open. The remaining sounds, both vowels and consonants, 
 require for normal expression the complete closure of the choanse; 
 and if such closure does not exist, all the sounds are of nasal 
 character. And this is most apparent in the sounding of the 
 labial, lingual and palatal consonants. And in case of extensive 
 labial clefts, the sounds of e, g and z cannot be correctly formed; 
 r is changed to erl; p, q and t lose their sharpness, while the 
 
STAPHYLORRAPHY. 675 
 
 vowels are not pronounced clearly and distinctly. And if there 
 be a cleft through the hard palate, this interferes more with 
 articulate speech than does a cleft through the soft one. The 
 subjects of such defect become timid and prefer silence to speech; 
 their language is limited and monosyllabic. 
 
 The closure of the cleft in the soft palate where the defect has 
 been limited to that part, has often disappointed both the patient 
 and the surgeon; in fact, this disappointment has sometimes 
 been so great that the patient has asked to have the closed parts 
 reopened. 
 
 In order to improve phonation Billroth operated at an early 
 age; he found, however, that the voice was not thus materially 
 improved. 
 
 Trelat taught that the subsequent improvement of the voice 
 •depended much on the antero-posterior diameter of the pharyngo- 
 buccal cavity; if this diameter be short, the improvement will be 
 much less than if the diameter be a long one. These conditions, 
 whether favorable or unfavorable, are unchangeable, and must 
 be accepted by the operator. 
 
 Passavant, who made this subject a matter of research, 
 announced, in 1863, that defective phonation was due to the 
 palatal tension, and the inability to close the choanse; and as 
 corrective means, Passavant advised to effect adhesion between 
 the palatal veil and the wall above; he recommended to form 
 adhesion between the median .portion of the soft palate and the 
 wall of the pharynx, so that only small orifices may remain. 
 
 Bearing on this subject Pitha made the observation that the 
 voice was materially improved in a patient in whom tijere was 
 accidental closure of the choanne. Pitha furtiier concludes that 
 the uvula performs some part in the production of voice, and 
 hence, in his operations for closure of cleft palate, he preserved 
 the uvula; or if this part did not exist, he endeavored to form one. 
 
 Mason, an English surgeon, to improve the voice after closure 
 of the cleft palate, cat away the soft veil from the pterygoid proc- 
 esses, on each side, close to the hamular process; the intention of 
 such section was to allow the closure of the choanse by the pen- 
 dulous palate. 
 
 To improve the condition after staphylorrhaphy, Langenbeck, 
 in 1885, advised to apply electricity to the parts, and to practice 
 massage of the throat, and in the latter work the fingers must 
 be introduced into the throat, and the structures rubbed and 
 kneaded. 
 
67(3 PALATAL CLEFT OR DIVISION. 
 
 After the staphylorrhaphic procedure has beeu done, should 
 the work not have beeu wholly successful, and one or more gaps 
 remain, the operator should not hasten to repair these defects; 
 for undue haste, through the reopening of the points of adhesion, 
 may lose what has been gained. But after three months have 
 elapsed, such remaining gap may be trimmed and closed by 
 suture. If the opening be small, closure may be attempted by 
 cauterizing with the hot iron, nitrate of silver, or by cantharidal 
 vesication. 
 
 In the case of cleft in the soft palate which has been acquired 
 by wound or disease, closure may be attempted by some of the 
 methods described for closure of congenital cleft. If the breach 
 be a wound, of which the edges are raw, closure may be done by 
 simple suture; but if the wound has cicatrized, leaving an open- 
 ing, pare tiie borders of the latter and unite by suture. But when 
 the breach has originated from disease, an attempt at closure 
 should not be done until the tissues around the opening have 
 become sound or freed from any scrofulous or syphilitic taint, 
 which has been the cause of the palatal perforation. If the cause 
 be syphilitic, which is the usual one, the patient must first be 
 submitted to a course of appropriate treatment for a number of 
 weeks, until the disease has yielded; then such o])eration can be 
 done with a prospectively successful event. If there has been but 
 little loss of structure, the work can be done by trimming and 
 sutural closure; but if tlie breach.be a greater one, then lateral 
 incisions must be made, on one or both sides, so as to admit of free 
 movement towards the median line. 
 
 The lateral incisions which are made to aid in the closure of 
 congenital or acquired palatal cleft, sliould, in most cases, reach 
 quite through the soft palate, and must be from a half inch to an 
 inch in length, and should be made near the lateral, attached 
 part of the pendulous veil. In some cases the writer has made 
 these liberating cuts after .sutural closure of the breach; for if 
 thus done, they may be incised where there is the greatest tension. 
 
 The lateral subsidiary incisions in the soft palate soon close; 
 and so rapid is this healing that some operators have maintained 
 them patent for a time by means of plugs of lint inserted in lliem 
 for three or four days. There is no danger that these openings 
 will not heal; for plastic nature, so tardy in the median line of 
 the palatal vault, redoubles her effort to repair breaches along 
 the sides of the roof of the mouth; slie seems indulgent of a 
 central breach, but cannot tolerate a lateral one, and the impor- 
 
URANOPLASTY. 677 
 
 tant principle here figuratively expressed is the underlying 
 groundwork on whicli rests the chief operative procedures 
 resorted to for the closure of clefts through the long palatal 
 vault: procedures to which the reader's attention is next directed. 
 
 Uranoplasty. — Uranoplasty is derived from Ouranos, signifying 
 the sky or firmamental vault, and plazein, to mold; and the pro- 
 cedure dates from 1824, when Krimer, a German, made the first 
 effort to close a breach in the osseous vault. The operation was 
 done on a girl eighteen years of age, in whom Krimer dissected 
 up two lateral flaps, turned them over, and shifted them over the 
 gap. The work was only partially successful. Near the same 
 time, Diefifenbach performed a similar operation with only partial 
 success. Diefifenbach proposed to divide or split off a portion of 
 the bony roof, and push this into the opening. This operation, 
 as well as another one proposed by Dieffenbach, in which the 
 palatal bones should be united by silver wure, seems never to 
 have been done by him. In 1850 Biihiing wrote that he had 
 performed such an operation for the closure of a cleft which was 
 two-thirds of an inch wide; following Dieffenbach, whom he cites, 
 Biihring split off the margins, and forced these towards each 
 other by means of lint, which was stuffed in the lateral openings. 
 As Biihring had neglected to pare the edges, there was no union 
 until, at a later period, he trimmed the borders, reopened the 
 lateral openings, introduced waxed silken sutures, and thus suc- 
 ceeded in getting closure. In the same year, Wutzer published 
 an account of similar operative work; he announced that, in 
 1834, he had closed the bony palate in a young man as follows: 
 cuts which exposed the bone were first made antero-posteriorly, 
 two lines from the border of the cleft, and then a knife was thrust 
 through the soft palate at the junction of the latter with the 
 osseous palate. Through such orifice made on each side, a small 
 saw, made from the mainspring of a watch, was passed and the 
 bone sawn through from behind forwards. Through the lateral 
 clefts thus made with the saw, strong threads were passed and tied 
 so as to approximate the long bony bridges. -In this way partial 
 union of the bridges was secured; the gaps which remained were 
 made to close by means of tincture of cantharides. In this man- 
 ner complete closure was obtained, yet phonation was not much 
 improved. 
 
 Roux, who had done so much in the field of staphylorraphy, 
 at an early period, announced five uranoplastic operations, of 
 which three proved successful. Uranoplasty, first proposed and 
 
678 PALATAL CLEFT OR DIVISION. 
 
 done on German soil, was cultivated and attained great perfection 
 in the hands of Bernard von Langenbeck, who published, in 1860, 
 an exhaustive account of his method. He first reviews the 
 method of Dieffenbach of splitting off parts and sliding these 
 inwards; also, his own efforts to close the breach by uplifting and 
 displacing inwards the palatal mucous membrane; but the 
 unsatisfactory results gotten by these ways of operating, led 
 Langenbeck to try a third method, in which he used, as repa- 
 rative material, the muco-periosteal covering of the hard palate. 
 He was emboldened to try this plan from having observed that 
 the detachment of the periosteum does not endanger the life of 
 the uncovered bone; also, that tissue, which is invested with 
 periosteum when placed on naked bone, will adhere to it; and 
 finally that when tissue is shifted which carries periosteum, the 
 latter will produce l)one in its new situation; and thus the new 
 bone will fortify and strengthen the transplanted structure. In 
 his first essays, from the want of proper instruments, Langenbeck 
 was unsuccessful ; later he was more fortunate, when he was 
 armed with the following instruments: (1) Blunt hooks to pull 
 back the angles of the mouth. (2) Mouth mirror and tongue- 
 depressor. (3) Long-toothed forceps. (4) Assorted knives, one 
 lance-shaped, one with a convex edge, and a third one of sickle- 
 shape. (5) A raspatory. (6) Elevators. (7) Xeedle-holders. 
 (8) Thread of different colors. (9) Thread holders to hold and 
 separate the threads which have been passed. (10) Sponges, 
 syringes and forcej)s. 
 
 This armament of instrumental equipment is greater than 
 that used by many operators; the mouth mirror and tongue- 
 depressor were not used by Dieffenbach, wdio says: "One must seize 
 the proper moment, as he who would shoot a swallow on the 
 wing. And hence, one must not use corks which are forced 
 between the teeth to hold the mouth open; nor should the tongue 
 be depressed with spatula or handle of a spoon, in order to see 
 better antl have more room to work in." 
 
 Langenbeck begins by seizing the uvula, or side of the soft 
 palate, and then he trims off the border from behind forwards. 
 Trim from without inwards, since thus more of tiie mucous mem- 
 brane will be removed. Next, the levator palati and the palato- 
 pharyngeus muscles are to be severed; the latter is incised by 
 a cut, which penetrating near the hamular process cuts from 
 without inwards and forwards. This incision avoids t?ie pos- 
 terior palatine artery. The hard structures which invest the 
 
URANOPLASTY. 679 
 
 bony roof are next to be divided on eacli side by an incision 
 which passes along the alveolar process close to the teeth and 
 reaches to the bone. These lateral cuts begin at tlie incisions 
 that were made to divide the muscles; and they terminate at the 
 interspace between the inner and outer incisor teeth. Or if tlie 
 closure can be accomplished by one lateral flap, let this end in 
 front at the space between the outer incisor and the bicuspid 
 tooth. The bridges are a third of an inch wide in front; and 
 the palatal artery enters them behind. The bleeding that fol- 
 lows can be arrested by pressure or cold water. Next detach this 
 bridge from the bone, commencing in front; and in the separa- 
 tion be sure that the periosteum is uplifted. The detachment of 
 the structures is easily done behind; in front it is tedious, and 
 must be done cautiously. 
 
 When the detachment has been completed to near the pos- 
 terior edge of the osseous roof, the posterior or upper mucous 
 covering of the velum is to be divided, and the separation of the 
 parts is then to be continued until the swinging bridge is quite 
 detached from the horizontal palatal plate; and when this is 
 done, the bridge swings freely and the two are actually in contact. 
 The sutures are next inserted, of which the number may vary 
 from ten to twenty-two; and these must be introduced from 
 before backwards. Langenbeck begins to remove the sutures on 
 the fourth day, and finishes on the tenth day. 
 
 After the operation the patient is to be fed on liquid food; and 
 to allay tliirst ice may be given. 
 
 Gangrene occurred in no case. There was much swelling of 
 the shifted structure, so that the lateral vacant spaces were nearly 
 covered on the day following the operation. This swelling was 
 due to the tumefaction of the uplifted periosteum. And in no 
 case was there necrosis of the bone. The periosteum of the 
 shifted structure, which was placed on the inner edge of the gap, 
 seemed to quickly adhere to the subjacent bone; and this 
 adherence tended to lessen the cleft, in case the bridges failed to 
 unite in the median line. New bone was produced from the 
 periosteal surface of the flap that covered the cleft; such new 
 osseous growth was verified in two cases, which had been operated 
 on by Langenbeck. 
 
 Langenbeck urgently insists that uranoplasty should be done 
 before staphjdorraphy; also that staphylorraphy should not be 
 done in infants, since, througli its interference with swallowing, 
 nutrition is interfered with. Two children, between one and a 
 
680 PA LATA r, (LEFT OK DIVISION. 
 
 lialf and two and a lialf years of age, operated on for closure of 
 the soft palate, died from not taking food ; uranoplasty^ might be 
 done at an early age, since it does not seriously interfere with 
 swallowing. 
 
 Urano{)lasty gave much improvement in speech; and this 
 was much greater if the operation was done before twelve years 
 
 of age. 
 
 Soon afterwards, Langenbeck reported forty-two operations of 
 uranoplasty; in some of the patients the cleft was wide, being 
 an inch or more in breadth, and the sides stood nearly vertical. 
 
 In some of tlie patients, he let one lateral incision end at the 
 inner incisor tooth, and the other at the canine tooth. Having 
 found that the swinging bridges often sank too low when the 
 sides of the cleft were vertical, to correct this, Langenbeck 
 resorted to the device of intermediate attachment; this consisted 
 in leaving the flap adherent to the bone adjacent to the first 
 molar tooth. Such a peduncle of adhesion on each side, pre- 
 vented the excessive swaying downwards of the swinging bridges. 
 Both silk and silver sutures were used; yet preference was 
 given to silk. 
 
 In some cases, in which one or both sides of the palatal bones 
 stand vertical, Langenbeck varied the operation somewhat from 
 the plan above given; in place of lateral peduncular attachment, 
 he made an attaclimcnt to the vomer, which, for this purpose, is 
 to be denuded, so that the uplifted flap can be sutured to it. 
 This may be done on one or both sides, according as one or both 
 palatal margins lie in vertical position. 
 
 As has been mentioned, Langenbeck let the uranoplastic 
 operation precede that of staphylorraphy in cliildren; but in 
 adults he advised that staphylorraphy should precede urano})lasty. 
 Langenbeck claimed that operations iu which palatal closure 
 was done materially improved the voice; and that the improve- 
 ment continued until the lingual defects nearly disappeared. 
 
 Soon after this publication, the English surgeons claimed 
 that a similar operation had been done by tliem; Hulke asserting 
 that both Fergusson and Pollock uplifted the i)eriosteum along 
 with tlie mucous membrane, in tlie flap that was used for closure 
 of the palatal breach. But while tlie.se discussions in regard to 
 priority were in action, Fergusson resuscitated the abandoned 
 method of Dieffenbach, in which, on one or both sides of the 
 cleft, portions of the palatal bones are split off, and moved 
 median- wards into the breach; and in 1876 he reported fifty-six 
 
URANOPLASTY. 681 
 
 operations, in which there were but two failures; and the 
 announcement of this successful work gave favor and fashion to 
 the osteo-plastic procedure. A plea in favor of this procedure 
 is that it dispenses with the tedious dissection of the muco- 
 periosteal tissue. And if the cleft reached through both the soft 
 and the hard palate, the closure of both was comprised by Fer- 
 gusson in one operation. 
 
 To perform this operation, the work begins with paring the 
 edges of the cleft along its total length; then an incision should 
 be made on each side, parallel with the alveolar process, but 
 somewhat internal to the latter, quite through the muco- 
 periosteal structure. These lateral incisions begin in the soft 
 palate, and extend forwards to within a few lines of the alveolar 
 arch. Through the bone thus exposed, the blade of a chisel may 
 be forced, either with the hand or with a mallet. To make the 
 entrance of the chisel more easy, and to prevent fissured deflec- 
 tion of the osseous wound, Fergusson was accustomed to first 
 pierce the bone with a number of openings by means of an awl- 
 like instrument. It may be recalled that Dieffeiibacli used a 
 three-angled borer, with which he pierced the bone in the oper- 
 ation of closing palatal cleft. The chisel, with which Fergusson 
 split off the bone, was used as a lever to pry or force the frag- 
 ment inwards. The lateral portions being thus prepared, sutures 
 are introduced, and the parts united. In the lateral openings, 
 lint was introduced. The sutures, in most cases, merely passed 
 through the soft structures; should this not be feasible, holes 
 may be drilled through the detached parts, and the sutures passed 
 through their margins. Or, as Fergusson sometimes did, the 
 sutures may pass through the lateral openings., and thus closure 
 be done. 
 
 The writer, who has performed this operation several times, has 
 sometimes found difficulty in the union of the detached portions; 
 and this can occur where the breach is very wide; also in cases 
 in which one side of the horizontal palatal process is attached to 
 the vomer. In case of great breadth of breach, it requires sutures 
 of strong tension to effect median coaptation; and in such a 
 case, operated on by the author, the excessive pressure on the 
 detached parts by the wire in which they were included, caused 
 strangulation and death of a portion of the united parts; the 
 staphylorrajDhy was successful ; but the attempt to close the 
 osseous breach was a partial failure. Cases in which such a 
 result menaces the operator, are those in which, besides great 
 44 
 
082 PALATAL CLEFT OR DIVISION. 
 
 width of cleft, the structures which bound the cleft laterally are 
 atrophied, the bones reduced to thin plates, and their covering to 
 film-like tissue which is poorly su[)plied with blood. The writer 
 has seen such tissue which was almost like tendon in its bloodless 
 character. In patients having a cleft of this kind, it is wise to 
 leave the osseous breach untouched, and to limit the work to 
 closure of the soft palate; the opening which then remains may 
 be closed b}^ an obturator, which can be devised and constructed 
 by the mechanical dentist. 
 
 In cases in which there exist conditions similar to those 
 mentioned, or in which there has been failure to obtain union, 
 rather than abandon the patient to the unending annoyance of 
 wearing an obturator, there are other operative methods by 
 which closure may be attempted. For this purpose, occluding 
 material has been obtained in the nasal passages, from the 
 pharynx, from the adjacent alveolar wall, and from the contigu- 
 ous cheek; and, lately, a new mode of closure, from the remaining 
 palatal vault itself has been proposed by an English surgeon. 
 
 Lannelongue, in 187G, closed a cleft with material which was 
 obtained from the nasal septum; he since reports two closures 
 thus effected. 
 
 Schonborn, in 187G, reported the closure of a cleft in the palate 
 by means of material obtained from the wall of the pharj'iix. 
 The aim of Schonborn was to close the breach in such a way that 
 the posterior nares would be closed, and thus phonation improved. 
 To do tliis, a flap which was nearly an inch wide, and two inches 
 long, was dissected up from the pharyngeal wall, and this flap, 
 adhering below, was inclined forwards and sutured in the gap. 
 By such a procedure, Schonborn thinks a defective velum might 
 be repaired. 
 
 In 1868, Thiersch reported that, two years previously, he had 
 closed a breach in a hard palate, in which a uranoplastic opera- 
 tion had failed in the following unique manner: two teeth 
 were removed from the side of the upper jaw, and then a section 
 of the alveolar process was removed with a chisel. Through the 
 breach thus made, there was carried a flap which had been 
 formed from the entire thickness of the cheek. This flap was 
 over two inches long, and was fastened in the cleft by eight 
 sutures. The gingival integument was preserved so that the 
 exposed portions of the alveolar process were fully covered there- 
 with. The scar which remained in the cheek was not conspicu- 
 ous. A portion of the flap died, yet enough lived to greatly 
 
URANOPLASTY. 
 
 683 
 
 improve the patient's condition. An inconvenience, however, 
 was afterward experienced from the beard growing from the flap 
 which had been transplanted into tlie mouth. 
 
 The alveolar processes have furnished material for closure of 
 the anterior portion of the osseous cleft ; and as these cases are 
 often associated with hare-lip, in the operation of repairing the 
 lip, something may be done in closing the adjacent palatal 
 breach. When the bony cleft is a small opening, the closure of 
 the labial cleft in the infant will aid in the spontaneous closure 
 of the front portion of the palatal cleft; but if the latter be a larger 
 breach, then something more should be done, in case the patient 
 be a child. For this purpose, on one side in the bicuspid region, 
 divide the alveolar arch vertically with a small saw; and having 
 drilled holes through the process on each side of the cleft, pass a 
 sfilver wire through, and close the median cleft, leaving a lateral 
 one in the arch, which will afterwards fill up. In this work of 
 median displacement, care must be used to spare the dental 
 roots; neglect of this rule, cost the patient a tooth in a case 
 operated on b}'' the author. 
 
 Another procedure has been announced, in 1890, for the closure 
 of the osseous cleft; its author, Davies-Colley, proposes its use 
 especially in cases in which there has been a failure to get union 
 
 Figure 88. Showing Davies-Colley's uranoplastic procedure. 
 
 by some other method. The understanding of this procedure, is 
 facilitated by the accompanying diagram, Figure 88. To do 
 this, two flaps are to be constructed from the hard structures of 
 the bony palate. The first, formed on the broader side, is made 
 
684 
 
 PALATAL CLEFT OR DIVISION. 
 
 by an incision, which, commencing at a, near the last molar 
 tooth, runs forwards along the alveolar arch to h, near the 
 incisior teeth ; thence it curves inwards and runs backwards near 
 the margin of the cleft, until it reaches, at c, the soft palate. The 
 flap thus traced out is now to be carefully dissected from the 
 bone. Next an incision is made on the other side, which is to 
 begin near the anterior end of the cleft at d, and thence passing 
 outwards to the alveolar arch, it is to be carried backwards 
 along this arch to e, in the soft palate, where the cut ends 
 near the cleft. The structure, thus circumscribed, is to be 
 dissected from the bone, so that there will be formed a semi- 
 elliptical flap, which has attachment along the inner margin of 
 the cleft. This flap is now folded inwards so as to lie on, and 
 close the greater part of the palatal cleft. To retain this flap in 
 place, two or three sutures are used. Next, tlie pedunculated 
 flap from the other side is turned across the median line, so that 
 its raw surface will rest on the raw surface of the previous flap; 
 and this is retained in ])lace by a few sutures which pass through 
 its anterior end. Should this cros.sing flai> not readily reach to 
 the point where it is to be fastened, then the flap must be dis- 
 sected up somewhat more at its base. The procedure of Davies- 
 CoUey when completed is shown in Figure 89. 
 
 Figure 89. Showing the appearance after closure of tlie parts according to 
 the plan of Davies-Colley. 
 
 Davies-Colley, who recommends this operation in infants in 
 whom the breach is wide, or in whom an operation has failed, 
 gives the following as its advantages and disadvantages: its 
 advantages are that there is less haemorrhcige ; less bruising of 
 
URANOPLASTY. 685 
 
 the parts ; less sacrifice of tissue, less tension of flaps ; and it can 
 be performed at an early age, viz , between one and two years of 
 infancy. Its disadvantages are that the bony palate alone is 
 closed, and that an opening is apt to be left in the front part of 
 the cleft. 
 
 In concludingthe chapter on staphylorrhaphy and uranoplasty, 
 it must be added that, though surgery has accomplished here 
 some of its most commendable achievements, yet tlie best work 
 done seldom greatly improves the patient's defective speech; to 
 drop his ill sounds, and to acquire the normal shaping and 
 expression of the elements of articulate language, depend on the 
 individual effort of the patient; he is in the position of one who 
 learns a new language; he need not hope to reach faultless 
 excellence, yet perseverance will bring him towards such a goal; 
 possibly so near, that he will not differ much from the many who 
 have no palatal defect. Besides diligent practice in articulation^ 
 in which there must be repeated a series of words containing the 
 .defectively pronounced sounds, there should be practiced passjve 
 motion of the parts, in the form of friction, massage and knead- 
 ing. But to accomplish any great benefit, there must be an 
 unabated, untiring effort; fortunately, the desire to escape from 
 the chagrin which the sound of his voice continually renews in 
 the rational child or adult, is generally present as a prompting- 
 spur to such diligence. The implantation in the human lieart 
 of the desire to merit the approval of others lies at the foundation 
 of things great and small; it builds a bulwark in defense of pub- 
 lic morals; and equally awakens in the individual a dislike of his 
 abnormal feature or word, and inspires him with courage to- 
 break the fetters of such embarrassment. 
 
CHAPTER XX. 
 
 TOXSIL. 
 
 Surgicol Anatomy. — The tonsil's function, though the part is 
 so accessible to research and inspection, remains to be determined; 
 if a collection of lymphatic glands, as some contend, it has failed 
 to be the metastatic point for development of the elements of 
 malignant disease which may be located in the tongue, pliarynx 
 or choanae. It is composed of closed spheroidal spaces or vesicles, 
 which are adjacent to depressions which mark the surface of the 
 tonsil; and from the resemblance of this surface to tliat of an 
 almond, the tonsil has derived the name by which it is popularly 
 known in some languages. 
 
 The tonsil lies between the arches of the palato-glossus and 
 palato-pharyngeus muscles; and as these arches do not stand 
 vertical, so the contained tonsil has an oblique position from 
 before backwards, and from without inwards; and this obliquity 
 permits the view of the part when the jaws are fully separated. 
 Its vokirae is variable; nominally it is a half inch long, a third 
 of an inch thick, and the same in l)readth, and when it is of this 
 normal size, the tonsil scarcely rises beyond the sides of tlie arches 
 which inclose it. 
 
 The tonsillar surface, instead of being dotted with depressions, 
 may be entirely smooth, or the surface may be rough and irreg- 
 ular in consequence of ulceration or suppuration. And again, 
 there have been seen cases in which the tonsil presented near the 
 middle part of its surface a gap or common space, into which all 
 the mucous follicles emptied. The deeper or external portion of 
 the tonsil rests on the superior constrictor of the pharynx. 
 
 Between the ramus of the lower jaw and the pharynx exists 
 a prismoidal, triangular space named the maxillo-pharyngeal 
 space; its base rests against the vertebral column, and its narrow 
 part ends at the insertion of the constrictor muscles. In tliis 
 space are contained the internal carotid artery, the internal jugu- 
 (686) 
 
SURGICAL AXATOMY. 687 
 
 lar vein, and the pneumogastric and sympathetic nerves. The 
 tonsil rests on the inner T^'all of this space and has close relations 
 with the internal carotid artery; the vessel lies outwards and 
 backwards from the tonsil, while the internal pterygoid muscle 
 lies inwards and forwards. The insertion of the pterygoid muscle 
 into the angle of the jaw, and the position of this angle, are such 
 in reference to the tonsil that the latter can be pressed outwards 
 against the jaw; this fact, pointed out by Richet, was utilized by 
 him in the establishment of compression of the tonsil in the case 
 of a haemorrhage from the part. 
 
 An occasional abnormal situation of the internal carotid 
 artery was noted by Chassaignac; he observed that sometimes in 
 the aged subject, the vessel in the maxillo-pharyngeal space is 
 curved inwards, with convexity directed towards the tonsil, so 
 that the artery, in such a case, is unusually imperiled through a 
 wound of the tonsil. 
 
 The tonsil receives its blood from the inferior palatine, which 
 is a branch of the facial artery; also from the ascending pharyn- 
 geal branch of the external carotid, and from the posterior 
 palatine, a branch of the internal maxillary artery. Hyrtl has 
 observed an occasional anomaly in which the inferior palatine 
 artery (called also the internal palatine) is so large as to replace 
 the internal maxillary artery; and, in such case, the inferior 
 palatine gives off the branches which are normally derived from 
 the internal maxillary artery. Such enlarged anomalous vessel 
 might be the source of a dangerous bleeding. Normally, the 
 external carotid is so distant from the tonsil that a wound of the 
 latter could not reach it; j^et Flihrer has shown that from a 
 morbid rigidity of the vessel, where it passes behind the posterior 
 belly of the digastric, the external carotid can approach so near 
 the tonsil that the vessel would be imperiled in extirpation of the 
 tonsil. Besides the structures which lie in the maxillo-pharyngeal 
 space, there is a loose cellulo-adipose tissue wliich communicates 
 with the cellular tissue of the neck; and through this tissue 
 inflammation located in the tonsil can travel downwards; and in 
 case of suppuration, the pus has appeared below the chin, and on 
 the neck even as low as the clavicle; at this remote point it was 
 observed by Yelpeau. 
 
 In regard to the site of the tonsil some further points should 
 be noted. It may be wholly sessile, and be closely adherent to 
 the parts in which it rests; or it may be so loosely attached, 
 especially in cases in which it is enlarged, that it is so easily 
 
688 TONSIL. 
 
 moved that it seems to be peduncated ; in fact, the free portion is 
 much larger than that of the base. It also sometimes extends 
 so far downwards in its fossa that the lower part can only be 
 seen b}^ depressing the tongue. The tonsil may scarcely reach to 
 the environing arches; or it may extend to them so as to be 
 tightly embraced, or even constricted by the arches; a constric- 
 tion w'hicii augments when the arches are inflamed. In such 
 anatomical condition, the astringent application used to allay 
 inflammation seated here, would add to, rather than abate, the 
 congestion of the tonsil. 
 
 An important anatomical relation, which the writer has 
 frequently seen, is the adherence of the stylo-glossus or stylo- 
 pharyngeus muscle to the tonsil; in some cases the arches may 
 be so shifted upon the body of the tonsil that the latter is partly 
 buried up; the arch being so continuous with the tonsil, that it is 
 not easy to' separate one from the other. In this way the upper 
 posterior portion may be concealed. Such adherence or muscular 
 development may conceal pus which is seated in the upper 
 posterior part of the tonsil, and it may also greatly interfere with 
 the excision of the part. 
 
 Chassaignac describes what he names a '"demi-capsule" of the 
 tonsil. This structure lies on the outer face of the part and 
 separates it from the constrictor muscle. This capsular structure 
 is much denser and stronger than the remaining tissue of the 
 tonsil; for if one pushes a probe through the tonsil, it is arrested 
 by the capsule, which is difficult to perforate. He claims that 
 this capsular septum afifords protection in the work of enucleating 
 the tonsil. 
 
 Chassaignac also describes a movement of the tonsil, which he 
 calls "spiroid;" this is seen when the base of the tongue is 
 depressed; also when there is the movement of retching or vom- 
 iting in the throat; at such times, the tonsil will be found to make 
 a rotatory movement, in the direction of the vertical plane in 
 which it lies. The writer has seen that this movement sometimes 
 interferes with seizing the tonsil, in the work of excision. 
 
 Tonsillitis. — Tonsillar inflammation has been named, according 
 to the casual agency which produced it, catarrhal, rheumatismal, 
 exanthematous, etc. Many of these cases lie outside of the 
 province of surgery. 
 
 The clinical conditions and manifestations present in inflam- 
 mation of the tonsil are the following: There is the feeling as if 
 there were some body in the throat, which the patient tries to 
 
TONSILLITIS. 689 
 
 dislodge and swallow, or expel from the throat; and these move- 
 ments are often involuntary, and are the sources of pain and 
 annoyance; such pain, at first slight, soon increases, and finally 
 becomes very severe; and then swallowing becomes nearly impos- 
 sible; in fact, the passage of a small quantity of fluid excites a 
 j)ainful cough, and some of the passing material enters the 
 posterior nares. In the worst cases, the breathing is so difficult 
 that the patient, if an adult, fears strangulation. The pains 
 shoot towards the ears; and from swelling, the Eustachian tube 
 may be partly or wholly closed, and some deafness thus arise. 
 Or the swelling, valve-like, may momentarily occlude the tube, 
 and then the part may reopen; and thus a painful crackling 
 arises; especially, when the lower jaw is moved. The face is 
 flushed; the tongue is often dry from breathing through the 
 mouth, and the pulse accelerated, and the temperature elevated. 
 Should the swelling descend into the larynx, the dyspnoea may 
 become so great, that, to escape the impending suffocation, tra- 
 cheotomy has been done; usuall}', however, relief may otherwise 
 be obtained. 
 
 The normal secretion of the tonsil is increased in amount, 
 and is altered in character; it is extremely tenacious and adher- 
 ent to the pharynx, so that there is excited a teasing cough, 
 accompanied by repeated efforts to clear the throat. 
 
 The site, extent and nature of the disease are to be learned 
 by an inspection of the pharynx. In the adult this can usually 
 be done through simply directing him to open his mouth, breathe 
 outwards, and articulate the sound ah; but in some cases, it is 
 not easy to open the mouth ; the lower jaw is fixed by contraction 
 of the masseter muscles against the upper jaw, so that it is with 
 some effort that the mouth can be opened. When this can be 
 voluntarily done, then by means of the handle of a spoon or a 
 tongue spatula, the base of the tongue can be pressed downwards, 
 and a full view of the tonsils obtained. This work, in the adult, 
 can be done with the surgeon's finger; and often, as the writer 
 has verified, the index, by pressure at different points, can open 
 a view which cannot be obtained with any tongue depressor. 
 But woe betide the finger that is thus trusted in the child's 
 throat; it may be badly bitten; and wdiat is worse, it may when 
 wounded be poisoned by the septic fluids of the mouth; hence the 
 use of the tongue depressor is preferable. 
 
 To inspect the child's pharynx and tonsils is often a diflf^cult 
 matter; the youngster, with the liberty of childhood, fortified by 
 
690 TONSIL. 
 
 indocility, in wliich the parents take i)ride, declines to open liis 
 mouth; and will only do so under a discipline to which he has 
 b.een a stranger. In such a contest, the surgeon stands in a 
 position not to be envied ; but a,s it is a contest in which disci- 
 pline wages war with the raw recruit, the former usually wins; 
 yet to insure liis victory, the surgeon would do well to exclude 
 the parents from the scene ; as, from the writer's experience, an 
 appeal to the latter may render the contest a much more 
 doubtful one. 
 
 In the exploratory view one learns the extent of tlie disease, 
 whether one or both tonsils are affected, and in which one the 
 swelling is greater ; for, as a rule, one is much more affected than 
 the other. The swollen tonsil is often covered with a film of 
 pseudo-diphtheritic matter. 
 
 The trismus-like contraction of the masseter muscle is so 
 great sometimes, that the lower jaw cannot be depressed, and an 
 accurate view of the pharynx is prevented. In such condition, 
 should the disease be of much gravity, it will be necessary to 
 open the jaws by the aid of an interdental lever ; an instrument 
 consisting of two blades which are united at one end, and are 
 separable at the other by means of a screw, which being turned 
 lifts one blade from the other. Through the space thus opened 
 both eye and finger can explore the pharynx. 
 
 Fortunately for the patient, the acutely inflamed tonsil runs 
 a rai)id course, and ends by resolution or suppuration ; or the 
 inflammation may lapse into a chronic form, and then it can 
 entail a permanent enlargement. 
 
 In the disappearance of the tonsillitis by resolution, the pain, 
 swelling and dysphagia gradually vanish, and the tenacious 
 mucous secretion disappears; or it is transformed into normal 
 mucus. The diminution of volume is sometimes promoted by 
 the bleeding which sometimes arises from the bursting of blood- 
 vessels in the surface of the inflamed part. 
 
 In case both tonsils are inflamed, one is commonly more 
 severely affected than the other; and thus one may be the site of 
 resolution and the other of suppuration. 
 
 In almost all cases of acute tonsillitis, the ending is in the 
 formation of pus; and such event is heralded by increase of the 
 swelling and pain, and augmentation of the tonsillar and salivary 
 secretions. The pain, though constant, appears in accessions of 
 greater intensity, which reveal themselves in facial contortions. 
 The patient is tormented with a sense and fear of suffocation, due 
 to increasing narrowness of the fauces. 
 
TONSILLITIS. 691 
 
 The pus in its site may be superficial, deep or subtonsillar. 
 It may be in the front, posterior, or inferior part of the tonsil; or 
 it may be in the summit; and when in tlie summit, or posterior 
 part, it may be partly covered with the pharyngeal arch, and 
 masked from view. It may likewise be invisible when located 
 in the lower part of the tonsil ; and in this situation the patient's 
 life may be further imperiled by swelling and oedema reaching 
 into the lar3^nx. Pus in this inferior site, in opening may descend 
 into the larynx and asphyxiate the patient. 
 
 Pus formed in the subtonsillar location instead of pointing 
 towards the fauces, has been known to form for itself a way 
 through the outer wall, and to appear beneath the skin at the 
 angle of the jaw; or it may gravitate downwards and appear on 
 the side of the neck even as low as the clavicle. 
 
 Weber has described a species of suppurative inflammation 
 which commences beneath, or within the pharyngeal muscles, 
 which implicates the .tonsil. And this affection sometimes takes 
 on a phlegmonous character, and then, under the name of phleg- 
 monous angina, it occupies a large portion of the pharyngeal 
 wall. This form of disease is of a graver character than any of 
 the preceding ones described ; it may have a rapidly fatal termi- 
 nation, as the writer has witnessed in a few cases. 
 
 In severe cases of tonsillitis, whether ending or not ending in 
 suppuration, the disease induces swelling of the adjacent soft 
 parts; and in this tumefaction the glands participate, which are 
 situated in the parotidean sulcus behind the ramus of the jaw. 
 These glands rarely suppurate. The cervical tumefaction induces 
 a temporary wry-neck. 
 
 When the event is the formation of pus, the site of this may 
 often be detected with the finger before it is visible to the eye. 
 Unless deep-seated the pus soon approaches the surface, and, with- 
 out aid, will open itself a way into the pharynx. If located deep 
 in the tonsil, the material may reach the internal carotid artery, 
 and by erosion open this vessel. Grissole, Caytan and Le Fort 
 report each a case in which this accident happened. Caytan saw 
 a case in which a secondary suppuration ensued, and the latter 
 penetrated the artery and caused a fatal haemorrhage; the open- 
 ing was spontaneous. The history of the cases reported by 
 these surgeons shows that the bleeding, which has sometimes fol- 
 lowed the lancing of a suppurated tonsil, may have arisen from 
 the erosion of pus rather than from the point of the lance. It is 
 fortunate that in the field of operative surgery such perad ventures 
 
692 TONSIL. 
 
 exist, in which the surgeon's conscience and reputation may 
 find refuge when his thoughtfully planned work ends in failure. 
 Though in such refuge the bitter flavor of disappointment may 
 alloy the solace therein found, still the result is to stimulate the 
 professional mind to renewed vigilance in operative effort, and to 
 more carefully studied endeavor; and if the surgeon's work be 
 thus planned and guarded, the deciding balance will rarely incline 
 towards n on -success. 
 
 Tonsillitis may terminate in gangrene of the part. Such 
 event has been seen by Trousseau, Hardy, Frank and Borsieri. 
 According to Borsieri, tonsillar gangrene is the expression of the 
 highest intensity of tonsillitis. It probably depends on some 
 special condition of the body; and perhaps is due sometimes to 
 infection of the part with some toxic agent. That such infection 
 does not occur oftener is a wonder, when one considers the hetero- 
 geneous materials which are in constant transit across the phar- 
 yngeal isthmus, and the numerous follicular pockets into which 
 these matters may pass and find lodgment, and, by retention, 
 become septic, if they were not primarily so. And from such 
 morbific cause disease proportioned to the originating agency 
 can arise; and such tonsillar affection may vary in grade from 
 a transient irritation to a destructive gangrene. 
 
 Other concomitants of tonsillitis are affection of hearing, and 
 palsy of the muscles concerned in deglutition. 
 
 The inflammation, as has been stated, is seldom limited to the 
 tonsil; it often travels to the Eustachian tube, and, entering this 
 canal, may so swell its w^alls as to nearly or quite occlude the 
 passage; and thence arises temporary deafness, which may be 
 partial or comi)lete. Such impaired hearing vanishes as the 
 tumefaction subsides. But if the disease pass along the tube to 
 the tympanum, and suppuration occur there, the hearing of that 
 ear is seriously compromised. And in the worst cases, the sup- 
 purative process, wandering far from its tonsillar site, has passed 
 to the tympanum, and thence it has migrated and entrenched 
 itself within the mastoid antrum, requiring, in such cases, the 
 opening of the outer wall of the mastoid bone. Suchniigratory 
 action, fortunately, is rarely seen. 
 
 Palsy of the pharyngeal muscles originating in tonsillitis,, 
 has been observed. Its appearance in the tonsillitic patient 
 is much less frequent than in the diphtheritic; so much so 
 that in the cases reported it was claimed that there had been 
 an error in diagnosis. Palsy thus arising may be limited to the 
 
TONSILLITIS. 693 
 
 site of the inflammation, or it may be much more diffused. It 
 appears early. From the loss of movement of the palatal veil 
 the tone of the voice is altered; and the approach of the paralysis 
 may be suspected when a nasal tone of voice is perceived. 
 Besides phonation, deglutition suffers from pharyngeal palsy; in 
 swallowing, food may stray into the air-passages, and in order to 
 swallow, the patient is sometimes forced to close the nostrils; for 
 such closure, in some degree, replaces the normal closure of the 
 choanse by the palatal veil. In this condition an inspection of 
 the pharynx will show that the pendulous veil is hanging loosely, 
 and if the parts be touclied, they are insensible and are not 
 awakened to normal reflex movements. The possible ill result- 
 ing from such palsy^is the passage into the larynx of foreign 
 materials, as particles of food, which entering the lungs may irri- 
 tate and inflame their tissue; and in a patient already reduced in 
 strength, from such irritant ichorous pneumonia may originate. 
 
 This paralytic condition of the throat is sometimes followed 
 by retinal affection; and vision is impaired from this cause as 
 well as from interference with the power of accommodation. 
 
 In a few cases this anginous palsy has become general, and 
 ihe patient has been deprived of motion in large sections of his 
 body. This paraly.sis, both local and general, is rarely permanent 
 in duration. 
 
 A singular complication of tonsillitis is that in which the 
 genital organs become consecutively affected. In 1857, Verneuil 
 reported his observation of a case in which there occurred an 
 effusion into the tunica vaginalis testis, as a metastatic sequel of 
 inflammation of the fauces. He claims that there is a morbid 
 determination towards the genital organs in tonsillitis. In 1859, 
 James, an English writer, endeavored to show that there is the 
 relation of cause and effect between tonsillitis and an affection of 
 the ovaries. In a young woman who was the subject of a ton- 
 sillitis, James saw implication of the ovary corresponding to the 
 inflamed tonsil; and then, the other tonsil inflaming, the ovary 
 on that side also became inflamed. 
 
 In 1886, Joal and Verneuil reported observations of similar 
 metastasis, in which orchitis or ovaritis appeared consecutive to 
 tonsillitis; the cases were not seen in those under pubert}^ nor in 
 the aged; and such secondary disease lasted from fifteen to 
 twenty days. 
 
 Youth is much oftener the subject of tonsillitis than infancy 
 or old age, and the young, vigorous and robust are oftener 
 
694 TONSIL. 
 
 attacked than those of feeble liabit. Its causatiou is obscure: in 
 fact, undetermined; yet its fre(iuent coincidence with exposure 
 to cold air, or sudden change of temperature, makes it probable 
 that such variation has, at least, a predisposing agency. As a 
 rule recovery may be expected. 
 
 Treatment. — Louis and others claim that tonsillitis is not 
 materially sliortened in its course by treatment; in cases which 
 were vigorously treated Louis reports that the disease ended in 
 nine clays ; but when it was allowed to run its course, it lasted but 
 one day longer. Few patients, however, are tolerant of passive 
 expectation; and should the physician imbued with tiie nihilistic 
 skepticism in his art, now prevalent, prefer to confide the matter 
 to nature, he will scarcely find concurrei^ce on the part of the 
 patient. And an extended observation has convinced the writer 
 that a proper management of tonsillitis both abridges the disease 
 and greatly ameliorates the patient's condition. 
 
 A century ago, when venesection was the cliief weapon 
 wielded against disease of the sthenic type, acute tonsillitis, with 
 kindred inflammatory affections, rendered tlie customary tribute. 
 This practice, after being consigned to seeming oblivion for a 
 time, has recently been recalled into use; Aran, Mestivier and 
 others have reported excellent results from general bleeding. 
 The mass of recent authority, however, is unfavorable to general 
 blood-letting; the latter is being superseded by the use of leeches, 
 externally applied, or by scarification of the inflamed surface. 
 The use of leeches, applied to the skin as near as possible to the 
 affected part, has been done; experience not confirming the ben- 
 efit once claimed for leeching, this practice is being abandoned; 
 in fact, instead of relief following the abstraction of blood by 
 leeches, it is claimed tliat the patient is rendered worse by the 
 local congestion which is thus induced. 
 
 Mention should be made of venesection from the ranine or 
 sublingual veins; such treatment was recommended by numer- 
 ous ancient authorities, as Hippocrates, Galen and many others. 
 The fear of causing a hemorrhage which would be diflieult to 
 check, inspired some of the lines of caution which Celsus has 
 written when treating of operations in the sublingual region. 
 And, tliough bleeding from these ve.'^sels has lost much of its 
 ancient credit, yet Aran states that in the Department of the 
 Gironde such bleeding is still commonly practiced, and praised 
 in the treatment of tonsillitis. Aran has so often been witness to 
 the good effects of such depletion, that he advocates its use. And 
 
TOXSILLITIS. 695 
 
 the writer would add that there scarcely would have been such 
 unanimity among the ancients in the use of such bleeding, if it 
 did not possess some advantages; the limited list of therapeutic 
 means used in antiquity permitted an accurate verification of 
 their utility or inutility; and the credit in which sublingual 
 bleeding was held during so many centuries, would seem to 
 justify a re-trial of the plan, as Aran has done. 
 
 The immediate or direct abstraction of blood by scarification 
 of the tonsil is commended by all recent authority. As a 
 rational procedure it commends itself in this, that thus the 
 engorged surface is emptied of its blood, and the several vessels 
 do not admit of the return of the blood and its passage through 
 them. To scarify properly, the surgeon's bistoury or scalpel 
 should have an edge that is faithfully sharp; the incisions made 
 should be superficial, transverse in direction, and numerous. 
 And to promote the bleeding afterwards, the patient should 
 gargle with tepid water, that has been made alkaline with car- 
 bonate of potassium or carbonate of sodium, or with tepid lime- 
 water. If the scarification be well done, it need not be repeated. 
 
 After the local depletion has thus been effectively done, to 
 favor contraction and retraction of the inflamed structures, 
 astringent gargles should be prescribed; and, as agents of this 
 class, one may select the mineral or vegetable astringents: for 
 example, alum or tannin. And as adjuvants the topical use of 
 tinctura iodini composita, tinctura gallse, or tinctura benzoini 
 compositamay be resorted to. In those cases of abnormal dis- 
 position of the environing pharyngeal muscleSj in which the 
 tonsil is begirt as with a constricting band, the localized and 
 isolated use of the latter remedies is better than the diffused 
 application, as happens in the use of gargles; since the latter, 
 acting on the parts around, constrict and congest the in-walled 
 tonsil; but if the latter alone be touched, the full effect of the 
 remedy will be obtained. The patient should also be given frag- 
 ments of ice, by which the heat of tlie mouth will be lowered. 
 
 To these means saline cathartics sliould be conjoined. 
 
 The prompt and judicious use of the procedures and remedies 
 mentioned will, sometimes, stay the disease midway in its course, 
 and secure the desired termination by resolution; but quite as 
 often these means do not arrest tlie progress of the inflammation; 
 it then proceeds to suppuration. 
 
 Inflammation rarely limits itself to an isolated structure, or an 
 organ; it commonly overleaps the artificial barriers \vlncli have 
 
696 TONSIL. 
 
 been set for its isolation by the classifying hand of the nosologist, 
 and this often occurs in affections of the tonsils; inflammation 
 may appear in it primarily, or it may extend to it secondarily 
 from contiguous structure; and hence, when the event is sup- 
 puration, the pus, according to the location of the inflammation, 
 may be tonsillar, or peritonsillar, in site. Pus is oftenest devel- 
 oped in the connective tissue which lines the niche in which the 
 tonsil lies; and this is most frequent above or behind; and, as 
 previously remarked, the focus of pus is discoverable by touch 
 rather than by sight. Free scarification, opportunely done, often 
 prevents suppuration; but this failing, and pus forming, the lat- 
 ter must be liberated by incision. If the purulent material be 
 near the surface, it is reached by a slight cut with the lancing 
 instrument. The opening may be made with a scalpel or bis- 
 toury; and if the hand be inexperienced, the incising blade ma}' 
 be wrapped with cloth, so that only a small portion of the 
 pointed part will remain exposed; such protection, however, 
 to a disciplined hand would prove but an impediment. If the 
 pus be deep, then a shallow incision may be made over it, and 
 afterwards, a blunt dissector or large l)lunt probe may be ])ushed 
 through the remaining wall. But if the pus lies behind and 
 adjacent to the tonsil, care must be used in opening; since the 
 internal carotid artery lies external to the pus, being only 
 separated from it by the superior constrictor muscle and the 
 pharyngeal fascia. Pus in this situation has perforated this thin 
 wall, and, b}' erosion, opened the arter}'' and caused hreraorrhage, 
 speedily fatal, as was ob.served by Grisolle. If it becomes neces- 
 sary to liberate with the lance }>us seated over the vessel, the 
 point of the instrument should be directed rather towards the 
 posterior pharyngeal wall, than towards the side; the bistoury 
 should pass backwards and not laterally. Thus doing, the fatal 
 work of opening the vessel which has been reported by Beclard 
 and others, will be avoided. 
 
 Some writers advise against opening the collection of pus, 
 and prefer to allow it to burst spontaneously; such is the teach- 
 ing of Stromeyer, who claims that lancing the suppurated tonsil 
 awakens new inflammatory and additional suppurative action. 
 It is true that after one collection of pus, another ma}' appear 
 later; yet this second one was in process of formation, and if the 
 first had not been opened, the two would finally have fused 
 together; but opening the two as they respectively mature, 
 greatly limits the suppurative process ; and materially lessens the 
 patient's pain. 
 
HYPERTROPHY OF THE TONSIL. 697 
 
 When the pus Las exit, the subjective accompaniments of 
 pain, discomfort and functional impairment, at once lessen and 
 gradually disappear. As a detersive gargle to aid in the removal 
 of the excreta, some alkaline solution, as aqua calcis, may be 
 used. This will be rendered more agreeable to the patient by 
 the addition of menthol or mint-water; mint-water, to which car- 
 bonate of potassium has been added, will act well. By treatment 
 as described, the purulent content will be eliminated, the hollow 
 breach will close, and, afterwards, the tonsil will present an 
 irregular surface. 
 
 There are patients, usually adults in the prime of life, who 
 are the subjects of recurring attacks of suppurative tonsillitis, 
 the disease occurring annually, or at longer intervals. In such 
 persons an attempt may be made to arrest the disease at its onset, 
 and for this purpose, Bell, in 1842, announced that gum guaiac, 
 given internally, is an excellent remedy, and at the same time 
 the patient should be purged. Herpin, of Geneva, cauterized 
 the sufface of the tonsil with pure nitrate of silver. Reel-Ogez, 
 as abortive treatment, advises to gargle hourly with the subjoined 
 solution: — 
 
 R. Pluinbi Acetatis gr. v ad. x 
 
 Gum Acacise giv 
 
 Syrupi ^ss 
 
 Aqu8e Ey 
 
 Misce. 
 
 These, and other local remedies, are inferior to simple scarifi- 
 cation of the surface of the tonsil; if this be done early, and well 
 done, the disease may often be arrested in its incipience, and reso- 
 lution obtained. 
 
 Hypertrophy of the Tonsil. — The tonsil may be abnormally 
 enlarged as a permanent condition. The structural conditions 
 present consist mainly of a multiplication of the component ele- 
 ments; the stroma of connective tissue, intervening between the 
 lacunps and follicles, is thickened and hardened, so that it resists 
 and creaks under the incising blade. Though hard, the structure 
 is usually more friable than normal tonsillar tissue. In the 
 enlarged lacunae are lodged masses of epithelial excreta; and 
 sometimes calcareous concretions are found there. The tonsil's 
 volume is commonly augmented to two or three times its normal 
 size, and, exceptionally, this may be much exceeded. The color 
 may be normal; often it is pale and bloodless in hue. The sur- 
 45 
 
698 TONSIL. 
 
 face may be smooth, or it may be rough, lobulated and pitted with 
 depressions. As a rule, the enlarged tonsil is painless; more 
 rarely, pain can be awakened by pressure. 
 
 When the tonsils are much hypertrophied, they displace the 
 palatal veil, so that this part, partly or entirely closes the choanae. 
 They touch each other in the median line, or so nearly do so, that 
 a small space remains for the passage of air and food. Sometimes, 
 the adherent pharyngeal arches repress the tonsils, and then their 
 encroachment upon the pharynx is much lessened. 
 
 Tonsillar hypertrophy may impair audition and plionation, 
 impede respiration and deform the chest, and cause catarrhal 
 trouble in the nostrils, phar3mx and air-passages. 
 
 Disturbance of hearing, for a long time, was thought to depend 
 on the closure of the openings of the Eustachian tubes. In a 
 study of the subject, Harvey, Crisp, and others, deny that deaf- 
 ness is thus caused; they refer it to lessening of the calibre of the 
 tube through tumefaction and swelling of its lining membrane. 
 In fact, the direction of the enlargement of the tonsil is rather 
 away from, than towards, the tube; and the effect of it is to pull 
 open the mouth of the tube. But, as the tube's lining is thickened 
 by extension of the tonsillar trouble, whatever lessens the latter, 
 improves the hearing. And the observation of this fact was the 
 secret of the successful career of an eminent charlatan, St. John 
 Long, who some years ago enjoyed, in London, a transient era of 
 prosperity in the cure of deafness. His treatment consisted in 
 the excision of the tonsils, and thus, it is said, he cured or relieved 
 many cases of deafness. But as many cases of deafness do not 
 originate from such cause, the imjnense practice of this empiric 
 soon fell off, and he was remanded to the obscurity from which 
 he had lately emerged. 
 
 The obstruction of the choanse interferes with the normal de- 
 velopment of the vocal sounds; the patient speaks with a nasal 
 tone; or rather, the voice seems muffled. 
 
 The enlarged tonsils obstruct the entrance of the air to the 
 lungs, and thus respiration is seriously embarrassed. The child 
 which is tlie subject of such hypertrophy, ceases to breathe 
 through the nose, in consequence of the labor which nasal respi- 
 ration demands; the child breathes through its partly opened 
 mouth, and in so doing, it presents a picture of mental imbecility 
 and forbidding stupidit3^ It is, however, during sleep that the 
 enlarged tonsils specially obstruct breathing; the tongue then, 
 particularly in the dorsal position, presses the epiglottis backwards 
 
HYPERTROPHY OF THE TONSIL. 699 
 
 and downwards, so as to nearly close the glottis; in this closure 
 the large tonsils concur, both by their volume and weight. Such 
 sleep approaches the nature of profound angesthetic narcotism, 
 and the analogy is close when one records that the little sleeper 
 is often congested in its face, and slightly cyanosed, owing to the 
 want of a proper amount of air. The guttural rhoncus of the 
 inspiratory effort and tlie occasional closure of the mouth and 
 temporary suspension of breathing, often alarm the parent or 
 nurse. And so great has been the parental anxiety, that it has 
 been recorded by Roger that the mother of such a child was 
 accustomed to nightly watch her infant, and with her hand press 
 the chin downwards, so as to prevent the mouth from closing. 
 
 This unusual respiratory effort, when prolonged in the child,, 
 finally induces a deformity of the thorax. In 1828, Dupuytren 
 called attention to the frequent coincidence of deformity of the 
 chest-wall with enlarged tonsils. He merely noted the concur- 
 rence of, and not the causal connection between, the two condi- 
 tions. 
 
 Warren, of Boston, in 1838, published his observation that 
 enlarged tonsils cause deformity of the chest. And, near the 
 same time, similar observations were made by Coulson, of London. 
 
 Moity, in 1858, announced that enlarged tonsils impair hear- 
 ing, taste, and dwarf the intellect; the retarded flow of blood 
 to the brain interfering with its normal evolution, mentality is 
 thus abridged. 
 
 Most writers upon this subject describe two classes of thoracic 
 deformity associated with tonsillar deformity: one in which the 
 subject is rachitic, and the other in which this constitutional dis- 
 ease does not exist. 
 
 In these cases of perverted thoracic form, the deformity con- 
 cerns chiefly the lower part of the chest; the upper part retains 
 its normal contour. In the lower half of the chest the ribs are 
 incurved; and this depression is greatest near the middle portion 
 of the ribs. The sternum likewise shares in the deformity ; the 
 lower portion is deviated inwards, while the upper part remains 
 in normal position. The thoracic deformity due to rachitis differs 
 from that of pure tonsillar hypertrophy; in rachitis the costal 
 cartilages are unduly prominent, while the ribs are sunken at the 
 sides of the chest, so as to form two vertical gutters, one on each 
 side, extending through the entire height of the chest. 
 
 Different explanations of the fhoracic deformity from hyper- 
 trophied tonsils have been offered; Robert thinks that it arises 
 
700 TONSIL. 
 
 from the diminished tension of tlie air contained in the chest 
 during the effort of inspiration, the weight of the external air 
 forces inwards the lower part of the sides of the chest. Tliis 
 explanation does not account for the upper jiart of the thorax 
 remaining in situ, though it is acted equally on by the atmos- 
 pheric pressure. 
 
 Lambron, who has ])ublislied an exhaustive monograph on 
 the tonsil, refers the incurvation to the action of the diaphragm. 
 In ordinary breathing, the inspiratory effort is made by tlie dia- 
 })hragni; and as this muscle is inserted into the ribs forming the 
 lower half of the chest, the deformity is limited to the lower 
 portion of the chest. A favoring condition which the author 
 suggests, is the greater mobility of the lower ribs, which becomes 
 especially conspicuous, when the normal chest is inflated by a deep 
 inspiratory effort. Emphysema of the lungs is often associated 
 with the tonsillar and costal deformity; and it is correlated to 
 the incurvation of the lower part of the cliest, since the pulmo- 
 nary tissue, by its expansion above, compensates for the dimin- 
 ished cell-room below. Again, the attending mobility of the 
 lower part of the tliorax, gives it some immunity against those 
 diseases which find a starting-point in the summits or the upper 
 parts of the lungs. 
 
 The tonsil is sometimes enlarged through constitutional syph- 
 ilis; an instance of this was seen by the writer, in wliich a 
 recovery was obtained through excision of tlie tonsil and anti- 
 sypiiilitic treatment. 
 
 Treaiment. — As treatment, one may resort to means which will 
 oppose or correct the predisposition to tonsillar enlargement: 
 also means may be resorted to which applied to the enlarged 
 tonsils, cause reduction of their volume; and finally, the attempts 
 in these directions proving fruitless, the part should be removed. 
 
 The scrofulous or tubercular diathesis which often accomj)a- 
 nies the hypertrophy, should be combated by means of iodide of 
 potassium, iron and arsenic. Sulphur baths, and the local use 
 of sulphureted water in the form of douche directed on the ton- 
 sil, have acted curatively against its enlargement. The remedial 
 efficacy of this treatment will be especially manifest in those who 
 are likewise tlie subjects of herpetic or eczematous disease. 
 
 Patient effort in the use of topical remedies will lessen the 
 enlarged tonsil ; of these means, the best are those which have an 
 astringent action. One of the most effective is a combination of 
 iodine and galls, in the following mixture: — 
 
TONSILLOTOMY. 701 
 
 1^. Tr. lodini compositee. 
 
 Tr. Gallse aa gi 
 
 Misce. 
 
 Let this be applied with a brush to the tonsil, once daily. This 
 compound is better than pure tincture of iodine, which is often 
 used, topically. Also, one may apply to the part a saturated 
 solution of glycerine and tannin. Astringent gargles containing 
 alum, zinc or borax, if diligently used, may have some agency 
 in lessening the volume of the tonsil. It is probable that friction 
 or massage of the tonsils would favor their reduction; the rebel- 
 lious reflex movements of the parts, which at first would be 
 awakened, w^ould soon disappear. As a means to curtail the 
 -volume of the tonsils, in 1869, Ruppaner applied to them the 
 following mixture: caustic soda, caustic potash, and caustic lime, 
 in equal parts, were moistened with alcohol and applied with a 
 glass rod to the tonsil. From six to fourteen applications were 
 needed to reduce to normal form. With such treatment, Rup- 
 paner reports that he cured one hundred and twenty-three cases. 
 If the general and local treatment here mentioned fail in its pur-, 
 pose, the part should be excised. 
 
 Tonsillotoviy, Amygdalotomy, or Excision of the Tonsils. — The 
 chirurgus or surgeon of ancient Rome excised the tonsils; says 
 Celsus: ''When the tonsils have, through inflammation, become 
 indurated, and they are covered with a thin coating, one should 
 thrust the finger in around them and thus pluck them out; but 
 if they cannot thus be loosened, it is proper to catch them with a 
 hook and cut them off" (hamulo excipere et scalpello excidere)^ Near 
 the same period, ^tius, who lived fifty-four years after Christ, 
 directed to remove the prominent part of the hypertrophied 
 tonsil; that is, about half of it; for those who excise the entire 
 tonsil, remove also sound structures, and cause great bleeding. 
 Paul of iEgina counseled the removal of the tonsils ; and his- 
 method was followed by Albucasis and the Arabian physicians; 
 their method was as follows : The tonsil is first to be caught with 
 a dissecting hook, and to be lifted up as much as possible with- 
 out acting on the surrounding parts; then the tonsil is to be 
 removed wholly from the cavity in which it is contained by 
 means of a bistoury, which is held in the hand, and corresponds 
 in its form to the curvature of the tongue. Albucasis feared 
 when the base of the tonsil was large, that in its removal, thero 
 might occur a liEemorrhage which would be difficult to control. 
 
 In the middle ages, tonsillotomy, sharing the fate of the liga- 
 
702 TONSIL. 
 
 tul"e, fell into disuse; and in the renaissance of medicine, the 
 operation was approached with timidity and distrust. Ambrose 
 Pare mentions ligation of the tonsils; but headvised tracheotomy 
 in patients menaced by suffocation by enlarged tonsils. Guille- 
 meau, pupil of Part^, did not favor tracheotomy, but he advised 
 the ligation or excision of the enlarged tonsils, of which the base 
 is small. He advised care in the selection of the cases in which 
 the tonsils should be removed. Soon afterwards, Severini, of 
 Naples, in an epidemic in which the tonsils were affected, cau- 
 terized and excised these parts. Dionis, who wrote in 1G72, 
 opjtosed excision, eradication, and other means employed to 
 destroy the tonsils; he thought the parts had some functional 
 importance, and should not be removed. Portal adopted this 
 advice. Junker favors partial excision; and he prefers to do this 
 with tlie ligature. Heister opposes excision as barbarous and 
 difficult; he prefers to remove by means of cauterization. He 
 speaks of the danger of the excised tonsil falling into the throat. 
 Sharp claims tonsillar ligation as an English procedure; and he 
 believes that, thus operating, the hemorrhage which may follow 
 excision can be avoided. In 1734, Wiseman, in writing on 
 removal of the tonsil, considers cauterization, actual or j)otential, 
 as the simplest method. In cases in which he did excision, he 
 first passed a tliread tli rough the tonsil, and then, cutting behind 
 the thread, he guarded against the exei.^ed part falling into the 
 glottis: a fatal accident which occurred to Moscati, near this time. 
 As a safer plan, Moscati afterwards crucially divided the tonsil, 
 and when suppuration had ensued, he excised each fragmentary 
 C[uarter that remained. Museux, who invented the toothed 
 forceps which bears his name, used this instrument to fix the 
 tonsil, which he excised with curved scissors. Early in this cen- 
 tury, a rude tonsillotome was devised; the tonsil, engaged in the 
 end of a furcated staff, and held tliere with a tenaculum, was 
 excised with a blade tliat passed through the ensheathing 
 furcated staff. 
 
 In the early part of this century, Samuel Cooper preferred the 
 use of the ligature to excision. Dupuytren used toothed fixing 
 forceps, and he cut off tlie tonsil with a bistoury, of wliich the 
 greater part of the blade had been wrapj)ed in a bandage. In 
 1840, Pappenheim heralded an innovation, in' which he intro- 
 duced his left hand in the mouth, and, having seized the tonsil 
 witli the thumb and finger, and then pressing down tlie tongue 
 with the remaining fingers, he cut off the uplifted part with 
 
TONSILLOTOMY. 703 
 
 curved scissors, held in the right hand. Dieffenbach caught the 
 tonsil with a hook and excised with a knife. Synie and Liston, 
 leaders in English surgery, operated with a hook and a bistoury, 
 of which the greater part of the blade was wrapped in cloth. In 
 1858, Larghi, of Turin, revived the ancient method of Celsus, 
 which might be named the ungual method; with his finger nails 
 he detached the tonsil from above downwards; and he pronounces 
 the plan an easy one. As the majority of the cases requiring 
 tonsillar removal are in children, the plan of introducing the 
 fingers into the mouth would imperil the operator quite as much 
 as the jDatient; and between the two, it is probable that liis own 
 wounds would be the greater unless pains were taken to hold the 
 jaws ajar. 
 
 Interstitial cauterization done by means of chloride of zinc, 
 and much used by Maisonneuve, was tried in the enlarged tonsil; 
 the difficulty of reaching the part, and the dangerous possibility 
 of some of the escharotic material escaping into the throat, have 
 caused this method, as well as others which consist in the use of 
 potential caustics, to be abandoned. 
 
 Ligation, which has been advocated by many surgeons, 
 besides being a difficult procedure, exposes the patient to the 
 nauseous condition, of swallowing much of the septic matter and 
 gangrenous material which arise from this plan of tonsillar 
 removal; and such toxic materials may descend through the 
 trachea to the lungs and awaken disease there. To avoid these 
 accidents, the constricting chain or wire of the ecraseur has been 
 passed through and around the tonsil, and the separation been 
 done at once; but ligation, whether done instantaneously or 
 tardily, is no longer employed as means of tonsillar removal. 
 
 Delay in doing the work in the child has been counseled with 
 the hope that the tonsils might become of less volume, when the 
 subject reaches puberty; such hope is but exceptionally realized ; 
 and, meantime, the delay may permit thoracic malformation to 
 arise as the result of such hypertrophy. Besides the vicious 
 conformation of the chest, and its attendant ills, which project a 
 shadow in which the patient must ever afterwards walk, the 
 young patient's existence is peculiarly menaced, should he 
 become the subject of diphtheritic disease of the throat; for then, 
 a slight addition to the volume of the tonsils may prevent the 
 entrance of air to the lungs, and cause suffocation. Here the 
 early removal of the enlarged tonsils in the child is a prophylactic 
 measure against such casualty. 
 
704 TONSIL. 
 
 Ill regard to the age at which the operation should be done, 
 Guersant, who is authority in tliis matter, counsels that it should 
 be done early; he operated often in children from eighteen to 
 twenty-four montlis of age; if done early, there is less danger of 
 lurmorrhage. In one thousand children operated on, he never 
 saw hsemorrhage; while in adults, it occurred in one-fourth of 
 the cases. St. Germain would fix as time for the operation tlic 
 a.o-e between two and eight years; though so excellent a surgeon 
 w^ould, no doubt, have done the operation at a later age, sliould 
 the exigency have arisen. The writer, whose experience in this 
 matter has not been limited, deems the period when the child 
 has reached the age of reason, a more satisfactory time for the 
 work than that of earlier infancy. In his surgical experience he 
 recalls no operative work that was more difficult than a few 
 cases of tonsillar excision in the infant. If the removal be done 
 without anresthesia, the work of immobilizing the patient requires 
 a restraining force of assistants, and much boisterous effort; in 
 fact, it is a struggle or a battle from which the operator would 
 retreat could he do so with decorum, and especially so, where the 
 infant has parental reenforcement; viz., a father and mother who, 
 though feigning forgiveness, rarely pardon the rude w'ay in which 
 the victory over their offspring is won; and in such cases the 
 requital which is made for the services has but a tliin gilding of 
 gratitude. 
 
 To render the task an easier one, the child may be anaesthet- 
 ized; yet this aid brmgs the serious inconvenience that the throat 
 is so nearly closed that when narcotized, the child's life is imper- 
 iled by suffocation; the base of the tongue and the tonsils falling 
 together quite close the pharynx. Hence, during the work, the 
 tongue must be continuously withdrawn from the mouth with 
 appropriate forceps. Besides, when the patient is anaesthetized, 
 there is danger of blood entering the larynx and causing asphyxia. 
 The writer's experience leads him to operate without anaesthesia; 
 and not unfrequently, the child may be beguiled into the work, 
 and one tonsil may be removed before he becomes aware of what 
 is intended, and ere the surprise which the w^ork has awakened 
 has fully passed, the remaining tonsil may often be removed. 
 
 There are two methods of tonsillotoujy, which have their 
 respective advocates: excision with a scalpel or bistoury, and 
 excision with a special instrument named tonsillotome.or tonsillar 
 guillotine. 
 
 To excise with a blunt-pointed scalpel, or bistoury, or blunt 
 
TOXSILLOTOMY. 705 
 
 scissors, there is required a pair of toothed forceps, or a long- 
 handled tenaculum; aho a tongue-depressor, intermaxillary 
 gag, and sponges. If a bistoury be used, all of the blade, except 
 an inch and a half from the point, should be covered with adhe- 
 sive plaster, or a bandage to guard against any unnecessary 
 cutting of the surgeon or patient. The tonsils having been 
 cocainized, and the patient being a tractable subject, the work is 
 done as follows: one assistant standing behind steadies and 
 supports the head; another aid is ready to hold the hands, should 
 the patient be timid, and a third may be needed to depress the 
 tongue. The patient's right tonsil having been seized with the 
 toothed forceps, is to be drawn inwards, so that its base or pedicle 
 will be accessible to the knife; tlien with the cutting instrument, 
 the tonsil is to be severed from below upwards, by sawing move- 
 ments. Should the tongue fall backwards, it must be pressed 
 downwards and forwards with a depressor; this act is often 
 unnecessary, since, as soon as the tonsil is caught with the tenac- 
 ulum, or toothed forceps, it can easily be brought into view. The 
 upward cutting is to be so done that tlie palatal veil and arclies 
 will not be wounded. 
 
 Should the patient be a rebellious child who has not reached 
 the age of reason, or whose fears have temporarily bereft him of 
 reason, then a small troop of assistants, says St. Germain, will be 
 needed to coerce him into the necessary quiet; one should hold 
 his head; a second should hold the arms, and a third may hold 
 the legs, and a fourth may depress the tongue, and also sponge 
 out the throat, as rec|uired. All the aids except the last, stand at 
 the side, so as not to be in the way of the work. Nearly all this 
 force of assistants (of wliich St. Germain doubles the number 
 here mentioned) may be dispensed with, if the child beanjesthet- 
 ized; and from the writer's experience, the restraint can be made 
 without ansesthesia by two aids, namely, one can hold the child 
 in his lap, and with one arm hold, support and steady tlie head, 
 and with the other he can hold the hands, while with his knees 
 he clasps and fixes the child's legs; the second assistant depresses 
 the tongue and wipes out the throat when needed. And a third 
 aid is sometimes required to hold in place the interdental dilator. 
 The patient, finding that his efforts of resistance are overcome at 
 every point, finishes by firmly and defiantly shutting his mouth 
 and clinching his teeth. To meet this some address is needed; 
 if the nose be held, in the moment when the mouth is opened, a 
 spatula may be thrust between the teeth, and, being pushed back 
 
706 TONSIL. 
 
 to the throat, the retching movement thus induced fully opens 
 the jaws, when some body, as a wedge-sliaped ])iece of wood, may 
 be inserted between the molar teeth, and the closure of tlie jaws 
 tlius prevented. At this point, the surgeon can proceed with the 
 use of his bistoury, and complete his task at his leisure. 
 
 Early in his professional career the writer did the excision 
 with a i)air of large curved scissors, an instrument which Cloquet 
 prefers for the woi'k. To use the scissors, the right tonsil sliould 
 first be cauglit with the fixing tenaculum, and being properly 
 lifted from its niche, the cutting is done with one stroke of the 
 scissors. In using the scissors the o[)erator should be careful to 
 have tlie tonsil well included between the blades before they are 
 closed. As said, in the use of either the bistoury or the scissors, 
 the patient's riglit tonsil should first be removed, since, for the 
 right-handed operator, this is tlie more difiicult act, because the 
 hands must be crossed in the work. The left one is next to be 
 seized and removed; and as the patient is restive from what has 
 been done, and there is some bleeding, it is well that the work 
 concludes with the easier act. 
 
 Whether the bistoury or scissors do the cutting, the operation 
 will fail of its purpose, if there be not excised one-half of the 
 tonsil; so that the remaining stump will scarcely reach to the 
 level of the bounding arches. 
 
 As the removal of the tonsils by the bistoury or scissors 
 demands some mechanical skill, which must be acquired by repe- 
 tition of the work, invention has sought to furnish the operator 
 with an instrument which may do the excision with little or no 
 manual dexterity. To do this, an instrument named tonsillotome, 
 of various forms, has been devised. The original model of the 
 tonsillotome was conceived and constructed in America by 
 Fahnestock. Several modifications and improvements of this 
 instrument have since appeared; in some the work is done by 
 pushing, guillotine-like, or by ])ulling the cutting blade. The 
 tonsillotome, in the main, consists of three parts: a staff" which 
 ends in an elliptical ring of which the inner border has a cutting 
 edge; a second staff similar to the first, of which the ring has a 
 cutting edge: and the two staffs are so attached together that the 
 second can be moved on the first; and, as this is done, the tonsil, 
 which is included in the rings, is cut off. And on the double 
 staff there is fixed a transfixor and elevator, which has a barbed 
 end like a fisherman's gig. The instrument is a combination of 
 most ingenious devices, awakening admiration of the numerous 
 
TONSILLOTOMY. 707 
 
 hands which have shared in the creation of its final, present 
 form; and not the least curious is the arrow-pointed transfixor, 
 which can be so adjusted as to lift the tonsil to any elevation 
 above the cutting edges which may be needed. 
 
 Though this tonsillotome works so nearly automatically, yet 
 some advice for its use is needed for the inexperienced. The 
 cutting edges should be very sharp. The containing ring should 
 not include any part of the adjacent muscular arches, the palatal 
 veil, or the uvula. The original instrument was worked by both 
 hands; the present one is worked with one 'hand; or if the left 
 one aids, it is merely in steadying the instrument. In doing the 
 work with one hand, the error is sometimes made of withdrawing 
 the instrument as the cutting is being done; this must be studi- 
 ously avoided by holding the outer staff in place, while the 
 inner is moved inwards or outwards, according as the cutting is 
 done by pulling (the usual way), or pushing; that is, one blade 
 must be held in place while the other does the excision. If both 
 be drawn together, the tonsil will escape from the grasp and much 
 of it will be left behind. And the same will result if the cutting 
 edge be dull. 
 
 No instrument is more difficult to be kept in good working 
 condition than the tonsillotome. After each operation the com- 
 ponent parts should be taken apart, washed and dried; otherwise 
 it will rust and be unfit for use when next required. And should 
 the edge be dulled, it must be sharpened. 
 
 As a training in the operation of tonsillotomy with the ton- 
 sillotome, the inexperienced would do well to learn the move- 
 ments of the instrument in the section of some soft material; nor 
 in this training practice, must the novice introduce his own finger, 
 as the writer once knew a physician to do, with the result of 
 cutting himself. 
 
 The operation consists essentially of three jorincipal acts: 
 First, having the patient's mouth securely opened^ pass in the 
 instrument and carefully include the tonsils, all neighboring 
 structures being excluded; then thrust the adjusted transfixor 
 through, and slightly uplift the included part; now, firmly hold- 
 ing the outer blade with one or more fingers, withdraw the inner 
 or cutting blade; this last act severs the included tonsils, when 
 the instrument with the excised part is withdrawn. 
 
 Of the three methods of removing the tonsils, viz., with the 
 bistoury, scissors or tonsillotome, general authority and usage 
 sanction the last instrument, as the one with which the excision 
 
708 TONSIL. 
 
 can be done most rapidly, easily and safely; if an exception be 
 made, it is the use of the scissors in excising the tonsils in the 
 adult. 
 
 The question is often asked by the patient whether the removal 
 of the hypertrophied part will give future exemption from a 
 regrowth of tonsillar structure; as answer, such exemption can 
 be promised in those cases in whicli the greater portion of the 
 tonsil has been removed ; such a patient need not fear recurrence: 
 but if, as often occurs, the removal has been but midway to the 
 base, then the stump may regrow; yet such recurrent develop- 
 ment rarely reaches such volume as to require another operation. 
 
 Another query often made is whether the excision will guard 
 against tonsillitis in a patient who has been the subject of it; to 
 this a reserved answer should be given ; for the writer has observed 
 several cases in which suppurated tonsillitis appeared, even 
 though the tonsil had been removed. The explanation of this 
 is that in the work a part of the tonsil had not been removed ; 
 follicular structure adjacent to, or concealed under, the pharyn- 
 geal arches, had escaped excision. In a few cases of the kind, in 
 the interim between attacks, the writer has re-operated, doing 
 the work with tenaculum and scissors, or with a sharp-edged 
 curette, similar to that used by the gynecologist. The curette can 
 excavate the tonsillar structure to a sufficient depth beneath the 
 arches, wlien the latter encroach on the tonsil. 
 
 The work of tonsillotomy is not free from accident and unex- 
 pected contingency. 
 
 The most unfortunate accident that can occur is the wounding 
 of tlie internal carotid artery. Be'clard, Burns and other surgical 
 writers have witnessed or known of this accident. The writer 
 has been told by an eye-witness that in a tonsillotomy done by 
 Dr. Geddings, a surgeon of South Carolina, the carotid was opened 
 and the life of the child was only saved by quickly tying the 
 primitive carotid artery. The ascending palatal artery may be 
 abnormally large, and if wounded, a violent bleeding would 
 occur. 
 
 An unfortunate contingency, yet luckily a rare one, is frac- 
 ture of the cutting blade of the tonsillotome. The })eril from 
 such accidentis that the sharp fragment may fall into the larynx or 
 (Bsopliagus, and in either case do great, and possibly fatal, injury. 
 In such a case every prudent effort should be made to remove 
 the foreign body. 
 
 In case the internal carotid be opened, the wound should 
 
TONSILLOTOMY. 709 
 
 instantly be compressed with the finder, either directly applied 
 or indirectly on a piece of sponge or lint; and while the bleeding 
 is thus controlled by an assistant, the common carotid should be 
 rapidly sought for and tied in its upper part. And if haemor- 
 rhage still continues from the distal end, as commonly occurs, 
 then the compression on the wound should be continued digitally 
 or instrumentally. 
 
 In every case of tonsillotomy, the wound should be kept under 
 observation until the bleeding has ceased, which commonly 
 occurs after a few minutes. In the child, the blood may con- 
 tinue to escape unobserved, since it is swallowed ; and in this 
 way fatal lia^morrhage has occurred: the true condition being 
 unsuspected until it was too late. An instance of this kind fell 
 within the writer's notice. A surgeon of reputation excised the 
 tonsils of a child one afternoon; the followiug morning the 
 writer was hastily summoned and found the child dying; and 
 with the history that its tonsils had been removed the day 
 before, and that a short time before my arrival it had vomited a 
 large quantity of blood; and until this vomiting, the parents had 
 not suspected bleeding. The child died soon after my arrival. 
 
 The bleeding may cease, and afterwards start again; an 
 instance of this occurred in the writer's practice. An enlarged 
 tonsil in an adult was removed; some hours afterwards, the 
 Avriter was summoned, and found that bleeding had commenced 
 some six hours after the operation. On examining the throat, a 
 small stream of blood was purling from tl^e wound. This bleed- 
 ing was easily controlled by the pressure of a finger against the 
 wound; the pressure was made by tlie writer for some minutes, 
 when the man offering to do the work, the task was committed 
 to him with satisfactory" result. A good recovery was obtained, 
 though a large amount of blood was lost before assistance was 
 sought. 
 
 Since fingers tire, or may be bitten by the patient, a better 
 substitute for them is a forceps-like instrument, which once 
 placed in position, will maintain constant pressure; but while 
 such instrument is being gotten, digital compression may be 
 done directly, or through the medium of lint or sponge laid on 
 the bleeding surface. This immediate compression may be 
 aided by indirect pressure on the common carotid, as advised by 
 Gensoul, to control such bleeding. As instrument for the com- 
 pression, long-bladed forceps may be employed; of these, one 
 blade is passed into the mouth and placed directly on tlie bleed- 
 
710 TONSIL. 
 
 ing surface, or a piece of sponge may intervene; the other blade 
 may rest on the angle of the jaw. A pair of forceps specially 
 constructed for this work has been devised by Ilatin. In the 
 absence of a special instrument, any pair of long-bladed forceps 
 would answer the purpose. And if this is not present, one might 
 extemporize a compressor from a strip of lead or copper, which 
 being bent into a U-forra, one of its ends is to be placed on the 
 tonsil, and the other outside, and then the ends can be forced 
 towards each other, and remaining so, continuous compression 
 would be made on the wounded surface. Such compression 
 should be continued for two or three days; and the appliance 
 should be removed in the morning, so that, for some hours, the 
 wound could be carefully watched. 
 
 Where the bleeding was not great, Chassaignac controlled it 
 with a piece of ice, which he pressed for some time against the 
 bleeding surface. As local means in such cases, the writer 
 would recommend tannin in powder, or the touching of the part 
 with the tincture of galls or catechu; from his experience, the 
 writer greatly j)refers the vegetable astringents to the salts of 
 iron, which are so often employed to control bleeding. The fer- 
 ruginous astringents have some disagreeable accompaniments 
 when used in the mouth to cheek bleeding. They darken the 
 teeth, and injure their enamel; and they blacken the tongue and 
 buccal mucous membrane. They overdo the intended purpose; 
 for besides forming the haemostatic clot, they have a superficial 
 escharotic action on the excised surface; so that when the eschar 
 falls there may be bleeding from the raw surface. To control 
 slight but troublesome bleeding, the thermal cautery has been 
 successfully used; the objection just mentioned against the salts 
 of iron, obtains against the actual cautery; the work is liable to 
 be overdone, and the detaching eschar leaves a surface which 
 can easily bleed. 
 
 But in cases in which the bleeding is very profuse, it would 
 be unwise to lose time in the use of the means mentioned, but 
 the surgeon should proceed immediately to ligation of the prim- 
 itive carotid artery; in such prompt action, there is much greater 
 security than in delay; for if the latter course be pursued, so 
 much blood may be lost that the patient may die from this 
 cause, even though the ligation be done. 
 
 Tonsillar Tumors. — Apart from enlargement through simple 
 hypertrophy, the tonsil is seldom the site of neoplastic develop- 
 ment; still malignant disease of the type of sarcoma and car- 
 
TONSILLAR TUMORS. 711 
 
 cinoma, or the latter's equivalent epithelioma, has made its pri- 
 mary appearance in the tonsil. The writer has seen a case of 
 tonsillar sarcoma. Epithelioma developing in the walls of the 
 pharynx, and still oftener in the hase of the tongue, may attack 
 the tonsil by migration. The author has seen several examples 
 of this kind. Malignant disease here has its usual history of 
 gradually implicating circumjacent and subjacent parts, with 
 final ulcerative destruction of the structures: life endino;, after 
 montlis of torture, through ichorous pneumonia, or starvation. 
 
 Treatment. — In 1856, Langenbeck published the treatment of 
 tonsillar cancer by tliermal cauterization. Though the disease 
 was not cured, yet in two cases thus treated, the disease was 
 retarded, and life was j^rolonged for some months. 
 
 For a time, chief attention in treatment was directed to means 
 which retarded the progress of the disease; but the unsatisfactory 
 results thus obtained finally led to more radical measures, in 
 which it was attempted to excise the affected tonsil. Operative 
 work in this line has been done by Cheever, Mickulicz, Lange 
 and others. 
 
 In 1883, Mickulicz rejoorted the removal of tonsillar cancer, 
 through an external opening, made as follows: An incision is 
 made from the mastoid process to the os hyoides; the soft parts 
 are then detached from the angle of the jaw, internally and 
 externally, and the angle then exsected; through the opening 
 thus made, an entrance is prepared into the pharynx, and the 
 tonsil is reached and removed. Thus done, the vessels become 
 visible and can be pulled out of the way; or if wounded, they 
 can be tied. The mutilation of the maxilla inferior is a serious 
 objection to the method of Mickulicz; and to avoid this, Cheever 
 and Lange have made an opening at the angle of the jaw into 
 the pharynx; and through such opening they reached and 
 excised malignant disease in the base of the tongue, or in the 
 tonsil. 
 
 In pioneering such a route to the pharynx, the position of the 
 external carotid artery must be remembered ; this lies under the 
 parotidean sulcus, or depression between the mastoid process and 
 mandibular angle, in which lies the dependent portion of the 
 parotid gland. The lower branches of the cervico-facial portion 
 of the facial nerve lie in the same dejDression, and they are neces- 
 sarily injured or severed, in an incision here; hence the risorius 
 Santorini muscle is thus temporarily, or permanently, 2:)alsied. 
 The cutaneous incision should lie just behind the lower jaw, 
 
712 TONSIL. 
 
 commencing an inch above the angle, and extend an inch and 
 a half along the lower border of the bone. In the horizontal 
 portion of the cut, the facial artery will be met, and it must be 
 ligated. From the middle of this semilunar cut, a vertical incis- 
 ion must be carried an inch and a half downwards. Through 
 such a cut between the lower jaw and the digastric muscle, a 
 free way is opened into the throat; and in its construction, the 
 external and internal carotid being exposed early in the work, 
 they can be avoided; and if the external jugular or its formative 
 branches, and the facial artery be doubly tied and divided, 
 the operation becomes nearly a bloodless one. This cervico- 
 pharyngeal opening can be utilized for extirpation of malignant 
 disease in the pharynx, tonsil and base of the tongue; and in the 
 last case, the cut permits of ligation of the lingual artery in the 
 first portion of its course, whereby one-half of the tongue will be 
 rendered nearly bloodless. 
 
 This cervico-pharyngeal route, besides the facility which it 
 offers for the removal of malignant disease within the throat, has 
 the additional advantage that it o])ens to view the lymphatic 
 glands which sooner or later become implicated, when there is 
 malignant disease within the throat; and such infected glands 
 require removal, and if this is not done, there will be speedy 
 recurrence of the disease. The field, when well opened, must be 
 diligently explored, and every gland which is found, whether 
 large or small, should be removed. A favorite lurking place for 
 such infection, as tlie author has verified, is in glands which lie 
 on or near the bifurcation of the primitive carotid. The wound 
 made also offers the best opportunities for thorough drainage of 
 the excreta which are thrown off from the wounded parts; and 
 thus pulmonary disease through swallowed ichor is avoided, and 
 speedy healing of the wound is obtained; four weeks, at most, 
 suffice for recovery. The scar remaining in the male is covered 
 by his beard ; and even in the beardless it is not very conspicuous. 
 
 As a more expeditious plan than the one just described, and 
 one by which the loss of blood would be reduced to a minimum, the 
 writer would suggest to begin the woric by ligating the external 
 carotid artery; and then through the cut made, continue the 
 incision into the pharynx. This prophylactic ligation would 
 enable the work to be done in almost bloodless structure, as the 
 writer has verified. 
 
CHAPTER XXI. 
 
 PHARYXX. 
 
 The pharynx is the site of inflammation, which may primarily 
 arise in it, or the affection may appear secondarily from inflamma- 
 tion, which, beginning in the tonsils, extends thence to adjacent 
 parts; and in either case, the symptoms are cognate to tonsillitis, 
 and, like it, tend to suppuration. The best treatment, if the 
 patient be seen early, is to scarify the affected parts, and thus let 
 the blood which has accumulated in the surface be evacuated. 
 If the patient be an adult, in whom such treatment can be prac- 
 ticed with more facility than in the child, free scarification 
 once suffices to arrest the inflammation; afterwards, resolution 
 will be promoted by painting the surface daily with the following: 
 
 ]^. Tr. lodini compos. 
 
 Tr. Gallse aa gss 
 
 Misce. 
 
 similar to what was advised for the inflamed tonsil. 
 
 Abscess of the Pharynx. — Pharyngeal abscess was first carefully 
 observed and written upon by Abercrombie, in 1819; a few years 
 later, the disease was studied by Fleming, Gillette, Jacquemart 
 and others. Such abscess may appear as an acute, or as a chronic 
 process. It is often named according to its sites; thus we have 
 abscess named retro-pharyugeal, latero-pharyngeal, and antero- 
 pharyngeal, according as it is located behind, at the side or in the 
 front portion of the pharynx. The most usual species is the 
 retro-ph ary ngeal . 
 
 Acute pharyngeal abscess occurs most commonl}^ in the infant; 
 thus of forty-six cases observed by Gautier, thirty-five were seen 
 in young children; and in twenty-six, the infant was less than 
 one year old. Abelin saw the affection in infants only three 
 months old. 
 
 Gillette, of Paris, in 1868, wrote on the retro-pharyngeal abscess, 
 drawing his material chiefly from the observations of such 
 46 (713) 
 
714 I'lIAKYNX. 
 
 abscess by French surgeons. In retro- pliaryngeal abscess, \vhieh 
 is the common form, he claims that the point of origin and of 
 commencement is in two lympliatic glands, peculiar to infancy, 
 and which are situated, according to the researches of Gautier, 
 Cocteau and others, on a level with the second vertebra, between 
 the superior constrictor pharyngeal muscle and tlie anterior recti 
 muscle of tiie upi>er part of the s[»ine; these glands are usually 
 two in number, separated by an interval of a half inch, and they 
 lie in a loose connective tissue. They are nearly a half inch 
 long and about a quarter of an inch broad; in the opinion of 
 some ol)servers these dimensions iiiay be due to abnormal devel- 
 opment, and in normal state, the glands are believed to be much 
 smaller. In later childhood these glands atrophy and vanish. 
 Gillette saw but one in a child wliich had passed beyond infancy. 
 The retro-pharyngeal abscess, which occurs so much oftener in 
 children, is thought by Gillette and Verneuil to begin in this 
 infantile gland. The cases seen have been of different dimensions ; 
 it may be limited to a small space, or it may reach down to the 
 sixth or seventh vertebra. 
 
 Predisposing causes of the disease are rachitis, scrofula, tuber- 
 culosis, syphilis and feebleness of body. It is frequently preceded 
 by disease in the throat, tongue and tonsils; and commencing in 
 these sites, it is probable that it is thence propagated by structural 
 continuity. As local irritant, a foreign body lodged in the throat, 
 has caused abscess; thus a coin has acted. 
 
 There are two stages: the inflammatory and the suppurative; 
 and in the former, there is diSiculty in swallowing, return of the 
 material swallowed, whether this be liquid or solid; dryness of 
 the throat and a teasing cough. If the subject be an infant at 
 the breast, it has difficulty in drawing the milk. Later, there is 
 salivation, chills, oedema and swelling of the cervical glands. 
 The voice becomes hoarse or suppressed, and the head is bent to 
 one side, or backwards. There is often difficulty of opening the 
 mouth, in consequence of contraction of the muscles of mastica- 
 tion; viz., a trismus which might mislead by awakening the 
 suspicion of tetanus. If the jaws be opened, the exploring finger 
 will find swelling in the throat. 
 
 Through narrowing of the faucial isthmus, not only swelling 
 but also breathing is obstructed. Hearing may be impaired, or 
 temporarily lost, through closure of the Eustachian tube. Some- 
 times vision may be interfered with. The pus, when formed in 
 considerable quantity, may press on the vagus and the sympa- 
 
ABSCESS OF THE PHARYNX. 715 
 
 thetic nerve; and thence fundamental trouble can arise in the 
 peripheral districts which receive innervation from these nerves; 
 this fact analyzed offers an explanation of the lingual, pharyngeal, 
 laryngeal, pulmonic and gastric troubles, which singly or in 
 union are present. The closeness of the internal carotid and 
 internal jugular vein to the abscess may disturb the normal influx 
 and efflux of the blood of the brain; and in the worst cases, the 
 internal jugular may become the site of thrombus, which may 
 reach up into the sinuses of tlie dura mater, and induce a fatal 
 termination. 
 
 Pharyngeal abscess is generally preceded by some auginous 
 affection or traumatic cause; and this in the child may be, for a 
 time, overlooked. The first indication that pus is present, is the 
 difficulty which the patient has in swallowing ; and this evidence 
 will further be enforced, if swelling be found in the throat. As 
 the jaws are usually tightly closed, it is difficult to obtain a view 
 of the affected parts ; and to do this, the handle of a large spoon, 
 or, better still, a spatula, should be passed between the teeth, 
 backwards, to the fauces. The introduction of such an instru- 
 ment will excite an effort to vomit, by which the mouth is'well 
 opened; and during tliis, a wedge-shaped cork must be thrust 
 between the molar teeth, so as to maintain the jaws well asunder. 
 Through the opening thus prepared, the finger can safely enter 
 and reach the affected part ; then palpation will detect fluctua- 
 tion, or pointing of pus, if an abscess exists; as Gosselin says, the 
 displaced pus recoils as soon as the finger is lifted. If the abscess 
 has lateral position, the fluctuation is less sensible to the finger, 
 and the touch will be aided, if counter-pressure is made with the 
 other hand, on the outside. And if the pus lies still more ante- 
 riorly, it may be detected by bi-manual pressure on the sides of 
 the throat. 
 
 From the divergent observations of different writers it is diffi- 
 cult to give the duration of the disease ; among seven cases, the 
 disease lasted from one to ten days; in twelve others, the course 
 was from ten to twenty days; and in fourteen others, the dura- 
 tion varied from twenty to sixty days. However divergent and 
 discordant these numbers may be, they do not deter the statistician 
 from deducing his wonted percentage from them; a result of no 
 use to the practitioner; to the latter, the important truth is that' 
 the pharyngeal abscess, through tumefaction, closes the fauces, 
 through asphyxia, and finally, if unrelieved, destroys the patient. 
 
 The prognosis is more auspicious according as the disease 
 
•IG 
 
 PHARYNX. 
 
 has been correctly diagnosed at an early period ; thus Gautier, 
 who collected twenty-five cases in wliich the disease had not been 
 recognized, reports that all died; but in a list of sixty-six cases 
 which liad been early diagnosed, there were but sixteen deaths. 
 Again Roustan found that in a series of eleven cases wrongly 
 <liagnosed, there were eleven deaths; but in twenty-seven cases 
 which were correctly diagnosed, there were ten deaths. The 
 reader, along wMth the author, will doubtless admire the candor 
 that adorns these statements, and will, perhaps, wonder whetlier 
 the admission of so many mistakes would have been made else- 
 where. A writer who publishes his errors should be assigned a 
 front place among those who are enlarging the domain of medi- 
 cine; and the gaudy laurel which Fame hastens to place on the 
 brow of him whose daring has ended luckily, would be more 
 fittingly bestowed on him who has announced a faihire. 
 
 There is a chronic form of phar3nigeal abscess, in which the 
 course and evolution are latent; and which, quite unheralded by 
 any of the S3'mptoms wliich attend the acute form, finally 
 announces itself by difficulty of swallowing. Inspection then of 
 the fauces reveals a collection of pus in the lateral or posterior 
 wall of the pharynx. The patient, in such a case, is of tubercu- 
 lous, scrofulous, or, more rarely, syphilitic habit. And along 
 with the abscess, not unfrequeutly there may be vertebral caries 
 seated in the body of one or more of the cervical vertebrae. And 
 then, mingled with the pus there may be osseous detritus; or 
 even a necrosed fragment of bone of some size may be found in 
 the abscess. 
 
 Of whatever nature the general dyscrasy may be, the adja- 
 cent cervical glands will be im})licated; and this tumefaction 
 may lead to an exploration of the throat, and discovery of the 
 pharyngeal affection, long before the advent of dysphagia. 
 
 Treatment. — The proper treatment of the pharyngeal abscess 
 is to evacuate the pus at once ; for if this be delayed, the purulent 
 material will descend to a location from which the evacuation 
 will be much more difficult. Instances have been ol)served in . 
 which the pus has descended into the posterior mediastinum, 
 causing irreparable injury. 
 
 There are two routes through which the pus may be given 
 exit: one through the mouth, and another in which the material 
 is given outlet through an opening made in the upper side of 
 the neck. 
 
 The usual method has been to open and evacuate the pus 
 
ABSCESS OF THE PHARYNX. 717 
 
 directly into the fauces; and as far as possible, to allow the pus 
 to escape through the mouth. Tliis plan has certain trouble- 
 some accompaniments, to wit, that the material tends to escape 
 downwards, rather than upwards and forwards; and then the 
 material either enters the stomach and is absorbed, or it passes 
 into the lungs, and awakens morbid action there. Again, the 
 opening in the pharynx permits the lodgment of particles of 
 nutriment, or other materials which may be swallowed. Not- 
 withstanding these embarrassing conditions, the writer would 
 open the abscess, on the inside of the throat, in every case of 
 pharyngeal abscess of acute character. The opening may be 
 made with a scalpel of long handle; meantime, the patient's head 
 should be so situated that the liberated matter will have ready 
 escape through the mouth. If the subject be a child, the jaws 
 should be held asunder by some body interposed between the 
 molar teeth. It is probable that the aperture made v/ill close 
 and require re-opening; this can be done with a probe or blunt 
 dissector. • 
 
 In the event of the abscess being of chronic development, and 
 it being probable that the cervical vertebrae are involved, then it 
 has been recommended to liberate the pus by means of an incis- 
 ion made on the side of the neck, so directed as to reach the 
 purulent cavity. Such an operation was proposed and done by 
 Chiene, of Edinburgh, a few years ago. And as a preliminary 
 step in the work, he performs tracheotomy. Inasmuch as this 
 would be no small quota of the assault made on the patient, the 
 writer would not resort to it unless asphyxia were impending 
 from occlusion of the pharynx; but if suffocation were immi- 
 nent, tracheotomy should be performed as a prophylactic act. 
 And if this be performed, then ansesthetic inhalation must be 
 done through the tracheal canula. The incision is now to be 
 made, commencing with an external cut, not less than two inches 
 and a half long, along the posterior border of the sterno-cleido- 
 mastoid muscle; and in this the ascending branches of the super- 
 ficial cervical plexus should be avoided: easily done by carrying 
 the knife behind them. Next, there will probably be met, espe- 
 cially in the dyscrasic subject, enlarged lymphatic glands, which 
 should be removed. The advancing incision should be directed 
 obliquely inwards and backwards; and thus the transverse pro- 
 cesses of the second and third cervical vertebrae will be reached, 
 in front of which the incision must pass. The sterno-cleido- 
 mastoid is to be drawn forwards with a retractor, and the separa- 
 
718 PHARYNX. 
 
 tioii of tlie parts to be carefully continued until the pus is reached ; 
 and in this work, to avoid oj^ening into the fauces, the jaAvs hav- 
 ing been separated, a finger of one hand introduced into the 
 pharynx will serve as a controlling guide to the work wliich the 
 other hand is doing. The deeper portion of the dissection should 
 be done with a blunt dissector. This opening must be near the 
 transverse processes and the bodies of the cervical vertebrae; for 
 thus placed it will be situated quite behind the vessels and nerves 
 which lie in the lateral wall of tlie pharynx. AVhen the pus 
 cavity is reached, a free opening should be made, and the content 
 washed out with an alkaline solution; and this may consist of a 
 twenty per cent solution of carbonate of potash; such solution 
 is approximately formed by adding three drachms of. the salt to 
 two ounces of water. The solvent quality of the alkaline solution 
 will aid in cleansing out the cavity; and afterwards the rinsing 
 out may be finished with an alcoholic or sublimated solution. 
 The opening is to be kept patent by a drainage tube as long as 
 pus is formed, and detersive irrigation continued uniil the escap- 
 ing material is of serous character. If the bony wall be impli- 
 cated, then the affected surface should be scraped off with a strong 
 curette; and in this case the outlet to the site of disease must be 
 maintained open for a much longer time; but if there be no 
 osseous disease, the wound may be allowed to close in a few days, 
 as was done in a successful operation of this kind reported by 
 Carless, of King's College hospital. 
 
 Should the pus have lateral rather than median situation, 
 then the incision should be made on the side corresponding to 
 the abscess; and then the recovery would be more rapid, since in 
 such a case the vertebrse would probably not be affected, and the 
 opening to the abscess would be less deep. 
 
 The necessity of preliminary tracheotomy has been favored 
 and opposed by those who have written on the pharyngeal 
 abscess. The advantages claimed for it are that it at once dis- 
 poses of the peril of asphyxia; and, especially, it guards against 
 the penetration of pus into the air-passages, if the abscess is 
 opened intentionally or accidentally on the inside. For, however 
 carefully the opening be made into tlie fauces, some purulent 
 material must be inhaled into the lungs. Even if the intra- 
 pharyngeal opening is made with the head dependent, as pro- 
 posed and practiced by Rose in operations on the nose and throat, 
 then the strong inspiratory effort, which is involuntarily made, 
 will carry purulent materials into the lungs. And even trache- 
 
ULCERATION OF THE PHARYNX. 719 
 
 otoiii}' cannot prevent tliis unless the pharynx below be plugged, 
 which should be done with sponges. The same may be accom- 
 plished b}^ tamponing the trachea above the opening made in it, 
 which can also be done with sponges. 
 
 Notwithstanding the facts which have been offered as a plea 
 in behalf of preliminary tracheotomy in pharyngeal abscess, the 
 writer thinks there are but few cases in which it would be 
 necessary. 
 
 Jjlceration of the Pharynx. — Ulceration of the pharynx may 
 arise from an acute inflammatory process, whence arises an ulcer- 
 ative breach of surface; or the ulcer may arise from some consti- 
 tutional disease, which may be of syphilitic or tubercular nature. 
 
 Ulceration occurring as an event of some acute inflammatory 
 process, is usually of brief duration, vanishing soon after the 
 causal aff'ection has disappeared. For such ulcer simple remedies 
 only are required; the following gargle may be used: 
 
 B^. Potass. Chlorat 9ii 
 
 Aqiise Menthse 5 viij 
 
 Misce. 
 Use three times a day. For the same purpose claret wine diluted 
 with an equal part of water may be used. 
 
 The chronic form of ulcer, which is but a local manifestation, 
 and a fractional one at that, of a constitutional disease, is a most 
 troublesome affection which may indirectly imperil life. The 
 better knowledge now existing of syphilis and of the means to 
 cure it rarely permits the development of severe pharyngeal 
 ulceration ; exceptionally, however, such secondary manifestation 
 is seen. In such cases, the affection of the pharynx renders 
 deglutition painful, so that the patient takes but an insufficient 
 amount of food ; whence follow debility, emaciation and a rapid 
 waning of the forces of life. 
 
 Such dyscrasic ulceration is preceded by a period of infiltra- 
 tion; in the syphilitic subject this is gummatous in character 
 while it is tubercular in the scrofulous patient; and later, the 
 neoplastic infiltrate disintegrates, and, breaking down, there 
 remains a corresponding breach or ulcer. And if there exist 
 isolated points of infiltration, corresponding points of solution 
 will appear, of which the widening areas enlarge until there is 
 formed by their common fusion, a large denuded surface. And 
 this eroding process, besides lateral and superficial extension, also 
 penetrates into the subjacent structure. 
 
 Besides the mode of origination just mentioned, the pharyn- 
 
720 PHARYNX. 
 
 treal ulcer may result from an abscess, of which, the inner wall 
 sloughing, there may remain an ulcerated surface with but slight 
 tendency to heal. 
 
 Pharyngeal ulcer, when occupying a large portion of the wall 
 of the pharynx, if it heals, entails stricture of the pharynx; and 
 this stenosis, as the author has observed, may reach such a degree 
 of constriction as to partly or totally obstruct swallowing. 
 
 Treatment. — Isolated topical treatment of the dyscrasic ulcer 
 would be of no benefit; such a mode would resemble the pluck- 
 ing of an occasional leaf from a tree while the trunk is allowed to 
 remain in vigorous growth; to cure the patient, the genetic dis- 
 ease must be energetically treated ; and the preceding syphilis, 
 scrofula or other cachexy must take precedence in the manage- 
 ment; and this having received tlie prior and major care, atten- 
 tion may next be directed to the local affection in the throat. 
 
 Tlie ulcerated surface should be thoroughly destroyed either 
 by curetting or the thermal cautery; and, in some cases, the 
 curette may be followed by the cautery. Thus the diseased 
 infiltrated tissue is effectually disposed of, and the remaining 
 structure is placed in conditions favorable for healing. If the 
 thermal cautery follow curetting, the former should be done 
 sparingly. And along with the topical and constitutional treat- 
 ment, the nutrition of the patient demands special attention; he 
 should have a rich, generous diet, in which there should be a 
 due proportion of solid food. From the writer's observation, 
 meats in solid form contribute much more to the maintenance of 
 the body, in such cases, than liquid extracts; in one patient, 
 though he was bounteously fed on liquid food, yet emaciation 
 continued; finally the use of meat in solid form was followed by 
 immediate and rapid improvement. Hence in such disease, 
 solid meats and eggs are invaluable adjuvants in treatment. 
 
 The cicatricial contraction of the healing pharynx tends to 
 strictural narrowing, so that after recovery normal swallowing 
 is greatly obstructed. To obviate this tendency to narrowing, 
 dilating sounds or expanding instruments should now and then 
 be passed through the pharynx. 
 
 Sometimes the case only comes under observation after the 
 ulcerated wall has healed, and constriction has taken place. 
 The appropriate treatment in such a case is to incise tlie wall 
 vertically, and then dilate with sounds; or, what is better, one 
 may use handled forceps; and the blades being passed below the 
 constriction, the handles are separated, and the instrument 
 
PHARYNGEAL TUMORS. 721 
 
 withdrawn. In this way the calibre can be w^idened, and by 
 persevering effort, tliis can be maintained so ; yet to be success- 
 ful, instrumental dilatation must be continued for a year or two. 
 
 Pharyngeal Tumors. — The pharynx is the not infrequent site 
 of growths which may arise there primarily, or extend to it ■ 
 through emigration from adjacent parts. These neoplasms may 
 be benign or malignant in nature; the latter may be sarcoma- 
 tous or carcinomatous in species. The notorious naso-pharyngeal 
 tumor may arise from the upper part of the posterior wall; or 
 from the roof of the choanse; and for the description and .treat- 
 ment of this growth, the reader is referred to a preceding section 
 of this work. 
 
 A benign tumor of polypoid character has been observed in 
 the pharynx. Histologically, such tumor may be included in 
 the group of the fibromata. It may appear at any point of the 
 pharyngeal wall; and, when at the root of the tongue, or the 
 base of the epiglottis, or wdiere the pharyngeal isthmus merges 
 into the larynx and ossophagus, then the tumor may be over- 
 looked, and remain unseen and unknown to the patient until its 
 increased volume encroaches on the entrance of the air-passages 
 and interferes with respiration; or entering the oesophagus, 
 swallowing may be rendered difficult, or be entirely obstructed. 
 The tumor may be so located, as to obstruct both respiration 
 and deglutition. A case of the latter kind was reported to the 
 writer; the tumor had never been recognized during life; but 
 the patient dying suddenly from suffocation, an autopsy revealed 
 a tumor situated near the larynx. 
 
 The determination and diagnosis of the intra-pharyngeal 
 polyp may be made by means of the sound, digital palpation and 
 the pharyngoscopic mirror; and these are aided^ by the subjec- 
 tive symptoms to which the tumor gives origin. Any subjective 
 sign should receive due attention, and lead to a searching explo- 
 ration of the parts. 
 
 When found, such tumor must be radically removed; and 
 the facility or difficulty of doing this will depend on whether the 
 growth is pedunculated or sessile. If the tumor arise by a nar- 
 row footstalk, its extraction is easily done; by a pair of forceps, 
 the gxowth can be twisted and plucked from its ground. And 
 this may be done through the mouth. But if the location be 
 deep, and the tumor have a broad sessile attachment, the task of 
 removal becomes an arduous one; and the work may be done 
 through the mouth; or a shorter route may be made to it by an 
 
799 
 
 PHARYNX. 
 
 incision made between the larynx and the carotid artery. 
 Tiirough an opening tlius formed, tlie site of origin could be 
 readied directly, and the work of removal so thoroughly done, 
 tliat a re-growth would be prevented. After closure of the cervi- 
 cal wound, the nutrition should be maintained by means of 
 liquid food conveyed through an (esophageal tube. 
 
 Carcinoma may appear in the pharynx, primarily, or as an 
 emigrant; and when occupying this site, modern surgery in tlie 
 work of removal has sought to reach the growth by an incision 
 through the side of tlie neck, or by an opening in which the 
 maxilla inferior is divided. 
 
 Through the side of the neck, Langonbeck, in 1877, reached 
 the growth by the following incision: let the knife start at a point 
 midway ])etween the cliin and tlie angle of the jaw, and thence 
 pass downwards over the great cornu of the liyoid hone until it 
 reaches the level of the cricoid cartilage; in its course downwards, 
 this incision follows the direction of the thyro-hyoid muscle. As 
 the incision is cai-ried inwards, the superior thyroid, lingual and 
 facial arteries will be reached; the first and second must be 
 doubly tied, and divided; and the facial may also be ligated, if 
 it cannot be pulled upwards out of the way. The digastric and 
 stylo-hyoid muscles when reached must be detached from the 
 hyoid bone. Finally, the larynx is reached, and is to l>e turned 
 around somewhat on its axis and pulled aside, when the phar- 
 ynx being reached, it must be dissected from the parts to which 
 it is connected. The diseased pharynx may be divided above, 
 on a level with the pendulous veil of the palate; also below, at a 
 point corresponding to the inferior limit of the disease. The 
 detachment is not difficult if done at an earl}' period before the 
 disease has reached into, or beyond, the tissue which separates 
 the pharynx from the parts external to it. 
 
 The risk after the operation is the penetration of pus and 
 other materials into the lungs, and thence ichorous (gurgitant) 
 pneumonia can arise; to prevent or lessen these risks, Langen- 
 beck tracheotomizes and tampons the trachea above, and as fur- 
 ther aid he sutures the epiglottis to the opening into the larynx. 
 
 Fischer first opens between the hyoid bone and the thyroid 
 cartilage; that is, he performs sub-hyoid laryngotomy; and after 
 I'emovirig the affected pharynx, he fixes the end of the tesophagus 
 in the wound, and, letting it heal there, the patient is afterwards 
 fed tlirougli this opening. 
 
 Klister and Kroenlein, as fore-act in pharyiigotomy, divide 
 
FOREIGN BODIES IX THE PHARYXX. 723 
 
 the lower jaw near its angle, and then pass directly to the 
 affected part. Kroenlein operated as follows : a cut was made 
 from the angle of the mouth to the angle of the lower jaw, and 
 carried thence to the mastoid process; and then the lower jaw 
 was divided at the angle, and the ascending portion was so pulled 
 aside that the pharynx can be entered. After removal of the 
 disease, the ramus is restored to place, and united to the hori- 
 zontal portion by means of metallic suture. 
 
 Kiister deviated somewhat from this plan, in this, that, to 
 prevent subsequent maxillaiy anchylosis, he removed the ramus. 
 
 Lodgraent of foreign Bodies in the Pharynx. — The pharyngeal 
 isthmus is the site of lodgment of foreign bodies, which, in 
 their transit from the oral cavity, are caught and remain in 
 this space. Examples of such bodies are the pin, needle, fish- 
 bone or other sharp-pointed object. The movements of the 
 pharyngeal walls in deglutition are such as often arrest such 
 body, and thrust its point into the wall so that it remains fixed 
 there. A pin has thus been discovered lying crosswise, at the 
 entrance of the oesophagus; or it has been found situated verti- 
 cally, in one of the crevices or niches in the side of the pharynx ; 
 most often between the anterior and posterior arches. And 
 sometimes, the object enters the choanal; and there it escapes 
 detection, unless this space be specially ex[ilored. In case of 
 such accident, aided by what light the patient's account throws 
 on the matter, the surgeon must make a systematic search of the 
 walls and accessory recesses of the pharyngeal cavity, and if the 
 object is not found, the finger should next explore the parts. 
 
 iVs recesses into which bodies can fall and elude discovery 
 are two pockets which were described by Schutz, in 1844; these 
 spaces are boat-shaped, and situated beneath the tonsil; they 
 extend downwards and end on each side of the larynx. These 
 fossse are bounded behind by the palato-pharyngeal muscles; are 
 an inch long, and are spacious enough to receive and conceal a 
 body as large as a cherry seed ; and if special search is not made 
 for it, such object can remain hidden for an indefinite time. 
 
 When the body is found, whether in open or secluded site, it is 
 usually readily removed by rheans of a long pair of forceps. It 
 sometimes happens, hovrever, that a sharp-pointed object caught 
 in the throat has pricked or torn the surface; and though the 
 object is extracted, such remaining wound makes it difficult to 
 ■convince the patient that the object has been removed. And it 
 may be added, that the sensation from such wound has often led 
 
724 I'HAKYNX. 
 
 to a fruitless search for an object which lias been swallowed, or 
 dislodged from its pharyngeal site. 
 
 Hyrtl has directed attention to certain folds which lie in the 
 pharynx on the posterior wall of the larynx. These folds corre- 
 spond to depressions on each side, wdiich sink inwards between 
 the cricoid and the thyroid cartilages. This fold reaches from the 
 arytenoid cartilage to the end of the great horn of the hyoid 
 bone. The free edge of it is directed downwards and backwards, 
 and can have an elevation of three lines. It becomes more appar- 
 ent when traction is made on the trunk of the superior laryngeal 
 nerve. 
 
 This fold of mucous membrane does not obstruct the act of 
 swallowing; but it impedes the free escape of matter in the act of 
 vomiting. And where the fold is of unusual development, it 
 may present an insuperable obstacle to vomiting, as has been 
 seen in some subjects. Sounds which are passed down the 
 pharynx glide easily over this fold; but if the instrument has a 
 prominence, this can catch on the fold in tlie withdrawal of the 
 instrument; and if this be done rudely, the fold might be torn. 
 
CHAPTER XXII. 
 
 SUBLINGUAL REGION. 
 
 There remains for consideration only a small section of the 
 buccal cavity, viz., the free space beneath the anterior, or free 
 portion of the tongue, known as the sublingual space or region. 
 This space is of greater or less extent, according to the attachment 
 of the tongue to the floor of the mouth. This space is invested 
 with mucous membrane which abounds in muciparous glands. 
 Where the tongue separates from the floor of the mouth in the 
 median line lies the frtenum, of which the restricting action on 
 the lingual movements has already been considered. Close to 
 the frsenum lie the outlets of the Whartonian and Rivinian 
 ducts, or ducts of the sublingual gland. These outlets are 
 readily visible to the eye, and that of the Whartonian duct is so 
 large that it will admit a small probe. 
 
 The outlets of these salivary ducts lie in the summits of 
 irregularly-shaped papillae, which are vascular and erectile; and 
 when the tongue is uplifted, this erectile action is visible, while, 
 at the same time, the saliva flows from or is ejected from them. 
 These papillary bodies may enlarge and become the source of 
 anxiety to the subject, whose repeated examination of them irri- 
 tates and enlarges them. These enlarged outlets demand no 
 surgical treatment; the patient must be counseled to neglect 
 them, and, if possible, to forget them. The sublingual space, as 
 ancient history tells us, was utilized by Demosthenes, who is said 
 to have placed pebbles in it, in his elocutionary training; and in 
 imitation of the orator upon the Crown, to the writer's knowledge, 
 the m.odern sophomore thus trains his tripping tongue. 
 
 Beneath this space, and separated from it by the mucous 
 membrane, lie the sublingual gland and the sublingual bursa 
 of Fleischmann. The latter, from its occasionally being the 
 site of ranular cyst, demands description, which, in the lan- 
 guage of its discoverer, is as follows: " If from one or the other 
 
 (725) 
 
720 srr.LiNGUAJ. KWiiox. 
 
 side of the fraMium, one dissects up tlio mucous membrane, there 
 is found restinj^ on the genio-hyoglossus muscle, close to the 
 frccnum, and behind the ducts of Wharton and those of liivin- 
 ianus, a small mucous l.nirsa divided into smaller spaces by septa; 
 this is the sublingual bursa, the existence of which is important 
 to know, in order to have a proper knowledge of ranula." This 
 bursa is found by an antero-posterior section of the floor of the 
 mouth. Its origin is due to the se})aration of the lingual mucous 
 membrane and the genio-hyoglossus muscle by the interposition 
 of the sublingual gland. According to Tillaux, this bursal space 
 is flat in form, and is divided in the median line, into two parts 
 by the fraenum ; and it presents two faces, the one attached to the 
 floor of the mouth, and the other attached to the anterior face of 
 the genio-hyoglossus muscle. It is bounded in front, and at the 
 sides, by the lower jaw, and reaches as far back, on the sides, as 
 the first or second molar teeth. This bursal space lies behind the 
 sublingual gland and the duct of Wharton ; and, according to the 
 admeasurement of Tillaux, it is, from before backwards, nearly 
 two inches in length. This bursa in some subjects, is traversed 
 by septa which divide it into separate spaces. 
 
 Tlie free sublingual portion of the floor of the mouth may be 
 the starting-point of epithelial cancer, which, as a slight erosion, 
 may appear on each side of the fra^num, and remain there sta- 
 tionary for a time; and later, it may extend and attack the tongue 
 and the adjacent maxilla. Though the initial point of disease is 
 near the frtenum, it usually spreads unilaterally, rather than 
 bilaterally. The ulcerating process, in its extension, finally 
 attacks the lower jaw and penetrates the sublingual structures 
 and the side of the tongue; by metastatic propagation, the disease 
 travels along the lymphatics which surround the duct of Whar- 
 t<jn, and appears in the lymphatic glands which lie next to the 
 submaxillary gland; and, finally, the submaxillary gland itself 
 is attacked. The sublingual gland also becomes implicated in 
 the disease. 
 
 The proper treatment consists in thorough removal of tlie 
 aff'ected structures. The knife and thermal cautery should be 
 associated in the removal; the cautery should complete the 
 destruction of any diseased tissues which the knife may have 
 overlooked. If much of the tongue is to be excised, the lingual 
 artery must be tied as a preliminary act. To obviate recurrence, 
 infiltrated glands should be removed, and also the submaxillary 
 gland if it be indurated. Additional points concerning the 
 
RANULA. 727 
 
 treatment will be found in the chapter treating of cancer of the 
 tongue, 
 
 Ranula. — The sublingual region is the frequent site of a cystic 
 tumor which is named ranula. This term signifies a small frog; 
 but any relationship between this animal and the tumor is a 
 matter which the writer suspects would puzzle anatomist, pathol- 
 ogist or naturalist. 
 
 The ranula may vary in volume from the size of a pea to that 
 of an orange. When small, it lies superficially beneath the 
 mucous membrane; but when large, it may extend deep into the 
 sublingual floor. 
 
 Ranula, in reference to its cause, and the structures in which 
 it originates, has been the subject of thoughtful study on the part 
 of the surgical pathologist. In 1850, Haller of Dorpat, wrote a 
 dissertation on ranula, in which he gives the different opinions 
 which obtain in respect to its origin; and these he classifies 
 in four groups: 1. Ranular cyst may arise from retention of 
 saliva in the sublingual or submaxillary gland; or in the duct 
 of the gland; or from rupture of the same into the surrounding 
 tissues. 2. Or it may be a common cyst, originating as such do, 
 elsewhere. 3. Or the content may be mucus, and arise from the 
 retention of the content of a mucous follicle. 4. It may arise 
 from the enlargement of the bursa sublingualis, which lies between 
 the tongue and the genio-hyoglossus muscle. 
 
 From his individual studies, Haller concludes that the most 
 usual mode of origin is from the sublingual bursa; and, as such, 
 it is often divided into separate compartments. 
 
 Tillaux refers the usual origin of ranula to the sublingual 
 bursa. His attempt to explain the rapid appearance of a large 
 ranula, as dependent on augmentation of the content of the sub- 
 lingual bursa, is not convincing. 
 
 Dassen, in 1858, wrote on ranula and ascribes its origin to the 
 development of a cyst in the submucous tissue; and he asserts 
 that it does not depend on closure of the salivary ducts, or of the 
 mucous follicles. 
 
 Besides the ways enumerated in which ranula may originate, 
 the writer has observed cases in which the cyst undoubtedly was 
 connected with bursse mucosae which pertain to the muscles 
 which lie in the floor of the mouth; since, in the removal of the 
 ranula, its direct connection and relation with the sublingual 
 muscles were verified. 
 
 A comparison of the content of the ranular cyst with saliva 
 
728 SUBLIMJUAL KEGION. 
 
 has been made by means of cliemical analysis. Koiinal saliva 
 contains an organic principle named ptyalin; in examination of 
 the content of ranuhie operated on by U. Weber, he did not find 
 ptyalin. Sulphocyanide of potassium is usually found in saliva, 
 and is detected by a solution of iron, the union of the two giving 
 a rose-colored reaction. Weber did not get such reaction with 
 ranular content. He intimates, however, that the retention of a 
 secreted fluid, finally alters its composition; an example of which 
 is that of bile retained in the gall-bladder, which finally loses all 
 its normal character. And by analogy, the same might occur in 
 the case of retained saliva. 
 
 Weber and others have sought for an anatomical connection 
 between the ranula and the ducts of the sublingual and submax- 
 illary glands; a probe passed into the latter ducts did not enter 
 the cyst. Also chewing, which causes a flow of saliva from 
 these ducts, which is easily discovered in the open mouth, does 
 not lessen the volume of a ranula; and, further, if the mouth be 
 so opened that one can see the ducts beneath the tongue, if 
 pressure then be made on the cyst within the mouth or on the 
 floor from the outside, then no fluid can be seen exuding from 
 the ducts, nor is the volume lessened. 
 
 Again, as proof of non-connection between the ranular cyst 
 and the salivary glands is the fact that when the duct of the 
 latter is opened, or the gland wounded, the surgeon experiences 
 o-reat difficulty in closing the breach; but, on the contrary, if 
 such breach be made in the ranula, the difficulty is equally great 
 to prevent closure; the salivary fistula often remains open despite 
 all surgical effort; a breach in the ranula, with equal persistency, 
 will close. 
 
 From the preceding statements it may be concluded that the 
 ranula usually has origin independent of the salivary glands; 
 and if it does arise from the latter, it is exceptional. 
 
 Haller finds that ranula is definitely limited from the struc- 
 tures around it; it has a tendency to burst, and soon to refill 
 again; and this quality to close and refill is the cause of the 
 difficulty met in the attempts to cure the ranula. And the 
 treatment should be resorted to early, since, as Allan Burns and 
 others have found, a cure is far more easily accomplished then 
 than at a later period. Besides, the cyst being allowed to grow^ 
 it may attain proportions perilous to life; or at least to the parts 
 adjacent. Thus Ehrlich describes the following remarkable case, 
 in the practice of Cline: "A patient called to consult Mr. Cline, 
 
EANULA. 729 
 
 and was ushered into liis waiting-room; quickly afterwards the 
 surgeon heard a fall in his room, with screams and groans; and, 
 on opening the door, the patient was found unconscious and 
 suffocating on the floor. Cline, suspecting the cause to be a foreign 
 body in the windpipe, was proceeding to perform tracheotomy, 
 when lie perceived that the man's tongue was crowded backwards 
 by a ranula; he plunged a lance into this and gave relief by 
 giving vent to a large cjuantity of pus and lymph." And in the 
 records of the Society of Surger}^ in Paris, there is described a 
 ranula which had grown to such dimensions as to displace the 
 teeth. To prevent such disaster as here mentioned, early inter- 
 vention is prudent. For the cure many methods have been 
 announced, of which a review here follows. 
 
 Pare and Tulpius opened the cyst and then applied a hot iron 
 to its surface. Dionis opened and touched the inner surface with 
 sulphuric acid. Jobert first dissected the mucous membrane 
 from the cyst, and then he split the latter transversely, and 
 drawing the posterior portion backwards towards the tongue, he 
 stitched it there; and the anterior portion was pulled forwards 
 and fixed there by a suture. In this way the cyst is maintained 
 open, and not being able to refill, a cure is effected. Petrequin 
 cured ranula by passing a leaden suture through it and allowing 
 this to remain in place until the cystic cavity contracted and a 
 cure was obtained. Haller thinks tlie best methods are those in 
 which an inflammation is excited; and this may be done by 
 cauterization with the hot iron or seton, or by the injection of 
 irritant agents. In a case treated by Pisani, in which incision, 
 excision, suture of the walls and injection of irritating substances 
 had failed, a resort was had to the introduction of a gold tube, 
 which, being retained in place for years, finally eflfected a cure. 
 Gosselin cured ranula by removing a large portion of the outer 
 wall, and then cauterizing the interior surface with nitrate of 
 silver; this cauterization was repeated every third day, and, thus 
 proceeding, a cure was reached. 
 
 Paulli makes two classes of ranula: a primary and a second- 
 ary form; the primary is superficial, and seated on each side of 
 the frsenum; while the secondary form arises from the rupture 
 of the primary one, and this may penetrate the floor of the 
 mouth, in its growth, and at length reach and rest on the tendon 
 of the digastric muscle. As means of treatment, he advises the 
 injection of tincture of iodine, which, in curing the cyst, may 
 also induce atrophy of the submaxillary gland. Paulli mentions 
 47 
 
/oO SUBLINOrAL REGION. 
 
 that Dupuytren ourod ranula by the introduction of a small 
 hollow cylinder into the cyst; instead of tliis Paulli inserted a 
 ring that could be tij^htened or enlarged. The ring being jtlaced 
 in tlie cystic cavity, it causes an irritation, and granulations grow 
 over and about it; and these must occasionally be removed. 
 
 Bryk, from tlie observation of nineteen cases of ranula, finds 
 a not infrequent cause to be some inflammatory affection of the 
 floor of the mouth, especially dental disease; and he makes three 
 classes of the alfection, viz., sublingual, submaxillary and retro- 
 maxillary. His treatment consists of the seton, which is passed 
 through the ranula, and allowed to remain there ; or tlie work 
 may be done by cauterizing with the galvano-cautery, tlie wire of 
 which is passed through the cyst. 
 
 Michel, of Nancy, reports six operations for the cure of ranula, 
 in which the cyst was dissected out from the floor of the mouth : 
 in five of these cases he first slit the sack and then dissected out 
 the parts; in the sixth case he dissected out the cyst without 
 opening it. This radical treatment has been tried by the Avriter, 
 yet the disease returned, due probably to imperfect dissection. 
 In two cases the author stuffed the cysts with powdered capsicum ; 
 in one a cure was obtained; in the other the ranula reappeared, 
 but was finally cured by repeated excision of portions of the 
 cystic wall. 
 
 As an epitomized summary of means which may be resorted 
 to, the following is offered: open and pencil the inner surface 
 with a strong tincture of iodine, or with a strong solution of 
 nitrate of silver, or chloride of zinc; forty grains to the ounce of 
 either of these agents would be of sufficient strength. This 
 escharotic application should be used every second day until its 
 action has been tested; and, in case of failure, try the thermal 
 cautery. Should failure attend all these modes of treatment, then 
 resort to excision, partial or total. To perform such extiri)ation 
 through the mouth is attended with much difficulty, and there 
 is also danger of wounding vessels; to avoid these difficulties the 
 work of removal may be done through the floor of the mouth. 
 For this, let an antero-posterior cut be made through the skin 
 in the median line, and then, with a blunt dissector, separate 
 the genio-ln'oid and genio-hyoglossi muscles; thusthecyst might 
 be reached and enucleated; injured vessels could be tied and 
 drainage easily provided for, and the work done, possibly, with- 
 out entering the oral cavity. 
 
 In closing the chapter on ranula, reference should be made to 
 
EAXULA. 731 
 
 three bursee described by Yerneuil, and which, when enlarged, 
 may be named pseudo-ranuhe. 1. The ante-thyroid bursa, which 
 is subcutaneous and hes in front of the tLyroid cartilage; and 
 this cavity can communicate with a similar one which is situated 
 behind the origin of the sterno-thyroid muscles. 2. A deep sub- 
 hyoid bursa which arises through the friction of the hyoid bone 
 against the upper margin of the thyroid cartilage; and this sub- 
 hyoid bursa may be divided by a septum mto two smaller cavi- 
 ties. This bursa may enlarge and then extend under the hyoid 
 bone. Verneuil claims that the sub-hyoid ranula of Xelaton, in 
 place of originating from enlarged sublingual mucous glands, 
 arises from dropsy of the hyo-thyroidean bursa. 3. A supra- 
 hyoid bursa, which is only exceptionally seen; this is bounded 
 above and behind by the genio-hyoglossi muscles. 
 
 Verneuil combats the opinion of Xelaton that the sublingual 
 mucous glands can, by abnormal growth, penetrate the sublingual 
 structures, and, finally, appear under the chin; for such a develop- 
 ment would be arrested by the dense glosso-epiglottic, hyo- 
 epiglottic, and hyo thyroid membranes; and hence he claims 
 that, should the foregoing btirsa enlarge, the resulting cyst should 
 not be included under the head of ranula. 
 
 The writer has observed and treated cases of the bursal cyst 
 here described. The surest means of cure is to dissect out the 
 cj'st; and in doing this, unless the work be done with much care. 
 the scalpel can penetrate the lan,'ngo-pharyngeal cavity, and 
 seriously complicate the recovery. A means of treatment unat- 
 tended by the risk mentioned, would be to evacuate the content, 
 and inject tincture of iodine into the cavity. And, as occurs in 
 similar treatment of liydrocele, it may be necessary to repeat tliis 
 procedure two or three times. 
 
CHAPTER XXIII. 
 
 MAXILLA INFERIOR. 
 
 The function of tlie lower jaw is to contain and retain in 
 place one-half of the teeth; and, through the medium of eight 
 muscles, it becomes the instrument by which mastication is 
 accomplished; for the upper jaw is motionless in the acts of chew- 
 ing, while the lower one is the sole factor of these movements. 
 This important function must be borne in mind in the treatment 
 of maxillary luxation and fracture, and in all operations in 
 which the continuity of the bone is broken. 
 
 Surgical Anatomy. — Certain landmarks demand the attention 
 of the surgeon, and should be accurately known; these are the 
 mental foramen, the depression for the facial artery, the inferior 
 dental foramen, with the prominence of Spix, and tlie cond3'le. 
 
 The mental foramen, through whicli escapes the terminal 
 portion of the inferior dental nerve, is situated near the middle 
 of the central portion of the body of the lower jaw, or beneath 
 tlie second bicuspid tooth (Despres). In the maturity of adult 
 life this foramen lies midway between the upper and lower mar- 
 gins; but as the form of the jaw is changed under the wasting 
 agency of years, this opening finally becomes situated much 
 nearer the upper than the lower margin. It lies in the continua- 
 tion of a straight line which passes through the supra-orbital 
 and the infra-orbital foramina. 
 
 On the outside of the body of the lower jaw, near its union 
 with the ramus, and nearly an inch from the posterior margin of 
 the angle, there is a depression in which lies tlie facial artery 
 with its accompanying veins; and this point is sometimes utilized 
 for compresj^ing the vessel, when incisions are made which may 
 open the labial vessels. This depression becomes greater with age. 
 
 In the middle of the lower portion of the ramus of the jaw lies, 
 on the inside, an opening for the entrance of the inferior dental 
 nerve. This opening lies at the point of intersection of two lines, 
 (732) 
 
CONGEXITAL DEFORMITY. 733 
 
 one of which lies in the median line of the ramus, while the other 
 is in the median line of the hody ; and such point of intersection 
 corresponds to the axis of motion of the jaw in its upward and 
 downward movements; and in such axis the nerve, as Hyrtl 
 points out, is absolutely free from any pulling or stretching. A 
 prominence exists on the lower edge of this foramen, known as 
 the eminence of Spix, which may guide the searcher for the nerve 
 in the operation of neurectomy. 
 
 Another important landmark is the condyle of the lower 
 jaw, which lies in front of and close to the tragus. This rounded 
 eminence is easily felt through the integument; and when the 
 mouth is being opened, the condyle can be felt moving forwards; 
 and as it does so, it becomes more prominent. 
 
 Between the cond3de and the temporal bone is interposed an 
 interarticular cartilage, of meniscoid form. The condyle has 
 intimate relations with the branches of the internal maxillary 
 artery and the accompanying veins; and these vessels may 
 bleed freely if wounded in disarticulating the ramus of the 
 jaw. 
 
 The maxilla inferior has only a limited range of movement, 
 being arrested by the upper jaw above; and muscles and liga- 
 ments limit descent downwards. 
 
 The low^er jaw, in its work, is an example of a lever of the 
 third order; and in mastication, the work done by the incis- 
 ors requires more power than that done by the molars. The 
 reverse of this obtains in forcibly depressing the jaw, when 
 less power is needed in front than if the work be done further 
 backwards. 
 
 Congenital Deformity. — The lower jaw is the subject of con- 
 genital defect and -deformity, which have been studied by Ogston, 
 who, in 1873, wrote on this subject. His classification is as fol- 
 lows: (1) entire absence of the lower jaw; (2) unusual size of 
 the jaw; (3) unusual smallness of the jaw in its entirety; (4) 
 abnormal smallness on one side. He finds that such deformities 
 are rare. Entire absence of the bone has only been seen among 
 animals. Enormous largeness is rare, and, when present, is 
 associated with defect of other bones. Abnormal smallness is 
 likewise associated with other kindred deformities; unilateral 
 smallness is associated with other asymetrical conditions of the 
 skull; and, finally, the temporo-maxillary joint may be absent. 
 Congenital luxation of the jaw is a rare occurrence. 
 
 Alveolar Periostitis, Gingivitis, and dental Abscess. — The periosteal 
 
734 MAXILLA JNl-KKIOR. 
 
 and mucous tegumeiitary tissues of the alveolar process of the 
 lower jaw are the occasional site of inflammation. Since a sim- 
 ilar process occurs in the alveolar i)rocess of the upper jaw, a 
 description of the affections in the one jaw applies to those of 
 the otlier. As to the nomenclature, the term parulis is used to 
 denote this disease. 
 
 As causes of parulis may be mentioned dental disease, in 
 which one or more teeth may be affected, disease of the osse- 
 ous alveolar structure, or a wound of the gingival structure 
 itself The affection may be seated on a small portion of the 
 alveolar process; or a very large portion may be implicated. 
 The writer has observed it oftenest in the upper incisor region ; 
 though, not infrequently, it appears near the lower molar teeth. 
 
 The inflammation may commence in the gingival ti.ssue, and 
 thence reach and attack the periosteum; or, commencing in the 
 bone, it may pass to the mucous membrane. It may be on the 
 inner or the outer side of the maxillary arch; or both sides may 
 be simultaneously inflamed. And whether it begins centrally 
 or superficially, at first the gingival tissue swells, is hard, and is 
 intensely red. There is pain of a throbbing character, which is 
 usually continuous; and this may be felt in a field which is 
 much greater than the affected structure. 
 
 After a few days of tormenting annoyance to the patient, 
 suppuration supervenes; pus forms on or near the bone, and 
 commonly detaches, for a short space, the soft parts from the 
 bone; and thus arises an abscess, of which the purulent content 
 can be detected by the trained finger. 
 
 As just traced, such is the cause of an acute gingivitis ending 
 in suppuration; a form, more slow in its march, is sometimes 
 met, in which the causal agency is dental caries or disease of a 
 limited portion of the alveolar process. This form may have a 
 course which may continue indefinitely long; in its duration, 
 years are often counted. The abscess which here forms, opens, 
 and there remains a narrow passage or fistulous canal, which, 
 traversing the soft parts, reaches to, and penetrates into, or 
 passes quite through the alveolar process. 
 
 Treatment.— The treatment proper for the acute form differs 
 from that required in the chronic; for the former, seek for the 
 causal agency and remove that. But the all-important thing to be 
 done is to combat the disease in its early stage, by freely scarify- 
 ing the inflamed structures, and thus permitting the congested, 
 stagnating blood to escape. The incisions should be made with 
 
ALVEOLAR PERIOSTITIS AND DENTAL ABSCESS. 735 
 
 a knife which is faultlessly sharp, and when the bleeding has 
 ceased, the affected part should be painted with a mixture com- 
 posed of equal parts of tincture of iodine and tincture of nut- 
 galls. Intervention in this manner, at an early period, may 
 intercept and avert the approaching suppuration; but, as a rule, 
 the patient allows this desirable opportunity to escape: the case 
 usually has reached the suppurative stage when it is first seen; 
 and, as already said, the experienced touch can distinguish the 
 liquid content beneath, or within the tumefied structure. The 
 proper management here, is to lay the abscess open, so that the 
 purulent content of the abscess and the blood in its walls may 
 have ready escape; and to effect this, the incision must be free, 
 and reach to the bottom of the abscess, even to the roots of the 
 teeth, whether the disease be on the upper or on the lower 
 jaw. Thus, the abscess may easily be cured in most cases; but 
 if the causal agency be dental or alveolar caries, or necrosis, 
 the evacuation of the abscess gives but temporary relief, since 
 there w411 afterwards remain a fistulous opening which will have 
 indefinite continuance; and in its course, it will present alterna- 
 tions of closing, filling with pus, and reopening. The disease has 
 now assumed the character of chronic abscess communicating 
 with the surface by means of a fistula which, according as it is 
 located, may be named a dental or alveolar fistula. 
 
 The dental fistula is preceded by an abscess, commonly of 
 chronic development. The pus which forms on the alveolar 
 process may open inwards towards the tongue; or outwards 
 between the lip or cheek, and the alveolar arch ; or it may pierce 
 the lip, or cheek, and then appear on the outside of the attached 
 portion of the lip, or on the cheek; or, after perforating the floor 
 of the mouth, it may open through the skin behind the chin. 
 Exceptionally, such pus has gravitated and api^eared on the 
 front of the neck. Around such fistulous passage, the tissues are 
 cicatricially contracted, and are usually depressed towards the 
 site of the dental or alveolar disease, whence the pus arises. 
 Such fistula penetrates the bone, and may completel}^ traverse 
 the alveolar process. Or the disease may extend into the body of 
 the bone, whether this be the upper or lower jaw. Su23purative 
 disease of the antrum has found an outlet below, and resembled 
 alveolar or dental fistula. One of the worst cases of alveolar 
 fistula treated by the writer had its origin in an imperfectl}' 
 evolved incisor tooth. A large portion of the premaxillary bone, 
 in which the tooth was obliquely fixed, became the site of 
 
730 MAXILLA IXrKKIOK. 
 
 destructive caries. Such fistula has been observed by the writer 
 located in the lower jaw, and situated near the symphysis; and 
 in two cases of the kind, the osseous disease reached almost 
 through the bone, antero-posteriorly. The cutaneous of)enino- 
 would occasionally close, and afterwards, when i)us reformed, the 
 sinus reopened externally. 
 
 The dental or alveolar tistula is nearly jiainless, unless it 
 •should be so placed as to implicate the dental nerve; the cliief 
 trouble from it is the occasional purulent discharge; and it may 
 further disturb the patient by causing some deformity when it 
 has a cutaneous opening. 
 
 Treatment. — In those cases in which the affection primally 
 originates in a decayed tooth, the latter should be extracted; but 
 if the fistula has arisen from a limited caries of tiie maxilla, then 
 to radically cure, the carious structure must be removed. For 
 this work, a scalpel, small trephine, curette and small chisel are 
 required. When practicable, let the work be done within the 
 oral cavity; even when the fistula opens through the skin remote 
 from the affected bone, it is possible, in ahiiost every case, to 
 detach the labial or buccal structure from the alveolar process, 
 and find the affected point of bone within the mouth. The soft 
 parts are now to be uplifted from the bone; and when the diseased 
 structure is tlius brought into full view, a trephine, of three lines 
 diameter, is to be placed on the site of disease, and a circular 
 section of bone around the fistula thus removed. Care must be 
 taken that the trephine includes all the diseased bone: both 
 laterally and in depth. All irregularities of surface are to be 
 scraped or rasped off. After this, the adjacent soft parts are to be 
 brought over the breach, and, if necessary, fixed there by a suture. 
 This exsection may be done with a gouge or a round-edged 
 chisel; yet done in the latter way, some affected structure is more 
 easily overlooked than if one first circumscribes the whole with 
 the trephining crown. 
 
 xVfter the bone has been thus excised, the walls of the fistula 
 must be trimmed, and the wounded surfaces so opposed and 
 sutured as to efface, as much as possible, the preexisting 
 deformity. 
 
 By the treatment, as detailed, of the maxillary fistula, whether 
 dental, alveolar, or situated in the body of the jaw, an affection 
 may be gotten rid of in a few days, which has worried the patient 
 for years. 
 
 Wisdom Teeth. — The eruption of the posterior molar teeth, the 
 
WISDOM TEETPI. 737 
 
 so-named luisdoni teeth, is often accompanied by great trouble to 
 the patient; and tliis is limited almost wholly to those of the 
 inferior maxilla. This trouble may arise from the mal-position 
 and ill-direction in which the teeth grow; or it may arise from 
 the want of room for the appearance of this the last member of 
 the dental family. 
 
 Where the germ of the tooth is situated abnormally, as the 
 dental crown develops, it may impinge against the adjacent 
 tooth, or the front edge of the ramus; or be directed against the 
 walls of the alveolus on the inner or outer side. Thus ill-placed, 
 the growing tooth causes pain ; and this pain is the most excru- 
 ciating when the crown is deflected towards the ramus. The 
 worst condition is that in which the dental crown is so situated 
 beneath tlie margin of the ramus that it cannot appear in the 
 oral cavity; then, through pressure, it bores itself a way into the 
 bone; or, if there be partial space for its appearance, it separates 
 and uplifts the soft parts from the margin of the ramus; and 
 these soft parts are maintained in a state of painful ulceration. 
 Should there be ample space for the appearance of the tooth, the 
 process of its eruption will be of transient duration, and the pain 
 from it will be slight. 
 
 This dental trouble, in the cases in which some abnormal 
 condition impedes the eruption of the tooth, announces itself by 
 tumefaction of the superjacent or adjacent soft parts; the gingi- 
 val tissue is red and painful; and there is a pseudo-trismus 
 present, in wdiich the temporal and masseter muscles are con- 
 tracted and fix the lower jaw nearly immovably against the 
 upper one. The swelling may extend and appear on the outside, 
 near the angle of the jaw; and the lymphatic glands of the region 
 may also swell. The affection finally ends in suppuration of 
 the affected gingival structure; and in severe cases, this ma}^ 
 involve the adjacent soft parts. Where the tooth is imprisoned 
 beneath the border of the ramus, or, by ill-position, it is deflected 
 from the normal outlet, in such cases there occurs alveolar 
 necrosis, on a larger or smaller scale. This osseous disease 
 aggravates that of the soft part, so that, in the latter, the suppura- 
 tive action may traverse the soft parts and appear on the outside. 
 The aff'ection is rarely of so grave a character as this; in the cases 
 in which surgical assistance is usually sought, the tooth merel}^ 
 crowds against the neighboring tissues, and, uplifting these, 
 maintains in them a painful ulceration, which may continue for 
 many weeks. 
 
/OO MAXIKLA IXFKKIOK. 
 
 Ti'caimoit. — The luanagement of such affection is determined 
 by the causal agency and tlie resuUant conditions. In the milder 
 and usual form, relief will be obtained by catching with toothed 
 forceps the tissue 'wiiieh is ]»ressed open, and cutting this off with 
 scissors. But to do this, the mouth must first be opened, and 
 retained so. This may be done in one of the ways which the 
 writer has described, when treating of operations on the tonsil; 
 and in the absence of a specially devised instrument, a piece of 
 wood of wedge-shape ma}' be pushed between tiie upi)er and 
 lower molar teeth; and to assist in opening the mouth, let grad- 
 ual downward pressure be made on the chin. 
 
 If the trouble be of a sererer grade, of the form in which there 
 is insufficient space for the eruption of the tooth, if the crown has 
 so appeared that a dental forceps can seize it, let it be extracted ; 
 but if the crown be inaccessible, then the next preceding molar 
 tooth may be removed. Though this practice has the sanction 
 of high authority, it should not be resorted to until reasonable 
 effort has failed to get rid of the real offender. For example, by 
 the aid of scissors and cutting forceps, the soft tissues and the 
 bony structures can be so opened that the tooth can be exposed, 
 and drawn; and though this work may cost the patient much 
 pain, yet he wall have ample recompense in preserving the pre- 
 ceding molar, which will remain with liim as a lifelong friend; 
 while the M'isdom tooth is often only a transient sojourner, and, 
 during its stay, is often the occasion of so much annoyance, 
 that it will 1)0 a real boon when the cycle of evolution is com- 
 pleted which is destined to omit this tooth from man's mouth. 
 
 In case the dens sapiens is so ill-placed that it cannot escape 
 from its alveolar prison, then a dental cyst or partial maxillary 
 necrosis may result; and in such condition, operative interven- 
 tion, adapted to the conditions present, must be resorted to; and 
 if possible, this should be done within the buccal cavit}^; but if 
 this be impracticable, then an opening should be made around 
 the angle of the jaw, the soft parts reflected upwards and for- 
 wards, and the disease reached and removed. 
 
 Necrosis of the Lower Jaw. — The immediate or direct cause of 
 necrosis of the inferior maxilla (and this applies equally well to 
 the upper jaw) is inflammatory action ending in the formation 
 of pus next to, or within the bone; and such inflammation is 
 located in the periosteum. The necrosis may be partial, and 
 limited to the outer lamella of the bone; or it may involve the 
 entire thickness of the bone; and in the latter case, a large por- 
 tion, or the entirety of the maxilla may die. 
 
NECROSIS OF THE LOWER JAW. 739 
 
 Along with the work of necrosis, tlie ^jrocess of repair is like- 
 wise present, and new bone in diverse forms may be produced; 
 for example, this can grow in regular lamellated form, of even, 
 regular surface, and this may be as thick as the normal structure; 
 or it may be of paper-like tenuity; and the whole may be a 
 complete model, and an analogue of the necrosing maxilla, 
 which it surrounds. The site of this new bone is exterior to the 
 original maxilla, and it is produced from the inner face of the 
 2')eriosteal membrane; one isolated case is reported of reproduc- 
 tion of maxillary structure from the outer face of the periosteum. 
 Instead of a regular osseous envelope of the form mentioned, the 
 new growth may occur irregularly in the form named osteophytes; 
 the mineralogical term stalactite is sometimes used to designate 
 this formation. These osseous growths in spine-form or crest- 
 like ridges, originate from isolated sections of periosteum which, 
 from some exciting cause, are stimulated to excessive osteo-genetic 
 activity. 
 
 The reproduction of bone in case of maxillary periostitis does 
 not invariably occur; the inferior maxilla has been known to 
 die, and no new osseous structure has replaced it. The writer has 
 seen this wliere a portion of the lower jaw had been lost b}' 
 necrosis. Such defect in reproduction is fortunately not the rule ; 
 and where restorative material is nearly or quite absent, it will 
 usually be learned in the history of t]ie case, that new bone has 
 been formed, and afterwards it vanishes through absorption: 
 especially, if the dead sequestrum has been removed prematurely. 
 The reproductive force seems feeblest at the angle of the lower 
 jaw, and in the coronoid and condyloid process; and this may 
 be accounted for in the first and second of the sites mentioned, by 
 the periosteal covering being replaced by the insertion of muscles. 
 Where the outer thickness of the bone is restored, there is absence 
 of the inferior dental canal. 
 
 Necrosis of the inferior maxilla, though it may occur at any 
 point, appears oftenest in the middle third of the horizontal por- 
 tion of the bone: viz., in the part subjacent to the molar teetli. 
 As the disease advances, the teeth above may fall out, and 
 the dead bone be exposed to touch and site; and then the 
 necrosed bone lies, as it were, in a trough, of which the bottom 
 and sides consist of the normal bone thickened by new structure. 
 Instead of opening into the mouth, the suppurative process may 
 perforate the floor of the mouth and appear near the margin of 
 the lower jaw; and the outlet is often near the angle of the jaw. 
 
<40 MAX 1 1. 1. A INTKIUOR. 
 
 Such external opening lasts indefinitely long, and soon becomes 
 bounded by an uplifted fringe-like border of granulative tissue; 
 and if it be explored with a sound, tlie instrument will detect 
 dead bone at the bottom of the fistulous sinus. 
 
 Such necrosis is the special appanage of childhood; and 
 frequently dates from the advent of second dentition; yet no age 
 is exempt from it. The following may be mentioned as the chief 
 causal agencies in its production: (1) Dental caries, and irregular 
 development of the roots of the teeth; and such irregularity may 
 consist in a mal-position, in which, the root deviating from its 
 normal site, encroaclies on the maxillary structure; and sucli 
 encroachment can arise from both the radical and coronal portion 
 of the teeth. Also, it is probable that from abnormal closeness 
 of the developing teeth, the inter-dental alveolar structure may 
 die from the com[)ression. (2) Dental caries may arise from 
 mercury and phosphorus; and it has been claimed that arsenical 
 fumes can cause maxillary necrosis. The grinder of pearl-shell 
 has been observed to become the victim of such necrosis. The 
 necrosis arising from phosphorus will be treated of in another 
 cliapter. (3) Certain constitutional diseases may have maxillary 
 necrosis as a complication; thus it may arise from syphilis, 
 scrofula, scorbutus, rheumatism, measles, smallpox, scarlet fever 
 and typhoid fever. The writer has seen cases of maxillary 
 necrosis from syphilis; this is rarer in the lower than in the 
 upper jaw. As a remote sequel of measles and scarlet fever, the 
 writer has observed a few cases. (4) Some inflammatory affec- 
 tion of the mouth of a gangrenous character may cause necrosis; 
 thus from noma the writer has seen the death of the cheek 
 reach into and implicate the adjacent jaw; in such cases, death 
 usually relieves the surgeon of attention to the necrosis. 
 
 Necrosis, on a large scale, occurs much oftener in the lower 
 than in the upper jaw; and this is explicable from the fact that 
 the position of the lower jaw is such that it favors the lodgment 
 on, and gravitation into its structure of morbific materials. 
 
 Cotemporaneous with the appearance of suppuration, the 
 affected part becomes larger; and this, primarily, is due to thick- 
 ening of the periosteum; and subsequently, to the production of 
 bone on the inner face of the affected periosteum; and lience such 
 swelling with suppuration becomes one of the surest signs of 
 the necrosis; and the nature of this disease is clearly established 
 when a fistulous o])ening forms through which a probe can be 
 passed to the dead bone. 
 
NECROSIS OF THE LOWER JAW. 741 
 
 Tlie duration of maxillary necrosis varies according to the 
 part of the bone which is affected. When the necrosis is located 
 in, and limited to, the alveolar process, the course is a brief one; 
 death and detachment of the part affected can occur within a 
 few months. And where the causal agency is some exanthema- 
 tous disease, the course is a rapid one; here the immediate cause 
 is, jjrobably, an embolic closure of the nutrient vessel of the part; 
 and a portion of bone, being thus deprived of nutrition, it quickly 
 dies. In all cases, in which there is death of the entire thick- 
 ness of the bone, the work of separation and detachment of the 
 dead segment is a most tedious process, and, for final completion, 
 one may reckon on a period lasting from one and a half to two 
 years. 
 
 Prognosis. — Maxillary necrosis does not endanger the patient's 
 life; yet it may be reckoned as a most serious annoyance, since 
 the function of the jaw is seriously impaired. The condition in 
 wliich the pus has escaped through an external opening, is a 
 more fortunate one than that in which the purulent material and 
 osseo.us detritus enter the oral cavity, and are swallowed, or, 
 what is yet more deleterious, some of this material descends into 
 the lungs and affects the pulmonary tissue; in the latter case, 
 life is so seriously compromised that death has occurred; and in 
 the other case, the matter, being swallowed and absorbed, impairs 
 general nutrition. 
 
 Treatment. — The treatment consists in maintaining a conven- 
 ient outlet for the purulent matter until the dead structure has 
 become detached from the living bone; and finally, the necrosed 
 bone must be removed. 
 
 As soon as there is evidence of the existence of pus, one or 
 more openings must be made through which the purulent material 
 can have ready escape; and such opening should, if possible, be 
 through the soft structures near the lower border of the jaw. If 
 the decaying bone be of large dimensions, such orifice of escape 
 must be kept patent until the dead bone is loose within the 
 ensheathing new structure. 
 
 When the sequestrum has become loose within its envelope 
 of new bone, it should be extracted; and for this work there are 
 two routes, viz., external and intra-oral. If the destructive 
 process be limited to the alveolar portion of the jaw, the seques- 
 trum can be reached and extracted through the mouth; but if 
 the lower border be the affected part, then it is better to remove it 
 from the outside, and this can best be done by enlarging a fistu- 
 
/42 MAXILLA INFKHIOR. 
 
 lous 0])cning, if such exist. Wliere the horizontal portion is 
 extensively necrosed, and listukc exist tlirouuli wliicli the puru- 
 lent detritus escai)es, an incision connecting two or more of 
 these oi^enings should be made, and then through tlie incisir)n 
 the bone can be examined and the dead j^ortion removed tiirougli 
 an orifice in the new bone; and if this orifice be too small, it may 
 be enlarged to the necessary extent. In case the sequestrum 
 be long and conoidal in sha})e, then it should be extracted by its 
 base rather than by its smaller end, for if the attempt be made 
 to extract the reverse of this, the sequestrum will become wedged 
 in the conical canal and immovably fastened there. The experi- 
 ence of the writer furnishes this suggestion. 
 
 The work of extraction may often be facilitated by dividing 
 the sequestrum at its middle, and then removing each fragment 
 se})arately. Such division can be done with a pair of small- 
 bladed cutting forceps. 
 
 During the preliminary sequestration of the dead bone, as 
 well as after it has been removed, tlie buccal cavity should be 
 rinsed out with mint-water, tar-water, cidorinated water, al(;o- 
 holized water, camphor Avater or other detersive antise})tic 
 solution. 
 
 The fistuhe which accompany maxillary necrosis, and open 
 intra-orally or extra-orally, will soon heal after removal of the 
 sequestrum; and this closure will be accelerated if the granula- 
 tive tissue which lines the canal be removed; and this may be 
 done with scissors and curette. 
 
 If this work be done prior to the appearance of the second 
 teeth, there is danger of destroying the germs of the latter, unless 
 the j)ortions of the alveolar process containing these germs can 
 be left intact; and, as far as it is possible, the o[)erator should spare 
 these portions. Besides this, it is equally important that tlie 
 necrosed bone should not be removed until the whole of it can be 
 extracted; and this time is usually cotemporaneous with the 
 development and completed formation of the new bone, which 
 replaces the original maxillary structure. 
 
 In case of a considerable portion of the inferior maxilla being 
 lost, the replacing material, even when toothless, has enabled the 
 patient to masticate food which was not very hard; and if its 
 use in this respect is unsatisfactory to the patient, he is at least 
 in a condition to wear an artificial set of teeth, since such pro- 
 thetic substitute is more readily maintained in position on the 
 lower than on the upper jaw. 
 
PHOSPHOEUS-XECROSIS. 743 
 
 Phosphorus- Necrosis.— The industrial occupations of civilized 
 man have widened the bounds of surgical pathology and surgi- 
 cal practice; and this applies to those who manufacture the 
 lucifer match, for to this occupation, as causal agency, is referred 
 a form of maxillary necrosis. As this industry has flourished, 
 especially on German soil, one finds that the first study of the 
 subject was made in Germany: to the pen of Lorinser, of Vienna, 
 and afterwards to Heyfelder are due the original descriptions of 
 the disease. The observation was early made that necrosis of the 
 jaws often occurred among the laborers of the match factory. 
 
 Lorinser, pioneer in th'e study of the subject, claimed that the 
 disease was due to the inhalation of fumes of phosphorus. This 
 was contested by others, who urge that the maxillary disease is 
 due to exposure of the laborer to currents of cold air. Others 
 again claim that the subjects of such necrosis were already labor- 
 ing under affection of the teeth, the gums or the alveolar process, 
 and that witliout exposure to fumes of phosphorus these same 
 persons would have developed necrosis. 
 
 But, despite the opinion of a few dissenters, who, here as else- 
 where, seek to ply their barks against the current of common 
 opinion until the force of that current overwhelms them, general 
 observation agrees that phosphorus is the cause of the maxil- 
 lary disease, and in its action there is an analogy with that of 
 mercury. As is known, mercury introduced into tlie organism 
 in large amount finally induces salivation and inflammation of 
 the gingival tissues, and the alveolar processes ; in some way 
 cognate to mercurial action, phosphorus exercises its destructive 
 action on the dental and alveolar structure; yet in what form the 
 metalloid acts, whether as an acid, a salt, or as pure phosphorus, 
 remains for determination by the pathological chemist. Decayed 
 teeth and a diseased condition of the soft parts around the teeth 
 seem to prepare the way for the action of the phosphorus; and if 
 these conditions are absent, the disease does not appear. That it 
 is not frequent among laborers who are exposed to phosphorus is 
 shown by the observation of Meyer, that among twelve hundred 
 laborers during a period of thirteen years, there occurred but 
 three cases of maxillary necrosis. The disease attacks both the 
 upper and the lower jaws ; yet is much oftener seen in the inferior 
 one, since the position of the latter favors the lodgment and action 
 of morbific agents. Von Bibra and Geist have instituted experi- 
 ment on rabbits in which the animals were exposed to the fumes 
 of phosphorus; and the}'' found that the animals were not affected 
 
744 MAXii.i.A infi:ki()K. 
 
 unless their teeth and jaws had previously been subjected to 
 some injury. 
 
 The disease commences as an alveolo-dental inflammation; 
 the gingival tissues are swollen and spongy, and suppuration 
 occurs around tlie teeth; and at this stage, siiould the laborer 
 cease his occu|)ation, tlie disease is arrested; and thougli the 
 teeth loosen and drop out, yet necrosis does not occur in the jaw; 
 but if the exposure is continued, sub-periosteal abscesses develop), 
 and the maxillary body is next attacked and dies in continuity, 
 or in different sections. These abscesses rupturing into the 
 mouth, leave ulcer-like fistulous openiiigs. The teeth fall from 
 the affected part, the subjacent bone dies, and new bone, in regu- 
 lar or irregular outline, is developed around tlie central seques- 
 trum. 
 
 Meantime the jaw is swollen and there may be tumefaction of 
 the adjacent soft parts; and the pus thence resulting may jDerfo- 
 rate the containing wall, and appear externally. Pain in the 
 teeth is the initial symptom, and this may be fixed in one point, 
 or it may shift erratically and be felt in the ear, temple, or even 
 in the shoulder. The pain may be bilateral and sliglit, or it may 
 be intense and concentrated in one point of the face, similar to 
 neuralgia. When pus has formed and a free discharge estab- 
 lished, the pain lessens and may qiuie vanish. 
 
 As the disease progresses, the new osseous production, desig- 
 nated osteophytic, presents itself in two forms. The one which 
 is denominated phosphoric osteophyte, remains fastened to the 
 dead bone and the surface of the latter; and this consists of fine 
 lamelltB which intercross and are mingled in an irregular man- 
 ner; and these, in mass, resemble the structure of spongy 
 platinum, or pumice stone. In the other kind of production, 
 the new o.sseous growth, in stratified layers, is adherent to the 
 periosteum, and this may be eburnated, or of spongy texture. 
 The so-called phosphoric osteoj^hyte occupies the deeper portions 
 of the new osseous production; while that of lamellated structure, 
 and which is of periosteal origin, is situated more externally. 
 hi this abnormal osteogony the process of rarefaction exceeds 
 that of eburnation or condensation. And each of these condi- 
 tions is favorable to, or permits death or regressive action in the 
 new-formed bone; in the dense form there may die isolated tracts 
 through insufficient blood su})ply; and in the rarefied species the 
 enlarged vessels which traverse it may cause absorption. Tliis 
 new os.seous growth, examined chemically and microscopically, 
 conforms to the structure of new bone arising elsewhere. 
 
PHOSPHORUS-NECROSIS. 745 
 
 The sequestrum formed has an irregular surface ; it is porous 
 and of a dirty grajdsh color; and, in its porous structure, it resem- 
 bles somewhat the new growth of bone which is developed around 
 it; and again, at another point, the dead bone may be dense and 
 ivorj^-like. The process of inflammation, suppuration, destruc- 
 tion and repair of the maxillary structures differs but little from 
 the same process which attends necrosis arising from other causes ; 
 if that from phosphorus has any special characteristic, it is its 
 obstinate persistence. 
 
 The necrosed maxillary structure tends usually to make its 
 exit by way of the mouth; the way is opened and remains so, in 
 this direction, in consec[uence of the slight reproduction of bone 
 which occurs here; this applies to the alveolar processes of the 
 upper and lower jaw: but in the body of the lower one, the 
 sequestrum is so inclosed by the new structure, that usually 
 surgical aid is needed to permit its escape. 
 
 Besides the upper and lower jaws, the proximal facial bones 
 may become implicated in the necrosis; this action is not pri- 
 mary, but is consecutive to tliat beginning in the maxillae. 
 Such secondary invasion has been seen in the malar, palatal and 
 the turbinated bones; also in the vomer and the ethmoid; and 
 sometimes, by remote propagation, the disease has attacked the 
 frontal, the temporal, the sphenoid, and even the occipital bones. 
 
 The manner in which the new bone is produced is similar to 
 that occurring in maxillary necrosis from other causes. Such 
 restoration is never complete and tl^e reproduction takes place 
 much oftener in tlie lower than in the upper jaw. The incom- 
 pleteness of the new structure is partly due to abnormal develop- 
 ment; and also to the fact that the new-formed bone is usually 
 liable to be lessened by subsequent absorption of some of the new- 
 formed layers of bone. According to Salter, tlie regeneration of 
 the inferior maxilla, even in the best form which such regrowth 
 presents, is very far from normal maxillary type; and even 
 though the arch be fairly restored, after some years, the bone 
 becomes greatly reduced in size. Such atrophic process may 
 continue eight or ten years. Osseous reproduction has rarely 
 been seen in case of phosphorus-necrosis of the upper jaw. 
 
 Visceral complication concurrent with phosphorus-necrosis 
 has been observed in a few cases. Haltenhoff reports amyloid 
 degeneration of the liver, spleen and kidneys; also renal inflam- 
 mation has been seen. Bucquoy reports the autopsy of a woman 
 who died from phosphorus-necrosis, in which the manifestations of 
 48 
 
74*3 MAX 1 1. 1. A INFKIUOR. 
 
 general poisoning from phosphorus were ])resent, viz., falty degen- 
 eration of tiie heart, liver, kidneys and the muscles. Inasmuch 
 as fow die from phosphorus-necrosis, there have been but few 
 opportunites for tiie determination of visceral complication; such 
 complication is probably rare, else indications of it would show 
 themselves in the living patient. 
 
 Wlien the subjective phenomena are .studied, the patients 
 may be divided into two groups. In one elas.s, described by 
 Lailler, the patient's general health is so little impaired that he 
 does not discontinue his occu[»ation; he remains at his work, 
 thinking but little of his ailment until the sequestrum loosens, 
 and, perhaps, escapes into his mouth; especially if the disease 
 be in the upper jaw. And in others, the. patient is so little 
 disturbed by his affection, that he does not seek surgical aid 
 until the disease is well advanced; the bone is dead and fistulic 
 open to it. In another class, the disease is more severe; there is 
 extensive swelling, with violent pain and general fever. AViieii 
 suppuration occur.s, the patients become j^ale, feeble and ema- 
 ciated; albumen appears in the urine; and the vital forces being 
 consumed, death, after a long period, occurs from exhaustion. 
 
 The prognosis is inore unfavorable than in any other form of 
 maxillary necrosis. According to Trelat, when both upper and 
 lower jaws are the site of phosphorus-necrosis, one-half of the 
 cases die; if the upper jaw only is affected, one-third of the 
 cases die; but if the lower jaw is the seat, one-fourth of tlie 
 patients die. At Ziirich, Billroth observed four deatlisin twenty- 
 four cases. Yet in the history of the fatal cases, death generally 
 resulted from sotae accidental complication ; so that it may be 
 concluded that tho.se who are otherwise in ro])ust health, rarely 
 die from phosphorus-necrosis. 
 
 Treatment. — The jiatient should, at once, be removed from the 
 causal agency of his disease; he must abandon his occupation in 
 the match manufactory. 
 
 Internal medication has been advised, and benefit from tlie 
 use of iodide of potassium has been claimed. The excreta from 
 the necrosing bone should be removed from the buccal cavity 
 through irrigation with alcoliolized water, mint-water, dilute 
 claret wine; or a weak solution of borax or chlorate of pot:i.sh 
 may be used. As mastication is trammeled by the affected teeth, 
 care must be taken that tlie patient shall have an ample nourisli- 
 ment from semi-liquid food. 
 
 In respect to the management of tlie necrosing bone, two 
 
PHOSPHORUS-XECROSIS. 747 
 
 plaDs of treatment, opposite in character, have their emulous 
 advocates; in one, the practice is to extirpate the dead bone at 
 an early period; in the other, the removal is deferred to a late 
 jDeriod. 
 
 Early intervention is advocated by Billroth, who counsels, in 
 cases in which the disease threatens to run a course of a year or 
 more, to intervene long before there is a furrow of separation 
 between the dead and the living bone, and to remove the diseased 
 part; for, thus doing, one diminishes or arrests the suppurative 
 stream at its source, and its exhausting consequences are averted. 
 It is true that such early interference is not followed by a com- 
 plete cure; two or three subsequent operations may, perhaps, be 
 necessary. The subsequent necrosis which occurs, is not to be 
 referred to the operation; it is merely the natural course of the 
 disease; and the disposal of the bone which is already dead 
 places the patient in a better condition to endure that which fol- 
 lows. The section of the dead from the living bone, Billroth 
 thinks, enables the latter to better resist the process of necrosis. 
 In the single case in which the disease is limited to the surface 
 of the alveolar process, he would wait for the bone to become 
 loose, before extracting it. 
 
 Another ground, on which an early removal is advocated, is 
 that, thus doing, the conditions are favored for new osseous pro- 
 duction; for the prolonged presence of the necrosed bone pro- 
 motes absorptive action of the newly-regenerated structure; in 
 fact, the new bone has sometimes nearly vanished from this 
 cause. 
 
 Hence those who counsel early intervention would operate at 
 the end of six or eight months; at that time the dead and living- 
 bone can be distinguished from each other. 
 
 Lorinser advises to interfere at a late period: and this practice 
 is also followed by Trelat. Lorinser would only operate at an 
 early period on those patients in which the pain is excessive, or 
 the suppuration is exhausting the strength. As principles which 
 should serve for guidance in operative work, Trelat has formu- 
 lated tlie following: as long as the sequestrum remains immov- 
 able, one should not attempt its extraction; one should never 
 attack with the resecting instruments parts which are sound; 
 but when the dead part is movable, then, by division of the soft 
 parts and section of the bone, the sec[uestrum may be removed. 
 In operating early, Trelat urges that tlie surgeon runs the risk of 
 doing too little, or too much : serms of the disease are left behind. 
 
748 MAXILLA IXFERIOR. 
 
 whence the iiiHammation is rehghted; and the atlectiou return- 
 ing, may destroy life by exhaustion. 
 
 Hence, as appears, the surgeon has authority to justify either 
 early or tardy intervention: tiie writer espouses the former plan, 
 and, as advised first l)y Billroth, and afterwards by ^h^isonneuve 
 and Verneuil, he would attack the disease in the beginning; and, 
 by thus doing, hope to stay its progress. 
 
 The operation of sequestrotomy for tiio relief of phosphorus- 
 necrosis consists of three acts: detachment of the })eriosteum, sec- 
 tion of the bone, and extraction of the dead bone; and to aid in 
 the removal, it may be necessary to divide the sequestrum into 
 two or more parts. If the dead bone be of small size, the work 
 may be done through the mouth; but if the sequestrum be of 
 much magnitude, an external incision should be made, through 
 which the removal can be done; and when thus done, it should 
 be a cardinal rule to avoid, as far as possible, entrance into the 
 buccal cavity; and this is best done by keeping the chisel or 
 blunt dissector in contact with the bone, in separating the soft 
 parts from the maxilla. After the diseased osseous structure has 
 been removed, the remaining wound should be sim})ly treated 
 in accordance with rules already given for the management of 
 operative work within the oral cavity; the chief thing to be done 
 is to frequently cleanse tlie cavity, and thus avoid the swallow- 
 ing of septic matters. 
 
 GrowtJis in the Maxilla Inferior. — Maxillary tumors may be 
 classified as benign, semi-malignant and malignant. Within 
 the first class may be included the dental cystoma, odontoma and 
 fibroma; in the second, epulis; and in the third, sarcoma, epi- 
 thelioma and carcinoma. Of the benign and semi-malignant 
 classes a somewhat extended description will be given ; but the 
 third class will be noticed more briefly. 
 
 JIaxillo- Dental Cystic Tumors. — Guibourt, in 1845, inade a study 
 of cystic growths which develop within the maxillary bones. He 
 finds that such growths have been seen by Petit, Cooper and 
 Hawkins, yet tiie nature of the tumors was imperfectly undt-r- 
 stood by these surgeons. The subject was afterwards the matter 
 of research by Dupuvtren and X^laton, who partially solved the 
 proVjlem of the nature and mode of origin of the maxillary cyst. 
 
 As a compendious history of such tumor Guibourt gives the 
 following: the growth commences as a slightly painful and slowly 
 developing tumor in the maxillary region, which finallv crepitates 
 an<l fluctuates when ^n-essed on; and when it attains some magni- 
 
MAXILLO-DENTAL CYSTIC TUMORS. 749 
 
 tude, the teeth fall out, and the overl3'ing bone disappears by 
 absorption. 
 
 According to Nelaton it can arise in one of three wars: (1) a 
 morbid condition of the dental vesicle, wlience arise hypertrophy 
 and an excessive secretion of liquid or semi-liquid material, 
 which usually arrests the development of the tooth; or the tooth 
 may develop in the cyst. (2) From mal-position of the tooth, the 
 latter crowds on the adjacent bone, and creates a cavity in which 
 fluid is secreted from the dental capsule. (3) From the unusual 
 vital activities of the maxillary bones, conditions are present which 
 favor such development. 
 
 In 1873, Magitot wrote an exhaustive monograph on maxil- 
 lary cysts, from which, as well as from the writings of Broca, the 
 writer has derived many of the facts which hereafter follow. 
 
 Every maxillary cyst is either of dental or -periosteal origin. 
 It appears normally in any portion of the alveolar process, from 
 the symphysis in front, to the last molar tooth behind, and 
 in such situation it occupies the position normally filled by 
 one or more teeth. Yet, exceptionally, the cyst may be situated 
 abnormally, viz.: it may appear in the nasal process of the 
 upper jaw, in the orbital portion of the same, in the canine 
 fossa, finally, in the ramus of the lower jaw. And these, like 
 those appearing in the alveolar process, are follicular in char- 
 acter, and have arisen from the displacement of dental follicles. 
 
 These cysts may seem to have a compound character, which, 
 however, is not really so, for the compound or divided form has 
 arisen from the diseased dental follicle having encountered some 
 hindrance, such as an inter-dental septum; or it may arise from 
 two or more follicles having united or pressed together. 
 
 The cyst may vary in volume from the size of a pea to a much 
 larger volume. In its development it may grow into the mouth; 
 or it can expand, and, encroaching on the parts around it, it may 
 push these aside. The mucous membrane which covers it, be- 
 comes vascular and injected with blood; but should it grow 
 towards the skin, the latter remains unchanged. 
 
 When the cyst is of periosteal origin, in developing, it may 
 awaken an inflammatory action which finally ends in suppuration; 
 and through suppurative action the cyst may open, and discharge 
 its contents, and afterwards fill again. Or, if there be growth 
 without inflammation, the cyst may continue to enlarge until its 
 osseous structure is absorbed, and the remaining wall consists only 
 of mucous membrane. This thin wall may be invested with villi, 
 
iOU MAX 1 LI. A INFKIilOK. 
 
 or it may be smooth, shining and transparent. It is not always 
 adherent to the adjaeent pans. The structure of this -wall is sim- 
 ihir to that of the dental follicle, and contiguous periosteum. 
 
 In cysts of both follicular and periosteal origin, the content is 
 thin, clear, serous, or mucous in cliaracter in those cases in wliich 
 the development has been slow; but if the growtli has been rapid, 
 the content may be discolored. Besides those with the liquid 
 content mentioned, cysts also occur of which the content may be 
 bloody, purulent or fat-like. 
 
 According to the time of origin, Broea classifies these cysts 
 into those of the embryoplastic period, tlie odontoplastic period, 
 and tlie coronary period. 
 
 The embryoplastic class corresponds to that period in the 
 evolution of the tooth, in wdiich the germ is contained in a sack 
 or follicle; such -cysts have liquid content in which there may be 
 sebaceous matter. The odontoplastic class arises at the time when 
 bony matter, or ivory, is being formed on tlie developing tooth: 
 and such cysts present a liquid content in whicli are osseous 
 masses. Tlie cysts of the coronary period correspond in date to 
 a later period in the evolution of the tooth; in such cy.st is found 
 the crown of a tooth, or an entire tooth. The last class is the 
 most numerous. 
 
 When there is a dental cyst, as a rule, there is the absence of 
 one or more teeth ; yet this is not always so, for all the teeth may 
 be present, and then such cyst is referable to a supernumerary 
 dental follicle. 
 
 From the observation of one hundred ca.ses, Magitot concludes 
 that when it is congenital the cyst may remain undeveloped for 
 some years. From birth until twenty-nine years of age, the fol- 
 licular form is the more frequent; but after that time, the perios- 
 teal form is the more common one: to be explained, proljably, on 
 the ground that in infancy and early life the follicular dental 
 germ is in a state of high activity, while later, the dental perios- 
 teum is the frequent subject of morbific action from the adjacent 
 teeth. The origin of the follicular form is a matter of conjecture ; 
 while the periosteal species is referable to some agency which 
 awakens a periosteal inflammation. In the follicular form, rem- 
 nants of teeth are found; numbers varying from two to twenty 
 dental crowns have been seen; and from this circumstance this 
 species has been named dental coronal cyst. 
 
 In the periosteal s|)ecies the mode of development is, that the 
 periosteum becomes uplifted from the cenientum, especially from 
 
MAXILLO-DENTAL CYSTIC TUMORS. ' 751 
 
 the end of the dental root; and followino- the periosteal detach- 
 ment there is poured into the opened space a small quantity of 
 fluid; and this is retained, since there is no outlet for its escape. 
 The effused material augments, and finally causes decay in the 
 root of the tooth; and this tooth becomes imperfect; and others 
 adjacent may become implicated, and also deca3\ If the tooth is 
 full-formed, then its displacement causes dragging on the nerve 
 that is supplied to it; and thus pain arises. Later the nerve 
 dies, and the pulp in the root of the tooth, likewise, decays; and 
 the affected tooth then has a gray, dark or bluish appearance. 
 The cyst thus formed can develop laterally; and encroaching on 
 tlie adjoining tooth, this may be uprooted; or the cyst may form 
 around it. 
 
 In regard to pain, the follicular dental cyst in its first stage, 
 is painless; but, at a later period, when nerves are encroached 
 upon, it is painful. But the periosteal cyst is painful in the 
 beginning, so that the patient desires the removal of the tooth; 
 and such tooth being early extracted, a small cyst will be found 
 in the root. If the tooth is not removed, the cyst will continue 
 to grow, until finally it attains large dimensions ; and its walls 
 may then be so thin, that they yield under pressure, giving the 
 crackling sensation of parchment. The large follicular cyst is 
 also compressible; but such attenuation of "wall is only attained 
 after many years of growth. In the periosteal species, if the 
 affected tooth be extracted at an early jieriod, further develop- 
 ment may sometimes be prevented; sometimes, however, the 
 opening in the alveolar process may close up, and the cyst con- 
 tinue its growth. 
 
 The maxillary cyst, through suppurative action may open; 
 also, when the content is of serous character, it may rupture and 
 discharge; and when an opening thus occurs, the breach may 
 close, and remain so for a time. 
 
 The maxillary cyst may pulsate, and thus simulate an aneurys- 
 mal tumor; such pulsatile action is due to vessels in the wall of 
 the tumor. Doubt as to the nature of the case would be cleared 
 up by the use of an exploring needle. 
 
 Solid tumors, whether of osseous or other tissue, within tlie 
 lower jaw, thrust the adjacent bone in every direction; but if the 
 tumor be cystic, it extends more towards the face,, that is, out- 
 wards. Should a tooth be absent in a young subject, this indi- 
 cates a cyst of dental origin. A multilocular maxillary cyst, the 
 origin of which is not traceable to either dental follicle or to 
 
,.yl MAXILLA IXFKKIOll. 
 
 dental periosteum, lias been observed. Its occunenee is exceed- 
 ingly rare. This tumor presents an irregular surface, being ])ro- 
 tuberant or embossed at points; and a protruded ])ortion may be 
 bounded by a wall so thin that it crepitates wlien pressed upon. 
 This non-dental cyst has sometimes developed very rapidly; in 
 other cases, the growtli was of long dui-ation. 
 
 Treatment of ihe Maxillary Denial Cyst. — The cyst of periosteal 
 dental origin, sliould be treated by removal of the tooth or teeth 
 which are affected; and should the extraction be done before the 
 disease has progressed far, then an immediate closure of the part 
 may be reached, and an early cure obtained. Should, however, 
 the disease have progressed so far as that a large cavity is formed, 
 then the process of rejjair will be tedious, and the treatment will 
 reach through a period of many months. In the species origi- 
 nating from the dental follicle, the volumereached in development 
 is commonly greater than that from periosteal origin; and 
 consequently, though the case is always curable, yet, from the 
 writer's experience, to effect this, patient and continued effort is 
 demanded. In two cases treated by him, the disease had evi- 
 dently originated in the embryoplastic period. The-operation 
 done was to open the cavity, excise a portion of the parchment- 
 like wall, and to remove the contents; and then the inner surface 
 of the cystic wall was carefully curetted. The cavity which 
 remained was then filled with lint saturated with alcoholized 
 water. In this manner the wound was daily redressed, and after 
 protracted attention, the cases were cured. The writer's experi- 
 ence has taught him that the most important part of such oper- 
 ation is to remove all that is possible of tlie outer wall of the cyst ; 
 thus done, the cavity is secured against premature closure, and a 
 final cure is insured. AVhere the cyst has a favorable conforma- 
 tion, and is easily accessible, it might be possible to remove the 
 outer osseous wall, and so retain its mnco-periosteal investment, 
 that this could be made to cover the remaining wall; and thus a 
 speedy care be obtained; yet tlie writer's experience justifies the 
 prediction that the attempt here indicated would usually fail, and 
 the wound then heal by granulation and cicatrization. 
 
 Odontoma. — The odontoma is a solid tumor which has an 
 indirect relationship to the teeth; it is composed of elements cog- 
 nate to those of dental structure; and was formerly named a 
 dental exostosis. Our present knowledge of this growth is chiefly 
 due to the researches of Broca. 
 
 Broca finds that the odontoma originates from a hypertrophy 
 
ODONTOMA. 753 
 
 of the dental pulp; remaining for a time in a soft state, 
 this afterwards ossifies, or dentifies, as Broca styles it. There 
 primarily occurs a hypergenesis or multiplication of the inceptive 
 dental elements; and this structure, when it has passed througli a 
 soft and vascular stage, next becomes the site of osseous or dental 
 deposits, either within the tumor, or on its outside. When the 
 growth is in its soft stage, it is named the non-dentified odon- 
 toma; but after ossification, it is named dentified odontoma; in 
 the former, the soft structure is homogeneous in composition ; but 
 in assuming the dentified form, the primitive material is differ- 
 entiated, and forms, remotely resembling teeth, are developed in 
 it. These odontoid structures may be separable, or tliey may be 
 crowded together into a shapeless mass. 
 
 . The hypertrophic action may take place near the crown; and 
 this form is named the coronary odontoma; and here, at the base 
 of the crown, there occurs a lateral exostosis composed of dental 
 ivory and enamel. Or the hypertrophy may proceed from the 
 radical portion of the tooth: a form named radical odontoma. 
 The radical odontoma can encroach on and imprison the roots of 
 adjacent teeth. 
 
 The era of the development of the odontoma is during the 
 period of second dentition; it is most common in the molar 
 region; the coronary odontoma, however, occurs only in the region 
 of the incisor teeth. 
 
 During development the odontoma causes pain of a neuralgic 
 character. Its appearance is announced by swelling and pain, 
 constant or recurrent; and later, an abscess forms, and bursting 
 leaves fistulous openings. 
 
 It is often difiicult to distinguish between the dental cyst and 
 the odontoma; and to do so, an exploratory incision may be 
 necessary; then, if the case is cystic, one enters a hollow cavity; 
 but if it be an odontoma, solid structure is met. The non- 
 eruption of adjacent teeth denotes odontoma. 
 
 Treatment. — The coronary odontoma need not be interfered 
 with, since it causes no inconvenience. In all cases in which the 
 growth causes no pain, non-interference should be the rule; but 
 if pain be present, the tooth should be removed. Also, if the 
 odontoma be contained within the maxilla and a fistulous open- 
 ing lead to it, then an opening should be made through which 
 the odontoma can be removed; and in this work it is sometimes 
 required to remove with a chisel or forceps a portion of the con- 
 taining alveolar wall. 
 
754 
 
 MAXILLA IXl'KKIoi:. 
 
 Fibroma. — Fibroma, as a very infrequent growth, has been 
 observed in the u})i)er and lower jaws; it has been seen more fre- 
 quently in the inferior maxilla. In site it is included, or seated 
 within the bone; and thus it resembles the odontoma and the 
 maxillary cystic tumor; and this analogy has led to confusion and 
 controversy in regard to the origin of the fibroma. It is akin 
 to the fibro-plastic species of epulis. Its development corresponds 
 to the period of second dentition; and but little })ain is caused 
 by it unless it encroaches on a nerve. In the upper jaw it may 
 partially obstruct a nostril, or wholly occlude the lachrymal 
 canal. In the lower jaw the fibroma may prevent the closure 
 of the teeth, and thus interfere with mastication. Luxation of 
 the lower jaw has thus arisen. The teeth implanted in such 
 tumor stand in divergent irregularity, and finally fall from tlieir 
 gockets. 
 
 The maxillary fibroma can attain great dimensions, and then 
 cause extreme deformity of the face. An example of this was 
 seen by Bauchot in which the lower jaw attained an immense 
 volume, as is shown in the adjacent sketch of the patient. Grow- 
 
 FiGUKE 90. Showing an enormous maxillary fibroma observed by Bauchot. 
 
 ing towards the neck, it may encroach on the air-passages and 
 obstruct breathing. And if it prevents clo.su re of the mouth, it 
 allows the saliva to escape, and thus weakens the patient. The 
 
EPULIS. Too 
 
 mucous membrane covering it remains intact, and is pale in color. 
 It is hard to the touch; less so than the odontoma, and more so 
 than a cystic tumor; and it becomes of larger volume than the 
 cj'st. The adjacent glands remain unaffected. If thoroughly 
 removed it is non-recurrent; and should it return, it would be 
 evidence that the tumor was not a pure fibroma, but of epuloid 
 rather than of fibroid character. 
 
 The fibroma should be removed; and the facility of doing 
 this will vary according as the tumor is sessile, partly peduncu- 
 lated, or wholly pedunculated. The tumor must be circumscribed 
 at its attachment, and the removal be done as close as possible 
 to the bone ; for if a fragment be left, from this a new fibromatous 
 production will probably arise. In case the growth be included 
 within the maxillary structure, then the bone must be opened 
 and the tumor thus extracted; and should this be in the lower 
 jaw, the removal may require the division of the body, or a pro- 
 cess of the bone, so that a false joint will result. But should the 
 tumor be included in the upper jaw, the accompanying mutila- 
 tion will be of less import than in the lower jaw; in the latter 
 an attempt should be made to restore the interrupted continuity 
 by metallic ligature. After this ligation an attempt should be 
 made to put the part at rest by a properly devised splint; and 
 for this purpose the surgeon may select one of the appliances 
 employed in the treatment of fracture of the inferior maxilla. 
 
 Osteoma. — Exostosis sometimes occurs in the maxillary bones. 
 It is round or lobulated in form, and is not adherent to the skin ; 
 and if one thrusts into it a needle, this will be arrested by the hard 
 bony structure. In site this growth may be central or peripheral ; 
 that is, an enostosis or an exostosis. The exostosis that is sub- 
 jjeriosteal in its site, is the more frequent one; it is oftenest in 
 the young; and may originate in a dental non-suppurating 
 periostitis. Such osseous growth has been seen near the inferior 
 dental foramen. These osseous growths rarely demand treat- 
 ment; but if they trammel mastication, or are an inconvenience 
 to the patient, they should be removed; and for this purpose 
 chisel and mallet or bone forceps, are instruments with which the 
 work can be done. 
 
 Epulis. — This name, etymologically, refers to a growth seated 
 on the gum of the upper or lower jaw. The term has been used 
 somewhat vaguely, since it has been employed to represent 
 tumors which vary in point of origin, and in elementary struc- 
 ture. 
 
7.")'') MAX 11. LA INFERIOR. 
 
 Ill 1868, Fouilloux stated, as the result of his studies of epulis, 
 that its place of origin may be cue of the following })oints: (1) it 
 can s[)ring from the medullary canal of the jaw; and this form 
 may a})pear as late as the thirtieth year. (2) It may arise from 
 the periosteal covering and submucous tissue of the alveolar pro- 
 cess near the roots of the teeth. (3) It may originate from the 
 neuroglia, or constituent tissue of the pulp of the teeth; and 
 here tlie growth is similar to a myxoma. (4) It can grow from 
 the epithelial coating of the gums, or from that of the cheek. (5) 
 An eiiulis may proceed from the numerous glands situated in the 
 structure of tlie gums. Fouilloux saw cases of purely epithelial 
 origin. 
 
 Studied histologically, epulis may be divided into two classes, 
 viz., the fibro-plastic and the myeloid. The fibro-plastic species 
 consists of fibroid elements, and it springs from the periosteum; 
 or if it commences in the gum, it soon reaches to the periosteum. 
 It is composed of elongated spindle-shaped cells; and among 
 these, multi-nuclear round cells occur. 
 
 The myeloid species presents cells of two kinds: the round, 
 simple nucleated cell, and the giant cell, in which the large cell 
 may be viewed as compounded of several rounded, nucleated cells, 
 inclosed in one common enveloping cell. In this species, as well 
 as in the fibro-plastic, one finds but little inter-cellular material. 
 In the myeloid species vessels are developed; and more so than 
 in the fibro-plastic species. In a few cases observed, vessels have 
 been formed so abundantly tliat pulsation was perceptible in the 
 growth. The epulis is usually soft in texture, and of a violet 
 color; exceptionally its structure is hard and resistant. 
 
 The epulis may be sessile or pedunculated; in the former, it 
 occupies a larger space than in the latter, in which the growth 
 may so jiroject from its alveolar origin that it is movable. It 
 a))pears equally, in the upper and lower jaw; and its site on the 
 gum may primarily be on the inside, or on the outside of the 
 teeth ; and in each case it tends to grow towards the other side. 
 It may arise between two teeth; and Dolbeau claims that the 
 common point of origin is the osseous wall or ridge which sepa- 
 rates two dental alveoli. 
 
 When the growth is of hard texture, and of a bright red 
 color, it is of the fibro-plastic species; but when it is soft and of a 
 dark red or violet hue, then it belongs to the myeloid class, and 
 arises from the bone; and if the tumor pulsates, this is further 
 proof that the growth belongs to the myeloid species. 
 
EPULIS. 757 
 
 The writer has seen several cases of the disease; these were 
 always in the young subject; viz., in those between six and 
 twenty-four years of age; and all the cases w^ere females except 
 one. The growth was nsuall}^ in the lower jaw, and in the 
 region of the incisor teeth. The teeth were sound, and the gums, 
 outside of the affected portion, were also sound. The growth was 
 first observed as a swelling of the point of the gum which lies 
 between two teeth. This swollen tissue was of a purplish hue, 
 softer than the normal tissue of the gum; and free from pain, 
 even when pressed between the fingers; and pressure did not 
 cause bleeding, as would occur in a gum affected with scurvy or 
 other disease. No glandular enlargement was present. 
 
 Excepting this neoplasm, the health of the subject of epulis is 
 perfect; and in consequence of this, as w^ell as of the painlessness 
 of the growth, the patient, if an adult, rarely applies for surgical 
 aid until the tumor has attained such dimensions that it inter- 
 feres with mastication. 
 
 Treatment. — Epulis has been classed as a semi-malignant 
 neoplasm; and ma}' be viewed as a growth located in the line 
 which separates malignancy from non-malignancy, with a root 
 springing from each field. AVith such nature, as thus figuratively 
 conceived, the treatment, to be successful, must take into account 
 this twofold character. Unless the growth be sought for and 
 extracted from its most retired site of origin, it will soon recur. 
 
 Tlie patient soliciting assistance, whether child or adult, 
 usually has perfect incisor teeth; and when told that some of 
 these must be sacrificed, not unfrequently there is a revolt against 
 such a proposition; such has been the writer's experience; and 
 the patient then following less radical tre^Jtment, has not only 
 failed to be cured, but has found herself in a much worse condi- 
 tion; the disease, through extension, finally involving teeth which 
 were previously unaffected. 
 
 A permanent cure can only be secured by an operation in 
 which the affected section of the alveolar process with the teeth 
 contained in it, is excised. This operation was practiced by 
 Mutter, of Philadelphia, as early as 1850. His plan is to first 
 extract a sound tooth on each side of the growth; and through 
 the gaps thus made, a vertical cut is to be made with cutting- 
 forceps; and then, having horizontally divided the soft parts with 
 a scalpel, the bone is to be severed with cutting forceps. Instead 
 of forceps, the writer has used a small resection saw; and thus a 
 smooth surface, and one more favorable to immediate healing, is 
 
7o8 MAXILLA INFLmOR. 
 
 obtained. Siiould, however, there be doubt whether the affected 
 part has wholly been removed, the wound may be touclied with 
 the ferruni candens, and allowed to heal by i^ranulation. 
 
 The author, before proceeding to this mutilating process, has 
 attenjpted to destroy the growth by the actual cautery; and 
 though the cauterization was thoroughly done, gum nnd inter- 
 dental tissue being charred by heat, yet there was invarial^ly a 
 recurrence; and tlie only advantage from it was, that it made the 
 patient submit more contentedly to the radical excision just 
 described. 
 
 Though one or more teeth be lust, the maxillary arcli remains 
 so that artificial teeth can be placed in the breach. 
 
 Malignant Growths. — Sarcoma, chondroma and carcinoma 
 ap^jcar in both the upper and lower jaws. Sarcoma of an epuloid 
 ty2)e is not infrequent; in fact, the myeloid species of ei>ulis so 
 closely resembles sarcon'ia that the two terms, as reciprocals might 
 replace each other. There arises here, as in many sections of 
 surgery, a temptation to reconstruct the existing nomenclature. 
 The example of the well-planned efforts of such innovation by 
 Piorry, Leidy and otliers, of wliich l>ut fragmentary traces have 
 escaped oblivion, warn the prudent writer not to waste effort in 
 tr\'ing to check the powerful current of u.sage; and thus conserv- 
 atively proceeding, myeloid epulis may be viewed as a species 
 or cognate form of sarcoma. 
 
 Chondroma in the maxillary region is closely akin to the 
 cancerous growth. It occurs oftenest in the Highmorian sinus of 
 the upper jaw; yet it occurs also in the inferior maxilla; and 
 here its origin may be central, the chondroma beginning within 
 the bone; or it may start })eripherally ; and then it commences in 
 .the periosteum, A tumor which begins latently, and forces its 
 way thi'ough the bone without causing ulceration, and is of 
 tuberous outline, often containing cystic compartments, is a 
 central (diondroma. But when the tumor is of periosteal origin, 
 its nature becomes apparent at a much earlier period. Tlie 
 chondroma sliould bo extirpated; and care must be used to 
 remove the growtli in its entirety; and to be assured of this, the 
 operator must carr}-- the line of excision well into the contiguous 
 sound structure. 
 
 Carcinoma. — Cancerous growth of the type of epithelioma may 
 appear primarily in both the upper and lower jaw; or the disease 
 may occur secondarily through propagation from neighboring 
 [)arts. "When it is a primitive growtli, the disease commences in 
 
CAKCIXOMA. 759 
 
 the mucous surface of the gum, or in the periosteal covering of 
 the bone. When it begins in the mucous snriace, its develop- 
 ment is similar to that of epithelioma elsewhere; thickening of 
 surface is finally succeeded by ulceration that penetrates gradually 
 to the bone. Such disease, from the writer's experience, often 
 appears Ijehind the incisors of the lower jaw, and, burrowing 
 inwards, finally attacks the alveolar process, and exposes the 
 roots of the teeth, which remain in place until the alveolar 
 structure which contains them has been destroyed. 
 
 The carcinoma originating in the periosteum grows somewhat 
 diflferently from that just mentioned; in the growth of the tumor, 
 the periosteum is detached from the bone at an early period, and 
 thus its osteo-genetic action is stimulated, and, as result, new 
 bone is caused to grow. In this way osteophytes are produced 
 which become a part of the tumor. 
 
 Carcinoma occurs in those who are advanced in age; the 
 reverse of which is the case with chondroma and sarcoma. 
 Carcinoma occurring primarily in the maxilla develops rapidly: 
 often within six months from the commencement of the growth; 
 it comprises within its domain the entirety of the jaw, and the' 
 adjacent parts becoming implicated, are hard in texture, increased 
 in volume, and lose their accustomed mobility. The infiltrated 
 structures soon ulcerate, and ichorous fluid and particles of the 
 decaying structures are discharged. In epuloid sarcoma and 
 chondroma, there is little or no glandular infection; but in 
 carcinoma the neighboring glands become affected at an early 
 period, and, in their voluminous growth, they add greatly to the 
 tumefaction of the soft structures; this applies specially to the 
 lymphatic glands which lie within the arch of the inferior 
 maxilla. 
 
 As means of diagnosis, a harpoon-like instrument can be 
 thrust into the growth, and, a fragment being withdrawn, a micro- 
 scopic examination will determine the nature of the tumor. 
 From the writer's experience, the microscope when questioned in 
 regard to the nature of growths, frequently gives a Delphic 
 response, one that can be interpreted as much for as against 
 malignancy. In fact, the true nature of the growth is to be 
 learned from a study of its clinical history; and in this inquiry, 
 macroscopic rather than microscopic evidence should be given 
 precedence. A hard tumor fastened to the bone, so immovable, in 
 fact, that it simulates an exostosis; and which is usually painless 
 until it ulcerates; and is of rapid growth, and accompanied by 
 
7(JU MAXILLA INFERIOR. 
 
 earlv glandular infection: such are the historical elements of 
 maxillary carcinoma: a history clearly intelligible to experience; 
 and in such a case, the microscope would furnish confirmation, 
 redundant rather than necessary. 
 
 Treatment. — The only possible relief for a patient of carci- 
 noma springing from the maxillary bones lies in an excision 
 of the atft'Cted bone; and this to be effective, must be done early. 
 For after the glands have become largely swollen, or the soft parts 
 are perforated by ulcerative action, the disease has obtained 
 indisputable hold of the patient's life, and any operation, how- ■ 
 ever thorough it may be done, will prove but a mutilation. 
 An oi)erative attempt then made, instead of ameliorating the 
 jtatient's condition, will only prove an ally of the disease; and 
 the final result will probably be an abridgment, rather than an 
 extension of life; since, through surgical lesion, a wider field for 
 cancerous devastation will be laid open. Hence, as a cardinal 
 rule of treatment, remove the affected structure as soon as the 
 disease is recognized: and this introduces the study of excision 
 of the inferior maxilla. 
 
 Excision of the lower jaw has awaicened and stimulated surgi- 
 cal ingenuity,' and from mutual emulation to improve the meth- 
 ods, numerous rival procedures have arisen. As famous pioneers 
 in the work were Gensoul, Syme, Be'gin, Forget, Heyfelder and 
 Schillbach. 
 
 The excision may be partial or total according to the extent 
 of the disease, viz., the operation may only embrace one side; 
 or the median or mental portion may be exsected; or the max- 
 illa in its entirety may be removed. In the removal of the greater 
 part, or of the whole of the lower jaw, there is encountered an 
 unexpected difficulty, to wit, the regression or retroversion of the 
 tongue and retraction of the structures in the maxillary cavity, 
 whereby the patient may be suffocated; this does not occur in 
 partial excision unless the part which is removed be the anterior 
 median portion. 
 
 The methods which have been used for unilateral or partial 
 excision, will first be considered. In 1842, Syme did this work 
 through a cut described by him as follows: "The best course for 
 incisions through the cheek is first downwards from that angle of 
 the mouth which is opposite a sound part of the jaw, and then 
 along the base as far as the tumor extends; and if necessary, up 
 along the posterior ramus to the condyle. The flap thus formed 
 having been separated from the tumor, the jaw is partially cut 
 
CARCINOMA. 761 
 
 through with a small saw, and tlieii completely divided by strong 
 cutting pliers. The surgeon then grasping the detached portion 
 turns it outwards, and separates its connection witli the muscles 
 and membrane of the mouth. . . . The only arteries that 
 require to be tied are the facial and the transverse branches of 
 the temporal." And should it be required to remove the ramus, 
 the temporal muscle must be divided, so that the joint can be 
 exposed; the knife is then to be "carried close around the condyle, 
 so as to avoid the internal maxillary artery, which crosses the 
 neck of this process on its inner surface, about a half an inch 
 below the joint." The amount of deformity which follows exci- 
 sion of a greater part of the lower jaw was found by Sj'me to be 
 smaller than could be conceived without actual observation; and ' 
 on this account, as well as on account of the relief which it 
 afforded the patient, "the operation may be regarded as one of 
 the greatest improvements in modern surgery." 
 
 In 1850, Huguier advised to make a cut for excision, which 
 should lie horizontal, below and parallel with the duct of Steno; 
 thus flaps were made which were reflected upwards and down- 
 wards; through this cut the bone having been sawed through, 
 half of the jaw can be removed without injury to the facial nerve. 
 
 J. F. Heyfelder and his son, Oscar, were early operators in 
 this field; in 1857 the latter wrote on the maxillary excision a 
 monograph, in which is found a review of the work done by 
 his father and others. He wrote that prior to 1843, excision of 
 the lower jaw was feared on account of the nearness of the carotid 
 artery, and suffocation from retraction of the tongue; and to 
 lessen the dangers where total excision was done, in 1843, Sig- 
 norini removed one-half, and at a later period he ventured to 
 remove the other. After this, total excision was done by Pitha, 
 He3'felder, Dumreicher, Maisonneuve and Carnochan. In 1853 
 Heyfelder removed the entire jaw, after having divided the bone 
 at the symphysis. The incision of Heyfelder, similar to that of 
 Huguier, before mentioned, commenced at the angle of the mouth 
 and passed straight backwards, stopping two-fifths of an inch 
 anterior to the lobule of the ear. The bone being divided in 
 front, it is separated from the soft parts by a blunt dissector by 
 which vessels are spared : the facial artery only need be severed. 
 In severing the external pterygoid muscle, one must be careful 
 to avoid the internal maxillary artery. For a time the work was 
 done without dividing the lower lip. Instead of the high hori- 
 zontal cut, Langenbeck made one along the lower margin of the 
 49 
 
762 MAXILLA INFEKIOR. 
 
 maxilla to the angle, and thence upwards to opposite the tongue. 
 Maissonneuve also incised along the lower edge of the maxilla, 
 yet he did not continue his cut upwards on the ramus. In the 
 plan of Maisonneuve it is difficult to reach the summit of the 
 ramus and divide the muscles there. Verneuil followed this 
 plan, and, having sawed the bono through in front, he caught hold 
 of this, and i)ulling violently, he severed the muscles attached to 
 the ramus. But others condemn this mode of extraction as peril- 
 ous to the vessels. Chassaignac reported a case in which the 
 internal carotid was thus ruptured. Though the periosteum i)0 
 preserved by this method, it is rare that new bone has been 
 re-formed. 
 
 Forget, also an authority on maxillary excision, directs that 
 special care be used in dividing the bone; the sawing should be 
 so done that no sharp angles can pierce through the overlying 
 soft parts. And should the lip be the site of cancer, Forget 
 directs that this should first be removed and the flaps for closure 
 be constructed, before the bone is severed. As soon as the 
 divided bone has been detached from its site, extensive bleeding 
 will occur from the sublingual region; and this bleeding, which 
 is arterial and venous, should be controlled by ligature. To 
 guard against and to be able to control such haemorrhage, 
 Dupuytrcn did not close the wound for at least an hour. 
 
 Schillbach, an exhaustive writer on this subject, describes the 
 operation for partial and total excision of the maxilla inferior. 
 For unilateral removal he advises to begin the incision in front 
 of the ear, and carry this down to the angle, and thence along 
 the lower margin to the symphysis; then saw through and detach 
 the soft parts from before backwards; in this dissection spare the 
 inferior dental nerve and artery, until the soft parts beyond are 
 separated; lastly, se\'er the artery and nerve, and tie the bleeding 
 vessels. The steps are similar where the entire bone is removed. 
 The vertical cut should not be carried beyond the lobule of the 
 ear; thus the facial nerve and parotid gland are left uninjured. 
 Schillbach advises also to avoid tlie division of the facial vein ; for 
 if this be cut and tied, much swelling from retained blood will 
 ensue. 
 
 The later operators counsel that in doing the operation the 
 mucous membrane of the mouth should be opened as little as 
 possible; and that this opening be made late in the work. As 
 a method more conservative than any which has been men- 
 tioned, Larghi did the excision wholly through the mouth w'ith- 
 
CARCIXOMA. 763 
 
 oat any external incision; also, Heyfelder excised in this way, in 
 some of his later work. 
 
 Despite the encomium passed on inferior maxillary excision 
 by Syme, it has its shadowy side; during the operation, and for 
 some days afterwards, there is danger of suffocation from lingual 
 retraction; also, the face is greatly deformed. These points will 
 next be considered. 
 
 Lingual retraction after removal of the lower jaw has been the 
 subject of study by Begin, who thinks that tlie operation destroys 
 the equilibrium of the muscles which surround the larynx and 
 pharynx, so that these parts tend to close; and this is mainly 
 done by the posterior muscles, which, pulling on tlie larynx and 
 hyoid bone, cause their convex surface to look upwards. The 
 effect of such action is to lift tlie anterior end of the glottis up- 
 wards, so tliat the fissure of the glottis stands vertical; and in 
 such position the air can hardly enter it. 
 
 Asphyxia from lingual retraction, according to Begin, may be 
 primary or secondary; the primary takes place within forty-eight 
 hours, while the secondary occurs at any time afterwards, ujitil 
 the muscles have become securely cicatrized; and this secondary 
 retraction has occurred most unexpectedly, when the patient was 
 considered out of danger. To guard against this accident some 
 surgeons have passed a thread through the tongue and fastened 
 this to the teeth. This plan is not favored by Begin: he advises 
 to place a wire framework, similar to a mask, around the head, 
 and to tie the thread to this, in front. He advises not to close the 
 wound perfectly; he would leave the lateral cuts open; exact 
 closure in the antero-posterior direction, he claims, tends to force 
 the tongue backwards. 
 
 Heyfelder finds that the position of the head has much to do 
 in producing lingual retraction ; he observed that it occurred when 
 the patient lifted his head, yet that retraction disappeared when 
 he lowered the head towards the sternum. He passed a thread 
 through the tongue, and committed the charge of this to a nurse; 
 meantime he placed the patient on the side. 
 
 Pitha, who made a study of this subject, thinks lingual retrac- 
 tion is not a mere passive act, but that it is due to a spasmodic 
 action of the muscles;' and so violent was this in one case, that 
 the tongue could not be lield by a ligature which passed through 
 it; and to accomplish fixation a pair of bulldog forceps was used. 
 
 The lingual retraction in a case operated on by the writer was 
 counteracted by passing a ligature through the tongue, and then 
 
7G4 MAXILLA JXFKKIOK. 
 
 attaching this to a baud whicli j)assed behind the head; and in 
 another case, the retaining cord was tieil around the ear, and then 
 a strip of adhesive plaster was jjUiced around tiie licad and on the 
 ear so that the cord was retained securely in its place. 
 
 Sprengler, in 1SG4, writing on total excision of the lower jaw, 
 remarks that if th.o entire bone be removed, the soft parts retract 
 backwards, until they are almost on a level with the underlying 
 larynx. Also, considerable deformity will result if only one side 
 of the anterior median portion be removed. Langenbeck has 
 sought to avoid this deformity by removing the bone in sections 
 at different times. He also tried to avoid deformity by dividing 
 the bone that was to be excised into two parts; and then removing 
 one portion, he loft the other to supply its place. Thus, in such 
 a case, hes})lit the ramus into two jKirts, and then, having excised 
 one of the latter, he shifted the remaining portion so that it occu- 
 }>ied the vacant site of the body which had been removed. 
 Though the results obtained in the case were not all that could 
 be wished, 3'et from experiments on the cadaver, Langenbeck 
 became convinced that the work could be satisfactorily done in 
 this way. 
 
 Instead of doing the work as done by Langenbeck, others 
 have sought to lessen the deformity following the inferior maxil- 
 lary excision by introducing some artificial appliance in the site 
 of the excised bone. Lecat, Langenbeck and others tried this 
 plan, and mechanical devices, similar to those used by the dentist, 
 liave been tried. The material of which the aj)pliance was made 
 was leather, silver or vulcanite, and it was held in place by 
 straps which encircled the neck and head. The pain and incon- 
 venience from such substitute was so great that, in most cases, the 
 patient would not tolerate it. 
 
 In closing this chapter on excision of the lower jaw, the writer 
 should add that where the whole or a greater portion of the max- 
 illa is removed, direful deformity of the face is inevitable, and the 
 l)ower to masticate food will be lost; in the male, a beard may 
 somewhat mask the deformity; but the ability to chew food will 
 be lost; and the unfortunate subject must afterwards subsist on 
 nutrient material which is in liquid or semi-liquid form. Yet 
 life with such impediments is always accei)ted by the i)atient, 
 and by him, as well as by its surgical paternity, the attendant 
 deformity is viewed with complacency. 
 
 Anchylosis of the Maxilla Inferior. — The buccal cavity is divided 
 into two compartments by the alveolar dental arches: the one 
 
ANCHYLOSIS OF THE MAXILLA INFERIOR. 765 
 
 space is contained between the arches and tlie cheeks and lips; 
 the otlier lies within the arclies, and is the proper oral cavity; the 
 external one is easily entered, whether the jaws be opened or 
 closed; the inner cavity can only be reached through the separa- 
 tion of the lower jaw from the upper one, or by a circuitous route 
 behind the molar teeth, where the two spaces inter-communicate. 
 
 Normally the inferior maxilla is easily depressed from the 
 upper jaw; yet the degree of separation varies in difiPerent mouths, 
 as is evident from the observation of mouths which are opened 
 to their utmost. The limitation to opening may depend on 
 some tethering conditions existent in the mucous lining of the 
 cheeks, in the muscles composing the latter, in the ligaments con- 
 necting the jaws, or in the osseous structures. And where one or 
 more of those limiting conditions is in excess, the lower jaw may 
 be immovable, or at least inseparable from the superior maxilla; 
 that is, the maxilla inferior is anchylosed. 
 
 Bonnet has studied tlie causes of maxillary anchylosis, and 
 finds that it can arise from an inflammation in the soft parts 
 around the joint; or in the osseous parts composing the joint. 
 Besides these modes of origin, a more usual one is ulceration, 
 abscess, or some lesion of the oral cavity; and, finally, it may arise 
 from muscular retraction and cicatricial shortening. 
 
 Schulten, of Finnland, in 1879, classified thecauses of anchylosis, 
 as follows: (1) Anchylosis from disease in the maxillo-temporal 
 joint. (2) Myogenous anchylosis, in which immobility arises 
 from some abnormal condition of the muscles. (3) Cicatricial 
 contraction dependent on ulceration or wounds of the mucous 
 lining of the oral cavity. (4) Anchylosis from some deformity of 
 the lower jaw: a species rarely met with. 
 
 The author has seen a case in which the prime causal agency 
 was mercurial gangrene in which the cheek was lost by slough- 
 ing, due to excessive use of calomel. 
 
 Treatment. — For practical purposes the causes of immobility 
 may be reduced to two classes: in one, it arises from an abnormal 
 state of tlie soft parts; and in the other, it depends on some abnor- 
 mal condition in the osseous structures; and hence have arisen two 
 different plans of treatment: in one forcible separation, tenotomy, 
 myotomy, and plastic procedures are resorted to; in the other, 
 relief is obtained through osseous division, or resection. Forcible 
 dilatation to overcome anchylosis has been done by a double lever- 
 like instrument, in which the blades are separated by means of a 
 screw which traverses the blades. And afterwards, to maintain 
 
7GG MAXILLA INFERIOR. 
 
 the jaws asunder, corks may be inserted between the teeth and 
 allowed to remain there. The advantage of this plan of treat- 
 ment is that after the jaws have once been separated, the patient 
 himself can continue the work of separation. 
 
 Among the earliest essays in this section of surgery was an 
 operation done by Blasius, for relief in a case in wliicli the cheeks 
 were grown to the jaws, whereby the inferior maxilla became 
 immovable. He made a cut backwards from each angle of the 
 mouth, and then, having dissected the cheeks from the jaws, 
 through the wounds made he next turned the skin inwards, and 
 attached it by sutures to the wounded edge, so that closure of the 
 cuts was prevented. There was thus formed a wide mouth, 
 through which the work of depressing the lower jaw was effected; 
 after mobility was secured, the wide mouth was reduced to nor- 
 mal dimensions by detaching the infolded skin, and uniting the 
 inner mucous border to the inner mucous border, and suturing 
 the derm above to the derm below. 
 
 Gussenbauer, in 1877, reported a case in which he operated 
 for relief in a patient in whom the cheeks, having become adher- 
 ent to the jaws, caused the latter to be immovable. The work 
 commenced with two incisions, which began at the angle of the 
 mouth and extended backwards to the masseter muscle; the flap 
 thus made was folded inwards on itself, so that the derm was 
 turned inwards, and its mucous surface outwards and united to 
 that of the cheek, the two surfaces having been made raw. After 
 union of the raw surfaces, the flap was severed behind, and 
 unfolded so that its base was carried forwards, and became the 
 commissure of the mouth. The disposition of the parts after- 
 wards was such that the inverted derm could not cohere to the 
 jaw, and thus the lower jaw became separable from the upper one. 
 
 The plastic procedures of Blasius and Gussenbauer did not 
 find many imitators; on the contrary, many operations w^ere 
 reported in which the work was done subcutaneously, by tenotomy 
 and myotomy. A brief review of the methods pursued in this 
 work, will herewith follow. 
 
 In 1840, Mutter, of Philadelphia, did the work of myotomy by 
 intra-oral submucous section of the interior portion of the mas- 
 seter muscle; the same was done by Buck. Velpeau, who tried 
 this plan in three cases, afterwards had recurrence of the 
 anchylosis. 
 
 The muscles on which myotomy was done by those who 
 practiced this plan, were the masseter, the temporal and the 
 
ANCHYLOSIS OF THE MAXILLA INFERIOR. 767 
 
 internal pterygoid. Bonnet thinks that division of the internal 
 pterygoid muscle is unnecessary; and that in most cases, section 
 of the masseter is sufficient; and if not, then the temporal muscle 
 should be cut. Bonnet advises that the masseter be divided in 
 its upper portion, since there, tlie facial nerves and the duct of 
 Stenson are not endangered by the knife; besides, if section be 
 made lower down, the muscle there is so adherent to the bone 
 that relief would not follow its division. 
 
 Schmidt divided the masseter in its upper part, yet he did 
 the work inside of the mouth; he commenced at the anterior 
 margin of the muscle, and thence cut backwards, meantime 
 lifting the skin so as to protect it from injury. 
 
 Fergusson, also, performs myotomy of the masseter, on the 
 inside of the mouth ; he commences beneath the opening of the 
 parotidean duct, and cuts, at first, but one-haif of the muscle; 
 fourteen days afterwards, he finishes the operation by dividing 
 the remainder of the muscle. 
 
 Bouvier did the myotomy from the outside; after penetrating 
 deeply, he cut towards the skin; he divided the muscle in its 
 middle, and thus avoided the duct of Steno. Bouvier claims that 
 the median section divides all the fibres of the muscle, which is 
 not the case if the division be higher or lower. 
 
 In the division of the temporal muscle, Bonnet finds that the 
 work can be done above or below the zygoma; but the lower sec- 
 tion is more effective, since the tendon of the muscle is there 
 more loosely surrounded by connective tissue. In the old subject, 
 however, for example, in those over thirty years of age, the coro- 
 noid process ascends so higli that the temporal tendon cannot be 
 reached below the zygomatic arch. Also, where the upper and 
 lower teeth glide by each other, section of the tendon cannot be 
 made below the arch. The section above tlie zygoma is less 
 effective, since the temporal muscle there is fastened to the bone 
 by its fibres. Also, branches of the temporal artery may be^ 
 wounded there, and extensive ecchymosis may ensue. Fergusson 
 made the section from the inside of the mouth; but Bonnet did it 
 from the outside, and cut both above and below the zygoma; and 
 he penetrated quite to the bone, and tlience cut outwards. In 
 section above the arch the temporal artery must be shunned. 
 
 To sever the internal pterygoid, Gue'rin cut from the inside, 
 internal to the ascending ramus; yet Fergusson fears that by 
 thus doing, the internal maxillary artery and inferior dental 
 nerve may be severed. To sever the internal pterygoid, the 
 
708 MAXILLA INFERIOR. 
 
 writer would do the work from the outside, through a crescentic 
 cut bordering the mandibuhir angle: thus with the j»arts open to 
 view, the muscle can be wholly severed; and afterwards, the 
 wound could be closed, and united primarily. 
 
 Jaesche, of Xovogorod, obtained relief in an anchylosed jaw by 
 extending the oral commissure on the affected side and forcibly 
 opening the mouth. At a later period he closed the breach by 
 drawinor the mucous and submucous tissues from above and 
 below and uniting them. And in this closure, tlie work was so 
 done that no raw surfaces were left by which the cheek could 
 reunite to the jaws. 
 
 Sprengler reports the cure of a case in wliich he divided the 
 scar and subsequently placed corks between the jaws to maintain 
 separation ; and as aid, he also severed the masseter muscle. 
 
 In 1858, Wilms, of Berlin, reported a case of anchylosis of the 
 lower jaw, in which, having tried ineffectually various modes of 
 treatment, he divided the bone on the right side, one and one- 
 half inches from the median line, and then he removed a seg- 
 ment of the jaw over an inc-li long. Thus a gap was formed 
 which filled with fibrous tissue, and a pseudarthrosis remained. 
 The patient's condition was so improved that he afterwards 
 could chew with the left side of the jaw. AVilms' claim for 
 priority in originating this method was assailed, and it was 
 shown that Bruns had operated thus three years previously, and 
 also that Dieffenbach had advised to form a false joint in such 
 cases. 
 
 In 1860, Verneuil, in anchylosis of the lower jaw that could 
 not be overcome by any other means, divided the maxilla with 
 Liston's forceps at a point corresponding to the insertion of the 
 masseter muscle. 
 
 In 1800, Esmarch wrote exhaustively on this subject, and he 
 gives the credit to Dieffenbach of introducing the plan of coat- 
 ing with mucous membrane the raw surfaces made in the work 
 of liberation. Esmarch reviews the methods of osteotomy 
 which have been resorted to where the work could not be accom- 
 plished by division of the contracted soft parts. He notes that 
 Bruns and others made an artificial joint, yet the error was usu- 
 ally committed by these operators of making the false joint 
 behind instead of before the binding tissue, and hence the jaw 
 remained afterwards as functionless as it was before. 
 
 The germinal idea of creating a pseudarthrosis for relief in 
 cases of pseudarthrosis is referred by Verneuil to Rhea Barton. 
 
ANCHYLOSIS OF THE MAXILLA INFERIOR. 769 
 
 of Philadelphia, who performed such an operation above the 
 knee. As an early ally in the work Carnochan may be men- 
 tioned, who, in 1845, after division of the masseter, in attempt- 
 ing to open the jaw, fractured it, and found this an aid in the 
 matter of movement. 
 
 In 1860, Rizzoli announced an operation in which he sepa- 
 rated the soft parts within the mouth, and then iie divided the 
 maxilla through the site of a bicuspid tooth, or through that of 
 the first molar; this division was made with the saw, or Liston's 
 forceps, without sacrifice of bone, and the result obtained was 
 satisfactory. 
 
 In 1865, Mathd reported a number of operations for relief of 
 maxillary anchylosis. In seven cases in which there was no loss 
 of the skin as causal agency, he simply sawed through the max- 
 illa; of these six were cured. But in six cases in which there 
 had been structural loss of the cheek two recovered, three died, 
 and one was a failure. Mathe' reports tliat after resection or 
 division of the jaw, relapse not unfrequently occurred. 
 
 Math ^ specifies the point as most proper for tlie division to 
 be between the last molar and the wisdom tooth. In this oper- 
 ation, he divided and uplifted the mucous membrane and peri- 
 osteum, so that, after the bone was divided, these structures could 
 be replaced, and the wound in the bone covered. In case some 
 plastic work is rec[uired, this should be done some time after the 
 artificial joint has been formed. 
 
 In 1885, Ranke, of Groningen, reported operations done by 
 the method of Bottini: this consisted in an incision along the 
 lower edge of the zygoma, over one inch in length, and to this a 
 vertical cut is to be made an inch in extent. Next, detach the 
 masseter from the zygoma, and dissect down to the condyle; 
 then saw this through its neck and remove the condyle. And 
 in some cases it is well to divide the coronoid process. The 
 writer thinks this plan could be resorted to with advantage in 
 patients in whom the causal agency is in or near the maxillo- 
 temporal joint. 
 
 In operations for relief of maxillary anchylosis, if an anses- 
 thetic be used, this should be carefully watched, since the tongue 
 falling backwards mav cause strangulation. Ranke says that 
 one patient was thus lost. 
 
 In whatever way the treatment of maxillary anchylosis is 
 pursued, the subsequent orthopedic work is highly important; 
 and this may be done by forcing wedges between the jaws on 
 
770 MAXILLA INFERIOR. 
 
 each side. Cork is often used for such wedge, or tlie dilatable 
 double-lever before mentioned is a convenient instrument, which 
 the patient can use after some instruction by the surgeon. The 
 dilating appliance is more safely used between the upj)er and 
 lower bicuspids and molars than between the incisors, for the 
 Latter would be in danger of being broken. And along with 
 these instrumental means, the muscles and soft j)arts which are 
 contracted should be subjected to frequent massage. 
 
 Luxation of the Maxilla Inferior. — The anatomical cliaracter- 
 istics of the temporo-maxillary joint require some mention as an 
 aid to a proper understanding of the luxation of the lower jaw. 
 
 The head of the condyle is separated from the temporal bone, 
 in the glenoid fossa of which it is lodged, by an inter-articular 
 cartilage, and the inclo.sing parts around are so loose that the 
 head of the condyle and the cartilage can leave their cavity and 
 glide forwards upon the articular eminence, which lies in front 
 of the glenoid cavity. Such movement occurs when the mouth 
 is widely opened or the jaw is advanced forwards. The constant 
 pressure of the liead of the condyle, aided by the occasional 
 pressure on the cartilage, tends to perforate the central part of 
 the cartilage. The lines which represent the long axis of the 
 masseter muscle and that of the ramus of the lower jaw are 
 normally nearly parallel, but when the jaw is luxated, these lines 
 approach above, and finally touch or cross each other. This is 
 explained by the fact that in luxation the condyle moves for- 
 wards and, as it does so, the angle below moves backwards; and 
 hence, when the condyle is thus displaced, the contracting mas- 
 seter holds both condyle and angle in their abnormal sites. 
 
 Celsus says the maxilla may be luxated forwards, and this 
 may be unilateral or bilateral. If the luxation be unilateral, 
 the jaw and chin are inclined to the other side; the teeth below 
 do not correspond to their fellows above, but the canines lie 
 underneath the incisors. If luxation be on both sides, the entire 
 chin is advanced and depressed, and the lower teeth project 
 beyond the superior ones. The temporal muscles appear tense. 
 This description is so nearly like that of Hippocrates that it is 
 probable that Celsus copied it from Hippocrates. And Hippoc- 
 rates says further concerning the accident that it is rare and 
 occurs during gaping. 
 
 Hippocrates greatly overrates the gravit}'- of dislocation of 
 the lower jaw; he says that if double luxation is not reduced 
 immediately, the patient commonly succumbs within ten days 
 
LUXATION OF THE MAXILLA IXFERIOR. 771 
 
 to a continued fever or a grave coma. And to guard against 
 Ijeril Celsus directs bleeding. These statements do not corre- 
 spond with modern observation, and are surprising since the 
 ancients rarely err in their account of fractures. 
 
 In a dissertation on maxillary luxation Beaugrand states that 
 its true pathology was announced by Fabricius d'Aquapendente, 
 Monro, and Delpech. Delpech says that from the inside of the 
 mouth one can feel and verify the position of the coronoid pro- 
 cess, which in luxation rests against the makir prominence, and 
 he thinks that the lodgment at that point is the chief impedi- 
 ment to reduction. 
 
 According to Xelaton, in luxation of the inferior maxilla, the 
 anterior wall of the articular capsule must be opened, and the 
 condyle advanced C[uite beyond the anterior root of the zygoma; 
 the external lateral ligament is rendered tense, though not sev- 
 ered; and the coronoid process may be thrust into the teniporal 
 muscle, and thus reduction is rendered difficult. The coronoid 
 process can reach and rest against the malar bone. 
 
 Steinlein, of St. Gall, Switzerland, in 1852, studied the mecli- 
 anism of the luxation of the inferior maxilla: he finds that in 
 the beginning of the opening of the mouth, the lower jaw repre- 
 sents a one-armed lever, of which the fulcrum is tlie summit 
 of the condyloid process; but as the condyle advances forwards 
 in the movement, the axis of motion is shifted downwards, to 
 near the insertion of the external lateral ligament; finally, the 
 condyle reaches and stands on the summit of the articular tuber- 
 cle, when the center of movement will descend downwards on the 
 ramus, towards the angle. As soon as the jaw has reached this 
 position, all the masticatory muscles, except the external ptery- 
 goid, will unite in drawing the condyle beyond the articular 
 tubercle; and if the submaxillary muscles add their quota to 
 those above, then the articular capsule will be ruptured, and lux- 
 ation becomes complete. 
 
 Hippocrates says that luxation arises from separation of the 
 lower jaw from the upper one, combined with lateral deviation. 
 
 It has occurred during violent gaping, laughing, vomiting, 
 and other acts in which the mouth is opened greatly. Luxation 
 has occurred during an epileptic convulsion; also in pulling teeth, 
 and in forcing open the jaws to use the stomach tube for alimen- 
 tation or vomiting. The writer has known a case caused by the 
 dentist; and another arose during efforts made by himself to 
 introduce the stomach tube in a case of attempted suicide. It 
 
7T-> 
 
 iMAXILLA INFERIOR. 
 
 occurs oftener in women, in consequence of the greater laxity of 
 the peri-articuhir structures in the female. 
 
 The suhject of luxated inferior maxilla i^resents himself to 
 the surgeon "with open mouth, separated jaws, with advanced 
 chin, and this is deviated to one side, if the luxation is uni- 
 
 FiGURE 91. Luxation of Inferior Maxilla. 
 
 lateral. The appearance is shown in Figure 91. The saliva 
 is escaping from the mouth; articulate speech is interfered with, 
 since the labial and mute sounds cannot be properly formed. 
 Though the patient suffers but little pain, his usual ignorance 
 of the nature of his case often gives him an expression of fear 
 and anxiety. The writer has a vivid recollection of a man 
 who called on him for treatment at a late hour of night. In 
 answer to the question, what ailed him, after repeated efforts 
 to make himself comprehended, he was understood to say, "I 
 have got the lockjaw." And, literally, this was no mean descrip- 
 tion of his condition. 
 
 The prognosis is favorable; for, if seen early, no luxation is 
 more easily reduced; and even if seen some weeks after the acci- 
 dent, it is commonly reducible. The dislocation may recur; and 
 such recurrence, if often repeated, ultimately takes place so easily, 
 that by a voluntary act the patient may luxate and again reduce 
 the jaw. Such a patient the writer knows, who within a few sec- 
 onds could luxate and again return the condyle to place. This 
 disposition to dislocation might be avoided by proper care after 
 
LUXATION OF THE MAXILLA INFERIOR. '773 
 
 the primary accident. Anchylosis may occur where tlie joint 
 remains unreduced for a long period; this, however, has rarely 
 been observed. 
 
 Treatment. — The plan of Hippocrates has served as a model 
 for succeeding generations of surgeons. One assistant grasps and 
 steadies the head; the surgeon grasps with his fingers the jaw, 
 both on the inside and the outside, near the chin; meantime, 
 while the patient is opening the mouth as wide as possible, the 
 surgeon, for some time, moves the jaw; and as he does this, he 
 directs the patient to move the jaw, and yield as much as possi- 
 ble to the movements tliat are being made; then to reduce, three 
 movements are to be made; lift the jaw towards its normal 
 place, push it backwards, and close the mouth. After reduction, 
 retain the chin in place by a bandage. 
 
 Celsus, following this plan soniewhat, advises the surgeon to 
 insert his thumbs into the patient's mouth after he has wrapped 
 them in linen so that they cannot slip (he might rather have said 
 to avoid being bitten); with the remaining fingers on the outside, 
 the jaw is strongly grasped, and the work of reduction is then 
 finished by shaking and depressing the chin, and then forcing 
 the maxilla into its site. Feed the patient on a liquid diet, and 
 let him not speak. 
 
 Fabricius d'Aquapendente advises to do the work so simi- 
 larly to the above that it is probable he was a close student and 
 follower of the Fathers of Medicine; nevertheless, Fabricius has 
 the fame of originating the plan of reduction now in use. 
 
 The surgeon usually finds the luxated jaw tightly fixed in the 
 abnormal situation; to overcome this, press the jaw downwards 
 and move it, as the old authorities direct; this is more applicable 
 where some time has elapsed since the luxation, and adhesions 
 between surfaces have formed. Most authorities use a similar 
 method of reduction in both unilateral and bilateral luxation. 
 Leo, however, directs in bilateral luxation to reduce each condyle 
 separately; he claims that in this way the reduction is more eas- 
 ily accomplished. 
 
 Maisonneuve, from experimental luxation of the inferior 
 maxilla in the cadaver, found that the articular capsule is not 
 torn; nor did he find the coronoid process entangled in the tem- 
 poral muscle as taught by Nelaton. After luxation, even if the 
 coronoid process were exsected, he did not find the reduction 
 any easier. His plan of reduction was to gently depress the 
 chin, and with the thumbs to press the coronoid process back- 
 
774 MAXILLA INFERIOR. 
 
 wards. Maisonucuve's plan of reducing does not differ materially 
 from that of Nelaton, who introduced his thumbs within tlie 
 mouth, and placing them against the ascending portion of the 
 jaw, he pressed this backwards and downwards. And the work 
 can be done without an assistant, if tlie surgeon standing behind 
 supports the patient's head, wliile he makes pressure on the jaw 
 on the outside. 
 
 If seen early, as the writer has learned from experience, noth- 
 ing is easier than to reduce the luxated maxilla: let the patient 
 rest his head against a wall while the surgeon, standing in front, 
 grasps the cliin with one hand, and pushes backwards, while 
 with the other, seizing the angles of the jaw, he pulls downwards 
 and backwards. Should he fail to replace in this way, let a 
 couple of pieces of w'ood, wedge-shaped at one end, be introduced 
 between the upper and low^er jaws behind: and with these small 
 levers the lower molars can be separated from the upi)er ones; 
 and while the jaw is being depressed behind on one or both sides, 
 according as the luxation is unilateral or bilateral, let the chin 
 be uplifted in front, and likewise pressed backwards; or briefly 
 put, to reduce, first depress the jaw behind, and then lift the chin 
 and press it backwards. 
 
 In case the patient has no molar teeth, or has teeth so decayed 
 that they cannot bear pressure, then the wedge-sha})ed levers 
 must be wrapped in cloth, or elastic rubber material, so that the 
 gums will not be injured. , 
 
 Where the luxation has existed for some time, reduction 
 becomes more difficult; yet it has been effected after luxation has 
 continued for three or four months; Gosselin and Michon reduced 
 one which had existed for one hundred and thirty days. In such 
 cases, the peri-articular structures have contracted and shrunken, 
 similarly to what occurs in cases of unreduced luxation elsewhere, 
 and this becomes an obstinate hindrance to reduction; hence, the 
 first step in such cases is to break up adliesions and lengthen the 
 contracted tissues. This may be accomplished, in some degree, 
 by depression and lateral movements of the chin. 
 
 Complex contrivances have been devised to effect reduction; 
 such instruments consist, in the main, of two blades which are 
 separable by a screw which traverses them; and tlie whole is to be 
 fastened to the head by horizontal and vertical straps. Instead 
 of this complicated instrument, the work of separating the poste- 
 rior teeth and depressing the ja,w behind can easily be done with 
 the double lever before mentioned: one or two should be u.sed. 
 
FRACTURE OF THE LOWER JAW. 775 
 
 according as luxation is on one or both sides. The ends of these 
 should be padded. That reduction has been effected will be 
 shown by the condyloid eminence appearing in its usual place 
 before the tragus; the chin is uplifted, the mouth can be closed, 
 and the teeth of the lower jaw correspond to those in the upper 
 one. 
 
 The luxation can easily recur, and care must be taken to pre- 
 vent this: viz., the mouth must not be widely opened; and this 
 precaution is the more needful after a luxation of long standing. 
 To lessen the mobility of the jaw, the food should be taken in 
 liquid form. 
 
 Fracture of the Lower Jaw. — The fracture of the lower jaw, 
 according to Despres, is one of the most infrequent in the general 
 list of fractures; yet Emmert, on the contrary, says that it is of 
 frequent occurrence. These statements show that surgeons may 
 differ greatly in their experience. Gurlt, in a collection of two 
 hundred and seventy-four fractures of the bones of the face, 
 reports that one hundred and fifty-three were those of the lower 
 jaw. 
 
 The lower jaw can be broken at any point; and the causal 
 agency may act directly or indirectly. 
 
 Direct violence, as the kick of a horse, a blow with a club or 
 fist, a stone hurled with the hand, or a gun-shot missile, may 
 cause such fracture. Or the violence may act indirectly, as by 
 pressure; and then the two branches of the maxillary arch may 
 be forced towards each other, and cause fracture in front of, or 
 behind, the point of pressure. Or fracture may arise from widen- 
 ing of the arch; and this can occur from pressure on the chin; or 
 from explosion of powder within the mouth, the arch may be 
 widened and fracture ensue. In experimental fracture of the 
 lower jaw, Linhart found that the site of fracture, when the 
 branches are forcibly pulled apart, is not at the symphysis, but 
 at some distance behind that point. 
 
 For consideration, fractures of the inferior maxilla may be 
 divided into those of the body, the ramus and the condyle. 
 
 Fracture of the body may be incomplete; or it may be com- 
 plete, with integrity of the soft parts; or complete with laceration 
 of the soft parts; .and lastly, there may be multiple fracture. 
 
 Incomplete fracture involves but a portion of the bone; the 
 outer plate alone may be broken. This fracture often escapes 
 observation; it was studied by Cluzeau, who finds that it is situ- 
 ated oftener on the inner side of the jaw. 
 
77C MAXILLA INFKEIOK. 
 
 Incomplete fracture of the jaw may concc-ni ihe alveolar i)ro- 
 cess alone; and this commonly arises from a blow or fall against 
 the teeth; and it is indicated by the displaced teeth: one or more 
 teeth having forsaken their normal position. Such fractured 
 portion, though attached to the jaw, is movable. Some swelling 
 soon appears in the soft tissues at the site of injury. 
 
 In complete fracture of the body, when tiie soft parts are 
 intact, the broken surface may be smooth, notched, or otherwise 
 irregular. The line of fracture, when studied in reference to the 
 vertical height of the body, may be nearly perpendicular; or it 
 may run obliquely: and in the latter case, its usual direction is from 
 above downwards and backwards. And when examined in ref- 
 erence to the thickness of the bone, it commonly runs from before 
 backwards and inwards. There may be but slight displacement; 
 and sometimes, impaction exists. This com}>lete fracture without 
 perforation of the soft parts occurs oftenest near the canine teeth; 
 more rarely near the symphysis. Less solidity of the bone 
 near the canine teeth favors fracture there. Fracture at the sym- 
 physis, mentioned by Hippocrates, has been denied by modern 
 surgeons: but more careful observation has placed on record a 
 number of cases. The indications of com])lete submucous frac- 
 ture are swelling, and sometimes ecchymosis at the site of frac- 
 ture; the subject is able to use his jaw in masticating, yet there 
 may be perceived a grating or crepitating sound at the j)oint of 
 fracture. Also, if the patient open his mouth, and the jaw be 
 grasped and vertical ti'action be made on the chin, then motion 
 ■will be perceived at the site of fracture. Such movement must 
 be cautiously made, lest the submucous injury be converted into 
 an open wound. 
 
 In case the fracture be one in which the soft parts have been 
 opened, the visible breach of the bone renders the diagnosis easy; 
 and by manual movement of the part, crepitation and gaping of 
 the fragments are produced. In case the fracture is single, there 
 will be but slight displacement of the broken ends, but when 
 the fracture is multiple, there is often considerable loss of normal 
 form. If the fracture be on both sides of the chin, for example. 
 in the vicinity of the canine or bicuspid teeth, then the front 
 portion of the broken arch may be displaced by the sublingual 
 muscles, while the posterior fragments can be drawn upwards by 
 the masseter muscles. Again, if the double fracture comprise a 
 segment of the side of the jaw, this can be displaced upwards or 
 downwards according to its site. In case of multiple fracture, the 
 
FRACTURE OF THE LOWER JAW. 777 
 
 site is commoul}^ near the canine tooth. The opening through 
 the soft parts permits the escape of blood from, the artery wliich 
 is opened in the dental canal, a bleeding rarely great in quantity. 
 
 Whether the fracture be single or multiple, the line of the 
 breach often lies between the roots of two teeth, so that the latter 
 remain fixed in the jaw; or the alveolar cavity may be impli- 
 cated so that one or more teeth become loosened, and then, or 
 later, they fall out. 
 
 Fracture may have its site in the ramus, or in the condyloid 
 or coronoid process. The fracture of the ramus is most often sit- 
 uated near its angle; and whether there, or higher upwards, it 
 would be revealed by crepitation and pain in the upward and down- 
 ward movement of the jaw. Bimanual pressure, made by the 
 hands grasping the two branches, would detect mobility, and 
 probably crepitation, in the broken side. But little displacement 
 attends single fracture of the ramus : but if multiple, the displace- 
 ment is determined by the direction of the muscular movement 
 acting on the detached fragment. 
 
 Fracture of the condyle is seldom seen as an isolated injury; 
 there is usually cotemporaneous fracture of the body of the jaw, 
 and usually, both condyles share. in the complicated injury. As 
 signs of such fracture are swelling over the injured point, and 
 ]3ain when the jaw is opened and an attempt to masticate is 
 made; and in this movement crepitation might be detected. 
 Bleeding from the ear is often present. 
 
 The coronoid process is so safely entrenched behind the 
 zygoma, that its fracture is usually accompanied by a fracture of 
 the zygomatic arch. Great violence directly applied is necessary 
 to produce it. The injury would be indicated by pain when the 
 teeth were clenched: a movement calling into action the tempo- 
 ral muscle, and consecjuently, traction on the fragment. 
 
 A causal agency of fracture of the lower jaw is the bullet: 
 and when gunshot wounds of the face are enumerated, those of the 
 inferior maxilla are the most frequent. Such fracture may be 
 single or multiple, and at any point. The missile may enter in 
 front or at the side; or having entered at a point distant from 
 the jaw, by direct or meandering route, the ball may reach and 
 break the lower jaw. A small ball may enter and lodge in the 
 body of the jaw. The ball may be spent, and cause a mere fis- 
 sure, the simplest form of incomplete fracture; or if the impact 
 be of greater force, a comminuted fracture may result. A small 
 ball, moving with great velocity, may pass through the jaw with- 
 50 
 
778 MAXILLA INFERIOR. 
 
 out severing it in its entirety: the injury being limited to the 
 shot canal, without furtlier fracture. Such simple injury would 
 speedily heal; but whore tlie fracture is comminuted, and tlie 
 soft parts are extensively lacerated, recovery is tedious: necrosis 
 and repair by callus consume many months in reaching their 
 conclusion. 
 
 The diagnosis of the entrance and exit points of the missile is 
 determined by the principles which have been considered in 
 the chapter, which treats of gunshot wounds of the cranial wall. 
 
 The fracture of the lower jaw is often accompanied by other 
 injury; for example, the violence from a fall upon the chin, is 
 but partially expended in a fracture of the jaw: a part of the 
 force is transmitted to the base of the skull. And thence have 
 arisen fracture of the petrous portion of the temjioral bone, injury 
 of the middle ear, and concussion of the brain. 
 
 The prognosis depends on the condition of the soft parts cov- 
 ering the fracture: if opened to the broken bone, the manage- 
 ment is difficult, the recovery tedious, and, sometimes, doubtful. 
 In fact, Richet, from a study of the fracture, finds that it may 
 end fatally. In a collection of tliirtj^-six cases six terminated 
 fatally. Even cases which primarily seemed simple, at a later 
 time developed grave complications. And this is in accord with 
 the author's experience. For not rarely, suppuration has 
 appeared at some point below, and near the place of fracture, 
 and an abscess of greater or less volume has arisen, and seriously 
 interfered with recovery. Besides the loss of teeth, which is a 
 frequent occurrence, necrosis of the broken ends, and more often 
 of a separated fragment, leads to non-union, which renders the 
 jaw nearly functionless. In case the soft parts are so open within 
 the mouth as to lead to tedious suppuration and the escape of 
 septic materials, which pass down the throat, then the general 
 health may seriou.sly suffer through pulmonary implication or 
 perverted nutrition. Heath observes that from such fracture 
 haemorrhage has arisen, so severe as to demand compression of the 
 carotid artery to arrest the escaping blood. Hence it is apparent 
 that compound fracture of the lower jaw, though seemingly 
 holding a subordinate place among fractures, may, in its final 
 consequences, assume proportions of ominous gravity. 
 
 Treatment. — Hippocrates, and after him Celsus, treated this 
 fracture by both intra-oral and external appliance. "Where frac- 
 ture existed without displacement, they depended chiefly on liga- 
 ture of the teeth: and in this work, not one alone, but several 
 
FRACTURE OF THE LOWER JAW. 779 
 
 teeth on each side of the fracture were included and held by gold 
 wire; or still better, with linen thread carefully tied. If displace- 
 ment exists, after careful coaptation, tie the teeth together, and 
 then apply a contentive apparatus on the outside. Hippocrates, 
 though writing in the incomparable Greek, modestly admits 
 the difficulty of clearly describing surgical dressing: "The 
 reader must draw an idea as best he can from what has been 
 written." The external appliance consisted of two strips of Car- 
 thaginian leather, about two inches broad. The one piece is fas- 
 tened on the jaw by means of adhesive glue, beginning a short 
 distance from the fracture, and it passes thence, including the 
 chin, along the opposite cheek to the summit of the head: the 
 other strip is similarly glued to the jaw at a point near the frac- 
 ture, and is carried upwards over the head, and there the two 
 thongs are tied. The patient must lie on the injured side. The 
 Hi^jpocratic method contains the germinal elements of traction 
 and counter-traction which enter so largely into the modern 
 treatment of fractured limbs. Fixation by means of wire includ- 
 ing the teeth, so much in vogue in antiquity, usually loosens the 
 included teeth: hence this contentive means is rarely resorted 
 to by the modern surgeon: in only exceptional cases has the 
 writer used it: cases of obstinate displacement, in which two or 
 more teeth, on each side of the fracture, could be included in the 
 ligature; thus distributing and lessening the ill effect of the pres- 
 sure. 
 
 The treatment of the fractured lower jaw demands that atten- 
 tion be given to the following points: (1) Where displacement 
 exists, the fragments must be accurately adjusted, (2) Immobili- 
 zation and retention of the fragment in this corrected position. 
 (3) Frequent cleansing and disinfection of the oral cavity. 
 
 1. Where displacement exists, adjustment is easily accom- 
 plished by grasping the two sides with the hands and lifting the 
 two ends into normal place; and even if there be an isolated 
 fragment, this is easily restored to jDlace. Evidence that the 
 fragments have been restored to normal site will be furnished by 
 a return of the teeth to their accustomed ranks and natural rela- 
 tion. Such teeth must not deviate inwards nor outwards, nor 
 stand higher nor lower than their fellows in the adjacent broken 
 end. 
 
 2. Restitution to normal form is rarely difficult; yet mainte- 
 nance of that form is difficult: so difficult that innumerable 
 means have been devised to accomplish it. As in pertussis the 
 
780 MAXILLA INFEUIOR. 
 
 countless remedies proposed denote their fallibility and impo- 
 tence, so the many appliances which have been devised for tlie 
 treatment of the broken maxilla have similar signification; the 
 perfect device has not yet been invented. 
 
 Cases in which there is no displacement of the broken ends 
 recover through the use of any contcntive appliance; any form 
 of splint, which, slipper like, includes the chin, and which is 
 retained in place by a bandage including chin, cheeks and sum- 
 mit of the head, will secure satisfactory immobilization of the 
 fracture; and especially is this the case where the soft parts sur- 
 rounding the bone are unopened. In case the soft parts are 
 opened, a disagreeable complication that frequently arises in the 
 course of the treatment is abscess, which may appear at some 
 point near or subjacent to the fracture. From the writer's expe- 
 rience, it is an exception when such abscess does not occur; and 
 occurring, it interferes with the contentive dressing. 
 
 In case of compound multiple fracture, in which the broken 
 jaw consists of two or more fragments, exact maintenance of these 
 parts in normal site is extremely difficult; in the writer's exten- 
 sive ex{ierience in fractures, he has encountered no problem of 
 which the solution has been more embarrassing, and, in its 
 solution, the author will next brief!}'' notice the methods whicli 
 have been employed. 
 
 The appliances may be divided into two classes: those 
 which are applied externally, and those placed within the mouth; 
 and in many cases, internal and external appliances are com- 
 bined. And in the use of whatsoever kind of appliance, coapta- 
 tion must precede and accompany the contentive means. 
 
 To pass in review the numerous splints which have been 
 devised for outward fixation, would be a tiresome enumeration 
 of mechanical appliances, many of whicli. happily for the j)atient, 
 repose in the lumber room of oblivion alongside of similar ones 
 which have preceded them. 
 
 A simple splint, the invention of which is attributed to Dr. 
 Physic, may be made of an oblong piece of felt or thick paste- 
 board, fifteen inches long, and five inches broad; let this be cut 
 at its middle, half way through its breadth; thus prepared, it can 
 be folded so that the cut edges overlap each other. Thus is 
 formed a slipper-like trough in which the chin can rest, and the 
 whole be retained in position by a bandage which passes under 
 the jaw and obliquely over the summit of the head, and horizon- 
 tallv around the chin and behind the neck. The horizontal and 
 
FRACTURE OF THE LOWER JAW. 781 
 
 oblique turns of the bandage cross each other like a figure of 
 eight, on each side, near the angle of the mouth. Since the 
 bandage is easily deranged, a safer plan is to fix such a. splint in 
 place by means of a starch or gypsum bandage; and to jjrotect 
 the ears and hair, there must be placed beneath such bandage a 
 stratum of cotton wadding. Instead of the felt or pasteboard, 
 the writer has used gutta percha ; of this a strip of suitable size 
 immersed in hot water, can be molded to the fractured jaw, and 
 retained in place by one of the bandages just mentioned. 
 
 Adjuvant appliances placed on the inside of the mouth are of 
 three forms: one applied on the inside of the jaw, between the 
 jaw and the tongue; another, which rests on the outer side; and a 
 third one which, trough-like, rests on and includes the lower 
 teeth; and sometimes it is hollow both below and above, and 
 then it receives the upper and the lower teeth. The material 
 from which these intra-oral splints is best made is gutta percha, 
 or vulcanized India rubber. The last kind is the most efficient 
 one, and this may be so constructed as to include the upper and 
 lower teeth, and also ensheathe the lower alveolar process on the 
 inside and outside. In its construction and application, the 
 services of an expert dentist will materially aid the surgeon. 
 Should a tooth be absent above or below, a corresponding open- 
 ing should be made through the splint, through which a tube 
 can pass for alimentation and irrigation. Such intra-oral appli- 
 ance must be combined with an external bandage. 
 
 During the use of such a splint, the oral cavity must be 
 washed out several times daily; and always after the use of food. 
 AVithout this precaution, the cavity becomes a pest-hole of foul- 
 ness. Such disinfecting irrigants are mint-water, alcoholized 
 water, or chlorine water well diluted. Such fluid may be intro- 
 duced through a tube which is carried through an interval 
 between teeth, or through the space behind the molar teeth. As 
 instrument for the irrigation, a flexible catheter and a flexible 
 syringe may be employed ; the latter can readily be converted 
 into a siphon. 
 
 The patient must be nourished with liquid food, such as 
 milk, soups and similar articles of diet. This can be introduced 
 by means of a tube passed between or behind the teeth, as just 
 mentioned. 
 
 In ordinary cases, consolidation occurs within a period of 
 thirty days; but in cases in which there is laceration of the con- 
 taining soft parts, with multiple or comminuted fracture entail- 
 
782 MAXILLA INFERIOR. 
 
 iiig recurrent displacement, the injury will require two or three 
 mouths for recovery. 
 
 In cases in which the attendant displacement is irrepressible 
 by any of the appliances mentioned, as an additional aid metallic 
 suture may be resorted to. This method was first done by Bau- 
 dens in 1840; it has since been done and recommended by E. S. 
 Cooper, Kinloch, Giordano and others. The writer has resorted 
 to it, with satisfactory result, in a few cases. Such suture is done 
 within the mouth, by means of silver wire passed through holes 
 drilled through the fractured ends, and knotted between the 
 cheek or lips and the jaw. And, sometimes, even this fails to 
 maintain accurate coaptation; and then a splint and bandages 
 must also be used. Despite the treatment here described, 
 recovery is sometimes attended with irregularity of form; one of 
 the fractured ends is higher than the other; yet, in such cases, the 
 future work of mastication will tend to reduce the teeth to a com- 
 mon level, and in time greatly lessen the deformity. 
 
 Finally, should non-union result, through loss* of osseous 
 structure or other cause, then the fractured ends should be 
 exposed by dissection, and, after removal of the intermediate 
 fibrous tissue, the ends should be iinited by metallic suture, and 
 the case treated as a compound fracture. 
 
CHAPTER XXIV. 
 
 FACIAL NEURALGIA. 
 
 As synonyms of facial neuralgia are the names prosopalgia 
 and tic douloureux; the latter is of Gallic extraction. Tic signi- 
 fies a convulsive movement and refers to a spasmodic movement 
 of the affected parts, which is often present. 
 
 Neuralgia literally signifies a painful nerve; and thus defined 
 the term has relations with the entirety of Pathology, for the 
 most important element in every Pathos is the subjective one of 
 pain. And pain is the result of some textural change in nervous 
 material of which the normal function is common sensation; and 
 to awaken this, some Nosos or irritant is needed. And such irritant 
 may be located within, contiguous to, or near to the nerve which 
 responds by pain, and which, though so clearly appreciable by 
 the subjective sufferer, may not be so to the objective observer; 
 since in many cases, no structural change is determinable by 
 chemical or physical test, or by means of touch or any special 
 sense. Macroscopy failing in the search, has committed the 
 quest to microscopy, which, though aided by its lens of immer- 
 sion, has caught no glimpse of the fugitive pain. It is probable 
 that such search will not always be in vain; and that along with 
 the metrical appliances which have been introduced as aids in 
 scientific exploration, an sesthiometer and odynometer will 
 sometime be included. In such search and research, cognizance 
 must be taken of the molecular changes which occur from the 
 action of pain-annulling and pain-awakening agents: a most 
 abstruse problem, in the solution of which Chemistry must lend 
 the patient investigator its single elements, and also its com- 
 pounds of double, triple and variously and diversely multiplied 
 elements; and Physics, with its thermal, electric, luminous and 
 spectroscopic means, will be invoked to contribute its quota of 
 assistants. 
 
 Uspensky, who has labored on this question, refers \)QXn to 
 
 (783) 
 
78-i FACIAL NEURALGIA. 
 
 the contact with nerve-tissue of the elements of disintegration, 
 which arc acid in nature; and that in the normal, or what may 
 be styled tlie anodyne condition of the tissues, the acid compounds 
 excreted are neutralized by the alkaline nuiterials of the lymph 
 and blood. Uspensky offers a few facts in confirmation of this 
 theory. The writer would suggest that this notion might be 
 amended by adding the work of integration to that of disintegra- 
 tion; or that in both progressive and regressive tissue-metamor- 
 phosis, materials may arise which by contact with sensory nerves 
 can awaken pain. Inasmuch as neuralgia is relieved by numer- 
 ous plans of treatment, some differing much from each other, it 
 is possible that the chemical tlieory, here mentioned, may either 
 directly or suggestivel}^ indicate one pathway leading to relief. 
 
 The face is the usual site of neuralgia; and a portion or the 
 whole of the trifacial nerve may be affected there. While this 
 nerve, by virtue of its isolated function, furnishes watchful 
 guardianship of the special sensory apparatus, it is also the 
 medium of intense suffering when it is the object of some morbific 
 agency. The seventh or facial pair of nerves, stands to the 
 fifth pair as its motor correlate, since its function, as commonly 
 stated, is exclusively that of motion. Yet it is probable, that a 
 few fibers pass from the fifth to the seventh pair, in the parotidean 
 region; and to such inter-communication is due the simultaneous 
 advent of pain and motion as the predominating symptoms of 
 facial neuralgia. 
 
 Stromeyer claims that every manifestation of normal sensa- 
 tion has its correlate of motion; and that a painful sensation has 
 its motor reflex, so sudden as to be of the nature of spasm : 
 examples of which are seen in anal, vesical, and palpebral spasm 
 awakened by some sensory irritant. 
 
 A characteristic of facial neuralgia is the exquisite acuteness 
 of the pain which is present; also its inconstant nature. There 
 are also points where the pain predominates; this fact was pointed 
 out by Valleix; though reasoned away by writers wlio have no 
 clinical communion with the disease, yet the subject of them can- 
 not so readily do so. 
 
 The trifacial nerve beyond the Casserian ganglion divides 
 into three branches, which diverge, and at their ending, each 
 one has its isolated and individual peripheral field; and these 
 fields have different bounding lines of demarcation, which are as 
 follows: The district of innervation of the ophthalmic or superior 
 branch has tlie foUowintr boundaries: draw a line from the 
 
FACIAL NEURALGIA. 785 
 
 cranial vertex across the anterior portion of the temporal plane to 
 the ouier angle of the eye; then pass inwards through the palpe- 
 bral sHt to the inner angle of the eye; thence run clown the nose 
 to its point; and thence upwards to the point of departure. In 
 this field is also included the mucous lining of the superior and 
 middle turbinated bones, and the other intra-nasal structures 
 corresponding to, and on a level with, these bones. 
 
 The superior maxillary branch is distributed to a field 
 bounded as follows: Draw a line from the outer angle of the eye 
 to the angle of the mouth; and in this field is included within 
 the nose the inferior turbinated bones, and that portion of the 
 intra-nasal structure which is not concerned in olfaction. This 
 branch also supplies the teeth and the soft parts investing the 
 upper jaw and hard palate; also, the soft palate and tlie clioanse 
 have nervous sup[)ly through the superior maxillary nerve. 
 
 The inferior branch of the trifacial supplies innervation to 
 structures W'hich lie behind and below the districts supplied by 
 the ophthalmic and the superior maxillary branches; behind, 
 this field is bounded by a line drawn from the vertex of the head 
 to the ear, and thence to the chin. Within the mouth it supplies 
 filaments to the floor of the mouth and to the entire tongue, 
 except that portion of the base which lies behind the papillee 
 .circumvallatse. It likewise supplies the lower teeth, the inferior 
 alveolar process, the lower lip, and the mucous lining of the 
 cheeks within the buccal cavity. 
 
 The i^rimary terminal branches of the three divisions of the 
 fifth nerve appear on the face in a vertical line, at the following 
 points: the supra-orbital and infra-orbital foramina, and the 
 mental foramen. The doctrine that neuralgic pain is especially 
 concentrated at these points, as before stated, is contested by some 
 authorities; the writer, however, within his professional experi- 
 ence, has seen cases in which the pain greatly predominated at 
 one of these sites: especially, at the mental foramen; and the 
 diagnosis thence drawn that the inferior maxillary branch was 
 the site of the affection was confirmed by the relief which followed 
 neurectomy of that nerve. 
 
 A knowledge of this abstruse disease can best be gained by a 
 ^eviewof the literature on the subject, which the author will now 
 compendiously present. 
 
 In 1849, Xeucourt, writing on this subject, divides facial 
 neuralgia into two groups: that which arises from pressure,, 
 and that which originates spontaneously, in wdiich only some 
 
7SG FACIAL NEUKALCJIA. 
 
 remote morbid condition can be referred to as causal agency. 
 Valleix espouses tiie opinion of indirect or spontaneous origin. 
 As alleged causes of tbe indirect class are cborea, hysteria, rheu- 
 matism, plethora, tlie use of narcotics, heat, cold, miasma, syphilis 
 and gonorrha-a. Some of these so-called causes, when examined, 
 vanish to verbiage: names in which the realist seeks in vain fur 
 substance. Neuralgia may arise from pressure on the dental 
 nerves through disease of the teeth; and in such cases, some 
 swelling can be found nround the tooth: or the alveolus in the 
 aged can undergo a change, in which through slow atrophy, 
 sometimes accompanied by i)ain, the root of the tooth is dis- 
 placed. Neuralgia can occur in all portions of the face; and it is 
 often situated in small S])Ots, in which one can only find filaments 
 derived from the facial nerve. It may disappear from one part 
 of the face and appear at another. 
 
 Trousseau finds in the species of neuralgia, which the French 
 name tic douloureux, an epileptiform element; in this form, 
 pain can be awakened by some slight cause: for exami)le, from 
 a touch, eating, speaking, and even from an emotional thought. 
 The attacks of pain are of extreme vehemence, and are attended 
 by a trembling or spasmodic movement of the neighboring facial 
 muscles. This form is difficult to cure. 
 
 In 1859, Schramm wrote on facial neuralgia, in an essay in 
 which were detailed the observations of one hundred and ninety- 
 five cases. In two-thirds of the cases, the affection was in the 
 inferior branch of the trifacial. It was often associated with 
 intermittent fever; and then the attacks occurred periodically, 
 assuming in some a quotidian, and in others a tertian form. 
 The periodical form, though seemingly cured, commonly recurs. 
 In other cases, the disease "was coincident with dental disease, 
 rheumatic or gastric trouble. The u.se of quinine, arsenic and 
 iron cured many of these cases. 
 
 Oppenheimer finds facial neuralgia to depend on affection of 
 tlie nasal mucous niembrane; or it may arise from nasal polyp; 
 such cases were only cured through treatment of the nose. 
 
 Salter, of Guy's Hospital, published, in 1S6S, his investigations 
 of facial neuralgia. He finds that it may arise directly or reflexly ; 
 it may appear in the supra-orbital or infra-orbital nerves, and the 
 pain be felt in the temple, eye and near the summit of the head. 
 Where the trouble has continued long, the skin is red and hot. 
 Facial neuralgia may extend and implicate some portion of the 
 cervical and brachial plexuses of nerves; and thus the arm may 
 
FACIAL XEURALGIA. 787 
 
 lose its muscular power. Salter infers a connection between 
 the trigeminus and the nerves of the arm, especially with the 
 ulnar nerve. Spasm and weakness of the affected muscles 
 are present. As initial causes of such nervous trouble are caries 
 of the teeth, exposure of the dental pulp, periostitis, exostosis, 
 and crowding of tlie teeth against each other. Salter cites numer- 
 ous cases which support his doctrine; cases in which, concurrent 
 with the neuralgia, were kindred affections, as trismus, torticollis, 
 tetanus, epilepsy, neuralgia in the neck and arm, amaurosis and 
 deafness. Salter places much stress on dental disease; he con- 
 siders this the direct or indirect cause of neuralgia. 
 
 Anstie, of London, in 1868, wrote on facial neuralgia. Char- 
 acteristic conditions of the affection are the tendency to exacer- 
 bate and intermit, and the disproportion between the violence of 
 the jjain and the accompanying constitutional disturbance. The 
 pain is often confined to one branch of a nerve-trunk, and is 
 usually unilateral; or if it be on both sides, then the pain mav 
 be symmetrical; or there may be a greater number of branches 
 affected on one side of the face than on the other. And the pain 
 is influenced by the condition of the body; for example, it is 
 intensified by fatigue or other depressing causes. Under the 
 head of aetiology, Anstie enumerates the following as causal 
 agencies or influences: heredity, malaria, and prolonged centrif- 
 ugal or centripetal irritation. As examples of such irritation 
 are excessive use of the eye, pus in the vicinity of a nerve, or 
 syphilitic growths encroaching on the nerve. Again, syphilis 
 may cause a morbid change in the central nervous system. In 
 cases in which the neuralgia has continued long, or has a 
 high degree of intensity, then there may be present the points 
 of pain, noticed by A^alleix. There may be secondary implica- 
 tion of the secretor}'- glands of the mouth and face; or through 
 action on the vaso-motor nerves, there may be altered nutrition 
 of the parts, and, as result, muscular paresis, and some degree 
 of anassthesia. Anstie is certain that there is a morbid change 
 in the sensory nerve, or in the centre whence it arises; and 
 finally, an interstitial atrophy may occur in the nerve, ending 
 in degeneration of its tissue. 
 
 Benedict, in 1871, advises the division of neuralgia into two 
 classes: in one the paroxysms may have a continuous character, 
 though the intensity may rise and fall ; and a second class in 
 which the attacks are not continuous, but consist of momen- 
 tary attacks. The second class comprises the excentric neuralgic 
 
788 FACIAL NEURALGIA. 
 
 affections. If trij^eminus neuralgia be thus divided, tic doulou- 
 reux belongs to the second class. In tic douloureux, temperature 
 is increased, the facial muscles are tense, and there is cedema of 
 the superjacent surface. Benedict has observed in long-standing 
 facial neuralgia a dilatation of the carotid artery; and in some cases 
 the vessel was widened and tortuous. The dilatation seemed coin- 
 cident with (edema and increased temperature. In some cases the 
 vessel seemed narrow; and in such the parts sui)[)lied by it were 
 cyanosed. Benedict does not refer the widening of the carotid to 
 obstruction of the peripheral capillaries; but he deems it due to 
 widening of these capillaries, and an extension centrally of this 
 widening. And this dilated condition of the carotid I'urnishes a 
 therapeutic hint for ligation of the vessel. 
 
 According to the writer's experience, facial neuralgia occurs 
 much oftener in the male than in the female, and this is dueto 
 the more frequent ex|)Osure of the former to cold, or traumatic 
 violence. 
 
 The prognosis is doubtful. The physician may promise relief 
 by internal medication; and this relief, in most cases, is only 
 partial and transient; exceptionally, it may be permanent. The 
 phy.sician has numerous medicines which he may successfully 
 tr3% until he finds the one suited to the case; and along with the 
 remedies used to cure the neuralgia, anodyne and anaesthetic 
 means should be used to lessen the pain. A review of these 
 means will now follow. 
 
 As internal remedies, the following may be tried: quinine in 
 full doses; and its action will be improved by combining the 
 quinine with morphia. Atropine may be given in doses of one- 
 sixtieth of a grain, conjointly with morphia. Additional reme- 
 dies are guarana combined with gelsemium, strychnia, aconite, 
 colcliicum and cimicifuga. Pfaff recommends the internal use 
 of turpentine. Fowler's solution of arsenic and carbonate of iron 
 may be tried. Phenacetin in ten-grain doses, or antipyrin in 
 similar doses, relieves some cases. Bromide of zinc, bromide of 
 caffein, and the oxide of zinc have given relief. In syphilitic 
 subjects mercury in some form should first be given, and after- 
 wards the mercury should be given with iodide of potassium. 
 The writer saw an inveterate facial neuralgia yield to an atro- 
 cious ptyalism : the cure cost the patient his teeth. 
 
 Along with internal medicines, or subsequent to their unsuc- 
 cessful trial, local remedies may be used on the sites of pain, or 
 injected into the affected structures; of such means the following 
 
FACIAL NEURALGIA. 789 
 
 may be tried. The external application to the painful part of 
 Daphne mezereum has relieved; likewise inunction with an 
 ointment composed of morphia and extract of Belladonna has 
 given relief. Lusanna used by inunction a similar compound, 
 viz., three grains of atropine to half an ounce of adeps; and of 
 this he rubbed in a small portion, which contained about one- 
 eighth of a grain of atropine. Lombard advises the inhalation 
 of fumes arising from burning a mixture of opium, benzoin and 
 sugar. 
 
 Morphia and cocaine may be used parenchymatously ; of either 
 one, from three to six minims of a five per cent solution may be 
 injected into the painful part; and such injection would contain, 
 in the one case, one-eighth of a grain, and in the other, one-fourth 
 of a grain. 
 
 As additional remedial agencies the follow^ing have been used 
 and commended. In 1792, Parry advised the comjDression of the 
 carotid artery to relieve facial neuralgia. Later this treatment 
 was commended by Liston, Preston, Trousseau, Malapart and 
 Tlirck. Li 1850, Tiirck published the account of cases of facial 
 neuralgia which were thus successfully treated. Tiirck's expla- 
 nation of the mode of action of compression is, that it acts 
 through pressure made on branches of the vagus and sympathetic 
 nerves. As far as possible, the internal jugular vein should be 
 avoided. 
 
 Desterne claims to have cured facial neuralgia by touching 
 the membrana tympani. 
 
 Electricity has been found beneficial in some cases; Benedict, 
 especially, commends galvano-therapy: he applies the positive 
 pole to the mastoid process, and passes the current upwards. 
 Many others have verified the efficacy of the electrical treatment. 
 
 Andre reports the cure of obstinate cases of facial neuralgia 
 by surrounding the site of the pain with fenestrated adhesive 
 plaster, and then cauterizing the exposed part with caustic potash : 
 and as soon as the eschar was detached, the cauterization was 
 repeated until the bone was reached. 
 
 In 1850, Malgaigne reported the successful treatment of facial 
 neuralgia, as well as neuralgia elsewhere, by cauterization of the 
 external ear: in eighteen cases thus treated, six were cured. 
 According to the author's experience, such cauterization applied 
 directly on the seat of pain, often gives relief. As thermal agents 
 which he has tried are the galvanic or simple thermal cautery, 
 burning sealing wax and melted diachylon. 
 
790 FACIAL NEURALGIA. 
 
 Numerous operative procedures have been resorted to for relief 
 of facial neuralgia; prominent among these are ligation of the 
 afferent artery, the simple division of the nerve, and exsection of 
 a portion of the affected nerve. 
 
 Liiiation of the carotid arterv, bv which the blood is diverted 
 from the affected structures, has been done in a few ca>es, and 
 relief thus obtained. In a case of violent facial neuralgia, seen 
 by the writer in 18G6, the common caroti'd was tied, and the 
 neuralgia permanently relieved. No cerebral or nervous compli- 
 cation followed tlie woi'k, but, as this sometimes occurs, it would 
 be prudent to reserve this radical procedure for last resort: medi- 
 cation, cauterization and electricity having failed, should it then 
 be found that compression of the carotid artery removes the pain, 
 as a means of permanent compression, the writer would ligate 
 the carotid in the lower part of its course. 
 
 Some of the primary essays in neurectomy were made by an 
 ignorant tinker, who lived in an obscure corner of Paris. Richet 
 records that this man, for thirty year.s, had relieved patients of 
 dental neuralgia by a cut on the side of the face near the ear. 
 Richet, who did not disdain to learn from so humble a source, 
 learned and performed his operation, which was done as follows: 
 introduce a bistoury through the skin between the tragus and 
 the condyle of the lower jaw, to the depth of three lines. In such 
 an incision, the knife would meet the auriculo-temporal branch 
 of the inferior maxillary nerve; and the temporary relief which 
 often follows such incision must be due to incision of this nerve. 
 
 Neurectomy often falls short of its purpose : the relief from it 
 is but temporary; the divided nerve reunites, and the neuralgia 
 returns: and to render the work more effective, neurectomy, or 
 removal of a portion of the trunk of the nerve, has superseded 
 simple division. 
 
 The pioneer in the work of neurectomy was Bdrard, who, in 
 1830, announced an operation of this kind ; and he was followed 
 by Roux, who, in 1854, reported numerous neurectomies. This 
 work of Roux is reviewed by Beau, who, finding that many of 
 the operations had not resulted satisfactorily, refers tlie failure to 
 the fact that in the resection too small a portion of the nerve 
 had been excised. To guard against reunion of the ends of the 
 severed nerve, Beau advises that a section of it, an inch and a 
 half long, should be removed from the trunk of the affected nerve; 
 and he approves of the counsel of Malgaigne and others to 
 remove the nerve as deep as possible. 
 
FACIAL NEURALGIA. 701 
 
 In a dissertation published in 1858, Schuh offered some general 
 notions concerning facial neuralgia and neurectomy ; and he like- 
 wise indicated the routes by which the branches of the trifacial 
 can be reached for their division. 
 
 Schuh claims that the operation is not dangerous,, and that 
 some relief, if not a perfect cure, is always obtained by it. It is 
 difficult to locate the site of a pseudoplasm, which by pressure is 
 the causal agenc}^ If the cause be deep, the j^ain radiates periph- 
 erally; but if the cause be more external, the pain pursues 
 a central course. Pressure, friction and- muscular movements 
 aid in determining the chief site of pain. 
 
 In the sections of the excised nerve which Schuh examined 
 microscopically, he failed to discover any structural changes: yet 
 he found in the sheath of the nerve neoplasms and osseous 
 changes, wdiich he regarded as causes of the neuralgia. 
 
 The following indications are given by Schuh for the opera- 
 tion, viz.: where the neuralgia depends on a superficial scar; 
 where it becomes chronic, very intense, and medicines fail to 
 relieve. It should be done, also, in cases in which but one sensi- 
 tive branch, or but few branches of one trunk are affected, and 
 the latter is anatomically accessible. To decide that a nerve is 
 really affected, there must be a fixed point of pain in the struc- 
 tures supplied by the nerve; and also a point whence the pain 
 radiates. And even in cases in which such point of pain was 
 absent, neurectomy gave relief for some months. 
 
 To operate on the frontal and supra-trochlear nerves, Schuh 
 incises along the supra-orbital margin to the bone: the perios- 
 teum is then reflected downwards, and the eye pushed down- 
 wards. The frontal nerve will be perceived glistening through 
 the reflected periosteum: divide it as far backwards as possible, 
 and remove a section of the nerve. Through the same cut the. 
 supra-trochlear nerve can be found and divided. 
 
 To resect the infra-orbital nerve make an incision along the 
 lower edge of the orbit, and, entering the orbit, lift up the eye 
 with a spatula, and then sever the nerve as far back as possible 
 in its canal. This division is done with scissors, and both 
 artery and nerve are severed. In this division, the instrument 
 should not enter the antrum. Next, reflect the soft parts down- 
 wards, until the infra-orbital foramen is found; and when the 
 nerve is seen, draw it out from the canal, and cut off the part 
 withdraw^n. Should a portion of bone be found encroaching on 
 th-e nerve, the bone should be exsected; and in this work care 
 
702 FACIAL nj:lkalgia. 
 
 must be taken not to let any fragments of Ijone drop into tlie 
 antrum. 
 
 Schuh reached the subcutaneous mala) through a cut by which 
 the outer lialf of the floor of the orbit is opened, and the nerve being 
 found there is divided as far back as possible. To reach the poste- 
 rior branches of tlie superior maxillary, let the mouth be elongated 
 laterally, so that the tuberosity of the upper jaw can be reached, 
 and its mucous membrane divided and so turned aside tliat the 
 nervous filaments which lie there can be reached and severed. 
 The division of the nerve is best done with a chisel. In two cases 
 Schuh destroyed the nerves with a hot iron. 
 
 Tlie temporal nerve can be reached througli a vertical cut in 
 front of the tragus, and being separated from the artery, the nerve 
 may be divided. 
 
 Schuh sought the lingual nerve b}' a cut in the floor of the 
 mouth, made near the posterior teeth ; this route for finding the 
 nerve is less mutilating than that of lloser, who by incision, 
 elongated laterally the commissure of the mouth. Michel 
 divides the lingual nerve through a cut in the floor of the 
 mouth, next to the molar teeth; and as aid in the operation, the 
 tongue was drawn outwards towards the other side. 
 
 Paravicini sought and reached the inferior dental nerve 
 through an incision in the back of the mouth, in which he 
 pierced and opened the internal pterygoid muscle; through this 
 opening he forced his finger and found the dental foramen and 
 the nerve entering it; from the nerve thus found, a section was 
 cut out. Some bleeding accompanied the operation. 
 
 Bratsch, in 1863, reported ninety-eight cases of neurectomy 
 done for the relief of neuralgia; these operations were mostly 
 j^erformed by Nussbaum of Munich. Of these operations, almost 
 an average of six were done on the same person, so that the 
 actual number of patients treated was about sixteen. Almost all 
 of the branches of tlie trifacial were o})erated on. The occipital 
 was also divided. 
 
 The general result obtained by these operations was a favor- 
 able one; and the fact that rela})se ensued in several of the 
 patients, Xussbaum thinks was no objection to the w^ork, since 
 the patients always demanded to be operated on again. The 
 relapses occurred in from six to fourteen months. 
 
 In several of these cases, in which the pain seemed located in 
 one branch of the trifacial, the division of this branch did not 
 remove the pain ; relief was only obtained by the removal of all 
 
FACIAL NEURALGIA. 793 
 
 three branches of the trifacial. And where this radical exsec- 
 tion failed, relief was finally obtained tlirough the ligation of the 
 carotid. 
 
 Roser, who has operated several times for the relief of facial 
 neuralgia, gives the following directions for finding the lingual 
 nerve. An incision is made through the cheek opposite the base 
 of the tongue, and through this cut the tongue is reached, and 
 the nerve, being found, is exsected on the base of the tongue, below 
 the insertion of the stylo-glossus muscle. For the division of the 
 inferior dental nerve, Roser divided the masseter muscle, and 
 having laid bare the ramus of the inferior maxilla, a trephine 
 crown was placed on this midway between the coronoid process 
 and the lower margin, of the angle of the jaw; the outer por- 
 tion of the jaw was removed, and the nerve, being found, was 
 exsected. Michel in a case of neuralgia seated near the angle of 
 the mouth, concluded that the affection w^as in the buccal nerve; 
 and this supposition was verified by division of the nerve, which 
 was done by a cut made along the anterior border of the masse- 
 ter muscle, when a finger inside of the mouth uplifted the nerve, 
 and brought it into position for division. 
 
 An examination of the jDublished results of several operators 
 reveals the fact that neurectomy does not always accomplish its 
 intended purpose; for in some of tlie patients the operation 
 has partially failed, and in a few it has been wholly unsuccessful. 
 A search for the cause of this has led to the conclusion that, in 
 such cases, the nerve had not been attacked deeply enough. This 
 was the notion of Goux, of Strassburg, who wrote on the causes of 
 relapse, and concluded that it is due to the causal agency exist- 
 ing on the proximal side of the site operated on; or it may arise 
 from the pain traveling from the branches of a trunk which has 
 not been divided into the branches of the trunk already divided. 
 In such a case the branches of the cut and uncut nerves anasto- 
 mose; that is, there is propagation in a manner which the writer 
 would denominate anastomatic radiation. 
 
 To insure success in neurectomy, Goux recommends to divide, 
 in rebellious cases, all the branches of the trifacial nerve. 
 
 To destroy the nerve as deeply as possible, after neurectomy, the 
 central stump has been cauterized by some surgeons b}" means of 
 a heated wure, which was thrust into the stump. Such cauteri- 
 zation has chiefly been done in the case of neurectomy of the 
 infra-orbital nerve. 
 
 In patients in whom neurectomv, as above described, failed 
 51 
 
79-1 FACIAL NEURALGIA. 
 
 to cure, indicating that the causal agency was more deeply 
 located, surgical enterprise has passed the boundaries which the 
 prudent conservatism of the past liad fixed as the Ultima Thule 
 for the surgical exidorer; and the intre})id feats here done seem 
 cognate to the daring depicted by the classic Mantuan, in whicli 
 the Promethean race launched their barks upon and crossed for- 
 bidden seas. Indeed, by means of the Promethean liglit with 
 which Anatomy illumines the way of the scalpel, old boundaries 
 have recoiled, and the surgeon now penetrates to the base of the 
 skull, and there divides the middle and inferior branches of the 
 trigeminus; and recently even tlie cranial w^all has been opened, 
 and the trifacial branches divided close to their encephalic 
 origin. 
 
 In tlie work of dee[) extra-cranial neurectomy, the name of .J.M. 
 Carnochan, of New York, merits special mention. His operation, 
 done in 1855, was on tlie superior maxillary nerve, which he 
 severed near the foramen rotundum; and in the operation, the 
 spheno-palatine ganglion was also excised. Carnochan placed 
 much stress on the removal of this ganglion. The operation 
 began by the formation of a triangular flap on the cheek, which 
 being uplifted, the front wall of the antrum as well as the infra- 
 orbital foramen were exposed. This wall was now excised and 
 the antrum freely opened. Afterwards, the posterior wall was per- 
 forated, so that the spheno-palatine fossa was opened to view. The 
 superior maxillary nerve will there be seen prior to its entering 
 the infra-orbital foramen ; and also the spheno-palatine (Meckel's) 
 ganglion. A segment of this nerve together with the ganglion is 
 to be excised. The pioneer case thus operated on was seen by the 
 writer a few days after the operation; also the segment of nerve 
 which had been removed. The ganglion was unusually large, 
 as well as the trunk of the nerve. The breach in the man's face 
 was a great one: since the work was done previous to the time 
 when the cosmetic element began to share in the surgeon's 
 operative work on the face. The patient seemed delighted with 
 his mutilation, since in exchange for it, he was wholly freed from 
 his neuralgic torture. 
 
 The operation of Carnochan might be so modified as to avoid 
 much of the deformity which was left by the work : namely, the 
 anterior wall of the antrum might be uplifted in connection with 
 the soft parts, and afterwards replaced. 
 
 The bold procedure of Carnochan has given his name an 
 enduring place in operative surgery. In works on surgery, no 
 
FACIAL NEURALGIA. 795 
 
 matter in what language written, in the chapter upon neurectomy; 
 one finds a mention of tliis operation. 
 
 In 1872, Woodbury reported that Pancoast, of Philadelphia", 
 performed an operation, somewhat analogous to that of Carnochan, 
 for the relief of neuralgia seated in the inferior maxillary nerve. 
 This was done as follows : A pedunculated flap was made over the 
 ramus of the inferior maxilla; this flap was detached above and 
 allowed to hang attached below. Thus he reached the coronoid 
 process, and resected the same; then arresting the htemorrhage 
 by means of Pagliari's styptic, he reached and tied the internal 
 maxillary artery. The next step was to pluck out the fatty 
 tissue, and detach the external pterygoid muscle from its attach- 
 ment to the sphenoid bone; and finally, the foramen ovale being 
 reached, exsection was made of the inferior maxillary nerve. 
 
 Through the same route, Pancoast proposed to reach the fora- 
 men rotunduni, and then, having thrown a ligature around the 
 superior maxillary nerve, pull it out and excise a portion of it. 
 And if one desired to remove a large portion of the nerve, he 
 could lay bare the infra-orbital foramen, and having seized the 
 nerve there, it could be pulled out, and thus removed. 
 
 In exsection of the inferior maxillary, at the foramen ovale, 
 Pancoast found that the sense of taste was lost on the correspond- 
 ing side of the tongue. 
 
 The deforming mutilation caused by the operation of Pan- 
 coast, and the interference with mastication which it entails, are 
 serious objections to it. Nevertheless, the pain of facial neural- 
 gia is so intense, in many cases, that the patient is willing to be 
 quit of it at any cost; yet, before undertaking an operation so 
 deforming as either of the operations mentioned, the surgeon 
 should be very certain in his diagnosis that the patient will not 
 afterwards have a revolting deformity added to his uncured neu- 
 ralgia. 
 
 The undismayed foot-tread of surgical audacit}^ not content 
 with reaching the cranial base, has recently overleaped that bar- 
 rier and attacked the sensory trunk of the trifacial near its emer- 
 gence from the pons Varolii. Surgical enterprise failing to sub- 
 due the enemy by an attack on the outworks, has, adopting the 
 maxim, Fledere si nequeo superos, Acheronta movebo, penetrated 
 within the citadel of life. Diefi'enbach and Stromeyer were so 
 inimical to neurectomy as done in their time, that they declined 
 to give a description of the operation in their works on surger}^ ; 
 had they foreseen that the Casserian ganglion some day would 
 
796 FACIAL NKUllALGIA. 
 
 be the objective aim of tlie excising instrument, their liostility 
 would doubtless have swollen with a higher tide of indignation. 
 
 This operation is now in the experimental and expectant 
 stage, and whether the hand of critical adjudication, which is now 
 adjusting the scales, will turn them towards the side of acceptance 
 or rejection, remains for decision in the future; nevertheless, in 
 the meantime, one must admire the boldness of the work done 
 here by Rose, Andrews, Hartley and Horsley. 
 
 Rose has lately published five operations of this kind, done 
 for relief of neuralgia seated in the superior and inferior maxil- 
 lary nerves. 
 
 The fifth nerve resembles a spinal nerve in this, that it con- 
 sists of a sensory and a motor portion; and in the sensory por- 
 tion, similar to the posterior root of a spinal nerve, there exists 
 the Casserian ganglion. Rose's operation removes this ganglion, 
 which lies outside of the dura mater on the upper face of the 
 petrous bone, near the inner end of the bone; and the work is 
 done as follows: the eye is closed by stitching the lids together, in 
 order to protect this organ, which by the operation will be deprived 
 of its normal sensibility; and, in consequence of this, the eye 
 will be unduly exposed to injury from the contact of foreign bodies. 
 Next, an inci-sion is made along the lower border of the z3^goma, 
 terminating at its posterior end; now this incision, reaching only 
 through the skin, is carried downwards to the angle of the lower 
 jaw, and then forward alongthe lower margin of the jaw to the facial 
 artery. The flap thus outlined is next dissected forwards, with- 
 out wounding the facial artery, nerve or Stenson's duct. The 
 zygoma is next divided and uplifted and turned forwards, carry- 
 ing with it the masseter muscle. The coronoid process is next 
 divided and shifted upwards with the attached temporal muscle; 
 and, in later operations, Rose removed the process. The internal 
 maxillary is next ligated, and then divided. The external 
 pterygoid muscle is then separated from the sphenoid bone and 
 the external pterygoid plate. Next, a trephine, of hiilf inch diam- 
 eter, is made to penetrate the cranial wall, just anterior to and 
 outside of the foramen. The trunk of the inferior maxillary 
 nerve served as a guide in the act of trephining, and likewise in 
 the subsequent search for the Casserian ganglion. After Rose had 
 thus reached the ganglion, he excised it with curved hooks, tak- 
 ing care in the division not to open the neighboring cavernous 
 sinus. The result of these operations was satisfactory. 
 
 Horsley penetrated yet deeper, and having removed a par.t of 
 
FACIAL NEURALGIA. 797 
 
 the squamous portion of the temporal bone and Hfted up the 
 brain, he severed the trifacial at its emergence from the pons 
 Varolii; the patient died a few hours afterwards. 
 
 The temptation inspired by V envie des autres rivaux has led 
 surgery onward until it has now reached the ultimate of opera- 
 tive effort, unless some one ambitious of mention within the lists 
 of unjustifiable temerity, should lay bare the medulla oblongata, 
 and, penetrating alongside of the vital point of Flourens, should 
 reach and destroy the nuclear origin of the trigeminus; and the 
 bold hand who would do this would add another name to ojDera- 
 tive nomenclature, viz., nudearedomy. But if tlie prudent voice 
 of conservatism be listened to, one hears the chiding remon- 
 strance that there is a limit beyond which it is not allowed, para- 
 phrasing the words of the Muscovite potentate, for even surgical 
 heroes to pass. 
 
 To conclude this chapter on facial neuralgia, the writer will 
 add his experience in reference to neurectomy. In eight patients, 
 the subjects of facial neuralgia which had resisted all other plans 
 of treatment, exsection of the nerve was resorted to ; in six of the 
 cases, the superior maxillary and inferior dental nerves were 
 operated on; and in two patients, along with these two nerves, 
 the supra-orbital nerve was also exsected. The subjects were all 
 males, and were over forty years of age, except one, who was 
 twenty-five years old. The neuralgia was seated on the right 
 side of the face in the majority of the cases. 
 
 The methods pursued in reaching the nerve were as follows: 
 To divide the inferior dental, a crescentic cut was made around 
 and close to the angle of the lower jaw; the insertion of the 
 external pterygoid muscle was separated from the jaw by means 
 of a chisel. Into the opening thus formed the finger can be 
 passed, and the dental, foramen found by means of the process 
 of Spix, a spike-like prominence of bone surmounting the lower 
 edge of the foramen. The nerve and accompanying artery can 
 now be caught with a blunt hook and torn asunder. In another 
 case, after a proper incision was made, and the soft parts detached 
 on the outside, a trephine was used, and the bone which lies 
 opposite the foramen was removed, and tlie nerve thus readied 
 was sundered with forceps. This method of approaching the 
 nerve directly from the outside is more deforming than the pre- 
 ceding method, just mentioned. 
 
 The middle branch of the trifacial was reached by the method 
 of Schuh, Wagner and others. An incision is made along the 
 
79S FACIAL NEURALGIA. 
 
 int'ra-orbital margin, tlio inner end of the cut terminating 
 two lines outside of the lachrymal sack. This incision must 
 penetrate to the bone; and the lower edge of the incision having 
 been pulled downwards so as to display the infra-orbital foramen, 
 the upper lip of the wound is next lifted up, and the dissection 
 continued backwards along the floor of the orbit. This work is 
 best done with a blunt dissector, by which the periosteum is 
 separated from the orbital floor; and done thns, bleeding will be 
 minimized, the peri-orbital fatty couch will not be injured, and 
 can easily be lifted up; but if the periosteum be fenestrated, the 
 adipose tissue will jiout through the openings. This separation is 
 to be continued until the inferior orbital fissure is reached. The 
 infra-orbital nerve is readily traced backwards; for, with a good 
 light, the nerve can be seen beneath the thin stratum of bone 
 which lies over it. The orbital floor is so thin and fragile in the 
 aged that it can easily be broken; in fact, it was so thin in one 
 case that in the w^ork it was ruptured, and a fragment of sponge 
 catching in the breach, escaped into the antrum. Knowing that 
 sponge will float in water, the writer filled the cavity with 
 water, when the sponge floated to the top and was removed. As 
 aids in this work w'ere a small gilded spoon, and direct illumina- 
 tion with sunlight. The nerve and attendant vessels were 
 caught at their entrance into the canal with a small pair of 
 forceps, and severed with scissors in front of the forceps. The 
 central end held by the forceps was pulled and twisted, so that 
 the nerve was acted on much beyond tlie point of division. The 
 nerve was next seized at the infra-orbital foramen, and the por- 
 tion within the canal was extracted. The wound, cleansed with 
 alcoholized water, was next closed with fine wire sutures; and to 
 maintain drainage, a small tube w^as used in the early opera- 
 tions; later, instead of this, a silken thread was substituted, and 
 answered equally well. Recovery ensued with a scar, which, in 
 the subject over fifty years, was almost imperceptible after six 
 months. 
 
 The frontal nerve was reached through a cut made along the 
 inner half of the supra-orbital margin; the nerve and artery 
 were seized, and divided; and on the central end traction and 
 torsion were made. If this cut be made near the palpebral fold 
 it will afterwards be scarcely visible. After section of the infra- 
 orbital and frontal nerves, the wound was dressed with simple 
 cold water; and the healing was rapid, and almost without sup- 
 puration. 
 
FACIAL NEURALGIA. 799 
 
 The operations done within the orbit necessitated some pres- 
 sure on the bulb of the eye: a circumstance which gave the 
 writer some anxiety in his early operations; in no case, however, 
 was the eye injured by such pressure; nor, from the violence 
 done the nerves, has the nutrition of the parts, deprived of 
 sensory innervation, been in any way impaired. The results 
 obtained in the eight patients operated on have been highly 
 favorable to neurectomy; the most of the patients were wholly 
 relieved; and in the few in which there was a recurrence, the 
 pain was trivial in comparison with that which existed prior to 
 the neurectomy. 
 
CHAPTER XXV. 
 
 NECK. 
 
 General Remarks. — The neck, which connects the head with 
 the trunk, is elHptical transversely, in its lower portion; while 
 above, it is elliptical antero-posteriorly. It is isthmus-like, a 
 region of transit for important structures between the head and 
 trunk. These structures are all important, and some of them 
 necessary to existence, and tlie latter become the objects of 
 destructive attack from tlie hand of suicide, which desires to put 
 a period to life; also of the hand of justice in its work of punish- 
 ing malefaction. 
 
 The hand of the surgeon makes also frequent visitations to 
 this field; and in conservative etfbrt and operative work, sur- 
 gical art offers many examples of humane intervention : instances 
 of wdiich are correction of abnormal position, the combating of 
 stenosis or occlusion of the laryngo-tracheal and aesophageal 
 canals, and the removal of growths which compress nerves con- 
 cerned in respiration, or vessels which furnish blood to the head. 
 Such are the highly important subjects which will be considered 
 in the coming chapters of this work. 
 
 Surgical Anatomij. — At the threshold of the matter, it is neces- 
 sary to notice topograj)hically some of the anatomical components 
 of the neck, of which an accurate knowledge is necessary to the 
 surgeon. 
 
 The anterior surface of the neck is an elongated quadrangle, 
 which is divided by the larynx and trachea into two lateral 
 fields, also quadrangular in outline; and each of these lateral 
 fields is divided by the sterno-cleido-mastoid muscle into two 
 somewhat symmetrical triangles, which may be named the inner 
 and outer triangles; the base of the outer one is the clavicle, 
 while the base of the inner one lies above. And the two inifer 
 ones combined may again be conceived to be a great median tri- 
 angle, of which the sides, formed by the sterno-cleiflo-mastoid 
 (800) 
 
SURGICAL ANATOMY. 801 
 
 muscles, are equal; and-the apex of this median triangle ends at 
 the manubrium of the sternum. This space contains nearl}- all 
 the vitally important structures of the neck. 
 
 The fasciae in the anterior portion of the neck should be 
 well known to the surgeon; these are three in number; the 
 superficial, middle and the deep. These fascial structures vary 
 much in strength, between extreme tenuity and one of strong 
 resistance: sometimes so thin as scarcely to be demonstrable. 
 
 These fascial strata form partitions which bound spaces 
 within which lie certain parts which enumerated from without 
 inwards, are as follows: between the skin and the superficial fas- 
 cia lie the platysma myoides, the fatty couch, and the branches 
 of the superficial plexus of nerves. The adipose layer varies 
 greatly in both infants and adults; it may be absent, or amount 
 to an inch or more in thickness. It is thicker in subjects in 
 whom the neck is short. This fatty couch closely concerns the 
 operation of tracheotomy; when very thick, it becomes a serious 
 obstacle to the operator in the work of penetrating to the 
 trachea. 
 
 The subcutaneous fascia extends laterally from the median line, 
 and reaching the sterno-cleido-mastoid muscles, forms a sheath for 
 the latter; it passes thence to the anterior border of the trapezius 
 muscle, which it also incloses, by an anterior and posterior layer. 
 At the median line, the superficial fascia is thickened, and this is 
 named the cervical linea alba. The fascial sheath of the sterno- 
 cleido-mastoid is thinner below than above; thus, pus contained 
 within this sheath may perforate the thin anterior layer below 
 and appear under the skin. The superficial fascia is attached 
 inferiorly to the anterior margin of the sternum. 
 
 The middle layer of fascia starts above from the hyoid bone, 
 in common with the superficial layer; the two soon separate, and 
 the middle passing below is inserted in the periosteum which 
 lines the posterior face of the sternum and is attached also to the 
 clavicle. Thus a space is left between the superficial and middle 
 layers, which being thin above is ecjual to the thickness of the 
 sternum and clavicle below. The middle layer forms sheaths for 
 the sterno-hyoid, sterno- thyroid and omo-hyoid muscles; also a 
 sheath for the great vessels and nerves, and passing thence out- 
 wards, it penetrates between the scalene muscles, and reaching the 
 transverse processes of the vertebree, it is inserted into them. 
 
 In the space between the outer and middle cervical fascia is a 
 layer of lamellated cellulo-adipose tissue; and in this are con- 
 
802 XKCK. 
 
 tained lymphatic glands. In this space-occurs the hroad phleg- 
 mon of Dupuytren, a })hleginonous abscess which may occupy 
 the greater i)art of the front cervical region. Pus contained in 
 this space forces the anterior wall forwards; and it is prevented 
 from pressing nnich on the i)arts behind by the resistant middle 
 laj'er of fascia; and through the ])rotection given by this firm 
 median fascia, dyspnoea and vascular obstruction are lessened or 
 avoided. 
 
 This middle layer, which from its attachments may be named 
 the hyo-sterno-clavicular fascia, has been assigned by the anato- 
 mist Allan Burns, the very important function of protecting the 
 trachea during the respiratory act of respiration. For a time 
 this notion was generally accepted; its incorrectness has, however, 
 been shown by the fact that in immerous surgical operations, in 
 which the fascia was opened, no such collapse of the trachea 
 ensued. In a great number of operations performed in this 
 region by the author, the middle cervical fascia was divided with 
 no ill effect; and in a few cases of thyreotomy, the entirety of 
 the cervical portion of the trachea being laid bare, breathing was 
 not obstructed. The patency of the trachea is maintained by 
 its cartilaginous walls; and only in cases in which the rings have 
 been softened and weakened by pressure, will the}', when laid 
 bare, yield to the atmospheric pressure. 
 
 The relation of this middle fascial stratum to the carotid 
 artery and jugular vein is more important than its connection 
 with the trachea. This fascia, as stated, forms a sheath for those 
 vessels; and in this is a partition separating the artery from the 
 vein. The middle stratum forms ensheathment for the omo- 
 hyoid muscle; and the latter, where it lies on the internal jugular 
 vein, is tendinous in structure; and by virtue of this structure of 
 unchanging volume, and its fixation in the fascia, pressure on the 
 vessel is avoided and the venous circulation favored. At its 
 inferior part the fascia is closely adherent to the expanded 
 termination of the jugular vein; and since the inspiratory move- 
 ment lifts the sternum forwards, the effect is to carry forwards 
 the middle fascia, and to open the vein. Thus a suction-like 
 action is exerted on the vein, and its blood is attracted towards 
 the heart. This suction is exerted, in some degree, on the affluent 
 veins which empty into the internal jugular vein; thus the afflux 
 of blood from the head and neck to the heart is promoted. The 
 advantage which the circulation derives from this anatomical 
 disposition is not shared by the surgeon in his operative work on 
 
SURGICAL ANATOMY. 803 
 
 the neck; for, if a large vein be opened, the inspiratory suction 
 may draw air into tlie veins, and this, mingling with the blood, 
 may fatally obstruct the circulation. 
 
 Allan Burns mentions a case in which the destruction of the 
 €ervical fascia in a surgical operation was followed by dyspnoea 
 after the wound had healed; during inspiration, the trachea was 
 compressed, and a hollow depression formed over the top of the 
 sternum. The j^atient breathed with effort, which was attended 
 by a wheezing sound. He suggests that relief might be obtained 
 in such a condition by applying a piece of leather, covered by 
 adhesive plaster, over the affected part of the neck; and to fix it 
 more surely, sealing wax dissolved in alcohol, might be applied 
 to the edges of the leather, which, thus fastened, would become a 
 substitute for the lost fascia. 
 
 The third layer of fascia, from its position, may be named the 
 prsevertebral ; and this stratum extending between the transverse 
 processes, covers the longus colli and other muscles situated in 
 front of the cervical vertebrae; it forms a sheath for the anterior 
 scalene muscles. 
 
 In the third inter-fascial space contained between the middle 
 and deep fasciae lie the important structures of the neck, viz., 
 the carotid arter}^, jugular vein, the air-passage, the oesoph- 
 agus and the nerves which form the brachial plexus. In the 
 lower part of this space lie also the subclavian artery and 
 vein. It contains, likewise, a loose cellular tissue. This space is 
 connected with that of the posterior mediastinum by means of the 
 trachea and oesophagus; and pus forming in the space may 
 descend along these tubes into the thorax; or it may follow the 
 trunks of the brachial plexus and appear in the axilla. The 
 strength and resistance of the middle stratum are such that 
 tumors forming in the third space are forced backwards and 
 laterally, and can cause perilous compression of vessels and 
 nerves. 
 
 The fourth space which lies behind the prsevertebral stratum 
 is filled with the muscles situated there; the only other structure 
 of importance found there is the sympathetic nerve; and to this 
 may be added the vertebral artery and vein which traverse the 
 transverse vertebral processes. 
 
 Besides the blood-vessels contained in the third interfascial 
 space, there lie there also, lymphatic glands and their vessels; and 
 likewise, the termination of the chylo-lymph trunks, which end 
 on both sides in the vessels formed by the union of the internal 
 
804 NECK. 
 
 jugular and subclavian veins. These terminal trunks should be 
 remembered in estimating the gravity of wounds which penetrate 
 these regions. 
 
 The glands lie chiefly in the space between tlie second and 
 third fascial strata; and a number, which have a special surgical 
 importance, lie along the course of the carotid artery and internal 
 jugular vein; and those in contact with the vein are especially 
 to be borne in mind, since when the glands inflame, they can 
 become so adherent to the vein that their removal by the sur- 
 geon imperils the venous wall; or their suppurative action may 
 weaken and open the vein. Again, the diseased glands encroach- 
 ing on the vein may occlude it through the formation of a tlirom- 
 bus which, growing upwards or downwards, may imperil life. 
 
 As stated, the antero-lateral region of the neck is a field which 
 offers numberless opportunities to surgery for operative interven- 
 tion; and the facility or difficulty of such intervention is deter- 
 mined by the form of the neck; if the neck be short and thick, 
 incision, excision, subcision, ligation and other technical proce- 
 dures become inconceivably difficult; but if the field is long, 
 spacious and accessible, the knife has freedom to do its best work. 
 And these methods have a bearing, commonly unnoticed, on 
 surgical statistics. 
 
 Torticollis. — As synonyms of torticollis are caput obstipum and 
 wry-neck. 
 
 In torticollis the head, instead of being erect, is deviated to 
 one side; and this arises from a distortion or inclination of the 
 neck in the same direction. The neck not only leans towards one 
 side, but it is also twisted on its vertical axis, so that the face is 
 turned towards the side opposite to that of the cervical inclina- 
 tion: that is, the head leans towards one side, while the face is 
 turned towards the other side, and the chin is uplifted. The 
 head is sometimes so fixed that the patient cannot move it, or 
 only slightly. 
 
 As classification of the directions in which the head may be 
 inclilicd, that of Duval is a convenient one, viz., anterior, poste- 
 rior, anterior oblique towards the right or left, and posterior 
 oblique towards the riglit or left. 
 
 The affection niay appear as a congenital deformity; or it 
 may arise after birth. 
 
 The head is oftener flexed towards the right side; and from 
 the author's observation, torticollis occurs oftener in the male sex. 
 
 If viewed in reference to the anatomicnl structure which is 
 
TORTICOLLIS, 805 
 
 affected, torticollis may be designated cutaneous, osseous, muscu- 
 lar or musculo-nervous. Cuignet of Lille adds another species, 
 viz., ocular torticollis, which arises from photophobia or diplo- 
 pia. 
 
 Congenital torticollis studied in reference to aetiology, has 
 been explained in three ways : (1) Mechanical, in which the ori- 
 gin of it is referred to abnormal pressure on the fretal head before 
 birth. This was the theory of Hippocrates and Dieffenbach. (2) 
 Musculo-nervous, which refers the origin to some pathological 
 condition of the muscles dependent on some lesion or defect of 
 the nervous centers. (3) Arrest of development, in which one 
 side of the head outstrips the other in growth. 
 
 Von Ammon, who has made a careful study of torticollis, 
 finds a connection between the greater frequency of the deform- 
 ity on the right side, and the position of the foetus in utero : viz., in 
 three-fourths of the cases, the foetal head is turned towards the 
 left side of the mother. And this may explain the fact that the 
 affection seems to be inherited in some famihes. He also observed 
 that parts of the foetus which are developed early in utero are the 
 most liable to congenital deformity. 
 
 The deformity was seen, by Von Ammon to occur soon after 
 birth ; and in such children there was an abnormal hardness and 
 density of the contracted muscle which caused the deviation. 
 
 The author has seen cases which arose at the time of birth, 
 and were due to some manual or instrumental manipulation used 
 in the delivery of the foetus, viz., version, or the use of the for- 
 ceps. In some of these children, the violence done the neck in 
 delivery caused swelling and suppuration of the injured muscle. 
 Duval has seen torticollis arise in the infant from a glandular 
 affection on one side of the neck, which causes the child to incline 
 the head towards the other side; thus, from habit, lateral devia- 
 .tion of the head and neck can arise. But if the muscles be 
 affected with rheumatism, the head will incline towards the 
 affected side. 
 
 The site of torticollis may be in the derm, the cervical mus- 
 cles and fascice, or in the cervical vertebrae: or the site may be 
 in two, or in all of these structures. 
 
 The removal of a large portion of the skin of the neck may be 
 followed by a torticollis; also a burn, followed by a contractile or 
 keloid cicatrix, may deflect the head. That arising from the 
 skin, which has been wounded or removed by a surgical inci- 
 sion, is rarely permanent. iVfter such operation the writer has 
 
8UG NECK. 
 
 seen a teiKlency to wry-neck; and so great was this tendency in 
 a few cases that it was necessary to use an orthopedic correcting 
 appliance. The surgeon may lessen cicatricial deflection, if in 
 his operative work he so plans the incisions or wounds made that 
 their closure can be done by vertical lines, rather than by trans- 
 verse ones. 
 
 Torticollis from musculo-fascial contraction occurs much 
 oftener than from any other cause. The muscles which are 
 implicated are, when named in tlieir anatomical ordei', the 
 platysma myoides, the sterno-cloido-mastoideus, the scaleni, the 
 trapezius, the prajverLebral and the retro-vertebral muscles. Of 
 these muscles, the one which is oftenest the causal agent through 
 its shortening, is the sterno-cleido-mastoid, together with its fas- 
 cial sheath. 
 
 As may be inferred from what has been stated, the shortening 
 of the muscle is commonly due to some lesion, or inflammatory 
 affection of its tissue; and wliere such direct agency is not discov- 
 erable, some recondite nervous disturbance of central, interme- 
 diate or peripheral location, has been sought for. 
 
 Long continuance of the contracted state, eventuall}^ induces 
 changes in the muscular structure; thus, as the writer has seen, 
 the tissue of the sterno-cleido-mastoid has become changed into 
 dense tendon-like structures; and this change implicated the 
 muscle's fascial envelope, as well as the overlying skin. This 
 shortening was accompanied by incurvation, so that the retracted 
 structures were adherent to the cervical vessels. 
 
 The third site in which the causal agenc}^ may be situated is 
 in the superior cervical vertebrae. Some writers do not include 
 under the head of torticollis cervical deviation which originates 
 in spinal affection; Malgaigne, however, in his chapter on torti- 
 collis, gives this mode of causation a prominent place. He finds 
 that torticollis may arise from a disease of the joint connecting 
 the axis and atlas; and of the articulation which unites the occip- 
 ital bone with the atlas. In such cases, the site of the disease can 
 often be discovered by an examination of the pharynx. A swell- 
 ing is thus detected, in which pus sometimes is found. The osse-^ 
 ous disintegration may proceed so far that sub-luxation can occur,, 
 and death ensue; as a rule, hewever, the vertebral displacement 
 is so limited that it is tolerated. If the atlas be displaced on the 
 axis, the luxation is commonly forwards; if the displacement is 
 lateral, then the odontoid process ceases to be the center of motion, 
 and what motion there is, is accomplished through the medium 
 
TORTICOLLIS. 807 
 
 of the adjoining sound vertebras. Or if tlie displacement between 
 the atlas and axis be on one side, then the rotation may be accom- 
 plished through the non-luxated side. 
 
 In cases in which there is a doubt whether the affection is 
 one of inflammation of the joint, or of osseous disease, it is safe to 
 decide that in severe cases, the bone is the site of trouble, and 
 that disintegration is present or impending; and such disease is 
 usually in tubercular subjects. In such patients, the spinous 
 processes of the region should be examined; and if undue prom- 
 inence be found, this denotes osseous disease. 
 
 In cases of sub-luxation, Malgaigne thinks that the danger 
 from an attempt to effect reduction is not so great as is com- 
 monly taught. 
 
 As accompaniments of torticollis, the following are often 
 present: the face is asymmetrical, arising from the imperfect or 
 arrested development of the side on which the distortion exists. 
 The nose is small, the cheeks are unlike, the eyes of unequal 
 size: all the parts of the face on the inclined side are smaller 
 than those of the other. And the cranium participates in the 
 malformation; it has an oblique, oval form; and this is due 
 to the half on the affected side being smaller than the other. 
 The cerebral hemisphere on the affected side is smaller than the 
 other. From this lessened cerebral form, the opposite side of the 
 body is slightly retarded in its development. Broca finds, also, 
 an impairment of intelligence in the subjects of congenital 
 torticollis. 
 
 This impaired development is caused by the pressure on the 
 carotid artery on the affected side: thence arising a lessened 
 blood supply to all the parts on that side of the head. Bouvier 
 has verified, by the necropsy of such cases, the lessened calibre 
 of the carotid on the distorted side. 
 
 As functional symptoms are the following: the patient can 
 only make limited movement of the head. When at repose, the 
 patient experiences no pain; but when an effort is made to erect 
 the head, pain is caused. A shifting of the head from the nor- 
 mal position may cause double vision. The movements of the 
 larynx are hampered; and phonation in some of its acts is 
 restricted. The oesophagus may be disturbed in form and func- 
 tion. The temperature is often slightly lowered on the affected 
 side. 
 
 Paralysis of one sterno-cleido-mastoid, or of other muscles on 
 one side, leads to inclination on the sound side; in such cases, 
 the patient is unable to move the head on the paralyzed side. 
 
808 XECK. 
 
 There is a foriii of torticollis which is intermittent or spas- 
 modic in its manifestation. Tlie affection is the result of invol- 
 untary contractions of the cervical muscles, viz., of the sterno- 
 cleido-mastoid, the trapezius and splenius. The subjects of this 
 are affected differently; in one case, it appears only when the 
 patient stands; in another, it appears when he walks; and in a 
 third class, it arises when the patient makes movements peculiar 
 to his oceu])ation. In a case of spasmodic torticollis treated by 
 tlic writer, the spasmodic deviation of the lieud was awakened 
 by any rotatory movement of the head; and the contractile 
 action was on the left side, and the head was drawn obliquely 
 downwards and forwards. This spasmodic act was not continuous, 
 but was marked by momentary, slight remissions; and these 
 cessations were not long enough to allow the head to assume its 
 erect position. 
 
 Torticollis, again, may arise under some moral influence, as 
 anger, fear or depression. It has been seen to appear at the 
 catamenial period. And it has arisen so j)eriodically, that its 
 cause has been referred to malarial poison. Bo3'er saw a case in 
 which the attacks came on when the patient began dinner; and 
 even if the dining hour was changed, the attacks came on as 
 previousl}'. 
 
 In these cases of intermittent torticollis, the attacks do not 
 appear when the patient is asleep. Asa rule, the spasmodic 
 action is unilateral; yet it may attack simultaneously both sides, 
 as was seen by Steudel in one case. 
 
 In conclusion, the attacks of spasmodic torticollis are, as a 
 rule, irregular in their occurrence ; in some cases, the recurrence 
 has been at long intervals. And the attacks are commonly 
 transient in duration. 
 
 Treatment. — Torticollis is often amenable to medical treatment; 
 and when causal conditions are present which indicate that the 
 patient can thus be cured, appropriate remedies should first be 
 tried, and when these have failed, some orthopedic or operative 
 measure must be resorted to. 
 
 In all cases of a grave or obstinate character, as a diagnostic 
 means to test the extent and persistence of the distortion, the 
 patient should be subjected to complete anaesthetic narcosis; and 
 the degree of the contraction being thus determined, the surgeon 
 is enabled to decide whether he should make a preliminary trial 
 of non-operative treatment, or resort at once to the knife. If, for 
 example, he finds that the shortened muscles easily relax, then a 
 
TORTICOLLIS. 809 
 
 non-operative coarse may be pursued; and, as means comprised 
 under this head, are electricity, manipulation, and orthopedic 
 appliances; and in spasmodic and periodically recurring cases, 
 internal medication must be employed. 
 
 Electricity was employed by Duchenne and Remak : the 
 former using the interrupted current, while Remak preferred the 
 continuous one. The continuous current, generated by a limited 
 number of galvanic elements, should be made to pass from the 
 spine to the lengthened muscle; and this is done by placing the 
 positive pole on the spine, and the negative one on the muscle. 
 The electric current in all cases, should act on the convex or 
 elongated side of the neck; it should not be continued over 
 twenty minutes, nor be repeated oftener than three times a clay. 
 This treatment promises most in torticollis of spasmodic charac- 
 ter and, also, in those of a paretic, or paralytic natin-e: the elec- 
 tricity being applied to the palsied muscles. 
 
 A number of authorities liave reported excellent results from 
 manual manipulation; among these maybe cited Seguin and 
 Delore, who, with the passive movement, have in some cases 
 combined volitional movements of the patient. 
 
 The plan of Delore is to deeply ansesthetize the patient, when, 
 the trunk being held, and the shoulders depressed by an assist- 
 ant, the surgeon grasping the head moves it in a direction which 
 is the opposite of the deviation. These movements are made 
 in tlie sense of flexion and rotation; and, at first mild, they are to 
 be gradually increased in force, until the head is restored to recti- 
 tude. This can be done in from ten to fifteen minutes. During 
 these movements the contracted parts are felt to yield with a 
 crackling sound. When the neck is restored to normal position, 
 it is to be retained so by means of a silicated immobilizing appa- 
 ratus, between which and the patient, a thick layer of cotton is to 
 be placed. This retentive dressing remains in place a month, 
 when it is to be removed, and another applied, if a cure has not 
 been accomplished. 
 
 Instead of the silicated apparatus, other surgeons, after having 
 broken the adhesions and relieved the distortion, use an appliance 
 of fixation which can occasionally be removed; and they claim 
 that, by so doing, there is less danger of sloughs from undue 
 pressure, since the apparatus can easily be removed and applied, 
 as exigency may demand. 
 
 Internal medication must be resorted to in cases of a spas- 
 modic or periodic character, and especiallv in those in whom 
 52 
 
810 NECK. 
 
 there is a suspicion of malarial infection. In such cases, quinine 
 in full doses should be administered. Fowler's solution of arsenic 
 may also be given. In those in whom there are rheumatic 
 symptoms, colcliicum and cimicifuga may bo given. An addi- 
 tional remedy that may be tried is salicylic acid. 
 
 The armory of electric, mechanical and medical means hav- 
 ing been exhausted with fruitless result, the knife remains as the 
 ultimate resort: and this opens the subject of tenotomy and 
 myotomy of the cervical muscles, for the relief of torticollis. 
 
 Tenotomy, or, more properly, myotomy, was first done for the 
 relief of torticollis by Eonhuysen,in 1670; he divided the sterno- 
 cleido-mastoid by first opening the skin and then severing the 
 muscle from within outwards, with a bistoury. Afterwards, the 
 division of the muscle was done with scissors by Florianus; and 
 Minnius divided the muscle, after he had exposed it by the aid of 
 an escharotic which destroN^ed the superjacent skin. This pioneer 
 work found but little imitation: in fact, it was decried, until the 
 two master surgeons Dupuytren and Diefrenbach, who flourished 
 during the first third of the nineteenth century, gave the opera- 
 tion its proper place in operative surgery; and priority in this 
 work is assigned to Dupuytren by Von Ammon, a German 
 authority. 
 
 Though the operation is a simple one and free from ill conse- 
 quences in most cases, yet this is not the universal report; ill 
 results, and even death, have followed it. Such ill results have 
 been from wound of the internal jugular vein, injury to nerves, 
 and occasionally, troublesome sup[)uration. 
 
 The internal jugular has often been wounded; even those 
 whose instruments were guarded with accurate anatomical knowl- 
 edge have unwittingly strayed from the ])rotective landmarks, 
 and have pierced the internal jugular. The writer once saw this 
 happen in an operation done by one who was reputed to be the 
 most skillful operator among those who speak the English tongue. 
 The famous surgeon had just premised the work by a few words 
 in which he dwelt on the danger attendant on the subcutaneous 
 section of the sterno-cleido-mastoid ; "that though one might 
 safely cross a bridge many times, yet if he approached too near 
 the edge, he might fall into the river;" and having said this, he 
 inserted his tenotome, and the gush of blood which instantly 
 flooded the parts, showed that he had wandered off the "Waterloo 
 bridge," and fallen into the river. 
 
 Bonnet claims that a puncture of the internal jugular vein is 
 
TORTICOLLIS. 811 
 
 free from danger; yet Gue'riu and Vallin teach the contrary, and 
 advise to scrupulously avoid the vessels. In one case, death 
 resulted frona a wound of the internal jugular. 
 
 Philippe, in 1847, wrote on the operation, and announced that 
 he had seen ill effects follow myotomy in the neck. He has 
 collected five cases in which the injury to certain unim2)ortant 
 nerves caused paralysis of parts. In one case, Phili^Dpe divided 
 subcutaneously the clavicular portion of the sterno-cleido-mastoid, 
 and in the operation some small nerves were cut, whence a 
 neuritis was awakened, that extended to adjacent nerves, and 
 produced palsy of the arm. This palsy finally extended to the 
 facial nerve. The writer cannot refrain from remarking that tlie 
 tenotome here may inadvertently have wandered from the route 
 appointed for it, and encroached on structures of which an injury 
 is punished with fatal forfeit. 
 
 A third ill result of myotomy and tenotomy is suppuration ; 
 it is probable, however, that careful asepticism will strike tins 
 out from the list of accidents which may follow these operations. 
 
 Upon the point whether cases may be cured without an oper- 
 ation, Dieffenbach admits that they can ; yet, that when the non- 
 operative course is pursued, the treatment is more tedious and 
 prolonged, and relapses are not infrequent. In fact, where only 
 orthopedic means have been used, Dieftenbach has seen the 
 muscles rebel and contract still more than they were before. 
 
 As a guiding rule on this subject, Guerin says that while the 
 muscle is yet in the condition of mere contracture, a cure can be 
 effected mechanically; but when the muscle has reached the 
 stage of permanent contraction, orthopedic appliances fail, 
 unless the muscle be divided; and the reason of this is, that in 
 the former, the muscle is in a normal state, and can easily be 
 extended; but wlien the muscle has passed into permanent con- 
 traction, it has undergone a fibrous change that does not permit 
 of elongation. 
 
 The section may be done at an early age, as was verified by 
 Dieffenbach, who operated on two infants which were only six 
 months old. 
 
 The sterno-cleido-mastoideus is the muscle usually contracted 
 in torticollis; and, as a rule, the sterno-mastoid is the portion 
 affected; so that, in many cases, the operation is limited to this 
 portion; but in cases which have continued for years, in which 
 fibrous change has occurred, it is generally necessary to divide 
 both portions of the muscle. 
 
812 NECK. 
 
 The point at which section is made lies in the lowermost 
 portion of the muscle, viz., from a lialf inch to an incli above the 
 sternal and clavicular endings. The section was, sometimes, done 
 liigher l)y Malgaigne. In the liigli division, the spinal accessory' 
 nerve sliould be borne in mind. 
 
 Where the skin is contracted into a fibrous cord, Dieffenbach 
 first removed the contracted portion, and then closed the wound; 
 some weeks afterwards, he divided the shortened mu.scle subcu- 
 taneously, and thus effected a cure. In a normal case of con- 
 tracted sterno-cleido-mastoid, he divided the n)uscle, at once, as 
 follows: if the contraction were on the right side, having seized 
 and lifted up the muscle with the left hand, then, with the right 
 hand, he pushed the tenotome between the trachea and muscle, 
 underneath the latter, and thus severed the muscle from beneath 
 towards the skin. As he cut, he pressed the skin and tendon 
 with the thumb of the hand. Having divided the sternal por- 
 tion he next passed the knife in the fossa beneath the clavicular 
 I)ortion, and divided this. 
 
 In some cases operated on b}^ Bonnet, after dividing the 
 sternal and clavicular portions of the muscle below, at a later 
 period, he divided the body of the muscle an inch and a half 
 higher up. 
 
 There has been a controversy whether the cutting should be 
 done from before, backwards, or reversely; and also whether the 
 knife should enter on the inner or outer side of the muscle. 
 Bonnet thinks it is unimportant which way the work is done. 
 When he divided the muscle in its body, he cut from behind 
 forwards; but when he cut but one portion, he severed from 
 before, backwards. After the division, should it appear that 
 certain fibres are unsevered, or that the shea-th has not been 
 included in the division, then a blunt knife may be passed behind 
 these parts, and their division effected. In the young subject, 
 liowever, the sheath may be allowed to remain unsevered; thus 
 doing, one obtains better reunion of the divided muscle. 
 
 As soon as the division is done, the site of puncture should be 
 compressed so as to check any bleeding which may follow. 
 Should a re-division of the muscle be necessary, Duval counsels 
 not to repeat the cutting in the same place; lie cuts at a new 
 point, and thus there is le.ss danger of wounding the vessel that 
 has become attached to the muscle through the previous cutting. 
 
 Dieffenbach, who operated a countless number of times, found 
 the seat of the trouble in most cases, to be in the sternal portion 
 
TORTICOLLIS. 813 
 
 of the sterno-cleido-mastoid muscle; he divided this a hah" inch 
 above the sternum. Should it be necessary to sever both por- 
 tions, he thrusts his tenotome on the inner side of the inner por- 
 tion, and on the outer side of the outer portion ; and cuts both 
 portions from behind, forwards. 
 
 The site of the muscular contraction has been found to exist 
 in the platysma myoides; also in the scalene muscles, lateral 
 portion of the trapezius and in the muscles behind the neck; of 
 the retro-cervical muscles, the trapezius and complexus are the 
 ones oftenest at fault. In whatever muscle the contraction exists, 
 this, in most cases, maybe divided subcutaneously ; should, how 
 ever, the muscle not be safely accessible in this wa}^ as, for exam- 
 ple, the deep-seated scalenus, then the muscle should be dis- 
 played by an open incision, and divided to the extent required. 
 The more superficial muscles, as the platysma myoides and the 
 trapezius, may be severed subcutaneously; 3^et the latter, if the 
 operator has not recently verified the site of the spinal accessory 
 nerve, is more safely divided by open incision. And the depth 
 of the scalene muscles is such that they can only be reached and 
 divided by an open incision, as Bauer did. 
 
 In cases of spasmodic and periodic torticollis which have 
 resisted internal medication, a resort may be had to neurectomy 
 of the spinal accessory nerve, and the branches of the superficial 
 cervical plexus. 
 
 The spinal accessory lies above in a four-sided figure, of which 
 the boundaries areas follows: draw a horizontal line from the 
 angle of the jaw backwards, and a second one on a level with the 
 upper boundary of the thyroid cartilage, then draw two other 
 lines, one in front of and another behind the sterno-cleido- 
 mastoid ; then a diagonal line, drawn from the upper and inner 
 angle of this figure to the lower and outer angle, will lie over the 
 nerve. It usually pierces the sterno-cleido-mastoideus; yet the 
 writer has found exceptions to this in his dissections. The 
 branches of the superficial cervical plexus escape from the pos- 
 terior border of the muscle, near the union of the upper and the 
 middle thirds of the muscle. 
 
 Campbell de Morgan having failed to cure a case of torticollis 
 by myotomy, afterwards exsected a portion of the spinal accessory 
 nerve, with successful result. The writer treated a case of obsti- 
 nate spasmodic torticollis, which was unilateral, and which was 
 not benefited by myotomy; the patient was finally cured by 
 neurectomy of the spinal accessory nerve and all the branches of 
 the superficial cervical plexus. 
 
814 XECK. 
 
 In recent times (1SS5) Volkmanu has done this work by 
 open incision; and having the parts exposed fully to view, he 
 divided freely the parts necessary to rectify the head ; this plan is 
 analogous to tliat of Price, who, having made an opening, passed 
 a grooved director under the muscle, and divided it. 
 
 After the myotomy was done, Eulenberg's practice was to 
 forcibly restore the head to normal position; and after breaking 
 up any adhesions which opposed this — the head was tlien allowed 
 to resume its abnormal position, and to remain thus for three 
 davs; then it was straightened and maintained erect by mechan- 
 ical appliances. 
 
 After myotomy, Petrali advises, before the application of a 
 mechanical support, to bring tlie shoulders to a horizontal posi- 
 tion, and having lifted the head to an erect posture, let it be 
 moved in the arc of a circle which is the opposite of tlie ill posi- 
 tion; and lastly, any secondary curves of the spine lower down, 
 must be corrected; and thus rectified, the jDarts must be main- 
 tained in place by orthopedic apparatus. 
 
 Inventive genius has given the surgeon mechanical appliances 
 of diversified models, to maintain the parts in rectitude after 
 division of the contracted muscles; and it is through the judicious 
 selection and proper use of these means, that the cure is finally 
 obtained; for, from the writer's observation, there is no thing 
 which is more strongly impressed on the surgeon through his 
 experience than that, however much his knife may aid him in 
 this work, it is through the slow plodding effort of well-devised 
 orthopedic appliance that the ultimate link in the cure of torti- 
 collis is reached ; the tenotome is merely the key that opens the 
 gate of the field in which lies his chief work. 
 
 The orthopedic appliances used in the treatment of torticollis 
 may be classed in the following groups: (1) A simple cravat. 
 (2) A cravat with apparatus for fixing the head. (3) An appa- 
 ratus for fixing the head in rectitude which is attached to one 
 fastened about the upper part of the trunk. 
 
 In mild cases, or those of recent origin, after the tenotomy of 
 the sterno-clcido-mastoid muscle, the cure may be acccomplished 
 by the use of a stiff cravat, which will prevent the head from 
 resuming the former false position. Such an appliance can be 
 made of felt pasteboard, leather, gutta percha,or of metal. 
 
 In the second group, the cravat is combined with some appli- 
 ance fastened about the head; and the latter maybe a simple 
 ring, to which straps are fastened which are attached to the 
 
TORTICOLLIS. 815 
 
 cravat at points wliicli will permit traction to be made in such 
 directions as will best maintain the normal rectitude of the head. 
 Or these straps may be fastened to padded rings through which 
 tlie arms pass; and tliese rings rest on the shoulders. Either of 
 these orthopedic apparatuses, though it restores the head to proper 
 position, may act faultily by lifting the shoulder abnormally 
 high; that is, when the head is brought to proper position, the 
 structures, which are abnorrnally short on the affected side, 
 lift the shoulders upwards. And in a cure thus obtained, the 
 correction would consist in an exchange of a distortion of the 
 neck for one of the shoulders. Bonnet has invented an appara- 
 tus in which, besides the thoracic portion, there is a neatly fitting, 
 well-padded cravat, and there ascend from the shoulders two 
 uprights, to which are fixed rods which press pads against the 
 face. The pads can be fixed at different points, and by their 
 pressure, the head can be made erect and rotated, and the face 
 turned towards the sound side. The apparatus of Bonnet is shown 
 in Figure 92, from which its mode of action can be understood. 
 
 Figure 92. Apparatus of Bonnet for correcting torticollis. 
 
 An apparatus has been devised b}'' Bigg, of London, which is 
 light in construction, and is composed of the following parts: a 
 light pelvic girdle to which a dorsal stem is fastened; to this is 
 attached above another light girdle, which encircles the chest 
 and passes close to the arms in the axillary spaces; and to the dor- 
 sal upright stem there is fastened a vertical piece which divides 
 above into two branches, of which the parts pass respectively to 
 
810 NECK. 
 
 the right and left sides of the face. These latter branches are 
 fastened to pads which rest against the sides of the face, antl 
 through them graduated compression can be made. The two 
 braneiies are so arranged that the head can be fixed in any posi- 
 tion which is desired. 
 
 Malgaigne, as appHance, used a corset to which were fas- 
 tened axiUary crutches, and a dorsal upright staff to which 
 retentive head-pieces were fastened. The head-gearing con- 
 tained an attachment for support, similar to what is known 
 as the "jury mast." Orthopedic apphances have recently been 
 devised, analogous to those described, by which continuous trac- 
 tion is maintained by means of elastic cords or straps. From 
 the writer's experience the advantages claimed for these stra[)S 
 are less than their inventors assert; they soon wear out, or become 
 weak, and demand constant renewal. 
 
 Among means to restore to normal position, after division of 
 the contracted structures, should be mentioned traction and 
 counter-traction made on the head and trunk. This method is 
 strongly advised by Stromeyer. For this work special beds 
 have been constructed, of a complicated character. Since the 
 introduction of the weight and pulley to maintain traction, the 
 work is simplified by converting the bed into an inclined plane, 
 and making attachment of the pulley to the head of the bed, and 
 fastening the tractile appliance to the head. Despite the emi- 
 nent authority of Stromeyer, his extension plan has not met with 
 general acceptance; in fact, Malgaigne utterly discards it; and 
 South disapproves of it. 
 
 From the writer's observation, there are cases of torticollis in 
 which, after 2:)rei)aratory myotomy, tiie surgeon will find it impos- 
 sible to return the head, neck and shoulders in proper i)lace by 
 the use of any of the ordinary orthopedic appliances. In such a 
 case, treated by the author, in which the usual instruments did 
 not effect the desired correction, a satisfactory result was obtained 
 through the application of a gypsum apparatus, applied as fol- 
 lows: the patient sitting on a stool with the head, neck and 
 shoulders brought into proper position, must have these parts 
 well enveloped in cotton w^adding, and firmly held in place while 
 the plaster dressing is being applied. For this maintenance in 
 position three assistants are necessary: viz., one to hold each arm, 
 and a third to fix the head. In spite of this care, there may be 
 some error in position found after the dressing has been applied. 
 Such error mav be that the chin is too high, and deviates from 
 
TORTICOLLIS. 817 
 
 the mediaii line; and that the shoulders do not stand on a level; 
 such were the faults of position which the author found difficult 
 to avoid; and it was only after repeated applications that such 
 faulty position was avoided. The gypsum bandage must encircle 
 the chest, shoulders, neck and head, crossing in a figure of eight 
 manner. The ears should not be covered, and the arms only so 
 covered as to immobilize the shoulder joints. Such a cast should 
 be worn for three months; and if the deformity be great and of 
 long standing, a longer period will be required. During its 
 use the patient can be allowed to walk and use the limbs not 
 included in the cast. And, for the continuance of the correction 
 which has thus been obtained, some one of the numerous ortho- 
 pedic appliances in vogue may be selected, and worn for from six 
 to twelve months. 
 
 In cases of many years' standing, though the faulty position 
 may be greatly amended by treatment, yet it is impossible to 
 comj^letely restore the subject to normal position and natural 
 figure. The long continuance of the lateral deviation has altered 
 the forms of the cervical vertebrte; the lessened supply of blood 
 to the affected structure has rendered those parts smaller; so that 
 though the head be rectified in position, yet one side of the face, 
 one eye, and one-half of the skull will remain somewhat dwarfed, 
 or malformed. And, for a time, vision is often disturbed after 
 rectification of the head; but the diplopia or obliquity of vision, 
 thence arising, finally disappears. 
 
 A method of corrective fixation, in cases in which the hair is 
 long enough, is to make two braids of this, and tie these around 
 the shoulder of the elongated side. The lawlessness, falsely 
 named liberty, indoctrinated into the modern child, was evi- 
 dently left out of account b\' the writer who advised this tricho- 
 pedie procedure. 
 
 In cases of torticollis in which the causal agency consists of 
 an affection of some of the cervical vertebra, it is seldom that 
 tenotomy need be resorted to. The shortened muscle or mQscles 
 are in a condition of simple contracture, which readily yields, if 
 the spinal column be rectified. A most troublesome task, how- 
 ever, is often encountered in the effort to straighten the spine; and 
 this is still more aggravated if there be added the complication 
 of an abscess arising from tubercular disease. In such cases, 
 an apparatus, so devised as to remove the most of the weight 
 from the spinal column, must be applied and worn. The con- 
 sideration of the method here referred to belongs rather to the 
 
818 xi'XK. 
 
 subject of special deformity; and in the chapter devoted to this, 
 tlie matter will be briefly considered by the writer. 
 
 The cha|)ter will conclude with a mention of a form of torti- 
 collis which originates in some lesion of the soft parts of the 
 neck, and may be called cicatricial. 
 
 In the removal of neoplasms from the neck, in which a large 
 tract of derm is sacrificed, and the wound is allowed to heal by 
 graimlation, the head becomes drawn towards the affected side. 
 Such lesion may be a burn, by which the skin being destroyed, a 
 slow-healing wound remains. The scar there formed is thick 
 and contractile, and of the nature of the semi-malignant structure 
 named keloid. In all such cases, in which an agency exists dis- 
 posing to distortion of the neck, the tendency to deviation should 
 be op[)Osed by a supporting and restraining apparatus. Such an 
 appliance may consist of a simple cap fastened to the head, and 
 from which straps or cords may pass to a girdle around the 
 up})er ])ortion of the chest. 
 
 Sometimes these cases only apply for surgical relief alter the 
 scar has been formed; especially is this seen where burns on the 
 neck have healed badly, or, percliance, have not healed at all. 
 In such a case the writer has seen the head flexed forwards, so 
 that the chin almost rested against the upper end of the sternum. 
 In this deformity, relief may be obtained by dissecting out the 
 cicatricial structure, and replacement by sound skin borrowed 
 from the contiguous surface, if sound derm exists there. Such 
 restoring material should consist of one or more pedunculated 
 flaps, which are carried into place by circumduction; and after- 
 wards the remaining wounds are to be closed by suture. Such 
 re[)lacing fla})S should be taken from sites where their loss will 
 cause the least possible tension. And during the time of healing, 
 the head should be immobilized by means of a head-dress pro- 
 vided with straps, which are fastened to it at such points as will 
 secure antagonism to the tendency to deviation. In cases in 
 wdiich closure by dermal flaps is not practicable, the process of 
 Thiersch may be resorted to, in wdiich large epidermal grafts 
 obtained from the femoral or humeral region, are transplanted 
 to the wounded surface. 
 
CHAPTER XXYL 
 
 CONGENITAL CLEFTS OR FISTULJE IN THE NECK. 
 
 These clefts which are of congenital origin, are related to, and 
 arise from, incomplete closure of the primitive branchial fissures, 
 which are present in the development of the embryo. 
 
 In the upper part of the anterior face of tlie embryo, in its 
 early development, Dzondi discovered certain openings, which he 
 named tracheal fistulse. Afterwards Heusinger, of Marbourg, 
 made a careful study of these congenital clefts, of which he col- 
 lected forty-eight cases in German medical literature; and Heu- 
 singer attributed them to an arrest of the normal embryonic fis- 
 sures. 
 
 For the comprehension of this matter, a short rehearsal of the 
 embryological constituents of the face and neck should precede; 
 and, briefly enumerated, these are as follows: there are four 
 arches, and three clefts lie between these. The first arch is the 
 budding point of the future structures of the face. The second 
 arch contains the germinal elements of the styloid process, and a 
 part of the hyoid bone; and the cleft between these becomes the 
 future tympanic cavity, and the Eustachian tube. The third 
 arch forms the body of the hyoid bone and the epiglottis; and 
 the cleft between this arch and the preceding is afterwards oblit- 
 erated. The fourth arch forms the future structures of the neck; 
 and the cleft between the third and fourth arches is afterwards 
 closed. 
 
 In its primary period of growth, the embryo presents above, 
 on the side towards which the head is turned, a cavity which may 
 be named the pharyngeal, bounded by arcii-like processes, which 
 are analogous to the costal arches which inclose the thorax. The 
 spaces between the arches above vanish during the process of 
 development, except some vestiges, which remain in the structure 
 of the auditory apparatus. Should the branchial arches not pro- 
 ceed to complete development, then some fissure will remain ; and, 
 as verified by observation, this occurs, and happens oftenest in the 
 
 (819) 
 
S20 CONGENITAL CLEFTS dK FISTUL.E IN THE NECK. 
 
 site of the second and third arches. In this way the existence of 
 congenital clefts in the anterior surface of the cervical region can 
 be explained. 
 
 This cervical defect has only recently been observed, or if 
 observed, the observation has seldom been recorded. Dupla}^ 
 and Gillette have collected a list of nearly seventy cases; of 
 these, the greater part were observed in Germany. 
 
 The causal agency which leads to an interruption in the com- 
 pletion of the branchial arches has not been explained; it lies 
 perhaps in the domain of those obscure, recondite, and probably 
 undiscoverable agencies, which presided over the animal bod}^ in 
 its previous phases of evolution; and which, beginning with the 
 embryonic form that primordially is similar in all vertebrates, 
 pursues such diverse paths to reach the adult stage. 
 
 Though the direct and immediate causes are unknown, yet 
 observation has noted certain indirect or contingent agencies, 
 which seem to influence such congenital defect; and prominent 
 among these is heredity or kindred. During three generations 
 in one family such defect was noticed eight times; and in one 
 family, of eight children, five were the subjects of the fissure. 
 Other collateral defects often coexist with them, especially defects 
 of the ear and face. 
 
 Duplay divides such defects into those which are congenital, 
 or exist at birth, and those which appear afterwards ; the latter 
 class is rare. 
 
 The branchial fistula may be complete or incomplete; the 
 former having an inner and outer opening, while the incomplete 
 may be a blind canal, which opens on the inside, or on the out- 
 side. 
 
 The complete fistula has a dermal outlet, and it opens into the 
 pharynx. This form is, according to Gusset, often associated 
 with imperfect pulmonary development. The opening outside 
 may be situated at any point from the thyroid cartilage to the 
 sterno-clavicular articulation. The higher the dermal opening 
 is, the more it ap])roaches the median line. This opening may 
 be fine and on a level with the skin, or somewliat uplifted on a 
 reddish papilla; and sometimes, the outlet has a valve-like fold 
 of skin as a covering. Instead of a fine opening, the outlet may 
 be much larger, viz., two or three lines in diameter; this, how- 
 ever, is exceptional, and the outlet may be so attenuated that a 
 fine probe can not enter it. When the opening is large enough 
 for inspection, one finds it invested with a coating similar to that 
 
COXGEXITAL CLEFTS OR FISTUL.E IX THE XECK. 821 
 
 of mucous membrane. Tiie canal between the outlets varies in 
 caliber; and may be uniform in dimensions, or with one or more 
 dilatations. It may be straight or sinuous. The internal orifice 
 opens into the pharyngeal cavity; and this may be above and 
 near the greater cornu of the hyoid bone; or it may be near the 
 palato-phar3'ngeus muscle; and this inlet may be small and dif- 
 ficult to discover; or it may be a pocket-like opening, in which 
 mucous or alimentary materials may lodge. 
 
 The external fistula, which is incomplete, may end at a varia- 
 ble distance from the cutaneous surface; this canal points towards 
 the hyoid bone, and is dilated at its blind ending. 
 
 There lias been some contest concerning the incomplete fistula, 
 which, opening in the inner mucous surface, descends thence 
 towards the skin. Some claim tliat such fistula originates 
 through a hernial protrusion outwards of the mucous membrane. 
 
 There have been observed, located somewhere near the inner 
 end of the branchial canal, fragmentary plates of cartilage, or of 
 cartilage and bone; and these lodged on the wall may vary from 
 a line to an inch or more in length. Such cartilaginous lamella 
 is movable, and is not adherent to the skin. And Duplay has 
 seen similar plates of cartilage in the structures of the front of the 
 neck where no fistulous opening existed. And such cartilage has 
 been seen so prominent that it was a source of inconvenience, 
 and its removal demanded. 
 
 A fistulous canal similar to those described has appeared 
 some time after birth. Duplay has called attention to this species, 
 and his explanation of it is as follows: A fi.stula which opens 
 internally at birth, may be covered with a film-like epidermal 
 coat; afterwards, materials entering the canal, the outer terminal 
 covering may be abraded and opened; and thus an incomplete 
 canal becomes a complete one. Such cases are extremely rare. 
 
 Besides the anatomical characteristics of the branchial fistula 
 which have been pointed out, its leading clinical characteristics 
 are the discharge of material from its external outlet, when the 
 latter exists; also, the collection and temporary sojourn of such 
 matters within the canal itself, and finally, the irritation wliich 
 such materials may cause while lodged in the canal, or after 
 their escape from it. 
 
 The canal is painless unless a sound be passed into it ; this 
 act awakens an unpleasant sensation, or even pain of a pricking 
 or burning character. In a case in wliich the author was con- 
 sulted, the passage of a probe was painful to the patient. This 
 
822 CONGENITAL CLEFTS OK FISTUL.E IN THE NECK. 
 
 fistula eiifU'd blindly; lienee the irritation awakened by the probe 
 did not arise from itscontact with the inner surface of the mucous 
 passages. 
 
 To make an accurate diagnosis of the nature of such a (istula, 
 colored fluid must be injected into the outer end; and for this 
 purpose, milk is one of the most harmless that can be selected. 
 If the canal have no opening inwards, the injected fluid would 
 regurgitate to the surface again; but if it be complete, it would 
 enter the air-passage and produce cough. The previous history 
 would show whether the fistulous canal may* have arisen from a 
 ruptured bursa in the hyoid region, or from, a gland that has 
 suppurated, and opening on the surface, has left an unhealing 
 sinus. Such fistulous canal might occupy the usual site of a 
 branchial fistula; yet the attendant phenomena of the former, 
 and the character of the discharge, would clearly distinguish the 
 former from a branchial orifice. The branchial fistula is often 
 associated with disturbrnce of the functions of respiration and 
 deglutition. Sarazin who has collected facts bearing on this 
 matter, finds that in fifty cases, ten of them had some pulmonary 
 trouble, such as catarrh, emphysoma, tuberculosis or pneumonia. 
 Such fistula rarely disappears spontaneously; still Duplay saw 
 a case which did thus close. 
 
 Treatment. — The majority of surgeons oppose operative inter- 
 vention in the complete fistula; or they limit the work to merely 
 an attempt to convert the complete canal into an incomplete one 
 which only opens externally. 
 
 As means used in the treatment of branchial fistula are the 
 following: irritant injections, thermal cauterization and excision. 
 
 Injections, which have a destructive or escharotic action on 
 the lining of the canal, have been commended ; and as such may 
 be tried, the tincture of iodine, a strong solution of nitrate of sil- 
 ver, or one of chloride of zinc. Such means could not be safely 
 used, in case the fistula be incomplete; for the entrance of the 
 irritant fluid into the air-passages must act injuriously. Hence, 
 such treatment should be reserved for the incomplete canal. 
 
 The thermal cautery, in the form of the heated galvanic 
 wire, or an iron wire or probe that has been heated to a red heat, 
 may be used; and such cauterization may be employed, not only 
 in the incomplete fistula, but in that which is complete, since 
 differing from the escharotic injection, the heat can have no ill 
 action on the air-passage, or alimentary canal. 
 
 The methods mentioned are tedious and less direct than an 
 
THYROID GLAND AND ITS AFFECTIOXS. 823 
 
 immediate attack with the kuife. Sarazin, AVeiiilechner aiid 
 Broca have practiced excision of tiie walls of the fistula, and have 
 effected cures, Saraziii's metliod was to introduce an elastic 
 sound into the canal, and cut this off on a level with the skin. 
 Then by a circumscribing cut the walls of the canal were dis- 
 sected wholly out, along with the sound. Or the canal might be 
 distended by injecting melted wax into it, and then excision be 
 done. 
 
 As such fistula causes but slight inconvenience, non-interven- 
 tion is the wiser counsel to the patient. Such was the course 
 pursued in a case which consulted the writer; in this patient, the 
 incomplete external fistula opened about midway between the 
 angle of the lower jaw and the sterno-clavicular joint. This 
 course is still further justified by the fact that, after the closure 
 of such branchial fistula, the patient has found that the site of 
 the'healed canal is the seat of unpleasant sensations greater than 
 before it was interfered with. 
 
 THYROID GLAND, AND ITS AFFECTIONS. 
 
 Surgical Anatomy. — The thyroid gland, according to Allan 
 Burns, lies a little below the cricoid cartilage, its, upper margin 
 being generally parallel to the second ring of the trachea. It 
 is generally composed of two lobes, which are joined to each 
 other by a slip which crosses the trachea, a few lines below the 
 cricoid cartilage. In one case Burns saw this isthmus placed 
 between the trachea and oesophagus; a peculiarity, he says, at all 
 times to be much dreaded. 
 
 This description, given by an eminent pioneer, will here 
 receive some supplementary completion by material furnished by 
 Marchant, in his essay upon the thyroid gland. 
 
 Viewed as a whole, the gland is in the form of a crescent, of 
 which the convexit}^ is directed downwards, and the branches 
 point upwards. This convex border has a notched depression 
 in it. The gland has an anterior and a posterior face, an 
 upper and lower and lateral borders, and a median portion, 
 named the isthmus. The posterior surface contains an excava- 
 tion or semi-canal, in which the air-passage and oesophagus lie; 
 and the isthmian band lies on two or three of the upper tracheal 
 rings. The recurrent laryngeal nerve lies close to the posterior 
 face. The upper border, as a rule, lies close to the cricoid carti- 
 lage. The inferior border is thick, short, and is often concave; 
 and from this border nass the tliA'roid veins. This inferior bor- 
 
824 THYROID (JLANI) AND ITS AFFECTIONS. 
 
 der in the adult, lies nearly one inch above the superior margin 
 of the sternum; and in the infant, the distance is somewhat over 
 a half inch. If, however, the head be well retro-flexed, then the 
 distance between the sternum and gland is increased nearl}' a 
 half inch. The lateral borders which are inclined backwards, 
 are thick, and each one presents a furrow in which lies the ])rim- 
 itive carotid artery. The inner edge of this furrow corresponds 
 to the oesophagus, while the outer one forms a slight separation 
 between the carotid arteiy and internal jugular vein. 
 
 The gland is included in a thin capsule of fibro-cellular tissue, 
 wdiicli comes to the aid of the operator in the work of enucleating 
 the gland. This capsular envelope seems to accompany the 
 superior thyroid artery, and, when it reaches the gland, it expands 
 and forms the investing capsule. 
 
 There is often seen a divergence from normal form; and the 
 diversity or variation may concern the lobes, the isthmus, or the 
 accessory portion, named the pyramid. 
 
 The lobes ma}'' ascend to unequal heights; one of them ma}'' 
 rise to the middle of the thyroid cartihige, while the other nearly 
 reaches the lower border of the cartilage. The lobes may be 
 developed unsym metrically or irregularly. They may also be 
 replaced by lobules or fragmentary portions which are loosely con- 
 nected together. And the thyroid gland thus lobulated, may, 
 according to Madelung, -who has carefully studied this abnormal 
 form, assume various forms. Hence, as seen, the lobes may vary 
 in site, direction and in the disposition of the component lobules. 
 
 The isthmian portion may be thick, or merely a thin band; 
 or narrow, or broad. And in height, it mav vary from a half 
 inch to almost two inches in elevation; or it may not exceed two 
 or three lines in height. 
 
 From the upper border of the gland there often ascends a 
 pyramid-like portion; and this is so constant that the anatomists, 
 Meckel and Morgagni, rarely saw it absent This process may 
 arise from the middle of the isthmus; or from the connection of 
 the isthmus w^ith a lateral lobe; or it may proceed from the lobe 
 itself And according as it rises from tlie median line, or has 
 lateral origin, so it will stand vertical or oblique in direction. 
 The pyramid terminates in a fibrous cord, which extends upwards 
 and is fastened to some portion of the thyroid cartilage; or it may 
 reach to the hyoid bone. 
 
 Very exceptionally, the thyroid gland consists of a right and 
 left portion unconnected by the normal istlimian bridge. 
 
GOITRE. 825 
 
 The arteries which supply the gland are the superior and 
 inferior thyroid arteries; and, in about ten per cent of cases, there 
 exists a vessel, entering from below, named the middle thyroid 
 artery, and which springs from the arteria innominata; this 
 vessel is named the artery of Xeubauer. The superior thyroid 
 arteries are given off near the commencement of the external 
 carotid arteries; and, at their beginning, lie superficial in a 
 triangle formed by the sterno-cleido-mastoid, digastric and omo- 
 hyoid muscles; the inferior thyroid arteries, at their origin from 
 the subclavian arteries, lie deep ; and each passes behind the 
 correspoi],ding primitive carotid and the sympathetic nerve; and 
 a ganglion of the nerve is named thyroid from its position on the 
 inferior thyroid artery. The thyroid arteries are normally of 
 C|uateruary magnitude; but in goitre they may acquire the diame- 
 ter of a finger, as was seen by Burns. 
 
 Goitre. — The thyroid gland, or body, as it is often denomi- 
 nated, may be the site of wounds and inflammatory action; it is, 
 however, remarkable as the seat of a growth named bronchocele; 
 more commonly called goitre. In Derbyshire, in England, the 
 affection is so frequent that it is known there as Derbyshire neck. 
 The Germans wrongly name this affection struma. The name 
 goitre has been borrowed from the French, and was originally 
 derived from the Latin word guttur, signifying throat. 
 
 Goitre is an affection of the thyroid gland in which there is 
 an enlargement of its structure; and the latter maybe solid or 
 liquid. Or, as Celsus puts it, "there is a tumor, which the Greeks 
 name bronchocele, that grows between the skin and the trachea, 
 and which sometimes is composed of torpid flesh ; and again, it 
 may include some liquid similar to water or honey; and some- 
 times it contains hair mingled w'ith bones." 
 
 This growth may comprise in its development the entire gland; 
 or the tumor may be confined to one lobe, as the isthmus, or the 
 pyramidal portion, or to two or more of these parts. It may 
 vary in volume from a small nodule that is almost undiscovera- 
 ble, to one so large that it may occupy all the space from the 
 chin to the sternum; and if Fischer and Mittermayer are to be 
 credited, such tumor has become pendulous and reached beyond 
 the umbilicus. The writer does not insist on the reader believing 
 this; yet he would record that he has seen a case in which a 
 goitrous tumor depended to the middle point of the sternum. 
 When the tumor is symmetrically developed, there is a median 
 depression between the lateral lobes. In deglutition, the goitrous 
 63 
 
S2G THYROID GLAND AND ITS AFFECTIONS. 
 
 gi'owtli makes excursions upwards and downwards; and when 
 the tumor is not large, in the act of swallowing, there will be 
 observed a well-marked fossa in the middle line of the neck. 
 This hollow will be less in proportion to the development of the 
 isthmus. When the goitre is developed laterally, it carries the 
 carotid artery forwards and laterally; indeed, in such a case, the 
 artery will be found lying under the skin, a long distance from 
 the median l;ne. This lateral displacement of the vessels is an 
 anatomical fact of the utmost importance in the surgical treat- 
 ment of goitre; and it must not be forgotten in the operation of 
 thjTotomy. 
 
 In this lateral shifting of vascular location the internal jugular 
 vein also shares. In one case, however, seen by the writer, the 
 carotid artery was not displaced, but the internal jugular vein 
 was uplifted and lay flattened as a blue ribbon over the goitrous 
 tumor, which had developed from the left lobe of the gland and 
 grown only towards the left, carrying the vein with it; a perilous 
 anomaly. 
 
 In the development of the goitre, its anatomical structure will 
 be determined by the element which j)redominates in the growth : 
 thus according as the fibrous, vascular, or glandular tissue is pre- 
 dominantly developed, so the goitre is distinguished as fibrous^ 
 vascular, cystic, or follicular goitre. Ecker, who has made a 
 study of goitre, published, in 1S45, the following classification: 
 vascular, cystic and glandular. 
 
 The vascular species arises from congestive hyperfemia of the 
 gland, often due in the female to parturient elfort: also such con- 
 gestion may be due to the changes which attend puberty; and 
 such afflux may arise from menstruation and pregnancy. From 
 this congestion, the capillaries and smaller arteries dilate and 
 become varicosed, and ultimately rupturing, Ijlood is effused into 
 the parenchyma of the gland. This extravasated blood becomes 
 the starting-point of the cyst; and in the formation of the cyst 
 the colored cells perish and become absorbed, or are converted 
 into other forms of organic matter, which may be crystalline or 
 amorphous. Or if the blood be considerable in quantity, then its 
 fibrinous content may be deposited on the containing wall, and 
 thus a cyst is formed. 
 
 The vessels sometimes undergo calcification, and this change 
 favors rupture of the walls; and some even claim that such 
 calcification precedes and occasions h^^persemia. The calcified 
 material may form calcareous concretions. The chalky matter 
 
GOITRE. 827 
 
 may be precipitated in stratified form; and also other exuded 
 matter may be arranged in layers. The calcareous material 
 for such calcification is thought to be derived from the lime- 
 containing water used by the subject. In the third species, named 
 glandular, since all the constituents of the gland concur in its 
 formation, the tumor is found filled with gelatinous, or albumin- 
 like material. If such goitrous structure be incised, it presents 
 a yellow stroma in which bluish, diaphanous masses are seen; 
 and these pellucid masses may have any A^olume from that of a 
 pin's head to that of a child's head. The content resembles boiled 
 sago. When such content is in large amount, it crowds on and 
 renders denser the surrounding glandular structure; and this 
 compression may be such as to quite obliterate all traces of the 
 true structure. Ecker's explanation of the origin of tliis colloid 
 or gelatinous tumor is, that the efferent lymphatic vessels fail to 
 remove the matter formed in the glandular vessels; and he com- 
 pares it to a cyst from retention. The vessels remaining after 
 such a tumor has formed, lacking their normal support, burst 
 and add blood to the colloid content. 
 
 Rokitansky, the veteran pathologist of A^ienna, whose study of 
 disease as revealed in the dead-house has been surpassed by no 
 individual, claims that the different kinds of goitre are derived 
 from, and referable to, one common genus, viz., the vascular. 
 From this common class, according to the course followed in the 
 evolution of the tumor, it may be named exogenous or endoge- 
 nous. In the exogenous class are comprised those forms in which 
 the development is excentric, or from within outwards. In the 
 endogenous type, the cells or compartments grow through the 
 development of smaller growths within the primary one. If a 
 tumor of this type be opened, the secondary growths can be seen 
 adhering to the parent wall. In this form vessels can be seen 
 passing from the primary wall to the secondary endogen. And 
 when such a growth has reached full maturity, it becomes sterile; 
 and then neither nucleated nor glandular elements can be found 
 within it. This stage is the terminal one of the goitre; and such 
 a growth corresponds in character to cysts in other regions of the 
 body. 
 
 Returning from this morphological history of goitre, and utiliz- 
 ing the facts here learned, a practical and compendious division 
 of the subject is into two classes: solid and liquid or semi-liquid. 
 
 In the solid species the constituents are both multiplied and 
 enlarged. Such a tumor has the solid feel of muscular tissue; it 
 
82S THYROID ULAND AND ITS AFFECTION'S. 
 
 is slightly elastic, yet on percussion, it yields no impulse of fluc- 
 tuation. It is painless; and even when strongly compressed there 
 is awakened only a dull pain, or nnj)leasant feeling. When the 
 tumor is displaced, its connection with the air-passages is shown 
 in this, that the air canal obeys the movements of the goitre. 
 The overlying skin is of natural hue, and has but little or no 
 attachment to the goitre. If the solid goitrous growth be split 
 open, an appearance akin to that of the normal glandular struc- 
 ture will be presented to the eye; and such section on ]>ressure 
 will yield glandular elements, viz., vesicles and a syrup-like fluid 
 Sometimes in such tumors, alteration of tissue will be found 
 which denotes the transition to the cystic formation. 
 
 In the second general form, the constituent elements on 
 examination are found multiplied and enlarged. Vesicles diff'er- 
 ing in volume will be discovered; and these contain a content 
 Avhich is liquid, or gelatinous in character. Sucii a goitre pre- 
 sents analogy to the multilocular cyst of the ovary. If the 
 examination be made at a later period of development, larger 
 cavities containing cystic material will be found, which have 
 arisen from the confluent fusion of a number of smaller cavities. 
 And by a continuation of growth, degeneration and fusion, tiie 
 multilocular subcysts are transformed into one large cystic cavit}-. 
 Or instead of one, the tumor may contain two or more separate 
 cystic compartments. 
 
 The content of the goitrous cyst presents several varieties. In 
 a few ca.ses seen by the writer, it was a transparent fluid of 
 remarkable clearness; more often, however, such content is turbid, 
 and on the walls of the cavity there will be found a detritus, 
 which is the remnant of clotted blood. And when shaken up, 
 the liquid content is similar to the lees of wine. Again, the con- 
 tent may resemble semi-liquid gelatine, discolored with pigmen- 
 tary' matter, and this may be of different degrees of fluidity. 
 Sometimes a steatomatous or adii)Ose material is found in the 
 cyst. During the development of the cyst, the blood-vessels in 
 the distending walls may be ruptured; and thus blood is added 
 to the cystic content; or one of the compartments may be quite 
 filled with blood, of which the coagulum remains and becomes 
 a permanent constituent. 
 
 Besides the content mentioned, sometimes there are found 
 osseous or calcareous concretions, either alone or along with 
 liquid content. 
 
 A form of goitre not very unusual is that in which the exces- 
 
GOITRE. 829 
 
 sive development concerns the vessels; the arteries enlarge enor- 
 mously, so that they constitute the chief component of the tumor; 
 and in such a case, the tumor consists of a mass of aneurysmal 
 varices. If this tumor be grasped in the hand, there will be felt 
 in it a pulsating thrill, a movement and expansion synchro- 
 nous with the pulse. The aneurysmal goitre, though it attains 
 less dimensions than the cystic form, yet the former through its 
 vibratile motion and buzzing sound, becomes a source of great 
 annoyance to the patient. 
 
 Maunoir, of Geneva, claims that frequently the so-called goi- 
 trous cyst is not of thyroid origin; and he names them hydrocele 
 of the neck. Tillaux concedes that this ma}' be so, exceptionally, 
 viz., that it may arise in the bursse of the prse-laryngeal muscles; 
 also a lymphatic gland of similar site may simulate goitre; yet 
 Tillaux has found in his dissections that in doubtful cases there 
 could be traced a connection between the thyroid gland and the 
 tumor; and such connection was often in the form of a narrow,, 
 elongated pedicle. And he formulates as an anatomical axiom, 
 that in those cases in which a tumor located in the sub-hyoid 
 region ascends and descends during the movements of degluti- 
 tion, it almost always originates in the thyroid gland. 
 
 Trained digital palpation can often recognize the nature of 
 the goitrous content; yet, to arrive at absolute certaint}^ the hypo- 
 dermic syringe should be used, and some of the content with- 
 drawn. The determination of the nature of the goitrous content,, 
 if interesting in surgical pathology, is yet more so to the practical 
 surgeon, since it indicates the course to be pursued in the treat- 
 ment of the disease. 
 
 The goitrous tumor when small, and seated high in the neck, 
 gives the patient but little inconvenience; yet when it becomes 
 voluminous, and even when diminutive, if seated near the ster- 
 num, it gives trouble through compression. 
 
 Bilz, in 1850, studied the changes of form and position of the 
 trachea which such pressure can produce, and found that the 
 trachea might be misplaced laterally; also the tracheal canal 
 may be flattened, or converted into a triangular, prismoidal form. 
 
 Compression acts most deleteriously when the tumor grows 
 inwards rather than outwards; or when it is deep-seated and rests 
 closely on the important structures which traverse the neck. 
 Such pressure can narrow the tracheal and sesophageal canals, 
 and can disturb the function of the recurrent, sympathetic, pneu- 
 mogastric and phrenic nerves. 
 
830 THYROID GLAND AND ITS AFFECTIONS. 
 
 Bonnet, wlio has studied the functional disturbance resulting 
 from the mechanical action of such tujuors on contiguous struc- 
 tures, finds that a small goitrous growth seated at the junction of 
 tlie neck and thorax, can cause dyspnoea, numbness in the arms, 
 and aphonia or impaired voice. And such compression is aug- 
 mented when the tumor glides behind the clavicle, or the sternum. 
 "When the trachea is thus narrowed, the entering air expands 
 the trachea above the constriction; and the air returning from the 
 lungs, being obstructed in its exit, causes abnormal expansion of 
 the air-passages below the constriction; and then, as Bilz has 
 found, an emphysematous condition of the lungs is induced. In 
 some cases, the sterno-cleido-mastoid muscle, when uplifted or 
 stretched by the goitre, may be the chief factor in the pressure; 
 so much so that Bonnet, to get relief, severed the muscle. 
 
 Rose, in the Archivfur Klinische Chirurgie, in 1878, published 
 his observations of the mechanical effects of goitre on the trachea. 
 He finds that alteration occurs about the first tracheal ring. 
 Patients unconsciously correct this curve or inflection; but when 
 the subject is ana3sthetized, the inflection returns, and respiration 
 may thus be seriously interrupted. Rose found cases in which 
 the trachea was maintained patent through the goitre surround- 
 ing it on all sides; in such cases, the removal of the tumor should 
 be preceded by tracheotomy. 
 
 Kaufmann, in 1883, describes a form of goitre, which from its 
 situation he names the retro-pharyngeal and retro-oesophageal 
 goitre, and which interferes with voice, breathing, and swallowing. 
 The goitre may be unilateral or bilateral ; and in the former case, 
 it can only be moved towards one side. The remedy in such a 
 case is extirpation. 
 
 In 1887, Heise reported three cases of goitrous tumor within 
 the air-passages; the growth was attached to the posterior wall of 
 the larynx and trachea, and was not connected with the thyroid 
 gland. The subjects were young, and the tumor caused dyspnoea. 
 The growths were removed by laryngo-tracheotomy. Streckeisen 
 saw such a growth seated higher, within the arch of the hyoid 
 bone. 
 
 Having concluded the description of the anatomical char- 
 acteristics and the symptomatic phenomena of goitre, a consider- 
 ation of its causation is next in order : this subject has occupied 
 the pens of many theorists and also many practical observers. 
 It is a polenical field beset with diverse and antagonistic opin- 
 ions, in which the only points settled beyond contest are that 
 
GOITRE. 831 
 
 goitre has its favorite topographical habitats, and in most cases 
 occurs in the female; and further that it is in some way asso- 
 ciated with the generative function. 
 
 In the south of Europe there is a popular belief that the sex- 
 ual act enlarges the previous virginal neck ; and allusion to this 
 is in the line of Catullus; non hesterno poterit collum circumdare 
 filo. And Malgaigne mentions that the watchful matron tests the 
 moral character of girls between fifteen and twenty years of age 
 by placing the two ends of a measuring cord between the incisor 
 teeth, and then passing the loop over the head; such a close-fitting 
 loop can contain the neck of the intact; but it will not include 
 the neck of the other class. In these admeasurements the male's 
 neck seems to have been forgotten. 
 
 The straining efforts of the female in parturient labor act espe- 
 cially on the thyroid gland, which becomes for the occasion a 
 reservoir in which the blood takes temporary refuge; and there 
 finally results a permanent enlargement of the part; the writer 
 has known several cases of goitre which arose in this way. As a 
 rule, goitre of puerperal origin is bilateral, and does not attain 
 large dimensions. Suppression of the menses is sometimes coin- 
 cident with development of the thyroid gland. 
 
 Heredity is a disposing agency. And the disease has devel- 
 oped in the foetus; and to such dimensions that it caused suffo- 
 cation of the new-born. 
 
 The disease often appears in the subject of fair complexion 
 and lymphatic temperament. The scrofulous subject is likewise 
 disposed to goitre. And this is so usual, that it has influenced 
 the nomenclature of goitre: since goitre is universally designated 
 struma by the German writer. That this name is appropriate, 
 the writer will not concede; though it may be somewhat justified, 
 when a writer of such eminence as Bazin says that, in nearly all 
 cases of goitre, he has found other symptoms of the scrofulous 
 constitution. Hypertrophy of the thj^roid body seems to be 
 cognate to scrofula, in the same manner as the hypertrophy of 
 the thymus gland is related to syphilis. 
 
 Occupation in which there is laborious and continued mus- 
 cular effort, favors thyroid hypertrophy. 
 
 Besides the agencies enumerated which figure in the causa- 
 tion of goitre, there are others of a more obscure nature, which 
 have claimants among surgical and medical writers. 
 
 The fact that the disease is endemic, in fact, pandemic in 
 some geographical regions, has led to a search in those places, for 
 
832 THYROID GLAXD AND ITS AFFECTION.S. 
 
 the disposing- cause. Tlie countries iu whicli goitre prevails are 
 Derbysliire, in England, the warm countries of the Tyrol, the 
 Alps, and especially the Alpine region of Isere, Savoy and Pied- 
 mont, in southeastern France. In the vicinity of Uriage, in the 
 southeast of France, visited by the writer, there is a village in 
 which goitre and cretinism in amiciible sovereignty have aljsolute 
 control; a region in which nature, having placed her sublimest 
 pictures, afterwards, in mocking ironv, formed humanity dwarfed, 
 deformed and imbecile. 
 
 The cause of this endemic goitre has been sought for in the 
 air, water, and food on which the inhabitants subsist. The use 
 of water from the melted snow has been assigned as a cause; 
 also, the presence of dissolved magnesian limestone in the 
 w'ater has been urged as the cause; and much proof in favor of 
 this agency has been brought forward. Bromine, lithium and, 
 recently, fluorine have been given place as causal agencies. A 
 dog fed by Maumon^ on fluoride of sodium for four months, devel- 
 oped a general tumefaction of the neck. The intemperate use of 
 ice-water has been offered as one of the causes of goitre. 
 
 Chatin, in 1852, announced a new theory in regard to the 
 origin of the disease; he referred the origin of goitre to the 
 absence of iodine in the air, water and food used by the subject. 
 To confirm this hypothesis he made a long journey in the Jura 
 Alps, Lombardy and other regions in which the affection was 
 prevalent, and examined the air, water and food chemically. 
 Though he found in Lombardy facts which were in discord with 
 his doctrine, yet these seemed insufficient to alter his opinion 
 that, where goitre prevails, it is due to the ab.sence of iodine; 
 and his inference is that in non-goitrous countries, the inhab- 
 itants continually use enough iodine to counteract the develop- 
 ment of the disease. Chatin's doctrine is accepted by Moleschott, 
 in his noted work entitled the "Circulation of Life." The author 
 has observed facts at variance with Chatin's theory; on the 
 Isthmus of Panama, on the western coast of Nicaragua and 
 Mexico, he has observed cases of goitre in persons who had 
 always breathed the air from the ocean, impregnated with iodine. 
 A similar observation has been made among the inhabitants of 
 California, among whom the writer has seen several cases of the 
 disease, in both males and females. Hence the theory of Chatin 
 is untenable; or if it contains a grain of truth, the most that can 
 be granted to it is to hold a conjectural place among the causal 
 agencies of goitre. 
 
GOITRE. 
 
 In a search for the causation of goitre, some claim that there 
 exists a mutual relation between the parotid and thyroid gland; 
 viz., that where the parotis remains in a state of inertia from 
 non-use, as in the case of shejDherds who chew but little, and 
 consequently there is but slight excretion of saliva, the thyroid 
 gland enlarges; but on the contrary, those who live on vegetable 
 food, and hence masticate freely, are exempt from goitre. 
 Hence, for prophylaxis and cure, Grynfelt advises the use of food 
 that demands active use of the muscles of mastication. The 
 author has had under his observation two cases which militate 
 against this theor}^ viz., two persons who in infancy through 
 cicatricial contraction of the structures of the side of the face lost 
 the power of using the lower jaw; in these cases there was no 
 thyroid enlargement observable. 
 
 In 1860 Collin reported an epidemic of goitre which occurred 
 in a body of French troops stationed at Brian^on, and in another 
 body stationed at Clermont. At Briancon, the disease appeared 
 suddenly in a number of men. Collin, who had the surgical care 
 of these soldiers, referred the origin of the disease to the slight 
 elevation of the place above the level of the ocean, in consequence 
 of which the air was rarefied, and produced difficulty of breath- 
 ing; thus, he claimed that congestion of the gland arose, and 
 that this was promoted by the soldiers' uniform, which caused 
 constriction of the neck and chest. The exercise of carrying 
 burdens up the hill, also, contributed to such congestion. 
 
 In the regions of the Alps where the disease is pandemic, that 
 the disease depends on some local cause or causes is indisputable 
 from the fact that, besides man, numerous domestic animals 
 become also the subjects of the disease. Thus, Baellarger saw 
 goitre in the horse, the dog, the cow, the sheep, the goat, the hog, 
 and especially in the mule. And in such regions persons unaf- 
 fected wdth the disease, coming and sojourning, may become the 
 subjects of goitre; and also in those in whom the disease has com- 
 menced to appear, should they leave the locality, the disease 
 recedes. 
 
 In those regions in which goitre prevails, especially in certain 
 mountainous districts of Switzerland, there also prevails a con- 
 stitutional disease denominated cretinism; and in many cases 
 goitre and cretinism occur in the same individual. 
 
 Cretinism is a disease in which there is a general arrest of 
 development of the subject. There is cranial deformity in which 
 the frontal and parietal eminences are unusually prominent, 
 
834 THYROID GLAND AND ITS AFFECTIONS. 
 
 and ossification is retarded, or imperfect. The teetli are irregular 
 in formation and position, and second dentition is wanting, or 
 imperfect. Tlie muscles, tendons and aponeurotic fasciie are ill 
 formed; and as result, the subject is liable to hernia. The 
 functions of digestion and assimilation are imperfectly performed, 
 and there may be pyrosis, ill appetite or inordinate voracity. 
 The pulse is often small, and too frequent. The patient is 
 emaciated, the skin loose and flabby, and the tissues are cedem- 
 atous. The generative faculty is feeble, perverted, or lost. 
 Melancholy, hysteria, mania and dementia are present. The 
 intellect is clouded, narrowed or nullified to complete idiocy, so 
 that the mentality of the cretin is reduced to a few fragmentary 
 traces which might be designated instinctive rather than 
 rational. And this dwarfed human parody may have as an 
 additional touch of degeneration, a goitrous neck; and so often 
 is this true, that there must be an intimate consanguinity between 
 the causal agencies of cretinism and goitre. 
 
 Perhaps the goitrous enlargement,encroaching on the adjacent 
 vessels and nerves,may arrest the growth of the brain and disturb 
 the functions of the heart and lungs; and in the child such 
 deranging influence would promote general corporeal degenera- 
 tion, viz., cretinism, or something akin to it. 
 
 Treatment. — This may be placed under three heads: prophy- 
 lactic and restraining, medical and surgical treatment. 
 
 A })reeaution of great prophylactic value, when practicable, 
 is the removal of the patient from the region in which he is 
 exposed to the external influences which promote the goitrous 
 growth. Kneading and rubbing the tumor should be practiced 
 so as to awaken a counter-action to the morbid processes occurring 
 in the gland; thus, a healthy cell-metabolism and return to 
 normal structure will be promoted; and though the goitrous tissue 
 may not be made to disappear, or even recede, yet further prog- 
 ress in the direction of glandular degeneration may thus be 
 arrested. 
 
 As a means of restraining growth, a cravat or bandage about 
 the neck has been used. Such a compressive bandage might be 
 made of elastic material. There is a serious objection to this 
 repressive treatment, since, thereby ,the growth is crowded against 
 the cervical vessels, and thus congestion of the head is maintained; 
 and a further fault is that a growth which is compressed back- 
 wards is caused to grow in that direction, and to deform the 
 tracheal canal, and also to insinuate itself between the windpipe 
 
GOITEE. 835 
 
 and the oesophagus; or else to include and to encircle these 
 passages. 
 
 Medical Treatment. — In 1S20 Coindet announced the successful 
 treatment of goitre by means of iodine. Other medicinal agents 
 have since been advised; 3'et none have yielded the satisfactory 
 results which have been obtained from iodine. This agent may 
 be used externally, parenchymatously, or it may be given by 
 the mouth, 
 
 "When externally employed, iodine may be in the form of the 
 simple tincture of iodine, or the compound tincture; or the simple 
 or compound ointment of iodine may be used. The solution of 
 iodine in glycerine or collodion has been employed. The simple 
 or compound tincture of iodine is applied by means of a brush; 
 a number of coats are to be applied daily. "When the scarf-skin is 
 loosened, this must be removed, and the painting renewed on the 
 freshened surface. This treatment to be effective, must be con- 
 tinued for a long period: many months, at least. And as the 
 favorable result is so slowly obtained that it is nearly impercep- 
 tible, the patient and surgeon, in most cases, finally lose hope of 
 reaching a cure in this way; and the former is hastened to such 
 a conclusion by the pain with which he is harassed by the irri- 
 tating action of the iodine. Instead of using the tincture of 
 iodine, the writer prefers a solution in collodion : thus the action 
 is hastened, and the compressive action of the collodion is added 
 to the specific action of the iodine. For this purpose let the 
 following compound be used: — 
 
 ^. Collodii .?ij 
 
 lodi puri gr. xij 
 
 Potassii . lodidi ^ss 
 
 Misce. 
 
 Let a number of coats be painted on and around the goitrous 
 enlargement. The collodion forms a constricting capsule about 
 the tumor; and the included derm is irritated or vesiccated, so 
 that the iodine penetrates the tissues. After this crust, including 
 the epiderm, has become loosened, it should be detached and a 
 new coat applied. To render this application less painful, the 
 fresh surface can be cocainized. 
 
 Iodine in combination with mercury, has been used in the 
 form of an ointment, which is made as follows: — 
 
 IjL. Hydrarg. Biniodidi ji 
 
 Adipis grs. xxx 
 
 Misce. 
 
83G THYROID GLAND AND ITS AFFECTIONS. 
 
 A portion of this is to be rubbed daily on the tumor, for some 
 minutes, and then the part must be exposed to the rays of the 
 sun. This treatment was introduced by a layman in the East 
 Indies, and afterwards, adopted and used in some thousands of 
 cases of goitre, with beneficial effect. 
 
 By a long use of the iodine externally applied in one of the 
 ways mentioned, the goitrous affection may be checked in its 
 growth, and, perhaps, made to recede; yet the employment of 
 the remedy hypoderraically is less circumstantial, and is more 
 prompt and more effective in action. The hypodermic use of 
 iodine in the treatment of goitre was announced in 1853 by 
 Woerner, whose observations were made on cases treated in the 
 surgical clinic of Tubingen. Tiiese cases were of the cystic form, 
 and the work was done as follows: by means of a trocar the 
 liquid content was evacuated, and then, into the emptied sack 
 there was injected from one to two drachms of pure tincture of 
 iodine, which was permitted to remain. About one-half of the 
 cases were cured, while the others remained uncured. After the 
 injection, a burning feeling was experienced in the sack; the lat- 
 ter soon refilled, but in a month or two. the tumor began to lessen, 
 and continued to do so until a cure was effected. In 18G7, Luton 
 published a pa{)er on the same subject, in which he claimed to 
 have taken the initiative. He injected the tincture : and accord- 
 ing to the volume of the tumor, and the number of its lobes, 
 more or less was employed; and the amount thus used varied 
 from one scruple to four scruples. The injection was followed 
 by a burning pain, and if a lateral lobe was the part attacked, 
 then the pain extended upwards towards the side of the head^ 
 and downwards to the shoulder. The injected part swelled, and 
 it remained swollen and painful for some days. The patient 
 perceives the taste of iodine in his mouth, and the agent can be 
 detected in the urine. iVfter this the tumor begins to diminish, 
 yet the curative results are not fully realized until after the lapse 
 of some months. Hence, Luton says, the injections need not be 
 often repeated. After each injection, one should wait until its 
 action has become exhausted. Tlie induration arising results 
 from the coagulation of the albumen from contact with the 
 iodine. 
 
 This interstitial treatment gave the best results in the soft 
 and diffused species. The polycystic species is also thus curable ; 
 and Luton and Monod found that it was not necessary to first 
 empty the sack; the cystic content serves as an excellent medium 
 
GOITRE. 837 
 
 by which the iodine is brought in contact witli the walls of the 
 goitre. Large goitres can thus be treated with a fair probability 
 that the volume will be diminished, though the tumor will not 
 wholly vanish. In the multilocular species, the injection into 
 one section has caused general lessening; yet in such it is better 
 to attack several lobes. This interstitial treatment is not suited 
 to the aneurysmal species of goitre. 
 
 Luton reports forty-eight cases of goitre thus treated; of these 
 thirty-two were completely cured; twelve were made better, and 
 in the remainder, no benefit was derived from the treatment. 
 Subsequent work done by this plan of treatment has further 
 demonstrated its utility. Where ill results followed the use of 
 iodine thus employed, they were not more severe than those 
 which occur after the use of the agent, when given by the mouth. 
 The instrument used for this work was the syringe of Pravaz, or 
 that employed for the ordinary subcutaneous injection. 
 
 In 1872,Schwalbe reported in Virchow's Archives one thousand 
 cases of goitre treated by the interstitial injection of remedies. 
 He uses the hypodermic syringe as a diagnostic aid to determine 
 whether the tumor be cystic, vascular, glandular or fibrous; from 
 the cystic, liquid content escapes; from the glandular and fibrous, 
 nothing escapes; while blood escapes from the vascular. He used 
 a syringe somewhat larger than that of Pravaz; and a point that 
 is conical is better than one which is ground down on one side, 
 since the latter can bend or break. 
 
 The treatment is not free from danger; in one case, after an 
 injection, the patient complained of prickling in the arm and leg; 
 convulsions soon followed, ending in death. In many cases pain 
 radiated along the course of the adjacent nerves. 
 
 Schwalbe, for a time, used the tincture of iodine; later, believ- 
 ing that alcohol was the chief agent in the work, he used this 
 alone, and obtained satisfactory result. The quantity used was 
 from ten drops to a drachm. The injections were repeated at 
 intervals of from three to eight days. Along with these injec- 
 tions, fifteen grains of iodide of potassium were taken, daily, by the 
 mouth. To be sure that a blood-vessel was not penetrated, 
 Schwalbe, after inserting the point, let it remain a short time, in 
 order to determine whether blood would escape. 
 
 Instead of the tincture of iodine. Fowler's solution of arsenic 
 has been used. In 1882, Griinmach reported the treatment of 
 nearly one hundred cases, by the subcutaneous injection of the 
 tincture of iodine. He diluted the remedy with an equal amount 
 
838 THYIIUII) GLAND AND ITS AFFtCTlOXS. 
 
 of water, and of this he injected a half Pravaz syriugeful, two 
 or three times a week. 
 
 A third mode of treatment is the administration of remedies 
 by tiie mouth; thus iodine, arsenic and tlie nmriate of lime may 
 be given. Yet such indirect route of reaching the tumor should 
 not wholly be trusted to ; it sliould be combined witli tlie ender- 
 mic or inierstitial use of one of the anti-goitrous remedies; thus an 
 attack being made from within and without, the treatment 
 becomes more effective. 
 
 Electrolysis as an anti-goitrous treatiuent has its advocates; 
 the writer has observed cases in which the use of the constant 
 current not only retarded the growth but caused diminution of 
 the existing volume; and since this method commends itself by 
 its painlessness and simplicity, it may be tried. Both the con- 
 stant and interrupted currents may be employed; yet the gal- 
 vanic or constant current has, from experience, received greater 
 sanction. 
 
 Should the means of treatment which have been enumerated 
 prove unsuccessful, then a resort may be had to some operative 
 procedures; that is, one may adopt as a guide the Hippocratic 
 axiom. Quod medicina non sanat, ferrum sanat: What medicine 
 cures not, the blade cures. 
 
 The treatment advised by C'elsus is first to attempt to destroy 
 the goitrous tunic by escharoties ; and when the tumor is thus 
 opened, the content will flow out if it be thin; but if it be thick, 
 it should be pulled out with the fingers; and then the ulcer which 
 remains is to be healed by proper dressings. But Celsus says a 
 cure with the scalpel is speedier; and for this, the tumor is to be 
 incised in the median line, and the tunic exposed; then with the 
 finger the cyst is to be separated from the .sound structures, and 
 removed, with its contents. The wound is now to be cleaned with 
 vinegar to which salt or nitre has been added; and its lips are 
 next to be closed by means of sutures, and dressed in the manner 
 pursued in other wounds. 
 
 This description of the Celsian treatment shows that the 
 Koman surgeon managed the goitre intelligently and dextrously; 
 and one finds in it the elements of the operative treatment of the 
 present time. 
 
 Goitre has been treated operatively by the following proced- 
 ures: the seton, simple incision, inci-sion and suture maintaining 
 the wound open, strangulation by circumscribing ligature, ligation 
 of vessels, and enucleation. 
 
GOITRE. 839 
 
 The treatment by seton originated with Reid and 0. Beirne, 
 and should be limited to the cystic species; it has been recom- 
 mended by Nagel and Hamburger. The plan of Hamburger was 
 to so introduce a tube that it would afford drainage at the most 
 dependent portion of the tumor; the lower opening was made 
 larger than the tube. The seton caused much reaction. Adel- 
 mann advises the seton in the goitrous cyst of thin walls. The 
 author treated a case by the use of the seton in 1869; this 
 was a large cystic goitre, and the treatment reached through a 
 period of many months. Though a cure was thus obtained, the 
 writer would not adopt this plan again. 
 
 The method of treatment by incision is suited only for the 
 cystic species, and in this way Adelmann cured some cases. In 
 1867 Patruban treated by incising the goitrous cyst freely; and 
 then having uplifted the bottom, this was transfixed with 
 threads, and these were then fastened to the neck outside, so that 
 the cavity was nearly obliterated. Xo serious reaction followed, 
 and a cure in six weeks was obtained. After making a free 
 incision, and the content having been evacuated, the inner wall 
 of the cyst may be brushed with a strong solution of iodine; and 
 then the cavity may be filled with iodoform gauze, and redressed 
 as required. 
 
 The method by strangulating ligature is adapted to the solid 
 species of goitre. It was used by E. S. Cooper, of San Francisco, 
 in a case observed by the writer. As the operation was done in 
 the suppurative age of surgery, the unsatisfactorv result which 
 followed the work, was not a fair test of this plan of treatment. 
 It is probable that subcutaneous circumscription of the vascular 
 or glandular form of goitre, done aseptically, would effect a cure. 
 
 Goitre has been treated by ligation of the nutrient arteries; 
 this has been chiefly done in the vascular species. In 1829 Langen- 
 beck tied the superior thyroid artery on the right side; and in 
 another case he tied the common carotid artery. Soon afterwards 
 Chelius performed ligation of the superior thyroid arteries in 
 four cases, with success. And in 1852, Porta tied the superior 
 and inferior thyroid arteries for the cure of goitre. Tins plan of 
 treatment has been pursued by but few surgeons. When it is 
 done, it would serve a better purpose were it the preliminary act 
 in the work of enucleation. 
 
 A more satisfactory treatment is to remove the growth at. once 
 by the plan known as enucleation. AVolfier, in his monograph 
 on the surgical treatment of goitre, says that in 1771, A^ogel 
 
840 TIIVKUID GLAND AND ITS AFFECTIONS. 
 
 partially excised the goitrous tumor after having tied the vessels. 
 In 1791 Desault removed one-hall" of the diseased thyroid gland. 
 The gland was first systematically removed \>y Iledenus, in 1800; 
 he separated the muscles from the gland, and tied all the vessels. 
 In 1817 Von Walter tied the superior thyroid arteries with the 
 intention of inducing atro])hy of the gland. Galen noticed that 
 the recurrent nerve might be im})aired in the removal of the 
 gland. Zang, in modern times, observed that loss of the voice 
 might result from removal of the thyroid gland. Jobert, in 
 1843, advised electro-puncture; and later, extirpation was done 
 by the galvano-caustic process. 
 
 Ill 1842, Sedillot published an account of the extirpation of a 
 large goitre; his incision was made along the border of the 
 sterno-cleido-mastoid muscle; twenty vessels were tied, some of 
 which were as large as the little finger. 
 
 Dieffenbach, for the cure of goitrous tumor, advises to extir- 
 pate the glandular siiecies; to treat the vascular by ligation, and 
 the cystic form by the seton. 
 
 Woerner, who wrote in 1853, would treat the cystic form by 
 incision, butthe solid species by extirpation. Extirpation, which 
 he pronounces a perilous operation, is to be done by a long incis- 
 ion, in which the tumor is laid bare and dissected out with the 
 fingers, the handle of the scalpel, closed scissors and forceps. 
 When large vessels are brought into view, then a pair of curved 
 scissors should be carried under them, and along this an aneu- 
 rismal needle, carrying two threads, so that the vessel can be tied 
 at two points, and then divided between the ligatures. Large 
 veins which swell up during the dissection, should be tied, and then 
 severed. Thus, step by step, the operation is so done that the 
 surgeon works almost in non-bleeding tissue. If large processes 
 pa.ss underneath the sternum, Woerner divides them with the 
 ecraseur. One of the risks attending this extirpation was sec- 
 ondary bleeding; and from this some patients were lost. 
 
 In 1872, Warren Greene, an American surgeon, reported cases 
 of extirpation of goitre, done as follows: lay bare the tumor by a 
 straight incision, in which the capsule must not be opened. 
 When the tumor is thus well displayed, its capsule is to be opened 
 and the contents enucleated and removed with the fingers and 
 handle of the scalpel; and he advises to do this rapidly and 
 regardless of the hgemorrhage; the aim of the operator being to 
 reach the thyroid arteries as soon as possible, and to tie them. 
 When the inferior attachment or pedicle is reached, it is to be 
 
GOITRE. 841 
 
 transfixed with a blunt needle and each half securely tied, and sec- 
 tion then made above the ligature. 
 
 Kocher, in 1S74, wrote on the treatment of goitre; his method 
 was similar to that of Luecke; he treated the hyperplastic form 
 by injections of tincture of iodine. This injection, in the 
 cystic form with thick walls, will not cure; indeed, such injection 
 only thickens the walls. The cystic species is better suited for 
 treatment by incision. But in the gelatinous, vascular, hsemor- 
 rhagic and soft follicular species, as well as in the fibrous form, 
 the best treatment is enucleation of the tumor. The proper 
 method of doing this is to divide the skin over the growth, open 
 the fibrous capsule, and tie all the vessels which are met. Next 
 proceed with the enucleation, and when large vessels are found 
 in the peduncular part of the growth, they are to be ligated. 
 Where the growth is firmly attached to the trachea, the mass 
 must be included in a ligature, severed, and the remaining stump 
 cauterized with carbolic acid. The edges of the remaining cap- 
 sule are to be drawn outwards, and sutured to the skin. In cases 
 of gelatinous material, Kocher opens the growth and clears out 
 the content with his fingers, and temporarily fills the cavity with 
 sponge ; after the bleeding is thus arrested, he fills the cavity with 
 carbolized lint, wdiich is changed from time to time. 
 
 In 1879, Wolfler reported on the extirpation of goitre as pur- 
 sued in the surgical clinic of Billroth. Instead of a T or V- 
 incision, the tumor was laid bare by a vertical cut which was 
 median in position, or along the border of the sterno-cleido- 
 mastoid muscle. The capsule was opened on a grooved director, 
 and to control bleeding, the forceps of P^an was used. The 
 recurrent nerve must be carefully guarded, as there is danger of 
 injuring it. In eighteen months he operated fifteen times; and 
 only in one case was it necessary to perform tracheotomy. The 
 removal was done under the thymol spray. In four of the cases, 
 the recurrent nerve w^as partially palsied, yet, afterwards, its 
 function returned. Garre, of Basel, describes and commends the 
 method pursued by Socin in the removal of goitre ; he laid bare 
 the capsule of the growth, and then removed the component 
 nodules with his fingers (the plan of Celsus). The hsemorrhage 
 was not great, and was controlled by clasp forceps. 
 
 Between the years 1877 and 1896 the author has performed 
 
 enucleation in eighteen cases of goitre; many years prior to this, 
 
 in 1858, the, writer, when a junior member of the surgical corps of 
 
 the United States Navy, removed a goitre of moderate dimensions 
 
 54 
 
842 THYROID GLAND AND ITS AFFECTIONS. 
 
 from a woiiian iii Chinandega, a city of Nicaragua. Of tlie eigiit- 
 een, fifteen recovered, and three died. One death was from second- 
 ary bleeding; this patient, a mulatto, was neglected by the nurse 
 and allowed *to bleed nearly to death before the medical attend- 
 ant, who had been intrusted with the case, was notified. Another 
 died from collapse of the trachea after the tumor had been 
 removed and the wound closed. After the wound had been 
 closed, syncope ensued, which was thought due to the large 
 amount of blood that was lost during the operation. Artificial 
 respiration by Silvester's mode was resorted to; also inversion of 
 the body and bandaging the limbs to force the blood to the 
 brain ; and, as last resort, the wound was reopened, when the 
 trachea was found so collapsed that it was probable that in the 
 movements of artificial respiration, but little air had entered the 
 lungs. Though the trachea was opened, and a tube inserted and 
 air blown in, yet the patient did not rally. Death in this patient 
 was clearly due to the collapse of the trachea, of which the walls 
 had lost their powers of resistance through the continued pressure 
 of the tumor. In the third fatal case, there arose, soon after the 
 operation was completed, a tumultuous action of the heart, the 
 pulse beating over one hundred and forty times a minute. This 
 inordinate cardiac action continued until death, which occurred 
 on the fifth day after the operation. The heart, being exhausted 
 from over-action, ceased to beat. An explanation, which may be 
 offered of the disturbance of the heart in this case, is that, in the 
 enucleation, the cardiac branches of the sympathetic nerve were 
 wounded ; those nerves, which regulate or inhibit excessive action, 
 were deprived of their controlling influence. During the five 
 days which this patient lived, the wound healed rapidly; in fact, 
 there was almost comf)lete closure without suppuration. 
 
 The operation as done by the author consists in making an 
 incision by which the tumor is brought into view; and such 
 incision should be made vertically in the median line of the 
 derm covering the goitre. The first operation done by the writer 
 was performed prior to the era of "antiseptic surgery,'" and before 
 the introduction of the haemostatic forceps, which has given the 
 surgeon such perfect and speedy control of bleeding. This oper- 
 ation was performed on a woman in Chinandega, Nicaragua, in 
 1859; and as aids were a German and an American physician, 
 residents of that city. As it Was thought possible that the woman 
 might die during the operation, the priestly official with his 
 tapers and other appanage in use there in the death ceremonial, 
 
GOITRE. 843 
 
 stood near by to perform the last offices, should the knife render 
 them necessary. Tiie patio of the Spanish house, and the street 
 in' front, were crowded with curious spectators of tlie bloody 
 drama which was to be enacted : a scene in which the operator and 
 patient played parts as interesting to that motley company of 
 witnesses, as did the gladiators of old to the Roman corona, which 
 once filled the Coliseum. The operation was a very bloody one, 
 and midway in the work, the bleeding was so profuse that one 
 of the assistants was seized with panic, and begged that the work 
 should cease there. These remonstrances were not heeded; the 
 patient could not have run more .risk from concluding the work 
 than from leaving the half-enucleated tumor in her neck. By the 
 careful ligation of vessels, and dissection of the growth from the 
 parts to which it was attached, the work of removal was brought 
 to a fortunate issue. The patient soon recovered, and was amply 
 repaid for the risk of submitting to an operation which had 
 rarely been done : risks here augmented through submitting to a 
 knife which had been disciplined by but little experience. 
 
 In subsequent operations done by the writer, after the skin 
 was divided, the muscles which lie on the goitre were uplifted 
 
 Figure 93. Representino; the transfixor used by the writer in the enuclea- 
 tion of goitre. 
 
 and turned aside, and held ^o by large blunt retractors; thus the 
 capsule was divided, and if the growth were cystic or cystoid in 
 structure, it was enucleated, and the vessels which entered it 
 were doubly tied and divided between the ligatures. If the 
 tumor be of the vascular or glandular species, then the work is 
 much more difficult than if the development is cystic; a great 
 number of ligatures must be tied ; every artery and vein must be 
 carefully secured. And to accomplish this safely, the writer 
 practices a method that may be named interstitial transfixion. 
 For this purpose he uses an instrument which from its use may 
 be called a transfixor. This instrument, as seen from the drawing, 
 is an extremely curved forceps, of which the points are somewhat 
 blunt, yet are sharp enough to permit of the instrument being 
 
844 THYROID (JLANK AND ITS AFFECTIONS. 
 
 thrust through the structure underneath vessels. "When the 
 traiisiixor is thrust through a section of the tumor, the points 
 are opened, and two ligatures are caught and drawn through. 
 The material used for ligature was silken thread which hud been 
 carbolizedor saturated with alcohol. The two threads were tied, 
 leaving an interval between tliem, wdiich was divided with blunt 
 scissors. Thus proceeding, section by section containing vessels 
 may be tied and severed. In his recent operations the writer 
 has used catgut ligatures. 
 
 If large vessels be met, these should be isolated from the 
 neighboring tissues as much as .possible, and ligated. The writer 
 has not seen that large development of the arteries which some 
 surgeons report to have met in this operation. The veins, in 
 number and calibre, exceed the arteries; and these vessels are 
 also to be tied doubly, and severed between the ligatures. Thus 
 done, there will be lost but little blood, and the danger of intra- 
 venous aspiration is avoided. 
 
 "When the tumor is of the glandular species and the isthmus 
 with one or both lobes is enlarged, then the growth is closely 
 adherent to the trachea, and separation of the two demands cau- 
 tious dissection, lest the windpipe be opened. Also, the traction 
 made on the trachea lessens its calibre; enough, in fact, to asphyx- 
 iate the patient, unless the surgeon occasionally suspends the 
 work until' the cyanosis is relieved by free respiration. In cases 
 in which the growth penetrates into the niche between the 
 trachea and the oesophagus, then in the removal of the tumor, 
 the recurrent laryngeal nerve will be imperiled; especially so, if 
 the growth is seated on the left side. "With due care, the nerve 
 can be spared; and though partial or complete aphonia may 
 follow the operation, yet, as a rule, this will finally disap])ear. 
 If, however, the nerve on both sides be severed, the voice will be 
 permanently lost; if the division be only on one side, then the 
 voice will be reduced to a species of falsetto which will remain 
 permanent. And as these aphonic accidents cannot always be 
 foreseen, the surgeon should apprise his patient of the possibility 
 that the voice may be injured or lost by the operation. In no 
 patient operated on by the waiter has aphonia been produced; 
 yet in the majority of patients there has been some temporary 
 change in tone of the voice. 
 
 Jankowski, in 1885, wrote on the aphonia which sometimes 
 follows the removal of goitre; he finds in six hundred and 
 twenty operations that aphonic conditions occurred eighty-seven 
 
GOITRE. 845 
 
 times; that is, in fourteen per cent of the cases. Richelot, wlm 
 wrote on this subject, says such aphonia might arise from pres- 
 sure of the tumor prior to the operation; or it can arise from 
 lesion of the nerve during the extirpation ; and finally, from sub- 
 sequent cicatricial contraction, the nerve may be compressed, and 
 aphonia thus arise. 
 
 For a few days following the operation, the patient experiences 
 great difficulty in swallowing food. He should be fed on liquid 
 diet, which should be introduced in small quantities; thus 
 the movement of the parts is reduced to a minimum, in degluti- 
 tion. A drainage tube should be inserted and retained in the 
 wound for a few days; and an alcoholized dressing should be 
 applied on the wound. During the treatment, to permit the 
 escape of the excreta, the patient slfould lie on the side, much of 
 the time. 
 
 In 1883, Kocher reported two hundred and forty extirj)ations 
 of non-malignant goitre, of which twenty-eight died; that is 
 eleven and six-tenths per cent. 
 
 Rotter of Wiirzburg, in 1885, wrote on the mortality which 
 follows the removal of goitre. He finds that of fifty-four cases 
 operated on before 1850, seventeen died; from 1850 to 1876, of one 
 hundred and fifty-four cases operated on, thirty-one died, and the 
 result in five cases was not published. And since the era of 
 antiseptic surgery of four hundred and five cases collected by 
 Rotter, fifty-two died; that is, with the improvement in the 
 method of operating, the mortality has been reduced to near eight 
 per cent; and later 'statistics give a still lower mortality; so 
 that the operation has acquired an abiding place in surgery 
 among those procedures which lessen human suffering and pro- 
 long life. 
 
 Recent experience has revealed the fact that the removal of 
 the goitre is not always an unalloyed blessing to the patient. In 
 1883 J. L. and A. Reverdin, famous for the introduction of skin- 
 grafting, observed that the entire removal of the thyroid gland 
 was followed by loss of appetite, irregular gait, paleness of the 
 skin and dementia; that is, a species of idiocy was induced; and 
 the conditions present are similar to a disease described and 
 named by Sir William Gull, myxoedema. The Reverdins claim 
 that the loss of the thyroid gland leads to a deposit of mucin in 
 the tissues, and causes a disturbance in the central system of the 
 sympathetic nerve. They advise that the gland should not be 
 wholly removed. In the same year Kocher announced that in 
 
846 THYROID GLAXD AND ITS AFFECTIONS. 
 
 eighteen cases in wliicli the gland was wholly removed, there 
 were two in whom the health was impaired; while in sixteen 
 there was a disturbance of the general health, and a degeneration 
 of the patient's physical and mental powers. The limbs were 
 weak, heavy and easily tired, and there was transient or perma- 
 nent oedema of the skin. Kocher names this condition cachexia 
 strumipriva, and he regards it as akin to dementia or idiocy. In 
 1884 Crede' reported fourteen cases of total extirpation of the 
 gland, and the strumiprivous cachexia did not occur in any of 
 the cases. About the same time, Schiff and Zesas experimented 
 on cats and dogs, in which the thyroid gland was removed. 
 SchifF found that dogs thus treated died within a month. Zesas 
 thinks the gland regulates the circulation of the brain. And to 
 compensate the loss of the»thyroid gland in man, it has been 
 recommended to introduce ])ortions of the gland derived from the 
 sheep into the structures of the connective tissue, or into the 
 abdominal cavity. 
 
 About this period, a new disease hitherto unknown was 
 noticed, described and named myxcedema : a morbid state in 
 which there are conditions present similar to some which exist in 
 cretinism, and, also, are very analogous to those which follow 
 total removal of the thyroid body: an analogy, in fact, so close 
 that it is permitted to infer that cachexia strumipriva and 
 myxcedema are cognate or identical, and should be amenable 
 to similar treatment. And as a remedy, the fluid extracted from 
 the thyroid gland of some animal, as the ox or sheep, suggests 
 itself as a rational remedy to be used by the mouth, or b}' 
 interstitial injection. 
 
 In 1887 there were additional contributions to the literature 
 of this subject by Bruns and Hoffa, who claim that the entire 
 thyroid body cannot be removed with impunity: the cachexia 
 strumij)riva will certainly supervene; and that when such 
 cachexia has not followed thyroid extirpation, it was because the 
 gland had not been entirely removed, or that a portion of it had 
 been reproduced. Again, the absence of cachexia strumipriva 
 can be explained by the coexistence of an accessory thyroid gland ; 
 the exi.stence of such supernumerary thyroid lias been verified 
 by the researches of Gruber, Streckei.sen, Zuckerkandl and Made- 
 lung, who have found that such an anomaly is not infrequent. 
 
 Bruns advises to remove but one-half of a bilateral goitre: 
 thus proceeding the cachexy will always be avoided. Bruns 
 announces that he has operated on forty-eight cases of goitre. 
 
EXOPHTHALMIC GOITRE. 847 
 
 leaving a portion of the gland in each ; and in no case did the 
 cachexy appear. 
 
 In his recent thyroidectomies the writer has pursued the plan 
 here suggested; where the entire thyroid body was goitrous, a 
 fragmentary portion of it was left, with favorable result. In one 
 case, the fragment which was left enlarged so as to cause some 
 trouble; yet this enlargement was arrested and caused to recede 
 by the hypodermic injection of the tincture of iodine; and 
 hy the occasional use of such injection during a period of four 
 months, the patient was permanently relieved. 
 
 Many reports have been made of total extirpation of the 
 thyroid gland, and yet no ill consequence resulted to the patient; 
 and in some of the writer's first work, prior to his knowledge of 
 cachexia strumipriva and its associate myxoedema, he believed 
 that he extirpated the part totally and still no trouble followed. 
 It is possible, however, that here the removal was not complete, 
 and that some fragmentary portion, fortunately for the subject, 
 was left behind. 
 
 In conclusion, then, a rule in the performance of thyroidectomy 
 should be, to leave behind a portion of tlie gland ; and this 
 should be the least affected part of the gland; and its site, if 
 Ijossible, should be lateral and not median; and should this 
 remaining part become the seat of goitrous degeneration, it 
 should be treated by the hypodermic injections of iodine, as has 
 been described. 
 
 Exophthalmic Goitre. — In the field in which Surgery and 
 Internal Medicine have possessory rights, the actual claims of 
 each being undetermined, lies a disease akin to goitre, and which 
 from one of its symptomatic features is named. Exophthalmic 
 Goitre. And, as is usual in the cure of disease which has been 
 noticed by a number of cotemporaneous observers, a number of 
 other names have been applied to it; and among these are the 
 names of two of the original observers: to wit, it is sometimes 
 known as Grave's disease; also Basedow's disease. Another name 
 less objectionable than the latter two, may be constructed from 
 its leading symptoms, viz., goitrous ophthalmic tachycardia. 
 
 Basedow was more fortunate than other students of the dis- 
 ease in observing that three afiections are here united in one, 
 viz., of the eye, thyroid body and the heart. 
 
 The symptoms of the disease are as follows: the subject, 
 usually a female, is generally chlorotic, anaemic and hysterical; 
 she complains of cardiac palpitation, throbbing in the prsecordial 
 
848 THYROID GLAND AND ITS AFFECTIONS. 
 
 region, and an upheaval of tlie chest-wall in front of and below 
 the region of the heart; the cervical vessels beat and swell; and 
 finally the thyroid gland becomes enlarged, and is the seat of a 
 fremitus and blowing impulse and sound. Respiration is dis- 
 turbed, and cough is easily excited. Along with these phenomena 
 the eye becomes more prominent, and the exposure of an unusual 
 amount of the surface of the sclerotica gives the eye a striking 
 appearance. This ocular prominence is referred by Fano to 
 abnormal development of the vessels of the orbits; especially of 
 the veins. The adipose structure "within the orbit is also 
 developed beyond its usual dimensions; and this contributes to 
 ocular prominence. And Neumann has observed that tlie globe 
 itself is sometimes enlarged. Visual acuity is seldom impaired. 
 
 The sympathetic nerve in its cervical portion has frequently 
 been found in an abnormal condition. And this may, the writer 
 would suggest, act on those longitudinal muscular fibers in the 
 lid, discovered by Miiller, which have the function of dilating the 
 palpebral slit. Rudolf Wagner verified such action by applying 
 electricity to the divided nerve in the neck of a criminal whose 
 head liad just been decapitated. 
 
 Of the trio of symptomatic phtenomena which are present, 
 much attention has been given to the enlargement of the thyroid 
 body. Tliis hypertrophy never reaches the voluminous dimen- 
 sions which are often seen in cases of common goitre. The devel- 
 opment is usually uniform and bilateral; though exceptionall}^ 
 it is limited to one side. The changes in the gland are limited 
 chiefly to the vascular constituent, and the anatomical condition 
 is similar to that of erectile tissue. The dilated arteries have 
 numerous intercommunications; and their walls are often the 
 site of atheromatous change. The veins are also altered ; they 
 may be obliterated into fibrous cords; or they may be dilated, 
 and present varicose pouches. The proper glandular tissue may 
 be unchanged; yet it is, sometimes, somewhat h3'pertrophied. 
 
 Alterations have also been noted in the heart; the organ is 
 hypertrophied; the ventricles are passively dilated, and there is 
 valvular imperfection, fatty degeneration of the cardiac tissue, 
 and atheromatous changes in the aorta. 
 
 Females are predisposed to the disease; the writer has not 
 seen it in the male. Withuisen, who has collected fifty cases 
 of exophthalmic goitre, found that of these only eight were in 
 men. The affection occurs oftenest between the ages of twent}' 
 and forty years; yet Stokes and Fischer have each seen a patient 
 much older. 
 
MALIGNANT DISEASE. 849 
 
 The symptoms which have been enumerated indicate tlie 
 nature of the affection with sufficient definiteness to enable the 
 surgeon not to confound exophthalmic goitre with ordinary goi- 
 tre; a matter of much importance, since the treatment of the 
 former is medical and seldom surgical. Should, however, there 
 be doubt as to the true nature of the case, it is better for a time 
 to subject the patient to a course of internal medication. The 
 patient must be placed in the best possible hygienic conditions. 
 There should be a change of residence from inland to the sea- 
 side or the reverse, according as the patient belongs to one or the 
 other location. Hydrotherapy is specially praised in the man- 
 agement of such cases. Ice-cold compresses over the region of 
 the heart are commended. 
 
 As internal remedies, iron and arsenic may be used; also 
 digitalis. Iodine, so valuable in ordinary goitre, usually fails to 
 bring relief in the exophthalmic form. 
 
 If, in spite of the means here indicated, the patient should 
 become the subject of a large goitrous development, then it would 
 be proper to attack the growth by some of the means described 
 in the previous chapter. 
 
 Maligyiant Disease of the TJtyroid Gland. — Malignant disease of 
 the sarcomatous and carcinomatous form appears in the thyroid 
 gland. Sarcoma is said to occur here more often than carcinoma. 
 
 The writer has seen but one case, which was that of carcinoma, 
 which appeared in the thyroid gland of a man who was fift}^ 
 years of age. When first seen, the growth, somewhat globular in 
 outline, occupied the entire site of the gland, and was somewhat 
 more than three inches in diameter. It was closely adherent to 
 the air-passages, and of dense structure, unyielding to pressure. 
 The overlying skin was slightly puckered or plicated, and so 
 inseparably adherent to the growth that it seemed to be a part of 
 the latter. The tumor had become slightly painful, and from its 
 connections with the trachea and oesophagus, it interfered some- 
 what with breathing and swallowing. 
 
 An attempt was made to remove this growth, yet the task was 
 a difficult one; and the adhesions to the trachea were such that 
 it was impossible to thoroughly remove the growth without open- 
 ing the windpipe; and since this would have left an unhealing 
 breach there, it was deemed prudent to leave the tracheal canal 
 intact, which was accomplished by removing the tumor in cunei- 
 form sections. The cancerous tissue was similar to the cicatrized 
 scirrhus occurring in the mammary gland. It was non-vascular, 
 so that tlie work was done with but little loss of blood. 
 
850 THYROID GLAND AND ITS AFFECTIONS. 
 
 The result of the operation was some temporary relief to the 
 patient; the latter, however, survived hut a few months; and 
 would probahly have lived as long if the tumor had not been 
 interfered with. 
 
 From the experience in tliis case, should a similar one present 
 itself, instead of extirjiation, tlie writer would make trial of the 
 l)arenchymatous injection of an arsenical solution, viz., Fowler's 
 solution, of which there should first be injected five drops; and 
 should this not cause much irritation, the dose injected may 
 gradually be increased in amount. Thus beginning with a few 
 drops, the author has found that by slowly increasing the quan- 
 tity, finally the patient will tolerate, without dangerous reaction, 
 thirty drops of Fowler's solution, injected at different points in 
 the malignant growth. The tolerance of so large a dose is proba- 
 l)ly due to imperfect development of the absorbents in the neo- 
 plasm. 
 
 Wounds of the Thyroid Gland. — Traumatic lesions of the gland 
 named in the order of their frequency are the contused, incised, 
 and penetrating. The gravity of such wound is less in the sound 
 gland than in that which is goitrous. 
 
 The contused wound may accompany an attempt at strangu- 
 lation done by the patient himself; or it may be inflicted by the 
 hands of others. The prominent symptom is the ecchymosis of 
 blood due to rupture of the thyroid vessels; and tliis maybe 
 slight or so extensive as to permeate the tissues from the chin to 
 the sternum. The overlying skin is livid or i)urple, and there is 
 tumefaction proportionate to the effused blood. Difficulty of 
 breathing and swallowing may be present, due to pressure. 
 
 If such contused wound is limited to the thyroid gland, recov- 
 ery may be ex})ected; but if the larynx or trachea be fractured or 
 torn, then life is imperiled; in the former case, the treatment 
 should be that employed in a simple contusion, local means 
 which will favor absorption of the effused blood. But if the con- 
 tusion be associated with additional injury of the air-passage, 
 then the patient's chances of recovery will be increased by an 
 early performance of tracheotom}', in which the canula must be 
 inserted below the injured gland. Should su])puration ensue, 
 the pus should be given escape by an early incision. "Where 
 the contusion has destroyed the thyroid structure, so that the 
 patient is similar to one from whom the gland has been removed, 
 then symptoms of cachexia strumipriva may occur, as happened 
 in a case seen by Guerlon-Dudon; the gland here had been 
 destroyed by the passage of a wlieel over tlie neck. 
 
THYROIDITIS. 851 
 
 The incised wound is generally from an attempt at suicide, in 
 which the wound is made with a razor, or other knife-like instru- 
 ment; or such w^ound may be made by the surgeon in the opera- 
 tion of tracheotomy. In such wound, the first duty of the surgeon 
 is to arrest and control the bleeding; and means to do this are 
 ligation of the vessels in the open wound, or by transfixion; and 
 should the rapid escape of blood not permit this, then plugging 
 the wound with the first material at hand, should be resorted to. 
 Styptics, so often used, are not trustworthy, since through the 
 destruction of tissue which they cause, secondaiy haemorrhage 
 can ensue. Transfixion and inclusion of masses of the vascular 
 structure in ligatures would be one of the safest and speediest 
 ways of controlling the bleeding. 
 
 In the performance of tracheotomy, bleeding is avoided by 
 careful dissection, and likewise, by seizing and twisting the vessels 
 which may accidentally be opened. The proposal to seek for the 
 thyroid arteries and ligate them in such cases, is ill advice; for it 
 is probable that before the operator had fully displayed the 
 quadrangle containing the four vessels, his patient would scarcely 
 require further attention. 
 
 The penetrating wound is rare in the normal gland; but as a 
 means of treatment in the goitrous gland it is frequent; and as a 
 rule, such wound is harmless; yet exceptionally, it has proved 
 fatal. Liicke, Demme, Schmidt and Schwalbe have seen death 
 soon result from suff'ocation, after injections into the goitrous 
 gland. Severe, and even fatal bleeding has resulted from such 
 slight penetrating wound. Suppuration thus arising has caused 
 the patient's death. 
 
 TJiyroiditis. — Inflammation of the thyroid gland maybe acute 
 or chronic; the acute form is that in which surgical aid is often- 
 est sought. 
 
 It occurs somewhat oftener in females; and a goitrous condition 
 predisposes to such inflammation. It is announced by a chill, 
 and a rise in pulse and temperature. There are pain and a sense 
 of oppressive tension about the neck. The tumefaction maybe 
 unilateral, or on both sides. The writer saw a case in which the 
 swelling was uniform, both on the sides and on the front of the 
 neck. 
 
 There may be headache, ringing in the ears, and in the sever- 
 est cases, delirium. The tumor obeys the movements of the 
 larynx, rising and falling in deglutition ; yet it may be so extensive 
 as to prevent such movement; and then, according to Gosselin, 
 
852 THYKOID GLAND AND ITS AFFECTIONS. 
 
 such immobilization of the air-passage disappears in the same 
 ratio as the agglutinative tumefaction vanishes. 
 
 By palpation, the hard and tense structure of the swollen 
 gland can be traced out; and if lateral, the tumor will be felt 
 above, passing under the sterno-cleido-mastoid muscle; while 
 below, it may dip underneath- the clavicle and sternum, and, 
 also, be felt on the outside of the sterno-cleido-mastoid muscle. 
 
 Such tumor, from pressure on the windpipe, may obstruct 
 breathing; it may also obstruct swelling; and, from pressure on 
 the recurrent nerve, coughing and hoarseness may arise. And 
 great pressure on the vagus nerve has caused sudden death. 
 
 Thyroiditis may terminate by resolution, induration, suppu- 
 ration or gangrene; and, as stated, speedy death may arise 
 through pressure causing suffocation. 
 
 In the cases which disappear by resolution, the swelling 
 appearing on the second day, increases till the fourth or fifth day, 
 or even later in severe cases; then it remains stationary for a 
 variable time, and finally disappears at the end of two or three 
 weeks. This normal, or desirable course, may be varied by 
 accessions, remissions, cessations and other variations, which are 
 determined by the morbid elements present in the case. The 
 rapidity of disappearance is dependent on the condition of the 
 venous and absorbent routes through which the redundant 
 elements composing the structure may find escape. Such resolu- 
 tion may be incomplete, and then the gland remains enlarged, 
 and the condition becomes one of indurated goitre. 
 
 In cases (jf more intense action, the event may be suppuration; 
 here chills, increase of volume, pain and other functional disturb- 
 ance are present. There is cedennitous tumefaction of the integ- 
 ument; and this may reach from the chin to the sternum, and 
 even extend down on the chest-wall. Fluctuation is slow to 
 appear, and the usual evidences of pus are absent. The tume- 
 fied structures are dense, tense and unyielding to pressure; and 
 if the forming pus is deep-seated, it may remain undiscovered for 
 a time, and in the interim, the pus may migrate laterally, or 
 penetrate dee})er. In the graver cases, the imprisoned pus may 
 erode the subjacent tracheal or laryngeal cartilages; or penetrat- 
 ing the interstices between these structures, it may enter the 
 windpipe. In a patient seen by the writer, in which the inflam- 
 mation extended beyond its ])rimary site, the deep-seated pus 
 penetrated the larynx, and finally destroj-ed the woman's life. 
 
 The pus has perforated the oesophagus; and this has occurred 
 
PHLEGMON AND ABSCESS. 853 
 
 during the act of vomiting, in which the thin intervening wall 
 was ruptured. 
 
 By gravitation the pus has descended to, and entered the 
 pleural cavity; and such event is a most unfavorable one, since, in 
 the cases reported, death through exhaustion generally occurred. 
 
 Gangrene, resulting from suppurative thyroiditis, has not 
 unfrequently been observed. In the case cited by the author, 
 there was gangrene of the overlying derm; and this destructive 
 process implicated the subcutaneous fatty tissue. In seven cases 
 of this kind collected by Lebert, there were four recoveries. 
 
 From an attempt to calculate the mortality of thyroiditis, 
 Lebert finds eleven deaths in thirty-two cases; that is, one-third 
 of the cases died. These figures of fatality are manifestly too 
 high. The complication of goitre in the patient adds much to 
 the gravity of the disease; and where this is absent, thyroiditis 
 may be considered nearly free from danger. 
 
 In the treatment of the disease, an attempt should be made to 
 remove the congestion of the affected structure ; and this may be 
 directly affected by the application of leeches to the part. Or 
 this may be done by scarification, in which slight penetrating 
 wounds are made into the swollen gland; and though there 
 might be risk of wounding arteries, yet the bleeding that thence 
 might arise could be controlled by temporary pressure. After 
 this, the inflamed surface should be painted frequently with 
 tincture of iodine. The free circulation of blood through the neck 
 must be promoted by proper position. As a resolvent, mercurial 
 ointment ma}^ be applied in the later stage of the inflammation. 
 
 Should the means mentioned not arrest the inflammation, and 
 there be indications of the formation of pus, there should be no 
 delay in making one or more incisions to give the pus exit- 
 Such incision is at the risk of opening a vein or artery; this risk, 
 however, is slight, if one determines beforehand the presence of 
 pus by a small hollow needle. The purulent material should be 
 washed out, and its site well irrigated with some antiseptic fluid. 
 The treatment may then end by the application of poultices or 
 antiseptic compresses. 
 
 Phlegmon and Abscess of the Neck. — Phlegmonous inflammation 
 of the neck may be rapid or acute in course; or it may be chronic; 
 and it may be generally diffused; or the action may be limited 
 to a small part of the surface of the neck. When circumscribed, 
 the aff'ection may be limited by the anatomical components of 
 the neck ; and then it may lie above, or below the hyoid bone; in 
 
854 THYROID GLAND AND ITS AFFECTIONS. 
 
 fact, it may be situated at any point on the front surface of the 
 neck; or the bauk of the neck may be the isohited site of the 
 phlegnjDD. This classihcation of site is that of Gillette, who 
 refers the inflammation to local and general causes. 
 
 As local causes are those of a traumatic character; and these 
 comprise the various lesions of the neck which may arise from 
 some external agency; even wounds made by the surgeon him- 
 self have awakened a widespread phlegmon on the neck. Lesion 
 of the mucous membrane of the oral and buccal cavity has, 
 through the lymphatic channels, awakened iufiammation in the 
 neighboring glands of the neck; and the latter have transmitted 
 the same to the adjacent connective tissue. Eruptions of the 
 skin of the face or neck may light up a morbid action of the cer- 
 vical glands, and thence suppuration may arise. Disease in the 
 pharynx and larynx has extended from its })riniary site, and 
 appeared in the cervical glands. 
 
 The fracture of the low^er jaw, in cases in which the gingival 
 structure is opened, may cause abscess in the supra-hoidean 
 region; and such pus may descend much lower on the neck. 
 Calculus in the submaxillary gland, or in its ducts, may develop 
 cervical phlegmon or abscess. 
 
 Adenoid disease dependent on syphilis or scrofula ending in 
 suppuration of the glands and peri-giandular tissue, is a frequent 
 cause of abscess; and this usually runs a tedious course. Cell- 
 multiplication due to the dyscrasic vice is the initial phenome- 
 non; and the superabundant cells at that stage probably act as 
 mechanical irritants. And other diseases, as the eruptive ones 
 of the skin, in which the organism is laden with effete detritus, 
 besides awakening abscess elsewhere, has a special tendency to 
 cause suppuration in the cervical structures. 
 
 The terms phlegmon and abscess, though representing morbid 
 conditions closely cognate, differ in this respect, that phlegmon 
 is a suppurative process in which unlimited diffusion is the 
 characteristic feature ; while in abscess, the action is isolated, and 
 within palpable and visible bounds. Phlegmon has the accom- 
 paniment of severe constitutional disturbance, viz., general fever, 
 and sometimes delirium ; while abscess is limited to local pain, 
 swelling and suppuration. Phlegmon produces great destruction 
 of the ti-ssues; in fact, it may terminate life through gangrene 
 and general pyiiimic destruction. 
 
 The phlegmonous or diffused suppuration may be superficial, 
 or outside of the superficial cervical fascia: viz., external to that 
 
PHLEGMON AND ABSCESS. S55 
 
 fascia which extends from the hyoid bone to the front of the 
 sternal manubrium and clavicle; and which laterally includes 
 the sterno-cleido-mastoid muscles and the trapezei. Or the pus 
 may form between the superficial and middle fascise; or it may 
 be between the middle and inmost fascial structure. The power 
 of these fasciiB to limit and prevent the passa<^e of pus through 
 them is overrated; these fasciae are too thin in texture to exercise 
 such imprisoning force in cases in which there is a large purulent 
 collection. 
 
 Thesupra-hyoid structures, and those in the floor of the mouth, 
 from their proximity to the site of infecting lesions, are the fre- 
 quent site of suppurative inflammation; and such pus may per- 
 forate the skin and appear externally; but occasionally, it appears 
 beneath the tongue, within the mouth; and in this site, the pos- 
 sibility of a sialolith being the causal agency, should not be for- 
 gotten. The supra-hyoidean collection of pus may point also 
 towards the pharynx, the larynx or oesophagus; and in any of 
 these events, there may be disturbance of the voice, breathing or 
 swallowing. 
 
 The wisdom tooth has been the cause of such abscess; and this 
 has appeared at the angle of the lower jaw. 
 
 Vidal and Duplay have seen cases of abscess which arose in 
 the structures at the base of the epiglottis. Such cases are accom- 
 panied by oedematous swelling within the pharynx, and all the 
 functional disturbances which arise from swelling there; and of 
 these, by far the most important is the swollen condition of the 
 aryteno-epiglottidean folds of mucous membrane, which may be 
 so great as to fatally narrow the air-passage. 
 
 An occasional site of such inflammation and suppuration, as 
 pointed out by Velpeau, is within the sheath of the sterno-cleido- 
 mastoid muscle; the muscle becomes painful and contracted, and 
 as result, the head is deviated to that side. But more frequently, 
 this suppurative action is connected with the chain of glands 
 which lie along the vessels and close to the muscle. The swell- 
 ing, owing to the implication of the cervical plexus, is attended 
 with much pain; and as just said, there is torticollis from con- 
 traction of the sterno-cleido-mastoid. The morbid action is of 
 phlegmonous character in its manifestations; and the pus fre- 
 quently travels downwards, or in some other direction away from 
 its primary point of origin; sometimes, penetrating the- thorax. 
 A form of suppuration of the neck of a widely diffused character, 
 was observed and described by Dupuytren. This abscess may 
 
856 THYROID GLAND AND ITS AFFKCTIONS. 
 
 appear in j)i'oportious so great that it occupies the entirety of the 
 region, from the mastoid process to the clavicle, and reach later- 
 ally to the trapezius muscle. The dominant feature is tumefac- 
 tion, which is so great as to obscure, or blot out, the normal 
 prominences of the neck. And the }»us which forms can gravi- 
 tate into the thorax, or appear on its outer wall. Dupuytren 
 observed this affection among public criers and auctioneers. 
 
 The writer has seen two cases of that wide-opened cervical 
 phlegmon, wiiich was due to an adynamic form of erysipelas: 
 both speedily ended in death. In the cases described by Dupuy- 
 tren, the course was a slow one; and in the pus which infiltrated 
 the structures subcutaneously, there was generated gas, which 
 yielded crepitation on pressure. 
 
 These severe forms of cervical suppuration are often connected 
 with some anginous disease in the pharynx; a septic trouble 
 there located is transmitted through the lymjihatic vessels to the 
 cervical glands; the first morbid phenomena being lymphangitis 
 and adenitis. 
 
 Phlegmonous inflammation may occur on the posterior side 
 of the neck; yet the anatomical structures of the neck behind 
 are less adapted to such morbid development than those of the 
 anterior side; the paucity of loose connective tissue, the close 
 adherence of the muscles, and the small number of the cervical 
 glands, are conditions unfavorable to phlegmonous diffusion. 
 The posterior cervical phlegmon is exceedingly painful; due to 
 tiie thick, un3delding character of the overlying skin; and also 
 to the tendon-like density of the muscles composing the nuclea. 
 
 The diffused phlegmonous abscess situated in the anterior 
 cervical region, often requires special attention on the part of the 
 surgeon to rescue the patient from the disastrous events or com- 
 plications which may arise in the course of such disease, viz., the 
 irruption of the })us into the tliorax, the trachea, or (jeso})hagus; 
 and a 3'et more formidable event is the erosion and 0})ening of 
 tlie carotid artery or the internal jugular vein. The opening of 
 tiie air-passage may necessitate the performance of tracheotomy; 
 and the perforation of a blood-vessel would demand immediate 
 tamponing; and the subsequent ligation of the vessel. In a 
 l^tient seen by the writer in which the suppuration was of glan- 
 dular origin, the suppurative action had so weakened the wall 
 of the internal jugular that when an opening was made into the 
 purulent collection, the internal jugular spontaneously burst into 
 the cavity, and for a moment bled in a frightful manner. This 
 
PHLEGMON AND ABSCESS. 857 
 
 was controlled by a plug of sponge, and some days afterwards, 
 when this was removed, no more bleeding occurred; yet it is 
 probable that if aid had not been at hand, death would have 
 occurred within a few minutes. 
 
 The unsparing pen of the surgical historian has not failed to 
 keep in remembrance an error committed by Listen, in which 
 this famous surgeon inadvertently mistook an aneurism on the 
 neck for an abscess, and, against the warning of his clinical 
 assistant, he thrust a bistoury into the tumor and caused a bleed- 
 ing which ended fatally. The memory of this act, as he con- 
 fessed to a friend, remained as an enduring sorrow in his heart. 
 This case fully illustrates the need of deliberate thought accom- 
 panying, as a guiding mentor, all surgical work. Unthinking 
 routine erelong stumbles upon danger. 
 
 Dolbeau was compelled to tie the external carotid on account 
 of ulcerative erosion of the lingual artery. As a rule, however, 
 according to the observations of Gross, Duplay and others, such 
 ulcerative erosion occurs oftener in the large vessels of the neck 
 than in the small ones. 
 
 The pus, while the overlying skin is yet intact, may perforate 
 the air-passage, and then be expelled by coughing; and also, 
 gravitating to the lungs, it may produce ichorous pneumonia. 
 
 As already mentioned, the pus from the cervical phlegmon 
 may, if deep seated, pass down the plane of the prsevertebral 
 muscles and, entering the pleural cavity, it may develop pleuritis 
 and empyema ; such complication is very perilous; usually, after 
 long continuance, ending life by exhaustion. 
 
 Deep-seated abscess of the chronic type may have its origin 
 in vertebral disease; and such suppuration may be near the 
 pharynx and discharge into the pharyngeal cavity, but if the 
 disease be lower down, then the pus might open into the air- 
 passage, or into the oesophagus, or it might gravitate into the 
 thorax, and appear in the mediastinal space, or penetrate the 
 pleural cavity: any of which events would be very perilous to the 
 patient. The most fortunate event would be that the purulent 
 material should form an opening posteriorly, since such a route 
 of escape would be the least injurious to the structures. 
 
 Dumesthe, who wrote on cervical abscess in 1864, observed 
 that the anatomical conditions of the neck are such that the 
 superficial abscess will open externally, while the deep-seated 
 tends to gravitate. As means of diagnosis of the deep-seated 
 species he directs to press the finger down on the anterior edge of 
 55 
 
858 THYROID GLAND AND ITS AFFECTIONS. 
 
 the sterno-cleido-mastoid while those of the other hand are forced 
 down close to the outer margin; now between the fingers thus 
 insinuated, the fluctuation of deep-seated pus may be detected. 
 Deep-seated abscess contiguous to a vein may receive and trans- 
 mit a venous murmur. But the most important act in diagnosis 
 is the distinction of a collection of pus from an aneurisnial tumor, 
 where the former is the seat of a movement and vibratile impulse 
 similar to what occurs in an aneurism. If studied, there is a dif- 
 ference in the movements of the two: the purulent collection is 
 lifted directly upwards by the subjacent pulsating artery; buttlie 
 aneurismal tumor expands in all directions; the abscess can some- 
 times be displaced from the vessel, and then the impulse will 
 vanish. And, as a crucial test, where palpation cannot solve 
 doubt, the hypodermic needle of fine calibre may be used; if the 
 tumor be aneurismal, arterial blood w^ill escape through the 
 needle; but if there be pus, a drop of this may be drawn out. 
 Such exploratory acupuncture is harmless, whatever the content 
 may be. 
 
 Treatment. — The cervical phlegmon and abscess have been 
 treated by different methods; collected in general groups, these 
 are antiphlogistic, resolvent and operative. 
 
 As antiphlogistic means are bleeding, general and local, and 
 vesication. General bleeding would rarely be appropriate; only 
 in the plethoric subject should it be resorted to. Depletion may 
 be done locally by leaching and scarification; preferably by 
 scarification. To scarify, one should use a sharp-pointed lance 
 or bistoury, and a number of vertical stabs, reaching through the 
 skin slightly into the subcutaneous tissue, should be made; and 
 to promote bleeding from these wounds, the surface should be 
 bathed with water rendered alkaline with carbonate of soda or 
 potassa, or with aqua calcis. An antiphlogistic measure which 
 has had numerous advocates is vesicatio volans, or the flying 
 blister, as it is popularly stvled. The action of the cantharidal 
 vesicant for such purpose was pointed out by Dr. Physic, many 
 years ago: Physic claimed that impending gangrene could thus 
 be prevented. Velpeau and Quinart have recommended vesica- 
 tion in the cervical phlegmon. Quinart applies a blister which 
 covers the site of the abscess, and extends some distance beyond 
 its border. After the epiderm is thus detached, he dresses the 
 surface with mercurial ointment. And when the surface heals, 
 he reapplies the vesicant; and thus proceeding, Quinart claims 
 that the course of such abscess may be greatly shortened. 
 
PHLEGMON AND ABSCESS. 859 
 
 As resolvent local applications, lint saturated with an alkaline 
 solution, or with simple warm water, acts well. Or LinimentQin 
 Calcis, used in the same way, is an excellent application. As an 
 unguent, mercurial ointment, or stramonium ointment diluted to 
 one-fourth the officinal strength, may be used. And, finally, 
 despite the censure and obloquy that have been cast on the poul- 
 tice by fastidious criticism, it yet lives. The charge that it is 
 dirty is due rather to the compounder than the compound itself; 
 it assuages pain and brings ease and comfort to the inflamed part, 
 and from the alleviation which it once brought to the writer, the 
 linseed cataplasm has an abiding place in affectionate memory; 
 so kindly, indeed, that he fully concurs with the agreeable eulogy, 
 which the surgeon Gibson has joaid the poultice. And along 
 with the cataplasm, some resolvent ointment may be used. And 
 these means are often advantageously employed along with the 
 surgical methods, which will now be considered. 
 
 Of operative means by which the cervical phlegmon or abscess 
 may be attacked, the simplest is that of tapping, which is done 
 with a hollow needle or trocar of small calibre: a method which 
 was inaugurated by Voillemier and highly commended by him; 
 and was named by him capillary puncture, or tapping. An 
 analogous plan is that of withdrawing the pus with an aspirator; 
 this has been pursued by Lawson Tait. A'^oillemier resorted to this 
 plan in infants three or four years old, in whom abscess arose 
 from inflamed cervical glands. With a fine trocar, he withdrew 
 what pus would easily flow out; and this procedure was repeated 
 on the second, third and fourth days, until no more material 
 would escape; then for a week, some resolvent ointment or poul- 
 tice was used. By such a course, the abscess was quickly cured,, 
 and scarcely a visible trace remained of the work done. 
 
 Lawson Tait used an aspirator with a small needle, and 
 repeated the tapping until the pus ceased to reform. In aspi- 
 rating, the needle must not traverse the same point twice. The 
 needle must be inserted obliquely; and this should be done from 
 before backwards; yet the reverse is permissible; and as to the 
 number of times, Tait fixes no limit; in one case he aspirated 
 fifty consecutive times, and obtained a cure. 
 
 This method is applicable to both the acute and chronic forms; 
 yet in the chronic abscess, the tapping will have to be repeated 
 more times, and the treatment is often protracted. 
 
 Two points of much importance should be remembered in this 
 plan of tapping or aspirating; the surface operated on must be 
 
800 THYROID GLAND AND ITS AFFECTIONS. 
 
 well cleansed before it is opened, and no air sliould be allowed 
 to enter the cavity; especially, in tlie chronic form; for its 
 adniis.'fion greatly aggravates the case. The advantage claimed 
 for the method described is its simplicity ; and especially, the 
 slight scarring which arises from it; an important thing on the 
 surface of the neck, where scars remain as a visible deformity. 
 
 A second plan of treatment is the introduction of a seton 
 through the wall of the j)us-cavity. This procedure was practiced 
 and commended by Darby; also by Bonnafont. Cotton or silken 
 thread was used. Wire was also used for this purpose. Crean, of 
 Manchester, reports the treatment of twenty-eight cases of scrofu-' 
 lous or critical abscess, as he names it, v.'hich were treated by the 
 introduction of silver wire introduced as a seton through the wall 
 of the abscess. 
 
 Though a cure may be obtained by the seton, yet, as St. Ger- 
 main counsels, caution should be exercised in its use; the thread 
 or wire should not be permitted to remain in place until it causes 
 ulceration, or the formation of granulative tissue at the entrance 
 and exit points of the thread. As soon as such ulceration begins 
 the seton should be removed, and the pus permitted to flow 
 through the opening thus made; and if such opening is insuffi- 
 cient, then the seton might be introduced at another point. 
 
 The seton is obnoxious to two grave objections; during its use, 
 should the pus harden and occlude the opening around the cord 
 or wire, then an erysipelatous inflammation may be excited there, 
 and invading the contiguous structures, spread thence indefinitely. 
 And another objection is that the seton inevitably leaves a scar 
 which time will not efface. Hence, as a means of treatment, the 
 writer would discard the seton; it is less efficient and satisfactory 
 than the following method. 
 
 Drainage. — The drainage tube was introduced by Chassaignac; 
 and though assailed by countless arrows of its adversaries, yet 
 these are becoming fewer; it has nearly outlived opposition, and 
 gained an assured place in the list of surgical weapons. 
 
 The use of the drainage tube mu.st be preceded by one or more 
 incisions which penetrate to the pus; and these openings should 
 be made in the long axis of the neck, so that the pus can follow 
 the natural course of gravitation; viz., from above downwards. 
 The drain should be made of black rubber tubing; it must be 
 fenestrated, or have lateral openings in the portion which is to lie 
 in the cavity. It should reach to the bottom of the cavity; and, 
 in some cases, it is well to let the tube traverse the cavitv and 
 
PHLEGMON AND ABSCESS. 861 
 
 reach somewhat beyond the outlet and inlet. As a rule, it is 
 better to have one or more tubes, of which one end lies buried 
 in the cavity, while the other rises somewhat above the surface. 
 As the cavity closes, the tube is extruded and must be cut 
 shorter, from time to time. If the tube is placed permanently 
 in, and its ends tied together, then it should daily be cleansed by 
 injecting an aseptic fluid through it; but if sections of tubing 
 are introduced into the cavity, these should daily be removed,, 
 cleansed and replaced. The dressing should be done gently, 
 lest the reparative process be disturbed; for violent injection 
 may tear asunder the adhering walls; also, displace the new- 
 formed cells, and open vessels, and cause bleeding. But if 
 the fluid be permitted to purl through the pus cavity with- 
 out pressure, then the disturbances mentioned will be avoided, 
 and the surgeon will second the work of restoration to struc- 
 tural integrity. The drainage tube should not remain too long;; 
 as soon as the material discharged changes from a purulent 
 to a serous nature, then the tube is no longer needed, and its 
 longer retention in the wound will increase the scar, which must 
 remain afterwards. In fact, the chief charge against the drainage 
 tube is that it is an irritant, and always leaves some cicatricial 
 vestiges of its use. 
 
 The usual and most important operative procedure is that of 
 incision by which a direct outlet is formed for the pus. For this 
 purpose, the scalpel, bistoury or other instrument in the use of 
 which the surgeon has acquired facility, may be employed. 
 If the case be one of circumscribed abscess, then a single 
 opening will suffice; but if it be a diffused phlegmon, then 
 several openings should be made, so that the purulent ma- 
 terial may have ready escape. And these openings should be 
 made by first dividing the skin and superficial fascia, and then 
 boring through the remaining wall with a blunt dissector, or the 
 finger; thus proceeding, there is but slight risk of wounding 
 vessels. The incisions should be made in the longitudinal axis 
 of the neck. After the pus-space has been freely opened, the 
 purulent material should be well rinsed out with a sublimated 
 or other aseptic fluid; and if the cavity be deep, then the drain- 
 age tube should be inserted, as before described, and detergent 
 irrigation practiced. Lint, moistened with sublimated or alco- 
 holized water, should be placed over the affected part, and daily 
 changed. 
 
 The time when the opening should be made is a matter of 
 
862 TIIYKOID GLAND AND ITS AFFECTIOXS. 
 
 controversy: some urge early opening; others advise delay until 
 the pus has reached the skin; most surgeons adopt the former 
 plan; and this is the practice of the writer, who opens the skin 
 and adipose stratum with a short-handled scalpel, and then con- 
 tinues the penetration with some blunt instrument. If the 
 phlegmon be extensively diffused, then two or more openings 
 should be made and, through short tubes inserted into each, irri- 
 gation should daily be done. By this proceeding at an early 
 period, the destruction of the connective tissue will be lessened; 
 and the extravasating wandering of the ichorous pus will be 
 avoided, or greatly curtailed. 
 
 There is a form of phlegmonous disease which was described, 
 in 1845, by Metzler, which, differing from the species above 
 described, has been reserved as an appendix to this chapter. 
 
 Metzler finds traces of its history in the works of Gregory, 
 Frank and Ludwig; and he thinks it may be regarded as an 
 anomalous form of typhus, with a tendency to special localiza- 
 tion. Associated with general symptonis of typhus, there is 
 deposited a yellowish, gray, fat-like matter in the subcutaneous 
 tissue of the neck; and this tumefaction is usually unilateral, and 
 commonly seated near the parotid gland, or lower jaw; it is not 
 red or painful, and the overlying skin is movable. In about ten 
 days, gangrene commences, with an increase of the constitutional 
 symptoms. 
 
 This affection has been seen both in the acute and chronic 
 forms; in the former, death may ensue in ten or twelve days; but 
 in the chronic form this may occur at a much later time. Recov- 
 ery may occur by dispersion, with perhaps a few points of gan- 
 grene in the skin; or there may be extensive suppuration and 
 breaking down of tissue, and still recovery may take place. Fis- 
 tulous openings may continue for a long period, and even the sub- 
 jacent bone be affected. In some cases, there may be a recession 
 of the tumor, and death quickly ensue; more often, however, the 
 fatal ending is due to an exhaustive suppuration; or a large ves- 
 sel may be ojicned by erosion, and the patient then quickly 
 bleeds to death. The pressure on the vessels and nerves of the 
 neck may contribute to a fatal issue. 
 
 The necropsy shows that the adjacent muscles are decom- 
 posed, while the glands show but slight changes; the parotid has 
 been found but slightly affected, though it is in the midst of dis- 
 organized structure. 
 
 This affection occurs oftener in the young than in the aged. 
 Death occurred in one-half of those attacked. 
 
PHLEGMON AND ABSCESS. 863 
 
 Metzler observed a similar affection of the subcutaneous cellu- 
 lar tissue in otlier parts of tlie body. 
 
 The treatment used in the disease in the commencement com- 
 prised emetics, mild laxatives, diaphoretics, blistering the affected 
 surface, and discutient ointments. In some cases the affected 
 part was vesicated, the epiderm thus detached, and, as dressing, 
 lint was applied, saturated with the following solution: — 
 
 ^. Hydrarg. Chloridi. Corrosivi 9j 
 
 Aquse ^i 
 
 Misce. 
 Apply this until an incrustation is formed, and then use moist 
 dressing over the surface. Should pus form in spite of this treat- 
 ment, open with the bistoury. 
 
 The writer in his comment on this form of cervical abscess, 
 thinks its causation may be found in the embolic processes which 
 sometimes attend or follow typhus or typhoid fever of adynamic 
 form ; and of which a usual site is the parotid gland. The 
 obstructed vessels retard the current of blood, or wholly suspend 
 its movement; and thence the tissues, not being nourished, the 
 conditions for developing phlegmon or, its kinsman, gangrene 
 are present. The writer has seen a few cases which fell within 
 this group, and, as a rule, they ended fatally. 
 
CHAPTER XXVII 
 
 TUMORS OF THE NECK. 
 
 The cervical region, especially the anterior portion, is richly 
 fertile in neoplastic growths, which, here as elsewhere, naturally 
 separate themselves into two classes: the benign and the malig- 
 nant. 
 
 The benign class may be divided, as Konig has done, into 
 those of liquid content, viz., cysts, and those of solid or semi-solid 
 content. 
 
 Cystic tumors of the neck are thus classified by Konig, to 
 whom the writer is indebted for much of the material which fol- 
 lows: (1) Those containing air. (2) Those of serous content. (3) 
 Those containing blood. (4) Echinococcus cyst. (5) Those cysts 
 that have arisen from the softening or liquefaction of solid growths 
 
 Cysts containing air are directly connected witli the air- 
 passages, as the larynx or tracliea; and they arise from a j)rotru- 
 sion of a portion of the wall of one of these passages. One of the. 
 most common is that whicli arises from a hernia-like protrusion 
 of the thyro-hyoidean membrane, due to dilatation of the ventricle 
 of Morgagni, which is contained in the larynx. Cysts thus aris- 
 ing have been seen here, of the dimensions of a small walnut. 
 
 An air-cyst may arise from the trachea; and this tracheocele 
 has been seen in front, at the side, or on the posterior wall of the 
 trachea. This cyst may be congenital, and be due to imperfect 
 closure of the branchial cleft; or it may arise from violent expi- 
 ratory effort, as severe coughing, or vomiting. 
 
 Such air-cyst has a mucous wall similar to that of the trachea; 
 and besides air, mucous material is also contained in the cyst. 
 It is dilated and contracted alternately in expiration and inspira- 
 tion. Respiration is rarely much affected; yet the voice may be 
 weakened by such cyst. 
 
 Something analogous to this is the pneumocele, which has 
 been observed in the subclavian fossa, above the clavicle, and 
 whicli is due to the apex of the lung protruding hernia-like. 
 (864) 
 
TUMORS OF THE NECK. 865 
 
 The tracheocele and pneumocele demand no treatment; and 
 a knowledge of them is chiefly of diagnostic value: viz., such 
 air tumor should not be mistaken for an abscess, liquid cyst, or 
 other tumor. Only in the case of the tracheocele causing much 
 trouble should an attempt be made to extirpate it; yet this neces- 
 sity will seldom occur; the rule being in such cases to limit 
 treatment to simple compression, should the cyst disturb by its 
 volume. 
 
 Cysts of liquid content are sometimes found in the median 
 line of the neck near the upper border of the thyroid cartilage 
 and hyoid bone. Near the notch or incisura in the upper edge 
 of the thyroid cartilage, is often found a bursal space; and this is 
 not near the skin, as anatomists have stated, but it is subfascia, 
 and close to the cartilage. Near this space, which may be named 
 the prse-thyroid bursa, there is found, sometimes, a bursal space 
 just below the hj^oid bone in the median line of the neck, which 
 may be named the thyro-hyoid bursa; and a third bursa occa-. 
 sionally exists near the upper border of the hyoid bone close to 
 the insertion of the genio-hyoid and the genio-hyo-glossi muscles.^ 
 
 The blind cul-de-sac, known as the foramen csecum, at the 
 base of tlie tongue, and a small gland which lies on or near 
 the middle of the hyoid bone, and likewise abnormally located 
 portions of the thyroid gland, may give rise to cystic devel- 
 opment. 
 
 The bursal spaces mentioned are normally so small that they 
 are unknown to the possessor; yet from any cause that can 
 excite inflammation, they may become cystic tumors of greater 
 or less dimensions; and then they contain a viscid fluid; and 
 should they be highly inflamed, pus may form in tiiem. 
 
 A cyst arising from the prse-thyroid bursa presents itself as a 
 round tumor located on and above the Pomum Adami. Inas- 
 much as it is often small and painless, if it be of small size, it may 
 escape observation; but when it attains a large volume it pro- 
 trudes externally, and likewise internally, beneath the tongue. 
 In deglutition it follows the movements of the larynx. 
 
 A cyst from enlargement of the thyro-hyoid bursa or of the 
 supra-hyoid bursa, is of frequent occurrence; and its nature 
 would be indicated by the attachment of the cyst to the hyoid bone. 
 
 These cysts, when they grow upwards and encroach on the 
 sublingual space, simulate ranula; and such cyst is not inaptly 
 named a pseudo-ranula. In the chapters devoted to ranula, this 
 matter has been treated of. 
 
860 TUMORS OF THE NECK. 
 
 Boclidalek and Zuckerkundl have observed cases of cyst 
 derived from occlusion and subsequent dilatation of the fora- 
 men ciecum. And Zuckerkundl has seen cysts which were 
 derived from a degeneration of the small gland which lies near 
 the body of the hyoid bone. 
 
 An accurate diagnosis of these bursal cysts based upon struc- 
 tural origin is difficult, sometimes impossible; and this is due to 
 the structural ground of origin being so limited; and also to the 
 fact that the bursfe whence they arise are ver}' close together; 
 such diagnosis, however, is of no practical advantage to the 
 patient. 
 
 From irregularities in development of the visceral arches and 
 closure of the intermediate clefts cysts arise; and these, in situa- 
 tion, may be on the side of the neck or near the median line; 
 those on the sides arise from the ill-closure of the horizontal 
 clefts between the arches, while those in the median line arise 
 from defective closure of the anterior ends of the arche.s. The 
 cysts comprised in this group may contain dermoid, atheromatous 
 or liquid content. 
 
 Dermoid cysts of large volume have been observed here; the 
 content of such may be epithelial detritus, sebaceous matter and 
 hair. Or, not infrequently, it is a pure atheromatous tumor of 
 sebaceous content unmixed with other material. 
 
 The cyst of liquid content may originate from irregular 
 closure of the clefts between the arches; and the usual sites of 
 such cyst correspond to that of the second and third branchial 
 clefts. And the content may be clear, serum-like ; or it may be 
 viscid and gelatinous in character. 
 
 Both the cysts of atheromatous and serous content are remark- 
 able for the firmness and density of their containing sacs; and 
 this sac is closely adherent to parts around; the latter character- 
 istic is one which the surgeon who has removed them has well 
 learned. 
 
 An anomalous miniature thyroid gland may degenerate and 
 assume a character similar to some of the cystic forms that have 
 just been mentioned. Likewise, the lymphatic gland may undergo 
 changes in which it assumes a cyst-like form. 
 
 The cysts which have been considered, whether of dermoid, 
 atheromatous, or liquid content, may be })resent at birth; or the)' 
 may develop after birth. They can remain stationary for a long 
 time ; and then they may, from some cause, often unknown, be 
 awakened to fresh development. They are commonly located in 
 
LYMPH-ANGIOMA. 8G7 
 
 some part of the space between the larynx and the parotide an 
 space, frequently near the angle of the jaw. Yet in a few 
 cases the growth was located on the lowermost part of the 
 neck. Exceptionally, such cyst has been found located within 
 a lipomatous tumor of the neck. 
 
 These cysts may run a long course without giving inconven- 
 ience, sometimes even not attracting the attention of the pos- 
 sessor; again they may attain such dimensions, that through 
 compression on muscles, nerves or vessels they cause trouble. 
 The cyst may open externally; and, very exceptionally, it has 
 ruptured into the pharynx, as was seen by Savory. 
 
 When it opens externally a fistulous orifice may remain indef- 
 initely long ; and inflammatory action, alternately appearing 
 and disappearing, may seriously interfere with the health and 
 comfort of the patient. And when such perforation is threat- 
 ened, it is better to resort to some plan of treatment which will 
 avert the consequences of a rupture of the cyst. 
 
 Treatment. — As curative methods of these cysts are excision, 
 injection, and subcutaneous ruj)ture; the latter two are only 
 suited to cases of liquid content, as, for example, the bursal. 
 
 In extirpation the containing wall must be wholly removed ; 
 a fragment left behind will insure a recurrence of the cyst; a fact 
 which the writer has verified by observation; and he regrets to 
 add, also, in practice. The close adherence of the cyst's walls to 
 parts contiguous renders dissection tedious ; and the field of 
 work is obscured by the bleeding which results from opening 
 small vessels which enter the wall of the sac. The liquid species 
 may be treated with injection of tincture of iodine. 
 
 Lymph- Angioma. — A recent chapter has been added to the sur- 
 gery of the neck, detailing a cystic tumor which has its origin in 
 the lymph vessels of the neck. Koster and Wegner have dis- 
 covered the lymphatic origin of these growths. Both the lym- 
 phatic vessels and the lymphatic glands are concerned in the 
 origin of this tumor, which is correctly named by Wegner, a 
 lymph-angioma. It is chiefly found in the newborn child, yet 
 it has developed in adults ; and it may occur elsewhere than in 
 the neck. 
 
 At birth the lymphatic cyst may be well developed; or it may 
 be in the first period of development. In the foetus, miscarried 
 at an early age, such tumor and other deformity have been seen. 
 
 Such growth is a congeries of smaller cysts"; and in volume 
 these may vary from the size of a pea to that of an apple. The 
 
868 TUMORS OF THE NECK. 
 
 growth may be on the back of the neck, and divided there into 
 two parts by the ligamentum nucha3. The containing wall 
 may be thin or thick; and sometimes thin plates of bi)ne or 
 cartilage are found in it. From the main wall polypoid processes 
 sometimes project into the cystic cavity. The content varies; it 
 may be a translucent serum, or it may be discolored with pig- 
 ment; and in some cases it is gelatinous in character. 
 
 This cystic tumor is usually multiple, and then contains a 
 number of hollow spaces, in chain form, necklace-like; or as an 
 irregular conglomerate, it may lie in the spaces of the cervical 
 connective tissue, in which normally lie the lymph vessels. 
 And following the loose connective tissue spaces of the neck, the 
 growth develops laterally, as well as inwards; the muscles and 
 vessels are severally forced asunder; and sometimes the cj'st is 
 closely attached to the veins. It grows in the direction of the 
 least resistance; and may ascend on the face, and penetrate the 
 floor of the mouth; and below, it may penetrate the thoracic 
 cavity. 
 
 Though this cystic growth attains great dimensions, it rarely 
 injures the muscles on which it encroaches; though from such 
 pressure the salivary glands may be caused to atrophy. 
 
 In some cases, this cystic growth remains subcutaneous in 
 site, and then uplifting the skin, the surface of the latter is ren- 
 dered nodulated, or uneven. But if the growth commences deep 
 in the structures of the neck, it may remain invisible for a long 
 period, especially if the panniculus adiposus be thick. The over- 
 lying skin commonly remains unaffected in its texture, and often 
 it remains freely movable over the subjacent tumor. 
 
 The functional disturbance which can arise from the lymph- 
 angioma depends on its site; if ^it lie superficial, although of 
 broad extent, it causes but little trouble; but if it lie deeper, it 
 may impede the return of venous blood from the head, and dis- 
 turb breathing and deglutition; such functional disturbance is 
 exceptional; and commonly, the infantile subject shows no symp- 
 tom except slow emaciation. And then, if the lymph-angioma 
 lies deep, the diagnosis of the causal agency of such emaciation is 
 not easy to determine; but in cases in which the growth is pres- 
 ent as a nodulated development on the neck, then the cause of 
 failing nutrition is evident. It might be mistaken for a lipoma- 
 tous growth ; yet a puncture with the hj^podermic needle would 
 banish doubt, since the cyst would yield its characteristic content. 
 
 The prognosis of this lymphoid cyst is not auspicious; a few 
 
ANGIOMA. 869 
 
 cases through spontaneous rupture of the tumor have recovered; 
 a few have yielded to surgical treatment; but the greater number 
 of infants so affected have perished through gradual atrophy. 
 
 As treatment, extirpation, free incisions and injection have 
 been resorted to; extirpation is difficult to do, and attended with 
 risk of life, owing to the irregular tumor penetrating deeply into 
 the structures of the neck; so that such operation has often been 
 suspended before completion. Multiple incision has been found 
 to be a safer plan; such incision causes inflammatory, and per- 
 haps suppurative action, tending to obliteration of the lymphoid 
 cystic spaces. Cases have been treated by injecting into the 
 affected parts some corrosive fluid, as a solution of chloride of 
 zinc or the tincture of iodine; this work must be done carefully, 
 else swelling may be provoked which will cause suffocation. 
 The introduction of a seton through the affected structure is rec- 
 ommended by Smith, who has cured cases in this way; others, 
 however, strongl}^ condemn it. 
 
 Amidst these conflicting opinions of the surgical authorities, 
 the practitioner, who may have a case to treat, is left in wavering- 
 uncertainty whether he shall commit his i:)atient to the resources 
 of nature, which here are equivocal, or adopt one of the means 
 mentioned, of which the event is equally equivocal; and were the 
 writer to adopt the latter course, he would inject, drop by drop, 
 a five per cent solution of chloride of zinc. 
 
 The cystic lymph-angioma, as stated, has rarely been seen 
 except in the infant; a few cases, however, have been seen in the 
 adult, and were situated near the sterno-cleido-mastoid muscle, 
 either above or below. In some of the cases, the tumor was 
 easily extirpated. 
 
 Angioma. — Every grade of angioma, from the superficial 
 blood-mark and capillary telangiectasis to the massive cavernous 
 tumor, has been observed on the neck. Of such growths, the 
 cavernous tumor of venous structure is not unfrequent; and this 
 tumor is often distinguished by its tendency to spread over a 
 large part of the surface of the neck; and though its favorite site 
 is the supra-clavicular fossa, yet it may extend beyond the limits 
 of the neck, and then appear upon the thorax below; or the 
 growth may appear above on the cheek, or within the mouth. 
 
 The venous angioma may be congenital; or it may appear 
 later in life; and it may remain of an unchanging volume; or it 
 may lessen in form; or from some cause, patent or latent, it may 
 be excited in increase of growth. Through compression, the vol- 
 
870 TUMORS OF THE NECK. 
 
 ume may usually be reduced; yet, if the angioma have but 
 .slight commuuication with contiguous vessels, then pressure 
 scarcely changes its form. The angiomatous tumors when near 
 the surface are easily recognized; but when situated deep, they 
 liave resemblances to the deep-seated lymphangioma or lipoma; 
 in such cases, doubt can be exchanged for certainty by the use of 
 the hypodermic needle, through which the content, if liquid, can 
 be obtained. The lipoma, through its attachment to the skin, if 
 displaced, carries the skin with it, and maps the latter off into 
 rounded elevations and intervening depressions. 
 
 Treatment. — As treatment, numerous plans have been advised; 
 those meriting mention are the following: (1) Excision and 
 immediate or subsequent closure of the breach by one of tlie plas- 
 tic procedures; (2) transfixion of the structure with heated pins; 
 (3) inclusion of the transfixed structure by elastic or inelastic 
 ligature; (4) cauterization thermally, or potentially. 
 
 In case the angioma occupy a limited space, the speediest and 
 most satisfactory means of liberation from the growth is to excise 
 it at once. To do this, surround the growth by a circumscribing 
 cut, which shall lie in tlie normal tissue, directly contiguous to 
 the growth; thence pass inwards between the affected and unaf- 
 fected structures; and should a vessel be opened, close this by 
 torsion or ligature; by the former, if possible. And then proceed 
 to closure of the breach by juxtaposition through lateral sliding 
 of the dermal margins; and, if possible, this must be done, so 
 that the line of closure will be vertical and not transverse; for 
 thus placed, the movements of the neck M'ill but slightly disturb 
 the wound. In case direct apposition cannot be thus affected, a 
 pedunculated replacement-flap can be uplifted from the lateral 
 integument, where the skin is least tense, and can best be spared. 
 If the bridge can not then be dermally bridged over, it can be 
 accomplished epidermally, by means of Thiersch's method of 
 closure by cuticular grafts, in which elongated strips of epiderm 
 are removed with a razor from some part of the body (by prefer- 
 ence from the thigh), and are transplanted on the raw wound. 
 
 Another method is transfixion with pins, which may be thrust 
 in after being heated; or the heat may be applied to the pin after 
 its introduction by a plan that lias already been described in the 
 section devoted to angioma seated on the head. After such heated 
 pins are in place, they may be constricted by elastic cord, by 
 which the included structure will be strangulated. The cure 
 obtained in this way is objectionable, since it consists in the 
 exchange of the angioma for an unsightly soar. 
 
BLOOD-CYST. 871 
 
 The treatment by actual cauterization may be done by apply- 
 ing heat to the surface of the angioma; but this superficial appli- 
 cation of heat is unsatisfactory, since in order to thus consummate 
 the work, the cauterization must often be repeated. But should 
 the potential cautery be preferred, then one of the following escha- 
 rotics may be used: chloride of zinc mingled with an equal part 
 of wheaten flour; potassa fusa mixed with a similar amount of 
 calcined magnesia; Emplastrum Picis Burgundicae, on each square 
 inch of which there has been sprinkled one grain of Antimonii 
 et Potassse Tartras; or Pulvis Ipecacuanhge commingled with an 
 equal quantity of vaseline may be applied on the surface of the 
 angioma. By means of the first two agents, the surface to which 
 they are applied is quickly deprived of its vitality and becomes 
 gangrenous; but by the compounds of Ipecacuanha and Antimony, 
 the work of destruction is done through severe pustulation. The 
 action of the fused potash penetrates deeply; while the pustula- 
 ting compounds act more superficially; and all are subject 
 to the inevitable fault, that they leave a most conspicuous 
 cicatrix. 
 
 Blood-cyst. — Michaux and others have observed cysts on the 
 neck, of which the content is blood, and the origin of which is 
 explicable in one of the following ways: the cyst may arise from 
 some congenital defect of a blood-vessel; or it may originate in 
 an angioma seated in the wall of a vein, and which, finally, by 
 pressure, establishes a communication with the vein; and also, 
 a varicose dilatation may form in a vein, near its entrance into a 
 larger vein; and such dilated space maybe so walled off as to 
 resemble a cyst. And in whatever way the cyst may form, as a 
 rule it is compressible and reducible through its blood being 
 forced into an adjacent vessel; still there are exceptions to this, 
 as in some instances observed, the volume was not lessened by 
 compression. 
 
 It is probable that the blood-cyst may, sometimes, arise from 
 a cyst of serous, lymphoid or other fiuid content, through atten- 
 uation of the walls and the consequent rupture of a neighboring 
 blood-vessel, and the replacement of the previous content of the 
 cyst by blood. 
 
 The blood- cyst, whether appearing congenitally or subsequent 
 to birth, may remain of limited proportions; or it may grow 
 until it reaches great dimensions, and covers a large space, whicli 
 may encroach on the thorax below, or on the head above. The 
 skin is usually not implicated in the growth. Such tumor may 
 
872 TUMORS OF THE NECK. 
 
 cause 110 inconvenience, yet when voluminous and near some 
 vessel, it has caused much trouble by pressure. 
 
 The modes of treatment employed have been total excision, 
 the injection of some coagulating agent, or coagulation induced 
 by the introduction of a heated needle into the cyst. Total excis- 
 ion is the best method, provided the anatomical conditions are 
 such as will permit of the entire removal of the cyst. A less 
 radical method, if the tumor has no vascular connection or outlet, 
 is to attempt coagulation by injecting into the cyst tincture of 
 iodine, tincture of nut-galls, or a solution of a salt of iron. Should 
 the cyst have a connection with a vessel, then this method of 
 coagulation is hazardous, as the clotted blood might enter the 
 circulation, and become the agent of embolic occlusion; in such 
 cases the choice would lie between non-interference, or a perilous 
 extirpation. 
 
 C yst-like collections of blood may arise from external violence, 
 through which a vein or artery is rujDtured subcutaneously; and 
 afterwards, the channel of communication becomes closed. Such 
 cyst, when small, disappears through absorption; but if larger, 
 the content may be aspirated, and the cystoid space closed by 
 compression. 
 
 Cystic tumor of parasitic origin has appeared on the neck, the 
 causal agent being echinococcus; and the site of the growth was 
 the sides of the neck, and never directly in front, or behind. 
 This lateral location points to the probable fact that the causal 
 agents have reached the region through the large vessels on the 
 neck, and then entering the smaller vessels have thence penetrated 
 into the tissues, in which they further developed. 
 
 The echinococcus cyst has been known to attain great dimen- 
 sions on the neck, and to cause serious trouble through pressure 
 on the vessels and nerves; in the case reported by Dixon, the 
 tumor so pressed on the subclavian artery where it crossed the 
 first rib, that the circulation in the vessel was arrested; and as 
 result of this, the pulse disappeared at the wrist. And in another 
 patient the growth developed upwards, and encroached on the 
 pharynx. 
 
 The content may be transparent, yet it may be mingled with 
 pus. A characteristic of the tumor is that it may suddenly grow 
 rapidly, and then cease for a period, and, afterwards, start into 
 activity again. Usual qualities of the tumor are the absence of 
 albumen in the fluid, the presence of benzoic acid, and of frag- 
 ments and booklets of the parasite; tiiese booklets, discoverable 
 by the microscope, definitely decide the nature of tiie tumor. 
 
SOLID GROWTHS OF THE NECK. 873 
 
 This tumor is commonly painless, and if it remains small, it 
 may -be borne without inconvenience; yet when voluminous, 
 there is danger that it may press on a vessel, and opening its 
 wall, serious bleeding can thus occur. Boegonhold reported a 
 case of fatal hsemorrhage thus arising. 
 
 Treatment. — The usual treatment is excision and enucleation 
 of the cyst; or, what is safer, the cyst may be opened by an inci- 
 sion, and then the sack, separating itself from the neighboring 
 structures by suppuration, may be more safely removed than if 
 directly dissected out with the knife ; in the latter way there is 
 more peril of opening a vessel. 
 
 Solid Growths of the Neck. — The lymphatic glands are the 
 frequent site of neoplastic development; and these may be benign 
 or malignant in nature. 
 
 Simple hypertrophy of the cervical glands, which may be 
 named benign lymphoma, is a phenomenon familiar to both 
 physician and surgeon; let there be a lesion of the derm, mucous 
 membrane or intervening structures of the neck, which is attended 
 by suppuration for a few days, and there will occur a swelling in 
 one, or several of the lymphatic glands, which are near the site of 
 lesion. If such gland could be microscopically examined, the 
 enlargement would be found to be due to a multi^^lication of the 
 glandular elements. The tumor is painless, and even in the 
 observing adult, it may long remain unknown unless it be acci- 
 dentally discovered by the subject of it, or by his physician. 
 
 Such hyperplased glands which have arisen from simple puru- 
 lent irritation, may remain of constant volume for a number of 
 days, or even weeks; and then they usually vanish without sup- 
 puration. Should the causal agency be of tubercular nature, or 
 should the local lesion be associated with a tubercular diathesis, 
 then the prospect of an early disappearance is less promising; for 
 in such cases, suppuration and perforation of the skin, are the 
 usual events. 
 
 The sovereign remedy for the hypertrophied glands of the 
 neck is iodine given internally, and applied externally. As 
 external application, iodized collodion, previously referred to in 
 this work, is one of the best remedies; the collodion compresses, 
 while the iodine exercises its dispersive action. And should this 
 method fail, a resort may be had to enucleation, described 
 hereafter. 
 
 As a means of reducing the glands, especially when the enlarge- 
 ment is due to tubercular disease, the writer advises the injection 
 into the tumor of the following mixture: — 
 56 
 
874 TUMORS OF THE NECK. 
 
 R. Iodoform 51 
 
 01. Oliva). 
 
 Aether. Sulph iia 3vij 
 
 Misce. 
 
 Of this inject a few drops every third day. It may be added that 
 Garre' of Tubingen has lately reported the cure of a large number 
 of cases of goitre by this interstitial use of iodoform. 
 
 Sarcoma of the Cervical GlancU. — The sarcoma may appear in 
 an isolated lymphatic gland; or the disease may appear simul- 
 taneously in several glands. 
 
 "When an isolated gland is the seat of sarcoma the first 
 symptom is enlargement; and, if examined, the characteristic 
 round cell of different dimensions will be found; also the fusi- 
 form cell may be seen, which has arisen from a transformation of 
 the round cell. The normal glandular elements may be entirel}^ 
 replaced by these round or elongated cells. The enlarging gland 
 crowds on the overlying skin, and perforating it, an ulcerating, 
 self-producing, and self-destroying neoplasm forces itself into 
 view. The self-asserting growth takes possession of the contig- 
 uous space around and underneath ; and, in doing so, it erodes 
 and penetrates vessels and muscles: thus bleeding on a small 
 or large scale can arise. Also, from lesion of the vessels, a door 
 is opened for the admission of sarcomatous elements: thence the 
 reappearance of the disease in parts near by or remote; yet more 
 commonly at some distance from the site of origin. As a rule, 
 the immediately adjacent glands are overleaped in this metastatic 
 development. Sites of distant reappearance are the lungs, liver, 
 spleen and other remote parts. The disease commonly ends 
 life, according to Winiwarter, within eigliteen months. Some- 
 times, however, the disease runs a prolonged course of some 
 years. 
 
 Instead of confinement to one point in its origin, this glandu- 
 lar sarcoma may appear simultaneously in a number of the 
 cervical glands: a form that may be named multiple sarcoma- 
 tous adenoma. And this may run a rapid or a slow course; and 
 it tends to metastatic diffusion similar to the form just described. 
 The writer has seen several examples of this form, in wliich, 
 during a few months, the glands of one side of the neck became, 
 almost simultaneously, the site of sarcomatous disease. In one 
 case an attempt at extirpation served no better purpose than to 
 give the disease general diffusion. 
 
SARCOMA OF THE CEEYICAL GLANDS. 
 
 875 
 
 Sarcoma of adenoid origin, in which sarcomatous and cystic 
 structure were commingled, has been seen by the writer ; in such 
 a case shown in the adjacent sketch the tumor was borne by the 
 man until it had reached a volume equal to his head. After the 
 removal of this tumor, it was found, on section, to consist of 
 adeno-sarcomatous tissue, in which were spaces filled with serum- 
 like fluid. It seemed to have originated from glands in the 
 parotidean sulcus, behind the ramus of the lower jaw, and in its 
 development it had distended and greatly displaced the derm of 
 the cheek and neck: and in the subdermal tissue were numerous 
 veins of dimensions greater than the normal external jugular 
 vein. 
 
 Figure 94. Exhibiting a sarcomatous tumor successfully removed by the 
 writer. 
 
 As setiological factor, Konig refers to slight traumatism near 
 by or remote as causal agency. 
 
 The treatment of these cases will be given at the close of this 
 chapter. 
 
 Malignant glandular disease, similar to the forms mentioned, 
 has been described under the liead of carcinoma by some writers. 
 Yet these are pathological types which decline to be stereotyped; 
 for elements which forsake the physiological domain often 
 indulge in ruleless liberty and lawless riot, and in their altered 
 
570 TUMORS OF THE KECK. 
 
 form they embarrass the diagnostician. In the microscopic 
 examination of many specimens of malignant growths, the 
 writer has occasionally found resemblances so close to both sar- 
 coma and carcinoma that the tumor would not have been inaptly 
 named sarcoma-carcinoma. Such a name would screen surgeon, 
 writer and microscopist from mistaking tlie one form for the 
 other, and would properly designate those tumors which the writer 
 has occasionally seen, in which the cell-forms of both sarcoma 
 and carcinoma coexist. 
 
 The glands of the neck are often the site of secondary 
 enlarsrement, as the metastatic concomitant of carcinoma, sarcoma 
 or of a primary syphilitic chancre in the lips, or a secondary 
 syphilitic lesion of the buccal cavity. 
 
 Carcinoma seated in the scalp, any part of the face, within 
 the mouth, throat, or oesophagus, or within the larynx, sooner or 
 later infects the glands of the neck through tlie medium of the 
 lymph-vessels which connect the affected part with the glands. 
 
 Mammary carcinoma occasionally presents a metastatic tran- 
 sition from its primary site to the glands which lie in the lower 
 portion of the neck near the clavicle; in such cases the disease 
 has previously appeared in the axillary glands, and in those 
 beneath the pectoralis major, near the clavicle. Supra-clavicular 
 glandular affection, as a consequent of mammary cancer, is an 
 omen of ill import ; such metastasis indicates recurrence which 
 is incurable. This glandular infection is rarer in mammary 
 sarcoma; and it is oftener seen in sarcoma arising in the parotid 
 gland and other .structures of the head. 
 
 Syphilitic affection of the glands near the chin has originated 
 from labial chancre; glandular infection, as an accompaniment 
 of constitutional syphilis, is seen in all the glands of the neck, 
 both superficial and deep; and such infection, usually referred 
 to vaguely as a manifestation of secondary syphilis, is probably 
 referable to some local secondary lesion; namely, an ulcer or 
 breach of surface on the tongue, floor of the mouth, palatal 
 structure, tonsil or phar3'nx. A breach of surface in any of the 
 parts named seems to be inoculable by the salivary or mucous 
 secretions of the patient; and thus through the lymph-channels 
 the glands of the neck may be tertiarly affected. 
 
 The syphilitic glands ma}^ attach themselves to the skin, and 
 from non-treatment or improper management, the glands may 
 suppurate, and finally perforate the skin. If permitted to run 
 its own course such a gland disintegrates from the center towards 
 
MALIGNANT LYMPHOMA. 877 
 
 tlie circumference; and as it does so the broken-down elements 
 are eliminated through a fistulous opening; and the derm around 
 the opening becomes of a purplish color, which continues long 
 after the gland has disappeared through suppurative or absorp- 
 tive action. 
 
 Scrofula or tuberculosis often appears secondarily, and some- 
 times, primarily in the cervical glands. Frequently but one or two 
 glands are, at first, the seat of enlargement; thence the affection 
 extends to adjacent glands; and it may, finally, appear as a 
 nodulated chain of enlarged glands from the chin to the ster- 
 num. The tendency is to suppuration, though under appropri- 
 ate treatment, the glands may be restored to their normal 
 volume without suppuration. When suppuration ensues the 
 glandular structure may liquefy, and be found as a cheese-like 
 substance; or, what is not unusual, the content is of a thin, 
 cream-like consistence, in which the microscope discovers numer- 
 ous quadrangular crystals of cholesterine. 
 
 Malignant Lymphoma. — There is a form of malignant disease 
 of the glands of the neck which is closely akin to sarcoma; but 
 it differs from sarcoma in this, that its development is confined 
 to the lymphatic glands, while sarcoma may arise in any tissue 
 of the body, and invade in its growth the contiguous structures. 
 Sarcoma seated in the neck, and of glandular origin, has already 
 been mentioned ; and a leading characteristic of the tumor 
 described is that it fastens itself to the overlying skin and finally 
 perforates the dermal covering. But in the malignant disease 
 now under consideration, the most remarkable clinical feature is 
 that the skin remains unaffected; and, also, in most cases, the 
 containing capsule of the gland remains, in a great measure, 
 unaffected by the glandular disease. 
 
 The anatomical structure of the lymphatic gland has been 
 studied by Teichmann, Kolliker, Robin and others ; and in the 
 main, these structural elements may be grouped as follows: the 
 gland is contained in a fibrous capsule consisting of connective tis- 
 sue; and from the inner face of this proceed trabeculated partitions, 
 dividing the gland into alveolar spaces. The gland when en- 
 larged is often easily separated from this wall: and, when in 
 the work of enucleation, the gland is adherent to a vessel, or 
 dangerously near it, then the operator may Tvork safely by merely 
 incising one side of this envelope, when he is able to enucleate 
 the proper glandular structure. As said, within this capsule, 
 and subdivided by trabecular septa, is contained the glandular 
 
S7S TUMORS OF THE NECK. 
 
 substance: a tissue abounding in nuclei and cells resembling 
 lymph-corpuscles; these elements are more numerous near the 
 outer part of the gland; wliile towards the central portion of the 
 gland one finds a mesh of blood-vessels and lymph-vessels. 
 
 In the malignant lymphoma, named also lympho-sarconia, 
 there is also a great increase of the proper glandular elements; 
 but the containing capsule is usually but slightly tliickened, 
 and is easily separable from the glandular tissue. An exception 
 to this was observed by Verneuil, who saw a case in which the 
 enlargement consisted wholly in a great thickening of the capsule; 
 so much so, that he named tlie growth capsular lymphoma. In 
 this patient there were a number of sucli enlarged glands in the 
 neck, separated by slight intervals. 
 
 The malignant lymphoma is usually soft in structure; occa- 
 sionally, examples have been seen in which it was hard. In 
 fact, in the history of the malignant lymphoma, though there be 
 a M'ant of unanimity on some points, yet most writers agree that 
 the disease commences as a soft form, and thence changes to a 
 hard one. 
 
 In malignant lymphoma, the disease appears unsuspected^ 
 and, for a time, unseen ; when discovered it consists of an enlarge- 
 ment of one or more of the cervical glands; and these enlarged 
 glands finally a})pear in segregated groups on one side of the 
 neck; yet exceptionally the disease attacks the glands on both 
 sides of the neck. These masses are commonly three in num- 
 ber. In the soft variety the enlarged glands are exceedingly 
 movable. If such a growth be removed and examined, it will 
 present, on section, a grayish yellow, non-vascular structure; and 
 though less soft, it resembles the substance of the brain of an 
 infant ; with the microscope, one discovers that tlie tissue con- 
 sists of elements analogous to those of the normal gland; yet the 
 cells are increased both in number and in volume. The struc. 
 ture is homogeneous from periphery to centre. 
 
 In case the glands become indurated, they often excite some 
 inflammatory action contiguous to them, so that they are less mov- 
 able than in the soft form. 
 
 In both the soft and hard species, according to Winiwarter, 
 the new growth is from the preexisting cellular elements of the 
 gland; and the new structure is, at first, soft, and afterwards 
 hardens through conversion into indurated or fibrous tissue. 
 
 If the disease is behind the angle of the lower jaw, the tonsil 
 becomes involved. Instead of the affection remaining unilateral, 
 
MALIGNANT LYMPHOMA. 879 
 
 it, exceptionally, appears on both sides of the neck; and in each 
 case the subjacent glands which lie in the axilla, in the mediasti- 
 nal space, and those about the tracheal bifarcation, finally, 
 become infected. The mesenteric glands are next implicated, 
 and become so enlarged that they can easily be felt through the 
 anterior abdominal wall, in the hypogastric and iliac regions. 
 During the time that the disease is confined to the cervical glands, 
 the patient, who is in childhood or mature youth, is in general 
 good health; but when the disease penetrates the chest, there 
 often arises a teasing cough, due, probably, to pressure on the 
 sensory nerves of the langs. A tenacious material is expectorated; 
 and there is some elevation of temperature.*' As the disease 
 proceeds, localized infiltration takes place in the lungs, spleen 
 and liver; and such infiltrate is texturally similar to that of the 
 affected glands. The general nutrition is imj^aired; the patient 
 becomes pale and listless; his tissues become soft, flabby and 
 anasarcous; and there is often an ascitic accumulation. The 
 chyle-channels being obstructed, the nutritive materials are 
 directed from their destination, and, as in enteric fever, they 
 excite a diarrhoea. The ill nourished heart fails in its propulsive 
 power; and life commonly ends within two years, if the disease 
 has not been arrested by treatment. 
 
 After this enumeration and description of the glandular affec- 
 tions that appear on the neck, before entering on the treatment, 
 something should be remarked in regard to their diagnosis, and 
 the signs by which one class can be distinguished from another. 
 
 The true nature, in case of simple hyperplastic enlargement 
 arising from some traumatic,, eczematous or other lesion of the 
 adjacent surface, is revealed by a discovery of »uch lesion. In 
 the tubercular or syphilitic subject, the appearance of glan- 
 dular enlargement is due to the existing dyscrasy, wdiich, if 
 not at once apparent, is discoverable in the history of the patient. 
 If the case be one of sarcoma or carcinoma, it will be character- 
 ized by growth without suspension of development, or limitation 
 of volume; and with a tendency to invade and penetrate neigh- 
 boring structures; and finally, to perforate the skin and to pre- 
 sent a mass of growing and disintegrating tissue. Metastasis 
 may occur in parts remote, as well as in structures near by. 
 Before the disease has reached these widespread dimensions, its 
 malignant nature ceases to be a matter of question. But as an 
 early determination of the disease is important for operative 
 purposes, hence, as aid, a particle of the growth may be extracted 
 
S80 TUMORS OF THE NECK. 
 
 with a small harpoon, or special acupuncture needle, and its 
 nature determined by the microscope. The prominent and dis- 
 tinguishing features of the malignant lymphoma have been 
 detailed, and ofifer a well-defined diagnostic picture of the disease; 
 to rehearse the principal of these, the following may be mentioned : 
 the infantile, youthful or vigorous subject, the softness and great 
 mobility of the glandular tumor, and the aggregation of these 
 into definite groups on the neck, are facts sanctioning the diag- 
 nosis of malignant lymphoma. 
 
 Tlie diagnostician is sometimes held in doubtful embarrass- 
 ment by the apprehension that the case may be one of aneu- 
 rismal tumor; for example, any glandular tumor which is so 
 contiguous to an artery as to receive the pulsatile movement 
 of the vessel may closely resemble an aneurism. Distinguish- 
 ing aids in such a case are the following: if the aneuri;<m be 
 grasped gentl}^ between the fingers, it will swell during arterial 
 diastole, and, by pressure, its volume is reducible; such pressure, 
 however, should be done cautiously, lest the fibrinous clots be 
 loosened within the tumor. If the pulsatile tumor be noi:i- 
 aneurismal, it is not expansible nor comj)ressible, and frequently 
 it can be so moved or displaced from its site on the vessel that 
 the pulsatile movement cannot be perceived in it. Should the 
 evidence still be equivocal, there is a ready escape from the diffi- 
 culties in the use of the hypodermic syringe; for, as soon as this 
 enters an aneurismal tumor, a fine stream of red blood will 
 escape; but if it enter a solid or semi-solid tumor, nothing will 
 be seen, unless it be a drop or two of serous or sanguinolent 
 fluid. 
 
 Treatment of the Cervical Glandular Twmors. — The treatment 
 may bo divided into two methods: the non-operative and the 
 operative or surgical; and not unfrequently the two methods are 
 resorted to in the same case; medical means having been tried 
 and failed, the aid of the scalpel is invoked. 
 
 Certain classes of these tumors are amenable to and sometimes 
 are curable by endermic or interstitial treatment; viz., the syphi- 
 litic glandular enlargements and the malignant lymphoma. 
 
 The syphilitic glands, whether due to contiguous chancrous 
 inoculation, or to constitutional syphilis, are often reducible by 
 the internal use of iodine and mercury, and the local use of the 
 tincture or ointment of iodine. An external application which 
 acts well is the mixture of the compound tincture of iodine and 
 tincture of galls before referred to; this should be well painted 
 
CERVICAL GLANDULAR TUMORS. 881 
 
 on the swollen glands once daily. Or, instead of this mixture, 
 the compound of iodized collodion may be applied. Thus by 
 treatment, general and local, syphilitic glandular enlargements 
 may be reduced, and deforming scars thus avoided. 
 
 Local treatment often fails to accomplish the reduction of 
 scrofulous glands, and some operative method is usually resorted 
 to for relief in such cases. 
 
 Cervical glandular enlargement, due to some simple lesion of 
 surface near by, is removed by the topical use of iodine, and of 
 the iodized preparations, iodized collodion is the best; and this 
 should not be so strong as to blister the surface. Such weak- 
 ened mixture is the following:. — 
 
 5^. Collodii gij 
 
 lodinii puri gr. xvi 
 
 Kalii lodidi gr- xij 
 
 Misce. 
 
 Apply with a camel-hair brush once daily over the swollen 
 glands. By such an application compression and absorptive 
 disintegration are obtained, and diminution of volume secured ; 
 to effect this it is often necessary to continue the application for 
 some weeks. And even should suppuration occur, the tincture 
 of iodine may be used aloug with a cataplasm. In fact, by the 
 union of these seemingly antagonistic means the writeiihas seen 
 absorption accelerated, and, if suppuration was not arrested, still 
 it was lessened. 
 
 The glandular disease of the neck in which internal medi- 
 cation has won its chief laurels is malignant lymphoma. It has 
 been discovered by Billroth, with the active cooperation of 
 Winiwarter, Czerny, Israel and Tholen, that this disease can be 
 arrested and sometimes cured by the internal use of arsenic. 
 Long ago arsenic was given internally and applied outwardly in 
 the cure of malignant disease; and this fact led to recent exper- 
 imentation, which verified the belief previously existing. 
 
 To remain on the hither side of the line of danger in the 
 use of arsenic, in the essays with it, the patient was ordered at 
 first a small dose, and then to gradually increase the dose ; and 
 along with it some gave a preparation of iron or some bitter 
 tincture. Fowler's solution was the form in which the arsenic 
 was administered. The dose must be graduated to the age of 
 the subject. If a child, commence with one drop of the solution 
 three times a day, to which a half-teaspoonful of the wine of 
 
S82 TUMORS OF THE NECK. 
 
 iron, or of the infusion or tincture of gentian or Peruvian 
 bark, may be added; and, if the patient be aniemic, the wine of 
 iron is the preferable adjunct. If tlie patient be an adult, then 
 the incipient dose should be five drops. These doses in the child 
 or adult should be continued for three days, and then increased one 
 drop; and every third day the dose should be increased thus, 
 until the medicine causes some constitutional disturbance; and 
 this, in the child, will probably arise when the dose reaches 
 ten or fifteen drops, and in the adult twenty to thirty drops. 
 The irritant action on the constitution, as described by Tholen, 
 was as follows: in one patient the toxic effects of the arsenic 
 were manifested in an impairment of sight and hearing. In 
 another case the lymphomatous growths receded very rapidly, 
 and, as this occurred, there supervened a hsemophilic or general 
 h^emorrhagic condition, with sudden enlargement of the spleen : 
 and these conditions rendered the suspension of the remedy 
 necessary. In most cases the growths were rapidly reduced in 
 volume, and such reduction was attended by some pain in the 
 shrinking structures. Children were less affected by the arsenic 
 than adults; in the latter, the prolonged use of the ar.senic gave 
 rise to sleeplessness or disturbed sleep, trembling and unsteadi- 
 ness of the muscles; the patient was unfitted for mental and 
 phj'sical exertion; and finally, from general weakness, loss of 
 appetite*and energy, the patient sank into melancholy. The use 
 of the arsenic sometimes is limited to accessions of remittent 
 fever of a mild form ; this fever appears on the fourth or fifth 
 day of the administration of the remedy. 
 
 Besides the internal administration, the remedy was used by 
 Winiwarter interstitially with the hypodermic syringe. To do 
 this, let the needle be carefully cleansed on its surface; for if 
 used moistened with the solution it is apt to cause suppuration. 
 The needle should be inserted deeply into the gland, and a drop 
 of the fluid there deposited, and this may be repeated three 
 times daily. Should signs of suppuration appear, the evolution 
 of the pus should be favored by the use of warm poultices. 
 
 The remedy should be discontinued when its atrophic action 
 has been obtained, or temporarily suspended, should the toxic 
 action of arsenic appear. 
 
 Though the arsenical treatment may cause almost a total 
 recession of the glandular enlargements, yet unfortunately this 
 reduction is usually not permanent; as a rule, after some 
 months or a year or two, the disease occurs, and it becomes 
 
CERVICAL GLANDULAR TUMORS. 883 
 
 necessary to repeat the treatment. Though a complete care is 
 exceptional, and despite the fact that the remedy causes local 
 pain, and a depressing cachexy, yet the respite which has been 
 obtained in this grave disease must give arsenic a distinguished 
 place among the therapeutic acquisitions of modern medicine. 
 
 A'^erneuil has announced some essays with favorable result in 
 the use of phosphorus against malignant lymphoma; he gave 
 of a solution in oil from one to three milligrammes of phosphorus 
 daily. 
 
 The observation was recorded by Winiwarter that malignant 
 lymphoma may recede under the action of erysipelas which has 
 invaded the affected parts ; and an attack of articular rheuma- 
 tism has had a similar effect. And carcinoma has vanished in 
 the same way. Be'rard mentions a malignant tumor in the 
 neck which quickly disappeared under an attack of erysipelas, 
 yet it soon afterwards reappeared. And Reclus has observed a 
 patient in whom a malignant lymphoma quickly receded under 
 an attack of er3^sipelas on the arm; yet the permanency of the 
 cure remained undetermined, since the patient died from the 
 erysipelas. The facts here cited are suggestive of the probable 
 efficacy of the injection of the dilute culture of erysipelas in the 
 treatment of malignant lymphoma. 
 
 Mention should be made of other means of treatment of the 
 cervical lymphoma, whether benign or malignant; and among 
 these electrolysis deserves prominent notice. The electrical 
 treatment has been tried and commended by Schuster, Adams, 
 Duchenne and others. Duchenne found it to act the best in 
 cases in which the glandular enlargements are small, movable 
 and superficial. Demarquay is an ardent champion of this 
 treatment; he claims that failure to thus cure is rare. As a rule 
 the enlargement simply vanished; but in a few cases suppura- 
 tion was excited. 
 
 For a time the galvanic or constant current only was used , 
 later Meyer advised the employment of the interrupted current. 
 Generally the electricity was transmitted from the surface of the 
 skin; a few applied the current directly through needles which 
 penetrated the tumor. Meyer, who used the interrupted current, 
 reports some remarkable results by the employment of a very 
 strong current; by this means he claims to have sensibly reduced 
 the tumor within a minute or two. The reports are sufficiently 
 favorable of the action of electrolysis in the reduction of adenoid 
 growths to justify its trial in such disease. 
 
884 TUMORS OF THE NECK. 
 
 Trial has been made of massage, or rhythmical compression, 
 in the treatment of these affections; or in place of interrupted 
 compression, continued pressure has been employed. Larrey 
 and Recamier have recommended this plan. Kneading may 
 be done with the hand ; but if continued pressure is emj)loycd^ 
 this may bo done by means of compressed or ordinary sponge, 
 whicli is retained in place by a bandage, adhesive stri{)S or some 
 clasping and fixing instrument, of which one branch rests on, 
 and presses the sponge or lint against the enlargement. Such 
 pressure must be watched, lest it be carried to the extent of caus- 
 ing sloughing of the integument. Massage was used by Baudens 
 as a means to loosen the tumor, and thus facilitate the operator 
 in his work of removing it. 
 
 Malgaigne, Velpeau and others have practiced subcutaneous 
 laceration or discision of tlie gland by means of a fine needle, 
 which, being inserted in it, was twirled about so as to divide the 
 glandular structure in different directions. Suppuration was 
 sometimes induced in this way. 
 
 Cauterization, thermal and potential, has been advised in 
 the treatment of glandular enlargements. Verneuil advocates 
 thermal cauterization, done either on the surface or by igni- 
 puncture, in which heated points are thrust into the enlarged 
 gland. Potential cauterization has been practiced by IMaison- 
 neuve, who applied the escharotic peripherally or centrally. For 
 central cauterization he made a mixture of chloride of zinc and 
 flour, wiiich, being cut into arrow-shaped bodies, were thrust 
 through incisions in the skin into the gland. By this plan sec- 
 tions of the glands were destroyed; and also atrophic contraction 
 was induced in tlie portion which remained. A serious objec- 
 tion obtains against tlie treatment by cauterization, in the fact 
 that it is painful and entails deforming scars of the surface. ■ 
 
 The use of one of the several methods which have been 
 described will, sometimes, cure the benign glandular tumor; and 
 may be tried in patients whose lack of courage forbids the use of 
 the knife, or in whom the cure by non-operative measures is 
 desirable; but in a large number of cases, viz., in most malig- 
 nant growths, and in a number of the benign class, the aphorism 
 of Sanctorius is the proper rule for guidance; strumous or glan- 
 dular tumors will never be cured unless they be extirpated. 
 
 Writers under the exclusive inspiration of patriotic national- 
 ity have claimed for their countrymen the honor of originating 
 the method of excision in the treatment of the cervical alandu- 
 
CERVICAL GLANDULAR TUMORS. 885 
 
 lar tumor. Thus Gillette claims this palm for Petit, Chopart, 
 Desault, Dupuytren and Begin; esjiecially for the latter two. 
 The impartial writer, however, will find that besides the Gallic, 
 Anglican and American surgery has claims which would com- 
 mand recognition in such an international court of adjudication. 
 The surgeon who approaches the cervical field should be 
 warned that his presence there will only be justified by the pos- 
 session of certain natural gifts: coldness, intrepidity, skill, self- 
 possession. Such being the requisites, they are acquisitions possi- 
 ble to those who, Mezentius-like, will hold close communion with 
 the cadaver: one who has sacrificed uncounted and innumerable 
 hours in the dissecting room, will fearlessly penetrate and sepa- 
 rate the anatomical structures of the neck, even though they be 
 pathologically entangled and confused. 
 
 The surgical strategist, when he proposes to invade an}'- region, 
 should first mentally recount the anatomical elements which 
 exist there; and those structures, which are vitally important 
 and will be imperiled, should be noted in memory by ever visible 
 warning marks; thus proceeding, with a moderate share of manual 
 skill, the surgeon makes his way safely among the apprehended 
 impediments of any region, and is normally able to add another 
 unit to the statistician's column of " Successes." 
 
 In this mental survey of the topography of the neck, the 
 operator will remember that the external jugular veins lie near 
 the skin, and may be shunned by cuts in the long axis of the 
 neck; but transverse incisions will endanger the veins: a danger, 
 however, which can be obviated by double ligation and inter- 
 mediate section of the vein. Superficial nerves, viz., the branches 
 of the superficial cervical plexus which rest on or near the upper 
 portion of the sterno-cleido-mastoid muscle, can generally be 
 shunned; the auricularis magnus nerve should not be injured; 
 for this lesion disturbs the patient through the ansesthesia, 
 which is caused in the integument of the pinna. The spinal 
 accessor}^ pierces or passes behind the upper third of the sterno- 
 cleido-mastoid muscle, and its section will leave the trapezius 
 muscle, which it supplies, functionless. 
 
 The sterno-cleido-mastoid muscle has frequently been divided 
 without much detriment to the subject; and even a large jDart of 
 the muscle has been sacrificed bj' the writer, in the extirpation of 
 malignant growths, without ill consequence. The division of the 
 omo-hyoid muscle has also given no inconvenience. 
 
 As the knife penetrates deeper, and passes from the median 
 
SS6 TUMORS OF THE XECK. 
 
 line laterally, the following structures will be met: the laryngo- 
 tracheal tube and thyroid body; the superior and inferior laryn- 
 geal nerves; the latter 13'ing in tlie grove between the trachea 
 and the oesophagus; the carotid artery, the pneuniogastric nerve 
 and the internal jugular vein; and behind this vasculo-nervous 
 group lie tlie sympathetic nerve and its three ganglia, which have 
 connection with the heart. On the side of the larynx and hyoid 
 bone, besides the external carotid and its branches lie numerous 
 veins of large calibre; also the hypoglossal nerve. In the lower 
 part of the side of the neck lie the confluent roots of the brachial 
 plexus; and on the anterior face of the scalenus anticus muscle 
 lies the phrenic nerve, which enters the chest between the subcla- 
 vian artery and vein. The subclavian artery, arch-like, appears 
 on the lower part of the side of the neck. This subclavian 
 arch in different subjects has a varying height above the clavicle; 
 a variation that has, sometimes, led astray the searching scalpel. 
 
 The deep portion of the cervical region is separated from the 
 thoracic cavity by a thin pleural septum; a partition which must 
 not be forgotten in the hazardous excavations sometimes made 
 here to enucleate glandular neoplasm. Such a perforation 
 announces itself by a whispering or hissing sound of air rushing 
 to fill the vacuum arising in the inspiratory act. Tlie breach, if 
 accidentally made, may be occluded by lateral displacement of 
 some contiguous tissue. 
 
 Though the structures enumerated are so important, yet their 
 loss can be tolerated provided the destruction be limited to one 
 side. Duplication of structure, here as elsewhere, becomes an ally 
 in the continuance of life. Vessels have been closed by ligation, 
 both arteries and veins, and even sections of them excised in the 
 removal of malignant growths, and yet no serious trouble followed. 
 The pneumogastric and the phrenic nerves have been destroyed 
 on one side, and life still continued; nevertheless, though patients 
 have tolerated such mutilation of nerves, yet it should be avoided; 
 for it is safe to conclude that if death follow the destruction of 
 the vagus and phrenic on both sides, their unilateral destruction 
 cannot be an unimportant assault on the organism. 
 
 The vessels must be sedulously cared for; and the veins 
 demand a greater share of this care; since a large one being 
 opened, not only may death occur from the escape of blood, but 
 also from the aspiration of air into the vessel. This latter danger 
 was long ago observed, and many explanations of the fact have 
 been offered. The first impression was that the air contained some 
 
CERVICAL GLANDULAR TUMORS. 887 
 
 toxic principle; this has been abandoned, and replaced by the 
 theory that the air admitted into the right heart expands there, 
 so that ventricular closure is prevented; others, however, claim 
 that the air mingles and forms with the blood a gaseous emul- 
 sion, which entering the lungs interrupts the current of blood, 
 and fatal asphyxia thence results. And like the fish which 
 drowns itself when trying to escape from the angler's hook, so 
 the victim of aspirated air dies from too much air in his lungs. 
 
 It should be stated that Pirogoff asserts that the danger of 
 death from air entering a vein is much exaggerated; in fact, in 
 experiments on animals, he states that a large amount of air can 
 be tolerated if it be admitted slowly. Few share Pirogoff 's opin- 
 ion that air in the veins is not dangerous: authority is united in 
 teaching that it should be shunned as an element of extreme 
 peril. In vivisective experimentations E. S. Cooper, of San 
 Francisco, was accustomed to show his students the fatal action 
 of air thrown into the vessels; and as means of relief, he with- 
 drew with the same instrument the air which he had introduced, 
 when the dog, which the experiment seemed to have killed, 
 quickly rallied, and was none the worse for the surgical lesson 
 which he had taught. 
 
 As preparation for an operation on the neck, the patient's 
 chest should be somewhat uplifted, so that the head will be 
 slightly retroflexed; and the surface which is to be operated on, 
 should be well illuminated, and not darkened by shadow of 
 surgeon or his assistants. 
 
 As instruments required in the operation are the following: a 
 scalpel, blunt retractors, scissors, clasp-forceps in number propor- 
 tioned to the extent of the operation, blunt dissector, thread, 
 needles, drainage tube, sponge, antiseptic solution and aseptic 
 lint or gauze for dressing. 
 
 The primary incision, as a rule, should be longitudinal in 
 direction; in some cases, the cut may be made transversely or 
 obliquely. AVhen practicable, such cut should be made in the 
 line of the normal depression of the skin: for example, along the 
 anterior margin of the sterno-cleido-mastoid muscle; the scarring 
 is thus somewhat masked. The initial incision is best made as 
 an uninterrupted cut, which is carried from above downwards, 
 and should pass over the summit of the tumor. It should be 
 long enough to permit of complete exposure of the growth; and 
 will be best made when the derm is divided by one stroke; for 
 such a wound permits of perfect marginal coaptation and reunion, 
 
888 T^•^r()RS ok thk neck. 
 
 and leaves a vanishing scar. One incision often suffices; but if 
 the tumor be a large one, two parallel cuts some distance asunder 
 •U'ill facilitate the extirpation; for through the two incisions which 
 include the growth, the dissection can penetrate alongside of, and 
 beneath it; and through one lateral cut, the fingers can enter, uplift 
 and thrust the tumor out through tlie other incision. Also, the 
 dissection can be pursued on one side and tlicn on the other, 
 with such alternate displacement as will bring the subjacent 
 structures to view. In case the glandular growth lies beneath the 
 sterno-cleido-mastoid, the incisions should run along the borders 
 of the muscle; and then through one incision the introduced 
 fingers can force the tumor upwards and outwards through the 
 other cut; thus, without injury to the muscle, growths beneath it 
 can be removed. By the aid of such parallel incisions, an intact 
 dermal bridge will remain, which will span the breach which is 
 made, and promote the healing of the latter better than would 
 integument which had been sutured. 
 
 Incisions of flap-form are sometimes made; an objection to 
 this form is that the multiple incisions composing it do not 
 admit of such accurate coaptation as do single or parallel lines. 
 Also, the angles, wlien included in sutures, may become gangre- 
 nous and prolong the time of healing. 
 
 The removal of enlarged scrofulous glands is frequently 
 demanded: for such removal intrusted to nature is unendingly 
 tedious. Such diseased glands lie chiefly near the vessels; and 
 if they become inflamed, they contract adhesions with the vessels, 
 which render their extirpation difficult and perilous, from the 
 risk of opening the vessel. The incision should reach to the 
 capsule of the gland; and this being opened, the gland can be 
 enucleated with a curette, a blunt dissector or the finger; and, 
 though there be adhesion to a vessel, the gland can be loosened 
 and lifted out without disturbing the adherent capsule. This 
 capsule being left becomes a bulwark against bleeding. This 
 enucleation always proves a longer task than was at first calcu- 
 lated; the removal of one only opens to view another gland; the 
 searching index ever finds new work for the scalpel, or safer 
 curette; and finally, when the terminal link of the glandular 
 chain has been reached, there remains a deep chasm in the neck, 
 in the bottom of Avhich lie the carotid artery and internal jugular 
 vein, bared as if for an anatomical demonstration. In this glan- 
 dular excision it is rarely necessary to ligate vessels; veins are 
 oftener wounded than arteries; and when these are of some 
 
CERVICAL GLANDULAR TUMORS. 
 
 calibre, they should be doubly tied and intermediately divided. 
 The internal jugular vein is more endangered than the carotid 
 artery, since during the struggles, and expiratory efforts of the 
 patient, the vein becomes turgidly swollen with blood; and in 
 this state, a frightful flood of blood will follow its rupture. Such 
 a wound of the vein was treated by Wattmann by lifting up the 
 wall of the vein around the breach, and tying this: a procedure 
 known as parietal ligation. From the possibility of this proced- 
 ure leading to the formation of a clot in the vessel, it has had but 
 few advocates. Veins which are entirely divided, sometimes 
 retract so as to temporarily cease to bleed; and afterwards, when 
 the patient makes an expiratory effort, the bleeding may begin 
 again; and in such case, it is often difficult to find and seize the vein 
 in its retreat: hence to avoid such difficulty, the operator should 
 tie before cutting the vein; or what answers as well, seize the 
 vein, before cutting it, with forceps, and then apply torsion to both 
 ends. 
 
 Should a large vein be opened into which air might be aspi- 
 rated, the surgeon should instantly close the breach with his 
 finger; and then, while compression is being made on the vein 
 on the cardiac side, the vessel may be sought for and ligated. 
 A precautionary measure, which the writer has resorted to, is to 
 have an assistant maintain constant pressure, after the vessels 
 are reached, on the lower part of the neck above the clavicle; 
 such pressure will prevent the admission of air into an opened 
 vein. 
 
 In the treatment of the malignant lymphoma, as before stated, 
 internal medication is chiefly to be depended on ; yet from the 
 writer's experience, he is convinced that the scalpel may be a 
 valuable ally of the arsenic which is given internally. After the 
 enlarged glands were removed in a t^^pical case of malignant 
 lymphoma, the internal medication was continued for some 
 time: some five years afterwards, when the girl was reaching 
 puberty, the disease reappeared on the neck, and was treated 
 similarly without subsequent return of the affection. The opera- 
 tion in such a case is a simple one, since the glands are usually 
 movable, and, as soon as the containing capsule is open, the gland 
 can be isolated from the latter and removed with the loss of but 
 few drops of blood. 
 
 The removal of the sarcomatous or carcinomatous glandular 
 tumor is often one of the most difficult pieces of surgical work; 
 especiallv if the tumor has already attained large dimensions. 
 57 
 
890 TUMORS OF THE NECK. 
 
 During the earh' period of its growth, the sarcomatous glandular 
 tumor is movable, and, at that time, its extirpation is not diffi- 
 cult. The work can be done in the manner described for 
 removal of the benign glandular growth. If, however, such 
 tumor lias been neglected until it has formed adhesions with 
 the adjacent muscles and vessels, and become immovably fixed 
 to the deep structures of the neck, tlien the removal becomes a 
 laborious task, in which the blood-vessels must be severely 
 guarded, while dissection, proceeding stroke by stroke, accom- 
 plishes the work of removal; and this, to be a benefit to the 
 patient, must be complete; for incomplete excision not only 
 weakens the patient, but opens the way for a speedy return of 
 the disease. The subject of malignant disease can ill lose blood; 
 all loss of this must be watchfully avoided. To do this, initial 
 steps should be taken to seek the artery on the cardiac side, and 
 the vein on the distal side, of the tumor; and if one or both be 
 inextricably adherent to the growth, then ligation should be done; 
 and this accomplished, the operator proceeds cito, into etjucunde 
 with his work in almost bloodless tissue. 
 
 If the dimensions of such a growth be such that it reaches 
 below into the thoracic cavity, or above, it has involved the 
 structures which emerge from the foramen lacerum, or it penetrates 
 the carotid canal of the cranium, then the operation should not be 
 done, since it can have no other eff"ect than the immediate destruc- 
 tion of, or the abridgment of, life. Such unfortunates should be 
 told that they have a kindlier friend in the poppy than in the 
 scalpel; the acquisition of the opium habit will serve as a dis- 
 traction during the brief remainder of their existence; and 
 instead of shortening, it will probably lengthen life. 
 
 The wound should alwaj^s be so situated that the excreta 
 eff'used into it will have free escape, both in the sitting and the 
 recumbent posture. In some cases the wound may be entirely 
 closed, and the way or ways for drainage then are made through 
 the sound contiguous derm. If the mouth of the wound be on 
 the inner side of the sterno-cleido-mastoid muscle, it may be 
 closed, and a drainage tube passed underneath the muscle, and 
 carried through the surface beyond. Thus done, the tube will 
 lie on the vessels and must not be allowed to remain there long, 
 lest it erode or injure the coats of the vessels; and to avoid this, 
 the tube should be withdrawn somewhat, on the third day, and 
 shortened. The dressing should consist of lint moistened with 
 an alcoholized lotion. 
 
CERVICAL GLANDULAR TUMORS. 891 
 
 In the nucha or posterior structures of the neck neoplastic 
 developments occur, which are of non-glandular origin, and 
 beuign in nature ; such tumors are the lipoma, fibroma, and the 
 osteoma. 
 
 The lipoma is of the most frequent occurrence, and commonly 
 occupies the median part of the nucha. The normal capsular wall 
 of the lipomatous tumor, so well defined elsewhere, is commonly 
 not distinctly formed on tlie nucha; sometimes it does not exist, 
 and then the tumor is fused indefinably with the neighboring 
 structures. This ill-bounded li^^omatous development commonly 
 abounds in fibrous tissue, so that texturally it is denser, harder, 
 firmer, and less movable than the normal lipoma; and the fibrous 
 adhesion of such growth to the adjacent and subjacent structures 
 embarrasses the surgeon in the work of extirpation. 
 
 These adipose neoplasms may be sessile; or, in development, 
 they may project from the surface and, through their massive 
 form and weight, acquire a pedunculated form. Such a pedun- 
 culated tumor, shown in figure 95. was operated on by Little- 
 
 s 
 
 Figure 95. In which is exhibited an enormous pedunculated adipose tumor 
 arising from the posterior face of the neck. (From Dictionaire Encyclopedique 
 des Sciences Medicales.) 
 
 wood; though arising from the upper part of the nucha, it was 
 pendent, and rested like a sack of wallet-shape on the upper 
 part of the back. It w^eighed when removed nearly eight 
 pounds. In surgical literature a number of such cases have 
 been recorded, and, as a rule, such voluminous growths have 
 had deep connection with the structures of the neck; and where 
 the growth has had lateral location the connections with the 
 
892 TUMORS OF THE XECK." 
 
 vessels have been such as to render the removal a critical task. 
 Exceptionally, the tumor has been found to have only superficial 
 connection with the subcutaneous tissue. 
 
 The fibrous tissue may so far predominate in the formation 
 of the tumor that the neoplasm is properly named a fibroma; 
 the leading characteristic of such a tumor is its extreme hard- 
 ness; in other respects it closely resembles the lipoma, and, as 
 already remarked, the fibrous and fatty elements may so equally 
 concur in the structure of the neoplasm that a proper title for it 
 is fibro-lipoma. 
 
 These growths cause no pain, and become only sources of 
 inconvenience when their volume interferes with the dress of the 
 patient's neck; or, from dragging or encroaching upon the 
 lateral structures of the neck, they interfere with the freedom of 
 the circulation. And when the tumor attains large dimensions 
 it may interfere with the recumbent posture of the subject. 
 
 An osteoma may arise in the nucha, and has, as starting 
 point, the spinous or transverse process of a cervical vertebra- 
 Such crrowth seldom reaches a size which is eitlier a marked 
 deformity era source of trouble to the patient; should it do so, 
 it maybe removed by means of scalpel, chisel and mallet; or 
 when the growth has been freed from the soft parts, if it be 
 pedunculated, it may be excised by means of a resection-saw or 
 chain-saw. 
 
 The extirpation of the lipoma or fibro-lipoma, when situated 
 elsewhere on the body, is the simplest of surgical operations, but 
 when seated on the back of the neck, the task becomes much 
 more difficult. In the first place, some effort is reciuired to 
 place the j^atient so that the growth is accessible to the knife. 
 The patient must lie nearly prune, with the breast somewhat ele- 
 vated, and the head inclined forwards, positions difficult to main- 
 tain in the anaesthetized suliject. The patient lying in position, 
 a vertical incision is to be made, and the growth dissected from 
 the structures in which it lies imbedded. For this dis.section a 
 scalpel with thick, strong blade and large handle is needed. In 
 the deeper part of this dissection blood-vessels will be met, which 
 should be ligated, for, if not tied, they will continue to bleed, 
 since they lie in tendino-muscular structures, which interfere 
 with their normal contraction. A case remains vivid in the 
 writer's memory in which a neglect to secure all the vessels at 
 the time of the operation was followed by haemorrhage and a 
 tedious healing of the wound. After careful ligation of the 
 
CARBU^X'LE, ANTHRAX. 898 
 
 vessels, the wound should be closed by strong sutures passed 
 deeply by means of a long curved needle; such sutures approxi- 
 mating the sides of the wound will favor healing. 
 
 Carbuncle, Anthrax. — The carbuncle, of which the Greek syn- 
 onym is anthrax, occurs in several regions of the body, yet the 
 tissues on the posterior face of the neck and the upper part of 
 the back are specially liable to this affection. It is a localized 
 inflammation of the dermal and subdermal connective tissue, 
 probably beginning in the w'alls of the sudoriparous and seba- 
 ceous glands. It resembles the malignant pustule, and the 
 furuncle; it is less severe than the former, and more so than the 
 latter, so that a carbuncle is not inaptly named an assemblage of 
 furuncles or boils. 
 
 The usual site of the carbuncle is on the upper part of 
 the neck, where the nucha merges into the hairy scalp ; it 
 commences as a hard, painful, isolated swelling, in which the. 
 affected part is uplifted above the surrounding skin, and pre- 
 sents one or several A'esicles; these vesicles, at first filled with 
 a gelatinous fluid, soon become filled with pus. If the cuti- 
 cle be removed, these pustules will be found to penetrate 
 inwards, so that the surface has a cribriform appearance. These 
 sieve-like openings are the seat of a necrosing process, which 
 penetrates inwards as well as laterally, so that tliere is finally 
 death of a considerable extent of surface. The part which thus 
 dies is only slowly detached, and, in the dying mass, small islets 
 of living structure may escape the gangrenous destruction which 
 is occurring around them. The slough is, at first, blue or dark, 
 and afterwards assumes an ashy gray color. It has not much 
 odor. The gangrenous process extends sometimes more rapidly 
 and widely under the skin than on the surface. 
 
 The disease was well described by Celsus as follows: "Of tlie 
 diseases which deeply affect the body none is worse than the 
 carbuncle, of which the marks are the following: redness of sur- 
 face, on which a few pustules project, and these, for the most 
 part, are black, yet they may be sub-livid or pale. These pus- 
 tules within are black and contain sanies. The body is dry and 
 harsher than usuaL There is a crust on and around it, and this 
 is begirt with inflammation. The skin of the part cannot bo 
 uplifted, but seems to be attached to the subjacent parts. Some- 
 times there is shivering, or fever, or these may both be present. 
 This disease seems to creep, as if with latent roots, in the subja- 
 cent parts, extending sometimes more rapidly, sometimes more 
 
894 TUMORS OF THE NECK. 
 
 slowly. And while thus spreading, the surface above is at first 
 palish, then it becomes livid and small pustules appear." This 
 Celsian picture of the disease is as correct as any w^hich modern 
 surgery lias sketched. 
 
 John Hunter says carbuncle begins almost like a pimple, and 
 goes deeper and deeper, spreading with a broad base under the 
 skin. It produces a suppuration, but not an abscess, somewhat 
 similar to erysipelas. The matter lies in cells, where it is 
 formed, almost like water in anasarca. A diffused ulcera- 
 tion on the inside for the exit of matter takes place, making a 
 number of openings in the skin. 
 
 Ludlow, wdio published on this subject in 1855, found that 
 carbuncle may appear at any time in life; it is seen in early 
 youth as well as in old age, and occurs oftener in men than in 
 women. It may appear without a warning signal, or it may be 
 preceded by insomnia, headache, vertigo, fatigue, loss of appe- 
 tite, constipation and a profuse discharge of the urates in the 
 urine. A low form of fever usually accompanies carbuncle. It 
 varies in size from an inch to ten inches in diameter. In case 
 of recovery, the average duration is seven w^eeks. 
 
 Prichard, in an essay on carbuncles read before the British 
 Medical Association in 1865, stated that the disease was annually 
 increasing in England; for example, in 1842 there died in all 
 England but forty-two persons; in 184G, seventy-seven died; and 
 yearly the numbers of deaths increased until, in 1855, there were 
 reported tw^o hundred and fifty-five deaths. The disease was 
 nearly three times oftener among men than women. A few 
 cases occurred among children, but none among nursing infants. 
 The most usual sites of the disease were the neck, back, buttocks, 
 and the extensor surface of the limbs. Where the central slough- 
 ing is slow in formation, the disease spreads rapidly around the 
 affected part, and this has been referred to the density of the skin, 
 which prevents the exit of the ichor and causes its diffusion 
 underneath. Death, Prichard finds, can occur from exhaustion 
 caused by pyaemia, also from tetanus, and thirdly from the 
 disease extending into and affecting some adjacent cavity; thus 
 the disease may penetrate into the pleural cavity, also into the 
 peritoneal cavity, and, occasionally, into the intra-cranial serous 
 cavity. 
 
 Laycock found that the disease was not specific and could not 
 be communicated by inoculation. 
 
 James, an English writer, in 1866, wrote on carbuncle. He 
 
CARBUNCLE, ANTHRAX. 895 
 
 thinks that there are two kinds of inflammation, one tending to 
 localized isolation, and the other to indefinite diffusion. The 
 carbuncle tends to circumscription, and appears especially in 
 very vascular parts: for example, on the neck and in the peri- 
 neum about the urethra. Its ending is a circumscribed circle of 
 dead tissue around the central point of origin. Berard found 
 that in one-third of the cases of carbuncle, erysipelas arose, but 
 modern antisepsis has removed this from the Hst of events. 
 
 Carbuncle occasionally appears in the glycosuric or diabetic 
 subject, and in such cases the disease is of a severe form; the 
 carbuncle is then large, and combined with the existing constitu- 
 tional malady, it usually destroys the patient's life. 
 
 Copland says "that anthrax rarely occurs excepting in habits 
 of body evincing more or less of cachexy with sanguineous pleth- 
 ora and disorder of the digestive functions. For some days 
 before its eruption the patient complains of anorexia and 
 increased disorder of these functions, and of lassitude, chills, or 
 shiverings. With the development of the tumor, the febrile 
 commotion increases, and presents the usual concomitants of 
 inflammatory fever. If sphacelation takes place, or if the ulcer- 
 ation is protracted, the attendant fever assumes gradually an 
 adynamic character; and in delicate, old, or very cachectic per- 
 sons, it is nervous or adynamic from the commencement." 
 
 E-ichet, in 1868, finds that carbuncle may appear in different 
 grades of severity; and he warns against treating all cases alike, 
 since difTerent cases demand different management. 
 
 Croly thinks carbuncle is a diphtheritic jDroduct, against 
 which he advises the local use of carbolic acid. 
 
 Diagnosis. — The carbuncle is much larger than the boil; if a 
 number of boils were to arise simultaneously contiguous to each 
 other, the condition would not be distinguishable from a car- 
 buncle; but boils appear as individuals separated by some space 
 from each other; and the boils are of different ages, and, when 
 coexisting, are at different stages of development; hence these 
 conditions make a clear distinction between the boil and the 
 carbuncle. 
 
 The carbuncle has often been confounded with the malignant 
 pustule the latter is a more severe and a more dangerous afiec- 
 tion Malignant 23ustule owes its origin to inoculation with the 
 virus known as cattle-poison. Such inoculation may be direct 
 from contact with the diseased animal; or it may be carried from 
 the carcass by a fly, which, by its bite, infects the human sub- 
 
896 TUMORS OF THE NECK. 
 
 ject. Such inoculation speedily produces death of the infected 
 part. Its sites are the hands and exposed surface of the face. 
 The infected part presents the condition of moist gangrene, and 
 spreads without limit; and if the disease is not arrested, the 
 patient dies within a few days. These features clearly distin- 
 guish the malignant pustule from the carbuncle. 
 
 Prognosis. — Carbuncle is not a dangerous affection when 
 it occurs in the strong and otherwise healtliy subject; but in the 
 subject whose muscular, digestive and assimilative functions are 
 enfeebled, and whose fund of vital resources has been curtailed 
 by spirituous or other exhausting excess, and also in the diabetic 
 subject, carbuncle sometimes ends fatally; and in all cases in 
 which the disease embraces a large amount of structure, though 
 the patient may escape, yet he approaches perilously near to 
 death. 
 
 When carbuncle ends fatally, it is often tlirough the disease 
 reaching some visceral cavity; for example, the encephalic, the 
 pleural or the peritoneal. 
 
 Treatment. — If the disease be seen in the beginning, its prog- 
 ress may sometimes be checked, and the disease arrested by the 
 hypodermic use of carbolic acid. For this purpose liquefied 
 carbolic acid is to be used; and to do this, charge a Pravaz 
 syringe with a few drops of the acid, and insert the hollow 
 needle at some four or five points in the carbuncular structure, and 
 inject a drop at each point. The pustulated surface may also 
 be cauterized with the carbolic acid. Instead of this agent the 
 compound tincture of iodine may be used hypodermicaily. In 
 this way the author has seen the development of the carbuncle 
 arrested, and the patient given speedy relief. 
 
 Other local remedies used as abortive means have had ear- 
 nest advocates; of these the following deserve mention: Tlieil- 
 mann treated three hundred and forty-three cases of carbuncle, of 
 which all except five recovered; his treatment was simply local 
 applications, and consisted of the following compound: turpen- 
 tine and spirit of camphor, of each one ounce, the yolk of an egg, 
 and a pint of the decoction of chamomile; and in some cases- he 
 gave acids and camphor internally. Rigby used the tincture of 
 icdine externally; Cook used belladonna locally; an opium 
 j^laster was used by Gutzeit, the extract of opium by Shillitoe, 
 and the acid nitrate of mercury by Startin. 
 
 Early in this century. Dr. Physic of Philadelphia treated the 
 carbuncle by blistering; and in 1876 the same was recommended 
 
CARBUNCLE, ANTHRAX. 897 
 
 by J. Guerin. Guerin asserted that by this treatment, a hard, 
 tense and painful tumor was clianged into a painless and benign 
 one. The blister should have an opening through the centre; 
 and on the blistered surface a cataplasm should be applied. 
 Guerin thinks the vesication extracts the virus from the car- 
 buncle. 
 
 The greater number of surgeons have advocated some more 
 energetic treatment than the means above enumerated; such 
 treatment may be classified under the heads of cauterization, 
 incision, open or subcutaneous, and excision. 
 
 Celsus, in the following words, advised the actual cautery: 
 Nothing is better than to immediately burn it: nor is this 
 severe, since the flesh having already died does not feel. And 
 the burning is only to end when the sense of pain is felt in the 
 parts acted on. The force of the attack should be proportioned 
 to the magnitude of the disease. 
 
 In 1821 Ph3'sic published the beneficial results which he had 
 derived from the escharotic action of caustic potash; he applied 
 this as soon as vesicles appeared on the skin, and so destroyed the 
 latter that there was a free opening for the escape of the acrid 
 matters. In all cases he found that the pain of the carbuncle 
 ceased as soon as the action of the potash had terminated. In 1863 
 Prichard recommended the use of caustic potash; he used the 
 solid stick, and thrust this deeply into the carbuncle. To abate 
 the pain from the caustic he placed on the part a mixture of salt 
 and ice. On the remaining diseased surface Prichard painted 
 the following mixture: — 
 
 ^. Collodii li 
 
 lodi. 
 
 Potasii. lodidi , aa 9 j 
 
 Misce. 
 
 On the cauterized surface Prichard applied resin ointment; 
 he wholly discarded poultices in the treatment of the carbuncle. 
 
 The writer has derived benefit from the escharotic action of 
 sulphate of zinc applied in crystals to the interior of the car- 
 bunculous structure, after the latter has been freely incised; thus, 
 sections of the affected structure can be made to rapidly slough 
 off, and detach themselves from the sound tissues. 
 
 The Celsian plan of attack with the actual cautery has been 
 employed in a few cases by the writer. For this purpose use the 
 incising point of the thermal cauter}^ and burn deep furrows 
 
898 TUMOES OF THE NECK. 
 
 into the diseased part. Over the carhuiicle tlius furrowed, place 
 a poultice which may consist of boiled chamomile flowers, or 
 boiled starch, or boiled carrots. Under this treatment the 
 detachment of the gangrenous tissues will be accelerated. 
 
 Compression was advised by O'Ferral and Colles: this was 
 done by means of an adhesive plaster which contained opium. 
 Others have used lead plaster and collodion. 
 
 Trelat advises prolonged baths and dressing with wadding. 
 
 The plan of treatment which is most in favor, is that of 
 incision; and yet like all surgical procedures this one has had 
 its opponents. 
 
 One of the earliest advocates of treating the carbuncle by 
 incision was the English surgeon "Wiseman of the time of Charles 
 the Second, who wrote: "I advise scarifying or cutting deep into 
 it (the carbuncle) to give a breathing to the humor." And he 
 awakens our incredulity when he says: " I never saw a true car- 
 buncle suppurate." Free incisions were practiced by Cooj^er, 
 Abernethy and most of the English surgeons. The French give 
 to Dupuytren the credit of ])opularizing this method of treat- 
 ment. 
 
 The method of incision has been practiced in several ways. 
 The most conservative j)lan was that of (jruerin and Gosselin, who 
 did the work subcutaneously. They introduced a narrow bladed 
 knife through the skin, and then twirling the instrument about, 
 they divided the structures circularly around; and thus a large 
 wound is shunned through which pysemic infection can occur. 
 Hueter advocates the method by subcutaneous incision. 
 
 In a discussion of this subject in 1881, Le Fort, See, Marjolin, 
 LeDentu, Boinet and other French surgeons recommended the 
 treatment by incisions; yet some would limit the work to subcu- 
 taneous division. Verneuil and Tillaux are more conservative, 
 and the former thinks that in eighty per cent of the cases the 
 patient may be cured without incision. Desprds advocates the 
 expectant method; yet his report of fifty-seven cases which he 
 thus managed, and of which six died, does not encourage the 
 adoption of his mode of treating the disease. 
 
 Ludlow strongly i)rai.ses the treatment by free incisions; and 
 this should be done early in the disease, since it will lessen the 
 pain, and diminish the development of the carbuncle. 
 
 Colles advises to make a number of incisions deep enough to 
 divide the superficial fascia; for he contends that this tissue 
 causes strangulation and death of the structures which are con- 
 
CARBUNCLE, ANTHRAX. 899 
 
 fined beneath it. Velpeau makes multiple incisions, from twelve 
 to fourteen in number, in case the carbuncle be of large dimen- 
 sions. The method commonly in practice is to make a crucial 
 cut, which will traverse the carbuncle from border to border, and 
 penetrate quite through the affected structure. In such work 
 the scalpel will creak or cry as if it were dividing leather. 
 
 The effect of such free incision is free, but not excessive bleed- 
 ing, and a draining or "breathing out," as Wiseman calls it, of 
 some of the morbid elements of the affected parts. For a few 
 moments the pain caused by incising is great; yet it brings quick 
 cessation of the pain which previously existed. A free outlet is 
 thus made for the disintegrating and gangrenous carbuncular 
 structure. 
 
 After incising the carbuncle, the breaking down of the dis- 
 eased tissue should be favored by an anodyne poultice; fortius 
 purpose a mixture of moist hops and poppy leaves may be 
 applied. As soon as shreds loosen, they should be detached with 
 forceps and scissors; thus dead material may be gotten rid of at 
 once, which otherwise would encumber the wound for several 
 days. Besides the cataplasm, the wound should occasionally be 
 cleansed with some disinfectant lotion ; for this purpose, dilute 
 chlorinated water, or a weak solution of permanganate of potash 
 may be used for cleansing the wound; and the same maybe 
 added to the cataplasm. 
 
 The eminent English surgeon, Paget, besides his opposition to 
 the free incision of the carbuncle, does not favor the practice in 
 use of giving the carbuncular patient spirituous drinks and 
 generous diet. The experience of the writer does not accord 
 with this course; the patient fed to repletion and allowed wine, 
 or other spirits, will do better than one confined to an abstemious 
 regimen. As internal medication, the adult may be given three 
 times daily, a teaspoonful of the compound tincture of gentian, 
 or cinchona; and if to each dose there be added a teaspoonful of 
 pulverized ice and a half tablespoonful of cognac, the mixture 
 will awaken the desire for other food. 
 
 Should the pain continue after the carbuncle has been freely 
 incised, then an opiate should be given: viz., a fourth of a grain 
 of morphia every five or six hours; and the efficienc}^ of this 
 will be augmented, if to each dose there be added a grain of 
 camphor and three grains of quinine. 
 
 The ragged breacli in the nucha will be slow in healing; and 
 there will remain a large uneven scar, to mark the site of the 
 carbuncle. 
 
900 TUMORS OF THE NECK. 
 
 There remain to be mentioned certain modifications of the 
 method of treatment by incision. In 1SG6, Foucher advised to 
 lay open the carbuncle, and then apply over the cut surface a 
 large suction cup; thus Foucher sought to extract the affected 
 fluids of the diseased structures. 
 
 In 18G5, Bi-oca announced to the Society of Surgery, that, 
 struck with the gravity of carbuncle, he had conceived the 
 notion of treating it as a malignant growth; he had not, how- 
 ever, carried out his idea, since it is difficult to foresee the extent 
 to which tlie carbuncle may develop. Blackley, an Irish surgeon, 
 pursued this plan in one case; after freely opening the affected 
 structure with the knife, he then proceeded to excise the car- 
 bunculous structure with scissors ; this done he replaced the flaps 
 and compressed them wdth adhesive strips, and obtained a speedy 
 cure. The author has put this plan into partial practice, in this 
 way, that after making the cruciform incision, he excised the 
 diseased structure from beneath the four angular sections, leav- 
 ing the skin as a covering. Some benefit resulted from the 
 excision, since the sloughing process was lessened, and there 
 remained less diseased structure for detachment. 
 
 In conclusion of this chai)ter upon carbuncle, the writer 
 would advise the following treatment of the disease: if seen in 
 the commencement, endeavor to arrest by the interstitial injec- 
 tion of carbolic acid; if seen somewhat later, incise crucially, 
 and use an anodyne cataplasm ; and if seen still later, when the 
 tumefied structure is perforated with gangrenous sinuses, then in- 
 cise crucially or stellately, and excise the diseased structure which 
 is accessible, and dress with an opiated ointment, or cataplasm. 
 
 Malignant Pustule. — There is an affection so closely cognate to 
 carbuncle that a consideration of it here is deemed proper; this 
 is malignant pustule. 
 
 This aff^ection commences as a red point, which is but little 
 elevated above the surface, and is the site of itching and prick- 
 ling. Such initial red points appear in numbers; the part swells; 
 the cuticle is uplifted like a slight blister; and the underlying rete 
 mucosum and coriura are of a dark red or purplish color. The 
 dermal tissue has suddenly become the site of moist gangrene; 
 and the sensation there is rather that of tightness and tension 
 than of severe pain. The general circulation is much disturbed; 
 the pulse is small and often irregular; nausea, vomiting, delirium 
 and great physical depression are present. When located on 
 vascular and distensible parts, there is great swelling. The affec- 
 
MALIGNANT PUSTULE. 901 
 
 tioii has no tendency to self-limitation, but rather to indefinite 
 diffusion. If near the brain the latter becomes congested. 
 
 The disease is caused by a special contagious virus, which is 
 developed in cattle, sheep, and rabbits; the human subject con- 
 tracts the disease from such affected animal. From their occu- 
 pation, the butcher, skinner, tanner and scavenger are the most 
 usual subjects of malignant pustule. Tlie disease occurs oftenest 
 in wet weather. 
 
 Pasteur and others have studied the causal virus and found 
 that it is very tenacious of existence and power of infecting: 
 qualities which are not lost by long burial of the dead animal. 
 And the virulent intensity is so concentrated that it remains, 
 though the virus be greatly diluted in water. 
 
 The disease is reported to have arisen in man without actual 
 contact with an aiTected animal. This may be doubted and has 
 arisen from the lack of accuracy which too often obtains among 
 patients in regard to their ailments. For the subject of grave 
 disease in his state of physical pain and alarm must necessarily 
 furnish a history alloyed with many errors: errors too great to be 
 sifted out by the attendant who is not a severely critical analyst. 
 
 The use of the flesh of animals thus affected may cause serious 
 illness; this probably depends on whether the meat has been 
 imperfectly or thoroughly cooked. 
 
 Bourgeois, who saw many cases of this disease in France, says 
 that he never saw any delirium attend it; and this is in accord 
 with the writer's experience. 
 
 The affection is preeminently a dangerous one, tending 
 to death unless it be vigorously treated at the onset. This 
 depends on the fact, that the part which is the site of the gan- 
 grenous process is in immediate and uninterrupted connection 
 with the adjacent living parts : no wall of coagulated proteinace- 
 ous material is formed as a barrier betv/een the dead and the 
 living tissues; the infecting content of the former enters and 
 does its fatal work in the latter. And thus the diseased area 
 continually widening, the ichorismic process is rapidly augmented. 
 
 In surgical literature the malignant pustule has been con- 
 founded with the carbuncle; and as the two radically differ in 
 nature and treatment, it is necessary to clearly indicate their 
 diagnostic differences. Carbuncle is more of a local trouble, and, 
 ■commencing on the outside, it penetrates inwards; malignant 
 pustule is more rapid and thorough in its destructive work, 
 completely killing at once, the structures which it attacks. 
 
902 TUMOKS OF THE NECK. 
 
 Carbuncle has, as its more special sites of development, the neck, 
 back, and buttocks; but malignant pustule appears almost 
 exclusively on the uncovered ])arts of the body; and its action is 
 limited to the skin, wliile carbuncle attacks chiefly the subcu- 
 taneous celluhir tissue. In carbuncle, the affected part is hard, 
 red and circumscribed; malignant pustule, however, tliough liard, 
 is pale and not well defined, and vesicles appear on it. Carbun- 
 cle is painful, but malignant pustule occasions a sensation of 
 biting, burning and tension. 
 
 According to Ancelon, malignant pustule begins as a 
 phlyctsena-clad surface, and it penetrates rapidly inwards; from 
 the affected focus reddish streaks radiate into the surroundino- 
 skin; and as the disease advances peripherally, the central part 
 dying becomes cold and insensible. A shooting, burning pain is 
 felt in the sinuous border. 
 
 Pathological Changes Present after Death. — The slough or gangre- 
 nous structure of the surface primarily attacked is seldom more 
 than a line in thickness, and is brown, livid or black in color; and 
 the blood-cells contained in it appear under the microscope, dis- 
 integrated, and the blood contains microphytes which will pres- 
 ently be considered. 
 
 The blood-vessels are lilled with a black and liquid blood. 
 It has been noted that the left side of the heart contains but a 
 small quantity of blood; and this is uncoagulated. The blood 
 putrefies with the greatest rapidity, and is found to contain but 
 little fibrin. The serous cavities, as the pericardial and pleural, 
 contain a blood-stained serum. 
 
 Davaine and Raimbert have made a microscopic study of the 
 fluids of animals and men who have died of malignant pustule, 
 and they have found bacterial corpuscles; these have been the 
 su1)ject of nnich experimental research on the part of Davaine. 
 These microphytes are discovered in the serous fluid which 
 intervenes between the masses of aggregated blood- cells; and in 
 their form they are elongated, rod-shaped, smooth, of equal size 
 from one end to the other; and are found floating, or at rest. 
 Though generally elongated and straight, yet sometimes they 
 are curved, or bent at an acute angle. The blood which con- 
 tained these bacterial microphytes had lost its power of coagu- 
 lating and the microscopic forms which existed in it were not 
 destroyed by water or alkaline fluids. 
 
 Treatment. — Treatment to be effective should be commenced 
 early and pursued with prompt diligence. That the disease i'- 
 
CHANGES PRESENT AFTER DEATH. 903 
 
 curable has been verified several times in the writer's experience. 
 
 If seen early, the vesicles must be opened, and their content 
 removed. The subjacent gangrenous surface should be incised 
 crucially and the four flaps should be dissected from the unaffected 
 underlying structure, and excised; thus one radically disposes 
 of the sloughing structure which is teeming with the elements of 
 the disease. The dissecting knife should confine itself to the line 
 which separates the dead from the living tissue; thus done, no 
 bleeding occurs. After this excision of the gangrenous structure, 
 the actual cautery is to be applied to the denuded, as well as to 
 the contiguous affected, structure; the line of cauterization must 
 pass somewhat beyond the vesicular and indurated structure. 
 The pointed cautery should be made to penetrate quite through 
 the diseased tissue. 
 
 The potential must reenforce the actual cautery; and for this 
 purpose, numerous agents are at our service; those which have 
 best repute are the chloride of zinc, the chloride of antimony and 
 caustic potash. The chloride or butter of antimony is preferred 
 by Enaux, Chaussier, Bidault and others. To use this, let por- 
 tions of lint saturated w^ith the agent be placed at different points 
 of the affected surface, and covered with dry lint, and the whole 
 fixed in place b}^ adhesive plaster. Caustic potash is a very 
 effective escharotic ; this may be rendered less severe b}^ mixing- 
 it with an equal amount of calcined magnesia or powdered 
 Sanguinaria. The severe action of the potash requires that some 
 precautions be used to prevent it reaching and attacking the 
 adjacent sound parts; for this purpose, let these parts be covered 
 with adhesive plaster. The writer has often applied the caustic 
 potash in pencil-form as an escharotic, in cases other than the one 
 here treated of. For this purpose, the fused material fixed in a 
 holder can be applied, and the tissues destroyed to the extent 
 one wishes. The escharotic action can be arrested by pouring 
 water or olive oil over the cauterized structure. The action is 
 speedy and attended by little pain. 
 
 In 18G4, a charlatan in France had wonderful success in treat- 
 ing the disease; and his secret, published at his death, consisted 
 in the application of pure corrosive sublimate to the diseased 
 surface. This salt was applied to all of the surface which was 
 the site of vesicles; the affected structure was thus wholly 
 destroyed, and detached itself On the part thus cauterized, an 
 ointment compounded of styrax was applied. 
 
 The author has treated several cases of malignant pustule 
 
904 TUMORS OF THE NECK. 
 
 which had been contracted from dead cattle: the disease was 
 commonly on the hands; j-et in one case it was on the face; and 
 the manner of treatment which was pursued, and proved almost 
 uniformly successful, was as follows: by ecraseur or scraping 
 with some blunt instrument, the vesicular surface is to be removed; 
 and then, if the subjacent derm has not become gangrenous, 
 apply to it the following solution of bromine : — 
 
 li. Bromi 3ss 
 
 Aquae 3 xij 
 
 Glycerini 5iv 
 
 Misce. 
 
 Let the diseased surface be well covered with this, and then 
 let a piece of lint be saturated with the same and placed on the 
 affected site. As the odor of bromine is disagreeable, and may 
 have a pernicious effect on the patient, the dressing should be 
 included in a piece of oiled silk. If the disease be on the hand, 
 as is commonly the case, the limb should be flexed and carried in 
 a sling. The dressing should be removed daily. 
 
 Should the erasure of the vesicular surface not be followed by 
 the exuding of normal red blood from the denuded corium, this 
 indicates that the derm is passing into gangrene ; and in such 
 condition the scraping must be continued, and carried deeper 
 into the true skin; and if it is found that this is wholly gangre- 
 nous, then the dead skin should be excised, the subjacent tissues 
 thermally cauterized, and over this cauterized surface the dress- 
 ing of bromine should be applied. By this treatment, without 
 any internal medication, the writer has successfully treated sev- 
 eral cases in which the disease was on the hands. One patient, 
 in whom the disease was on the side of the face and scalp, did 
 not recover; it should be mentioned that the disease was -far 
 advanced when first seen, and death occurred on the fourth day. 
 In this treatment, if the patient be addicted to alcoholic drinks, 
 these should be continued. 
 
CHAPTER XXA^III. 
 
 AVOUNDS OF THE XECK. 
 
 "WouxDS of the neck have been classified most diversely. Not 
 content with the old division of incised, lacerated and contused, 
 penetrating and gunshot wounds, some have proposed the classi- 
 fication of penetrating and non-penetrating; others according to 
 gravity have named them fatal and not fatal. Others have 
 adopted a regional nomenclature in which one finds the groups 
 supra-hyoidean, sub-hyoidean, thvroidean, etc., according to the 
 site of injury. A practical division is into superficial and deep 
 wounds, which may be further defined by mention of the struc- 
 tures involved. 
 
 The wound ma}' result from accident, from violence infiicted 
 by a criminal hand, or surgery itself may be responsible for it; 
 thus in tracheotomy, oesophagotomy, tenotom}^ and particularly 
 in the removal of growths from the neck, wounds of greater or less 
 severity are made by the surgeon. 
 
 Dupuytren has observed that the dress of the neck often 
 protects the part from injury; and hence in winter, when the 
 neck is thickly dressed, wounds are rarer than in summer when 
 the neck is more exposed. 
 
 The superficial wounds may be longitudinal, transverse or 
 oblique in direction; and when transverse the gaping is thegreatest. 
 If only the derm is involved, such wound is of little importance; 
 but if one or more of the superficial jugular veins be divided, 
 then there may be dangerous bleeding; in one reported case a 
 f|uart of blood was lost, with the result of destroying the patient's 
 life. Besides haemorrhage, aspiration of air into these veins has 
 occurred with the perils arising from this accident. 
 
 Besides the gaping of these wounds alluded to, there may be 
 
 in-roliing of the borders; and this, which is due to the action of 
 
 the platysma myoides, occurs more at the upper part of the front 
 
 of the, neck than at the inferior portion. And to correct both 
 
 58 ~"(90o) 
 
906 WOUNDS OF THE NECK. 
 
 these conditions, the suture, twisted or knotted, has been used by 
 some surgeons; yet Dietfenbach and many modern surgeons, 
 having found that suppuration occurred under such closed 
 wounds, have discarded the suture, and attempted union by 
 adhesive plaster; in fact, fearing such suppuration, they have 
 left the wound somewhat open. The writer, however, advises clos- 
 ure by catgut or metallic suture after the wound and adjacent 
 surface have been rendered aseptic. And such stitch should be 
 so inserted as to retain the unrolled edges aptly united; and to 
 accomplish this the margins should* be everted during the pas- 
 sage of the needle. The surface should be painted with the com- 
 pound tincture of benzoin, covered with isinglass plaster, and the 
 whole covered with cotton wadding. The wu:»und should be 
 inspected daily, and, if no irritation appears in it, the metallic 
 sutures may remain in site for four or five days ; but if there be 
 indications of suppurative action, then each alternate suture 
 should be removed, and a dressing applied consisting of lint wet 
 with a twenty-five per cent solution of alcohol. In case the 
 suture consist of catgut, this will vanish through absorption; 
 and as such absorption may occur before firm closure of the 
 wound, the writer gives preference to fine wire as material for 
 suture. 
 
 Deep or penetrating wounds may im})licate the nucha, side or 
 front of the neck. 
 
 The deeplv penetrating wound of the nucha is most frequently 
 caused by the sword, sabre, knife or gunshot missile. The records 
 of military surgery contain numerous cases of deep incised 
 wounds on the back of the neck; often frightful wounds in wdiich 
 the subject was half decapitated. If the lesion does not impli- 
 cate the spinal column it is not necessarily fatal. Such wound 
 has been in flap form, and the flap, as in the case of Larrey, 
 being pendulous downwards. Such wound should be closed by 
 metallic suture, and the patient remain absolutely at rest in the 
 lying posture. In Larrey's case, though the patient recovered, he 
 remained without generative power. 
 
 The penetrating blade may enter the spinal canal and injure 
 the cord. The new-born infant has had its existence criminally 
 ended by a needle which has been thrust between the atlas and 
 the occiput, or between the atlas and axis into the spinal cord. 
 A bullet or other missile would be equally sure to terminate life. 
 
 Deep wounds on the side and front face of the neck rarely 
 fail to imperil .some structure of vital im[)ortance; and should 
 
W-OrXDS OF THE XECK. 907 
 
 the common carotid artery or the internal juguhir be divided, 
 tlie work of deatlr is so speedy that the surgeon's services are 
 dispensed with, Xelaton has said that it takes a man four min- 
 utes to bleed to death from the severed carotid, and but two min- 
 utes for the surgeon to tie the vessel; if he were on the ground 
 and prepared, the writer will add. The writer recalls the case 
 of a man in tlie Xew^ York Emigrant Hospital, who bled to 
 death in much less than four minutes after cutting his throat; 
 a surgeon, who was at the side of the suicide within a minute, 
 found him dying. 
 
 In the study of these wounds it is most convenient to start 
 from the posterior part and proceed towards the median line. 
 
 Wounds in the outer or lateral part of this region may impli- 
 cate superiorly the upper part of the sterno-cleido-mastoid mus- 
 cle, some branch of the superficial cervical plexus, and the exter- 
 nal jugular vein; lower down, in addition to these structures, the 
 formative trunks of the axillary plexus, and the subclavian 
 artery and vein, and the phrenic nerve may be wounded. The 
 treatment of such deep wound should be the reunion of the sev- 
 ered muscle when the ends are much separated; and an opened 
 vessel should be ligated; and such ligation becomes most efficient 
 when the vessel is tied on each side of the wound, and then 
 severed between. 
 
 Above the hyoid bone lies a space bounded superiorly by the 
 inferior maxilla, which is rarely the site of wounds, neverthe- 
 less a penetrating instrument entering here may wound veins of 
 some magnitude: also the facial and lingual artery: likewise 
 the submaxillary gland, the duct of Wharton, and the hypoglos- 
 sal nerve. As treatment, wounded vessels should be tied, and if 
 the wound opening tlie duct of Wharton remains as a salivary 
 fistula, the most rational management is to remove the source of 
 supply, viz., to extirpate the submaxillary gland. This is readily 
 done by a cut two inclies long parallel witli the margin of the 
 maxilla and midway between this margin and the hyoid bone. 
 Through this cut the gland is reached, and the facial artery, 
 wljich is imbedded in or on the gland, is to be ligated doubly and 
 divided intermediately: then the gland is readily enucleated 
 from its niche; and when this is done it will be found suspended 
 to the gustatory nerve above, and to its excretory outlet in front; 
 these being sundered, the work of extirpation is done. This 
 extirpation of the submaxillary gland has been practiced by the 
 writer eight times in the removal of epithelioma of the tongue 
 
908 WOUNDS OF TIIK NKCK. 
 
 or iVuni the lloor of the luoutli; and it was so easih' done, and 
 tlie wound liealed so (juickly, tliat though the procedure may 
 appear soniewliat radical, yet lie advises it as the proper treat- 
 ment of an unclosing fistula in the duct of Wharton. It is 
 probable that if the hypoglossal or gustatory nerve were severed, 
 continuity miglit be restored by a suture of the two ends of 
 the nerve. 
 
 The suicidal knife sometimes enters this region, and may 
 accomplish its fatal purpose; yet, as a rule, such wound fails of 
 its intent. The treatment of this wound will be considered 
 hereafter. 
 
 A\'ithin the triangular space having its ba.se at the hyoid 
 bone, and bounded laterally by the sterno-cleido-mastoid nms- 
 cles, lie the laryngo-tracheal canal, the oesophagus, and the large 
 cervical vessels and respiratory nerves. A wound of any of 
 these, if it does not destroy, will at least imperil life. 
 
 The median air-canal is often opened; of thirty-one wounds 
 of the ileck seen by DiefFenbach, of which lifteen ended fatally, 
 two implicated this channel. Horteloup has collected one hun- 
 dred cases of such wound. 
 
 The suicide and homicide have furnished many examples of 
 this lesion, in which the wounds passed from without inwards; 
 and, reversely, violent expiratory effort has wounded the trachea 
 from within outwards, leading to emphysematous diffusion of air 
 into the tissues of the neck. Wounds penetrating the air-canal 
 may be caused by an infinite variety of instruments; in fact,^ 
 they can arise from any sharp-pointed instrument or object, from] 
 a needle to the wooden staff of a rocket; an example of the lat- 
 ter was seen by the author. 
 
 Of wounds which implicate the tracheo-laryngeal canal, the 
 figures of Durham and Plorteloup show that the upper portion 
 is less often wounded than the lower part; the former found that 
 of one hundred and fifty-eight cases fifty-six, or about one-third, 
 were situated above the thyroid cartilage; and these figures do 
 not differ much from those of Horteloup. 
 
 The direction of the wound is usually oblique or transverse, 
 3'et such wounds in longitudinal direction have often arisen from 
 the surgeon's knife. The wound may be a single one or it may 
 be multiple; the maniacal inspiration of the suicide has fur- 
 nkshed frightful examples of the multiple form; his instrument, 
 frec[uently dull or unsuited to such work, seeks, often in vain, to 
 penetrate the larynx, which offers a {)rotective barrier to vessels 
 
WOUNDS OF THE NECK. 909 
 
 which lie at its sides. And this security is increased by the 
 ossific change which, in the old subject, occurs in the larynx and 
 trachea. In his maddened fury to effect his destruction, the 
 desperate subject has been known to wound his thyroid cartilage 
 at several points, and sometimes he has detached a large part of 
 the larynx. Of the ferocity with which, sometimes, such self- 
 inflicted wounds are made is the case narrated by Jameson : a 
 woman who had cut her throat and was unable to speak, drew 
 from her jDocket the cricoid, the arytenoid cartilages, a portion 
 of the thyroid cartilage, and a tracheal ring, which she had cut 
 out. This woman lived thirty-four hours, and had she been 
 found dead, her death would certainly have been attributed to 
 violence perpetrated by an assassin's hand. 
 
 That such violence can be inflicted by the subject himself 
 seems incredible, and it could not be done were it not that in his 
 frenzy he becomes insensible to pain. This fact the writer has 
 verified by statements of those who have attempted self- 
 destruction : in one case a w'oman had thrust a knife, handle and 
 all, into her chest, and yet she had no recollection of any pain 
 from the act. And this statement has been corroborated by 
 others who failed in their suicidal attempts. 
 
 The wound implicating the laryngo-tracheal canal, owing to 
 the complexity of structure, presents a variety of conditions, and 
 these, according to their time of appearance, may be immediate, 
 recent or late. 
 
 As immediate results which may arise are emphysema, bleed- 
 ing, which may cause syncope and asphyxia, and gaping of the 
 divided tissues; and, as respiratory trouble, there may be suffo- 
 cation, and disturbance of or loss of voice. As subsequent mor- 
 bid development there may be swelling and cedema of the 
 mucous membrane, supjDuration, and inflammation of the air- 
 canal, and this may reach into the lungs. As phenomena which 
 can arise still later, are narrowing of the canal, disturbance of 
 phonation, cicatricial retraction, and consequent displacement of 
 parts; and in case of non-closure a fistulous orifice may remain. 
 
 In case the wound is a large free opening of the air-channel, 
 the air is inspired and expired through the wound; but if the 
 wound consist of a narrow fistulous canal, then the patient will 
 breathe in the air through the mouth or nose, but will expire it 
 partly through the narrow wound ; and as the exit through the 
 latter is not free, the escaping air may enter the subcutaneous 
 tissue and produce a puffy swelling around the wound; and this 
 
910 worxDs OF THE neck. 
 
 iiitravasation of air sometimes occurs on an enormous scale. 
 In a case seen by Pard the emphysematous diffusion extended 
 from the neck to the bod}-, the entire surface of which became 
 swollen. The air, instead of entering the subcutaneous tissues, 
 has penetrated underneath the mucous membrane and lessened 
 the calibre of the canal, and^ if this should encroach on the glottis, 
 the patient may be asphyxiated. In the operation of trache- 
 otomy subcutaneous emphysema has been seen; such accident is 
 referable to inexpertness in doing the work. 
 
 If vessels are opened near the tracheal or laryngeal wound, 
 the escaping blood ma}'' be aspirated into the air-passages and 
 cause aspliA'xia; such unfortunate accident, as the writer's expe- 
 rience can authenticate, has brought to a sudden halt the work 
 of the tracheotomy, for the clotted blood lodged in the bronchial 
 branches can obstruct aeration as effectually as can the crou[)al 
 pseudoplasm fixed in the trachea or lar3'nx above. And sucli 
 blood may arise not only from lesion of vessels outside of the 
 canal, but a wound of the congested mucous membrane, accord- 
 ing to Gueterbock, has yielded blood which asphyxiated a feeble 
 subject. 
 
 In the improper closure of a wound which has opened the 
 larynx or trachea, by which gaping vessels were concealed, l)lood 
 has laterally entered the air-tube, and entering the lungs, it has 
 maintained, for a time, a harassing cough : and this in its turn 
 favored the bleeding. 
 
 If the amount of blood lost be considerable, it may induce 
 syncope, and this syncopal state has lasted so long in some cases 
 as to simulate the moribund condition. Horteloup records cases 
 in which this condition lasted eight or ten hour.s. 
 
 The gaping of the wound may be great; for example, if it lie 
 transversely, the divided muscles retract greatly, but if the wound 
 pass irregularly from its outer to its inner ending, then it s{)onta- 
 neously closes, valve-like, especially in the inspirator}^ act. A 
 transverse wound in the thyrohyoidean space, or the cricothy- 
 roidean membrane, may leave a widely gaping breach in the 
 air-tube. If it is yet lower, the trachea may be wholly divided, 
 and a considerable interval be left between the ends. Through 
 such widely gaping wound the patient breathes, and, in cough- 
 ing, mucus and pulmonary excreta are expelled through it. 
 
 The wound opening into the air-tube, if below the glottis, 
 influences the voice; if it be large, complete aphonia results; but 
 if the wound be small, the voice may be changed in tone and 
 
WOUNDS OF THE NECK. 911 
 
 strength. The large gaping wound which annuls phonation is 
 taken advantage of by the vivisectionist to enforce the silence of 
 his victim. 
 
 Injuries of the larynx, if severe, as a rule, annul or destroy 
 the voice; yet there are reports of cases in which the voice still 
 remained, although the larynx had been opened near the vocal 
 cords. In such cases, which are at variance with the accepted 
 facts of physiology, perhaps, the superior thyro-arytenoid liga- 
 ments vicariously represent the normal chords. 
 
 In these laryngo-tracheal wounds, if the inferior laryngeal 
 nerves be intact, then a closure of the wound will enable the 
 patient to speak aloud. And in legal medicine this fact has been 
 utilized; the wound has been temporarily closed to permit the 
 subject to speak the name of him who has wounded him: and 
 with the object of restoring phonation, Pare was accustomed to 
 close such wounds. 
 
 Wounds of the air-passage can, soon after their receipt, awaken 
 an inflammation and oedema of the mucous membrane, which, 
 besides obstructing the respiration, may cause extensive suppura- 
 tion, from which the pus, entering the air-channel, may descend 
 into the lungs and cause a low form of pneumonia. In addition 
 to the pneumonic trouble, the pus may descend on the outside of 
 the trachea and enter the thorax; such gravitating material may, 
 fortunately, be arrested b}^ the sternum and clavicle; in fact, from 
 the writer's observation, the anterior and lateral spaces are so 
 well closed by their attachment to the sternum and clavicle, that 
 pus descending will rarely pass beyond these barriers; however, 
 downward escape of pus, along the nerves forming the axillar}'- 
 plexus, into the axilla has occasionally been observed. Bat pus, 
 which enters the air-tube, or oedema developing there, may 
 descend and awaken disease in the lungs; thus fatal pneumonic 
 disease has not uufrequently arisen. And to avert such ill action, 
 an external exit should be prepared for all pus, or pus-like excreta; 
 and the position of the patient should be such that gravitation 
 will become an ally, and not an opponent of the surgeon, which 
 it often does become, through his inattention to a familiar physi- 
 cal law. 
 
 Besides the primary and early secondary results of wounds of 
 the larynx and trachea, there is a third class, which may be 
 denominated, from their time of appearance, remotely secondary 
 events: such are cicatricial contractions, displacement of parts, 
 and fistulous openings: also vocal and respiratory disturbances 
 
912 WOUNDS OF THE NECK. 
 
 thence arise. Cicatricial shrinking of the structures which have 
 been wounded may, according to site, lessen the laryngeal or 
 tracheal canal. Thus the air-tube may be so narrowed, tliat it 
 barely permits the passage of air sufficient for respiration; and in 
 such cases, tlie breathing is labored, and for its accomi)lishment 
 some voluntary effort is necessary. Such patients are trammeled 
 in their movements, since they can only indulge in active exercise 
 at the cost of labored respiration, or even of painful dyspn(]ea. 
 
 The condition of the healed parts may be such that in expira- 
 tion the tube is nearly of normal calibre, yet during inspiration 
 the covering of the opening is drawn inwards, and so narrows 
 the passage that breathing is hampered. And when the respira- 
 tion is excited from any cause, this indrawing of the cicatrized 
 breach is so great as to painfully impede the breathing. Again, 
 there may be a valve-like formation which develops within the 
 air-canal, in the healing of a wound, and which, in the inspira- 
 tory or the expiratory movement, is uplifted, and partly occludes 
 the canal. Both of these cases, in which the passage is alternately 
 narrowed and then reopened, have been observed as the result of 
 tracheotomy performed by the writer; such occlusive result, 
 fortunately, rarely follows this operation; yet in a series of fifty 
 tracheotomies done by the writer, it occurred twice, and remained 
 as a troublesome result of the operation. 
 
 Such tracheo-laryngeal wound may not close, but leave a 
 fistulous orifice; and this fistula, according to its position and 
 size, will influence the voice. If the opening be underneath the 
 vocal chords and be large, the voice will be obliterated, or reduced 
 in tone and force; but if the opening be above the glottis, then 
 the voice may also be weakened, and whatever may be the site of 
 the opening, the voice will be altered in its character; and its 
 tone may be pij)ing, sibilant, harsh and unnatural. If the 
 wound be laryngeal and near the glottis, in healing, w'hether the 
 wound remains open or closes, the vocal chords may be forced 
 into various mal-positions; and the cicatricial contraction in such 
 wound may render the chords convergent or divergent, thus caus- 
 ing the glottis to be abnormally narrow or unusually wide; and, 
 again, the triangular form of the opening may be converted into 
 a rounded or other irregular outline. And such variety of out- 
 line must furnish equal diversity of phonation. 
 
 Alteration, or a loss of voice, can arise from lesion of the 
 inferior laryngeal nerve; and if this lesion be only unilateral, 
 the voice will be nearly altered to a falsetto tone; this the writer 
 
WOUNDS OF THE NECK. 913 
 
 has observed in two cases of unilateral recurrent lesion. In one 
 case, the vagus, in the removal of a growth on the neck, was 
 severed above the origin of the inferior lar3aigeal nerve, and the 
 voice was reduced to a creaking falsetto; and, in a second case, 
 the nerve was injured but not destroyed on one side, in the 
 removal of a goitrous tumor; in this case a falsetto phonation 
 resulted, which continued for a number of months; yet finally, 
 the voice was restored to normal character. 
 
 In these injuries of the laryngeal vocal apparatus, writers 
 have reported cases in which the patient could not pronounce 
 correctly certain letters; it is probable that such irregularity was 
 dependent on some defect of the organs of articulation, rather 
 than of the larynx or trachea. 
 
 Remote trouble from wounds involving the air-passages may 
 arise from adhesions, which interfere with the ascent and descent 
 of these parts in deglutition; also, such cicatricial adherence may 
 interfere with motions which normally occur in the use of the 
 voice. 
 
 In case an opening remains in the air-passage in the male 
 who has an abundant hirsute investment of the parts, the hair 
 may grow inwards from the inverted derm, and obstruct the 
 canal. Thus in a case seen by the writer, in which there remained 
 an opening into the larynx, the hair penetrated the air-passage, 
 and almost suffocated the patient. This occurred at sea, the 
 man being a sailor, and but for his presence of mind in tearing 
 open the wound when he was nearly suffocated, he would have 
 died. At a later time when a similar accident seemed impend- 
 ing, the patient consulted the writer, who performed an operation 
 on him for the permanent closure of the wound. 
 
 Along with the lesion of the larynx or trachea, the oesopha- 
 gus may also be wounded. In the suicidal attempt to cut the 
 throat, if the wound be high on the neck, it may penetrate the 
 pharynx; also, in the wound which is lower, in which the tra- 
 chea is wounded, occasionally the adjacent oesophagus shares 
 in the injury. At whatever point the oesophagus be wounded, it 
 would be indicated by the escape of mucus from the wound. 
 Also, should the patient swallow a fluid, especially a colored one, 
 as milk, this would escape from the wound, and be evidence that 
 the gullet had been opened. Again, the oesophagus alone may be 
 wounded ; and this lesion may be from the inside, or from the 
 outside. On the inside, wounds can arise from some sharp object 
 which has been swallowed; it may be surgical, as in internal 
 
Ul-l WOUNDS OF THE NECK. 
 
 (esopbagotoniy. And wounds from the outside ma}' be from 
 external re.so[)liagotoniy, or from some accidental cause. Such 
 wounds, wiien longitudinal, gap less than when they lie trans- 
 versely: and the former are more readily healed. 
 
 The simultaneous opening of the cesopliagus along with the 
 air-passage is more frequent than an isolated wound of the 
 former. And the wound, according to Horteloup, is usually of 
 large dimensions. Such large wound has, as sym})toms, the con- 
 stant escape of mucus, the exit of food which is swallowed, and 
 retraction of the lips of the wound; and even when the section 
 of the tube is incom})lete, tlie lower end is retracted. 
 
 Small penetrating wounds are less dangerous; still, in the 
 case observed by Craveilhier, in wliich tlie small blade of a. knife 
 pierced the oesophagus al)Ove the sternum, the patient died. 
 
 The oesophagus, though so narrow in calibre, may be wounded 
 by the gunshot missile; and such wounds often leave a fistulous 
 opening; or, should tliey close, tlie canal remains in a narrowed 
 condition. 
 
 Besides the alimentary and air-passages which are contained 
 in the inner cervical triangle, there are situated there the great 
 vessels, which being wounded, the patient's life is at once lost or 
 greatly imperiled. The simultaneous severing of the primitive 
 carotids, done with suicidal |)urj)ose, quickly destroyed life in a 
 case before mentioned, which occurred within the author's o])ser- 
 vation. 
 
 As vessels which may be opened here, are the carotid artery, 
 internal jugular vein, the thyroid and vertebral arteries, and their 
 attendant veins. The innominate artery rising abnormally high, 
 as it does sometimes, would be endangered by a wound in the 
 lower part of the right side of the neck. A penetrating Avound 
 may implicate a single one of the cervical vesisels; and the 
 diagnostic determination of the one injured is often a difficult 
 problem to solve. For example, when the vertebral is wounded, 
 the surgeon is puzzled to decide whether the resulting htemorrhage 
 may be from the middle or inferior thyroid, carotid or vertebral 
 artery: especially, where the wound wliich reached the vessel 
 was a narrow one, and traversed the overlying structures, 
 obliquely. 
 
 Besides the danger of bleeding from a wound of the carotid 
 artery or internal jugular vein, the patient's life is sometimes 
 imperiled by the means which are employed to arrest the bleed- 
 ing. The ligation of the carotid artery has interfered with the 
 
WOUXDS OF THE NECK. 915 
 
 nutrition of the brain, and, as result, the patient has remained 
 crippled in motor power, sensation and intellect. As excep- 
 tional accident, the ligation of a wounded internal jugular vein 
 has led to a thrombus which reached into the venous sinuses of 
 the lesion, and caused irreparable mischief there. The aspira- 
 tion of air into such venous wound has already been considered. 
 In forensic medical inquiry the Cjuestion ma}'- arise, whether 
 the wound on the neck was self-inflicted or was the work of an 
 assassin's hand. In 1868 Achille Juhel announced the followino- 
 as the result of his study of this matter: the assassin's cut pro- 
 ceeds from the patient's right toward the left side; the cut passes 
 from below upwards, and from before, backwards. The wound 
 is deepest in front where the knife first entered. The suicide's 
 cut lies nearly horizontal, and is more on the left side, running 
 towards the right. The assassin, as a rule, severs more muscles 
 and vessels than does the saicide. 
 
 The prognostic augury of wounds of the neck is often a 
 sinister one. The opinion of DiefFenbach, and which other sur- 
 gical writers generally acce^^t, is formulated as follows: Simple 
 wounds of the neck which are limited to the cutaneous structures 
 rarely heal by first intention. And when the wound is deep, 
 even though it does not enter the air-passages, it may cause 
 death by suppuration within the cellular tissue, and by deep 
 burrowing of pus. The dangers here referred to are less since 
 the advent of the antiseptic treatment of wounds. 
 
 Treatment. — The treatment will vary according as the wound 
 is superficial or deep, and, when deep, according to the parts 
 which are injured. 
 
 The superficial wound, if its edges are smooth, should be 
 closed by suture; but if the margins are lacerated or irregular, 
 they should be trimmed, and then united by proper sutures. 
 Such closed wound may be dressed with the compound tincture 
 of benzoin, and covered with isinglass plaster. In this way, the 
 writer has often obtained union by first intention ; yet this fortu- 
 nate termination is not alwa^'s arrived at: the w^ounded parts 
 may suppurate, and healing be prolonged. From the writer's 
 experience, suppurative action is less frequent if such wound be 
 dressed after sutural closure with lint retained moist with a dilute 
 alcoholic solution. To promote healing, all movements, as 
 flexion and extension of the neck, should be guarded against, as 
 much as possible, by some contentive appliance. 
 
 If the wound be deep and situate^ in tlie anterior region of 
 
91() WOUNDS OF THK NECK. 
 
 tlie neck, and involves, as it often does, the vessels and the air- 
 passage, then, as immediate cojisequences, are gaping of the 
 wound, bleeding from the opened veins and arteries, ])ossible 
 aspiration of air into the veins, and impending asphyxia from 
 the flowing or suction of blood into the air-passages. To fore- 
 stall the fatal termination to which these accidents tend, })rompt 
 thought and speedy action are demanded: action free from error, 
 since a mistake there made can only be corrected in the next 
 opportunity. 
 
 If vessels are opened, the first thing to be done should be to 
 com])rcss the wound with one hand so as to check the bleeding; 
 and then with tlie other hand make pressure on the cardiac side, so 
 as to control tlie arterial bleeding; or this comjjression can be 
 done bv an assistant who may press with one hand on tiie central 
 side, and with the other, on the peripheral side of the wound. 
 Compression thus done, will control both arterial and venous 
 bleeding, and will prevent asjtiration of air; and the bleeding 
 being thus, for the moment, controlled, the vessels must be sought 
 for and caught with clasp forceps, an.d then, one by one, carefully 
 tied. And if there be refluent blood from the untied end, tliis 
 end must likewise be tied. 
 
 Should the tliyroidean structure be wounded along with the 
 air-passage and there is general bleeding, as from a wet sponge 
 which is squeezed, then the peril of asphyxia deserves the first 
 care; and the best means to avert this is to quickly turn the 
 patient so that the blood will flow outwards rather than inwards; 
 and as soon as possible, introduce a tracheal canula into the o[)en- 
 ing in the air-passage; such canula should be large enough to 
 fully occupy the tracheal calibre. If the wound be of such char- 
 acter or shape that it is unsuited for the admission of the canula, 
 then an opening may be made lower down. And thus provision 
 being made for respiration, the surgeon can search for the open 
 vessels and tie them; and in the case of parenchymatous haemor- 
 rhage, in which the vessels are indistinguishable, then circum- 
 scriptive ligation in mass may be practiced. 
 
 In the event that the patient is asphyxiated or drowned from 
 his own blood, then the practice has been resorted to of with- 
 drawing this blood by suction: a plan akin to that of Hueter. 
 by which he extracted bronchial excreta. This procedure of 
 suction was also advised by Roux; but, though rational, it does 
 not appear to have often been resorted to. Such aspiration, or, 
 better named, expiration, may be done by means of a catheter 
 
WOUNDS OF THE NECK. 917 
 
 constructed of A'ulcanized rubber, to -which the suction end of a 
 rubber syringe is attached; or, instead of the syringe,. a compress- 
 ible elastic bag may be attached, and the blood or other material 
 thus withdrawn. 
 
 A fragment of cartilage has been detached and in.spired into 
 the air-canal, and obstructed the breathing; such fragment might 
 be extracted with a long pair of forceps. Or the fragment might 
 be in the shape of a pedunculated valve; and this valve during 
 inspiration, could be drawn inwards so as to obstruct breathing. 
 In such a case, a canula should be introduced througii the wound, 
 or underneath it. 
 
 The deep gaping wound of the air-canal has been the matter 
 of much contentious controversy among surgeons. Shall such 
 wounds be left open, or closed by suture? 
 
 The older surgeons, chief among whom is Pare, completely 
 closed such wounds by suture. He treated three cases of cut- 
 throat by complete sutural closure, and of the number but one 
 lived; and so little personal credit did the pious surgeon assume 
 to himself, that concerning his work, he wrote the famous sen- 
 tence wdiich stands over-the speaker's rostrum in the £cole de 
 Medecine, in Paris, "J treated him, but God cured him." The old 
 Huguenot showed a degree of modest humility now seldom 
 seen. The boastful manner in which the surgical feats of to-day 
 are sometimes heralded to the world, is in ill accord with the 
 self-abnegation of Ambroise Pare. In more recent times Sabatier 
 and Dieffenbach have espoused the opposite plan of treatment, 
 viz., of non-suture of such wounds, owing to the difficulty of get- 
 ting immediate union. As reasons for the difficulty of obtaining 
 union after such sutural closure, Dieffenbach offers the foUowino;: 
 the wound is composed of tissues which are complex and differ 
 in character; and there is unusual laxity of the cellular tissue; 
 and, as a result of such conditions, it is diffictilt to obtain com- 
 plete coaptation of the edges of the wound, which are often 
 infolded: and also, difficult to immobilize the parts. Berth erand, 
 who has studied these wounds, thinks the wound should be 
 suturally united when the wounded surfaces are smooth and 
 regular; and in such condition of surface, union will be gotten, 
 provided the sutures are properly introduced. If the sutures are 
 only superficially inserted in such a case, there may be failure of 
 complete union. If the closure is merely superficial, tlie wound- 
 will reopen. To prevent this, the suttires 'should be introduced 
 deeply; such suture, including the skin, muscles and fascise, so 
 
;>18 WOUNDS OF THE NKCK, 
 
 immobilizes the parts that union is not interfered with. The one 
 wounded face must be brought accurately against the o})|iosite 
 one, and the two then sutured together. 
 
 Such evenly wounded surfaces rarely occur; when seen, the 
 treatment of Bertherand might be safely j)ursued; butin ordinary 
 cases, iu which the surfaces are ragged, lacerated, or in some way 
 irregular, the author advises that the closure of the wound should 
 be incomplete ; the sutures should be introduced only at the ends 
 of the gajiing breach, while the middle, or immediate portion, 
 should remain open. Thus an outlet will remain through whicli 
 excreta and disintegrating tissue can escape externally ; for 
 should such a wound be wholly closed, after the skin unites, as it 
 usually does, the pent-up excreta would pass into the air-canal, 
 and (lesceml to the lungs. 
 
 Gosselin, Xelaton and others, within recent times, have prac- 
 ticed the introduction of deep sutures, in which the breach in 
 the cartilage of the trachea or larynx is closed by sutures; and 
 this, from its site, might be named the cartilaginous suture. Tlie 
 outer part of the wound is pernntted to remain unclosed, that is, 
 the soft parts are left unsutured. And- in case the wound be in 
 the h3"othyroidean membrane, or in the cricothyroidean mem- 
 brane, deep closure may be done, in which the cartilage is 
 pierced by the suture only on one side. In a case cited by Hor- 
 teloup, the suture passed through the upper border of the thyroid 
 cartilage and included, on the other side, the hyoid bone. 
 
 According to South, the plan to be pursued must conform to 
 the freedom or difficulty of respiration which occurs when the 
 wound is closed; for, sometimes, when the wound is closed, the 
 patient finds it difficult to breathe; and, in such a case, the plan 
 of non-closure must be pursued, which will permit a part of the 
 inspired air to enter through the wound. But if the breathing is 
 unimpeded when the union is complete, then South would totally 
 close the wound. 
 
 Other surgeons, rejecting the suture entirely, have closed the 
 wound by adhesive strips, which may be prepared from rubber 
 adhesive plaster; or isinglass jjlaster may be used, which is made 
 yet more adherent, and impermeable to water, by being covered 
 with collodion. Though not adopting this plan, the writer thinks 
 it might be made an adjuvant to the suture ; namely, after the 
 wound, in which the surfaces are uneven, has been partially 
 sutured, the closure might be completed by means of the adhesive 
 strips. 
 
WOUNDS OF THE NECK. 919 
 
 Whether closure or incomplete closure of the wound be done, 
 an important aid in the treatment is to counteract, as far as practi- 
 cable, the movements of the head and neck. A simple plan to 
 do this ,is to fasten a cap on the head; and from this straps 
 descend, which are to be fastened to the shoulders, and also to a 
 circular band around the waist. The same may be done by 
 strips of adhesive plaster, or by a gypsum bandage. The appli- 
 ance of fixation by a gypsum bandage, though unsightly and 
 heavy, is more trustworth}^ than the other plans mentioned. For 
 this purpose, in a manner similar to that mentioned in the 
 treatment of torticollis, let the head, except the face, be covered 
 with a cap, and the shoulders and armpits be enveloped in cotton 
 wadding; and about tlie parts thus protected, let the gypsum- 
 covered bandage be carried and so placed as to leave an opening 
 for dressing the wound; and as this is being done, the head must 
 be so inclined that all tension should be removed from the 
 wounded parts; and this position must be continued until the 
 hardened plaster will maintain the uplifted head in permanent 
 fixation. 
 
 As additional j^recaution to be observed, tlie movements of 
 deglutition should be avoided as far as possible; and this may 
 be done by passing aliment in fluid form, through an oesophageal 
 tube; and should there be a large wound in the oesophagus, for 
 some time the tube of alimentation may continue downwards 
 through the wounded portion to the stomach. If this cannot be 
 done through the mouth, the food may be carried through a tube 
 which is introduced through the inferior meatus of the nose, 
 pharynx and entire oesophagus. Permanent retention of the tube 
 in place, rather than its occasional introduction, is advised ; for, 
 in the latter w^ay, the healing wound may be disturbed, or 
 reopened. 
 
 In the cicatrization of wounds which open into the air-canal 
 and oesophagus, there is often a tendency to strictural contraction. 
 Such narrowing may be counteracted by the occasional introduc- 
 tion of a sound into the air-passage, or the oesophagus. In the 
 event of the wound having healed, and stenosis remains, the 
 latter may be relieved by the plan of Dolbeau and others, in 
 wdiich a narrow-bladed knife is passed into the contracted canal, 
 and an incision made by which dilatation can be done and main- 
 tained by means of sounds introduced daily, or once in two days. 
 A recent authority of distinction in this work is Schrotter, wlio 
 has invented a series of sounds by which narrowing in the 
 
920 WOUNDS OF THE XPXK. 
 
 larynx can be overcome. As aid in this work, the mucous mem- 
 brane of the parts may be rendered insensible by means of 
 cocaine. 
 
 Instead of stenosis the wounded oesophagus may become the 
 site of dilatation at or above the site of the lesion; a species of 
 diverticulum is thus formed, which may be relieved by excision 
 of a section of the pouch. 
 
 Emphysematous infiltration of air in the subcutaneous and 
 cellular tissue seldom occurs to an extent that demands attention : 
 should it do so, the treatment of Hennen may be pursued, viz., to 
 make numerous punctures into the emphysematous structure, 
 and then make compression .so as to express the air through the 
 openings. 
 
 In some wounds of the air-passage there may arise a harass- 
 iuQ cough, cau.sed bv inflammatorv action within the trachea or 
 larynx. Formerly, to combat this inflammation, free bleeding 
 was resorted to; this treatment has pro})erly beconje nearly obso- 
 lete, and if practiced, it should only be done in the very plethoric 
 subject. If there be such indication, the abstraction of blood 
 might be done locally by leeches. The functional irritation can 
 generally be alleviated by the administration of opium or hyos- 
 cyamus. Should the cough and spasmodic movement of the 
 parts depend on the retention of muco-purulent matter, which, 
 not having exit, causes these troubles, then relief could scarcely be 
 expected from the means just mentioned, and the better cour.se is 
 to open the Avound, so that tlie.se materials may have more direct 
 escape. Later, when the excreta become less viscid and less in 
 amount, the woun<l can be reclosed. 
 
 Secondary haemorrhage, occurring early, or at a later [)eriod 
 has sometimes supervened, and given much trouble; indeed, 
 death has thus occurred in cases which promised a recovery; and 
 this has happened in ca.ses which had been closed, as well as in 
 those left open. To guard against this, diligent search for, and 
 accurate ligation of, all vessels ogened, should be done at the 
 first dressing of the wound; for such work done after the parts 
 have lost their natural features is one of the most difficult of 
 surgical ta.sks: so difficult indeed, in some cases, that the surgeon 
 has sought refuge in the dubious expedient of the tampon. Only 
 in the case of parenchymatous bleeding, in which it is impossible 
 to secure the vessels, should one resort to plugging the wound. 
 Tlie material for such tampon may be of lint or gauze moistened 
 with alcohol, camphor, or other asepticizing agent. Sponge has 
 
WOUNDS OF THE NECK. 921 
 
 been used for the same purpose; and, as a mechanical hseraostatic, 
 it is one of the best which can be selected. 
 
 In case there remains a fistula into the air-canal or oesophagus, 
 after the healing of a wound which implicated these canals, 
 closure of the same may be attempted by a plastic procedure, 
 according to one of the following plans: — 
 
 1. If the fistula be small and deep, and the parts adjacent 
 easily movable, then closure may be accomplished by carefully 
 and thoroughly excising the wall of the fistula, and then closing 
 by one or more deep metallic sutures, which should not be too 
 tightly closed. If no suppuration occurs, the sutures should 
 remain in site for a week, and, after their removal, the closure 
 should be maintained by adhesive plaster. 
 
 2. If the fistula be deep or shallow and the inner portion be 
 surrounded by immovable cartilage, then the tissues which 
 inclose the cartilage must be opened and dissected from the 
 cartilage, and then closure be made with metallic sutures. Upon 
 the external dressing, some pressure should be made so as to force 
 the occluding soft parts into the opening, and thus complete closure 
 is insured. 
 
 3. Should closure not be feasible by one of the plans men- 
 tioned, then, after trimming the walls of the fistulous opening, a 
 pedunculated flap may be uplifted from the side where it can be 
 best spared, and twisted and carried into the opening,, and 
 retained there by sutures. 
 
 4. Balassa advised, as a plan of closure, to form a flap, which, 
 when put in position, will leave the epidermal surface turned 
 inwards. An objection to this plan is that the flap would contain 
 hair-bulbs, whence liair developing, would be seriously out of 
 place, and certainly disturb respiration. 
 
 In the fistula of small calibre, such as is usually met with as 
 tlie result of wounds opening the larynx or trachea, closure is 
 commonly practicable by the first method; but should there be 
 some loss of cartilaginous structure resulting in a larger opening 
 of the air-canal, then it would be necessary to employ the third 
 method ; and then, if the breach were a large one, some broncho- 
 plastic, or rather chondroplastic, procedure would be required; 
 for if merely a bridge of soft parts were stretched across the 
 breach, then such movable operculum would sink during inspira- 
 tion and interfere with breathing. To obviate this, the expedi- 
 ent might be resorted to of shifting a small section of the carti- 
 laginous wall so as to support and give fixity to the replacing 
 59 
 
022 WOUNDS OF THE NECK. 
 
 bridge. Such sustaining arcli might be devised by shifting a 
 part or whole of a tracheal ring. 
 
 Roux, to close sucli fistulio, dissects off the lining membrane 
 and thrusts this inwards; then he closes the outer opening with 
 deep sutures. He next forms a canal near by, of which the 
 inner end lies in the inner part of the fistula; thus proceeding, 
 the outer part of the old fistula is closed, after which the new 
 one will close spontaneously. 
 
 Wounds of the air-passages in which there is no breach of 
 the derm will now be considered; this list contains fracture of 
 the hyoid bone and of the thyroid and cricoid cartilages, and, 
 finally, hanging. 
 
 Fracture of tlie Hyoid Bone. — The os hyoides may be broken by 
 external violence acting directly; it may also occur from mus- 
 cular action. 
 
 The fracture is usually limited to one or more of the cornua. 
 As exceptions to this are the gunshot wounds, from which the 
 bone may be broken in any part of its body or processes. 
 
 South states that he had only observed this fracture in per- 
 sons who had been executed by hanging. Casper, whose official 
 duty it was to examine the dead bodies of those who had died 
 by hanging (of suicidal subjects as well as of those who had 
 been executed), says that in no case did he find the hyoid bone 
 broken. And Mackniurdo, who was surgeon to the famous New- 
 gate prison in London, in wliich occurred numerous executions, 
 found the hyoid bone broken in but one case. 
 
 In the hanging of Wirz, executed in 1868, for his inhumnn 
 treatment of Union prisoners, the executioner, in his work, out- 
 did that done at Newgate, viz., the bone was broken at six 
 points: whether by accident or otherwise is best known to the 
 hangman. A strong hand grasping the upper part of the neck 
 in front can fracture the hyoid bone, and this may be verified by 
 experimentations on the cadaver. It has been seen by Mur- 
 chison, Dieff'enbach, and others, as the result of criminal attempt 
 at strangling. Harley and Wood saw the bone broken from 
 falls, in which the point of impact of violence was on the bone. 
 And, as a rare occurrence, the bone has been broken from mus- 
 cular action, in which, the subject falling backw^ards, there 
 occurred such violent contractions of the muscles of hj^oidean 
 attachment as to break the bone. 
 
 This fracture is followed by interference with the .several 
 movements or actions in which the bone is directlv or indirectlv 
 
FRACTURE OF THE LARYNX. 923 
 
 concerned: thus there is trouble in speaking, swallowing, and 
 other movements of the tongue. There is swelling, which may 
 reach into the larynx and cause labored breathing. If the frag- 
 ments are in contact, pressure over them elicits crepitation; and 
 usually there is deviation from the normal form of the bone; and, 
 if the violence has been great, a fragment may be driven through 
 the pharyngeal mucous membrane, and bleeding result. In 
 one case reported a fragment was driven between the epiglottis 
 and the glottis, and caused death. 
 
 Treatment. — Recovery with perfect restoration to form is 
 scarcely to be hoped for, since some of tlie indispensable func- 
 tions of the phar3aix will necessitate occasional movements 
 which will disturb the coaptated fragments. 
 
 Nevertheless, restitution to normal form must be attempted 
 by external and internal manipulation. Should the broken 
 ends tend to jut outwards, correction may be made by a small 
 compress held in place by adhesive strips; and should the ends 
 fall inwards, as suggestion for trial, this compression may be 
 made near the end of the great cornu. Should the displaced 
 ends defy simpler means of rectification, then tracheotomy 
 being premised, the throat may be plugged with lint, and pres- 
 sure on the outside be maintained by compresses fixed by 
 adhesive plaster; and, meantime, liquid food may be given 
 through an oesophageal tube, which has been introduced through 
 the inferior nasal meatus. Most cases, however, may be treated 
 in a very simple way, viz., to restore the broken parts to normal 
 site, nourish with liquid food, which may be swallowed or con- 
 ducted through a tube, with injunction to maintain the parts at 
 rest as nearly as possible. 
 
 Fracture of the Larynx. — The larynx, from its more exposed 
 position, is oftener fractured than the hyoid bone, and the 
 causal agency may be any kind of outward violence acting on 
 the part, viz., hanging, great compression, a blow, and falling 
 against a hard object. Casper never saw the larynx broken 
 by hanging; still cases thus arising have been reported. Mor- 
 gagni, an accurate observer, saw such fracture from hanging. 
 To decide this matter, experimentally, Haumeder suspended, as 
 in the act of hanging, twenty-six cadavers, with the following 
 result: the hyoid bone was broken in twelve cases. The cornua 
 of the thyroid cartilage were fractured in but six cases; and in 
 one single case, in which the cord was placed beneath the thy- 
 roid cartilage, the cricoid cartilage was broken. 
 
924 WOUNDS OF THE NKCK. 
 
 Ccivasse has likewise done some experimental work in this 
 field; he found that from a blow on the front of the laiynx 
 there can be produced a median fractnre or a lateral one; and he 
 considers a fracture in the median line more apt to unite than 
 one at the side. Tiie cricoid cartilaf^e was only fractured at the 
 side. The cricothyroidean memVjrane was often torn, but tiiat 
 of the interior of the larynx was found intact. In a case in 
 which the cadaver was hanged by a rope, the larynx was frac- 
 tured; in another it was uninjured. In violently grasping the 
 throat, the larynx could be broken, provided the pressure was at 
 the upper part. Maclean and others have oljserved laryngeal 
 fracture which had arisen from falls against some hard ol)j('ct, as 
 the edge of a box or a table. In twenty-nine cases collected by 
 Hunt, he found that the fracture occurred at an age prior to 
 ossification of the cartilage. 
 
 The mo.st usual fracture of the larynx is that in wliich the 
 superior cornua of the thyroid cartilage are broken; and this 
 arises as follows: in pressure, such as is caused b}' hanging, the 
 cartilage is forced backwards, the wings are separated by the 
 vertebral column, and the upper horns, being forced against the 
 column, are broken. And at the same time, the tliyrohyoidean 
 membrane being stretched, may tear off one or both horns of the 
 OS hyoides. 
 
 Symptoms. — Cavasse observed the following: trouble in breath- 
 ing, aphonia, cyanosis, swelling, and ecchymosis of blood in some 
 cases. There is expectoration of blood-stained, foani}^ mucus. 
 
 Palpation of the laryngeal region detects crepitus or undue 
 mobilit}' of the parts composing the larynx. Swallowing is 
 impossible or attended with great trouble. The carotids beat 
 violently, and the face is turgid, or perhaps pale from compres- 
 sion of the carotids. 
 
 Laryngeal fracture is exceedingly dangerous. Hunt found 
 that death occurred in seventeen patients in a series of twenty- 
 nine who had fractured larynx; and the cases invariably died 
 in whom the mucous membrane had been wounded and trache- 
 otomy was not performed. Death is not unfrequent from partial 
 or complete closure of the laryngeal canal; in some recorded cases 
 death immediately followed the fracture. 
 
 Treatment. — In laryngeal fracture to guard against asphyxia 
 from sudden occlusion of the air-canal, tracheotomy should be 
 performed at once, and a canula worn until the broken parts 
 have reunited. If the ala be broken, and it be impossible to 
 
STRANGULATION, HANGING. 925 
 
 otherwise maintain the parts at rest, then a resort may be had to 
 metallic ligature, fine silver wire being used for the purpose. 
 As a rule, it is enougfi to bring the parts into proper site, and 
 enjoin the maintenance of rest. Meantime the calibre of the 
 laryngeal canal should be maintained patent by means of the 
 occasional introduction of a sound, which may be passed througli 
 the mouth from above; or the sound can enter the tracheal 
 opening if the latter has been made for tracheotomy; thus doing, 
 fragments which have been displaced inwards can be forced out- 
 wards, and satisfactor}'^ calibre preserved. 
 
 Strangulation, Hanging. — The neck is the site of parts of which 
 the functional activity is essential to life, viz., vessels through 
 which blood passes to, and returns from, the head; the air-canal 
 through wdiich air reaches to and returns from the lungs; and 
 nerves which are concerned in respiration. The accessibility 
 and exposed situation of these structures render the neck the 
 chosen point towards wdiich the hand of Penal -Justice, as well as 
 that of the assassin and the suicide, are directed in their work of 
 abruptly ending life. The means used to accomplish this fatal 
 purpose are, in the main, strangulation and hanging. Though the 
 greater portion of this subject falls for consideration to the medi- 
 cal jurist, yet it claims the attention of the surgeon sufficiently 
 often to be entitled to a chapter in a work upon surgery. 
 
 Laugier, who finds a marked difterence between violence 
 done by strangulation and by hanging, defines strangulation to 
 be "an act of violence consisting in constriction exercised directly 
 on the front, or on the entire circumference of the neck; and 
 which has the effect of so compressing the vessels and the air- 
 canal as to cause death through the sudden suppression of the 
 encephalic circulation and the respiration." The violence may 
 be done with the hands, or by means of a cord ; that done with the 
 hands is wholly homicidal; that with a cord may be homicidal 
 or suicidal; and in each case, the work may be complete or 
 incomplete; if done with the hand, one or both hands may be 
 used; or if a cord be used, this may vary in size, and be applied 
 in different w^ays. 
 
 The amount of violence necessary to cause death through 
 strangulation done by the hands, will vary with the subject. 
 Thus a small force will suffice in the aged subject, in the one 
 weakened by disease, and in the infant. Likewise, if tlie neck be 
 small or emaciated, so that the hands can grasp it in its entirety, 
 death can be caused by a much smaller degree of force than when 
 
926 WOUNDS OF THE NKCK. 
 
 the subject is strong, or lias a well-developed neck. The com- 
 pression may be done with both hands, wlien the neck rests 
 behind ngainstsonie hard object; and the pressure may be back- 
 wards and laterally : or it may be directly backwards. Again, 
 it may be made with one hand in front, and while the other sup- 
 ports the nucha. Or, instead of backward compression, the force 
 may be directed upwards, so that the tongue being forced against 
 the posterior wall of the pharynx, death results from occlusion of 
 the larynx, and may be caused thus by a small amount of force. 
 
 Manual compression acts mainly on the larynx ; the carotid 
 arteries, which share in the violence done by the rope, often 
 escape manual violence. Yet a singular exception to this was 
 observed by Laennec, in which the larynx escaped and the 
 carotids only were compressed. 
 
 In all cases in which the violence is fatal, the result is accom- 
 plished speedily in subjects unable to resist; death is less rapid 
 in persons who are able to resist. 
 
 If the violence be done by a partially or wlioU}'' encircling 
 agent, this may be a large or small cord, a handkerchief, or a 
 portion of clothing, or a sheet. Ingenuity stimulated by the fury 
 of purpose which animates either the assailant or the suicide, 
 has evinced marvelous invention. 
 
 Faureand Hoffman have experimented in this field; and they 
 found that the fatal phenomena, whether the strangulation be 
 done suddenly or slowly, consist first in the induction of uncon- 
 sciousness, which deprives the victim of the power of resistance; 
 and secondly, in the occlusion, partial or complete, of the air- 
 passage, which completes the destruction of life. In regard to 
 death caused by strangulation with a cord, it must be stated that 
 opinion varies as to whether death results more from obstruction 
 of the vessels, or of the air-passage; each opinion has as active 
 partisans in its behalf, as has the subject of death from chloro- 
 form, whether the fatal work be mainly due to action on the 
 heart, or on the lungs. In whatever way death bj^ strangulation 
 arises, local traces of violence can be found on the neck, and 
 symptomatic phenomena remain on other parts of the body, 
 the leading ones of which are the following. 
 
 The face of the strangled subject is usually found swollen and 
 purplish in hue; and the tinting is irregular, or mottled, or 
 marbled in dis[>osition. Yet in case of death having been rapid, 
 the face may be })ale or colorless. The eyes are commonly open, 
 prominent and congested, and the pupils dilated. The tongue, 
 
STRANGULATION, PIANGING. 927 
 
 swollen and black, may be found between the teeth, or lying 
 behind them. A fluid containing blood and foamy in character 
 escapes from the mouth; and blood has also been seen escaping 
 from the ears. According to Tardieu, conditions found most fre- 
 quent are multiple ecchymoses found beneath the ocular and 
 palpebral conjunctiva; likewise in the skin of the face and neck. 
 Contusions or marks of great violence from the efforts of the 
 assailant may be found on other parts of the body. Special 
 marks of violent force are found on the neck and throat, which, 
 in form and location, farnish evidence of an assailant's hand. 
 Prints of finger nails will be found; and such being usually 
 made with the right hand, they are chiefly on the left side of the 
 subject's neck. 
 
 If the strangulation has been done with a rope or cord, there 
 will remain some compression of the latter in the cervical integu- 
 ment; certain professionals in the hideous work of strangling 
 have so perfected their art, in the use of a broad band, that scarcely 
 any outward mark remains to indicate the violent work which 
 has been done. In the use of the ordinary rope, a mark corre- 
 sponding to its breadth or narrowness is left on the surface. 
 Such mark made by the strangler's cord usually passes horizon- 
 tally over the larynx, or the trachea; but the hangman's cord is 
 placed obliquely, and is usually situated above the larynx, and 
 between it and the hyoid bone. The hangman's cord leaves a 
 deeper impression than does that of the strangler; for in the 
 former case, the weight of the body and the usually longer 
 continuance of the violence both tend to deepen the furrows on 
 the victim's neck. The depression of the hangman's rope 
 diminishes from before backwards; that of the strangler dimin- 
 ishes from behind forwards. 
 
 The subcutaneous structures may be the site of much more 
 violence than is indicated by lesions visible on the surface; the 
 former may be severely bruised or torn, while the skin is but 
 slightly injured. Ecchymosed blood may be discovered in the 
 intermuscular spaces, as low down as the sternum. The hyoid 
 bone, larynx and trachea have been the site of fracture from 
 manual strangulation: no infrequent occurrence, according to 
 Henocque. Within the air-passage there is found ecchymosis in 
 the mucous membrane; and according to Tardieu, an invariable 
 accompaniment of such strangulation is a sanguinolent mucus 
 studded with minute bubbles, lining the larger air-passages. 
 
 The lungs present variable apj^earances; they may be nearly 
 
028 WOUNDS OF THE NECK. 
 
 normal; or congestion may be found; and most frequently, super- 
 ficial air- vesicles are ruj)tured, and some emphysematous extrav- 
 asation is present; and from this condition a crackling sound is 
 caused when pressure is made on the part. 
 
 In the encephalon, marks of congestion are present, or slight 
 apoplectiform rupture is found. 
 
 In brief, the changes which are found in tlie body after death 
 from strangulation are sucli as should arise from a sudden 
 obstruction of circulation of blood in the cervical vessels, and 
 an arrest of the passage of air through the laryngo-tracheal 
 canal. 
 
 In case the victim has survived the force of the assailant, 
 traces of the violence done will remain on the body of the subject. 
 And as there has been a prolonged struggle, in which the victim 
 successfully resisted the attack, he will have marks of the same 
 on other parts of the body, besides the usual red points, or abra- 
 sions, about the neck. In one case, the ears of the woman who 
 survived, had been torn nearly from the head. It has also been 
 remarked that such survivors often present more extensive 
 ecchymoscs on the neck than do those who have succumbed to 
 the assault: for in the former, the blood has had time to suffuse 
 itself within, or underneath the skin. As functional symptoms 
 there are present the following: bloody foam is escaping from the 
 mouth and nose; the voice is altered, broken and sometimes 
 extinguished, and deglutition is interfered with: and the.se condi- 
 tions may continue for a few weeks. And from the contusion of 
 the cervical structures, suppuration may arise. 
 
 Again, the assault may only be of momentary duration, and 
 cause syncope, in wliicli the subject becomes quite unconscious 
 for a short time ; or the unconsciousness may continue longer, 
 and be accomjjanied by convulsive movement of the muscles. 
 
 Strangulation, ordinarily the result of a criminal attack, may 
 arise from causes purely accidental; and in the latter case, the 
 position and surroundings of the dead body, would aid in the deter- 
 mination of the mode of death. If the work be that of a criminal, 
 the number, arrangement and deviation of the lesional marks on 
 the neck, indicate the relative position of the assailed and assail- 
 ant. If a right hand has done the violence, there will be found 
 the imprint of four fingers on the left side of the neck, and that 
 of the thumb on the right side; or the reverse, if the a.ssailant be 
 left-handed. 
 
 Strangulation may be counterfeited : for example, it may be 
 
HANGING. 929 
 
 done on one already dead. Yet the conditions found would 
 differ from those of genuine strangulation in this, that in the 
 former, the spots of ecchymosis are slight or wanting; or in the 
 event that the work of fraud has been done so soon after death 
 that ecchymosis may result, yet there will arise no swelling of the 
 face, nor cyanosis of the skin : for these only arise from violence 
 done during life. And in such post-mortem strangulation, a 
 necropsy will find none of the appearances which have been 
 mentioned as present in cases in which the strangulation was the 
 fatal agency. 
 
 In some cases, strangulation has been done by some one upon 
 himself for the object of visiting the penalty on some one else, on 
 wliom would rest the suspicion of having done the act; and such 
 work is so cunningly planned, that the expert has difficulty in 
 disentangling the plot; and especially if the planner has tran- 
 scended his purpose, in actually killing himself. The impostor 
 in such case, less wise than the expert who afterwards investi- 
 gates his work, often leaves out a link in the chain of evidence 
 which he forges against the would-be assailant. A case akin to 
 this, was that of the colored student at the military school of the 
 United States a few years ago. He was found tied with his ears 
 cut off; and whether this mutilation was self-inflicted, or was 
 done by his j)ersecutors as he claimed, was a problem which 
 remained unsolved by the commission of inquisition; his friends 
 believed that he was the victim of a brutal outrage; his enemies 
 declared him an impostor, and that his deception was justly paid 
 for by the forfeiture of his ears. 
 
 Hanging. — Hanging is defined by Laugier to be an act in 
 which a rope-like cord, which is attached to a fixed point, is 
 passed around the neck, when the body being abandoned to its 
 own weight, traction is caused, which destroys life, through either 
 the arrest of the circulation in the head, or by the closure of the 
 air-passages; or death may arise from both these agencies. Hang- 
 ing differs from strangulation only in the direction or manner in 
 which the violence acts; the weight of the body becomes the 
 agency of death. This act is oftenest that of the suicide; of 
 seventy-nine thousand five hundred fifty-seven deaths self- 
 caused collected by Brouardel, nearly one-half were caused by 
 hanging or strangulation; and nearly thirty thousand of this 
 number were men. 
 
 The subjective phenomena of hanging have been learned 
 from the experience of those in whom the fatal purpose failed of 
 
930 WOUNDS OF THE NECK 
 
 completion ; and who recovering were able to narrate their sen- 
 sations. And Fleischmann, a zealous student of the subject, stud- 
 ied his own sensations after suspension for a brief time; and the 
 following has been reported by Laugier concerning this matter: 
 The instant the body is suspended and abandoned to its own 
 weight, the face reddens and the head is hot, and there is a gen- 
 eral sensation of heat through the entire body; there is a hissing 
 and buzzing in the ears, sometimes amounting to loud noises, 
 like some loud music; the legs feel exceedingly heavy ; finally, 
 all sensation vanishes. In some cases, the first })lienomenon is 
 total syncope, in which consciousness is lost at once. The popu- 
 lar idea propagated by a few writers, that in the first moments 
 of suspension the subject experiences voluptuous sensations, is 
 incorrect ; the seminal escape sometimes seen, occurs when the 
 patient is in an unconscious condition. 
 
 The I0.SS of consciousness which takes place in the first period 
 of hanging is soon succeeded by a convulsive stage, in which the 
 muscles of the face and eyes are distorted, and the limbs are 
 spasmodically moved. The suspended one striking his feet 
 against the floor or wall has apprised those near by of his 
 suicidal act. 
 
 HolTmann and Amussat have studied the efiect on the cer- 
 vical vessels of hanging; and tliey have found that the internal 
 and middle tunics of the carotids are often lacerated. They 
 have likewise discovered that when the loop of the cord is placed 
 near the cliin, the effect is to arrest the flow of the blood through 
 the carotid arteries, even when the body is but imperfectly sus- 
 pended. Hoft'mann states that when the rope is above the lar- 
 ynx, that is between the larynx and hyoid bone (its usual site in 
 hanging), the larynx is not closed by compression on it, but 
 through the root of the tongue being forced against the posterior 
 wall of the pharynx so as to close the passage. This he found 
 in section of frozen cadavers. Brouardel in experimenting in 
 this field, finds that suspension can be done in such a mantier 
 that blood may continue to flow through one carotid while the 
 other is closed. 
 
 Hoffmann has also directed attention to the efiect of the com- 
 pression of the rope on the nerves of respiration which lie in the 
 neck; he probably overestimates this action: since the jiressure 
 on the vessels and air-pnssages is sufficient to destroy life inde- 
 pendently of any action on the adjacent nerves. 
 
 In case of fracture of one or more of the upper cervical verte- 
 
HAXGIXG. 031 
 
 bne, there may be injury done to the medulla oblongata, which 
 will, at once, destroy life; such cases are rare, yet when they 
 happen, death occurs independently of any obstruction of the 
 air-canal or blood-vessels. 
 
 Sudden death has also been seen as the result of syncope 
 from the instant induction of cerebral anaemia through closure 
 of the vessels; the face of the cadaver in such cases presents a 
 waxen discoloration. On the contrary, if the cord is so placed as 
 to close one carotid and permit the passage of some blood through 
 the other artery, and at the same time, the jugular veins do not 
 allow the return of the blood, then death will occur slowly, 
 through congestive apoplexy; in such subjects, the face will be 
 cyanosed or purple. Such cases are those in which resuscitation 
 is possible; while in those in whom death is in.stantaneou.s, 
 according to Brouardel, life cannot be recalled. Xotwith.standing 
 this eminent authority, an attempt should be made to resuscitate 
 in all cases; for failure cannot make the unfortunate subject's 
 condition any worse. 
 
 In a small number of cases observed, the violence done has 
 not destroyed life at once; the patient found suspended was dis- 
 covered before life was extinct, and an attempt to resuscitate has 
 been partly succe.ssful; yet after some hours, or even days, death 
 sometimes ensued. In one such subject who lived twenty-four 
 hours, the body ne\^r became warm. The necropsy revealed no 
 other lesion than an intense encephalic congestion. And in 
 another case the attempt at suicide was not immediatel}^ success- 
 ful. The skin of the face was red and swollen; resj^iration and 
 circulation were restored. Later, there appeared hemiplegia, 
 also muscular oentracture; and finally, the patient returned to 
 consciousness and was able to speak rationally; on the sixth da}^ 
 he died, with sym])toms of pronounced meningo-encephalitis. 
 
 From those who have recovered after temporary hanging 
 some knowledge has been derived; the sensations remembered 
 were those which have been mentioned above; and in one who 
 recovered, the subsequent symptoms were loss of memorv, voice 
 nearly extinguished, incontinence of urine and paralysis of the 
 rectum, sharp pains and convulsive movements of Vne limbs; 
 likewise, cough and bronchial catarrh with dyspnoea. In another 
 case there remained pains in the head, giddiness and trouble of 
 swallowing. 
 
 The ])atient in one case was rescued after being suspended 
 seven minutes. Taylor thinks recall to life is pos.sible after 
 
932 vvOUXDS OF THE NECK. 
 
 Imnging five minutes. It is clear that the time is subject to 
 variation, dependent on the manner in which the rope has been 
 adjusted about the neck, and also, whether there has been a fall 
 along with tiie suspension. A fall of the body through a fen' 
 feet after the cord has been fixed around the neck, becomes the 
 more important factor in the fatal work. This has been verified 
 in the work of judicial hanging: the long space through which 
 the body has dropped has frequently caused the cord to make a 
 deep cut in the structures included; and in one case known to 
 the writer, the work was so eifectually done tlint the head was 
 severed from the body in the fall. 
 
 General facts of cardinal importance, to which reference has 
 been made, are that if the suspension has been brief, and the 
 death immediate, the face is pale and of natural api)earance, the 
 eyes half closed and the lips are discolored without swelling; 
 but where the dying has been slow, then the face will be found 
 cyanosed and swollen. 
 
 Death has often occurred when the body had not been totally 
 suspended; life has been extinguished where the body was partly 
 supported by the feet; also in cases of half reclination, either in 
 the supine or prone position. 
 
 Epicharis, one of the conspirators against Nero, after being 
 terribly tortured to extort her secret, destroyed wliat life remained 
 in her by sitting in a chair and passing hei*head through a loop 
 of her girdle, and attaching the latter to the top of her chair. 
 "Thus dying, she put to shame many men who hastened to 
 betray their fellow accomplices." (Tacitus.) 
 
 The im})ression made by the suspending cord has been care- 
 fully studied; and this may be slight; it may also be abseiit, or 
 it may be distinctly formed; and in certain circumstances the 
 cord may cut or tear the structures of the neck. 
 
 The impression has been so slight that it was not discoverable; 
 thus a broad or elastic band may leave no trace of its action; yet 
 usually, there may be detected some red discoloration of the 
 derm; however, the interposition of a dense beard, or a thick 
 cravat, or a layer of clothing, may render the impression of the 
 cord invisible. These cases are ujiusual, and the rule is, that 
 the rope or suspending agent leaves a clearly discernible 
 furrow on the neck, of which the site, direction, form and depth 
 have been carefully studied. 
 
 In most cases this cord-mark passes transversely over the 
 front of the neck, between the larynx and the chin. In a col- 
 
HANGING. 933 
 
 lection of one hundred fifty-sis recorded cases, the furrow was 
 found in one liundred twenty-seven cases above the larynx, 
 and oftenest between the larynx and the hyoid bone; in twenty- 
 six cases the mark was on the lar^mx, and in six, it was below 
 the lar3^nx. And the furrow was always lower down when the 
 subject was in oblique suspension. 
 
 The furrov/ commencing at the h3'oid region ascends upwards 
 and backwards behind the mastoid processes to some point on 
 the nucha, where the ends of the cord meet in the closing knot; 
 and if the knot is near the median line, behind, then the figure 
 of the imprint will be that of an ellipse, which opens somewhat 
 above and behind. The figure will be less regular, if the knot is 
 at the side of the nucha. And if the knot be near the ear, then 
 the action of the cord will be oblique and irregular, and the com- 
 pression may thus occlude one carotid, and permit the passage of 
 some blood through the other vessel. 
 
 The form, breadth and depth of the furrow depend on the 
 form of the cord. A cord passed twice around the neck may 
 .produce a double impression ; and these may be adjacent, or have 
 an irregular interval between them ; or if a hard broad band, as 
 one of leather, be used, then its two edges may leave impressions, 
 which are parallel. 
 
 The breadth of the furrow is generally less than that of the 
 constricting cord; and the depth is directly proportional to the 
 thinness of the cord and the time that the suspension is continued. 
 The greater the development of the fatty couch is, the deeper 
 will be the furrow produced by the cord. If the cord have knots 
 or other irregularities, these Mall be represented in the furrow. 
 
 As to the color of the imprint caused by the constricting 
 agent, this depends on its depth, and whether the bottom of the 
 sulcus is soft, or dry and parchment-like. If there be no depres- 
 sion, the skin may remain of natural tint. But when there is left 
 a decided furrow which is soft, tliis will be of a pale white color: 
 in fact, whiter than the parts adjacent. Instead of a white hue 
 this may be a dirty blue, due to a thinning of the skin, which 
 permits the color of the subjacent muscles to be perceptible, or 
 the attenuated and condensed skin may assume a bluish tint. 
 
 The skin lining the furrow may be dry and parchment-like, 
 and then the color may be an orange-yellow, or a reddish-brown. 
 Again the dried compressed skin may have a shining or pearly 
 hue. The borders of the furrow are slightly elevated, and of a 
 violet hue, dependent on a superficial congestion of the derm. 
 
914 AVOUXDS OF THK NECK, 
 
 If the air be very moist, this desiccation does not take place ; and 
 for its full a[)pearance, the furrow must be exposed some time to 
 the dr}' atinos})here. 
 
 To obtain the discolored })archment-like furrow, the following 
 j)roliminary conditions are needed: suspension with a cord that 
 will produce a depression; the cord must maintain pressure 
 enough to force the blood from the walls of the fiirrow ; and after 
 the removal of the cord, the part must be exposed sometime to a 
 dry air. 
 
 Hoffmann has examined a great number of bodies of young 
 and vigorous men wiio had died by hanging, and in no one did 
 he find penile erection. In case, however, the bod}' had remained 
 hanging for a considerable time after death, then there was found 
 genital turgescence, which he referred to hypostatic congestion. 
 Tardieu is not so positive on this point; he admits the possibility 
 of genital erection, as a reflex act awakened by the violence done 
 to the upper part of the spinal cord. And admitting the possi- 
 bility of such reflex action, which, as stated, has been denied by 
 most observers, there are two species of genital turgescence which 
 may follow hanging, the one wliicli is found immediately after 
 death : and that which occurs later, and is purel.y a physical 
 condition, the result of the position of the body ; and in case the 
 former occurred, the latter might follow it some time afterwards, 
 provided the body remained in suspension. 
 
 Luxation or fracture of the upper cervical vertebrse was not 
 seen by Casper, Tardieu and Hoffmann in cases of suicidal hang- 
 ing; it was only seen in the neck of the hanged criminal ; and 
 occurred oftener in former times than at present, when the work 
 is done with more complaisance to the victim. 
 
 Besides the violence done by the suspension, the body of the 
 subject may present other marks of violence; thus there may be 
 found contusions of surface, costal fracture and other lesions 
 which arose during the struggle in which the victim w^is over- 
 powered. And marks of wounds received some days prior to the 
 hanging may exist. Such injury will have characteristics which 
 will indicate its age. 
 
 The body being found hanging, it is often a question of 
 importance in forensic medicine to determine how long the body 
 had been suspended; and this question is still more important to 
 those on whom devolve the task of resuscitation. If the body be 
 yet warm, and the suspension has been incomplete, or there has 
 been no fall, then an attempt is to be made to recall the victim, 
 
IXSUFFLATIOX. 935 
 
 provided he be not in tlie list of those ^vhose Hfe has been for- 
 feited through crime; the death of the latter being decreed by 
 the law, he is denied the privilege which the merciful hand of 
 medicine extends to him who is the victim of suicidal or homi- 
 cidal violence. A consideration of the means of i^estoration here- 
 with follows. 
 
 Artificial Besjjiration. — -The principal means of resuscitation of 
 the subject which has been the victim of strangulation or sus- 
 pension, is that of artificial respiration. And this is also resorted 
 to in those who are seemingly dead from immersion in water or 
 semi-liquid materials; or whose air-passages have been occluded 
 by earth, sand or other means; or where breathing has been 
 nearly or ciuite arrested by a narcotic or an^stlietic agent, or an 
 asphyxiating gas; in all such cases, it is possible to relight or 
 reanimate the expiring spark of life by resorting to artificial 
 respiration: by which is meant the alternate introduction of air 
 into, and its expulsion from, the lungs. 
 
 Resuscitation of the subject vrho is apparentl_y dead from any 
 of these causes may be attempted by several methods. If life be 
 realh' extinct, it will be indicated b}^ certain signs, among which 
 may be enumerated rigor mortis and loss of the contractile |)Ower 
 of the pupil. If the cornea of the dead subject be pressed on, the 
 pupil v\-ill be displaced, and its circular form converted into an 
 irregular one, which remains. And finally, if signs of decompo- 
 sition are present, these denote that the undertaker's duties 
 rather than tho.se of the resuscitator, are demanded: for then, in 
 the words of the great Dramatist, medicine "knows not where is 
 that Promethean heat that can this light relume.'"' 
 
 As resuscitating methods, the following may be named : (1) in- 
 sufflation, or blowing the air into the lungs; (2) aspiration, in 
 which the thoracic cavity is enlarged by some procedure so that 
 the air spontaneously enters the air-passages, and then by revers- 
 ing the procedure, the air is expelled ; (3) intermittent pressure 
 on the cardiac region; (4) rhythmical extraction and retraction of 
 the tongue; (5) electrical excitation of the respiratory nerves. 
 
 Insufflation. — Of all the means employed to restore the inani- 
 mate to life, insufflation is probably the oldest. Traces of this 
 method are manifest in the Biblical account of Elisha recalling to 
 life the widow's son. Insufiiation may be done orally, in which 
 air is blown from mouth to mouth, the nostrils, meantime, being 
 occluded; or it may be done with a tube which is passed through 
 the mouth into tlie larynx, or into the mouth simply, or into one 
 
930 WOUNDS OF THE NECK. 
 
 nostril, the remainder of the nose and mouth being closed. An 
 instrument Avliicli may be carried into tlie larynx is a common 
 male catlieter, either of silver, or of gutta percha. This is a good 
 means of reviving tlie still-ijorn infant, which the author, on 
 several occasions, has employed successfully. A gntta percha 
 catheter of smallest calibre should be used. To do this work 
 properly, some preliminary practice must be had on the cadaver; 
 the index must be trained to find the opening into the glottis, 
 which is distinguished by its hard, cartilaginous borders. The 
 end of the left index being fixed in this o})ening, the catheter can 
 be carried along the palmar side of the bent finger, and readily 
 introduced into the air-passage. It should be carried into the 
 upper part of the trachea, and then external compression being 
 made so as to close the trachea around it, the air, with moderate 
 force, is to be blown into the lungs. If this work be proper!}'' 
 executed, the chest will dilate as in normal inspiration, and when 
 this has readied average expansion, the walls must be compressed 
 to expel the air; thus inspiration and expiration are represented, 
 and should be repeated twenty tin'ies in the minute. The rigidity 
 of the walls of the trachea and larynx of the adult, as well as the 
 longer distance which must be traversed to reach the part, and 
 also the contracture of the muscles which close the lower jaw, 
 render the introduction and use of such a tube difficult in the 
 adult or aged subject. And, as an easier way of doing the work, 
 jNIarchand advises to pass a tube into one nostril, and then clos- 
 ing the other and the mouth, the air can be blown into tiie nostril 
 and can thus be made to descend to the lungs. As a tube wliich 
 is usually at hand, and can easily be used, is the common pipe- 
 stem. Marchand commends this means of insufflation above all 
 others; and he i:»ronounces it superior to all other methods of 
 artificial respiration. The air from an clastic balloon can be 
 utilized; or the operator can force the air from his own chest into 
 that of the patient; and if the operator takes pains to forcibly 
 expire and then deeply inspire, the air used will be sufficiently 
 free from carbonic acid. 
 
 Objection to insufflation is that the air may jiass through the 
 oesophagus to the stomach, and filling this, the movement of the 
 diaphragm is interfered Avitli. This is true, especially if the air 
 be blown from mouth into mouth ; the writer has seen the stom- 
 ach of a new-born child greatly distended in this way. Another 
 objection is that air thus violently forced into the lungs may 
 rupture the pulmonary tissue: and that, after resuscitation in this 
 
IXSUFFLATION. 937 
 
 T\-ay, there may remain an emjjhysematous condition of the 
 lungs. Observation and experimentation on this subject are dis- 
 cordant. Thus, Dumeril and Magendie, appointed a commission 
 to report on this method, say that they have seen fatal laceration 
 of the lungs in animals thus operated on; and they have seen 
 similar lesions iu cadavers subjected to such insufflation. They 
 admit, however, that insufflation in the apparently dead subject, 
 and in the living robust one, is a different procedure: the former 
 passively admits the air, while the latter, if an animal, vehemently 
 resists It. And the commission also found that lesion of pulmo- 
 nary tissue was only seen in cases in which the air had been 
 forced in continuously, and with violence. Depaul, who exam- 
 ined this question, found that the fears of injuring the lungs are 
 baseless, provided an}^ prudence be used in the work; and the 
 experiments of Budin confirmed the statement of Depaul. His 
 experiment consisted in attaching a large inflated bladder to the 
 lungs of a cadaver; a board was placed on tlie bladder, and two 
 jDersons sat on this, so as to force the air into the lungs; such vio- 
 lence repeated on several lungs, only caused a slight injury in 
 one case. The practical conclusions deducible from these exper- 
 iments and observations are, that insufflation practiced either by 
 the mouth or an instrumental appliance, is safe wdaen the work 
 is done gently and with rhythmical interruptions. Instead of 
 insufflation through, the nostrils or mouth, the air may be blown 
 through a canula or tube, wdiich has been introduced directly 
 into the trachea after the performance of tracheotomy. This 
 plan has been advocated by Hueter : and as special advantage 
 which he claims for it is, that by means of the tube, mucus and 
 other obstructing materials can be withdrawn from the air- 
 passage. 
 
 In a case in whicli the patient had apparently died from an 
 ansesthetic, the writer rescued the man by quickly plunging a 
 pocket scalpel into the trachea, and inserting a silver catheter, 
 through which air was blown into the lungs. Breathing for 
 nearly an hour was very slow: yet by persevering effort, the 
 patient's life was saved. 
 
 Against insufflation Pacini urges that it is the reverse of the 
 ordinary respiratory act, viz., in this artificial procedure the air 
 being forced in increases the pressure in the lungs; while in 
 natural breathing there is a diminution of pressure. In the 
 former condition, the carbonic acid contained in the blood has 
 no tendency to escape, and the pulmonarv capillaries are in a 
 60 
 
938 WOUNDS OF THE NECK. 
 
 slate of compression; the heart, also, is pressed on, and is interfered 
 with, in its normal action. Though these objections are not 
 groundless, yet Pacini gives them too much importance when he 
 says that the method, instead of saving, destroys life. That life 
 may be revived by insufflation is shown in the observation of 
 Guerard, that of one hundred and eighty-five persons immersed 
 in water who were restored to life, in fifty-four cases insufflation 
 was the only means employed. 
 
 Aspiration. — By the method of aspiration the thorax is dilated; 
 and this may be accomplished by several methods: among these 
 may be mentioned the plan of removing the pressure from the 
 outside of the chest, so that a species of vacuum is created in the 
 thorax; or this may be done by pressure so as to lessen the tho- 
 racic space, which reexpanding forms a partial vacuum ; or by 
 traction on the arms, so as to dilate the thoracic cavity. 
 
 The first method, by which there is formed a partial vacuum 
 within the chest, has been accomplished by means of a somewhat 
 complicated apparatus invented by AVoillez, and named spiro- 
 phore, a hybrid name.like too many others, compounded from the 
 Latin and Greek. This consists of a metallic envelope of cylin- 
 drical form, into whicli the body is to be introduced, except the 
 head, which is exposed. Around the neck there is placed some 
 flexible material, which hermetically closes the metallic cylinder. 
 To the lower part of the apparatus an air-extractor of bellows- 
 form is attached. Bv the aid of the extractor, the air can be 
 removed from the interspace between the body and the cylinder, 
 so that the chest is caused to dilate, and air is thus drawn tlirough 
 the nostrils and mouth to the lungs. And by a reverse action of 
 the extractor, the air can be expelled from the lungs. Thus, as 
 seen, the two actions of inspiration and expiration are imitated: 
 and, as AVoillez found, two pints of air can be aspirated. 
 
 This method has its analogue in action in a corset-like appli- 
 ance, which being provided with straps and buckles, and placed 
 around the thorax, by alternately tightening and relaxing, the 
 space within the chest is lessened or increased. This plan was 
 examined by the Royal Humane Society of London, but its use 
 as a means of resuscitation was not advised. In fact, any means 
 which is similar to the methods mentioned, is open to the 
 fatal objection that time is lost in its application: the minutes 
 which must be consumed iu applying the vacuum cylinder of 
 AVoillez, or the corset girdle of Leroy d'fitiolles, are those precious 
 moments in which tlie resuscitator has the only opportunity of 
 
ARTIFICIAL RESPIRATION. 
 
 939 
 
 rescuing the victim : before such meclianical device can be placed 
 in proper position for use, the latent spark of life will be wholly 
 extinguished. 
 
 A method, celebrated and commended bv the Royal Humane 
 Society, is that of Marshall Hall, in which the body is so placed 
 
 that by rolling movements the chest cavity is alternately lessened 
 and enlarged; and this is done as follows: the subject being 
 placed on a flat surface, is first turned so that the face is prone, 
 and the chest rests on a cushion; and while in this posture, the 
 mouth should be opened, tongue drawn forwards, and mucus 
 and other material wiped from the buccal cavity: also, pressure 
 
940 
 
 ^vou^•I)S of the nkck. 
 
 1 nn the back between the shoulder-blades. From 
 should be made on he back b ^.^^^ ^^.^^.^^^ ^.^^^^ ^^^ 
 
 a cushion, and while thus ace { ,i,, thoracic space, 
 
 on the upper or exposed side, so as 
 
 
ARTIFICIAL RESPIEATIOX. 
 
 941 
 
 • something analogous, is shaped into a cushion, and placed 
 beneath tlie stomach, while the subject is turned with face and 
 chest downwards; in this position, the tongue being drawn for- 
 ward, the buccal cavity is freed from all extraneous material; 
 and in this posture liquid material lodged in the throat, or air- 
 passages, will flow from the mouth. The body is next turned on 
 the back, which rests on the cushion; the hands are uplifted, 
 crossed and placed underneath the subject's head, and retained 
 there by an aid, who also holds the protruded tongue. The sur- 
 geon kneeling b;/ the patient, grasps and compresses the thorax 
 on each side at its lower portion, and continues this for three 
 seconds; then he suddenly relaxes his hold, when the air rushes 
 into the expanding chest. Thus expiration and inspiration are 
 represented. Howard names his plan the "direct method," and 
 he claims for it advantages over all the others. 
 
 The next method to be considered is that of Silvester, exhib- 
 ited in Figure 9S, which is executed as follows: the patient is 
 
 FiGUEE 98. Showing Silvester's method of artificial respiration. From 
 Harley ; Holmes' Surgery. 
 
 placed on his back with a small supporting cushion under the 
 chest. The mouth and nostrils must be freed from all extrane- 
 ous matters. The tongue must be somewhat withdrawn, and 
 held so as to retain the pharynx open. The surgeon now stands 
 behind the head of the patient, and to do so, the latter should lie 
 on a table, at the head of which the surgeon stands, while the 
 one retracting the tongue occupies a lateral position towards the 
 feet of the patient: if he stands near the chest, he will be in the 
 
042 WOUNDS OF THE NECK. 
 
 way of the operator. This the writer has learned from ex[)eri- 
 ence; and also, that instead of elevating the chest as Silvester 
 does, it is better to lower the head, so that the blood will easily 
 rcach the brain. The operator now raises the extended arms 
 above the head and makes some traction on them, during a period 
 of two seconds; then the arms are lowered, and flexed at the 
 elbows, wliich with the upper arms are to be forced against the 
 sides of the tliorax. The upward traction of the arms acts on the 
 chest through the following muscles, which have costal attach- 
 ment : the pectoralis major and minor muscles in front; the serra- 
 tus magnus muscle at the side, and the latissimus dorsi muscle 
 behind ; the one which aids most efficiently is the serratus mag- 
 nus, which extending from the posterior border of the scapula 
 and being attached to eight ribs, is tlie medium through which 
 much costal elevation can be effected. Since this muscle lies 
 somewhat obliquely, to bring it into full action, the arms must 
 be drawn upwards and somewhat backwards; and these move- 
 ments should be repeated about fifteen times each minute, to 
 correspond to normal breathing. 
 
 Though the method of Silvester is simple, yet the first time 
 it is attempted, it will be awkwardly done, as the writer l)as 
 observed in his collegiate instruction; to be well done, .some pre- 
 vious training is necessary. 
 
 This method was examined by the Medico-Ciiirurgical Society 
 of London, and pronounced superior to that of Marshall Hall; 
 by Hall's plan only ten cubic inches of air were taken into the 
 lungs, while by that of Silvester, the amount was from thirty to 
 fift}' cubic inches. It was also found that if rigidity of the mu.s- 
 cles existed in the commencement, this vanished as the proce- 
 dure was continued, .so that the amount of air that was drawn in 
 at tlie close of the movements was nearly double that which it 
 was at the commencement. It has also an advantage over Hall's 
 method in this, that both sides of the chest are acted on uni- 
 formly, while in the former, tiie action is, in a measure, limited 
 to one side. 
 
 Pacini has introduced a method somewhat similar to the last 
 described: the patient is stripped and placed on his back, and the 
 buccal cavity 1)eing liberated of all materials, the operator seizes 
 the shoulders above with the hands, so that tlie thumbs pa.ss in 
 front and the fingers behind, and he then lifts. In this work the 
 outer ends of clavicles are elevated and thus the intra-thoracic 
 space is augmented. Pacini was led to this procedure by observ- 
 
ARTIFICIAL RESPIRATIOX. 943 
 
 ing that when the cadaver was thus carried iu the dissecting 
 room, air entered the lungs witli an audible sound: and this 
 escaped when the body was put on the table. 
 
 A plan similar to this has been proposed by Bain, who places 
 the hand in the armpits and uplifts the shoulders; the difference 
 between this plan and that of Pacini is that Bain fixes the hand 
 in the axilla from behind, while Pacini fixes the hand in front. 
 
 The methods of traction described act through the medium of 
 the arms; in 1878, a plan was projDosed by Max Schiiller, in which 
 the traction is made at the lower part of the chest. To do this, 
 let the patient be placed horizontally on his back, with a small 
 pillow under the neck. The operator now stands or sits near the 
 head of the patient, with his back turned towards the latter; and 
 thus placed, he grasps the lower part of the thorax on each side, 
 and, in so doing, he insinuates the hands under the false ribs. 
 Thus holding on the lower costal arches, the operator pulls 
 upwards and outwards, so as to expand the chest; then he com- 
 presses so as to force out the aspirated air: and in rhythmical 
 succession, corresponding to natural respiration, these movements 
 are continued. To aid in the work, an assistant should lift up 
 the limbs, so as to relax the abdominal walls. Should the sub- 
 ject lie on the ground, the operator must kneel alongside of him. 
 
 For the revival of the still-born child Schultze has jDroposed 
 a plan which he names swinging. This consists in grasping the 
 lower limbs of the child and alternately lifting and lowering the 
 lower part of the trunk. By the elevation, the abdominal viscera 
 are made to move against the diaphragm, and to narrow the 
 thoracic space from below; and when the trunk is lowered, this 
 space is again enlarged, and so, in some degree, natural respira- 
 tion is represented. 
 
 Schultze's method has recently been criticised, the opponents 
 claiming that by such movement the abdominal organs may be 
 injured. Thus Korber, of Dorpal, asserts that in the work the 
 liver may be lacerated, vessels opened, and blood effused. He 
 claims that though the child be born alive, yet it can die through 
 such hEemorrhage. Such lesion appears in the form of hepatic 
 h^matomata, which may be inclosed by serous membrane; blood 
 may actually be effused into the abdominal cavity. Schultze, on 
 the contrary, replies that such rupture of the hepatic v^essels is a 
 jDhenomenon commonly present in the still-born child, and he 
 supports the statement by reports of necropsies of still-born chil- 
 dren which were made by Pokitansky, Forster, and Weber, 
 
944 WOUNDS OF THE NECK. 
 
 before the swinging method was })racticed. The cause of such 
 lesion is to be found in tlie conditions of the foetal circulation in 
 the asphyxiated child; its lung not being able to receive the blood, 
 the latter accumulates through the medium of the umbilical 
 vessels in the liver to such an amount that finally open rupture 
 and a hsematoma may arise. Thus Schultze, ingeniously and 
 intelligently, vindicates his method. From the discussion of 
 this plan by several writers the inference may be derived that 
 such swinging is improper in cases in which the bones of the 
 child have been fractured; also, if the infant be a very heavy 
 one, the work should be done cautiously, since in such a child 
 lesions can more readily be produced. And to practice this 
 work properly the operator should previously make trial of the 
 method on the infantile cadaver. 
 
 Schultze's method seems not to have been tried on the adult 
 and though theoretically it is inferior to some of the plans which 
 have been described, yet it is evident that in the alternate eleva- 
 tion and descent of the lower part of the trunk, not only is the 
 diaphragm subjected to rhythmical compression, but the blood is 
 moved to and from the brain, conditions which favor the reani- 
 mation of the subject. But since the changes of dimension of 
 the intra-thoracic space produced by such movements are slight, 
 in order to accomplish much, the movements should be much 
 more rapid than in normal breathing. 
 
 Recently Konig, of Gottingen, has announced a method of 
 resuscitation by means of manual compression over the heart, 
 and, while this compression is being done, an aid also compresses 
 the chest. The pressure over the heart forces the blood towards 
 the lungs; and such pressure should be made on the left costal 
 cartilages, near the ensiform process of the sternum. Konig 
 pressed from thirty to forty times per minute, but his assistant 
 Maas proposes to do the work as often as one hundred and twenty 
 times in a minute, and to press midway between the sternum and 
 the site of the apex-beat. 
 
 In 1892, Ivraske modified the plan of Silvester in this wise: 
 that after five breaths, during full expiration he closes the 
 mouth and nose of the subject, and then the arms are to be 
 uplifted in the inspiratory movement. In this way the move- 
 ment of the blood is promoted. 
 
 A verv simple ])rocedure has recently been recommended as 
 a means of resuscitating the asphyxiated subject. This is to seize 
 the tongue with a pair of forceps, and to draw it out of the 
 
ARTIFICIAL RESPIRATION. 945 
 
 mouth and then return it. Let these movements be rapidly con- 
 tinued and they will have the effect to quickly awaken an inspi- 
 ratory act, as the writer has verified on several occasions. This 
 extraction and retraction of the tongue should he done simulta- 
 neously with Silvester's or Pacini's resuscitating protraction and 
 retro-traction of the arms. 
 
 Electrical excitation of the respiratory nerves has been pro- 
 posed as a means of resuscitation by Ziemssen, yet long before 
 the publication of Ziemssen, electricity was used to arouse the 
 apparently dead subject. As a way of applying it, one pole may 
 be applied at the apex of the heart and the other on the back of 
 the neck. The bold step has been taken of introducing a needle 
 through the thoracic wall to the heart, or even into the cardiac 
 wall, and then connecting this needle with an electrical battery. 
 Though the patient might be revived by this method, it would 
 be too perilous for employment, except in cases which were 
 hopeless, for resuscitation with a cardiac wound, or coagulum 
 within the heart, would offer an inauspicious prosjoect for the 
 patient even though life v/ere prolonged. 
 
 Ziemssen's procedure consists in applying an electrode over 
 the phrenic nerve where it lies near the middle of the outer bor- 
 der of the sterno-cleido-mastoid muscle, and the other can be 
 placed over the diaphragm or at the praecordia, and pressed well 
 inwards. Thus doing, the diaphragm is made to contract and 
 enlarge tile thoracic space. The induced current is employed, 
 and the current is to be broken at intervals similar to those in 
 normal respiration. By this procedure the alternating contrac- 
 tion and relaxation of the diaphragm imitate that in the mechan- 
 ism of normal breathing. Many years before the announcement 
 of Ziemssen; the w^riter, in cases of interruption of breathing, as 
 from an anassthetic or from any other cause, employed electricity 
 developed by a Faradic machine; and the nerves which were 
 selected for excitation were the cardiac branches of the sympa- 
 thetic in the neck and the pneumogastric and phrenic nerves. 
 To stimulate the sympathetic, one electrode is to be pressed down 
 on the structures which overlie the vasculo-nervous group near 
 the cricoid cartilage; at this point the electric current will act on 
 both the pneumogastric and the sympathetic nerves; and to com- 
 plete the chain of connection, the remaining pole should be 
 placed on the left side of the epigastrium, close to the heart, and 
 contiguous to the diaphragm. The current should be interrupted 
 once in' three seconds, so as to imitate inspiratory and expiratory 
 
940 WOUNDS OF TIIK NKCK. 
 
 action. The upper electrode may now and then be shifted to the 
 site over the phrenic nerve. In thus proceeding one awakens a 
 triple innervation, viz., on the sympathetic, pneuraogastric and 
 the phrenic, the effect of which will be stimulating action on tlie 
 diapliragm the heart, and the lungs. In the latter, through the 
 vagus, tlie desire of air (bcsoin de rcspirer) is awakened. 
 
 If this electrization l)e continued for a long period, the pro- 
 longed contraction of the subjacent cervical muscles will awaken 
 an inflammation followed by suppuration. The writer has 
 observed this in a patient who, from opiate narcotism, was saved 
 from death by respiration maintained, by the electrical means 
 described, for three hours. The violent irritation of the sterno- 
 cleido-mastoid muscle during so long a period was followed by a 
 large abscess in and around the muscle. 
 
 All methods having failed to recall the patient to life, the bold 
 procedure proposed by Langenbcck might be essayed: which 
 consists in making an incision through the lower thoracic wall on 
 the left side and near to the ensiform cartilage. Through such 
 an incision, which would pass to the heart through the skin, the 
 attached margin of the diaphragm and the pericardium, Langen- 
 bcck suggests that the heart could be reached, grasped with the 
 hand, and compressed so as to force the blood from the organ. 
 Before this procedure be resorted to, some experimentation should 
 be done on the cadaver to determine how much the general 
 circulation could be influenced by compressing the heart. 
 Though proposed by eminent authority, it is not probable that 
 this procedure will be put into practice, unless in cases in wliich 
 apparent death actuall}" touches on real deatli. 
 
 Dvowninrj. — Life is sometimes endangered or lost througli 
 partial or total immersion of the body in water; and in case of 
 deatli, the fatal ending is familiarly known as drowning. 
 
 This subject has been studied and written on by both the 
 pathologist and the humanitarian: the former seeking to deter- 
 mine how deatli thus arises, and the discoverable evidences j^oint- 
 ing to such death ; the work of the humanitarian has been chiefly 
 directed to rescuing the partially drowned. Medical writers 
 eminent in this field are Reaumur, Louis, Haller, Sprengel, Good- 
 win, Fothergill and Bert. 
 
 Any liquid or semi-liquid entering and closing the air-passages 
 can destroy life througli asphyxiation : the blood not being aerated 
 in the lungs, life soon ceases. Water is usually the obstruct- 
 ing agent, yet, in a few instances, the subject has been fatally 
 
DROWXIXG. 947 
 
 immersed in wine. English history records the drowning of a 
 prince in a butt of malmsey; and the writer knew a case of 
 drowning in a yat of new-made wine. 
 
 Drowning may be from mere immersion or partial immersion 
 of the head; yet ordinarily, the entire body is submerged. The 
 act may be voluntary, accidental or homicidal. 
 
 In more than half of the deaths from drowning, Devergie 
 claims that asphyxia and syncope are associated in the extinction 
 of life; and that but one-fourth die from asphyxia alone, while 
 about one-eighth die from syncope and cerebral congestion. 
 
 Falk, Hoffmann, Bert and others distinguish three stages in 
 asphyxiation caused by immersion; and this division of the 
 subject has been founded on experiments made on animals, and 
 on the experiences of those who had been partially drowned, 
 
 1, The first sensation felt when the head is immersed is a 
 feeling of occlusion of the ears and a rushing sound in them; an 
 unpleasant fullness in the nostrils, especially in the uj^per part of 
 them, and a sensation of tightness about the chest. The immersed 
 animal, and also man, when unexpectedly immersed, inspires the 
 water, and then with a strong exj^iratory effort, he expels the 
 fluid, along with some of the reserved air of the lungs. Taylor 
 says that when a person falls into the water, and retains his con- 
 sciousness, he at once makes violent efforts to breathe; this 
 applies to him who is suddenly surprised by immersion; he who 
 knows how to swim will hold his breath until he is exhausted,or. 
 becoming unconscious, he attempts to breathe. 
 
 2. In the second stage, according to Hoffmann, the submerged 
 subject makes deep and short inspirations, followed by expira- 
 tions, similar to what occurs in other forms of violent asphyxia 
 And this stage ends in convulsive movements of the body. Bert 
 and others state that the first surprise of immersion is followed 
 by a calm in which the subject makes no effort; then the water 
 which has entered the air-passages excites movements of cough- 
 ing; but between the acts of coughing, the glottis is reflexly 
 closed, so that nothing can enter it. Both the French and Ger- 
 man observers state that the second stage ends in spasmodic 
 movements and convulsions. 
 
 Taylor has well described the acts of the suddenly snbmerged 
 subject, who in rising to the surface inspires air, but while he does 
 so, since the mouth is on a level v\dth the water, the latter is also 
 drawn into the air-passages; and some is likewise swallowed: 
 thus some of the aspirated water passes into the lungs, and some 
 
948 WOUNDS OF THE NECK. 
 
 into the stomach. The struggle for life continues for a longer or 
 shorter period of time, according to the strength of the subject, 
 yet uliimately lie becomes exhausted, and s])eedily lapses into 
 insensibility; then the body sinks so that the mouth and nose are 
 quite underneath tlie water; tlieair can no longer enter the lungs, 
 and a pari of that wliicli they contain, tlien escapes, and appears 
 on the surface of the water, as bubbles; and tlien the subject 
 becomes entirely unconscious. 
 
 3. In the third stage, during which the subject passes into a 
 condition of unconsciousness, inspiratory acts are made at con- 
 siderable intervals; the mouth is widely open, the pupils dilated 
 and the muscles are convulsed clonically. At last, the sphincters 
 relax, and there is absence of all voluntary or reflex movement 
 and death finally occurs, though the heart continues to beat for 
 some time. 
 
 The time requisite to drown man has been a matter of differ- 
 ence among writers; and those who have ex[)erimented on ani- 
 mals do not agree as to the time required to destroy life. Faure 
 hxes the time for the animal, at one minute and a half in cold 
 weather, and nearly twice that time in warm weather. The 
 Medico-Chirurgical Society of London, pronounces these figures to 
 be too small, and fixes the time required to drown, at from three 
 minutes and a half to four and two-thirds minutes. Taylor 
 thinks that submersion during one minute may so as])hyxiate the 
 subject that he makes no more efforts to escape from his impend- 
 ing fote; and as a rule, he thinks that a human being who has 
 been submerged four or five minutes, cannot be resuscitated. 
 Thougli the heart continues contracting for three or four minutes, 
 this is no indication that the victim can be revived. In the 
 annals of the Royal Humane Society, there are recorded but two 
 cases in wiiich life was restored after submersion lasting more 
 than five minutes. 
 
 Death has sometimes arisen from mere syncope or fright 
 arising from accidental or unex])ected submersion: and sucli a 
 subject makes no effort to rescue himself. 
 
 There are ca.ses again, in which the body whicli has been 
 rescued from water, and which presented all the signs of life, 
 nevertheless died after some hours; two" such ca.ses are mentioned 
 by Taylor. 
 
 In death from drowning, tliebody presents diverse conditions 
 depending on the time which it has remained submerged. 
 
 Tlie cadaveric rigidity may be of long or short duration; it 
 
DROWNING. 949 
 
 is believed to be brief in tliose who suddenly died from syncope, 
 rather than from prolonged asphyxia. 
 
 In death from sinking in cold water, the skin is pale; but if 
 the submersion has continued some hours, then the most depend- 
 ent parts of the body are purplish or cyanosed, through hypo- 
 static gravitation of the blood. And if submersion has lasted 
 many hours, the temperature of the body will correspond with 
 that of the containing medium. The action of the cold on the 
 cutaneous muscles causes the irregularity of the dermal surface, 
 familiarly known as goose-skin; and this is thought to be proof 
 that the subject has been submerged while living, and not dead. 
 
 The attitude of the body will furnish evidence as to whether 
 death was immediate from syncope, or after a struggle; in the 
 former, the limbs denote repose; but when the subject endeavored 
 voluntarily or involuntarily to save himself, the limbs are in 
 constrained or unnatural positions; the hand has seized, and is 
 clasping, some object, and the face is disfigured by distortion of 
 the features, in which fright and pain are legible. A lad known 
 to the writer, who was rescued when nearly drowned, was found 
 by a diver at the bottom of a pond of water, clinging strongly 
 to the root of a tree. 
 
 Additional signs of death by drowning are dilated pupils and 
 foam in the mouth and nose; and if the body has remained 
 immersed for a long period, the epiderm is softened through 
 imbibition of water. But as such epidermal imbibition can occur 
 in the living subject, its existence only denotes a prolonged 
 immersion in water. Pare' observed that the skin of the hands 
 and feet is often excoriated, due to movements against a hard 
 surface, during the last struggle. 
 
 In the cavity of the mouth there is found a quantity of foam 
 white or pink in color; though this has nearly always been 
 observed in the drowned man, it seems to be absent in the 
 drowned animal, according to Montana and Bergeron. 
 
 A condition to which great importance is attached in the 
 decision of the question of death by drowning, is the presence of 
 a quantity of white or red foam in the larynx, trachea and 
 bronchial tubes. This was seen in the drowned animal by 
 Morgagni, Haller and other observers. 
 
 Orfilaand Piorry have not found this foam in the air-passages 
 of those who, having been wholly submerged, remained so until 
 death ; subsecjuent observers do not sustain Orfila in this state- 
 ment: nearly all have found this foam present: even in those in 
 
1)50 wor.NDS OF Till-: xkck. . 
 
 whom death was suddenly induced by syncope after submersion. 
 Should this foam be absent, it could only be exi)licable by death 
 having instantly arisen from syncoj^e uncomplicated with 
 asphyxia. A\'iien this mucus is i)i-osent and tinted with blood, 
 the death can be inl'erred as being preceded by a struggle of the 
 victim. 
 
 The lungs of tlie drowned subject have been carefully 
 observed; and the conditions found differ. In case the i)erson 
 has been submerged and died without rising to respire, the lungs 
 are found in a normal state, and similar to those in whom the 
 death has arisen from being buried under sand or earth. But if 
 the victim has, in his struggles, risen and inspired air, then there 
 is found a condition named by Brouardel and the old observers, 
 aqueous emphysema. The pulmonary tissue has lost its normal 
 elasticity, and when pressed on, it retains the imprint of the 
 fingers. The density of the pulmonary tissue is considerably 
 augmented. This augmentation hasV)een pronounced to be three 
 or four times that of the normal density; yet later estimates 
 make this much less. The lungs fill the thoracic space com- 
 pletel3^ 
 
 If the death has been sudden and chiefly from syncope, the 
 lungs will present no exterior spots indicative of congestion ; but 
 if life has ended through asphyxia, there will be found marked 
 congestion; then the exterior surface will be reddish or violet, and 
 not of uniform character. Spots denoting ecchymosis are visible, 
 here and there. 
 
 The congested pulmonary tissue and the ecchymosed spots 
 indicate a struggle for life on the part of the individual, and 
 such local marks are greater, the longer such struggle has lasted. 
 The lungs may present superficial em})hysematous marks. If 
 tlie pulmonic parenchyma be incised, there will escape a foamy 
 liquid tinged with blood. Also, small clots of blood from rup- 
 tured capillaries, are sometimes revealed by incision. 
 
 The epithelial cells of the air-pa.ssages undergo alteration in 
 the drowned subject, viz., they are found increased in size, and 
 their protoplasmic content is abnormal. This change is referred 
 to aqueous imbibition. 
 
 The blood of the recently drowned subject is characterized by 
 unusual fluidity; but little or no coagulation is found; if this 
 exists, it should be discovered in the cardiac cavities. This 
 liquid blood has l)een studied, and it lias been discovered that it 
 contains a smaller number of red cells than normal blood. The 
 
DROWNING. 951 
 
 blood of animals drowned experimentally, and which have strug- 
 gled in the water and inspired some air, is found to contain fewer 
 cells; the number may be reduced one-fourth or one-third, in 
 respect to the containing serum: that is, the serum being increased 
 through the absorption of water, there is an apparent, not real, 
 reduction of the red cells. Hence in the act of drowning, a 
 state of hydrsemia is induced, in subjects in whom much water 
 penetrates the air-passages. 
 
 The general deduction from these facts is, that when the sub- 
 ject has been suddenly drowned, then clots may be found in the 
 heart and vessels, and the red cells exist in normal proportion to 
 the serum ; but if the drowning has been prolonged, then there 
 will exist hydraemia, in which the volume of blood is augmented 
 one-fourth or third above normal quantity, and it will be liquid; 
 and should there be an open wound, blood will continue to flow 
 from this for some time; and in the blood of such subject, there 
 will be a seeming diminution of red cells. 
 
 That water, which colors the air-passages, can be absorbed, 
 has been experimentally demonstrated by injecting the fluid into 
 the trachea. The quantity which can thus be absorbed is con- 
 siderable; but as the animal resists the work and expels some 
 which has been introduced, it is inferable that in slow drowning, 
 a much larger quantity is absorbed, and that thus the hydreemia 
 can be accounted for. 
 
 In the act of drowning, a quantity of water is swallowed; and 
 to this Paul of iEgina attributed death from immersion. This 
 was an error, and the amount swallowed was overestimated. In 
 experimental drowning Brouardel and Vibert found that w^hen 
 the oesophagus of the animal was ligated, no water was found in 
 the stomach; but in those animals in which the oesophagus was 
 not tied, then water was found in the stomach, and the hydree- 
 mia of the blood was much greater in the latter than in those in 
 which the oesophagus had previously been tied: hence the con- 
 clusion, that in drowning, the water enters the blood both from 
 the lungs and the stomach; but the greater part enters through 
 the lungs. The hydrsjemia will be greater in the case of slow 
 than of sudden drowning. The amount of w^ater found in the 
 drowned subject's stomach has been variously given; in some 
 cases seen by Taylor, none was found; and Hoffmann never saw 
 a large quantity in the stomach. Bergeron and Montana state 
 that they always found watei* in the stomach of the drowned: the 
 normal amount being equal to a quart. 
 
952 WOUNDS OF THE NECK. 
 
 The question has arisen whether water may penetrate the 
 stoniacli after deatli: a few admit the possibility of this; the most 
 deny it. 
 
 The encephalic vessels have been found engorged in the 
 drowned; this, however, is not always so; and when present, it is 
 attributed by Taylor to congestion of the lungs. 
 
 In his final review of death by submersion, Laugier, to whom 
 the writer is indebted for much that has here been presented, 
 says that the individual may die in diiferent ways: he may die 
 suddenly from syncope and cerebral congestion; or in so brief a 
 time, that there may be no struggle. And in such cases, the 
 concu.ssion from the fall, the coldness of the water, the startling 
 fright, or drunkenness, may be, singly or combined, agencies of 
 syncope, or cerebral congestion. Or death ma}^ result from 
 asphyxia after a long struggle for life; and then tlie asphyxia is 
 not due to swallowed water, as Paul of ^Egina thought; nor the 
 collection of blood in the right ventricle of the lieart through 
 pulmonary inaction, as Coleman and Sprengel believed; nor 
 from apoplexy caused by respiratory obstruction, as taught by 
 Littre and Boerhaave; nor from the occlusion of the glottis pre- 
 venting the entrance of air, as Beau claims; nor from the vitia- 
 tion of the blood due to lack of contact with pure air. as believed 
 by Orfila; but death is caused by the penetration of water into 
 the pulmonary pa.ssages. That life is thus destroyed in drown- 
 ing has been demonstrated by careful and judicious experimen- 
 tation by Paul Bert, Riedell, Bergeron, Montana. Brouardel and 
 Yibert. 
 
 The suction of water into the air-passages which occurs in the 
 first stage, when the subject is surprised by immersion under 
 water, becomes much greater in the third stage when asphyxia 
 has commenced; then, according as Bert has noticed, the water 
 is drawn into the lungs by deep inspirations automatically pro- 
 duced : the mere continuance of the accustomed habit of breath- 
 ing. And these movements are so strong that the water is drawn 
 into the deepest portions of the lungs and there reaches the ulti- 
 mate vesicles; then the unconscious patient, with the desire for 
 air instinctivel}' remaining, breathes the w^atery medium instead 
 of air. And the water being abundantly introduced into the 
 lungs, hydrsemia is induced through its absorption; and thence 
 is formed that foamy liquid which is discovered in all parts of the 
 air-passages, and also, in the pharynx and buccal cavity. The 
 aqueous transudation in the finer vessels produces changes in 
 
DROWNING. 
 
 953 
 
 the protoplasmic content of the epithelial investment of the finer 
 tubes. 
 
 Death may come from immediate suffocation; or it may come 
 after the subject has been rescued yet alive from the water, at a 
 later period, varying from minutes to hours or days ; and some- 
 times, death occurs because the nearly dead lungs cannot expel 
 the admitted water; or the epithelial lining of the tubules and 
 vesicles has been so changed, and is so degenerated through 
 aqueous imbibition, that the oxidation and decarbonization of 
 the blood are imperfectly accomplished. If enough water has 
 not entered to produce these effects, then resuscitation is pos- 
 sible. 
 
 Many means have been resorted to to revive the partly 
 drowned patient ; and among these, that of removing the water 
 which had been swallowed was one of the most popular: since 
 from antiquit}^ the notion was current that the swallowed water 
 was the prime cause of death. As a rude way of accomplishing 
 this regurgitation, the patient was suspended by his feet. Intel- 
 ligent medical men long ago decried this procedure; among 
 whom may be mentioned Plater in the sixteenth century, who in 
 a pithy comment on the plan, said that in suspension, more water 
 flowed from the subject's clothing than from his mouth. And 
 yet, to-day, among sailors, as soon as the submerged victim has 
 been rescued from the water, the first cry is to "roll him; " and 
 quickly "suiting the action to the word," the unfortunate one is 
 rudely, and often violently, rolled to and fro, with the result that 
 his body is more bruised than emptied of its water. Intelligent 
 resuscitation has long since dropped from its methods vertical 
 suspension and horizontal rolling. 
 
 Subsequently, the theory of Littre and Boerhaave, that death 
 from drowning arises from cerebral apoplexy, led to withdrawal 
 of blood by bleeding; and this was deemed to be most effective 
 when the bleeding was done from the jugular vein. 
 
 Finally, when the cause of death had been solved by observa- 
 tion and experimentation, the methods of revival reduced them- 
 selves to two classes of management : one, in which general and 
 local excitation of the body is resorted to ; and the other method, 
 in which are comprised the different means of artificial respi- 
 ration. 
 
 Among the means of excitation, which fall under the first 
 head, a popular one is the application of heat to the patient; this 
 has been recommended by Tissot, Fothergill and others. Heat 
 61 
 
954 WOUNDS OF THE NECK. 
 
 may be applied in the form of warm water, warm sand, a warn, 
 plate from a stove, or any warm object which is accessible and 
 applicable. Warm embrocations may be applied, consisting' of 
 flannels which have been dipped in hot water, and on which 
 alcohol or turpentine has been sprinkled. Such excitant warnitli 
 may be a])plied to all parts of the body; it is best done, however, 
 over the heart and lungs, since the chief aim is to awaken the 
 functions of these organs. Friction with the palm of the hands 
 may be done. Another excitant is electricity; also thermal cau- 
 terization of the limbs and prsecordia. The tickling of the 
 nostrils is an efficient means of awakening a reflex action, in 
 which the diaphragm will be made to contract in acts of cough- 
 ing and sneezing. Also titillating the pharynx awakens reflex 
 actions of a respiratory character. And akin to this, as coun- 
 seled by Heister and Desgranges, is the passage to the stomach 
 of a tube or tampon, armed with a brush, with which friction can 
 be made. Volatile stimulants may be introduced into the mouth 
 and nostrils; and one usuall}' at hand, is camphor spirit; and 
 another yet more energetic is spirit of ammonia, of which the 
 escaping fumes will excite the respiratory mucous membrane. 
 The parenchymatous injection of alcohol may be done, and to 
 hasten absorption, the penetrated structures should be well 
 rubbed; thus the alcohol is made to enter the vessels, and its 
 general action is hastened; and, at the same time, the friction 
 diminishes the tendency to local irritation of the injected tissues. 
 Strychnia may also be hypodermically used. These means are 
 applicable in those cases in which apparent death has arisen 
 from syncope, rather than from asphyxia; in all such the local 
 excitants should be sedulously plied. 
 
 In case apparent death is from asphyxia, the jaws are some- 
 times found tightly clenched, and must be forcibly opened by 
 means of some wedge-shaped object, or other divulsive instru- 
 ment. And then through an aspirating tube wljich has been 
 introduced into the throat, foam}^ material which has lodged 
 there may be aspirated. 
 
 In addition to the use of the local and general excitant means 
 which have been enumerated, there should be an immediate 
 resort to artificial respiration; and of the methods before 
 described, the author recommends that of Silvester as the most 
 trustworthy; and this should diligently be proceeded with, while 
 the local remedies are being used. 
 
 As a prelude to Silvester's method, which has already been 
 
FOREIGN BODIES IX THE AIR-PASSAGES. 955 
 
 described, the subject's mouth and pharynx should be wiped out; 
 and during the traction and retro-traction of the arms, the 
 tongue should be drawn well forwards, and held in this position. 
 And along with this work, rapid pressure, done intermittently, 
 should be made on the left side of the thorax, near the ensiform 
 cartilage. 
 
 The length of time necessary to destroy the human subject 
 by submersion is probably about five minutes; yet numerous 
 cases are on record, in which resuscitation occurred after a much 
 longer period. For example : the Royal Humane Society of 
 London mentions return to life after submersion for forty 
 minutes. The memoirs of the Society of Amsterdam mention 
 cases of rescue after the subject had been three-quarters of an 
 hour under water. Franck has recorded a case which outstrips 
 the record of his predecessors, viz., life was saved after three 
 hours' immersion. 
 
 Tliough these statements of the historians of submersion are 
 probably exaggerations, yet they justify the resuscitator in his 
 efforts, and to err rather on the side of prolonged than of cur- 
 tailed perseverance, in his liumane work. 
 
 Foreign Bodies in the Air-passages. — Foreign bodies of the 
 most diversified character have entered the air-passages, and 
 finding temporary or prolonged lodgment there, have imperiled 
 or destroyed the life of the subject. Such body, if of inorganic 
 composition, may remain unchanged in its volume, being 
 neither lessened nor augmented ; but if it be of organized material, 
 it may increase in size, or lessen through solution or disintegra- 
 tion ; an example of the inorganic is a bead, a shot or coin, while 
 of the organic class, fragments of food, the pea, bean, grain of 
 corn, are familiar examples. "Within the writer's observation, 
 the bean and grain of corn have caused the greatest number of 
 accidents of this kind. 
 
 Several writers have contributed to the literature of this sub- 
 ject; prominent among them have been Jobert de Lamballe, S. D. 
 Gross and Chassaignac. 
 
 Jobert de Lamballe, writing in 1850, states that the foreign 
 body usually enters the right bronchus. The weight of the body 
 and the suction to which it is subjected carry it into the air- 
 passages. The uplifting of tlie epiglottis is not necessary, since 
 this valve never lies downwards and backwards, but its position 
 is such as to form a kind of a guiding or conducting sulcus, 
 along which passes any material which traverses the pliarynx. 
 
956 WOUNDS OF THE NECK. 
 
 The entrance of the body is indicated by disturbed breathing, 
 cough, constant or intermittent pain, and bronchial discharge, 
 which is often tinged with blood. A peculiar rhoncus is lieard, 
 and the breathing is louder on the side which the body did not 
 enter. A large body can cause immediate death througli 
 asphyxia, but a smaller body acts more slowly^ namely: it causes 
 suppuration, eni})hysema and progressive asphyxia. If the body 
 exceeds four lines in diameter, it cannot be expelled by coughing; 
 yet when less than four lines, there is a chance that the bod}' 
 may escape. Jobert advises the early performance of tracheot- 
 omy; and then, to facilitate the exit of the body, he tickles the 
 mucous membrane of the trachea to provoke expulsive cough- 
 ing; and when thus the body has escaped, close the wound with 
 sutures which do not enter too deeply. In case the body is not 
 at once dislodged, then the wound must be retained open. 
 
 In 1854, S. D. Gross wrote an elaborate monograph on foreign 
 bodies in the air-passages; and the materials for this work were 
 derived from personal observations ^nd from published records, 
 amounting to about 250 cases. 
 
 From an analytical study of these cases, he deduces the follow- 
 ing facts: the body may remain in the larynx or descend into 
 the bronchial division of the trachea; and then it usually lodges 
 in the right bronclius. The form and weight of the body often 
 determine tlie point of lodgment. A small, round and lieavy 
 body, as a bean, shot, or gravel, etc., descends more easily into 
 the passages than a light, rough, or angular one. The body often 
 changes position, passing from one bronchus to the other, or 
 into the trachea or larynx. 
 
 As soon as a body has entered the air-passages there is an 
 irresistible desire to cough, and a feeling of impending suffoca- 
 tion; the face is livid, and the patient may fall into a state of 
 unconsciousness. After some time the violence of these symp- 
 toms subsides and remains so for some minutes. If the body has 
 entered the larjmx, the voice is altered, and there is commonly 
 present a croup-like cough, and the resonance of air entering the 
 lungs is diminished. In case the body is not fixed but is floating 
 in the larynx, then tlie spasms of cough often recur, as if tlie 
 body had only just entered. Such movement of the body can 
 be felt by the patient, though it may be imperceptible to the 
 examining physician. A large body has so completely filled a 
 bronchus, that the corresponding lung collapsed. And in some 
 cases, the site of the lodged body is indicated by a fixed local 
 pain. 
 
FOREIGN BODIES IN THE AIR-PASSAGES. 957 
 
 The body can destroy life at once, or at a later period ; and 
 the dangers of sudden death are greater when the body can move 
 to and fro, and become engaged in the glottis. If it lodge in the 
 lungs a fatal inflammation may arise from it. If the body be 
 caught in one of the ventricles of the larynx, it causes less 
 trouble than anywhere else; yet in some cases, though the body 
 was lodged in the larynx, it caused a dangerous inflammation. 
 
 As treatment, Gross discards errhines, vomiting, inversion of 
 the body, striking and shaking the thorax; but he depends wholly 
 on tracheotomy, or laryngotomy; the latter is only to be done 
 when the body is in the larynx. The opening should be one 
 inch long in the child, and one inch and a quarter in the adult. 
 And when the body is not found, or at once expelled through the 
 opening, then invert the patient, shake and strike the chest; and 
 these acts failing, then retain the gap open by means of retractors. 
 And whether the body escapes early or later, close the wound as 
 soon as the former has made its exit. 
 
 Kapesser of Giessen observed thirty-two cases in which bodies 
 had entered the air-passages; tracheotomy was done in all, and 
 in the greater number tlie patient was rescued at once; in three, 
 the body was coughed up at a later period ; and in one case, the 
 patient was lost from bleeding during the operation. If the 
 body is lodged in the upper portion of the windpipe, it causes less 
 irritation there than if it be lower down, since, as Erichsen has 
 observed, the mucous membrane is less irritable in the upper 
 part of the trachea. 
 
 As a rule, the body lodges in the right bronchus; yet in one 
 necropsy, Ortli found it in the left bronchus. 
 
 In the case of the entrance of a foreign body into the wind- 
 pipe, Chassaignac advises an immediate operation; and in the 
 event of the body being felt, he cuts directly down on it; other- 
 wise, Chassaignac performs the usual operation of tracheotomy. 
 
 The writer has had personal observation of five cases in which 
 foreign bodies had entered the windpipe. The object in one case 
 was a small cylindrical hollow metallic body, which was a line in 
 diameter and three lines in length; the second was a grain of 
 Indian corn; and in the other three the object was a bean. 
 
 In four of these cases, tracheotomy was done; in the one 
 unoperated upon, the child died of pulmonary disease three weeks 
 after the body was inhaled; on post-mortem examination, a 
 grain of corn was found in the right bronchus. In the child 
 which had mis-swallowed the metallic cylinder, tracheotomy was 
 
958 WOUNDS OF ,THE NECK. 
 
 <lone, and the object found in the upper part of the hirynx. 
 When the traeliea was opened, a flexible catheter was passed into 
 the wound, and the body pushed upwards into the pharynx, and 
 caught there. In another child in which the object was a bean, 
 ihe object was not discharged at once through the tracheal open- 
 ing; but the wound being retained open, tlie body was expelled 
 one vv^eek afterwards, and the child recovered. And in the 
 remaining two, though tracheotomy was done, yet the body 
 remained lodged in a bronchus, and the children died of pulmo- 
 nary inflammation. 
 
 In those cases in which the body remained impacted deeply 
 in a lung, there was only occasional coughing ; the predominant 
 symptom was accelerated breathing, with lessened respiratory 
 murmur on one side, and increased or puerile breathing on the 
 other side. And in the case in which a grain of corn was the 
 obstructing agent, so long were the intervals between the parox- 
 ysms of coughing, that it seemed scarcely probable that they 
 could arise from the presence of a foreign body. It would appear, 
 then, that the longer the body remains in the bronchial tube, the 
 less irritation does it cause: that is, the most marked and mislead- 
 ing condition in such cases is, that long lodgment of such body 
 gives tolerance, and finally nullifies the reflex action of the local 
 irritant. 
 
CHAPTER XXIX. 
 
 CESOPHAGUS. 
 
 The name cesophagus is derived from the Greek words oisein. 
 to be about to carry or bring; smd 2)hagein, to eat. The word is 
 used by Hippocrates and Aristotle to indicate the gullet; but 
 later Greek writers employed the word stomachos as name for 
 this part. Even Vesalius used the latter name. This confusion of 
 terms may have arisen from the equivocal passage in Hippocrates' 
 short chapters on the anatomy of the trunk; he says there that 
 the cesophagus takes its beginning from the stomach, and ends 
 in a hollow space; and the former, on account of being a great 
 mouth (stoma) to this digesting cavity, is named stomach. In tlius 
 paraphrasing the Hippocratic text the latter has not been greatly 
 elucidated by the license taken by the translator. 
 
 The oesojDhagus is a canal of variable calibre, which, according 
 to Henle, begins at the lower border of the cricoid cartilage, or at 
 the union of the sixth and seventh cervical vertebrse, and reaches 
 thence downwards to the diaphragm, through which it passes to 
 the stomach, into which it opens at a point corresponding to the 
 body of the eleventh thoracic vertebra. Its beginning is some- 
 what indefinite; but it properly commences where the circular 
 muscular fibres appear below the constrictor pharyngis inferior. 
 AVhile the pharynx has muscular attachment to the cranium, 
 lower jaw and hyoid bone, the cesophagus has only very loose 
 adherence to contiguous parts; the tube severed from the inferior 
 border of the pharynx can easily be detached from the parts 
 around. 
 
 The oesophagus, except when dilated by materials which have 
 been swallowed, or those which regurgitate from the stomach, is 
 closed, and is similar to a flat cylindrical cord, due to the contrac- 
 tion of the muscular walls; and the inner mucous wall is disposed 
 in longitudinal folds, so that if a section of it be made it has 
 a radiated appearance. The contracted ossophagus measures in 
 diameter nearly a half inch. 
 
 ( 959 ) 
 
960 cesophaGus. 
 
 Mouton has measured the calibre of the distended oesophagus, 
 by filling it witii gypsum, when he found the diameter to be, at 
 the beginning, three-quarters of an inch; at the middle, an inch 
 and a half; and at the lower end, nearly an inch. From its 
 varying diameter, the oesophageal tube has been compared to the 
 male urethra, which is narrower at its ends than at its middle. 
 
 If the distance be measured from the incisor teeth to the point 
 where the oesophagus ends in the stomach, it is, on an average, 
 seventeen inches long; and five-eighths of this pertains to the 
 oesophagus; and the latter consists, according to situation, of a 
 cervical, thoracic and abdominal portion. The upper portion of 
 the oesophagus lies between tlie trachea and the spinal column; 
 and at its entrance into the thorax, it deviates towards the left 
 side; then it returns to its median situation again ; and commonly, 
 in consequence of the trachea deviating towards the right, when 
 the oesophagus readies the point where the trachea bifurcates, the 
 former is situated behind the left bronchus. Lower down, the 
 ("esophagus lies behind the pericardium, and it is attached to the 
 latter; and thence downwards it is preseed away from the spinal 
 column by the aorta and the vena azygos, and when it reaches 
 the lower edge of the left fourth costal cartilage, it lies nearly in 
 front of the thoracic aorta. Its connection with parts around is 
 through the medium of an extremely elastic tissue. 
 
 The wall of the undistended oesophagus is one line thick, and 
 three-fourths of this is of muscular tissue: the inner lining being 
 mucous membrane. 
 
 The muscular wall consists of longitudinal and circular 
 fibres. The longitudinal fibres lie external, and arise above by 
 three sections : two lateral and a median. The lateral portions 
 start from the elastic structure in which the palato-pharyngeal 
 muscles end; while the middle portion springs from the posterior 
 part of the cricoid cartilage, through the medium of a three-sided 
 elastic membrane. The circular muscular coat lies internal to the 
 longitudinal fibres; and both the longitudinal and circular fibres 
 })ertain to the striated species, in the U[)per fourth or third of the 
 canal; below that distance, the non-striped, or organic species of 
 fibre, replaces the former; this change occurs where the cervical 
 portion reaches and enters the thorax. 
 
 As before stated, the pharyngeal portion of the alimentary 
 canal is formed and supported by muscles which have bon}' ori- 
 gin; somewhat analogous are the miniature muscles whicli con- 
 nect the oesophagus to contiguous structures. Thus Hyrtl has 
 
CONGENITAL DEFECTS OF THE iESOPPIAGUS. 961 
 
 described the broncbo-oesopbageus and tbe pleuro-oesopbageus 
 muscles. Muscular slips bave been described which connect the 
 oesophagus with the pericardium and aorta. These muscles, 
 which are of organic species, serve the purpose of maintaining 
 the tube straight ; and according to Henle, they screen adjacent 
 vessels from compression. These muscles, also, are the means of 
 attaching the oesophagus to the diaphragm. 
 
 The oesophagus receives its supply of blood from the inferior 
 thyroid, oesophageal and phrenic arteries. The veins below empty 
 into the portal system: and from this connection, these veins 
 become swollen in cases of cirrhosis of the liver. 
 
 The innervation of the oesophagus is through the medium of 
 the vagus; and this nerve has its nuclear origin in the medulla- 
 oblongata. The branches of the vagus, which are chiefly con- 
 cerned in. this involuntary innervation, are the superior and 
 inferior laryngeal nerves; other branches, when experimentally 
 stimulated, have been found without action. 
 
 Some interesting vivisective work on the oesophagus has been 
 done by Angelo Mosso, who found that an impression, made on 
 the mucous membrane in the upper part of the oesophagus, trav- 
 eled gradually downwards in a peristaltic manner; and what was 
 most remarkable, this movement continued, even though the 
 oesophageal tube were divided into two parts. The excitant irri- 
 tation which awakened this movement lost its effect, if repeated 
 too often. 
 
 Congenital Dejects of the Oesophagus. — The oesophagus some- 
 times presents congenital defects which are explicable through 
 an arrest of growth during the period of embryonic evolution. 
 
 In the development of the embryo, the alimentary canal con- 
 sists of an anterior, middle and a terminal portion ; and of these, 
 the anterior becomes the pharynx and oesophagus; and cotem- 
 poraneously with this, the trachea and lungs are developed. At 
 an early period, the tracheal and oesophageal structures form a 
 common canal which opens into a hollow below, from which 
 hollow the lungs are formed. As growth proceeds, a partition 
 develops and separates the common tube into an anterior one, 
 the treachea, and a posterior one, the oesophagus. But from 
 some unknown cause, this differentiation of parts may take an 
 abnormal course, and defects arise. Thus, instead of a continu- 
 ous canal, the oesophagus may abruptly terminate in a blind 
 sack; or the oesophagus may open into the trachea, or into a 
 bronchus; or there may be a combination of defects, in which 
 
962 (ESOPHAGUS. 
 
 there is abnormal ending, as well as interruption and closure of 
 the canal. And finally, the oesophagus may be reduced to a 
 cord-like structure, throughout a part or the entirety of its length. 
 
 Examples ilhistrating congenital oesophageal defect are the 
 following, collected by Luton, A new-born child died on the 
 fourth day, and on necropsy it was found that the oesophagus 
 ended blindly near tiie tracheal bifurcation, and a ligamentous 
 structure seemed to continue to tlie stomach. In another infant, 
 the examination revealed the ftict tliat the upper part of the 
 oesophagus ended blindly at the middle of the canal; the part 
 below opened into the trachea. In another child which died on 
 tlie seventh day, there was found an absence of the oesophageal 
 tube; and the stomach contained no cardiac orifice. In another 
 infant, which died on the eleventh day, the oesophagus ended in 
 a cul-de-sac an inch below the pharynx; the inferior end opened 
 into the trachea above, and into the stomach below, so that fluid 
 from the stomach regurgitated through the trachea; and the 
 blind portion and the lower portion were connected by an im- 
 perforate cord. In another infant which died on the fifth day, 
 there was closure found in the oesophagus two inches below its 
 origin; the inferior section opened into the trachea on the pos- 
 terior face of the latter. In another case, there was found clo- 
 sure of the oesophagus nearly two inches above the tracheal bifur- 
 cation; and thence downward the oesophagus was found obliter- 
 ated to a cord, which pierced the diaphragm to reach the stomach; 
 and the oesophagus communicated with the trachea, in this case. 
 In another infant the pharynx was closed, and there existed a 
 tracheo-cesophageal fistula ; and with these defects coexisted im- 
 perforate anus, club-foot, hare-lip, deformity of the fingers, and 
 absence of the genital organs. In another infant, in which the 
 universality of deformity rendered the child's body a miniature 
 museum of teratology, the normal oesophagus was lacking, and, 
 in its stead, the trachea consisted of two tube-like portions, of 
 which one passed to the stomach and the other to the lungs. 
 
 Hence, as seen, the congenital defects of the oesophagus offer 
 much diversity of form; in most cases the tube opens into, or 
 communicates with, the trachea or a bronchus; and in a few 
 infants the oesophagus is reduced to an impermeable cord. In 
 both conditions life cannot continue, for in all the nutriment 
 cannot properly reach the stomach; and in some starvation and 
 asphyxia unite in the destruction of the victim. 
 
 Surgery seems to have seldom intervened to lend assistance 
 
STRICTURE OF THE ESOPHAGUS. 963 
 
 to such unfortunates; they have been permitted to perish by 
 inanition, death occurring in from five to ten days, life usually 
 ending within a week. Yet in this era, when operative surgery 
 has accomplished so much in restitution to continuity of the 
 intestinal tube, when occluded by neoplasm or other agency, 
 would it not be well to make some essays in this unexplored 
 field, which patiently awaits the advent of operative effort? 
 While every cubic inch of the intra-abdominal space bristles 
 with edomies, otomies and ostomies, why not open the neck of the 
 new-born infant, and seek for the deformed oesojihagus, and, 
 where viability is but slightly interrupted, restore permeability 
 by some procedure suggested by operations done on the intestine 
 and urethra? By such operative eff'ort, let it be never so hazar- 
 dous, there could not be added one unit to, but possibly one 
 might be subtracted from, the chances of death which otherwise 
 overhang the life of the little patient. 
 
 Stricture of the OEsophagus. — Stricture figures in many affec- 
 tions of the oesophagus; it is the causal agency of disphagia, or 
 difficulty of swallowing. 
 
 From complete closure occurring in the new-born, the transi- 
 tion is easy to incomplete closure, which has been observed in the 
 infant: a case was reported in 1833, by iEger. Should such 
 defect be discovered, the appropriate treatment would be gradual 
 dilatation by means of graduated sounds. 
 
 Of causal agencies whence stricture may originate a frequent 
 one is the destruction of the inner surface by caustic action, which 
 may be from a heated fluid or an escharotic; thence may arise 
 gradual cicatricial closure. 
 
 Steiger, of Wlirzburg, in 1861, wrote on oesophageal stricture, 
 and he claimed that the only certain means of diagnosing it is 
 the use of the sound: this meeting an obstacle indicates stricture. 
 Additional signs of such stricture are difficulty of swallowing, 
 which commonly comes on imperceptibly. The trouble in deglu- 
 tition is not always proportioned to the narrowing, since some- 
 times there is much difficulty when the stenosis is slight. In 
 case the stricture be low down, the patient locates the trouble in 
 the stomach. The symptom which usually first attracts the 
 patient's attention is vomiting or a tendency to vomit. The 
 vomiting may not be constant, but it may recur occasionally and 
 especially when certain foods are used; and it is accompanied by 
 violent retching and strangling, and the substances rejected are 
 streaked with blood. There may be intervals when this tendency 
 
964 GESOPHAGUS. 
 
 to vomiting quite vanislies, and hence such symptoms arc easily 
 confounded with gastric ulcer or cancer. 
 
 Steiger used for the discovery of the site, or sites, and the 
 determination of the size and extent of the stricture, a sound 
 devised by Trousseau, which consists of a shaft, on the penetrat- 
 ing end of which are olive-shaped enlargements, which increase 
 in size from the lower end upwards, so that if one enlargement 
 passes, this or another enlargement may be arrested by a stricture 
 lower down; nnd thus the site of stenosisis is found and its size 
 determined. lie finds that there may be more than one strictured 
 point, with an intermediate s})ace of normal calibre. As a rule, 
 the stricture is only for a short distance, yet it may be a half 
 inch or more in length. There ma}'' be a stricture near the stom- 
 ach and one or more higher up. The sound touching and enter- 
 ing the stricture causes pain; and, in withdrawing the sound, 
 particles of food, mucus and blood may be drawn up. Steiger 
 depends mainly on the sound as a means of treatment. Should 
 there be ulceration accompanying the stricture, Iloppe gave 
 muriate of ammonia, one grain daily, mixed with sugar; he 
 claimed thus to have cured oesophageal stricture. 
 
 Boiling water, steam, and heated fluid, as tea or coffee, from 
 accident or inadvertent ingestion, have burned the inside of the 
 upper part of the alimentary canal. Except in cases of explo- 
 sion of steam boilers, such accidents usually are seen in the 
 child, whose tender years and limited experience have not taught 
 it to dread fire. Within the writer's observation the spout of 
 the heated tea or coffee-pot has tempted the young mouth to filch 
 a draught of the scalding fluid. Such heated fluid seldom reaches 
 far into the oesophagus, but does its work chiefly w^ithin the 
 mouth and the pharynx, since the violently irritated muscles at 
 once contract, and thus naturally resist the further ingress of the 
 fluid, and they expel it. The burning action rarely reaches 
 beyond the upper part of the oesophagus. 
 
 The steam from highly heated water, as from a boiler which 
 explodes, may enter the mouth and pass thence downwards; and 
 as it does so it penetrates towards the lungs rather than towards 
 the stomach, so that the lesion is chiefly in the air-passages. 
 Whether from steam or water which has been heated to over one 
 hundred and sixty degrees Fahr., the effect of the heat is to 
 coagulate the albuminoid element of the mucous membrane, and 
 destroy the vitality of the latter; and such coagulation may reach 
 into the submucous structures, provided the heat be intense 
 
STRICTURE OF THE ESOPHAGUS. 965 
 
 enough. The structures so burned soon slough from the unburned 
 tissues, and thus a raw surface remains, which, in healing, con- 
 tracts and lessens the calibre of the pharynx and the upper portion 
 of the oesophagus. And this contractile process, which is com- 
 mon to all parts of the buccal and pharyngeal cavities, and 
 especially so in the lower part of the pharynx, continues in 
 action long after the surface has healed, and may proceed to such 
 an extent that the canal is reduced to a narrow fistula. 
 
 The treatment of such a burn should have two aims: one 
 immediate, to counteract the early detachment of the -burnt sur- 
 face; and one later, to oppose the cicatricial narrowing of the 
 canal. For the first purpose cold should be used in the form of 
 ice water; and, to get the best effect of this, let fragments of ice 
 be taken in the mouth and allowed to dissolve, and the water to 
 be swallowed. To retard the detachment of the burnt mucous 
 tissue, an astringent should be used ; and for this the decoction 
 of oak bark, or of Peruvian bark, may be locally applied, or 
 tannin in iced water may be used. 
 
 As soon as the dead surface has detached itself, and the new- 
 formed separative tissue commences to undergo the regressive 
 action of the final stage of cicatrization, in which the canal will 
 be narrowed, this must be counteracted by the introduction of 
 a round sound, which may be solid or hollow. If a solid one be 
 used, it should be passed several times daily; not less than once 
 in every six hours ; and should this not arrest the tendency to 
 narrowing, then the sound should be used every three or four 
 hours. For this work, a black rubber instrument, similar to 
 the urethral sound, is the best. To introduce this, the head 
 must be turned well backwards, the mouth well opened, when, the 
 distal end of the sound being curved to correspond to the axis of 
 the pharynx, it is passed into the oesophagus. Should the 
 instrument catch on the posterior wall, it must be retracted and 
 then the point being turned in another direction, the attempt to 
 carry it down is repeated; and such manipulation, if not done 
 with too much effort, will always succeed in carrying the instru- 
 ment into the oesophagus. The patient, if an adult, can soon 
 learn to do this himself 
 
 These repeated introductions, however, of the sound are 
 objectionable, since one may thus irritate the wounded surface, 
 and cause it to bleed; to avoid such irritation, a permanently 
 lying sound may be placed in the oesophagus; and this should 
 be hollow, so that nutrient material may be passed through it 
 
966 CESOPHAGUS. 
 
 into the stomach. Such a tube should pass through the lower 
 meatus of one nostril, and be fastened at the nostril, so that it 
 cannot escape downwards. This tube must be of llexible rubber, 
 and the j)ortion which lies in the nose must be smaller than that 
 which lies beyond; especially in the adult; but in the child, the 
 tube may be of uniform calibre. That used in the adult of 
 unequal calibre should have the large portion introduced first 
 towards the stomach ; then having passed a thread through the 
 nostril by means of a looped wire, the end of the tube having 
 been attached to the thread, it is drawn through the nostril from 
 behind forwards, and secured in position by ligature and plaster. 
 Through such a tube, nutrition can easily be maintained; and 
 to successfully resist cicatricial contraction, the tube must be 
 used for man}'- M'ceks. It should be removed, cleansed, and 
 reintroduced every week. 
 
 The swallowing of an escharotic liquid, for example, of a 
 concentrated alkaline or acid solution, destroys the surface of the 
 pharynx and oesophagus as quickly and extensively as does 
 boiling water. In such a case the medical attendant should 
 make speed to administer a neutralizing agent, viz., dilute acetic 
 acid, in case caustic potash, soda or lime have been swallowed. 
 Instead of an acid, one may use olive oil or any other oil which 
 miglit be at hand. But in case an acid has been swallowed, then 
 an alkaline basic agent should be used: for exam})le, a solution 
 of soda or potassa. By thus proceeding, the destructive action 
 of the escharotic can be lessened; and proba])ly, the exfoliation 
 of the mucous membrane reduced to a thin stratum of structure. 
 And, afterwards, the oesophageal tube above mentioned should 
 be introduced, and the treatment pursued as described in case of 
 burning by steam or hot water. 
 
 After the inner surface of the oesophagus has been healed, the 
 process of contraction continues for a long period; so that the 
 calibre of the tube gradually diminishes, and sometimes it is 
 almost reduced to an impermeable condition; and not infre- 
 quently the patient only reaches the surgeon when this imper- 
 meable condition has arisen. Two such patients have been seen 
 by the author; in one the contraction had arisen from the child 
 attempting to swallow sulphuric acid; in the other case, the 
 cauterizing agent was a solution of caustic potash; and the latter 
 child did not remain under observation until the completion of 
 the case. In the child whose mouth and j)harynx had been 
 severely burned by sulphuric acid, healing had occurred, and 
 
STRICTURE OF THE ESOPHAGUS. 967 
 
 the lower part of the pharynx was narrowed to a fissure so small, 
 that only liquid material could pass slowly through it. The 
 most narrow portion was where the pharynx merged into the 
 oesophagus. The treatment consisted in the use of long-bladed 
 forceps and assorted India rubber sounds. The forceps had 
 long blades, which were of the same curve as the pharynx, and 
 the blades could be separated beyond the normal diameter 
 of the canal. When this instrument was introduced into the 
 stenosed part, the handles were opened and retained so by a 
 cork, which was placed between them; and thus the blades were 
 separated and caused to press on the sides of .the passage. After 
 this had been continued for five or ten minutes, the instrument 
 was removed and the round sound introduced. By this treat- 
 ment continued for three months, a stricture tliat was nearly im- 
 permeable was overcome, and the child's throat restored to 
 nearly normal condition. 
 
 Certain morbid agencies acting on the pharyngeal and oesoph- 
 ageal wall finally cause stricture; examples of such disease are 
 syphilis and tubercular disease. Each of these may encroach on 
 the canal through neoplastic development and lessen its calibre; 
 thus the gummatous syphiloma and the tubercular growth may 
 develop in the wall, and growing inwards, lessen the canal. 
 After such encroaching neoplasm has existed for a time, it may 
 ulcerate and the canal temporarily be restored to normal calibre; 
 and later through cicatrization, strictural deformity may arise. 
 
 Cognate to the causal agency just described is that of epithe- 
 lioma or sarcoma originating in the pharyngo-oesophageal wall ; 
 the former occurring much oftener than the latter. In the aged 
 subject and where difficulty of swallowing has appeared, and is 
 •gradually increasing, malignant disease may rationally be sus- 
 pected. As the disease proceeds, the patient will emaciate 
 through insufficient nutrition, and finally present the character- 
 istic countenance of malignant disease. The sound will be 
 interrupted by a well-defined, resistant and unyielding indura- 
 tion. The swarthy or irregularly pigmented skin of the patient, 
 his emaciation and general . vital depression, the constantly 
 increasing dysphagia and stenosis detected by the sound, are 
 symptoms clearly indicating the existence of malignant disease 
 in the oesophagus. 
 
 An occasional causal agency of stricture here is the polypoid 
 neoplasm, which may develop from the inner wall of the pharynx 
 or oesophagus. Such a neoplasm may be sessile or pedunculated 
 
968 CESOPHAGUtf. 
 
 ill its mode of origin, and may vary in volume from that of a pea 
 to much larger dimensions. In a case of tiiis kind reported to 
 the writer, the growth obtained such dimensions that it wholly 
 filled the oesophagus, and caused the death of the patient through 
 starvation. It was discovered at the necropsy that the tumor was 
 situated so near the })harynx that its removal could easily have 
 been effected. 
 
 In the case of such polypoid growth, an ai^propriate treat- 
 ment would be to remove it by means of forceps through the 
 pharynx; and should this not be practicable, then an opening 
 should be made through the neck by oesoi'.hagotomy, and the 
 tumor reached and removed. Such operation would be a safer 
 method than prolonged groping to seize an unseen object; and 
 when seized the work of removal would probably be imperfectly 
 done. 
 
 While these pages have been passing through the press, the 
 Avriter has removed a growth, of suspected sarcomatous nature, 
 from the lower part of the right lateral wall of the pharynx. 
 This tumor had close connection with the anterior (upper) face 
 of the epiglottis. It was an inch in its long diameter. The 
 operation consisted in first performing tracheotomy, and the 
 insertion of a tracheal canula; next the external carotid artery 
 was tied, and then just behind the angle of the jaw an opening 
 was made into the pharynx; and then the lower jaw was 
 depressed, and retained so by an interdental gag, permitting one 
 hand to enter the mouth and force the growth into the wound, 
 so that it could be dissected out, and its removal safely effected. 
 The case proceeded well until ^the fourteenth day, when bleeding- 
 occurred from the site of the ligated artery; and to control this 
 htemorrhage, the common carotid artery was tied. Ten days 
 aiterwards, there was severe bleeding again from the floor of the 
 sloughing wound which penetrated into the pharynx; and this 
 blood appeared to come from the internal jugular vein near its 
 origin at the base of the skull. To arrest this, a piece of sponge 
 was crowded into the bleeding cavity, and held there by digital 
 pressure. After three days, the tamponing sponge was carefully 
 removed and replaced by another. By a continuance of this 
 course for three weeks, during which faithful fingers and a 
 tractable patient mutually aided each other, the bleeding was 
 controlled, the wound healed, and the life of the patient saved. 
 The results obtained in this case renew the writer's grateful obli- 
 gations to Otto Weber for the knowledge derived from him of the 
 valuable properties of sponge as a mechanical h?emostatic. 
 
STRICTURE OF THE -ESOPHAGUS. 069 
 
 The pharyngo-oesophageal tube may be partly or entirely 
 occluded by the lodgment of a foreign body in it. The history 
 of the case would indicate the nature of the causal agency and 
 throw light on its nature; and verification of the same may be 
 made with the sound. And to relieve the patient, an attem23t 
 must be made to remove the obstructing agent with properly- 
 devised forceps, as will be more fully described hereafter. 
 
 Obstruction may arise from some growth encroaching on the 
 wall of the canal; and the invading agent may be a solid 
 neoplasm ; or it may be an aneurismal or a cystoid tumor. A 
 solid tumor may be of adenoid or goitrous character; also a 
 carcinomatous or sarcomatous growth contiguous to the canal 
 may so press on the latter as to interrupt its continuity. In the 
 event of such tumor not contracting adhesion with the pharynx 
 or oesophagus, the latter will recede before the pressing agent, and 
 continuity remain, despite the encroachment on the canal; the 
 involvement, however, of the wall in a malignant neoplasm 
 inevitably leads to partial or complete occlusion of the canal. 
 
 One of the most dangerous of occlusive agencies acting parie- 
 tally, is the aneurismal tumor, which may arise from the con- 
 tiguous aorta in the thorax, or from the primitive carotid in the 
 neck; the aortic aneurismal tumor being the more perilous on 
 account of the magnitude and the inaccessibility of the vessel. 
 The occlusion of the oesophagus by the aortic aneurism is less 
 frequent than one might apprehend from the closeness of the 
 vessel to the oesophagus. A number of cases have been recorded 
 in which the aortic tumor burst into the oesophagus, causing 
 speedy death. The case of the surgeon Liston is famous, in whom 
 a thoracic aortic aneurism burst into the oesophagus, and after 
 the loss of an enormous quantity of blood by vomiting, the 
 patient had a respite for several months, when the tumor reopened 
 and death soon occurred from hsemorrhage. 
 
 Narrowing of the pharyngeal or oesophageal canal may be 
 caused by an abscess or collection of pus outside of the passage, 
 which attains such a volume that it forces the wall adjacent to it 
 against the opposite side. Such pus may have a prsevertebral 
 site; or it maybe situated in the mediastinum, arising in the 
 latter case from the suppuration of the mediastinal glands. 
 Immediate relief may come in such cases from the abscess burst- 
 ing into the canal and the pus thus escaping. The rupture of 
 such abscess may be caused by the pressure of the dilating 
 sound, or swallowed food; similarly to what occurs in peri- 
 urethral abscess from the passage of the catheter or sound. 
 62 
 
970 OESOPHAGUS. 
 
 In the after treatment of cases of the kind mentioned, caution 
 must be exercised in the ingestion of nutrient material, that tlie 
 latter does not penetrate the cavity of the abscess, and lodging 
 there, maintain the suppuration. To avoid this, the materials of 
 food should be passed to the stomach through a tube. 
 
 A long-continued irritation of the oesophageal walls may end 
 ill their hypertrophy, which has been seen, in a case reported by 
 Fontan, to proceed to such an extent, as to occlude the canal and 
 destroy life by inanition. 
 
 Unexpected relief has sometimes come to the patient of 
 pharyngeal or oesophageal stenosis througli gangrene or slougi)- 
 ing of tlie narrowed part; such may occur in malignant disease, 
 for example, epithelioma. Though relief occur in this way it 
 can be but transient, since the advancing disease would probabh^ 
 soon appear in the adjacent structures, and thus induce narrow- 
 ing above and below the ulcerated breach. Such cases would be 
 but slightly amenable to treatment; the dilating sound could 
 give only temporary aid, and its use must soon stimulate, rather 
 than lessen the growth of the neoplasm. 
 
 As shown, stricture of the pharyngo-oesophageal canal may 
 arise from a number of agencies, which, when studied as to site, 
 mav be grouped in three classes : one situated adjacent to but 
 quite outside of the canal; a second class seated in the wall 
 itself; and a third one. in which the causal agent arises from the 
 inner wall ; and a fourth class might be added, in which the 
 occlusion is from a foreign body, lodged in the passage. 
 
 Certain general symptoms are common to stenosis arising 
 from any of the causes comprised in these classes. These symp- 
 toms are greater or less difficulty of swallowing, pain or uneasi- 
 ness in this act, emaciation from defective nutrition, and other 
 conditions determined by, and dependent on, the nature of the 
 cause. 
 
 The act of swallowing will be imperfect or embarrassed, 
 according to the site of the stricture : for example, should this be 
 high in the canal, the ingesta will scarcely enter the ])assage; but 
 if the obstruction be low down, then the material will have 
 normal passage through the pharynx, and suffer detention below. 
 In the commencement of the trouble, there is merely a hesitation 
 in swallowing, the act is prolonged. Presently, the patient is 
 compelled to select his food; he eschews the solid and uses that 
 which is liquid or semi-fluid ; he is much more careful than 
 formerly to masticate his food thoroughly. And if the narrowed 
 
SPASM. 971 
 
 portion be low down, the ingested material may collect there in 
 considerable quantity, and finally be regurgitated ; and perhaps,, 
 as done by the ruminant, it is rechewed and reswallowed; or lying 
 a long time in the canal, it undergoes a change, sometimes 
 named oesophageal digestion. 
 
 The accumulation of the food in the oesophagus finally causes' 
 a dilatation above the stenosed portion, and, as a result of this, the 
 muscular wall will become attenuated and less able to act on the 
 contained matter. Should the lodgment be in the cervical por- 
 tion of the oesophagus, the patient learns to aid the latter in its 
 propulsive work by pressing the arrested mass downwards. 
 
 The increased work of the oesophagus induces uneasiness,, 
 fatigue, and, finally, pain. The eff'ort to swallow may tear the 
 .wall, and thus lead to an ulcerative breach, which is painfully 
 irritated by the contact and pressure of the pressing material. 
 
 And, besides the pain thus awakened in the oesophageal wall, 
 the accumulated material pressing against the trachea can induce 
 a sense of suffocation. Also, respiratory disturbance might arise 
 from pressure on the vagi, of which the left rests on the front 
 wall, and the right one on the posterior wall of the affected 
 canal. And the proximity of the aorta in the thorax is such 
 that the descending bolus may protrude against the vessel, and 
 become a disturbing element in the movement of the blood, 
 demanding a greater cardiac effort to overcome and pass the 
 obstructing agency; and though this be slight, yet it must be 
 mentioned in an enumeration of causes which trammel the free 
 movement of the blood. 
 
 Spasm. — In 1870 Hamburger wrote extensively on spasm of 
 the oesophagus, of which he makes a migrating or movable form 
 and a fixed form. 
 
 Migrating spasmodic stenosis is the usual one; in this the 
 spasm commences at some inferior point, and thence travels 
 upwards, and seats itself in some special point. A mild form of 
 this is globus hystericus, in which the spasm travels upwards,, 
 and is so mild in its character that it is painless and does not 
 hinder swallowing. But in a more active form the spasm may 
 continue for hours, and the effort to swallow is painful; and in 
 such a case one may suspect organic trouble. In a third degree, 
 the spasm is still more severe, and is attended by reflex disturb- 
 ance, in which breathing is disturbed. In those cases, swallow- 
 ing is quite impossible, and even the sight of food excites 
 strangling movements. 
 
972 CESOPHAGUS. 
 
 (Esopliageul spasm may be caused by erosion, catarrh, or 
 worms; yet tlie cause may be quite outside of the oesophagus. 
 It occasionally occurs in the nervous, antemic, depressed, and 
 chlorotic subject. As remote agencies are leucorrhea, ulceration 
 of the cervix uteri, uterine fibroma, or some abnormal position 
 of the fo-tus in the uterus. 
 
 The migrating spasm is to be treated by baths, arsenic, 
 quinine, atr(>})ine, opium and its derivatives. 
 
 Spasmodic stricture, \vl)ich is localized, is much rarer than 
 the movable form. The sound here finds an obstruction, which, 
 under some pressure, gives way. From a small number of obser- 
 vations of Hamburger, he concludes that this localized form of 
 stricture is the premonitory symptom of approaching cancer of 
 the stomach; in a few cases of the kind necropsy discovered 
 cancer in the stomach, though the oe.sophagus was found in 
 sound condition. 
 
 There are phenomena present in the act of deglutition which 
 are not alone perceptible to the patient, but it is claimed that 
 tliey can be discovered by auscultation. The subject of stenosis 
 feels that the material ingested successively halts and advances 
 until it traverses the narrowed part of the canal. Hamburger 
 has made a study of the sounds which are heard as material 
 traverses the narrowed canal. He makes three stages or degrees 
 of the stenosis. In the first degree, in the passage downward of 
 fluids, there may be heard bubbles, which pass from below 
 upwards through the descending fluids. In a greater degree of 
 narrowness, there is heard a trickling or gurgling sound; and in 
 the third stage, which approaches impermeability, there is 
 detected the sound of materials ascending in the act of regurgi- 
 tation. Hamburger claims that a study of these sounds will 
 give more accurate information concerning the degree of narrow- 
 ness than can be learned through using the sound; also that the 
 site of the stricture can thus be located, and, further, that auscul- 
 tation can be utilized to determine the progress that is being- 
 made in treatment. The writer will admit that long training of 
 the ear might enable the auscultator to attain such power in dis- 
 crimination; but if he persevere in the use of the sound, he will 
 attain great diagnostic accuracy with far less labor, and, in fact, 
 learn thus to discover, with approximate certainty, the character, 
 nature, and extent of the stricture. And this leads to a consid- 
 eration of this method of exploration. 
 
 The oesophageal sound should measure in its entire length 
 
SPASM. 973 
 
 twenty-four inches, of which five inclies will serve for tlie handle. 
 Inventive genius has produced sounds of various forms and of 
 diverse materials. A not infrequent one is that constructed of 
 soft flexible rubber, similar to that of the urethral sound. That 
 of black rubber is preferable, since the vulcanized rubber finally 
 hardens and is liable to break, while the former is more perma- 
 nent in its structure and elasticity. A good instrument is a 
 sound with a waxed end, which will receive and retain an 
 impression of the narrowed part. One of the most convenient 
 sounds is that of which the shaft is whalebone, and the exploring 
 end is armed with an olive-shaped body, in which the shaft 
 is fastened. There is a screw-like thread on the end of the 
 shaft, which is received in a spirally grooved hollow in the 
 olive-shaped body; that is, the staff ends in a screw which is 
 received in a nut formed by the olivary body. The staff is of 
 whalebone, and thin enough to be somewhat flexible. There 
 should be an assortment of the olive-shaped bodies, varying from 
 a small size to that approaching the normal thickness of the 
 oesophagus. 
 
 Instead of a whalebone staff, the latter may be of silver, 
 which is flexible enough to adapt itself to the pharyngo- 
 oesophageal canal. The writer prefers the elastic staff of whale- 
 bone, since, when this has been bent so as to pass through the 
 curved part of the pharynx, it becomes straight again, while a 
 staff of silver or copper being curved remains so, and the end 
 thus bent must press on one side of the canal as it descends. 
 
 To introduce the sound, let the patient sit in a strong, low- 
 backed chair, and recline his head backwards as far as he can, 
 with chin uplifted and mouth well open. The right-handed 
 surgeon stands at the patient's left side, and then, slightly bend- 
 ing the lower end of the whalebone shaft, he inserts this into 
 the pharynx; and as this is done, the patient should be directed 
 to swallow the terminal olivary bulb. The bulb is often caught 
 in the wall of the pharynx or larynx, and, when this occurs, the 
 instrument must be withdrawn and inserted again. The car- 
 dinal rule is that the sound must be passed without being forced. 
 The first few times that the instrument is used the canal resists 
 and prevents the onward movement; but with patient persever- 
 ance and some address, the instrument can be moved down- 
 wards, provided the bulb is not thicker than the canal to be 
 traversed. A spasmodic action of the muscular. wall may catch 
 and hold the instrument temporarily, and then the wall, relaxing, 
 
974 CESOPHAtiUS. 
 
 allows the sound to proceed. Such sijasmodic constriction resem- 
 bles true stricture, yet its sudden disappearance reveals the 
 actual condition. 
 
 The sound should be passed slowly; thus going it explores 
 and learns the nature of the structures which it traverses: and 
 imparts this knowledge to tlie guiding hand. Thus an abrupt 
 stenosis or a gradual one is discovered; also, the handle, deviat- 
 ing in an}^ direction, denotes induration of the opposite side of 
 the canal. 
 
 Besides one constriction, there maybe two or more; and these 
 may differ in length and breadth. To learn the characteristics 
 of multiple stricture, bulbs of different sizes must be affixed to 
 the staff; and by thus using assorted bulbs, the size of different 
 strictured points in the canal can be determiued. 
 
 Besides the determination of the site, number and breadth of 
 the strictures, other knowledge can be obtained through the use 
 of the sound. Thus, the dense, unyielding structure of cicatricial 
 tissue, can be felt and diagnosticated; or if the structure be 
 inflamed and painful, the touch of the sound will reveal this; 
 and lastly, hardness on one side, while the opposite wall remains 
 unaffected, can be detected with the sound. And, in a limited 
 portion of the neck, the palpating hand may follow the descend- 
 ing bulb, and verify somewhat the obstacles which the latter 
 encounters. 
 
 Treatment. — The treatment of a case of stricture at some point 
 in the pharyngo-oesophageal canal varies according to its nature 
 or causal agency; and accordingly, it may be placed under one of 
 the following heads: medical, dilating, escharotic or operative. 
 
 In case of narrowing from syphilis, in the form of gumma- 
 tous infiltration of the wall, the stenosis may rapidly recede 
 before the administration of mercury and iodine. A case is 
 described by Luton, in which there was a stenosis almost occlud- 
 ing the oesoi:)hagus, in a man aged forty; the suspicion of specific 
 disease led to the administration of fifteen grains of iodide of 
 potassium, three times a day. Under this treatment, the patient 
 was permanently relieved, though dilatation by sounds had been 
 tried. And should the stricture depend on malignant disease, 
 the use of the iodide of mercury has retarded the growth ; and in 
 the experience of the writer, the growth has seemed to be 
 lessened; and his repeated observation would justify him in the 
 general statement that neoplastic development, irrespective of 
 nature, is lessened by the use of the mixture of iodine and 
 mercurv. 
 
SPASM. 975 
 
 The dilating method has ah-eady received sucli exhaustive 
 consideration that hut little more remains to be said, than to add, 
 that besides the ivory-bulbed sound mentioned, instrumental 
 means akin to this have been resorted to. Thus one surgeon 
 dropped a leaden ball attached to a cord to the narrow point, and 
 allowed this to lie there for some time; one sees in this the peril 
 of detachment of the leaden body; and it is clear that a substitute 
 for such compression might be devised by affixing the leaden 
 body to the handle of the sound which has been introduced to 
 the stricture. 
 
 In case the stricture be yet permeable, the ingenious device of 
 Baillarger may be used: this consists of an elongated narrow sac 
 that is fastened to the end of the sound, and passed beyond the 
 narrowed part; this done, the sack is inflated and the staff then 
 withdrawn; by such compression the narrowed calibre maybe 
 widened. This procedure is reported to have cured a case. 
 These devices, intended to replace the ordinary sound, have not 
 been generally accepted; the simple sound, as in the treatment of 
 stenosis elsewhere, still holds its place as one of the most satis- 
 factory means of treatment in many cases of oesophageal stricture. 
 In the use of the sound gradual and progressive dilatation should 
 be aimed at, rather than immediate widening. 
 
 Potential cauterization has been done as aid in oesophageal 
 stricture; and for this purpose potassa fusa has been employed. 
 This is done by taking a narrow tube, open at the lower end, and 
 when this is passed to the stricture, a small fragment of the fused 
 potash, as large as the half of a small pea, is dropped into the tube, 
 and forced by a wire through the lower opening into the nar- 
 rowed part, and let dissolve there, and do its escharotic work; 
 thus an opening is made into the cicatricial structure, which 
 becomes an aid in the use of progressive dilatation with a sound. 
 A less active agent is nitrate of silver, which has been employed 
 in the same way. 
 
 Pharyngotomy and oesophagotomy have been done, both from 
 the inside and the outside. When the narrowing is in the 
 pharynx, incisions can be made into the inner wall with a 
 bistoury. This work, as the author has found, can be done with 
 almost any cutting instrument, the finger serving as guide. 
 After such incision, dilating forceps may be introduced, widened 
 and withdrawn, and thus narrowness can be temporarily over- 
 come. And the work can be continued with large sounds. 
 
 If the stenosis be lower down, then an instrument similar to 
 
976 0ESOPiiA(;rfc>. 
 
 that used iu internal urethrotomy might be employed, in fact, 
 any of the modern urethrotomes might be used. And similar 
 to urethral cutting, the work can be done by cutting from above 
 downwards; or reversely, the in.>?trument liaving been carried 
 with its concealed blade through the stenosed j^art, the blade can 
 then be uplifted and made to cut, as the shaft is withdrawn. 
 Such cutting is better done laterally, that is, on the right and 
 left sides, than on the front and posterior walls ; for the close 
 proximity of the vagi to the latter walls renders deep section of the 
 same perilous to these nerves. And besides the pneumogastric 
 nerve, tlie aorta is close to the posterior wall, so that the blade of 
 the cesophagotome penetrating deeply might open this vessel: a 
 wound that would quickly end life. Hence, the cutting should 
 be towards the right or the left side ; or if done on the front or 
 posterior wall, it should be merely superficial. 
 
 To be of advantage, this internal tiesophagotomy must be 
 accompanied by gradual dilatation by means of assorted sounds, 
 as has been described. 
 
 Should the dilatation not be practicable b}^ the methods 
 named, as ultimate aid a resort may be to external oesophagot- 
 omy. Cases in which this operation is indicated are patients in 
 whom the pharynx or oesophagus is the site of sarcoma or epithe- 
 lioma, through which occlusion has occurred; or in those cases 
 of cicatricial stricture in which relief cannot be obtained by 
 internal incision and progressive dilatation ; and finally, it may 
 be done to extract a foreign body lodged in the lower part of the 
 pharynx, or in the oesophagus. 
 
 External oesophagotomy was first done by Goursauld, in 
 1738. This operation, for a long time, was only resorted to, to 
 form a way by which bodies lodged in the passage could be 
 extracted ; and in such cases, it was not unfrequently done many 
 weeks or months after the occurrence of the accident which 
 demanded it. Later in the history of cesophagotomy, the opera- 
 tion was done to give a respite of life to those in whom death 
 from starvation was impending: such respite being gained through 
 the formation of a way by which food can be introduced; or, 
 perhaps, through such an opening the occluding obstacle maybe 
 removed. 
 
 To perform this operation, in consequence of the deviation 
 of the oesophagus towards the left, the opening is made on the 
 left side of the trachea. As aid in the work, a sound curved at 
 the lower end, should be passed through the mouth down to the 
 
SPASM. 977 
 
 strictured portion, and then the bent part of the sound must be 
 turned towards tlie left and somewhat forwards. On the struc- 
 ture thus uphfted, an incision is to be made through the skin. 
 Such cut should lie vertical, close to the trachea, in the space 
 bounded by the trachea and the left steruo-cleido-mastoid. The 
 cut is to be continued deeper until it penetrates the space between 
 the trachea and the left carotid artery. To aid in the work the 
 trachea and artery should be separated by means of retractors. 
 In this dissection, the fascial sheath of the vessels and nerves 
 should be left as nearly intact as possible: since, being opened, 
 excreta from the wound might enter and gravitate. The site, 
 hue and structure of the oasophagus will distinguish it from the 
 trachea; and the contained sound being moved, will aid as a 
 guide. The point of a tenaculum being inserted into the 
 oesophagus, it is thus uplifted, or pulled laterally, at the will of 
 the surgeon, who then penetrates into the canal by a short verti- 
 cal cut. In incising to the oesophagus, as well as in the work 
 of cutting into it, the left recurrent laryngeal nerve must be 
 avoided. As soon as the sound has been reached, a grooved 
 director should be passed tlirough the wound, and the incision 
 elongated to the extent required. This method is known as that 
 of Verduc-Guattani ; and the cut made is from two and a half 
 to three inches long in the skin. 
 
 The plan of Eckholdt is to make a cut somewhat oblique 
 over the lower part of the sterno-cleido-mastoid mascle, and hav- 
 ing split the muscle there enter the space between the sternal and 
 clavicular legs of the muscle; thus opening backwards and 
 towards the trachea, one reaches the oesophagus. The author 
 admits that the work might be done in this way, yet it would 
 not be a very direct route to the oesophagus. 
 
 Begin says that the procedure of Verduc-Guattani is an 
 impracticable one, and he substitutes for it another, which is 
 done as follows: the patient must lie on a narrow bed, with the 
 head and shoulders slightly uplifted, and the head turned back- 
 wards; thus placed, the neck is uplifted and easily accessible to 
 the operator, who makes an incision through the skin between 
 the trachea and the sterno-cleido-mastoid muscle, extending from 
 the sterno-clavicular joint to the thyroid cartilage. As this inci- 
 sion penetrates, an aid with a retracting instrument pulls the 
 trachea inwards, while the surgeon inserts his fingers underneath 
 the margin of the sterno-cleido-mastoid, and pulls it laterally 
 outwards, and, in so doing, he displaces the vessels outwards, and 
 
978 
 
 CESOPIIAGUS. 
 
 gives tlicni security from his knife. The omo-hyoidean muscle 
 will be met iu the middle of the incision, and must be uplifted 
 on a grooved director, and divided. The a3sophagus will now 
 present itself; and the furtlier work ])roceeds differently, accord- 
 ing as the operation is to relieve stricture, or to remove a foreign 
 body, or a growth in the oesophagus. 
 
 The oesophagus when reached is recognized by its rounded 
 form, and especially, by the movements which it makes when 
 the patient is made to swallow. If the sound be moved in 
 the passage this will indicate its site. Besides the sound men- 
 tioned by the writer, which can be extemporized from a cathe- 
 ter, a urethral sound of any flexible metal, or a thick wire that 
 has been so doubled as to form a loop, a special instrument has 
 been devised by Vacca Berlinghieri. This oesophageal guide, 
 shown in Figure 90, is provided with a spring that can be 
 
 FiGUr.E 99. Representing tlie instrument invented by Vacca Berlinghiera as guide in the 
 work of opening the cesophagns. Tlie spring is shown uplifted. 
 
 uplifted so as to render the wall of the passage prominent. 
 When the instrument is })assed down, the side containing the 
 spring is directed towards the incision, and then the spring is 
 made jirominent by the aid of a device at the handle. That the 
 operator has opened the canal will be shown by the appearance 
 of mucous material in the wound. 
 
 Tlie purposes of the operation here considered, are j^rimarily 
 to open a way by which food can reach the stomach, and the 
 patient rescued from death by starvation ; and subsequently, to 
 uslore the continuity of the canal, and to attain these ends, the 
 course to be pursued must varj' according to the causal agency, 
 v/hich oljstructs the canal. 
 
 If the pharynx or oesophagus be occluded by malignant dis- 
 ease which has arisen there primarily, or which has appeared 
 there by propagation, then the aim will be to add a few months 
 to the patient's life by an opening into the alimentary canal 
 bele)W the diseased part. Should the disease be high in the pas- 
 sage, the work is easily done; an opening is made in the sound 
 part below, and a permanently lying tube is inserted, and fixed 
 
SPASM. 979 
 
 there by being securely fastened. Such a tube should be of 
 flexible rubber; and to prevent its accidental escape, the outer 
 end may be transfixed by a thread which is tied or fastened to 
 some outside object; or the tube may be transfixed by a safety- 
 pin. Such a tube must remain in the passage during the 
 remainder of the patient's life, if he have inoperable or incurable 
 disease of the j)art. In case the stricture is dependent on con- 
 tracted cicatricial structure, then the insertion of the tube may be 
 accompanied by some operation looking to restoration of the 
 canal. And such operation may consist, in cas3S of slight con- 
 striction, of simple longitudinal incisions on the inner surface; 
 and then having effected some dilatation through the use of 
 sounds, let a tube be introduced which will prevent recontraction, 
 and also serve for the passage of nutrient fluids. 
 
 In such a patient progressive dilatation should be continued, 
 in which the sound is passed down through the mouth. In the 
 event that the canal has been converted into a hard fibrous cord 
 of limited extent, then an effort may be made to restore continuity 
 by excising the affected part, and reuniting the ends by suture ; 
 and through this sutured part a tube should be passed and let 
 remain for some weeks. And from experience it has been found 
 Letter, that this tube enter an opening made in the sound wall 
 above the narrowed part; and such opening may be formed by a 
 continuation upward of the wound which was made in the work 
 of excision. After healing and union of the ends, the tube may be 
 removed, and the work of maintenance of calibre be continued 
 by the use of sounds passed through the mouth. 
 
 There remain to be considered certain cases of stricture which 
 do not fall within any of the classes which have been described, 
 and imong those may be mentioned dysphagia lusoria, dyspha- 
 gia spasmodica and dysphagia paralytica. 
 
 Dysphagia lusoria was first described by Bay ford, and it has 
 been observed by Richter, Valentin and others. It arises from 
 an arterial anomaly, in which the subclavian artery passes 
 between the oesophagus and the spinal column. It appears at 
 the time of puberty, and is manifested by cardiac palpitation, 
 a sense of threatening sufibcation, and the pulse in the right 
 hand is weak and intermittent; the right arm is weak and 
 shrunken, and there is trouble in swallowing ; and this may be 
 constant. The treatment as counseled by Autenrieth consists in 
 the frequent introduction of the sound; and his advice to divert 
 the blood from the upper to the lower part of the body is a mat- 
 ter easier in precept than in practice. 
 
980 CESOPHAGUS. 
 
 Spasmodic dysphagia depends on some perversion of the 
 innervation of the i)harynx and oesophagus. This trouble is 
 usually seated in the lower portion of tlie oesophagus; and it is 
 so often associated "with impetiginous cutaneous disease, that 
 Clielius designates it an impetiginous angina. It may appear 
 after some catarrlial affection of the throat. The writer, how- 
 ever, has observed cases of spasmodic stricture, in which there 
 was no cutaneous disease. In the patients, the most of whom 
 were females, the pharyngeal and oesophageal muscles were 
 uuduly sensitive, and became the site of constrictive action from 
 slight cause. The attempt to swallow, especially cold drinks, 
 awakened such movement. The spasmodic contraction often 
 ends in a regurgitant movement, in which the material ingested 
 is expelled upwards. There is an excessive watery or mucous 
 secretion from the canal, which may cause nausea. This spas- 
 modic stricture is to be treated with the sound, and the adminis- 
 tration of remedies of a nature calculated to control the irregular 
 action. The chief curativ^e means, however, is the daily intro- 
 duction of the sound, of which the frequent contact with the wall 
 of the passage will render it less sensitive and irritable. In this 
 work, sounds should be used of gradually increasing thickness; 
 and often, at one sitting, the surgeon may rise from one of small, 
 to one of much greater thickness; and in this mechanical treat- 
 ment, it is the contact of the instrument rather than its dilating 
 action, which accomplishes the cure. 
 
 Finally, there is a form of paralysis, or rather inertia, of the 
 pharynx and oesophagus which simulates stricture. This has 
 been observed in the aged subject: also in the apoplectic patient; 
 and this condition is indicative of grave intra-cranial disease, 
 or of affection of the upper part of the sj^inal cord. A viscid 
 mucus is often excreted from the surface, and harasses the patient 
 by its presence. Solid matters are passed more readily than 
 fluids. Such patient swallows more readily, when he is erect, 
 and has the advantage of gravitation; and this condition is a 
 hint to the diagnostician to search for the cause intra-cranially, 
 or in the spinal canal where it may arise from meningeal or 
 vertebral disease. 
 
 When dependent on osseous disease or affection of the me- 
 ninges, a rational medication would be the use of iodine locally 
 and internally: also pungent gargles; for example, those pre- 
 pared from capsicum, zingiber and pyrethrum. The oesophageal 
 sound should be used ; yet when the causation is considered, it is 
 
SPASM. 981 
 
 evident that the recovery must be doubtful; and should no relief 
 follow the use of the means mentioned, then the patient's nutri- 
 tion must be maintained by the introduction of liquid food 
 through a tube, which, provided with an infundibuliform mouth- 
 piece, is passed to the stomach. In the palsied throat, care must 
 be taken that the instrument does not, in its introduction, stray 
 into the air-passage, which mistake might lead to drowning the 
 patient. That the material has reached the stomach will be 
 manifested by the warm or cold sensation which it will awaken 
 there. 
 
CHAPTER XXX. 
 
 FOREIGN BODIES IN THE PHARYNX AND (ESOPHAGUS. 
 
 Bodies of every conceivable variety may find lodgment in 
 the pharynx and oesophagus: and these in volume exceed, as a 
 rule, the diameter of these passages; yet the body may not equal 
 this diameter, and still remain there through the spasmodic con- 
 traction of the containing walls. 
 
 The symptoms of such lodgment are choking, strangling and 
 involuntary efforts to expel the body. There is a sense of sullb- 
 cation due to the contraction of the glottis, the actual closure of 
 the larynx, or to the pressure over the trachea from the body in 
 the contiguous oesophagus. 
 
 The foreign body may be arrested at any point; j^et this 
 occurs oftenest at the upper or lower end of the oesophagus, the 
 narrowest portions of the passage; so that if it be not found in 
 the upper end, it may be sought for at the lower one. 
 
 The nature of the material of which the body consists, as well 
 as the form of the bod\', have a bearing on the trouble which 
 may thence arise. Thus a hard or insoluble body lodged in the 
 oesophagus, and especially if its surface be irregular, causes much 
 more trouble than one which is soft, or has a smooth surface; if 
 the lodgment, however, be at the pharyngeal entrance of the 
 canal, these distinctions vanish; since occlusion there from a soft 
 body may imperil, or even destroy life. Thus South mentions 
 a necropsy which he made of a man who, while at his supper, 
 rose quickly and ran out of the room and suddenly died; the 
 examination revealed a lump of beef which had completely 
 closed the pharynx. Death at the time was supposed to be from 
 apoplexy. Another case is reported by South, in which suffoca- 
 tion from similar cause was happily averted by the patient him- 
 self extracting the body that had caught in his pharynx. Such 
 soft body descending lower might have harmless lodgment, until 
 it was loosened spontaneously, and escaped into the stomach; 
 
 ( 982 ) 
 
FOREIGN BODIES IN THE PHARYNX AND CESOPHAGUS. 983 
 
 but one which is insoluble erodes the wall on which it presses,' 
 and especially if the surface be rough. 
 
 Among the numerous objects which have lodged in the phar- 
 ynx and oesophagus, the following have often been seen: coins, 
 fish-bones, the crushed bones contained in meat of different kinds, 
 ill-chewed articles of food, the mesocarp of fruits, fragments of 
 wood and of metal, and needles, fish-hooks, knives, especially 
 the clasp-knife, and blades and other objects with which jugglers 
 disport for the amusement of audiences; and to complete the 
 enumeration, there should be added the toys of children, which 
 intentionally or accidentally have found a resting-place in the 
 pharynx or oesophagus; and, finally, no small contingent of 
 these objects have been furnished by the dentist's hand, in the 
 different forms of artificial teeth, which, being detached from 
 their place in the mouth, have passed downwards. 
 
 The surgeon is sometimes consulted in reference to the removal 
 from this passage, of a foreign body which he fails to discover; 
 in such cases, the body has found only temporary lodgment, and 
 during its sojourn, it wounded the wall; this has been seen where 
 a pin or fish-bone has been swallowed. Such irritation of surface 
 is oftenest observed in the upper part of the passage, where visible 
 inspection can be made. Such patients are hard to convince that 
 the body is not present of which there is so clear a sensation. 
 And the sensation remaining after a body has been removed 
 may continue to annoy the patient for some time. Thus suppu- 
 ration has arisen and stricture of the passage resulted. 
 
 The foreign body has caused death; Crequy in 1860, reported 
 eight cases of death from this cause. Death was partly due to 
 hunger; in some cases it was caused by suppuration, and in 
 others, by haemorrhage through sloughing which opened vessels. 
 Lavacherie reported twelve fatal cases from sloughing and 
 haemorrhage. Death occurred between the sixth and tenth day 
 To avert such an ending Crequy recommends that the oesophagus 
 be opened early, viz., on the second or third day. 
 
 In 1868, Adelmann of Prague, and Martin of Paris, wrote on 
 foreign bodies in the cesophagus. The report is given of three 
 hundred and fourteen cases; one-third of these were bones, and 
 the remainder were chiefly needles and coins. When the bodies 
 were classified in reference to character of surface, the number of 
 rough ones exceeded that of the smooth ones. Recovery occurred 
 in one hundred and ninety-one cases. Spontaneous recovery 
 occurred in several cases through vomiting; and in a few patients. 
 
9S4 FOREIGN BODIES IX THE PHARYNX AND lESOPHAGUS. 
 
 expulsion occurred through sneezing or laughing. Death occurred 
 in twelve cases by the body penetrating to, and piercing the 
 aorta. The carotid artery was fatally opened in three cases; the 
 subclavian in one, and the pulmonary artery in one case, caus- 
 ing death in each patient. 
 
 Kreyser, in 18-17, reported a death from a body penetrating 
 the aorta. The body "was a bone, an inch long, wliich lay across 
 the oesophagus. The luemorrhage from the aorta was into the 
 left pleural cavity. 
 
 Inasmuch as spontaneous recovery occurred in but a small 
 number of juitients, Adelmann teaches that instrumental interfer- 
 ence should be resorted to at an early period ; instruments 
 designed to catch the body, should first be tried; and these fail- 
 ing to relieve, oesophagotomy should be done. Adelmann finds 
 of sixteen cesophagotomies, that eleven recovered. 
 
 Before resorting to the knife simpler measures should be 
 tiled. Titillation of the fauces wliich provokes emesis may dis- 
 lodge and remove the body by the mouth ; thus a barbed vertebra 
 of a fish was removed by the writer. And vomiting caused by 
 the introduction of forceps to catch the body, has evacuated the 
 latter. 
 
 Where the body is of a harmless character, and cannot be 
 removed upwards, Brodie counsels to force it dov>'nwards to the 
 stomach ; and if this is found impracticable, then he allows it to 
 remain in place, when the body will often slowly pass downwards. 
 Few patients, the writer suspects, would accept so conservative a 
 plan; the victim of a body in the oesophagus is frightened and 
 anxious for its removal; he is in no mood to brook delay in the 
 work; and such advice would but speed him to a less conserv- 
 ative counselor. 
 
 Any article of food which has lodged, and of which the tex- 
 ture is not hard, can be caused to pass to the stomach by pressure 
 from above; and this can be done by means of a piece of whale- 
 bone to which a portion of sponge has been securely tied. The 
 usual probang employed in pharyngeal treatment may be made 
 to do such service. And sometimes, the propelling sound can be 
 aided by pressure with the hand on the outside, in cases in which 
 the body can be felt externally. 
 
 In case the arrested object be a pin, needle, fish-bone, or any 
 similar thing, it should be extracted, and not pushed downwards; 
 and to accomplish this, various instrumental devices have been 
 invented, or extemporized by the ingenuity of the medical 
 
FOREIGN BODIES IN THE PHARYNX AND OESOPHAGUS. 985 
 
 attendant. Such a device was that of Mutter, who attached a 
 number of looped threads to the end of a probang, which being- 
 passed down and twirled around, caught the object in its 
 meshes. The writer would suggest that a small balloon fastened 
 to a hollow tube could be passed down, inflated with air, and then 
 being withdrawn, the object might be caught and removed. The 
 effort should always be made to remove such body upwards; 
 thus done the patient is relieved of further anxiety. 
 
 The pricking body extracted, there remains p.ain in the 
 oesophagus for some hours; and if this does not abate soon, it 
 indicates ulcerative or suppurative action'; or what has been seen 
 in a few cases, there was another body which, remaining, main- 
 tained the irritation, until the object was removed. 
 
 Coins frequently find lodgment in the oesophagus: it is 
 sometimes seen in the adult, though oftener in the child. Among 
 such cases recorded, that told by Habicot is remarkable. A boy 
 swallowed nine pieces of gold (pistoles) wrapped in a piece of cloth; 
 the package lodged in the narrow part of the pharynx, and caused 
 suffocation, so that to save life, tracheotomy was done; impend- 
 ing death being thus averted, the pistoles were thrust down with 
 a sound, and finally passed by the rectum. The epigrammatic 
 comment of Habicot was that the boy's life was saved, and the 
 gold was not lost. 
 
 A case was seen by the writer, of an old man who had swal- 
 lowed a silver half dollar, which lodged in the cesophagus. An 
 exploratory search with a sound provoked vomiting, in which 
 the coin was expelled. During its sojourn of thirty days the 
 silver had become well blackened. The man suffered no subse- 
 quent inconvenience. 
 
 To remove coins the elder Graefe invented an instrument 
 which consisted of a long slender hollow handle, to the end of 
 which were fastened rings, one of which could be turned about 
 at right angles to the other; and in this form the instrument was 
 withdrawn, and the coin caught by it and extracted. It may be 
 suggested that looped wires passed through a flexible catheter 
 could be made to act in the same manner as the coin-catcher here 
 mentioned. Such an instrument might be employed to remove 
 other bodies. 
 
 Long-bladed forceps may be used for the extraction. Such 
 forceps shauld have a curve corresponding to the axis of the 
 pharynx; and the joint of the blades should be near the lower 
 end. With such an instrument, by careful manipulation, the 
 body may sometimes be found and extracted. 
 63 
 
086 
 
 FOItEIGX BODIES IN TPIE rHAKYXX AND (ESOPHAGUS. 
 
 An ingenious instrument has been invented by Mathieu of 
 Paris, wiiich may be named a many-jointed forceps, and isslio\\[U 
 in Figure 100. This handled forceps consists of a number of 
 
 Figure 100. Exhibiting Mathieu's esophageal forceps. 
 
 articulated sections, the whole so disposed that when the handles, 
 are opened or closed the grasping end will open or close. The 
 jointed sections permit some flexibility of the shaft of the instru- 
 ment. With this instrument one can enter the stomach, and 
 thence remove an object; it was first devised to remove a key 
 from the stomach of an insane man, and tlie extraction of the 
 key was thus successfully accomplished. The writer removed 
 with it a large forked fish-bone that was lodged in the lower 
 part of the oesophagus; this was done by passing it down to the 
 lower end of the oesophagus, then opening and withdrawing it, 
 when the bone was caught and drawn upwards. With this 
 instrument almost any object lodged in tlie passage miglit be 
 cauglit and witlidrawn. 
 
 The fisherman has been so maladroit as to cast his hook into 
 his own throat, and to become the subject of the surgeon. In 
 such a case -Miitter, of Philadelphia, succeeded in detaching and 
 removing the hook Ijy passing the cord through a coi-k of suit- 
 able size, and then forcing the cork down with a sound until it 
 reached tlie hook, which was thus unhooked from the wall, then 
 the cord being pulled on, the hook, cork and all were drawn out 
 through the mouth. In a case reported by South the subject was 
 relieved similarly of his hook bypassing a perforated bullet down 
 the cord until it became engaged in the hook, when the latter 
 was thus successfully withdrawn. 
 
 An object of less gravity than the preceding is the bristle 
 from the tooth-brush, which, passing into the pharynx, becomes 
 fixed there, through one end penetrating the mucous membrane. 
 A small fish-bone may act similarly; and the object so lodged, 
 though innocuous, may greatly distress the patient, and the 
 
FOREIGX BODIES IN THE PHAEYXX AND OESOPHAGUS. 987 
 
 reflex movements which it awakens in the throat, instead of 
 releasing the object, tend to fix it more lirmly in its place. A 
 careful exploration of the pharynx will usually bring the object to 
 view; or, failing to see it, the surgeon may find it by a search 
 with his finger. If visible, the object can be seized with forceps 
 and extracted. Should it elude sight or touch, the object may 
 sometimes be caught and removed by means of a probang, to 
 which there is attached a piece of sponge; by twirling and mak- 
 ing various movements with this, the object may sometimes be 
 caught and removed. 
 
 Artificial teeth have frequently escaped from their place- in 
 the mouth and lodged in the pharynx or oesophagus. Among 
 the earliest cases of this kind reported is one contained in. Fro- 
 riep's jSTotizen, in 1845; the false teeth swallowed remained in 
 the oesophagus until the containing wall was penetrated, the 
 aorta opened, and fatal haemorrhage ensued, ten pounds of blood 
 were found in the stomach at the necropsy. In 1856 Cock, of 
 Guy's Hospital, reported a case in which a dental plate was swal- 
 lowed ; a tube was introduced alongside of it, and the patient 
 then given an emetic; this, failing to expel the plate, Cock per- 
 formed oesophagotomy and removed the body: the patient recov- 
 ered. In 1858 Buisl made a necropsy on a drunkard wdio had 
 swallowed a dental plate with two artificial teeth; it was nearly 
 two inches long and one ihch broad. This had lodged near the 
 cardia, and had penetrated the wall of the gullet, and made an 
 opening into the pericardial sack, which was found distended 
 with ill-smelling pus and gas. In 1878, Maclean, of New York, 
 reported two cases in which artificial teeth had been swallowed 
 and had remained in the oesophagus. In one patient the plate was 
 swallowed during sleep; a sound was passed down and used as a 
 guide in opening the oesophagus; the opening was made on the 
 left side, and the plate extracted. In the second case the teeth 
 remained lodged some months. CEsophagotomy was performed, 
 and, to shun the recurrent nerve, the opening was made more 
 posteriorly than was done in the former case, in which the nerve 
 was wounded. In each case the wound was left open, yet food 
 only escaped through it for a short time, and the wound soon 
 closed. 
 
 This chapter may conclude with the advice that when a for- 
 eign body has lodged in the pharynx or oesophagus, an attempt 
 should be made to remove it by some of the non-operative pro- 
 cedures which have been described; and, if these prove ineffec- 
 
988 FOREIGN BODIES IX THE I'lfATtYXX AXD (ESorilAGUS. 
 
 tual, then a resort sliould be luul to oesophagotomy; ami in the 
 performance of tliis operation the writer desires to enforce the 
 fiict that anatomical perils are close to the knife on every side ; 
 for the field of work is crossed above by the superior thyroid 
 artery, and below by the inferior thyroid; the deep position of the 
 latter especially endangers it; and on the inside lie the trachea 
 and the inferior recurrent nerve, so much concerned in phona- 
 tion; and on tlie outer side, close to the knife, lies the common 
 carotid artery. These imperiled structures may be avoided l)y 
 the diligent use of the blunt dissector and the blunt retractor. 
 
 Should the body lie in the lower end of the (Te.sophagus, and 
 be so impacted or impaled in the structures tliat it cannot be 
 extracted by a route above the diaphragm, then a resort must be 
 had to gastrotomy, in which, an opening being made through 
 the stomach, the body is extracted and the wound closed, accord- 
 ing to rules derived from experience in the treatment of wounds 
 which open the stomach or bowel — a subject which cannot prop- 
 erly be treated of here. 
 
CHAPTER XXXI. 
 
 PHARYNGEAL AND (ESOPHAGEAL NEOPLASMS. 
 
 Neoplastic disease of the pharynx and oesophagus may 
 appear in benign or malignant form. 
 
 Benign growths have frequently been seen seated in the pos- 
 terior wall of the pharynx; and in that case springing from the 
 retro-pharyngeal fascia, the anterior vertebral ligament, the 
 periosteum of the upper cervical vertebnE, or from the anterior 
 face of the vertebra. Such benign growth is constituted of 
 fibrous tissue, and, classified pathologically, it is a fibroma. 
 
 The retro-pharyngeal fibroma, following the usual course of 
 an enlarging tumor, develops in the direction in which it finds 
 the le^st resistance; and hence, should it arise behind the easily 
 receding structures of the pharyngeal w^all, the tumor will pro- 
 trude prominently into the pharynx. But if the origin be behind 
 the anterior vertebral ligament, or the periosteum, then the neo- 
 plasm will be flat in its form, and w'ill develop less forwards than 
 in the previous case. Again, the tumor may arise in contiguous 
 structures and appear secondarily in the pharynx. And this 
 immigrant may then come from the palatal or tlie laryngeal 
 region. 
 
 Such growth seated in the posterior pharyngeal region may 
 displace the tonsils, invade and, partly or wholly, occlude the 
 entrance of the Eustachian tube, and cause deafness; or it may 
 enter the choanse and interfere with the voice and nasal breath- 
 ing. A yet more perilous encroachment is that in which the 
 fibroma obstructs the opening of the larynx. 
 
 Another important functional disturbance is that of dys- 
 phagia; the patient has trouble in swallowing, greater or less 
 according to the site and volume of the growth. In a case seen 
 by the writer the canal of the throat was so attenuated that the 
 patient swallowed with extreme difficulty, and, through insuffi- 
 cient nourishment, death by starvation was imminent. 
 
 (989) 
 
900 I'lIAllYNCK.M, AND (KSUl'II AciKAL NKoPLASMS. 
 
 The tumor, through lateral extension, may press on the 
 internal jugular vein and the internal carotid artery, and thus 
 disturb the intra-cranial circulation through inducing aniemia 
 or hyperjemia. 
 
 Treatment. — Such tumor must lie removed; and this may 
 usually be done through the mouth, if the tumor be discovered 
 before it has grown to large dimensions, or before it has entwined 
 its root-like processes about the adjacent vessels. Through the 
 mouth the writer has removed three retro-pharyngeal tumors. 
 The three subjects were adult males. In one the tumor had so 
 nearly tilled the pas.sage of the throat, that as an aid in the work, 
 tracheotomy was preliminarily done. In a second, the Rose posi- 
 tion, in which the recumbent head is dependent, was u.sed; and 
 in a third, the patient lay recumbent, with the head somewhat 
 elevated. The experience had in these cases induces the writer 
 to advise preliminary tracheotomy; thus fortified, the operator 
 proceeds without apprehension that the patient will be drowned 
 by his blood entering the air-passages. 
 
 The mouth being well opened, and the jaws retained asunder 
 by an interdental wedge, a vertical cut is made through the 
 mucous covering of the growth, and the latter then detached 
 with a blunt dissector from the adjacent structures. After the 
 removal, the wound should be brushed with pure alcohol, and 
 left unsuturcd. Nutrition should be maintained per rectum, or 
 through the stomach tube; and nothing except water be per- 
 mitted to come in contact with the wound. 
 
 In case the growth is inaccessible by the oral and buccal 
 route, a more direct one has been proposed by Malgaigne, and 
 named by him sub-hyoid laryngotomy; but by Langenbeck it is 
 called sub-hyoid pharyngotomy. 
 
 Sub-hyoid phar3'iigotomy has been done for the removal of 
 both vessels and pedunculated growths in the opening of the 
 larynx, and also in the lower part of the pharynx. And in case 
 it be done, tracheotomy at some lower point is sometimes neces- 
 sary to insure uninterrupted respiration during the removal of a 
 tumor, and, also, to permit the tamponing of the upper portion of 
 the trachea, so that blood cannot descend to the lungs. 
 
 To perform sub-hyoid pharyngotom}'^, a transverse incision is 
 made, two inches long, along the lower border of the body of the 
 hyoid bone. After division of the skin, platysma myoid and 
 sterno-hyoid muscles, tlie thyro-hyodean membrane is reached, 
 and to aid in the incision through this structure, it is seized with 
 
GROWTHS IX THE CESOPHAGUS. 991 
 
 a pair of forceps, uplifted and divided. The mucous membrane 
 is next severed; and in doing tliis, caution is to be used not to 
 split or penetrate the epiglottis, which is attached to the body of 
 the hyoid bone. At the termination of the cut on each side, lie 
 the superior laryngeal artery, and a branch of the superior laryn- 
 geal nerve; those parts, however, are situated so far to the side 
 that the opening into the pharynx can easily be made without 
 peril to them. When this opening is made, the epiglottis should 
 be seized and drawn out through the cut. As soon as the thyro- 
 hyoidean membrane has been well severed by this transverse 
 incision, the larynx descends so as to widen the cut to an extent 
 that will allow of attacking the growth which is sought to be 
 removed. After the growth has been removed, the wound 
 should be closed by sutures, and the head bent forwards and 
 retained so by a proper bandage. 
 
 Warts, Cysts and Polypoid Grouihs ra the (Eso'phagv.s. — Besides 
 large neoplasms, small growths of wart-like conformation occur 
 here, gathered in groups, or isolated in situation; and these are 
 oftenest seen in the aged subject. In the act of deglutition, the 
 frequent passage of materials over these prominences finally 
 erodes them, and causes a burning pain in the part. 
 
 A cyst may arise here from the closure of one or more mucous 
 follicles, and the accumulation of the retained fluid. 
 
 The polypoid growth has frequently been observed in the 
 oesophagus. Such neoplasm appears oftenest in the lower part 
 of the pharynx, and in the wall next to the larynx. The fre- 
 quent action of swallowing tends to displace such tumor down- 
 wards, and to elongate its pedicle. And, in time, it may thus 
 acquire considerable length; an instance was seen by Rokitansky, 
 in which the growth had attained the length of seven inches; 
 and it was two and a half inches broad. And such tumors may 
 be multiple; or rising from a common point, it may divide into 
 two or more branches. Dermoid cyst has been seen here; and 
 cases of lipoma have been reported by Klebs. 
 
 Such pendent tumor becomes ulcerated from repeated irrita- 
 tion; and it has been known to be detached, and the patient 
 thus freed from his trouble. 
 
 The subjective phenomena of the oesophageal polypoid tumor 
 are the sensation of a foreign body in the passage; and the 
 patient makes repeated efforts to reject the same. In conse- 
 quence of the difficulty of swallowing, the patient confines him- 
 self to licjuid or semi-liquid food; and this is often swallowed 
 
992 PHARYNGEAL AND CESOPHACiKAL NEOPLASMS. 
 
 "with effort, a part of it regurgitatiii<; and escaping tliroiigli tlie 
 month or nose. 
 
 Respiratory disturbance may be produced through the tumor 
 pressing against the trachea; such pressure attenuating the 
 calibre of the air-canal. A more dangerous condition is present 
 when the growth, being seated in the upper part of the oesopha- 
 gus, is carried upwards and falls, like a closing valve, on tlie 
 opening of the air-passage. In such state, the patient has speed- 
 ily perished from strangulation. Blood-tinged mucus is some- 
 times vomited. When of unusual volume, the tumor may cause 
 a swelling which is visible on the neck. 
 
 Besides the respiratory trouble which such j)olypoid growth 
 can cause, the partial closure of the alimentary tube interferes 
 with the digestion of the normal quantity of food, and, conse- 
 quently, such patient is inadequately nouiished. 
 
 In the diagnosis of these growths, the oesophageal sound can 
 assist; an obstruction may be detected with it, and the movable 
 or immovable nature of the tumor can thus be determined to 
 some extent. 
 
 The proper treatment of these growths is extirpation ; and 
 this should be done radically; for if a peduncular fragment be 
 left behind, the growth will reappear. Different ways have been 
 proposed to do this work. In the earliest es.says at removal, this 
 was done by ligating the pedicle and permitting the tumor to 
 slough off. A second way was to seize the growth with forceps, 
 and then twist it off, or })luck it from its attachment to the wall. 
 The growth has also been cut off, without ligature: a metliod not 
 to be pursued, since troublesome bleeding may thus ensue. The 
 thermal cautery has been used: the loop of the heated wire includ- 
 ing the pedicle and cutting it off. Or if the removal is not 
 possible by any of these ways, then a direct route may be cut to 
 the growth, either through the interspace between the hyoid 
 bone and the larvnx; or bv external cesophagfitomy. 
 
 Malignant Growths in the Pharynx and Oesophagus. — E[)ithe- 
 lioma, the form in which cancerous disease here presents itself, 
 has often been observed in the oesophagus; but as to its location 
 there, surgical opinion varies. Zenker, from a series of cases 
 too limited for a proper induction, finds that the di.sease occurs 
 in the upper part of the canal in nearly fifteen per cent of tlie 
 cases; and in the middle portion, in fifty-one per cent of the 
 cases; and in the lower third, in sixty-three per cent; thus, as 
 would appear from these figures, the disease increases in frequency 
 
MALIGNANT GROWTHS IN PHARYNX AND (T:S0PHAGUS. !J93 
 
 as one descends. Mackenzie, in a series of one hundred cases, 
 finds the order of occurrence nearly reversed: to wit, he finds 
 forty-four per cent in the upper third, twenty-eight per cent in 
 the middle, and twenty-two per cent in the lower third, and six 
 cases in the lower half of the canal. 
 
 The most usual sites of the disease are where the canal passes 
 behind the bronchus, and where it traverses the diaphragm; for 
 at these points, the canal, in its functional action, is more apt to 
 be irritated; especially so, where the oesophagus passes through 
 the diaphragm. 
 
 The disease occurs oftenest in ring form, in which a transverse 
 section of the canal is involved ; and such circular segment may 
 vary in height from a half inch to three inches. In some cases, 
 this ring-like invasion does not include the whole circumference; 
 a small segment of the mucous membrane may be found not 
 diseased. And instead of this regular form, the disease may be 
 situated at different points; that is, there is interruption in its 
 continuity. The disease is sometimes diff'used over a larger 
 surface: sometimes extending through the whole extent of the 
 canal. 
 
 The epithelioma, whether on a small or large scale, tends to 
 narrow the oesophageal canal; and this stenosis is greatest when 
 the neoplasm exists in narrow circular form; for then the 
 disease reaching the iimer circular muscular fibres, shortens 
 them. The disease having involved the entire thickness of the 
 wall may invade structures contiguous. Ulceration appearing in 
 the surface of the affected structure, the stenosis is lessened, and 
 the functional trouble seemingly diminished. The extension of 
 the disease to neighboring parts may so fix the oesophagus, 
 through adhesions, that the movement of swallowing is impeded : 
 solid food may lodge and afterwards be regurgitated. Also, 
 from prolonged sojourn at one point, the alimentary matter vaay 
 produce erosion: or cause an extension of the ulceration, which 
 already exists. By penetration througli the wall, an opening 
 may be made into the trachea, bronchus, pleural or pericardial 
 cavity; such penetration must soon end the patient's life; and 
 life would end most speedily if the ulceration extended to and 
 opened the aorta. Above the narrowed point there is dilatation : 
 due to the collection and accumulation of the ingested material 
 above the strictured part. 
 
 Metastatic propagation of the disease has been observed, 
 according to Petri, in nearh' sixty percent of the cases; thus the 
 
994 PHARYNGEAL AND CESOPHAGEAL NEOPLASMS. 
 
 disease lias reappeared in the glands which had anatomical con- 
 nection with the diseased site; and it has been seen in much more 
 distant situations: viz., in the lungs, liver, brain and bones. 
 
 The remote reappearance of the disease in glands, as well as 
 in non-glandular structures, has been underrated ; and according 
 to Zenker, metastatic development is oftenest in the tracheal, 
 bronchial and epigastric glands. If the disease be in the upper 
 third of the iiesopliagus, the cervical glands may be implicated; 
 the glands wliicii are especially infected are those situated near 
 the bifurcation of the carotid artery; also, the glands which lie 
 above and near the clavicle, on the constituent nerve trunks of 
 the brachial })lexus. Such swollen, indurated gland, like an 
 index, points to the cancer, and its situation in the a3sophagus. 
 
 The general symptoms of cancer in the oesophagus vary in 
 different patients: some emaciate and present poor health with- 
 out marked local symptoms; in others the stenosis is the leading 
 symptom. The pain is variable; its site is not so fixed that the 
 surgeon can locate the cancerous point through the pain, since, 
 often, the chief symptom is a disagreeable feeling at the pit of 
 the stomach. 
 
 Betz, in 1853, gives the following as signs indicative of epi- 
 thelial cancer in the oesophagus: when the disease is at the lower 
 end, there is pain near the ensiform cartilage, or in the pra^cordia; 
 but if in the u})per part, then the pain will be in the throat; and 
 in the middle portion, the pain will be felt in the middle of the 
 chest. But if the entire canal be affected, then there will be the 
 sense of a hot cord stretched from the throat to the stomach. 
 Pain, wherever it may be, is awakened and increased by swallow- 
 ing. Betz found the cancer in its structure to be medullary or 
 fasciculated. 
 
 Ziemssen finds that the pain from oesophageal cancer is more 
 severe at night. The canal becoming stiffened in its walls, and 
 likewise narrowed, the difficulty of swallowing soon results. 
 There is muscular unrest of the part, and the patient makes 
 continuous efforts to swallow; or there is a retrograde action of 
 the parts, manifested in retching and regurgitation. According 
 to the site, the symptoms will vary; if the disease be situated low 
 down, a considerable dilatation ma}' take place above the nar- 
 rowed portion, in which the solid ingesta may find lodgment; 
 and then the retained content may only, now and then, be 
 rejected. In the regurgitated material there is seen a thick 
 gelatinous mucus, — a secretion from the irritated glands; and 
 this has been compared to thickened milk. 
 
MALIGNANT GROWTHS IN PHARYNX AND (ESOPHAGUS. 995 
 
 After the epitlieliomatous disease has lasted some time, and 
 has caused abnost entire closure of the canal, there may occur 
 extensive disintegration and sloughing, by which the canal is 
 reopened, and the calibre so restored that deglutition becomes eas}?-, 
 and the patient is cheered with the temporary illusion that his 
 disease has vanished. 
 
 The recurrent nerve which lies close to the oesophagus may 
 be implicated in the growth, and thus the laryngeal muscles, on 
 one or both sides, may be disturbed in their function: a condi- 
 tion revealed by the suppressed or altered voice. 
 
 The sound can aid in determining the fact that the canal is 
 obstructed, or narrowed. Any instrument, whether used for 
 exploratory or alimentary purposes, must be introduced with 
 cautious care; for the unseen point may stray from its proper 
 route, and a false passage be bored into the wall. Surgical 
 history abounds in accidents of this kind; and the swallowing of 
 food, by the victim of such false passage, has precipitated the 
 death which the cancer was more slowly bringing. 
 
 Matters vomited, or caught in the ear of the sound, subjected 
 to microscopic study, may furnish additional proof of the presence 
 of cancer. 
 
 Tlie dry, swarthy skin of the patient, his rapid emaciation, 
 reaching to the extreme of corporeal waste, the sunken abdom- 
 inal wall, through which can be seen and felt the contained vis- 
 cera, are symptomatic accompaniments of epithelial cancer of the 
 oesophagus; and these are the visible expression of continued 
 hunger, and progressing cancerous infection. The patient's scanty 
 food is vitiated by the ichorous excreta of his disease. 
 
 The regurgitated matter can easily enter the air-passages, and 
 become the cause of profuse bronchial discharge, and finally, 
 ichorous pneumonia: a complication which will soon end life. 
 In some reported cases, an opening has occurred into the pleural 
 or pericardial cavities, with speedy death. 
 
 If unrelieved, the subject of oesophageal cancer dies within 
 two years; Mackenzie places the average duration of the disease 
 at eight months. The author, who has seen a number of cases, 
 would place the medium duration at not less than one year; and 
 as the time w^hen the disease began is alwa3's unknown, it is 
 probable that the disease has a longer duration than the figures 
 here given. 
 
 Epithelial cancer in the oesophagus occurs oftenest in persons 
 at the middle period of life; according to Mackenzie, the average 
 
096 PlIAKY.\(ii:AI. AND a:S01>n AGKAL NEOPLASMS. 
 
 period ill man is about fift3'-two and a half years; in woman, 
 forty-five and a half years. In forty-four cases seen in Berhn, 
 only three were females. 
 
 The reason for the greater frequency in man may be found 
 in his habits of drinking stimulating drinks : also his irregularities 
 in eating food rapidly, or too hot. The subject of chronic dys- 
 pepsia is predisposed to cancer in the oesophagus, througii the 
 frequent eructations of acid or irritating matters from the stom- 
 ach. Chronic catarrhal affection of the ce.'^ophagus or stomach 
 favors cancerous development. A scar which has altered the 
 form of the canal, and which impedes swallowing, furnishes the 
 leading causal element in the evolution of cancer, viz., continuou ; 
 irritation. 
 
 The disease is one which appeals most strongly for aid to the 
 hands of the surgeon : for unrelieved, it slowly and surely 
 destroys life ; yet surgery with all its advances, can only offer uncer- 
 tain relief. Epithelioma here, as at the threshold of the 
 alimentary canal, is, for a period, a purely local affection ; and if 
 so situated that it can be wholly excised, a cure may be safely 
 reckoned on. Unfortunately, the lower portion of the oeso|>hageal 
 canal is so located that disease there has a safe refuge from the 
 surgeon's knife. Though the walls of the thorax have been 
 opened, and its interior with imi»unity invaded, yet no hand has 
 yet had the hardihood to lay bare the oesophagus in tliis recon- 
 dite site, and make it the subject of operative attack. But when 
 the di.sease is situated in the upper portion of the canal, it is 
 within reach of some curative procedure, which may be cauteriza- 
 tion or excision. Excision is the preferable method.and this might 
 possibly, if the disease were high in the canal, be done through 
 the mouth; a better way is to open a route from the outside, and 
 remove the part when brought openly before the eye. Such an 
 operation was ])roj)Osed by Billroth, in 1870; but was done at a 
 later [)eriod by Czerny. As preparatory work to oesophageal 
 excision, Czerny first did the experiment of oj)erating on a dog: 
 he removed two inches from the cesoj)hagus, and stitched the 
 inferior part of the canal in the cervical wound. A sound was 
 occasional!}" passed. The dog was soon allowed to take food by his 
 mouth; but deglutition was not wholly satisfactory, since not 
 long afterwards, a large piece of food lodged in the pharynx, and 
 required removal. The wound rapidly healed, and to maintain 
 proper permeability, a sound was passed from time to time; and 
 while the dilatation was continued, the dog swallowed his accus- 
 
MALIGNANT GROWTHS IN PHARYNX AND CESOPHAGUS. 907 
 
 tomed food, and remained well nourished. Later, the dog was 
 killed, and there was found remaining a scar, which was not 
 more than a half line broad, and this could readily be dilated 
 and traversed by a sound. 
 
 This fortunate operation on the dog emboldened this ingen- 
 ious surgeon to make a trial of the operation on a woman, aged 
 fifty-one years, who was the subject of oesophageal cancer. For 
 this purpose, on the left side of the trachea, Czerny made a cut 
 from the hyoid bone to near the sternum, along the inner border 
 of the sterno-cleido-mastoid muscle. The omo-hyoid muscle was 
 severed; and the thyroid vessels, which were encountered, were 
 caught, doubly tied and divided. The diseased oesophagus fortu- 
 nately had contracted no adhesions to the contiguous parts. 
 There was removed about two and a half inches of the oesopha- 
 gus, which was the site of a cancerous growth, of circular form. 
 The inferior portion of the canal was brouglit into the wound and 
 fixed to the skin by eight sutures; a soft catheter was inserted 
 into this, and the patient fed through this tube. The wound 
 healed rapidly, and some months after the operation, the woman 
 recovered, and was able to do her accustomed work. The patient 
 preferred to retain the fistula, rather than to have an attempt 
 made to restore the continuity of the canal. 
 
 Czerny has demonstrated by his work that a portion of the 
 oesophagus can be excised: and hence, such an exsection is 
 indicated in cases in which the cancerous disease is limited to an 
 accessible portion of the canal. For example, if the affection be 
 insulated or circular in site; but if it be diffused over an extensive 
 tract of the canal, then such excision would be impracticable. 
 Also, if the larynx were implicated, the exsection of the air- 
 passage and the cesoj)hagus would be a formidable or impossible 
 operation. And whatever the site or extent of the disease might 
 be, as long as deglutition were possible, the patient would reluc- 
 tantly consent to an operation, which would exchange the site of 
 entrance of his aliment from the mouth to an opening in tlie side 
 of the neck. An operation to be effective should be done early: 
 a condition too often excluded through the patient's preferring to 
 abide with evils with which he is familiar rather than to take 
 refuge in those unknown. And to this hesitancy may often be 
 referred the lack of success of the deferred operation : for if tlie 
 powers of repair are nearly exhausted, tlie surgeon's wound may 
 only be an added factor in the destruction of life. 
 
 In the cases unfitted for total excision of tlie affected portion 
 
998 PHARYNGEAL AND (ESOPHAGKAL NEOPLASMS. 
 
 of the oesophagus, it may still be possible sometimes to open the 
 occluded canal, so that a tube for nutrition may be introduced, 
 and tl)e patient thus fed: thus a brief reprieve from impending 
 death may be obtained. 
 
 In cases unsuited for resection, by the prudent use of the 
 sound, the closed canal has been reopened, so that normal deglu- 
 tition was possible for a short time; in such dilatation, force must 
 be avoided, and the fatal consequences of a false passage must be 
 borne in mind. 
 
 If the closure of the oesophagus be in the tliorax, then life 
 may be prolonged by the use of a gastric fistula, through 
 which food can be introduced. The work done in this field by 
 Sydney Jones, Schonborn and Verneuil has shown that it is. 
 possible to form a mouth directly into the stomach, and that life 
 thus may be prolonged. As a rule, the respite gained has been 
 so brief, that many authorities are undecided as to the value of 
 the procedure. A patient seen by the writer, on whom gastros- 
 tomy was performed by Verneuil, was an example of the benefit 
 of the procedure, in a properly selected subject; the patient was a 
 youth, who was in good health in every way, except that his 
 ffisophagus was occluded by a neoplasm; this young man 
 received permanent relief from gastrostomy. 
 
 Wounds of the (Esophagus. — Among the wounds of the oesoph- 
 gus must be mentioned those of which the surgeon's knife has been 
 the cause: as in resection of the canal, or oesophagotomy, done 
 from the inside or outside. And, again, this canal has inadvert- 
 ently been opened in tracheotomy, in which the knife wandered 
 from its tracheal field, and implicated the oesophagus. 
 
 The accident of opening tlie oesophagus in tracheotomy is apt 
 to occur in cases in which there has been much haste in opening 
 the trachea: as may be demanded in the subject who is moribund 
 from asphyxia arising from closure of the air-passage. Also, if 
 tracheotomy be done by one stroke, instead of by successive 
 steps of dissection, there is danger that the knife will reach the 
 subjacent oesophagus: such an error can only be shunned by the 
 experienced and well-disciplined hand. Where this accident 
 has occurred, to prevent the entrance of materials from the oesoph- 
 agus into the trachea, the patient should be fed through a tube 
 reaching to a point beyond the wound. This tube should pass 
 through the inferior nasal meatus, and be fixed permanently in 
 its site. Wounds may be inflicted by an assailant, or by the 
 subject himself: and such may be large, in which the oesophagus 
 
WOUNDS OF THE (i:SOPHAGUS. 999 
 
 is wholly or partly divided ; or it may be a small penetrating 
 wound. When small, the escape of mucus and saliva would 
 denote perforation of the canal; and in a large wound, the char- 
 acter Avould be evident to sight and touch. 
 
 The treatment of a large w^ound usually consists in partial 
 closure by suture, and alimentation through an oesophageal 
 tube; but the small wound should be completely sutured, and 
 the patient afterwards fed through a tube. 
 
 Gunsliot wounds involving the oesophagus were the subject of 
 study by Wolzendorf in 1880; of one hundred and forty-five 
 wounds seen by him the most were produced by the gunshot 
 missile. In eiglit cases, the external jugular vein was wounded, 
 the internal jugular once, and the carotid artery in five cases. 
 The spinal canal and cord were injured in three; and in three 
 others, the brachial plexus was wounded. In seven cases, the 
 windpipe was opened to save life, and'in but one patient was this 
 successful. 
 
 Pernicious, or ichorous suppuration may arise from opening 
 the posterior wall of the oesophagus. Fifty-two cases of such 
 wounds have been recorded : ichorous pneumonia was thus 
 caused; and six patients died from this complication. 
 
 Wolzendorf finds that gunshot wounds of the oesophagus are 
 twice as frequent as incise^ wounds: death from the former 
 occurred in forty-four and two-tenths per cent of the cases; but 
 from the latter twenty-two and five-tenths per cent died. 
 
 Stricture occurs oftener after gunshot wounds than after 
 incised ones; yet fistula oftener follows the incised wounds. 
 
 When the oesophagus is entirely severed, mortality is twice 
 as great as when the canal is but partially divided. And cases 
 in which the thyroid cartilage is also wounded, are much more 
 dangerous than those confined to the oesophagus. 
 
 Death from such wounds is caused most frequently by suffo- 
 cation; yet it may come from general exhaustion. The fatal 
 result can be accelerated by emphysema of the mediastinum, 
 swelling of the larynx, or the entrance of fluids into the air- 
 passages; and finally, haemorrhage, or palsy of the vagus, may 
 destroy life. 
 
 The local treatment consists in arresting the bleeding, pro- 
 viding for respiration, nutrition and the escape of the excreted 
 matters. One should not attempt complete closure of the wound, 
 eitlier of the oesophagus or larynx ; 3^et Wolzendorf advises par- 
 tia closure: and for this, he employs deep sutures; and such deep 
 
lUU" PHAHYNGEAL AXI> (ESOPHAGEAL NEOPLASMS. 
 
 fetitch should include both the oesophagus and air-passage, if 
 these both be wounded. If the (esophagus be wholly severed, 
 and the ends not freely movable, then one may loosen the 
 ends, and approximate them by looped threads attached to the 
 ends. 
 
 During the treatUR-nt of lh<." (esophageal wound, the nutrition 
 may be maintained tlirough the rectum by nutrient injections; 
 and as the wound sonutimes has healed in a few days, the entire 
 nourishment may be introduced in this way. Should the period 
 of healing be prolonged, then Wolzendorf would not depend on 
 rectal nutrition, but lie would introduce a tube through the 
 mouth ; and if this could not be done, tlien it should be passed 
 through the wound, and permitted to remain in the canal, for 
 some time. Nutrition was less embarrassed by the gunshot wound 
 than by the incised one. 
 
 In cases in which nutrition cannot be maintained by the rec- 
 tum, nor by means of a tube passed through the mouth or the 
 wound, then an opening should be made, lower down, into the 
 (Desophagus, and a tube introduced tliere. 
 
 The usual result of wounds of the cesophagus is narrowing of 
 the normal calibre; to prevent this, a resort should be had to 
 dilating sounds, which will counteract the tendency to stenosis. 
 The daily use of such sotmds should be continued, until the 
 tendency to contraction has ceased: a period usually reaching 
 through several months. 
 
 TRACHE(JT0MY; BKoNfPKJTOMV. 
 
 Many generations of physicians and surgeons have read and 
 adopted the writings of Hippocrates as articles of faith which 
 should not be questioned ; unfortunately for the advance of Me(,li- 
 cine, these doctrines contained some serious errors: as an exam- 
 ple of this may be cited the apliorism in which it is stated that 
 section of cartilage or bone will not be repaired. And this erron- 
 eous belief retarded surgical advance, since it condemned as in- 
 curable, cases in Mhicli interference with these structures was de- 
 manded. For wlio would venture to wound cartilage, if such 
 wound would not heal? Men, however, had eyes, and wounds of 
 tliese structures came under their observation, in which repair 
 did take place ; but the error was planted so firmly by the Father of 
 Medicine, that the hands of many generations of medical men 
 were required to pluck it up, and to plant in its place, the fact that 
 cartilage when wounded will heal. The studies of Goodsir, Vir- 
 
tkacheotomy; bronchotomy. 1001 
 
 chow and Billroth have discovered that the repair is mainly ac- 
 complished by cells that are the offspring of the maternal tissue. 
 
 The trachea was opened long before the knowledge had 
 been gained that cartilage, when divided, would reunite; yet the 
 work was so done as to avoid the cartilaginous element of the 
 tracheal wall. Thus Paul of JEgma, in the fourth century, 
 relates that Antyllus opened the trachea for relief where suffoca- 
 tion was impending, or a foreign body had entered the air- 
 passages : and his plan was to make a transverse incision, between 
 the third and fourth tracheal rings. In thus cutting, the carti- 
 lage was spared. The sudden exit of the air, and the extinction 
 of the voice, proved that the air-canal liad been opened. The 
 wound was maintained open by means of two hooks. As soon 
 as the patient could breathe easily, the wound was closed by 
 sutures. 
 
 From the time of Paul of ^gina to the sixteenth century, one 
 finds in the annals of medicine, references to this operation of 
 Antyllus; the Arabians, as Avicenna, and the early French sur- 
 geons, also mention it; but it appears to have only been resorted 
 to, in cases of emergency, in which life was imperiled by impend- 
 ing suffocation. 
 
 The operation was done by the Italian surgeons in the six- 
 teenth century. . Fabricius d'Aquapendente operated by first 
 making a vertical cut through the skin; then he entered the 
 tracliea transversely between two rings. He used a canula to 
 permit the passage of air, and his pupil Casserius gave the 
 canula a curved form; and he held this in place by cords which 
 passed around the neck. In the latter part of the sixteenth cen- 
 tury Sanctorius, of Padua, made the opening into the air-canal 
 by means of a trocar, which, being thrust in, the ensheathing 
 canula was left in place. 
 
 In the seventeenth century the operation was done in Ger- 
 many, France, Italy and Portugal. In France it was done by 
 Habicot on a boy who had swallowed coin; and to save his life, 
 the trachea M^as opened. 
 
 In the eighteenth century there were two methods pursued 
 in the work: in one the operation was done by a trocar, which 
 was plunged into the trachea at one thrust; thus Richter and 
 Decker operated, and, as will later be seen, this old plan of Sane 
 torius has had its advocates in the nineteenth century. But as 
 anatomy was more studied, and operative work became more 
 accurate and adroit through preliminary exercise of the hand on 
 64 
 
1002 rHAUYXGKAL AND CESOPHAGEAL XEOl'LASMS. 
 
 the cadaver, then the surgeon ])referrcd to open the air-passage 
 bv methodical dissection ; and then, the fear haviuir been dis- 
 xjardc'd that wounded cartihige woukl not heal, a vertical incision 
 was l)o]<lly made through the anterior wall of the trachea. And 
 the error taught by Hippocrates ceased to exist after its long 
 course through the centuries: a circumstance which finds a sem- 
 blance in the two great rivers of the Western World, of which 
 the clear waters of the one receiving the turljid waves of the 
 other, the current of the two remains clouded afterwards, and 
 the turbid pollution of the water only vanishes wlien the great 
 stream has traversed a continent: a lesson to medical or surgi- 
 cal authority to avoid adding perturbing error to the ever 
 changing and yet enduring course of our venerated science. 
 
 Tlie operation was originally named bronchotomy, but in the 
 eigthteenth century it was given the name of tracheotomy, 
 which name gradually superseded the older one. 
 
 The single canula was used for a long time; a double one 
 was introduced by jMartin, which device offered the advantage 
 that when one canula'was removed the other remained in place. 
 
 Despite the brilliant successes which were obtained through 
 the operation, it did not become popular until Louis, an eminent 
 authority, wrote a monograph on the subject, which tended to 
 generalize the procedure. Louis claimed that in some cases the 
 operator had not penetrated the tracheal canal ; and that this 
 fatal mistake was not confined to Louis' times, but is sometimes 
 committed to-day, lies within the writer's observation. 
 
 Tiie operation was first done for the purpose of removing 
 foreign bodies, which, having entered the air-|)assages, caused 
 suffocation ; later, tracheotomy was done for relief in cases in 
 which asphyxia was induced by other causes: for example, by 
 fracture of tlie larynx, or in wounds of the throat which led to 
 tumefaction and closure of the air-canal. In the eighteenth cen- 
 tury the sphere of the operation was yet further widened through 
 its employment for relief of suffocation originating in anginous 
 disease of tlie throat. Thus in cynanche trachealis, to-day desig- 
 nated croup, it was proposed by Home to open the trachea, and 
 thus permit ingress of air below the site of the occluding disease. 
 
 •Such an operation was successfully done by John Andrew, 
 in London, in 1782. The operation at first found but few advo- 
 cates; in fact, though advocated by Crawford, Stoll and other 
 eminent authorities, it was generally 0[)posed. Tracheotomy, 
 for relief in croup, found in the nineteenth century earnest advo- 
 
tracheotomy; bronchotomy. 1003 
 
 cates in Bretonneaa and Trousseau, in France, and in Pitha, 
 Roser, Langenbeck and Hueter, in Germany; the greatest credit 
 is due to Trousseau, whose able pen pleaded eloquently for it, and 
 whose scalpel achieved a success for the operation, which place 
 it among the truly life-saving procedures; and as tracheotomy 
 is usually done on the young subject, surgery is able to point 
 with satisfaction to achievements here in which many ^^ears of ' 
 existence are given to the rescued patient. 
 
 In recent times tracheotomy has obtained a still wider sphere 
 of application. An enumeration of the various cases in which 
 the operation may be resorted to as a remote aid, or as one at 
 once necessary to save life, are the following : — 
 
 1. Foreign bodies which have entered tlie air-passages, and 
 which, unremoved, will destroy life. 
 
 2. Scalding from steam, hot water, or an acid or alkaline 
 solution, which cauterizes or destroys the mucous surface with 
 which it comes in contact. 
 
 3. Injuries of the larynx, as fracture of the thyroid or cricoid 
 cartilage, fracture of the os hyoides; also, for relief after incised, 
 lacerated, or gunshot wounds of these parts. 
 
 4. Inflammatory or cedematous processes in which, through 
 cell-growth or local hypersemia of the parts, the air-passage is 
 rendered too narrow for the transit of air in respiration. An 
 abscess at the entrance of the larynx or in the cervical structures, 
 so situated as to compress the air-canal, may demand tracheot- 
 omy to save life. Likewise, a neoplasm, benign or malignant, 
 by encroachment on the air-canal, may lessen its calibre and 
 become an indication for the operation. 
 
 5. (Edema, or inflammation in the lower jDart of the trachea, 
 may so narrow the canal that a sufficient amount of air cannot 
 be received to maintain life; through an opening, made into the 
 upper part of the trachea, air may be admitted, and a way 
 opened by which the affected part can be reached and treated. 
 
 6. In cases of apparent death from an anjesthetic or from 
 hanging, submersion in water or other asphyxiating medium, 
 tracheotomy furnishes the most direct route by which air can 
 be introduced into the lungs. Also, when apparent death has 
 arisen from immersion in carbonic acid or other asphyxiating 
 gas, then a tracheal opening furnishes the shortest way by which 
 air can reach the lungs for restoration of the patient. 
 
 7. Laryngeal and tracheal stricture from some chroniq mor- 
 bid process seated in the wall of the air-passages may require 
 tracheotomv. 
 
1(»(»4 PIIAKYXGEAL AND QvSOPH AGF:AL XEOl'LASMS. 
 
 8. Tracheotomy ma}' be dcniaiulcd by aneurism or by .some 
 body lodged in the ceso[)hagus. 
 
 9. Neophism springing from the inner wall of tlie trachea or 
 larynx may be reached by tracheotomy. 
 
 10. Ill palsy of tlie recurrent nerves which supply motor 
 innervation to the muscles whicli maintain the glottis open, the 
 operation may be done. 
 
 11. As a preparatory act to some operation on the pharynx 
 or larjmx, or as an aid in the removal of growths from the neck, 
 tracheotomy is sometimes preliminarily performed. 
 
 12. Croup and diphtheria: for the relief of the patient suffo- 
 cating from these diseases, tracheotomy is oftenest resorted to; and 
 under this head the instrumental apparatus for, as well as the 
 methods pursued in, tiie operation of tracheotom}' will be fully 
 considered. 
 
 Foreign bodies in the air-passages: this accident has been 
 treated of, and it remains here to say that after the non-operative 
 means have been fruitlessly tried, then tracheotomy, or laryngot- 
 omy, as the case may indicate, should not be deferred. Prompt- 
 ness, and not delay, should be the rule of action ; for by procras- 
 tination the foreign agent may irritate and inflame the parts 
 with which it lies in contact; and, besides, during the lodgment, 
 the subject is deprived of the normal amount of air. 
 
 Scalding from steam, hot liquid, or the swallowing of acids, 
 alkalies or other escharotic agents: the injury from any of the 
 agencies here named may excite an oedema or inflammatory 
 swelling of the interior of the larynx, which may suddenly close 
 the glottis and cause death ; in such emergency, if suffocation 
 seems imminent, tracheotomy should be resorted to; and a 
 canula being introduced must be worn until the patient lias 
 recovered from the effects of the injury. And sliould the injury 
 have been inflicted by an escharotic agent which can be neutral- 
 ized by some counter agent, then the tracheal opening will serve 
 as a way by which the corrective means can be introduced: thus 
 oil may enter and check the destructive alkali ; or an inert 
 alkali may arrest the action of an acid. And should subsequent 
 stricture impend through cicatricial contraction, then the surgeon 
 must not be in haste to remove the canula, but this must remain 
 in place, while the mechanical treatment is being carried out, to 
 prevent the formation of a stricture, or for the removal of a 
 stricture already formed. Such treatment consists in the occa- 
 sional introduction of graduated sounds into the larynx or trachea, 
 
tracheotomy; broxchotomy. 1005 
 
 as the case may demand. If it be probable that the heat or 
 escharotic has penetrated below the larynx, then the opening- 
 should be made as low as possible in the trachea. The tracheal 
 opening may sometimes be utilized for the admission of instru- 
 ments in the treatment of the stricture. 
 
 Injuries of the larynx, as fracture of its component cartilages, 
 with or without fracture of the hyoid bone, may so close the air- 
 passages that death may speedily occur. Gurlt has collected 
 a series of forty-two cases of such injury ; in the most of these, 
 the larynx alone was fractured; yet in a small number, along 
 with this there was also fracture of tlie hyoid bone, or of the 
 trachea. Death occurred in nearly all these patients in whom 
 tracheotomy was not performed. Hunt has reported twenty- 
 seven cases of such fracture, of whom seventeen died, ten recov- 
 ered, and in six of the latter tracheotomy was performed. 
 Durham has collected a series of sixty-two cases of such injury, 
 of whom fifty died; only twelve recovered, and in eight of the 
 recoveries tracheotomy was performed. 
 
 A result of such injury is dislocation of the fragments, caus- 
 ing occlusion ; or there may be effusion of blood in the submucous 
 tissue, and swelling, which closes the canal. Or the fracture may 
 lacerate the mucous membrane, and lead to emphysematous 
 infiltration of the soft parts: in respiration, the inspired or 
 expired air being pumped into the tissues, until fatal occlusion 
 of the passage is produced. The facts stated show the gravity of 
 laryngeal and tracheal fracture; and so greatly are the chances of 
 life increased by tracheotomy, that it has been advised to perform 
 it, when the diagnosis of fracture has not been clearly established. 
 After the trachea has been opened, there is offered an opportunity 
 for replacing the ill-placed fragments; also facility is thus offered 
 for checking subsequent strictural encroachment of the broken 
 parts on the canal. 
 
 Langenbeck counsels tracheotomy in all cases in which a 
 wound has been made which involves the glottis or epiglottis; 
 for such wounds may end fatally, as was seen in the young- 
 assassin Blind, who attempted to kill Bismarck, and afterwards 
 tried to kill himself by thrusting a penknife into his neck; the 
 instrument penetrated the base of the epiglottis and produced an 
 extravasation of blood into the tissues, which caused fatal 
 suffocation. 
 
 In cut-throat, in which the trachea, larynx or pharynx is 
 wounded, tracheotomy is often demanded as projihylaxis against 
 
lOOG 
 
 PHAKYXGEAL AND (ESOPHAiiKAL NEOPLASMS. 
 
 tlie suffocation which may arise from the Avoiiiid; for in such 
 injury, a portion of the kiryngeal wall may be slictd off, and act 
 as a valve which can close the passage, and speedily sulfocate: 
 and the knife of the suicide has done similar work in splitting 
 the epiglottis, and converting it into a fatal valve. 
 
 In case of an incised wound that completely sunders the 
 trachea, permitting the lower end to bury itself in the cervical 
 structures, then the divided ends should be reunited, and a canula, 
 shown in the subjacent figure 101, may be inserted at the site of 
 
 Figure 101. From Scliiiller, showing: a canula tliat can be inserted in 
 sections a and h; and M'lien placed in site, the sections can be locked, as shown 
 at the left, abcL 
 
 the wound; or, what would be preferable, should the space permit 
 it, an opening should be made into the trachea below the wound, 
 and an ordinary canula inserted there: thus done, there would 
 be less interference with the union of the divided ends. 
 
 Among the indications given for the performance of trache- 
 otomy, an important one is that under the fourth head, in which 
 the air-passage is obstructed by oedema, or some inflammatory 
 process. (Edema, in which serum is effused beneath the mucous 
 membrane, w4ien situated in the aryteno-epiglottidean folds of 
 this membrane, may fatally close the entrance of the larynx; 
 also, oedema invading the glottis itself, may early close that 
 narrow passage. The loose adherence of the mucous membrane 
 to the vocal chords is an anatomical condition which disposes to 
 serous accumulation here, in case the efferent veins of the laryn- 
 geal or cervical structures are compressed, through some enlarge- 
 ment or tumefaction. And this causal agency is sometimes 
 
tracheotomy; bronchotomy. 1007 
 
 23resent in diffuse pharyngitis or tonsillitis, which ends in suppu- 
 ration. Or such inflammatory and suppurative process may 
 arise in the tissues which lie outside of, but close to, the larynx; 
 such aifection not unfrequently travels and climbs over the 
 thoroidean walls, and entering the cavity of the larjaix, obstructs 
 the passage. 
 
 Instead of arising passively through obstruction of the veins, 
 as simple oedema, it is probable that, quite as often, the process is 
 an active one, in which through inflammation a cell-growth is 
 formed, which, as an interstitial element, adds to and so thickens 
 the normal tissues as to diminish the normal calibre to a degree 
 that breathing is interfered with. 
 
 In tliese cases, whether from passive oedema, or active ii:iflam- 
 matory swelling, tracheotomy is given high rank as a life-saving 
 operation by Pitha, who, in 1857, wrote on the subject. He 
 claims that it is of signal service in both oedema of the glottis 
 and laryngeal stenosis from other cause; and that the tracheal 
 opening tends to dissipate the obstruction. Even cicatricial 
 narrowing above the tracheal opening seems to gradually widen. 
 And he observed that where the respiration is hampered, the 
 tracheal mucous membrane, as well as that of the passage above, 
 becomes swollen; in such cases, tracheotomy, like a charm, 
 removes the turgid state of the parts, and the cyanosis from 
 venous blood, soon passes away. Also, when, from ulcerative 
 action in the larynx, catarrhal excretion inenaces suffocation, 
 then tracheotomy gives relief 
 
 If an abscess by its pressure occludes the air-passage, the former 
 should be freely opened; and this will usually suffice for the 
 removal of the dyspnoea; should it not do so, then the trachea 
 should be opened below the constricted part. Also a tumor, 
 lymphomatous, goitrous, sarcomatous or carcinomatous in nature, 
 may encroach on the air-canal and diminish its calibre; in such 
 cases the difficulty of breathing can commonly be alleviated by 
 extirpating the growth; but should the growth recur, then a 
 recourse must be had to tracheotomy for further relief 
 
 In the cases here cited, an invariable rule for guidance can 
 scarcely be established; whether tracheotomy should be per- 
 formed will depend on the amount of dyspnoea that is present; 
 and, also, whether this is increasing or lessening; and if it be 
 increasing, the surgeon should not delay to furnish relief by a 
 tracheal opening, even though the alleviation be transient. 
 
 Another indication for tracheotomv is that in which tlie tra- 
 
1008 PHAKYNGEAL AND (ESOPHAGEAL NEOPLASMS. 
 
 chea is narrowed below the site where section can be made, b}' 
 oedematous or inflammatory change, or by the pressure of a 
 growth; in such cases, relief can be given through trache- 
 otomy which permits the introduction of a long canula through 
 the narrowed canal. Such a canula may reach into the chest; 
 and can maintain patency sufficient for respiration, despite the' 
 encroachment of the constricting agency. An example of sucli 
 use of tracheotomy was seen by the writer in a case of lym- 
 phomatous enlargement of the glands, in which the neoplastic 
 development involved the glands around the trachea in the 
 upper part of the mediastinum. Though the disease was incura- 
 ble in the patient referred to, yet signal relief was obtained by 
 the operation, and life prolonged. 
 
 Tracheotomy is a means of relief in cases of asphyxiation 
 through chloroform and narcotizing gases; as well as an aid in 
 resuscitation of those who have been suffocated through sub- 
 mersion in a liquid or semi-liquid medium, or who have been 
 buried in sand, earth or other pulverulent material. 
 
 In a case of apparent death from a mixture of ether and 
 chloroform, used as an ansesthetic, the writer recalled the man 
 to life, by rapidly opening the trachea and blowing air into tlie 
 lungs. It was necessary to continue the insufflation of air for 
 some time, before normal breathing was resumed by the patient. 
 
 An objection has been offered against such insufflation of air 
 into the lungs, that the thoracic walls remaining .stationary, there 
 is not room for expansion of the lungs; and that the air being 
 forced into them would rupture the air-cells. This risk might 
 be avoided, and the work done better, if insufflation were com- 
 bined with artificial respiration, done according to Silvester's 
 plan; that is, the air should be blown into the lungs when the 
 arms are U[)lifted, corresponding to the inspiratory act; and the 
 insufflation should be suspended during the expiratory act of 
 lowering the arms, and compressing the chest. Done in this 
 way, the air blown in would not injure the pulmonary tissue. 
 This procedure maybe done in all cases in which there is appar- 
 ent death from a poisonous gas, or from suffocation by submer- 
 sion in sand or some agent which would close the entrance to 
 the air-passages. 
 
 In case the asphyxiating agent which has entered the air- 
 passages, be a liquid or a semi-liquid material, then tracheotomy 
 is urgently demanded as an aid in restoration; since it opens a 
 more direct way by which the material may be removed. Tiiis 
 
tracheotomy; bkoxchotomv. lOUy 
 
 subject lias been studied by Sclililler, of Greifswald. After the 
 entrance of such matter, he finds that it is in vain to attempt 
 removal by emetics, since the patient is so nearly dead that these 
 cannot act; it is better to make a tracheal opening as Hueter has 
 practiced, and through this pass a flexible tube, and by suction 
 extract the matter. 
 
 Schiiller experimented on animals to determine to what 
 extent the presence in the air-passages of such materials can be 
 tolerated. He found tliat if water were slowly admitted along- 
 with air, a large quantity could be borne with impunity; in 
 twenty -five minutes, there was admitted an amount of water 
 equal to one-thirtieth of the rabbit's body. The animal lived for 
 some da^'s, after such addition of water to the blood. An exam- 
 ination of the lungs did not reveal any special changes in their 
 tissue; the water had disappeared through absorption. The 
 animals thus treated, as a rule, lived but a few daj^s ; proving 
 that the sudden introduction into the blood of such large quan- 
 tities of water imperils or destroys life. Milk was also injected, 
 and considerable quantities of it were tolerated ; and, on necropsy, 
 it was found that the most of it had been absorbed; 3'et milk 
 globules were found in the interstitial tissue of the lungs. The 
 lungs were found to possess the power of absorbing a considera- 
 ble quantity of milk ; but if a thicker or semi-liquid material 
 was thrown in, but a small quantity of it was tolerated. Thus of 
 a mixture of milk and flour, or of flour and water, not more than 
 three cubic centimetres could be tolerated, while of pure water 
 thirty-two cubic centimetres could be borne. After the injection 
 of the mixture of flour in limited amount, the animal continued 
 to live; and afterwards wdien killed, remains of tlie flour were 
 found in the alveolar tissue of the lungs. 
 
 Schiiller concludes that simple artificial respiration does not 
 aid in restoring the patient sufl'ocated by semi-fluid material; in 
 fact, it tends to imbed such matter more deeply in the branches 
 of the bronchi; but more effectual aid will be rendered the sub- 
 ject of such asphyxiation, if a tracheal opening be made, and 
 through this a tube be introduced and the material directly 
 drawn out through suction through the tube. But if the material 
 be a thin liquid, then artificial respiration, unaided by such 
 aspiration, will suffice to cause the expulsion of the matter. 
 
 Schiiller discovered that the amount of the liquid or semi- 
 liquid material which could be introduced varied according to 
 the kind of animal experimented on; thus the rabbit was less 
 
1010 I'lIARVXGEAL AND CESOPHAGEAL NEOPLASMS. 
 
 tolerant tliaii the doo- ; the do<i would bear the introduction of a 
 quantity of water equal to one-fourth the weight of his body. 
 Also, the manner in which the material was introduced had an 
 inlluence on the amount which could be borne: thus, if slowly 
 introduced, a much greater amount was borne than if it were 
 injected rapidly. 
 
 Along with this worlc of as{)iration that of artificial respiration 
 should be done; and this may bo done synchronously through 
 traction on the limbs; or it may be done alternately with aspira- 
 tion done through the tracheal 0})cning. 
 
 In all these ca.ses of restoration from apparent deatli, in which 
 traciieotomy is done, it will not be necessary to retain the tube in 
 place for a long time; for as soon as restoration has been fully 
 accomplished, the canula can be removed, and the wound closed. 
 
 An important indication for tracheotomy is constriction of the 
 tracheal or laryngeal canal through some disease seated in the 
 walls of these passages; and such disease is oftenest tubercular or 
 syphilitic: more frequently, syphilitic. This has been studied by 
 Tre'lat, who, in 18G0, wrote on the subject from the observation 
 of two cases, and from the liistory of twenty-five others found in 
 surgical literature. 
 
 Trelat finds that the ravages of syphilis in the air-passages 
 diminish as one descends towards the lungs. The morbid 
 changes occur oftenest in the larynx; and the points usually 
 ulcerated are the aryteno-epiglottidean folds, and the base of the 
 epiglottis. In only five cases was the ulceration found in the 
 trachea. Stenosis from such lesion occurs only in the later 
 stages of the disease. The primary gummy infiltration continues 
 for a longer or shorter time; then ulceration succeeds; and finally, 
 this cicatrizes, and narrows the passage. Some four or five years 
 are required to reach this contractile period. As verifying this, 
 in seventeen cases tracheotomy was done only after five years 
 and a half had elapsed from the beginning of the sy})hilitic 
 disease. Of these seventeen cases four died. 
 
 Demar(|uay made a study of this subject, and found that 
 syphilitic ulceration in the adult often leads to stricture. Symp- 
 toms of such narrowing are impeded respiration without loss of 
 voice the breathing is labored, and, in in.spiration, the larynx is 
 drawn down towards the sternum. There is immobility of the 
 larynx and trachea during swallowing; and, finally, the trachea 
 and the tissues about it seem thickened. When such symptoms 
 ai)pear, Demarquay performs tracheotomy. 
 
tracheotomy; bronchotomy. 1011 
 
 In case the stricture lies deep, the tracheal opening should 
 be made just below it; thus, the stricture is accessible from 
 underneath, and in some cases, its dilatation has been accom- 
 plished. For the work of widening, special instruments in 
 graded dimensions are needed. One which Trelat used was a 
 canula consisting of four blades, so divided that the blades could 
 be separated or spread apart; and thus dilatation could be slowly 
 or rapidly done. Such dilatation, to be successful, must be 
 patiently continued many months. 
 
 It has fallen within the experience of the writer that there are 
 cases in wdiich the dilatation cannot be satisfactorily accomplished; 
 and in such the canula must be continuously carried. Tlie 
 patient finally tolerates the instrument, and becomes oblivious of 
 the annoyance which it gave in the commencement of its use. 
 When the canula must remain permanently in the trachea, it 
 should be provided with a fenestra, through which enough air 
 can pass to awaken the vocal chords to vibration; and, thus 
 provided, the patient can, at will, close the outlet of the canula 
 with his fingers, and force the expired air to pass through the 
 glottis, and do the service of phonation. A canula which must 
 remain long in place is better constructed of hard rubber than of 
 metal: since the latter corrodes, or is tarnished by the excreta 
 which constantly come in contact with it. 
 
 An occasional demand for the operation is an aneurism press- 
 ing on some portion of the air-canal, and which is so located 
 that the trachea can be opened below it. Such an aneurism 
 might arise from the primitive or secondary carotids, and 
 possibl}^ from a branch of the subclavian artery. This indica- 
 tion, according to the writer's experience, is rare. 
 
 A body entering the oesophagus, and too large to be swallowed, 
 has pressed on the trachea and nearly closed it. In such a case, 
 should the attempt to remove the body fail, and suffocation be 
 impending, or apparent death have supervened, then tracheotomy 
 should be speedily done; and the emergency having passed, steps 
 may be taken for removing the compressing object; and when 
 this has been accomplished, remove the canula and close the 
 wound. 
 
 A neoplasm may spring from the inner wall of the larynx or 
 trachea, and interfere with respiration; if in the trachea, such 
 growth is most easily removed through an opening made into 
 the trachea; and afterwards, a canula may be worn for a short 
 time, or the wound may be closed at once. Such opening should 
 
1012 I'lIARYXGEAL AND (ESOPHAGEAL NEOPLASMS. 
 
 be mtide at a j^oiiit which will render the growth most accessible. 
 Tlie adept in tracheoscopy, and who is expert in the manipula- 
 tion of instruments in the air-])assages, miglit possibly reach tlie 
 growth per iv'rts nrt?»ra^(?s, and extir})ate it; yet such visual and 
 manual art is too infrequent to render it probable that the work 
 will ever be withdrawn from the province of the general surgeon. 
 There is a winged insect whicli the writer once heard Milne- 
 Edwards describe, which bores through the base of the corolla to 
 the treasure to which the long tube denies access; in a similar 
 way, the surgeon niakes a short route to the growth by opening 
 the trachea. 
 
 A uecessity for tlie operation may occur from the })alsy of the 
 inferior laryngeal nerve, whereby the posterior arytenoid muscles 
 lose their function of maintaining patency of the glottis. Such 
 indication is rare, since it will rarely happen that the two are 
 palsied; unilateral palsy would cau.se but partial closure; never- 
 theless, Ziemssen has collected a few cases of the so-named recur- 
 rent palsy, and' in six cases tracheotomy was done to save life. 
 Mackenzie saw ca.ses of palsy of the outer muscle of the larynx 
 which caused stenosis of the glottis. The posterior arytenoid 
 musclemay be temporarily paralyzed b}'' hysteria; in such patient 
 to open the trachea would be an error; electrization should be 
 resorted to; or the cold douche, if continued long enough, will 
 conquer the rebellious muscles, Skey quaintly remarks. 
 
 Therecurrent nerve, on one side curving around tlie aorta, and 
 on the other, around the right subclavian artery, may be com- 
 pressed by aneurism at these sites; thus recurrent palsy arising, 
 some relief of the consequent dyspnoea has been obtained by 
 tracheotomy. 
 
 In tetanus, the dyspnoea which arises from spasmodic contrac- 
 tion of the laryngeal muscles, may have palliation through 
 tracheotomy. In such a case the author performed it, and 
 though the patient's life w^as not saved, yet it was prolonged, and 
 his condition made more tolerable. 
 
 Tracheotomy is sometimes done as a prophylactic preliminary 
 against the entrance of blood into the windpipje, during operations 
 on the tongue, floor of the mouth, maxilhe and pharynx. For 
 this purpose it was done by Xu.ssbaum prior to 1870; but in 1S70, 
 an improved method of doing the work was [)roposed by Below 
 and Trendelenberg. Below's plan was to open the trachea, and 
 pass in, and inflate an elastic balloon above the wound; thus 
 done, blood descending from the parts above could not pass 
 
tracheotomy; broxchotomy. 1018 
 
 beyond. Trendelenberg made a study of such tamponing, and 
 found that Below's plan was imperfect; and besides, the tampon 
 caused constant irritation and cough. To shun tliese inconven- 
 iences Trendelenberg invented a tampon that was similar to a 
 small India-rubber balloon which surrounded the vertical stem 
 of the canula; and when the latter was inserted, the balloon being- 
 uplifted, the trachea was completeh' occluded, so that nothing 
 could descend below the canula. 
 
 The writer, in cases in which only temjDorary tamponing is 
 needed, has accomplished this work in a somewhat different 
 manner, as follows: an ordinar}^ canula is inserted in the 
 tracheal opening, and then the phar\'nx Is closely plugged with 
 a sponge; thus prepared, any cutting procedure can be done on 
 the parts above, without risk of the blood entering either the 
 oesophagus or the air-canal. As soon as the bleeding has been 
 controlled, the sponge may be removed; and the canula can be 
 left in the trachea for whatever time the case recjuires. 
 
 But if the case be one in which the healing will be tedious, 
 and the excreted detritus may be considerable, to guard aigainst 
 the descent of the latter to the lungs, and the resultant ichorous 
 pneumonia, then the canula with tampon should be used. Such 
 canulated tampon maybe continued in place for eight or ten 
 days; and even if it be continued for a longer period, no ill 
 results from it. An objection that can be urged against this pro- 
 cedure is that in some cases the tampon causes an irritating cough. 
 And the same, however, might be urged against the simple 
 canula; in his experience in its use, the writer has met with 
 patients in whom the inserted canula caused an irritating cough; 
 and it could only be borne by giving some medicine to lessen 
 this irritability; and for this purpose, the camphorated tincture 
 of opium may be given to a child, or morphia to an adult; and 
 instead of these remedies, the bromide of potassium maybe given 
 in doses of three grains to the child, and a larger amount to an 
 adult; and such remedy need only be continued until tolerance 
 of the canula has been acquired. 
 
 Of the various emergencies or morbid condhions which 
 demanded tracheotomy, the one which stands preeminently in 
 the foreground, is stenosis of the air-canal caused by croupal or 
 diphtheritic neoplasm. Whether this occluding neoplasm is of 
 single or dual origin is more a matter of controversy among 
 pathologists than among practitioners of medicine who Imve 
 frecj^uent opportunities to observe the disease. American and 
 
1014 l'IIARY.\(iKAI. AND (KSOl'II A< iKA Ti NKOl 1. ASNFS. 
 
 English pliysiciiuis agree in the nuiiii that crouf) ;iin] (liphtlioria 
 are difi'ereiit and distinguisiiable diseases; the Freiicli, liei-e, as on 
 another great pathological question, are divided into unicists and 
 dualists; the Germans, as a rule, teacli that croup and diphtheria 
 are different forms of the same disease. The writer's observations 
 confirm him in accepting the doctrine of duality, viz., that there 
 are two diseases, in which the inflammatory process is followed 
 by the appearance of a membranous structure on the mucous 
 surface of the air-passages. This pseudo-mombranous develop- 
 ment is much more limited in crou]) than in diplithei'ia; in the 
 former, the false membrane a[)pcars chiefly in the larynx and 
 trachea; but the diphtheritic neoplasm, besides appearing in 
 these parts, is present on the mucous membrane of the entire 
 pharynx and nasal passages. The diphtheritic growth has been 
 seen, as a rare occurrence, on the mucous lining of outlets of the 
 genito-urinary organs, and the rectum. 
 
 When compared in respect to contagiousness, croup is not 
 communicable, while diphtheria is eminently so. Croup is the 
 disease of infants, and is only exceptionally seen in adults; 
 diphtheria occurs in both infants and adults. Croupal disease is 
 limited and suporticiul in site; diphtheria, besides its tendency 
 to superficial invasion and generalization, penetrates inwards; 
 and the se})tic principle existing in the affected surface is conveyed 
 by the lymphatics to the neighboring glands, and awakens in the 
 latter a rapid cell-growth. This glandular enlargement occurs 
 first in the floor of the mouth, and at the angle of the lower jaw; 
 thence it extends downwards on the side of the neck, in the 
 chain of glands, which are adjacent to the large cervical vessels. 
 This glandular enlargement is remarkable for its rapid develop- 
 ment, and the great volume to which it can attain in a brief 
 time. In croup, such glandular implication does not occur. The 
 di^jhtheritic disease may aflect the sinuses of the dura mater and 
 cause coagulation of blood; and thus the encephalic circulation 
 may be fatally interrupted, as was the case in a patient of which 
 the writer witnessed the necropsy made by Bouchut. Such 
 thrombus or embolism in the vessels of the cord, may account 
 for the palsy that sometimes follows diphtheria. 
 
 The results of tracheotomy differ greatly in the two cases: an 
 operation in the patient of diffused false membrane rarely saves 
 life; but in the patient in whom the disease is confined to the 
 larynx and trachea, life is often saved. From these clinical facts 
 the inference is deducible that the distinction of these morbid 
 
tracheotomy; bronchotomy. 1015 
 
 processes into two different classes is not only permissible, but it 
 is necessary. 
 
 And filially, on the scene of this investigation, another witness 
 appears: the bacteriologist finds a microphyte which is present in 
 diphtheria, and is absent in croup; and to this microphyte is 
 assigned the causal agency of the diphtheritic process. This 
 microphyte may be the inceptive factor in causation; but the sub- 
 sequent dissemination of the disease is partly due to the septic 
 matter that arises from the death and putrefaction of the mem- 
 branous pseudoplasm. 
 
 Returning from pathology to the domain of. internal med- 
 icine, what chiefly concerns the tracheotomist in croup and 
 diphtheria is the narrowing of the air-canal by a pseudo- 
 membrane, and which, unrelieved, progresses until the laryngo- 
 tracheal canal is so small that fatal asphyxia ensues. In eacli 
 disease the operation relieves temporarily or permanently the 
 oppressed respiration, and furnishes air by wdiich the circulating 
 blood is unburdened of the carbonic acid which unfits it for the 
 maintenance of life. 
 
 For a time, the anatomists led by Allan Burns tauglit that 
 serious ill would result from the vertical section of the cervical 
 fasciae which overlie the trachea, and were supposed to relieve 
 the tube of some of the pressure of the atmosphere; but the 
 operation repeated innumerable times has long since demonstrated 
 the groundlessness of these apprehensions; exposure of the canal 
 in the otherwise healthy subject is not followed by collapse of its 
 walls; and after recovery from such exposure or section, the 
 trachea loses none of its functions. 
 
 The time when the operation is done in these diseases has 
 great bearing on the successful or unsuccessful result; an unsuc- 
 cessful result too often depends on delay in the work. When the 
 tissues are once laden with non-aerated blood, the free admission 
 of air into the lungs, though it mitigates the urgent symptoms, 
 yet often comes too late to the rescue. Hence the watchword 
 should be to meet the enemy early, before he has mastery of the 
 citadel. The advance of the disease is insidious and by no means 
 uniform ; the neoplastic structure, in some cases, developing 
 slowly, in others, rapidly. An enumeration here follows of the 
 symptoms which denote that the subject of croup or diphtheria 
 has reached the stage in which delay is perilous: The inspiratory 
 act is made with effort, and it is accompanied by a hissing sound 
 from the air being sucked through the narrowed canal; and, 
 
1016 PHARYNGEAL AND CESOPIIAGEAL NEOPLASM.^. 
 
 at the same time, from the vibration of the vocal chords, a hoarse 
 or croaking sound is produced. Tliis sound may besimuhited by 
 the vocal sound which is made when air is drawn into the lungs : 
 such phonatioD as the ventriloquist sometimes uses in his art. 
 From an insufficient quantity of air reaching the lungs, the blood 
 is iniperfectly oxygenated; and, that venous blood is circulating 
 in the arteries is apparent in the cyanosed or purpli^^h hue of 
 the lips and cheeks. And as a result of this, the })atient is in a 
 state of partial anaesthesia, so that an incision awakens but slight 
 pain. This anaesthetic condition has been especially noticed by 
 Bouchut. Though such insensibility to a wound exists, yet the 
 patient is in a state of great restlessness, throwing his limbs 
 hither and thither; and, in his disorderly movements, the patient 
 seems seeking a position in which he can breathe more easily. 
 In his efforts to get more air, he tries to catcli or seize it with his 
 mouth. And this labored breathing is revealed by unusual 
 movement of the nostrils, mouth, neck, chest and prsecordial 
 region. The nostrils contract, the corners of tlie mouth are 
 drawn laterally, and the lips, especiall}^ the lower one, are 
 everted. The front })art of the neck, and particularly the jugular 
 fossa, are drawn inwards and downwards, under the border of the 
 sternal manubrium, during the inspiratory act; and these parts, 
 in expiration, recede again to their normal position. The action 
 of the diaphragm is peculiar: it contracts in inspiration as usual, 
 but as the lungs do not receive enough air, through stenosis of 
 the afferent canal, to fill them, a vacuum would arise if the prse- 
 cordial wall and the sides of the thorax did not sink inwards. 
 In fact, the in-sinking of the jugular fossa and the lower part of 
 the thorax and prnecordia is due to the weight of the external air 
 resisting the formation of a vacuum, which, otherwise, would arise 
 within the thorax. Such change in the form of the chest occurs 
 in a far less degree in the adult, whose costal structures, both 
 osseous and cartilaginous, are less yielding. 
 
 As the disease advances, the dysi)noea, which, at first, was so 
 prominent a symptom, may lessen and awaken the illusive hope 
 that the disease is stayed in its })rogress, and that the patient is 
 better: and thus the medical attendant may be lulled into inac- 
 tion and allow the precious moment to escape when an operation 
 might have saved life. As signs that the patient is not better 
 are the rapid breathing, and the livid lip and cheek, showing 
 that venous blood is replacing arterial; in such cyanosed patient 
 the insidious truce is an additional monitor to prompt surgical 
 
tracheotomy; bronchotomy. 1017 
 
 action ; as Hippocrates puts it, medicine failing to cure, the knife 
 may. 
 
 Among the advocates of tracheotomy there are differences of 
 opinion in reference to the site to be cliosen for the work, the man- 
 ner in wliich it is to be done, the risks whicli attend the operation, 
 the use or non-use of the canula, the form of tlie latter, and 
 numerous other points of greater or minor importance; hence 
 with, perhaps, some risk of repetition and of tediously elaborating 
 this chapter, the writer will proceed to the citation of a number 
 of authorities who have written on tracheotome^ and expressed 
 their opinions on these points. 
 
 Petel, in 1841, offered a report of one hundred and twelve 
 tracheotomies, among which were twenty-eight cures. He 
 advises where the danger of suffocation is imminent, to make an 
 immediate incision into the windpipe, regardless of haemorrhage, 
 since bleeding soon ceases after the opening has been made. In 
 one hundred and nine cases operated on by Trousseau, in'no one 
 was he compelled to resort to ligature or torsion. After the open- 
 ing w'as made, Petel used a piece of sponge, a feather, or injec- 
 tions of water to remove the excretions found in the trachea. 
 
 As after-treatment of the patients on whom he had operated. 
 Trousseau, in 1842, recommended, as an application to the interior 
 of the trachea, a solution of nitrate of silver, in the strength of one 
 grain to the ounce of water; of this he dropped into the canal 
 from fifteen to twenty drops, four times on the first day, three 
 times the second day, and twice the third day. Where the cough 
 is dry and the expectoration slight, Trousseau counsels to drop 
 into the trachea, every hour or two, from ten to fifteen drops of 
 water. A dry adhesive excretion resembling mucilage of gum 
 Arabic, is an ill omen. Of one hundred and twelve operations, 
 twenty-seven recovered. 
 
 Though Trousseau had no trouble from hsemorrhage in his 
 operations, yet others have had ; and this sometimes depends on 
 vascular anomaly, especially that in which there is a fifth thyroid 
 artery. Gruber having frequently met this artery, published, in 
 1844, a carefully written dissertation on the subject. He found 
 that it occurs one time in ten cases. The vessel arises oftenest 
 from the innominate artery; though sometimes, it arises from the 
 arch of the aorta between the innominate and the left carotid ; and 
 exceptionally, it arises from the carotid or the inferior thyroid. 
 When found, it is oftener on the right side. The middle lobe of 
 the thyroid gland was found in one-half of the cases. 
 65 
 
1018 PHARYNGEAL AND CESOPHAGEAL NEOPLASMS. 
 
 Gruber advises when the opening is made through the crico- 
 thyroidean membrane to make the cut a transverse one, and 
 through the upper third of the space; that is, close to tlie lower 
 margin of the thyroid cartilage. 
 
 In 1850, Sestier wrote exhaustively on tracheotomy; and 
 especially in its use as relief in oedema glottidis. As ill events, 
 which may complicate the ojx'ration, are the entrance of air into 
 the veins, and tlie entrance of blood into the air-passages; also, 
 the trachea may be imperfectly opened, and it may afterwards be 
 occluded through swelling of the submucous tissue. As more 
 remote complications are suffocation from spasm of the bronchial 
 muscles, closure of the bronchi with mucus, bronchitis, delirium, 
 convulsions, ill results from the premature removal of the canula, 
 the entrance of fluids into the wound from careless drinking; 
 finally, a fistula may remain after the operation. 
 
 Impending suffocation from oedema is an indication for its per- 
 formance. And if the patient is dying, or has ceased to breatiie, 
 Sestier would do it; and he would u.se for opening the windpipe, 
 the first instrument at hand; even a ])ocket-knife would do, and 
 crooked pins might do the service of retractors, and a quill act as 
 a temporary canula; and in such emergency, he would operate 
 high up, viz., througli the crico-thyroidean space, the cricoid carti- 
 lage, or through the cricoid cartilage and theupper tracheal rings. 
 When a choice of site is permitted, Sestier would select cricotomy 
 or crico-tracheotomy, since these sites allow the best inspection of 
 the air-passage: and should the cricoid cartilage be ossified, then 
 the section should be made through the upper tracheal rings. 
 The Pomum Adami serves as a guide for finding the cricoid. 
 
 For the admission of air, a double canula is a better means 
 than the various dilators, which have been employed for the 
 purpose. Remove the canula as early as the condition of the 
 patient will permit: and as the tracheotomies described by Ses- 
 tier were done for the relief of oedema of the glottis, it was gen- 
 erally possible to remove the canula, at an early period. 
 
 In 1841, Maslieurat-Lagdraard wrote on the substitutes 
 which may be used in place of the canula; being led to a study 
 of the matter by an operation, in which having no canula at 
 hand, he retained the opening patent by means of pins which 
 were bent into the form of fish-hooks. These bent pins after 
 being inserted into the lips of the wound, and through the subja- 
 cent cricoid cartilage, were held in place by threads attached to 
 them and tied behind the neck. Instructed by the results 
 
tracheotomy; broxchotomy. 1019 
 
 obtained by this plan, he afterwards had a dilator constructed, 
 which, similar to eyelid retractors, held the lips of the wound 
 asunder. The special advantage claimed for this plan was that 
 the child, after the o|)eration, could lie on its side and expecto- 
 rate the matter from the windpipe, and thus dispense with the 
 frequent cleansing which must be done when the canula is 
 employed. This method is of special service when the tracheot- 
 om}" is done for the removal of a body that has entered the air- 
 passage, and which not being found, the wound must be main- 
 tained opened for the subsequent expulsion of the body. 
 
 Des Chenais suggests as an improvement on Maslieurat- 
 Lagemard's pins or wire spring, the use of hairpins, or iron wire 
 bent into proper form, and retained in place by India rubber 
 bands. Such a device as is liere proposed was constructed and 
 used by Dr. Asa Clark, of Stockton, California; having no canula 
 in a case of emergency in which he opened the trachea, he so 
 bent a hair-pin that when introduced, it retained the passage 
 open. And on an occasion in which the author found himself in 
 a similar strait, he inserted into the wound a pair of dressing- 
 forceps, of which the handles were separated and kept apart by 
 means of a cork, of which the opposite sides were so furrowed that 
 the cork remained in place. 
 
 In 1852, Thompson announced a mode of tracheotoni}' simi- 
 lar to that done by the ancients; to wit, he made a transverse 
 incision between the first and second tracheal rings. He oper- 
 ated with a species of bronchotome, of which the blades, after the 
 opening was made, could be separated, and a canula introduced 
 between them. 
 
 Near the same time, Chassaignac announced, as an aid in 
 operating, a peculiar tenaculum that was grooved on the posterior 
 side; when the point of this was fixed in the trachea, the scalpel 
 was carried along this groove, and an opening made, at once, into 
 the trachea; and as soon as this was done, a dilator was inserted 
 and the wound so widened that a canula could be introduced. 
 By this method Chassaignac claims that the opening can be 
 made, and the canula introduced so quickly, that no blood enters 
 the air-passage. 
 
 Guersant, in 1851, reported one hundred and seventy-one 
 tracheotomies, with thirty-six recoveries ; and, in the work, he 
 says that the special dangers to be avoided are the vessels which 
 lie on each side of the trachea, and, in the lower part of the field, 
 the innominate artery; and, as a guard while incising, the finger 
 
1020 I'HAKYXGEAL AND (ESOPHAGEAL NEOl'LA.SMS. 
 
 should be placed over tlie latter vessel. Instead of using a tenac- 
 ulum, Guersant used his finger to fix the trachea, and directed 
 the point of the bistoury with the nail. He extracted the false 
 membranes with a long pair of forceps. 
 
 Pitha, writing in 1857, does not find the operation an easy 
 one: the position of the trachea may be deep and difficult 
 of approacli : its calibre is sometimes small ; it is in constant 
 motion; and besides these obstacles, the anxiety and unrest of 
 the patient, and the haste which the surgeon must make to out- 
 speed death, are conditions of gravest moment which surround 
 this operation. 
 
 Pitha's three sites for the opening are, first, between the thyroid 
 and cricoid cartilages, second, above, and third below the thy- 
 roid isthmus. The first site is ill suited to cases in which the 
 canula must lie long in the canal, since it can cause necrosis of 
 the adjacent cartilages. To make this opening in the adult, 
 measure one inch downwards from the hyoid bone, and from the 
 inferior end, cut one inch downwards in the median line. Having 
 found the crico-thyroidean membrane, cut transversely through 
 the upper third of the space: thus incising, one .shuns the 
 crico-thyroid artery, w^hich lies near the inferior edge of this 
 space. Be sure that the cut has reached through the mucous 
 membrane. The bleeding is not great; and in place of aspirating 
 the blood which enters the trachea, insert the canula as soon as 
 possible. 
 
 Should there be a largely developed middle lobe of the 
 thyroid gland, Pitha operates below^ it, unless it be possible to 
 uplift the part and operate behind it: and for such work, a cut 
 should be made an inch and a half long, commencing at the 
 lower edge of the cricoid cartilage. In the adult, an opening a 
 half inch in diameter, can be made through the crico-thyroidean 
 membrane. 
 
 Pitha praises the bronchotome of Bromfield, especially in the 
 inferior operation ; and here the tracheal rings should be well 
 exposed to sight, before the instrument is used. 
 
 Pitha objects to the usual canula, finding it too short; also, 
 that its ill curved form causes too much pressure on the posterior 
 wall of the trachea; and, as an improvement, he devised one with 
 a catheter-like beak, and which had two oval fenestrae. Other 
 surgeons who used this canula were not pleased with it, finding 
 that, by its length, it irritated the trachea; and also, that the lat- 
 eral fenestra? easilv became obstructed with nmcus. 
 
TRACHEOTOMY; BRONCHOTOMY. 1021 
 
 About this time, the observation was made that pneumonia 
 often followed tracheotomy. Pitha claimed that the pneumonia 
 had already commenced when the operation was done ; but Schuh 
 finds the causal agency in the operation. He contends that the 
 normal air-passage is shortened and made 'rregular by the canula; 
 and also, that the changing calibre and frequent movements of 
 the canula, and the occasional closure of it in the work of remov- 
 ing the mucus which accumulates in the canula and trachea, have 
 an ill effect on the tender tissue of the lungs. 
 
 The large calibre of the canula is sometimes found inconven- 
 ient by the adult patient; and he breathes more easily when the 
 outer mouth is lessened by a slip of adhesive plaster. 
 
 In 1857, Fuller introduced a modification of the canula, which 
 consisted of an outer portion that was composed of two blades, 
 speculum-like, which could be introduced through a small fissure 
 and dilated; and between the expanded blades the inner tube is 
 then inserted. 
 
 In 1858, Neudorfer constructed a canula, which was double, 
 and so arranged that- the outer tube could be removed. The 
 canula had a small mirror attached to the outer part, so that a 
 view could be had of the vocal chords, and of the different jjor- 
 tions of the trachea. 
 
 In 1858, Hard}^ wrote a history of tracheotomy from the time 
 of Asclepiades (who is reputed to have done the first operation at 
 Rome), to Bretonneau and Trousseau, who gave the operation a 
 permanent place in surgical work. He reviews the two methods 
 of opening the trachea, by one sudden cut, or by slow dissection; 
 the latter plan, pursued by Trousseau, Hardy prefers, since 
 bleeding is thus more easily avoided. An objection to incision 
 suddenly done is that the cutaneous cut may not correspond to 
 the deeper one. Hardy proposed to use the cricoid cartilage as 
 the guiding landmark in the work of tracheotomy. 
 
 In the same year, Passavant advised to fix the trachea with a 
 tenaculum, and, after the opening is made, to retain the tenaculum 
 for a few minutes, transfixing the tracheal wall, as aid in insert- 
 ing the canula. 
 
 In the hospital for children in Paris, from 1850 to 1857, 
 Guersant performed three hundred and ninety tracheotomies ; of 
 these eighty-six recovered. In most cases, the operation was 
 done when the child was near death. Guersant would not 
 operate in diphtlieria; the condition, according to him, for the 
 operation is a gradually increasing asphyxia; and as long as this 
 is only intermittent, he would delay. 
 
1022 PHARYXdEAL AND ^ESOPHAGEAL NEOPLASMS. 
 
 In 1859, Pduli. of Laudau, wrote a dissertation on tracheotomy, 
 in which he formuhited the following doctrines: — 
 
 Tracheotomy, though sometimes necessary in croup, can 
 never become the principal means of curing that disease. When 
 done by an experienced surgeon, the operation is nearly free 
 from danger; when danger attends it, it is usually from the 
 entrance of blood into the trachea. Tracheotomy should always 
 be done before the disease has gained mastery over the patient: 
 that is, before the patient has lost his strength, and the pulse has 
 become small and r/eak; and prior to the appearance of delirium. 
 The opening should be made just below the cricoid cartilage. 
 
 In 185S, Bouchut advised as a substitute for tracheotomy, the 
 passage of a tube into the trachea through the mouth : a method 
 that has recently been revived. This procedure was examined 
 by Trousseau, who reported adversely to it. In experiments 
 made on dogs, Trousseau found that the inserted tube caused 
 ulceration of the glottis; and would probably end in destruction 
 of these parts. A canula which has been inserted through a 
 tracheal incision, can be tolerated for a much longer time. 
 
 In 1859, Fock reported twenty-four cases of tracheotomy, of 
 which twelve were successful. The children varied in age from 
 fifteen months to nine years. The period of recovery varied 
 from nineteen to one hundred and twenty-seven days, and the 
 canula was carried from ten to twelve days, in most cases; yet in 
 one it remained in the trachea twenty -six days. Success was 
 more often in those cases in which, from the commencement of 
 the disease, there was constantly augmenting dyspnoea. The 
 emaciated child with a long thin neck is a better subject for 
 recovery than one which has a short, thick and adipose neck 
 The existence of the obstructing membrane in both the larynx 
 and the trachea does not make the case a worse one for recovery. 
 The work is far from being completed when the operation is done; 
 the child must have a skillful nurse, who can cleanse the canula, 
 from time to time; and the surgeon should see the case twice 
 a day. 
 
 The advice in regard to skilled attention receives full sanc- 
 tion from the writer of this work ; more than once he has seen 
 an excellent operation frustrated through the ignorance and 
 incompetence of those to whom the subsequent care of the 
 patient was intrusted. 
 
 In 1860, Barthez wrote upon croup, and the proper stage of 
 the disease for the performance of tracheotom}'. He makes three 
 
tracheotomy; bronchotomy. 1023 
 
 stages of the disease; in the first there is no dyspnoea; in the 
 second stage it appears intermediately; and in tlie third one the 
 dyspnoea is constant, and suffocation seems impending; and 
 finally death comes from asphyxia. He finds but little difference 
 between croup and diphtheria ; there is a toxic element, also one 
 of asphyxia, in the disease, and these elements are difficult to 
 distinguish. Barthez finds that in the first and second stages of 
 croup, relief may be obtained from internal remedies, but in the 
 third stage the only relief is from tracheotomy. When the 
 disease is of the pronounced diphtheritic form, there is no relief 
 from either medicine or an operation; of seventeen operations 
 done in such patients, seventeen died. The appropriate time for 
 the operation is in the second stage; done then, the patient often 
 rallies. If the tracheotomy be deferred until the third stage, the 
 child makes no effort to expel the false membrane, or the fluids 
 which flow down into the bronchial tubes. But if the opening- 
 be made earlier, then the admission of increased quantities of air 
 gives strength ; the child coughs vigorously, and expels the false 
 membranes. 
 
 In 1862 an elaborate report was made by Lissard of tracheot- 
 omies done by Roser, of Marburg. Roser does the work by slow 
 dissection, and then he opens just below the cricoid cartilage, 
 dividing three or four tracheal rings. To separate and retain 
 asunder the lips of the wound, he employed hooked retractors; 
 and this device is praised, as it enables the surgeon to operate 
 almost without an assistant. An elastic catheter with large 
 fenestrEe was inserted into the opened trachea, and by means of 
 it, the mucus and false membrane were aspirated. And if the 
 patient be asphyxiated, this tube may be used for blowing air 
 into tlie lungs. 
 
 Instead of the ordinary double canula, Roser used a triple 
 one, of which each tube contained one that was smaller than the 
 one containing it. The external plate was immovable, and the 
 entering end was conical. After the fourth or fifth day, when the 
 false membrane had been entirely discharged, then the triple 
 tube was removed and replaced by one that avoided the erosion 
 caused by the ordinary tube. 
 
 The position of the patient for the operation according to 
 Roser, should be the recumbent one, with a support under the 
 neck, so as to uplift the part to be operated on. Sponges large 
 and small should be at hand ; and it is better to clean these with 
 a towel than with water. A cut is to be made reaching almost 
 
1024 rilAKYNGEAI. AND (ESOPHAGEAL NEOPLASMS. 
 
 from the larynx to the sternum ; the structures are to be uplifted 
 with toothed forceps; thus small ])ortions of tissue can be uplifted 
 and divided without severing the vessels. Anomalous vessels 
 should be remembered and sought for with the finger. The work 
 is most safely done by circumscribing the vessel with a ligature. 
 
 If the thyroid gland be large, it can be pulled aside, some- 
 times; in others, it can be circumscribed with ligature at two 
 points, and divided between the ligatures. 
 
 To open below the gland is difficult in children having short, 
 thick necks; for in such, emphysema often arises during the 
 work; and a still greater peril is that from wounding the fascia; 
 since from subsequent suppuration, pus may pass behind the 
 sternum. 
 
 Before opening the trachea, the bottom of the wound should 
 be well explored, and the tracheal rings brought fully into view; 
 and when this is done, the trachea should be seized with toothed 
 forceps, and being steadily held, an opening should be made 
 leisurely into the canaL After the cut is made, before inserting 
 the canula, Roser passes a ligature through the lips of the wound 
 on each si<lo, and ties these threads around the neck. With 
 these ligatures the wound is under control, and can be kept 
 patent during the introduction of the canula. After cleansing 
 the wound insert the canula. 
 
 After the operation is completed, the child should be placed 
 in a room of which the temperature is sixty-eight degrees 
 Fahrenheit. In many of the cases oi)erated on by Koser, this 
 precaution was neglected; the child was transported to its home 
 through inclement winter, and no ill resulted. After the oper- 
 ation, the child received medical treatment; it was given calo- 
 mel and bicarbonate of soda. 
 
 During the after-treatment, the child sometimes has trouble 
 in swallowing; a convulsive movement ensues that causes 
 strangling. The canula must be carefully watched, and cleansed 
 from time to time, with a feather. 
 
 An erosion or ulceration of the anterior wall of the trachea 
 may arise, and death has arisen from this cause. If such event 
 occurs, try a canula of different form. During the subsequent 
 treatment for the removal of the excreta from the trachea, Roser 
 sometimes used a catheter. Should the wound become covered 
 with diphtheritic-membrane, touch the affected part with nitrate 
 of silver, or with sugar of lead. 
 
 Of forty-two cases operated on by Roser, nineteen recovered : 
 proof of the excellence of his method. 
 
tracheotomy; bronchotomy. 1025 
 
 In consequence of the perils attending tlie ordinary method 
 of tracheotomy, in 1861, Maisonneuve advised a new procedure, 
 viz., incision from within outwards. The point selected for the 
 operation was the crico-thyroidean membrane, and thence down- 
 wards towards the sternum. He invented a tracheotome for the 
 work. The instrument is first forced through the membrane, 
 and is then made to cut the cricoid cartilage, and the subjacent 
 tracheal rings. The crico-thyroidean membrane is chosen as the 
 initial point, since it is easily found. After the opening cut is 
 made, the wound is enlarged by means of a dilating instrument. 
 During the cutting, the parts adjacent to the instrument are to 
 be pressed against the latter, so that no blood can enter the 
 wound. 
 
 From observation of the ulcerative action which arises from 
 the pressure of the canula, in 1862, Bouvier was led to make an 
 exhaustive study of this instrument. He refers to Roger, who 
 had noticed such trouble, and proposed changes in the form of 
 the canula. In the history of the canula, Bouvier finds that 
 Fabricius d'Aquapendente is accredited with having first used this 
 instrument, of which there have been two forms: a lateral one, 
 and a central or tubular one. For about two hundred years, the 
 lateral one was the only kind used; and this was inserted into 
 and occu}ned one side of the trachea, and it was only in con- 
 tact with one side of the air-passage. It was straight or curved 
 in form, and had the disadvantage of only having the diameter 
 of the glottis. 
 
 In 1812, Maunoir constructed a canula of lead, which more 
 nearly corresponded with the diameter of the trachea; and this 
 was still further improved by Bretonneau, who constructed a 
 canula of two tubes: one resting inside of the other; and this 
 filled the trachea. 
 
 Bretonneau had a suggestion for his invention in an instru- 
 ment devised by Gendrin, in 1835. This consisted of two plates 
 attached to a cylinder, and so arranged that the blades could be 
 made to approach or separate, according as change of adjustment 
 was required. This instrument, though popular for a time, 
 finally was superseded by a dilating, screw-like apparatus. 
 Though the use of an internal tube, which can be withdrawn at 
 pleasure, dates back to an earlier period, when such a device was 
 used by Martyn, yet to Bretonneau is chiefly due the instrument 
 in its present state of perfection. 
 
 The curved double canula has the disadvantage that it 
 
lOi^G i'iiAi;YN(ii:Ai, AM) (i;soi*iiA(ii;AL Ni<:orLASMS. 
 
 presses aguiiist and produces erosion of the wall of the traehea; 
 for the trachea is straight, while the caiiula is curved. This 
 erosive action is increased when the canula moves up and down, 
 or when the patient bends his neck. Mathieu advises to give 
 the canula a curve equal to ninetv degrees; yet Bouvier thinks 
 this would be too great in the child. The external plate, which 
 is fastened to the canula, should be fixed to the latter at an angle 
 of thirty degrees, so as to lessen pressure. And to lessen or 
 avoid pressure, Roger had an instrument so made that the plate 
 is movable, and permits the attached canula to move in all 
 directions; and such a canula follows or yields to the motions of 
 the neck. Other modifications of the canula have been devised, 
 with the design of avoiding pressure and erosion; these have 
 been but partially successful ; and hence the prevalent rule, to 
 remove the canula as early as possible. 
 
 Burow, of Konigsberg, in 1862, reported eleven tracheotomies, 
 which were done as follows: a cut was first made through the 
 skin, and then the dissection was continued with toothed forceps, 
 with which the tissues were pulled asunder; thus vessels were 
 shunned, and if encountered, where they could not be avoided, 
 they were tied. When the muscles have thus been separated, 
 the lips of the wound are pulled apart by means of eyelid 
 retractors; and when the white trachea is found, open it with a 
 falciform tenotome. In some cases Burow used a canula; in 
 others he used a specially-contrived dilator. 
 
 In 18G3, Llicke observed that the innominate artery often 
 rises so high that it is imperiled in tracheotomy. This knowl- 
 edge was verified to his dismay in one case in \yhich finding the 
 tracheal opening too small, he continued the incision through 
 another tracheal ring, when a vessel was opened which flooded 
 the parts with blood, and caused death. At the necropsy it was 
 found that the cut had divided the second to the seventh tracheal 
 rings, and had opened the innominate artery. He infers that 
 the operation is more perilous when the incision is low in the 
 neck. 
 
 About the same time Hueter examined the thyroid gland in 
 young infants, and found that tiie isthmus is so adiierent to the 
 trachea, that if one pulls the gland downward, he cannot expose 
 more than two tracheal rings; hence he counsels crico- 
 tracheotomy. 
 
 Millet, of Brussels, finds the following risks in tracheotomy: 
 bleeding from the wounded veins and arteries; blood entering the 
 
tracheotomy; bronchotomy. 1027 
 
 air-passages from detachment of the false membrane (and such 
 blood should be sucked out with a suction syringe); wounding 
 of the thyroid gland and the oesophagus; and, as later compli- 
 cations, pneumonia, excessive secretion from the bronchi and 
 entero-colitis. 
 
 In 1864 a modification of the tracheal incision was recom- 
 mended by Porter, of Dublin; instead of the vertical cut, he 
 practiced cutting out a circular portion of the wall. The advan- 
 tages claimed for this plan were that the canula could be inserted 
 more easily, and the false membranes, blood, and excreta could 
 be more readily extracted. Also, the canula completely fills the 
 round orifice, and there remain no angular openings above and 
 below through which blood can enter the trachea, as is the case 
 when the straight incision is made. Such oval opening can be 
 used in cases in which the canula cannot be borne; also, when 
 the tracheotomy is done for the removal of a foreign body from 
 the air-passages. Porter does not fear that such loss of tissue 
 will lead to narrowing of the trachea. He makes the incision by 
 seizing the edge of the vertical cut with a tenaculum, when he 
 cuts out a semi-circular section. 
 
 The writer would offer as comment on this plan of excision, 
 that it has not been sufficiently verified by experience to justify 
 its adoption; the slight power of cartilage to reproduce itself 
 where there has been structural loss, is a serious objection to it. 
 The contractile scar tissue would end in lessening the calibre 
 of the trachea in the adolescent subject; and, hence, narrowing 
 must finally appear, that would trammel the freedom of respira- 
 tion, and lead to intermittent or permanent dyspncea. 
 
 In 1866, Simon reported twelve cases of tracheotomy, with 
 five recoveries. He made the operation by an incision through 
 the cricoid cartilage, and one or two tracheal rings; by this high 
 opening, the isthmus of the thyroid gland, which lies high in 
 young children, was shunned ; likewise, the thyroid veins and the 
 innominate artery were avoided. An incision below the thyroid 
 isthmus imperils these vessels. Aftef the opening was made, 
 Simon introduced a catheter, and sucked with his mouth the 
 blood and mucus from the passage; and he counsels to do this 
 with the mouth, rather than with a syringe. 
 
 The writer would pronounce this oral aspiration an unjustifiable 
 personal risk to the surgeon; and which would hardly be consistent 
 with the Homeric estimate of him, viz., that he is worth a thou- 
 sand men. Diphtheria has been contracted by medical men in 
 
1028 PHAKYls'GEAL AND CESOPHAGEAL NEOPLASMS. 
 
 this waj; and in several cases it ended fatally. The warrior 
 imperils or gives one life for the multitude; but the physician 
 who would aspirate the toxic excreta does much more, since he 
 risks his life for the possibility of saving that of an individual. 
 
 Dusch, in 1867^ made a study of the em])hysematous infiUra- 
 tion of air that sometimes occurs during the operation of trache- 
 otomy; he attributes it to opening the deeper fascia near the 
 sternum, and as a result, tlie air is sucked underneath this 
 during inspiration, and thence diffused into the tissues. As soon 
 as the trachea is opened so that air can freely enter, the infiltra- 
 tion ceases, and the air which is so diffused soon vanishes. 
 
 The writer's observations in regard to the appearance of air in 
 the tissues have led him to an opinion differing somewliat from 
 that of Dusch: instead of arising from the outside air during 
 inspiration, he has seen the emphysema arise from air within the 
 trachea, viz., that which was escaping from tiie lungs during 
 expiration. During the operation, the trachea, l)esides being 
 occluded with false membrane, lias its caHbre lessened by })ressure 
 or by displacement; and in this condition the author has observed 
 that a prick made with the tenaculum or scalpel was instantly 
 followed by an escape of air, which, being caught in the wounded 
 tissue, at once appears as an emphysematous diffusion of air. 
 He has also seen such infiltration in cases before the operation 
 had commenced; and then the air had escaped between the 
 tracheal rings; and this could only have happened during the 
 expiratory effort. Hence, though the writer would not wholly 
 deny that the air may enter the cervical structures in the manner 
 claimed by Dusch, yet he is convinced that a frequent source of 
 origin is from air witlun the trachea; and also that if care be 
 used by the operator not to prematurely pierce the canal, such 
 infiltration may be avoided. 
 
 In 1867, Gueterbock reported on the operations done in the 
 Bethanien Hospital, at Berlin; recovery occurred in about one- 
 third of the cases operated on. Of fourteen tracheotomies done 
 in children over seven years of age, only two recovered. 
 
 In the same year, Boeckel published reports of tracheotomy 
 done by several operators: the recoveries were about thirty-three 
 per cent. During a period when the disease is epidemic, and 
 assumes a malignant form, almo.st all the cases die; and during 
 such season, Boeckel would not operate; or only exceptionally. 
 
 In 1867, Bourdillat, a French surgeon, advised to operate by 
 making a single cut; he claims that this is an easier and a 
 
tracheotomy; bronchotomy. 1029 
 
 speedier plan, and is attended by less bleeding than the usual 
 plan of slow dissection. 
 
 The plan of opening by one cut, is liable to the grave objec- 
 tion that the cut may pass through the trachea and open the 
 subjacent oesophagus: such mistake in a reported case, led to the 
 death of the child. 
 
 Peter, a French authority, in 1867, called attention to the 
 difficulty of operating on small children in whom the neck is fat 
 and thick; the tracheal canal is small, not being more than two- 
 fifths of an inch in diameter in a child aged seventeen months. 
 In such children there is a risk of mistaking the thyroid cartilage 
 for the cricoid, a mistake made by Peter, who divided the thyroid 
 cartilage. There is also a danger that the trachea will slip, and 
 the incision go astray. And in thus wandering from its aim, the 
 knife may wound the closely contiguous carotid artery. A case 
 was reported to the writer in which this occurred, and the victim 
 of the error died from haemorrhage, in a few moments. In chil- 
 dren of such conformation, the surgeon runs the risk of slightly 
 wandering from his intended course and incising the side of the 
 trachea. In such a case, the inserted canula would be deflected 
 to one side; and, situated thus during the respiratory movement, 
 the ill-placed instrument would irritate the parts, as the writer's 
 experience has verified. 
 
 In cases in which croup and pneumonia coexist, Grisolle and 
 Nelaton advise to perform tracheotomy as a means of relief 
 That tracheotomy cannot cause inflammation of the lung is shown 
 by the fact that pneumonia does not arise from the operation 
 which has been performed for the removal of foreign bodies from 
 the windpipe. 
 
 In 1868, Barthez made a comparison of cases of croup in 
 which tracheotomy was performed, with those in which no opera- 
 tion was done; of the unoperated cases, only one in eleven recov- 
 ered; while of those operated on, two in seven cases w^ere rescued: 
 and the operation should be done early. He thinks that there is a 
 fair future for tracheotomy ; and that it will not share the fate of 
 trephining, which is falling into discredit. 
 
 In the same year, Steiner published the report of fifty-two 
 cases of tracheotomy, of whom eighteen recovered. One child 
 died from bleeding caused by the operation. From a study 
 of the fatal cases in which necropsy was made, Steiner refers 
 death to one of the following causes: a chronic swelling of the 
 laryngeal mucous membrane, which was a sequel of the antece- 
 
1030 PJIAKVNOKAL AND (ESC )1'1IA( i KAL NEOPLASMS. 
 
 dent croiipal ])rocess; or from ulceration from the same cause; 
 and a third cause of death was palsy of the glottis. Steiner 
 operates as soon as emetics fail to give relief. 
 
 TJie risk to which the surgeon is exposed in tlie treatment of 
 croupal diphtheria was illustrated in the experience of KroU, of 
 Baden, in 18GS : in the treatment of a patient, the latter coughed 
 out excreta which came in contact with the face, moutii, eyes, and 
 nose of the physician. KroU soon afterwards became the subject 
 of a severe attack of tlie disease, which ahnost ended fatally. He 
 concludes that the excreted matter of the diphtheritic patient 
 can, through contact, cause the disease in a healthy person, and 
 the time necessary for such development, as shown by his own 
 case, is given by KroU as about six days. 
 
 In 1868, Hasse wrote on tracheotomy: his observations were 
 made in the operations done by Wilms, of Berlin. To avoid the 
 risks whicli attend the removal of the canula, forceps were used 
 by the aid of which the lips of the wound could be held asunder, 
 and air admitted. Hasse thinks the form of the canula should 
 be modified. Instead of having the form of a quadrant or fourth 
 of a circle, he would give it a curve of about one-sixth of a cir- 
 cle: for the latter form permits of the matter being expelled more 
 easily. His canula is straight in its lower third, and is one-sixth 
 of a circle in its upper two-thirds. 
 
 As an aid in the introduction of the canula, Couper first 
 passed in a small rod of flexible gutta percha, over which the 
 canula was slipped and guided into the trachea. 
 
 Huter, in 1869^ from an extended experience in tracheotomy, 
 advises the section through the cricoid cartilage. The advantage 
 claimed for this point is its superficial position, and its easy 
 fixation with the tenaculum. He attaches much importance to 
 the aspiration of the matters collected in the trachea, after the 
 opening has been made. And this should be repeated after- 
 wards, whenever the material collects in the air-passage. The 
 aspiration was done by the aid of a flexible tube, which being 
 admitted through the wound could be carried down to any extent 
 desired. 
 
 From a comparison of cases thus treated with those not as}>i- 
 rated, Hliter finds that more of the former recover; also, that in 
 cases which ended fatally, life was prolonged in those in which 
 aspiration was practiced. 
 
 In 1872, there was published a report of three hundred and 
 thirty tracheotomies done by Wilms, in Berlin : of these, one ban- 
 
tracheotomy; broxchotomy. 1031 
 
 dred and three recovered ; that is, a little over one-third of the cases 
 operated on. The canula was removed between the fifth and eighth 
 days, as a rule. If some hours after the operation the pulse is 
 much accelerated, it indicates a fatal ending; but a low rate of 
 pulse and a diminution of temperature are signs of a favorable 
 termination. If after the canula has been introduced, the respi- 
 ration is not improved, but the patient continues to breathe 
 rapidly, the portent is unfavorable. 
 
 In 1872, Bruns wrote on tracheotomy done by means of the 
 galvano- cautery. He states that the operation was thus done by 
 his father, in 1867, and in 1869. There are other claimants for 
 priority in this method ; and it is probable that several operated 
 thus, near the same time. 
 
 Bruns says the operation with the cautery is not so free from 
 the danger of bleeding as has been claimed; indeed, in one case 
 he was thus operating on, the heemorrhage was so excessive that 
 he was compelled to finish the work with the knife; he also finds 
 that the operation is by no means an easy one. From the state- 
 ment of Bruns and others concerning galvano-caustic tracheotomy, 
 and from the writer's personal observation of this method of 
 incision, this plan seems really deserving of so little commenda- 
 tion, that were the author concerned in the matter of its priority, 
 he would cheerfully resign his share of the quest to others. The 
 writer was a witness to a number of operations done in Paris 
 with the galvano-caustic knife, in 1876; among them was the 
 excision of a cancerous breast, and the removal of a vesical cal- 
 culus. In the removal of the breast the entire cutis was sacri- 
 ficed, and the excision, commencing at the peripheral margin of 
 the part, proceeded thence by concentric circles of detachment, 
 until, after great perseverance, the task was accomplished; but so 
 much time was consumed in the work, that, when it was com- 
 pleted, nearly every seat of the room was empty, which, at first, 
 was filled with those whom the fame of the eminent surgeon had 
 attracted to witness the new method ; all learned that the excis- 
 ion done with the galvano-caustic blade, so far from being a 
 blood-saving method, was a blood-wasting one, and the wound 
 made was of such a form that many weeks would be required for 
 its closure. The first cystotomy thus performed illustrated how 
 much, of barbaric rudeness and uncouthness can be introduced in 
 and mar an operation which, by centuries of revision, has been 
 brought to a marvelous stage of perfection when done by a 
 cold-bladed knife in an adroit hand. And a further remonstrance 
 
1032 i'iiakyn(;i:af. and a:s<M'HAGEAL neoplasms. 
 
 against the method was the near approach of the patient to death 
 through subsequent inflammation of the wounded parts. And 
 tracheotomy done by the thermal metliod, must leave similar ill 
 concomitants and events, and prevent its further continuance. 
 The galvano-cautery in traclieotomy, like some other ])rocedures, 
 has had its brief hour on the surgical stage, and will only be 
 recalled to view by the pen of the historian of tracheotomy, and 
 by him cited as an example of the irrepressible spirit of innova- 
 tion that has attended the develo})ment of every operation done 
 by the surgeon. 
 
 Korte, a German writer, in 1879, published an article con- 
 cerning the granular growths, cicatricial narrowing, and ulcera- 
 tion, which may follow and seriou.sly complicate tracheotomy: he 
 saw this, especially where the operation was done low down in 
 the trachea. As treatment of such cases, curetting and cauteri- 
 zation may be resorted to; also, a canula of a peculiar form lias 
 been employed. 
 
 Petel, of Paris, observed the granulative complication : after 
 the wound had healed, the granulative tissue grew inside to such 
 an extent that the trachea was nearly occluded, and partial 
 asphyxia occurred. 
 
 Madelung, about the same period, pointed out (Archiv fiir 
 Klinische Chirurgie) certain difficulties which may arise in tra- 
 cheotomy from the presence of accessory or anomalous portions of 
 the thyroid gland. He classifies these anomalies, according to 
 their site, into superior, lateral, anterior and posterior accessory 
 portions. And in the adult, the anomalous part may become 
 goitrous. Such thyroid structure might be so situated as to 
 embarrass the work of tracheotomy. 
 
 Ipsen, of Copenhagen, in 1881, reported the observations made 
 by Bloch in the necropsies made in thirty cases of unsuccessful 
 tracheotomy. Sloughing was found in sixteen cases, which had 
 arisen from the pressure of the canula. The silver instrument 
 becomes darkened in such cases, and the detaching slough may 
 be followed by htemorrhage, which, in some cases, may be so 
 serious as to contribute to, or even cause death. The detached 
 slough may be succeeded by a polypoid mass of granulative tis- 
 sue. To guard agiiinst sloughing, Ipsen advises to use a canula 
 composed of India rubber, rather than of silver. 
 
 Zimmerlin, in 1882, wrote on the haemorrhage that may arise 
 during the operation of tracheotomy: he describes two species, 
 extra-tracheal and intra-tracheal ; and it may be arterial, venous, 
 
tracheotomy; bronohotomy. 1033 
 
 •capillary, or parenchymatous. Arterial bleeding may originate 
 from opening the innominate or the thyroid artery; and this 
 may arise primarily, from a direct wound of the vessel; or it may 
 occur later from sloughing, through pressure of the canula ; and 
 lisemorrhage is more apt to arise when the tracheal opening is 
 made low down. Venous haemorrhage is from the thyroid veins. 
 The chief means of control advised by Zimmerlin is pressure, 
 which is to be made around the canula. The author would add, 
 that if the bleeding be from a vessel of considerable size, no 
 other treatment offers certain security, except that of finding the 
 bleeding vessel and ligating it. And hsemorrhage will generally 
 be avoided if, at the time of the operation, care be used to tie 
 vessels which are wounded, or which, being laid bare, may subse- 
 quently open through pressure of the canula, or through pseudo- 
 membranous invasion and disintegration. 
 
 Chaym, of Berlin, in 1883, wrote on tracheotomy in children 
 "under two years of age; in such subjects great difficulties are 
 encountered, especially in the first year, from the thick, fatty 
 couch of the neck, tlie large volume of the thyroid gland, and 
 from the smallness and mobility of the trachea. Of nine hun- 
 dred and seventy-seven infants operated on under two years 
 of age, eighty-five per cent died. To obtain better results 
 Chaym counsels to do the operation before the appearance 
 of asphyxia; and the opening should be made just below the 
 cricoid cartilage^ not including that part. By observing these 
 precautions, he finds that twenty-nine children under one year, 
 and fifty-eight under two years of age, were oj^erated on success- 
 fully. Chaym finds recorded two hundred and twenty children 
 under two years of age, who were saved by tracheotomy, Isam- 
 bert, in 1868, advised tracheotomy in the infant. 
 
 Gresswell, in 1884, wrote on the trouble of breathing wliich 
 may arise after the removal of the canula; he disagrees with 
 those who refer this trouble to the sinking of the tracheal wall 
 around the opening which has been made through it; his expla- 
 nation is that the child has unlearned, or forgotten, to open the 
 larynx when the respiratory muscles act. To avoid such subse- 
 quent trouble, Gresswell resorts to the novel artifice of creating 
 some dyspnoea in the child, before the removal of the canula ; 
 for this purpose, he devised a canula which was provided with 
 lateral openings, which could be closed or opened so as to dimin- 
 ish or augment the amount of admitted air; and thus the child 
 was compelled to make some effort in breathing. 
 66 
 
1034 j'iiaryxui<:al and (Icsophagkal xeoi'lasms. 
 
 Besides the difficulty referred to, Kolil in 1887, mentions others 
 wljich may follow the removal of the canula: these are relapsing 
 diphtheria; inflammation of the vocal chords; granulative growths 
 iu the wound; curvature and other alterations of form which 
 may arise in the air-passage as the result of the operation ; relax- 
 ation of the anterior wall of the trachea; tracheal stenosis due to 
 external pressure; primary or secondary palsy of the laryngeal 
 muscles; paresis from non-use of the parts; spasm of the glottis; 
 and too long retention of the canula in the trachea. From the 
 author's experience, nearly all of these troubles will be avoided, 
 if the canula can be removed at an early period. 
 
 In cases of croup in which the pseudo-membrane penetrates 
 deeply into the air-canal, tracheotomy will furnish but slight 
 relief, if means be not used to extract the false membrane. In 
 such patients after the tracheal opening is made, Pienazck, in 
 1886, advised the use of forceps of which the blades are long and 
 narrow; and he claims that with this instrument the surgeon 
 can penetrate into, and extract the pseudoplasm from, the right 
 and left bronchi. But in case the pseudo-membrane penetrates 
 into the secondary trunks of the bronchi, then it cannot be 
 reached with forceps ; and in such patients, death is inevitable, 
 according to Pienazck. The writer in cases in which the mem- 
 brane has reached this low site, has found some relief in the 
 inhalation of an atomized solution of chlorate of potassa, or of 
 Aqua Calcis. The atomized vapor may be conducted into the 
 mouth of the canula through a funnel, which has been inserted 
 into it. 
 
 After this extensive review of the teachings of authorities 
 who have written on tracheotomy as a means of relief of the 
 patient, who is the su!)ject of obstruction of the air-passage 
 through croupal or diphtheritic pseudoplasm, the writer will 
 proceed to an application of the principles deducible from these 
 doctrines. 
 
 The first and cardinal point in regard to the operation is that 
 it be done timely, opportunely and jtrudently; the moment for 
 opening the air-passage should be so chosen that one may apply 
 to it slightly paraphrased the classic expression of Tacitus: fclix 
 opportunitate mortis vitandfe {fovtnnnte in the oppoiiiuiity of escap- 
 ing death); and the moment for operating should be so chosen 
 that the surgeon can neither be accused of undue haste, nor of 
 fatal delay. Dyspnoea which is continuous and constantly 
 increasin'g, denotes that the pseudo-membrane is encroaching on 
 
tracheotomy: bronchotomy. 1035 
 
 and lessening the calibre of the air-passage; this means that the 
 amount of air being admitted is insufficient for the maintenance 
 of life ; and that cyanosis will soon be present, when unoxygenated 
 blood occup^dng the arteries, the chances for a successful opera- 
 tion will be slight. 
 
 The site at which the air-passage should be opened has been 
 the matter of varying opinion, as the reader has seen in the 
 previous citations of authorities on that point. An enumeration 
 of these sites in the order of their succession from above down- 
 wards is as follows: the section maybe made between the thyroid 
 and cricoid cartilage; through the cricoid cartilage; tlirough the 
 cricoid cartilage and one or two rings of the trachea; through 
 three or four of the uppermost tracheal rings; through the 
 tracheal rings which lie behind the isthmus of the thyroid gland; 
 and lastly, through the portion of the trachea that lies just below 
 the thyroid gland. As seen, the operator has amplitude of choice 
 in the selection of site. 
 
 The first point mentioned, which lies between the thyroid and 
 cricoid cartilages, is too small in the child for the operation; but 
 in the older subjects this space occupied by the cricoid ligament 
 is large enough ; and this site is sometimes selected for what may 
 be named inferior laryngotomy. The section of the cricoid 
 cartilage in the child would not give an opening which would 
 admit a canula of sufficient calibre for normal breathing; in the 
 adult it might suffice ; yet if an opening were desired at this 
 location, it would be better to incise the crico-thyroidean (conoid) 
 ligament, cutting transversely, close to the up|)er margin of the 
 cricoid cartilage; thus incising, one shuns the crico-thyroid artery, 
 which pierces the ligament above its middle, at a point where 
 a lymphatic gland is often found. 
 
 Should an emergency arise in the adult from diphtheritic 
 occlusion, or other cause, demanding section through the cricoid 
 cartilage, the work should be done as follows: to locate the part,, 
 let the finger pass searchingly from the pomum adami down- 
 wards; the yielding interstice filled by the conoid ligament will 
 be found, and then underneath tliis, the cricoid cartilage is sit- 
 uated ; though less prominent than the thyroid cartilage, yet the 
 cricoid is enough so to be distinguishable from it, and also from 
 the subsequent tracheal ring. Since the crico-thyroid muscles, 
 which are somewhat concerned in vocal function, lie on the 
 sides of the cartilage, these structures must be avoided in the 
 division of the cricoid. And no less important, though less 
 
1030 niAUYXiJEAL AND GSSOPHAGEAL NEOPLASMS. 
 
 imperiled than the muscle, is the external branch of the su[)e- 
 rior laryngeal nerve, which passing under the sterno-thyroid 
 muscle reaches and penetrates the cricoid-thyroid muscle. The 
 operations of Ilueter have repeatedly demonstrated that the 
 cricoid cartilage can be divided without impairment of the voice; 
 yet to do this the opening must be made in the anterior median 
 line of the cartilage; and the dissection which is done to reach it 
 should be neath', and not laceratingly made: thus the nerve will 
 be shunned and the muscle left intact. A vertical line dropped 
 from the notch in the t]i3'-roid cartilage above, to the sternal 
 incisura (or hollow space in the manubrium of the sternum) will 
 indicate tlio site of the median section to be made; and should 
 the division of the skin and the platysma myoid muscle have 
 wandered from the surgeon's aim, correction can be made by 
 continuing the incision through the line which separates the 
 sterno-hyoid muscles. There is a considerable interval between 
 these muscles above; but this becomes less below where the two 
 muscles meet; and after contact in the median line, they diverge 
 again as they pass to their respective points of insertion. With 
 these guides, the scalpel need not lose its way; finally, the white 
 cricoid structure being reached, the operator transfixes it with a 
 tenaculum, and holds it steady while he divides it. 
 
 Isolated cricotomy is no longer resorted to as an operation 
 for the relief of pseudo-membranous occlusion of the air-passages; 
 but when this cartilage is divided, the section is generally made 
 along with two or more of the tracheal rings. 
 
 An objection against cricotomy in tlie adult is, that the cri- 
 coid cartilage in the old subject is ossified ; this does not obtain 
 in the child, in whom the cricoid ring is as easily divided as the 
 succeeding tracheal rings. The operation thus done is known as 
 crico-tracheotoni}-; and this has been decided as the one which, 
 anatomically, offers the most advantageous conditions when it 
 becomes necessary to open the infant's air-passage. Among 
 these conditions may Ije ]nentioned the thinness of tlie soft parts 
 which must be divided, their usual freedom from vessels, the 
 certainty with which the part may be found, and the facility 
 which an opening made there offers for reaching the occluding 
 membrane, whether tlie latter be seated in the larynx above, or 
 in the trachea below. 
 
 In the median line of the neck, in descending from the hyoid 
 bone, the air-passage becomes buried deeper as one approaches 
 the sternum; so that the lower portion is quite impalpable in 
 
tracheotomy; bronchotomy. 1037 
 
 the child of short, fat neck ; but, fortunately, in the critical 
 moment which demands prompt and speedy action on the part 
 of the tracheotomist, there is for him a landmark which can 
 always be easily felt, though it may not be visible: this is the 
 prominent eminence of the thyroid cartilage: a cartilage which, 
 in the work under consideration, is not to be touched by the 
 scalpel; but in the infant, the finger passing directly downwards 
 from this point a half inch, can fix the point where the scaljDel 
 being held vertically, is to be thrust downwards and backwards; 
 and this incision is to be continued until it encounters the white 
 cricoid ring, below which lies the trachea, of which one or more 
 rings are to be divided. 
 
 Besides the thinness of the soft parts which rest on the cri- 
 coid cartilage and upper tracheal rings, these structures are less 
 often traversed by vessels which would bleed freely, if cut, 
 than are the structures lower down. A third advantageous con- 
 dition which this site offers is that the air-canal can be found 
 more readily here, than below; the finger can easily distinguish 
 the cricoid ring by its unyielding firmness; and its separate 
 mobility from the thyroid cartilage above will enable the opera- 
 tor to avoid the latter. And, finally, an opening made here 
 enables the surgeon to remove the false membrane which may 
 lie in the passage above and below the opening. The conditions 
 enumerated speak strongly in favor of the crico-tracheal site, 
 which Hueter and other authorities unite in selecting as the 
 appropriate one for the performance of tracheotomy. 
 
 The next site, viz., through the upper tracheal rings, is usu- 
 ally so encroached on by the isthmus of the thyroid gland that it 
 offers insufficient space for the opening; in fact, the isthmian 
 bridge commonly spans the passage at a point corresponding to 
 the second tracheal ring; and occasionally an anomalous lobe so 
 encroaches on the limited space, that the latter is quite too nar- 
 row for operating here. 
 
 The post-isthmian site is rarely a suitable one for the opera- 
 tion; the vessels in the isthmus are often of such calibre, that 
 the section would cause copious bleeding: an event which seri- 
 ously embarrasses the operation; in fact, in many cases, such 
 bleeding has caused death. In some cases, however, the isthmus 
 is only a thin filamentous structure, in which only diminutive 
 vessels exist; in such favorable conditions the tracheal section 
 could be made at this point. 
 
 Below the isthmus of the thyroid gland there is a space of vary- 
 
1038 PHARYXciKAL AND U>OI'IIAUEAJ> NICOIM.ASMS. 
 
 ing distance in which tlie trachea niay be opened; in the child of 
 lone:, thin neck, there is ample room lor the work; but in a neck 
 which is short and thick, this site is ill fitted for tracheotomy. An 
 advantage which the opening here offers is this, that section made 
 there will probably be below the diseased portion of the air- 
 passage; the pseudo-membrane will be above the fenestra opened 
 by the surgeon in the tracheal tube. Objections which some- 
 times far outweigh this advantage are the occasional anomalies 
 of the vessels in this region, to which some reference has been 
 made; the innominate artery may rise unusually high; it was 
 once seen by Allan Burns so high that it reached the lower, 
 border of the thyroid gland; he saw also the right carotid cross 
 in front of the trachea. Both carotids may originate from the 
 innominate, and then the left one will cross the trachea. The 
 inferior thyroid artery may arise anoujalously as a single trunk 
 from the sub-clavian; and then, as stated by Burns, tlie vessel is 
 so situated as to be endangered in the operation. These anom- 
 alies are so frequent that the surgeon may expect to encounter 
 one of them in eight cases: frequency sufficient to command 
 cautious advance of the knife. Again, the gradually deepening 
 position of the trachea, as one approaches the sternum, is a disad- 
 vantage that is present in all patients, and is especially serious 
 in the short, adipose neck. 
 
 Despite these several impediments, this site was the favorite 
 of one of the most celebrated surgeons, B. von Langenbeck, whose 
 operations the author has repeatedly witnessed. The deliberate 
 manner in which this eminent surgeon operated enabled him to 
 shun the perilous vascular anomalies which occasionally occur 
 there; and should the right or left carotid have encroached on 
 the trachea, or the subclavian have reversed its course and desti- 
 nation, or any of the vascular surprises have presented them- 
 selves, which have been described and delineated b}^ Henle and 
 Tillaux, the self-contained bistoury of Langenbeck would have 
 slwfted its point to a portion of the trachea less beset with perils, 
 and there have completed its work. One of less experience would 
 do well to avoid such a region, and select one of less possible 
 hazard; and a reflective study of the various sites in which tra- 
 cheotomy has been performed leads the writer to select that of 
 crico-tracheotomy ; besides the commendation of this site by 
 Hueter and other authorities, the writer's own experience, 
 embracing a series of sixty tracheotomies, confirms this choice. 
 
 There is another obstacle which often confronts the surgeon 
 
tracheotomy; broxchotomy. 1039 
 
 on the threshold of his purpose; this is the opposition of the 
 parents or relatives of the patient to the operation : or if consent 
 is given, it is often at so late a stage in the croupal disease, that 
 the work is in vain. Much address is often needed to overcome 
 this obstacle. An argument sometimes used by the writer, and 
 which usually has a convincing effect, is the following: Your child 
 will die within a few hours, unless the operation be done; if 
 done, it will give it one chance in four of saving its life ; should 
 it die uuoperated on, it will die by slow strangulation; the child's 
 condition is the same as if a cord encircled its neck, which is being 
 tightened every minute; the operation proposed will cut this 
 cord and give the child easy breathing ; and if this be done, 
 though the child may not be saved, it will render its death an 
 easy one. A statement of this purport will rareh'' fail to obtain 
 permission for the operation, even from one ignorant, or preju- 
 diced against surgical work, xlnd should these arguments still 
 fail of purpose, then, as occurred in a case which the author saw, 
 the final appeal may be in the following form : I offer the child 
 a reasonable chance for saving its life; if you deny it this privi- 
 lege, who will be accountable for its death? Such an appeal, as 
 in the writer's case, extorted a reluctant permission; and though 
 the case ended fatally, yet the relief obtained by the operation 
 was so marked, that the obstinate parent found no cause for 
 regret that the operation had been done. The number of suc- 
 cessful tracheotomies, which have been done in all parts of the 
 world where intelligent surgery exists, has now nearly banished 
 the prejudice again.st it, with which the old generation of surgeons 
 was forced to contend, and, as Trousseau says, it " must hence- 
 forth be looked upon as one more conquest of the healing art." 
 
 To perform tracheotomy, the surgeon should have a properly 
 lighted room, a table on which the patient will rest, assistants in 
 his work, and a small number of instruments. It is true that in 
 an emergency, it can be done anywhere, and in a room so poorlv 
 lighted that fingers rather than eyes will do the seeing. Under 
 such embarrassment the writer has been forced to operate; and 
 with perhaps an incompetent assistant, and with oitly the small- 
 est instrumental ecjuipment. 
 
 If there be time, as is usually the case, for deliberate prepara- 
 tion, and it is during sunlight, the patient should be' so j^laced 
 that the operator will not overshadow the field of his work : that 
 is, his shadow should fall behind him. And the light from the 
 southward cpiarter of the sky will be better tnan that from the 
 
1U4U J'JIAKY.NGKAL AND (liSuriiAUKAF. NKOl'LASMS. 
 
 northward. Also during the night, the patient should be so 
 placed that the surgeon and his aids will not darken the opera- 
 tive field. In case the room has a central, suspended light, the 
 patient should not be placed directly under it, but slightl}^ to one 
 side. If light must be gotten from lamps, these should be placed 
 on a small table, near the side of the patient, opposite to the sur- 
 geon. The light should not be held in the hand of an assistant: 
 lest he, fainting, should drop his light, and leave the room in 
 darkness, as occurred once in the author's practice. 
 
 An operating table may be extemporized by placing together 
 two or three small stands or tables; or it can be made by unhing- 
 ing a door and placing this on two stands, or small tables: and if 
 tables be used, they should not be too wide. The table may have 
 as covering, a quilt or blanket; and a small, hard pillow or cush- 
 ion must be provided, which placed beneath the child's neck and 
 shoulders will ui)lift the neck, curve the head backwards, and 
 expose the surface to be operated on. 
 
 As aids, the surgeon should have one to administer the 
 ansesthetic, one to sponge, one to manage the retractors, and one 
 to arrest or control any irregular movements of the child. As 
 such aids may not be present, the surgeon if he has had experi- 
 ence in emergencies, might anpesthetize the patient, and then do 
 the work with one untrained assistant; or if he has learned to 
 operate where the luxury of assistance was denied, then it would 
 be possible to do the work alone, after placing the child in com- 
 plete aucesthetic narcosis ; yet in such an attempt, one would run 
 many risks, which assistants would remove. In case the child is 
 nearly moribund, which is too often the condition present w^ien 
 surgical aid is invoked, then anaesthesia may be omitted, since 
 unoxygenated blood circulating in the arteries will render the 
 tissues nearly insensible; and in such patient, only dark venous 
 blood will ooze from the divided sti'uctures; and as the incision 
 is being made, the slight movements of the patient will clearly 
 show that the work is nearly or quite painless. 
 
 And finally, to operate with ample facility, the following 
 instruments should be at hand : — 
 
 1. A sharp pointed, short-bladed scalpel, and a probe-pointed 
 bistoury :, and these two may be contained in a sheathing handle 
 similar to that of a clasp-knife. 
 
 2. Two blunt retractors, the form of which is shown in Figure 
 102. Tiiese instruments have two points, blunt and separated a 
 quarter of an inch from each otlier. This retractor has been of 
 
TRACHEOTOMY ; BROXCHOTOM Y. 
 
 1041 
 
 eminent service to the author; it serves a twofold purpose: for, 
 besides separating and holding the lips of the wound asunder, it 
 can do hemostatic duty : for, as soon as a vessel of small size is 
 opened, the retractor can be so shifted that one of its tines rests 
 on, and compresses the vessel. Such pressure made by lateral 
 traction will control ordinary venous bleeding : but if an artery 
 be opened, it would be safer to tie it. It often happens that 
 beneath the skin, near the median line, the surgeon finds one or 
 tw^o anterior jugular veins, which, when encountered, can be 
 
 Figure 102. Exhibiting the blunt retractor. 
 
 caught by the retractor, and pulled aside from the point of the 
 knife. Of all the instruments which the writer uses in the oper- 
 ation, he places the highest estimate on this retractor: it is an 
 assistant in dilating the wound and controlling bleeding; and it 
 may be added, that it is no small aid in the dissection: for with 
 it the tissues can be caught, and by lateral traction separated 
 from the subjacent structure. 
 
 3. The blunt dissector, shown in Figure 103: to this instrument 
 the writer assigns a position in importance near that which he has 
 given to the retractor. After the skin has been divided, with 
 
 Figure 103. Showing the form of the blunt dissector. 
 
 this instrument the subjacent structures can be separated rapidly, 
 and almost bloodlessly; and should vessels be met, they can be 
 loosened with the blunt point, caught by the retractor, and pulled 
 aside. This instrument can, in a great degree, replace the 
 scalpel after the skin has been divided. It is of special use in 
 the management of the thyroid gland, should this part encroach 
 on the field of the operator: for the blunt point can be thrust 
 under the margin of the gland, above, below% or at the side, and 
 the gland then pushed away so that the trachea can be exposed.. 
 
104"J l'HAKYN(JKAI. AND (KSUl'ilAGKAl. XKOI'LASM-S. 
 
 The gland is sometimes very closely adherent to the trachea ; 
 and even in that case, with care the parts can be separated; and 
 thus, as the writer has done, the supra-thyroid section can be 
 extended downwards by the division of one or two tracheal rings, 
 which are bridged over b}' the th3a'oid gland. 
 
 4. Two or more hiemostatic forceps should be at hand, with 
 which bleeding vessels, which cannot otherwise be controlled, 
 may be seized and the forceps left in place until the opening has 
 been made, provided asphyxia seems imminent ; if, however, the 
 patient's condition will permit, let the vessel be tied, and the 
 forceps removed. 
 
 5. Thread for ligating vessels should be provided ; also a 
 threaded needle for suturing a portion of the wound, after the 
 canula has been inserted. And for removing blood, a fine 
 sponge is needed; and in the absence of this, aseptic mops, or 
 even a towel or soft cloth, will suffice. 
 
 6. Some instrument should be provided, with which the semi- 
 liquid excreta can be aspirated from the opened trachea ; this 
 may be a soft catheter or rubber tube, to which a suction bulb, 
 or tlie suction end of a syringe, has been attached. This suction, 
 as before stated, has been done by the surgeon's mouth: and 
 though the act was one of philanthropy, it also proved to be 
 one of fatal rashness. Recently, in England, a father at the 
 suggestion of his physician extracted with his lips the excreta 
 from the wound in his own child, and became infected with 
 diphtheria; the parent instituted legal proceedings against his 
 physician, and blind Themis turned her scale against the latter, 
 and the parent recovered heavy damages. It is fortunate that in 
 the web of common humanity, such brutal thread has rarely 
 been inwoven; though the tooth of the ingrate is sometimes felt, 
 yet the tear of gratitude oftener flows. 
 
 7. The operator should have an assortment of double canulte 
 — at least three: one of small calibre, another of medium size, and 
 a third still larger; and if the case be an adult, a canula of the 
 irreatest diameter will be needed. A form of canula which the 
 writer has found very satisfactory is that represented in Figures 
 104 and 105. The canula may be of silver, hard rubber, or 
 aluminum; that of aluminum shares with that of rubber the 
 advantage that it is very light, and hence will be less apt to 
 erode than one of silver. That of silver has done excellent serv- 
 ice for the writer; and within his experience he has rarely seen 
 ulceration arise from it. A more important thing in the canula is 
 
TRACHEOTOMY ; BEONCHOTOM Y. 
 
 1043 
 
 that it should be solid in its construction; and especially, that the 
 horizontal plate to which the outer tube is attached should be so 
 firmly fastened that the two cannot separate: or if motion 
 between the two has been provided for, as is the case with that 
 made by Luer in Paris, then this connection should be secure 
 against separation: for the history of tracheotomy contains 
 records of several accidents, in which the canula descending into 
 the trachea, the patient had the double calamity of having coupled 
 
 Figure 104. Showing the 
 canula of usual form. 
 
 FiGUEE 105. Showing the canula with 
 the inner tube partly withdrawn. 
 
 with his croupal trouble, also a foreign body in his ai-r-passage ; 
 and this has descended so deep as to be inextricable. In a case 
 recently published, the operator was so fortunate as to extricate 
 the tube by suspending the patient with head downwards, and 
 then striking the thorax, when the tube descended and was 
 extracted. 
 
 Morax, who measured the trachea of children between two 
 and fifteen years of age, finds that they vary from three and one- 
 half to seven and one-half lines in diameter; and, of assorted 
 canulae, he would have four, viz., one of three, one of four, one of 
 five, and one of six lines in diameter. 
 
 The horizontal plate of the canula, on each side near its end, 
 is provided with orifices, in which cords are to be tied, and 
 passed around the neck, and tied so that the instrument cannot 
 be dislodged. 
 
 The inner tube of the canula is fixed and held in the contain- 
 ing tube by a kind of key or latch which is fastened to the hori- 
 zontal plate, and can be so turned as to fix or release the inner 
 
1044 PHARYNGEAL AND (ESOPHAGEAL NEOPLASMS. 
 
 tube. The inner tube should extend downwards somewhat 
 bevond the outer one. The canuhi being thus constructed, wlien 
 it becomes obstructed with detritus or excreta, the containing 
 ke}' is turned, and the inner tube is removed, cleansed and again 
 replaced. The outer tube is provided with a fenestra, at the site 
 of its greatest curvature, which is intended to let the air pass 
 through the larynx, when the latter becomes permeable. By 
 means of this ingenious contrivance, the advance of the patient 
 towards recovery can be determined; to test this, let tlie inner 
 tube be extracted, and then, when the external outlet is closed, if 
 the larynx be free, the patient can breathe in normal manner; if, 
 however, the obstructing agency is still present, breathing will be 
 correspondingly impeded, and phonation absent. 
 
 8. Two tenacula should be present for seizing and fixing the 
 trachea when this is found ; the work can, however, be done with 
 one; yet by the aid of two, when these are inserted somewhat 
 laterally, the tracheal wound can be made between them, and its 
 lips pulled apart. 
 
 9. A basin of aseptic water should be provided, to be used for 
 cleansing sponges or gauze used in the work. Feathers from the 
 wing of a fowl are needed for cleansing out the mucus that may 
 lodge in and obstruct the canula: for the use of these will dispense 
 with the frequent removal of the inner tube. 
 
 Many tracheotomists, particularly Trousseau, use an instrument 
 specially intended for dilating the wound made in the trachea; 
 and, in the absence of the tenaculum, such an instrument might 
 be necessary; but with two tenacula, and the aid of the small, 
 blunt retractors, the dilatation can readily be done; and the 
 work being done in this manner, the surgeon can easily extract 
 the morbid material from the opened trachea. The writer pre- 
 fers the method in which the wound is retained open with 
 retractors as aid in extracting the false membranes : for, in the 
 plan advised by Trousseau, there is danger of thrusting the 
 material further downwards. 
 
 Such is the equipment for the sN'stematic performance of 
 tracheotomy when the operation can be leisurely done; some- 
 times, the condition of the patient permits no formal prepara- 
 tion; only prompt action can baffle death. In such an emer- 
 gency {occasio pracep^) the writer once made an opening with a 
 clasp pocket bistoury, with one stroke, and, as a temporary 
 substitute for a canula, a silver catheter was used. In such 
 urgent case the intuition of the surgeon will usually suggest 
 
tracheotomy; bkoxchotomy. 1045 
 
 means and manner by which the work can be best and quickest 
 done. A remarkable example of how difficulties may be sur- 
 mounted in such a strait is that of an American pliysician M'ho 
 performed tracheotomy in the midst of a forest, while on a hunt- 
 ing expedition. In the absence of a canula, he constructed one 
 which answered the purpose, from a leaden bullet, which he 
 hammered into a thin sheet, and then he molded this into the 
 shape of a canula. 
 
 Whether the patient should be anaesthetized, will depend on 
 his condition; if he be cyanosed or near complete asphyxia, an 
 anaesthetic is unnecessary; in fact, if anaesthetized he would run 
 a risk of dying during the operation; but previous to the cya- 
 notic stage, the mixed anaesthetic or ether should be given; as 
 t!jus, the j)atient will be spared pain; and what is more, the 
 slumber of ansesthesia will relieve him of terror. But in the 
 partly asphyxiated child, both mentality and sensibility are so 
 depressed, that, as the writer has witnessed, scarcely a struggle 
 will be made while the knife is dividing the cervical structures. 
 
 The patient, surgeon, assistants, and instruments next take 
 their respective positions: the patient on the table with nucha 
 and upper part of the shoulders so uplifted as to bring the front 
 of the neck into prominent relief; the surgeon, with his instru- 
 ments near his right hand, must stand on the right side of the 
 patient, so that in using the knife, the incision will proceed 
 downwards. An assistant will stand behind the head and main- 
 tain this fixed, with the chin turned backwards so that the latter 
 will not be in the surgeon's way; but in this, the skin of the' 
 neck must not be displaced from its normal site, lest the median 
 line be shifted to one side. 
 
 Another assistant should stand so that he can hold the 
 lower extremities; and if the child be small, this aid can easil}' 
 hold both arms, and legs; in doing which he stands on the side 
 opposite to the surgeon, and resting his left arm across the child's 
 knees, he grasps the latter's right hand, and pulls it downward, 
 while with his right hand he draws the patient's left arm down- 
 wards, alongside of the trunk : and thus held, the patient's arms 
 will not disturb the surgeon's work. Another assistant must aid 
 in holding the retractors. This aid should, if possible, be one 
 who has had some training in such service; if such a person is 
 not at hand, the surgeon must choose, from those present, some 
 one who may appear to have the best requisites for such duty. 
 
 After the instruments have been rendered pure, and the sur- 
 
1040 PHARYNGEAL AND CESOPHAfJKAL NEOPLASMS. 
 
 face to be incised lias been sponged well with, first an alkaline, 
 and then an alcoholic solution, the operation begins by an 
 incision made exactly in the median line, the cut beginning just 
 above the cricoid cartilage and extending well towards the sternal 
 manubrium. And that the median line shall not be deviated 
 from, it is well first to trace it with an aniline pencil; for if this 
 precaution is not taken, though the scalpel may start right it 
 may stray from the intended route and end on one side; and 
 this deviation is oftenest towards the surgeon. 
 
 There are advocates of rapid work, in which the opening is 
 made with one continuous stroke; prominent among these is St, 
 Germain, who has operated thus many times, and successfully. 
 His method is to seize the trachea between the thumb and fingers 
 of the left hand, and then, with one or two strokes, to enter the 
 air-passage, and, immediately after this, insert the canula. A 
 practical hand, like that of the Parisian })rofessor, might safely 
 do this, but ere the operator could acquire such deft precision, it 
 is probable that more than once the point of his instrument 
 would pass the forbidden mete beneath, and enter the cesophagus: 
 an error which would insure a fatal result. Hence the writer 
 does not commend this method ; audit should only be resorted 
 to where imminence of death forbids deliberate work. Trousseau, 
 whose pen and scalpel have given tracheotomy a place in sur- 
 gery, directs that the w^ork be done as follows: "I cannot insist 
 too nmch on the necessity of incising the tissues, layer by layer, 
 and of separating the vessels and muscles with blunt hooks; and 
 thus proceeding, to fully lay tlie trachea bare before opening into 
 it; I insist on the absolute necessity of working slowly; and if, 
 during the work, the child becomes suffocated, then cease for a 
 moment, and let it struggle, and sit up until it regains its breath ; 
 and though a minute may thus be lost, this is not to be feared. 
 I have never seen slowness cause an accident ; but I have often 
 witnessed difficulties and peril from doing the work too rapidly, 
 even though the work were done by an adroit operator." 
 
 The difficulties sometimes encountered will be slight in the 
 child w'liose neck is long, and in whom the structures lying in 
 the trachea are thin; in such a case, as soon as the skin is 
 divided, one is near the trachea; and if the wound is then dilated 
 by the retractors held by the assistant, the surgeon, using the 
 blunt dissector, can easily pierce and separate the thin structures 
 which lie on the trachea; and the retractors can aid in this dis- 
 section. And when tlie trachea is reached, it will be recognized 
 
tracheotomy; beonchotomy. 1047 
 
 by the white color of the rings; and these are distinguishable 
 from each other by the tissue of pinkish liue which connects the 
 rings together. And wlien the trachea has been sufficiently dis- 
 played, the surgeon transfixes it longitudinally, somewhat aside 
 from the median line, with the tenaculum, and commits this 
 instrument to the hand of the aid who held the retractors: and 
 the surgeon next transfixes the trachea on his side with a 
 tenaculum, and holds this in his left hand. AVhile the tenac- 
 ula are thus held, the surgeon pierces the wall vertically, and 
 then continues the incision downwards until three rings are 
 divided. Or if the cricoid cartilage be divided, then it will 
 suffice to sever two tracheal rings. And this longitudinal open- 
 ing should be made with blunt scissors or with a probe-pointed 
 bistoury, as extension of the first aperture made, and it must 
 lie in the median line; if not, the inserted canula will be 
 defiected to one side. 
 
 The writer commonly uses but one transfixing tenaculum; 
 yet in cases of urgency, he has found that greater expedition can 
 be made with two tenacula, since by their aid, as soon as the 
 trachea is opened, the lips of the incision can be drawn laterally, 
 and air thus quickly admitted. 
 
 As soon as the incision is made into the trachea, air gushes 
 forth, carrying with it blood, mucus, and perhaps false membrane; 
 and this material often bespatters the surgeon's face and dress. 
 And as the disease has thus been communicated, the prudent 
 operator, at the m.oment when he makes the opening, may direct 
 his assistant to hold a cloth which may receive the expelled 
 matter: or the operator's open hand may be so held as to receive 
 it. The first expiratory effort forces out the most of the semi- 
 liquid material; but if there be bleeding, as often happens from 
 the wounded mucous membrane, then this blood, flowing into 
 the tube, causes coughing, and, at short intervals, the blood is 
 expelled through the tracheal incision. The opening being- 
 completed, the free supply of air, like magic, relieves the agony 
 of the patient; and the relief is such that the unangesthetized 
 child ceases to struggle, and is content with what has been done. 
 The lips of the wound are now to be held asunder, while the 
 interior of the trachea is examined and freed of any obstructing 
 material, visible or accessible; and for this purpose, both forceps 
 and an aspirating tube are to be used. When the passage has 
 been made clear, the canula is to be introduced. In the subject 
 of thin neck, in which the work is here supposed to be done, this 
 
1U48 rilAKYXGEAL AND (JOSOPH A(;1:AL XKOIM.ASMS. 
 
 insertion is easily accomplished through the dilated wound. The 
 canula should be of a calibre which will quite fill the trachea: 
 neither too large, lest it erode; nor too small, lest it be too 
 movable, and be inadequate for the transmission of the due 
 amount of air for normal breathing. The moment the canula 
 enters, it generally causes a momentary irritation, and a spasm 
 of coughing ensues ; if, however, the patient has been aniesthetized, 
 or is in a cyanosed state, this spasm of coughing may not appear. 
 The introduction of the canula is always an easy matter, if a 
 free opening has been made, and the lips of the wound be held 
 well asunder; and when it is inserted, the pieces of tape, which 
 are fastened to the fenestrse of the horizontal plate, must be 
 carried around the neck and tied; and this knot should be on 
 one side, so that it will be easily accessible. This tying should 
 be so done that it will surely hold; also, the tapes should be 
 neither loose nor tight; for if tight, the constriction will interfere 
 with the circulation of the head; and if loose, the canula may 
 slip from its place in the trachea. 
 
 When the canula has been inserted and fixed securely in its 
 place, the wound must be closed by suturing, either above or 
 below; and then to prevent friction of the parts by the horizontal 
 plate, there should be placed a strip of rubber adhesive plaster 
 underneath. The work being completed, the patient is next 
 removed to his bed, and the head laid low. The head should lie 
 on a very low pillow; for if the usual thicker one be used, there 
 is a risk that the patient's chin will encroach on and obstruct the 
 canula. 
 
 The tracheotomy on the patient just described, in which the 
 anatomical conditions rendered the operation a very simple one, 
 is so absolutely free from difRculties that the young operator, to 
 whom such a case has fallen, may conclude that the difficulties 
 and obstacles enumerated by writers as confronting the surgeon 
 are exaggerated; this opinion, however, will receive severe 
 correction, should his next patient be a child of short, thick 
 neck. In a child of such conformation the shortness of the neck 
 renders but a small portion of the trachea accessible; in fact, the 
 larynx will occupy tlie middle third of the neck, and being- 
 buried there beneath a thick adipose stratum, it runs much peril 
 of being inadvertently injured. In such a patient, the voice 
 would be irretrievably lost, were the scalpel to divide the vocal 
 chords b}' a rash thrust; but if the M'ork be done leisurely, such 
 accident may be avoided. In a patient of the conformation 
 
* TRACHEOTOMY; BEOXCHOTOMY. 1049 
 
 referred to, the nucha should be well uplifted, and the head 
 turned so backwards as to lift the air-passage upwards to the 
 greatest possible extent. The child thus placed, an incision 
 should be made in the median line of the neck, embracing the 
 second and third fourths of the front of the neck. The knife, 
 held vertically, is passed through the skin; then being inclined, 
 it is carried downwards. The skin being divided, close to the 
 median line, theanterior jugular veins are sometimes found; and 
 these swell to such a volume as to present a formidable appear- 
 ance to the untrained operator. These veins may be tied: a 
 precaution that is seldom necessary; but instead, one may catch 
 them both with the retractor, and draw them to one side; or the 
 veins may be separated, and one pulled to one side, and one to 
 the other. The incision and dissection now proceed with 
 cautious steps towards the trachea; and, first of all, the operator 
 must now determine accurately, what is before him. For 
 example, he may find that a portion of the thyroid cartilage lies 
 in the way which he had intended to traverse with his knife; 
 then the field of work must be shifted downwards. The palpat- 
 ing index can now feel vvhat it could not do through the intact 
 skin. Every care must be used to continue the backward incision 
 in the sagittal or median plane; and this is not difiicult if the 
 initial cut was correct; and even if this was wrongly made 
 through displacement of the skin, it is not too late to correct it; 
 for then the knife can be shifted to the right or left, as may be 
 required. 
 
 In the course of the deepening incision, veins are often 
 encountered, which traverse the adipose structure; these can 
 usually be displaced with the blunt dissector, and held aside with 
 the point of the retractor; or this failing, the vessels may be 
 tied. The thick couch of adeps, including the superficial and 
 middle cervical fasciae, being severed, the trachea is sometimes 
 reached without any further impediment: such good fortune, 
 however, is rare; normal, or anomalous thyroidean structure 
 often interposes a perilous barrier to further progress of the knife; 
 and what further intensifies the gravity of the occasion is, that 
 the dyspnoea is rapidly becoming more oppressive: a condition 
 that urges expedition; and audibly admonishes the operator "It 
 were well it were dorie quickly." In such contingency, if the 
 child is ceasing to breathe, the knife should be urged amain, and 
 borne quickly athwart visible and invisible obstacles, until an 
 opening is made through which the cauula can be inserted. 
 67 
 
1050 PHAKYXGEAL AND CESOPHAGEAL NEOPLASMS. 
 
 And if, ill this deep cutting, vessels be opened which bleed freely, 
 the patient should be quickly turned on his side, so that the 
 blood can escai)e from, and not flow into, the tracheal opening. 
 In thus doing, though for an in.stant death may ai)[)ear to have 
 won the victory, yet, as the writer has witnessed, breathing may 
 recommence; and this has the effect to lessen or arrest the 
 hsemorrhage. Should bleeding from an artery continue, this 
 must be caught and tied. 
 
 But should the patient's condition be less pressing and admit of 
 deliberate action, and if the thyroidean structure be found in the 
 way, whether isthmus or anomalous lobe, this should be loosened 
 from the trachea with the blunt dissector, and drawn away from 
 the rings which must be divided. Should this displacement not 
 be possible, then let the structure be grasped by two pairs of 
 clasp-forceps, and divided between ; and should bleeding follow 
 the removal of the forceps, then each portion must be tied. 
 
 In the deej)er part of the incision, besides the thyroidean 
 structure mentioned, anomalous vessels, if they exist, will be 
 encountered : and the most common one is the middle thyroid 
 artery, which is so frequent that the surgeon may reasonably 
 expect to soon meet it in his operations. Should this be found, it 
 must be doubly tied and divided. More formidable vessels, as 
 the carotid, the subclavian or the innominate, may confront and 
 call the knife to a sudden halt. The discovery of such an anom- 
 aly would compel the surgeon to shift the site of his work to a 
 higher point, viz., the crico-thyroidean space, the cricoid carti- 
 lage, and the uppermost tracheal ring. And should this route be 
 deemed impracticable, then one could resort to the bloodless 
 method of intubation. 
 
 In regard to the manner of opening the trachea when this is 
 reached, something more should be said than what has already 
 been stated: for authorities here differ. Some operators discard 
 all instruments of fixation, and do this by seizing the exposed 
 trachea between the thumb and index. The objection to this 
 plan is that there is not sufficient room for the insertion of the 
 fingers; and, hence, the trachea would be compressed, and robbed 
 of some of its space, so precious to the suffocating patient. Trous- 
 seau pressed his finger nail against the upper surface of the 
 trachea, and used this as a guide in making the first incision into 
 the trachea. Archambault, the favorite pupil of Trousseau, hav- 
 ing reached and verified the trachea with the index finger, rests 
 this on a tracheal ring, and then carries the knife down on the 
 
tracheotomy; broxchotomy. 1051 
 
 volar side, and thus makes the first puncture. He counsels to 
 touch lightly; for the less the pressure is, the less apt is the knife 
 to stray from the proper track. He totally discards, in a flippant 
 line, the use of a fixing tenaculum. It is true that the opening 
 can thus be made : and the writer has so done it; but, by so doing, 
 one loses the control of the trachea at a moment when such con- 
 trol is so needful. During this most eventful moment in the 
 work of tracheotomy, the forcible respiratory movements carry 
 the trachea upwards and downwards; and these movements are 
 increased in the un anaesthetized child by the terror awakened by 
 the whistling sound of the air entering or escaping from the first 
 puncture. In such an anxious moment, when neither delay is 
 allowed, nor error permitted, and the arbitrament of a life 
 depends on faultless action, nothing can so exempt the young 
 operator from disorderly confusion, nor so maintain the unper- 
 turbed coolness acquired by the tuition of experience, as to be 
 able to hold and accurately fix the trachea, when the opening- 
 through its wall is being made. And in no way known to the 
 writer can this be more surely and well done, than with a tenac- 
 ulum of well-curved point, which has been inserted into the 
 trachea longitudinally, alongside of the point where the opening 
 is to be made. And still greater advantage will be given by the 
 use of two such instruments; the second one being inserted paral- 
 lel with the first, on the other side: for with these the trachea is 
 easily steadied and fixed; and when the incision is made, the 
 tenacuia can be used as lateral retractors, by means of which the 
 tracheal wound can be laterally opened so that an ample current 
 of air can enter the air-passage. 
 
 Instead of tenacuia, Trousseau, Archambault and many 
 eminent tracheotomists use a dilator, wliich is inserted into, 
 and made to widen the tracheal fenestra as soon as this is 
 made. Archaml)ault and his great master expatiate on the 
 utility of this instrument: yet it has the unavoidable disadvan- 
 tage that it may catch and carry with it the pseudo-membrane, 
 which, when present, it is so desirable to remove. But 
 with the tenacuia, besides dilating the new-made window for the 
 free admission of air, the operator can also retain this patent 
 until the obstructing material has been removed; it would be 
 impossible to extract this successfully, if the passage were 
 obstructed with a dilating instrument. An objection urged 
 against the tenaculum is that it wounds the tracheal wall; in 
 reply, the writer would state, that from repeated employment of 
 
10")2 i'iiai:yn(;kal and (esophageal neoplasms. 
 
 the iiistramont in traclieotomy, he has seen no had effects follow 
 its use. 
 
 When the opening has been made, and the trachea freed from 
 visible or accessible obstruction, then conies the important act of 
 introducing the canula. Diflerent methods of doing this have 
 been adopted. Archambault used his index finger as a guide, 
 which being inserted into the wound, the canula is carried down 
 on the palmar side, and, as this is done, the finger is withdrawn 
 and the canula slipped into its place. The objection to this plan 
 is, that in so doing the trachea is wholly closed, and breathing 
 arrested for a moment or two: a serious fault. Guersant, to insure 
 against failure which has occurred in the introduction, inserted a 
 flexible male catheter into the tracheal wound, and over this the 
 canula was passed. Others have devised and used a guiding 
 instrument of smaller dimensions than a catheter. If the wound 
 be opened by tenacula, no such guide is needed : for the lower end 
 of the canula is pas.sed into the well-opened wound and carried 
 straight backwards; and as soon as it reaches the posterior wall, 
 the outer end is uplifted and carried backwards through the arc of 
 a circle, while the inferior end descends. The contact with the 
 mucous membrane often causes a fit of coughing, which will soon 
 subside if the instrument be held in place. As soon as the canula 
 is in place, the tapes attached to it are to be passed around the neck 
 and tied ; and this done, the tenacula may be removed. If the 
 tenacula be removed too early, there is danger that the canula 
 may be expelled in a fit of coughing, and the operator be much 
 embarrassed to reinsert it. Such accident cannot occur if the 
 tenacula remain in place until the canula has been secured by 
 tying. Should the canula be accidentally dislodged, then the 
 ins})iratory effort will close the outer wound, and the child will 
 get but little air until the wound is reopened, which may be done 
 with the retractors used in making the incision. Also, from the 
 struggles of the child, the wound may again bleed; yet the inci- 
 sion, thus hidden from view, may be opened with the retractors, 
 when, if possible, one side of the tracheal cut should be caught 
 with a tenaculum or forceps, and so pulled aside that the canula 
 may be replaced. But if this plan fails, then a finger should be 
 introduced through the wound into the air-passage, and the 
 canula carried quickly along the volar side into the trachea. 
 
 When the primary oj)ening has been made in a subject in 
 which the structures are thick, if a fixing tenaculum has not been 
 used, the difficulties just recounted may be met; and in the 
 
tracheotomy; broxchotomy. 1053 
 
 attempt to insert the canula, the entering end of the canula may 
 catch on the front wall, and, instead of passing into the trachea, 
 it may be forced down in front of it. And this mistake has been 
 an occasional cause of death during the operation: an accident 
 that would have been avoided, had the operator first secured 
 control of the trachea with the tenaculum before opening it. 
 
 Another occasional complication of serious nature is haemor- 
 rhage, just as the final opening is being made: and this may be 
 caused by the opening of a large vein, or by division of thyroi- 
 dean structure. Or an artery may be opened, and in this case, 
 the bleeding will be in jets. No vessel of size should be severed 
 before it is ligated; to do otherwise could only be justified by 
 extreme asphyxia and imminent death. And even then, before 
 incising vascular structure, or dividing a vessel, the precaution 
 should be taken to catch with clasp forceps on each side, and then 
 sever between them. 
 
 Most authorities teach that, when asphyxia impends, the 
 operator should hasten to conclude the opening, and, though 
 minor vessels or vascular structure be in the way, he should 
 open, at once, through these into the trachea. It is claimed that, 
 by so doing, the bleeding will cease as soon as the canula is 
 inserted and respiration is freely restored. This doctrine is 
 fallacious, as has more than once been verified by the author's 
 experience; for if an artery is opened, it will surely continue to 
 bleed until tied, twisted, or its mouth is stopped with a clot. 
 And a mesh of th^^roid veins being severed, the little sheet of 
 blood thence flowing will continue for a brief time, despite the 
 tracheal opening; and, also, large thyroid veins being cut will 
 continue to bleed. Free breathing accelerates the circulation; it 
 does not slacken it ; the inspiratory effort attracts the venous 
 blood towards the heart: facts well known to the practical 
 surgeon. Hence, before dividing vascular structure, it is safer to 
 include it in a circumscribing ligature, or catch it in clasp 
 forceps and subject it to compression or torsion, until the vessels 
 are closed. 
 
 In case of parenchymatous bleeding, control of this is some- 
 times obtained by the pressure of the canula ; and to get this action, 
 the canula should be in close contact with the contiguous wound. 
 In such a case it is advised to remove the canula and replace it 
 by one somewhat larger, which will completely fill the wound in 
 the trachea. The wound usually bleeds most from the upper 
 angle, owing to the greater pressure of the canula on the lower 
 
1054 PHARYNGEAL AND (JCSOPHAGEAL NEOPLASMS. 
 
 portion; hence some aid can be derived from passing a suture 
 through the sides of the wound above ti)e canuhi, so as to lessen 
 the wound ; thus doing, the writer lias more than once controlled 
 bleeding. The use of the solution of the chloride or sulphate of 
 iron, as a styptic to arrest bleeding in tracheotomy, is oi)posed by 
 all autliorities; for the agent, in its work of coagulation, forms a 
 soft compound tliat can readily enter the trachea, to the ulterior 
 detriment of the patient. And it may be said of the use of such 
 agent, employed here or elsewhere, that though the bleeding is 
 thus arrested, the evil hour is only postponed: for, when the coag- 
 ulum is detached, bleeding sometimes ensues; and the parts are in 
 an ill state for healing, since the salt of iron acts as an escharotic. 
 
 When blood from the wound has entered the lungs, in even 
 moderate amount, it interferes with bleeding; and, in a subject 
 that is partly asphyxiated, this added trouble can quickly end 
 life; hence, such blood should be removed. As the writer has 
 verified, the titillation of the mucous membrane of the trachea 
 below the wound sometimes causes an expulsive effort, which 
 brings the blood up, and frees the lungs, so that breathing is 
 easy. The aspiration of such blood by the mouth of the operator 
 brings peril to the surgeon rather than relief to the patient, since 
 the aspiration could only be done imperfectly by oral suction. 
 As already indicated, an elastic tube with suction balloon would 
 do the work better. Or in the absence of this, a soft catheter 
 attached to the suction point of a syringe might be employed. 
 
 In the haste sometimes demanded in the operation, the 
 surgeon finds that his incision is ill placed in the trachea: 
 instead of being in the median line, it is in the side of the canal: 
 or commencing in the median line of the trachea it may have 
 diverged somewhat towards the right or left side. In the second 
 case, the error of place will not interfere much with the use of 
 the canula, since the outer end of the latter will be near its 
 proper site. But if the tracheal incision be wholly on the side, 
 its ill position will so interfere with the use of the canula that 
 authorities counsel to make a new opening, parallel with the 
 preceding one. In making this new opening, the error has been 
 committed of carrying the new cut into the first one and form- 
 ing a movable spur in the front wall of the trachea. If this be 
 done, it would interfere with the subsequent form of the trachea, 
 when the wound lias healed. And, again, should no spur be 
 made, there is still the risk that the narrow bridge-like slip of 
 cartilage between the two incisions may die, and thus leave a 
 
teacheotomy; broxchotomy. 1055 
 
 breach in the wall of the trachea, whence stenosis of the canal 
 vYOuld remain after healing. Hence, the writer advises to use the 
 lateral slit when this has inadvertently been made, rather than 
 to attempt to form a new one; thus doing, though the canula 
 deviates to one side, a satisfactory result has been obtained by the 
 writer. 
 
 A more serious error is that of perforating the posterior wall 
 of the trachea, and probably entering the oesophagus. A mere 
 perforation of the wall might cause no trouble; but should the 
 oesophagus be opened, the condition would be a very serious one, 
 since in the swallowing of food, especially that which is liquid, 
 a portion of the same would enter the trachea and pass to the 
 lungs. Such a complication would almost certainly cause death. 
 As a means of rescuing the patient, one might resort to alimen- 
 tation through an oesophageal tube; thus treated, the patient 
 would have a chance for recovery, which otherwise, would be 
 denied him. 
 
 The emphysematous infiltration of the air into the surround- 
 ing tissues is an occasional occurrence; it has been observed a 
 few times by the writer in his operations. It disappeared with- 
 out treatment. The case might be otherwise, were tlie emphysema 
 to arise from the mouth of the canula becoming so buried in 
 the wound that the expired air could not escape, but would enter 
 the structures which rest on the outlet of the canula. This 
 condition may arise from swelling of the wound: and then to 
 prevent infiltration of air, a longer tube must be used. And as 
 a further aid, the surface of the w^ound may be covered with a 
 coating of collodion. Any attempt to remove air which has once 
 entered the tissues of the neck will prove futile. Left to itself, it 
 will spontaneously vanish. 
 
 Should a case occur in which there is an intolerance of the 
 canula, then some other method of maintaining the tracheal 
 wound open must be resorted to. In such a patient, the writer 
 made two incisions in each side of the tracheal cut, which so 
 converged that a thread could be tied to each side, and the sides 
 pulled laterally, so as to hold the wound open. In this way the 
 wound was easily maintained j^atulous for almost a week. 
 
 The operation having been completed, the patient is placed 
 in bed, with the head low, so that the chin will not obstruct the 
 canula: and the mouth of this may be left uncovered; or there 
 may be placed over it a few layers of thin gauze. The covering 
 of the outlet of the canula with gauze is highly recommended by 
 
1056 PHARYNGEAL AND CESOPHAGEAL NEOPLASMS. 
 
 Trousseau. He claims that this muffling screen, becoming warm 
 and moist, prepares the air for admission to the hmgs, in the 
 same manner as if it were breathed through the mouth or nose. 
 
 Special attention should be given to maintaining the air of 
 the chamber at a uniform temperature; and for this purpose a 
 thermometer should be placed near the bed of the patient, and 
 the air maintained at seventy degrees, Fahrenheit. The error is 
 often committed of keeping the room too warm; and, when the 
 thermometer denotes more than seventy degrees, cool air must 
 be admitted until the heat is reduced. 
 
 The patient must be properly cared for, and this duty should 
 be committed to a nurse, if possible, who has had experience in 
 such work; but if such aid cannot be had, then some person of 
 self-possession and intelligence must be instructed by the surgeon 
 in the duties required. The most important task, for a time, is 
 to prevent the child from reaching to and disturbing the canula. 
 Through lack of care in this respect the writer has seen the 
 canula nearly plucked out from the trachea. Hence, for an 
 hour or two, the child's hand should be held, or prevented from 
 doing mischief. Another task quite as important as the preceding 
 is to watch the canula, and see that it does not become obstructed 
 with excreta from the air-passage. Such material, in a liquid or 
 semi-liquid state, in coughing is continually lodging in the 
 canula; and, in time, it becomes inspissated and adherent to the 
 inner wall of the canula. To prevent such accumulation, the 
 assistant should, occasionally, pass a plumed feather into the 
 tube, twirl it around, and thus catch and extract the matter. 
 For this purpose, the smaller wing feathers of the domestic fowl 
 will do the work well. This is pliant enough to easily traverse 
 the canula, and, being turned about, it will dislodge the adherent 
 matter. In using this, the plumed end which is inserted should 
 be carried somewhat beyond the lower end of the canula, so as 
 to entirely detach the obstructing matter. In the beginning, this 
 will irritate the mucous membrane and provoke coughing; later; 
 this does not occur. 
 
 Soon after the work is completed, and breathing through the 
 canula is freely established, the patient falls asleep; and in this, 
 the breathing is so noiseless that the inexperienced watcher fears 
 that something is wrong. Besides being noiseless, the respiration 
 may be slower than usual: which arises from the canula admit- 
 ting more than the normal quantity of air. 
 
 Visitors and useless attendants are to be excluded from the 
 
tracheotomy; beonchotomy. 1057 
 
 patient's room; for the presence of such will render the air 
 impure, to the patient's injury; and the curious and inquisitive 
 gaze of visitors will disturb, if not alarm, the child. The presence 
 of the parents in the room, unless they lose their self-possession, 
 may be allowed 
 
 To arrest the pseudo-membranous formation, and to aid in 
 the solution of that which may be present, a valuable auxiliary 
 is to atomize some agent near the patient which has such solvent 
 action. For this purpose, some alkaline agent may be used ; as 
 examples of such are lime water, or a solution of bicarbonate of 
 potash, or soda. The writer's preference is for lime water, of 
 which the officinal preparation may be used in a simple atomiz- 
 ing apparatus. The vapor thus generated may occasionally be 
 thrown into a funnel which is inserted into the mouth of the 
 canula. Or the current of vapor may be made to simply play 
 over the patient's neck; and to protect the dress and the bedding 
 from moisture, these should be covered with India rubber cloth 
 during the use of the atomizer. Another agent used in atomized 
 state that has enjoyed some celebrity, is chlorate of potash: this 
 may be used in saturated solution, viz., fifteen grains to the ounce 
 of water. The peroxide of hydrogen may also be used in atomized 
 form. 
 
 In spite of all the care used in cleansing the canula, some 
 material, in hardened form, will collect on the inside of the 
 canula, and attenuate its calibre; hence the inner tube must be 
 removed, every hour or two, and cleansed. This cleansing will 
 be much facilitated if a solution of bicarbonate of potash be 
 employed for the purpose. In the act of removing the inner 
 tube and replacing it, the nurse, if untrained, must have special 
 instruction. The key, which attached to the horizontal plate 
 fastens the inner tube, sometimes works ill. If the retaining 
 key does not work well when the inner tube is shifted, the child 
 will be disturbed and probably thrown into a spasm of coughing: 
 all of which will be avoided by the selection of the canula with- 
 out such defect. 
 
 Trousseau and other authorities recommend to drop occasion- 
 ally, a few drops of warm water into the canula; they claim that 
 doing this one compensates for the absence of moisture which 
 arises from the admission of air through the canula; instead of 
 through the nose or mouth. The use of an atomizer, in the 
 manner before referred to, renders it unnecessary to do this, since 
 the vapor thus generated would be ample to moisten the air- 
 passages. 
 
lOoS rJIAUYNGEAL AND OESOPHAGEAL NEOPLASMS. 
 
 The iuterual medication which usually has been plied 
 assiduously, and often to excess, may be reduced to a minimum, 
 or discontinued, when tracheotomy has been done: but the nutri- 
 tion of the patient must be well maintained. 
 
 There usually occurs at once a great amendment in the 
 condition of the patient; and both parent and surgeon indulge 
 in exaggerated hope; but the experienced medical man tempers 
 such hope with prudent reserve; for he has long ago learned tliat 
 apparently assured victory may end in defeat. The improvement 
 is too often merely temporary; the slow breathing, within a few 
 hours, may become hastened; the pulse, likewise, accelerated; 
 and the tranquil composure of the patient may be exchanged for 
 one of restless anxiety. The child tosses its arms about and 
 makes the same appeals for help which it did before the operation. 
 But should the peaceful composure which instantly followed the 
 tracheotomy, continue into the second day, there is a fair prospect 
 of recovery. 
 
 A change to the worse is announced by hastened breathing, 
 cpickened pulse, and increase of temperature. The accelerated 
 breathing may bo caused by obstruction of the trachea below 
 the opening into it; or it may arise from pneumonic cedema or 
 actual inflammation. The conditions of the lungs supervening, 
 a fatal ending may be apprehended; for within some hours, or a 
 day or two, at most, the pulmonar}' breathing space becomes 
 reduced to such small limits, that life cannot be continued. 
 Along with hastened respiration, the air -passage becomes dry- 
 but little material collects in the canula, and this is remarkably 
 thick and adherent. The breathing is accompanied by a creak- 
 ing or whistling sound. In this unfortunate condition the writer 
 has seen relief from the frequent use of the atomized lime water; 
 but as a rule, such patients die in the latter part of the second 
 day, and all that is done but prolongs the scene of struggling 
 agony. 
 
 The case is otherwise where the unfavorable condition arises 
 from obstruction of the trachea through an accumulation of 
 inspissated mucus in the canal, or from the formation of 
 croupal membrane there; in such patients the surgeon can often 
 give relief by extracting the impeding material. In some cases, 
 though the false membrane be thoroughly removed at the time 
 of the operation, yet some hours afterwards it reforms, and the 
 ))atient breathes with difficulty, similar to that which necessitated 
 the 0])eration. In such condition, the canula must be removed 
 
tracheotomy; broxchotomy. 1059 
 
 and, the lips of the tracheal wound being securely grasped and 
 held, a pair of slender forceps is to be introduced into the trachea, 
 and the material caught and removed. If the matter be thin, 
 instead of forceps, a small probang may be passed down the 
 trachea, twirled around, and the passage thus freed of the 
 obstructing matter. If the obstruction arises from a membra- 
 nous formation that has reappeared, it is well, after the removal, 
 to apply some solution which will prevent the re-formation. For 
 this purpose, a solution of corrosive sublimate, in the strength of 
 one part in a thousand, may be used. The agent whicli the 
 w^riter has found most effectual is nitrate of silver applied in 
 solution, of which the strength is eight grains to an ounce of 
 distilled water. This may be applied with a small probang, 
 which, being passed through the tracheal opening, is caused to 
 ascend and descend rapidly, in contact with the tracheal wall. 
 The surgeon should do this himself, and not commit the work to 
 even an expert nurse. 
 
 Tlie first few days which follow the operation are hours 
 crowded with weighty duty for the surgeon; at short intervals^ 
 he, or his representative should revisit the patient; and of equal 
 importance, one or more assistants disciplined in such work 
 should unremittingl}^ watch the case. For upon the faithful 
 discharge of those minor duties, as well remarks Archambault, 
 depend the chances of success, rather than upon perfection in the 
 operation. 
 
 At the end of forty-eight hours, if all has proceeded favorably, 
 a strong hope of recovery may be entertained; and the conditions 
 justifying such expectation are the following: the pulse is under 
 a hundred, the temperature does not exceed one hundred and a 
 half, or one hundred and one degrees; the cough is absent or 
 slight, and the air-passages are moist. But, as before mentioned, 
 the ominous symptoms are constantly accelerating respiration and 
 disappearance of moisture from the air-passages ; the supervention 
 of these conditions upon the previous favorable ones almost 
 certainly portend death of the patient w^ithin twenty-four or 
 thirty-six hours. 
 
 The child which has been operated on is sometimes disturbed 
 by finding that it cannot talk as hitherto; though its tongue and 
 mouth shape words, yet not even a whispering sound is uttered: 
 and this silence renders the patient anxious, sad and dispirited: 
 so that to the attendant falls the further task of amusing the 
 patient, and causing him to forget his condition. If the case is 
 
lOGO PHARYNGEAL AND CESOPHAGEAL NEOPLASMS. 
 
 going favorably, the child may soon be permitted to sit up in 
 bed; or lie may be lifted ilom bed and held in the arms of the 
 nurse. The tractable or intractable character of the child will 
 determine how this management must be pursued. 
 
 The precautions given in regard to maintaining the room at 
 a uniform temperature are of much importance; and besides this, 
 should albumen be found in the urine, the child must be well 
 clothed both during the time that the canula is used, and also 
 after the removal. 
 
 In feeding the patient, care must be used that no foreign 
 matter enter the canula: and though the nutrient material be 
 liquid, its entrance into the air-passage would prove extremely 
 detrimental. Such accident occurs oftenest when the child takes 
 too large a draught, and a portion escaping from the mouth 
 overflows on the neck and enters the wound. More care in giving 
 food will avoid this accident. 
 
 After the lapse of a few days of anxious solicitude and weighty 
 suspense, the fortunate patient is rescued from most of the perils 
 which menaced him: yet one more eventful period must be passed ; 
 and this is that in which the canula must be removed. The 
 child, which, at first, was alarmed by the new mouth-piece to the 
 air-passage, soon learns to tolerate it, and finally fears to part 
 with it; and a similar fear often harasses the surgeon: his 
 uncertainty voices itself in the famous words, "If it were done 
 when 'tis done;" and if he has had little experience in such cases, 
 he is embarrassed by hesitation in the selection of the proper hour 
 for this work. 
 
 The canula can onl}^ be removed when the calibre of the 
 superjacent air-passage is fully restored : and in case the instru- 
 ment be taken out before this restoration, the expectation that the 
 wound will freely admit air is seldom realized. It often occurs 
 that, the canula being withdrawn, the altered condition alarms 
 the child, and causes it to struggle and breathe violently, the 
 result of which is that the lips of the tracheal wound close and 
 allow but little air to enter; and in such condition, the writer 
 has seen the patient almost lost by asphyxia. The violent 
 struggling movements of the child render it extremely difficult 
 to reinsert the canula; and this can only be done by the aid of a 
 couple of assistants. In such emergency, dispensing with tenac- 
 ulum or retractor, the writer has used a pair of dressing forceps, 
 of which the closed blades being introduced, the instrument is 
 then opened and the wound dilated so that air can enter, and the 
 canula be replaced. 
 
tracheotomy; bronchotomy. 1061 
 
 The modern canula is so constructed that the suro;eon can 
 determine before its abstraction whether its absence can be borne: 
 this consists in an opening in tlie outer tube at a point where 
 the expired air can pass upwards through the natural route, 
 when the outer mouth of the tube is closed. To test the permea- 
 bility and patency of the larynx, let the inner tube be withdrawn ; 
 and when the patient's attention is withdrawn, place the finger 
 over the mouth of the outer tube and thus test the degree of 
 permeability of the larynx: and if the breathing be free, then a 
 more prolonged test of this can be made by closing the canula 
 with a cork. If such closure be tolerated for some time, then the 
 canula may be withdrawn; and if all has proceeded favorably 
 from the time of the operation, then removal can sometimes be 
 done as early as the fifth day: but usually, this cannot be done 
 before the ninth or tenth day. 
 
 After the canula is removed, some authorities permit the 
 wound to remain wdth little or no dressing: others, on the con- 
 trary, approximate the lips of the opening with adhesive plaster. 
 For this purpose, the author uses isinglass plaster, of which 
 strips six inches long and a half inch wide may be so stretched 
 across the opening as to approximate the sides. For some hours 
 after such closure, the air in inspiration and expiration wall pass 
 through the interstices of the plaster: and this may continue for 
 some days, before the w'ound is so closed as to prevent the passage 
 of air. Ordinarily, the wound heals without delay: exceptionally, 
 this does not occur; especially in the subjects of severe diphthe- 
 ritic disease. 
 
 The most frequent embarrassment, which tlie operator 
 encounters after the removal of the canula, is an excessive gran- 
 ulative growth which develops in the wound; and such, growth 
 often so encroaches on the tracheal canal that respiration is 
 interfered with. This occurred in two cases of tracheotomy done 
 by the writer, and amounted to a formidable obstacle to recovery. 
 In the first patient, the canula was removed on the tenth day, 
 and for two or three days the case proceeded favorably, and an 
 early recovery seemed probable : but as the wound was near the 
 point of final closure, the breathing became difficult, and in a few 
 hours the dyspnoea reached such a gravity that it became 
 necessary to reopen the trachea and introduce the canula again. 
 In this work it was found that thegranulative tissue had reached 
 inwards, and, in polypoid form, nearly occluded the tracheal 
 canal. This neoplasm was excised, and the deeper portion of the 
 
1062 I'HAKYMiKAL AND CESOPIIAGKAL NEOl'LASMS. 
 
 wouiul cauterized with nitrate of silver. After a few days, the 
 canuhi was again removed, when similar difficulty in respiration 
 recurred. It M'as treated similarly, with the same result as 
 occurred the first time. The procedure next attempted was to 
 trim olT all the raw surface, and convert the old wound into a 
 new one, in which the walls were fresh wounds: then the incision 
 was carried downwards, and the canula having been inserted in 
 this lower point, the upper portion of the wound was closed by 
 deep suture. Thus the old wound quickly healed, after which 
 the canula was removed from the new one, which, also, healed. 
 In this way perseveringly pursued, through difficulties which 
 have been but half recounted, the patient was finally cured: and 
 but a tithe of the service paid for, since the parent held the 
 operation responsible for the later difficulties which were encoun- 
 tered: as logical as are many of the ingrates for whom Medicine 
 saves life. In the patient here mentioned, after recovery, respira- 
 tion was untrannneled. 
 
 In another patient, still greater trouble was encountered in 
 dispensing with the canula: after the removal of the latter the 
 trachea soon became obstructed by graniflative tissue, and it was 
 necessary to reopen the wound, and replace the canula; yet 
 before doing so, the new tissue was thoroughly excised. After 
 the second removal of the canula, the granulative growth soon 
 reappeared: and this time, instead of removal by excision, it was 
 done by cauterization with the small blade of the thermal cautery. 
 This cauterization was done a second, and even a third time, 
 before the exuberant growth was so repressed as to admit of 
 closure of the tracheal wound. This child recovered, yet the 
 tracheal canal was left in an imperfect condition. When the 
 boy was at rest, and breathing was not accelerated, there was no 
 embarrassment; yet when active exercise induced a greater 
 demand for air, then the respiration was labored; and it was 
 evident that there was stenosis of the trachea at the point where 
 it had been opened. This lad has now reached manhood, and 
 though his respiratory difficulty has lessened, yet enough of it 
 remains to seriously disturb him when he engages in active 
 exercise. 
 
 In a third patient there was encountered similar difficult}^ 
 yet there was less trouble in repressing the granulative growth 
 and dispensing with the use of the canula: the work was here 
 done with the thermal cautery. 
 
 From the writer's observation he concludes that tlie prolific 
 
tracheotomy; bronchotomy. 1003 
 
 granulative growth arises from retaining the canula too long in 
 place: for it did not appear in patients in whom the instrument 
 had been removed early; and it only occurred in those in whom 
 the canula had been used for ten days, or longer. Hence, in 
 practice may be formulated the rule to remove the canula as 
 soon as the air-passage above is sufficiently permeable to permit 
 free breathing; and this can often be done as early as the fifth 
 day after the operation. 
 
 A singular difficulty sometimes met is that the child having 
 breathed for a few days through the canula forgets the habit of 
 breathing through the nose or mouth; or does so with distrust; 
 and such a patient, after the extraction of the canula, from slight 
 causes may have a panic of dyspnoea, in which it quite loses its 
 breath, and life is so imperiled that it becomes necessary to 
 replace the canula. Such trouble was experienced in a case 
 operated on by the writer. This child was cajoled into natural 
 breathing by removing the inner canula, and then when the child 
 fell asleep, the remaining canula was closed by a cork, and 
 allowed to remain so after the child awoke; breathing then 
 occurred normally through the fenestra of the remaining tube. 
 By this management the child was finally trained to breathe 
 without the aid of tlie canula. 
 
 Instead of excessive growth from the wounded tissues, there 
 may be a defect in their reparative action; and sometimes there 
 is an "ulcerative action, by which the wound is increased in 
 dimensions. In such a case there is encountered no dyspnoeic 
 difficulty, since there is ample ingress of air tlirough the wound, 
 as well as through the laryngeal canal: but there is trouble in 
 effecting closure of the wound. Such ulcerative action, or indo- 
 lence in the work of repair, may arise from mal-nutrition of the 
 subject, which previously existed, or may be caused by the diph- 
 theritic disease which led to the operation. Such patient should 
 be fed as generously as the digestive powers will permit, and to 
 awaken appetite, there may be given three times daily a wine- 
 glassful of decoction of bark or gentian, which has recently been 
 made, and acidulated with hydrochloric acid. As a local stimu- 
 lant, the surface of the wound may daily be touched with a 
 solution of nitrate of silver, viz., one grain to the ounce of distilled 
 water; or with a ten per cent solution of alcohol. Exercise in 
 the open air and sunshine will act favorably: yet a portion of 
 the time, the patient should be in a recumbent position, in which 
 the afflux of blood to tlie part will be promoted. And to retard 
 
10G4 PHARYNGEAL AND CESOPHAGEAL NEOPLASMS. 
 
 and hold tlio blood in the tissues about the wound, the neck may 
 be encircled with two strips of adhesive plaster placed horizon- 
 tally, and so situated as to include the wound between them. 
 Instead of adhesive plaster collodion may be used. 
 
 In some unfortunate cases, owing to some constitutional 
 cachexy, or to depression of the vital forces through the virulence 
 of the diphtheritic poison, the wound becomes the site of pro- 
 gressive gangrene: instead of healing, the parts die; and in such 
 cases the death of the patient, as a rule, soon afterwards follows. 
 To ujdift the enfeebled vital forces, the chief reliance should be 
 placed in concentrated nutrition and a free use of stimulants; 
 and as local treatment, a cataplasm composed of powdered char- 
 coal and pulverized Peruvian bark moistened with red wine may 
 be used. And to combat the probable microphytic causal agency, 
 the surface of the wound may be penciled dailj'' with Oleum 
 Terebinthinse. Such a course of treatment should be diligently 
 carried out: more in the line of duty than with the expectation 
 of saving the patient. 
 
 A grave intercurrence which sometimes appears in the subject 
 of tracheotomy, is pais}' of the muscles of the pharynx and 
 throat, which are concerned in the function of deglutition. This 
 ill event is referable to alterations in the nerves which fui'nish 
 motor and sensory influence to these structures : such nerves are 
 the glo.sso-pharyngeal, and branches of the pneumogastric dis- 
 tributed to the pharynx and larynx. It is probable that the cell- 
 growth which accompanies the diphtheritic process penetrates 
 and trammels the ofRce of these nerves: that such infiltration 
 does occur the pathologist has verified: it was inferable from 
 the macroscopic appearances of the structures in necropsies made 
 by Virchow and Bouchut, wliich were witnessed by the writer. 
 That the disease traveled centrally from the throat along the 
 nerve sheaths to the medulla oblongata, and there exercised its 
 paralyzing action, is problematical, though Bouchut endeavored 
 to show this in his demonstration made at the Hospital des 
 Enfants, Paris. The morbid action is exerted, probably, chiefly 
 or wholly, on the terminal ramuscules of the nerves supplying 
 the })alsied parts. 
 
 As results of such loss of innervation are the loss of voice, and 
 difficulty of swallowing. The voice is first reduced to a whisper, 
 and this soon disappears: and then the effort to talk is reduced 
 to mimic movements of the tongue and lips, similar to those 
 made b}' the patient when aphonia arises from the trachea being 
 
tracheotomy; bronchotomy. 1065 
 
 occupied b}^ the canula: the muscular movements are made 
 which should coin the voice into articulated sounds, yet the voice 
 for coinage is absent. The graver trouble is the inability to 
 swallow : at first, the component acts of deglutition are wrongly 
 coordinated; and strangling occurs; and finally, a portion of the 
 liquid food, instead of taking the normal route, enters the larynx 
 and descends to the lungs; so that the child has a violent fit of 
 coughing every time it attempts to swallow liquid nutriment.' 
 The result of this is that the patient is but partly nourished, and 
 the lungs receiving foreign matter, soon become affected with 
 ichorous pneumonia. The harassing cough which is aroused by 
 swallowing finally causes the child to refuse food. 
 
 As treatment which has proved most beneficial in such case 
 is electricity and strychnia. Potain has reported a case in which 
 electricity speedily overcame the palsy. Also, Dr. Colin, of San 
 Francisco, has had excellent results from the administration of 
 strychnia : even where the palsy was general and not limited to 
 the throat. The writer has found that it is better to give food in 
 solid, rather than in liquid form : bread can be swallowed, when 
 milk would cause strangling. And as an important adjuvant, 
 rectal nutrition should be resorted to; and for this, no article of 
 aliment is equal to milk ; and the absorption of this will be aided 
 by the addition of the extract from the salivary glands and the 
 pancreas of the ox, hog and sheep. ^ 
 
 A complication sometimes arising from tracheotomy is sup- 
 puration in the wound, from which pus gravitates downwards, 
 and may enter the anterior mediastinal space of the thorax. 
 This results from unskilled work in operating, in which the 
 structures are needlessly lacerated and separated from each other, 
 so that blood and excreta from the wound, instead of escaping, 
 enter and gravitate downwards. Also, from awkward insertion 
 of the canula, the structures may be forcibly dissected from the 
 trachea, and thus a route is opened into which the materials 
 mentioned may enter and descend. This pus lodged behind 
 the sternum is concealed from sight, and is onl}^ revealed by a 
 necropsy ; and as such examination is often not made, the exist- 
 ence of the pus is not suspected, though it was a material factor 
 in causing death. If, however, it be detected, an attempt to 
 remove it should be made by partially inverting the patient, as 
 often as every six hours, and washing out the cavity with alco- 
 holized water : thus diligently working, the purulent cavity might 
 finally be closed. And should pus originating from any other 
 68 
 
lOGG PHARYNGEAL AND CESOPHAGEAL NEOPLASMS. 
 
 cause during tlie course of tracheotomy, for example, from ery- 
 sipelas or phlegmonous inflammation, enter the thorax, thena 
 similar treatment might be pursued. Such work falls rather 
 within the line of hopeless action, id alt quid feci sse vichamur. 
 
 A complication sometimes disturbing the course of a trache- 
 otomy is ulceration of the trachea. This may arise from pressure 
 of the canula, and may occur in the margins of the tracheal 
 incision, or where the convexity of the tube rests against the pos- 
 terior wall of the trachea; or it may be lower down, where the 
 end of the canula rests on the .tracheal wall. It has been seen 
 oftenest in the lower part of the tracheal cut. This ulcerative 
 action may be very superficial, or it may reach quite through the 
 thickness of the wall. And cases have been recorded in which 
 the perforation reached and opened the wall of a vessel, and seri- 
 ous or fatal bleeding occurred. 
 
 Such ulceration is partly due to the pressure of the canula; it 
 is likewise promoted by the erosiveaction of the instrument, which 
 is kept in constantmotion by the respiratory movements : and such 
 agency, whether pressure or erosive friction, will have greater 
 effect when reinforced by infectious diphtheritic disease. And if 
 such disease be of a virulent character, then there may occur 
 extensive gangrenous destruction of the walls of the trachea. 
 
 The pain from such ulcerative or gangrenous action, though 
 present, is liardly distinguishable from that caused by the con- 
 tiguous wound: and lience it is of little diagnostic value; the 
 diagnosis is to be made rather by the dark discoloration of the 
 canula, provided this be of silver. The silver tube becomes 
 blackened through the formation of the sulphuret of silver, which 
 is due to the contact of the tube with the disintegrated cartilage, 
 which contains sulphur. And the location of this black stain 
 will indicate the point where the tube caused pressure: namel}', 
 if it be at the lower end of the canula, it can be inferred that 
 pressure there is causing ulcerative chondritis; or if the posterior 
 convex curve be blackened, this denotes disintegration at that 
 part of the trachea; or should the entire canula be blackened, 
 then the inner surface of the trachea, wherever it touches the 
 canula, is breaking down from mechanical cause, or from di})h- 
 theritic infection. But should the upper end of the canula and 
 the horizontal plate be darkened, this may proceed from the pus 
 of the wound, and, meantime, the trachea be intact. 
 
 In case the canula be of material which can form no colored 
 compound with sulphur, then the diagnostic aid of discoloration 
 would be wantincr. 
 
tracheotomy; bronxhotomy. 1067 
 
 As means of treatment, the following may be resorted to : if 
 the ulceration wholly arises from erosive action of the canula, 
 this may be remedied by the use of an instrument of a different 
 size, or model. To lessen or avoid erosive attrition, a canula has 
 been constructed by Luer, under the direction of Roger, of which 
 the tubular section is movable within the horizontal portion. Bv 
 this device the horizontal plate is not disturbed by the movement 
 of the head and neck; and the unfixed or movable canula can 
 cause but little attrition during the respiratory movements. 
 
 But in the event that the ulceration or gangrene is produced 
 by diphtheritic infection, it must be combated by some topical 
 remedy; and for this purpose pure alcohol or the spirit of turpen- 
 tine may be applied to the affected part. 
 
 The writer will here briefly refer to his own experience in 
 tracheotomy. He has operated sixty times, and has saved 
 twelve cases; that is, twenty per cent. The cases were children 
 suffering with croup or diphtheria, and at ages varying from 
 two and a half to seven years of age. In many of the patients 
 the operation was only permitted when the child was in a hope- 
 less condition: and so near death were a few of the children that 
 they died during the operation: in these, and in others, had the 
 operation been done earlier, the writer is convinced that one- 
 third of the patients would have been rescued. The section 
 ■was always the high one in which the cricoid cartilage was 
 sometimes included. Other facts concerning these operations 
 have already been referred to. 
 
 In the foregoing collection of facts, it has been the purpose of 
 the author to furnish the reader with a full store of materials 
 which may serve for guidance in the critical work of tracheotomy. 
 As before stated, the operation may be one of the simplest char- 
 acter: a few strokes of the scalpel then suffice to open the tracheal 
 fenestra. But exceptionally, this narrow field may be the lurk- 
 ing place of uncounted difficulties; so that though the operator 
 may have in his mind an ample store of shifts and expedients, 
 still chance may summon up, anon, some contingency which he 
 did not expect; but with wdiich it is believed the preceding expo- 
 sition of facts will enable him tD satisfactorily cope. 
 
 No moment in the surgeon's life can be happier than the one 
 in which he saves a life. And if life be valued by its number of 
 3^ears, upon no one's work can a higher estimate be placed than 
 on that of the tracheotomist: for he rescues from death the young. 
 And should the operator fail to save his patient, as he often does. 
 
10G8 PHARYNGEAr. AND (ESOrHAGEAL JS'EOPLASMS. 
 
 yet lie lias tlie satisfaction of knowing that he has not shortened 
 life; and, further, that, though death won the victim, yet. the 
 former was robbed of its terror: for tracheotomy assures a pain- 
 less death, — enthanasia, or happy death, as the Greek beautifully 
 expresses it. 
 
 As concluding advice to tlie tracheotomist, the latter must 
 bear in mind that his task to end well must be one of tireless 
 care and constant attention to minute details: for here, as else- 
 where, the crown of success awaits him who best toils and best 
 watches. 
 
CHAPTER XXXII. 
 
 LARYNGOTOMY. 
 
 A SUBJECT cognate to tracheotomy is laryngotomy, which will 
 next be considered. As tracheotomy is yielding a portion of its 
 work to the intubationist, so that of laryngotomy is being some- 
 what supplanted by the procedures of the laryngoscopist: and, as 
 usual, the old method has not willingly borne the encroachment 
 of the new; so that the laryngotomist and the laryngoscopist at 
 the present hour are vigorously wielding the foils of heated con- 
 troversy; and in listening to the dialectics of the respective 
 claimants the observant reader is both diverted and instructed, 
 and is convinced that each, with some selective care, may be 
 followed. 
 
 In laryngotomy, the entire larynx may be opened; yet it is 
 rare that such an extensive operation is demanded: usually 
 the opening is made through the cricoid cartilage, the crico- 
 thyroidean ligament, the thyroid cartilage, or through the thyro- 
 hyoidean ligament. AVhen a vertical section is made through all 
 the component parts of the larynx, the work is named total 
 laryngotomy; and it may be remarked that the indications for 
 such an extensive operation will seldom present themselves; 
 usually, the purpose for which the operation is performed can be 
 accomplished by an opening througli one of tlie component parts 
 of the larynx: and when it is desired to do this, the incision may 
 be made through the ligament above or below the thyroid car- 
 tilage. The operation generally designated by laryngotomy is 
 that in which the thyroid cartilage is partly or wholly divided: 
 yet the term thyreotomy, by which this operation is often desig- 
 nated, is the more appropriate name. An operation cognate to 
 the one just named is that in which a passage is made through 
 the lateral or anterior face of the larynx, by exsecting a portion 
 of the thyroid cartilage. 
 
 The operation of laryngotomy is an old one; it is mentioned 
 by writers of the seventeenth century; and in the eighteenth 
 
 ( 1069 ) 
 
1070 LARYNGOTOMY. 
 
 ceiiuuy it is mentioned by Detluirdini;-, of Rostock; also by Vic 
 d'Azyr and Sabatier in France. The operation referred to by 
 these writers was that in which an opening was made into the " 
 larynx through the crico-thyroidean space. The authority who 
 merits special credit for the advocacy of laryngotoniy in the 
 eighteenth century was Desault, whose intelligent hand also 
 advanced other sections of surgery. One finds in the first half 
 of the present century the records of a number of cases of laryn- 
 gotoniy: the operators were German, French and Fnglish ; and 
 the work was chiefly done for the removal of foreign bodies 
 which had entered and lodged in the larynx, usually, in tlie 
 ventricle of Morgagni. Thus needles and the seeds of cherries 
 and plums, were extracted. 
 
 The first operation of thyreotomy recorded was performed by 
 Brauers, who opened the cartilage for the removal of an intra- 
 laryngoal growth; tlie patient recovered and lived twenty years 
 afterwards. 
 
 Laryngotomy was done by Larrey in his experience as mili- 
 tary surgeon, for relief in gunshot wounds of the larynx: he 
 operated but a few times, and on the whole with doubtful result. 
 The operation was done twice by G. Buck, of New York. 
 
 Laryngotomy has been done for the following purposes: for 
 tlie removal of foreign bodies which have lodged in the larynx, 
 as aid in certain injuries of the i)art, for relief of laryngeal 
 stricture, and to,prepare a way for the removal of intra-laryngeal 
 growths. 
 
 As before mentioned, wliether the relief for the exigencies 
 enumerated may best be done by a route incised througli the 
 laryngeal wall; or whether the way proposed by nature is the 
 better one, is an unended contest between the surgeon with his 
 scalpel, and the laryngoscopist; with his mirror and forceps, the 
 latter justly occupies the greater part of tlie field, yet the general 
 surgeon holds a portion of it, and will continue to do so: and 
 when the controversy is ended, the two should occupy this 
 ground in common, and remain mutual allies of each other. 
 
 The most ordinary object for which laryngotomy, for a long 
 time, was performed, was the removal of some body lodged in 
 the larynx. As a preliminary aid in this case, to get immediate 
 relief for the pressing demand for breath, tracheotomy should be 
 done; and even though the dyspnoeic symptoms are not great, it 
 is well to first open the trachea, and introduce a canula; for thus 
 doing, the surgeon forestalls the possible emergency in which 
 
LARYNGOTOMY. 1071 
 
 the shifting of the foreign body may induce a fit of strangling, or 
 fatal suffocation. 
 
 Also, through the tracheal opening it is sometimes possible 
 to pass an instrument upwards into the larynx and dislodge the 
 body; and for this a convenient instrument is a soft, flexible 
 sound: the urethral sound of India rubber or gutta percha may 
 be emplo3^ed. In this manner the writer removed by the aid of 
 tracheotomy a large metallic body that had lodged in the larynx, 
 by forcing it upwards. As soon as the object was expelled, the 
 breathing was easy, and there being no need of a canula, it 
 was dispensed with, and the wound closed by sutures. 
 
 Should the attempt prove fruitless to thus force the body 
 upwards, or to extract it through the tracheal opening, then let 
 the tracheal wound be maintained patent by means of a pair of 
 dressing forceps, passed inwards and downwards, and then 
 opened ; then having lowered the patient's head, introduce the 
 nozzle of a syringe and throw a stream of water through the 
 larynx. If the head be well dependent, such a stream of water 
 will flow towards the pharynx and escape through the mouth or 
 the nostrils: the same as blood does in operations done in the 
 Rose position; that is, wdth the trunk raised and the head 
 lowered. In this way it is probable that a body which is lodged 
 in the larynx would be carried by the water into the oral cavity. 
 If the object be sharp-pointed, as a needle or a fish-bone, and 
 have become fixed by insinuating its point into the mucous 
 membrane, even then such a stream of water might dislodge and 
 carry away the object. And as this hydraulic washing would be 
 harmless, it should be tried before the more formidable procedure 
 of laryngotomy is resorted to. Another method akin to irrigation 
 would be to attach a piece of sponge to a thread and carry the 
 thread by means of a flexible tube through the w^ound upwards 
 through the larynx into the mouth ; then by traction on the 
 cord, the sponge could be drawn through the larynx; and in its 
 passage, it would probably sweep out any object lodged in the 
 canal. And finally, should these non-operative plans fail, then 
 a resort to thyreotomy would be permissible. 
 
 Thyreotomy, done for the removal of foreign bodies, has 
 generally proved a successful operation. Durham has collected . 
 a list of twelve cases, done for this purpose, which terminated 
 successfully; and in most of the patients the work done did not 
 injure the voice. 
 
 In case of wounds of the larynx from gunshot or other causes. 
 
1072 LAKYXGOTOMY, 
 
 laryngotomy may become necessary: but here, to insure a free 
 route for breathing, tracheotomy should first be done, and a 
 canula inserted. After this, the surgeon may leisurely {jrocecd 
 to treat the laryngeal wound, in which one of the main objects 
 is to replace dislocated fragments. Sometimes, the restitution to 
 form can be done througli the wound: and this may be enlarged 
 if the opening be too small for the introduction of probe, forceps, 
 or other instrument needed in the rectification of the fragments. 
 Where the wound cannot be thus utilized, then, as Eichenmann 
 has done, an incision may be made through the crico-thyroid 
 ligament and the lower part of the thyroid cartilage; and thus 
 reposition of fragments can be effected. For retention of the 
 fragments in proper site, a T-shaped canula may be used: and 
 this is to be constructed of two rectangular sections of which 
 each can be introduced separately, and when united, a canula is 
 formed of tliem, of which one portion lies vertical, reaching 
 above and below the laryngeal wound, while the horizontal part 
 traverses and reaches beyond the laryngeal wall. One part of 
 this ingeniously contrived instrument can be removed, while the 
 other remains in site. This instrument must be maintained in 
 its place for a number of weeks, until the injured larynx has 
 healed : for if it be removed prior to healing, then cicatricial 
 contraction can occur and interfere with voice and respiration. 
 
 Injury of tlie interior of the larynx from the entrance of 
 caustic liquids, as acids, or alkalies, as well as from boiling water, 
 according to Durham, becomes an indication for thyreotomy. 
 The laryngoscopist would claim that these cases lie within his 
 domain : and always in the adult the non-operative course should 
 first be tried; and should this fail, the more radical way remains 
 open to the surgeon. But iu. case of children, who are the usual 
 subjects of such laryngeal injury, the laryngoscopist would find it 
 hard to carry out his treatment. In such patients, tracheotomy 
 should first be done; and then through the tracheal fenestra, the 
 conservation of the calibre of the laryngeal passage might be 
 accomplished by the passage from below upwards of an elastic 
 sound: and if a stricture has already formed, then the writer 
 suggests that through the tracheal opening dilating sounds 
 might be passed, and the calibre finally enlarged to satisfactory 
 dimension. If an opening into the air-passage be made by 
 crico-tracheotomy, then through this sub-laryngeal route, the 
 treatment referred to could easily and successfully be carried out; 
 and when the laryngeal > canal is restored, then the tracheal 
 
LARYXGOTOMY. 1073 
 
 wound could be closed. But in case the stricture has already 
 formed, then the narrowed calibre can often be restored by 
 gradual dilatation, by means of instruments introduced through 
 the mouth and throat: and this work, to be effective, must be 
 done with infinite gentleness and patience; for the laryngologist 
 and the urethral surgeon have both learned that a narrowed 
 canal cannot be hastily restored to normal calibre, and that the 
 compressive action of tlie instrument, gently manipulated and 
 long used, finally causes absorptive action in the encroaching 
 wall. Should this plan be impracticable, or, for some cause, not 
 be feasible, then tracheotomy must be done, and a canula worn 
 until healing has taken place: and when this has taken place, 
 it will be necessary afterwards to practice endo-laryngeal dila- 
 tation. 
 
 And finally, as indication for laryngotomy is the presence of a 
 neoplasm within the larynx. Until recently, it was not thought 
 possible to remove such growth in any way, except to open a 
 route to it with the knife: but the increased adroitness of the 
 laryngoscopist, in discovering and attacking such neoplasm by 
 the bloodless endo-laryngeal way, has rendered a resort to the 
 surgical method a rarer procedure than formerly. Bruns, a 
 partisan of the former method, has collected, within a period of 
 twenty-five years, one thousand cases of laryngeal tumor, removed 
 by the endo-laryngeal method: and during the same time, there 
 were but one hundred operations in which the removal was 
 done by opening the larynx. These statistics show that the 
 laryngoscopic plan is greatly in the ascendant: nevertheless, 
 the better method to be pursued in the removal of these growths 
 will be indicated by their location in the larynx, and by their 
 nature: for in certain locations, the neoplasm is nearly or quite 
 inaccessible by the natural way; and, if it be of malignant 
 character, its extirpation could be less radically done by this 
 method, than by laryngotomy. 
 
 Bruns studied the location of the endo-laryngeal growth in 
 eleven hundred cases, and he finds that in eight hundred and 
 thirty-six, or about seventy-six per cent of the cases, the 
 neoplasm was on the vocal cord, or the anterior commissure 
 of the glottis: and this location is favorable for the removal by 
 the laryngoscopist. But if the growth be seated below the vocal 
 chords, or if seated within the ventricle of the larynx, then the 
 work should be done by laryngotomy. Such cases, however, are 
 rare. Again, if the growth be of malignant character, then its 
 
1U74 LAKYNGOTOMY. 
 
 removal can be far more effectually done by thyreotomy, in 
 which the neoplasm being cx{)osed to view, its removal can be 
 more accurately and safely done. 
 
 The determination of the nature of the growth is not an easy 
 matter: the microscope is not a faultless mentor: that its state- 
 ment is frequently erroneous is a fact which has fallen within 
 the writer's observation, a number of times: and no more striking 
 example can be cited than the case of the late Crown Prince of 
 Germany, in whom the microscope gave a report that proved to 
 be erroneous, though it was in the hands of the ablest micros- 
 copist and pathologist of the century. The truth is, that 
 infinite training and experience cannot always warrant infalli- 
 bility in this work; the eye may wrongly see what is within the 
 visual field. And, further, connective tissue and ci)itlielial cell 
 and intercellular elements do not always conform to the schematic 
 framework which the pathologist has constructed for them. 
 Nature delights in variation, and rigorously eschews the thral- 
 dom of uniformity; no two hands are alike; no two vascular 
 systems agree in disposition: slight difference or abrupt anomaly 
 occurs ; and so no two specimens of epithelioma or sarcoma are 
 identical; the bounding line inclosing one group of cells in one 
 specimen would not geometrically fit those of another specimen 
 of identical nature. The indefinite bounds between fibroma and 
 sarcoma, and between the latter and carcinoma, will often cause 
 hesitation, and interfere with accurate diagnosis. Should the 
 evidence in favor of malignancy predominate, then the only hope 
 of cure depends on thorough removal of the growth; and for this 
 purpose laryngotomy offers many advantages over the other 
 method. The removal should be complete; suspicious tissue 
 should not be spared; and if partial removal does not promise a 
 cure, then extirpation of the entire larynx should be done: it is 
 only by proceeding in this way, that the surgeon can offer his 
 patient a hope of immunity from recurrence. 
 
 The sessile or pedunculated form of the growth determines 
 the difficulty or facilit3Mn the removal of the laryngeal neoplasm: 
 thus, the growth with footstalk can easily be plucked from its 
 nutrient ground; and such a case is well suited forendo-laryngeal 
 extraction ; but when it is sessile, and especially if the growth 
 be of multiple form, the laryngoscopist must travel the tiresome 
 way countless times, before he brings away the final fragments 
 of the growth. 
 
 If one compares the endo-laryngeal with the extra-laryngeal 
 
OPERATION OF LARYXGOTOMY. 1075 
 
 method, in respect to the chance of impairment of the voice, a 
 preference may be claimed for the latter: for tiie operator has, 
 when the larynx is opened, directly under his eye, the parts 
 which are to be removed, and hence he can do it without peril 
 to the vocal chords. The surgeon sometimes finds an irregularly 
 formed thyroid cartilage : one side may project further beyond 
 the median line than the other, and thus there is danger of 
 injuring the vocal chords at their anterior insertion, whether the 
 section be done from the inside or the outside. Again, it some- 
 times occurs that in healing the two halves do not unite symmet- 
 rically; or the closure may take place by loose ligamentous 
 tissue, and then the vocal chords lacking firm insertion in front, 
 their function may thus be impaired. Hence, as seen, phonic 
 impairment may follow the work of thyreotomy. The perils 
 which menace the voice are less when the operation is limited to 
 partial laryngotomy ; that is, when the growth is reached by an 
 opening above or below the thyroid cartilage. 
 
 Thyreotomy has an advantage over the endo-laryngeal method 
 in this, that the treatment is concluded in a shorter time in the 
 former. Of forty-four cases of laryngotomy, healing occurred in 
 nearly half of them within one week; and in nearly all of the 
 remaining cases, the patients were well within two weeks. In a 
 few cases, by the endo-laryngeal procedure, the work may be 
 concluded instantaneously, yet when the tumor is less favorably 
 situated for removal, weeks and even months may be required to 
 effect complete extirpation. 
 
 Operation of Laryngotomy. — In many cases it is prudent to 
 precede laryngotomy by tracheotomy; and, as additional aid, 
 the air-passage may be tamponed above the canula. If the 
 vertical division of the laryrix be carried below the thyroid 
 cartilage, then the canula may rest in the lower part of the cut, 
 that is, in the crico-thyroidean space. But, as a rule, it is better 
 to make a separate opening in the trachea for the canula: and 
 then above this, a tampon may be introduced, and allowed to 
 remain for two or three days. 
 
 In the operation of laryngotomy, to reach the larynx but a 
 thin stratum of soft parts requires to be divided; the prominence 
 of the larynx lies just underneath the skin. If thyreotomy be 
 done, no vessel is imperiled unless the knife carelessly stray 
 beyond the proper field of work. Only in case it be necessary to 
 extend tlie cut into the crico-thyroid, or thethyro-hyoidean space, 
 "would the vessels there be endangered. And then such vessel 
 
1O70 LAKYXGOTOMY. 
 
 should be tied. Another element of embarrassment is an abnor- 
 mal development of the thyroid gland: this gland may have a 
 middle lobe reaching upward on the thyroid cartilage. Should 
 this be present, and it not be possible to deflect it aside with the 
 blunt dissector, then the glandular structure should be circum- 
 scribed by ligature at two points, and division done between the 
 ligatures. 
 
 The patient to be operated on should rest on a bed or table 
 where he is accessible on each side; and a cushion must be placed 
 under the shoulders, so as to render prominent the field of 
 operation. 
 
 The instruments required in the work are the following: 
 scali^el, two retractors similar to those used in tracheotomy, a 
 fine saw, scissor-shaped forceps, needles, silken thread, sponges 
 and a canula. 
 
 The work commences with simple tracheotomy: and if 
 thought necessary, through this tracheal wound a sponge may 
 be introduced, and the trachea plugged well, just above where 
 the canula is to lie. This preliminary being concluded, the 
 thyroid cartilage is next to be reached and exposed by an 
 incision in the median line. The cartilage being in view, the 
 manner in which it may be opened will be determined by the 
 age of the patient. For example, in the youthful subject, the 
 cartilage can readily be divided with a strong knife, and this can 
 be dune, in the median line, from before backwards. If the 
 cartilage has become partly or wholly ossified, as is the condition 
 in the old subject, then the division is not so easily done. The 
 instrument for the work may then be a fine, narrow-bladed saw, 
 such as is used in resection of bone; or a strong knife, if wielded 
 by a strong hand, will answer the purpose. And such ossified 
 cartilage is divided from the outside inwards, by some operators: 
 others divide from within outwards; and in this case, a probe- 
 pointed knife is used. To use the blunt knife, let an opening be 
 made at the upper or lower border of the tliyroid cartilage, in 
 the median line; and through the opening insert the knife and 
 then make the division from behind forwards. This is the 
 method devised by Sclmller and Hueter. If the small saw is 
 used, its track should first be prepared by a division of the 
 mucous membrane with the knife. Instead of knife or saw, the 
 section may be made with narrow-bladed bone forceps, or with 
 strong narrow-bladed scissors. 
 
 After this division of the thyroid cartilage, should the space 
 
OPERATION OF LARYNGOTOMY. 1077 
 
 exposed be found insufficient to do the work intended, then the 
 section of the parts may be continued upwards, or downwards- 
 and in the latter direction, the cricoid cartilage may be severed. 
 And after this complete laryngotomy, or after the division of the 
 thyroid cartilage, should the space be inadequate for the removal 
 of the laryngeal growth, or too small for any other purpose for 
 which the opening is done, then a portion of one or both sides of 
 the thyroid cartilage may be exsected. Such exsection was done 
 by Heine; and his plan is as follows: after the median cutane- 
 ous incision has been made, and the cartilage having been 
 reached has been divided vertically, then let the cartilage be 
 freed from its lining, both internally and externally, and next, 
 with strong scissors or resection forceps, remove the required 
 portion of cartilage. 
 
 The excision of a portion of the thyroid cartilage may enable 
 the operator to enter the larynx and do his work without further 
 division of the parts: that is, a window may be made at a point, 
 which the laryngoscopic examination indicates will render the 
 growth most readily accessible to the surgeon; and as this may 
 be at the lower or upper margin, so a corresponding cut is to be 
 made, the larynx uncovered of its soft parts, and then a portion 
 of the wall is excised. The location of such opened fenestra 
 should be such as not to interfere with the vocal chords. 
 
 According to the purpose for which the laryngotomy has been 
 done, so will the operator proceed when the cavity has been 
 opened: whether the case be one of neoplasm, of stricture, or of 
 dead cartilage, the surgeon should bear in mind that his work 
 should be well and thoroughly done: so completely done that 
 there will be no occasion for another operation. Still a lar3a]got- 
 omy has been done a second and even a third time, on the same 
 patient: but it were better, for both patient and surgeon, that the 
 work should be so fully done as to exclude such future contin- 
 gency. 
 
 How the wound is to be closed has been a matter of disagree- 
 ment among surgeons : some favor and others oppose closure by 
 suture. Against the use of the suture its opponents urge that it 
 may cause emphysematous infiltration of air in the wounded tis- 
 sues; also, that the suture may be the cause of necrosis in the 
 cartilage. Krishaber reports such emphysema in a case in which 
 suture was used. That the ill which may arise from suture has 
 been magnified, is apparent from the results obtained in thirty- 
 five cases so treated : in twenty-nine of these, the wounded carti- 
 
1078 LARYNGOTOMY. 
 
 lage united by first intention; and only in five of the cases was 
 the healing prolonged by suppuration. 
 
 Where suture is used for closure, silk or wire may be 
 employed : the author would use silver wire, in case it is intended 
 to penetrate the entire thickness of the cartilage. But in case 
 merely the lining membrane of the cartilage is traversed, then it 
 is immaterial whether silken or metallic suture be employed. In 
 case steady fixation of the parts can be made by simply including 
 the perichondrium, it should be done in this manner: and expe- 
 rience has shown that this superficial suture suffices. After the 
 laryngeal wound has been closed, the wound in the skin and 
 soft parts must be closed by more superficial sutures. 
 
 Closure of the wound can often be satisfactorily done without 
 the use of sutures, namely, by adliesive strips placed transversely 
 across the part; and these may be aided by compresses laid on 
 each side, and the whole retained in place by means of a bandage 
 around the neck. 
 
 The canula inserted in the preliminary tracheotomy should 
 remain in place in children for a time varying from a few days 
 to some weeks: thus doing, one guards against respiratory 
 obstruction through intra-laryngeal swelling. In the adult, it 
 is sometimes necessary to let the instrument remain in place 
 many weeks: and in some cases it has been found necessary to 
 let the canula remain in j)osition for months, and sometimes for 
 years. The prolonged use of the canula is required in the adult 
 in whom the endo-laryngeal growth may so(5n recur, and sud- 
 denly obstruct the air-passage. 
 
 In concluding this cliapter upon laryngotomy, the writer will 
 formulate as a rule of guidance, that in all cases in which the 
 operation is contemplated, a consultation should be held between 
 the laryngoscopist and surgeon, and if in the opinion of the 
 former, the case can surely, or even probably, be successfully 
 treated by the endo-laryngeal method, then the latter should be 
 pursued: but incase this method be deemed impracticable, or 
 have failed in its purpose, then the case should be committed to 
 the surgeon, and one of the methods heretofore described, be 
 pursued. 
 
 INTUBATION. 
 
 About 1858, Bouchut advised as a substitute for trache- 
 otomy, the introduction of a tube or canula into the larynx. 
 In 1859, Trousseau who had gained great eclat by his successful 
 
INTUBATIOX. 1079 
 
 operations in tracheotomy, and was the leading champion of this 
 operation, violently opposed the new procedure of Bouchut. 
 Trousseau founded his opposition on the observations of dogs, in 
 which such tube was introduced into the larynx, and worn for 
 some days, with the result that the tube caused ulceration of the 
 glottis, and if it were to remain long in place Trousseau claimed 
 that it would cause necrosis of the larynx. The high authority 
 of Trousseau, and the general antagonism of the medical profes- 
 sion in Paris to Bouchut, prevented the adoption of intubation as 
 a method of relief in croup and diphtheria. Bouchut, though 
 deprived of his well-merited honor, lived to see the method 
 revived and adopted in the New World. 
 
 In 1870, Weinlechner, of Vienna, resorted to intubation in the 
 treatment of croup and diphtheria. He first tried the plan of 
 passing a solid sound into the air-passage, and with this, he 
 attempted to remove the impediment existing there : and this 
 failing to relieve, he next passed a tube that was closed by an 
 obturator, and when introduced, the latter was removed, and the 
 tube allowed to remain. So much benefit was derived from this 
 procedure that Weinlechner recommends that it be tried before 
 tracheotomy is resorted to. Besides in croup and diphtheria, he 
 recommends tubage in oecleraa of the glottis, laryngo-spasmus, 
 as])hyxia, stricture of the larynx or trachea, and foreign bodies 
 in the air-passages. 
 
 Despite the attempts to substitute tubage or intubation, as it 
 is now generally named, for tracheotomy, the procedure fell into 
 disfavor and was soon abandoned. In 1884 it was again called 
 to life by Dr. Joseph O'Dwj^er, to whom more credit is due than 
 to an originator, since in his work he has reclaimed a procedure 
 that had twdce or thrice been tried and rejected. O'Dwyer's 
 early attempts were not crowned by remarkable success; yet it 
 was enough to direct the attention of the profession to the method, 
 and to enlist a few followers. Among those who adopted and did 
 much to popularize the procedure may be mentioned Dr. Wax- 
 ham, of Chicago, and Dr. Dillon Brown, of Xew York. Early in 
 1885, Dr. Waxham, an ardent advocate of intubation, read a paper 
 on the subject, before the Chicago Medical Society; and later in 
 the year, he read another paper, in which were detailed the 
 results obtained in a few cases. Some improvements had been 
 made in the instruments first employed. Dr. Byford also praised 
 the method, for its simplicity, safety and the immediate relief 
 obtained; and another strong point in its favor is that the opera- 
 
1080 LARYNGOTOMY. 
 
 tion is less objectionable to i^arents than that of tracheotomy. 
 About the same time, O'Dwyer reported two successful cases, in 
 which the tube had been worn ten days. No oedema of the 
 larynx was caused by the tube. In very young children he coun- 
 sels to occasionally remove the tube and cleanse it. 
 
 In 188G, Dr. Dillon Brown, of New York, having collected 
 eight hundred and six cases of intubation, read a paper on the 
 subject before the New York Academy of Medicine. The num- 
 ber of medical men who had employed the procedure were sixty- 
 five ; the recoveries obtained were two hundred and twenty-one, 
 that is, about twenty-seven and five-tenths per cent. The average 
 age of those who died was three years and two months; and of 
 those who recovered, a little over four years. The average dura- 
 tion of the laryngeal trouble, before the introduction of the tube, 
 in those who died was one day and nineteen hours; and in those 
 who recovered it was two days and nine hours. The usual cause 
 of death was the passage downwards of the diphtheritic disease. 
 The advantages claimed by Brown for intubation are that the 
 operation is bloodless, the air in breathing is admitted through 
 the natural route, there is no shock, and the procedure incurs no 
 opposition from the parents or friends of the child. 
 
 Northrop has made post-mortem examination in one hundred 
 and seven cases in which intubation had resulted unsuccessfully. 
 In a few cases, the lower end of the tube had caused ulceration 
 of the trachea. 
 
 Huber found that after the introduction of the tube, it might 
 be coughed up; and even coughed up and swallowed. The tube 
 may also become closed with false membrane. In swallowing 
 food, particles of matter may enter the tube, and, passing down to 
 the lungs, become the cause of pneumonia. Huber saw ulcera- 
 tion and bleeding caused by the tube. Swallowing is difficult; 
 and sometimes the breathing is suddenly arrested. And the 
 most improved forms of the tube have not guarded against the 
 troubles mentioned. 
 
 The instruments used by O'Dwyer for intubation, shown in 
 the accompanying figure, are the following: assorted tubes (A), 
 varying from small to large; an applicator (D) or instrument 
 which is attached to an obturating stem, and by the aid of which 
 the tube is inserted into the larynx; a gag (C) for holding the 
 jaws asunder, and the mouth open; an extractor (E), by the aid 
 of which the tube (A) is seized and withdrawn; and a gauge (B) 
 for admeasurement. 
 
INTUBATION. 
 
 1081 
 
 Of the tubes there should be five of differmg calibre, and 
 lengths varying from one and three-fourths to two and a half 
 inches. The tube lias attached to it a silken thread by which it 
 is held and withdrawn, if in the work of insertion it is not prop- 
 erly placed: but when the insertion is properly done, the loop of 
 the thread is cut, and the latter removed. 
 
 In the work of introducing the tube, the hand of the opera- 
 
 FiGUEE 106. Exhibiting O'Dwyer's instruments for intubation. 
 
 tor should have previous training on the cadaver; for to attempt 
 the introduction without some preliminary training, will be 
 attended with much bungling effort, and may end in failure. 
 The index must be taught to recognize the hard cartilaginous 
 entrance into the larynx, and to distinguish this opening from 
 that of the gullet : for the mistake oftenest occurring in the intro- 
 duction is to place the tube in the oesophagus, instead of in the 
 larynx: yet by means of the tethering thread, the tube can be 
 drawn back and replaced again. 
 
 The fear was entertained for a time that the tube might slip 
 downwards through the glottis into the air-passages; to avoid 
 this the tube is now provided with a larger shoulder around its 
 mouth. And, as Ingalls remarks, even should the tube pass down 
 into the air-passages, its length is such as to prevent it escaping 
 so far that it could not be reclaimed through the natural route; 
 or, this failing, it might be removed by tracheotomy. The 
 length of the tube is such that it reaches to within one inch of the 
 bifurcation of the trachea. 
 d9 
 
iOS2 LAKYXGOTOMY. 
 
 The applicator and the obturating appendage are to be 
 attached, and then the tube being placed on the former, the 
 instrument is ready for insertion. 
 
 To introduce the tube, let the child be held in the nurse's lap 
 wrapped about with a cloth that securely incloses tlie arms. An 
 assistant firmly holds the head turned backwards, while the gag 
 is introduced, well back on the left side of the mouth. The 
 surgeon sitting in front passes his left index finger into the 
 throat behind the epiglottis and seeks for the opening into the 
 larynx; and holding the finger there he guides the tube along 
 its palmar surface, into the glottis. When the tube has been 
 inserted to its shoulder, a slide on the applicator is pushed 
 against the latter, and then the applicator being withdrawn, the 
 tube is left in the destined position. In this work of insertion, 
 O'Dwyer advises to commence with the handle of the applicator 
 near the child's breast, and then gradually to lift the handle as 
 the introduction advances; thus elevating well the handle, there 
 is less danger of slipping the tube into the oesophagus. As soon 
 as the tube has been introduced, after the obturator and appli- 
 cator have been extracted, the child wall soon breathe easier. 
 
 Should the tube become obstructed with mucus or false 
 membrane, it must be removed with the extractor, cleaned and 
 re-inserted. As a rule, the tube should be removed as early as 
 the fifth day, and a test made of the patient's condition; and 
 should breathing remain free, the tube may be dispensed with; 
 but should dyspnoea reappear, then the tube must be inserted 
 again. 
 
 A critical contingency sometimes occurs during the wearing 
 of the tube, viz., that the latter is expelled by coughing : and at 
 the time of such accident, if the surgeon is not present to replace 
 the instrument, the patient may be lost: and hence, here, as in 
 case of tracheotomy, there must be ever at hand an assistant or 
 nurse, who is capable of meeting the emergency; and such an 
 aid, if not a medical man, should be someone who has had 
 medical training, and especially in the work of inserting the tube- 
 
 Ingalls, an early reporter on intubation, selects the following 
 cases as pro})er fur its use : — 
 
 1. In diphtheritic and croupous stenosis of tlie larynx in 
 children under three and one-half years of age. 2. In cases of 
 these affections in which the surgeon, from any cause, desires to 
 defer tracheotomy. 3. In thpse cases in which consent to tra- 
 cheotomy cannot be obtained. 4. Those cases in which proper 
 
INTUBATION. 1083 
 
 nursing cannot be obtained. 5. Severe cases of spasmodic 
 croup in children less than ten years of age. 6. Simple 
 stenosis of the larynx, not diphtheritic, in children. 7. With 
 tubes of proper size it might be of value in the treatment 
 of various forms of laryngeal stenosis in adults. He intimates 
 that a formidable risk in intubation is the coughing out of the 
 tube, in the absence of any one who could re-insert it. Ingalls 
 thinks intubation is especially suited for small children, since in 
 these tracheotomy is usually unsuccessful. As large a tube as 
 possible should be used, since one of less than one-fourth of an 
 inch in diameter does not permit enough air to pass to main- 
 tain life. 
 
 Casselberry thinks a part of the success of O'Dwyer's proced- 
 ure depends on the use of a long tube: the short tube employed by 
 Bouchut rendered it difficult to be used, and caused the method 
 to be abandoned. Casselberry fears that trouble will arise in 
 feeding children who are the subjects of intubation; and that 
 when the food is liquid, some of it will enter the air-passage. 
 On this point, Parkes thinks there will not be much difficulty if 
 a tube be so selected that it will fit well, and permit the epiglottis 
 to close well over it in swallowing. 
 
 According to Northrop, the beginner in the practice of intuba- 
 tion is apt to use too small tubes, with the result that such are 
 coughed up. He says there is no risk of the instrument slipping 
 down into the trachea, since the head of the tube cannot pass 
 beyond the cricoid cartilage, where the narrowest portion of the 
 passage is situated. He cautions against premature removal of 
 the tube. After the removal of the tube, whether it will be 
 necessary to re-introduce it, will depend on whether the air canal 
 remains free from obstructing membrane, or the lungs continue 
 unaffected. The re-appearance of pseudo membrane demands 
 re-insertion of the tube; and if ausculation shows that the lungs 
 are becoming impeded in their work, then the tube must be used 
 again. The pulse gives some information; its rapidity corre- 
 sponding with pulmonary implication is an indication for intuba- 
 tion. The objection is urged sometimes that in the insertion of 
 the tube, false membrane may be pushed before it and occlude 
 the tube; the same, according to Northrop, applies also to 
 tracheotomy. Intubation has the advantage over tracheotomy, 
 that it can be done without an anaesthetic. Another advantage 
 which it has is, that the air enters the mouth and is warmed and 
 moistened before it enters the lungs. 
 
1084 LARYXiiOTOMY. 
 
 Xear the close of the year 1893, Waxham reported the results 
 of intubation in four liuntlred and sixty-six cases: in the first 
 one hundred there were twenty-seven recoveries; in the second 
 one hundred, thirty-four recoveries; in the third one hundred, 
 forty recoveries; in the fourtli one hundred, thirty-eight recov- 
 eries; and of the last sixty -six cases, twenty-two recovered. The 
 assertion that intubation is done early, and hence is more success- 
 ful than tracheotomy, Waxham denies: for in many of the cases 
 which he reported, it was done late, when the child was moribund 
 and unconscious: and in many patients to which he was sum- 
 moned, the children were dying, and expired before anything 
 could be done. The cases reported were not selected ones, but 
 were of ages varying from early infancy to much older children, 
 and had been treated by physicians who had tried unsuccessfully 
 to relieve the patients by other means. And many of them were 
 among the poor and destitute and were badly nursed; even under 
 such conditions, the results obtained were very satisfactory. 
 
 The instruments employed were an improvement on those 
 originally introduced : the introducer could be used more readil}'^; 
 the obturator was not jointed, as it was in the original form. 
 The instruments were purely metallic; and also the case which 
 contained them, so that all could be washed in hot water, and 
 rendered aseptically free from the bacterial virus with whicli 
 they must come in contact in the treatment of croupal or diph- 
 theritic disease. 
 
 At the sixty-fifth meeting of the Association of German 
 Naturalists and Physicians, lianke, in the section of diseases of 
 infants, made an exhaustive report on intubation; and drew a 
 comparison between intubation and tracheotomy. The figures 
 presented by those who engaged in the discussion varied much 
 in regard to success: and this is explained as de|)endent on the 
 benign or malignant type of the diphtheritic disease, for whicli 
 the tubage was done. In the cases reported, the procedure was 
 only resorted to when the larynx had become so occluded with 
 false membrane that tracheotomy would have been necessary to 
 prolong life, if intubation had not been done. All cases, without 
 reference to age, were operated on, and the whole number reported 
 amounted to twenty-five hundred. 
 
 The cases operated on were classified as those of primary and 
 those of secondary diphtheria; in the former, the recoveries from 
 intubation were thirty-nine ])er cent; while from the latter there 
 were twenty-two and three-tenths per cent of recoveries. Of one 
 
INTUBATION. 1085 
 
 thousand three hundred and twenty-four cases of primary diph- 
 theria in which intubation was done, it was afterwards necessary 
 to perform tracheotomy in two hundred and fort3'-two patients; 
 and of these over eight per cent w^ere saved; and that a greater 
 number was not saved arose from the disease having descended 
 into the bronchi. 
 
 Ranke thinks that intubation is especially suited for the 
 country practitioner whose surgical skill is insufficient to perform 
 tracheotomy. He thinks that in the country there might be 
 saved twenty-five per cent of diphtheritic patients, which ordi- 
 narily die. 
 
 In instituting a comparison between intubation and tracheot- 
 omy, the number of recoveries obtained by the two methods is 
 about equal. In children under two years of age, there are more 
 recoveries by intubation than by tracheotomy; hence, intubation 
 should be done in the very young. 
 
 In cases of diphtheria in which the membranous formation is 
 very extensive, and the pharynx is much swollen, Widerhofer 
 advises tracheotomy; also, to avoid ulceration from the tube, in 
 cases in which this must be carried for more than five days, he 
 advises that intubation should be followed by tracheotomy. 
 When the membranous formation extends downwards towards 
 the lungs, only in very strong children should tracheotomy be 
 resorted to as subsidiary aid. In the course of intubation, should 
 asphyxia suddenly appear, tracheotomy should be done: for 
 through the tracheal incision, the surgeon can often extract the 
 false membrane; or the laryngeal tube being removed, the 
 patient is able to cough out the membrane. 
 
 The general opinion expressed by the German physicians was 
 that intubation is a valuable procedure, and that, by it, the 
 prediction of Malgaigne will be fulfilled, viz., tubage will one day 
 bring as great a revolution in the treatment of croup as lithotrity 
 has brought in the treatment of vesical calculus. 
 
CHAPTER XXXIII. 
 
 JiXTIRPATION OF THE LAKY>'X OR OPERATION OF LARYNGECTOMY. 
 
 The removal of the larynx by the knife, was suggested some 
 time before it was done; and the final realization of this bold 
 procedure was rendered possible by experiments on the dog. In 
 1870, it was proved from operations on the dog by Czerny, that 
 the larynx could be removed, and the animal continue to live: 
 and his results justified him in believing that the operation could 
 also be safely done on man. Long prior to Czerny's work, Albers 
 in Bonn did similar work on the dog, with the object of deter- 
 mining wd] ether the animal could live without the larynx. And, 
 finally, when the operation had been done on man, other sur- 
 geons, and among them Yon Langenbeck, announced that they 
 had previously conceived its possibility, and had even planned 
 to remove the human larynx. 
 
 The first operation was done by Billroth in 1S73, who did it 
 for relief in a case of carcinoma of the larynx. In this patient, 
 laryngotomy had been performed to remove the endo-laryngeal 
 neoplasm; but four weeks afterwards, the growth reappeared, 
 when Billroth proceeded to dissect the larynx from the contigu- 
 ous parts, and having removed it, the patient was provided with 
 an artificial larynx by means of which he was able to talk. This 
 patient lived in fair health for some months, yet the carcinoma 
 returned, and death occurred about a year after the operation. 
 This operation, in which the larynx was removed and replaced 
 by an artificial appliance for phonation, attracted the eyes of the 
 surgical world: and it was believed that if the work were timely 
 done, the subject of laryngeal cancer might be rescued from 
 a malady, which had hitherto been regarded incurable: and ani- 
 mated with this hope, or inspired with the desire to be among 
 the first in this new field of daring, a number of surgeons has- 
 tened to repeat the new operation. Heine in Prague, Maas in 
 Breslau, and Bottini in Italy, reported each an extirpation. In 
 the case of Bottini, the disease was sarcoma; and after the 
 ( 1086 ) 
 
EXTIRPATION OF THE LARYNX. 1087 
 
 removal, the patient was attacked with erysipelas, which delayed 
 the recovery. The man finally became well and resumed his 
 former occupation as letter-carrier. The attack of erysipelas, 
 now regarded as antidotal to malignant disease, may have 
 stamped out all traces of the disease which had escaped the knife. 
 
 Since these pioneer operations, the extirpation of the larynx 
 has been announced in all parts of the globe, in which surgery 
 exists as a cultivated science and art. The published results, 
 though not flattering, have been sufficiently encouraging to give 
 this procedure an enduring place in surgical art. 
 
 Before having recourse to so radical a procedure, the surgeon 
 does wisely who first opens the larynx by a vertical incision in the 
 median line, and endeavors to remove the affected parts through 
 such an opening: in fact, in the history of laryngeal extirpation, 
 one finds that in many cases it has been preceded by thyreotomy, 
 by which the neoplasm being removed and having recurred at 
 an early period, the more radical procedure of total extirpation 
 has been done. And a proper rule for observance in cases which 
 have applied for relief early in the disease, is to first perform 
 thyreotomy; and should the disease afterwards recur, the surgeon 
 is justified in resorting to a more extensive operation: wliich may 
 be removal of one side, or the whole of the larynx. If it be pos- 
 sible to limit the ablation to one side, or one-half of the part, 
 the patient will be left in a much more favorable state for the 
 introduction of an artificial vocal apparatus, than if the whole 
 larynx be extirpated. Hence, from what has been said, the 
 extent to which the knife will proceed in laryngeal extirpation is 
 to be learned and decided on, as the surgeon proceeds with his 
 work: one-fourth, one-half, two-thirds, or the whole, as the con- 
 ditions denote and demand. 
 
 As stated, the operation is done for the removal of malignant 
 disease, viz., carcinoma or sarcoma ; and it is important to note 
 that the results of operations in the two are different: the pros- 
 pects of a removal securing future immunity, are much more 
 promising in sarcoma than in carcinoma; the latter has almost 
 always returned, while permanent cures have followed the extir- 
 pation of sarcoma. 
 
 As an adjuvant and prophylactic preliminary to extirpation 
 of the larynx, tracheotomy has been done by most operators: 
 thus certain provision for respiration during the work is secured. 
 Some operators have done this a few days prior to the extirpa- 
 tion ; and this plan seems to be a good one, since, thereby, famil- 
 
1088 EXTiurATiox OF Tin-: j>ai;ynx. 
 
 iarity with this unusual route of breathing is early acquired ; and 
 it is likewise claimed that there results from this wounding of 
 the cervical structures an adherence of the trachea to the sur- 
 rounding structures, so that it will not sink downwards, to much 
 extent, after the removal of the larynx. The site of the trache- 
 otomy must be as low as possible; for thus done, it will be 
 removed from the operative field ; and this low site offers another 
 important advantage, that it permits tamponing the passage 
 above the canula, so that no blood or subsequent excreta can 
 enter the air-passage, and generate pneumonic trouble. The 
 occlusive tampon of Trendelenberg was used in extirpation of the 
 larynx by Czerny, Heine, Wegner and others, and is advised by 
 them; others have operated on the patient placed in the Rose 
 position, and thereby diverted the passage of blood from the air- 
 passages. 
 
 In the absence of a specially devised tampon, the closure of 
 the upper end of the trachea can be done by means of sponge 
 which has been purified by immersion in alcohol diluted with 
 four parts of water: one or more pieces of sponge with cord 
 attached may be forced into, and made to fill tlje upper end of, 
 the trachea. Foulis, of Glasgow, successfully performed laryn- 
 gectomy ; and as tampon he used a large leaden tube, which 
 completely filled the trachea above the opening made in the 
 provisional tracheotomy, and was closed by India rubber in the 
 shape of a plate. This occlusion is done after the patient bus 
 been well anaesthetized. The operation of laryngeal extirpation 
 commences with an incision in the median line wdiich s'lould 
 begin at the hyoid bone, and be continued downwards to the 
 upper portion of the trachea. Through this longitudinal cut, 
 the larynx may be exposed by dissection, and the entire work of 
 removal done; other operators however have enlarged the oper- 
 ative field by intersecting the vertical cut by a transverse one. 
 Or to the longitudinal cut, two transverse ones may be made, so 
 that a lateral flap is formed on each side. The median longitu- 
 dinal cut has been found sufficient by many operators ; 3'et should 
 it be found inadequate as the work proceeds, then such sub- 
 sidiary incisions may be made, as the conditions found may 
 necessitate. 
 
 If the surgeon confines himself to the single longitudinal cut, 
 this must penetrate to the cartilaginous structures, when, by 
 means of the blunt dissector, the cutaneo-muscular tissues are to 
 be reflected laterally. In this dissection there will be encountered 
 
EXTIRPATION OF THE LAKYNX. 1089 
 
 above, the laryngeal arteries, penetrating the hyo-thyroidean 
 membrane; and below, the crico-thyroidean arteries which per- 
 forate the crico-thyroidean membrane. In each case, the vessel 
 is to be doubly ligated, and divided between the ligatures. By 
 following the surface of the thyroid cartilage, the middle cervical 
 fascia and the included muscles can be uplifted. The sterno- 
 hyoid muscles may remain unsevered; but thesterno-thyroid and 
 the thyro-hyoid muscles must be severed from their connection 
 with the thyroid cartilage. In these soft structures are contained 
 lateral lobules of the thyroid gland; and with care the nutrient 
 arteries of these parts need not be disturbed. 
 
 When the larynx has thus been separated from the soft parts 
 and exposed fully to view, then the removal may be done from 
 above downwards, or from below upwards; and each mode has 
 its advocates. 
 
 After exposing to view the larynx and upper part of the 
 trachea, the removal from below upwards commences by a trans- 
 verse cut between the cricoid and thyroid cartilages; and if then 
 the cricoid cartilage be found sound, it may be left, and the 
 thyroid and attached arytenoid cartilage may be pulled outwards, 
 uplifted and separated from the oesophagus, and tissues to which 
 they are adherent behind; and when the hyoid bone is reached, 
 the structures may be divided just below. In this separation, the 
 superior and inferior laryngeal nerve will be severed; an unim- 
 portant sacrifice, since the parts which these nerves innervate are 
 removed. Should any vessels be met in the detachment, these 
 should be carefully ligated. In regard to the epiglottis, authority 
 is divided respecting its removal, or retention : those who would 
 preserve it, claim that it would prevent the entrance of foreign 
 materials into the artificial larynx; on the contrary, Czerny and 
 Maas found that if it was retained, it fell into the artificial larynx, 
 and interfered with its proper action. Wegner, who removed the 
 larynx, preserved the epiglottis, and from his experience he 
 prefers this mode; hence, with eminent authority for and against 
 the procedure, it is probable that it is a matter of little import 
 which m.ethod is selected. When its ablation, complete or total, 
 is decided on, the part may be seized v/ith forceps and drawn 
 into the upper part of the cut, and then as much may be excised 
 as is desired. Should it be suspected that the epiglottis is affected 
 with malignant disease, it should be wholly extirpated, and even 
 the excision may encroach on the base of the tongue. 
 
 In whatever way the work be done, whether from below. 
 
100(> KXTIRPATIOX OF THE LARYNX. 
 
 Upwards, or I'roiii above downwards, it will be well to open the 
 larynx by a.longitudinal cut in front, through which an inspec- 
 tion can be made of the inner surface ; tlius a more correct notion 
 can be obtained of tlie isolation or diffusion of the disease. By 
 this means, both the upper and lower ends can be examined, and 
 thus the excision may extend as far as may be required. If it be 
 found that the cricoid cartilage is sound, it may be left in its 
 entirety: or, perhaps, a portion of it may be spared, and thus the 
 support for the vocal prothesis will be improved. 
 
 A troublesome complication may exist in the extension of the 
 disease to, and implication of, the oesophagus; and in such 
 condition it becomes necessary to extend the sphere of the opera- 
 tion, and to include the affected portion of the oesophagus. Such 
 removal must be thorough, since to leave a fragment of disease, 
 however small this might he, would not improve the patient's 
 condition. And such removal, interfering as it must with 
 normal deglutition, will cast an additional shadow on the patient's 
 future. If but a limited portion of the canal be implicated, then 
 it might be possible to excise a section, and then approximate 
 and effect an anastomosis between the remaining ends. If the 
 disease were so extensive as to prevent restoration of continuity, 
 then the affected part must be removed, and alimentation main- 
 tained by means of a tube introduced into the distal portion of 
 the remaining oesophagus. 
 
 In not a small number of cases observed, the oesophagus has 
 been the part in which the malignant neoplasm commenced; 
 and thence extended to the larynx. If such a case be early 
 recognized, it might be possible to remove the disease by an 
 exsection of the oesophagus, with the removal of a limited portion 
 of the larynx ; and in this case, if the excision of the oesopliagus 
 be extensive, then it would probably become necessary to nourish 
 the patient through a tube retained permanently in the cervical 
 opening. 
 
 Cases also occur in which the disease, commencing in, and 
 extending from the larynx, spares the ossophagus, but attacks 
 the parts situated laterally. When the disease is thus situated, 
 besides laryngeal ablation, the muscles and other structures 
 which are found implicated must be liberally sacrificed. 
 
 As appears from what has been stated, there is but little 
 uniformity in the local development of laryngeal cancer; and 
 the more favorite sites of the disease are indicated in tlie follow- 
 ing statistics of Ziemssen and others. In eighty-two cases, the 
 
EXTIRPATION OF THE LARYNX. 1091 
 
 disease began in the epiglottis in thirteen; in thirty-six, it was 
 unilateral, occurring seventeen times on the right side, and nine- 
 teen times on the left side. Of thirty-seven cases seen by Fauvel, 
 it was unilateral in all the cases except one; and in nearly all the 
 patients, the afifection was seated on the left side. 
 
 The limitation of the disease to a small part of the interior 
 surface of the larynx has led to thyreotomy, in which the carti- 
 lage being opened, the diseased part was removed. This conserv- 
 ative plan has usually been followed by recurrence; and hence, 
 to insure against a return of the disease, there should be a 
 thorough extirpation of the affected and suspected structures. 
 
 When the affection is unilateral in site, the work may be 
 limited to the removal of one side of the larynx. This partial 
 ablation has been done successfully by Billroth; the remaining 
 vocal chord sufficed for the function of voice; and thus the 
 necessity of an artificial larynx is dispensed with. The caution 
 here is proper, that there should not be too much economy in 
 the work of the knife, lest the uneradicated disease may reappear. 
 Every surgeon in the review of his operative work in the treat- 
 ment of malignant disease, has cause to regret such economy. 
 This statement is painfully supported by the personal experience 
 of the author. 
 
 After thorough excision of the diseased tissues the remaining 
 surface should be carefully inspected to determine whether all 
 traces of the disease have been removed; and if this has been 
 accomplished, the wounded surface should be sponged with a six 
 per cent solution of chloride of zinc. 
 
 The remaining treatment of the wound is a subject of discus- 
 sion among operators; as closure or non-closure of the cut-throat 
 has been a matter of contention among surgeons, so a similar 
 question has been mooted between the operators of laryngectomy. 
 Schiiller advocates the open or partially open treatment of the 
 wound, claiming that, thus proceeding, the surgeon is better able 
 to observe the progress of the healing, and to obviate or relieve 
 any intercurrent disturbance. If the wound be thus treated, the 
 opposite walls of the opening will advance towards each other so 
 that soon there remains a hollow canal, incompletely closed in 
 front; and this closure often proceeds so rapidly, that it becomes 
 necessary to reopen, and retard the rapid approach of the opposite 
 walls towards each other. In case, however, lateral flaps are 
 made, then partial closure should be made by means of one or 
 two sutures, which pass through the angles of the flaps, so as to 
 
1092 EXTIRPATION OF THE LARYNX. 
 
 fix and hold them in place. By this incomplete closure, there 
 will remain an intermediate opening sntticient for the purpose 
 just mentioned. It should be stated that in a case of successful 
 laryngectomy done by Bottini, he pursued the opposite plan: he 
 closed the wound completely by sutures. 
 
 If only a small opening be made in the pharyngeal or oesoph- 
 ageal wall, this should be closed. 
 
 If the trachea when severed were not fixed in some way, it 
 would descend and become buried and closed by the dermal 
 structures; to prevent this descent, the lower end should be 
 securely sutured in the wound so that it will remain in its site, 
 and not become closed ; and to insure patency of the trachea, a 
 canula should be introduced at once, and allowed to remain per- 
 manently in position. 
 
 Another important part of the operation is to make provision 
 for the alimentation of the patient; and this is done by introduc- 
 ing a tube through the wound which has opened the cesophagus, 
 and letting this reach to the stomach and remain permanently in 
 the canal: and around the tube, the w^ound can be packed with 
 aseptic lint or gauze. 
 
 The tracheal canula, through the aid of a tamponing accom- 
 paniment, or other occlusive means, should so fill the trachea 
 that no excreta can enter it; and to insure against such descent 
 of matter, the wound should be redressed daily. In this dressing, 
 the surface of the wound should be cleansed with alcoholized 
 water; and also the mouth should, at short intervals; be rinsed 
 with camphor water, or mint water. 
 
 Through the oesophageal tube, limited amounts of liquid 
 nutrient material must be introduced to the stomach ; such nutri- 
 ment may consist of soups, milk, wine-whey, milk with brandy, 
 and other articles of food of which the liquid character will per- 
 mit of introduction through the tube. Nutrition by the rectum 
 may also be resorted to; and for this purpose, pancreatinized 
 milk may be employed. 
 
 If the lesion of the pharynx or cesophagus be a small one, so 
 that it may close soon, then the tube for transmission of nutri- 
 ment may be passed through the mouth, and the patient thus 
 fed; thus proceeding, the healing may advance more rapidly. 
 After these operations, patients soon learn to swallow : difficulties 
 which were great at first, are gradually overcome. The base of 
 the tongue is drawn towards the ])osterior wall of tlie pharynx, 
 so that the food is carried through the faucial isthmus to its 
 
EXTIRPATION OF THE LARYNX. 1098 
 
 proper channel below. Long ago, the physiologist Longet deter- 
 mined by vivisective trial, that the dog deprived of the epiglottis, 
 soon learns to swallow food; and this fact has been corroborated 
 in the human subject, in whom, from ulcerative disease, the 
 epiglottis has been lost: the subject soon learned to swallow, 
 without strangling. 
 
 In the case operated on by Billroth, the patient was able to 
 swallow liquids after one week ; and after three weeks he could 
 swallow solids. The patient of Foulis swallowed fluids after five 
 days; and that of Bottini, after a short time. From the cases 
 observed, it is clear that the troubles apprehended from dyspha- 
 gia after laryngectomy have fortunately not been verified. 
 
 Total extirpation of the larjmx in the removal of the vocal 
 chords necessarily deprives the patient both of voice and articu- 
 lated speech: he becomes dumb; and thereby, is shut off from an 
 important part of the enjoyment of life. In the treatment of 
 criminals, condemnation to silence is one of the severest punish- 
 ments. Thanks, however, to surgical ingenuity, the operator who 
 takes from the patient his natural organ of voice, is able to give 
 him, instead, an artificial one: the deft hand of Vincent Czerny, 
 who gave surgical art this novel operation, gave, also, the yet 
 more novel device of the artificial larynx. In his operations on 
 the dog, Czerny introduced into the trachea a canula, in which 
 there was placed a vibrating metallic tongue ; and from this ger- 
 minal device, of which the action was first verified in the dog, 
 sprang a more complex appliance, designed by Gussenbauer and 
 made by a mechanician in Vienna, for use in a man from whom 
 Billroth had extirpated the larynx ; and this was successful in ena- 
 bling the man to talk in articulate speech. In language, the single 
 function of the larynx is the development of sound; this sound 
 is converted into articulated words composed of single or multi- 
 ple elementary sounds, by means of movements made by the 
 pharynx, soft palate, nostrils, inner walls of the cheeks, lips and 
 tongue: the last instrument, though it has given its name to 
 language, performs but a minor part in lingual function, since it 
 really shapes but three elementary sounds. For the restoration 
 of articulate speech after the removal of the larynx, it is only 
 necessary to restore the function of the latter by introducing in 
 its place a cord, thread or metallic tongue so fixed as to vibrate 
 in the current of expired air: and, what is remarkable and diffi- 
 cult of explanation, the coinage of words, though somewhat 
 uncouth, can be made bv a current of insoired air. The artificial 
 
1094 
 
 EXTIRPATION OP THE LARYNX. 
 
 larynx has for its office the generation of sound: its possessor 
 being given a sound, coins the hitter into the infinitude of forms 
 which compose speech. A number of such devices have been 
 contrived ; that of Gussenbauer was the first that was used in 
 
 man. 
 
 The artificial larynx of Gussenbauer, shown in Figure 107, is 
 composed of the following parts: a tracheal portion, a laryngeal 
 portion, and the apparatus for phonation. Tlie first and second 
 parts are made of hard rubber, while the vocal portion is made of 
 German silver. The tracheal portion is a long curved part, in 
 shape similar to the canula used in tracheotomy; and this is first 
 
 Figure 107. Sliowing the inferior of Gussenbauer's artificial larynx. 
 (From Schiiller.) 
 
 put in place, when the laryngeal part is next introduced into the 
 wound, corresponding to the site of the larynx; and then through 
 an opening in the latter, the part for phonation is placed, and is 
 similar to a drawer which can be moved inwards or outwards; 
 and this contains a metallic tongue which vibrates in the current 
 of passing air. This phonic section communicates above and 
 below with the laryngeal and tracheal portions; it also opens 
 externally; and hence when the instrument is in use, this latter 
 outlet must be closed. To the laryngeal portion there is attached 
 above and in front a movable valve, wliich is designed to act tlie 
 part of an epiglottis. This portion was afterwards found unnec- 
 
EXTIRPATION OP THE LARYNX. 1095 
 
 essary, and left off: since in swallowing, the base of the tongue 
 moving backwards can dispense with an epiglottis. • - 
 
 Hueter adapted an artificial larynx to a man who in attempt- 
 ing self-destruction, excised a portion of the larynx; this consisted 
 of a single canula, which was so bent as to be in bayonet form. 
 The tracheal portion was larger and narrower than the upper or 
 laryngeal portion; and in the latter there was a simple vibrating 
 tongue. At the junction of the two portions, the canula had an 
 opening through which passed the inspired and expired air: 
 and, when the subject desired to talk, this opening was shut so 
 that the expired air passed upwards and caused a vocal tone, 
 which could be shaped into articulate speech. 
 
 In the patient from which Foulis, of Glasgow, extirpated the 
 larynx, he simplified the matter by using only a tracheal canula, 
 in which he inserted a vibrating tongue; this tongue, drawer- 
 like, could be dravs^n in and out. In this device, the vibrating 
 tongue was so placed that the expired air came chiefly in contact 
 with the free end of the tongue. Foulis tried different materials, 
 in the construction of the tongue, such as vulcanite, iron, horn, 
 reed and metals. The tongue compounded of copper and silver 
 he found to be the one which yielded the loudest sound; yet 
 those from non-metallic material, though weaker, gave a sound 
 most nearly like that of the human voice. 
 
 The construction of the artificial larynx in the different 
 forms in which it has been made, has afforded ample opportu- 
 nity for the exercise of mechanical ingenuity; still, some difficul- 
 ties have been encountered in the work, which can scarcely be 
 said to have been wholly overcome; the one is the length of the 
 laryngeal portion, which, when it reaches too high upwards, 
 interferes with the backward movement of the tongue in deglu- 
 tition: and the other is that mucus and foreign matter tend to 
 lodge on the sounding tongue, and to interfere with its proper 
 action. According to the writer's judgment, in the simple device 
 of Hueter, and the somewhat more complex one of Foulis, these 
 difficulties have been most successfully met: yet after the best 
 that has been done, when compared with Nature's simple model, 
 the effort of Art has but slight cause for exultation. 
 
CHAPTER XXXIV 
 
 VESSELS OF THE NECK. 
 
 When the neck is viewed in respect to its vascularity, it is 
 found that all the vessels of importance lie in tlie anterior region ; 
 those lying behind are of minor calibre. 
 
 The vessels in front may be divided into two classes; those of 
 intercommunication between the trunk and the head, and those 
 connecting tlie upper extremity and the trunk; the former is 
 the carotid artery, and on its outer side, lies its great satellite, the 
 internal jugular vein. 
 
 The term carotid, according to Rufus of Ephesus, is of Greek 
 origin, and refers to the fact known to the ancients that when 
 the carotids are compressed, such pressure induces coma. 
 
 AVhen the primitive carotids are compared with each other, 
 the left is somewhat longer than the right, and it lies deeper, 
 and, as a rule, it is smaller in diameter. In their lower portion, 
 these vessels lie about three-fourths of an inch behind the clavi- 
 cle, the left carotid being somewhat deeper. While the left 
 carotid lies wholly on the left side of the trachea, the right one 
 encroaches on the right side of the trachea, for a short distance. 
 
 Cutaneous landmarks, which serve as guides for finding the 
 arteries, are the following: on the right side, a line, drawn 
 from the space or sulcus between the ramus of the lower jaw 
 and the mastoid process to the inner end of the clavicle, lies 
 over the right carotid. But for the left carotid, let the line, 
 starting from the similar space on the left side, reach down to the 
 interspace between the sterno-mastoid and cleido-mastoid mus- 
 cles, at their insertion: that is, the left vessel lies further from the 
 median line of the body than does the right vessel. Allan 
 Burns remarks that, as a rare anomaly, the carotid artery may 
 bifurcate as low in the neck as the sixth cervical vertebra; in 
 such a case, the surgeon, instead of finding one, would find two 
 trunks. The usual site of bifurcation is on a level with the 
 upper border of the thyroid cartilage. At the point of division 
 ( 1096 ) 
 
VESSELS OF THE NECK. 1097 
 
 the primitive carotid presents a fusiform enlargement: an 
 enlargement which has been mistaken for an incij)ient aneurism. 
 The author was once consulted by a surgeon who was laboring 
 under such apprehension. In this case, as in similar ones 
 observed, there was tenderness, amounting almost to constant 
 pain; yet no further enlargement occurred: nor did the incon- 
 venience thus arising ever exceed the limits mentioned. 
 
 At their commencement the carotids are covered b}' the sterno- 
 hyoid, sterno-thyroid and the sterno-cleido mastoid muscles : also 
 by the subclavian veins; but above, near the bifurcation, the 
 artery is covered only by the skin ancLinner margin of the sterno- 
 cleido-mastoid muscle. The left carotid lies near the oesophagus, 
 while the right one is more remote from this passage; and both 
 vessels lie on the inner border of the internal jugular vein, 
 which swells during expiration, and overlaps the carotid, espe- 
 cially in the lower part of its course. The carotids lie near the 
 anterior tubercles of the transverse processes of the cervical 
 vertebrae; and the tubercle of the sixth vertebra is so prominent 
 and distinguishable that it serves as a guide to find the vessel, 
 and thence it has been named by Chassaignac the carotid tuber- 
 cle. The inferior thyroid artery in its ascent lies behind the 
 carotid arter3^ 
 
 The artery has an important relation with the omo-hyoid 
 muscle, which crosses it in its descent downwards and outwards; 
 thus the vessel is mapped off into a supra-omo-hyoid and an 
 infra-omo-hyoid portion. From the observation of a great num- 
 ber of ligations of the vessel, it appears that when the work is 
 done above the muscle, there are more recoveries than deaths ; 
 but when done on the infra-omo-hyoid portion, the case is 
 reversed, the deaths exceed the recoveries. 
 
 Besides the cutaneous landmark before given for incising to 
 the vessel, another guide is the inner margin of the sterno- 
 cleido-mastoid. It must be remembered that these guides are 
 not infallible when the head is inclined far backwards: for then 
 the vessels lying on the convex surface of the vertebral column 
 slide and shift their positions laterally. And this accounts for 
 the frequent failure of the suicide's knife to reach the vessels: for 
 with the head turned far backwards, as the writer has known, a 
 frightful yet unimportant cut may be made in which the air- 
 passage is but slightly opened. In his wild and determined 
 attempt to fatally cut his throat, the suicide may not only be 
 prevented by the retreating vessels, but the frightful sound of the 
 70 
 
109S VESSELS OP THE NECK. 
 
 air escaping from the opened windpipe makes liim believe that 
 he has aceompHslied his work, when in reality he has only 
 but slightly wounded himself. 
 
 In many emergencies in which hiEmorrhage occurs about the 
 face, or in the mouth or throat, an arrest of the bleeding is 
 accomplished by compression of the corresponding primitive 
 carotid. By such compression the loss of blood can be tempora- 
 rily controlled, until the bleeding vessel can be tied. The site 
 advised for compression is over the carotid tubercle, in the lower 
 part of the neck ; yet from the writer's experience, he has found 
 that such compression can be made ujuch more effectively if done 
 higher up; that is, alongside of the larynx: for here the vessel 
 can easily be felt; and if the acting fingers be directed from 
 without inwards, the carotid in the ordinary subject can be easily 
 fixed, and held alongside of the air-passage. By such com- 
 pression the writer has controlled bleeding from some part above, 
 until some means of permanently controlling it could be resorted 
 to. In case of violent epistaxis, the bleeding has thus been 
 retarded, so that a clot could form at the bleeding point, and the 
 h?emorrhage thus be controlled; or if the site of bleeding l)e an 
 accessible one within the mouth, or externally, on the face, then 
 such compression can so lessen the escape of blood tluit the j^oint 
 can be seen and secured by ligature, or other heemostatic means. 
 
 Affections of the Carotid Artery. — The carotid artery is the sub- 
 ject of disease or injury; and this agency may be indirect or direct 
 in its action. 
 
 As an example of disease originating indirectly, may be cited 
 that arising from an abscess in proximity to the carotid, which 
 through its closeness or contact with the vessel, may attack and 
 disintegrate its walls. The starting i)oint of such abscess may be a 
 diseased gland, which, enlarging, presses on the vessel, and, finally, 
 the latter may be involved in the suppurative disintegration of 
 the gland. The true nature of such a case may not be sus]3ected, 
 and grave error arise from too hasty action in the treatment. 
 This occurred in the practice of a famous English surgeon, who, 
 on making a visit to his hospital one morning, was shown a 
 patient with a swelling on the neck, which he mistook for an 
 ordinary abscess, which, according to rule, the case should have 
 been ; but this case, unfortunately, proved to be an exception, as 
 was painfully verified by the surgeon, who, with more precipita- 
 tion than reflection, plunged his lance into the tumor, and his 
 wound was followed by a haemorrhage which ended fatally. 
 
AFFECTIONS OF THE CAROTID ARTERY. 1099 
 
 In the plan often pursued of curetting the suppurating gland, 
 there is peril of inadvertently injuring the cervical vessels. The 
 curette, however, endangers the wall of the vein more than that 
 of the artery, since from the more quiescent condition of the vein, 
 adherence to it is facilitated; and, besides, the wall of the vein 
 being thinner and weaker, it can more readily be opened. 
 
 Besides joeril from su^Dpurative action, the walls of the carotid 
 may become implicated in erosive or ulcerative disintegration 
 seated in structures adjacent, and the vessel thus opened. As 
 such erosion would be open to view, the watchful surgeon might 
 intervene with his ligature, before the wall was perforated. 
 
 The anterior cervical structures are sometimes the seat of 
 general phlegmonous inflammation in which there is a rapid 
 breaking down of the tissues, and acrid pus appears in profusion, 
 in which the vessels lie, and their walls are exposed to its corro- 
 sive action; and the final result may be a perforation of the vas- 
 cular wall, with profuse subcutaneous haemorrhage. The writer 
 has known the coats of the internal jugular vein to be thus 
 opened; but the thicker wall of the carotid, and the early incision 
 by the surgeon of the sloughing parts, would guard against 
 arterial haemorrhage. 
 
 The more common injury of the carotid is that of traumatic 
 nature, which may be a contusion, or the wound may be caused 
 by a cutting blade, a gunshot missile, a pointed instrument, as a 
 needle, arrow, lance, or other penetrating agency that cuts or 
 tears a way into the tissues. 
 
 A severe contusion of the anterior cervical structures may 
 involve and so injure the carotid artery that the vessel may rup- 
 ture; and such rupture might be confined to a miniature cleft, 
 through which blood could merely escape; or a large opening 
 might occur through which fatal haemorrhage could quickly 
 ensue. 
 
 The incised wound of the carotid may vary from a minute 
 prick to a complete division of the vessel; and the gravity of the 
 case will be proportionate to the wound. 
 
 A wound in which the wall is simply pricked, as by a needle, 
 or a small blade of a knife, may bleed rapidly for a short time, 
 and then cease through the formation of clot, either in the 
 opened wall, or in the canal-like wound made by the injuring 
 agent in reaching the vessel. The peril in such a case is that 
 the bleeding is perhaps only temporarily arrested, and may soon 
 recur; or if this does not ensue, a false aneurism mny originate, 
 
IIUU VKsiSELS OF THE NECK. 
 
 at tlje site of tlie wound. If it be evident that the wound is only 
 a :?light one, tlie approi>riate treatment would be to put the patient 
 immediately at rest, and then place an adhesive compress on the 
 wound, and retain this in place by means of a circular bandage, 
 or adhesive straps, around the neck. A slight wound might thus 
 be successfully treated. If the wound were a larger one, the 
 hcemorrhage would be profuse, and would .soon end life, unless 
 the wound had some peculiarities of form which would aid in tiie 
 formation of a clot, that might give the victim a temporary 
 respite; for example, if the track of the wound were sinuous, or 
 its walls uneven through retraction of severed muscular .struc- 
 ture, then clotting blood might occlude the wound. The direc- 
 tion of the wound might cooperate in this coagulation; for 
 instance, were thp direction of the canal the opposite of that of 
 the blood-current, this would retard the exit of blood, and favor 
 occlusion by a thrombus. In such a patient, it would be impru- 
 dent to expect that the bleeding would thus be permanently 
 arrested, and that clo.sure of the wounded wall would ensue with- 
 out operative aid ; in such a case, ligation should be resorted to 
 as the proper safeguard against an early return of the haemor- 
 rhage. 
 
 If the wound traverses the tissues for some distance before it 
 reaches the carotid, though it make a large wound in the wall, 
 or wholly sever the vessel, yet, if compression were prof)eriy 
 made, it would be possible to save the patient by immediate liga- 
 tion, as the following famous case demonstrated: a girl was 
 stabbed with a knife, in the upper part of the neck; with a large 
 stream of blood gushing from the wound, she reached the estab- 
 lishment of a druggist near by, who with fortunate presence of 
 mind, thrust his finger into the wound and arrested the external 
 bleeding until the surgeon Michon, who was summoned, arrived. 
 Miclion found the patient bloodless and almost dead; the soft 
 parts around the wound were greatly swollen by the passage of 
 blood into them from the wound, that was only closed externally. 
 The surgeon introduced his finger through the wound, and find- 
 ing the artery entirely severed, he inserted the finger into the 
 cardiac end; with the other hand he cut down and exposed the 
 distal end, which being tied, he proceeded to ligate the proximal 
 one. By this prompt work, the life of the girl was saved. 
 
 In such extensive wound, both ends of the carotid artery must 
 be tied: for if the cardiac end alone were tied, then through the 
 intercommunicating circle at the base of the brain and through 
 
LIGATION OF THE PRIMITIVE CAROTID. 1101 
 
 the numerous anastomoses between the right and left external 
 carotids, blood can soon reach, and escape freely from the distal 
 end. Though cases have been reported in which ligation alone 
 of the proximal end has controlled the hgemorrhage, yet bleeding 
 has so often arisen from single ligation, that in case of a large 
 wound, or the total division of the carotid, the prudent surgeon 
 will tie both ends. 
 
 Ligation of the Primitive Carotid. — The carotid may be tied as 
 a preliminary to operative work on structures in which the trunk 
 or some of its branches will be wounded. Thus, in the removal 
 of growths within the throat, or the infra-maxillary region of the 
 neck, ligation of the primitive or external carotid is sometimes 
 called for. Again, when the tumor lies lower down, and by 
 pressure has w^eakened the arterial walls, ligation is indicated. 
 Also, in those cases in which the growth has reached, infiltrated, 
 and incorporated the arterial wall in itself: in such condition, the 
 vessel should be ligated in its sound portion, and the diseased 
 part, along with the growth, being removed, the distal end should 
 be tied where it is intact. 
 
 The malignant tumor is sometimes so situated that in its 
 radical extirpation, a portion of the carotid artery is left bare, 
 and cannot be covered by any plastic shift, in the effort to close 
 the wound. For example, there fell under the writer's observa- 
 tion an operation in a Parisian hospital, in which a large benign 
 tumor was removed from the anterior cervical region, in which 
 the destruction of parts was so extensive that the carotid artery 
 was left exposed for some distance. The operator was in doubt 
 whether he should ligate, but decided not to do so. A few days 
 afterwards, the exposed part of the carotid opened, and a fatal 
 bleeding took place: and in a clinical lecture on the case, the 
 operator candidly acknowledged his error, with keen regret that 
 he had not tied the vessel at the time of the operation. 
 
 In the event of the internal carotid beiug opened in an 
 operation in the pharyngeal region, the corresiDonding primitive 
 carotid should be tied; and should bleeding still continue from 
 the distal open end, through refluent blood which has reached 
 the wound through the circle of Willis, then if death be impend- 
 ing through loss of blood, the surgeon would be justified in tying 
 the opposite primitive carotid, as the writer did in a case which 
 hereafter shall receive mention. 
 
 The primitive carotid is the occasional site of aneurism. This 
 is an infrequent occurrence, as appears from the figures of Crisp, 
 
1102 VESSELS OF THE NECK. 
 
 who lias collected a list of five liundred and fifty-oiie aneurisms, 
 of which only twenty-five were situated in the primitive carotid; 
 that is, it occurred one time in thirty cases. Of these twenty-five 
 cases, thirteen occurred in women, in whom such aneurism 
 appears often er than in men; wliile in other regions, aneurism 
 occurs oftener in men. 
 
 The most usual cause of aneurism, here as elsewhere, is 
 atheromatous change in the arterial walls; it has arisen excep- 
 tionally, from some violent expiratory effort, as vomiting. It has 
 been seen in the infant, though, as a rule, it only occurs in 
 mature adult life. As to the part of the carotid which is oftenest 
 the site, authorities disagree; Burns and others place the more 
 common site near the bifurcation, while Robert says the inferior 
 portion of the vessel is the more usual site. The upper portion 
 is probably the most common seat of aneurism ; and this is 
 dependent on anatomical conditions, viz., the bifurcation there, 
 and the attenuated stratum of overlying structures. Almost the 
 entirety of the primitive carotid is pressed on by the sterno-cleido- 
 mastoid muscle; but the upper fifth is nearl}^ free from muscular 
 pressure; and on this account, the artery can expand more freely. 
 And this takes place especially in expiratory efforts, as in cough- 
 ing, when the expansion of both the artery and vein is visible 
 to the eye; and under such circumstances, it is rather to be 
 wondered at, that dilatation or rupture of the vessel is not a more 
 common event. 
 
 The aneurismal tumor is, at first, a small tumor, passing, for 
 a time, unobserved b}'^ the patient; finally, its enlarged volume 
 is not only visible, but, by its pressure, it causes inconvenience, 
 and even severe pain. This trouble arises from compression of 
 nerves which lie adjacent to the growth: also, from disturbance 
 of the circulation in the head. When the tumor is low on the 
 neck, by peripheral extension it may disturb the function of the 
 pneumogastric, the inferior laryngeal nerve, the phrenic and the 
 symi:>athetic nerves; and, thence, parts remote from the tumor, as 
 the lungs, diaphragm, heart and laryngeal muscles, may act 
 irregularly. Also, through the sympathetic, the pupil may be 
 caused to dilate or contract. On the left side, the tumor may 
 encroach on the thoracic duct, and thus prevent the evacuation 
 of the lymph and chyle into the venous system, which occurs 
 near the seventh cervical vertebra. The tumor can also com- 
 press and deform the oesophagus and tracheal canal. The patient 
 is often disturbed by the movement of the tumor and the blowing 
 sound, which usually is present in it. 
 
LIGATION OF THE PRIMITIVE CAROTID. 1103 
 
 Sliould the aneurism be situated higher up, then the functional 
 disturbances enumerated will be present; that from the pulsa- 
 tion and blowing sound will be yet greater, and the power to 
 utter vocal sounds may be quite lost. There is often congestion 
 of the face on the side of the aneurism due to the tumor inter- 
 rupting the return of the blood from the head. Vertigo, dizziness 
 and ringing of the ears are sometimes present. 
 
 AVhen seated high up, the tumor may encroach on the super- 
 ficial cervical plexus, and cause pain that radiates along the 
 nerves which arise from this plexus; thus pain in the pinna 
 occipital region, and, also, in the acromial and clavicular regions 
 may arise. Not unfi^equently, a troublesome cough is present 
 from irritation of the superior laryngeal nerve. 
 
 A very troublesome result of carotid aneurism often seen is 
 difficulty of breathing, arising from pressure on the windpipe, 
 by which the latter's calibre is narrowed ; and this narrowing is 
 augmented, or mainlj'- produced, through cedematous swelling of 
 the mucous lining of the air-canal. This stenosis increasing may 
 finally fatally suffocate the patient. 
 
 Carotid aneurism may be slow in its development; or having 
 grown, for a time, slowly, it maj^ suddenly begin to increase in 
 volume, and soon attain large proportions. 
 
 The diagnosis of the carotid aneurism has sometimes been a 
 matter of much embarrassment. For example, if it be in the 
 commencement of the vessel, it is difiicult to decide whether the 
 tumor maybe of aortic, innominate, subclavian or carotid origin; 
 and sometimes the true nature of such cases has only been deter- 
 mined through necropsy, in which the exact site of the tumor was 
 discovered. 
 
 The greatest difficulty in diagnosis has arisen in case of 
 abscess, lipoma, lymphoma, encephaloid growth and other 
 neoplasm situated on, or adjacent to, the carotid. The proximity 
 of such tumor to the vessel has permitted the pulsatile motions 
 of the latter to be imparted to the tumor; and besides these 
 movements, the pressure of the tumor on the vessel may alter the 
 form of the latter and thereby cause a sound very similar to that 
 arising in the aneurismal tumor. A condition in which sounds 
 and movements resembling those of the aneurism are present, 
 exists in the vascular encephaloid growth ; yet this tumor, from 
 the writers observation and experience, rarely develops on the 
 neck; its usual site is on the extremities. The differentiating 
 means by which the ordinary tumor can be distinguished from 
 
1104 VESSELS OF TIIK NECK. 
 
 the aneurism ure iii;ij)|)licable to the vascular encephaloid. 
 Perhaps the best distinctive characteristic by which tliis ence})h- 
 aloid growth (Hffers from tlie aneurism is in its form; it usually 
 is elongated in the direction of the longitudinal axis of the part 
 on which it is situated; it has connections with the skin which 
 do not exist in the aneurism; and its volume is less reducible by 
 compression than that of the aneurism. 
 
 In case of the solid tumor which rests on the artery and 
 receives the jnilsatile movements of the latter, this movement 
 may be made to disa{)pear through lateral displacement of the 
 growth; such displacement is Cdnimonly easily made, and tlius 
 the true character of the tumor is decided. Occasionally, 
 however, the intimate anatomical connection is such that the 
 two cannot be separated; and in this condition the tumor must 
 move synchronously with the diastolic movement of the artery; 
 and it continues to do so, even though the growth be consider- 
 ably moved from its normal site. This oftenest occurs wlien 
 the growth is of glandular origin, since the gland, whence an 
 adenoma arises, often rests on the sheath of the vessel and, in 
 developing, forms attachments to tiie sheath. And if the tumor 
 be malignant in character, it often penetrates the arterial wall ; 
 and in this case it participates in the movements of the vessel. 
 In all such cases, the tumor would be but slightly compressible; 
 and it would be harder than an anoui'ism. xVnd should the 
 evidence from these sources not clear u[) the diagnostic obscurity, 
 as last resort, the hypodermic syringe may be forced deeply into 
 the tumor, and thus its neoplastic or aneurismal character will 
 be determined. The hollow needle used for this work should be 
 one of the smallest. 
 
 The tumor having been determined to be aneurismal, the 
 question to be decided is what treatment will most safely and 
 speedily relieve the patient. The curative procedures are numer- 
 ous, the most trustworthy may be comprised under the following 
 heads: compression, induction of coagulation by means of con- 
 stitutional remedies which slacken the circulation, means which 
 act directly on the content of the sack, and cause coagulation, 
 and finally, ligation. These methods for the cure of aneurism 
 have already l)cen generally considered ; a more detailed account 
 of them will here a|>pear. 
 
 The manner in which the cure is accomplished is through 
 coagulation of the blood in the aneurismal sack; and this occurs 
 when the blood is caused to move slowly ; it may take place when 
 
LTGATIOX OF THE TRIMITIYE CAROTID. 1105 
 
 the movement is wholly suspended; yet under the latter condi- 
 tions, the clot that is formed is soft and ill constituted for 
 permanence, and may disintegrate, and induce gangrene in the 
 Avails of the sack. And even when the occluding coagulum has 
 formed slowly, yet if the mass of it is so great that it receives 
 less blood than is needed to maintain it alive, then the clot may 
 die, and the superjacent wall sloughing and opening, violent 
 hsemorrhage ensues, which usually ends the patient's life. The 
 conditions, then, under which the treatment may successfully 
 accomplish its purpose, are to retard the movement of the blood in 
 the aneurismal cavity; and, in this manner, the coagulating blood 
 will deposit itself in laj^ers wdiich will assume the properties of 
 living tissue of a low grade of organization. And whichever of 
 the curative procedures here mentioned is selected, the surgeon 
 should bear in mind that the problem of cure must be solved in 
 accordance with the principles just mentioned, w^hich have been 
 established by the painstaking study and researches of Broca. 
 
 Compression may be done digitally or mechanically : that is, 
 W'ith the fingers, or with some appliance by which pressure is 
 made upon the vessel. A strong and trustworthy nurse can do 
 the work by placing two fingers of one hand longitudinally over 
 the vessel, and reenforcing these by two or more fingers of the 
 other hand, placed transversely across the first. As fingers tire, 
 two men should be selected for the work, who will alternately 
 relieve each other in the task. Too much pressure which will 
 wholly arrest the current of blood is faulty; and so is slight 
 compression which will permit free movement of blood within 
 the aneurism. Hence those doing the work must be instructed, 
 supervised and controlled; the rule should be not to wholl}^ 
 interrupt the blood-current, some jDulsatile movement should be 
 perceptible in the vessel beyond. The time requisite to continue 
 the compression varies much in different cases, and is dependent 
 on certain anatomical conditions of the walls of the sack. The 
 form and size of the opening in the wall, have an influence in 
 this matter; also, whether the sack so lies that it facilitates or 
 retards the return of the blood. If the inner wall of the sack 
 presents an irregular surface, this favors the coagulation of the 
 blood. For such reasons an aneurism may be cured by compres- 
 sion at periods varying from a few hours to several days. As 
 criterion that the compression has accomplished its purpose is 
 the cessation of the blowing sound and the pulsating movement 
 in the tumor : it must be added, that sometimes when occlusion 
 
JlUG VESSELS OK TIIK NECK. 
 
 appears lo have been accoinplislie(], the })ulsatile uiovement of 
 the tumor may rt'appear for a time, and then vanish perma- 
 nently. 
 
 Compression lias been done at different points, viz., on the 
 proximal side of the tumor, on the distal side, and also, directly 
 on the tumor: it is usually made on tlie cardiac or proximal side; 
 and the work then can be done near to, or reifiote from, the 
 tumor; compression on the distal side is only done in cases in 
 which it is not practicable to make it on the cardiao side. And 
 still more exceptionally, the compression has been made on the 
 tumor itself. As is known, nearly every aneurismal tumor has 
 a tendency to spontaneous occlusion through the gradual precipi- 
 tation of coagulated blood on its walls; and should this work 
 have advanced near to the stage of completion, then direct 
 digital pressure might soon occlude the remaining cavity. An 
 indication that the tumor is one suited for direct compression 
 Avould be, that it is but slightly compressible on account of 
 thickness of its Malls. In such a case in the po})liteal region, 
 tlie author witnessed the curative action of direct compression 
 accomplished by means of a compressor constructed by the 
 patient himself 
 
 As trustworthy hands cannot always be obtained, and even if 
 they could be, yet fingers tire, and cannot act with the steadiness 
 and unwavering continuity of a mechanical appliance, hence 
 digital compression, once so much resorted to, has nearly been 
 superseded by the mechanical, in which a device is used, known 
 as the arterial compressor. The compressor is analogous to the 
 tourniquet, and like that instrument it may be circular or semi- 
 circular; and in each form it is so constructed that the action 
 can be made on the artery while the adjacent structures are free 
 from pressure, and the circulation in them is not arrested. The 
 horseshoe or semi-circular compressor accomjdishes its work in 
 this manner; outside of the vessel compressed, the circulation 
 through compensating trunks is unimpeded. 
 
 The rules given in regard to digital compression, apply to 
 mechanical: the work must not be overdone, nor defectively 
 done: the passage of blood through the vessel must not be 
 entirely interrupted. To do the work so that there will be no 
 danger of sloughing from excessive compression of the surface 
 acted on, there should be two compressors, which will act alter- 
 nately on different points. For the treatment of aneurism of the 
 carotid artery a compressing appliance has been devised, which 
 
LIGATION OF THE PRIMITIVE CAROTID, 1107 
 
 is similar to a cravat which can be strapped around the neck, 
 and pressure made on the artery, where desired. In the use of 
 such a compressor, some trouble has been found in so fixing the 
 compressing pad that it will not shift its site. Besides, patients 
 are sometimes intolerant of such pressure; in one case, tlie 
 patient, after having made trial of this means, declared that 
 nothing could induce him to submit further to the compression. 
 
 A plan of treatment occasionally resorted to for the cure of 
 aneurism is the administration of remedies which will promote 
 the coagulation of blood in the sack. A few medicines have the 
 repute of acting tlius: their mode of action is difficult to explain. 
 Agents thus administered by the mouth are ergot and iodide of 
 potassium; the two may be given in combination, viz., a drachm 
 of the fluid extract of ergot, with ten grains of the iodide of 
 potassium, three times daily. This constitutional medication is 
 resorted to chiefly in cases in wdiich the aneurism is inaccessible 
 to other methods of treatment. Such curative means rarely find 
 use in the treatment of aneurism of the carotid artery. 
 
 A third method of treatment is the employment of means 
 which act directly on the blood in the sack and cause its coagu- 
 lation ; such means are electricity and styptic agents, which, being- 
 introduced, cause coagulation. 
 
 Ciniselli has made extensive trial of electricity for this pur- 
 pose ; he used the static current, which may be generated by a 
 series of small zinc and copper plates, connected by a saline 
 medium, and having poles terminating in needles, which can be 
 inserted into the aneurism. In the electrol3^tic action thus 
 induced, different materials are drawn towards the positive and 
 negative poles, viz., to the positive one acid elements are attracted, 
 while alkaline elements are drawn towards the negative pole: as 
 mnemonic aid to retain these facts in memory is the dissyllable 
 panalk: positive, acid, negative, alkaline. The acid materials 
 which collect as a coagulum about the positive pole are firmer in 
 consistence than the alkaline matter at the other pole; hence it 
 is desirable to make the positive pole do the work of coagulation: 
 and to accomplish this, the positive point alone should enter the 
 tumor, while the negative one may be placed on tlie cutaneous 
 surface outside of the aneurism. The skin around the penetrat- 
 ing needle is cauterized by the electricity; and hence the action 
 must not be prolonged too far, lest a large section of the skin be 
 caused to slough, and the purpose of the work be defeated : and 
 also the needle at each application must be introduced at a 
 ■different point. 
 
lies VESSELS OF THE NECK. 
 
 Tiie aneurisniul .sack luis been oeciiuled \>y iudueing coagula- 
 tion by means of a styptic fluid, which is injected into the cavity. 
 The agents most employed for this purpose are the salts of iron; 
 for example, a solution of the chloride or the persulphate of 
 iron. Such a solution may be injected by means of a hypodermic 
 syringe; and this must be done carefully, drop by drop. As 
 there is a risk that the coagulated blood may not remain in site, 
 but may float out of the sack into the general current of blood, 
 and work embolic mischief elsewhere, tliis ])l!in of treatment lias, 
 at present, few or no advocates. And coagulating injection, if 
 resorted to at all, is reserved for the cure of the aneurismal 
 varix, in which, with the exercise of some care, there is but slight 
 risk of dislodging the coagulated blood. 
 
 The most usual method resorted to for the cure of aneurism 
 is the ligation of the vessel. Where the vessel is easy of ap- 
 proach, however, an endeavor should be made to cure by com- 
 pression: since this method in no way imperils the patient, and 
 does not preclude a resort to the ligature, should compression be 
 unsuccessful. 
 
 The ligation of the artery for the cure of aneurism, is one of 
 the signal triumphs of surgery, dating from the early part of the 
 nineteenth century. The first successful operation was that of 
 Sir Astley Cooper, done in 1805. That the carotid could be safely 
 tied had been proven by other surgeons. Fleming, in a case of 
 attempted suicide, tied the carotid, in 1803, with recovery. And, 
 prior to this, the ligation had been successfully done by 
 Hebenstreit. The first ligation of Abernethy, as well as that of 
 Cooper, resulted in failure; later Cooper tied the primitive 
 carotid for aneurism, and the man soon recovered, and resumed 
 his occupation as a laborer. At this early period, it recjuired a 
 bold hand to essay such a task, when, as Allan Burns says, 
 surgeons were "balanced between hope and fear" as to the results 
 which might occur. Secondary haemorrhage was feared as the 
 inevitable sequent of such a venture. Daring hands soon put 
 the matter to the crucial question of trial, and the answer was 
 satisfactory. 
 
 As remarks Burns, "In no operation is a current knowledge 
 of the locality of the parts concerned more indispensable than 
 in the case under consideration." And these difficulties increase 
 as one proceeds from the distal to the proximal portion of the 
 vessel. Frequently the location of the aneurism is such that 
 one is compelled to operate low in the neck. When done low 
 
LIGATION OF THE PRIMITIVE CAROTID. 1109 
 
 down, besides dividing the skin, platysma myoides and the 
 cervical fasciee, the sternal bead of tbe sterno-cleido-mastoid must 
 be drawn aside. The sheath containing the artery, vein and 
 vagus nerve, is next found, and when opened, the next difficult 
 step is to separate the interiial jugular vein from the artery. He 
 who is only familiar with the parts in the anatomical room, will 
 be surjDrised at the ever-changing volume of this vein: in 
 inspiration sinking to a small cord, but in expiration greatly 
 swelling, so as to overlap the artery: "and the transitions from 
 emptiness to fullness are so rapid that sufficient time is not given 
 to detach it from the carotid." In the w^ork of separating the 
 vein from the artery, the former has sometimes been injured, 
 and no ill resulted; and the writer would remark that in his 
 experience in detaching the femoral vein from the adjacent 
 artery, a prick of the former has caused no serious trouble. 
 
 In the low ligation on the left side, Burns thinks there is a 
 risk of wounding the thoracic duct, which he finds behind the 
 carotid, in some subjects, mounting pretty high up in the neck, 
 before it curves downwards and outwards to join the subclavian 
 vein. A nerve severed may reunite, but the duct w^ounded. 
 Burns thinks, would not heal, and there is no substitute for it. 
 The duct here is diminutive, and especially so when unfilled by 
 chyle; yet after a fall meal, it is so swollen that the containing 
 chyle is visible through the thin walls of the duct. 
 
 The possibility of arterial anomaly must be borne in mind, 
 in the inferior ligation of the carotid; instead of one trunk, there 
 may be two arteries side by side, viz., the carotid and the verte- 
 bral arteries, which on the left side may spring from tlie arch of 
 the aorta, and ascend close to each other; and also on the right 
 side, the two have been found close together, though the vertebral 
 arose from its normal point. In such a dilemma, pressure made 
 on each vessel would clear up all uncertainty, and indicate the 
 one to be chosen for ligation. 
 
 The bifurcation of the carotid sometimes occurs low on the 
 neck, and in that case the surgeon might be embarrassed to 
 know what the conditions were, and what vessels he had before 
 him; as aid in such a case would be branches arising from one 
 trunk, w^hich would denote the external carotid. 
 
 If ligation be done for the cure of aneurism, it may be done 
 on the proximal side, close to, or remote from, the tumor. The 
 operation done near the aneurism on the cardiac side is known 
 as that of Anel, an Italian surgeon who had the good fortune to 
 
1110 VKSSELS OF THK XKCK. 
 
 be the pioneer in this oj)eration, and thus to secure a })ennanent 
 place in surgical literature, especially among French writers. If 
 the ligature approach more toward the heart, the name of Hunter 
 is affixed to the operation by English authors. The o|)eration of 
 Hunter is the preferable one where this is practicable; but should 
 space not permit this, then the less desirable site of Anel must, 
 perforce, be adopted. And, again, if the aneurism occupy the 
 first portion of the artery, where proximal ligation would not be 
 possible, then distal ligation must be done; and this procedure 
 having been first proi)Osed or done by a French surgeon, Brasdor, 
 his name has been given to the operation. 
 
 Of the three sites mentioned, the Hunterian offers more chances 
 for a successful issue to the jtatient than can be obtained by tliat 
 of Anel or Brasdor: the closeness of the ligation to the aneurism 
 in the operation of Anel disposes to secondary hsemorrhnge; and 
 to the operation of Brasdor there are serious anatomical and 
 physical objections. 
 
 The method of performing ligation has been the subject of 
 much modification: as done by 8ir Astley Cooper, the work first 
 consisted in finding the artery, and tying it at two points near 
 each other, and then severing the vessel between the ligatures. 
 One end of each cord was allowel to remain long, while the 
 other was cut short; and the wound was then closed by sutures, 
 with the two threads projecting from it. Thus the operation for 
 the cure of an aneurism was first done by Sir Astley Cooper; and, 
 as he records, "the first ligature came away on the twenty-second 
 day, and the second one, on the twenty-third day after the 
 ligation. The wound was along time in healing: first from a 
 sinus in the course of the ligatures, and afterward, from a fungus 
 where the sinus had formed. The man was discharged well in 
 about twelve weeks after the ligation was done." 
 
 The purpose intended by doubly tying and dividing the 
 vessel was to put at rest the distal portion, and thus favor the 
 coagulation in the tumor. 
 
 The way so beset with apprehended perils having been safely 
 traversed, the surgical world elsewhere was not tardy in following 
 in the footsteps of the great English surgeon. The plan of 
 doubly ligating was soon superseded by that of the single ligature; 
 and then the continuity of the vessel was interrupted and severed 
 by the including ligature sloughing out, after a few week.s. 
 These early methods, reflecting honor on those who introduced 
 them, have been succeeded by those which are simpler and 
 
LIGATION OF THE PEIMITIVE CAROTID. 1111 
 
 safer in their action. The small silken cord which has been 
 rendered aseptic is used for the ligature; and the artery being 
 tied, both ends of the thread are cut short, and the wound is 
 closed, and the work so done that healing is obtained by primary 
 union. Instead of silk, catgut cord is often used for arterial liga- 
 tion. Strangely enough catgut cord was tried and rejected by 
 Sir Astley Coojjer. 
 
 The anterior or inner margin of the sterno-cleido-mastoid 
 muscle serves as a guide to find the jDrimitive carotid in a great 
 portion of its course: but as the artery ascends, it inclines inwards 
 from the muscle; and the result is that in its upper portion, the 
 artery has but a slight covering of soft parts, while near the 
 sternum, the vessel lies behind the sternal portion of the muscle; 
 and this has led one surgical authority to give the rule to seek 
 for the vessel in tlie interspace between the sternal and clavicular 
 portions of the muscle. Though the inner edge of the muscle 
 serves as a guide to the artery, yet a more satisfactory guide is a 
 line drawn from the slight fossa behind the lobule of the ear to 
 the sterno-clavicular articulation; and such a line below will lie 
 over the inter-muscular interstice just named. Tliis cutaneous 
 line above, lies over the external carotid artery, and, hence, it 
 enables one to find this vessel also. 
 
 By the aid of the guide given, it is easy to find the common 
 carotid artery, in the lean subject; but in one of short, thick, 
 rotund neck, in which there is a deep layer of fatty tissue, the 
 ligation becomes a more difficult undertaking: the primary cut 
 must be longer than usual to permit of penetration to the vessel. 
 
 The patient must lie on the back with the shoulders uplifted 
 upon a pillow, or cushion, so situated that the head will fall 
 backwards, and the neck will be accessible. This position shifts 
 •the artery, somewhat in reference to the adjacent muscle: espe- 
 cially in its upper portion. The pulsating movement of the 
 artery indicates its position ; yet, sometimes this movement is so 
 feeble that it is scarcely sensible to the touch ; and this feeble- 
 ness is especially present in cases in which the heart has been 
 weakened by the loss of much blood: also in the patient who has 
 been profoundly anaesthetized. 
 
 In the emaciated subject, a short cutaneous cut made in the 
 carotidean landmark will suffice; but if the subject be one of 
 short, thick neck, then the outer cut must be a long one; and 
 the incision should be made by first penetrating quite through 
 the skin: an act in which the scalpel stands upright; then tlie 
 
1112 VKSSELS OF THE NECK. 
 
 handle of the instrument .'^liouhl bo lowered, but raised to a 
 per])eiidicular again when it reaches the end of the incision. By 
 thus incising, no space will be lost at tiie ends through the skin 
 liaving been incompletely divided. The ])lunt-pointed retractors 
 are to be inserted, and committed to an aid, who has been 
 instructed not to displace the wound by pulling the lips too 
 much towards one side, or the other. As the work proceeds, the 
 sterno-cleido-mastoid muscle will be encountered, and, unless 
 the ligation be in the lower fourth of the carotid, the muscle 
 must be pulled externally, by inserting the retractor under its 
 margin. But if tiie tying be done near the sternum, then it is 
 recommended by Zang that the incision be made between the 
 sternal and clavicular portions of the muscle; and to obtain room 
 the sternal portion must be drawn inwards. Or, in this inferior 
 ligation, the plan of Coates may be followed, wdiich was to make 
 an incision on the inside of the sternal limb of the muscle, and 
 then having passed a grooved guide under this portion, the latter 
 is to be severed from the sternum. The writer may state that in 
 a few ligations below the omo-hyoid muscle, he has found it 
 possible to reach the vessel by a cut made between the trachea 
 and the muscle: and when the inner edge of the latter is exposed, 
 if the head be pulled to one side, the muscle may be drawn 
 outwards and the vessel reached. 
 
 In making this cut to reach the vessel, small vessels, chief! 3' 
 veins, are often met; and as a bloodless field is necessary to 
 enable the surgeon to carry his work to completion, these vessels 
 should be caught and subjected to torsion, so as to close them: 
 torsion is better than tying, since the latter would leave material 
 in the wound that would retard immediate closure. 
 
 There is no point where the artery cannot be reached, if the 
 operator has freshened his anatomical knowledge by a recent 
 rehearsal on the cadaver; and disciplined by such rehearsal, the 
 operator will encounter no difficulties which he cannot vanquish, 
 tuto etjucimde. Tlie artery lies in a sheath-like envelope along 
 with the internal jugular vein and the pneumogastric nerve: 
 and the latter two must not be included in the ligature. The 
 sheath should be caught up with the forceps, and uplifted so as 
 to form a conoidal figure, of which the apex is held by the 
 forceps. This act, though simply told, is less simple in accom- 
 plishment: for in catching the sheath, it is easy to include the 
 tunica adventitia of the artery: and to be sure that the latter is 
 not seized, the uplifted cone should be moved in different direc- 
 
LIGATION OF THE PRIMITIVE CAROTID. 1113 
 
 tioiis, when the seizure or exclusion of the artery will be 
 determined. Should the error be committed of including the 
 arterial wall, then in the section of the uplifted cone, the artery- 
 might be opened, or wounded. The inexperienced may have 
 trouble in distinguishing the sheatli from the outer arterial tunic 
 especially if there be adhesion between tlie parts due to some 
 morbid action: yet in normal state, the sheath is easily moved 
 on the arter}'. 
 
 Should the operating hand be inexperienced, and the index 
 not versed to the nail in finding the right way through the 
 tissues, then instead of thus uplifting the vaginal cone, the 
 operator had better substitute the simpler plan of scratching 
 through the sheatli with a grooved director: and as evidence that 
 he is wounding the sheath and not the artery, will be the slight 
 bleeding from opening the vasa vasorum which abound in the 
 sheath; and also that as soon as this latter has been perforated, 
 the grooved director can be inserted between the vessel and the 
 sheath. That these minute directions are not pedantic refine- 
 ments more calculated to mislead than to guide, the writer is 
 certain; experience ma}' not need them, yet inexperience will 
 have use for them. 
 
 The next step, when the sheath has been opened, is to extend 
 this opening a quarter of an inch upwards and downwards, in a 
 longitudinal direction: and tliis can be done with a blunt 
 bistoury on the grooved director; or with small blunt scissors. 
 Through the opening thus made, the aneurismal needle can be 
 passed and carried underneath the vessel, so that its point will 
 emerge on the opposite side near where it entered: and if this 
 be carefully done, the vessel will be included in the hollow of the 
 needle, with but slight disturbance of the sheath. In this act, 
 the sheath should be detached as little as possible from the artery. 
 When the aneurismal needle has thus been carried underneath 
 the artery, the thread must be passed into the needle's point, and 
 the instrument removed so as to draw the thread beneath the 
 vessel. The aneurismal needle may have a movable point, which 
 can be detached; and this form, which is known as Mott's needle, 
 is easily used, since when it has been passed beneath the artery, 
 the point can be unscrewed and removed; thus the attached 
 thread w^ill be carried under the artery. This needle is accom- 
 panied by a key which is used to detach the movable point. 
 
 In the absence of the Mott needle, or that with immovable 
 point, the surgeon can easily construct a substitute : a piece of 
 71 
 
1114 VESSELS OF THE NECK. 
 
 iron wire bent on itself so as to be in loop-form, can be inserted 
 in the fenestra in the sheath, and carried beneath and around the 
 vessel: and when the loop api)ears, the thread can be passed 
 through it, and drawn beneath the vessel. From experience, the 
 writer can bear witness to the facilit}' with which the ligature 
 can thus bo carried around the artery. 
 
 Of the materials used for ligature, viz., thread of cotton, linen, 
 catgut, silk, or wire, the autlior prefers the simple silken thread : 
 and before using this, it should be immersed in alcohol for an 
 hour, by which it is rendered aseptic. The tying is next to be 
 done, and this must be effected by a simple square knot. The 
 old method of drawing the thread so tightly as to divide the 
 inner and middle coats of the vessel is unnecessary; the purpose 
 will be accomplished if the constriction be carried to the extent 
 of bringing the inner walls together, so as to entirely close the 
 artery and prevent the passage of the blood. It is not necessar}' 
 to divide the artery as was ultimately accomplished by the former 
 method of very tight tying. When done with aseptic silken 
 thread, the latter is cut short, and finally becomes encapsulated 
 in the tissues. 
 
 The tying being completed, there should next be laid a thread 
 or two of aseptic silk, or catgut, in the wound, so placed that one 
 end will hang outside. This thread replaces the drainage tube, 
 formerly used; and it serves as a vehicle for conducting outwards 
 the excreta which may form in the cavity of the wound. Next a 
 .sufficient number of sutures must be inserted to close the wound. 
 Over the wound, lint saturated with alcoholic lotion (twenty-five 
 one-hundredths) is to be placed, and retained in site by a circular 
 bandage. The lint must be retained moist by occasionally 
 remoistening it with the lotion. The threads for drainage are 
 to be daily observed, and on the second or third day, one may 
 be removed; and as soon as all excreta cease to appear, the last 
 thread may be removed. The excreted material is usually 
 small in quantity; and the wound will heal in a few days; 
 complete closure with firm union of the walls of the wound can 
 be obtained in from ten to fourteen days. To favor rapid heal- 
 ing, the patient should lie in bed, and the head should be 
 retained as nearly motionless as possible, during the treatment; 
 and care should be used to avoid much movement of the 
 neck, for at least twenty-five days: for this precaution being 
 neglected, the site of the wound may be inflamed and suppura- 
 tion take place; and such accident occurring, not only is the 
 
LIGATION OF THE PRIMITIVE CAROTID. 1115 
 
 treatment prolonged, but there is the risk of secondarj^ bleeding. 
 The author had a case which took this unfortunate course, and, 
 despite the various means that were tried to control the haemor- 
 rhage, the bleeding recurred from time to time, until life was 
 terminated by exhaustion. To avoid such catastrophe, the 
 patient should be enjoined to keep the part at rest, for at least a 
 couple of weeks after the wound has healed. 
 
 The carotid has also been tied for the relief of epilepsy or 
 neuralgia seated in the head. When the brain of the epileptic 
 subject is seen during his convulsive paroxysm, the anaemic 
 condition in which it has been observed by Brown-Se'quard and 
 others, would contraindicate ligation as a means of relief: indeed, 
 the consequent detraction from the normal supply of blood, 
 should assist, and not resist, this reported causal agency of 
 epilepsy. In the light of present knowledge, the author neither 
 counsels nor rejects this procedure, since it may be said to be on 
 trial as one of the heroic measures for the cure of epilepsy. Epi- 
 lepsy finds its causation in so many agencies located centrally or 
 peripherally, that he who treats the disease is warranted in 
 freighting his therapeutic sling with many pebbles; and if he 
 includes this one from the stream of surgery, it caniiot prove 
 more vakieless than many others which he may essay; and 
 should it cure the patient, the latter will be content, and the 
 physiological therapeutist will have had an experience which he 
 may share with the empirical practitioner who is satisfied with 
 effect, but leaves to the scientist the search for a cause. 
 
 The ligation of the carotid for the relief of cranial or cephalic 
 neuralgia has proved successful in some cases; and its mode of 
 action consists in diminishing the amount, and, consequently, the 
 pressure of tlie blood, in the affected part. After ligation, the 
 pulse-wave vanishes, for a time, in the branches of the tied carotid, 
 and though blood reaches them through compensating channels, 
 yet it is a long time before normal pressure and pulsation are 
 restored: meantime, pain may disappear through the affected 
 part being restored to integrity. There is a risk that the cure 
 will not be permanent, and that, when the circulation becomes 
 normal, the neuralgia may return. An example of this fell under 
 the writer's observation. In 1868, in a man who was the victim 
 of atrocious pain on the side of the head, especially in the tem- 
 poral and parietal region, other means having failed to relieve, 
 the writer tied the right carotid artery. The patient was, at 
 once, free from his pain; and this relief continued for nearly a 
 
1110 VESSELS OF THE NECK. 
 
 year, when the trouble reappeared, and continued until the man's 
 death, some two years afterwards. 
 
 In 1867, Carnochan advised and practiced ligation of vessels 
 for the cure of elephantiasis; thus he successfully treated a case 
 of elephantiasis of the face: he first tied the corresponding primi- 
 tive carotid; and six months afterwards,he tied theotlier carotid. 
 The result was a gradual shrinkage of the hyperlrophied struc- 
 ture, which continued for eight years. 
 
 Ligation has sometimes been done as a preliminary step to 
 the removal of growths in the region supplied by the vessel; for 
 this object, such ligation has been strongly advocated by Verneuil 
 for the subjoined reasons: it guards against exhaustive haemor- 
 rhage, and thus the surgeon is not disturbed by bleeding from 
 vessels which he may wound during his operative work ; and 
 finall}', through the lessened attlux to the parts operated upon, 
 the subsequent inflammation will be lessened or quite prevented. 
 Richet opposes the procedure, claiming that in the rapid reap- 
 pearance of the blood in the vessel beyond the ligated i)oint, the 
 loss of blood is by no means avoided; and a still graver objection 
 urged by Richet is in the encephalic disturbance which the liga- 
 tion can occasion. 
 
 For many years the writer has practiced preliminary ligation 
 of the carotid in cases in which the internal carotid or the exter- 
 nal carotid artery might be opened in surgical operations: and he 
 has not encountered severe bleeding from the reappearance of 
 blood in the opened vessels; nor in tlie cases thus treated has 
 cerebral disturbance arisen. Hence he advocates preliminary 
 ligation of the carotid in operations wliich otherwise must be 
 attended by much loss of blood; an exception to this would be 
 where the preliminary tying of the external carotid would serve 
 a similar purpose. In the amputation of limbs the author's cus- 
 tom has been, as a substitute for the tourniquet, to preliminarily 
 tie the main artery a short distance above the site of amputation: 
 thus doing, the operator greatly lessens the loss of blood, and 
 husbands the vital resources for the demands which are about to 
 be made on them. 
 
 Reference has been made to the disturbance which can be 
 caused in the head by ligation of the carotid artery. That such 
 complication is not infrequent appears from the figures of Pilz 
 of Breslau, who finds in a list of six hundred ligations that cere- 
 bral symptoms arose in about one-third of the operations; and or 
 these, fifty-six per cent died. These figures vary somewhat from 
 
LIGATION OF THE PRIMITIVE CAROTID. 1117 
 
 those reported by Reis in the Archiv flir Klinische Chirurgie: he 
 presents a collection of seventy-three ligations, in which cerebral 
 disease appeared in seventeen cases, viz., about twenty-three per 
 cent. From the writer's personal experience, and from observa- 
 tion of the operations of others, he is convinced that these figures 
 are too high. The diminished frequency of such cerebral com- 
 plication maybe attributed to the superior methods which obtain 
 in the surgical work of the present time. The quondam out- 
 hanging thread that was suspended to the artery, besides 
 being a standing menace of secondary bleeding until its detach- 
 ment and closure of the sinus in which it lay, also maintained a 
 chronic inflammation of the site of ligation: an inflammation 
 tliat may implicate the sympathetic plexus of nerves which 
 embrace, or lie near, the carotid artery. The rapid cure now 
 effected by the buried aseptic ligature lessens or prevents such 
 irritation: so, that in future, it is probable that such cerebral 
 complication will be a matter of infrequent occurrence. 
 
 Cerebral complication following carotid ligature has appeared 
 at once, after the operation, or it has supervened at a later 
 period. 
 
 As primary or immediate consequences are dizziness, tendency 
 to sleep, palpitation of the heart, and painful or abnormal sensa- 
 tions on the side of the head corresponding to the ligature. 
 There may be cough, and muscular spasms general, or limited to 
 one or more groups of muscles. The muscles of the lar^aix and 
 of the pharynx are sometimes implicated, inducing aphonia and 
 difiS.culty of swallowing. The muscular disturbance may be 
 confined to one side of the body, or both sides may be affected. 
 These disturbances may be transient; or they may appearand 
 disappear; or they may continue for a considerable period. 
 
 Instead of appearing immediately, the morbid phfenomena 
 caused Ijy ligation may occur some time after the operation. 
 These disturbances can be divided into three classes: mental, 
 sensory and motor. Mental disturbance commonly presents 
 itself in the form of lessened power of the mind, viz., loss of 
 memory, and inertia of the thinking power, which may reach 
 to absolute dementia; the patient then quite loses the capacity 
 of caring for himself. 
 
 Sensory disturbance may exist in perverted function of one or 
 more of the special senses, especially of vision; also of common 
 sensation, which may be unilateral or universal in extent. Deaf- 
 ness has also been observed. 
 
Ills VESSELS OF THE NECK. 
 
 As result of ligation of the carotid, motor power may be lost 
 on one side of the body; and tliis is on the side opposite to that 
 of the ligation for all portions of the body except the face, where 
 the palsy corresponds to the side ligated. Palpitation of the 
 heart and difhculty of breathing have been so violent in some 
 cases as to speedily terminate life. 
 
 Aphonia arising from ligation of the carotid has been studied 
 by Ehrmann, who published a dissertation on the subject in 
 18GG, in which he states that writers have disagreed in reference 
 to the causation. Horner finds the cause in an increased afflux 
 of blood to the thyroid gland; Bertherand refers it to the lesion, 
 or inclusion of filaments of tlie sym})athetic nerve in the ligature ; 
 Giraldes attributes the loss of voice to swelling of the wound that 
 crowds on the vagus nerve; Broca thinks it ma}^ be due to a 
 neuritis of the vagus through lesion of the nerve. In a case of 
 ligation done by the writer in which the cause was evidently 
 referable to inclusion of the sympathetic nerve, the aphonia was 
 not complete, yet it remained until the death of the patient, some 
 weeks afterwards. 
 
 As a rule, this aphonia is not })ermanent: in one case it dis- 
 appeared after two weeks; and in others it vanished after some 
 months. It is, also, of infrequent occurrence; for Ehrmann found 
 that in a series of two hundred and seventeen ligations it was 
 rarely observed. In one case in which a necropsy was made, the 
 vagus was found divided by the ligature. And in another case 
 of aphonia, there had been thrown a provisional ligature around 
 the external carotid, and though the knot was not tied, yet the 
 voice was extinguished. 
 
 The writer believes that such aphonia is wholl}- due to lesion 
 of nervous filaments in the work of tying: such lesion arising 
 from mal-adroit manipulation in exposing the vessel, and pass- 
 ing the thread around it. In the case seen by the writer, the 
 patient was bleeding from a wound of the external carotid; and so 
 profuse was the haemorrhage that precipitate haste was necessary 
 in order to rescue the patient from fatal Ijleeding. Though the 
 conditions were not verified subsequently by a necropsy, yet there 
 is no doubt that in tlie hasty manipulation, the vagus was 
 included. 
 
 In regard to most of the accidents enumerated which may 
 follow ligation of the carotid, whether occurring primarily or 
 ulteriorly, they may be referred to disturbed encephalic circulation, 
 throueh the closure of a channel through which the brain receives 
 
LIGATION OF THE PRIMITIVE CAROTID, 1119 
 
 more than one-fourth of its supply of blood. In this condition, 
 the nutrition of a portion of the brain must be disturbed; for a 
 time, the current, in which the blood reaches its destination by 
 stagnant reflux, rather than by normal afflux, fails to maintain 
 those fine metaplastic processes of elementary interchange, by 
 which the normal life of animal tissue is maintained. Another 
 agency which may have a disturbing influence moy be an irreg- 
 ularity in the formation of the circle of Willis: thus, as the writer 
 has observed in dissection, one of the posterior communicating 
 branches which connect the internal carotids with the posterior 
 cerebral arteries may be unusually small; and also tlie anterior 
 communicating trunk of the circle may be small. Such an 
 irregularity must have an important bearing after ligation of the 
 common carotid, or vertebral artery. 
 
 That the work of molecular interchange may be disturbed by 
 ligation of the carotid was illustrated in a case in which the 
 writer ligated the vessel as aid in an extensive operation done 
 for the removal of a cancer involving the side of the tongue and 
 the pharynx. A few days after the operation, the patient became 
 hemijDlegic on the side of the ligation. As the palsy appeared 
 almost instantaneously, it was deemed to be dependent on the 
 sudden rupture of a vessel: and with the hope of finding a 
 thrombus that could be removed, and relief thus obtained, the 
 cranium was opened and the brain exjiosed corresponding to the 
 motor tract. No clot was found, and the uncovered cortex 
 instead of being the site of hypersemia, was pale, and the vessels 
 of the investing pia mater were nearly empty of blood. The 
 cerebral structure was abnormally soft, and was in the initial 
 stage of softening. And along with the motor tract the con- 
 tiguous surface of the cerebrum participated in the structural 
 degeneration. 
 
 Besides the interruption and disturbance of the blood supply, 
 just assigned as causation of the cerebral trouble, it is probable 
 that there are faulty or dyscrasic conditions of the body which are 
 predisposing contributory agencies; and as examples of such 
 agency may be cited that of vitality depressed through renal 
 disease, ill assimilation of nutriment, or other enfeeblino- ailment. 
 In tlie presence of such constitutional condition, any severe 
 surgical assault is ill tolerated; and if delay be permitted 
 before operating, the surgeon should subject his patient to treat- 
 ment which will improve his condition, and add to his power 
 of resistance; in some cases, unfortunatel3% the urgent demand 
 
1120 VE^.SEJ.S OF THE XECK. 
 
 for immediate ligation gives no truce for preparatory fortification. 
 
 LUjation of BotJt Prhnitive Carotids. — Tlie essays in the work of 
 simultaneously tying botli carotid arteries have almost uniformly 
 terminated disastrously. Valentine Mott reports a case in which 
 lie tied at once the two vessels, and death occurred a few liours 
 afterwards. Key, of London, tied the right carotid, and death 
 having quickly followed, the necropsy showed that the left 
 carotid was nearly obliterated, and that the fatal result occurred 
 under conditions similar to simultaneous ligation of both vessels. 
 The result has been different where an interval of a week or 
 more of time has intervened between the ligations. And experi- 
 ence in this operative field has shown that ligation of both 
 vessels with a considerable interval of time between the two 
 operations is not only tolerated, but that the cliance of cerebral 
 disturbance, occurring after such double ligation, is not greater 
 than after single ligation. 
 
 The writer has demonstrated that simultaneous ligation of 
 both carotids is jDOssible without any ill result to the patient. 
 Six years prior to the date of this writing, in the removal of an 
 epithelial cancer which occupied the right side of the base of the 
 tongue, and the right pharyngeal arch, the internal carotid was 
 opened, and despite ligations of the right carotid, the haemor- 
 rhage recurred so profusely that the patient's death was immi- 
 nent. Comj^ression within the throat did not check the bleeding; 
 and when the patient was moribund, the left primitive carotid 
 was reached by a rapid incision through the skin, and quick 
 digital penetration to the vessel, when the latter was tied. The 
 left carotid artery was ligatod in less than one hour after the 
 right one hud been tied. And even this double ligation did not 
 prevent some oozing of blood from the pharyngeal wound: a fact 
 demonstrating how rapidly the blood of the vertebral arteries 
 traversed the circle of Willis and reappeared in the carotids. 
 This patient made an uninterrupted recovery, disturbed by no 
 cerebral or other complication ; and the freedom from such com- 
 plication the writer refers to the loss of blood which occurred: 
 and should he find it necessar}'- to perform simultaneous ligation 
 where such loss has not already occurred, the author would 
 premise the work by a vigorous bleeding. The history here 
 referred to is interesting, as this is the first case of simultaneous 
 ligation of the primitive carotids which has tei-minatod success- 
 fully. 
 
 Ligation oj the Ext (rnal Carotid. Artery. — In recent years the 
 
LIGATION OF THE EXTERNAL CAROTID ARTERY. 1121 
 
 ligation of the external carotid lias been advised and practiced 
 as a substitute for the ligature of the primitive vessel. The lead- 
 ing argument in its favor is that thus the encephalic circulation 
 not being interfered with, the danger of cerebral complication is 
 avoided. 
 
 The cutaneous landmark for finding this artery has been 
 given: it is a continuation of that for reaching the common 
 carotid, viz., the upper third of a line drawn from the sterno- 
 clavicular joint to the fossa behind the lobulus of the ear. 
 Writers are not in accord as to the ease or difficulty with which 
 the external carotid can be displayed for ligation. Allan Burns 
 says that "it is much easier to pass a ligature around the exter- 
 nal carotid artery than eitlier the internal or the common carotid 
 artery: for both the latter are in contact w^ith large nerves and 
 the internal jugular vein." Chelius says: "Tying the external 
 carotid artery is considered one of the most difficult operations, 
 on account of the vessel being surrounded with arteries, veins 
 and nerves: and, therefore, it is usually recommended to tie the 
 common trunk instead of it." It was tied first in 1827, b}' 
 Bushe, for the arrest of haemorrhage which followed the excision 
 of an anastomotic aneurism located in the temporal region. 
 And as a prophylactic precaution against the loss of blood in the 
 removal of growths seated in the n?axillary or cervical region, 
 the artery was ligated by Mott, Lizars and other surgical opera- 
 tors. The manner of reaching and displaying the vessel for 
 ligation was first accurately described by Diedrich, in 1831. His 
 incision consists of a cut tiirough the skin which is a half inch 
 inside of the inner margin of the sterno-cleido-mastoid muscle, 
 and which, commencing on a level with the upper margin of the 
 thyroid cartilage, ends above, a little below the inferior margin 
 of the lower jaw. If the wound be dilated by retractors, the 
 sterno-cleido-mastodd will be seen on the outside, the corner of 
 the hyoid bone on the inner side, the sub-maxillary gland in 
 the upper angle, and the omo-hyoid muscle at the lower end. 
 As the dissection penetrates, there will be reached the thyroid, 
 lingual and facial veins, which converge and uniting form a 
 trunk of considerable magnitude, which passes to the internal 
 jugular vein. This vessel will bleed profusely if opened; and, if 
 it is necessary to divide it, it should first be doubly tied and di- 
 vided between the ligatures. 
 
 The depth to which the dissection must proceed before reach- 
 ing the vessel varies in the obese and emaciated subject: in the 
 
1122 VKSSKLS OF THK NECK. 
 
 latter, the vessel is near the skin; but the distance may be an 
 inch in a subject of short, thick neck, laden with adeps. And 
 these conditions determine the facility or difficulty of the work : 
 nothing in the list of ligations can be easier tlian the one, and 
 notliing more difficult than the other: lience arise the discord- 
 ant statements about tliis matter. 
 
 The dissection having penetrated to the internal and external 
 carotids, how may these be distinguisljed? The external carotid 
 lies anterior to the internal one; that is, the external carotid is 
 nearer the median line of the neck than is the internal one. 
 Between the two there is but little appreciable difference in 
 magnitude. The best differentiating means is the fact that 
 vessels arise from the external one, while normally, no branches 
 spring from the internal carotid. In exceptional cases vessels 
 have been found to proceed from the internal carotid: viz., 
 vessels which should arise from the external vessel. Again, the 
 common carotid, in a case seen by Allan Burns, and in one seen 
 by the writer, ascended almost to the base of the skull before it 
 bifurcated: and then the branches which normally originate 
 from the external carotid, arose from the primitive carotid. 
 Such knowledge of anatomical anomalies should be stored in the 
 memory of the surgeon who would be read}' to meet every 
 emergency which his knif# may encounter in operating on the 
 neck. The general rule is that the blood-supply to the side of 
 the neck, tongue, face and temporal region is from tlie branches 
 of the external carotid; and hence the latter is named, some- 
 times, the facial carotid. 
 
 The numerous branches given off by the external carotid led 
 to the belief that, if tied, the vessel would not become occluded, 
 and, hence, that such tying would end in secondary haemorrhage. 
 Guyon's researches and work in this field showed that such fear 
 was groundless ; and Madelung, on the same subject, collected a 
 series of sixty ligations, of which thirteen died: and of the fatal 
 cases Madelung sliowed that death in seven patients Avas not 
 caused by the ligation. The writer has done this ligation seven- 
 teen times, and all ended favorably except one, in which death 
 arose from cerebral trouble caused by ligating the primitive carotid 
 on the other side. In only one i)atient, elsewhere referred to, did 
 secondary bleeding take place; and to arrest this, the common 
 trunk was ligated. A few days afterwards there was another 
 profuse haemorrhage from the original wound, which was con- 
 trolled by a piece of aseptic sponge crowded into the wound, and 
 
LIGATIOX OF THE EXTERNAL CAROTID ARTERY. 1123 
 
 retained there by digital compression. This sponge was occa- 
 sionally replaced by a new one; the compression was continued 
 until the wounded vessel was closed and the patient's recovery 
 insured. 
 
 The vessel having been reached, it should be so displayed as 
 to present the thyroid, lingual and facial branches wdiich arise 
 from its anterior side; and the ligature may then be placed in 
 the space between the first and second, or between the second 
 and third of these vessels : as a rule, there is the most room 
 between the thyroid and lingual branches. Should the space be 
 short, as may be in a subject of short neck, then, as the author 
 did in one case, besides the external carotid, the superior thyroid 
 artery may be tied, also. Thus the formation of an occluding 
 clot is insured. 
 
 After the exposure of the vessel, should another point appear 
 more favorable for applying the ligature than the one just indi-' 
 cated, then the work should be done there: the rule for observ- 
 ance being to place the ligature as far as practicable from a 
 branch, or branches, which would interfere with the formation of 
 an occluding thrombus. 
 
 The ligature having been placed and the cord cut short, the 
 wound is to be closed and treated in the same manner as that 
 detailed for the ligation of the primitive carotid. 
 
 Certain branches of the external carotid are sometimes tied: 
 and those in which this is chiefly practiced are the superior 
 thyroid and the lingual arteries. 
 
 The superior thyroid is sometimes ligated as an antecedent 
 step to removal of the thyroid gland : also, as a means to arrest 
 the growth and induce atrophy of the enlarged thyroid gland. 
 The method proposed by Linhart, of Munich, to find the vessel is 
 to expose the external carotid, and then tie the first branch which 
 is given off. And in the same way, he would search for the 
 lingual artery, which is the second branch given off from the inner 
 side of the external carotid. The author has already given a rule 
 for finding the lingual: but in case the operator loses his way, or 
 from any cause becomes embarrassed in his search, then he may 
 follow the method of Linhart for finding the lingual. To elimi- 
 nate all uncertainty, when the method of Linhart is practiced, the 
 incision should be long enough to expose the bifurcation of the 
 common carotid: otherwise, error can arise in the enumeration 
 of the branches given off from the external carotid; for example, 
 the lingual miglit be mistaken for the facial, or superior thyroid. 
 
1124 VESSELS OF THE NECK. 
 
 but if tho bifurcation bo found, then the first brunch above must 
 be the superior thyroid, and the second branch the lingual. 
 
 •Should the internal carotid be the one which it is intended to 
 ligate, then a cut is to be made similar to that for the external 
 carotid: the dividing i)oint of the common carotid into its two 
 branches must be sought for; and when found, the posterior 
 branch will be the internal carotid, which is close to, and i)artly 
 covered on its outer side by the internal jugular vein. From the 
 proximity of the internal carotid to the external caroti'd on one 
 side, and to the internal jugular on the other, it is a difficult act 
 to pass the aneurismal needle underneath it: and as prelude, the 
 external carotid must be detached and drawn inwards, and the 
 internal jugular detached and drawn outwards; and for this 
 work blunt hooks, or small retractors, should be used. The 
 internal carotid has very intimate relations with the sympathetic 
 nerve, which forms a sheath-like plexus about the arter}': and 
 this nervous structure should not be included in the ligature. 
 Besides the obstacles enumerated, the operator will find some 
 trouble in uplifting the vessel ; for the writer's experience in this 
 work has shown him that the artery is rigidly stretched between 
 the primitive trunk and the bony canal through which it enters 
 the petrous portion of the temporal bone. Nevertheless, despite 
 these difFiculties, by patient effort, the ligature can be passed and 
 the tying done. Owing to the rigidity of the artery, in tightening 
 the ligature, care must be used not to cut or break the vessel. 
 
 The ligation of the internal carotid can cause cerebral dis- 
 turbance in the same manner as ligation of the common trunk, 
 already mentioned; but as there is an intercommunication 
 between the external and internal carotids in the orbit, the 
 chances of restoration of the circulation after tying the internal 
 carotid must be better than after the ligation of the primitive 
 trunk. The difficulties, however, which beset the operator in 
 reaching the internal carotid are so great that it is not probable 
 that this ligation will supersede that of the prime trunk: cer- 
 tainly not in the subject of short, thick neck, in which the 
 internal carotid is very short. 
 
 The marvelous progress which has been made elsewhere in 
 operative work has also extended to the cervical region; and 
 arteries which hitherto had been exempt from interference, have 
 recently become the occasional subject of ligation. An example 
 of such operation is the tying of the vertebral artery. 
 
 The vertebral artery, as will be remembered, is the first 
 
LIGATION OF THE EXTERNAL CAROTID ARTERY, 1125 
 
 branch given off from the subclavian, and, a variable distance 
 beyond its origin, the vertebral enters an interrupted, bony canal 
 which traverses the transverse processes of the six upper cervical 
 vertebrae; that is, all of these vertebrse except the seventh ; then 
 the vessel enters the foramen magnum, and becomes one of the 
 four vessels which furnish blood to the brain. From the basilar 
 prolongation of the confluent vertebral arteries emanate the pos- 
 terior cerebral arteries, which aid in forming the circle of Willis : 
 and, as has already been pointed out, one of the posterior commu- 
 nicating branches, which connect the posterior cerebral arteries, 
 may be very diminutive: so much so as to be an obstacle to 
 restoration of the circulation after ligation of the vertebral, or the 
 common carotid artery. 
 
 The aid of the surgeon, as before stated, has recently been 
 invoked in the treatment of epilepsy ; and, besides the ligation of 
 the common carotid, or the internal carotid artery, the tying of 
 the vertebral artery has lately been advised and practiced, as a 
 means of curing this disease. In regard to the value of this 
 procedure experience has not yet pronounced its verdict. But 
 as the "Comitial" disease usually begins in childhood, and, 
 according to the Hippocratic aphorism, may vanish before 
 puberty, hence in that period of life many remedies acquire the 
 credit of curing; but, after twenty-five years, the disease, as a rule, 
 only "dies with the patient," and durnig this period, epilepsy 
 seldom surrenders to ligature or trephine. 
 
 The more usual purpose for wdiicli the vertebral is tied is to 
 control hsemorrhage from the wounded vessel : and such hsemor- 
 rliage, as well as its control by ligature, has been studied by 
 Kocher, who has collected twenty-one cases, one of which he 
 treated himself. In his case there had been a stab which had 
 penetrated about one inch outside of the median line of the neck, 
 in the region of the fifth or sixth cervical vertebra. After three 
 weeks of constant bleeding, he cut down and sought for the ves- 
 sel; the proximal end of the vertebral was caught and tied, while 
 the return of blood from the distal end was controlled by tam- 
 poning with a styptic plug. The patient recovered, though an 
 attack of erysipelas occurred during the treatment. 
 
 There is difficulty in distinguishing whether such a wound 
 has opened the vertebral or carotid artery: for compression on 
 the tubercle of the sixth vertebra, presses both on the carotid 
 and vertebral artery: and to accurately discriminate, one must 
 make pressure from without inwards, testing each part in sue- 
 
1126 VESSELS OF THE NECK. 
 
 cession. The carotid is best compressed by including it along 
 with thesterno-cleido-mastoid muscle. 
 
 The vertebral artery is only open for ligation for a little over 
 two and a half inches: viz., from its origin to its entrance into 
 the sixth cervical vertebra. 
 
 The Hunterian ligation, which is not advised by Kocher, is 
 made by a cut along the outer side of the sterno-cleido-mastoid. 
 In case of a wound of the vertebral, he prefers the old plan of 
 Anthyllus, in which a cut is made down on the wound, and the 
 ends there ligated. 
 
 Fracy, in 1847, writing on ligation of the vertebral, advises to 
 make a cut upwards, from the sterno-clavicular articulation on the 
 inner side of the sierno-cleido-mastoid muscle, and, when the 
 vascular group is found, it is to be drawn outwards along with 
 the overlying muscle: then the vertebral artery will be found in 
 the triangle between the scalenus auticus and longus colli mus- 
 cles. Tie one inch belo\v the carotid tubercle. In this work, the 
 inferior thyroid artery and the sympathetic nerve are endangered. 
 
 In 1867, Gherini wrote on wounds of the vertebral artery, 
 from a collection of ten cases; and he finds it hard to decide, 
 in penetrating wounds in this region, whether the carotid or ver- 
 tebral artery be wounded. He finds, also, that aneurism of the 
 vertebral artery has usually been mistaken for that of the ca- 
 rotid; and the mistake has been made of tying the latter; and as 
 treatment, Gherini would first try compression, and, this failing, 
 he would endeavor to tie the vertebral. 
 
 Gherini's plan is to circumscribe the artery by means of a 
 thread passed between two of the transverse processes through 
 which the artery passes; a serious objection to this is, that impor- 
 tant parts, as nerves, might be included in the ligature. Others, 
 again, have simply stitched up the w^ound ; but this plan is faulty, 
 since the opened artery would continue to pour out its blood into 
 the tissues, and produce a false aneurism. Kocher finds that 
 some cases have been cured by simple compression on the wound, 
 while the head is maintained at rest. 
 
 The mode of ligating the vertebral artery as prescribed by 
 Farabeuf, is as follows: first seek the carotid tubercle of the 
 sixth cervical vertebra, which, according to Chassaignac, becomes 
 unduly prominent and distinguishable, through the effacement 
 of the anterior tubercle of the seventh vertebra by the action of 
 the vertebral artery that rests on it: and immediately below this 
 tubercle is the artery. Incise along the outer border of the 
 
SUBCLAVIAN ARTERY. 1127 
 
 sterno-cleido-mastoid muscle, similarly to the cut made for find- 
 ing the carotid artery. When the vasculo-nervous group of 
 structures is found, pull them inwards, when the vertebral artery 
 will be seen and the ligature can be passed around it. 
 
 Albert of Vienna, writing in 1881, says the ligation of the 
 vertebral is very difficult, and, till that time, had onl}^ been tied 
 three times. To do the work, make an incision on the outer 
 margin of the sterno-cleido-mastoid, from the point where the 
 external jugular vein crosses the muscle to the clavicle. This 
 cut is about two inches long. If the vein is in the way, it may 
 be tied. The sterno-cleido-mastoid muscle and the vessels and 
 nerves are to be caught with a retractor, and drawn towards the 
 trachea. At this point it will be of aid, if the head which was 
 previously bent backwards be bent forwards. The carotid 
 tubercle which lies about three fingers' breadth above the clavi- 
 cle, is next to be found. The artery is now to be ligated below 
 this eminence; and the vessel lies there somewhat inwards, 
 between the insertions of the scalenus anticus and longus colli 
 muscles. The vertebral vein lies on the outside of the artery, 
 and in throwing the ligature around the latter, the vein must be 
 pulled outwards. Instead of doing the work thus, one may do as 
 Maisonneuve did, viz., make the incision on the inner side of the 
 sterno-cleido-mastoid where both the vertebral and inferior 
 thyroid arteries may be tied. 
 
 To compress the vertebral artery, Fracy directs to make 
 pressure on the lower part of the neck, against the carotid tuber- 
 cle; such compression acts both on the carotid and the vertebral 
 artery. If compression be made higher up, then the common 
 carotid only is acted on; this was proven by Fracy by injecting 
 into the aorta during pressure made separately on each of the 
 two points; in the case of pressure made low down, the injected 
 material did not enter either carotid or vertebral , but when made 
 above the carotid tubercle, the material only enters the vertebral 
 artery. 
 
 Subclavian Artery. — A great part of the subclavian artery is 
 situated in the lowermost portion of the anterior cervical region. 
 Functionally, this artery ranks with the most important vessels 
 of the body; through the two subclavians nearly one-half of the 
 blood supply to the brain is furnished; and the upper extremity 
 derives its blood through the same channel. The right and left 
 subclavian arteries differ from each other; the right springing 
 from the innominate is shorter, and more superficial than the 
 left artery. 
 
1128 VESSELS OF THE NECK. 
 
 For convenience of description and guidance in operative 
 work, the surgical anatomist maps off the course of the vessel into 
 three sections: the first of these extends from its origin to the 
 inner border of the scalenus anticus muscle; the second portion 
 lies between the anterior and posterior scalene muscles, and is 
 the shortest section of the three; and the tliird and torniinal 
 section extends from the inter-scalene space to the lower border 
 of the first rib, where the vessel becomes the axillary artery. 
 
 The ligation of the subclavian artery has been done for three 
 purposes: to control bleeding when the artery lias been wounded; 
 for the cure of axillary aneurism, and in Brasdor's and Ward- 
 sop's operation for relief in aneurism of the innominate artery. 
 It should be done as a preliminary step in the amputation of the 
 humerus with the scapula. The author has tied the vessel twice 
 in cases of innominate aneurism, and twice for the cure of 
 axillary aneurism. 
 
 In case of stabbing wounds of the vessel, or of fracture of the 
 adjacent rib or clavicle, in which a fragment has pierced the 
 artery, it might be necessary to seek tlie vessel and ligate it on 
 the proximal side of the wound; such an operation would be 
 involved in great difficulties; for tlie structures saturated with 
 ecchymosed hlood would obscure tiie anatomical landmarks, so 
 that tlie surgeon would be forced to trust to touch, rather than 
 to sight. 
 
 In cases of aneurism seated in the axillary artery, ligation of 
 the subclavian has been done. Early in this centur}-- the opera- 
 tion was attempted by Astley Cooper on a patient, in whom the 
 tumor involved a part of the third portion of the subclavian : the 
 aneurism so uplifted the clavicle that this celebrated operator 
 was baffled in the attempt to pass a ligature around the vessel. 
 Near the same time, in 1809, Ramsden, of 8i. Bartholomew's 
 Hospital, tied the subclavian; yet the patient lived but six days. 
 These pioneer surgeons found much trouble in passing tlie 
 ligature around the vessel, owing to the want of an instrument 
 properly constructed for the purpose. Invention has since 
 remedied this in furnishing devices which easily carry the 
 thread around the vessel; and of these, one of the best is that 
 used by Valentine Mott, of which the curved point can be 
 attached and detached, and the thread thus carried beneath the 
 vessel. 
 
 The ligation is most easily done in the third section of the 
 artery; and if the work cannot be done there, the vessel may be 
 
SUBCLAVIAN AKTERY. 1129 
 
 sought between the scalene muscles and there tied; and should 
 approach to the vessel in its third or second portions be imprac- 
 ticable, then the work may be attempted in the initial section of 
 the artery. 
 
 The subclavian artery was tied in the first part of its course 
 by the Irish surgeon, C. Colles, in 1813, who pronounces the feat 
 not difficult on the right side, for one who has a steady hand, and 
 is a good anatomist; but Colles finds it far otherwise, on the left 
 side; here it may be declared to be an impossibile undertaking. 
 Here, as Colles shows, and as Hyrtl indicates in greater detail, 
 the left subclavian is contiguous to the vagus, phrenic, sympa- 
 thetic and inferior laryngeal nerves; also, the thoracic duct is 
 near by, and likewise the apical saccule of the pleural cavity. 
 Danger in this field, as elsewhere, stimulates to daring: and 
 despite the deterrent caution of Colles, and undismayed by the 
 failure of others, the ligation of the left subclavian in its 
 incipient portion, has frequently been essayed, and properly, too, 
 the author thinks, since such operation, if it does not save life, 
 may sometimes prolong it. 
 
 The subclavian is usually tied in the third section, beyond 
 the 'scalene muscles. As cutaneous guide to find the vessel, 
 Allan Burns directs "to draw a line from the junction of the 
 clavicle and coracoid process to the cleido mastoid muscle, two 
 inches in the adult above the sternum." The subclavian lies 
 below this line, and the arteria transversalis colli and arteria 
 cervicalis superficialis lie above it. To find the subclavian, make 
 an incision below this line, parallel with and above the clavicle, 
 two and a half inches long. This incision, if carelessly made, may 
 cut tlie external jugular vein: shun this "reef" as Farabeuf calls 
 it, by pulling the vein aside. To best display the artery, let the 
 patient lie with the thorax somewhat uplifted, and the shoulder 
 of the side to be operated on inclined backwards. An aid will 
 assist by making downward traction on the arm. As soon as 
 the skin is opened and retracted, and the external jugular placed 
 in safety, the work advances by penetrating through a mass of 
 adeps, which occupies the subclavian triangle. This fatty tissue 
 is loose and easily opened. As a rule, the operator is apt to seek 
 too near the upper border of tlie clavicle for the artery. At this 
 stage of the work, the surgeon is solicitously directed by the topo- 
 graphical anatomist to seek for the scalene tubercle, on the first 
 rib, as guide to the vessel; yet from the writer's experience, the 
 artery is usually found before the tubercle is discovered; hence 
 72 
 
1130 VESSELS OF THE NECK. 
 
 search for the hitter is dispensable. The artery having been 
 found and its sheath opened, an aseptic silken cord is to be 
 carried round, tied, and cut short; and the incision being sutured 
 is to be treated as an ordinary Avound. 
 
 Should the conditions contravene ligation in the third 
 portion of the subclavian, the next best site is where the artery 
 lies between the scalene muscles; and this may be done by an 
 incision similar to tlie preceding, if the cut is carried fm-ther 
 towards the median line of the neck. The fatty layer being 
 opened with a blunt dissector, the anterior scalene is found; and 
 lying on its anterior face there is seen the phrenic nerve, a small 
 reddish white cord. This precious structure being drawn aside, 
 the muscle is next divided, and the artery brought to view and 
 ligated. Exceptionally, the subclavian artery lies in front of the 
 anterior scalene muscle; and then the artery and subclavian 
 vein would lie side by side: normally, the vein lies here in front 
 of, and the artery behind the scalenus anticus. In the third 
 portion of the subclavian, the vein lies below the vessel, and is 
 so hidden by the clavicle that the operator rarely sees it, but in 
 the first and second portions of the artery, the vein is closer to 
 the vessel, and would be imperiled by careless manipulation.* 
 
 In case the conditions forbid ligation in the third or sec- 
 ond portions of the subclavian, then the surgeon should seek 
 and tie the vessel in the first portion of the artery; and the 
 preceding cut, carried to the median line with division of the 
 cleido mastoid muscle, will open the way for finding the vessel. 
 The deeper work must be done with the blunt dissector, and, 
 though the way be beset with dangers, it can be safely traversed 
 by the hand which has acquired steadiness and boldness through 
 hours of discipline at the side of the cadaver. 
 
 Tlie writer has ligated the subclavian artery four times: twice 
 for the cure of aneurism implicating the axillary artery, and twice 
 in patients of innominate aneurism, in which tlie right carotid 
 and the right subclavian were simultaneously tied. In all these 
 cases, the ligature was applied to the third or terminal portion 
 of the artery. Of the cases of axillary aneurism, one recovered; 
 in the other case secondary hiemorrhage occurred, to control 
 wliich the artery was tied in the first part of its course, and also 
 retied in its third portion, near the aneurism; the patient died 
 on the nineteenth day. 
 
 Of the cases of innominate aneurism, one patient survived the 
 ligation but one week; but the other patient recovered and 
 
LIGATION OF THE EXTERNAL JUGULAR VEIN. 1181 
 
 resumed his business as watchman: he lived but six months, 
 death being caused by pulmonary disease which was indirectly 
 induced by the pressure of the aneurismal tumor on the summit 
 of the right lung. 
 
 Ligation of the External Jugular Vein. — From wounds of the 
 external jugular vein, there may be so much bleeding as to 
 require ligation; and this may be done by percutaneous suture 
 in which a needle armed with silk thread is carried through the 
 skin and platysma myoid muscle beneath the vein, so that when 
 the thread is tightened, the vein is included with a portion of 
 the skin. And such a ligature should be double, viz., one on 
 each side of the wound. In tliis work aseptic thread sliould be 
 used, and the skin well cleansed before ligating. On the fourth 
 day, the thread can be cut and removed. 
 
 Sometimes projected surgical work on the neck will involve 
 the external jugular vein; and not unfrequently in such proposed 
 work, as a preliminary act, the writer has resorted to percutane- 
 ous circumscription done in the way just described, above and 
 below the contemplated wound. The superficial venous circula- 
 tion of the front of the neck may consist, on each side, of an 
 anterior and posterior external jugular vein; and there may 
 even be a third vein between these two. This increased number 
 of veins necessarily lessens the calibre of each vessel ; thence arises 
 the variability in the caliber of the external jugular vein. The 
 external jugular is constituted of trunks which collect the blood 
 from the temporal, auricular and maxillary regions; these trunks 
 fuse into one trunk at the angle of the jaw, which runs thence 
 on the side of the neck to the middle of the clavicle, where it 
 ends in the subclavian vein : thus its course traverses the field 
 which is so often the scene of operative action. If this work is 
 of a character to consist only of longitudinal incisions, then 
 the external jugular vein, as wxll as the anterior and median 
 ones, can often be shunned by a cut which lies alongside of the 
 vessel, so that with a retractor inserted into the wound, the lip 
 containing the vein can be pulled aside, and the vessel thus left 
 unopened. But should a transverse incision also be necessary, 
 then percutaneous circumscription may be resorted to; or what 
 the writer has often done, the vein having been dissected up for 
 a short space, it may be seized with two pairs of forceps, and 
 divided between these; and then each end is to be twisted on its 
 axis, at least six times. Closure being thus done, air cannot enter 
 the vein, as has been recorded to have occurred after wounds of 
 
1132 VESSELS t)F THE NECK. 
 
 this vessel. The aspiration of air is favored in cases in wliicli 
 the vein is unusually largo; and also when in the o[)erative 
 work, the lij) of the transverse wound has been uplifted so as to 
 open the vein. As a precautionary measure where tlie vessel lias 
 not been closed by torsion or circumscription, tlie surgeon should 
 direct an aid to maintain compression over the vein on the 
 cardiac side of the wound; that is, above the middle of the 
 clavicle: yet, as before said, it is always safer before opening tlie 
 vessel to occlude it by torsion or ligation. 
 
 Wounds of the luteiiial Jugular Vein. — When the internal 
 jugular has been opened freeh', the resultant bleeding is profuse; 
 and if the wound has been made by the surgeon himself, the 
 scene initiated is one of the most startling emergencies which 
 can arise in operative work. On such occasion the field is 
 instantly inundated with a wave of dark blood, that fills tlie 
 wound and conceals everything tliere: and to this occurrence, 
 (|uite terrible enough, may be superadded that of another yet 
 more alarming, viz., the sound of air inspired into the wound. 
 The blood-wave may be met and stayed by the disciplined hand 
 of the surgeon: but the air aspirated in large amount penetrates 
 to the heart beyond manual reach, where it may speedily 
 end life. 
 
 The internal jugular is often endangered in the removal of 
 the tubercular glandular tumor or malignant growths, which are 
 adherent to the vessel. A number of lymphatic glands lie in 
 chain form along the track of the cervical vessels; and they are 
 in close relation with the veins. As result of this contiguity, the 
 gland, when it enlarges and inflames, becomes closely connected 
 with the vein, and may involve and weaken the wall of the 
 latter. In fact, cases are recorded in which the venous wall 
 opened and the cavity of the gland became filled with blood. 
 The malignant lymphoma does not contract adhesions to the 
 vessels: indeed, a thing remarkable in the removal of this 
 growth is the facility with which it may be enucleated without 
 disturbing the adjacent vessel. But the conditions of the tuber- 
 cular lymphatic gland are far different: in many cases the sep- 
 arktion of the multiple tumors from the vessels is a task which 
 tires head and hand. And instead of complete removal of the 
 entire gland, the knife and blunt dissector, near the conclu- 
 sion of the work, should be replaced by a blunt curette, with 
 which along the line of danger tlie work of fragmentary detach- 
 ment can be pursued a little further. Since the introduction of 
 
WOUNDS OF THE INTERNAL JUGULAR VEIN. 1133 
 
 iodoform as a remedy against such glandular disease, the local 
 use of this agent lessens the work of the knife. 
 
 In cases in which the walls of the vein are found diseased, or 
 in which during the removal of a tumor a laceration of the vein 
 is unavoidable, the precautionarj^ step should first be taken to 
 tie the vein at two points, viz., above and below the part that 
 is endangered. The ligation of the vein, whether done singlj- 
 or doubly, as here advised, is free from danger: in fact, as the 
 writer has repeatedly verified, no inconvenience arises from it, 
 for there remain intact abundant anastomotic routes through 
 which the blood can reach the heart. 
 
 Instead of removing tubercular glands through a free incision, 
 the work is sometimes done by making a small cut to the diseased 
 gland, and through this, reaching and scooping out the affected 
 structure. Operating in this blind way endangers the vein much 
 more than by a free incision and exposure of the part. In oper- 
 ating thus in two patients, the writer has had the misfortune to 
 lacerate the wall of the vein, and, as result, to have caused an 
 unexpected hEemorrhage which was only controlled through 
 ligation of the vein on each side of the breach in its wall. 
 
 In the presence of such a wound two things demand imme- 
 diate attention: the prevention of the entrance of air into the 
 wounded vein, and the arrest of haemorrhage. The entrance of 
 air is prevented by pressure made over the vein, on the cardiac 
 side of, and close to, the wound; and prophylactically, such 
 pressure should be made in all cases in which there is a proba- 
 bility that the vein may be opened. To arrest the haemorrhage, 
 the surest means is to tie the vein on each side of the opening; 
 and in doing this, besides compression on the carotid side, pressure 
 must be made above, or on the peripheral side of the wound. The 
 pressure on the peripheral side prevents the blood from reaching 
 the wound and disturbing the search for the vessel; and when 
 the latter is found, and doubly tied, the result will be favorable, as 
 has invariably been the case in patients so treated by the writer. 
 In this double ligation, the ligature on the cardiac side guards 
 against the inspiration of air into the vein; while the other 
 ligature prevents further bleeding. Such ligatures should be 
 near the wound: for if they be distant, blood might still reach 
 the wound through an intercommunicating vein. 
 
 In another case treated by the writer, during the removal of 
 a glandular tumor which was attached to the internal jugular 
 vein where it commences at the foramen lacerum posterius, the 
 
1134 VESSELS OF THE NECK. 
 
 vein was torn open, foilowcd by a ureat gush of blood. To ligate 
 on the cranial side of the wound within the foramen posterius 
 was impossible, and the only refuge was in an occluding tampon. 
 Such a tampon was devised from a piece of sponge rendered 
 aseptic by alcohol, and was pressed down to the wounded vein 
 and held there b}" the finger. This occlusion was so done as not 
 to interrupt the current of blood: a condition necessary for the 
 recovery of the patient; for, had the venous channel been whollv 
 closed, an intra-cranial thrombus might have formed and closed 
 the lateral sinus, with action disastrous to the integrity of the 
 encephalon. As stated, the fenestra in the vein was closed by 
 sponge that was retained in site by pressure of the index finger 
 of a trustworthy nurse, whose hand was occasionally relieved by 
 the hand of the patient. This work was continued for four days 
 and nights by one of those unsleeping sentinels which it is the 
 privilege of the surgeon to occasionally meet as a second in his 
 work. For such service, superhuman endurance and self-sacrifice 
 must be united. 
 
 After this compress had been kept in })osition for four days, 
 the removal of the sponge was commenced by carefully loosen- 
 ing its outer portion. The outer part so detached, gradually 
 expanded, and, in doing so, drew on the part which lay deeper 
 in the wound. In this way the tan:pon was latently extracted; 
 and after its removal, the wound, which was watched, soon 
 closed. The compression here mentioned might be done b}' 
 some tourniquet-like device, yet a nurse of proved fidelity would 
 accomplish the work .still better, since finger and eye would 
 stand watch together. 
 
 In 1867, S. W. Gross published his studies upon wounds of 
 the internal jugular vein; he finds such injury more dangerous 
 than that of the common carotid: since, to the danger of ha3mor- 
 rhage, there is added that of the entrance of air into the opened 
 vein. He finds no recorded case of recovery after a gunshot 
 wound of the internal jugular, while he does find it after such 
 wound of the carotid. 
 
 In twenty cases 'of death from wounds of the internal jugular 
 vein, one-fourth died from entrance of air into the vessel, one- 
 fourth from primary bleeding, one-fourth from secondary haem- 
 orrhage, and the remainder died from jivieniia. 
 
 Arterio-venous aneurism was seen in ten patients in whom 
 there was simultaneous wounding of the internal jugular and the 
 carotid artery. 
 
WOUNDS OF THE INTERNAL JUGULAR VEIN. 1135 
 
 Gross found that in forty-one cases of extirpation of cervical 
 tumors the vein was opened, and tied; and of those so treated, 
 but one died. Death following the ligation of large veins usually 
 occurs from secondary bleeding. 
 
 As means of treatment which have been resorted to, are com- 
 pression and ligation. In fourteen cases compression controlled 
 bleeding, yet this is painful and may cause suppuration. In some 
 cases treated by pressure, though secondary haemorrhage occurred, 
 yet under a continuance of this treatment, the patients were 
 cured. Complete division of the vein diminishes the bleeding 
 and renders it easier to carry out compression. 
 
 The fear of awakening phlebitis has deterred from ligation, 
 yet Malgaigne declares that tying the internal jugular vein is 
 not more dangerous than that of the carotid artery. Ligation of 
 the internal jugular is not a new operation: Thomas Gale writes 
 that it was done in the sixteenth century. 
 
 Parietal ligation, done by Travers in 1816, on the femoral 
 vein, was tried by "Wattmann on the internal jugular vein; the 
 method is unsafe and has been discarded. Instead of this plan 
 in which only a section of the w^all is included, the proper way is 
 to tie at two points and divide between. 
 
 In wounds of the internal jugular Langenbeck tied the com- 
 mon carotid. The peripheral anastomosis of the vein and artery 
 do not justify such ligation; and Bardeleben writes that he saw a 
 case in which, though the carotid had been tied to control bleed- 
 ing from the wounded internal jugular, yet haemorrhage from the 
 latter was not controlled. 
 
 When a vein is included in a single ligature, Gross finds that 
 it becomes closed by a thrombus on the distal side, while the 
 cardiac side is closed by the inner tunic adhering to itself. 
 
 In case the wound were in the lower part of the internal jug- 
 ular vein, close to the subclavian vein in which it terminates, 
 then the plan of treatment which suggests itself to the writer 
 would be to tie the vein on the distal side of the wound, and then 
 apply an aseptic sponge tampon on the wound, and retain this in 
 site by digital or mechanical means. 
 
 The admission of air into the opened cervical veins, esjDecially 
 the internal jugular, has been mentioned: and as it is a matter 
 of much gravity, the matter merits detailed consideration. In 
 surgical work done on the neck, on more than one occasion the 
 writer has observed slight aspiration of air into a wounded vein; 
 3^et pressure instantly made on the wound, and compression on 
 
113G VESSELS OF THE NECK. 
 
 the cardiac side continued during- the remainder of the opera- 
 tion, forestalled further trouble which otherwise might have 
 occurred. The rai)idity with which life may be extinguished by 
 as[)irated air was observed by the author in a man from whom an. 
 immense giowth had been removed from the axilla, and when 
 liealing seemed assured, secondary bleeding occurred from the 
 axillary vein. The jiatient being nearly moribund, it was 
 decided to resort to transfusion; and as no i)roper instrument 
 was at hand, a common syringe was used: but owing to the haste 
 which the occasion demanded, and inaccurate mani[)ulation due 
 to inexperience, when an amount of blood had been injected 
 into the axillary vein, probably sufficient to rescue life, some air 
 Avas admitted, and ended life as quickly as could be done by an 
 electric stroke: one croaking gasp, and life was extinguished. 
 
 Death from entrance of air into the veins was observed and 
 mentioned by Red i in 1667; and early in the present century, 
 death from this cause was observed in dogs who had been the 
 subjects of experiment. In 1842, there were recorded several 
 observations of death thus occurring in man. Simon mentions 
 a case in which death was perilously near ensuing from the 
 entrance of air into the basilic vein, as the result of an opening 
 made for ordinary bleeding. 
 
 Various explanations of the way in which death is thus pro- 
 duced, have been offered: Marchal maintained that through the 
 contact of the admitted air with the blood, carbonic acid is 
 evolved which acts as a toxic agent. Mercier claims that the air 
 mingles with the blood, and that the mixture thus formed 
 becomes an elastic one, and cannot be propelled by the heart's 
 walls, but regurgitates into the veins: and further, that such a 
 compound of air and blood cannot pass through the lungs, even 
 though it reach these organs. 
 
 Wattmann, also in 1842, wrote on this subject. He finds 
 that air is apt to be aspirated, when the veins are rendered tense, 
 or are being pulled on when they are wounded. Again, when 
 the walls of the vein are thickened from any cause, and but 
 partly divided, then, during inspiration, air is apt to be aspirated, 
 especially if the patient is erect. When such accident happens, 
 it is announced by a sharp hissing sound; or by a dull gur- 
 gling sound: and in the latter case, blood and air are commingled. 
 The patient makes a sudden outcry; he is pale, perspires, and may 
 faint or be thrown into convulsive movements. As treatment, 
 AVattmann would lower the head, throw water on the face, and 
 
WOUXDS OF THE INTEKXAL JUGULAR VEIX. 1137 
 
 give stimulants. He does not approve of bandaging the chest, 
 nor the sucking out the air with a tube, nor tracheotomy, nor 
 the injection of fluids into' the veins: means advised by some 
 authorities. 
 
 In 1843 Erichsen, writing on this matter, offers the opinion 
 that the air mixes with the blood and forms a foam which cannot 
 pass through the lungs. Elliott claims that the air reaching the 
 heart cannot pass beyond it, since the cardiac valves are so con- 
 structed that they cannot force the air outwards, but when it 
 enters the right ventricle it returns again to the auricle: and 
 thus the air is alternately moved backwards and forwards. Also 
 in the heart the air expands so as to hamper the movement of 
 the organ; and finally, should the air reach the lungs, it would 
 be cooled there and forced back to the heart. 
 
 Where such accident is feared during an operation Erichsen 
 counsels to bandage the chest so that a deep inspiration cannot 
 be made. And in a patient in whom such accident, has occurred, 
 he would lower the head and bandage the limbs, so as to force 
 the blood to the nerve centres. 
 
 In 1850 in the removal of a tumor from the arm-pit by Gay, 
 air entered a vein and the patient fell into syncope and did not 
 rally for an hour. Lane, who was a witness and reporter of the 
 accident, claims tliat the following are the disposing agencies to 
 such aspiration: deep breathing b}^ which the blood is moved 
 towards the heart; traction on a vein by a tumor, or by an over- 
 lying muscle, favors the entrance of air into the vessel when 
 opened. The trapezius, sterno-cleido-mastoid and the platysma 
 myoides are muscles which may cause such traction. 
 
 Poiseuille taught that if the opening in the vein were an inch 
 distant from the thorax, the air would not enter, since its admis- 
 sion would be prevented by the pressure of the external air. 
 
 iSfecropsy after death from this cause has discovered that the 
 left ventricle was contracted, while the riglit side of the heart, 
 especially the right auricle, was found full of blood mixed with 
 air; also, blood mixed with air was found in the pulmonary 
 artery; and the lungs were congested and contained blood 
 mingled with air. Hence death is from asphyxia, and is not 
 from the friction of the air in the vessels of the brain, as Bichat 
 thought; nor is it from palsy of the heart, or the i:)resence of 
 carbonic acid there, as others have taught. 
 
 As means of resuscitation. Lane recommended stimulants, 
 brisk friction of the skin, and artificial respiration. 
 
1138 VESSELS OF THE NECK. 
 
 Couty, of Paris, writing iu 1S7G, opposes the notion that the 
 ill effect of admitted air is due to embolic obstruction of the 
 lungs: he thinks that death is caused by asystole of the right 
 heart, resulting from the presence of air there; and as final result, 
 death ensues through suspension of the pulmonic circulation. 
 The action of admitted air is classified by Cout}'' under four 
 heads: (1) diminished aortic pressure and increased cardiac 
 action; (2) aortic pressure still more diminished, and action of 
 the heart still further increased; and in this stage the conditions 
 present are paleness, syncope, rapid breathing, and dilated pu{iils; 
 (3) blood pressure vanishes, breathing is slow, and the urine 
 and faeces escape involuntarily. In the fourth or final stage, 
 there is cessation of breathing, and later, cessation of the heart. 
 
 In 1876 Picard experimented on animals in which he 
 admitted air into the portal vein, with the result of inducing 
 hypertemia in the rootlets of the portal system. Besides thi.?, 
 the heart's action was increased, and the respiration was rendered 
 slower; and the general temperature was lowered. 
 
 Fischer, in 1877, in Yolkmann's Klinische Vortiage, wrote on 
 this matter. He had observed two cases in which air was 
 admitted, and yet the patient recovered. He refers to Langen- 
 beck's advice to first dissect bare the vein which may be injured: 
 this cannot always be done, owing to a tumor lying in the way; 
 or the parts may be diseased. In Fischer's cases recovery took 
 place through coughing, which forced out the air through the 
 wound; and hence the subject of such accident should be made 
 to cough, sneeze or vomit: for thus the blood is forced back and 
 out, and carries the air with it. 
 
 Yivisective experimentation has lent its aid in the study of 
 the aspiration of air into the veins. In 1859 and 18G0 Dr. 
 E. S. Cooper exhibited before a class of medical students in San 
 Francisco the effect of throwing air into the veins. The femoral 
 vein of a dog being exposed, a tube was passed into it, and air 
 was forced into this by means of a syringe. The dog ceased to 
 breathe, and seemed to be dead; the Jiandle of the syringe was 
 then drawn back and blood and air withdrawn, with the effect 
 of restoring the dog to life. He never had an opportunity of 
 applying this means of restoration in the human subject : yet 
 the writer thinks it might be done; and in the attempt to do so, 
 he would use, if possible, the vein that had been opened. 
 
 In Berlin, in 1870, some experiments were made by Uterhart 
 on dogs, in v\'hich he injected air into the veins. He found that 
 
CONGENITAL DEFECTS OF THE SPINAL COLUMN. 1139 
 
 when the air was introduced into a vessel remote from the heart, 
 as for example the crural or femoral vein, then no injury resulted 
 from it: but if the air was injected into the external jugular 
 vein, then death quickly ensued under symptoms of cerebral 
 anaemia. But if the air was thrown into the arteries, no ill 
 resulted to the animal, no matter whether the point of injection 
 was near or remote from the heart. 
 
 CONGENITAL DEFECTS OP THE SPINAL COLUMN (SPINA BIFIDA). 
 
 A congenital deformity not unfrequently seen is that in which 
 the arch of one or more vertebrae is defective, that is, the arch is 
 bifid, or from arrest of development, the spinous process has not 
 been developed. And this defective formation may extend 
 further forwards: in fact, to such an extent that the containing 
 wall of the spinal canal is quite wanting behind, and at the sides. 
 This defect occurs much oftener in the lower part of the spinal 
 column than in the upper portion; yet it has been observed in 
 the region of the atlas, and it involved the occipital bone. And 
 this might have been apprehended, when the fact is recalled that 
 the occipital bone in its growth and form so nearly resembles a 
 vertebra, that tlie bone is evidently a transformed vertebra 
 This theory, the induction of a Goethe's fancy, has been confirmed 
 by the comparative anatomist: and additionally established by 
 the observation of the pathologist, that the occiput may present 
 an opening similar to that of a bifid vertebrse, which has been 
 imperfectly developed. 
 
 As a consequence, or accompaniment, of such breach in the 
 spinal canal, there protrudes through the opening a pouch-like 
 tumor, which contains a fluid similar to that normally existing 
 in the spinal canal. This fluid is always contained in the 
 meninges of the cord: but in relation to the spinal medulla, the 
 fluid may develop within the primordial central canal of the 
 cord, and so increase in amount as to ruj^ture its medullary wall: 
 and then the normal meninges will be the containing tunic: or 
 the fluid, identical with that of the cerebro-spinal, may lie out- 
 side of the cord, and be contained within the dilated meninges. 
 
 As stated, the condition of the cord differs according to the 
 site of the fluid: when originating centrally, the cord may be 
 attenuated to a film-like structure; but when the fluid arises and 
 lies eccentrically, then the normal integrity of the cord may not 
 be altered. 
 
1140 VESSELS OF THE NECK. 
 
 There may result serious nervous disturbance from the cleft 
 spine; or the organism may suffer but little from it; and these 
 differences j)robably depend on the central or eccentric site of 
 the fluid. 
 
 Though much oftener in the lumbar and sacral region than 
 in the upper part, yet it is not infrequent in the cervical region: 
 two cases have been seen l)y the writer in which the tumor was 
 large and was located in the region of the fifth, sixth and seventh 
 vertebrie; and the patients had reached adult age, and possessed 
 average strength of body. The spinal cord must have been 
 intact in these cases. In another patient, the defect was in the 
 lumbar region, and evidently had implicated one-half of the 
 cord, since one limb was paralyzed, ill developed below the 
 knee, and the foot was in the position of varus. And should a 
 specialist, whose knowledge does not extend beyond one narrow 
 angle of the human fabric, attempt to correct such a club-foot by 
 mechanical appliance, then nature would avenge such blunder- 
 ing by extensive sloughing. In such cases justice unfortunately 
 misses its aim, and the forfeit demanded is vicariously paid by 
 the guiltless patient. 
 
 Tiie tumor of spina bifida may have a wide and free communi- 
 cation with tlie spinal canal; that is, the tumor is sessile, and 
 has no intermediate connecting foot-stalk; or there maybe a 
 narrow opening into the canal; and then the tumor is, in a 
 manner, pedunculated, and capable of being isolated from the 
 spinal canal. And this character is determined by the brer.dth 
 or narrowness of the osseous vertebral cleft; for when the spinal 
 breach is wide, the tumor rests on a broad base: but when the 
 opening is a narrow fissure, the base of the tumor may be so 
 compressed that it has a pedunculated form. 
 
 If the narrow cleft should close, then there will remain a 
 cvst-like tumor, which retains its volume under pressure: but in 
 tijc usual form of spina bifida, pressure on the tumor lessens its 
 volume by forcing the liquid content into the spinal canal; and 
 if the fluid be great in quantity, then reduction of the tumor will 
 cause symptoms of cerebral compression ; similar to what takes 
 place when pressure is made on the protrusion of meningocele. 
 
 The diagnosis is not difficult; the location of the tumor in 
 the median line behind, its reducibility by compression, and the 
 effect of such compression on the subject with the history of 
 congenital appearance, would indicate the true nature of the 
 tumor. And the withdrawal of some of the fluid by the aid of 
 
CONGENITAL DEFECTS OF THE SPINAL COLUMN. 1141 
 
 a hypodermic needle would furnish additional proof of the 
 nature of the tumor, and would distinguish it from a lipoma, with 
 which it is possible to confound spina bifida. The lipoma has the 
 characteristic that when one attempts to displace the skin cover- 
 ing it, the latter becomes mapped off into quilted sections 
 corresponding to the convolutions of tlie lipoma; but in spina 
 bifida, such configuration of surface is absent. 
 
 If the tumor be of small volume and pedunculated, it is 
 curable: but if it be voluminous, with large communication with 
 the spinal canal, the attempt to relieve encounters many diffi- 
 culties. x4.nd finally, if other defect coexist, such as deformity of 
 the face or head, even though the surgeon remove the spinal 
 tumor, he is confronted with a more difficult task in the treat- 
 ment of the other deformities. And should there be rhachischisis, 
 or cleft of the cord, complete or incomplete, as has been observed 
 by Koch, then the case will not lie within the range of much 
 amelioration by surgeon or physician. But if the defect be 
 confined to simple spinal meningocele, the case may be improved 
 or cured by surgical means. 
 
 Treatment. — The modes of treatment may be placed under 
 four heads: compression, obliterating injection, obstructive con- 
 striction, and excision and closure by plastic work. 
 
 Compression may be maintained upon the tumor either by 
 means of a truss-like appliance, in which a compressing pad is 
 held in place by an elastic band which surrounds, or, in some 
 way, clasps the body. Such compression may be made as a 
 means of protection against external violence; or it may be used 
 as a means of cure. As a protective agent the compress is oftener 
 used in the adult; but it may be used in the infant to repress the 
 fluid during the time that the congenital breach is gradually 
 closing during the growth of the child. The hope of such 
 occlusion is rarely realized; so that compressive means, when 
 employed, are used rather for the purpose of protecting the 
 tumor against violence, than of causing its disappearance. 
 
 A second method of treatment consists in the injection of 
 some irritating agent which will lessen and perhaps finally 
 occlude the cavity of the tumor. Such agent is the tincture of 
 iodine, or a solution of the chloride or sulphate of iron; the 
 former has been most frequently used. Brainard, of Chicago, 
 reported cures effected by the use of injection of iodine. To' 
 accomplish occlusion in this way, the tumor must have but a 
 small communication with the spinal canal, which, through the 
 
1142 VESSELS OF THE NECK. 
 
 occlusive action of tlie injected iodine, will be closed, and then a 
 cyst-like cavity will remain, which may, also, finally become 
 smaller, and disappear througli absorption. This plan of treat- 
 raent has so often failed that, similarly to what has occurred in 
 hydrocephalus, it has fallen almost into disuse. Its use should 
 certainly be limited to those cases in which the conformation of 
 the tumor is such as to be easily isolated from the sjiinal canal. 
 
 A third method of treatment is like that once in vogue for 
 the cure of umbilical hernia: it consists of a constricting clamp 
 which having included the base of the tumor, the clamp is so 
 tightened as to interrupt the circulation, and cause sloughing, 
 and consequent destruction of the tumor. For this plan to be 
 successful, the tumor must be pedunculated, or capable of being 
 isolated from the adjacent spinal canal. Chaffy, in 1881, 
 successfully treated a case in this manner; and as constricting 
 instrument, lie used the clamp employed by Spencer Wells in 
 ovariotom3\ Having applied the clamp, Chaffy excised the 
 ])art beyond and then let the clamp remain in place for four 
 days. The healing was by granulation. 
 
 A plan cognate to the preceding method is to include the 
 neck of the sack in a subcutaneous circumscribing ligature, 
 which, being tightened, isolates the cavity : and when the isolation 
 is thus complete, the part beyond the ligature may be excised. 
 
 The fourth method which has been successfully practiced by 
 the writer is to excise a portion of the wall of the tumor; also 
 dissect from the remaining wall its serous lining; and then 
 having juxtaposed the raw surfaces, unite these by suture. 
 
 In a communication read at the recent International Medical 
 Congress at Rome by Mayo Robson, of England, there were 
 reported twenty cases treated by the last method, with such 
 satisfactory results that the writer urgently advocates the pro- 
 cedure. His plan consists, in the main, of dissecting the serous 
 sac from the skin, and then having removed the excess of the 
 sac to cljse this by buried sutures; and lastly, so close the skin 
 that the buried and dermal sutures will not lie one on the other. 
 Robson finds that this plan may be successfully employed in all 
 cases of spina bifida, in which the patient is not hydrocephalous, 
 paraplegic, or in a state of marasmus. 
 
 In a case of spina Ijifida treated by the writer, the base of the 
 tumor was sutured in sections; the tumor beyond was excised, 
 and the remaining wound soon healed under alcoholic dressing. 
 Hence of the four methods of treatment described, the author 
 prefers that of simple excision and closure by suture. 
 
CONGENITAL DEFECTS OF THE SPINAL COLUMN. 1143 
 
 Besides the bifid cleft described, which may deform the 
 spine, there are other defects, which, though rare, should be 
 noted. 
 
 One or more vertebrae may be imperfectly developed; and 
 thus lateral or antero-posterior curvature, or deviation of the 
 column, may arise. Also the two halves of a vertebra may 
 remain ununited; whence abnormal mobility may arise. 
 
 Should such defect be recognized, the surgeon ma}^ use a 
 corrective appliance, designed to maintain the column in proper 
 line: and as examples of such apparatus may be cited the 
 orthopedic appliances employed in spinal curvature. 
 
 A congenital abnormity sometimes seen in the lower part of 
 the neck, is an elongation of the transverse process of the seventh 
 cervical vertebra. Or this process may be transformed into a 
 supernumerary rib; and then, as Luschka has observed, such 
 costal anomaly may be a fragmentary rudiment, consisting 
 merely of a head, neck and tubercle; or it may extend further 
 forwards, and then represent a false rib, at the upper end of the 
 thorax; and, lastly, there may be a completely formed rib, 
 attached to the spine behind and sternum in front. 
 
 In the second form, in which the rib ends b}^ a free point in 
 the subclavian triangle a little above the clavicle, the terminal 
 end may infringe on the constituent trunks of the brachial 
 plexus, and cause pain extending along one or more of the 
 nerves distributed to the arm. Such anomalous rib might 
 endanger the subclavian artery which lies in contact with it. 
 The writer has seen an example of such anomaly, which in its 
 development was impaled or imbedded in the brachial plexus, 
 and caused severe pain. Relief was obtained by an incision 
 exposing the rib, of which an inch of the free end was excised. 
 The work of excision was difficult and perilous, owing to the 
 contiguous subclavian artery, which, with much difficulty, was 
 so pulled aside as to permit the section of tlie rib. The operation 
 was successful in delivering the patient from the pains in the 
 arm with which she was previously tormented. 
 
CHAPTER XXXV. 
 
 LUXATION OF THE CERVICAL VERTEBRA. 
 
 Surgical authorities in the early part of this century were 
 united in the opinion that isolated vertebral luxation is an 
 impossibility. Delpech declared that dislocation of the vertebral 
 body cannot occur. Abernethy says, "There can be no such 
 dislocation, surgically speaking:" or, rather, if sucli accident 
 occurs, there must be, at tl)e same time, a fracture. Sir Ashley 
 Cooper asserts that if such injury ever does occur, it must be 
 extremely rare; and in tlie numerous instances of injury of the 
 spine which he had seen, he had never observed the separation of 
 one vertebra from another, without a fracture of either the 
 articular process or the body of the vertebra. And Boyer 
 doubted though he did not den}' the possibility of vertebral 
 luxation. 
 
 Since this period of skepticism in regard to vertebral luxation, 
 the sphere of observation has widened, and thepossibility of such 
 injury has been verified by the observation of tliis luxation in 
 the living subject, and still further demonstrated by experimen- 
 tation on the cadaver. 
 
 In 1871 Stephen Smith, of New York, made experiments on 
 the dead subject, in which fracture and luxation in the region 
 of the atlas and axis were studied. He finds that the atlas 
 belongs fundamentally to the head, and the odontoid process of 
 tlie axis is the center of the movements of the atlas and head: 
 and those forces wliich act from the head on the spinal column, 
 and those from the spine below which act on the head, are 
 directed towards, and are exerted on, the odontoid process. The 
 alar or check ligaments which extend from the summit of this 
 process to the occipital bone, in the work of limiting movement 
 must bear much; and much resistance must be offered by the 
 base of the odontoid i)rocess, on which a lever-like force is exerted. 
 
 Smith concludes that when a person falls on his head, the 
 
 (1144) 
 
LUXATION OF THE CERVICAL VERTEBRAE. 
 
 1145 
 
 Tiolence is directed against the alar ligaments and the base of 
 the odontoid process. The odontoid process must support more 
 than the anterior arch of the atlas, or the transverse ligament. 
 If violence be applied to the part, the axis will break before its 
 odontoid process; and this process does not break when it is 
 forced against the anterior arch of the atlas, or the transverse 
 ligament. The alar ligaments have more strength than the 
 odontoid proces.^. 
 
 Figure 108. Exhibiting com- Figure 109. Exhibiting bilateral lux- 
 
 plete antero-posterior luxation. ation. (From Albert.) 
 (From Albert.) 
 
 Vertebral luxation may be, according to the extent and char- 
 acter of the injury, divided into two classes : complete and partial. 
 In the complete form, the vertebra has its articulating facets dis- 
 placed entirely from their normal location: and the displacement 
 may be forwards, or backwards, as shown in figure 108. In the 
 incomplete form, the displacement may be unilateral, in which 
 the luxation is backwards or forwards: or it may be bilateral, in 
 which the vertebra is turned about its vertical axis, with luxation 
 backwards on one side, and forwards on the other, as show^n in 
 figure 109. ^ 
 
 Along with vertebral luxation there must be rupture of the 
 inter- vertebral ligaments: and that such rupture may occur, 
 greater violence is required as one descends in the column. This 
 fact was demonstrated experimentally by Malgaigne, on the 
 cadaver. He found that to rupture the intervertebral ligaments 
 required one hundred pounds force in the cervical region; one 
 hundred and fifty pounds in the thoracic region, and from two 
 hundred and fifty to three hundred pounds in the lumbar region. 
 73 
 
1146 LUXATION OF THE CERVICAL VERTEBRAE. 
 
 In case, liowever, the subject be an old one, then the partial or 
 entire ossification of the connecting ligaments may give them so 
 much resistance that fracture, and not luxation, ensues. The 
 elastic ligaments of the child and youth permit of movements at 
 that age, which cannot be made in later life. Long continuance 
 of the upright position temporarily exhausts the elasticity of 
 these ligaments; hence the lessening of stature of him who has 
 been standing for many hours. 
 
 The age of the subject* has an important iuHuence on the 
 occurrence of vertebral luxation: in childhood, and prior to 
 complete growth, the bones are not fully ossified from their early 
 cartilaginous stage, and the ligaments are extensible: hence, at 
 this period of life, though the spine is often subjected to violence 
 from accidental or voluntary movement, yet luxation or fracture 
 is seldom seen; but such injury is seen oftener in mature, or 
 advanced age. This accords with the experience of Porta, who 
 made a study of these injuries. 
 
 In 1865, Porta published a work on luxations in all parts of 
 the body, comprising a series of five hundred dislocations, of 
 which twenty-seven were of the vertebral column: and of the 
 latter seven were of the cervical vertebrae. An important diag- 
 nostic distinction which he indicates between luxation and 
 fracture of the spine is, that a simple fracture leaves no percep- 
 tible displacement or irregularity in the outline of the column: 
 but if the case be one of luxation, there is evident deformity. In 
 the cases seen by Porta, the subjects? were adults; and the causal 
 agency was a blow, or a fall. He finds that the anterior longi- 
 tudinal ligament is stronger than the posterior one; and the 
 intervertebral disks and articular ligaments are easily torn. The 
 interspinous ligaments of the dorsal region are so strong that 
 unless tlie spinous processes are broken, the ligaments prevent 
 displacement. Hence the usual coincidence of fracture and lux- 
 ation. 
 
 The prognosis of luxation in the cervical region is unfavorable: 
 for death can occur at once, on the receipt of the injury, or at an 
 early period, from acute inflammatory action; or the case may 
 end fatally after an indefinitely long duration. The spinal injury 
 may be associated with other complication caused by the lesion 
 of the cord: such trouble may be tetanus or encephalitis; like- 
 wise, sloughing from pressure of the recumbent body; there may 
 also be vesical atony in which the urine is retained, or is voided 
 involuntarilv. 
 
LUXATION OF THE CERVICAL VERTEBRA. 1147 
 
 Though death, as a rule, follows such luxation, yet exception- 
 ally, recovery may occur. As treatment, Porta does not favor an 
 operation; but on the contrary, reduction should be attempted 
 by extension and counter-extension; and means designed to 
 limit inflammation, should be employed. 
 
 Hueter, in 1868, from his personal studies offered a new 
 classification of vertebral luxation: he makes two classes founded 
 on the manner in which the causal violence acts; luxation from 
 rotation or abduction, in which the dislocation is caused by 
 torsion of the spine; and luxation produced by flexion. He dis- 
 cards the terms lateral and anterior dislocation. In brief, Hueter 
 refers all spinal luxation to violence which acts by twisting, or by 
 bending the vertebral column. 
 
 The spinal cord may be injured by the displaced vertebrae; 
 yet when the luxation has taken place, it seems that the primary 
 pressure gradually lessens; or the cord acquires a tolerance of the 
 compression. As consequence of the injury there may be palsy 
 from pressure on the nerves where they emerge through the 
 intervertebral foramina. 
 
 In his treatment of the injury, Hueter does not approve of 
 the methods of extension and counter-extension which are 
 employed by Schuh, Martin and others; but instead of these 
 methods, Hueter advises one which seems to have originated 
 with Richet. This plan consists in bending the head towards 
 the shoulder, towards which the head is abnormally directed : that 
 is, towards the shoulder of the side on which the chin is uplifted; 
 and when this is done, turn the head so that the ear which was 
 inclined towards the shoulder shall be directed forwards, and the 
 other ear backwards. This plan is suited for reduction of the 
 first species of the injury, viz., that arising from excessive torsion; 
 and in this way Hueter accomplished reduction. But if the 
 luxation be from violent flexion, then the same method may be 
 resorted to; and one must resort to it on one side, and then on the 
 other. 
 
 Wagner, in 1884, from the study of two hundred cases of ver- 
 tical luxation which he found in surgical literature, published', 
 the following: in forward luxation the head is not always bent 
 directly forwards: there is no definitely typical position. And 
 where the luxation is caused by excessive rotation, the position of 
 the head differs according to the relative position of the dis- 
 placed articular processes. When unilateral luxation is complete,, 
 the head is bent towards the displaced side, and the chin is rotated 
 towards the sound side. 
 
1148 LUXATION OF THE CERVICAL VERTEBR.E. 
 
 As treatment, Wagner counsels in cases of incomplete disloca- 
 tion, simple rest and fixation; but if the displacement be com- 
 plete, then he would try to reduce, after placing the patient under 
 chloroform. 
 
 From a study of occipito-atloid dislocation, Malgaigne has 
 found that the head might be luxated backwards, or the atlas 
 forwards. The atlas may be so tilted forwards as to greatly 
 incline the head forwards: and then the odontoid process may 
 so press on the cord as to cause instant death: or the displace- 
 ment forwards of the atlas may be yet greater, causing more or 
 less palsy; and, again, the atlas may be rotated on one side, only. 
 Where the atlas is luxated forwards, the chin is caused to 
 approach the sternum; but if the displacement be unilateral 
 and has arisen from torsion, Malgaigne found the head inclined 
 towards the luxated side, while the face is directed towards the 
 sound side. In these high luxations, something may be learned 
 by a digital examination of the pharynx. As treatment Mal- 
 gaigne counsels rest in the horizontal position; and in the worst 
 cases, he would attempt to reduce by flexion, extension, traction 
 and counter-traction. 
 
 The following is a summary of the })lans of treatment which 
 have the sanction of authority. In mild cases, which may be 
 named subluxation, authorities have concurred in limiting treat- 
 ment to rest in the horizontal posture; but in more extensive 
 injury in which the dislocation is complete, the plan has gener- 
 ally been to attemi)t reduction by forcible movement, which may 
 be done in one of the following directions: extension and flexion; 
 abduction to the right or left; rotation to the right or left; trac- 
 tion and counter-traction. That movement in each case should 
 be selected which will act correctively on the existing displace- 
 ment. And one should not limit this manipulative treatment to 
 cases of complete dislocation, it should also be tried in those of 
 subluxation. 
 
 It must be confessed that these methods are not exempt from 
 peril: for despite the most diligent diagnostic exploration, the 
 exact conditions may not be determinable ; and then the manip- 
 ulative procedure, in place of restoring the vertebra to proper 
 position, may add to the existing displacement: and then if the 
 injury be high up, fatal injury to the cord inigiit be inflicted. 
 The deplorable condition of such patient, deprived as he is of 
 sensory and motor power, justifies resort to a hazardous venture: 
 for to the victim of such condition death is better than life. 
 
LUXATION OF THE CEHVICAL VERTEBRAE. 1149 
 
 A resort to operative work as a means of relief seems to have 
 seldoin beeu tried: jet in a case of anterior luxation of the atlas, 
 the writer availed himself of this method. This case was as 
 follows: from a fall, the jDatient remained with fixation of the 
 head, and with the chin directed forwards, without elevation or 
 depression. "When seen the condition had existed for nearly a 
 year: the man was unable to move the head, the eyes were 
 unduly prominent: the power to form articulate speech was Yery 
 defective; there was partial loss of motor power to such a deo-ree 
 that the patient was unable to walk without assistance. There 
 was continued pain at the site of injury; and a depression could 
 be distinguished beneath the occiput. The diagnosis was ante- 
 rior displacement, and it was decided to cut down posteriorly, 
 and having exposed the parts, do what might be possible for 
 relief. This was done : through a vertical incision the posterior 
 portions of the axis and atlas were brought into view. The atlas 
 was found displaced forwards to the extent of a quarter of an 
 inch, so that its posterior arch was crowded against the cord. It 
 being evident that an attempt at replacement would be fraught 
 with more danger than prospect of relief, it was decided to 
 remove the posterior part of the atlas, which was done by divid- 
 ing the ring on each side, so that a small segment could be 
 removed. This was easily done with bone forceps. After the 
 removal of the small bridge which was crowding on the cord, the 
 latter at once rose in the interstice, as if it had previouslv had 
 insufficient room. This work was done without any lesion of the 
 structures within the canal; and as soon as the man passed from 
 the influence of the ansesthetic, there was found some improve- 
 ment of motor power in the arms and legs. This amelioration 
 in the patient's power of movement was followed, a few days after 
 the operation, by symptoms of acute myelitis and encephalitis: 
 there appeared spasmodic movements of the limbs, and the 
 patient became wildly delirious, in which he required restraint 
 to prevent him from doing violence to those attending him. On 
 reopening the wound, the cord was found swollen and protruding 
 through the breach which had been made in the vertebral canal. 
 The patient died two weeks after the operation. It is possible 
 that in case of an irreducible luxation lower down in the spinal 
 column an operation might eventuate more favorably, since it 
 would permit of better immobilization than is possible in the 
 region of the atlas, which is near the pivotal point of the move- 
 ments of the head upon the trunk. 
 
1150 LUXATION OF THE CERVICAL VERTEBR-E. 
 
 Fracture of the J^ertcbrae. — The spinal column may be broken 
 at any point, yet conforming to the scope of this work, the present 
 chapter will, in the main, be briefly devoted to fracture of the 
 cervical portion of the column. 
 
 The vertebra is constituted of several ])arts which function- 
 ally differ: viz., a body, seven processes and two lamellae. The 
 processes aid in articulation, or serve as points for the attachment 
 of ligaments and muscles; and the lamellae form the lateral and 
 posterior walls of the spinal canal. And as one or more of these 
 constituent ])arts may be broken, there may be isolated fracture 
 of the body, lamella, articular, transverse or spinous process: or 
 two or more of these parts may be fractured conjointl}". 
 
 A^ertebral fracture may arise from violence indirectly or 
 directly applied; that from indirect force occurs oftener than that 
 from direct. 
 
 Molliere, of Lyons, in 1887 wrote on spinal fracture caused by 
 indirect violence; and in his researches of the subject, lie made 
 experiments on the cadaver. In these experiments the body 
 was fixed in a sitting posture, and then violence was applied 
 directly downwards; or it was done by bending the body back- 
 wards or forwards; and the following results were noted: (1) 
 Only when the intervertebral ligaments remain intact, does 
 crushing of the vertebral bodies take place. (2) Fracture of 
 the vertebral arches only takes place wdieii the bodies remain 
 intact. (3) When one produces fracture by violently flexing the 
 body, then the fracture will be found in the vertebral bodies; 
 and these bodies will be found crushed in their anterior portion. 
 (4) Fracture occurring in the dorsal region is accompanied by 
 costal fracture, or sternal fracture, or by injury of the costal 
 cartilages. If the flexion be confined mainly to tlie spinal 
 column, then fracture isoftenest in the dorsal region; but forcible 
 flexion of the trunk is more apt to break the spine in the lumbar 
 region. 
 
 Molliere has found these results verified in surgical practice. 
 In twelve cases of spinal fracture caused b}' falling on the feet, 
 gluteal or sacral region, the fracture was found in the lower part 
 of the spine, viz., the portion between the eleventh dorsal and the 
 third lumbar vertebra. And in eight cases in whicli the vio- 
 lence was from falls on the head, tlie site of fracture was in the 
 dorsal region. 
 
 An epitomized summary of Molliere's researches is the fol- 
 lowing: fracture of the spine occurs indirectly from forced 
 
FRACTURE OF THE VERTEBRA. 1151 
 
 flexion of the entire trunk; or it may arise from forced flexion of 
 the normal curves of the spine; and in the latter case the 
 violence acts on both ends of the column. And, finally, violent 
 flexion (.'an break the spine by acting on one end. 
 
 Fracture may arise from violence acting directly on some 
 part of the median line of the back: and the causal agent may, 
 or may not, penetrate the soft parts. Excepting the projectile, 
 such causal agency is rare: for spinal fracture originates, as a 
 rule, from indirect agency: for example, a fall on the feet or on 
 the buttocks may break the spine. In the history of this injury, 
 there are many cases recorded in which it occurred from the 
 subject falling head downwards, and so striking, that the violence 
 traversed the head, neck and expended its force on the spine. A 
 great weight falling on the head, inclined neck, or shoulders, has 
 broken the spine, and such force usually fractures at some point 
 in the upper part of the column. Dupuytren saw a case, in 
 which a slaughtered ox thrown from a wagon upon the shoulders 
 of a man caused fracture of the processes of the fourth, fifth and 
 sixth vertebrae. In the work of mining, a mass of over-hanging 
 earth or rock falling on the shoulders of the laborer may fracture 
 the spine: a few cases thus occurring, have fallen under the 
 observation of the author. In athletic sport, in the act of 
 turning about a bar, a young man fell striking on his head and 
 received an injury in wdiich all parts below the neck were 
 paralyzed, and death occurred within an hour. From the 
 simple overthrowing of a wagon, the spine was fractured near 
 the middle, in a case seen by the writer. 
 
 An accurate diagnosis between vertebral luxation and frac- 
 ture is difficult to be made: in fact, the change of form caused 
 by the two, and the morbid conditions resulting from them, are 
 often so similar as to baffle the attempt at differentiation: and 
 the difficulty is further augmented by the fact that in many 
 cases, luxation and fracture coexist. The body of the vertebra, 
 for example, may be fractured, and its articular processes lux- 
 ated, so that the vertebra is displaced backwards, forwards or 
 laterally. 
 
 Vertebral fracture is usually limited to one vertebra; excep- 
 tionally, two vertebrae are involved, and more rarely several 
 vertebree may be implicated in the injury. In case of multiple ■ 
 fracture, the injury is usually in the arches. 
 
 If vertebral fracture were an isolated lesion, it would not be a 
 matter of great import: but as the spinal cord is commonly 
 
11. VJ 
 
 I.rXATIOX OF THE CKRVKAI. VKUTKBK.i:. 
 
 involved, the gravity of the injury is dependent on tlje location 
 and extent of the lesion of the cord. If the cord be severed, or 
 so crushed that the part beyond is rendered functionless, then 
 the effect is disastrous to the part of tlie body which receives its 
 supply of nerves from the portion of the cord which has been 
 cut off. 
 
 In degree or extent, the fracture may vary from that which 
 is simple to that which is very extensive: viz., from a lesion 
 indiscernible, to one completely crushing the vertebra: and from 
 such varving conditions, there mav be founded a classification 
 into that of mere seam or fissure, compression, and a still higher 
 degree, in which the vertebra is broken into two or more pieces, 
 and these may or may not be displaced. 
 
 The fissure may be nearly or quite invisible; or it may 
 slightly gape. 
 
 In the second form, the upper and lower faces of the body 
 may be flattened and caused to approach each other: and along 
 with the vertical thickness of the vertebral body, the interverte- 
 
 Figure 110. Showins: complete frac- 
 ture of the vertebral column. (From 
 Albert.) 
 
 Figure 111. Showing fracture of a 
 vertebra. (From Albert.) 
 
 bral disk is crushed and forced from its place. The compressive 
 force may merely act on the borders of the articular facets of the 
 body; or the violence may be such as to essentially shorten the 
 vertical thickness of the body: in the former case, the cord would 
 escape all pressure; but in the latter, the canal would be 
 encroached on, and the cord subjected to some pressure. 
 
 Where the vertebral body has been broken into two or more 
 pieces, the line of fracture is usually oblique or horizontal; and 
 
FRACTURE OF THE VERTEBRAE. 1153 
 
 this is usually nearer the upper surface than the lower one: and 
 then the smaller upper fragment is displaced forwards; and 
 along with this, the superincumbent column above is carried 
 forwards. , In such displacement, the spinal cord is pressed 
 on by the upjDer displaced portion of the column; and if the 
 displacement be considerable, the cord may be lacerated, or 
 even entirely severed. Examples of vertebral fracture are seen 
 in figures 110 and 111. 
 
 The proof that the spine has been broken and the cord 
 injured is furnished by the impairment, or entire loss of motion 
 and sensation in the parts deriving their nerves from the portion 
 of the cord that lies below the fracture. As there are many 
 varying conditions conceivable in the injury, so there may be 
 variety in the functional disturbance. Charles Bell discovered 
 and proved that the anterior portion of the cord is the source of 
 motor innervation, and that the posterior portion is concerned in 
 sensation. As a result of such anatomical disposition, it is 
 evident that a lesion limited to the anterior or posterior portion 
 of the cord would have the effect of destroying or disturbing- 
 motion or sensation in the parts below the injury. As the canal 
 is larger in the upper part of the spinal column than in the 
 lower portion, hence functional disturbance would ensue from 
 less displacement in tlie lower than in the upper part of the 
 spine. 
 
 If the displacement were lateral, or in the direction of torsion, 
 and were slight, then the cord might escape pressure, and the 
 constriction be limited to the nerves which escape between the 
 displaced vertebrae: and in such a case, the nerves which are 
 given off beneath the injury, would retain unimpaired function: 
 and the remarkable condition would be present that a zone of 
 the body would present impaired movement and feeling, wdiile 
 above and below such zone, there would be integrity of move- 
 ment and sensation. 
 
 Again, the displacement may be slight in any of these direc- 
 tions, yet from lesion of blood-vessels, a clot may form and 
 produce pressure on the cord, and thence conditions can arise 
 which are similar to actual severing or laceration of the cord. 
 But as the clot would lessen through absorption, the paralytic 
 condition would gradually disappear. And it is probable that 
 in those cases in which the subsidence of the paralysis is referred 
 to accommodation of the cord to the compressing vertebra, the 
 actual condition has been one of compressing clot rather than 
 vertebral displacement. 
 
1154 LUXATION OF THE CEEVICAL VERTEBRA. 
 
 Observation has often found that the sphere of sensory 
 impairment is less than that of loss of movement; for example, 
 muscular i>ovver may be abolished in a limb, while the sensory 
 endowment is not com.jiletely extinguished. An exj^ilanation of 
 this may be found in structural difi'erence between the antei'ior 
 and posterior roots: the posterior roots are larger than the 
 anterior ones; and the ])Osterior roots have a ganglionic enlarge- 
 ment, in which there is resident some sensory endowment 
 probably independent of the cord. The position of this ganglion 
 in the intervertebral canal may protect it from lesion of the 
 adjacent bony structure. These anatomical conditions give the 
 posterior or sensory trunks an advantage over the anterior ones. 
 Another circumstance which may have an influence is that in 
 antero-posterior displacement (the usual one), the cord is more 
 infracted in its anterior than in its posterior section; and thence 
 may arise a greater disturbance of motor than of sensory 
 function. 
 
 The area of paralysis may be irregular below the site of the 
 injured cord: for example, it maybe hemiplegic; and again, it 
 ma}' be complete on one side and incomplete on the other. A 
 reason which may be suggested for this inequality is that in the 
 injury, some of the nervous fibrillse of the cord may remain 
 undivided, or but slightly compressed: and hence the continuity 
 of innervation is not wholly interrupted. 
 
 The remarkable condition in which nerve function is not 
 wholly annulled in parts below the spinal injury may be 
 explained in yet another way, which, though a conjecture, seems 
 to the writer not improbable. If one studies the symiDathetic 
 nervous cord, there are found to be numerous intercommunicating 
 trunks which connect the sympathetic to the spinal cord. And 
 through intercommunicating bands, in the case of rupture of the 
 cord, there remains an indirect channel of connection and com- 
 munication between the two portions of the spinal marrow. In 
 such condition, the sympathetic cord may serve as a bridge across 
 the breach. The plexus which is formed by converging trunks 
 from separate points of the cord, and which distributes diverging 
 branches, becomes a medium for the restoration of innervation 
 through indirect routes: and through such by-path the nervous 
 influence may jflnd transit for itself. And, again, at the periph- 
 eral ending of nerves there may be intercommunication between 
 filaments which arise from separate sections of the cord. And, 
 finally, sensation may survive in the surface through some 
 
FRACTURE OP THE VERTEBRA. 1155 
 
 special ganglion-like formation at the end of the peripheral 
 filament. 
 
 As the limits of this work exclude a special consideration of 
 the parts of the body below the neck, the remainder of this article 
 will be confined to a short consideration of spinal fracture occur- 
 ring in the cervical region. 
 
 Fracture in the upper part of the vertebral column occurs 
 most frequently between the fifth cervical and first dorsal verte- 
 brse, yet it may take place at any other point: and the most 
 common causal agency is from forcible anterior flexion. The 
 spinal marrow rarely escapes injury: yet the large caliber of 
 the spinal canal, especially as one approaches the occiput, may 
 screen the cord from injury, provided the displacement is slight 
 or absent. In case the fracture originate from super-flexion, if 
 there be displacement, this will consist of the upper segment of 
 the column being carried forwards, beyond the one below; and 
 thence must arise compression, laceration, or complete division of 
 the spinal marrow. 
 
 The consequence of such injury will be different according to 
 the amount of lesion of the cord: if the division of the latter be 
 incomplete, the palsy arising will also be incomplete. The 
 brachial plexus is formed by the commingling of the four lower 
 cervical and first dorsal nerves: and should the origin of one or 
 more of these nerves escape injury, then the tract to which the 
 same is distributed, will escape paralysis. And according to 
 Thorburn, who has studied this subject, such palsy may be in the 
 scapular muscles of the upper arm, lower armor hand, according 
 as the injury is limited to the fourth, fifth., sixth, seventh, eighth 
 or ninth nerve. And, hence, as examples of isolated injury of the 
 motor and sensory endowment of the upper extremity, the follow- 
 ing may be mentioned. Rupture of the cord between the fourth 
 and sixth vertebrse will affect the power of elevation, flexion, 
 abduction and supination of the upper arm and elbow; rupture 
 above and near the sixth vertebra will interfere with the exten- 
 sion of the elbow: that is, it will palsy the triceps extensor cubiti. 
 Rupture at the seventh vertebra will paralyze the extensors of the 
 wrist; and if the injury be a little lower, the flexion of the wrist 
 will be lost. 
 
 In consequence of the cilio-spinal center or nucleus of the 
 innervation of the iris being located in the lower part of the 
 cervical portion of the cord, injury of that part may disturb the 
 normal movements of the pupil. 
 
1150 hUXATKix OK THE CERVICAL V Kiri' i;i!i;.i:. 
 
 By far the most iiiijDortant nerve wliicli origiiuitcs I'roin tlic 
 cervical section of the spinal cord is the ]»hrenic: its origin is 
 from the fourth and liftli cervical nerves; and this corresponds 
 approximately to the fourth cervical vertebra. A fracture below 
 this point permits the continuance of life for at least a few days; 
 but if the cord be broken above this, death is instantaneous. 
 Hence the movement of thediaphragm,in case of spinal fracture 
 in the cervical region, if unimpaired, denotes fracture below the 
 fifth vertebra: if incomplete, it signifies probably fracture through 
 the fifth vertebra. Many years ago, Marshal Hall visited a hospi- 
 tal to which the writer was attached; the learned neurologist 
 was shown a patient who had recently fractured his spine in the 
 cervical region: the physician, as the first step in the examination, 
 passed his hand beneath the covering of the patient, and finding 
 that there was free movement of the diaphragm, he remarked 
 that the fracture was below the origin of the phrenic nerve; and 
 the diagnostic acumen displayed, great for that period, awakened 
 admiration among the young medical men who were present. 
 
 If the lesion should be in the thoracic region of the spine, 
 besides the phrenic nerve, some of the intercostal nerves might 
 be spared : and then, in breathing, besides the movement of the 
 diaphragm by which the inspiratory act is normally accom- 
 plished, the movement of expiration might be aided by the 
 intercostal muscles. 
 
 If the injury be so high that only the phrenic nerve escapes, 
 then the normal inspiratory movement will be rhythmically 
 made: the diaphragm descending, the lungs will be filled with 
 air: but in this, the work of respiration is but half done; an 
 equally important part remains to be accomplished, viz., the 
 expulsion of the air: this is but imperfectly eftected by the 
 resilient movement of the compressed abdominal viscera forcing 
 the diaphragm upwards; also by the elastic force inherent in the 
 pulmonary structure, due to the muscular tissue which Moles- 
 chott finds that the lungs possess; and, lastly, there is some 
 expulsive force exerted by the recoil of the u[)lifted walls of the 
 chest. By these united forces, which are all of a passive charac- 
 ter, the inspired air is only incompletely expelled. And, further, 
 those acts of the body which require expiratory effort, cannot be 
 performed. For example, the subject of such injury cannot 
 cough; an attempt to do so is of a spasmodic character, similar 
 to sneezing. 
 
 In case of fracture below the origin of the phrenic nerve, 
 
FRACTURE OF THE VERTEBRAE. 1157 
 
 besides the respiratory disturbance mentioned, there arise other 
 serious troubles, which require description. In a few cases 
 observed, the temperature was lowered; sometimes much below 
 the normal standard; but, as a rule, the temperature rose, and 
 has been known to reach one hundred and nine degrees Fahren- 
 heit; and even an elevation of heat to one hundred and twenty-two 
 degrees was seen by Teale; but probabh^ there was an error in 
 this observation, or its record. 
 
 The pulse may not vary much from normal in the early stage 
 of the injirry; but in the more advanced stage the pulse becomes 
 accelerated. 
 
 The secretion of urine maybe normal for a time: yet fre- 
 quently, it is lessened in amount. Sometimes, from passive con- 
 gestion of the coats of the bladder, blood escapes from the turgid 
 vessels, and hsematuria is present. In composition the urine 
 remains normal for a period; later, it becomes alkaline. 
 
 As the bladder is palsied, it retains the urine and soon 
 becomes excessively distended; and as a result, there is an 
 increased excretion of mucus, that alters the constitution of the 
 urine, which, in turn, reacts ill on the vesical w^all. And these 
 morbid agencies are soon reenforced by the appearance on the 
 scene of rapidly multiplying bacteria. The power of voiding the 
 bladder is entirely lost; and the urine continues to augment until 
 the neck is forcibly dilated, and then the urine, from time to 
 time, trickles away. And should such escape not occur, then the 
 bladder slowly expands and rising into the abdominal cavit}', 
 resembles an immense cyst-like tumor. Though the timely use 
 of the catheter may prevent such accumulation, still the urine 
 usually becomes laden with mucus charged with ammonia, and 
 is otherwise abnormal in composition; and then the walls of 
 the bladder become the seat of changes similar to those of chronic 
 cystitis. Inasmuch as the trunk is paralyzed, the patient is quite 
 insensible to these conditions of the bladder, which in the non- 
 palsied subject would be the source of indescribable torment. 
 
 These conditions of the bladder cannot continue without 
 finally implicating. the kidneys: the latter are impaired in func- 
 tion, and become trammeled in their work of depuration. The 
 blood being imperfectly oxygenated and depurated is unable to 
 maintain the tissues at their normal standard of vitality: hence 
 the readiness with which parts slough when they are subjected 
 to pressure. In the normal condition of the blood, the pressure 
 though prolonged on the gluteal and dorsal structures, is toler- 
 
1158 LUXATION OF THE CKRVICAL VERTEBK.E. 
 
 ated ; for example, in the phthisical patient such pressure will be 
 endured for an indefinitely long time; while in the subject of 
 fracture existing high in the spine, immense sloughing will soon 
 take place. This tendency to sloughing from slight cause may 
 find some explanation in the loss of sensory innervation of the 
 parts: for, as is known, the sensory nerves have some agency in 
 the nutrition of the tissues: verification of this is obtained in 
 vivisective work in animals, or, its counterpart, in surgical work 
 on man. In recent periods, when the surgeon's knife has invaded 
 regions once considered impenetrable, the cranial cavity has been 
 opened and the trifacial nerve has been severed for relief of facial 
 neuralgia: and though the pain was thus extinguished, vision 
 was lost through sloughing of the cornea. 
 
 An occasional accompaniment of spinal fracture is priapism; 
 the patient has no consciousness of the condition: this erectile 
 state is by no means a constant one: in nearly all the cases of 
 spinal fracture seen by the writer, it was absent; and when pres- 
 ent, the erection was imperfect; and it was rather one of passive 
 congestion of the part, than of active priapism. The erectile 
 condition rarely appears until the bladder has become distended 
 with urine; or until the viscus has been irritated by the intro- 
 duction of a catheter. 
 
 Through the weakened condition of the abdominal wall the 
 normal compression is withheld from the bowels; and as a result 
 of this, they become tympanitic. Tliis tympanites interferes 
 with the movement of the diaphragm, and disturbs the inspira- 
 tory movement of respiration; but, on the other hand, it i)romotes 
 the expulsion from the lungs of the inspired air. 
 
 The sphincter muscles of the rectum are wholly palsied; and 
 as result, there is no restraining action exercised by the bowel 
 on its content. The anomalous state of the bowel presents itself, 
 in which constipation and diarrhoea succeed each other, alter- 
 nately. The fsecal content collects in the colon until the mass is 
 so great that it descends by its weight; and when the hardened 
 portion has passed out, the succeeding li(|uid material continues 
 to escape for some time, similarly to what occurs in diarrhoea. 
 The bowels unaided will move once or twice a week. And 
 though sensation is absent in the parts, yet the patient is con- 
 scious of the accumulation of fseces through flushed face and 
 headache. 
 
 As stated, cervical fracture above the fourth vertebra is 
 quickly fatal, but in the region of the fifth, sixth, seventh or 
 
FRACTURE OF THE VERTEBRAE. 1159 
 
 eighth vertebra, death is not so immediate : but in such patients 
 life is rarely prolonged beyond the fourth or fifth day. Hence 
 vertebral fracture in the cervical region of the spine is an exceed- 
 ii^gly gi'ave injury, in fact, one of the most perilous that can 
 befall the human body. 
 
 Though the injury be grave, its gravity may be increased if 
 the patient be incautiously lifted or carelessly carried: fur 
 through such negligence, the incompletely ruptured cord may 
 be entirely severed. Hence the subject of this accident should 
 be lifted and placed on a stretcher or carrying appliance, 
 which should be solid or unyielding. A broad plank seven feet 
 long laid on two cross-bars will answer for such carriage. To 
 place the patient on this, four assistants are necessary: viz., one to 
 lift the lower extremities, two the trunk, and one to support the 
 head. By such assistance, the patient is so lifted, that the spinal 
 column is safely cared for, and no sliding nor displacement of the 
 broken part can take place. If the plank mentioned be used for 
 transporting the patient, the head should be somewhat supported 
 by a pillow laid beneath it; and this support can be formed of the 
 patient's coat, properly folded. The patient should be carried 
 feet foremost: in the same manner as the wounded soldier is 
 borne from the field. And thus carried, the subject of spinal 
 fracture can have additional care from an assistant, who, follow- 
 ing, places his hands on each side of the patient's head, and pro- 
 tects it from jostling. With these precautions, the patient is to be 
 borne to the room where he is to remain during treatment. The 
 next thing demanding careful attention is to prepare a proper 
 bed for the patient. For this purpose, the bed used for the treat- 
 ment of the fractured femur may be used: viz., the so-called 
 fracture bed ; but in place of the hair or straw mattress, the bed 
 must have an air or water sack, upon which the patient will lie. 
 This sack is made of India-rubber cloth, and is provided with an 
 opening at one of its corners, through which air or water can be 
 introduced, and retained there by a stop-screw. In case the 
 injured patient can yet move himself, the air-couch is preferable 
 to that of water; since in moving laterally on the latter, the fluc- 
 tuating water may roll the patient out of bed. The writer knew 
 of such an accident, in which the subject of spinal lesion was thus 
 cast from the bed, and injuries received that finally ended life. 
 It should be remarked that such ejection from the bed could more 
 readily occur from a narrow, than from a wide one. And in the 
 construction of the bed, provision should be made for lowering a 
 
1160 LUXATION OK TlIK CKRVICAL VKKTKBRyE. 
 
 portion of it, so that a vessel for receiving excrement may be 
 used as occasion requires. The bed may liave other appliance 
 or attachment, according to the i)lan of treatment which is 
 pursued. 
 
 The bed being arranged, tiie patient must be removed from 
 the stretcher to the bed : and the shifting from the carrying 
 stretcher must be carefully done, the same assistants are needed, 
 and the same precautions must be observed, as were used in plac- 
 ing the patient on tlie stretcher; one aid should lift and maintain 
 the head at rest; two should support the trunk, and one should 
 carry the lower extremities. The patient, being lifted by these 
 assistants from the stretcher, is to be carefully laid on the per- 
 manent bed that has been made ready for him. 
 
 The prognosis of spinal fracture in the cervical region is inaus- 
 picious in the extreme: in fact, is fatal if the cord has been 
 wholly divided; j^et, as the extent of the wound is often indeter- 
 minable, no effort looking towards reparation of the injur\^ 
 should be neglected. The treatment may be classified under three 
 headings, that of simple rest, mechanical, and operative. 
 
 The method of rest is to reduce the broken parts to normal 
 position, and then to maintain the body as nearly motionless, as 
 possible. 
 
 Should the lesion of the cord be a slight one, and the func- 
 tional impairment arise from clotted blood which has been 
 effused, then it is probable that absorption may occur, and the 
 slight breach in the cord be repaired. Such re})air will be tedi- 
 ous, since tho disposition of the rhacliidian vessels is far from 
 favorable for restitution to integrity. And the dorsal posi- 
 tion of the patient, disposing as it does, to hypostatic plethora of 
 the injured part, is an agency which opposes recovery : in fact, 
 renders complete repair scarcely possible. 
 
 This stasis of blood about the injury from dorsal recumbence 
 has, probabl}'', not been taken sufficiently into account; and the 
 query arises, Would it be possible to avoid this by placing the 
 patient in a prone, or nearly prone, position? There would cer- 
 tainly be many difficulties which would antagonize an attempt to 
 pursue treatment in such position, yet the advantages whicli it 
 would give in preventing congestion commend a trial of it. That 
 such position can be tolerated is shown by the observation of 
 Blandin, who announced, as early as 1S45, that patients suffering 
 from spinal disease can be treated in the prone posture, and 
 though the position is uncomfortable at first, yet the patient soon 
 learns to tolerate it. 
 
FRACTURE OF THE VERTEBRA. ll(jl 
 
 One of the grave complications of spinal fracture is the super- 
 vention of sloughing of the parts subjected to pressure; atten- 
 tion should be given to this, and an attempt made to avoid it 
 as far as is possible. For this purpose, continuous pressure of 
 a part should be avoided by supports which will distribute the 
 pressure, or take it from prominences which rest on the mattress. 
 Besides this, the parts acted on may be given some resistance bv 
 washing them with alcohol, or with a weak solution of corrosive 
 sublimate: viz., one part in one thousand. The part may be hard- 
 ened by occasionally sponging it with Tinctura Gallse; and it may 
 be given a protective coating with the compound tincture of 
 benzoin. 
 
 The evacuation of the patient's bladder is a matter which 
 demands unremitting attention: the urine should be removed 
 with a soft aseptic catheter three times in twenty-four hours. 
 The removal of the urine in this way will prevent its decomposi- 
 tion, which otherwise would ensue. Despite these precautions, 
 should the urine undergo alkaline putrefaction, then, beside the 
 evacuation of the urine, there is the need of using means to purify 
 the vesical cavity, and for this purpose a solution of boracic acid 
 may be injected. For this purpose, one may also use simple 
 boiled water, which has been slightly acidified with nitric or 
 hydrochloric acid. 
 
 The bowels should be evacuated once in forty-eight hours; 
 and this is best done by means of a stimijlating enema; and for 
 this purpose, the following mixture may be employed : — 
 
 ^. Ex. Sennse Fl. 
 
 Glycerin! .aa gss 
 
 OL Tiglii gtti 
 
 Misce. 
 
 And should this finally fail to act, the croton oil should be 
 increased to two or three drops, in each injection. 
 
 The attentions to the skin, bladder and bowels which have 
 been described, are applicable to, and demanded in, all cases, 
 whether the patient be treated by simple rest, mechanically, or 
 operatively. 
 
 In 1844, Hecker, from a study of the means then in use in 
 the treatment of fractured spine, and the unsatisfactory results 
 obtained, urged that some other method should be resorted to; 
 and thus avoid the slow and agonizing death, in which such 
 accident usually terminates. Hecker has some hope of a better 
 74 
 
11G2 LUXATION OF THE CERVICAL VERTEBRA. 
 
 ending by the use of extension, which had been advised and 
 practiced by Crawfoot. In the treatment of a few cases, Craw- 
 foot obtaineil excellent results by fastening the patient's trunlc to 
 a bed, and then making traction on the feet. Hecker thinks 
 such extension should be tried in all cases of spinal fracture: and 
 this failing, he would trephine tlie spinal column at the site of 
 injury. 
 
 The object of extension being to restore the broken column 
 to normal line, the traction should be continued for some time 
 in order to be effective: at least for two months, which is the 
 average time required for the union of a broken bone. The 
 work may be done on the water or air bed by means of weights 
 and pulleys, with attachment at the feet. Before tiiese retentive 
 weights are applied, an attempt should be made to reduce the 
 broken vertebra? to normal situation: and this can be accom- 
 plished b}^ firmly holding and fixing the head, wliile traction is 
 being made on the feet; or the traction might be made on both 
 the head and the feet; and while such extension is being made, 
 the surgeon may cooperate and control the adjustment of the 
 displaced parts by pressing against the portion of the spine 
 which projects and deviates from the normal line. This control- 
 ling work of reduction must not be overdone, lest the lesion of 
 the cord may be increased. 
 
 Inasmuch as the paralyzed parts of the body will not tolerate 
 compression without ploughing, there is a serious objection 
 to attaching the appliance of traction to the palsied inferior 
 extremities; therefore, it is better to do the work otherwise. For 
 this purpose let the bed be converted into an inclined plane, 
 sloping toward the feet; and then include the head in a 
 fenestrated, halter-like helmet, which can be fastened to the head 
 of the bed: or a cord attached to the head-gear can be passed 
 over a pulley, and by means of weights, any degree of traction 
 needed can be made. The head-gear here used is similar to that 
 employed by the orthopedist for suspension of the body in cases 
 of spinal curvature. 
 
 When the patient is treated in this manner, the body, tending 
 to slide down the inclined bed, acts as an extending force, and 
 maintains the broken parts in corrected position. 
 
 Another plan of treatment which has its advocates is to 
 suspend the patient in the suspending appliance of the orthope- 
 dist, and having reduced the broken spine to integrity of outline 
 and form, to enclose the upper part of the trunk in a gypsum 
 
FRACTURE OF THE VERTEBRiE. 1163 
 
 casement. In the application of the gypsum, care must be used 
 npj: to compress the thorax: for it must be recollected, that in the 
 high spinal fracture here under consideration, the ribs do not 
 move actively, since the breathing is done by the diaphragm. A 
 tightly-fitting gypsum casement would interfere with the action 
 of the diaphragm, and render the breathing more laborious: in 
 fact, the patient's life might be destroyed. Even in the healthy 
 subject, it is perilous to encase the thorax tightly in plaster of 
 Paris. 
 
 This was illustrated, a few years ago, in the application of 
 gypsum to the trunk of a man for the purpose of making his 
 bust. The man's trunk was incased in the plaster and he was 
 left alone, for some time. The material hardened, and the case 
 became smaller, so that the man could hardly breathe when 
 found, and with difficulty he was rescued from his perilous position. 
 
 The subject of spinal fracture is so rarely cured by the 
 methods which have been described, that from time to time, in 
 the history of the injury, surgeons have sought to get relief 
 through operative means: viz., to open down on the fractured 
 spine, and thus uplift or remove the portion of the vertebra 
 which compressed the cord. The early essays in this section of 
 surgery, as a rule, resulted so unsatisfactorily, that such opera- 
 tions were rarely done; and, in fact, some recent authorities, dis- 
 couraged by the frequent failure to cure by operating, do not 
 advise it; for example, Burrell, of Boston, in 1887, discarding 
 knife and trephine, advises to suspend the patient, and having 
 thus rectified the displacement, he applies a gypsum cast. But 
 in recent years, better results have been obtained, so that 
 rachitomy, as the operation may be denominated, may now be 
 said to have an accredited position among surgical operations;, 
 and this is justified by the statistics of White, who finds the- 
 results of twenty-seven operations to be the following: six entire 
 recoveries, six incomplete recoveries, eleven cases in which there- 
 was no benefit from the operation, and fourteen patients who 
 died soon after the operation: the result being a death-rate of 
 thirty-eight per cent. Though the number of observations was 
 too small to generalize from, yet the facts speak in favor of 
 interference. 
 
 Among the early operators for spinal fracture was Potter,, an 
 American surgeon, who, in 1863, in a case of fracture in the cer- 
 vical region, in which there was palsy of the upper and lower 
 extremities, trephined and removed the arch of the fifth vertebra. 
 
llG-1 LUXATION OF THE CKUVJCAL VEKTi;i;i;.i:. 
 
 and the spinous process of the sixth one. The result was that 
 the wound healed readily, and there was a sliglit return of motor 
 function on the left side, especially in the left hand. The patient 
 remaining in a helpless condition, three years afterwards, Potter 
 operated again, and claims to have removed the fourth, fifth and 
 sixth vertebra}. This operation afforded no relief, and it was 
 discovered by it, that the ruptured cord had not healed. lie 
 0])erated in other cases of similar character, and obtained in one 
 case, a complete recovery. He states that after the operation, 
 the patients emaciated for some time, and remained thus tem- 
 porarily; and later they regained and retained their flesh. The 
 report of Potter's operative work is less extended than could 
 be wished; yet enough was learned to justify further effort of the 
 kind in a class of patients, who, otherwise, would remain hope- 
 lessly palsied. 
 
 In the case of fracture due to a blow or body striking the spine, 
 that is, to direct violence, the indications for operating are more 
 positive and imperative, since the causal agency, acting from 
 behind on one or more vertebne, would probably be limited 
 to the spinous processes, or vertebral arches. In injury thus 
 arising, the patient being placed in a prone position, and a 
 longitudinal incision being made in the median line, the spinous 
 processes can be reached, and, by means of a chisel or blunt 
 dissector, separated from their periosteal and ligamentous 
 investment; and if the injury be found to be limited to one or 
 more spines which are broken and pressed into the spinal canal, 
 then the operation could be completed b}'^ the simple removal of 
 the loose spine or spines. If the fracture be more extensive, and 
 involve the laminated wall of the canal at its side or pedicle, 
 then a detached fragment may be removed, and the remaining 
 part of the wall be uplifted and restored to proper site. A 
 careful search for spiculse should be made, and, if found, they 
 must be removed. This work having been done aseptically, the 
 wound may be closed by sutures, and dressed with lint saturated 
 with a twenty-five per cent solution of alcohol. In injuries of the 
 limited kind mentioned, healing of the wound will be obtained 
 in a few weeks; but if the cord be injured to any extent, the 
 patient may require a long time to recover from the motor and 
 sensory disturbance which has arisen from the injury 
 
 In case the fracture has arisen from violent torsion, flexion or 
 extension of the spinal column, then the injury is commonly 
 more extensive than that which has just been considered; since, 
 
FRACTURE OF THE VERTEBRA. 1165 
 
 besides fracture of the arch, the vertebral body may be broken; 
 and, with the fracture, there may be displacement. In such 
 injury two or more vertebrae may be implicated in the fracture. 
 
 The treatment, here, should commence with an attempt to 
 restore the broken column to proper position by traction and 
 counter-traction : in fact, the work to be done is analogous to that 
 resorted to, to restore to position the fractured parts of a broken 
 bone of the arm or leg ; while traction is being done, the hands 
 of the surgeon should be applied to the injured part, and 
 coaptation accomplished as far as possible. When this work has 
 been done, if the cord has merely been compressed, it is probable 
 that the motor and sensory disturbance will disappear. Should 
 such fortunate result follow the work of traction and coaptation, 
 the remaining treatment will consist in retaining the patient in 
 recumbence for a number of weeks; and, in this, the prone is 
 better than the supine position. 
 
 The attempt to restore the broken vertebral column to normal 
 form, will, owing to the conditions pres'ent, rarely bring relief; 
 yet to passively fold the hands, and to commit the case to nature 
 already overburdened, is most unsatisfactory. To make an effort, 
 even though nothing is hoped from the attempt, is more satisfac- 
 tory to the victim than idle abandonment of him. And there is 
 the chance that by the exposure of the spinal column and exsec- 
 tion of a portion of one or more vertebrge, the work of traction and 
 counter-traction may effect restoration to normal anatomical form. 
 
 In the operation here proposed, the patient should lie prone, 
 and provision be made for traction and counter-traction, when the 
 excision has been done. A longitudinal cut should be made to 
 the spinous processes corresponding to the site of injury; the soft 
 parts are then to be reflected laterally; and in this separation of 
 these parts from the bones, the periosteum, as far as possible, 
 should also be included and reflected laterally. By such prepara- 
 tory incision, which should be ample in dimensions, the field is 
 opened in which the broken vertebrae can be seen, and any work 
 done on the latter which the cliaracter of their injury may 
 indicate. For example, a lateral opening may be made with a 
 trephine at one or more points, and the cord examined. And 
 then with cutting forceps, enough of the wall may be removed to 
 liberate the cord from all pressure. And should there be dis- 
 placement of one or more of the vertebral bodies, it may be 
 possible, by extending and counter-extending, to restore the dis- 
 placed parts to normal position. The excision, as reported done 
 
11G() LUXATION OF THK CI-^KVICAL VKKTEnit.K. 
 
 by some surgeons, seems to have included a large portion of one 
 or more vertebrae: and such removal appears to liave been 
 readily tolerated. 
 
 In the reports of operative work done for relief in such injury, 
 the dura mater was opened for the purpose of removing a clot of 
 blood, or of restoring the continuity of the ruptured cord. After 
 this has been done, the dura mater must be closed by means of 
 fine catgut suture. 
 
 The work of rhachitomy being completed, the wound is 
 to be closed, with or without drainage, as the conditions may 
 demand. And should there be danger of displacement of the 
 rectified spine, then immobilization may be done by means of a 
 g3'psum casement comprising the neck and the upper part of the 
 trunk. 
 
 Instead of operating thus in tlie median line, the j^lan of a 
 Lateral incision suggests itself to the author in which an incision 
 might be made to the spine between the transverse and spinous 
 processes, and the cai5al being opened by the aid of a chisel, 
 the spinous segment of the canal could be reflected towards the 
 other side, and the cord having been liberated from pressure, the 
 wound could be closed. The advantage of this procedure is that 
 no bony structure would be sacrificed. For, despite the assevera- 
 tions of surgeons that no ill consequence results from removing 
 sections of one or more vertebra, the avoidance of sucli sacrifice 
 would evidently be one improvement on the usual method of 
 rhachitomy. 
 
INDEX 
 
 Abscess, dental, 733; treatment, 736; of 
 pharynx, 713; treatment, 716; phleg- 
 mon of neck, 853; treatment, 858; of 
 maxillary sinus, 393; treatment, 395; 
 of tongue, 618; treatment, 620 
 
 Acne ciliaris, hordeolum or sty, 471; 
 treatment, 471 
 
 Adams, on malignant lymphoma, 883; 
 deflection of septum, 347 
 
 Adelmann, on goitre, 839; foreign bodies 
 in cesophagus 983 
 
 Adherent pinna, 296 
 
 Adhesion, inflammatory, 28; palatal, 656 
 
 Affections, of auditory canal, 298; treat- 
 ment, 299; of carotid artery, 1098; of 
 external ear 288; of eyebrow and eye- 
 lid, 455; of membranes of brain, 210; 
 treatment, 214; of scalp, general clas- 
 sification, 14 
 
 Air passages, foreign bodies in, 955 
 
 Alar marginal defect, 421 
 
 Albert, of Vienna, ligation of external 
 carotid artery, 1127 
 
 Alquie, on concussion of brain, 226; 
 rhinoplasty, 414 
 
 Alveolar periostitis; 733; treatment, 734 
 
 Amussat, on hanging, 980; atresia of 
 mouth, 549 
 
 Amygdalotomy, tonsillotomy or excision 
 of tonsil, 701; authorities cited, 702 
 
 Ancelon, on hare-lip, 566; malignant 
 pustule, 902 
 
 Anchylosis of maxilla inferior, 764; 
 treatment, 765 
 
 Andr6 on facial neuralgia, 789 
 
 Andrew, John (and other authorities) on 
 tracheotomy, 1002 
 
 Anel, on ligation in aneurismal tumors, 
 117 
 
 Aneurism, of scalp, 14; of tongue, 650 
 
 Angioma, in neck, 869; treatment, 870; 
 on nose, 336; treatment, 337; in paro- 
 tidean region, 517; treatment, 518; in 
 scalp, 103 
 
 Aiikyloblepharon, blepharophimosis or 
 narrowness of palpebral opening, 475; 
 treatment, 475 
 
 Ankyloglossa, or tongue-tie, 613 
 
 Anstie, on facial neuralgia, 787 
 
 Anthrax, carbuncle, 893; diagnosis, 895; 
 prognosis, 896; treatment, 896 
 
 Antrum of High more, or maxillary 
 sinus, 391; cj^sts in, 397; treatment, 
 898; fistula of, 396; treatment, 397 
 
 Aran, on fracture of cranium, 160; on 
 tonsillitis, 694 
 
 Archambault, on tracheotomy, 1051 
 
 Arlt, on symblepharon, 477 
 
 Arnold, on glossitis, 617 
 
 Arteries, in the scalp, 10 
 
 Artery, carotid, affections of, 1098; sub- 
 clavian, 1127 
 
 Artificial respiration, 935 
 
 Aspiration, 938 
 
 Astringents, 46 
 
 Atresia, 547; treatment of, 548 
 
 Atrophy, of scalp, 89 
 
 Auditory canal, affections of, 298; treat- 
 ment, 299; cerumen or foreign bodies 
 in, 301, 303; occlusion of, 300; poly- 
 pus in, 301 
 
 Auditory passage, hemorrhage from, 306 
 
 Autenrieth, on stricture of cesophagus, 
 979 
 
 B 
 
 Bain, on artificial respiration, 943 
 Baillarger, on spasin of cesophagus, 975 
 Baker, on excision of tongue, 637 
 Balassa, on wounds of neck, 921 
 Ballon, on meninges of brain, 209 
 Bamberger, on nasal injury, 829 
 Bardelelaen, on cranial bullet wounds, 
 
 178 
 Bartels, Max, on hare-lip, 559 
 Barthez, on tracheotomy in croup, 1022, 
 
 1029 
 Barton, Ehea, on anchylosis, 768 
 Battle, on fracture of skull, 166 
 Bauchot, on maxillary fibroma, 754 
 Baudens on cervical glandular tumors, 
 
 884 
 Bayford, on stricture of cesophagus, 979 
 Bean, on facial neuralgia, 790 
 Beaugrand, on luxation of maxilla in- 
 ferior, 771 
 Beaussenat, on purulent tumor, 348 
 Beck, on cerebral concussion, 226 
 Becquerel and Breschet, thermo-electric 
 
 tests, 18 
 Begin, on maxillary excision, 763; 
 
 spasm of cesophagus, 977 
 Bell, on tonsillitis, 697 
 Benedict, on facial neuralgia, 787 
 (1167) 
 
1]68 
 
 INDKX. 
 
 Bc'ran<Ter-Ferraud, on nasal injury, 329 
 
 Benird, on neurectomy, 790; piirotis, 
 52-4; parotidean tumors, 527 
 
 BeriT, on labial cancer, 600; lingual 
 cancer, 637 
 
 Bersjmann, on cranial bullet wounds, 
 178 
 
 Berhnsfhieri, Vacca, on spasm of oesoph- 
 agus, 978 
 
 Bernard, Claude, on parotidean fistula, 
 532 
 
 Bert, Paul, on plastic sun^ery, 449; 
 drowning, 947 
 
 Bertherand, on wounds of neck, 917 
 
 Betz, on gunshot wounds of cranium, 
 181; oesophageal neoplasms, 994 
 
 Beziers, on palatal cleft, 664 
 
 Bichat, on cancer, 139; pathology, 23; 
 trepan, 201 
 
 Bidalot, on hare-lip, 562 
 
 Bigg, on torticollis, 815 
 
 Billroth, on inflammation. 18, 2G; ex- 
 tirpation of larnyx, 1080; malignant 
 lymphoma, 881; phosphorus-necrosis, 
 747; nasiil polypus, 352; staphylorra- 
 phy, 675; excision of tongue, 635; 
 bullet wounds in cranium, 181 
 
 Bilz, on goitre, 829 
 
 Bird, Golding, on nasal obstruction, 
 351 
 
 birkett, on external ear, 288 
 
 Blackley, on carbuncle, 900 
 
 Blandin, on hare-lip, 578, nostrils, 345; 
 rhinoplasty, 415 
 
 Blasius, on anchylosis, 766; hare-lip, 
 579 
 
 Bleeding, from nose, 371; treatment, 
 376 
 
 Blepharophimosis, ankyloblepharon or 
 narrowness of palpebral opening, 475; 
 treatment, 475 
 
 Blepharoplasty, 491 
 
 Blood cvst, on neck, 871; treatment, 
 873 
 
 Bluhm, on trephination, 104 
 
 Blunienbach, 320; on nostrils, 345 
 
 Bochdalek, on tumors of neck, 866 
 
 Boeckel, on hare-lip, 566, 580; tracheot- 
 omy, 1028 
 
 Boinet, on cerebral contusion, 247 
 
 Bonafont, on parotidean fistula, 502; 
 phlegmon and abscess, 860 
 
 Bones, nasal fracture of, 329; treatment, 
 330 
 
 Bonnet, on anchylosis, 767; carbuncle, 
 898; ectropion,' 482; goitre, 830; tor- 
 ticollis, 812, 815 
 
 Bouchut, on tracheotomy, 1022; larny- 
 gotomy, 1078 
 
 Bf>urdillat, on tracheotomy, 1028 
 
 Bourgeois, on malignant pustule, 901 
 
 B'luvier.on anch}'losis,767; tracheotomy, 
 1025 
 
 Boyer, on atresia of mouth, 549; lingual 
 prolapsus. 612; surgery of frontal re- 
 gion, 323; malignant growths of 
 tongue. 633 
 
 Brain, concussion of, 223; diagnosis, 
 230; prognosis, 231; treatment, 232; 
 compression of, 234; diagnosis, 238; 
 prognosis, 239; treatment, 240; con- 
 tusion of, 245; prognosis, 247; treat- 
 ment, 248; hydrocephalus, 272; treat- 
 ment, 275; inflammation of, 250; 
 surgical atl'ections of membranes of, 
 209; meninges of, 208; meningocele 
 and encephalocele, 270; treatmentj 
 272; microcephalus, 278; pachymen- 
 ingitis, 215; syphiloma of, 262; tu- 
 bercle of, 220;" treatment, 220; men- 
 ingeal tumors of. 220: tumors of, 261 
 
 Brainard, 46; on defects of spinal col- 
 umn, 1141 
 
 Brasdors operation, 117 
 
 Bratsch, on neurectomy, 792 
 
 Breionneau, on tracheotomy, 1025 
 
 Broca, on carbuncle, 900; on trephining, 
 
 Brown, Dillon, on laryngotomy, 1080 
 
 Brouardel, on hanging 930 
 
 Bronchotoin^-, 1000 
 
 Broussais, 17 
 
 Bruns, on goitre, 846; hare-lip, 566, 
 578; hydrocephalus, 277; laryngotoni}', 
 1073; parotis, 524; tracheotomy, 1031 
 
 Bryant, on injuries of brain, 236 
 
 Bryk, on ranula, 730 
 
 Buchanan, on external ear, 286; excision 
 of tongue, 635 
 
 Buc'juoy, on phosphorus-necrosis, 745 
 
 Biihring, on uranoplasty, 677 
 
 Bulbo-palpebral union, or symblepha- 
 ron, 476; treatment, 477 
 
 Biinger, on rhinoplasty, 408 
 
 Burns, Allan, on subclavian artery, 1129; 
 ligation of primitive carotid, 1109; 
 eyelid, 468; parotid gland, 524; surgi- 
 cal anatomy of neck, 802; malar and 
 parotidean regions, 524 
 
 Burow, on blepharoplasty, 493; labial 
 cancer, 601; plastic surgery, 436; 
 tracheotomy, 1026 
 
 Busch, on benign tumors of parotis, 52C 
 
 Butcher, of Dublin, on hare-lip, 579; 
 resection of upper jaw, 541 
 
 Cancer, commencement and course, 591; 
 
 cause, 594; labial 598; statistics, 598; 
 
 scirrhus and encephaloid types, 142; 
 
 treatment, 144 
 Cavbuncle, anthrax, 893; diagnosis, 895; 
 
 prognosis, 896; treatment, 896 
 
INDEX. 
 
 1169 
 
 Carcinoma, or cancer, labial, 590; diag- 
 nosis, 596; prognosis, 597; statistics, 
 598; treatment, 599; in lower jaw, 
 758; treatment, 760; in parotidean re- 
 gion, 523; in scalp, 139; treatment, 
 IM 
 
 Carless, on pharyngeal abscess, 718 
 
 Carnochan, on anchylosis, 769; ligation 
 of primitive carotid, 1116; neurec- 
 tomy, 794 
 
 Carotid artery, affections of, 1098; prim- 
 itive, ligation of, 1101, 1120 
 
 Carotid artery, external, ligation of, 1120 
 
 Casselberry, on laryngotomy, 1083 
 
 Catarrh, nasal, orozsena, 383; treatment, 
 385 
 
 Cauchois, on lipoma of tongue, 625 
 
 Cavasse, on fracture of larynx, 924 
 
 Cavity, mastoid, 808 
 
 Cay tan, on tonsillitis, 691 
 
 Celsus, on cancer, 139, 603; carbuncle, 
 893, 897; nasal defect, 422; foreign 
 bodies in ear, 308; nasal fracture, 
 331; goitre, 825, 828; inflammation, 
 88; fracture of lower jaw, 778; luxa- 
 tion of inferior maxilla, 770; pathol- 
 ogy, 23; nasal polypus, 356; rhino- 
 pTastj^, 408; plastic surgery, 434; trep- 
 anation, 187 
 
 Cerumen, or foreign bodies in auditory 
 canal, 301 
 
 Cervical glands, sarcoiBa of, 874; treat- 
 ment, 880; vertebrae, luxation of, 1144 
 
 Chabdon, on trephination, 198 
 
 Chalazion, or gelatinous or fibrous tumor 
 of eyelid, 471; treatment, 472 
 
 Championniere, on trephination, 191 
 
 Charcot, 26; on pachymeningitis, 214; 
 trephination, 190 
 
 Chassaignac, on ligation of external 
 carotid artery, 1126; concussion of 
 brain, 225; foreign bodies in air pas- 
 sages, 957; phlegmon and abscess, 860; 
 prominent septum, 346; tonsil, 688; 
 tracheotomy, 1126 
 
 Chatin, on goitre, 832 
 
 Chaym, of Berlin, on tracheotomy, 1033 
 
 Cheek, wounds of, 504 
 
 Cheever, on tonsillar tumors, 711 
 
 Chelius, on goitre, 839 
 
 Chiari, on epistaxis, 378 
 
 Chiene, on pharyngeal abscess, 717 
 
 Cicero on tongue-tie, 613 
 
 Clark's device in tracheotomy, 1019 
 
 Clarke, Farlie, on lingual prolapsus, 
 612; fibroma of tongue, 626 
 
 Cleft-lip, hare-lip, or labium leporinum, 
 555; double, 675; operation, 566, 575 
 
 Clefts, congenital or fistuhe in neck, 819; 
 treatment, 822; palatal, 659; treat- 
 ment, 663 
 C16mot, on hare-lip, 568 
 Cloquet, on staphylorraphy, 665 
 Cohn, of San Francisco, treatment of 
 paralysis from diphtheria, 1065 
 
 Cohnheim, on inflammation, 18, 26 
 . Coindet, on goitre, 835 
 CoUes, on carbuncle, 898; subclavian ar- 
 tery, 1129; excision of tongue, 642 
 Collin, on goitre, 833 
 Collis, on fibrous polypus, 366 
 Comparetti, on external ear, 286 
 Compression of brain, 234; diagnosis,. 
 
 238; pi-ognosis, 239, treatment, 240 
 Compte, Auguste, 20 
 Concretion, salivary, 516; treatment, 
 
 517 
 Concussion of brain, 223; diagnosis, 230; 
 
 prognosis, 231; treatment, 232 
 Condensation, inflammatory, 28 
 Conditions for ti'ephining, 240 
 Congenital deformity, of e_yelid, 489; 
 treatment, 489; of maxilla inferior, 
 733; treatment, 734; defects of oesoph- 
 agus, 961; of spinal column, 1139; 
 treatment, 1141; clefts in neclc, 819: 
 treatment, 822 
 Constitutional tumors in brain, 219 
 Constrictive agents, 4G 
 Contusion of brain, 245; prognosis, 247; 
 
 treatment, 248; of scalp, 65 
 Cook, on carbuncle, 896 
 Cooper, Sir A., on palatal adhesion, 657; 
 subclavian artery, 1128; treatment of 
 . cystoma, 95; of erysipelas, 46; fungous 
 nasal tumor, 349; ligation of primi- 
 tive ^arotid, 1108 
 Cooper, E. S. , on goitre, 839; vi^ounds of 
 
 internal jugular vein, 1138 
 Cooper, Samuel, on tonsillotomy, 702 
 Coote, Holmes, on nasal injur}^, 329 
 Copland, on carbuncle, anthrax, 895 
 Cornil, on epithelioma of brain, 218 
 Costes of Bourdeaux, on pneumatoceph- 
 
 alus, 312 
 Couper, on tracheotomy, 1030 
 Couty, of Paris, on wounds of intern:il 
 
 jugular vein, 1137 
 Crampton, Sir Philip, on entropion, 488 
 Cranium, 152; fracture of, 159; treat- 
 ment, 166; traumatic lesions of, 153; 
 gunsliot wounds of, 172; treatment, 
 179; incised wounds of, 157 
 Crawfoot, on fracture of vertebrse, 1162 
 Crean, on phlegmon and abscess, 860 
 Crespi, on cranial gunshot wounds, 173 
 Criquy, on pharynx and oesophagus, 983 
 Croly, on carbuncle, 895 
 Cruveilhier, on cancer, 140 
 Cutaneous transplantation, Thiersch's 
 
 method, 449 
 Cusco, on ankyloblepharon, 476 
 Cystic growths, of tongue, 624; tumors, 
 
 maxillo-dental, 748; treatment, 752 
 Cystoma, labial, 589; in scalp, 93 
 Cysts, in antrum, 397; treatment, 398; 
 
 in oesophagus, 991 
 Czermak, on staphylorraphy, 674 
 Czerny, on oesophageal neoplasms, 997; 
 on extirpation of larynx, 1086, 1093 
 
1170 
 
 INDEX. 
 
 Darby, on phlegmon and abscess, 860 
 
 Dassen, on ranula, 727 
 
 Davahie, on malignant pustule, 902 
 
 Davies-CoUey, on uranoplasty, 683 
 
 De Chauliac, Guy, on trephining-, 201 
 
 De Gattery, Mirza A. V., on parotidean 
 
 fistula, 530 
 Deguise, on parotidean fistula, 531 
 Defect, alar margin, 421 
 Defects, of ear, 288; of external ear, 
 297; of nose and nasal passages, 327; 
 from loss of side of nose, including 
 alar margin, 421 
 Deflection of nasal septum, 346; treat- 
 ment, 847 
 Deformities, of eyelid, congenital, 489; 
 treatment, 489; of maxilla inferior, 
 733; nasal, 402; palpebral, 473; treat- 
 ment, 473; of tongue, 609 
 Delore, on torticollis, 809 
 Delorme, on epithelioma in parotis, 522; 
 
 parotidean tumors, 527 
 Delstanche, on occlusion of auditory 
 
 canal, 300 
 Demarquay, on malignant lymphoma, 
 883; maxillary resection, 543; on ex- 
 cision of tongue, 634, 638; malignant 
 growths of tongue, 633; tracheotomy, 
 1010 
 Demme, 184; on glossitis, 615, 617 
 DeMorgan, Campbell, on torticollis, 813 
 Denonvilliers, on ectropion, 484; hare- 
 lip, 566; nasal defect, 421 
 Dental abscess, 733; treatment, 736 
 Denuc^, on wounds of palate, 650 
 Depaul, on insufflation, 937 
 Desarenes,on mastoid cavity, 310 
 Desault, on goitre, 840; hare-lip, 579; 
 
 laryngotomy, 1070 
 Deschenais on tracheotomy, 1019 
 Despr^s, on carbuncle, 898; nasal de- 
 formity, 405 
 Desterne, on facial neuralgia, 789 
 Destruction of uvula and soft palate, 657 
 Deviation of oral opening, 553 
 Devergie, on drowning, 947 
 Dezanneau, and other authorities, on fi- 
 brous polypus, 368 
 Di Carpi Berenger, on trephination, 200 
 Dieflfenbach, on alar margin defect, 422; 
 palpebral deformities, 474; ectropion, 
 480, 485; labial ectropion, 554; goitre, 
 hare-lip, 567; atresia of mouth, 650; 
 fibrous polypus, 368; trephining mas- 
 toid process, 308; maxillary resection, 
 539; rhinoplasty, 412, 415; staphv- 
 lorraphy, 666, 673; tonsillotcmiy, 703; 
 torticollis, 811; uranoplast}-, 677- 
 wounds of neck, 917 
 Dion is, on ranula, 729; tonsillotomy, 
 
 702 
 Diseases of eyelid, 471 
 Disintegrants, 46 
 
 Dispersion, immediate or retarded, in- 
 fianunatory, 27 
 
 Dolbeau, on phlegmon and abscess, 857; 
 osseous growths, 320 
 
 Drowning, 946; eminent medical au- 
 thorities on, 946 
 
 Dublin, on hare-lip, 579 
 
 J)ul)ois, on hare-lip, 563 
 
 Duchenne, on malignant lymphoma, 
 883; torticollis, 809 
 
 Dumesth^, on phlegmon and abscess, 
 857 
 
 Duplay, on fistulse in neck, 820; hsera- 
 orrhage from auditory passage, 306; 
 nasal polypus 359 
 
 Dupuytren, on compression of brain, 
 245; contusion of brain, 246; on hare- 
 lip, 563; tonsillotomy, 702; vesica- 
 tion, 47, 234 
 
 Dura mater, tumors of, 216; classes of, 
 217 
 
 Duret, of Paris, on concussion of the 
 brain, 227 
 
 Durham, on foreign bodies in nose, 382; 
 nasal polypus, 354; tracheotomy, 1005 
 
 Dusch, on tracheotomy, 1028 
 
 Duval, on torticollis, 804, 812 
 
 Eai', external, defects and affections of, 
 288; att'ections of auditory canal, 298; 
 mastoid cavity, 308; treatment, 299; 
 occlusion of auditory canal, 300; by 
 polypus, 301; by cerumen or foreign 
 bodies, 301; adherent pinna, 296; 
 hfemorrhage from auditory passage, 
 306; othematoma, 291; treatment, 
 293; rents, fissures, and loss of struc- 
 ture, 297; emphysema or pneumato- 
 cephalus, 311; treatment, 312; surgery 
 of the ear, 285; wounds of, 290; treat- 
 ment, 291 
 
 Ecker, on goitre, 826 
 
 Eckholdt, on spasm of oesophagus, 977 
 
 Ectropion, of eyelid, 478; labial, 654 
 
 Eigenbrodt, on hare-lip, 564 
 
 Elements of plastic surgery, 427 
 
 Elliott, on wounds of intei-nal jugular 
 vein, 1137 
 
 Emphysema, or pneumatocephalus orig- 
 inating behind the ear. 311; treat- 
 ment, 312; of eyelids, 469; in scalp, 
 145 
 
 Encephalitis, or inflammation of brain, 
 250; causes, 250; symptoms, 252; di- 
 agnosis, 255; treatment, 257 
 
 Encephalocele, meningocele, 270; treat- 
 ment, 272 
 
 Entropion, 486 
 
 Epicanthus, 490; treatment, 491 
 
 Epithelioma, of brain, 218; in paroti- 
 dean region, 522; in scalp, 131; treat- 
 ment. 135 
 
INDEX. 
 
 1171 
 
 Epulis, of maxilla inferior, 755; treat- 
 ment, 757 
 
 Erichsen, on wounds of internal jugu- 
 lar vein, 1137 
 
 Erysipelas, 38; treatment, 44; remedies, 
 46, 48; in ej-elid, 467 
 
 Eseharotics, 47 
 
 Esmarch, on anchylosis, 768; hare-lip, 
 579 
 
 Estlander, on gunshot wounds of the 
 cranium, 177 
 
 Eulenberg, on torticollis, 814 
 
 Everbusch, on plastic surgery', 451 
 
 Excision of tonsils, 701 
 
 Exophthalmic goitre, 847 
 
 External carotid artery, ligation of, 1120; 
 jugular vein, ligation of, 1181 
 
 External nose, growths aflecting, 334 
 
 Extirpation of larynx, 1086 
 .Eye, foreign bodies in, 500; treatment, 
 501 
 
 Eyebrow, surgical aflection of, 455 
 
 Eyelid, surgical aifection of, 455; anky- 
 loblepharon, 475; treatment 475; 
 blepharoplasty, 491; burns on, 468; 
 chalazion, or gelatinous or fibrous 
 tumor of, 471; treatment, 472; con- 
 genital deformities of. 489; treatment, 
 489; affections of, 471; ectropion, 
 478; emphysema, 469; entropion, 
 486; epicanthus, 490; treatment, 491; 
 erysipelas in, 467; foreign bodies in 
 eye, 500; treatment, 501; hordeolum, 
 acne, ciliaris or sty, 471; treatment, 
 471; palpebral deformities, 473; treat- 
 ment, 473; symblepharon, or bulbo- 
 palpebral union, 476; treatment, 477; 
 tumors arising from orbital wall, 494; 
 treatment, 495; tumors originating 
 within orbit, 496; wounds o^, 463 
 
 Eabricius, on luxation of maxilla infe- 
 rior, 773; symblepharon, 477 
 
 Eace, wounds of, 504; parotidean region 
 of, 509 
 
 Eacial neuralgia. 783 
 
 Fallopius, on flap wounds of cranium, 
 158 
 
 Pano, on concussion of brain, 225 
 
 Earabeuf, on rhinoplasty, 413; ligation 
 of external carotid artery, 1126 
 
 Eaure, on strangulation, 926 
 
 Eergusson, Sir William, on anchylosis, 
 767; plastic surgery, 448; staphylor- 
 raphy, 671; uranoplasty, 680 
 
 Eerrier, on trephining, 190 
 
 Eibrinous tumor of eyelid, 471; treat- 
 ment, 472 
 
 Fibroma, of maxilla inferior, 754; of 
 tongue. 626 
 
 Fibrous polypus, 360; treatment, 364 
 
 Eirst method in plastic sai-gery, 430 
 
 Fisher, on wounds of internal jugular 
 vein, 1138 
 
 Fisher, on pharyngeal tumors, 722 
 
 Fissures, rents, "and defects of external 
 ear, 297 
 
 Fistulae in neck, 819; treatment, 822 
 
 Fistula of antrum, 396; treatment, 397; 
 of neck, 819; parotidean, 528; treat- 
 ment, 529 
 
 Fleischmann, on hanging, 930 
 
 Flourens, on trephining, 190 
 
 Fock, on tracheotomy, 1022 
 
 Foreign bodies or cerumen in auditory 
 canal, 301, 303; in air passages, 955; 
 in eye, 500; treatment, 501 ;"in nasal 
 passages, 380; in pharynx, 723; in 
 tongue, 644; in pharynx and oesopha- 
 gus, 982 
 
 Forget, on maxillar_^ excision, 762 
 
 Fouilloux, on epulis 756 
 
 Foulis, of Glasgow on extirpation of 
 larynx, 1095 
 
 Fournier, on ozaena, 384 
 
 Fowler's solution, 129 
 
 Frabrieius, on sjmiblepharon, 477 
 
 Fracture, of nasal bones, 329; treatment, 
 330; of cranium, 159; treatment, 166; 
 of hyoidbone, 922; treatment, 923; of 
 larynx, 923; symptoms, treatment, 
 924; of maxilla" inferior, 775; treat- 
 ment, 778; maxilla superior, 533; of 
 vertebra?, 1150 
 
 Fracv, on ligation of external carotid, 
 1126 
 
 Frankel, on oz^na, 384, 387 
 
 Fredericq, on nasal polypus, 359 
 
 Fricke, method of, in blepharoplasty, 
 491 
 
 Fritsch, on hare-lip, 564; on trephining, 
 190 
 
 Fritz, on gunshot wounds in cranium, 
 177 
 
 Fuller, on tracheotomy, 1021 
 
 G 
 
 Gaillard, on entropion, 487 
 
 Galen, on meninges of brain, 208; lin- 
 gual prolapsus, 612; nasal injury, 329; 
 tonsillitis, 694 
 
 Gamgee, on excision of tongue, 635 
 
 Gangrene, 36; of scalp, 82 
 
 Garre, on goitre, 841, 874 
 
 Garwood, 60 
 
 Gay, on staphylorraphy, 674 
 
 Gelatinous tumor of eyelid, 471; treat- 
 ment, 472 
 
 Gensoul, on maxillary resection, 539 
 
 Germicidal agents, 48 
 
 Gherini, on ligation of external carotid 
 artery, 1126 
 
 Gillette, on retro-pharyngeal abscess, 713 
 
 Gingivitis, of maxilla inferior, 733 
 
 Gintrac, on meningeal tumors, 217; par- 
 asitic tumors, 219 
 
1172 
 
 INDKX. 
 
 Giraldes, on cysts in the antrum, o!t8; 
 liare-lip, 5G6 
 
 Glands, cervical, sarcoma of. 874; treat- 
 ment of, 880; thyroid, 823 
 
 Glossitis, or inflammation of tongue, 615; 
 treatment, 617 
 
 Godefroy, on harelip, 563 
 
 Goitre, medical treatment, 835; sursjical 
 treatment, 838; exophthalmic, 847 
 
 Gosselin, on carhunele, 898; erysipelas, 
 145; wounds of neck, 918 
 
 Gottstein, on oztena, 387 
 
 Goursauld.on stricture of oesophagus, 976 
 
 Goux, on neurectomy, 793 
 
 Graefe, on lahial cancer, 600; palpehral 
 deformities, 474; ectropion, 480; entro- 
 pion, 489; hare-lip, 568; rhinoplasty, 
 420; foreiijn hodies in (esophagus, 984 
 
 Graser, on plastic surgery, 451 
 
 Greene, Warreii, on goitre, 840 
 
 Gresswell, on tracheotomy, 1033 
 
 Griesinger, on cerehral concussion, 231 
 
 GrisoUe, on tracheotomy, 1029 
 
 Gross, on foreign bodies in air pas- 
 sages, 956; nasal polypus, 357; wounds 
 of internal jugular vein, 1134 
 
 Growths, lahial, 585; treatment 586; 
 lahial cancer, 590; lahial cystoma, 
 589; in parotid gland, 521; in lower 
 jaw, 758; in inferior maxilla, 748; 
 solid, of neck, 873; affecting external 
 surface of nose, 334; parotidean, 515; 
 in scalp, 121; vascular, in scalp, 114; 
 in tongue, 622; treatment, 623; cystic, 
 of tongue, 624- malignant, of tongue, 
 626; diagnosis 631; treatment, 623 
 
 Gruber, on polypus of ear, 301; on 
 tracheotomy, 1017 
 
 Griinmach, on goitre, 837 
 
 Grynfelt, on goitre, 833 
 
 Gu^rin, on anchylosis, 767; carbuncle, 
 897, 898; ectropion, 482; fracture of 
 superior maxilla, 534; torticollis, 811 
 
 Guersant, on hare-lip, 566; tonsillotomy, 
 704; tracheotomy, 1019, 1052 
 
 Gueterhock, on tracheotomy. 1028 
 
 Guilbourt, on maxillo-dental cystic tu- 
 mors, 748 
 
 Guillier, on excision of tongue, 636 
 
 Gummy periostitis in pericranium, 149 
 
 Gunshot wounds, general remarks, 72; 
 of cranium, 172; of scalp and skull, 
 75; treatment, 179 
 Gurlt, on cranial wounds, 177; tracheot- 
 omy, 1005. 
 Gussenbauer, on anchylosis, 766; extir- 
 pation of larynx, 1095 
 Guthrie, r)n flapwounds of scalp, 158 
 Gutzeit, on carhunele, 896 
 
 H 
 
 Haas, on concussion of brain, 225 
 Habicot,on foreign bodies in oesophagus, 
 985 
 
 IlicMiorrluige, 163; 'from auditory ])as- 
 sage, 306; from nose, 371; treatment, 
 376; authorities cited, 307 
 Hall, Marshall, on artiticial respiration, 
 
 939 
 Ilaller, on ranula, 727 
 JIaltenhoff, on phosphorus-necrosis, 745 
 llamhurger, on goitre, 839; stricture of 
 
 a'st>phagus, 971 
 Hamilton, on hare-lip, 566 
 Hanging, 929; aspiration, 938; insuffla- 
 tion, 935; artiticial respiration, 935 
 Hare-lip, 555; operation on, 566; double, 
 
 575; operation on, 575 
 Hardy, on tracheotomy, 1021 
 Harrison, on excision of tongue, 635 
 Hasner, on blepbaroplasty, 492 
 llaunieder, on fracture of lai-ynx, 923 
 Hasse, on surgery of ear, 292; tracheot- 
 omy, 1030 
 Haworth, on concussion of brain, 224 
 Hayem, on encephalitis, 251 
 Hecker, on fracture of vertebra?, 1161 
 Hedenus, on ozajna, 388, 386 
 Heise on goitre, 830 
 Heister, on tonsillotomy, 702 
 Henle, on meninges of brain, 208 
 Henri, on hare-lip, 569 
 Hensinger, on fistula in neck, 819 
 Hermann, on hare-lip, 564 
 Herpin, on tonsillitis, 697 
 Hervier, on orbital tumor 499 
 Heurtaux, on inflammation, 16 
 Heurteloup, on hare-lip 580 
 Heyfelder, on excision of lower jaw, 761, 
 763; maxillary resection, 539; orbital 
 tumor, 499 
 Highmore, antrum of, 391; see maxillary 
 
 sinus 
 Hilton, on parotitis, 515 
 Himly, on symblepharon, 477 
 Hippocrates, on erysipelas, 38; luxation 
 of inferior maxilla, 770; fracture of 
 lower jaw, 778; nasal fracture, 352, 
 355; on tonsillitis, 694; trepanning, 
 186; trephining, 200 
 Hitzig, on trephining, 190 
 Horta, on goitre, 846' 
 Hofl'man, on drowning, 947; strangula- 
 tion, 92G, 930, 934 
 Hordeolum, acne ciliaris, or sty, 471; 
 
 treatment, 471 
 Horsley, on intra-cranial tumor, 269 
 Howard's method in artificial rc>])ira- 
 
 tion,940 
 Huljer, on laryngotomy, 1080 
 Hiibscher, on plastic surgery, 451 
 Hueter, on ligation of lingual artery, 
 639; laryngotomy, 1076; extirpation 
 of larynx, 1095; tracheotomy, 1026; 
 luxation of cervical vertebrae, 1147 
 Iluguier, on excision of lower jaw. 761 
 Humphrey, on lingual prolapsus, 613 
 Hunt, on tracheotomj', 1005 
 
INDEX. 
 
 1173 
 
 Hunter, John, on cancer, 140; carbuncle, 
 894; ligation of vascular growths, 117; 
 inflammation, 36; contusion of scalp, 
 70; wounds, 50, 74 
 
 Hutchinson, on. compression of brain, 
 238 
 
 Hiiter, on tracheotomy, 1030 
 
 Hydrocephalus, 272; treatment, 275 
 
 Hyoid bone, fracture of, 922; treatment, 
 923 
 
 Hvpertrophv, labial, 553; treatment, 
 o53; lingual, 610; treatment, 611; of 
 tiasal mucous membrane, 370; of scalp, 
 88; of tonsil, 697; treatment, 700; 
 authorities cited, 699 
 
 Hyrtl, 9, 15; on mastoid cavity, 310; 
 "nasal fracture, 330; external nasal 
 growths, 334; parotid gland, 524; rhi- 
 noplasty, 412; wounds, 62 
 
 I 
 
 Immisch, on salivary concretion, 516 
 
 Incised wounds, 51; of cranium, 157 
 
 Inert agents, 46 
 
 Infantile sanguineous tuinor, 119 
 
 Inferior maxilla, 732; surgical anatomy 
 of, 732; congenital deformity of, 733; 
 treatment, 734, 736; growths in, 748 
 
 Inflammation, adhesion from, 28; of 
 brain, 250; causes, 250; symptoms, 252; 
 diagnosis, 255; treatment, 257; in- 
 flammation ending in condensation, 
 28; defined and discussed, 15; in dis- 
 pei-sion, immediate or retarded, 27; 
 mortification, 36; inflammation of pal- 
 atal structures, 647; treatment, 648; 
 suppuration. 29; of tongue or glossitis, 
 615; inflammation causing ulceration, 
 33 
 
 Inflammatorv'affections of parotid gland, 
 513 
 
 Injury, to nasal passages, 328 
 
 Insufflation, 935 
 
 Intra-cranial tumor, 261 ; svmptoms of, 
 263; syphiloma, 262; treatment, 267 
 
 Intubation, 1078 
 
 Ipsen, on tracheotomy, 1032 
 
 Jtard, on foreign bodies in auditorv 
 canal, 305 
 
 Iversen, Axel, on excision of tongue, 
 636 
 
 Jaccoud. on tumors of dura mater, 217; 
 
 epistaxis, 373 
 Jaesche, on anchylosis, 768 
 James, on carbuncle, 894: on tonsillitis, 
 
 693 
 Janskowski, on goitre, 844 
 Jasser, on mastoid cavity, 308 
 Jaw, lower, necrosis of, 738 
 •Jearsley, on palatal malfomiations, 653 
 Joal, on tonsillitis, 693 
 
 Jobert, on goitre, 840; narrow nostrils, 
 345; ranula, 729 
 
 Jones, Sydney, on oesophageal neo- 
 plasms, 998 
 
 Jones, T. Wharton, on ectropion, 482 
 
 Jordan, on compression of brain, 242 
 
 Junker, on tonsillotomy, 702 
 
 Jurasz, on deflection of nasal septum, 348 
 
 Jugular vein, external, ligation of, 
 1131; internal, wounds of, 1132 
 
 K 
 
 Kapesser, on foreign bodies in air pas- 
 sages, 957 
 Kaufmann, on goitre, 830 
 Keene, 281; on intracranial tumor, 269 
 Knapp, on symblepharon, 477 
 Koch, Robert, on tuberculin. 339 
 Kocher, on goitre, 841, 845; ligation of 
 external carotid arteiy, 1126; exci- 
 sion of tongue, 637 
 Kijlliker, on maxillary resection, 542 
 Konig, on tracheal aspiration, 944; nasal 
 
 deflection, 423; tumors of neck, 864 
 Korber, of Dorpal, on tracheal aspira- 
 tion, 943 
 Korte, on tracheotomy, 1032 
 Kaske, on tracheal aspiration, 944 
 Krevser, on foreign bodies in oesopha- 
 gus, 984 
 Krimer, on uranoplasty, 677 
 Krishaber, on laryngotomy, 1077 
 Kroll, on tracheotomy, 1030 
 Kronlein, on pharyngotomy, 722; tre- 
 phining, 196 
 Kiister, on cranial bullet wounds, 178; 
 pharyngotomy, 722 
 
 Labadie-Lagrave, on tumors of dura 
 mater, 217 
 
 Labial, cancer, 590; cause, 594; com- 
 mencement and course, 591: diagno- 
 sis, 596; prognosis, 597; statistics, 598; 
 treatment, 599; labial cystoma, 589; 
 labial ectropion, 554; labial growths, 
 585; treatment, 586; labial hypertro- 
 phy, 553; treatment, 553 
 
 Labium lepornium, hare-lip or cleft-lip, 
 555; operation, 566; double, 575; 
 operation, 575 
 
 Lacerated wounds, 60 
 
 Lamballe, Jobart de, on foreign bodies 
 in air passages, 955 
 
 Lancereaux, on pachymeningitis, 211 
 
 Lane, on wounds of internal jugular 
 vein, 1137 
 
 Lang, on tonsillar tumors, 711 
 
 Langenbeck, 111; on tracheal aspiration, 
 945; palatal chondroma, 651; paroti- 
 dean fistula, 532: goitre, 839; hare-lip, 
 566, 570; hydrocephalus, 277: fibrous 
 polypus, 367; maxillary resection, 
 
1174 
 
 INDEX. 
 
 541; rhinoplasty, 414; staphylorniphy, 
 669, 675; excision of tongue, 637; 
 malignant growths of tongue, 632; 
 tracheotomy, 10U5, 1039; jiharyngcul 
 tumors, 722; tonsillar tumors, 711; 
 uranoplasty, 678; cranial bullet 
 wounds, 178; flap wounds, 159 
 
 Lannelogue, 281; on hare-lip, 562; 
 uranoplasty, 682 
 
 Lanphear, on intra-cranial tumor, 269 
 
 Larghi, on tonsillotomy, 703 
 
 Larrey, on cervical glandular tumors, 
 884 
 
 Laryngectomy, operation of, 1086 
 
 Laryngotomy, 1069; operation of, 1075; 
 intubation, 1078 
 
 Larynx, fracture of, 923; symptoms, 
 924; treatment, 924; extirpation of, 
 1086 
 
 Laugier, on contusion of brain, 247; 
 hanging, 929; lipoma of tongue, 625; 
 strangulation, 925; trephining, 242 
 
 Lawson, on concussion of brain, 225 
 
 Le Bail, on hasmorrhage from auditory 
 passage, 306 
 
 Le Blanc, on lingual prolapsus, 612 
 
 Le Dentu, on carbuncle, 898 
 
 Le Fort, Leon, on carbuncle, 898; tre- 
 phination, 195, 242 
 
 Leheribel, on fracture of maxilla supe- 
 rior, 534 
 
 Lehmann, on maxillary resection, 642 
 
 Lesions traumatic, of cranium, 153 
 
 Leser, of Halle, on trephination, 190 
 
 Leyden, on compression of brain, experi- 
 ments, 235 
 
 Ligation of primitive carotid, 1101; 
 both primitive carotids, 1120; of ex- 
 ternal carotid artery, 1120; of external 
 jugular vein, 1131 
 
 Lingual prolapsus with hypertrophy, 
 6i0; treatment, 611 
 
 Linn, on trephination, 206 
 
 Lipoma, in scalp, 99 
 
 Lips, 544; atresia of, 547; treatment, 
 548; hare-lip, 555; double, 575; mac- 
 rostoma of, 550; treatment, 552 
 
 Lisfranc, on rhinoplasty, 415 
 
 Liston, on staphj'lorraphy, 673 
 
 Littlewood, on cervical glandular tu- 
 mors, 891 
 
 Lizars, on maxillary resection, 542 
 
 Lombard, on facial neuralgia, 789 
 
 Lorinser, on phosphorus-necrosis, 743, 
 747 
 
 Louis, on parotidean fistula, 531; lin- 
 gual prolapsus, 612; tracheotomy 
 bronchotomy, 1002 
 
 Liicke, on maxillary resection, 541; su- 
 perficial germicidal treatment, 48; 
 tracheotomy, 1026 
 
 Ludlow, on carbuncle, 894, 898 
 
 Lupus, 338; treatment, 339; rodens, 
 341; treatment, 342 
 
 Luton, on goitre, 837 
 
 Luxation, of maxilla inferior, 770; 
 
 treatment, 773; of cervical vertebrae, 
 
 1144 
 Lymph-angioma, in neck, 867 
 Lymphatic vessels and glands of scalp 
 
 'll 
 Lymphoma, malignant, 877 
 
 M 
 
 MacClellan, on parotidean operations, 
 528 
 
 Macewen, on intra-cranial tumor, 269; 
 
 MacKenzie,on labial cancer, 603; oesoph- 
 ageal neoplasms, 995 
 
 Macrostoma, of lips 550; treatment, 
 552 
 
 Madelung, on tracheotomy, 1032 
 
 Magitot, on maxillary cysts, 748 
 
 Maisonneuve, on nasal defect, 327; lin- 
 gual prolapsus, 612; growths of 
 tongue, 622; lipoma of tongue, 625; 
 tonsillotomy, 703; tracheotomy, 1025 
 
 Maiweg, on labial cancer, 598 
 
 Malar and parotidean regions of face, 
 503; surgery of, 503 
 
 Malar region, scrofulous ulcer of, 508; 
 treatment, 509; wounds of cheek and 
 side of face, 504; see parotidean re- 
 gion 
 
 Malformations, of palate, 652; treat- 
 ment, 653 
 
 Malgaigne, on nasal defect, 423; hare- 
 lip, 569; hydrocephalus, 277; facial 
 neuralgia, 789; parotis, 524; torticol- 
 lis, 806, 816; luxation of cervical ver- 
 tebrae, 1148 
 
 Malignant growths, of parotid gland, 
 521; in lower jaw, 758; tumors of 
 parotis, 523; in scalp, 121; of tongue, 
 626; diagnosis, 631; treatment, 633 
 
 Manec, on salivary concretion, 517 
 
 Mann, of Avignon, on fibrous polypus, 
 368 
 
 Marchand, on insufflation, 936' 
 
 Marchal, wounds of internal jugular 
 vein, 1136 
 
 Marchant, on trephining, 196 
 
 Marjolin, on carbuncle, 898 
 
 Marks, pigment, 120 
 
 Martin, on oz;ena, 384; pharynx and 
 oesophagus, 983 
 
 Martino, on external ear, -288 
 
 Mason, on lipoma of tongue, 625; on 
 staphylorraphy, 675 
 
 Maslieurat-Lag6mard, on tracheotomy, 
 1018 
 
 Mastoid cavity, 308 
 
 Math6, on anchylosis, 769 
 
 Mathieu, on extraction of foreign bodies 
 from oesophagus and stomach 986 
 
 Maunoir, on goitre, 829; tracheotomy, 
 1025 
 
INDEX. 
 
 1175 
 
 Maxilla inferior, 732; surgical anatomy 
 of, 732; anchylosis of, 764; treatment, 
 765; carcinoma in, 758; treatment, 
 760; congenital deformity of, 733; 
 treatment, 734, 736; epulis of, 755; 
 treatment, 757; fibroma of, 754; frac- 
 ture f f, 775; treatment, 778; growths 
 in, 748; malignant growths in, 758; 
 necrosis of lower jaw, 738; prognosis, 
 741; treatment, 741; luxation of, 770; 
 treatment, 773; odontoma, 752; treat- 
 ment, 753; osteoma, 75.5; alveolar 
 periostitis, 733; treatment, 734; ill po- 
 sition of wisdom teeth, 736; treat 
 ment, 738; maxillo-dental cystic tu- 
 mors, 748; treatment, 752 
 
 Maxillo-dental cystic tumors, 748; treat- 
 ment, 752 
 
 Maxillary sinus, or Antrum of High- 
 more, 391; abscess of, 393; treatment, 
 395; cysts in antrum, 397; treatment, 
 398; fistula of antrum, 396; treatment, 
 397 
 
 Maxilla superior, 533; fracture of, 533; 
 resection of upper jaw, 536 
 
 Melzer, on labial cancer, 598 
 
 Membranes of brain, epithelioma in, 
 220; surgical afi'ections of, 209; oste- 
 oma, 218; psammoma in, 219; syphi- 
 loma in, 220; tubercular disease of, 
 220; constitutional tumors, 219; para- 
 sitic tumors in, 219 
 
 Meningeal tumors, effects of, 220; treat- 
 ment, 221 
 
 Meninges of brain, 208 
 
 Meningocele and encephocele, 270; treat- 
 ment, 272 
 
 Menzel, on excision of tongue, 635 
 
 Mercier, on wounds of internal jugular 
 vein, 1136 
 
 Mestivier, on tonsillitis, 694 
 
 Mettauer, on staphylorraphy, 673 
 
 Metzler, on phlegmon and abscess, 862 
 
 Meyer, Ludwig, on othsematoma, 292; 
 malignant lymphoma, 883 
 
 Michaux, on maxillary resection, 539 
 
 Michel, on neurectomy, 793; on ranula, 
 730 
 
 Michon, in wound of carotid arterv, 
 1100 
 
 Mickulicz, on tonsillar tumors, Til 
 
 Microcephalus L, C. Lane's treatment 
 of, 278 
 
 Millet, on tracheotomy, 1026 
 
 Mirault, on ectropion, 480; hare-lip, 
 566, 569 
 
 Moleschott. on deflection of septum, 347 
 
 Molliere, of Lvons, on fracture of ver- 
 tebra, 1150 " 
 
 Morax, on tracheotomy, 1043 
 
 Morian, on hare-lip, 562 
 
 Mortification, 36; of scalp, 82 
 
 j^Ioscati, on tonsillotomy, 702 
 
 Mosso Angelo, on defects of oesophagus, 
 961 
 
 Mouth and oral cavity, 544; atresia of, 
 547; treatment, 548; labial ectropion, 
 554; labial hypertrophy, 553; treat- 
 ment, 553; hare-lip, or labium lepo- 
 rinum, 556; operation on, 566; deform- 
 ity of oral opening, 552; lips, 544; 
 macrostoma of lips, 550; roof of mouth 
 644 
 
 Mucous membrane, nasal hypertrophv 
 of, 370 
 
 3Iuseux, on tonsillotomy, 702 
 
 Miitter, on anchylosis, 766; epulis, 757; 
 foreign bodies in oesophagus, 985, 986 
 
 N 
 
 Narrowness of nostrils, 343; of palpe- 
 bral opening, 475; treatment, 475 
 Xasai bones, fracture of, 329; treatment 
 330; catarrh or oz^na, 383; treatment, 
 385; deformity and its relief, 402; hy- 
 pertrophy of mucous membrane, 370; 
 passages, 325; obstruction, 351; poly- 
 pus, 352; symptoms, 353; treatment, 
 355; partial repair, 420; deflection of 
 septum, 346; treatment, 347, 349; ne- 
 crosis of osseous septum, 351; perfora- 
 tion of, 400; tumors of, 348 
 
 Neck, 800; surgical anatomy of, 800, 
 823; angioma in, 869; treatment, 870; 
 blood cysts on, 871; treatment, 873; 
 carbuncle, anthrax on, 893; congenital 
 clefts, or fistula in, 819; foreign bod- 
 ies in air passages, 955; solid growths 
 of, 873; hanging, 925, 929; fracture of 
 hyoid bone, 922; treatment, 923; 
 larynx, fracture of, 923; symptoms; 
 treatment, 924; lymph-angioma in, 
 867; malignant lymphoma of, 877; 
 phlegmon and abscess of, 853; malig- 
 nant pustule on, 900; sarcoma of cer- 
 vical glands, 874; torticollis, 804; 
 treatment, 808; thvroid gland, 823; 
 tumors of, 864; treatment, 867. 880; 
 vessels of, 1096; wounds of, 905; treat- 
 ment, 915 
 
 Necrosis, of lower jaw, 738; prognosis, 
 treatment, 741 ; phosphorus-necrosis, 
 743; treatment, 746; of osseous sep- 
 tum, 351 
 
 Nelaton, on nasal defect, 422; hare-lip, 
 568; luxation of inferior maxilla, 771; 
 fibrous polypus, 360; sound, 182; ex- 
 cision of tongue, 634; tracheotomy, 
 1029; maxilla, dental cj'stie tumors of, 
 749; wounds of neck, 918; wounds of 
 cranium, 182 
 
 Neoplasms, pharyngeal and oesophageal, 
 989 
 
 Nerves of scalp, 12 
 
 Neucourt, on facial neuralgia, 785 
 
 Neudorfer, on hare-lip, 565; tracheo- 
 tomy, 1021 
 
 Neuralgia, facial, 783; of scalp, 14 
 
 Northrop, on laryngotomy, 1080,1083 
 
1176 
 
 INDKX. 
 
 Nose and nasal passacjes, 325; angioma 
 in, 330; treatment, 337; defects of, 
 327; fracture of nasal bones, 329; 
 treatment, 330; growths on external 
 surface of nose, 334; injury of, 327; 
 lupus in, 338; treatment, 339; lupus 
 rodens, 341; treatment, 342; obstruc- 
 tion of, 351; parasites in, 882 
 
 IXostrils and their diseases, 343; alar 
 margin defect of, 421; bleeding from 
 nose, 371; treatment, 376; defect from 
 loss of side of nose, 421; deformity of, 
 402; foreign bodies in, 380; hypertro- 
 phy of nasal mucous membranes, 370; 
 narrowness of, 343; necrosis of osseous 
 septum, 351; ozaena, or nasal catarrh, 
 383; treatment, 385; parasites in, 382; 
 polypus in, 352; symptoms, 353; 
 treatment, 355; fibrous polypus in. 
 360; treatment. 364; deflection of na- 
 sal septum, 346; treatment, 347; 
 tumors of nasal septum, 348; treat- 
 ment, 349 
 
 Nunneley, on malignant growths of the 
 tongue, 634 
 
 Nussbaum, on neurectomy, 702 
 
 o 
 
 Obstruction of nasal passages, 351 
 
 Occlusion of auditory canal, 300; treat- 
 ment, 301; by cerumen, foreign bodies 
 301 
 
 Odontoma, of maxilla inferior, 752; 
 treatment, 753 
 
 O'Dwyer, on larj-ngotomy, 1079 
 
 Oedema, 14 
 
 (Esophageal neoplasms, 989; tracheot- 
 omy, bronchotomy, 1000 
 
 CEsophagus, 959; foreign bodies in. 982; 
 congenital defects of, 961; malignant 
 growths in, 992; warts, cysts, and 
 polypoid growths in, 991; spasms of, 
 971; treatment, 974; stricture of, 963; 
 wounds of, 998 
 
 O'Ferral, on carbuncle, 898 
 
 Ogston, on congenital deformity of max- 
 illa inferior, 733 
 
 Oilier, on fibrous polypus, 366 
 
 Operation, <if laryngotomy, 1075; laryn- 
 gectomv, 1086; in parotideau region 
 526 
 
 Oppenheimer,on facial neuralgia, 786 
 
 Oral cavity and mouth, lip.--, 544; roof 
 of, 644; opening, deviation of, 552 
 
 Osseous septum of nose, necrosis of, 351 
 
 Osteoma, of maxilla inferior, 755; of 
 membranes of brain, 218 
 
 Othiematoma of ear, 291; treatment, 293 
 
 Otis, on gunshot wounds of cranium, 177 
 
 07,a?na, or nasal catarrh, 383; treatment, 
 385 
 
 O/.enne, on cystic growths of tongue, 
 625 
 
 Pachj-meningitis, 212; treatment, 214; 
 external, of puerperal origin, 215 
 
 Pacini, on insutllation, 937; on tracheal 
 aspiration, 942 
 
 Paget, Sir James, on carbuncle, 899; 
 cerebral concussion, 225; growths on 
 scalp, 124; excision of tongue, 635; 
 ulceration of tongue, 619; trephining, 
 189 
 
 Palate, destniction of soft, 657; malfor- 
 mations of soft and hard, 652; treat- 
 ment, 653; staphylorraphy of, 665; 
 tumors arising from, 650; uranoplastv 
 of, 677; wounds of, 649 
 
 Palatal structures, adhesion of, 656; cleft 
 of, 659; treatment, 663; inflammation 
 of, 647; treatment, 648 
 
 Palpebral, deformities, 473; treatment, 
 473; narrowness of opening, 475; treat- 
 ment, 475 
 
 Pamard, on diseases of eyelid, 499 
 
 Pancoast, on neurectomy, 795 
 
 Pappanheim, on tonsillotomy. 702 
 
 Parasites, in nasal passages, 382 
 
 Parasitic tumors, 219 
 
 Paravini, on neurectomy, 792 
 
 Par6 Ambrose, on ranula of sublingual 
 region, 729; trepan, 201; wounds of 
 cranium 155, 158; wounds of neck, 
 917 
 
 Parise, of Lille, on hare-lip, 562 
 
 Parotidean region, 509; angioma in, 517: 
 treatment, 518; carcinoma in, 523; 
 epithelioma in, 522; fistula in, 528; 
 treatment, 529; operation in, 526; 
 parotidean growths, 515; inflamma- 
 tory aft'ections of parotid gland, 521; 
 salivary concretion, 516; treatment, 
 517; surgeiy of, 503, 509; benign tu- 
 mors, 517 
 
 Parotid gland, inflammatory aflections 
 of, 513; treatment, 514; malignant 
 growths of, 521 
 
 Parotis, malignant tumors of, 523; treat- 
 ment, 523 
 
 Parotitis, 513; treatment, 514 
 
 Parrot, on epithelioma, 218 
 
 Passavant, on gunshot wounds, 183; 
 staphylorraphy, 675; tracheotomy, 1021 
 
 Pasteur, on pathology, 25; malignant 
 pustule, 901 
 
 Pathology, 23; cellular, 24 
 
 Patruban, on goitre, 839 
 
 Paul, of ^gina, on foreign bodies in 
 auditory canal, 305 
 
 Paul, of Breslau, on palatal adhesion, 
 656 
 
 Pauli, on ranula, 729; tracheotomy, 1022 
 
 Periat, on hare-lip, 564 
 
 Pericranium, and its atfections, 147; per- 
 iostitis, 148; wounds of, 147 
 
 Periostitis, alveolar, 733 
 
 Petel, on tracheotomv, 1017, 1032 
 
INDEX. 
 
 1177 
 
 Peter, on tracheotomy, 1029 
 
 Petit, on angioma, 108 
 
 Petrali, on torticollis, 814 
 
 P^trequin, on ranula, 729 
 
 Pfaif, on facial neuralgia, 788 
 
 Pharj'-ngeal, tumors, 721; neoplasms, 
 989; treatment, 990 
 
 Pharynx, 713; abscess of, 713; treatment, 
 716; foreign bodies in, 723, 982; ma- 
 lignant growths in, 992; ulceration of, 
 719; treatment, 720 
 
 Philippe, on torticollis, 811 
 
 Phlegmon and abscess of neck, 853; 
 treatment, 858; drainage, 860 
 
 Phosphorus-necrosis of lower jaw, 743; 
 treatment, 746 , 
 
 Physic, on carbuncle, 896; fracture of 
 lower jaw, 780 
 
 Picard, on wounds of internal jugular 
 vein, 1188 
 
 Pigment marks, 120 
 
 Pinna, adherent, 293 
 
 Pisani, on ranula, 729 
 
 Pitha,on maxillary excision, 763; staphy- 
 lorraphy, 674; tracheotomy, 1020 
 
 Plastic surgery, elements of, 427; first 
 method, immediate, 480; second meth- 
 od, adductive approximation by dis- 
 secting, 433; third method circum- 
 duction of pedicled flap, 440; other 
 methods, 445; care of wounds, 447 
 
 Pneumatocephalus, emphysema, from 
 middle ear, 311; treatment, 312; of 
 eyelids, 469; in scalp, 145 
 
 Podrazky, of Vienna, on excision of 
 tongue, 635 
 
 Poinsot, on mastoid cavity, 309, 310 
 
 Poiseuille, on wounds of internal jugular 
 vein, 1137 
 
 Polypus, in auditory canal, 301; fibrous, 
 360; treatment, 364; in nose, 352; 
 symptoms, 353; treatment, 355; poly- 
 poid growths in cesophagus, 991 
 
 Ponfick, on erysipelas, 42 
 
 Porta, on goitre, 839; luxation of cervi- 
 cal vertebrae, 1146 
 
 Porter, of Dublin, on tracheotomy, 1027 
 
 Potter, fracture of vertebra3, 1163 
 
 Prichard, on carbuncle, 894, 897 
 
 Primitive carotid, ligation of, 1011, 1120 
 
 Prochasky, on sneezing, 645 
 
 Prolapsus, lingual, with hypertrophy, 
 610 
 
 Psammona, 219 
 
 Pus, 29 
 
 Pustule, malignant, on neck, 900; path- 
 ological changes after death, 902; treat- 
 ment, 902 
 
 Quinart, on phlegmon and abscess, 858 
 R 
 
 Kamsden. on subclavian artery 1128 
 Pvanula, 727 
 
 Eanvier, 26; on epithelioma of men- 
 inges, 218 
 
 Kanke, on anchylosis, 769; laryngot- 
 omy, 1085 " '" 
 
 Kecamier, on cervical glandular tu- 
 mors, 884 
 
 Eeel-Ogez, on tonsillitis, 697 
 
 Region, sublingual, 725 
 
 Regnoli, on malignant growths of 
 tongue, 633 
 
 Reid, on nasal defects, 423 
 
 Remak, on torticollis, 809 
 
 Rents, fissures, and defects of external 
 ear, 297 
 
 Resection of upper jaw, 536 
 
 Respiration, artificial, 935; tracheal as- 
 piration, 938 
 
 Reverdin, J. L., on goitre, 845; plastic 
 surgery, 449 
 
 Rhinoplasty, 406 
 
 Richet, on ankyloblepharon, 476; car- 
 buncle, 895; facial neuralgia, 790; 
 surgery of frontal region, 320 
 
 Richter, on stricture of cesophagus, 979 
 
 Ricord, on surgery of scalp, 12 
 
 Rigby, on carbuncle, 896 
 
 Rizzoli, on anchylosis, 769 
 
 Robsen, Mayo, on defects of spinal col- 
 umn, 1142 
 
 Rodens, lupus or rodent ulcer, 341; 
 treatment, 342 
 
 Rodent ulcer, 341; treatment, 842 
 
 Rokitansky, on goitre, 837 
 
 Ronhuysen, on torticollis, 810 
 
 Roof of oral cavity, 644 
 
 Rose, on goitre, 830; neurectomy, 
 
 Eoser, on gunshot wounds, 183; neurec- 
 tomy, 793; tracheotomy, 1023 
 
 Rotter, on goitre, 845 
 
 Roustam, on pharyngeal abscess, 716 
 
 Roux, on palatal cleft, 664, 667; hare- 
 lip, 558, 563, 580, neurectomy, 790; 
 trephining, 200; uranoplasty, 677; 
 wounds of neck, 916, 922 
 
 Ruppaner, on hypertrophy of tonsil, 701 
 
 Ryba, on orbital tumor, 497 
 
 Sabatier, on wounds of neck, 917 
 Salivary concretion, 516; treatment, 517 
 Salter, on facial neuralgia, 786 
 Sanctorius, of Padua, on tracheotomy, 
 
 bronchotomy, 1001 
 Sanguineous tumor, infantile, 119 
 Sarazin, on fistulaB of neck, 823 
 Sarcoma, of neck, 874 
 Scalp, atfections of, 14; surgical anat- 
 omy of, 7; angioma in, 103; arteries 
 of, 10; atrophy of, 89; carcinoma in 
 139; contusion of, 65; cystoma in, 93 
 epithelioma of, 131; erysipelas of, 38 
 gangrene of, 82; malignant growths 
 in, 121; vascular growths in, 114; hy- 
 pertrophy of, 88; inflammation of, 14; 
 lipoma in, 99; lymphatic vessels and 
 
 75 
 
1178 
 
 INDEX. 
 
 glands of, 11; nerves of, 12; pcrici-;i- 
 iiiuni, 147; pigment murks on, 120; 
 
 ?neumatocephulus of, 145; surgery of, 
 ; trephination, 185; tumors oi", 89; in- 
 fantile sanguineous tumor on, 119; 
 ulceration of, 85; warts in, 91; 
 wounds of, 49, 147; gunshot wounds 
 of, 75; wounds, treatments of, 78 
 
 Scarification, 47 
 
 Schaefer, Max, on ozaena, 384, 386 
 
 Schillbach, on maxillary excision, 702; 
 trephining over frontal sinus, 324 
 
 Schmidt, on anchj'losis, 767; narrow 
 nostrils, 344 
 
 Schijuborn, on uranoplasty, 682; ceso])li- 
 ageal neoplasms, 998 
 
 Schramm, on facial neuralgia, 786 
 
 Schuh, on neurectomy, 791 
 
 Schiiller, on aspiration, 943; laryngot- 
 omy, 1076; tracheotomy, 1008 " 
 
 Schulten, on anchylosis, 765 
 
 Schultze, on artificial breathing, 943 
 
 Schuster, on malignant lymphoma, 883 
 
 Schiitzenberger, on scarification, 47 
 
 Schwabach, on external ear, 288 
 
 Schwalte, on goitre, 837 
 
 Scrofulous ulcer, in cheek, 508; trosit- 
 ment, 509 
 
 Sedillot, on laTjial cancer, 602; goitre, 
 840; malignant growths, 634; hare- 
 lip, 568; staphylorraphy, 673; trephin- 
 ation, 193 
 
 See, 16; on carbuncle, 898 
 
 Second method in plastic surgery, 433 
 
 Septum nasal, deflection of, 346; treat- 
 ment, 347; necrosis of osseous, 351; 
 perforation of, 400; tumors of, 348; 
 treatment, 349 
 
 Serre, on atresia of mouth, 549 
 
 Sestier, on tracheotomy, 1018 
 
 Severini, on tonsillotomy, 702 
 
 Sharp, on tonsillotomy, 702 
 
 Shillitoe, on carbuncle, 896 
 
 Sichel, on orbital melanoma, 400 
 
 Simon, on thermo-electric test of in- 
 crease of heat, 18; tracheotomy, 1027; 
 wounds of jugular vein, ''136; gunshot 
 wounds, 175 
 
 Sinus, frontal, 318; trephining over, 323; 
 maxillary, 301 
 
 Skull, gunshot wounds of, 75 
 
 Smith, on lymph-angioma, 869; palatal 
 malformations, 653, 668; luxation of 
 cervical vertebrae, 1144 
 
 Smyly, on staphylorraphy, 673 
 
 Socin, on goitre, 841 
 
 Soupart, of Ghent, on hare-lip, 583 
 
 South, on wounds of neck, 918; phar- 
 ynx and oesophagus, 982 
 
 Spasm, of oesophagus, 963 
 
 Spessa, on staphylorraphy, 665 
 
 Spinal column, congenital defects of, 
 1139; treatment; fUl 
 
 Sprengler, on anchylosis, 768; excision 
 of lower jaw, 764 
 
 Springer, on maxillary resection, 541 
 
 Stahl, 22 
 
 Staphylorraphy of palate, 665; authori- 
 ties cited in treatment, 673 
 
 Startin, on carbuncle, 806 
 
 Steiger, on ccsoj)hageal stricture, 063 
 
 Steiner, on tracheotomy, 1029 
 
 Steinlein. on luxation of inferior max- 
 illa, 771 
 
 St. Germain, on phlegmon and abscess, 
 860; tumor of brain, 270; tonsillot- 
 omy, 704; tracheotomy, 1046 
 
 St. Lager, on orbital tumor, 499 
 
 Strangulation, hanging, 925; artificial 
 respiration, 935; insufflation, 935 
 
 Streatfield, on entrypion, 489 
 
 Strieker, 16 
 
 Stricture, of oesophagus, 963 
 
 Stromeyer, on facial neuralgia, 784; on 
 tonsillitis, 696; on torticollis, 816; 
 on trephination, 194 
 
 Sty, hordeolum or acne ciliaris, 471; 
 treatment, 471 
 
 Subclavian artery, 1127 
 
 Sublingual region, 725; ranula of, 727 
 
 Suppuration, inflammatory, 29 
 
 Surgery, of external ear, 285; of frontal 
 region, 315; treatment, 315; i)lasiic, 
 427; of malar and parotidean regions 
 of face, 503; of scalp, 7 
 
 Surgical, affections, of eyebrows and 
 eyelids, 455; anatomy of neck, 800; 
 frontal region, 315; of membranes of 
 brain, 209; of maxilla inferior, 732; 
 of scalp, 7.; of thyroid gland, 823; of 
 tongue, 607; of tonsil, 686 
 
 Symblepharon, or bulbo-palpebral un- 
 ion, 476; treatment, 477 
 
 Syme, on excision of maxilla inferior, 
 760; lingual prolapsus, 612; excision 
 of tongue, 634 
 
 Syphilis, 149 
 
 Syphiloma, in brain, 262; treatment, 
 267; in membrane of brain, 220 
 
 Szymanowsky, on ectropion, 481 
 
 Tait, Lawson, on phlegmon and abscess, 
 859 
 
 Tagliacozzi, 418 
 
 Taliacotius, on rhinoplasty, 407, 418 
 
 Tardieu, on strangulation, 927 
 
 Tarsal, tumor, of eyelid, 471; treatment, 
 472 
 
 Taylor, on hanging, 031; drowning, 947 
 
 Tazon, on gunshot wounds of cranium, 
 173 
 
 Teale, on labial hypertrophy, 555; sym- 
 blepharon, 477 
 
 Teeth, wisdom, ill placed 763; treat- 
 ment, 738 
 
 Teevan, of London, on gunshot wounds 
 of cranium, 173 
 
 Textor, on orbital tumor, 495 
 
INDEX. 
 
 1179 
 
 Thierry, on hare-lip, 566 
 
 Thiersch, on lingual epithelioma, 634; 
 .method of dermal transplantation, 
 449, 450; uranoplasty, 682 
 
 Third method in plastic surgeiy, 440 
 
 Thomas, of Tours, on pneumatocephalus, 
 312 
 
 Thompson, on tracheotomy, 1019 
 
 Thudicum, on nasal polypus, 359 
 
 Thyroid gland, surgical anatomy of, 823; 
 aifeetions ef, 823; goitre, 825; medi- 
 cal treatment, 835; surgical treat- 
 ment, 838; exophthalmic goitre, 847; 
 malignant disease of, 849; thyroiditis, 
 851; wounds of, 850 
 
 Thyroiditis, 851 
 
 Tillaux, 8, 18; on aflections of auditory 
 canal, 298; foreign bodies in auditory 
 canal, 306; haemorrhage from audi- 
 tory passage, 850; external ear, 286, 
 mastoid cavity of ear. 308, 310; goitre, 
 829; parotidean fistula, 530; atfections 
 of parotid gland, 513 
 
 Tongue, 607; abscess of, 618; surgical 
 anatomy of, 607- aneurism^ 650; 
 ankyloglossa, or tongue-tie, 613; de- 
 formities of, 609- fibroma of, 626; 
 foreign bodies in, 644; growths of, 
 622; treatment, 623; cystic growths of, 
 G24; malignant growths of, 626; diag- 
 nosis, 631; treatment, 633; inflam- 
 mation of, or glossitis, 615; treatment, 
 617; lingual prolapsus with hyper- 
 trophy, 610 
 
 Tongue-tie, or ankyloglossa, Cicero on, 
 613 
 
 Tonsil, 686; surgical anatomy of, 686; 
 hypertrophy of, 697; ti-eatment, 700; 
 tonsillitis, 688; tonsillotomy, or ex- 
 cision of tonsils, 701 
 
 Tonsillar tumors, 710; treatment, 711 
 
 Tonsillitis, 688; treatment, 694 
 
 Tonsillotomy, amygdalotomy or ex- 
 cision of tonsils, 701 
 
 Torticollis, 804; treatment, 808 
 
 Toynbee, on encephalitis, 251 
 
 Tracheotomy, 1000 
 
 Transplantation, Thiersch's method of 
 skin grafting 449 
 
 Traumatic lesions of cranium, 153 
 
 Trelat, on carbuncle, 898; hart:-Mp, 562; 
 phosphorus-necrosis. 747; staphylorra- 
 phy, 675; ulceration of tongue, 620; 
 tracheotomy, 1010 
 
 Trephination, authorities cited, 188, 191; 
 conditions which favor or contraindi- 
 cate, 242; over frontal sinus, 323 
 
 Tricot, on hare-lip, 566, 567 
 
 Trousseau, on facial neuralgia, 786; 
 laryngotomy, 1079; o;^ffina, 383, 386; 
 tracheotomy, 1017, 1022, 1044, 1051, 
 1055 
 
 Tubercle, on membrane of brain, 220 
 
 Tulpius, on ranula, 729 
 
 Ttirck, on facial neuralgia, 789 
 
 Tumors, benign, 517; in brain, 261; 
 
 ■symptoms, 263; treatment, 267; con- 
 stitutional, 219; cervical glandular, 
 880; of dura mater, 216; epithelioma, 
 218; of eyelid, tarsal, gelatinous or 
 fibrinous, 471; treatment, 472; of 
 maxillary sinus, 398; maxillo-dental, 
 cystic, 748; treatment, 752; meningeal, 
 effects of, 220; treatment, 221; of neck, 
 864; treatment, 867, 495; osteoma, 
 218; from palate, 650; tumors in par- 
 otidean region, 517; of parotis, 523; 
 treatment, 523; parasitic, 219; phar- 
 yngeal, 721; psammona, 219; infantile 
 sanguineous, 119; of scalp, 89; ton- 
 sillar, 710; treatment, 711 
 
 u 
 
 Ulcer, scrofulous, in cheek, 508; treat- 
 ment, 509; rodent, 341; treatment 
 342 
 
 Ulceration, inflammatory, 33; of phar- 
 ynx, 719; treatment, 720; of scalp, 
 85; of tongue, 618; treatment, 620 
 
 Upper jaw, resection of, 536 
 
 Uranoplasty, 677 
 
 Uspensky, on facial neuralgia, 783 
 
 Uvula and soft palate, destruction of, 
 657 
 
 Uterhart, on wounds in internal jugular 
 vein. 1138 
 
 Valentin, on stricture of oesophagus, 979 
 
 Van der Haar, on lingual px'olapsus, 612 
 
 Van Helmont, 22 
 
 Van Swieten, on trephining, 243 
 
 Vascular growths, in scalp, 114 
 
 Velpeau, on carbuncle, 898; external 
 ear, 288; narrow nostrils, 345; phleg- 
 mon and abscess, 858; rhinoplasty, 
 415; trephination, 195; cervical glan- 
 dular tumors, 884 
 
 Verneuil, on anchylosis, 768; concussion 
 of brain, 223; carbuncle, 898; erysip- 
 elas, 42; excision of lower jaw, 762; 
 malignant lymphoma, 883; ozjena, 
 390; oesophageal neoplasms, 998; 
 fibrous polypus, 366; ranula, 731; 
 retro-pharyngeal abscess, 714; rhino- 
 plasty, 416; tonsillitis, 693; cej-vical 
 glandular tumors, 884 
 
 Vertebra, cervical, luxation of, 1144; 
 fracture of, 1150 
 
 Vesalius, on pathology, 23 
 
 Vesication, 47 
 
 Vessels of neck, 1096 
 
 Viborg, on parotidean fistttla, 552 
 
 Virchow, 24; on cancer, 140; inflam- 
 mation, 37; otha?matoma, 292; paroti- 
 tis, 513, 514; psammona, 219; orbital 
 tumors, 497 
 
 Vogel, on goitre, 839 
 
1180 
 
 INDEX. 
 
 Voillemier, on phlegmon and abscess, 
 
 8u!t 
 Volkniann, on excision of tongue, 638; 
 
 torticollis, 814 
 Von Amnion, on ankyloblepharon, 476; 
 
 on ectropion, 481; entropion, 487; 
 
 torticollis, 805 
 Yon Walter, on goitre, 840 
 Yulpian, 190 
 
 w 
 
 Wadsworth, on ectropit>n, 486 
 Wagner, on luxation of cervical verte- 
 bra, 1147 
 Walsham, on trephination, 198 
 Walther, palpebral deformities, 473 
 Warren, on staphylorraphy, *i73 
 Warts, in scalp, 91; in (esophagus, 991 
 Watson, on ozwna, 384, 387 
 Wattmann, on wounds of internal jugu- 
 lar vein, 1136 
 Waxham. on laryngotomv, 1084 
 Weber, Otto, on labial cancer, 603; la- 
 bial entropion, 555; inflammation, 16, 
 26; test for inflammation, 19; inaxil- 
 larv resection, 54-; maxilla superior, 
 537; parotidean tumors, 526; ulcer of 
 tongue, 620 
 Weinlechner, on laryngotomv, 1079 
 Weintrach, on occlusion of auditory 
 
 canal, 300 
 Weiss, on othsematoma, 291 
 Wegner, on extirpation of larynx, 1089 
 Wells, on entropion, 489 
 Whitehead, on excision of tongue, 636 
 Wilde's snare, 301 
 
 Wilm«, of Berlin, on anchylosis, 768; 
 tracheotomy, 1030 
 
 Winiwarter, on cervical glandular tu- 
 mors, 882 
 
 Wisdom teeth, ill placed, 736; treatment 
 738 
 
 Wiseman, on carbuncle, 898; on tonsil- 
 lotomy, 702 
 
 Witkowsky, on cerebral concussion, 226 
 
 Woakes, on hare-lip, 566 
 
 AViJlfler, on goitre, 839, 841; on excision 
 of tongue,'637 
 
 Wolzendorf, on wounds of oesophagus, 
 999 
 
 Worner, on labial cancer, 598; on goitre, 
 840 
 
 Wounds, of cheek and side of face, 504; 
 contusion, 65; of cranium, 172; in- 
 cised, of cranium, 157; of ear, 290; of 
 eyelids, 463; of thyroid gland, 850; 
 gunshot, general remarks, 72; wounds 
 of neck, 905; treatment, 915; of 
 oesophagus, 998; of palate, 649; of 
 pericranium, 147; of scalp and skull, 
 V'5; of scalp, 49, 147; of tongue, 64;!; 
 of jugular vein, 1132 
 
 Wut/.cr, on labial cancer, 601; lingual 
 prolapsus, 612; uranoplasty, 677 
 
 Zaufal, on ozwna, 384 
 
 Zauii', on ligation of primitive carotid, 
 
 1112 
 Zenker, on oesophageal neoplasms, 992 
 Ziemssen, on tracheal aspiration, 945; 
 extirpation of larynx, 1089; oesopha- 
 geal neoplasms, 994 
 Zimmerlin, on tracheotomy, 1032 
 Zuckerkandl, on tumors of neck, 866 
 

 
 
 
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