COLUMBIA LIBRARIES OFFSITE HFALTH SCIENCES STANDARD HX64053814 R D31 As3 1 920 Surgery, its pnncip EMi Ai3- Columbia (Bntoertfitp intljeCttpoflrtogork College of piPfiicians anb burgeons Htbrarp \* / Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgeryitsprinci1920ashh SURGERY ITS PRINCIPLES AND PRACTICE FOR STUDENTS AND PRACTITIONERS BY ASTLEY PASTfM COOPER ASHHURST, A.B., M.D., F.A.C.S. ASSOCIATE IN SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE EPISCOPAL HOSPITAL AND TO THE PHILADELPHIA ORTHOPAEDIC HOSPITAL AND INFIRMARY FOR NERVOUS DISEASES; COLONEL, MEDICAL RESERVE CORPS, U. S. ARMY SECOND EDITION, THOROUGHLY REVISED WITH 14 COLORED PLATES AND 1 129 ILLUSTRATIONS IN THE TEXT MOSTLY ORIGINAL LEA & FEBIGER PHILADELPHIA AND NEW YORK 1920 Copyright LEA & FEBIGER 1920 ^3 cr. TO RICHARD H. HARTE A SURGEON OF WIDE CLINICAL EXPERIENCE AN ABLE TEACHER A WISE CONSULTANT A SAFE AND SKILFUL OPERATOR THIS VOLUME IS GRATEFULLY DEDICATED BY HIS PUPIL, ASSISTANT AND FRIEND THE AUTHOR Copyright LEA & FEBIGER 1920 ^3/ ■^3 CT TO RICHARD H. HARTE A SURGEON OF WIDE CLINICAL EXPERIENCE AN ABLE TEACHER A WISE CONSULTANT A SAFE AND SKILFUL OPERATOR THIS VOLUME IS GRATEFULLY DEDICATED BY HIS PUPIL, ASSISTANT AND FRIEND THE AUTHOR PREFACE TO THE SECOND EDITION. Compliance with the request of the publishers for the preparation of a new edition of this work, which coincided with the return of the author from service with the American Expeditionary Forces, has been delayed by his retention for some months in the military service in this country, as well as by disturbances in the printing trade. A certain amount of new matter has been introduced, some sections have been entirely rewritten, and all portions of the volume have been thoroughly revised and so far as possible brought up-to-date. The growing importance of Reconstructive Surgery seemed to warrant assembling in one place paragraphs which in the first edition of the work were dispersed throughout the volume; these as well as new material derived from the writer's practice are presented as an entirely new chapter. The chapter on Gunshot Wounds has been entirely rewritten, as have also the sections in other chapters dealing with Shock, Infected Wounds, Infections of the Fingers and Hand, Meta- static Arthritis, Hydrocephalus, Carcinoma of the Tongue, Empyema, Typhoid Carriers and Surgery of the Pancreas. Seven new Colored Plates and over one hundred new illustrations have been inserted, some illustrations used in the first edition being superseded, and others being redrawn. The skillful services of Mr. Charles F. Bauer were again secured for this purpose. Most of the new skiagraphs from, the writer's services at the Episcopal and Orthopaedic Hospitals were made by Dr. Ralph S. Bromer; those from the W T alter Reed General Hospital were made by Major John H. Selby. The photographs illustrating the Carrel-Dakin method of wound treatment are from patients at the latter hospital under the care of Lieut.-Col. L. J. Owen and First Lieut. Barron Johns. It is to be regretted that these additions have added about sixty pages to the volume, in spite of continued efforts at conciseness of expression and omission of the unessential. Thanks are due the Publishers and the Printer for never-failing cooperation and aid in the revision, and to many of the author's (v) vi PREFACE TO THE SECOND EDITION friends for kindly criticisms and suggestions. All readers of the volume are again indebted to Dr. A. I). Whiting for the very excellent Index. In presenting this new edition of his work to the Surgeons and Students of Surgery of America, the writer cannot forbear expressing his gratitude for the cordial reception accorded to the volume every- where on its first appearance. lie ventures to hope that in its present form it may continue to meet with the approbation of his colleagues. A. P. C. A. 1629 Spruce Street, Philadelphia, 1920. PREFACE TO THE FIRST EDITION. It is the function of a work such as this to furnish the foundation on which a knowledge of Surgery is to be built. Didactic and clinical lectures, papers in current journals, classical monographs, and par- ticularly the student's clinical work and the surgeon's daily practice are valuable adjuncts, but unless the foundations have been laid broad and deep, no useful superstructure can be erected. A text-book should afford a true perspective, placing the various branches of study in their proper relative position, maintaining their just proportions, and providing a source of information which shall indicate where further knowledge is to be gained. A student seeks clear and accurate statements, and desires to have facts set definitely before him. If the present volume supplies these wants, if it helps the student to learn surgery and proves a useful reference work for the practitioner, it will have fulfilled its purpose. Every text-book, however, has its limitations. At best it can but teach the student to know; it cannot teach him to do. And though knowledge is power, much practical experience in laboratory, dis- pensary and hospital wards must supplement didactic instruction. In the present work emphasis is placed on the underlying principles, and pathogenesis, diagnosis, and indications for treatment have received particular attention. Descriptions of operations, however, have not been slighted. The more important operations have been described in detail, and in every case an attempt has been made to present clearly, if briefly, at least one method of operative procedure. The specialties of the Eye, the Ear, the Nose, and the Throat naturally are not included; and Genito-urinary Surgery, Gynecology, and Orthopedics have been discussed only so far as they come within the province of the general surgeon. Neither publishers nor author have spared any pains in the endeavor to furnish a text-book on Surgery which shall be acceptable to the profession. The illustrations, with very few exceptions, are entirely original, and are reproductions of photographs or sketches made by the writer in his various services, especially at the Episcopal Hospital of Philadelphia. To his long association with this Hospital he owes unsurpassed opportunities for clinical work; as well as to his associa- tion with the Orthopaedic Hospital, and to his former services at the (vii) viii PREFACE TO THE FIRST EDITION Pennsylvania, the Children's, and the German Hospitals. Most of the skiagraphs are derived from the Episcopal Hospital, and were made by Dr. Thomas S. Stewart or his assistant, Dr. A. R. Wilkinson. Those from the Orthopaedic Hospital were made by Dr. Wm. Van Korb. The illustrations of operative technique are based largely mi work done in the writer's Laboratory of Operative Surgery in the University of Pennsylvania. The credit for converting the author's diagrams and photographs into admirable illustrations is due to Mr. Charles F. Bauer. Much help has been derived from other text-books and systems of surgery. First and foremost among these must be mentioned the Principles and Practice of Surgery of John Ashhurst, Jr. The indebted- ness of the writer of the present work to that volume can be appre- ciated best by those who, like himself, acquired the basis of their surgical education from its pages. Every other source of information has been studiously sought; and, thanks to the facilities afforded by the Library of the College of Physicians of Philadelphia, this laborious task has been rendered comparatively easy. It w T as thought inadvis- able to cumber the text with bibliographical references, but the dates of publication of authoritative contributions, whether recent or of historical interest, have been indicated, and it is believed that by this means the original references may be more easily found in the Index Medicus or in the Index Catalogue of the Surgeon-General's Library, U. S. Army. The author is particularly indebted to the writings of Deaver on abdominal and prostatic surgery; and free citations have been made from the volumes published by this brilliant surgeon in collaboration with the writer. The text of the present volume has received the criticisms of several of the author's friends. Dr. Henry Winsor and Dr. Penn-Gaskell Skillern, Jr., have devoted themselves to this work most unselfishly, and have offered many valuable corrections and suggestions. -Dr. G. G. Davis and Dr. Frank D. Dickson have kindly reviewed the chapters on Orthopedic Surgery and on Diseases of the Joints. Dr. A. D. Whiting has assisted in reading the proof-sheets, and has made the index. A. P. C. A. 811 Spruce Street, Philadelphia, 1914. CONTENTS. GENERAL SURGERY CHAPTER I Inflammation 17 CHAPTER II Diseases Resulting from Inflammation 46 CHAPTER III Surgical Infections 74 CHAPTER IV Tumors 101 CHAPTER V Surgical Technique 135 CHAPTER VI Injuries and their Effects 159 CHAPTER VII Gunshot Wounds 190 CHAPTER VIII Amputations 212 CHAPTER IX Reconstructive Surgery 236 (ix) x CONTENTS SYSTEMIC SURGERY CHAPTER X Surgery of the Blood-vascular System 259 CHAPTER XI Surgery of the Skin, Burs^e, Lymphatics, Muscles, Tendons, and Nerves 290 CHAPTER XII Fractures 327 CHAPTER XIII Injuries of Joints 421 CHAPTER XIV Diseases of Bone 454 CHAPTER XV Diseases of Joints 492 CHAPTER XVI Orthopedic Surgery 546 REGIONAL SURGERY CHAPTER XVII Surgery of the Head 595 CHAPTER XVIII Surgery of the Spine 637 CHAPTER XIX Surgery of the Face, Mouth, and Neck 666 CHAPTER XX Surgery of the Breast, Chest Wall, Lungs, and Diaphragm . . . 748 CONTENTS xi CHAPTER XXI Hernia 805 CHAPTER XXII Abdominal Surgery in General, and Injuries of the Abdominal Viscera 853 CHAPTER XXIII Surgery of the Gastro-intestinal Tract 900 CHAPTER XXIV Surgery of the Gall-bladder, Liver, Pancreas, and Spleen . . . 974 CHAPTER XXV Surgery of the Bladder and Kidneys 1013 CHAPTER XXVI Venereal Diseases 1044 CHAPTER XXVII Surgery of the Urethra and Prostate 1070 CHAPTER XXVIII Surgery of the Male Genital Organs 1099 CHAPTER XXIX Surgery of the Female Genitals 1121 SURGERY: ITS PRINCIPLES AND PRACTICE. The word Surgery (old English Chirurgery) is derived from two Greek words, %tlp and epfov, signifying respectively hand and work; as distinguished from the work of the physician, surgery was there- fore formerly confined to such mechanical procedures as were carried out by the surgeon under the direction of the physician. Such was the position of the surgeon in the middle ages; but, since the time of Ambroise Pare (1509-1590), who is thus justly styled the Father of Modern Surgery, the Science and Art of Surgery have advanced step by step toward such a point of perfection as long since to have entitled them to equal rank with Medicine. And though the highest func- tions of surgery still remain mechanical in nature, it is no longer the physician who plans and directs the mechanical treatment, but the surgeon himself who selects the patient, devises the operation, and determines at what stage of the malady surgical measures shall be employed. Underlying all disease, and therefore necessary to an understand- ing of disease processes, surgeons encounter a pathological state which constitutes the process by which the bodily tissues react to injury. If the injury be very severe, immediate death of the part may ensue; and there will then be, in that part, no reaction to the injury. At the very outset of the study of surgery, it is proper to discuss at some length the reaction which takes place when the tissues are injured, because only when the underlying principles of disease and injury have been thoroughly mastered, can it be hoped to study with profit the special affections which subsequently will be discussed. CHAPTER I. INFLAMMATION. The process by which the tissues react to an irritant is known as Inflammation. The student must therefore learn what are the usual irritants which produce these changes; he must study the changes themselves, and their results; he must familiarize himself with the 2 (17) IS INFLAMMATION subjective and objective symptoms due to these tissue changes; and he must finally learn how to relieve the patient of his suffering. It therefore becomes necessary to discuss the causes, the pathology, the symptoms, and the treatment of inflammation. Causes. — The predisposing causes of inflammation are those which render the patient especially liable to the action of irritants, which are the exciting causes. Any constitutional state, therefore, which lowers the resistance to disease or injury will act as a predisposing cause. Age, especially the extremes of life, influences the develop- ment of inflammation in this way. Occupation and habits also have an undoubted influence, by undermining or by strengthening the con- stitution. Past or present diseases may very seriously modify the patient's resistance to the exciting causes of inflammation. In general it may be admitted that the exciting or determining causes of inflammation are either mechanical or chemical, using these terms in their broadest sense, and including in the latter all causes (thermal, electrical, radio-active, infective) which are not distinctly mechanical in their action. But while it is expedient to acknowl- edge that the process of repair which occurs after such mechanical injuries as contusions, fractures, aseptic wounds, and the- like is in very fact an inflammatory process, it is nevertheless proper to recog- nize the fact that the vast majority of inflammatory affections are directly due to chemical irritants produced in the tissues by micro- organisms, especially bacteria. Indeed, it is seldom susceptible of satisfactory proof that bacteria are entirely absent in the class of injuries first mentioned; for it is probable that all patients, and even persons in good health, have somewhere in their system certain bacteria which, being carried by the blood or lymph currents, eventually will reach the region of damaged tissue, and will there be enabled to prosecute their nefarious work to better advantage than where there exists no locus minoris resistentiw. Foreign bodies were cited formerly as examples of purely mechani- cal causes of inflammation; but unless it can be proved that the foreign body is aseptic, and that the part of the body where it lodges (eye, skin) is also free from bacteria, it is proper to assume even in such cases that the resulting inflammatory reaction, if noticeable, is due as much to bacteria as to the presence of a foreign body. Indeed, we know that many sterile foreign bodies (ligatures, sutures) constantly remain in the tissues after aseptic operations, and are productive of no manifest inflammatory reaction. Likewise calculi, formed in the internal organs, if sterile themselves, may be productive of only trivial discomfort until bacterial infection occurs in their containing viscus. The bacteria which surgeons most frequently encounter as causes of inflammation are the Micrococcus pyogenes (Staphylococcus) ; Strepto- coccus pyogenes; Bacillus coli communis; Gonococcus; Bacillus pyo- eyaneus; Pneumococcus; Bacillus typhosus; Bacillus tuberculosis; Bacillus tetani; Bacillus mallei; Bacillus anthracis; Bacillus aerogenes PATHOLOGY 19 capsulatus, etc. These microorganisms are known as Pathogenic Bacteria, because they are themselves the causes of disease; they take up their abode and thrive in living tissues, which they use as pabulum. They are to be distinguished from Saprophytic Bacteria, which exist only in dead tissues; these can be regarded as causes of disease only in a more or less indirect manner, because it is necessary that other agents, chiefly the pathogenic bacteria, shall have previously brought about the death of the tissues. In addition to bacteria, certain other forms of microorganismal life must be recognized as occasional causes of the inflammatory process in man. Among these are certain animal parasites, certain Yeasts, or Blastomycetes, and certain Moulds, or Hyphomycetes. Among the more important of the latter may be mentioned Oidium Albicans, which causes Thrush; the various forms of fungi, which cause the skin lesions of favus, tinea, etc.; and the Ray Fungus, which causes Actinomycosis. The chemical substances produced by pathogenic bacteria, as a result of their action upon the tissues, are described by the general name toxins (Roux and Yersin, 1888); endo-toxins are those substances formed in the bodies of dead or dying bacteria. Both toxins and endo-toxins act as chemical irritants, and it is these products of bacteria, and not the bacteria themselves, which are regarded as causes of inflammation. The products of pathogenic bacteria are albuminoid in nature; those elaborated by saprophytic bacteria are alkaloidal, and go by the general name ptomains. The action of 'thermal, electrical, and radio-active agents as causes of inflammation will be discussed under separate sections in other portions of this vokime. Pathology. — The pathology of the inflammatory process is the same in kind, though varying somewhat in its characteristics, according to the irritant cause, and to the particular tissue affected. Certain bacteria produce a reaction so peculiarly characteristic that surgeons have dignified the resulting processes by erecting them into diseases to which special names are applied. Such are Tuberculosis, Syphilis, Anthrax, Glanders, and other affections which are grouped together as the Infectious Granulomas. These diseases therefore are described in a separate chapter (Chapter III); in the present chapter will be described only those changes which are usually understood when the term inflammation is used. Even among the bacteria which cause the changes universally recognized as inflammation, the form of reaction varies considerably, so that it is sometimes possible to assert without microscopical or bacteriological examination that the inflam- mation is due to one variety of bacteria, not to another. It is also sometimes possible for the experienced observer to assert that the same variety of microorganism is the cause of quite divergent types of inflammation in different organs or tissues of the body. If one were to watch under the microscope the changes which occur in a part on which an irritant is acting, he would obtain a very accurate 1M) INFLAMMATION idea of the process of inflammation. This may be done in the patho- logical laboratory; but great experience is required properly to inter- pret what is seen; and for practical purposes it is better to study, at leisure, a series of illustrations of an inflamed area, made at various stages of the process. Studying first the vascular tissues, it is noted that the capillaries dilate, those which before were too small to allow the entrance of the cellular elements of the blood now increase in diameter, and it is even possible that new vascular channels may be formed. More blood comes to the part, more blood passes through it, and more blood leaves it, than in the normal state. This change is spoken of as active hyperemia {determination, fluxion of blood), to distinguish it from passive hyperemia or congestion; in this latter state, although there is more blood actually in the part than in the normal state, yet the blood is more or less stagnated in the part, and does not leave it, owing to ffHf Fig. 1 . — Subcutaneous tissue some distance above dead part in a case of spreading gangrene. Note stasis, margination, and migration. Three veins packed with leuko- cytes (I), which are escaping freely. Around the artery (below) there are none. Out- side the vessels many larger cells are seen. X 200. (Green.) venous obstruction, which is the prime cause of the congestion. In inflammation, although no cause of venous obstruction exists, the active hyperemia above described soon undergoes a change, so that the picture more nearly resembles that seen in congestion. The blood moves more slowly through the vessels, the blood cells, espe- cially the leukocytes, tend to cling to the vessel walls (margination), and eventually some of the leukocytes escape through spaces between the endothelial cells lining the capillaries by a process known as m igra- tion (J. F. Cohnheim, 1867). In some cases of severe inflammation PATHOLOGY 21 the erythrocytes may he forced out of the vessels as well (diapedesis). In the case of the leukocytes, however, the process is active (migration), and is not a mere matter of filtration by the vis a tergo. It is held by some that the erythrocytes escape from the vessels in the wake of the leukocytes, being sucked out by the currents produced in the blood-plasma by the migration of the white blood cells. In the process of migration of the leukocytes, first a portion of the cytoplasm, projected as a pseudopod, emerges through the vascular wall; then more of the cell body follows; and finally the portion still remaining within the bloodvessel flows out into that portion which has already migrated. It has been noted by Councilman that the portion of the cell to migrate first always contains the nucleus; and it has been suggested by Adami and others that there exists some relationship between "the labile, broken-up character" of the nucleus of polymorphonuclear leukocytes (perhaps karyokinetic figures) and their function of migration through the vessel walls. It is further evident that some of the plasma of the blood has escaped from the vascular channels and is infiltrating the perivas- cular connective tissue; for the connective tissue cells may be seen to swell up and become engorged with foreign fluid. This fluid exudate, however, is not unaltered blood-plasma; it contains a higher per- centage of proteids, and its specific gravity is higher; it also coagu- lates more quickly. Moreover, as will be pointed out presently, it is extremely rich in bactericidal and antitoxic substances. The increase of serum in an inflamed part is frequently very apparent macroscopically when incisions are made to relieve tension, especially in the loose subcutaneous tissues; and when inflammation occurs on free surfaces, as the peritoneum or the mucous membranes, or just beneath the cuticle, as in blisters, the outpouring of this fluid exudate is very evident. Its quantity and quality are also influenced by the variety of bacteria present. Looking a little later at the inflamed area, the first thing to be noted is that there has accumulated in the perivascular tissues an immense aggregation of small round cells. These cells accumulate in response to an influence of chemical nature exerted upon them by the bacteria or other irritant; this influence is known as ehemotactie action (Pfeft'er, 1888 1 ), and because the cells are drawn toward the acting body, we speak of it as positive chemotaxis, in contradistinction to negative chemotaxis, which term is used to describe the repelling action of certain cells or microorganisms. The endothelial cells lining the bloodvessel walls, under the influence of the positive ehemotactie action of the irritant, may be seen to swell up and bulge into the lumen of the vessels. In this manner they seem to become possessed of agglu- tinative characteristics, which aid in slowing the blood stream and in producing the margination of the leukocytes already described. 1 According to the late Prof. Ashhurst, the germ of the idea of chemotaxis is to be found in the writings of Haller. 22 INFLAMMATION It is not impossible that, by their change of form, these endothelial cells may render the vessel walls more readily permeable to the leukocytes. The origin of this vast aggregation of round cells next engages our attention. By reference to our previous study of the changes in the vascular tissues, it is quite evident that large numbers of the round cells found in the inflamed tissues have been derived from the leukocytes of the blood by migration. But even in tissues without bloodvessels, such as the cornea, a similar aggregation of cells occurs in inflammation; so that it is manifest that much of the round-cell infiltration is derived from other sources than the bloodvessels. These other sources are the lymph cells, which exist in the perivas- cular tissues within the lymph spaces and lymph capillaries; and the fixed connective tissue cells, which as the result of a retrograde metamorphosis come again to resemble the less highly developed lymphocytes (Strieker, 1881). Strieker also believed that the inter- cellular connective tissues could, under the influence of the inflam- matory process, revert again to the embryonal cells from which they were first derived. Whether Strieker's views should be accepted or not, is still perhaps open to discussion; but pathologists think it much more certain at present that a large proportion of the round-cell aggre- gation is derived from the endothelial cells lining the lymph spaces of the perivascular tissues. Indeed, according to some modern his- tologists there are no such structures as those formerly described as the fixed connective-tissue cells; for they hold that the only cells found in the tissues, besides the lymphocytes and the wandering leuko- cytes, are these very endothelial cells, and that the spaces (hypothetical or real) between them are to be regarded as lymph channels. In regard to the origin of the lymphocytes, Warthin (1906) follows Ribbert in teaching that they are in great part derived from rudi- mentary lymph nodes scattered through the tissues. The great number of cells which infiltrate the tissues at this stage of the inflammatory process, must not be regarded as a mere aggre- gation of previously existing cells. It is probable that all the cells multiply by continual division and subdivision under the stimulus of inflammation, and that the number of cells in the part is thus actually as well as relatively increased. This fact is evident from the mitoses which may be seen in an inflamed area under the microscope. Thus it is that we find three main types of cells composing this cellular infiltrate: (1) the emigrated leukocytes, which are chiefly poly- morphonuclear neutrophiles ; in the early stages of inflammation there may be a relative increase of eosinophile cells; (2) the lymphocytes, which seldom accumulate in great numbers until the inflammation has existed for some days; and (3) cells derived from the fixed con- nective tissue cells or from the endothelial cells, or from both. These last named cells are conveniently classified by Adami as fibroblasts and polyblasts, the latter term, first employed by Maximow, being intended to signify that they are immature types of various kinds of PATHOLOGY 23 fully formed cells; while the name fibroblast is still used to describe that form of immature connective-tissue cell on which the subsequent process of repair chiefly depends. When we come next to inquire into the object of this round-cell infiltration, we learn by observation that a veritable warfare is going on between the bacteria and these cells. We observe, for instance, that many of the cells (leukocytes and endothelial cells in particular) have, as it were, swallowed some of the bacteria; for we see such cells with one, two, three, or more bacteria in their interior. We may infer that some of the bacteria are being killed, both from the gradual diminution in their total number, as well as because the indi- vidual bacteria no longer stain so w r ell as at first; and we also per- ceive that many of the body cells succumb, because their nuclei swell up, their protoplasm becomes cloudy, they fail to stain, and finally disintegrate and disappear, while the triumphant bacteria attack other cells. This process, by which the cells devour the bacteria, is known as phagocytosis (Metchnikoff, 1893), and the cells wdiich thus act are called phagocytes. Moreover, in addition to the defence thus provided by the cellular elements called into action by the irritants causing inflammation, there exist in the body fluids certain substances (anti-bodies) which act as very important aids in the defence. In the normal blood- plasma exist certain chemical substances termed opsonins (Wright and Douglas, 1903), because they act as caterers for the phagocytes, by preparing the bacteria for destruction. Thus it has been found that though white blood cells are active phagocytes while still sur- rounded by blood plasma, they are absolutely indifferent to bacteria if deprived of plasma. In the fluid exudate which is produced during the inflammatory process there are also chemical substances, known as bacteriolysins (Nuttall, 1888), which are extremely destructive to these causes of inflammation; these bacteriolysins are classified as alexins (Buchner, 1890), which destroy the bacteria, and antitoxins (Behring, 1890), which neutralize the bacterial toxins. It is probable that they are both produced by disintegration of leukocytes. These inflammatory exudates have a specific gravity of 1018 or higher, and contain at least 4 per cent, of albumin; they may be distinguished thus from exudates due to venous stasis, and from those caused by hydremic conditions, the fluid in the latter instances having a much lower specific gravity, and containing less albumin. The process of inflammation, as thus far described, comprises clinically what has been termed the first stage of inflammation, or the stage of temporary hypertrophy. If at this stage of the process the invading microbes are vanquished, the parts return to their normal condition (resolution) without passing through the subsequent stages of inflammation. If, on the other hand, the strife is prolonged, the fluid exudate and the cellular infiltrate increase in quantity, and the product of the second stage of inflammation, known as inflammatory lymph, is formed (lymphization, lymphogenesis.) 24 INFLAMMATION Inflammatory lymph (Hunter, 1794) is a semi-solid, gelatinous substance, grayish white or slightly yellowish in tint. Though found at least for a short time in every ease of inflammation which extends beyond the first stage, it is best observed in peritoneal infections, and in iritis, in both of which instances the inflammatory exudate occurs on a free surface. The false membrane of diphtheritic inflam- mation is another instance of lymph formation. Lymph owes its semi-solid, plastic character to the fibrin it contains. The cellular elements are not usually very numerous in the early stages of its formation, when the exudate is still "serous," but as the quantity of cells increases, fibrin ferment is formed by the destruction of some of their number, and this fibrin ferment acting upon the fibrinogen and certain calcium salts already present in the exudate, eventually forms fibrin. Certain infectious agents call forth an abundant exudation of inflammatory lymph; while others are characterized rather by the excessive round-cell infiltration produced. For example, peritonitis due to the typhoid bacillus is characterized by profuse serous exudate; when caused by the streptococcus, or the colon bacullus, the exudate contains a much larger proportion of cellular elements, and therefore more closely resembles typical inflammatory lymph. Moreover, fluid exudation is more abundant on surfaces, and in the loosely built cellular tissues, than in denser structures such as bone. Lymph serves a useful purpose in more ways than one, for not only does it enmesh the microorganisms and thus prevent their diffusion in the tissues, but it also actively destroys them and their products by means of the bacteriolysins already described. It also prevents absorption of the microorganisms by protecting denuded endothelial surfaces. It is, therefore, to be regarded as a valuable defence of the body against infection, and not as a noxious product to be removed by the surgeon. Lymph may be absorbed, may become organized, may become converted into pus, or may undergo other forms of degeneration (caseous, calcareous, etc.). If the lymph is absorbed, its cellular elements pass away again into the neighboring blood and lymph streams, or remain as fibroblasts to produce new connective tissue in the area of inflammation. Where the process of inflammation is attended by coincident productive and absorptive changes, in approxi- mately equal degree, the condition is described as interstitial absorp- tion. This condition is seen particularly in some forms of osteitis. In the process of organization, which will be described more particu- larly in the section on Repair (p. 29), these fibroblasts pass through various stages until adult connective tissue is formed. It is very unusual, however, for complete regeneration (restitutio ad integrum) to take place; almost ahvays some of the cells remain in an immature state, while others are converted into scar tissue. In certain specialized forms of inflammation, lymph undergoes various forms of degeneration, as the caseous or calcareous, in tuberculosis; but in all cases in which PATHOLOGY 25 the inflammatory process continues, lymph is eventually converted into pus (suppuration, pyogenesis). Pus may be defined as the product of the third stage of inflamma- tion. By giving a broad definition such as this, we are permitted, Fig. 2. — Miliary abscess in a case of septic embolism of the kidney: a, leukocytes advancing toward and surrounding b, a mass of cocci, in whose neighborhood all trace of a structure has disappeared; c, renal epithelium too damaged by bacterial products to take the stain; d, kidney tissue staining normally; e, vein from which leukocytes are making their way to the commencing abscess. X 100. (Green.) as is pathologically proper, to include under the term pus, not only the healthy, laudable pus which the older surgeons were so delighted to behold, as an expression of adequate reaction on the part of the patient's tissues; but we may also embrace, under the term pus, the L'li i\i'L.\\tu.\rio\ products of tuberculous, syphilitic, and similar processes which, as Adami points out, "are identical with the tissue dissolution that occurs in acute abscess." Pus, when examined under the microscope, is seen to be composed of cells and of granular detritus, more or less homogeneous in char- acter, floating in a fluid known as the Liquor Puris. Bacteria usually are present also. The cells are the leukocytes, lymphocytes, and con- nect ive tissue cells, which formerly constituted the round-cell infiltra- tion of the earlier stages of the inflammatory process; but which have been killed by the bacterial toxins, etc. The granular detritus consists of the remains of the cellular elements and intercellular substance of lymph, which have been disintegrated by the ferments (peptones, etc.) generated during the warfare between the bacteria and their toxins with the body cells and their bacteriolysins. The Liquor Puris is the slightly altered fluid exudate already described. In other words, pus has been produced from lymph by a species of liquefaction necrosis. If pus is completely circumscribed by the body tissues it consti- tutes an abscess. If it is formed on the surface of a part it is said to be constantly "discharged." If neither formed on a surface nor well circumscribed, but rather diffusely infiltrated among the body tissues, the pus is said to form a phlegmon; and the inflammation is said to be phlegmonous in type. In any case, there is a certain surrounding area where the strife between the body tissues and the invading micro- organisms still continues. This area, when surrounding an abscess, was formerly spoken of as a pyogenic membrane, because it was believed that pus was secreted in the same way as the secretion of a gland is produced. If the body tissues succeed in holding their own, and the invasion comes to a halt, then there is formed in the area surrounding the abscess what is known as granulation tissue; if, on the other hand, the body tissues continue to be destroyed by the bacteria and their toxins, then the process is described as ulceration, provided the change occurs on a free surface (as on the skin after burns, or in the intes- tines in typhoid fever, etc.). For although, from a pathological point of view, the process which occurs at the so-called pyogenic membrane of an abscess is identical with that which occurs on a free surface on which pus is being produced by ulceration, yet the latter term is never applied to the former process; we merely say that the abscess continues to increase in size. Pus which exists in the form of an abscess may perhaps be absorbed, under exceptional circumstances, if the amount of pus be very small. When this occurs, the granulation tissue extends into the puriform mass, the debris is taken up by phagocytes, and is gradually carried away in the blood and lymph channels. In other cases, where the amount of pus is small, and where the abscess is deeply situated, the pus may become encapsulated, by the deposition in the surrounding granulation tissue of lime salts, or even by the development of extremelv dense fibrous tissue. In such cases the contained pus SUPPURATION WITHOUT BACTERIA 27 gradually becomes sterile. In all cases, however, in which there is any appreciable amount of pus present, the pus tends to seek an exit for itself in the direction of least resistance. When the pus has once discharged itself, the former abscess cavity will gradually assume the character of an ulcerating, or rather of a granulating surface, and the process of repair will be the same in both instances — that of an evacuated abscess and that of an ulcer. Role of the Nervous System in Inflammation. — In the account of inflammation so far given, no mention has been made of any part played by the nervous system. This is so, because it plays only a very insignificant part in this process. Experiments have proved that even when the entire nervous supply of a part has been cut off, the phenomena of reaction to injury, as described above, occur without appreciable difference; from which fact it may be assumed either that the local vascular system is endowed with a nervous mechanism of its own (which does not appear to have been proved), or that the vascular changes seen in inflamed areas take place without the inter- position of nervous action. According to Warthin (1906), however, it has been demonstrated experimentally that removal of the vaso- constrictor influence accelerates, while removal of the vaso-dilator influence retards inflammatory reaction. Too little is known of the pseudo-inflammatory changes which occur in the various neuropathies for pathologists to speak with authority about them. It is certain, nevertheless, that under certain circumstances lesions of the nervous system may very greatly influence the course of inflammation, as seen in the case of bed-sores in spinal diseases, and in certain so-called trophic lesions. Extension of Inflammation. — -This occurs (1) by continuity, as when bronchitis extends into the pulmonary tissue, causing pneumonia; or when urethritis extends into the prostate, producing prostatitis; (2) by contiguity, as when pneumonic inflammation extends to the pleura, causing pleurisy; or when peritonitis developes from appendicitis; (3) by the lymphatics, as when a felon in the finger is followed by lymphangeitis and epitrochlear or axillary lymphadenitis; or (4) by the blood stream, as in certain of the exanthemata, and in metastatic inflammations. Terminations of Inflammation. — Inflammation may terminate in two ways: (1) by resolution, a gradual return of the part to health; (2) by death of the -patient. It is sometimes said that inflammation may terminate in the local death of the part affected ; but as the surrounding parts will still be the seat of the inflammatory process, or of repair, until either death or recovery terminates the disease, it is more logical to recognize this fact in our definition. The manifestations of the local death of a part {sloughing, mortification, gangrene) will be con- sidered in Chapter II. Suppuration without Bacteria. — In what has been said above, it is assumed that the suppuration described has been caused by bacteria; and in the immense majority of instances this is the case. But it should 28 l.XFLAMMATlo.X not be forgotton that other chemical forms of irritation, as well per- haps as certain mechanical irritants, may produce pus, if their action is sufficiently virulent or prolonged. Hypodermic injections of tur- pentine, mercury, croton oil, or other sterile substances, may cause all the usual phenomena of inflammation, and this may proceed so far that a fluid will be formed, which will be found to consist of the disintegrated products of tissue metabolism, and which will be indis- tinguishable from pus as described above, except for the facts that no bacteria will be present, and no phagocytosis will be evident. It is quite apparent, nevertheless, that, even in such cases, the round-cell infiltration, which succeeds to the early hyperemia and congestion, has been produced by chemotactic action on the part of the irritant, and that the accumulated cells and tissue fluids in the process of their reaction are converted into substances which if not technically bacteriolysins, are some other form of antibodies none the less useful for the defence of the organism. Nor should it be assumed, on the other hand, in every case in which inflammation is produced by bacteria, that the process necessarily will extend to the stage of suppuration. In very many cases in which bacteria are present, the reaction on the part of the body tissues is sufficient to repel or to conquer the foe before pus is formed; but it is much more usual for this happy termination of the process to occur when the causes of the inflammatory reaction are sterile. This is well seen in the usual course pursued by clean wounds. Fig. 3. — Staphylococci in pus. X 1000. (Frankel and Pfeiffer.) Fig. 4. — Streptococci in pus. X 1000. (Frankel and Pfeiffer.) Pyogenic Bacteria. — Certain microorganisms are habitually pyo genie; certain others produce pus only under special circumstances while a few varieties have never been known to cause suppuration It is, therefore, possible to classify pathogenic bacteria in the follow ing manner: (1) Microorganisms characteristically leading to pus aim abscess formation — Staphylococcus, Streptococcus pyogenes, Bacillus REPAIR 29 anthracis. Of these, the varieties of the staphylococcus denoted by the suffixes aureus, albus, and citreus, and generically included under the term Micrococcus pyogenes, are those which are especially asso- ciated with acute, well-localized abscesses; they are found in felons, furuncles, carbuncles, acne, some cases of empyema, and certain forms of periosteitis, osteomyelitis, etc. The streptococcus, on the other hand, is associated with spreading infections, such as diffuse cellulitis, erysipelas, lymphangeitis; certain forms of osteomyelitis, peritonitis, etc. The Bacillus anthracis is the cause of a specific disease, which will be described in Chapter III. (2) Those causing suppuration only under exceptional circumstances — Pneumococcus, Bacillus typhosus, Bacillus coli communis, Bacillus pyocyaneus, Gonococcus, Bacillus tuberculosis, etc. (3) Those which are never known to cause the formation of pus — as Bacillus tetani. Pathological Summary. — The first action of an irritant when intro- duced into the tissues is chemotactic in nature; this influence extends, without the aid of the nervous system, to the endothelial and other connective tissue cells lying in the perivascular tissues; it also extends to the cells of the vascular endothelium, and even to the white cells of the circulating blood. The effect of this positive chemotaxis is to slow the blood current and to cause the endothelial cells of the blood- vessels to acquire agglutinative properties. As a result, hyperemia, and later congestion is produced; margination, followed by migration of leukocytes, occurs; exceptionally diapedesis of the red blood cells also is present. Round-cell infiltration is produced in this way, as well as by the multiplication of those cells already present in the inflamed part. This constitutes the first stage of inflammation, that of Temporary Hypertrophy. The warring hosts have been assembled and the battle between the invading microorganisms and the phago- cytes is next begun; the fluid exudate aids the cells in the fight by means of its bacteriolysins. Lymph is thus produced, constituting the second stage of inflammation. Owing to the progressive destruc- tion of leukocytes and other cells, ferments are produced, which liquefy the lymph, converting it into pus; thus by pyogenesis, the third and last stage of inflammation is reached. In the surrounding tissues progressive destruction (ulceration) continues, or gradual repair (granulation) terminates the process. Repair. — It has been pointed out (p. 28) that the inflammatory process may be terminated at any stage of its course as a result of the defensive powers of the organism overcoming the invasion of the irritant which was the primary cause of the inflammation. Speaking generally, we may recognize three more or less distinct ways in which repair occurs, corresponding to the three stages of inflammation described. 1. If the process of inflammation is arrested during the stage of temporary hypertrophy, before any exudate has been formed, the migrated leukocytes and other phagocytes, having destroyed the bac- teria, and being no longer attracted by the chemotactic influence of 30 INFLAMMATION the invaders, resume their normal functions and return to their usual spheres; the white blood cells re-enter the capillaries, the lymph cells swim away in the lymph stream, and the site of former inflammation can no longer be distinguished from the surrounding tissues; it is said to have undergone regeneration, complete repair, restitutio ad integrum. 2. If the process of inflammation is arrested during the stage of lymph formation, complete regeneration cannot take place, because the tissues are not capable of removing completely the results of the warfare between the irritant and themselves. Some of the cellular elements may pass away again in the blood and lymph streams, but almost without exception a goodly number will remain in the pre- Fig. 5. — Fibroblasts and granulation tissue. Section of a cutaneous granulation: v v', new-formed capillaries sprouting from depth of granulation and accompanied by connective tissue cells (c) and leukocytes (I). A layer of fibrin (/) covers the surface of the granulation. Between the superficial layers of the fibrin are seen large connec- tive tissue cells (d') springing from the granulation (d). X 300. (Cornil and Ranvier.) viously inflamed part, will become converted into fibroblasts, and eventually will form scar-tissue. It does not seem to be certainly known whether leukocytes can become converted into fibroblasts; but there is no doubt that most of the fibroblasts are produced from endothelial or fixed connective tissue cells. Fibroblasts are elongated, caudate, or spindle-shaped cells, occasionally stellate in form. The area of inflammatory exudation becomes vascularized by the out-growth of capillaries from the surrounding bloodvessels. These new capillaries grow as solid sprouts; and these solid processes, grow- ing out into the exudate of inflammatory lymph, either meet other similar out-growths, or become attached to a neighboring capillary, SYMPTOMS 31 thus forming more or less distinct loops; these loops subsequently become hollowed out, and the channels so formed are filled by blood from the surrounding capillaries. As the process of repair goes on, the fibroblasts become more and more fibrous in character "until the cell is represented by a meagre, attenuated nucleus, with but a trace of cytoplasm, lying surrounded by fibrils — white connective tissue.'' (Adami.) The conversion of the fibroblasts into white connective tissue and the invasion of the inflammatory exudate by the capillary loops go on hand in hand; the tissue thus formed is known as granu- lation tissue; and when the process occurs on a free surface the capil- lary loops form the so-called granulations. The granulation tissue is at first highly vascular and red; as the more fully developed scar- tissue is formed, granulation is succeeded by cicatrization, and the capillaries are squeezed out of existence as the process of contraction in the scar-tissue continues. Thus a scar which at first is red and angry in appearance, eventually may become white, glistening, and depressed below the surrounding tissues. The area of previous inflam- mation, which during the height of the inflammatory process was swollen and tense, thus finally comes to occupy less space than in health. 3. If the process of inflammation has progressed to the stage of suppuration, then in almost all cases it is necessary for the pus to be discharged by the rupture of the abscess before rapair can occur. It is extremely unusual for pus to be absorbed or for scar-tissue to be formed unless the abscess has first been converted into an ulcer. Repair in this instance, therefore, is best studied as it occurs on a free surface, and is the same as that which occurs in the healing of an ulcer (p. 52). Symptoms. — The symptoms of inflammation are local and general (or constitutional). Among the latter are the usual signs of fever, attended frequently by quickening of the pulse and respiration rate; headache, flushing of the face, brightening or injection of the eyes, and perhaps delirium at night; anorexia, with furred tongue, and sometimes nausea; dry, hot skin; thirst; usually the bowels are constipated, and the urine high colored and lessened in quantity. Under constitutional symptoms it may also be proper to include leukocytosis, an increase in the number of leukocytes present in the circulating blood. This leukocytosis is present in almost all acute inflammations; it is called forth by the chemotactic powers of the irritant, whose diffusible toxins, when they obtain admission to the circulating blood, are carried to the bone marrow and other portions of the body whence leukocytes are derived, and thus stimulate the production of leukocytes. In a few diseases, not usually classified as inflammations, the influence of negative chemotaxis is manifested in the diminution of the number of circulating leukocytes (hypo- leukocytosis, leukopenia). Among such diseases typhoid fever and tuberculosis are the most important. What were formerly called critical discharges may occur either at the approach of convalescence, 32 INFLAMMATION or upon an unfavorable change in the patient's general condition. These discharges are described as diarrhea, diuresis, profuse sweating, and sometimes hemorrhages from the mucous membranes. Their significance, as well as the probable causes and the pathology of inflammatory fever, will be considered in Chapter II (p. 69). When the inflammation is slight, constitutional symptoms may be trivial or entirely absent; when occurring in robust, healthy individuals, the sthenic type of fever is seen; when in the weak and debilitated, or, when the inflammation is overwhelming, even in the strong, a typhoid (asthenic, adynamic) type of fever will result. The local symptoms of inflammation have been described from the time of Celsus under the terms (1) Rubor, or redness; (2) Tumor, or swelling; (3) Color, or heat; and (4) Dolor, or pain; while to these classical symptoms has been added that of (5) Functio Lasa (modifi- cation of function); and again a sixth symptom (6) Modification of nutrition. One or more of these local symptoms may be present without the disease constituting inflammation; it may be impossible to elicit evidences of one or more of these symptoms, even when inflammation is present. Friction of the skin may produce a temporary hyperemia, accompanied by redness and heat, without true inflammation being present; the erectile tissues furnish another example where the pres- ence of one or two symptoms alone is not sufficient to qualify the affection as inflammation. On the other hand, it will be impossible in many deep-seated inflammations (meningitis, pleurisy, etc.) to detect redness, and sometimes impossible to demonstrate swelling, even though no doubt can exist that inflammation is actually present. Some of these local symptoms are more manifest in certain tissues, organs or localities, than in others. Thus conjunctivitis, periosteitis, orchitis, are especially painful; cellulitis is preeminently characterized by swelling; alteration of function is more evident the more highly specialized the tissue or organ affected (compare iritis with tonsillitis; neuritis with dermatitis, etc.); while in the cornea and in cartilage alterations of nutrition may be the only demonstrable change. Redness is nearly universally present in superficial inflammations. It is primarily due to the hyperemia and congestion of the inflamed part. Early in the course of the disease the redness is bright, flaming, intense, as in erysipelas; later it may become bluish or almost purple, as suppuration or gangrene impends. It is not sharply outlined in ordinary forms of inflammation, but blends away in the surrounding tissues so that it is often impossible to define its exact limits. The redness due to inflammation disappears when the finger is pressed upon the inflamed spot. The rapidity with which the redness returns after the removal of pressure gives a fair idea of the activity of the circulation; if suppuration or gangrene is threatening the circulation is sluggish. It should not be forgotten that a sluggish circulation may be due to organic disease of the heart, and that this will modify the local manifestations of inflammation even in an early stage, SYMPTOMS 33 Swelling is due to the hyperemia, to the round-cell infiltrate, and to the fluid exudate characteristic of inflammation. Thus tissues where exudation is profuse (eyelid, scrotum, and subcutaneous tissues generally) show more alteration of form than do such structures as bone or cartilage. Blebs frequently form in the skin as the result of effusion of serum beneath the epidermis; this is seen especially in burns and severe contusions, such as those accompanying fractures or dis- locations. Swelling is beneficial in so far as it tends to deplete the overloaded capillaries; it may be harmful by its tendency eventually to block the circulation and thus favor sloughing or gangrene. It may endanger life by occluding mucous channels — such as the glottis, the bile ducts, the appendix; or by compressing the urethra when the swelling occurs in the perineum. The swelling of the early stages of inflammation is tense, and rather elastic to the touch; later it becomes dense and brawny if due to exudate which is coagulable, or edematous and soft if due to non-coagulable effusion. When an inflamed area begins to "pit on pressure," it is often indicative of the presence of pus. Heat in an inflamed part usually is appreciable to the hand, when compared with a neighboring or similar part of the patient's body which is not inflamed. In arthritis the affected joint feels hot, while the corresponding joint does not. Local heat is doubtless produced in large part by the numerous chemical reactions constantly occurring in the inflamed area. The toxins, bacteriolysins, ferments, etc., are all of them produced by forms of biochemical activity which thus far are little understood. The mere hyperemia of the part is not suffi- cient to account for the heat present. Yet the local temperature is rarely if ever higher than that of the circulating blood; but it is rela- tively higher than is that of surrounding parts, because there is more blood in the inflamed part, and especially near the surface of the inflamed part, than in surrounding non-inflamed parts; moreover the temperature of the circulating blood may be higher than normal (inflammatory fever), but its abnormal heat is derived from the local changes, not the local heat from a primary increase in the temperature of the blood. The local heat is greatest at the height of the inflam- mation; as the disease progresses the local temperature falls, and when suppuration occurs it is no longer above that of surrounding parts. In the case of gangrene, the temperature of the mortified part naturally becomes subnormal. Pain due to the inflammatory process is caused by tension, from cel- lular infiltration and fluid exudation, producing pressure on the terminal nerve fibers of the part. The pain is much less in tissues which admit of much swelling than in fibrous tissues (felon) or bone (periosteitis) ; and it may be relieved by allowing the escape of the effusion through incisions. Inflammation in a part devoid of sensory nerves is not attended by pain. Referred pain is to be explained on anatomical grounds, and is due either to pressure on a nerve trunk, causing pain in its terminal fibers (as in the case of pain in the knee due to pressure 3 34 INFLAMMATION on the obturator nerve at the hip); or to overstimulation of a nerve causing an overflow of painful sensations into neighboring nerves derived from the same spinal segment: thus gall-bladder disease may cause pain in the shoulder through the spinal nerves derived from the same segment as that from which the pneumogastric takes its origin; pain in the testicle follows disease of the kidney or ureter; inflam- mation of the neck of the bladder is accompanied by pain in the head of the penis; pleurisy may cause cutaneous hyperalgesia of the abdo- men. The pain felt in an inflamed part varies with the tissue affected : in the skin (insect bites, etc.) or mucous membranes (conjunctivitis, hemorrhoids, etc.) it is manifested as an itching or scalding sensation; in serous and synovial cavities it is felt as a lancinating or stabbing pain (peritonitis, pleurisy, synovitis); in fibrous tissues it is dull, aching, or boring (periosteitis, etc.). Pain usually is greatest during the height of inflammation; if the nervous structures are poisoned by toxins, the pain may be slight; sudden cessation of pain frequently is indicative of gangrene (appendicitis, strangulated hernia). At the approach of suppuration, the pain assumes a throbbing character; mortification is frequently announced by a burning pain. Tenderness on pressure is an important modification of the sensa- tion of pain, and may persist when pain has been lost through gan- grene of the inflamed part. Thus even when the spontaneous pain of appendicitis has ceased on the occurrence of gangrene, tenderness may still persist in the surrounding area of the peritoneum. If pain is present in a part without local tenderness, the pain is referred pain, and the seat of inflammation is elsewhere. I have never seen both pain and tenderness present locally in an uninflamed part, unless the tenderness was a mere cutaneous hyperalgesia. Mistaking the latter once for a sign of local disease, I removed a normal appendix vermi- formis from a youth who twenty-four hours later developed symptoms of pleuropneumonia. Muscular rigidity is due to voluntary or involuntary contraction of the muscles governing the movements of, or protecting an inflamed part. Involuntary contraction is due to the impulse being referred to motor instead of sensory nerves, as is the case in referred pain. Impaired junction is more noticeable the more highly developed the inflamed structures. It is an old maxim that in inflammation the first functional change is always in the direction of excess. Parts which possess normally very little sensation may become acutely painful; glandular structures produce an abundant, though disordered secre- tion; muscular structures contract irregularly and spasmodically, as in fractured limbs, and in inflammation of the hollow viscera (appendix, stomach, gall-bladder, urinary bladder, etc.). The special senses are even more affected: scintillations of light and photo- phobia attend inflammatory affections of the eye; tinnitus aurium is annoying in certain diseases of the ear; perversions of taste, of smell, etc., are common in affections of the tongue and nose. At a later stage of inflammation the function of a part, instead of being TREATMENT OF INFLAMMATION 35 stimulated, is depressed or altogether abolished: during the height of nephritis, the urine is suppressed, and when the secretion is restored its nature may be markedly and permanently altered. Modification of Nutrition. — The temporary hypertrophy seen in the earlier stages may never be recovered from ; scars may become keloids ; callus may never be absorbed entirely; bones, the seat of osteo- myelitis, may remain permanently thickened; lymph-edema may suc- ceed to cellulitis. Atrophy, on the contrary, may take the place of a return to the normal ; in coxalgia the head of the femur may disappear by interstitial absorption. Chronic Inflammation. — It is an arbitrary thing to classify inflam- mation as acute, subacute, and chronic. The former has been described; the latter is an inflammatory affection of long duration, and charac- terized by slight or moderate reaction. Subacute is a mean between the two. The error should not be made of classing with chronic inflam- mation certain results of previous inflammations, which consist essentially in the formation of scar tissue or diffuse fibrosis. It is better to speak of such changes as old inflammations; and to limit the term chronic inflammation to a process of reaction which is still going on, even if very sluggishly. For strictly speaking a chronic inflammation is merely one in which the irritant is weak, but con- tinues long in action; in which only a slight reaction is produced, and in which some factor prevents healing. This reaction is not wont to go beyond the stage of formation of granulation tissue. The attacking force and the repelling garrison are so equally matched that neither can well overcome the other; cell accumulation is marked, but phago- cytic power is slight; exudation is slight; tendency to suppuration is slight. Such inflammations are seen in the case of the infectious granulomas. When healing occurs, the scar-tissue formed is propor- tionate to the previous hyperplastic condition. The symptoms are similar, but less in degree, than those seen in acute inflammation. As might be expected from what is known of the pathology of chronic inflammations, swelling is the most char- acteristic symptom. Pain usually is moderate, but may be intense, especially in bones and joints. Redness is slight. Heat often cannot be detected. Treatment of Inflammation. — Prophylaxis. — The consideration of the treatment of inflammation involves first of all a study of the means of prevention. Inflammation, even when it has once com- menced, frequently may be aborted by the prompt removal of the cause. If the insult to the tissues be due to a foreign body, the removal of the foreign body will prevent the reaction which its prolonged pres- ence undoubtedly would provoke. The removal of a cinder from the eye may prevent the development of conjunctivitis; that of a splinter from^the finger may prevent the formation of a felon. Prompt extraction of shell fragments and pieces of clothing, from gunshot wounds, may prevent the occurrence of gas gangrene. In some diseases and in certain parts of the body, prompt excision or amputa- 36 INFLAMMATION tion of the diseased member will prevent the development of an inflam- mation which might prove fatal. Prompt amputation of a hopelessly mangled limb will prevent gangrene and subsequent infection; imme- diate removal of an inflamed appendix will abort the disease by removing its cause, before the inflammatory reaction has spread to the peritoneum. As bacteria are the most frequent causes of inflammation, this may be most surely guarded against by preventing the entrance of bacteria into wounds, or by removing them or killing them after their entrance has been effected. The condition of the tissues when infected by bacteria is known as Sepsis; Asepsis is the condition when no bac- teria are present; Antisepsis is a method by which bacteria are com- bated by certain chemicals termed Antiseptics. The constant use of antiseptics on living tissues is open to the objection that the tissues are injured as well as the bacteria; though it is true that usually the injury to the tissues is insignificant. When once bacteria have gained entrance to the tissues there are only two ways by which their destruc- tion can be effected; the first is by the natural reaction of the tissues which we call inflammation, and which may be assisted artificially by the use of sera or vaccines (p. 44), the other method is by the direct introduction of antiseptics into the open wound. It has been learned by long and costly experience that pathogenic bacteria are everywhere present in civilization, and that mere ordi- nary cleanliness will not suffice to exclude them. They are not present in the air, however, unless this be dust laden, in number sufficient to be harmful; they are carried from place to place only by actual contact of instruments, dressings, etc., on which they may have lodged. They may be killed by boiling, or by dry heat at a sufficiently high temperature; and the instruments, dressings, etc., thus sterilized will, therefore, be aseptic. But unless the surgeon's or the nurse's hands be also aseptic, the mere momentary contact of such hands, or of any other unsterilized thing, with the aseptic instruments or dressings, will at once be liable to contaminate them, and they will again become septic — to what degree no one can tell. Neither the hands of the surgeon nor the skin of the patient can be sterilized by boiling or by dry heat; but by thorough washing in soap and water, and by the use of certain chemicals, practically all the bacteria present on the surfaces so treated may be removed; and those still remaining may be rendered so inert that they will be incapable of exciting inflammation. As an additional precaution, sterile gloves of thin rubber should be worn. The introduction of the practice of asepsis and antisepsis in surgery dates from 1867, when Lister published his first observations on the antiseptic method of wound treatment; his practice was founded on and confirmed by the researches of Pasteur, concerning fermentation and putrefaction; and although the science of bacteriology may be said to date from the discovery of the Bacillus tuberculosis by Koch, in 1882, the great advances made in modern surgery undoubtedly owe LOCAL REMEDIAL TREATMENT 37 their existence to Lister's initiative. When no antiseptics were used, the healing of wounds was tedious in the extreme, and the inflammatory reaction practically always extended to the stage of pus formation. Since the introduction of the practice of asepsis and antisepsis, sur- geons have become accustomed to having their wounds heal with little or with no apparent inflammatory reaction. Oilier reported a mortality of 80 per cent, from excisions of the knee before adopting the antiseptic method; after adopting this method, his mortality fell to 14 per cent. 1 Asepsis is generally acknowledged to be better than antisepsis, whenever it is practicable. In operative wounds asepsis is usually possible; but when the wound is infected before it comes under the surgeon's care, it is usually safer to adopt antiseptic principles. Wounds and wound treatment are discussed in Chapter VI. Cure of Inflammation. — The remedial treatment of inflammation may be divided into the Local and the Constitutional. Under the former head are included such methods as Rest of the inflamed part; its Position; the use of Heat and Cold; Narcotics and Counter- irritants; Bleeding, Leeching, etc.; Incisions and Operations; Compres- sion; Active and Passive Congestion; Massage, etc. Under the latter will be considered Constitutional Rest; Diet; Drugs; and the curative use of vaccines and sera. Local Remedial Treatment. — Rest of the inflamed part is desirable to decrease the hyperemia and congestion, when these are excessive; to lessen the cellular infiltrate and the exudation; and to enable all the forces of nature to be exerted in overcoming the causes of disease, instead of expending their strength in unnecessary physiological pro- cesses which functional use of the part would entail. Rest in bed is indispensable in a great many inflammations of the head, trunk, and lower extremities. Rest may be procured by the use of splints, when these are sufficient, as in many fractures, wounds of the extremities, felons, etc.; by gypsum cases when rest for a longer period is desirable, as in inflammations of certain joints; by bandages, or strapping with adhesive plaster, as in fractures of the ribs, slight sprains, etc. Finally rest may be procured by position. Position is of importance, because neglect to elevate an inflamed part, and thus to prevent or lessen congestion, may markedly increase the pain; may favor the occurrence of suppuration or sloughing; or invite gangrene by interference with the natural circulation of the part. Carrying the hand in a sling; keeping the foot elevated on a stool; or even going to bed for a time, will each of them prove of benefit in special cases. 1 It is true that the late Prof. Ashhurst (1895), in a series of 84 excisions of the knee-joint, had a mortality of only 8.3 per cent., the series extending through both pre-antiseptic and antiseptic periods; yet it is to be noted that he uniformly used scrupulous cleanliness, and virtual antiseptics (turpentine, alcohol, potassium permanganate) even before adopting Lister's principles of wound treatment. 38 INFLAMMATION Cold is an invaluable agent in the treatment of inflammation in its early stages. It is anesthetic, benumbing the part and lessening pain; it constricts the bloodvessels, decreasing the hyperemia, and some- times preventing excessive effusion; and it is not impossible that it lessens the physiological activities of a part, thus promoting rest. It probably lessens peristalsis in cases of peritonitis. Its chief use, however, is in inflammations of traumatic origin — wounds of the soft ] tarts, sprains, etc. It may be applied either dry or moist. The use of moist cold is apt to macerate the skin; but for short periods of time moist cold is very useful, as well in open wounds as in the case of subcutaneous injuries. In crushes of the extremities it is often possible to prevent wide- spread sloughing by the use of irrigation. If more elaborate appli- ances are not at hand, a pitcher may be hung over the affected part and a strip of gauze arranged to act by syphonage (Fig. 127). Dry cold is most conveniently applied by means of the ice bag; in using this, care should be taken to see that a fold of dry lint or a dry towel is kept between the skin and the ice bag, as the condensation on the surface of the latter will soon render the skin wet, and may cause superficial sloughing. Or Petitgand's method of mediate irrigation may be employed: a coil of thin-walled rubber tubing, of convenient length, is wrapped around the limb, or applied to the head, the breast, etc., and is held in place by a few turns of a roller bandage; a stream of cold water is then allowed to trickle constantly through the tube, being collected beside the bed in a suitable receptacle. The tempera- ture to which the surface of the inflamed part has been reduced may be ascertained by testing the fluid as it runs off. Leiter's coils, which may be purchased ready made, are of flexible metal. Heat, like cold, constringes the vessels of an inflamed part, and though not actually anesthetic, may prove more grateful to the patient. In the form of a hot water bag, dry heat is a household remedy. Baking is a valuable remedy in chronic inflammation. Moist heat is more often employed in acute inflammation than is dry. It is useful in sprains, etc., as an early application (hot water bath), having a tend- ency to limit or to prevent the development of subcutaneous edema. It is much more stimulating than cold, and when the circulation is sluggish, and sloughing is threatened, the surgeon may sometimes avert the danger by the use of very hot compresses frequently renewed. The use of moist heat in the form of a poultice is very agreeable to the patient, and is one of the most efficient ways of promoting sup- puration when this is inevitable, as well as in hastening the separation of sloughs when these have once formed. The poultice may be made aseptic by sterilizing its ingredients. It is sometimes said that there is no need to use antiseptics in wounds which already are infected, and that further infection will do good by establishing a free discharge of pus. This is an error; if there is no discharge of laudable pus in infected wounds, it only shows that the inflammation is extending, and that the body tissues LOCAL REMEDIAL TREATMENT 39 have not been able to produce a sufficient number of phagocytes to combat and to vanquish the invaders. Adding to the infection, or producing a mixed infection, will not mend matters; it should rather be the surgeon's care to support his patient's strength, and to aid his tissues in the unequal struggle by destroying as many as possible of the microorganisms already present. The alternation of heat and cold, in the form of douches, is useful in the later stages of the inflammatory process, aiding in the absorption of exudates and the restoration of the part to the normal condition. Narcotics sometimes are applied locally with benefit. The tincture of arnica, lead water with laudanum or alcohol, and lately magnesium sulphate, have been popular at various times. The last named sub- stance has the effect of a local anesthetic, and very remarkable effects are claimed from its use in erysipelas (Tucker, 1908), arthritis, orchitis, and other affections. Belladonna plaster is a favorite domestic remedy. Ichthyol, in the form of an ointment of 10 to 25 per cent, strength, is useful in soothing the pain of adenitis, in furuncles, etc., and by its sorbefacient effect seems to exert a directly beneficial influence on the course of inflammation. Ointments of belladonna and mercury are used in the same way. The internal use of mercury and the iodides may be combined advantageously with these local applications. Counter-irritants, when applied around but not directly over the inflamed part, are often productive of considerable benefit, especially in subacute and chronic inflammations, though their exact mode of action is still a matter of dispute. Under this heading come blisters, iodin, turpentine stupes, capsicum and mustard plasters; also silver nitrate, which is astringent, and copper sulphate. The actual cautery is occasionally of value as a counter-irritant. Local bleeding, by the use of incisions, or by means of leeches, may be of value in combating excessive inflammatory reaction. It will relieve the congestion, may perhaps prevent the formation of a harm- ful exudate, and almost without exception diminishes the pain. Leeches are seldom employed at the present day except in affections of the eye and ear. Venesection, or general bleeding, is now rarely employed. In cerebral compression its use is illogical, since the increased arterial tension is the effect, not the cause, of the lesion within the cranium. But in the robust, plethoric, or cyanosed, with symptoms of present or threatening toxemia, in the presence of inflammation of the sthenic type, venesection is sometimes of value. The use of incisions has already been referred to under the head of bleeding; by relieving tension they serve to lessen the pain, and may prevent sloughing by promoting discharge from the over-filled vessels of the inflamed area, thus aiding in the restoration of the circulation. The pain of orchitis is readily relieved by puncture of the tunica albuginea; after plastic operations (for hypospadias, etc.) multiple small incisions may prevent sloughing by reducing the edema; in extensive cellulitis the use of free incisions may prevent the development of widespread sloughing or gangrene (as in extrava- 40 INFLAMMATION satioii of urine). Finally the evacuation of pus is one of the main indications for incision. Operations are frequently required in the treatment of inflamma- tion. Drainage must be established in suppurative affections in all parts of the body (brain abscess; empyema; peritonitis); an invo- luerum must be cut away; sequestra must be removed; amputation and excisions must be performed, before the ultimate cure of the disease can be effected. Compression, applied before the inflammatory process has reached its height, may prevent excessive reaction; in the later stages it will assist in promoting absorption. Swelling of a sprained ankle may be prevented by strapping; a carbuncle will rapidly decrease in size when thoroughly suported at its periphery by adhesive plaster straps; strapping a leg ulcer is almost indispensable at times. Active mid passive congestion, as introduced by Bier (1905), are useful in some inflammatory affections. Congestion lessens the pain by benumbing the part, probably by direct pressure on the nerve endings through the subcutaneous edema produced, acting thus much like the usual forms of infiltration anesthesia. It produces its curative effect probably by increasing the number of phagocytes in the part; possibly also by increasing the quantity of the exudate and thus enhancing its bactericidal properties. It has seemed to me that the value of compression in carbuncles and chronic ulcers may be due at least in some measure to the chronic passive hyper- emia produced. Passive congestion is most used in the treatment of chronic arthritis; it is also of value in such localized infections as furuncles, felons, etc.; it is usually useless or actually harmful in spreading inflammations. Passive congestion is to be secured by bandaging the limb some distance above the lesion with an elastic bandage which is drawn tight enough to obstruct the venous current without intercepting the arterial. The limb below the seat of the con- striction should develop a comforting glow, the superficial venules being distended, and the skin becoming a dusky blue. Under no cir- cumstances should the constriction be tight enough to cause a fall of temperature in the limb. At first the treatment is continued for only one hour daily, but later may be used almost continuously, i^ctive hyperemia is secured by hot air applications (baking or the hot air douche), or by the use of cupping glasses, which are made in forms suitable to the various parts affected. Baking is particularly applicable to chronic forms of arthritis without effusion; while the cupping glass apparatus is said to be of value in the treatment of chronic sinuses, etc. ; it has also been used in uterine affections. Massage is of value in the later stages of inflammation, by pro- moting absorption of the exudate, rupturing slight inflammatory adhe- sions; and thus aiding the restoration of normal physiological action. In enforced confinement to bed, massage may be advisable to sustain the tone of the muscles of those parts not directly concerned in the disease. CONSTITUTIONAL TREATMENT 41 Constitutional Treatment. — Constitutional rest, as well as local rest of the inflamed part, is often requisite. Rest in bed, in a quiet, cool, darkened room, may enable the patient to be restored to his activi- ties in a few days, whereas a much longer period frequently would be required were he to persist in going about the house. Especially should such rest be insisted upon in the case of acute inflammations of the chief organs of the body — pyelitis, cystitis, prostatitis, affec- tions of the gall-bladder and other abdominal organs. Hygiene is of the utmost importance. The room of the patient, or the hospital ward, should be well ventilated, and easily warmed in winter, and cool in summer. Bathing must not be neglected, for the skin is an important excretory organ. The excretions must be watched daily, and in most cases a careful examination of the urine should be made, both as to quality and quantity. Cathartics should be given as needed; a brisk purge early in the attack is usually bene- ficial. A temperature chart should be kept, and the temperature, pulse, and respiration be recorded twice daily. As the patient will often be unable to entertain himself while laid up, the surgeon should see that such light entertainment as is deemed suitable is provided. The best surgeons are physicians also, and must not let their pro- fessional duty cease with the dressing of the wound or the applica- tion of a splint. On the other hand, I have sometimes seen patients who were exhausted by over-entertainment, all the members of the family congregating in the sick man's room to spend the evening, vitiating the atmosphere, and wearying the patient's mind by constant chattering among themselves. It is usually well to limit the visitors to two at a time; and to caution them to cease their visit and their conversation when the sick man no longer appears interested. The diet in cases of inflammation should be simple; so long as fever continues, liquid diet is preferable. Milk, which is the most univer- sally applicable article of food, usually can be taken by any patient, in spite of his prejudices, if he makes the attempt, and if the milk is fresh and cold. A few patients prefer it warmed. Its taste may be disguised by the use of vanilla, chocolate, coffee, etc. All kinds of broths are suitable; fresh beef juice often is relished, or the various prepared forms of meat juice may be employed. When the fever has gone, more liberal diet may be allowed: eggs, oysters, sweetbreads, chicken, chops, green vegetables, ice-cream, etc. As a rule, the patient's own desires and tastes furnish a fairly reliable guide to his diet; and if no injurious effects are manifest, he may be permitted to eat pretty much what he pleases. Drugs are of undoubted value in the treatment of inflammation. Those most employed may be classed as (1) Sedatives; (2) Cathartics; (3) Diuretics and Diaphoretics; (4) Stimulants; (5) Alteratives; (6) Tonics. Sedatives.— Opium is one of the most valuable single remedies in the pharmacopoeia; but its tendency to produce constipation must be guarded against; and it is too valuable a remedy to be used indis- I-' IN FLAM MM' ION criminately. It' the patient is in pain, it is the surgeon's duty to relieve the pain so far as is compatible with the cure of the disease; but usually pain may be relieved without resort to opium, by change of position, by prompt incision of an abscess, or by rest enforced by splint or bandages. If the pain really demands morphin for its relief, I think it is usually better to administer one-sixth of a grain hypo- dermically, and to repeat this in an hour if the patient is not relieved. Closely allied to its power of producing sleep is the action of opium for injuries of the head, in traumatic delirium, delirium tremens, etc. Besides relieving pain and securing sleep, opium serves to relax spasm; it thus proves of benefit in fractures, in retention of urine from congestion of the posterior urethra, in fissure of the anus, in pylorospasm and similar affections. If opium is contraindicated, other sedatives may take its place; among the most valuable of these are chloral, the bromides, hyoscin, cannabis and paraldehyde. Trional is a useful hypnotic, but has no influence on pain. Aconite may be given in small doses during the height of the inflammatory fever, when of the sthenic type. Cathartics usually may be administered with benefit in the early stages of inflammation. In this way toxins are withdrawn from the circulating blood, and prevented from reaching the kidneys in excess, where they are prone to cause cloudy swelling or desquamative neph- ritis. In peritonitis I believe the use of cathartics to be positively harmful. In meningitis it is desirable to keep the bowels freely open. A single dose of castor oil, or blue pill, or divided doses of calomel will be of more benefit in most cases than the popular use of salts. After having the bowels thoroughly opened once, it is usually inad- visable to continue purging the patient. If constipation persists, enemas may be used. Asafcetida suppositories, or milk of asafcetida by enema, are supposed to overcome flatulence. I have considerable doubt whether they have any very definite action. Diuretics and diaphoretics were much employed formerly, and they undoubtedly are of benefit in some cases. Plenty of water by mouth is the best diuretic; when this is contraindicated, or if it can- not be taken, resort may be had to rectal infusion of water (p. 145) or to subcutaneous or intravenous injections of saline solution. The kidneys are the chief organs of elimination for the toxins produced at the seat of inflammation, and by the imbibition of plenty of fluid the function of the kidneys is promoted, and the toxins are excreted in a more or less diluted form. Dover's powder combines the merits of an hypnotic with those of a diaphoretic. The vegetable salts of potassium and ammonium (citrate and acetate) are especially valuable as diuretics because they are not themselves irritating; moreover, they lessen the viscosity of the blood. Digitalis and strophanthus are more stimulating; these, or the citrate of caffein, may be used when the heart shows signs of failure. Stimulants seldom can be dispensed with in severe cases after the height of the fever has passed. Alcohol, when taken in small quanti- CONSTITUTIONAL TREATMENT 43 ties, aids the absorption of food ; it seems to act almost as a food itself when little else can be retained. It should be given in doses large enough to produce the desired effect; the amount naturally will vary with the age and habits of the patient, with his general condition, and with the condition of his heart and kidneys. The initial dose should be small (15 c.c. three or four times daily), and it should be increased rapidly so long as it appears to do good. In meningitis it is contra-indicated, as tending to increase delirium; but in delirious states due purely to adynamia, as in extensive burns or other exhausting diseases, the use of tonic doses of alcohol frequently will cause the mental state to clear up prompt!}'. Its use in delirium tremens is to be condemned. If the delirium, from any cause, is increased by the alcohol, it is doing the patient no good, and should be reduced in quantity or discontinued entirely. Whisky and brandy are the best forms in which to administer alcohol during the inflam- mation; during convalescence, ale, beer, porter, or the lighter wines may be used. Champagne is the only form in which it is usually advisable to administer alcohol during the continuance of high fever. Coffee, which may be administered by mouth or by enema, is a valuable stimulant. So is salt solution, as already noted when speak- ing of diuretics. Atropin, digitalis, and camphor are good cardiac and vascular stimulants. Alteratives are used frequently in inflammation. Antimony was formerly employed in the endeavor to abort inflammation by means of its so-called "anticipatory antiplastic effect." Calomel, for the same purpose, was strongly commended by the late Prof. Ashhurst, in the treatment of head injuries, and I constantly employ it with utmost satisfaction. The employment of mercury to cause the ab- sorption of inflammatory exudates (iritis, meningitis, etc.) is world- wide. Calomel is usually the best form for administration. The iodides of potassium, sodium, etc., are widely used to aid in the elimination of inflammatory products, especially in affections of the bones and joints. Tonics. — During convalescence it is almost always proper for the patient to take a tonic. Iron and quinin are the most valuable. Some patients will prefer Blaud's pills to the tincture of the chloride of iron, but the latter frequently is more effective. The tincture of nux vomica, or strychnin sulphate, with one of the bitters, aids materially in the restoration of appetite. In the case of children, cod liver oil, the syrup of the iodide of iron, the phosphates, or arsenic may be given. Stimulation of Phagocytosis. — This method has been attempted in both the prevention and treatment of inflammation. Mikulicz used local hypodermic injections of dilute nucleinic acid, in the effort to increase by positive chemotaxis the number of phagocytes and their bactericidal power for the prevention of peritonitis. Local inunctions of mercury are said to act in a similar way. The use of Bier's passive hyperemia has already been referred to. I I INFLAMMATION Vaccines and Serum Therapy in General. The phenomena of the inflammatory process arc merely exaggerations of phenomena which arc constantly occurring in the body in a state of health. As already mentioned, it is extremely probable that bacteria of some kind are constantly present in the body, and that phenomena of disease are prevented only by the natural resistance of the body tissues. Opsonins, as pointed out at p. 23, are normally present in the fluids of the circulating blood. When local inflammation or general disease arises, these resistive powers of the organism are increased; various other antibodies are produced, and on recovery from a certain disease a condition of immunity to that special infec- tion may be established, and may continue for a longer or a shorter time. This immunity may be conceived of as being due to the cells of the body having acquired by training the habit of resisting a certain specific infection; so that should this same infection again occur, the body cells would be fully prepared, as the result of their previous experience, to act rapidly and effectively in repelling the foe. Their habit of forming antibodies persists, and will result in attempts at re-infection proving ineffectual. The earliest instance in which practical application was made of the above theory, though of course the principle itself was not then understood, was the use of vaccination by Jenner (1798); in the origi- nal method the virus of the cowpox was inoculated into man, thus producing in him the disease known as vaccinia, which was considered to be a mild form of smallpox, the virulence of the smallpox virus having been attenuated by passing through the cow. By thus training the body cells to reaction against the virus of cowpox, an immunity to smallpox is established. The term vaccines is applied to those substances, used for pro- phylactic or curative injection, which contain the attenuated virus itself, not merely some of the anti-bodies produced in the course of the disease. Most vaccines contain no bacteria which have not been killed. Those substances which contain anti-bodies and perhaps dead bacteria, but certainly no living virus, are classed as sera ; they are subdivided into antitoxic and antibacterial sera. Prophylaxis and treatment by vaccines and sera are most suc- cessful in the case of diseases caused by specific microorganisms. Ordinary inflammations, in w T hich the cause is not a specific micro- organism, have not so far been treated with very encouraging results. Among diseases treated by vaccines may be mentioned, besides the prevention of smallpox already referred to, the prophylaxis and cure of anthrax (Pasteur), rabies (Pasteur), typhoid fever (Frankel, Richardson), and tuberculosis (Koch, Wright). Among those treated by sera are included: (1) By antitoxic sera, diphtheria (Behring), tetanus (Behring) ; (2) By antibacterial sera, typhoid, cholera, plague, dysentery, etc. Finally by the administration of both vaccines (active immunization) and sera (passive immunization), encouraging results have been obtained in anthrax by Sclavo (1903). VACCINES AND SERUM THERAPY IN GENERAL 45 Antistreptococcic serum has been used in ordinary types of spread- ing inflammation, in erysipelas, and in septicemia. (See Chapter II.) It is an antibacterial serum. The results are sometimes marvellous, while more often its use appears to be devoid of effect of any kind. Anticolon bacillus serum has been used by some observers, but without very constant results. As a general statement, it may be said that in acute diseases, where it is necessary to supply the patient with anti-bodies already formed, sera are used; while in chronic infec- tions, it is hoped by the administration of killed bacteria to rouse the patient's tissues to a more effectual production of anti-bodies. CHAPTER II. DISEASES RESULTING FROM INFLAMMATION. The surgical diseases resulting from inflammation may be classified as (1) Local Affections, including Abscess, Ulcer, Gangrene, Cellulitis, Erysipelas, etc.; and (2) General Affections, including under the gen- eral name of Sepsis, the varieties of systemic infection known as Sapremia, Toxemia, Bacteriemia (Septicemia), and Pyemia. LOCAL AFFECTIONS. Abscess. — The pathogenesis of an abscess has been described already (p. 25), and it may be defined as a collection of pus circum- scribed by granulation tissue. If the pus is not circumscribed by granulation tissue, it is not spoken of as an abscess. Thus pus in the pleural cavity is an empyema, if widely diffused; it does not become an abscess until it is walled off from the general cavity by the effusion of lymph and the production of adhesions. Pus widely infiltrating the cellular or muscular tissues does not form an abscess, but a phlegmon. Pus free in the peritoneal cavity is described not as an abscess of the peritoneum, but as diffuse suppurative peritonitis. Two main varieties of abscess are recognized; these are distinguished clinically by their symptoms, but the pathogenesis of both is the same; they are the acute or phlegmonous abscess, and the chronic, cold, or scrofulous abscess. The former alone is to be considered here; cold abscess is described in connection with surgical tuberculosis, in Chapter III. Clinical Pathology. — An abscess may arise in any place where inflammation exists. It may be caused by direct injury of the part, as by a fall, a kick, an infected wound, etc.; or it may arise second- arily, as the result of extension of inflammation from the primary focus. This extension may occur along the subcutaneous (sub- peritoneal, etc.) areolar tissue (causing cellulitis), along the lymphatic channels (causing lymphangeitis), or along the blood stream (causing phlebitis, and very rarely arteritis). When an abscess is suspected in a region which has not been directly injured, careful search should therefore be made for the original focus of infection; and it should not be forgotten that the intervening tissues may show no evidence of disease. Thus a sore on the foot may cause inflammation and eventual suppuration in the femoral or inguinal lymph nodes, without any evidences of lymphangeitis of the leg or thigh. Abscess of the liver may follow appendicitis, the virus of the disease having traversed (46) ABSCESS 47 the radicles of the portal vein without leaving evidences of its passage. Infection from a lesion of the mouth may spread to the areolar tissue of the neck, and there cause cellulitis and suppuration without giving signs of inflammation in the tissues of the floor of the mouth through which it passed. But in each and every case, before suppura- tion can occur, the earlier stages of inflammation must have existed in the part in which the abscess is ultimately formed. As the pus within the abscess accumulates, by progressive lique- faction necrosis of the surrounding layer of lymph, the size of the abscess increases; it spreads most rapidly in the direction of least resistance (usually toward the skin surface), and pointing of the abscess is said to occur when the pus is contained by the epidermis alone. Occasionally an abscess will point and rupture into a neighboring cavity, as a joint, or one of the great serous cavities (pleura, peritoneum, etc.) ; but in the case of suppuration in internal organs, sufficient plastic lymph at times is produced to confine the abscess on its inner surface, and to prevent rupture except externally. When an abscess is evacuated, the tract through which it discharges is called a sinus (p. 51). A fistula is a sinus which has two or more openings; these may be on the skin, or one may be on the skin, another in an internal cavity (intestine, joint, urethra, etc.), or both may be internal openings (as in gastro-colic, recto-vesical, and other similar fistula?) . Fig. 6. — Abscess of the groin, following direct injury, one month previously. Girl, aged eleven years. Episcopal Hospital. Symptoms. — At the onset of suppuration, the part already inflamed becomes more painful, the pain assuming a throbbing or pulsatile character; the tenderness is accentuated; the intense redness of the inflammation fades into a dusky or a bluish hue; the swelling becomes better localized; and frequently the abscess is seen to stand out above the surface of the surrounding skin (Fig. 6). As tfye amount of fluid within the abscess cavity increases, fluctuation, 48 DISEASES RESULT1NC Fh'uM FX FLA \l)l AT/UN at first indistinct, becomes unmistakable; the skin over the abscess may desquamate; it becomes thinner and thinner, and finally is entirely deprived of its nutrition at the point of greatest tension. A minute circular slough is then formed at this point, and, when this is cast off, the pus from within is discharged, the abscess cavity is more or less obliterated by the pressure of surrounding parts, and the abscess is finally converted into a granulating surface. When suppuration is deeply seated, an abscess may attain a considerable size before producing such characteristic symp- toms. In such cases the overlying skin may become edematous, pitting slightly on pressure, owing to the effusion of lymph and serum in the overlying parts; rigidity and immobility of the pro- tecting muscles are important signs; and the experienced touch of the surgeon may enable him to proclaim with certainty the presence of pus, when to one not possessed of the tactus eruditus a positive diagnosis would be impossible. Fig. 7. — Instruments used in treatment of abscess: bistoury, eyed probe, dressing forceps, exploring needle. Diagnosis. — It is not likely that an acute, superficial abscess, already pointing, will be mistaken for anything else. But there are many other affections with which an abscess at times may be confused. Careful and systematic examination of the patient should therefore never be neglected. The brilliant Irish surgeon, Dease, recklessly plunged his bistoury into a swelling in the femoral region, which he mistook at first glance for an abscess, and his patient died before his eyes from overwhelming and uncontrollable hemorrhage from the femoral artery, an aneurysm of which vessel had been opened. The diagnosis of an acute abscess may be determined by the history, by the local sigjis (fluctuation, pointing, etc.), and as a last resort by the exploring needle (Fig. 7) or ordinary hypodermic syringe. Fluctuation may be present more or less distinctly in many other swellings than those containing pus; besides aneurysms, effusions of blood, of scrum, of urine, etc., may produce such fluctuating swel- lings; and cystic and even fatty and some other solid tumors may give a similar sensation. The surgeon's fingers, moreover, in pal- pating a suspected swelling, should be placed longitudinally on the ABSCESS 49 part, since the belly of a large muscle, and even very fatty subcutaneous tissues may present indistinct fluctuation if this point be neglected. Prognosis. — This is good in most cases, provided treatment is prompt and efficient. But an abscess may be dangerous from its situation, from its size, or the prognosis may be peculiarly grave from the constitutional condition of the patient, or his age. A retropharyngeal abscess may cause suffocation; one in close proximity to a large bloodvessel may rupture into it, and cause death from hemorrhage or from pyemia; an abscess near a joint may penetrate its capsule and cause lasting disability or even death from pyar- throsis; an abdominal abscess may rupture into the peritoneum and cause fatal peritonitis. The drain on the patient's vitality from a large abscess, or from many smaller abscesses, may lead to death from exhaustion, or from amyloid degeneration of the viscera. In practically every case there will be loss of tissue, and a more or less evident cicatrix for years after the abscess has healed. Treatment. — Much may be done to prevent the formation of an abscess, as pointed out in discussing the treatment of inflammation. When pus has once formed, much may be done to ameliorate the symptoms, and to cure the patient with as little disfigurement as possible. Though the process of pointing can seldom be hastened, yet by appropriate treatment the sufferings of the patient may be very materially relieved until pointing occurs. Heat or cold, which- ever proves most grateful, may be applied locally, and anodynes may be administered internally, when required. Warm moist heat, in the form of a poultice, usually is most grateful to the inflamed part. But though these adjuvants may be employed with advantage in certain cases, prompt evacuation of the pus by incision is much more efficient in checking pain, by relieving tension and hastening the conversion of the abscess into a superficial ulcer. Moreover, the cicatrix resulting from a well-placed incision is much less dis- figuring than one which occurs when an abscess is allowed to burst of itself. In most abscesses affecting the. subcutaneous tissues it is better to postpone incision until fluctuation is evident, and until pointing has nearly occurred; but in other cases incision should be adopted much earlier, general or local anesthesia being employed as may seem indicated. When only the skin intervenes between the abscess and the surface of the body, no anesthetic is required, since the skin overlying such an abscess has nearly all its nerves devitalized by the anemic necrosis induced by pressure of the pus. In the case of deeper abscesses, I much prefer the hypodermic use of a local anesthetic, such as novocain, to freezing by the ethyl chloride spray; when the novocain is properly used the entire procedure is painless except for the initial prick of the needle. When the abscess is still more inaccessible, general anesthesia is to be preferred, since in some instances it may be necessary to undertake a formal operation, or even to open the abscess across a serous cavity (pulmonary, appendicular, cerebral abscess). In opening a superficial abscess without any local anesthesia, the 4 50 DISEASES RESULT I Xd FROM IXFLAMMATIOX surgeon should accomplisb his purpose by a sudden thrust of the bistoury, which is held as a pen, and with its cutting edge toward the surgeon; thus, as the patient draws away in momentary surprise or pain, the incision will be enlarged as the bistoury is withdrawn. The depth to which it is to be introduced must be determined before- hand, and regard must be had to the anatomy of the part, lest some important nerve or vessel be wounded. In opening an abscess in a dan- gerous neighborhood it is much safer to adopt Hilton's method (1863): to incise merely through the skin and superficial fascia, and then to introduce a grooved director, and burrow down to the abscess with this, or with a dressing forceps; when the pus is reached, the blades of the forceps are widely separated and the forceps is withdrawn, thus dilating the tract previously made. When an abscess has been opened, it should be allowed to dis- charge itself slowly; the surgeon may gently support its sides, to encourage the discharge of pus, but he should by no means attempt to express it by massage, and most em- 9phatically should he not introduce a curette into the abscess cavity to scrape away its lining membrane. Such a course destroys the granulation tissue surround- ing the abscess cavity, may open neigh- boring venules or lymphatic radicles, and is extremely apt to cause a spread of the inflammation. When the tension on the abscess cavity is relieved by the evacuation of the pus, its walls will col- lapse, and in the case of small abscesses union between these apposed walls will Pig. 8. — Drainage tube ot soft -. , . \ * -\ 1 .1 rubber, with numerous eyelets. take place 111 a COliple ot days by the process of secondary adhesion (p. 162), and a superficial ulcer alone will remain. In such cases no drain need be introduced into the abscess cavity; but in the vast majority of instances it is important to introduce between the lips of the incision some sub- stance which will keep them from uniting until healing of the under- lying abscess cavity is complete. A tube of soft rubber, commonly known as a drainge tube (Chassaignac, 1859) (Fig. 8), is much more satisfactory for this purpose than is any substance, such as gauze, which may become clogged with the discharging pus, and thus hinder, instead of promote the escape of pus from the depths of the cavity as healing progresses. It is only in A r ery small abscesses, where the discharge is slight, that a gauze drain is useful; even here, a strip of rubber tissue is preferable to gauze; and if the latter be employed in other cases, where it may be of value by acting as a tampon to check oozing of blood from the walls of the abscess cavity, it is better to use a tube as well; or a cigarette drain (Fig. 10) may be employed. In small abscesses sufficient drainage may often be procured by a few strands of silkworm gut. SINUS AND FISTULA 51 The dressings of an abscess (gauze) will absorb the discharges better if they are moist. A solution of sodium chloride, of corrosive sublimate, of alcohol, of potassium permanganate, or other suitable antiseptic may be used for this purpose. The gauze immediately Fig. 9. — Deep abscess of thigh; through-and-through drainage by rubber tube, safety-pins to prevent displacement of tube. Episcopal Hospital. next the discharging sinus should be well crumpled up before being applied; laying many layers of flat gauze over the part will dam up the pus in the abscess cavity. Fig. 10. — Cigarette drain, made by covering a wick of gauze with rubber tissue. Sinus and Fistula. — These are suppurating tracts, usually due to the incomplete healing of abscesses. A sinus, as pointed out at p. 47, has only one orifice, since its other extremity ends blindly in the former abscess cavity. 1 A fistula, on the other hand, is a suppu- rating tract with at least two, and sometimes several, orifices, which may be either external, internal, or both. Sinuses and fistulas may be kept from healing by the action of neighboring muscles (as in fistula in ano); by the presence of some foreign body (spicule of bone, ligature) which the tissues of the organism cannot destroy; or by the constant passage of the secretions of the part through the abnor- mal opening (salivary, fecal, or urinary fistula), instead of through the natural channel. Treatment.— They should be treated by removal of the foreign body; by removing the obstruction to the discharge of the secre- tions ; or by supporting the sides of the sinus with adhesive plaster or bandages to overcome the action of neighboring muscles. If the walls of the suppurating tract are thickened and indurated, they should be stimulated by the use of caustic injections (silver nitrate, zinc sulphate, etc.), or stimulating ointments (dilute mercuric nitrate, ichthyol, 1 Such a sinus often is called a "blind fistula." 52 DISEASES RESULTING FROM INFLAMMATION iodin) on a rope of gauze; by curetting the sinus with Volkmann's sharp spoon; or finally by slitting the tract open on a grooved director, cauterizing it with caustic potash or the actual cautery, thus producing a superficial slough and converting the sinus into an ulcer, and promoting healing from the bottom. In excessively obstinate cases a cure may be obtained by dissecting out the entire suppurating tract, and uniting the parts from the bottom with buried absorbable sutures. Some chronic sinuses, especially of tuberculous origin, may be cured by the injection of a bismuth-vaselin paste, as recommended by Beck (1908) (see Chapter XV). Ulcer. — Ulceration is defined as the molecular death of a part. Some writers distinguish between an ulcer and a granulating wound, limiting the former term to the result of the process of destruction known as ulceration, and therefore denying that an ulcer, as such, can ever heal; maintaining that as soon as healing commences the term granulating wound should be adopted. Certain ulcers, however, may be granulating at one portion of their surface, while still actively ulcerating at another point (serpiginous ulceration) ; so it seems better while acknowledging the distinction between ulceration (molecular death) and granulation (process of repair), to include as is usually done, both granulating and ulcerating surfaces under the general heading of ulcer. Park (1907) tersely defined an ulcer as "a surface which is or ought to be granulating." The repair of an ulcer occurs by granulation and cicatrization. The formerly ulcerating surface gradually loses its inflamed appear- ance; the discharge of pus lessens; the edges of the ulcer become firmer and more clearly defined; and granulations are seen springing up all over its surface. Soon these granulations become higher than the surrounding skin; often they become exuberant, forming what is known as "proud flesh." Around the edges of the ulcer the neighbor- ing epithelium proliferates, gradually covering in the granulations, and being easily distinguished as a faint blue line interposed between the healthy skin and the face of the ulcer. Occasionally little patches of new skin, with this same faint bluish tinge, may be seen in the midst of the granulations, evidently arising from epithelial cells which have survived the original destructive lesion. As these changes progress on the surface of the ulcer, beneath its surface proceed the changes which have already been described under the heading Repair (p. 29); that is to say, the fibroblasts become converted into white fibrous connective tissue (cicatrization), and as a consequence the face of the ulcer contracts, thus decreasing the superficial area which must be covered over by the surrounding epithelium. This con- traction, which is the prime characteristic of all newly formed cicatricial tissue, is most noticeable on the surface of the body in the healing of ulcers resulting from burns; and in mucous channels (urethra, esophagus), where strictures are the result. The less the infection on the surface of the ulcer, the less will be the contraction, and the more rapidly will it be covered by epithelium. ULCER 53 Certain varieties of ulcer are described by systematic writers. The most important are : Simple or Healthy Ulcer. — This is characterized by its innate tendency to heal. To secure prompt healing every other variety of ulcer must be converted into this form. Ordinary incised wounds healing by "second intention/' and superficial burns, afford good examples of a healthy ulcer. This ulcer, if not too large, will heal of its own accord if it be protected from injury. If exposed to the air after the granulations are well formed, a scab will form over it, and healing under the scab will take place as described at p. 162. Ordinarily it is better to cover the ulcer with some mild ointment, spread not too thickly on lint. There is no object in having the ointment spread over the neighboring healthy skin also; indeed to do so frequently causes maceration and delays healing. Inflamed Ulcer. — This is one in which infection is still progressing, the reaction of the tissues being insufficient to quell the invasion (Plate I, Fig. 3, p. 66). A very severe form of inflamed ulcer is the sloughing ulcer. The worst form of all is phagedenic ulcer, usually seen only in chancroidal sores; here the destruction of tissue is frightfully rapid, and nothing short of thorough cauterization of the entire ulcerated surfaces will suffice to check the phagedena. In ordinary cases of inflamed ulcer, confinement to bed, with elevation of the part, the local use of antiseptics, and tonics and stimulants inter- nally, may be necessary to arrest ulceration. Weak or Edematous Ulcer. — This is characterized by the granu- lations being large and flabby, apparently distended with serum, of very low vitality, and easily detached in masses from the sur- face of the ulcer. Usually it is an evidence that proper care of the wound has been neglected, or that poultices and mild ointments (zinc oxide and boric acid) have been continued too long. As granulations contain no nervous tissue, no hesitation need be felt in snipping off with scissors the exuberant masses of proud flesh; the patient will not feel a particle of pain. Any bleeding is readily checked by pressure or by cauterization with the stick of silver nitrate. Then more stimulating ointments should be applied, par- ticularly valuable being resin cerate, scarlet red, balsam of Peru, nitrate of mercury, ichthyol, etc. Neuralgic or Irritable Ulcer. — This is usually of small size, placed at the ankle, below or near to one of the malleoli, and is characterized by the intense pain experienced by the patient. The skin margins are usually thickened, the ulcer has little or no discharge, its surface being glazed and exquisitely sensitive. Frequently it is evident that the ulcer involves the terminal filaments of some sensory nerve, especially the musculocutaneous or the internal saphenous nerves at the ankle (Fig. 11). If rest in bed, with elevation of the part, and cauterization of the base of the ulcer fails to relieve pain, the affected nerve some three to six inches above the ulcer may be divided (Hilton, 1863). 54 DISK ASKS RESULTING FROM INFLAMMATION Indolent or Callous Ulcer.- This is the most frequent form of "leg ulcer," usually occurring in adults, on the lower half of the leg, and on the anterior or fibular aspect. The surface of the ulcer is dry, and sometimes glazed; the granulations are low and ill-formed; the edges are hypertrophied and dense, and give to the surface of the nicer a depressed or concave appearance (Fig. 12). As cure depends upon contraction of the base of the ulcer, and on concentric cicatri- zation proceeding from its edges, it is evident that destruction of the callous margins is the first step in this direction. These margins surround the ulcer like a cartilaginous ring, and by their lack of elasticity and by their very bulk prevent contraction of the ulcer's base; moreover, the surrounding epithelium appears indolent and unable to proliferate so as to cover in the granulations. The ulcer Fig. 11. — Neuralgic or irritable ulcer in a woman, aged forty-five years. Duration four weeks. Episcopal Hospital. Fig. 12. — Indolent or callous ulcers of the leg. Episcopal Hospital. usually is due to some trivial injury, repair of which becomes impossible from the necessity of the patients continuing their occupa- tions as means of livelihood, and because of some constitutional condition (obesity, arteriosclerosis) which interferes with the normal circulation of the blood and lymph in the part. If the patient be put to bed and the callous margins of the ulcer be softened by poultices or simple wet dressings, the ulcer usually will soon be con- verted into one of the healthy type, and cure will soon be brought about. As soon, however, as the patient resumes his occupation, the old ulcer is apt to reappear whenever the skin is bruised. It is important, on this account, to take great pains to avoid injury and to maintain the skin in good condition, when once the ulcer has healed. Scrupulous cleanliness should be enjoined; and ULCER 55 where a tendency to edema of the leg exists, much benefit may be gained from the use of an elastic bandage, which usually is preferable to an elastic stocking. But it may be impossible for the patient to be laid up in bed for some weeks, which is the shortest time in which a cure may be anticipated; yet even with- out the advantages of rest in the recumbent position, it is by no means impossible to bring about a cure of the ulcer. Poultices and wet dressings may be applied while the patient continues at his work, and w r hen the margins of the ulcer have become reasonably soft, it may be strapped with adhesive plaster, thus supporting the edges, preventing a re-accumulation of blood and lymph in the parts, and mechanically promoting healing of the base. The straps should be 2.5 to 3 cm. wide, long enough to encircle about three- fourths of the limb when oblique- ly applied; and are to be put on from below upward in an imbri- cated manner, two at a time, thus drawing the edges of the ulcer to- gether as the two straps are crossed (Fig. 13). The strapping, which should start an inch or so below the ulcer, and continue for an equal distance above its upper margin, should be covered in by a firm muslin bandage, extending from the patient's toes to his knee. This dressing may remain in place for from five days to a week; when it is to be removed, the skin should be washed with turpentine, the edges of the ulcer (just within the blue line of new skin) touched with the solid stick of silver nitrate, and the straps again applied and covered in with a firm bandage as before. When the ulcer assumes the character of a simple or healthy ulcer, strapping may be discontinued, and ointments may be applied; but frequently the ulcer will heal under the use of straps alone. The results of this treatment, when it is carefully carried out, are remarkable: ulcers which have been open for a year or more, and on which all manner of salves have been tried, may be completely healed within comparatively few weeks. It is usually best for the patient to continue to keep the leg bandaged for a long time after apparent cure has been obtained, since relapses are frequent. In the rare cases where rest in bed, poultices, and strapping, fail to cure an indolent ulcer, its conversion into a healthy ulcer sometimes may be accelerated by dividing its callous margin by several radiating Fig. 13. — Strapping a leg ulcer. Episcopal Hospital. 56 DISEASES RESULTING FROM INFLAMMATION incisions, or even by making criss-cross incisions extending through the base of the ulcer and its callous margin on both sides. Or the ulcer may be under-cut from the sides, separating its base completely from the deep fascia. Skin grafting (p. 230) has been employed to hasten the cicatrization of these ulcers, but without much success. Formal plastic operations (p. 240) occasionally have been adopted, but with no very permanent results. A great many of these callous leg ulcers are due to the unsuspected presence of syphilis. The typical syphilitic leg^ ulcer (Fig. 14) is situated above the middle of the leg, is characteristically round, is seldom very painful, and yields with Fig. 14. — Syphilitic ulcer of leg, mule, aged twenty-four years. Following "ru- pia" of six weeks' duration. Completely healed under anti-syphilitic treatment in three weeks. Episcopal Hospital. Fig. 15. — Varicose leg ulcer. Episcopal Hospital. remarkable facility to the administration of mercury and the iodides. But in many of the callous ulcers in which no definite history of syphilis can be obtained, much improvement often follows the adminis- tration of potassium iodide alone or with mercury. In almost all cases of leg ulcer of long duration the tibia immediately beneath the seat of disease becomes thickened; but in the case of syphilitic ulcers there is sclerosis of the bones, and as pointed out by Coues the diagnosis of syphilitic leg ulcer usually may be confirmed by a skiagraph. In very exceptional cases the callous ulcer is absolutely incurable. But life with an incurable leg ulcer is by no means impos- GANGRENE bi sible; indeed, many persons live for fifteen to twenty years, or longer, with unhealed leg ulcers, and are able to lead very active lives. It is only in the rarest instances, therefore, that amputation is justi- fiable; for the risk to life usually is much less from an unhealed leg ulcer than from amputation. Varicose Ulcer. — This is one associated with varicose veins (Fig. 15). It is difficult to heal, sometimes is attended by alarming hemorrhages, and frequently incapacitates the patient. The use of elastic bandages, hot baths, gentle massage, etc., by reducing the swelling, and improv- ing the circulation of the limb, sometimes will bring about a cure, or at least will keep the patient in comfort. Bed treatment is better. If palliative measures fail, excision of the affected veins may be done and often the ulcer heals; but the operation is one of more risk than when no ulcer exists, and should not be undertaken lightly. It should never be done in the presence of active phlebitis; and if the veins are thrombosed as the result of a former phlebitis, they should be divided through healthy portions above the limit of the clot. Homans (1917) urges excision of the ulcer whenever the deep veins are involved. Warty Ulcer.— Under this name Marjolin (1846) described a form of ulcer which of late years usually has been regarded as due to malignant changes. It is not correct, how- ever, to give the name of Marjolin to every ulcer which undergoes malignant transfor- mation, as his original description applied merely to the clinical appearance of the ulcer, as if covered with warts. Fig. 16 represents a typical warty ulcer, which healed rapidly under appropriate treatment. When of long standing a malignant ulcer whose surface is warty frequently is found to involve the bone, which is the seat of caries, perhaps due to a primary sarcoma of bone, or possibly involved secondarily by a surface epithelioma. If the warty ulcer is malignant, it is much safer to amputate the limb than to attempt excision; but if the malignant ulcer is of the heel (I have seen two cases following burns in this situation), resection may properly be done, with restoration of the foot by the method of Mikulicz, if the patient refuses amputation. Gangrene (sphacelus, mortification, slough- ing) is a term used to describe the process of death of the soft parts, or of an entire extremity with its contained bone, when this death occurs in mass; necrosis, though usually confined in its application to death of bone, is occasionally employed to describe the death of soft parts at a depth from the surface, where no marked inflammatory phenomena are Fig. 1G. — Warty ulcer of Marjolin connected with periosteitis eight months after typhoid fever. From direct injury. Aged fourteen years. Episcopal Hospital. r,s DISEASES RESULTING FROM INFLAMMATION present, the resulting necrotic masses corresponding very closely to the sequestra met with in necrosis of hone. In ulceration, the dead parts are casl off in the form of pus (liquefaction necrosis), and molecular death of the tissues is said to occur; whereas in gangrene (molar death) the parts cast off (sloughs) are of such size as to be clearly visible to the naked eye. The causes of gangrene are either direct (as in pulpefaction of a limb by crushing force, destruction by caustics, by heat or cold, by bacterial toxins, etc.), or indirect, from interference with the vascular supply. One of the most extensive cases of sloughing I ever saw was in a lad of sixteen years, whose whole low T er extremity had passed through cog-wheels; though there was no injury to the vascu- lar supply of the limb, the pressure of each cog produced immediate death of the area it crushed, and it was over ten weeks he- fore the sloughs had all separated and the resulting ulcers healed. The appearance of the cicatrices six years after the accident is shown in Fig. 17. Injuries which in a normal state of health would cause only trivial lesions, when complicated by vascu- lar obstruction or constitutional disease may result in very extensive sloughing Fig. 17. — Cicatrices from sloughing, six years after in- jury (cog-wheels). Episcopal Hospital. Fig. 18. — Gangrene following application for twenty-four hours by patient's mother of carbolic acid dressing. Episcopal Hospital. or gangrene. The same degree of inflammatory infiltration, which in the subcutaneous tissues w T ould be harmless, when occurring beneath the palmar fascia or other dense fibrous membrane may produce such a choking off of the blood-supply as to cause extensive necrosis of the structures involved. In the old, or in younger persons with marked arteriosclerosis, 1 so-called senile gangrene may follow trifling injuries, or may be caused by gradual occlusion of the arteries without external injury. In diabetics there is a special tendency to necrotic processes, among the mildest of which are furuncles with their central slough or core. In patients suffering from ergotism, gangrene of the fingers or 1 This is what Buerger (1908) has called thrombo-angeitis obliterans. SYMPTOMS OF GANGRENE 59 toes, perhaps symmetrical, is a not infrequent phenomenon. It is usually preceded by premonitory symptoms, such as formication, cramps, local asphyxia, etc. Certain lesions of the nervous system, probably through vaso-motor changes, may induce bed-sores, sloughing, etc., in an alarmingly short space of time. The so-called perforating ulcer of the foot (p. 291), probably is due to a similar change, though arteriosclerosis is usually a factor also. Carbolic acid gangrene (Fig. 18) results from the direct caustic action of the solution employed, and often follows the use of a weak solution which becomes concentrated by evaporation. Bacteria are not a necessary accompaniment of gangrene; their presence usually is incidental. In a few rare instances, bacterial toxins are believed to be the immediate cause of gangrene by causing endarteritis, phlebitis, and thrombosis. This is probably the case in noma (p. 62). Emphysematous gangrene (p. 88) is due to infec- tion with gas-producing bacteria, the production of gas preceding the development of gangrene. Saprophytic bacteria usually invade tissues which have already become gangrenous, and produce the malodorous gases characteristic of putrefaction. There are two main varieties of gangrene, the moist and the dry, dependent in large measure upon the amount of moisture in the part when the vascular current is occluded, and on the amount of evaporation which takes place. Moist gangrene usually is due to venous obstruction (thrombosis, pressure of tumors, splints, bandages, etc.); it is occasionally seen, however, after sudden occlusion of the main artery of a limb (embolism, wounds, ligation, etc.), if the venous blood already present remains in the part. Dry gangrene, of which the senile form is typical, usually is due to slowly progressing arterial occlusion, the parts deprived of vascular supply becoming mummi- fied. Diabetic gangrene is usually rather dry. Symptoms. — When a part which has been inflamed becomes gan- grenous, the color fades into bluish green or purple, and finally into black; the pain, at first burning and intolerable, suddenly ceases; the affected area becomes numb and senseless; the cuticle is raised in bullae filled with bloody or purulent fluid; the part instead of being tense feels doughy; and the local temperature falls. There is gradually formed, at the point where the resistive powers of the individual are sufficient to overcome the destructive lesions producing the gangrene, a line of demarcation, indicated by a red line encircling the gangrenous structures. In this region the usual phenomena of inflammation occur, and as this process continues, a line of granula- tions is formed, known as the line of separation. By the gradual increase of these granulations the dead tissues are pushed away, as it were; and unless assisted by the surgeon this tedious process will continue until the entire gangrenous area is extruded in the form of a slough. An entire limb may be amputated spontaneously in this way. During the formation of the line of demarcation, there is often 60 DISEASES RESULTING FROM INFLAMMATION considerable constitutional disturbance 1 , due to the sapremia caused by absorption from the imperfectly isolated gangrenous area; and even during the process of granulation, before the slough is cast off, the patient is constantly exposed to infection from the decayed struc- tures. These constitutional symptoms usually are much less or altogether absent in dry gangrene, where the process, as already mentioned, resembles mummification. Treatment/ — The separation of sloughs sometimes seems to be hastened by poulticing the part. The charcoal poultice is particularly useful in these cases, as it lessens the odor by absorbing the gases. The yeast poultice also acts well. Various chemical digestants, especially, of late, Dakin's fluid (see p. 170), have been used, in the effort to aid nature in dissolving the sloughs; but little more is thus accomplished than by simply keeping the parts clean and protect- ing them from outside infection. In the case of extensive gangrene, the most important thing is to prevent infection; amputation will surely be required later, but if infection is absent the surgeon can safely postpone it until some indication is present of the level at which it must be done. Early amputation is often needlessly high. In moist gangrene constant exposure to the sun or electric light is one of the surest methods of preventing infection; in dry gangrene it usually is sufficient to keep the parts well covered with sterile cotton. Periodical baking of the limb, as in chronic joint affections, is also of great service. In senile gangrene, where only one or two toes are affected, formal amputation may never be required, as nature will be able to remove the slough at one of the phalangeal joints with less constitutional disturbance than would be caused by an operation ; if the gangrene extends beyond the toes, how- ever, amputation should be done above the ankle; and if it extends above the ankle, amputation through the lower third of the thigh should be done: it is not advisable to wait for the line of demarcation, and to amputate at lower points than those named almost certainly would expose the patient to recurrence of gangrene in the stump. To determine the level at which amputation should be done Lejars employs (1909) the " comparativehy peremia" test: the limb is elevated, an elastic bandage is applied, exsanguinating it, and exsan- guination is maintained by an Esmarch band for five or ten minutes after the elastic bandage is removed; the hyperemic blush which follows the removal of the Esmarch band will extend only so far as healthy circulation is present, and amputation may be done safely at this point. In the healthy limb the hyperemic blush extends to the toes. In all cases, particularly of pre-senile gangrene, large quantities of fluid should be introduced into the system. In many cases of senile gangrene it is evident that any operation would only hasten the fatal termination; under such circumstances of course only palliative treatment is admissable. In diabetic gangrene (Fig. 19) amputation is not to be recommended until sepsis threatens. De Witt Stetten (1912) has shown the remarkable success which attends SPECIAL FORMS OF GANGRENE 01 Fig. 19. — Diabetic gangrene. Aged seventy-four years. Duration two months. Healed under conservative treatment. Episcopal Hospital. judicious conservative treatment, especially sterilization of the limb by repeated baking. In the only successful cases I have had, ampu- tation has been postponed until the patients had become "sugar free" and were again able to take moderately full diet. Amputation for gangrene following frost-bite and burns, should not be done until the line of demarcation has formed, as it is impossible to know beforehand at what level the limb must be removed. In the case of gangrene resulting from local injury due to crushes, compound fractures, etc., amputation should be done as soon as gangrene is manifest; it is impossible to prevent infection in such cases, and delay in resort- ing to amputation usually will cost the patient his life. When gan- grene is due to arterial occlusion (embolism, ligation for wound), amputation should be done at the site of the occlusion, as soon as gangrene is evident (Guthrie, 1815); but in the case of injury to the superficial femoral artery, amputation below the knee usually is suffi- cient, and occasionally in the upper extremity a collateral circulation may be established, so that here it may be justifiable to await the formation of a line of demarcation, un- less sepsis threatens. Special Forms of Gan- grene.— Decubitus or Bed- sore (Fig. 21) is due to necrosis of the skin and subcutaneous tissues from long continued pressure on bony prominences in those confined to bed, especially in those with debilitating diseases or in a helpless condition. Favorite sites are over the sacrum and fsacro-iliac joints (Fig. 22) ; but any point receiving constant pressure (occiput, scapulae, elbows, heels, malleoli) may develop bed-sores. They usually may be pre- vented by proper care of the skin, allowing no folds or creases in the Fig. 20. — Dry gangrene from embolism; male, aged forty years. In December embolus lodged in brain, causing right-sided hemiplegia; in March (three weeks before photograph) embolus lodged in right popliteal artery. Death a few weeks later. No operation. Episcopal Hospital. G2 DISEASES RESULTING FROM INFLAMMATION bed-clothes (the patient may lie on a blanket instead of a sheet), with frequent changes of position, and use of air-pillows, rings, water-beds, etc. Scrupulous cleanliness is most important, keeping the skin dry (in cases of involuntary dejections) and protecting it after use of stimu- lating lotions by dusting powders or soap plaster. The same measures are important in the treatment of a bed-sore when once it has formed. The slough should not be cut away until it is quite loose. Healing may be hastened by exposure of the ulcer to direct sunlight, gradually length- ening the exposures; or by nearly constant exposure to electric light. Constitutional treatment never should be neglected. Get the patient out of bed as soon as possible. Long continuance of a large bed-sore is a tremendous drain on the vitality and not infrequently is an indirect cause of death (exhaustion, sepsis, hemorrhage). Fig. 21. — Decubitus or bed-sore, in a patient, aged seventy-eight years; duration two months. The sloughs have been cut away. Episcopal Hospital. Fig. 22. — Cicatrices from bed- sores, in patient, aged twenty years, developing during typhoid fever five years ago. Episcopal Hospital. Hospital Gangrene {Sloughing Phagedena, Pourriture d'Hopital). — This scourge of military hospitals in former years is due, according to Vincent, to a specific "fusiform bacillus." Its clinical causes are crowding, bad ventilation and generally unhygienic conditions. It is now almost unknown. Only a very few cases appear to have occurred during the German War. It arises only in wounds, though the wounds sometimes are mere abrasions. The surface of the wound becomes dry, is covered with "a pulpy, ashen slough," and the circular shape and cup-like depression of the wound are con- sidered characteristic. By attention to hygiene, its development usually may be prevented. It is most successfully treated by strong antiseptics (bromin, iodin) and scrupulous cleanliness. Patients affected should be isolated. Amputation is scarcely ever necessary. Noma. — Noma is a gangrenous affection, almost exclusively con- fined to childhood, usually following the exanthemata (especially measles) or typhoid fever, Various bacteria have been found by AINHUM 63 different observers, certain forms of leptothrix being those most frequently present. As mixed infection, including saprophytes, almost always exists, the etiological relation of any one form is diffi- cult to determine. The disease affects the mouth {Gangrenous Stomatitis, Cancrum Oris) and the external genitals (Noma Pudendi), especially the genitals of female children. The ear and the rectum have also been affected. Whether in the mouth or the genitals, the disease usually starts on the mucous membrane, and in an incredibly short space of time, perhaps three or four hours, a gangrenous ulcer 3 cm. or more in diameter, may be present. The first thing to attract attention is often a shiny red spot on the exterior of the cheek, the gangrenous ulcer having nearly perforated before being discovered. But if this complication be kept in mind the disease may be detected at an earlier stage from fetor of the breath, disinclination for food, etc., which will lead the nurse or attending physician to examine the mouth. The constitutional symptoms are slight, and the child, though listless, may continue to play with its toys until the hour of death. The alveolus may be involved, the cheek perforated, and frightful destruction produced in a very short space of time. Treatment should be prompt and vigorous; the child being anesthe- tized, a mouth gag should be introduced, the cheek everted, scraped with Volkmann's spoon, and the base of the ulcer thoroughly cauterized with fuming nitric acid applied by a stout stick; or acid nitrate of mercury may be used. If the cheek has been perforated, it is best to exer- cise the whole ulcer; and it may be necessary to excise a portion of the alveolus (Fig. 23). Free stimulation must be employed afterward and the mouth kept constantly clean by the use of suitable washes. Death from exhaus- tion, bronchopneumonia, or pyemia, is the rule. The mor- tality varies from 70 to 95 per cent. If the child recovers, a plastic operation may be necessary to restore the cheek. Similar treatment should be adopted in the case of Noma Pudendi, which is a much rarer affection. Ainhum. — This is a rare tropical disease, generally ending in gangrene, which usually is dry, affects the toes, and is almost exclu- sively confined to the negro race. Unna, according to Freeman (1906), regards it as a circular scleroderma which strangulates the toe. The affected parts appear as if tightly constricted by a string, and spontaneous amputation occurs after the lapse of an indefinite time. The disease may extend over ten years. Fig. 23. — Noma following measles, in a child, aged three years; duration one week. The gangrenous parts have been excised. Death. Children's Hospital. <;i DISFASFS RESULTING FROM INFLAMMATION Symmetrical Gangrene. —Symmetrical gangrene is due to an obscure affection of the nervous system (Raynaud's disease), causing local asphyxia of symmetrical portions of the body, especially ringers and toes, probably from vascular spasm. As a rule only small super- ficial sloughs are formed. The symptoms are tingling, numbness, etc. Intermittent claudication may be an early sign. Little can be done in the way of treatment, except tonics and hygienic measures. Massage and hot baths, locally, may be of benefit. The patients usually recover, though successive attacks are usual. Noesske (1909) incises the finger tip down to the bone and applies a cupping glass; his theory is that the gangrene is due to stagnation of blood from venous obstruction; and that if a constant fresh supply of arterial blood is obtained by cupping, gangrene may be prevented until the spasm ceases. Fluids may be introduced through a duodenal tube. Gas Gangrene. — See p. 88. Cellulitis. — Cellulitis is the term used to describe inflammation of the subcutaneous areolar tissue. This tissue, it is known, consists essentially of lymph spaces lined by endo- thelial or connective tissue cells; and it is now generally believed that these spaces have no direct communication with the lymph vascular system. Certainly cellu- litis, as such, is clearly distinguished from Fig. 24. — Suppurative cellulitis of right forearm, eleven days' duration. From infected wound of wrist. Incised and drained through interosseous membrane. Children's Hospital. Fig. 25. — Scars from multi- ple incisions for cellulitis of calf. Episcopal Hospital. lymphangeitis on the one hand, and from infectious dermatitis on the other. The causes are almost without exception bacterial infection, streptococcic rather than staphylococcic, usually from some abrasion or lacerated wound; but occasionally cellulitis, extending to the stage of suppuration, follows a contusion, a sprain, or a simple fracture, "aw o W si a J2 o ft *■& 0) > o3 «-- ■* tH •- o a CS =3 g «g x Eh ■ '- s S_ffi 'Z M r. O ved n has pisco] fj 'S '."H B _o oj M >a rt t* o -— . — T3 so ci ioo S3 ^ -< M ERYSIPELAS 65 the infection in such cases being conveyed to the place of lessened resistance through the blood-stream. Cellulitis may also follow extra- vasation of urine, of blood, etc. Symptoms. — The symptoms are those of inflammation, widely diffused beneath the skin, not in it, and characterized especially by swelling, pitting on pressure, and the absence of marked redness (Fig. 24). Treatment. — In the early stages rest procured by splints, by the use of a sling, by elevation of the part, together with local anodyne (lead water and laudanum) and antiseptic (corrosive sublimate and alcohol) applications after proper opening of the focus of infection, may suffice to effect a cure. As soon as evidences of suppuration occur, the overlying skin should be incised, in as many places as may be necessary, to give exit to pus, sloughs, etc. If the part affected is very tense, as is frequently the case in the forearm and hand, it is advisable to make free longitudinal incisions even before pus is formed, as the relief of pressure will enable the body tissues to combat the infection much more readily, and may prevent extensive sloughing. Fig. 25 shows the scars of multiple incisions for cellulitis of the leg. Erysipelas. — Erysipelas (a word usually supposed to be derived from two Greek words signifying red skin), known formerly as St. Anthony's Fire, is a specific inflammation affecting the skin, the subcutaneous tissues, or both. Occasionally the mucous or serous membranes are involved. It is a specific disease clinically; and according to some authorities its cause, the Streptococcus erysipelatis (Fehleisen, 1884), is specific, in the sense that it causes no other disease; but equally good authorities maintain that it is not a specific microbe, but merely a variety of the common streptococcus, which for some unknown reason at certain times does not produce the usual symptoms. The seat of the inflammation is the lymphatic spaces of the skin itself (dermatitis) and of the subcutaneous tissues (cellulitis.) Erysipelas probably always is due to the presence of a solution of continuity of the skin or mucous membrane, through which the bacteria enter the tissues; but while it is not extremely rare in patients with lacerated wounds and compound fractures, it arises much more often as the so-called idiopathic variety, in which the wound probably is some insignificant abrasion. Especially is this the case with facial erysipelas, one of the most prevalent forms, the wound of entrance being probably some excoriation of the nasal mucous membrane. The eruption is characterized by its intense redness, which returns immediately on the removal of pressure; by its glazed or shiny surface; frequently by vesiculation; by the raised, irregular, and well-defined borders of the inflamed area; and by the erratic manner in which it spreads (Plate I, Fig. 2). The inflammation is always most intense at the periphery of the patch, while the center may begin to fade away very quickly. In simple erythema the patches have no ten- dency to spread, their edges are not raised, and vesiculation is 5 06 DISEASES RESULTING FROM INFLAMMATION unknown. In scarlatina the rash is not localized, it is neither well defined nor are its margins elevated above the surrounding skin; vesiculation is absent; it is a rare disease in adults; and a history of contagion may be obtainable. The dermatitis resulting from Rhus Toxicodendron is very difficult to distinguish from ery- sipelas, except by the history; the same is true of saprophytic dermatitis (erysipeloid of Roscnbach), due to local infection from decaying fish, etc. In ordinary cellulitis the redness is less, and the raised margins and vesicles of erysipelas are absent; and as the skin itself is not involved in cellulitis the disease does not affect the ears nor usually the skin over the tip of the nose, in which situations subcutaneous tissue is practically absent. In erysipelas, on the other hand, the pinna of the ear is prone to invasion. \ 1014 DAY OF MONTH c 7 8 8 1(1 11 u 13 li 15 111 17 16 111 8 '.' 1" n I'-' 1 ; 11 u 16 17 1- 19 2D 21 105 104 103 - 102 - - A z - " = _ - A _J 2 101 6 10 ° p 1? " Q 98 97 : EE \l 9G PULSE 72 > - 1 is 1 " 1 18 1 DISEASES RESULTING FROM INFLAMMATION its variations are extreme, and the absence of periodicity is charac- teristic (Fig. 30). The highest temperature (104° to 106° V. or higher) on one day may be at a certain hour in the afternoon, whereas the next day the temperature may reach its highest point in the morning or not until late at night; or hyperpyrexia may be absent for an entire day or so. Chills are frequent, immediately preceding the fall of temperature, and are often indicative of the lodgement of an embolus, which may be attended by sudden pain. Prognosis. The prognosis is extremely bad; a few patients, in whom the infection seems to be attenuated and the course of the disease chronic, occasionally recover. DAY OP MONTH •i:> •_>»; 21 2S 29 11)1 103 cr I 2 102 a: HlOJ < |100 H 99 '.IS •17 \ i < 1 ^ -*■ t \ \ A / . i- PULSE ^_ r S T T i T ? $ RESP. ^ s r B 35 ?i £ ~, S Fig. 31. — Sapremia; rapid fall of temperature after evacuation of retained secundines. Episcopal Hospital. Treatment. — Treatment is the same as for septicemia. Constant vigilance is needed to detect and locate metastatic abscesses, and they should be drained immediately, when accessible; and unless the patient is so ill that a formal operation will hasten his death, the surgeon should not hesitate to evacuate abscesses of the internal organs or even the brain. By ligating or excising the main venous trunks leading from the original lesion, the infection sometimes may be successfully localized (internal jugular in mastoiditis, ovarian in parametritis, angular in facial phlegmon, etc.). Sapremia. — When dead or dying tissue is in contact with living cells, the ptomains and other poisons elaborated by the saprophytic bacteria which infest the former may be absorbed into the patient's body, and thus produce the usual symptoms of toxemia. When healing in the wounded area has progressed to the stage of granu- lation, little if any absorption occurs; but injudicious probing of a granulating wound may destroy this barrier, and evidences of sepsis will follow. It is sometimes impossible to distinguish mild grades of sapremia from aseptic fever, or from a slight toxemia due to absorption of the products of pathogenic bacteria. But if the removal SAPREMIA 73 of dead and decaying tissue restores the patient abruptly to health, the affection presumably was sapremia. Sapremia is seen in its typical form in puerperal cases, absorption occurring from the retained secun- dines (Fig. 31). Hectic fever, which is classed by Park as chronic Fig. 32. — Tuberculosis of hip; hectic temperature arrested by excision of hip. Orthopaedic Hospital. sapremia, is most typical in patients with tuberculous bone disease, where sinuses exist, and as a consequence the decaying bone has become infested with saprophytic bacteria. Fig. 32, from a patient with coxalgia, formerly under my care at the Orthopsedic Hospital, shows hectic fever promptly arrested by excision of the hip. CHAPTER III. SURGICAL INFECTIONS. Situated pathologically half way between pure inflammation and neoplasms, exists a group of surgical diseases usually described as the infections granulomas. This term implies that although the lesions are definitely known to be caused by specific microorganisms (which is not the case with tumors), yet the tissue reaction to these specific irritants is characterized rather by cell accumulation than by actual destruction of tissue by suppuration. It is as if the irritant were too timid to provoke vigorous resistance, yet too enduring to be overcome at the first onslaught; the tissues of the body seem either indifferent to the invasion, or unable to continue the struggle with the success which usually attends their warfare in acute inflam- mation. While the more important of these modified forms of inflam- mation (Tuberculosis, Syphilis, Actinomycosis) partake of the nature of subacute or chronic reactions, there are others (Anthrax, Glanders, Gas Gangrene, Tetanus, Hydrophobia) in which the reaction is acute, and the lesions less circumscribed, but which it is nevertheless con- venient to discuss in the same chapter. CHRONIC INFECTIOUS SURGICAL DISEASES. Tuberculosis. — Surgical tuberculosis includes all manifestations of this infection, wherever situated, which are amenable to surgical treatment. The specific cause of the disease, the B. tuberculosis (Koch, 1882), gains entrance to the body usually through the digestive or the respiratory tract. It has been held by good authorities that the bacilli may pass through the respiratory or intestinal mucosa and produce no lesions in it. The bacilli lodge most frequently in the lung; next most frequently in the lymphatic nodes — cervical, bronchial, or mesenteric. Occasionally infection occurs through an open wound; inoculation with tuberculous material while dissecting produces the so-called anatomical tubercle. The bacillus is omnipresent in civilized life, and it is by no means improbable that it lives as a parasite in the bodies of most apparently healthy persons. It is always at hand to attack any place of lessened resistance, and to explain its prompt appearance in such locations it is usually necessary to assume that it was present previously, though latent, somewhere in the patient's body. Scrofula, formerly con- sidered a distinct disease, is now generally recognized as identical with tuberculosis; it may be considered tuberculosis in its primary, latent state. (74) SURGICAL TUBERCULOSIS 75 Tuberculosis is most often primary in the lungs, digestive tract, lymph nodes, urinary and sexual organs, and the bones. Surgical tuberculosis, which is said usually to be secondary to an inconspicuous lesion of the lungs, is seen especially in the lymph nodes, the bones and joints, the sexual organs, peritoneum, etc. 1 Pathology. — The local lesion produced by the B. tuberculosis is called a tubercle; its proper adjective is tuberculous; and it should be distinguished from a tubercule, a term which describes the anatomical form of the lesion of a skin eruption which is called tubercular, but which is in no way connected with tuberculosis. When the B. tuber- culosis begins to proliferate in the tissues, its first effect is to exert chemotactic action upon the connective tissue and endothelial cells in its immediate vicinity. It does not exert positive chemotaxis upon the leukocytes circulating in the blood, and leukopenia not leukocy- tosis is the rule; but the number of circulating lymphocytes may be relatively increased. Locally, as the tissue cells accumulate, their appearance changes, the cells swell up, become pale, and resemble epithelial cells so closely that they are widely known as epithelioid cells. This accumulation of epithelioid cells around the tubercle bacilli causes an anemia of the central area, and the epithelioid cells themselves gradually suffer from lack of nourishment, and, instead of actively dividing and multiplying their number as at first, they seem to be unable longer to carry on the processes of independent existence, and their cell bodies fuse; so that among the epithelioid cells there soon appear two, three, or more large cells with multiple nuclei, arranged around the periphery or at the two poles of the cell — the so-called giant cells. In the area immediately surrounding the giant cells and epithelioid cells, the lymphocytes accumulate; while the center of the tubercle is composed of tissue and cellular debris under- going caseous degeneration, which is the form of anemic necrosis particularly characteristic of tuberculosis. Some phagocytosis exists, but it sometimes seems as if the tubercle bacilli continued their exist- ence as parasites even within the cell bodies of their victim: they are most apt to be seen within the giant cells; they are frequently present in the epithelioid cells; but are said never to be found within the lymphocytes. The histological tubercle, thus, may be represented diagrammatically (Fig. 33) as composed of three portions: (1) a cen- tral caseous or necrotic area, in wdiich may be a giant cell, its own center showing commencing caseation; (2) the epithelioid cells sur- rounding the caseous center, and (3) the peripheral aggregation of lymphocytes. The products of the tubercle bacillus, spoken of generically as tuberculin, are not very well understood; it seems probable, never- theless, that caseation is induced by the toxins set free from the bodies of the bacilli when they die, but that the irritant action of the 1 Some modern investigators believe that the bovine form of Tubercle bacillus is responsible for "surgical tuberculosis," while the human form is that usually found in the lungs. 76 si lialc \l, INFECTIONS living- bacilli is only sufficient to provoke cell accumulation and multi- plication. These various products of tubercle bacilli usually exist in greater or less amount in the body fluids and excretions of animals suffering with tuberculosis; and, when injected into other animals afflicted with tuberculosis, the tuberculin contained in them produces a characteristic reaction which may be used for the purpose of diag- nosis (p. 79). Fig. 33. — Section through a tubercle. Upon the margin of the tubercle lymphoid cells may be seen; in the center epithelioid cells and a giant cell. (Lexer-Bevan.) The primary tubercle may be replaced by granulation tissue former! from the surrounding connective tissue cells, and healing may occur in a manner similar to that of simple inflammation. Or the "pyogenic membrane" may isolate and encapsulate the tubercle, and thus the disease may be arrested; calcification is a frequent sequel. On the other hand, some of the bacilli may escape through the cordon of epithelioid cells on guard, and, settling in a neighboring portion of the tissues, they may there proceed to form a new tubercle; and as many more tubercles are formed, the area may become visible to the naked eye, and the center of the entire mass may be seen as a caseous nodule surrounded by comparatively healthy tissue (Fig. 34). Two processes may thus be initiated — either productive or degenerative; the former gives rise to tuberculous {fungous) granulation tissue, fre- quently described as the tuberculous gumma (Figs. 35 and 37), because it is very difficult to distinguish it histologically from the gummas of SURGICAL TUBERCULOSIS 77 syphilis, actinomycosis, etc.; whereas the degenerative changes result in the formation of a cold abscess, so named to distinguish it from the ordinary abscess of inflammation, which is characterized by its heat. 8 M J Fig. 34. — Cross-section of tuberculous testicle, showing areas of caseation. Skin adherent. One sinus has been divided in the section. From a patient in the Episcopal Hospital. Tuberculous granulation tissue has a great tendency to displace all normal tissues with which it comes in contact: in bones it causes the disappearance of the normal osseous structure; in joints it grows upon Fig. 35. — Tuberculous gummas of leg, in a baby, aged eight months. Children's Hospital. the synovial membranes, producing fibrous ankylosis; in tendon sheaths it spreads along their course, gradually invading the tendons and in time causing their .entire disappearance. The degenerative SURGICAL INFECTIONS changes, which by the process of coagulation and liquefaction necrosis chance tuberculous granulation tissue into cold abscesses, are probably due, as already pointed out, to excessive destruction of tubercle bacilli with liberation of their endotoxins, and to the action of fer- ments set free by the death of cellular protoplasm. When the cheesy pus finds an exit for itself, the tuberculous abscess is converted into a tuberculous sinus, or if the walls of the abscess cavity are unable to collapse, as in bone, and often in the lungs, a tuberculous cavity remains. As the tuberculous sinus heals, it becomes converted into a tuberculous ulcer (Fig. 36). It was once hoped that by the admin- istration of tuberculin to tuberculous patients their tuberculous lesions could be disintegrated and caused to discharge; but, unfortunately, it has been found that sudden disintegration of tuberculous foci is Fig. 36. — Scrofulous ulcers, duration one month. Two months after incomplete operation for recurrent tuberculous cervical adenitis. Episcopal Hospital. Fig. 37.— Tuberculous dactylitis (tuber- culous gummas of fingers). Children's Hospital. more apt to be followed by acute generalized miliary tuberculosis, which may be succinctly described as tuberculous pyemia. Any secondary infection, moreover, of a tuberculous focus, is prone to aggravate the condition by weakening the protective layer of epithe- lioid and lymphoid cells which surround the tuberculous area. The great danger when any cold abscess discharges is that of secondary (pyogenic) infection. As Calot says, the opening of a cold abscess is the opening of a door by which death soon enters. Diagnosis. — The detection of the tubercle bacillus in the lesions renders the diagnosis certain; but in the vast majority of cases this is not requisite, as the clinical appearances are quite sufficient to justify the diagnosis of tuberculosis. The indolence of the reaction, the slow course of the disease; the characteristic cheesy material discharged from the sinuses; the absence of leukocytosis in uncom- SURGICAL TUBERCULOSIS 79 plicated cases; and the general appearance of the patient; these all, when combined in one individual, make the actual detection of the tubercle bacillus an unnecessary task in most cases of external tuber- culosis (bones, joints, lymph nodes, skin, etc.). In tuberculosis of certain internal organs, especially the kidney, it is highly desirable to detect the bacilli in the excretions. Another aid to diagnosis is the tuberculin test (p. 76): old tuberculin 1 is that generally used, the initial dose in adults being one-tenth of a milligramme (0.0001 gramme) hypodermically ; this may be increased at subsequent injec- tions to 1 and even to 5 milligrammes. The hypodermic use of tuber- culin gives reasonably accurate results, and I prefer this method to the conjunctival test of Calmette, or to the inunction of Moro's tuberculin ointment. The cutaneous reaction of v. Pirquet is usually to be preferred in children (under twelve years of age), but as it appears to indicate the existence of latent or healed tuberculosis (very rare in children) quite as readily as an active focus, it is not regarded as so accurate as the hypodermic test for adults. The hypodermic test, unless repeated, causes reaction only when there is an active focus in the body; but it does not necessarily indicate that the lesion suspected is tuberculous. If, however, its use causes an exacerbation of symp- toms in the suspected lesion (focal reaction) there can be very little doubt of its tuberculous character. After the hypodermic injection has been given, the patient's temperature should be recorded every two hours for a period of 24 hours: a positive reaction, indicating the presence of tuberculosis, consists in an abrupt rise of temperature to 101° or 102° F., occurring usually about the twenty-second hour. 2 Sometimes a chilly sensation is experienced as the temperature begins to rise. If the first injection is negative, a second and even a third may be given, gradually increasing the dose. I have never seen any untoward result. The reaction is positive in most cases of tuberculosis not in advanced stages; it is usually negative when secondary infection is present, with amyloid changes in the viscera and a hectic temperature; but in such cases the diagnosis is easy enough without this test. Indeed it is quite useless to employ a tuberculin test if the diagnosis can be made clinically. In v. Pir- quet's method three small areas on the arm are abraded, and into one or two of these the tuberculin is rubbed; the other abrasions being used as controls. On the second or third day, in tubercu- lous cases, the infected area shows a characteristic, erythematous, papular, and even vesicular eruption. 1 Old tuberculin is a filtrate of a concentrated glycerin extract of tubercle bacilli ; it is possible that some of the bacilli may not be excluded by the filter; to obviate this danger Koch prepared two new tuberculins: of these Tuberculin Oberst (T. O.) is the supernatant liquid obtained by centrifugalization of a concentrated glycerin extract- of tubercle bacilli; the sediment which forms, containing the bacilli themselves, is ground up and again centrifugalized, and forms Tuberculin Rest (T. R.). T. O. resembles old tuberculin, and may be used instead of it in diagnosis; T. R. is used in treatment. 2 An earlier rise, especially within a few hours of the injection, probably is due to some contamination. 80 SURGICAL INFECTIONS Treatment. -Constitutional and hygienic treatment are quite as important in surgical as in medical tuberculosis. The majority of patients with surgical tuberculosis are children of a school-going age. It is better for them to give up school for one or two years, until their constitution is strong enough for them to conquer the dis- ease, than to attempt to keep up in their classes and grow physically worse and worse. It may not be possible for them to sleep in the open air, but they can at least sleep with all the windows in their room open, and be out of doors as much as possible during the day. In hospitals provided with suitable roof-gardens, where the patients may be kept in the open air practically twenty-four hours out of the twenty-four, it has been found that operative treatment is scarcely ever-required. In institutions where it is impossible for one reason or another to keep the bed-ridden patients out of doors constantly, it usually is quite possible for their beds to be wheeled out of doors and left out from 7 a.m to 7 p.m. It is by no means necessary to have a hospital in the country for these patients: porches and balconies, even if roof-gardens cannot be obtained, will accomplish the same results in the most thickly settled parts of the city. Hand in hand with the open air treatment must go full, wholesome diet, especially milk and eggs; and the only medicine usually required is cod liver oil, which seems to act better than any other remedy in increasing the appetite and causing the patients to put on flesh. In the rare cases where it does not do good, the syrup of the iodide of iron, the compound syrup of the hypophosphites, or other remedies, may be tried. Locally, I am convinced that tuberculosis of the soft parts demands a different treatment from that of bone. In the latter case such re- markable results are obtained in children by local rest, without opera- tive interference, that I am extremely conservative in urging any other surgical treatment: the use of plaster casts, braces, weight extension in bed, together with proper hygienic treatment, will cure nearly all patients in whom these methods are adopted early. As regards tuberculosis of the soft parts (lymph nodes, generative and urinary organs, peritoneum), however, local rest is usually impossible to secure, and I feel sure that better results are obtained by radical operation, removing the entire disease; and when this is impossible, as in the abdomen, at least removing the primary focus. The local treatment adapted to each form of tuberculosis will be pointed out when the surgery of those portions of the body is discussed. Syphilis. — This is an infectious granuloma due to inoculation with the Treponema pallidum (Spirochceta pallida), a parasite described by Schaudinn and Hoffman (1905), and obtained in pure culture in 1911 by Noguchi and by Hoffmann. Pathology. — This organism usually gains access to the tissues through some abrasion or excoriation of the skin or mucous mem- branes, being inoculated directly from a sore in another person suffer- ing from syphilis (immediate contagion). Occasionally mediate con- PATHOLOGY OF SYPHILIS 81 tag ion occurs, the virus being transmitted by means of soiled towels, eating and drinking utensils, etc. When inoculated, there follows a period of incubation, averaging from three to five weeks, during which the microbes multiply at the site of primary invasion, and are carried by the lymph channels to the nearest lymph nodes; so that by the time the local reaction appears at the site of original inoculation, the disease is already diffused in the patient's body. Neisser found the blood contained the virus as early as the fifth day after inoculation. The local reac- tion (chancre) resembles the tubercle in some ways : a col- lection of round cells occurs, and there may be a few giant cells present ; but the chancre is particularly characterized by the great proliferation of the endothelial cells lining the capillaries. By proper stain- ing methods the presence of the Treponema pallidum may be demonstrated; otherwise the histological picture is not regarded as conclusive, though endothelial proliferation is always suggestive of a syphi- litic lesion. The chancre is situated in the true skin (derma) ; usually when first seen, exfoliation of the overlying epidermis has occurred, converting the primary lesion into a superficial erosion; in some cases the local reaction is much more marked, and the deep or Hunterian chancre develops. Usually very soon after the appearance of the chancre, enlargement of the regional lymph nodes may be detected; and not infrequently the lymphatics leading to these nodes are palpably enlarged. There follows the second period of incubation, lasting on an average about six weeks; during this period the virus of the disease is spreading past the first group of lymph nodes, and is carried by the blood-stream all over the patient's body. Various prodromal symptoms, such as fever, malaise, headache, vague "rheumatic" pains, etc., may be experienced during this time. As in typhoid fever, the infecting organisms lodge first in the cutaneous capillaries, and the well known rashes of syphilis {secondary lesions, syphilodermas) are produced; at the same time the lymph nodes all over the body become enlarged, especially the posterior cervical and epitrochlear groups. The lesions of this secondary period are not confined entirely to the skin; the mucous membranes usually are also affected, the eruption appearing in modified form in the mouth, the fauces, and the vagina. The histological picture of these secondary lesions presents 6 Fig. 38. — Treponema pallidum (Spirochseta pallida): a, red; b, white-blood corpuscles. (Lexer-Bevan.) 82 SURGICAL INFECTIONS nothing pathognomonic of syphilis; but the proliferation of the endo- thelial cells lining the bloodvessels is usually sufficient at least to sug- gest the syphilitic nature of the disease, and the specific organism usually may be delected by smears made from the ulcerated sores. Still later, more or less typical lesions appear in the deeper structures and in the internal organs. These, which are known as gummas, are characteristic of the third stage of syphilis; they consist essentially of an aggregation of round lymphoid cells, with an occasional giant cell at the periphery of the lesion; bloodvessels are less conspicuous in the tertiary than in the secondary lesions of syphilis. The Tre- ponema pallidum rarely can be found in these tertiary lesions; it is practically never to be detected in those with pyogenic infections. As in the case of tuberculosis, so here, there is a marked tendency for the center of these lesions to undergo various forms of degeneration, of which the hyaline and fatty are the most usual. Instead of the cheesy pus so characteristic of tuberculous suppuration, the product of syphilitic suppuration is known as gummatous pus. In tertiary as well as in secondary lesions, there is a marked tendency for the disease to be productive at the periphery of the lesions, while degenera- tion occurs in the center. This is thought to account for the charac- teristic serpiginous form of some of the later skin lesions (Fig. 1020). The tertiary lesions of syphilis heal by granulation and cicatrization, with resulting deformity from contraction of the scar-tissue. The •scars are typical, both on surfaces and in the interior of organs — in the former situations the regular outline, circular form, and depressed, shiny base of the cicatrix are nearly pathognomonic of a former syphilitic lesion; while the radiating, star-like cicatrices in the internal organs usually may be recognized at a glance. Secondary infection with pyogenic bacteria is a frequent occurrence in gummas; this hastens the destructive process and increases the subsequent deformity. No tissues are exempt from the ravages of syphilis. The favorite seats for the secondary lesions are the skin, mucous membranes, and iris. In tertiary syphilis the periosteum, bones, and joints; deep sub- cutaneous tissues; palate and nasal structures, iris, retina, and choroid; the internal and generative organs ; and the nervous system ; are those most usually affected. This brief sketch of the pathology of syphilis will suffice for the present chapter. The clinical aspects of the disease, as well as the treatment, will be discussed in Chapter XXVI, while important syphilitic lesions of the various parts and systems of the body will be described in chapters devoted to regional and systemic surgery. Actinomycosis. — The cause of this disease commonly is known as the Ray Fungus, from its appearance under low powers of the micro- scope (Fig. 39); but scientists differ as to w T hether it shall be classed with the moulds (hyphomycetes) or with bacteria (schizomycetes). This organism is found growing on hay and straw, and also in the ground, whence it may be incorporated in growing vegetable matter. It was first observed by von Langenbeck in 1845, in the pus from a ACTINOMYCOSIS SI! Fig. 39. — Grains of actinomyces from human pus. X 450. (Marwedel.) patient with caries of the vertebrae. Formerly, instances of the dis- ease were considered sarcomatous or carcinomatous in nature. In cattle the ray fungus is a frequent source of disease (lumpy jaw, swelled head) ; but few cases have been observed in which actual trans- mission from animal to man has occurred. The usual source of infec- tion in man is believed to be chew- ing of diseased grain; but J. H. Wright (1905) claims that the ray fungus is quite commonly found in healthy mouths, both of man and beast, and asserts that the action of the cereal is merely to prepare a locus minoris resistentioe where the fungus can develop. Pathology. — Like the other in- fectious granulomas, actinomycosis is characterized by a local produc- tive reaction. There is very little tendency to necrosis; but in man- kind secondary infections are the rule, and hence suppuration is much more frequent than in the lower animals. The cellular infiltrate surrounding the focus of disease consists of small round cells, giant and epithelioid cells; conversion into granulation tissue occurs, and this tends to cicatrize. The dis- ease is prone to extend along sinuous and branching tracts, suppura- tion occurring in the center, while the sinuses are lined with the granulomatous tissue. In the pus discharged from these tracts, the colonies of the fungus are visible to the naked eye, as minute yellow granules; these impart to the fingers a gritty sensation due to the presence of calcareous salts. The disease is chronic, and unless vital parts are attacked, life may be prolonged for years. Occasion- ally metastatic foci are developed through the blood-stream; but the disease never extends by the lymphatics, and enlargement of the regional lymph nodes usually is an indication of secondary infection (Frazier, 1906).' Symptoms. — Four distinct varieties of human actinomycosis are recognized: the oral, the pulmonary, the abdominal, and the cutaneous. The origin of the first has already been described; from the tissues of the mouth proper, the jaws, the cheeks, the neck, and even the skull and brain may be invaded. The pulmonary form, due to inhalation, usually assumes the character of a low grade basal pneumonia; pleural effusion and invasion of the thoracic parietes are frequent. The spine may be involved, and the cold abscesses formed may closely simulate those of tuberculosis. Abdominal actinomycosis, especially frequent in the neighborhood of the cecum, is of the hyperplastic type, abscess formation and intestinal perforation being rare; the dis- ease tends rather to produce adhesions to the parietal peritoneum, and to invade the abdominal wall, producing there the characteristic si SURGICAL INFECT l()SS lesions seen whenever the skin is invaded. Cutaneous actinomycosis frequently may be diagnosed without microscopical examination of the pus; the sinuses, with the involuted, hypertrophied skin; the chronic and nearly painless course of the disease; the typical "board- like" induration, sharply outlined; and perhaps the presence of hard cords under the skin running from the main lesions out in various directions; all make a picture which is not readily mistaken for anything else. Diagnosis. This must be made from malignant tumors, which may be closely simulated by the hyperplastic form; from osteomyelitis and tuberculous lesions of bones and joints; from inflamed sebaceous cysts of the face (Fig. 40), which, as pointed out by Lexer, some- times bear a striking resemblance to actino- mycosis; and from gummatous and other syphilitic lesions. Treatment. — If complete extirpation is possible, this should be done; but in most cases the surgeon must content himself with freely opening all the sinuses, removing the granulation tissue with Volkmann's sharp spoon (Fig. 509), cauterizing the remaining tracts with the actual cautery or some chem- ical caustic (chloride of zinc 10 per cent.), and packing the wounds with iodoform gauze. Iodide of potassium is said to have a remarkable effect, administered in large doses for two or three weeks at a time and then discontinued for one week. Bevan (1908) has used cupric sulphate pills, one quarter of a grain, thrice daily, with marked benefit; he also irrigates the wound with 1 per cent, cupric sulphate solution. This method is based on the agricultural treatment of the diseased grain. Out of door life, and hygienic measures, as for tuber- culosis, are of almost equal importance with topical remedies. Madura Foot. — Madura foot, first observed in Madura, India, in 1712, is occasionally seen in America. It is due to a fungus closely resembling the actinomyces; one foot only is involved as a rule; very occasionally the hand is affected. A painless swelling forms on the sole; softening and suppuration follow. The course is chronic. Fistulas form, heal, and again break open. Finally all the structures of the foot are invaded. Amputation is the best treatment. Blastomycosis. — This is a surgical infection whose chief lesions are manifested in the skin, caused by organisms of undetermined biological position, known as blastomycetes. A few cases of systemic infection have also been reported. According to Bevan (1908) "the cutaneous lesions have been mistaken most often for verrucous tuber- culosis, less often for syphilis, and occasionally for epithelioma. . . . Fig. 40. — Multiple seba- ceous cysts of the face simu- lating actinomycosis. Epis- copal Hospital. ANTHRAX 85 Tuberculosis is the disease which is most apt to be confused with systemic blastomycosis." The diagnosis is best made by micro- scopical examination of the pus from the cutaneous lesions, or by excluding the existence of tuberculosis by the usual tests. Bevan thinks potassium iodide is the most valuable remedial measure; he gives as much as 600 grains a day, well diluted. Cupric sulphate has also been used. Hygienic measures are important. In advanced cases the lesions must be treated surgically, by excision, curettement, cauterization, etc. Rhinoscleroma. — Hhinoscleroma, a chronic infiltrating, productive infection of the nasal mucous membrane (rarely of the pharynx, larynx, and hard palate), is almost unknown in this country, though common in Austria and southwestern Russia. It is possibly due to a diplobacillus (v. Frisch, 1882). It is highly destructive, invading all surrounding tissues, and clinically resembling other infectious granu- lomas. Excision is the best treatment; when this is impossible enough of the growth should be removed to facilitate breathing. ACUTE INFECTIOUS SURGICAL DISEASES. Anthrax. — This disease, due to infection by the B. anthracis (Davaine, 1873; Koch, 1877), is common in sheep, horses, etc., and may be transmitted to man directly, or through contagion from wool, hides, etc. Invasion occurs through abrasions of the skin or mucous membrane; or through the respiratory or the intestinal tract. The period of incubation is one or two days. The local reaction consists in a cellular and serous exudate, producing marked edema, with a tendency to central necrosis. Eighty-five per cent, of cases affect the head, face, and neck. In severe cases anthrax bacilli enter the blood current, and bacteriemia results; as the bacilli are too large to pass through capillaries of ordinary size, they are arrested at various places and produce carbunculoid lesions in these new situations. The cutaneous form (Charbon; malignant pustule) is characterized by the formation of a papule, changing into a vesicle, surrounded by an edematous area (Figs. 42 and 43) ; no pus is discharged. The vesicle dries up, a scab forms, central necrosis occurs, the black central core completing the typical picture. The pain ceases, and in mild cases the slough may be cast off, and spontaneous healing occur. In severer cases, lymphadenitis and angeioleucitis develop, toxemia becomes profound, and death may ensue in a few T days. The pulmonary form (icoolsorter' s disease) is of slight surgical importance; 80 per cent, of patients are said to die by the fifth day. The intestinal form is characterized first by symptoms of ptomain poisoning; then by hem- orrhages; and finally the lodgement of the bacilli in the cutaneous capillaries produces a widespread carbunculoid eruption soon followed by death. Diagnosis. — Anthrax is to be distinguished from other surgical infections by the history of exposure to the infection; by the local st; ACUTE TNFECflOUS SURGICAL DISEASES edematous reaction, with central Mack core; by the absence of pain and suppuration; and finally l»y detecting the bacilli in smears made from the lesion. \5* Fig. 41. — Anthrax bacilli. Spore formation. From an agar culture twenty-four hours old. About the margin of the photograph are a number of free spores. X 600. (Karg and Schmorl.) Fig. 42. — Anthrax of face. Episcopal Hospital. Fig 43. — Anthrax of face. Black slough in center of edematous area. Treatment. — Excision should be done when possible, as is usually the case when an extremity is affected. Injections of pure carbolic acid around the lesion (five drops in each puncture) have seemed to be beneficial in some cases. Pressure on the pustule is to be avoided. Locally, antiseptic applications are indicated. In severe cases Bar- lach (1908) surrounds the lesion by a circle of punctures made by the GLANDERS N< actual cautery; he has treated 23 cases with no deaths. Most im- portant of all, however, appears to be the use of Sclavo's serum (1897); in many cases of the disease (pulmonary and intestinal) it is the only remedy available; 30 to 40 c.c, in divided doses, are injected at different points in the abdominal wall. This dose may be repeated, if necessary, the following day. In severe cases intravenous injection should be tried (Lawen, 190S). By these means the mortality has been reduced to 6 and even to 3 per cent, in large series of cases. Glanders (Farcy), due to the B. mallei (Loffler and Schiitz, 1882), is common in horses, asses, and mules (equinia); sheep and goats are also affected. From these lower animals the disease is sometimes conveyed to man by « \ the spray emitted by the horse, mule, etc., • / \]\ b . \^\ in sneezing, or by means of the purulent < * ^ ^ < 5 ^ discharge from other sources. Occupation in \\ jj \W ^ W stables is therefore a predisposing cause. [ N^"^ f^ j x Invasion occurs by inoculation of an abrasion • \ ' A\ the respiratory or digestive tract. The result- ing infection runs an acute (very rarely a gian'dera^B^mSs'mllleo! chronic) course. The local lesion somewhat (Abbott.) resembles a tubercle ; the regional lymphatics - are affected early, and dissemination through the blood-stream is rapid. The lesions, wherever situated, are specially characterized by their tendency to rapid suppuration. Along the lymphatics, small hard nodules (farcy buds) appear, and soon suppurate. In the lungs multiple foci, which soon suppurate, are produced. A diffuse pustular eruption, sometimes mistaken for smallpox, frequently occurs in the skin (Fig. 45). In the subcutaneous tissues and muscles, hard, movable nodules appear, especially in the biceps, flexors of forearm, rectus abdominis, and pectoral muscles; the nodules soon suppurate. Bones may be invaded, and by implication of joints pyarthrosis may occur. Symptoms. — The period of incubation varies from three to seven days; malaise and indefinite typhoidal symptoms are the first to appear. In glanders, naso-pharyngeal granulomas are the earliest lesions, with ulcerations, causing sero-sanguineous catarrh ; then pneu- monic signs; and finally the cutaneous rashes, and subcutaneous and muscular nodes. Leukocytosis usually is not marked. In farcy, the skin affected becomes intensely inflamed; farcy buds appear along the lymphatics and soon suppurate; while the later symptoms resemble the last stages of glanders. Diagnosis. — In the acute cases this is rarely made before death. The patient's occupation, microscopical examination of the discharges, and a negative Widal reaction, are factors which may indicate the nature of the malady. By the time the characteristic nodes appear, the patient is beyond the reach of treatment. In animals the disease may be detected by the "mallein test" (similar to the tuberculin test, 88 ACUTE INFECTIOUS SURGICAL DISEASES p. 79). .The chronic form of the disease resembles the late stages of syphilis. Prognosis. The disease is extremely fatal (85 to 90 per cent, of cases). Death occurs in from one to three weeks. Treatment.- — Isolation should he immediate, as the disease is easily conveyed by both immediate and mediate contagion. If an extremity be affected, amputation is indicated. Localized lesions elsewhere should be excised when possible; at least they should be opened and treated with rigorous antiseptic methods. Curettement and scrub- bing are liable to disseminate the bacilli. Hygienic treatment often is all that is available. Fig. 45. — Pustular eruption in human glanders. (Dr. Zeit's case.) Gas Gangrene.' — Gas gangrene is a form of acute infection almost invariably observed only as a complication of severe compound frac- tures or lacerated wounds; but it has occasionally followed punctured wounds or even mere abrasions. There are recognized, according to Weinberg (1918), more than forty different bacteria as causes; but those most frequently found are the B. perfringens (known also as the B. aerogenes capsulatus, or B. welchii, 1892), B. sporogenes, B. cedematiens and the Vibrion septique, especially that first named. The B. cedematiens produces no gas, but causes a characteristic hard white edema of the subcutaneous tissues and skin. 1 Among the numerous synonyms may be mentioned traumatic gangrene (Renault, 1840), traumatic spontaneous emphysema (Malgaigne, 1845), gangrene foudroyante (Chassaignac, 1853), acute purulent edema (Pirogoff, 1854), erysipele bronze (Velpeau, 1855). The malignant edema of Brieger and Ehrlich, said by some authorities to be caused by a specific bacillus (B. cedematis maligni), is a closely analogous if not indeed an identical affection. H. Henry (1917) considers the modern B. sporogenes the same as the old B. cedematis maligni. GAS GANGRENE 89 Gas gangrene is rare in civil surgery, where I have seen only 3 eases in nineteen years; but during the German war it has been very fre- quent, largely owing to the character of the soil in which the fighting took place. For many generations this has been highly fertilized with human and bovine dejections, so that fecal contamination of the wounds was the rule rather than the exception. Two conditions are necessary for the development of gas gangrene: (1) the presence of the gas-forming bacteria in the wounds; and (2) conditions favorable for their growth. As the soldiers' clothing is nearly always impreg- nated with the B. perfringens, the lodgment of particles of clothing Fig. 46. — Emphysematous gangrene. Recovery after amputation at the shoulder-joint. Episcopal Hospital. in the wounds is especially dangerous; while any conditions which deprive the tissues of oxygen favor the growth of these anaerobic bacteria. Among these conditions may be mentioned mixed infection, especially with the streptococcus; the presence of a hematoma; and particularly rupture of the main artery of the limb. Prolonged application of a provisional tourniquet is another predisposing factor. Bruised and lacerated muscle tissue forms a very favorable nidus for the growth of these anaerobic bacteria, owing to the hemostatic properties of injured muscle. Indeed it has been claimed that gas gangrene always develops primarily in muscular tissue. It is at any rate rare in the feet, head, neck, trunk and almost unknown in the 90 ACUTE INFECTIOUS &URGtcAL DISEASES hands; while it is most to be feared in the muscular parts of the limbs, especially the thighs, calves of the legs, buttocks, upper arms and scapular regions. Three stages of the disease may be recognized, though the duration of each stage may vary greatly: (1 ) The wounds may be contaminated by bacteria of gas gangrene (as shown by smear and culture) without notable clinical symptoms, especially if the wounds are wide and gaping. Such cases do well after excision and debridement (p. 201) of the injured tissues. (2) When active infection is already present (usually after an interval of twenty-four to forty-eight hours from the time of injury), attention is attracted by the peculiar odor emitted from the wounds; it has been likened to the odor of mice, but is dis- tinctly sui generis, and easily recognized when once experienced. The patient complains of a sense of constriction in the affected limb, even if the dressings are loose, and on examination the part is found swollen, tense and exquisitely tender. Such tenderness in a battle wound is almost pathognomonic. There may be patches or large areas of bronzed erysipelas (the color is believed to be due to hemolysis) and these may be at a distance from the wound. At this stage, still, very wide debridement may suffice, unless the lesion includes a fracture, or injury to a large bloodvessel, or opens a joint, when amputation is demanded. (3) The stage of true gas gangrene has seldom been seen except shortly before the patient's death; the subcutaneous tissues, the muscles, the intermuscular planes, and perhaps even the medulla of bones may be affected. The muscles form a purplish, pultaceous, stinking mass; they are spongy to the touch, and foam exudes when they are compressed. Exposed surfaces are covered with an ashen or grayish slough. Emphysematous crackling extends with alarming rapidity along the course of the large vessels; the skin becomes dusky and mottled in appearance, and finally the vesications and bulla?, so characteristic of fermentative changes in already mortified parts, may develop. Incisions into the swollen and boggy tissues give exit to frothy fluid and malodorous gases. There is no pus. The usual constitutional symptoms of toxemia (p. 69) develop, rapid respiration being especially noted, though there may be little fever, and the pulse sometimes is slower than normal. Death usually ensues a short time after the infection reaches the trunk. The entire course of the disease may extend over only six or eight hours. While, accord- ing to Chalier (1917), the gases themselves are poisonous, it is the bacterial toxins and the metabolic products of muscle destruction which are usually held responsible for death. The only safe treatment for this emphysematous stage is immediate amputation high above the limit of disease. The amputation should be done by the einschnitt method of Esmarch (p. 218), called in France the guillotine method or amputation en savcisse; this method exposes the least possible area to re-infection (not unknown), and leaves the least possible granulat- ing surface for repair. If the amputation is done near the trunk, no tourniquet should be used, but the main vessels should be ligated and TETANUS 91 divided as the first step. In cases where amputation cannot be done, or even in addition to amputation, multiple (150 to 200) cautery punctures should be made through the deep fascia, as advised by Michaux (1914) and others, in the tissues bordering the gangrenous area as well as in this itself. Such punctures drain longer than inci- sions by the knife. Several antitoxic sera for gas gangrene have been introduced, notably by Bull, of New York City, and by Weinberg, of Paris. Their prophylactic use was being developed when the war closed. Therapeutically, in some cases their effect has been marvel- lous, one or at the most two injections seeming to bring back the patient from the verge of the grave. While they should always be used if available, they do not take the place of excision, debridement or amputation Tetanus (Lockjaw). — This disease, characterized by tonic and clonic convulsions, and especially by locking of the jaws, is caused by the B. tetani (Fig. 47), discovered by Nicolaier in 1884, and obtained in pure culture by Kitasato in 1889. The bacillus is anaerobic and is found especially in garden soil, barnyards, stables, etc. It prob- ably normally infests the intes- tinal tract of cattle, and is re- deposited with their dung. So long as the mucosa of their gastro- intestinal tract is intact, they are not liable to infection by this channel. Horses are particularly susceptible. Tetanus appears to be endemic in certain localities. T i ,. i ,, i Fig. 4/. — Tetanus bacilli, showing spore Inoculation OCClirS Only through a formation. (Kitasato.) wound. Cryptogenetic (formerly called idiopathic) tetanus is that form in which the wound of entrance cannot be discovered, having been insignificant in extent, or being on a mucous surface. Wounds contaminated with garden soil, street dust and especially those in which foreign bodies have lodged, are most to be suspected of harboring tetanus bacilli ; while their develop- ment is favored by anaerobic conditions of the wound. These condi- tions are found in punctured, contused and lacerated wounds. A mixed infection, especially with saprophytic bacteria, is favorable because these organisms, being aerobic, absorb all available oxygen, and provide anaerobic conditions for the tetanus bacilli. Tetanus is seen after compound fractures and gunshot wounds; during the puer- peral state, when inoculation occurs by the genital tract; in the new- born (tetanus nascentium) from infection of the umbilical cord; and not infrequently in cases of extensive burns. Contagion may spread from one patient to another by the medium of instruments, dress- ings, etc. Postoperative tetanus has been studied by Matas (1909), 02 ACUTE INFECTIOUS SURGICAL DISEASES who suggests that it is e given if the patient requires it, and less if it proves to be sufficient to relieve the pain and diminish the rigidity. Morphin is of very little value. Chloretone has given gratifying results (Hutchings, 1909). It is administered by mouth or rectum in doses of from 30 to 60 grains, dissolved in whisky or hot olive oil. Treatment by intraspinal injections of magnesium sulphate, intro- duced by Blake of New York in 1906, is based on the anesthetic effect of this drug, when injected into the subarachnoid space (Meltzer, I !>().">). It acts as a spinal depressant, and should not be used as a sub- stitute for antitoxin. Solutions of 12.5 to 25 per cent, strength are employed, and 5 to 10 c.c. are used at each injection (1 c.c. of the drug for every 25 pounds of body weight). It is a dangerous remedy, and several deaths have been reported following its employment. Carbolic acid injection*, introduced by Bacelli (1888), are supposed by some to have a specific action in tetanus. Subcutaneous injec- tions of \ per cent, watery solution are administered, every one or two hours, preferably along the spine, until 80 or 100 eg. are given in twenty-four hours, watching for constitutional symptoms of carbolic acid poisoning. Experimental evidence (Camus, 1912) shows this treatment to be useless, but clinically some good results are reported. 4. The nursing of the patient is very important. Clear the bowels by a brisk purge early in the disease; watch for retention of urine; guard against bed-sores. Enforce feeding, by the stomach tube passed under a general anesthetic if necessary. Hydrophobia (Rabies, Lyssa). — This disease, whose exact cause is unknown, is characterized by clonic spasms, especially of the faucial and respirator}' muscles; it results from inoculation with the virus contained in the saliva of rabid animals, notably dogs, wolves, cats (also foxes, sheep, goats, pigs, skunks, deer, etc.). Any mammalian may be affected. It is disputed that it is .ever conveyed from man to man. Though infection occurs in the vast majority of cases by bites, it may also occur through scratches by claws infected with saliva, or by an animal licking an existing wound. Wolf bites are most dan- gerous, because it is said the hands and face, unprotected by clothing, are usually bitten; and because the sharper teeth more readily pene- trate protected parts. It is possible that the virus may be partly wiped off the teeth of animals by passing through clothing. The disease is found in dogs in two forms, the furious and the paralytic. In the former, the dog is at first sullen, retiring to his kennel, and looking askance at every one; after several hours he becomes exceedingly fidgety, continually shifting his posture; suddenly he becomes irritable, with a snapping bark, an unsteady and staggering gait; the tongue lolls from his mouth, swollen and red; the saliva is profuse and viscid; there is loss of appetite and presence of thirst. Later, paralysis of the extremities occurs, breathing and deglutition become spasmodic, and convulsions bring on death. In the paralytic HYDROPHOBIA 97 form, the disease passes at once from the sullen to the paralytic stage; the dog is shy and melancholic; there is no disposition to bite; he is haggard and suspicious; has no fear of water, but does not drink; the tongue lolls, the saliva dribbles, breathing is difficult and laborious; and tremors, vomiting, and convulsions precede death (Youatt; quoted by Forbes, 1888). Pathology. — The virus, entering the wound with the saliva, and probably derived from the salivary glands, is absorbed by the nerves of the bitten part (Di Vestea and Zagari, 1887), and travels by them to the spinal cord; whether some toxin alone, or the infective agent itself is thus transmitted, is still unknown. Some of the virus may travel through the neural lymphatics. The virus, after reaching the cord, travels up it to the medulla, cerebellum, and cerebrum; it also travels out along the spinal and cranial nerves, and in this way reaches the salivary glands of the patient, especially the submaxillary and sublingual; the saliva becomes highly infectious. After death there are found in the cerebrum, cerebellum, medulla, and cord, and also in the salivary glands, various degenerative changes, especially marked in that part of the cord which receives the nerves of the bitten part. The most important microscopic changes are in certain of the per- ipheral ganglia and in the hippocampal convolution. Van Gehuchten and Nelis in 1900 found changes, seen best in the ganglia of the vagus and sympathetic nerves, consisting in proliferation of the endothelial cells lining the capsule of the ganglion, and filling up the spaces between the capsule and the proper cells of the ganglion. Negri (1903) found in the pyramidal cells of the cornu Ammonis, and in Purkinje's cells in the cerebellum, certain cell inclusions which he regarded as para- sites and the cause of the disease. Nearly all observers admit that these ganglionar changes and the presence of Negri bodies are pathog- nomonic of rabies; they are found in other diseases only with the greatest rarity; but many dispute Negri's claim that the bodies described by him are parasites, and deny that they are the cause of the disease. Rambaud (1907) points out that their distribution is not what would be expected of the specific cause of rabies; that the virus passes through filters which arrest the Negri bodies (Park thinks this not a valid objection) ; and that protozoa survive tempera- tures (45° C.) which readily render the rabic virus inert. Symptoms. — After inoculation, there is a period of incubation, varying from four or five days up to several months or a year. The average period in man is forty days (Ravenel, 1901). Incubation is shortest following bites of the face and other exposed parts, also fol- lowing wolf bites. The original wound usually has firmly healed long before any symptoms arise. The course of the disease was described by Virchow as embracing three stages: (1) The first stage, which may be absent, but which usually lasts from a few to twenty-four hours. There is malaise, lassitude, headache, twitching of the throat, stiff- ness of the neck, a feeling of suffocation, and rarely slight delirium. There is seldom any abnormal sensation in the wound. During this 7 98 ACUTE INFECTIOUS SURGICAL DISEASES stage the virus probably is ascending the cord. (2) The second stage is evidenced by increasing stiffness and pain in the tongue, throat, and jaw muscles; there is dysphagia, dryness, and great thirst; profuse salivation, the saliva being exceedingly tenacious and viscid; this necessitates repeated hawking which has been fancifully likened to the bark of a dog. Violent spitting is exceedingly charac- teristic. The patient is fearful of infecting those about him. Speech is difficult, being often choked off by gasps and sobs due to pharyngeal and laryngeal spasm. Swallowing becomes impossible, the sight of food or liquids, and sometimes the very sound of running water, bringing on renewed paroxysms. The special senses become pre- ternaturally acute; according to Kambaud, the slightest draught of air, as breathing gently on the patient, always produces faucial spasm. General convulsions ensue; there is high temperature, rapid pulse, and poly nuclear leukocytosis. The urine is deficient; it may contain albumin or sugar. The mind seems in terrific dread, in unutterable despair, or furious anger. Insane impulses and delusions are not uncommon; the staring eye, tensely drawn mouth, with bloody foam on the lips, and haggard countenance precede mania, which closes the second stage. The entire duration of this frightful scene may be twenty-four to forty-eight hours; and death from asphyxia in a convulsion is frequent. (3) The third, or paralytic stage is evidenced by exhaustion succeeding to mania and convulsions: saliva dribbles from the hanging mouth, the tongue lolls, and a horrible gurgling in the throat portends dissolution (Forbes, 1881). The entire course of the disease may be run in sixteen hours, or it may last four or five days; seldom longer. In rare cases the furious stage is entirely absent, the disease resembling the paralytic type seen in dogs. Diagnosis. — This affection, which is exceedingly rare, is distin- guished from pseudo-rabies (hysteria), by the history of a bite from a truly rabid animal; 1 by the period of incubation, which is never less than four days; and by the almost invariably fatal termination within ten days. In hysteria the symptoms are often immediate, the barking and hydrophobia are absurdly exaggerated, the dog is not mad, and death does not occur. Tetanus is due to a wound, not a bite; there is no excitement, fury or mania; the convulsions are tonic more than clonic; the jaws are firmly shut and cannot be opened; there is no spasm of the tongue and fauces. Tetanus is a quiet disease; apart from gritting of the teeth during convulsions, the patient makes no noise. Rabies is a furious and noisy disease. 1 To determine whether or not the animal is rabid, it should not be killed immediately, but should be kept under observation for several days, or at least until the clinical signs are noted by a competent veterinarian. If such is not avail- able, the dog's head should be cut off with an aseptic knife, and sent to a competent veterinarian or pathologist, who will determine from the microscopical appear- ances of the plexiform ganglion and cerebrum, whether or not the animal was afflicted with rabies. This fact may also be determined by inoculations into other animals, but this method may take several weeks, HYDROPHOBIA 99 Prognosis. — It Is now said that from 10 to 15 per cent, of those bitten by rabid animals are liable to develop the disease; it was formerly claimed by Pasteur and his followers that the incidence was much higher, even as much as 75 per cent. Not only is it an unusual disease in man, but it is by no means common in dogs and other animals. It is most frequent in France, Germany, and Russia; it is very infre- quent in Great Britain where there are extremely stringent quaran- tine laws against the importation of dogs; and almost unknown in Norway and Australia. Most surgeons never see a single case. I never saw one. Our entire knowledge of the disease is due largely to veterinarians and to directors of Pasteur Institutes. The disease when it really does occur is frightfully fatal. There are a very few well authenticated cases of recovery, accepted as such by competent critics. Treatment. — This must be both preventive and curative. The former includes police regulation of dogs and other domestic animals, as well as ordinary surgical treatment for a poisoned wound, and, if the patient wishes, the so-called Pasteur treatment by preventive inoculation. As soon as the wound is received, constriction should be applied on its proxi- mal side, to prevent possible absorption; and a cupping glass should be applied to suck out as much of the virus as possible. In emergency, the patient should suck the wound with his own mouth, spitting out the blood thus extracted. The best antiseptic, according to Rambaud, is corrosive sublimate (1 to 1000); the compound tincture of iodin is also good; lemon juice, which is an excellent antidote experimentally, may be used in emergency. Caustics are worthless, unless heat is used; and when available antiseptics are better than heat. The Pasteur treatment is based on the theory that, even during the period of incubation, inoculation with extremely attenuated virus, whose strength is gradually increased, will be sufficient to immunize the patient against the disease. The attenuated virus is obtained from the spinal cords of rabbits dead of hydrophobia; the quantity (not the quality) of the virus in the cords gradually diminishes in dry air. The first inoculation is made with an emulsion of a cord from a rabbit dead twelve to fourteen days, and the course of treat- ment extends over about two weeks. There is no doubt that in the vast majority of cases inoculation of healthy animals according to this system will immunize them against rabies; but to conclude from this, that inoculation of patients already infected will also be efficient, is not logical. From practical experience, however, it may be said that there is no good reason to doubt that inoculation according to Pasteur's method, under the latter circumstances, has rendered most of the patients so treated immune. But it must not be forgotten that the vast majority of patients treated in Pasteur Institutes never would have developed rabies under any circumstances; many of them are bitten by animals that are not rabid; and therefore their inoculation in most instances is perfectly useless. Moreover, there is not a shadow of doubt that in a few well authenticated cases no 100 ACUTE INFECTIOUS SURGICAL DISEASES Immunity has been procured by the inoculations, the patients sub- sequently developing and dying from the disease; and it has even been open to suspicion that these very patients might have been among that large number who, even without the inoculations, never would have developed the disease— in other words, that the danger of contracting rabies as the result of the inoculations, though very remote, is not altogether imaginary. The actual mortality attending the Pasteur treatment is given as less than 1 per cent.; but as from these statistics it is customary to exclude all those patients who develop rabies within fifteen days after the last inoculation (Rambaud), the number of those in whom immunity is actually produced is con- siderably less than would appear if this fact were not taken into con- sideration. Before a surgeon recommends the preventive treatment by inoculation he should, I think, place all these facts plainly before the patient; and if the patient wishes to take this very remote risk, and the surgeon is convinced that he was infected by a rabid animal, no time should be lost in having this treatment instituted. The curative treatment is nearly hopeless. Hyoscin and curare, hypodermically, are the best drugs; chloral and morphin have little effect. Proctoclysis of tap water, with large doses of bromides by the rectum, may be tried. Amyl nitrite or chloroform may be used for the convulsions. The saliva should be sterilized. CHAPTER IV. TUMORS. In studying the inflammatory process it was seen that the local reaction induced was usually sufficient to overcome and destroy the origin of the trouble; in the case of the infectious granulomas, instead of an efficient reaction, the indications of inflammation were found to be very slight, and cellular proliferation was the main characteristic of the process. Yet in both these instances the cell proliferation was incontestably in the nature of a reaction to external stimulus. In tumors we find a pathological process characterized by purposeless, more or less unlimited, cellular proliferation of unknown cause, pro- ducing practically no reaction in surrounding tissues. The cells of tumors seem to be a law unto themselves: they do not follow the ordinary processes which subserve the purposes of the organism as a whole; their only function appears to be proliferation, and this they evince without discoverable purpose or known cause. For an understanding of tumor processes a knowledge of embry- ology is necessary, because the most logical classification of tumors which has yet been proposed (Adami, 1902) x is that based on their histogenetic characteristics, and because the ultimate cause of tumor formation seems to lie in inherent characteristics of the cells them- selves, not in stimulus from without nor in relief from constraint by surrounding structures. Definition. — This is difficult, because the cause of tumors is not known; a definition therefore has to be formed solely from the objective characteristics of fully formed tumors. Adami accepts as satisfactory the statement of C. P. White that "a tumor is a mass of cells, tissues, or organs resembling those normally 'present, but arranged atypically. It groics at the expense of the organism without at the same time sub- serving any useful function." GENERAL CHARACTERISTICS OF TUMORS. The word tumor means a swelling, and all tumors are character- ized by a more or less localized swelling, which usually is both visible and palpable. Tumors may be multiple or single, may occur at any age, and in any situation. Form. — A tumor growing on the surface of the body assumes a typically rounded form (Fig. 50) ; one in the internal organs, or beneath 1 In the following paragraphs the teachings of Adami, and sometimes his words, have been closely followed. (101) 102 // MORS a resistant fascia, or compressed by other parts of the body will spread in the direction of least resistance; tumors may thus become irregular in form (nodular, papillary, etc.). Consistency varies greatly, being dependent upon the type of tumor: fatty tumors are soft; bony and cartilaginous are hard; fibromas and are more or less firm. Rate of Growth: This is usually slow, the increase in size being measured by months or years rather than by weeks or days; in general, the more rapid the growth, the worse the prognosis. Slowly growing tumors seem to provoke a feeble reaction in the surrounding tis- sues, so that they become sur- rounded by a more or less well defined capsule; those of rapid growth extend into normal tissues in various directions before a cap- sule can be formed. Manner of Growth: Growth occurs simul- taneously in all parts of a tumor, Fig. 50. — Lipoma of right arm. not only at the periphery or in the center, though in certain tumors growth at one place is much more marked than at others. The more rapid the growth, the more apt are the central cells to be squeezed out of existence, and therefore in such tumors cen- tral degeneration is common, leading at times to cyst for- mation. Size varies so greatly that no clear statement can be made (Figs. 51 and 52). Malignancy. — From the above it is evident that cer- tain tumors are less benign than others. Even tumors recognized as clearly benign may be dangerous from their size or position. The size of a tumor may impair the patient's health by requiring an extraordinary amount of nourishment; its position, even if small, may threaten life, as in growths of the larynx threatening suffocation, in the ali- mentary canal causing obstruction, or in the brain causing pressure Fig. 51. — Papilloma of fact THEORIES OF TUMOR FORMATION 103 on vital centers. But tumors comparatively small in size and innocu- ous in position may by their inherent characteristics be exceedingly dangerous to life. These characteristics are (Adami): Embryonic character of the tumor cells, leading to rapid growth; this in turn gives the surrounding tissues no opportunity to encapsulate the growth, with the result that infiltration of the surrounding tissues occurs, this infiltration extending far beyond the limits visible to the naked eye or discoverable by palpation. Metastasis: Some of the tumor cells by their rapid growth may break into bloodvessels and be carried by the blood to the nearest set of capillaries, and may even pass through these (pulmonic, hepatic) and enter the next set, in either situation lodging and, imless killed by the tissues of the part in which they are arrested, giving rise there to new growths {metastases) similar to the original tumor. (It is held by Orth and certain other pathologists that normal cells surrounding evi- dently malignant cells may become infected by the latter, and them- selves aid in the formation of the tumors. I think it is more reason- able to consider, with Ribbert, Adami, and others, that metastases are due to the proliferation solely of cells which have been trans- ported from the primary tumor.) The tendency to central degenera- tion and cyst formation has already been alluded to; in addition, super- ficial parts, those furthest removed from the blood-supply, whether on mucous or cutaneous surfaces, tend to sloughing and ulceration. These malignant tumors, moreover, tend to return after removal {recurrence), either because this was incom- plete in the first place, or because other previously normal cells become anarchistic in their turn. Further, malignant tumors produce cachexia; this is not in any sense a specific cachexia, but is caused by the drain on the natural resources of the body by the tumor, by anemia due to hemorrhages from its ulcerated surface, by toxemia through absorp- tion, or by intoxication from perverted metabolism. Fig. 52. — Excision of right clavicle for alveolar sarcoma, March 3, 1894, at age of nineteen years. Recurrent growth re- moved April 20, 1895. Present recurrence noticed September 1896. Grew very rap- idly after April, 1897. From a patient in the University Hospital under the care of the late Prof. John Ashhurst, Jr. THEORIES OF TUMOR FORMATION. Most of the theories in favor at the present day account only for one or two types of tumor. Cohnheim's theory (1877-80) is to the effect 104 TUMORS t hat during fetal life certain groups of cells become displaced from their normal site, remain undeveloped and Latent (cell "rests") until some future period of adult life, and then for some unknown cause begin to proliferate and form a tumor; this theory accounts very well for tumors of distinctly fetal origin (teratomas), hut there are many other tumors which under no circumstances can be considered due to cell rests. Ribbert's theory (1904-06), a modification of ('olmheim's, sup- poses that, besides fetal displacement, also post-natal displacement of nests of cells may occur; but that proliferation of such displaced cells is not due to stimulation from without nor to any inherent qualities of the cells themselves, but to lack of restraint by the sur- rounding tissues. Yet, in the process of regeneration (p. 29) cells exhibit such qualities in marked degree, yet no tumor results except in most exceptional instances. Parasitic Theory: This is based chiefly on observations which tend to show the infectiousness of cer- tain malignant tumors; such tumors (carcinoma and sarcoma) may be transplanted from animal to animal, their virulence, if it may be so called, being markedly increased by passing them through series of susceptible animals; and in many such tumors parasites of various kinds have been found. But the parasites are of various kinds, their etiological value has not been proved, and even if it were, this theory would explain the growth of only one class of tumors — the malignant. This reduces us, therefore, to the theory that the origin of tumors lies in perverted habits of the cells themselves, however it may be aided by the abnormal position of the cells (Cohnheim), by their release from restraint (Ribbert), or by their stimulation by parasitic forms of life. The utmost that we definitely know of tumor cells is, as Adami puts it, that they have gained the habit of grouih, and have lost that of function. CLASSIFICATION OF TUMORS. Functional development of cells necessitates their specialization. The most undeveloped cells are said to be toti-potential (capable of everything) ; more developed cells are pluri-potential (capable of more than one thing) ; while cells which are most developed are uni-yotential (capable of only one thing) (Barfurth). Basing his ideas of the nature of tumors on the inherent properties of the cells themselves, Adami recognizes three main groups of tumors, according to whether the tumor arises (1) from absolutely undifferentiated (toti-potential) embryonal cells, (2) from partially differentiated (pluri-potential) embryonal cells, or (3) from uni-potential cells, that is, cells which can form only one type of tissue. The first class (Teratoma) is derived from cells which might possibly, at a later period, be developed into any form of tissue or any organ, or even into a complete individual. The third class (Blastoma) is derived from cells which (before the tumor originates) have so far developed that they can give rise to only one form of tissue, e. g., connective tissue cells can produce only connective tissue tumors, epithelial cells can produce only epithelial CLASSIFICATION OF TUMORS 105 tumors, etc. The second or intermediary type of tumor (Terato- blastoma) is derived from cells only so far differentiated that they can produce more than one form of tissue, but not all forms (Fig. 53). Tumors composed only of one tissue are rare. Fig. 53. — Diagrammatic representation of section through vertebrate body to show ontogenetic relationship of the various orders of tissues. A. Of lepidic type: 1, epiderm and its glands (epiblastic) ; 2, mucous membrane of digestive canal and its glands, liver, etc. (hypoblastic) ; 3, endothelium lining serous cavities (mesoblastic) and glands, like renal cortex, of mesothelial origin; 4, vascular endothelium of late mesoblastic origin. B. Of hylic type: 5, spinal cord, brain, and nerves (epiblastic); 6, notochord (hypo- blastic) ; 7, connective tissues of the body (mesenchymatous) ; 8, myotomes, striated muscle of body (mesothelial). C. Cavities: 9, lumen of digestive tube; 10, body cavity. (Adami and McCrae.) Teratomas. — These are divided by Adami into two main classes, according to whether the teratoma is derived from the same indi- vidual as the person possessing the tumor, or whether it is derived from a twin which, becoming atrophic in embryonal or early fetal life, remains only as a fetal inclusion. This latter class produces the various forms of monsters, chiefly of interest to obstetricians. The former class comprises those tumors usually known by the name teratoma. These tumors may spring from germinal cells, or from non- I (Hi TUMORS germinal cells; in the former instance the tumor is found in the ovary (ovarian "dermoid"), where a large cyst is usually formed, or in the testicle, where the growth (rare) is chiefly solid, with only a small cyst; while in the latter instance the most frequent site is at one end of the cerebrospinal axis (epignathus, sacral teratoma). As such tumors spring from toti-potential cells, they may include all varieties of tissues. If the tumor contains elements formed from all three of the germinal layers it is known as an embryoma. Epithelial struc- tures are most frequently found, especially hair and teeth (epiblast), or glandular tissue (epi- or hypoblast) ; occasionally cartilage or bone (mesoblast). These tumors usually are present at birth (Fig. 54), but frequently are not noticed until puberty. Their size, shape, and consistency vary according to their location and the structures composing them. They usually grow rapidly when growth once begins, and may become malignant, giving rise to metastases. They are best treated by excision ; but in the newborn operation should be postponed until it is apparent that the child's constitution is otherwise suf- ficient to support life. Terato-blastomas. — These tumors, derived from pluri-potential cells, comprise most of the so-called "mixed tumors" — tumors in which tissues are found which do not nor- mally exist in the organ or tissue affected. In the parotid, and sometimes in the submaxillary gland, cartilaginous tumors are not unusual; in the kidney such tumors rarely have more than one variety of aberrant tissue, and have received various names according to the predominant tissue — rhab- domyoma, adenosarcoma, etc. The tumor known as chorio-epithelioma {deciduoma malignum) belongs to this group; it is formed by neoplastic development of cells of the chorionic villi. The placental mole is believed to be the early stage of such development; when the cells invade the uterine sinuses malignancy is evident and the deciduoma is present. The terato-blastomas, as well as the pure embryomas, often exhibit malignant characteristics, and are best treated by excision. Blastomas. — These tumors, forming by far the largest group of neoplasms, result from the independent growth of uni-potential cells. They are divided by Adami into two main groups, according as they are composed chiefly of cells arranged like epithelial, or rind, tissues (Lepidic tumors, Lepidomas), or of cells arranged like the stroma or pulp of tissues and organs {Hylic Tumors, Hylomas). The charac- teristic of all epithelial structures (skin, mucous membrane, endo- Fig. 54. ; — Sacro-coccygeal tera- toma. Italian girl, aged six months. Pennsylvania Hospital. XANTHOMA 107 thelium) is that the cells are placed closely together, there being an absence of definite stroma between the individual cells, and no blood- vessels penetrating between the various groups of cells. The char- acteristic of all pulp tissues (nervous tissue, muscle, bone, etc.) is that the specific cells lie in and are separated by a definite stroma, in which blood and lymph vessels may or may not be present. Lepidic and hylic tumors may be either typical or atypical. The typical blas- tomas are slow growing, and their structure approaches that of normal adult tissue; the atypical blastomas are composed of rather immature cells, do not closely resemble adult tissue, and grow rapidly. Typical blastomas are more or less encapsulated; the atypical are infiltrating. Typical blastomas are benign, atypical blastomas are malignant. Examples of typical (benign) lepidic tumors are papilloma, adenoma; of hylic tumors, are fibroma, osteoma. Examples of atypical (malig- nant) lepidic tumors are epithelioma, carcinoma; of atypical hylic tumors are the numerous varieties of sarcoma. In addition to distinct tumors, certain blastomatoid growths (Adami) must also be recognized; they approach more closely the reactive changes of inflammation, and correspond to the "continuous hyper- trophies" or "out-growths" of Paget (1853) as distinguished from the true tumor or " discontinuous hypertrophy" of that author. Typical (Benign) Hylic Tumors. — The most important of these are tumors resembling the following normal tissues: Fat (Lipoma) ; Fibrous Tissue (Fibroma); Cartilage (Chondroma); and Bone (Osteoma). Although many varieties of tissue may exist in the same tumor, yet one usually is so predominant as to give its name to the growth. If another tissue is present in fairly large amount, a compound term is used, thus fibrolipoma, the tissue present in greatest abundance always being named last. Lipoma. — This may consist rather in an hypertrophy of fat normally present (lipomatosis, a "continuous hypertrophy or out- growth") than in an actual tumor. Multiple lipomas are not rare. A lipoma rarely is well encapsulated. It grows slowly, produces no discomfort except from its size or position, and is absolutely benign. The skin over it is not discolored nor adherent, though a slight dimpling may be present occasionally, from fibrous bands supporting the tumor between the skin and deep fascia. It is soft, easily movable on the underlying tissues, and semi-fluctuating. A lipoma sometimes will gradually shift its position under the force of gravity. It may occur on any part of the body, and occasionally in the sub-peritoneal fat or omentum. Its seats of predilection are the limbs, trunk, and neck (Fig. 55). It frequently is fibrous in character, then being firmer than a pure lipoma (Fig. 56). It may be attached by a pedicle deep down in a muscular interspace, occasionally to periosteum. Mucoid degeneration may occur (myxo-lipoma) , especially in internal lipomas. Treatment.- — If any treatment is required, excision should be done. Xanthoma. — Xanthoma is a small flattened benign fatty and fibrous tumor in the skin, whose nature is not well understood. It is named 108 TUMORS from its yellow color, occurs mosl frequently around the eyes, and is sometimes seen in persons with gall-bladder disease. Usually no treatment is required. gfak* P> 2S* -J^m J0 flb i Fig. 55. — Lipoma of neck, duration nineteen years. Very soft, almost fluctu- ating. (Not goiter: Dot attached to larynx; does not lise in swallowing.) Episcopal Hospital. Fig. 56. — Fibro-lipoma of right cheek in a girl, aged fifteen years; growing slowly for last nine years. Sight of left eye lost from smallpox in infancy. Episcopal Hospital. Fibroma. — Tumors consisting solely of fibrous tissue are rare; they usually are small (Fig. 57), frequently multiple, grow slowly, and are well encapsulated. Depending upon the amount of fib- rous tissue present, fibro- mas are named hard or soft. The latter is the more frequent variety, and is well represented by the mucous polypi growing in the naso- pharynx. The tumor is firm to the touch, pale and glistening on section, with a capsule usually demonstrable. The favor- ite sites of development are the subcutaneous tis- sues, along nerve trunks, in periosteum, fascia, the uterus and mammary gland. Some of these must be regarded as fibroid over-growths rather than as distinct tumors, e. g., fibroma molluscum (Fig. 58). Fibromas frequently undergo Fig. 57. — Fibroma pendulum. Episcopal Hospital. KELOID OR CHELOTD 109 degeneration, particularly the mucoid, forming a tumor known as myxoma; this is especially frequent in mucous polyps; a tumor in or between the gluteal muscles usually is a fibro-myxoma. Malignant changes are by no means rare, the cells remaining immature, and proliferating with undue activity, forming the fibrosarcoma; myxo- sarcoma also occurs, as well as internal hemorrhage with cyst formation. Diagnosis. — Diagnosis is made by noting the long duration; indolent growth; firm consistence; rounded, apparently encapsulated character; and normal overlying skin. ^Treatment. — Frequently none is required; but any suspicion of malignancy (Fig. - r )«)), aroused by rapid growth, apparent myxo- matous or cystic changes, etc., justifies prompt extirpation. Recurrence is not very rare, even after removal of an apparently benign tumor, and, as a rule, the recurrent is more malignant than the primary growth. Keloid or Cheloid. — The hypertrophied condition of scars, known as the keloid of Alibert (1806), l is really a form of fibroma Fig. 58. — Neurofibroma- tosis (Fibroma molluscuiii) . Aged fifty-one years. Began at fourteen years. Father had the same condition. Episcopal Hospital. Fig. eration. t. — Fibroma of back, epitheliomatous degen- Patient aged seventy-three years; duration fifteen years. Episcopal Hospital. affecting the subepithelial tissues. It almost invariably follows some irritation, though individual predisposition has much to do with its development. Thus it is often seen in the negro race (Fig. 60) ; it may develop in the scars of burns, or of comparatively simple opera- tions (Fig. 61). There is some evidence that it is of tuberculous origin. It is a crab-like (keloid) or scar-like (cheloid) out-growth, covered by red, tense, shiny epithelium; it may extend into sound tissues in various directions. It usually is tender, and irritation in- creases its size. Occasionally the out-growths disappear sponta- neously; they usually recur after excision. 1 To distinguish it from the Keloid of Addison (1S54) or Morphoea, an affection belonging rather to dermatology than surgery. 110 TUMORS Treatment. — Treatment consists in protecting them from irritation by the clothes or opposing parts of the body. Ointments of tar and zinc, with animal rather than mineral bases, are valuable. Thiosinamin (5 to 10 per cent, solution) hypodermically, is recommended by Park (1907). Chondroma. — A tumor com- posed chiefly of cartilage. If it springs from preexisting cartilage cells it is termed ecckondroma (cartilaginous out-growth); if from other forms of connective tissue, especially fibrous, it is called enchondroma (cartilaginous tumor). Its occurrence as a terato-blastoma was men- tioned at p. 106. Chondromas are of stony hardness, unless degenerated; usually more or less lobulated, grow slowly, but usually faster than lipomas or fibromas, the growth occur- ring chiefly at the periphery; are painless, immovable, fre- quently multiple ; seldom affect the overlying skin; and are generally quite benign, but liable to form metastases. They are especially prone to mucoid degeneration, and when such occurs malig- nancy should be suspected. Sarcomatous changes are not unusual (Fig. 529). True bony changes (osteo- chondroma) sometimes oc- cur. If the skin sloughs, the cystic contents of the de- generated chondroma may discharge, leaving a most intractable sinus. Ecchondromas arise from epiphyseal lines before adult life, and later also from articular, costal, and intervertebral cartilages, larynx, trachea, etc. En- chondromas spring from from articular cartilages. Fig. 60. — Keloid (of Alibert) in scars toiiowmg a whipping from patient's mother. Patient of the late Dr. Isaac Massey, of West Chester, Pa. Fig.«61. — Keloid in scar of neck. Had brush burn in 1907, and keloid was excised one month later. Keloid recurred, and present photograph made one year after recurrence. Episcopal Hospital. periosteum or bone marrow, but not Chondromas develop in early life, espe- OSTOSES 111 cially in the rachitic; affect especially the phalanges, the flat bones (pelvis, scapula, skull), the femur, and the maxilla. When growing on the surface of a bone, beneath the periosteum, they may wear away its surface, leaving a distinct depression when they are removed. Diagnosis. — They are to be distinguished from bony tumors by their occurrence in younger patients, by their situation, and by their multiplicity; but a differentiation is not always possible without the .r-rays. Cartilage casts no shadow, or at most a very light one. Treatment. — Chondromas should be completely extirpated when- ever possible. Incomplete removal favors recurrence, and the recur- rences are more inclined to malignancy than the primary growths. Amputation, except of the phalanges, is rarely required. Osteoma. — A true tumor composed solely of bone is decidedly rare; most so-called bony tumors are really only osseous hypertrophies. True osteoma may arise on the surface of, or within the substance of bone. In the former instance it grows beneath the periosteum; in the latter it grows from the medulla, being then known as endosteoma. Either form may be com- posed of spongy or of compact bone. The tumor grows by cellular proliferation of its own elements, not from partici- pation of elements in the surrounding bone; these latter are compressed, pushed aside, and eventually disappear before the ongrowing tumor. Thus a periosteal osteoma will excavate the underlying bone, while an endosteoma will penetrate it, break through the cortical bone, and grow more freely when thus relieved from pressure. Occasionally an osteoma occurs in tissue which normally contains no bone. Such a tumor is a heteroplastic osteoma; it is possible that it develops from a fetal anlage, but usually it arises in a piece of cartilage or periosteum which has been displaced by trauma in post-natal existence. That true bone can form in chon- dromas has already been noted. Ostoses. — A diffuse bony out-growth is called a hyperostosis; a cir- cumscribed, more or less sessile out-growth is an exostosis; a projecting growth with narrow base is an osteophyte; while an osseous out-growth occurring in the centre of a bone (e.g., arising from the diploe) is termed an endostosis or enostosis. Occasionally an ostosis of one form or another appears to become neoplastic in nature, exhibiting autonomous proliferation. Exostoses, which are the most frequent of the bony hyperplasias, usually are multiple (p. 485), and very difficult to distin- guish from multiple ecchondromas, especially as ossifying changes in the Fig. 62. — Osteoma of upper jaw. Four years' standing. From a patient in the University Hospital under the care of the late Prof. John Ashhurst, Jr. 112 TUMORS latter are by no means rare. They occur in the same situations (except that exostoses are very rare on the hands), present the same charac- teristics, and run the same clinical course. The ivory exostosis of the skull is an exception, which it is usually possible to distinguish clinically. It is extremely hard, and if growing from the diploe (enostosis) may be as prominent on the dural as on the pericranial surface. Ostoses are sometimes developed in the accessory sinuses of the face. Bony changes occurring in tendons, muscles, etc., arc men- tioned at p. 306. Diagnosis. — Diagnosis, especially of endosteomas and enostoses, may be impossible without the use of the .T-rays, by which the denser shadow of osseous growths may sometimes be distinguished from that cast by cartilaginous tumors. Treatment.— Rarely is any required, unless removal of one or more circumscribed out-growths is necessary to relieve pressure on nerves, bloodvessels, the brain, etc. Recurrence after thorough extirpation is exceptional. Odontoma. — The teeth are developed from epiblast and mesoblast, and while a tumor having its origin in either element may occur in man, the vast majority of odontomas are derived from the epithelial portion, and are seen as "cysts lined with columnar or cuboidal epithelium or containing gland-like areas in their wall" (Simmons, 1907). This form, known also as adamantinoma, usually springs from the lower jaw, the tumor growing in and slowly distending the body of the bone; it is composed of multilocular cysts, with a bony framework (multilocular dentigerous cyst). It occurs especially in young females, is of slow growth, and usually symptomless except when causing pres- sure on neighboring parts. Crackling may be detected on palpation if the growth has thinned the overlying bone. Usually there is an unerupted tooth present. Diagnosis. — Diagnosis sometimes is difficult, especially from sar- coma. Carcinoma is more frequent on the upper jaw in older patients, and ulceration is common. Exostoses and chondromas are denser and the .r-rays may reveal the cystic nature of the adamantinoma. Sarcoma in this situation usually is periosteal in origin, grows rapidly, quickly invades the soft parts, is not cystic, and presents no "egg-shell" crackling. Treatment. — Opening the growth, and destroying its interior thor- oughly with the sharp spoon and actual cautery, usually effects a cure. It is essentially benign. The operation may be done from within the mouth. Myeloma. — The bone marrow contains two chief varieties of cells — those having to do directly with bone, and those supplying the blood. Adami classes under this section tumors derived from true bone marrow (osteogenetic) cells, and certain blastomatoid conditions due to disturbances of the blood cell elements in the marrow. Giant-cell Myeloma. — This, frequently spoken of as giant-celled sarcoma, is too little malignant to be classed with atypical hylic MYELOMA 113 tumors. It may develop beneath periosteum, sometimes occurs in the lower jaw or clavicle, but usually arises in the interior of shafts of long bones, near the epiphyses; it is almost the only tumor found in the radius (Figs. 63, 210 and 211); it occurs in the young (eighteen to twenty-five years), frequently (SO per cent, of cases) follows injury (or the patient's attention is called to it by injury), grows slowly and expands the overlying bone rather abruptly. The bony shell may grow so thin as to crackle on pressure (spina ventosa), and occasionally the tumor breaks through and invades the soft parts. The growth itself is rather soft, quite vascular, and when sectioned resembles splenic tissue or even currant jelly; if it breaks through its bony capsule, pulsation and occasionally bruit are present (false osteoid aneurysm, p. 487). Spontaneous fracture is rare. Skiagraphs fre- quently show evidences of trabeculation (Fig. 210). Fig. 63. — Myeloma (giant-cell sarcoma) of radius, duration two years; developing in a girl, aged twenty years, from no recognized cause. Recurred one year after opening and scraping. Entire lower end of radius then excised, and bone transplant inserted. (See Figs. 210 and 211.) No recurrence and useful hand five years later. Episcopal Hospital. The lymphatic system is not affected in pure myeloma; no metas- tases occur; and if the tumor is thoroughly removed, recurrence is unlikely. Occasionally, however, the tumor approaches spindle- celled sarcoma in type, the stroma cells being small, growth rapid, and recurrence usual. Diagnosis. — A slowly growing tumor, in the interior of a bone, and near the epiphysis, if in a long bone, occurring before twenty-five years of age, not producing metastasis or cachexia, expanding the bone abruptly, and appearing trabeculated in skiagraphs, is usually a giant-celled myeloma. The diagnosis from fibro-cystic osteitis and bone cysts is discussed at p. 487. The histological diagnosis, according to Bloodgood, who has studied the subject periodically since 1903, may be made from the characteristics of the stroma, with- out regard to the giant cells; the stroma resembles granulation tissue. Barrie (1913) goes further, and claims that it actually is granulation tissue; he terms the disease hemorrhagic osteomyelitis and considers it a stage precedent to fibrocystic osteomyelitis. He contends that it is traumatic in origin, results from rupture of osseous trabecula? near the medullary cavity, that spontaneous rupture of the thin-walled bloodvessels ensues from lack of bony support, and that the granu- lation tissue is an ineffectual effort to repair the damage. From long- 8 114 TUMORS continued low-grade irritation, here, as elsewhere in the body, he thinks this granulation tissue continues to proliferate and gradually expands the cortex. M. J. Stewart (1914), on the other hand, who studied 55 giant-celled tumors arising in bone, based his pathological diagnosis on the character of the giant cells which in the benign growths (50 out of the total ')') studied) resemble osteoclasts: their cytoplasm is abundant and vacuolated; the nuclei (small and very abundant) are collected in the center of the cell and arranged in whorls; and there are no mitoses within the giant cells. (Stewart's views on the malignant giant-celled sarcoma are mentioned at p. 119). It may be remarked, in regard to Barrie's views, that the giant cells form too prominent a feature of the histological picture to he relegated to the role of foreign body giant cells; the latter normally are col- lected around the periphery of the lesion which they are seeking to remove, and their histological structure is not such as is commonly seen in cases of myeloma. Clinically, at any rate, the myeloma is a tumor though a, 'benign one. Treatment. — Usually it is sufficient to cut away the overlying bone and clean out the interior; cauterization probably is of little value if the cavity is thoroughly scraped. If the cavity is small it may be allowed to fill with blood, its walls being crushed in; or it may be plugged with iodoform bone-wax (p. 478), the soft parts being com- pletely closed. If the grow r th is very large and vascular, the opera- tion may be done under Esmarch anemia (p. 476), and the cavity packed for several days with gauze, when secondary closure may be done. Only in cases very far advanced, or recurrent after incomplete operation (Fig. 63) is formal resection of the bone necessary. Ampu- tation is reserved for the aged or feeble, or those cases in which the disease is believed to be malignant. Myelomatosis. — This blastomatoid condition affects the red bone marrow chiefly of the vertebras, ribs, pelvis, and cranium; it is a primary multiple process (Borst). The growths are yellowish red, pulpy, and firm, and though it is due (Adami) to proliferation of the blood-forming elements of the marrow, there is in orthodox cases no involvement of the lymphatic system or spleen (such a condition being called myelogenous leukemia). Albumosuria (Bence-Jones, 1848) is frequent in myelomatosis, and relations of this disease to osteomalacia are not clear. Prognosis is bad, death from exhaustion occurring after an interval of months or years. Treatment is sometimes required because out-growths in the vertebra? press on the cord; excision or laminectomy should be done. Chloroma. — Chloroma, according to Adami, is an aberrant type of myelomatosis; it is a rather malignant, multiple growth of greenish- yellow tint, affecting especially the face bones; and is frequently associated with myeloblasts leukemia (Dock). Lymphomatosis. — As myelomatosis is due to proliferation of blood- forming marrow cells (myeloblasts, which produce leukocytes), so lymphomatosis is a corresponding state due to hyperplasia of lympho- ATYPICAL HYLIC TUMORS 115 blasts. There are many affections characterized by widespread enlargement of lymphatic tissue, notably tuberculosis; there are others, probably, but not certainly tuberculous; and there is Hodgkin's disease, of unknown cause (p. 302); leukemia is still another, but has no surgical interest. Adami, in addition to the above blastomatoid conditions, admits the existence of typical lymphoma; but far more frequent is atypical lymphoma, comprising the various forms of lympho- sarcoma (p. 304). Myoma. — The leiomyoma is a tumor composed of smooth muscle fibers, arranged in various directions, and inclosed in a fibrous stroma (fibromyoma). The older the tumor the more does fibrous tissue preponderate, so that finally muscular fibers may be inconspicuous (fibroids) ; this change may be a mere over-growth of fibrous tissue, or an actual metaplasia of muscle fibers (Adami). It occurs with over- whelming frequency in the uterus (Chapter XXIX), but occasionally is found in other portions of the genito-urinary system or in the diges- tive tract, where the stomach is most often affected. The tumors are usually multiple, may attain immense size, and frequently require excision. Rhabdomyoma. — The occurrence of this tumor, except in connec- tion with terato^blastomas (p. 106), is almost unknown. It appears usually to be malignant. Neuroma. — A true ganglionar-celled neuroma is so rare as to be of slight interest surgically, except when it occurs in the medulla of the adrenal (p. 1038). False neuromas are fibrous "out-growths" occurring upon nerves (fibromatosis nervorum). Amputation neuromas are somewhat similar (p. 221). Glioma. — This is a tumor developed from the stroma of nerve tissue (neuroglia) (Fig. 64); it is found, with few exceptions (retina, cerebral nerves), in the brain; and may be either hard (when pro- jecting into the ventricles); or soft, when it infiltrates the cerebral hemisphere without any attempt at encapsulation (p. 627). Chordoma. — Chordoma is a rare tumor growing from bone in the region of the pituitary bod}', and developed from remains of the notochord. Atypical (Malignant) Hylic Tumors. — Sarcoma. — The characteristics of malignancy in general (p. 102) and of atypical blastomas in par- ticular (p. 107) have already been considered. Sarcomas are atypical hylomas of mesenchymal origin, all possessing this peculiarity, that they are composed of embryonic connective tissue cells. Sarcoma may, therefore, occur wherever connective tissue exists; indeed, as pointed out by Bland-Sutton (1906), it may be regarded as a malig- nant tumor disease of connective tissue. Sarcoma occurs by prefer- ence, however, in bone, periosteum, fascia, ligaments, tendons, brain, ovaries, testicles, and skin; less often in the lungs, muscles, uterus, liver, and intestines. It grows rapidly, by cellular proliferation in all parts of the tumor, frequently assumes a lobular appearance, infiltrates in all directions, particularly along and inside of bloodvessels, and early gives rise to metastasis through the blood-stream. Though 116 TUMORS most sarcomas infiltrate equally in all directions, certain tumors extend in finger-like processes here and there, giving an organoid appearance to the section. Such growths have been termed alveolar and tubidar sarcomas. A special characteristic of all sarcomas is the extreme meagrcness of the stroma present; only with difficulty may stroma he detected, so closely are the sarcoma cells packed together. Sar- comas are highly vascular, and the walls of the bloodvessels are com- posed solely of endothelial cells; the sarcoma cells lie in immediate contact with the outer surface of the endothelium, and frequently grow inside the vessels. A characteristic of rapid growth and of the vascularity of these tumors is their liability to myxomatous and other degenerations, to internal hemorrhages, and to cyst formation (p. 103). NSW Fig. 64. — A, from the more typical portion of a glioma. B. Another region from same growth of more malignant type, a true gliosarcoma. (Thomas and Hamilton.) Sarcomas are classified according to the form and size of their component cells into small round-celled, large round-celled, and spindle- celled sarcomas (Figs. 65 and 66) ; or, where several kinds coexist, mixed-celled sarcomas. 1 The smaller the cell and the less the amount of stroma, the more malignant is the sarcoma; therefore, the large spindle-celled sarcoma (formerly called "recurrent fibroid") is the 1 M. J. Stewart (1914) as already noted (p. 114) recognizes a malignant giant- celled sarcoma, five specimens of which he studied; all the patients died within three years of the time of operation. He bases the diagnosis on the following microscopical appearances: The giant cells are of all sizes, and one may detect all stages of transition from ordinary tumor cells up to typical giant cells; mitoses are very frequent both in the giant cells and in the cells of the stroma, and the nuclei of the former are exceedingly irregular in size and shape, most of them being large, and seldom more than six being present in one cell. Vacuolation of the cytoplasm is rare. These features serve to distinguish it. from the myeloma. SARCOMA n: least malignant, probably because in the others the cells are less developed, the most so in this. The form of the sarcoma cell depends on the structure from which it is derived; thus, as pointed out by Adami, only cells which, in the course of their normal develop- ment, pass through a spindle-celled stage can give rise to spindle- celled sarcoma (connective tissue cells, plain muscle fibers, etc.); whereas round-celled sarcomas are developed from cells such as lymphocytes, which even when normally matured are still round. Finally, calling the above pure sarcomas, a group of intermediate sarcomas may be recognized, in which some of the cells develop beyond the embryonal stage sufficiently to give a tissue characteristic to the tumor, but do not reach full adult maturity: fibrosarcoma, lympho- sarcoma, osteosarcoma, chondrosarcoma, gliosarcoma, etc. Fig. 65. — Small round-celled sarcoma from skin. (High magnification.) (From Professor Klotz.) Fig. 66. — Spindle-celled sarcoma (recur- rent, from forearm) : a, delicate-walled bloodvessel in tumor. (From Professor Klotz.) It is an interesting question, as yet undecided by pathologists, whether the term sarcoma shall be applied to a tumor composed of any cells other than connective tissue cells. Thus, if, for example, a sarcomatous tumor is found in (smooth) muscle tissue, it may have originated (1) by sarcomatous proliferation of the connective tissue cells (not muscle cells) in the tissue of a normal muscle or of a typical leiomyoma (p. 115); (2) by malignant proliferation ab initio of the muscle cells themselves; or (3) by a secondary sarcomatous change (anaplasia) affecting the muscle cells in a previously formed myoma. To the first tumor the name myosarcoma is properly applied; the second, which many hold is not truly a sarcoma, is best described as a malignant myoma; while the third is distinguishable from the others by the term myoma sarcomatodes. According to Adami, this last is probably the most frequent form; but most pathologists, I believe, still regard the first as the most usual. The same question arises in connection with glioma, lymphoma, endothelioma, etc., and also with 118 Tf .units osteosarcomaj fibrosarcoma, etc., though not so pointedly in these hitter, because they are formed of connective tissue alone. Fig. 67. — Inoperable sarcoma of pelvis; rapid growth after exploratory laparotomy six months ago. Note ecchymosis of hip from recent bruise. Children's Hospital. Diagnosis. — Sarcoma occurs usually in the young (over forty years it is quite rare), not infrequently follows trauma, grows rapidly (weeks and months), causes early metastasis, especially in the lungs and skin; is frequently hot and painful; and eventually produces cachexia. It is firm but not bony to the gm touch if growing from bone or cartilage; ffl rather soft if in fibrous tissue or the viscera. m £ Prognosis. — This is gloomy. Recurrences are almost inevitable; and even if no recur- Jk rence occurs locally, visceral metastases, un- detected at time of operation, almost surely H kill within two or three years. wk Treatment. — Prompt extirpation, which often but not always implies amputation of the limbs, and wide cutting excision of other parts, offers the only chance of cure. Reoperation for local recurrences sometimes prolongs life, though rarely effecting a cure. ■tag ^n| If * ne tumor is inoperable when first seen, (i _.^ treatment with Coley's fluid should be tried; and in all cases it should be used after operation. The mixed toxins of the B. pro- digiosus and streptococcus, introduced by Coley of New York in 1892, are administered hypodermically, either into the growth itself or its immediate neighborhood (initial dose \ to | a minim), or in other parts of the body (initial dose 1 minim), the dose gradually being increased so that it is no more than sufficient to cause febrile reaction analogous to that seen with tuber- culin (p. 79). It has been a clinical observation for nearly fifty Fig. 68. — Spindle-cell sarcoma of the leg. Aged forty-four years. Direct injury November, 1914. Tumor noticed March, 1915. Photograph and operation, September 1, 1915. Coley's fluid for many months. No recur- rence four years later. Episcopal Hospital. PAPILLOMA 119 years that attacks of erysipelas occasionally had a healing influence on malignant growths; and it is not an illogical theory that bacterial toxins might influence tumor cells favorably, reducing the process more nearly to that of an inflammatory reaction. As a matter of fact, the use of Coley's fluid, especially in his own hands, has secured some surprisingly favorable results: in a few instances permanent cure has followed; in many the tumors have been reduced to operable states, or have been kept in abeyance, as it were, for sometimes they grow again when treatment is discontinued; in some, recurrence seems to have been prevented. My own experience with Coley's fluid has been limited, but on the whole favorable; the tumor has at least grown smaller, and the pain and discomfort of the patient have been noticeablv relieved. Fig. 69. — .Specimen removed from patient shown in Fig. 68, viewed from median aspect. Specimen includes entire thickness of tibia with articular surface of knee. See Figs. 212 and 213. Typical (Benign) Lepidic Tumors. — Papilloma. — This is an epithelial tumor growing from skin or mucous membrane (Fig. 51). It projects above the surface, sometimes as a single nodular mass, sometimes as a definitely papillomatous out-growth. Its nourishment is derived from vessels which are carried to it in a core of the underlying connective tissue; but the connective tissue itself typically undergoes no blastomatous change, merely growing as required by the inde- pendent growth of overlying epithelium. Most so-called papillomas (warts, etc., p. 290) are clearly not neoplasms, but hyperplasias due to chronic irritation. Some of the mucous polypi described as soft fibromas (p. 108) may be considered as forms of papilloma, if it is the epithelium and not the connective tissue core which becomes blasto- matous; the question is very hard to decide. True papillomas occur chiefly on mucous surfaces, especially the urinary bladder, where the tumor is composed of numerous fine finger-like projections (Fig. 70); stomach (polyposis); rectum; uterus, etc. Similar tumors often grow from the mucous lining of cysts, especially in cystic adenomas (intracystic papillomas) (Fig. 71). Treatment. — -As malignant changes (carcinoma) are not very un- common, papillomas are best treated by excision; and, unless this is thorough, recurrence is frequent, especially in the bladder. 120 TUMORS Adenoma. — Instead of the lining membrane presenting outgrowths, as in the case of papilloma, ingrowths may occur; as this change is almost limited to preformed glands, the resulting neoplasm is called an adenoma. It is not a very common tumor, being encountered most often in the mamma, thyroid, liver, prostate, and around the margins of gastric ulcers. In the two latter situations it is probable that the change is one of adenomatosis, a hyperplastic reaction to chronic irritation. The more important adenomas are discussed in connection with transitional lepidomas (p. 128). The true adenoma probably always originates in cell rests; it is well encapsulated, and has no communication through ducts with the excretory channels of the gland in which it lies. The cells forming an adenoma usually retain some of their glandular characteristics, and may secrete a Fig. 70. — Papilloma of bladder to show the long' finger-like papillomatous outgrowths. (Ribbert.) Fit;. 71 -Intracystic papilloma of breast. (Orth.) modified form of the natural product; this secretion then distends the acini, and a cystadenoma is produced. Into these cysts papillomatous growths frequently occur (Fig. 71), producing intracystic papilloma, or cystadenoma papilliferum. Here again it is exceedingly difficult to tell whether the projections are truly papillomatous or whether they are only apparently papillomatous, being caused by the adjacent in-growth of adenomatous cells. In many adenomas the fibrous stroma is markedly increased {fibroadenoma), and it is held by some that neoplastic proliferation of this stroma is the cause of the papilloma- tous intracystic projections, and that the epithelium overlying the projections is entirely passive. The cells of an adenoma always lie upon a well developed basement membrane, which invariably sepa- rates them from the underlying stroma ; when the tumor grows rapidly this basement membrane may be poorly developed; and when it is CARCINOMA 121 absent, and the epithelial cells have broken through, lying in immediate contact with the stroma, the tumor can no longer be considered an adenoma: it has undergone malignant (carcinomatous) change. Bland- Sutton (1917) denies that such a change ever occurs. An adenoma may be very small, or extremely large and ponderous; the smaller, harder, tumors of the breast are usually painful. Treatment. — Adenomas should be removed whenever possible; espe- cially does rapid growth render this imperative. Recurrence is not to be feared; and metastasis is unknown. Atypical (Malignant) Lepidic Tumors. — Carcinoma. — This includes all malignant tumors of epiblastic or hypoblastic origin. Under carcinoma of epiblastic origin are included all skin cancers, as well as cancers derived from the mammary and other epidermal glands, epithelium of mouth, salivary glands, naso-pharynx, etc.; while those of hypoblastic origin include carcinoma of the digestive tract, pancreas, liver, bladder, and respiratory tract, thyroid, thymus, tonsils, etc. Although the cause of carcinoma is totally unknown, most cases occur in persons over forty years of age, and it is most frequent in sites which have long been subjected to irritation, or in which unhealed and chronically irritated ulcers exist — e. g., lacerations of the cervix uteri, gastric ulcer, smokers' cancer of the lower lip, syphilitic ulcers of the tongue, chimney-sweep's (soot) cancer of the scrotum, cancer of the skin in workers in paraffin, pitch, chrome, etc. Carcinoma is due to the independent (autonomous) growth of epi- thelial cells; and this growth is atypical. That is to say, it differs not only from the growth of epithelial cells seen in regeneration (healing of ulcers), but it also differs from the growth of epithelial cells seen in an adenoma. In an adenoma, for instance, the epithelial cells retain to a certain degree their normal character; they line the gland tubules or acini, leaving usually a distinct lumen, and rarely forming more than one layer around this central lumen; and they are always placed on a distinct basement membrane. In carcinoma, on the other hand, the in-growths of epithelial cells are usually solid, finger-like masses; there is no lumen, except in certain cancers derived from preformed glands, and even then the cells tend to pile upon each other around the periphery and to encroach on the lumen; the basement mem- brane is absent, and the masses of epithelial cells are in direct contact with the surrounding tissues. When seen in cross-section it appears as if there were cell nests entirely detached, lying in the connective tissues; but rarely, if ever, is this the case. It has been shown by serial sections (Petersen) that these are directly continuous with the sur- face epithelium, being one of the claws of the crab-like growth which gives cancer its name. Not only does carcinoma extend in all directions into all surround- ing tissues, but it has a very extraordinary tendency to extend along lymphatic channels. It was formerly thought that this extension was largely in the way of metastasis, i. e., that groups of carcinoma cells were detached from the main tumor and carried in the lymph current 122 TUMORS away from their site of origin, until, lodged in the nearest lymph nodes, they there set up a metastatic growth entirely separate from the main tumor, leaving uninvolved tissue between. Thai this sometimes occurs may not be denied, but it is certain, owing chiefly to the researches of Handley (1905) in relation to mammary carcinoma, that in the vast majority of cases such extension occurs by direct, continuity (permeation) along the lymphatic spaces of the deep fascia, and along lymph vessels, and that the affected lymph nodes are connected with the primary tumor by innumerable fine cords of carcinoma celts. When the lymph nodes are invaded, dissemination beyond them may occur, the carcinoma cells eventually entering the blood-stream and being : : '-.m i^fa ?■*•;?,- - g v. If •■• * »v£ ©J* 2 - ■ .... .' Fig. 72. — Early epithelioma of tongue, to show (a) region of origin by down-growth from preexisting epithelium; b b, epithelial pearls; c, small-celled infiltration in sur- rounding tissue. (Petersen.) widely disseminated in the lungs, spine, etc. Occasionally, dissemina- tion by the blood occurs early, before the adjacent lymph nodes are palpably affected. These secondary growths, wherever found, repro- duce the character of the primary tumor; we may find in the humerus a secondary nodule with the characteristics of the glands of the rectum, nodules in the ovary with the features of the mammary gland, etc. Secondary deposits are rarest in muscle, most frequent in the skin, lungs, and bone, especially the vertebrae, as well as in organs anatomic- ally related to the primary growth. Two main varieties of carcinoma may be recognized: Epithelioma and Glandular Carcinoma. EPITHELIOMA 123 Epithelioma. — Though this term is applied by the French to all malignant tumors of epithelial origin, it is customary among English speaking surgeons to limit it to squamous-celled carcinoma, and it is so used in this volume. It affects the skin, especially muco-cutaneous junctures (lips, anus, glans penis, vulva), mouth, tongue, pharynx, esophagus, etc. Very exceptionally epithelioma has been found where no squamous epithelium normally exists (gall-bladder, stomach, uterus, etc.). Pre-cancerous changes are well recognized clinically. Among those of most importance are the senile or seborrheic patch (keratosis, p. 6G9); leukoplakia (p. 695); and Paget' s disease (p. 768). As already noted, any chronic irritation seems to predispose to the development of carcinoma. Two forms of epithelioma are distinguishable, the superficial, and the deep-seated, of which the last will be described first. 1. Deep-seated Epithelioma. — This, the more frequent variety, commences as a downward proliferation of epithelial cells which preserve fairly well the typical appearance of cells of the rete Malpighii, a few "prickle" cells frequently being discernible. These cells are very slightly anaplastic: they preserve their functions so far that they still tend to undergo horny changes, this keratosis resulting in the formation of "pearly bodies," which are really cross- sections of plugs in which the central cells have become horny, and, being compressed by those outside, produce a typical lami- nated appearance (Fig. 72). A little round-celled infiltration may be seen around these in- growths, evidences of reaction on the part of the stroma. This form of epithelioma when growing on the skin usually is first noticed by the patient as an induration (hyper-keratosis), commencing frequently in a senile seborrheic patch (p. 699) . Or it may develop from a papil- loma (Fig. 73). Soon the center becomes abraded, crusts, ulcer- ates, and gives the growth an umbilicated appearance (Fig. 74). This ulcer spreads; its edges may retain the features of the original nodule, but usually are less firm, ragged, and only moder- ately raised above the base of the ulcer. It occurs especially on the face and hands, the lower lip being a favorite site. The neighboring lymph nodes are invaded early (three to five months), and the progress Fig. 73. — Epithelioma of nose; aged sixty- three years; duration one year. (Developing in a papilloma.) Episcopal Hospital. [24 TUMORS Fig. 74. — Epithelioma of hand ; aged seventy- eight years; duration one year. Note uni- bilicated appearance. Episcopal Hospital. of the disease is imieli more raj>irays the favorable time for excision may be lost. In some inoperable cases of ex- ternal carcinoma relief may be secured by desiccation with the high frequency current by radium emanations, or by fulguration. The former are suitable only for surface growths, while fulguration is more useful for deeply seated tumors after curettement or partial extirpation. 2. Superficial Epithelioma (Ro- dent Ulcer, Jacob's Ulcer). — This was first described as a clinical entity by Jacob of Dublin in 1827. It was first recognized as a variety of carcinoma by Warren in 1872. 1 1 Borst and other pathologists class it as an endothelioma or alveolar sarcoma. Fig. 75. — Papillary epithelioma (superficial epithelioma lately show- ing more malignant characteris- tics); aged seventy years; duration five years. Episcopal Hospital. EPITHELIOMA 125 The epithelial cells which grow down from the skin are extremely atypical, rounded, polygonal, or even spindle-shaped. Because they do not form "epithelial pearls," Krompecher (1903) has named this type of epithelioma "basal-celled carcinoma," on the theory that it is the only type formed from basal cells; but Adami contends that all epitheliomas are so formed, and that whereas in all others the cells develop to the horny stage, in the rodent ulcer the cells fail to do so because they present a higher degree of anaplasia. The favorite site of rodent ulcer is on the upper half of the face, especially near the ala nasi, on the lower eyelid, or the forehead; it is almost unknown on other parts of the body. It is often preceded by changes in the skin (keratosis, etc., see p. 669) of an irritative character, and rarely is recognized until a small ulcer has formed, Fig. 76. — Rodent ulcer invading or- bit, in a woman, aged thirty-five years; duration eighteen months. (Dr. W. Walker's case.) Episcopal Hospital. Fig. 77. — Rodent ulcer; duration over five years. Eye destroyed. Had so far only x-ray treatment. Now inoperable Episcopal Hospital. scabbed over, and again become ulcerated several times. The ulcer spreads very slowly, gives little discharge, is painless; has raised, firm, glistening edges; and occasionally heals in one part while extending in another (serpiginous ulceration). It does not attack the neighbor- ing lymph nodes, and, contrary to what would be expected from its high grade of anaplasia, is in general much less malignant than the deep-seated epithelioma just described; but it destroys, surely if slowly, everything in its course — eating away cartilage, bone, con- tents of the orbit, opening the nasal cavities and sometimes exposing the brain, before death comes. Sometimes, after progressing slowly for many years, the rodent ulcer will suddenly take on rapid growth, and assume the character of a deep-seated epithelioma (Fig. 75). Diagnosis. — It must be distinguished chiefly from the deep-seated epithelioma. In rodent ulcer the edges are harder, more raised, 120 TUMORS glistening, and sometimes covered with fine capillaries; the base of the ulcer is Hatter and not so deeply placed; secretion is less; growth is much slower; the lymph nodes are not invaded; and microscopical examination of an excised portion will show no pearly bodies, and extremely atypical cells. Prognosis is good with proper treatment sufficiently early. Treatment. Excision should be done, but it is not necessary to remove the adjacent lymph nodes. Even in advanced cases com- plete excision is seldom followed by recurrence, so that operation should not be refused in any case where recovery from the operation itself seems certain. Very early treatment, by an expert, with radium emanations, frequently causes the ulcer to heal without visible scar; but recurrence is not unknown. The remarks as to .r-ray treatment, made at p. 124, apply here. The patient shown in Fig. 77 had been treated for fixe years with the .r-rays before she came to me for surgical advice; she then was a confirmed alcoholic and morphino- maniac, and the tumor was absolutely inoperable. Fig. 78. — -Microscopic appearance of adenocarcinoma (cylindrical-celled carcinoma) of the rectum. (Lexer-Bevan.) Glandular Carcinoma. — This is so called because it grows in glands. Two forms may be recognized, according to the extent that the tumor departs from the typical glandular form: 1. Adenocarcinoma. — The less atypical forms, known as adeno- carcinoma, are composed of alveolar spaces, lined with cells arranged around their periphery, and rarely piling up on each other so as to encroach on the lumen. This form is therefore known also as columnar or cylindrical-celled carcinoma (Fig. 78). By obstruction of the ducts and continued secretory action of, or from death and liquefaction of the cells, these alveoli may be converted into cysts (cystadeno-car- GLANDULAR CARCINOMA 127 cinoma). It affects especially the rectum, pylorus and lesser curvature of the stomach, cecum, etc., frequently developing from preexisting ulcers or adenomas; or from polypi, when it is wont to assume a cauliflower-like or fungating appearance. It occurs also, but more rarely, in the cervix uteri, naso-pharynx, larynx, and gall-bladder; also from cell-rests in the neck (branchiogenic carcinoma, p. 731). 2. Solid-celled Carcinoma. — The most atypical form of gland carcinoma consists of solid plugs of epithelial cells,- there rarely being any lumen whatever (Fig. 79). All grades may exist between this form and that previously described. Two main varieties of the solid-celled carcinoma are recognized, depending upon the amount Fig. 7'.). —Microscopic appearance of solid-celled carcinoma, arising in the neck of the uterus. (From "Diseases of Women," Bland-Sutton and Giles.) of stroma present: when this is excessive, the tumor is said to be a "scirrhus" (scirrhous carcinoma); when the stroma is deficient, and the cellular elements conspicuous, it is called a medullary carcinoma, or, from its gross resemblance to the brain on cross-section, " encepha- loid." When stroma and parenchyma are present in equal amount it is described as carcinoma simplex, or "acute scirrhus." Solid-celled carcinoma affects especially the mammary gland and the cervix uteri, though in both situations various combinations of carcinomatous growth may be encountered. Gland carcinoma is especially prone to ulceration, the ulcer being deeper than in epithelioma, and there being a much greater tendency 128 TUMORS to fungosity. Colloid degeneration is not unusual, particularly in carcinomas of the intestinal tract; it is due, according to Adami, to the accumulation within the cells of modified mucin which they cannot excrete, the result being that entire alveoli may be distended with this glistening, translucent material. Symptoms. — The. symptoms of gland carcinoma depend so much upon the seat of the tumor, that their description is best postponed to the chapters on regional surgery. Prognosis. — Untreated, or treated only palliatively, the expectation of life in carcinoma has been estimated at eighteen months for the medullary, and two and one-half years for the scirrhous variety; for, although, in the latter, many patients survive three, five, or even ten years, yet an equal number die in less than the average period men- tioned. The prognosis after operation will be discussed with regional surgery. Treatment. — All operable carcinomas should be excised, at the earliest possible moment, in one mass with the neighboring lymph nodes; when inoperable, palliative treatment consists in dressing the ulcer (of external cancers) with permanganate of potash or other deodorant, in treatment by the .r-rays, and in giving such stimulants, tonics, and anodynes as shall make life endurable. Certain palliative operations are applicable to inoperable internal carcinomas. Transitional Lepidic Tumors. — Mesothelioma and Endothelioma. — In addition to the classes of lepidomas already described (derived from epiblast and hypoblast), Adami places in a separate division those tumors derived from mesothelium and endothelium. As these were themselves derived from the mesoblast, and as this in turn was formed partly by epiblast and largely by hypoblast, it is but natural to find that mesothelial and endothelial tumors present at times the characters of lepidomas (epi-or hypoblast), at others those of hylomas (mesoblast). Therefore they are well named transitional lepidomas, because while they usually resemble ordinary lepidomas, they at times in whole or in certain parts grade so imperceptibly into hylomas that it is impossible to say to which class they really belong. In this group, embryogenetically at least, belong the lepidic tumors of the uterus; as these closely resemble similar tumors of epiblastic (mammary) and hypoblastic (intestinal) origin, Adami supposes that the epiblast has overgrown the primary mesoblast of the genital tract. These tumors, however, frequently appear either sarcomatous (i. e., mesotheliomatous) or endotheliomatous in parts, so it is evident that they possess primary mesoblastic characteristics. While there are typical transitional lepidomas (adenoma), the tumors in this group most important for the surgeon are atypical (carcinomatous) in nature. Adenoma and carcinoma of the prostate are included in this class, as well as rarer tumors of the ureters, seminal vesicles, and vas deferens; similar growths of adrenal, kidney, ovary, and uterus; also mesothelioma of the pleura, etc. For reasons already given, the tumors of the uterus resemble usually ordinary gland carcinoma. The TRANSITIONAL LE PI DO MAS 129 most important surgically of all the mesotheliomas is the malignant growth of the adrenal gland known as hypernephroma. Hypernephroma. — The medulla of the adrenal develops from the nervous system, and its cortex from the mesothelium, closely related to that which forms the cortex of the kidney. The adrenal medulla seldom gives origin to atumor; when it doesitforms a ganglioneuroma (p. 1038.) The hypernephroma (alveolar sarcoma, angiosarcoma, perithelioma, carcinoma, etc.) springs from the adrenal cortex, and is, therefore, classed as a mesothelioma. In it may be clearly seen the transitional type from carcinomatous (lepidic) to sarcomatous (hylic) arrange- ment of the alveoli (Fig. 80). Owing to fetal inclusions in ovary or testis, mesotheliomas may occur also in those organs, and more rarely in the kidney itself (Chapter XXV). The ordinary hypernephroma behaves as a malignant tumor, growing sometimes to immense size, invading the kidney, and possessing firm retroperitoneal connections. The only treatment is prompt excision, which implies nephrectomy; the operation is difficult and bloody, and recurrence is usual. Bony metastases occur, occasionally only a single metastasis (Scudder, 1910). nbnz 1 Fig. 80. — Hypernephroma of kidney. Transition from adenomatous to sarcomatous type of growth: nbnz', adenomatous overgrowth of solid columns or masses of cells of adrenal type nbnz", transition to sarcomatous arrangement; K, a kidney tubule involved in the growth. (Debernardi.) Mesothelioma. — Mesothelioma may arise in pleura, peritoneum, or rarely in pericardium or synovial membrane. The rare myeloid tumors of tendon .sheaths (Bellamy, 1901) belong here. It appears as a pseudo-inflammatory thickening of the serous membrane, producing a flattened, nodular or fungous tumor, composed of "elongated acini, lined with irregular swollen cells . . . resembling the curiously epithelioid type of cells we encounter in some endotheliomas," these acini lying in an abundant fibrous stroma (Adami). I have known a mesothelioma of the pleura, in a child of three years, to be mistaken for empyema. Endothelioma.— From this class should be excluded blood and lymph vascular changes not truly blast omatous. All such conditions as 9 L30 TUMORS new, telangiectases, etc., will be discussed under surgery of the vascular system (p. 276). Here we have to do only with typical and atypical neoplasms of endothelial tissues. They arc classed as hemangeio- endothelioma and lymphangeio-endothelioma; surgically they are not of much interest. Briefly, they are formed by concentric, and at times eccentric proliferation of endothelium of blood or lymph capillaries. An atypical hemangeio-endothelioma of the inner surface of the cranial dura mater, in which calcareous deposits have occurred, is called a psammoma. Perithelioma is a tumor in which the lymph cells lining the perivascular lymph spaces proliferate; when hyaline degen- eration occurs in these cells, the tumor is called a cylindroma. The growth occurs in the kidney, bones, and skin. Endothelioma occurs oftenest in the skin, in the region of the parotid, in the genital glands, bones, lymph nodes, and dura (Park, 1907). Tumors of the Carotid Body (p. 720) tend to the peritheliomatous type. Melanoma. — There is great uncertainty whether this tumor belongs among sarcomas or not. Adami is inclined to place it among transi- tional lepidomas. It arises by atypical proliferation of the pigment- containing cells (chromatophores) of the rete Malpighii in the skin, or of similar cells in the uveal tract of the eye. Ordinary pigmented nevi, which are either congenital deformities, or typical as distin- guished from atypical melanomas, sometimes become transformed in adult life into this most malignant type of tumor. Beginning in a cutaneous nevus or in the eye, a melanoma gives rapid and wonder- fully widespread metastasis, by both blood and lymph channels, to skin, internal organs (especially liver), bones, lungs, brain, etc. The only treatment is wide excision or amputation before metastasis occurs. Cholesteatoma. — Cholesteatoma is a tumor regarded by Borst and others as of endothelial origin; others (Ziegler) think it ectodermic, resembling ordinary dermoid cysts (p. 132). The contents consist of "white, pearl-like, glistening masses, which are concentrically arranged," (Lexer) apparently the remains of compressed and cornified epithelial cells. They occur in the middle ear, pia mater, and urethra. They vary in size from a cherry seed to a hen's egg. They may cause pressure symptoms in the cranium, or otitis media when in the middle ear. Excision is the best treatment. CYSTS. A cyst is an abnormal but encapsulated collection of fluid, in a cavity which is not provided with any outlet. The fluidity of the contents varies from liquid to semi-solid. One cavity (unilocular) or many (multilocular) may exist. A cyst is to be distinguished from an abscess, which is not strictly encapsulated; from dilatations (ectasia) of normal channels (varix, aneurysm) which still have an outlet; from effusions or transudations into preformed and normal cavities, which are classed apart (hydrops articuli, hydrocele, hygroma, hydrothorax, hydrocephalus, etc.) — though such collections may be encysted; and CYSTS 131 from cystomas, which is a term sometimes used to describe neoplasms in which cysts form incidentally (p. 120); but a distinction cannot always be made clinically between cysts and cystomas. Cysts may be classed as Extravasation, Retention, and Parasitic Cysts. All cysts tend to become spherical or oval unless compressed by neighboring parts. Extravasation Cysts. — These are encapsulated collections of fluid not in a preexisting cavity. An example is the hematoma, due to extravasation of blood, which as the result of reaction and condensa- tion in the surrounding structures, becomes in time encapsulated. Certain bursal tumors (p. 314) may belong in this class. Extravasa- tion of lymph, forming a chylous cyst, is very rare (p. 207). Extra- vasation of urine rarely forms a distinct cyst. Retention Cysts. — Retention cysts arise in preexisting cavities. They form the largest and most important class, and may arise either because there is no opening to the cavity, or because the normal opening is obstructed. In either case it is evident that secretion or transudation into the cyst must be more rapid than absorption. Generally speaking, these cysts may be classed as post-natal or antenatal in origin. Fig. 81. — Sequestration cyst, or dermoid (congenital abnormality) of scrotal raphe. Episcopal Hospital. I. Of Post-natal Origin. — Examples of cysts due to obstruction of ducts are Cysts of Bartholin's Gland, Galactocele, Sebaceous Cysts, Hydronephrosis, Hydrops Vesicce Fellea, etc. Examples of cysts formed in cavities normally having no outlet are corpora Intea and follicular cysts of the ovary, cystic goiter, etc. Sequestration Cysts deserve separate mention. They are due to the sequestration and detachment of portions of the true skin either 132 TUMORS (1) during ante-natal development, when they are congenital, and occur along the fissural lines of the body; or (2) are caused in post- natal life by implantation of portions of the true skin by trauma. Most dermoids belong to the former class (Fig. 81), though some, especially pilo-nidal cysts, are occasionally of post-natal development. Implantation dermoids are seen in the fingers of sewing women, or in the faces of shavers. I have several times excised from the face cysts supposed to be wens, which on opening were found to contain two or three long hairs growing from the interior of the cyst wall, which in such cases is lined with squamous epithelium, not with secreting cells. II. Of Ante-natal Origin. — These may be considered in three divisions: 1. Cysts Due to Persistence of Parts of Embryonic Ducts. — Thyro- glossal, Branchial, Vitello-intestinal, and Urachal Cysts: the "Tubular Cysts" of Bland-Sutton. 2. Cysts of Geniio-urinary Passages: (a) In the Male. — Encysted hydrocele of testis, probably due to per- sistence of the embryonic vasa efferentia. (6) In the Female. — From various tubules composing the parova- rium, and perhaps from the paroophoron. 3. Congenital Cysts of Glandular Organs. — The liver and kidney are especially affected. The pathology is obscure. (See p. 1038.) Parasitic Cysts. — In man, two main varieties of parasitic cysts are found, those due to Trichina Spiralis and Tenia Echinococcus. The trichina, much rarer, forms very small cysts, oftenest in muscles (p. 308). The echinococcus, commonly known as hydatid cysts, may attain an immense size. This parasite is an inhabitant of the intes- tinal tract of dogs, and the ova may gain entrance to the digestive tracts of those who have to do with dogs and whose habits are not very cleanly. It is a rather rare disease in this country. The shell of the ovum is dissolved by the patient's intestinal juice, and the larva, thus liberated, works its way through the intestinal mucosa usually into a branch of the portal vein, and thus reaches the liver; here it proliferates, and one large, or innumerable small conglomerate cysts will be found depending upon the stage of development. They are easily recognized by the "hooklets" they contain. The lungs, brain, and other parts of the body may also be affected. Treatment is discussed in Chapter XXIV. GENERAL REMARKS ON EXCISION OF TUMORS. The incision should correspond with the natural folds of the part; no skin need be removed in excising benign growths unless very large, when the redundancy may be removed with the tumor by an elliptical incision or one in the form of double SS (Figs. 82 and 83). If a tumor is very large, it is not wise to make the entire incision at once, as bleeding is more easily controlled by working down to the main blood-supply GENERAL REMARKS ON EXCISION OF TUMORS 133 through a small incision, and completing this when the main vessels have been ligatecl. Most external (i. e., not visceral) tumors are exposed on dividing the skin and superficial fascia; if beneath the deep fascia they should be approached through the proper muscular interspace. A tumor which is encapsulated usually may be enucleated, keeping the scalpel close to the capsule. Malignant tumors necessitate the removal of healthy tissues on all sides, and usually of the overlying skin ; as they frequently extend along and surround large bloodvessels, careful dissection is required. Cancers should not be removed by blunt dissection: the bruising of the tissues this entails causes egress of malignant cells into the surrounding tissues. A malignant tumor never should be cut into in the process of removal; to do this may infect the entire wound with cancer cells, and may cause alarming hemorrhage from the tumor itself w T hich it will be very difficult to control. If a tumor when exposed is found to be so placed that it cannot be removed with safety, the operation must be abandoned; Fig. 82. Elliptical incision for the Fig. 83. — Double SS incision for the removal of a tumor. removal of a tumor. in some cases the pedicle of the tumor may be secured, and the main bulk cut away; or the main vessels may be ligated, to starve the growth (p. 705). In gastric and intestinal tumors a palliative opera- tion is frequently possible. If a tumor, before operation, is clearly inoperable, of course no attempt should be made to remove it. Inoperability may depend on general conditions (the cachectic state of the patient, and probability or certainty of metastases which will kill the patient within the appointed time even if the primary growth were removed), or on the local condition; fixity of the growth, especially in the neigh- borhood of great vessels is always a sign to be seriously considered. It is important for the surgeon to have a clear understanding with his patient as to the extent of the operation possible and permissible. While often invading and obliterating veins, carcinoma generally respects arteries, even when entirely surrounding them (Crile) ; so that it is usually possible to dissect the artery free. In cases where it 134 TUMORS may become necessary, in the course of the operation, to sacrifice the main artery (especially the common carotid, Fig. 809) the tolerance of the patient for its loss may be determined by clamping it on the proximal side of the growth a day or two in advance of the opera- tion; if in the meantime threatening symptoms arise, the clamp (Fig. 233) may be removed, restoring the circulation. Everything but life may be disregarded in operating for malignant growths: thus it is entirely justifiable to amputate the thigh, if a tumor is so placed as to necessitate excision of the popliteal artery, which would surely cause gangrene; it is proper to excise muscles, tendons, bones, veins, arteries and even nerves, when, as in the neck, to do so will bring the operation to a successful conclusion without jeopardizing life. A patient will not miss one pneumogastric nerve or one carotid artery, and as a rule he will prefer to live without a clavicle and with a power- less arm than to keep his tumor and die. In some tumors resection of the thoracic or abdominal wall is necessary; the greater part of the stomach may have to be removed in one piece with the transverse colon, or the descending duodenum en masse with the head of the pancreas. CHAPTER V SURGICAL TECHNIQUE. There are readily available so many excellent works on Band- aging, Antiseptic and Aseptic Technique, Minor Surgery, Anesthetics, etc., that in the present chapter little will be attempted beyond discussing briefly the principles underlying these procedures. BANDAGING. Bandages are employed to hold dressings in contact with a wound, to maintain splints in position, or simply to support the part. Those most generally useful are made of unbleached muslin, which may be torn into any width. For the fingers a bandage should be 2.5 cm. in width; for the head and neck, 5 cm.; for the forearm, 7 cm.; for the arm and leg, 7.5 cm.; for the thigh and shoulder, 8 cm.; and for the trunk, 10 cm. wide. The length varies with the part to be bandaged and with the purpose for which the bandage is employed; the finger bandages are usually one or two, and the larger from six to eight meters in length. When prepared for use a bandage is rolled tightly into the form of a cylinder (roller bandage), the free end being known as the initial extremity. To roll a bandage by hand, fold one end on itself for about 15 cm.; again fold it in half, thus making four thicknesses of 7.5 cm. each; again fold it in half, making eight thicknesses 3 cm. long; and keep folding the bandage on itself until a solid core is formed. This core is then held in the left hand, between the thumb and first two fingers, and the free end is firmly but tightly grasped in the web of the right thumb (Fig. 84); then by alternately supinating and pronating the left hand, rotating the roller in supination but relaxing the grip on it during pronation, the free end of the bandage is guided on to the roller, which increases in size at each turn of the hand. The right hand should keep the bandage taut, so as to make the roller as firm as possible. A mechanical bandage winder is useful in hospitals or wherever many bandages are to be rolled. In applying a bandage, the initial extremity is placed on the part, and the roller carried around the limb transversely from left to right, once or twice, to fix the bandage. As the bandage gradually covers the part, each turn should be so applied as to overlie that just below by one-third or more of its width ; when it is found impossible to make the bandage lie flat on the limb, owing to the conical shape of the latter, the roller is to be carried off obliquely, the bandage fixed on the limb by the thumb or finger of the left hand, and the bandage reversed ( 135 ) 136 SURGICAL TECHNIQUE (Fig. 85). If the limb is conical it may be necessary (<> apply the initial extremity of the bandage obliquely in order to fix it without making a reverse. When the part has been completely covered in, the end of the bandage may be fastened with a safety-pin applied transversely to the end of the roller; or strips of adhesive plaster may be used instead. Large or complicated bandages may be held in place by stitching instead of pins. Fig. 84. -Rolling a bandage by hand. (Wharton.) Fig. 85.- -Method of making (Wharton.) Fig. 86. — Method of removing a bandage. (Whnrton.) In removing a bandage, nothing is so clumsy and time consuming as to drag the end around and around the limb as a long streamer. The entire bandage should be bunched up and passed from hand to BANDAGING 137 hand as it is unwound (Fig. 86). If soiled, it may be removed by band- age scissors (Fig. 87) , the blunt end easily slipping between the folds of bandage. Care should be taken not to cut over a subcutaneous bone (e. g., the shin), and always to keep the blades at right angles to the surface of the limb, for fear of pinching up the skin between them. As a general rule, bandaging should always begin below and proceed toward the trunk, and a bandage should not be applied to a limb without covering in the entire limb from fingers or toes up to and beyond the diseased part. In limbs slightly diseased, swelling of the distal part may not always follow the careful application of a bandage to the affected part alone, but usually the whole limb is more or less inflamed, and constricting it at the seat of greatest swelling may produce marked edema of the distal part if unsupported by the band- age, and cause great discomfort to the patient. Under no circum- stances should a bandage be applied so tightly as to interfere with the circulation. Hippocrates taught, and it is still absolutely true, that where it is desired to give pressure to a part by means of bandages, it is much safer to secure this by employing several superimposed bandages than to draw the primary bandage unduly tight. Fig. 87. — Bandage scissors. Gauze bandages are much employed at present; but they are inferior to muslin bandages except for holding dressings lightly in place; they are of most use for the head and neck, because they are so elastic that it is rarely necessary to make reverses. But if drawn at all firmly they pull into strings and are more liable than muslin to cause injurious constriction. Flannel bandages are of much value for support in cases of edema, varicose veins, etc. They are elastic, especially when cut on the bias, and are less apt to irritate the skin than muslin or gauze. Bandages of elastic icebbing are used for the same purposes. Varieties of Bandages. — The bandages most frequently employed are the spiral or spiral reversed (Fig. 85), which is universally used in the extremities; the recurrent (Fig. 88), used for stumps, the head, etc.; the spica (Fig. 89), which is employed to cover the shoulder, groin, buttock, etc.; figure-of-eight bandages (Figs. 90, 91 and 92), used to cover joints, to draw the shoulders backward or forward, etc.; T-bandages (Fig. 93), for holding dressings to the perineum; the many-tailed bandage, or bandage of Scultetus (1655) (Figs. 94 and 95), especially useful for abdominal wounds or other cases where the L38 SURGICAL TECHNIQUE patient cannot be supported while a roller bandage is applied. The application of these various bandages is sufficiently indicated in the accompanying figures. Fig. 88. — Recurrent bandage. (Wharton.) Fig. 89. — Ascending spica bandage. (Wharton.) Fig. 90. — Figure-of-eight bandage of the Fig. 91. — Figure-of-eight bandage of knr>o. (Wharton.) the neck and axilla. (Wharton.) Fig. 92. — Posterior figure-of-eight bandage of the chest. (Wharton.) BANDAGING 139 Fixed Dressings.— This is a term used for bandages into the meshes of which some substance has been incorporated which on drying becomes stiff. The materials usu- ally employed are starch, silicate of sodium, or plaster of Paris, espe- cially the last. The bandage itself is made of crinoline or coarse meshed gauze. Plaster of Paris. — This powder is hygroscopic; when moistened and allowed to dry it is converted into gypsum, the process being known as setting. It is worked into the meshes of the bandage by a spatula; the bandage is then loosely rolled, tied in waxed paper, and put away in an air-tight box until wanted. These bandages may be kept thus for several weeks, but are always better when freshly made. When it is desired to use them, one band- age is placed on end in hot water which completely covers it, and is allowed to remain in the water until bubbles cease to rise. The bandage is then removed from the Fig. 93.— Double tailed, or T-bandag Fig. 94. — Bandage of Scultetus (many tailed). Fig. 95. — Scultetus bandage applied; overlapping turns fastened with safety- pins. Episcopal Hospital. water, is grasped by its two ends in the hands, and is squeezed until nearly dry. It is then applied as an ordinary roller bandage to the I III SURGICAL TECHNIQUE part (Fig. 90), which must have been previously protected by one or two layers of flannel bandage or of cotton batting; bony prominences should be additionally protected by raw cotton or felt pads. A suffi- cient number of plaster bandages should be applied to render the Fiq. 90. — Plaster-of-Paris bandage being applied to leg. The foot should be kept at a right angle with the leg. Orthopaedic Hospital. bandage firm when it has set. Usually four to six are required for the foot and leg, eight to ten for the knee, and twelve or more for the pelvis or trunk. The bandages should be placed in the water only as needed ; they set quickly, and prompt action and skilful work are required to make a satisfactory gypsum case, or "cast" as it is popularly called. Fig. 97. — Removing gypsum case by means of Hunter's saw. Orthopaedic Hospital. Before the last bandage is applied, the projecting margins of the underlying flannel bandage may be turned down over the ends of the cast, and be held in place by a few turns of the last bandage : this covers in the rough edges of the cast, which, unless covered, cause great ANTISEPSIS AND ASEPSIS 141 annoyance to the patient. Finally some "plaster cream" may be rubbed all over the surface of the last bandage: this is made by adding just enough water to a couple of handfuls of plaster to make a thick paste. This refinement not only improves the appearance of the cast, but by giving it a glazed surface (enhanced by wiping with gauze moistened in alcohol) keeps the cast clean much longer. The gypsum usually is quite firm enough in half an hour for the patient to be moved easily. Starch. — Starch is applied in the form of a paste, by rubbing it into the bandages as they are applied. It is much more brittle and liable to break than gypsum, but may be used as a top dressing to a soiled cast which it is undesirable to remove. Fig. 98. — Gypsum dressing trapped. Orthopaedic Hospital. Silicate of Sodium. — Silicate of sodium is a pale yellow liquid of the consistency of mucilage. It is best applied to the bandages by rolling them on a winch in a trough full of the liquid, as in the apparatus of G. G. Davis. Silicate makes a light, ornamental cast, possessing all the good qualities of the gypsum, except that at least thirty-six hours are required for it to harden completely. It is much cleaner than plaster of Paris and is readily soluble in water. These fixed dressings are best removed, I think, by the use of Hunter's saw (Fig. 97); Avhen the gypsum is cut to the underlying bandage, a fact easily detected by the sensation imparted to the hand by the saw, the remaining bandages, and any part of the cast too soft to be cut by the saw, may be cut by a stout pair of bandage scissors. When desirable, a cast so removed may be sprung off and reapplied, being held together by adhesive straps or bandages. The gypsum may be cut away at any time (most easily while still setting) to make a "window" or "trap" through which a wound may be dressed (Fig. 98). ANTISEPSIS AND ASEPSIS. In order to prevent entrance of microorganisms into wounds at operation or other times, it is absolutely necessary to take such pre- cautions as will kill all bacteria which might be introduced through the medium of instruments, dressings, or the hands of surgeons, assistants, or nurses; or from the skin of the patient himself, or I 12 SURGICAL TECHNIQUE from septic structures within his body invaded during the course of operation. A thing is sterile when there are no bacteria on it, or when all the bacteria on it are dead. Everything that has not been sterilized is considered in surgery to be septic. It is next to impossible to remove bacteria, and entirely impossible to know clinically whether all the bacteria have been removed or not. The only recourse, therefore, is to kill them all. This is most readily accomplished by the use of moist heat (boiling), as no bacteria can survive a temperature of over 100° C. for more than ten to fifteen minutes. Everything that can be boiled may therefore be sterilized in this way, and must not again be touched by anything septic; if it is, it must be re-sterilized Before it can be used safely. Instruments, basins, buckets, etc., are readily sterilized by boiling. Enough sodium carbonate (washing soda) should be placed in the water to prevent oxidation (rusting) of the instruments (15 gm. to a liter). Dressings may be treated in the same way, but as they take much longer than instruments to cool off, and are nearly useless when wet, it is much more satisfactory to sterilize such things in a steam autoclave. For this purpose they are loosely wrapped in an outer covering, which is undone after they have been sterilized, and the contents of the package are removed only by sterile hands or instruments at the time of operation. If carefully wrapped and kept so, such dressings may be preserved in a sterile state for several days at a time; though it is always safer to re-sterilize them on the day of the operation. As the temper of knives is readily spoiled by boiling, and as their surfaces are smooth and therefore readily cleansed mechanically, I think it is best to use chemicals to sterilize them; placing them for twenty minutes in hot 1 carbolic acid solution (5 per cent.) and then in alcohol (70 per cent.) until used. The hands of the surgeon and his assistants, and the skin of the patient, however, cannot be sterilized by heat ; they must be prepared by mechanical and chemical processes. (When a surgeon speaks of his hands, he should use the term in the sense of the Greek word yj l ,°, which meant the hands and forearms up to and including the elbows.) The hands are best prepared by washing in hot soapsuds, with careful use of a nail-brush, for ten minutes; then the soap is rinsed off, and further removed by rubbing the hands and forearms with alcohol. The patient's skin is prepared in the same say, and is covered with dry sterile gauze until the time of operation. The mechanical cleans- ing with the nail-brush, aided by the macerating effect of heat and soapsuds, removes all loose epithelium and probably removes almost all the germs present. The alcohol by its dehydrating effects opens up the orifices of the cutaneous glands and allows penetration of the skin more effectively, thus weakening, if not killing, the germs always present in the deeper layers. Most surgeons in this country prefer to wear over their hands thin rubber gloves which have been 1 It is worth noting in this place that all antiseptic solutions are much more efficient when, hot than if cold or merely luke-warm. ANTISEPSIS AND ASEPSIS 143 properly sterilized. There is no doubt that they are a most valu- able addition to the surgical armamentarium, chiefly as a protection to the surgeon from contamination in septic cases. The use of gloves in no way absolves the surgeon from careful preparation of his hands, but it enables him in emergency to pass from a septic to an aseptic operation with an impunity which can never be enjoyed when he operates with bare hands. All persons concerned in the operation wear sterile gowns, and caps, and the operators wear face masks of gauze to prevent contamination of the wound or the instruments or dressings in any conceivable manner. Iodin Disinfection. — Grossich in 1908 found if the patient's skin (without previous preparation except dry shaving) were painted with a 10 to 12 per cent, alcoholic solution of iodin shortly before operation, at the time of operation, and at the close of the operation, the wounds healed better than after the habitual methods of skin preparation. This method is popular for its simplicity and efficiency, and is now in general use. Most surgeons find an alcoholic solution of from 3 to 5 per cent, strong enough, but many do not sufficiently appreciate the fact that the skin must be dry, to permit penetration of the iodin. It must not have been wet for three or four hours at least. It is im- portant not to use iodin whose strength has been increased by evapora- tion, and not to cover the areas painted with iodin until the latter lias dried. Either error may cause blistering of the skin. Picric Acid, in 2 per cent, solution, may be used in the same way as iodin. Antiseptic Methods of Operating were introduced before aseptic methods (Lister, 1865; Lucas-Championniere, 1869, 1876), and are still most widely applicable. Here, after preparing the dressings, instruments, and skin as above, the surgeon keeps his instruments in antiseptic solutions (2.5 per cent, carbolic acid); uses sponges soaked in antiseptics for mopping out the wound; and at the con- clusion of the operation applies a stronger antiseptic solution (3.5 per cent, iodin, 5 per cent, carbolic acid, 5 or 10 per cent, zinc chloride, 1 to 1000 corrosive sublimate, etc.) to the entire surface of the wound. In this way he makes sure that any microorganisms introduced into the wound, accidentally, will have an unfavorable soil for growth, and that in all probability they will be so weakened by the antiseptics employed as easily to be killed by the tissues of the body. This method of operating is applicable to all primarily septic conditions (compound fractures, necrosis, abscesses, malig- nant tumors, most amputations, etc.), and is valuable in a some- what modified form in all operations where the tissues are much bruised or long exposed to the atmosphere during the course of the operation (some excisions, ununited fractures, tedious dissections, etc.). When, however, the operation is of short duration (under half an hour), or when the tissues, even during a longer operation, are not bruised or otherwise unduly injured, and especially in visceral surgery, the aseptic method is superior. 141 SURGICAL TECHNIQUE Aseptic Methods of Operating have been in general use only for the last fifteen or twenty years, and were systematized largely by Terrier and his pupils. The instruments, dressings, etc., are sterilized, and the instruments are placed in sterile water or laid on a table covered with sterile sheets. The hands and the patient's skin are prepared in the usual way, but no antiseptics whatever are used during the course of the operation; everything coming into contact with the wound is sterile; and it depends on the unceasing and seemingly pedantic pre- cautions of the surgeon to keep the wound aseptic. If one mis-step is made, the aseptic has to be abandoned for the antiseptic method; and while I think the surgeon should always employ the aseptic method when he safely can, because antiseptics are at times harmful to the patient, and occasionally delay the process of repair, yet it cannot be denied that adherence to a strictly aseptic technique is much more difficult; and it must be acknowledged that many surgeons seem incap- able of practising it thoroughly. When either method is properly employed, the wound heals without noticeable inflammatory reaction, no stitch abscesses form, no discharging sinuses remain, no ligatures are slowly eliminated from its depths, no granulations persist at one end of the incision, the comfort of the patient is enhanced, and the after-treatment much simplified. MINOR SURGERY. Counter-irritation. — Counter-irritation is conveniently secured by the use of very hot compresses, by turpentine stupes, or by means of plasters of mustard, capsicum, etc. While these remedies are merely rubefacient in their effect, cantharides plaster will produce a blister (vesication); the surface of the plaster should be wiped with olive oil or petrolatum, so as to prevent it sticking to the cuticle. It should be removed in six or eight hours, and the blister will com- monly draw for several hours more; meanwhile it should be dressed lightly with an ointment, and when fully draw-n the tense cuticle should be punctured with an aseptic bistoury, and allowed to collapse on to the face of the blister as the serum exudes. When the blister shows a tendency to dry up, this may be encouraged by applying talc or other dusting powder. Cauterization is readily secured by means of the actual cautery. To produce vesication or still slighter degrees of counter-irritation, it is sufficient merely to touch the skin with the cautery iron when at a cherry red heat, or even to hold it close to the skin without bringing the iron into actual contact with it. Acupuncture. — Acupuncture is a little operation sometimes used in cases of lumbago, etc. After preparing the patient's skin as for an operation, six to ten sterile needles (ordinary hat pins will do) are thrust into the loins with a quick boring motion, and are allowed to remain in place a few minutes. Care, of course, must be exercised not to injure any superficial vein, nerve, etc., and not to enter the spinal canal. No anesthetic is required- MINOR SURGERY 145 Vaccination. — Vaccination, though usually done by the family physician, is a surgical procedure. The method I prefer is the follow- ing: the skin of the arm is rubbed briskly with an alcohol sponge, and vigorously dried with sterile gauze; this arouses the circulation of the part, and makes the virus more apt to "take." Then with the belly of an aseptic and rather dull scalpel, the cuticle is scraped oft' over an area about 1 cm. square until the surface is moist. Xo blood should be drawn. The vaccine is then quickly applied, and rubbed into the abraded area by means of the glass tube in which it is supplied. The vaccinated area is allowed to dry, completely, in the air, and no shield or bandage is employed. The wound should be painted every second or third day with a 3 per cent, solution of iodin. Hypodermic Injections. — Convenient tablets containing the requi- site amount of the drug are easily obtained from manufacturers. The tablet is dissolved in 2 c.c. of sterile water or saline solution, or the water with the tablet in it may be sterilized in a spoon over a flame. The fluid is then drawn up into the barrel of the hypo- dermic syringe previously sterilized by boiling or by soaking in an antiseptic solution (which should of course have been removed by rinsing the interior of the syringe in sterile water). The sterilized hollow needle is then screwed on to the nozzle of the syringe, and any bubbles of air are expelled by pressure on the piston, while the needle is held upward, until the fluid spurts. Then a fold of the patient's skin, prepared by vigorous rubbing with an alcohol sponge, is picked up between the thumb and finger of the left hand, and the needle quickly thrust obliquely into this fold, so that the point enters the subcutaneous tissues. Care must be taken to avoid entering a subcutaneous vein, wounding a nerve, etc. The best situations for hypodermic injections are over the deltoid muscle, on the outer surface of the thigh or calf, in the buttocks, the loins, or the lateral abdominal wall. No dressing is required for the needle puncture. Use of Saline Solution. — The object of this solution is to supply a fluid as nearly like the blood as possible. The following formula is recommended by Park: 1$ — Calcium chloride, 2 parts Potassium chloride, 3 parts Sodium chloride, 9 parts Sterile water, 1000 parts This should be prepared aseptically and should again be sterilized before use. In emergencies it is sufficient to add a teaspoonful of sodium chloride (table salt) to each half liter of water, boiling the solu- tion before using. This fluid is used hypodermically ( hy-podermoclysis I , by the bowel {proctoclysis), and by intravenous infusion. It is also widely employed, especially in abdominal surgery, as a substitute for sterile water. It should be injected at a temperature of from 105° to 110° F. For hypodermoclysis, proctoclysis, or intravenous use, it is convenient to let it flow out of a glass jar graduated from above downward, so that a glance will show how much has been given. 10 146 SURGICAL TECHNIQUE In emergencies, a sterile fountain syringe or funnel will answer the purpose. The main purposes for which it is used are to combat hem- orrhage and shock by restoring blood pressure (p. 265), and to dilute toxins circulating in the blood. Hypodermoclysis.- This is the subcutaneous instillation of saline solution. A long hollow needle, with large caliber, is used ; it is attached to a rubber tube connecting with the receptacle, which may be several feet higher than the patient. The clip on the tube is released, and, while the fluid is running from the needle, this is thrust into the sub- cutaneous tissues as in administering a hypodermic injection. The best sites for hypodermoclysis are under the mammary glands, in the flanks, the lateral abdominal walls, or between the scapulae. From 250 to300c.c. may be introduced through one puncture, the accumulat- ing fluid being gently rubbed out into the tissues. Rarely more than one liter is required by hypodermoclysis. The fluid is not absorbed very rapidly, and where immediate effect is desired it should be given intravenously. The needle punctures should be painted with collo- dion and sealed with a scab of absorbent cotton. Under the term axillary infusion has been described a method of hypodermoclysis by which absorption is very rapid: a puncture is made, with a bistoury, through the skin over the pectoralis major muscle about midway between the clavicle and anterior axillary fold; then, with the fingers of the left hand in the armpit as a guide, an infusion cannula (not dangerous because blunt) is thrust through this puncture into the cellular tissues of the axilla, traversing the pectoral muscle; the solution is then allowed to flow. Proctoclysis. — Proctoclysis, the rectal instillation of saline solution, 1 is widely employed in the treatment of peritonitis (Murphy, 1905). A soft rubber catheter is attached to the rubber tube leading from the reservoir, which should not be more than a few inches higher than the patient's buttocks; the eye of the catheter is placed, just within the anus. The solution should flow into the rectum very slowly, about 750 c.c. every forty to sixty minutes for an adult. If 750 c.c. of the solution are placed in the reservoir every two hours, 9 liters will be absorbed in a day, and the rectum will have periods of rest of an hour or more after each amount has been absorbed. The catheter is to remain in place continuously. This treatment may be continued for four or five days if necessary. If too much fluid is administered, slight edema of the ankles, hands, and even face may appear (Murphy). The solution is placed in the container hot (105° to 110° F.), and may be kept hot by hot water bags (Fig. 889) ; but it is probable that owing to its slow 7 flow, it is about the temperature of the blood or lower after traversing the tube to the patient. Intravenous Infusion. — Select a superficial vein (usually the median cephalic at the elbow), and tie a tight bandage around the extremity on the cardiac side of the vein selected, in order to render it visible 1 Sterile water, without the addition of salines, is just as efficient; it is not irritating to the bowel and is absorbed as readily (Trout, 1912). MINOR SURGERY 147 and fulh r distended. Prepare the skin and your hands in the usual way. With a fine sharp pointed hollow needle make a quick thrust through the skin, and endeavor to reach the lumen of the vein. This requires considerable skill and practice. It is sometimes better to make an incision somewhat obliquely to the course of the vein, about 3 cm. long, and cut down with light strokes directly on to the vein, which may be embedded in fat. Do not tease and maul the-fat; this favors infection of any wound. When the vein is thoroughly exposed in this way, thrust a grooved director across beneath the vein, and along the groove slip two ligatures. Draw one of the ligatures to the distal side of the grooved director and ligate the vein; draw the other liga- ture upward, on the cardiac side of the director, and loop it but do not tie it tight. Then pass a sharp scissors along the grooved director Fig. 99. — Intravenous infusion of saline solution. and, controlling the blood by a finger of the other hand on the cardiac side of the director, cut the vein half way across (Fig. 99). Lay aside the scissors, and take the infusion cannula (blunt pointed, with bevelled eye) in the right hand, have the clip removed from the tube, and, while the saline solution is running from the cannula, gently insert this into the gaping wound in the vein, pointing it toward the heart, and tie the ligature already placed so as to secure the cannula in the vein. Then withdraw the grooved director and have the bandage around the limb cut, so as to allow the venous current to flow. The reservoir should not be held more than a foot or two above the patient's body, and the saline solution should not flow more rapidly than 500 c.c. in ten minutes. The amount introduced must depend on the state of the patient's pulse. Usually a liter is more than enough; occasionally several liters will be required. Transfusion of Blood. — Direct transfusion, introduced by Crile (1906), implies the transference of blood directly from an artery of a 148 SURGICAL TECHNIQUE healthy person (known as the donor) to a vein of the patient (the recipient). It lias been almost entirely superseded by indirect tnnis- fusum, an old method recently revived with improvements, in which blood is first drawn into a receptacle, and then injected into the patient's veins. It is necessary to prevent clotting of the blood during the process. This is accomplished in two main ways: (1) By drawing the blood directly into a paraffin-coated flask, and reinjecting it immediately by transferring this Mask to the recipient (Kimpton, L913). The paraffin mixture is composed of: Stearin, 1 part; paraffin, 2 part-; vaselin, 2 parts (Beth Vincent, 1912). (2) By the citrate method popularized by Lewisohn (191.")): add slowly to the blood, as it is drawn, in the ratio of 1 to 10, a 2 per cent, solution of sodium citrate, which prevents coagulation. The selection of the donor is important; to obviate the possibility of hemolysis, his blood should conform to the same type as that of the recipient; and, of course, he should be not only free from disease, active or latent, but strong and husky. In hospitals the clinical pathologist should keep a list of available donors, and one of the proper type may be selected when occasion demands. Lewisohn thus describes his citrate method: The donor is put on a table, a tourniquet applied to the arm, and the vein punctured with a large size cannula (gauge 11). The blood is received in a sterile graduated glass jar (500 c.c.) containing 25 c.c. of a 2 per cent, sterile solution of sodium citrate. While the blood is running it is well mixed with the citrate solution by a glass rod. After 250 c.c. of blood have been taken another 25 c.c. of citrate solution are added, and blood up to 500 c.c. drawn. The citrated blood is then taken to the recipient, whose vein is punctured or exposed by a small incision, and the citrated blood is slowly introduced by gravity. It is possible to preserve this citrated blood in cold storage for as long as twenty-four or forty-eight hours before using it. Phlebotomy. — Phlebotomy which is usually preferred to arteriotomy for "letting blood," is generally done in the median cephalic or median basilic vein. The vein is made tense by applying a tight bandage above it, the skin is properly prepared, and a small incision (1 cm.) is made directly over and into the vein. No anesthetic is required. The spurting blood is caught in a suitable basin; it may be made to run more freely by having the arm dependent or by directing the patient to work his fingers around a bar, alternately tightening and loosening his grip. The patient should be in a sitting posture, so that any faintness may be quickly perceived. It is seldom desirable to draw more than half a liter. The wound is dressed with a pledget of sterile gauze, no suture being required; and the same wound may easily be reopened for further bleeding during the next few days. Leeching. — The Swedish leech, which is preferred, draws from 1(1 to 1.") c.c. of blood. The skin is carefully washed, and the leech applied over the part to be leeched, but not directly over a super- ficial vein. If the leech does not bite, a little milk or blood should be ANESTHESIA AND ANESTHETICS 149 placed on the skin. When he has drunk his fill he will fall off; or this may be hastened by applying salt over the leech and neighboring skin. The* blood usually continues to flow for some time, so that a much larger quantity may be drawn from one leech bite than the capacity of the leech. When enough has been drawn, the bite should be dressed antiseptically, and moderate pressure applied. Aspiration. — By means of a vacuum bottle it is easy to withdraw fluid collections through a hollow needle. Water pressure may be used to produce a vacuum, by attaching the exhaust tube to a hydrant of running water by means of a suitable connection, or an ordinary suction pump may' be used (Fig. 100). The bottle is first emptied of air as far as possible; the valves are then turned, and, the skin having been properly prepared, the sterile trocar and cannula are thrust through the overlying tissues into the collection of fluid (hydro- thorax, empyema, cold abscess, etc.). The trocar is then withdrawn, the valve turned to close its passage, and the valve leading from the cannula to the bottle is opened, allowing the fluid to flow. If the lumen of the cannula is blocked by flakes of lymph, a stylet may be passed through it from time to time. The puncture should be dressed antiseptically. Fig. 100. — Aspiration of a lumbar abscess. Episcopal Hospital ANESTHESIA AND ANESTHETICS. Certain gases, which are respirable, induce unconsciousness when absorbed through the lungs and carried to the nerve centers. The state so produced is called general anesthesia. In addition to uncon- sciousness, which implies analgesia and anesthesia, muscular relaxa- tion is also produced. 1 It is possible to secure the same effects from some such drugs when administered otherwise than by inhalation, as by rectal administration; but, as a rule, general anesthesia is secured 1 Crile maintains that general anesthesia secured in the usual way does not prevent nocuous impulses from the seat of operation reaching the brain along afferent nerves. If, however, the usual methods adopted to secure local anesthesia are added to the general anesthetic these nocuous associations are avoided. To this principle of operative surgery he has given the name Anoci-association. 150 SURGICAL TECHNIQUE by inhalation of the vapor of ether, chloroform, ethyl chloride, etc. Local anesthesia is produced by the local use of some drug, usually introduced by hypodermic injection, which acts on the peripheral nerves; novocain and eucain are most used for this purpose. General Anesthesia. — The patient should have his bowels well opened the day previously, and should have eaten no food for at least eight hours before the anesthetic is administered, as all general anes- thetics, especially ether, produce some degree of nausea. In opera- tions not involving the stomach or intestines, there is no objection to the patient drinking a glass of hot water half an hour before the operation. This prevents gastric irritation from any of the anesthetic unavoidably swallowed. Before giving an anesthetic, a thorough physical examination of the heart and lungs should be made, and the patient should remove false teeth, chewing gum, tobacco, etc., from the mouth, as well as hairpins, earrings, etc. Many surgeons have the habit of giving a hypodermic injection of morphin half an hour before com- mencing the anesthetic; in some cases it is valuable, but in others apart from being a pure waste of a valuable drug, it is actually harm- ful. The clothes should be loosened around the throat and so dis- posed as to make artificial respiration easy in case of emergency. During anesthetization and while recovering from the effects of anes- thetics, the chests and shoulders of patients should be carefully covered, as they are very prone to catch cold. No anesthetic should be administered in the dark; change of color frequently is one of the most easily recognized signs of danger, and unless the patient is being anesthetized in a good light this cannot be appreciated. The fre- quency of ether deaths in negroes is probably due to inability to recognize cyanosis readily in them. The patient should be supine, with the head comfortably supported, especially in the old and round- shouldered, in asthmatics, etc. Throughout the course of anestheti- zation the anesthetizer must pay strict attention to his own duties, and neither attempt to follow- the minute details of the operation nor to converse on irrelevant topics with bystanders. He is responsible for the life of the patient quite as much as the surgeon; and it is a sad fact that the disproportionate number of deaths from anesthesia which occur during trivial operations is usually due to carelessness of the anesthetist. With an ear for respirations, a finger on the tem- poral pulse, and an eye on the patient's pupils, the anesthetist need not fear to have his attention wander or to meet with unforeseen accidents. Ether 1 is the safest general anesthetic for major surgery, and probably is the most widely employed. Hewitt places its death rate at 1 in 16,000, five times safer than chloroform, though slightly less safe than 'Commercial ether contains many impurities, and J. H. Cotton (1917) claims that its anesthetic properties are due to some of the impurities, while others are responsible for its unpleasant after-effects. By administration of chemically pure ether to which have been added only the impurities which produce anesthesia, he claims to have obtained abolition of sensation without loss of consciousness. ANESTHESIA AND ANESTHETICS 151 nitrous oxide. Ether (ethyl oxide) is a heavy, highly inflammable liquid of strong pungent odor. Its vapor is heavier than air, and sinks to the floor; hence all lights should be kept high above the operating table, as occasionally patients have been seriously burned by ignition of ether fumes. I prefer to administer it by the so-called "open, drop-method," as follows: The patient's cheeks, nose, and lips may be greased with vaselin to prevent the rubefacient effect of the ether. Place eight to twelve layers of dry wide-meshed gauze across the patient's mouth and nose, and ask him if he can breathe through the gauze. He always answers "yes." Then directing him to shut his eyes and mouth, and to breathe through his nose, hold the gauze lightly in place, but do not exclude all the air from under its edges; drop the ether gently over the gauze, one drop every second or so, moistening an area an inch and a half in diameter just below the tip of the nose (Fig. 101). When given thus slowly very little if any respiratory irritation is produced, the patient continues to breathe in his natural way, and by the time 50 to 00 c.c. Fig. 101. — Etherization by the open, drop-method. Episcopal Hospital. have been administered he is usually unconscious, not having exhibited any "stage of excitement." The lower jaw should be constantly held forward by the fingers placed back of the angle, on the ramus, as anesthesia paralyzes the muscles, and unless supported the jaw may fall backward and allow the base of the tongue to force the epiglottis over the larynx. When the respirations become mechanical, like those of sleep, the pupils are found contracted but still reacting to light and the conjunctival reflexes are abolished; then, after a little more ether is administered muscular relaxation becomes complete. The time consumed is usually from ten to fifteen minutes. The operation may then be commenced. 1 The time may be shortened by excluding air more completely: this is easily accomplished by keeping the margins 1 Many very short operations (half a minute) may be done during the stage known as "primary anesthesia," described many years ago by Packard. The patient is directed to hold one arm aloft, when inhalations are begun, and to hold it up as long as possible. The moment the arm drops is the opportune time for surgical intervention. In Germany this state of first insensibility from the anesthetic is known as the "Ether Rausch." L52 si RG1CAL TECHNIQUE of the gauze in contact with the patient's face, and by adding more dr\ gauze mi top and using it as a roof under which to drop the ether. This concentrates the ether vapor, and requires less ether; but unless cautiously and gradually done is apt to cause choking. The anesthe- tist should never give enough ether to cause the pupils to dilate 4 ; if they are kept contracted, but reacting to light, the patient is in the proper state tor operation. Frequently during the course of an operation it may be possible to let the patient come so far from under the influence of ether as to allow his pupils to return to their normal dilated state, which should not be mistaken for the dilated state, without reaction to light, present in advanced ether poisoning. Home operators prefer and others will not allow the anesthetist to let the patient "come to" from time to time. Such idiosyncrasies must be learned by experience. In giving ether to children, who are not reasonable enough to lie still and breathe quietly, it is better to pour a teaspoonful of ether at once on the gauze, and hold this firmly in contact with the face. After a short struggle, and holding the breath until thoroughly "out of breath," the child will take a few deep inspirations, and by so doing will pass completely under the influence of the ether in a very much shorter time and with very much less discomfort and danger to himself than if the struggle had been prolonged by attempting to administer the ether by the drop-method. Certain accidents may occur during etherization: (1) When ether is first administered, the patient may stop breathing. This usually is due to neglect of the precaution to start the patient breathing through the gauze before any ether is dropped on it, or to pouring on a quantity of ether instead of giving it drop by drop. It is treated by removing the gauze, allowing the patient to breathe air, and then beginning over again. ('2) The patient, if an alcoholic, or if he has taken ether frequently before, may be unduly exhilarated by the stimulating effect of the ether. Hence it may be necessary to use forcible restraint, and preparation should accordingly be made. So long as respiration is good, the administration of more ether is indicated, as there are very few patients, indeed, Mho do not succumb to its influence in a short time. (3) The patient's throat may fill up with mucus, making respiration difficult, and producing cyanosis. This generally is due to too rapid administration of ether, to neglect to hold the jaw forward, or to a preexisting bronchitis, etc. It is best treated by pulling the jaw forward, as already described, thus opening the larynx; by turning the head to one side, or letting it hang over the edge of the table, thus allowing the secretions to accumulate in the cheek or to run out of the mouth; and finally by the use of a mouth-gag with direct removal of the mucus by sponging. The mouth-gag is rarely required by a good etherizer; but it should always be at hand for emergencies. Marine sponges are best for this purpose; each should be about 4 cm. in dia- meter, freshly wrung dry out of luke-warm water, and fixed firmly in a long handle. When the jaws have been opened by the gag, the tongue ANESTHESIA AND ANESTHETICS 153 Fig. 102. — Tongue forceps. is grasped with gauze or a suitable forceps (Fig. 102), and pulled forward and upward. This alone may make respiration easier. If necessary, the sponges are to be passed back into the pharynx, and by a combined sweeping and rotary motion are made to collect as much mucus as possible. (4) The patient may stop breathing from no foreseen cause. This fre- o quently is due to the admin- istration of too much ether, occasionally to reflex inhi- bition from injudicious trac- tion on the tongue or spong- ing, and rarely to the direct shock of the operation. It is treated by artificial respiration, by hypodermic stimulation, and by inhalations of ammonia and oxygen when once respiration is restored. (5) Vomiting occurs from neglect to abstain from food before operation, but will not occur after anesthesia is once complete, unless the patient is allowed to come out of the anesthetic too far. Chloroform. — One death among every 3749 chloroform anesthesias is attributed to the action of the drug. Its action is more rapid than that of ether, and the zone of safety is much narrower. It has been said that the danger signals appear and the collision occurs at the same instant; there is not sufficient warning, as there is in etheriza- tion, for disaster to be avoided. The most important thing in chloro- form anesthesia is to allow the mixture of plenty of air with the inhaled vapor. On this account I think the simplest way to administer chloroform is by dropping it slowly on one or two thicknesses of gauze stretched over a wire frame, made to fit over the mouth and nose in such a way that the part of the gauze moist- ened by the chloroform is always 2 cm. or more dis- tant from the patient's lips (Fig. 103). Even stricter attention to the pulse and respiration is required than in giving ether; but a stage of excitement scarcely ever occurs, little or no bronchial irritation is produced, and vomiting during recovery from anesthesia is very unusual. Ethyl chloride is a seductive but dangerous anesthetic. It acts as quickly as, and even more pleasantly than chloroform. Nitrous oxide, a gas which is universally employed for minor dental operations, may be equally well employed in surgery for short operations where complete muscular relaxation is not required. It exerts its influence in less than a minute and is the least unpleasant anesthetic to take. It acts largely by causing an accumulation in the Fig. 103. — Chloroform inha 154 SURGICAL TECHNIQUE blood of carbon dioxide. Special apparatus is used, including a tank containing the gas, a face mask with suitable valves to admit or exclude air or oxygen in conjunction with the nitrous oxide, and a rubber bag, inserted between the tank and the mask, in which the gas collects, hut from which the expired air is excluded by an automatic valve. When a suitable admixture of oxygen is permitted, skilful anesthetists may prolong the duration of anesthesia for several hours. Nitrous oxide frequently is used to induce anesthesia, ether or chloroform being substituted later. As I have seen it used in this way I have not been able to see any advantages over the skilful administration of ether from the start; but when nitrous oxide and oxygen are used alone, without any recourse to ether, recovery from the anesthetic occurs much more promptly, and there are no unpleasant after-effects. Choice of a General Anesthetic. — Unless contraindicated, ether is to be preferred, because it is the safest. Its greatest danger is post- operative bronchitis or pneumonia; but with proper precautions against exposure of the patient, and by giving it drop by drop, such com- plications are not to be feared. Moreover, it is better for a patient to be nauseated and to have bronchial irritation after recovery from ether than for him to be killed by chloroform or ethyl chloride. In cases where bronchitis, phthisis, etc., exist, or where the kidneys are seriously diseased, and where some general anesthetic has to be employed, nitrous oxide and oxygen should be preferred. Chloroform is particularly to be avoided in cases of heart lesion not properly compensated, and in cases of shock. Nitrous oxide causes cyanosis, stertor, and muscular regidity, with such increase of blood pressure that it is especially contraindicated in patients with arteriosclerosis; its successful administration requires much more skill and experience than does that of ether, but when skilful assistance is available, and the operation will not consume more than thirty or forty minutes, it is when combined with oxygen a safer and more desirable anesthetic than is ether for patients with visceral lesions other than those of the vascular system. It is preferable also in all septic conditions, as it introduces nothing which has to be eliminated by the viscera; both ether and chloroform are more or less toxic. Administration of General Anesthetic for Special Operations. — Head and Neck. — It is found often in operations on the head and neck that the anesthetist is very much in the way, and that the progress of the operation interferes with the proper administration of the anesthetic. One of the simplest methods of overcoming this is to have the ether vapor conducted to the patient's mouth through a tube, so that the anesthetist may stand at some distance. Through the cork of the ether bottle pass two tubes— an afferent tube which is connected with a hand bulb, and an efferent tube which is three or four feet long and leads to the patient's mouth. If a hooked metal tube is attached at the mouth end, it will hang in the angle of the mouth and keep its place without difficulty. The ether vapor has never caused, in my experience, any evidence of stomatitis. If its irritating effects are ANESTHESIA AND ANESTHETICS 155 feared, the vapor may be conducted by tube over or through a bottle of water before entering the mouth. The patient is first anesthetized in the usual way, and when thoroughly relaxed, the gauze is removed from the face, the mouth tube introduced, and the ether vapor forced into the mouth by use of the hand bulb. If avail- able a current of oxygen or of compressed air may be conducted through the ether bottle, thus replacing the hand bulb. Crile's plan is another convenient method. After the patient is anesthetized, the surgeon passes a well greased tube through each nostril to the naso-pharynx, and packs the mouth loosely with gauze. The outer ends of the nasal tube are connected by a Y-shaped glass tube to a long rubber tube, at the far end of which is a funnel lightly filled with gauze. The ether is then administered by being dropped on the gauze in the funnel. It is well to have a U-tube inserted somewhere in the tube which conducts the ether vapor to the patient, so that in it may collect any condensation from the ether vapor. Intrathoracic Operations. — When the pleura is opened, the lung partially collapses, and in consequence there may be considerable respiratory disturbance and interference with the administration of an anesthetic. To overcome this Sauerbruch, of Breslau, devised (1904) a plan for operating under negative atmospheric pressure, thus allowing the lung to remain expanded. In this method the patient is placed in a chamber in which negative pressure can be induced; his head projects through an opening in this chamber, and a rubber collar fitting closely around his neck makes the aperture air-tight. The anes- thetist sits outside the chamber, while the surgeon and his assistants must remain inside. This plan of operating under negative pressure entails expensive apparatus, and a specially constructed operating- room, which cannot be moved from place to place. Dr. Willy Meyer, of New York, is the chief supporter of the method in America, and has had a very complete operating suite constructed in the Lenox Hill Hospital in that city. Positive Pressure Method. — This was introduced by Brauer, of Heidelberg, very soon after Sauerbruch's method. Here the patient's head and the anesthetist are in a specially constructed chamber, in which the atmospheric pressure may be increased, by suitable apparatus, so that when the pleural cavity is opened the lung stays expanded. This appears to be a simpler method than that of negative pressure, and seems quite as efficient; but has not been used much in this country. Intratracheal Insufflation. — Meltzer and Auer, of the Rockefeller Institute, New York, found in experiments on dogs, in 1909, that if a tube was passed down, the trachea almost to its bifurcation, and if air mixed with ether was constantly blown in through this tube by suitable bellows, the dog's lungs remained expanded even when both pleurae were widely opened, that anesthesia could be maintained for hours, and that it was impossible to kill the dogs by an overdose of the anesthetic. This method was adapted for human beings by Elsberg, L56 SURGICAL TECHNIQUE of New York. Imt in most operations where it was formerly used, it is found sufficient to employ nasnl tubes conducting the ether vapor only as Far as the pharynx. This method is a greal convenience in operations on the mouth and pharynx, as it prevents aspiration of mucus or blood. Briefly described, the apparatus is as follows: An electric motor is used to pump the air by tube to the ether bottle, where the tubing is so arranged with stopcocks that (1) all the air may pass directly on to the patient without coming into contact with the ether; (2) all the air may pass through the ether bottle, and thus become saturated with the anesthetic before reaching the patient; or (3) some of the air may pass directly on to the patient while some passes through the ether bottle before reaching the patient. Thus the amount of ether to be administered may be accu- rately regulated. The ether enters the ether bottle by gravity, drop by drop, from a container, and is vaporized by contact with a heated cylinder. An oxygen tank may be connected with the tube leading to the patient, so that pure oxygen or oxygen mixed with air in any proportion may be inhaled. The tube leading from the ether bottle to the patient is connected with a manometer, and has a Y-ending, one branch for connection with the intratracheal tube, and the other to be used as a cut out, to allow collapse of the lungs at any instant desired. The apparatus may be obtained now in very compact form. The intratracheal tube should be fairly rigid, of the length of a stomach tube, and about half the diameter of the trachea. The patient is given hypodermatically morphin and atropin, and is anes- thetized in the usual manner. The tube is then passed through the larynx into the trachea. This is facilitated by the use of the broncho- scope- tube or speculum. When the intratracheal tube is momentarily arrested at the bifurcation of the trachea, it is withdrawn about 3 em. If the tube is in correct position air will enter both lungs; if it has been pushed in so far as to be arrested at the division of the right bronchus, no air will enter or leave the left lung. When in proper posi- tion, the tube is clamped just outside the dental margin by a frame supported on the ears, resembling a spectacle frame. "The tube is now connected with the air pressure apparatus, and air is blown through at a pressure of 10 mm. of mercury. After several minutes, the pressure is raised to 20 mm. and the operation can be begun. When the pressure of the inflowing air and ether equals 20 mm. of mercury, inspiration and expiration will continue, air being inhaled and exhaled by the side of the tube. If there existed a profuse secre- tion of mucus in the pharynx and trachea, this will be found to have ceased soon after the insufflation was begun. Every two to three minutes, an assistant opens a vent so that the current of air which enters the tube is interrupted for a moment." (Elsberg.) No ill effects have been noted from anesthesia maintained by this method. Far from favoring pulmonary complications, it seems to prevent them. ANESTHESIA AND ANESTHETICS 157 Local Anesthesia may be secured by freezing the skin with a mix- ture of ice and salt, or by a spray of ethyl chloride or rhigolene. The skin becomes white, covered with minute crystals of ice, and is rendered very tough. The anesthesia lasts only a few seconds, but sufficiently long for opening superficial abscesses, etc. If the patient only knew that the thawing hurts as much or more than a sudden stab with a sharp bistoury, he probably would prefer to have this form of local anesthesia abandoned. Novocain (procain) and eucain are the chief agents used for local anesthesia. They are now on the market in tablet form, and are used in half strength (0.45 per cent.) normal saline solution. Of eucain, a 1 or 2 per cent, solution is preferred; this is stable, not toxic in ordinary amounts, and may be sterilized repeatedly by boiling. Of novocain a 0.25 per cent, solution is sufficient. Adrenalin may be added but it is not necessary; it constringes the capillaries and prevents diffusion of the anesthetic. Where large quantities are used, it is convenient to prepare the solution in bulk. To make 0.25 per cent, solution of novocain, to 500 c.c. sterile normal saline solu- tion, add 1.25 gm. of novocain crystals; boil for ten minutes on two successive days. To make 1 per cent, eucain solution, add 5 gm. to 500 c.c. of saline solution, sterilize, and just before using add 3 drops of adrenalin chloride solution (1 to 10,000) to every 30 c.c. of the anesthetic. As a rule 15 to 30 c.c. of either solution suffices for a major operation. Cocain, on account of its toxicity, and because usually rendered inert by boiling, is little used except for applications to mucous membranes (eye, throat, urethra, bladder); a 2 per cent, solution may be used, and sometimes a 4 per cent, solution. It is dropped on the surface of the eye, and is applied to the nose and throat by a pledget of absorbent cotton; while it is injected into the urethra and bladder by means of the urethral syringe, catheter, or instillator. Hypodermic Use. — The skin is pinched up as in giving a hypodermic injection, but the needle, which enters at one end of the proposed incision, with its point directed toward the other end, is not passed into the subcutaneous tissues, but its point is arrested in the true skin, the first injection being endodermic, not hypodermic. As the piston of the syringe is pushed down, a distinct wheal is raised in the skin; the needle is then pushed on within the true skin until its point reaches the limit of the wheal, when another wheal is pro- duced, and so on until the entire length of the needle has entered. It is then withdrawn and reintroduced at the furthest point reached, and the process is repeated until the line of the entire incision has been anesthetized. An incision may then be made through the skin, and, with a few added drops here and there as required, this degree of anesthesia will suffice for circumcision, removal of sebaceous cysts and small tumors, opening cold abscesses, etc. When a more extensive operation is undertaken, as one for hernia, goiter, etc., special atten- tion must be paid to nerves, bloodvessels, and connective-tissue 1 58 SURGICAL TECHNIQUE bundles {infiltration anesthesia). Almost any quantity of the weaker solutions may be used, especially when local anesthesia is aided by constriction of the limb above the seat of operation. Nerve blocking may be accomplished by perineural or endoneural injections, the latter being preferable as more accurate and permitting a wider range of operative procedure. Certain nerves (ulnar, per- oneal) may be reached directly, but usually it is necessary to bare the nerve by the hypodermic use of novocain as already described. In the endoneural method, the solution is injected directly among the nerve fibers of the main trunks conveying sensation from the region to be operated on. Fig. 1U4. — Spinal analgesia. Needle between spines of second and third lumbar vertebrae. Posterior superior iliac spines marked with iodin. Episcopal Hospital. Spinal anesthesia is closely allied to nerve blocking. It was sug- gested in 1885 by Leonard Corning, of New York; was employed in 1889 by Tuffier; and has been more widely used abroad than in this country. The anesthetic acts on the roots of the spinal nerves, not on the cord itself. The injection is made usually in the second or third lumbar interspace (Fig. 104); as a rule, anesthesia (which affects both motor and sensory impulses, especially the latter) extends only to the region of the waist, and therefore operations best suited for spinal anesthesia are those on the lower extremities or pelvis. Stovain (4 per cent, solution) usually is preferred to other anesthetics. About 1.5 to 2 c.c. are employed. The anesthesia begins in a few minutes and lasts nearly an hour. As positive contraindications to spinal anesthesia may be mentioned: Advanced cachexia, bilateral nephritis with scanty excretion, myocarditis, pericarditis with effu- sion, non-compensated cardiac disease. Most operations in which spinal anesthesia may seem desirable, can be done equally well under local anesthesia. CHAPTER VI. INJURIES AND THEIR EFFECTS. LOCAL EFFECTS OF INJURIES. The local effects of injury depend on the part injured, as well as on the force exerted by, and the manner of action of the vulnerating body. A smart blow with a rope will produce a wheal; if the rope slips rapidly through the hands with violent friction, a brush-burn will result; but if the rope is twisted tightly around the part, strangula- tion will occur. Striking the foot against a large stone will cause a contusion, but if the same stone falls on the leg it may fracture the bones. Injury of parts with abundant and lax subcutaneous tissues will be attended by much greater swelling than where these tissues are firm and resistant; injuries of certain parts are much more dangerous than similar or severer injury expended upon other parts not so highly specialized or so vascular. The local effects of heat, cold, etc., are considered at p. 176. Abrasions. — An abrasion is an injury in which merely the epiderm has been re- moved by slight friction; brush-burns, produced by violent friction, resemble contused wounds (p. 166). An excoriation is an injury produced by scratching or scraping which involves the corium. The resulting ulcers heal readily when properly protected. Contusions. — A contusion is a subcuta- neous injury of the soft parts produced by blunt force (kicks, falls, etc.). There is al- ways a certain amount of blood extravasated among the lacerated tissues; when this blood is visible in moderate amount be- neath the skin, it is termed an ecchymosis (Fig. 318, p. 332); and as it undergoes ab- sorption it passes through various shades of purple, green, black, and blue. A very minute ecchymosis is called a petechia. Blood extravas- ated beneath the conjunctiva remains bright red a long time, owing to oxidation through the thin overlying tissues. When enough blood is extravasated to cause an appreciable collection of fluid, it is called a (159) Fig. 105. — Hematoma of left thigh ten days after a fall ; also fracture of shaft of left hu- merus. Age forty-eight years. Episcopal Hospital. 1G0 INJURIES AND THEIR EFFECTS hematoma; or if clotted a thrombus. The skin itself, though more resistant than the subcutaneous tissues, does not always escape injury in a contusion; such injury is manifested in the course of twelve to twenty-four hours by vesicles, blisters, and bulla?. These usually appear before the ecchymoses, which rarely become apparent until the second or third day. The diagnosis of a contusion is easy, being based on the history of injury by blunt force; on the indentation of the soft parts (especially on the scalp), often persisting when the patient is seen soon after the accident; on the local tenderness which is rapidly followed by swelling, extravasation, and ecchymosis. The prognosis is good, unless there is some undetected injury to nerves, bloodvessels, bones, joints, or internal organs. The hematoma which forms seldom causes anxiety; usually the bleeding ceases spon- taneously, or under the application of cold, elevation of the part, moderate pressure, etc. The treatment consists in securing local rest, in applying anodyne or slightly stimulating fomentations (arnica, dilute alcohol, ichthyol ointment), and in promoting absorption of the hematoma at a later date by gentle massage, firm bandaging, etc. Constitutional treatment is rarely required. Strangulation. — Strangulation of a part results from the inter- ruption of the circulation by the application of circular constriction so tight and sufficiently long as to cause passive changes somewhat resembling those seen in contusion. If the strangulation is not relieved (by elevation, by division of constricting bands, etc.), the part dies, and is removed as a slough by granulations at the point of constriction. All the dangers from infection, present in gangrene from other causes, arise, and life is occasionally lost. Wounds. — A wound is a solution of continuity of the soft tissues the result of violence. A wound is open if the skin is as widely divided as the underlying structures; or subcutaneous if the division of the skin is insignificant. Wounds are also described as incised, lacerated, contused, punctured, or poisoned. Gunshot wounds, which resemble contused wounds, are considered in Chapter VII. Incised Wounds. — Incised wounds, which may be regarded as the normal type, are those made by clean cuts w T ith sharp instruments, and are produced by the surgeon in every cutting operation. Most accidental wounds partake more of the nature of lacerated than incised wounds, as the instruments by which they are inflicted (pocket knives, broken glass, axes, etc.), are not as sharp as surgical instru- ments, and even if sharp (as razors) are not wielded with the delicacy and precision necessary in surgery. Pain, hemorrhage, and gaping are the main symptoms of incised wounds. The pain varies with the size of the wound, with the sensibility of the part wounded, and with the manner in which the wound is produced. A large wound hurts more than a small one; wounds of the face and hands hurt more than those of the back and buttocks where the cutaneous nerves are less developed; and a quickly made incision causes less pain than one which is bungled. The hemorrhage depends largely on the INCISED WOUNDS 161 location of the wound, and on the implication of large vessels. Wounds of the face and scalp bleed profusely, because of the vascularity of these parts, and because in the scalp the vessels cannot contract and retract. The gaping of a wound depends on the natural elasticity of the tissues divided. A wound which runs in the direction of the natural folds of the skin will gape less than one which crosses these folds; one which divides muscles transversely will gape widely; the divided ends of tendons, arteries, and nerves may retract for several centimeters from the point of division. Process of Healing in Incised Wounds. — As the result of the irrita- tion produced by the vulnerating body, tissue changes occur which are pathologically identical with those seen in the process of inflam- mation; so that the healing of an incised wound is the same as Repair after Inflammation (p. 29). It is convenient to recognize different ways in which union occurs after a wound has been inflicted, although the difference is purely quantitative, depending on the extent of reaction necessitated, and though the processes, so far as they extend, are identical in all cases. Historically, three ways of union are recog- nized: (1) By immediate union (to which the term "first intention" as used by Hunter (1784) 1 is correctly applied); (2) by adhesion, as understood by Paget (1853); and (3) by granulation, or by second intention. 1. Immediate Union. — If the edges of an aseptic incised wound are accurately apposed so that each tissue meets its corresponding structure in the other lip of the wound; and if no foreign particles, even if aseptic, or no blood-clots, remain between the lips of the wound, then the reactive process may extend only to the stage described as that of "temporary hypertrophy." Xo inflammatory lymph exudes, no granulation tissue forms, and the wound heals by immediate union, or by the first intention in the Hunterian sense. Very few incisions and yet fewer wounds heal by immediate union; very small wounds of extremely vascular parts (fingers, face), may occasionally heal without the process of reaction having extended beyond the stage of temporary hypertrophy. Such wounds when healed leave no visible scar — the tissues have undergone complete regeneration, restitutio ad integrum. 2. Union by Adhesion. — When the insult to the tissues has been greater, or when the tissues themselves have been less able to repair the damage, the process of reaction extends to the stage of lymph formation. The lips of the wound must be in accurate apposition, leaving no dead spaces, so that the effused inflammatory lymph serves as a framework in which fibroblasts and granulation tissue develop, as described at p. 30. It is this form of union which occurs in the vast majority of aseptic operative incisions, and which is com- monly spoken of as "union by the first intention," though strictly speaking this term should be reserved for immediate union; but as 1 It is the "first intention" of nature to heal wounds in this way. 11 162 INJURIES AND THEIR EFFECTS for at least seventy years it has been erroneously applied by the majority of surgeons, it is perhaps useless to register a protest now. In the process of union by adhesion a sear is always produced extend- ing to the depths of the ineision, but is least conspicuous in wounds made with the greatest precision and attended by the least trauma; so that the kind of sears left by a surgeon in operating often give an idea as to the delicacy and neatness of his operative methods. 3. Union by (Iran illation. — This form of union, also known as union by the second intention, is that which occurs when the reaction- ary process extends to the stage of pyogenesis. As already pointed out (p. 27), it is theoretically possible for pus to be formed without the intervention of microorganisms; and it is likewise theoretically possible for wounds to unite by granulation without the formation of any visible pus: but for either of these events to occur in practice is excessively rare. If the lips of the wound are not brought into accurate apposition, the gaping surfaces become covered with visible granulations, and always, I believe, some pus will be seen on the surface of the healing wound, or will be absorbed by the dressings. The process of cicatrization and contraction is pathologically identical with that seen in the healing of ulcers (p. 52). Union by secondary adhesion (the third intention) is that which occurs when two lips of a granulating wound are apposed by sutures, or in other ways, so that the fibroblasts and granulations on one lip grow across the obliterated gap into the granulation tissue on the opposite lip, thus hastening the process of repair. If there is much discharge from the wound such secondary adhesion will not occur. Healing by scabbing, by incrus- tation, or by subscrustaceous cicatrization, is that form of union (by adhesion or by granulation) which occurs under a scab formed of effused blood and lymph mixed with the dust, etc., which collects on the surface. Treatment of Incised Wounds. — The first effort must be to check hemorrhage and to prevent infection. In operating, aseptic or anti- septic principles will be strictly adhered to, and in wounds accidentally received the surgeon, after adopting the necessary measures for arresting hemorrhage (Chapter X) will employ such methods of cleansing the wound and the surrounding parts as have already been advised in Chapter V (p. 142). Very small wounds will gape so little that the proper use of plasters, compresses, bandages, etc., will keep the edges in contact. In most wounds, however, the edges must be united by sutures. Sutures are made of absorbable or of non-absorbable material. Absorbable sutures are usually made of catgut, which may be pre- pared in such a way that it will last a more or less definite time in the tissues before being absorbed (10-, 20-, and 40-day chromicized catgut). Non-absorbable sutures are made of linen, silk, silkworm gut, silver wire, etc. Interrupted sutures are shown in Fig. 106, each separate stitch being independent of every other stitch. Varieties of the interrupted suture are the twisted, or hare-lip suture (p. 683), METHODS OF SUTURE 163 and the quilled suture (Fig. 107). Continuous sutures are those in which several or all of the individual stitches are made by one thread which is knotted only at the beginning and end of the line of suture. Various forms of continuous suture are used in surgery; the overhand suture (Fig. 108) is most frequently used, and is well adapted for uniting edges of fascia, skin, etc., on which there is not much tension; jPHHH Fig. 100. — Interrupted sutures; each stitch is knotted separately. Fig. 107. — Quilled sutures; each stitch is double and tied over a quill, or prefer- ably a rubber tube, which prevents the stitches from cutting. Useful when there is much tension on the sutures. Fig. 108. — Continuous (overhand) suture. Fig. 109. — Chain or lock-stitch. Fig. 110. — Quilt or mattress suture. Fig. 111. — Sutures used to repair a deep wound: A, superficial suture (through the skin only) ; B, deep suture (passing deeply into the wound, but not a buried suture) ; c, c, buried sutures (to unite peritoneum, deep fascia, etc.). Fig. 112. — Figure-of-eight suture, em- ployed to unite parietal peritoneum, deep fascia and skin. the chain or lockstitch (Fig. 109) is useful where tension is greater; while the quilt or mattress suture (Fig. 110), by passing deeply into the tissues, is useful where there is tension on the deeper parts, as it tends to evert the lips of the wound. Other forms of continuous suture are used in intestinal surgery (Chapter XXII). A suture may be superficial, deep, or buried, as shown in Fig. 111. As a rule only absorbable material should be used for buried sutures. Deep sutures, 164 INJURIES AND THEIR EFFECTS also called mass sutures or splint sutures, are used to relieve tension (relaxation sutures), and to obliterate dead spaces in the depths of a wound in which it is not desirable to leave buried sutures; they must be strong and therefore are usually of non-absorbable material. The figure-of-eight suture (Fig. 112) is employed by some surgeons as a deep suture. Needles. Straight needles are most generally useful, except for inserting buried sutures, for which curved needles are to be preferred. Curved needles usually are held in a needle-holder (Fig. 113), but straight needles are easily managed in the fingers. Ordinary surgical needles are made with a triangular or a lance-shaped • A A B Fig. 113. — A convenient form of needle-holder. J) Fig. 111. — Various forms of needles. A, straight round-pointed needle. B, straight lance-pointed needle. C, curved round-pointed needle. D, curved lance-pointed needle. point, to facilitate their introduction; but round needles (either straight or curved) are used in intestinal work, as less liable to cause hemor- rhage or to allow fecal leakage through the puncture (Fig. 114). The eye of a needle should be large enough to be threaded easily with the suture desired; and the widest part of the needle (belly) should be Fig. 115.- -1. Reverdin's needle, showing at a eye opened, at b eye closed. 2. Ordinary mounted needle. situated where the cutting edges ceases, not on the shaft or at the eye itself. Special forms of needles are set in handles, and have the eye near the point: the aneurysm needle (p. 263) has a blunt point, and is used to pass ligatures around large vessels; the ordinary mounted needle has been modified by Reverdin by inserting a slide by which the SUTURES AND KNOTS 165 eye may be opened to facilitate threading (Fig. 115), and is useful in passing deep sutures. Suture of Wounds. — Superficial wounds may be united with super- ficial sutures only; if the deep fascia is divided, it should be united with either deep or buried sutures, as the subsequent strength of the part depends largely upon the accuracy with which this structure is sutured, and even in parts where strength is not requisite (as in the neck) neglect to suture the deeper layers carefully results in a spreading instead of a linear cicatrix. Divided tendons, nerves, etc., should be sutured separately by buried sutures. In extensive wounds, especially where the tissues have been much bruised, either by the in- jury or during the operation, it usually is desirable to pro- vide for drainage, to allow the Fig. 116. — The square or reef knot, uni- versally employed. Note that correspond- ing ends of the ligature pass under (or over) the loop of the knot. Fig. 117. — The surgeon's knot; em- ployed rarely, but useful if the first hitch of the knot tends to slip before the second can be pulled tight. The same as the square knot except that the first hitch is double. Fig. 118. — The granny knot. Note that of corresponding ends of the ligature one passes over and the other under the loop of the knot. Fig. 119. — The subcuticular suture; it may be used if no dead spaces are left in the deeper parts of the wound. The needle enters the true skin at each bite, not merely the subcutaneous tissues. escape of effused blood, lymph, etc., which would retard healing if allowed to remain between the lips of the wound, and perhaps cause sloughing from pressure if not evacuated. Hence the im- portance of accurate hemostasis in all wounds, especially where drainage is undesirable (as in operations for radical cure of hernia). No dead spaces should be left in repairing wounds: they will be filled bv blood-clot, and this will be a suitable culture medium for germs. 166 INJURIES AND THEIR EFFECTS • Sutures must be drawn just tight enough to appose the edges of the wound without constricting the tissues. Drawing a suture too tight may break it, or may cause sloughing with a resulting stitch sinus. Sutures are secured in position by knots, or occasionally by clamping them with perforated shot. The knot employed should be one that will not slip, especially the square or reef knot (Fig. 116), or the surgeon's knot (Fig. 117), never the granny knot (Fig. 118). Some surgeons employ little metal clamps (Michel) to appose the skin margins, instead of sutures; or a .subcuticular suture may be use. I (Fig- HID. Dressing of Incised Wounds. — On the surface of nearly every wound there will be a slight exudation of serum between the sutures. Aseptic wounds may be dressed with aseptic gauze, applied smoothly and in sufficient thickness and width to protect the part mechanically and effectually to prevent the access of any microbes from the sur- rounding skin or from the fingers of the patient accidentally inserted beneath the edges of the dressing. This dressing is then held in place by strips of adhesive plaster, with suitable bandages, splints, etc., as required. If a tube or a wick of gauze has been employed for drainage, the dressings are to be so arranged that the discharges will be conducted into the dressings without soiling the surface of the wound; this is accomplished by carrying the drain through slits in the dressing, and surrounding its outer end with sufficient crumpled gauze to absorb the anticipated discharge; and carefully protecting this superficial dressing from infection by sterile absorbent cotton or more gauze, the entire dressing being suitably bandaged in place. In aseptic incised wounds the drain, along with the superficial dressing, may be removed at the end of twenty-four or forty-eight hours, without disturbing the deep dressing. In infected wounds the drains must remain until their tract is lined with granulations (four to six days) converting it into a sinus, w r hich is to be treated according to the principles already discussed (p. 52) if it does not close spon- taneously. Non-absorbable sutures are to be removed from the eighth to the twelfth day, and in the case of aseptic incised wounds the dressing need not be changed until this time has elapsed. In small wounds of the face superficial sutures occasionally may be removed as early as the fourth day, but in the case of a larger wound, and especially in the case of deep or relaxation sutures, it is unsafe to remove them in less than a week or ten days. If a suture is found at the first dressing to be cutting out, it should be removed, trusting to the neighboring stitches to maintain the lips of the wound in apposition; and frequently it is safer to remove only alternate stitches at the first dressing, and leave the others a day or so longer, and to support the w r ound with strips of sterile adhesive plaster applied at right angles to its surface. Lacerated and Contused Wounds. — Lacerated and contused wounds may be considered together, as they are produced by the same acci- dents, and usually coexist. In lacerated wounds the edges are torn, LACERATED WOUNDS 167 jagged, and irregular, not sharply cut as in the ease of incised wounds; in contused wounds the lips of the wound and the surrounding parts are bruised and more or less devitalized by the original injury. Blows by blunt weapons (clubs, stones, etc.), and machinery and railroad accidents are the principal causes of contused and lacerated wounds; owing to the manner of their production they are almost invariably infected, from bacteria on the patient's skin, his clothing, or on the vulnerating weapon. Earth, machine oil, cinders, and other foreign matter frequently are carried into the depths of the wound. Gunshot wounds, forming a special variety of contused wounds are considered in Chapter VII. Symptoms. — The pain of contused and lacerated wounds is less sharp and more aching than in the case of incised wounds; hemorrhage is less, because the vessels are twisted and torn off rather than cleanly severed; and gaping is often much less than the extent of the injury would lead one to expect. Shock is often severe, and in case of crush or avul- sion of a limb may cause death so soon that no time is afforded for local reac- tion. This reaction in the wounded parts frequently extends to the stage of sup- puration, and the tissues are so much devitalized that more or less sloughing is the rule. Treatment. — In addition to combating shock and checking hemorrhage, the surgeon must pay particu- lar attention to cleansing the wound. Some of these injuries are so severe that nothing less than amputa- tion will save life (p. 212). But in lacerated wounds or crushes of the hands, much may be done without amputation, by excision of pulpefied tissue and splinters of bone, and by accurate suture of divided tendons, etc. (Figs. 120, 121). Occasionally a completely severed finger tip will grow in place if carefully sutured. General anesthesia usually is indicated to allow the necessary treatment to be carried out. The object should be to make the wound approach in character as nearly as possible to an aseptic incised wound. The wound, itself, is first packed with sterile gauze. Then the surround ing skin should be shaved (dry) and painted with 3 per cent, iodin Fig. 120. — Compound fracture of metacarpals, by circular saw injury. Excision of heads of meta- carpals, and suture of tendons. Episcopal Hospital. Fig. 121. -Same patient as Fig. 120. Earned nor- mal wages as carpenter. KiS INJURIES AND THEIR EFFECTS solution. Then foreign bodies arc to be removed from the face of the wound, slitting up (debridement, p. 201) pockets and crannies among the muscles and layers of fascia if necessary to extract bits of clothing, coal dusl and other foreign bodies (epluchage, p. 200). The filthy struct nrc- and parts of skin, muscle, fascia, or bone that are entirely devitalized should be cut bodily away (excision, p. 201). After the wound has been thus mechanically cleansed, it should be treated antiseptically, being swabbed out with gauze soaked in iodin solution. 1 have entirely abandoned the use of cor- rosive sublimate and carbolic acid in such cases, as I find strict adherence to the iodin technique secures better healing. Hydrogen peroxide is an- other efficient antiseptic; it may be applied after the iodin, but more than one thorough application tends to delay healing. Menciere's solution (p. 172) is much used in France. In all cases the cleansing should be done with gentleness, it being an excellent maxim of Sir James Paget's that "wounds should not be scrubbed, even with sponges." In spite of the utmost care it is not always possible to en- sure freedom from infection in these wounds, so it is alw r ays best to drain them, using only sufficient sutures to hold the tissues in apposition at the extremities of the wound. Inter- rupted sutures always are to be pre- ferred to continuous, in infected wounds, since one or more can be removed at any time to relieve ten- sion, without destroying the entire suture line. Instead of aseptic gauze it is better to use an antiseptic dressing, especially of gauze soaked in equal parts of alcohol and corrosive sublimate. In extensive wounds, where sloughing is feared, it is well to pour alcohol over the dressings every few hours, so as to keep them moist. Constant irrigation (p. 38) is often of great value (Fig. 122). If no undue rise of temperature or local pain indicates excessive reaction, the wound need not be inspected until the third or fourth day; and if then the surgeon finds evidence of damming up of secretions, abscess formation, or beginning cellu- litis, he should not hesitate to remove as many sutures as requisite (all, if necessary), and institute treatment as for an infected wound (see below). In such cases the wound gradually becomes converted Fig. 122. — Constant irrigation for crushes, contused and lacerated wounds, etc. The solution drips over the injured part by gauze syphonage. Episcopal Hospital. INFECTED WOUNDS 169 into an ulcer, and should be treated accordingly. The more free from infection a granulating area can be kept, the more rapidly the surrounding skin will proliferate and cover the granulations. If the skin is prevented by sepsis from thus proliferating, the wound depends for closure upon a infract inn of its base; this results in a thickened and unsightly scar. Infected Wounds; Chemical Sterilization and Secondary Suture. — The first requisite in the treatment of an infected wound, which resembles a phlegmon (p. 46) rather than an abscess, is that it be provided with free drainage for the products of inflammation. In the vast majority of cases, when this has been accomplished, the unaided forces of nature will procure healing, so long as no additional infection is admitted. 1 But there are wounds which will not heal of themselves, or whose healing unaided by chemical disinfection will take an inordin- ate time; hence all through the history of surgery efforts have been made to aid nature by various applications to the surface of the wound. But the difficulty has been that the intermittent application of antiseptics in concentrated form, even if it succeeded in destroying numerous bacteria, also destroyed the tissues to which they were applied. The ideal procedure is to employ a solution of a certain strength (or rather of a certain weakness) which shall by continuous application kill the bacteria without injuring the underlying tissues. Preparation of the wound for chemical sterilization is indispensable: so long as all parts of the wound are not readily accessible to the action of the chemical disinfectant, and so long as drainage is imper- fect, 2 sterilization cannot be obtained. Without providing complete accessibility, and without adequate drainage, it may be possible to keep the patients from becoming septic and to permit nature to procure gradual healing of the wound even without its sterilization; but in such circumstances the main object of the process, secondary suture of the wound, will not be a safe procedure. In most wounds infected with the hemolytic streptococcus this is the best that can be hoped for: by the time the wound is sterilized by chemical disinfectants it will be found to have healed of its own accord. But with wounds infected by other relatively innocuous bacteria chemical disinfection often may be procured within ten days or two weeks, and when this sterility has been maintained for a period of from four to six days, then secondary suture (p. 203) proves very successful. Proper preparation of an infected wound, therefore, often requires a secondary operation, in the nature of debridement, sequestrotomy, etc. 1 The value of heliotherapy in tuberculous conditions (p. 527), and of exposures to ordinary electric light in bed-sores (p. 61), is well recognized; and similar measures often are useful in the conditions now under discussion. 2 The theory formerly held, that dependent drainage is harmful and interferes with the Carrel technique, has been, 1 believe, abandoned by all intelligent sur- geons; for, as soon as Dakin's solution forms puddles, it ceases to be actively antiseptic. 170 tNJURIES AND THEIR EFFECTS Carrel-Dakin Method of Dressing Septic Wounds. — Dakin, an English chemist, came to the conclusion from experimental work, that a solu- tion of sodium hypochlorite, varying in strength only between 0.45 and 0.5 per cent., and free from caustic alkali, fulfilled the require- ments of an ideal antiseptic. 1 As the strength of the solution rapidly diminishes when introduced into the wound, it is necessary to provide for its periodic renewal as well as for bringing it into constant contact with all parts of the wound, as it is nearly impossible to sterilize one Fig. 123. — Carrel-Dakin treatment for chronic osteomyelitis of femur, following gunshot wound. Walter Reed General Hospital. part of a wound while others remain septic. For these purposes Carrel, a French laboratory worker, in association with Dakin (1916), sys- tematized a method of wound dressing which goes by his name; it is an assemblage of many equally important items, and requires special training to employ it successfully. The wound having been properly prepared, Carrel tubes are introduced in such a manner that when the solution is periodically injected through them it will be brought into contact with all parts of the w r ound. These tubes, of the size of No. 18 Fr. catheters (p. 1014), are tied at one extremity and are perforated from this point upward with numerous (8 to every 5 cm.) fine holes (0.5 mm. in diameter), made with a 2 mm. punch, the tubes being stretched before the perforations are made. These perfora- 1 The hypochlorites, in various forms, had been employed in surgery many years ago, notably as Labarraqne's solution of chlorinated soda (2.6 per cent.) and as the eau de Javelle. Eusol ("Edinburgh University Solution"), introduced in 1915 by Lorraine Smith, is made thus: to one liter of water add 12.5 gm. of com- mercial chlorinated lime; shake vigorously; then add 12.5 gm. boric acid powder and shake again. Let the mixture stand overnight, and filter before using. INFECTED WOUNDS 171 tions should all lie within the wound when the tubes are placed. In most wounds it is best to lay a single thickness of gauze over the granulations and to place the irrigating tubes gently on this, since in this way the solution is more evenly distributed to the wound surfaces. Very little other dressings are applied except very large cotton pads encased in gauze, which are loosely attached to the part by being clipped together. A number of tubes may be connected by glass elbows to one main afferent tube which leads from the receptacle hung at the bedside (Fig. 123). Every two hours or oftener the nurse lets run into the irrigating tube a quantity of solution sufficient to moisten (not to flush) thoroughly all the wound surfaces. When properly used there is no gross overflow from the dressings, and the patient is not constantly wet and miserable. 1 Once daily a strictly aseptic dressing is done, the tubes withdrawn, new tubes replaced, after caring for the neighboring skin with neutral soap, and alcohol, and then drying it thoroughly. The surrounding skin must in all cases be protected from possible contact with the solution which might trickle out of the wound, by being covered with strips of bandage gauze impregnated with vaselin, or by being anointed with zinc oxide ointment. At each alternate dressing, according to the strict Carrel technique, 1 Dakin's Solution. This is an aqueous solution of sodium hypochlorite never weaker than 0.45 or stronger than 0.5 per cent. It must be free from irritating contamination such as free alkali or free chlorin. Daufresne's method of prepara- tion is satisfactory where only small quantities are being used. If larger quanti- ties are employed it is better to prepare it from chlorin gas passed into a solution of sodium carbonate. It is a very unstable solution, should be prepared fresh daily, should never be heated, nor exposed to the light. Commercial preparations are valueless. 1. To make 10 liters take: Chlorinated lime (bleaching powder, having 25 per cent. active chlorin) 200 grams Sodium carbonate (dry) Solvay 100 " Sodium bicarbonate 80 " (The average strength in chlorin of the bleaching powder must be determined, as the quantity of the various ingredients varies according to this factor.) 2. Place in a 12-liter flask the 200 grams of chlorinated lime and 5 liters of water. Shake thoroughly two or three times and leave in contact over night. 3. Dissolve in 5 liters of cold water the carbonate and bicarbonate of soda. 4. Pour the solution of the sodium salts into the flask containing the macerated chloride of lime, shake thoroughly for one minute and then let the calcium car- bonate settle. 5. After half an hour syphon off the supernatant liquid and pass it through a double filter paper. This perfectly clear product should be preserved cool and protected from light (in a dark colored bottle). After manufacture," Dakin's solution must next be tested for its alkalinity: Pour 20 c.c. into a glass and add a few centigrams of powdered phenolphthalein. Agitate the liquid as if rinsing a glass. A red tint indicates the presence of a quantity of free alkali, or an incomplete carbonation due to faults in the technique. The completed solution must also be titrated: To 10 c.c. of solution add 20 c.c. of 1 to 10 iodide of potassium solution and 20 c.c. of acetic acid. To this mixture add a decinormal solution of sodium hyposulphite, until discoloration. Let n equal the number of cubic centimeters of hyposulphite employed; then the amount of hypochlorite present in 100 c.c. of the Dakin's solution will equal n X 0.0375. (Carrel and Dehelly: Le Traitement des Plaies Infectees, 2 e ed., Paris, 1917.) 172 INJURIES AND THEIR EFFECTS a smear is taken from the mos1 infected parts of the wound by means of a standard loop, and the number of bacteria per microscopic field i> counted and charted; over 00 to a field is counted as infinity, but when for three or four successive days there have been no bacteria it is considered safe to do secondary suture. As pointed out else- where (p. '202) it is probable that the quality rather than the quantity of the infecting organisms (within reasonable limits) is the important factor in permitting secondary suture. If the bacterial curve shows a plateau it is an indication of some focus of infection which requires operative removal. Fiessinger and Clogne (1918) have demonstrated that hypochlorites are detergent rather than bactericidal, and it has been pointed out by Hart well and Butler (11)18) that the more tissue debris there exists in a wound the more efficient is Dakin's solution; in contact with normal tissues it calls out such a quantity of body fluids that in less than one minute it falls below standard strength. Hence its use should not be continued when the sloughs are all digested and dissolved, but some other antiseptic should be adopted if the wound is still not sterile. A caution should be uttered also on the danger of secondary hemorrhage should Dakin's solution digest a ligature on an important vessel; silk and linen are more liable to destruction than catgut. Dichloramin-T '. — This is another of Dakin's preparations, used in 5 to 20 per cent, solution in chlorcosane. It is more stable than the hypochlorite solution, is not so irritating to the skin, retains its potency when in contact with the wound for eighteen to twenty- four hours, and its use does not require the complicated technique of Carrel. The solution, when kept in dark colored bottles, may be preserved for two or three weeks. At no time should it be in contact with water, alcohol, or hydrogen peroxide (Lee and Furness, 1918); benzine is preferred for cleaning the skin. At the time of operation on infected parts a 20 per cent, solution is applied to the surfaces, and the wound is lightly packed with gauze soaked in the solution. Evapo- ration should be encouraged, and not more than four layers of gauze are applied to the wound surface, and are lightly held in place by a few turns of a gauze bandage. Dressings are not required oftener than once in twenty-four hours, and at these a weaker solution (5 per cent.) usually suffices; this is sprayed over the entire wound or if all parts are not accessible to the spray, gauze wicks soaked in the oil are introduced so as to bring the solution into contact with all parts of the wound area. Mencieres Technique. — The solutions advocated by Menciere (1916) are used much in the same manner as is dichloramin-T. The embalm- ing solution 1 is applied at the time of the original debridement, as 1 Iodoform, Guaiacol, Eucalyptol, Balsam of Peru aa 10 grams Alcohol (denatured) 100 " Ether q.s. ad 1 liter PUNCTURED WOUNDS 173 iodin, dichloramin-T, or any other efficient antiseptic; the water 1 is used in large quantities (several liters) to flush the wound at the daily dressing; while the pommade 2 is used when granulations are well advanced. In wounds originally septic, he advocates thorough phenolization followed by embalment with the solution. It may be remarked once more that any and all methods of chemical disinfection are secondary to thorough debridement and drainage of infected wounds. Figs. 124 and 125. — Skiagraphs to localize needle in palm of hand. Punctured Wounds. — Punctured wounds, as the term indicates, are those produced by pointed instruments, and their importance arises from the fact that infection (not rarely tetanus) is frequent, as no free drainage exists; and because injury to deep structures (viscera, joints, nerves, etc.), may pass unperceived at first. In ordinary practice punctured wounds are produced most often by needles, nails, hat pins, splinters, umbrella tips, etc. If a needle remains in place, with part of the shaft projecting from the wound, it should be extracted, and unless known to be seriously infected, it is sufficient to cleanse the surrounding skin and apply an aseptic dressing. In a patient at the Episcopal Hospital a hat pin which punctured the chest produced no symptoms of any kind, though 1 Benzoic acid 200 grams Guaiacol 1000 " Alcohol 800 " Add of this "mother liquid" 10 c.c. to a liter of water to make the "water" of Menciere. 2 This is the same as the solution, except that vaselin (1 kilogram) replaces the alcohol and ether. 174 INJURIES AND Til KIR EFFECTS from the depth and direction of the wound it is certain that the liver, diaphragm, and lung were all traversed. If the point has broken off and is completely buried in the tissues, an immediate attempt to extract it should be made if its position can be detected by palpation; if no clue as to its location exists attempt at extraction should not be made until it lias been accurately located by the use of the a'-rays, two exposures in planes at right angles to each other being made (Figs. 124 and 125). The incision, for which local anesthesia some- times is sufficient, should be made obliquely to the course of the needle, being thus more apt to strike it than if made parallel. A needle buried in the palm is best exposed by turning up a flap of skin. If a large joint has been punctured, the part should be immo- bilized, the patient being kept in bed if necessary. In wounds from splinters and rusty nails the danger of tetanus developing is greater; accordingly the puncture should be slit up, to ensure the removal of all parts of the splinter, and to allow the application of antiseptics to all parts of the wound; and an immunizing dose of antitetanic serum should be given. Stab wounds occasionally are seen in civil practice; they partake of the nature of both incised and punctured wounds, and like the latter are of interest chiefly from the implication of joints, internal organs, bloodvessels, nerves, etc. Their treatment is considered in the chapter dealing with the surgery of these structures. Bayonet wounds are seldom seen nowadays, even in military surgery. In battles with Indians and other uncivilized tribes arrow wounds are sometimes encountered. The arrow-head is ven r easily detached from the shaft, and reckless attempts to extract the weapon frequently result in the head breaking off and remaining in the tissues as a foreign body. Sometimes it is better to push the arrow on and extract it through the counterpuncture. Indian arrows were frequently poisoned with rattlesnake venom or with earth containing tetanus germs, and Schell found it a universal custom to dip the points in blood which was allowed to dry on them; but such practices are rare at the present day. Tooth wounds, especially those due to human bites, are apt to be severely infected. Dog bites are less dangerous than those of cats, rats, and other domestic animals. Monkey and parrot bites are not very rare. I have treated a case of mole bite. Poisoned Wounds. — Under this heading it is convenient to consider snake bites and insect-stings. The latter are seldom serious in this part of the country, but in the tropics are sometimes fatal. The lesion consists in a localized, occasionally a spreading cellulitis, which is treated by evaporating and antiseptic lotions. The pain of stings is quickly allayed by plastering the bite with liquid mud, which should be washed off so soon as antiseptics are available; aqua ammonise also relieves the pain and neutralizes the acid poison. S7iake Bites. — Snakes (ophidia) are divided into two main classes, the Colubrines, mostly harmless, and the Viperines, usually poisonous POISONED WOUNDS 175 [thanatophidia — death-snakes). To know whether the injury is from a harmless or a poisonous snake, the bite should be examined: "If the snake is harmless, two uniform rows of tooth marks will be found ; if there are two or more distinct fang-marks, with or without tooth- marks, the snake is poisonous" (Fig. 126) (Mason, 1907). The venom is contained in a sac at the base of the hollow fang, which is on the upper jaw; this sac is compressed by the muscles which close the jaws, and the virus is squirted through the hollow fang much as through a hypodermic needle. Repeated biting soon empties the poison sac, and the snake is then comparatively harmless until more virus has been secreted. The most important constituents of snake venom are a globulin and a peptone. The former destroys the coagulability of the blood, and produces molecular changes in the vessel walls; this accounts for the extravasation and hemorrhages (subcutaneous, gastro- intestinal, renal), which are characteristic of snake poisoning. The peptone produces locally " rapid edema, putrefaction, and sloughing without extravasa- / • \ \ • : '• * tion; constitutionally, it in- : :' • - : • : " • creases blood-pressure, acceler- • : : • : . • at'es the respiration, and often : • • : • • causes convulsions." (Mason, • \ • ; \ : 1907.) In rattlesnake bites, • • : : almost the only kind seen in • • : this country, death occurs in from 12 to 25 per Cent, of Cases, FlG . 12 6._ Tooth marks made by snake USUally within twenty-four to bites: on the left a harmless snake; fang- . . " . . t\ i e marks in the center and on the right lndi- thirty-SLX hours. Death from C ate a poisonous snake. cobra bites, which are frequent in India, and not very rare in the Philippines, occurs usually in a few hours. Bites of copper-heads and moccasins are not so dangerous, though amputation may be required for sloughing, or septicemia may kill at a later date. Treatment consists, locally, in the immediate application of a ligature or tourniquet around the limb above the wound, and in suction of the punctures by the mouth, or by cupping glasses when available. The venom is not poisonous when taken by mouth, if the stomach is full; but it should of course be spat out. Free incisions will make suction more effective. Amputation or excision of an unimportant part may be done. The ligature should be used inter- mittently, admitting only small doses of the venom into the circula- tion at one time; and when the wound is far enough from the trunk to make it possible, it is well to apply a high and a low ligature alternately. Mason also recommends that the limb be bandaged from its two extremities toward the wound, so as to squeeze out all the venon possible. The best local applications after free incision are oxidizing agents, such as peroxide of hydrogen, or 1 per cent. 176 INJURIES AND THEIR EFFECTS solutions of potassium permanganate or chromic acid. The actual cautery (hot coals, burning gun-powder) should be employed if these remedies are not at hand. Local treatment should be prompt, as it is probably useless after the lapse of half an hour. In cobra bites Cal- mette's serum (antivenene) should always be employed when available; hypodermic injections of 10 to 20 c.c. of the stronger serum are given as soon as possible. Gastric lavage and catharsis are indicated to remove the venom excreted into the gastro-intestinal tract. Hope should not be abandoned too soon, some remarkable recoveries being recorded after the prolonged use of artificial respiration. Burns and Scalds. — The effect is essentially the same whether the injury is produced by flame (bum) or by hot liquid (scald). In scalds, however, the hair usually remains intact, while in burns it is singed. Gas and acid burns- are mentioned at p. 178. Symptoms. — Local symptoms vary with the degree of heat and the length of contact: mere singeing of the hair and a passing erythema may be caused by momentary contact of flame, while prolonged contact with some body at much lower temperature (e. g., hot water bottle) may produce a very destructive lesion. Burns may be classi- fied in three degrees: (1) Erythema. (2) Vesicles and Bullae. (3) Sloughing. The reactionary changes which occur in the burned part are identical with those already discussed in the chapter on Inflam- mation. Fig. 127. — Scald of hand, second degree; twelve hours' duration; showing bullae. Episcopal Hospital. Constitutional effects of burns depend much more on the area involved than on the depth of the burn. A superficial burn may be attended by the gravest consequences, even death, if extensive; whereas a very deep burn, if it involves only a small area, may be almost unattended by constitutional symptoms. As in other injuries, the constitutional effects of burns may be divided into those of shock and reaction; and there usually follows, in severe cases, a stage of exhaustion. The pain is intense, and in extensive burns may induce hyperpnea, which, according to the theory of Henderson (p. 181), produces acapnia, and so induces shock; patients may die in the first stage, without reaction. The unburned skin is pale, the patients feel chilly, and require to be covered up; the usual signs of shock are present. Often, however, reaction begins soon, sometimes before the patient is seen by the surgeon; and at this time prostration BURNS AND SCALDS 177 with excitement or traumatic delirium (p. 183) may dominate the scene. This stage lasts for a week or more, being accompanied by high fever, often with intense congestion of organs underlying the lesion (pneumonia, in thoracic burns; peritonitis, in those of the abdomen; meningitis in those of the head) . There is a tendency to fatty degener- ation of all organs; the liver, spleen, and lymph nodes may be enlarged; the urine is scanty, of high specific gravity, or entirely suppressed. The bile is believed to be abnormally toxic. The blood is prone to thrombosis, and capillary embolism is not infrequent; there is hyper- leukocytosis and polycythemia; hemoglobinuria and albuminuria may exist. The patient is excessively thirsty, but constantly vomits what is taken into the stomach; there may be septic diarrhea; he feels hot, is restless, and tosses off the bed-clothes. If he survives this stage, there follows that of exhaustion, with hectic fever, profuse sup- puration of the wounded surfaces, and perhaps metastatic (especially subcutaneous) abscesses. Death from Burns may be due to shock, to visceral complications, to exhaustion, or to hemolysis and auto-intoxication. Among the visceral complications may be included edema of the glottis, from inhalation of steam or hot smoke. 1 In fatal cases, death usually occurs within forty-eight hours. Prognosis. — In local burns prognosis as to life is good, even if the part be much deformed by subsequent cicatricial contraction. Burns of the trunk are more serious than those of the extremities. If a burn involves more than one-third of the body surface it usually is fatal. General burns are always fatal. Burns are particularly serious in infants, the aged, those of intemperate habits, those with diseased kidneys, etc. Treatment. — The indications in all cases are to control the pain, to combat the shock, and to prevent injection. In severe cases, where death is anticipated, the most that can be done is to promote euthan- asia. Shock is combated as described at p. 184; especially important is the dilution of the blood by saline solution, which relieves toxemia and at a later stage restores the fluid contents depleted by discharges from the burned surfaces. Massive burns with charred skin should be treated by immediate excision of the roasted area in the effort to prevent toxemia. Prevention of infection involves local treatment of the lesions; anything which protects them from the air lessens pain, and in extensive burns the simplest and best treatment is to spray the surface every two or three hours with some warm oily substance, such as liquid albolene; no dressing is applied, but the patient's entire body is kept warm and dry by exposure to electric light bulbs hanging from a cradle, itself covered by bedclothing. When granulations develop, burns of large extent should be immersed in a continuous bath 1 In rare cases duodenal ulceration (Curling, 1842), with hemorrhage or perfor- ation, develops, possibly from excretion of toxic substances through Brunner's glands, or as the result of embolism. Alexander (1912) observed this complica- tion in four out of twenty-seven patients with extensive burns. 12 17S INJURIES AND THEIR EFFECTS (saline or boric acid) for three hours at a time, with intermissions of six hours, until sloughs are removed. In hums of less extent it makes little difference what dressing is applied, so long as it is aseptic, and absorbs or does not dam up the discharges. Spray the burned surface lightly with peroxide of hydrogen, and surgically cleanse the sur- rounding parts. Do not scrub the burns. Open bullae with a sterile knife, and let the epidermis fall back in place as the serum escapes. The following may be used in recent burns of the first and second degree: Picric acid dressing: gauze soaked in 1 per cent, aqueous solution is laid on the burn and covered with absorbent cotton, not with waxed paper, as evaporation should be favored; the dressing is left in place four or five days. It should be used only over small areas, as constitutional poisoning has occurred. Senn's powder (boric acid, three parts; salicylic acid, one part) or Billroth' 's powder (equal parts of starch and zinc oxide) may be applied to small burns, and form a scab which need not be removed for several days. So soon as granulations have formed, the burn is treated as an ordinary ulcer (p. 53). The application of strips of adhesive plaster over the granu- lations keeps them from becoming exuberant and encourages prolifera- tion of epithelium. Various dressings of paraffin impregnated gauze have been used for the same purpose; or dichloramin-T may be used. When much skin has been destroyed, healing will be slow, and skin-grafting should be employed (p. 236). Great care must be exercised by proper use of splints, etc., especially in burns about flexures of joints, to prevent undue cicatricial contraction; but in some cases healing can be secured only as the result of such a process (Figs. 197 and 198), and the deformity must be overcome by sub- sequent plastic operations (Figs. 199 and 200). In severe grades of deformity, with painful scars which prevent conservative operations, amputation may be necessary. Occasionally epithelioma develops in such scars. Mustard Gas Burns. — Mustard gas burns were much seen in the German war, the gas especially attacking moist areas (axilla, groin). So soon as possible a soap and water bath should be taken to remove the deposit; and resulting burns, which may be slow in development, should be treated as burns from other causes. Acid Burns. — Acid burns resemble those caused by heat, but the acid should at once be neutralized by an alkali; soap is usually at hand. Effects of Cold. — In many ways these are analogous to those produced by heat, and depend more on the length of the exposure than on the intensity of the cold; moist cold, especially in a high wind, is much more apt to produce serious effects than a still, dry cold. Constitutional Effects. — Among predisposing causes are hunger, fatigue, alcoholism, etc. There occur painful sensations in the extremi- ties, perhaps chills, followed by uncontrollable lassitude, somnolence, coma, and death if the patient is not roused. The causes of death FROST-BITE 179 are cerebral anemia (sudden and progressive chilling); cerebral con- gestion (slow and continuous chilling) ; or embolism, in cases of sudden reheating (Lebastard). Persons apparently dead should be kept in a cool room, and treated by artificial respiration and gentle frictions with evaporating or stimulating liniments; when reaction commences (perhaps not for several hours), the temperature of the room may be raised gradually, stimulants administered, and the patient wrapped in blankets. Recovery has followed after being buried in the snow for eight days (Tedenat), and when the rectal temperature had fallen as low as 74.6° F. (Nieolaysen). Fig. 128. — Frost-bite of second degree; duration, four days. Episcopal Hospital. Frost-bite. — The local effect of cold is analogous to that of heat, and may be classified in three similar degrees: Erythema, Bullse, and Eschar. The exposed part, especially the fingers and toes, nose, cheeks, ears, or the penis, becomes first the seat of congestion, attended by some tingling and pain; soon, however, the part becomes blanched, numb, and stiff, and to all appearances dead. This stage is well exemplified when local anesthesia is produced by the ethyl chloride spray. With proper treatment, the local destruction may go no further; if this is neglected, vesicles and bullae form (Fig. 128), and if the cuticle is destroyed and infection follows, painful ulcers develop which are long in healing. Finally, the freezing may be so intense that a local slough, or gangrene of an entire limb may occur, the larger arteries and veins being thrombosed. Treatment of milder degrees of frost-bite consists in gentle frictions with snow or iced water until sensation is restored; the part, which now begins to tingle and burn, may next be painted with silver nitrate solution (1 or 2 per cent.), which allays these symptoms; the part is then protected from injury and maintained at an even temperature by absorbent cotton. When gangrene threatens, vertical suspension of the limb should be adopted (v. Bergmann, 1873) with immobilization by splints; as the swelling subsides the circulation ISO INJURIES AND THEIR EFFECTS improves. The resulting sloughs are treated as advised in Chapter II. Amputation should not be done until the line of demarcation has been established. Pernio or Chilblain is a vaso-motor disturbance of the skin following previous frost-bite of mild degree. It develops as the result of sudden variations in the temperature to which the part is exposed. Chilblains occur in parts most exposed to frost-bite, and are especially common in the anemic and run-down. A patient once affected is prone to have recurrence of chilblains on slight provocation. The symptoms and treatment are much the same as for mild degrees of frost-bite. Constitutional treatment should not be neglected. Trench Feet. — Under this name is described a condition resembling frost-bite due to long exposure to moist but mild cold in battle trenches, with compression of the feet swollen inside the shoes and leggings. Prophylaxis is very important, but difficult to secure. The feet should be frequently bathed, thoroughly dried, well powdered and dry socks put on. When the lesions are discovered no temporizing methods should be employed, but the soldier evacuated. Delay may result in loss of part or the whole of the foot. The feet should be maintained dry and in an elevated position, and active movement of all the joints should be practised. Sloughs and resulting ulcers are treated as when due to other causes. Electric Currents. — These produce local effects (electric burns) and general effects (electric shocks). The former are more severe the less the area of contact, while severe shocks and milder burns follow broader contacts. The burns do not differ from those due to other causes except in their extreme slowness in healing. Skin-graft- ing usually is unsatisfactory, but a plastic operation may succeed. The constitutional effects of electric currents are practically identical with those due to lightning strokes. Lightning Strokes. — -Death may be instantaneous. Stunning almost always is produced, and burns frequently exist at the points of entrance and exit of the current; they resemble burns due to electric currents; arborescent marks, typical of lightning strokes, are attributed to disorganization of blood in the vessels. Persons apparently dead may recover after many hours; the usual condition of a patient just after being struck by lightning resembles that seen in concussion of the brain. Treatment consists in artificial respiration, external heat, and other methods advised for shock (p. 184). X-ray Dermatitis. — This affection, carefully studied by Codman in 1902, is seldom seen except as the result of repeated and prolonged exposure to the Rontgen rays; before their danger was understood, skiagraphers took no precautions to protect themselves from exposure, and a dermatitis affecting the fingers was not unusual. The danger to patients is extremely slight, especially since modern methods permit very short exposures. The dermatitis does not develop for several days after exposure, and then is characterized by slight erythema, with pigmentation and exfoliation of epiderm; a severer GENERAL EFFECT OF INJURIES 181 degree is evidenced by the formation of vesicles and bulla 3 , while the third degree involves a slough of the entire skin. Eventually, dystrophies of the nails, keratoses, and epitheliomas may occur. Treatment. — No further exposure should be allowed, even if the patient thinks himself well protected by leaden shields, etc. For the intense pain which exists during the extremely slow casting of the slough, alkaline astringents give the best results. Ointments are said to favor carcinomatous changes (Leonard). When these occur, amputation is necessary. Therapeutic Uses of the X-ray. — These should be applied by an expert Rontgenologist in consultation with a dermatologist. Some cases of lupus, a few of keloid, and occasionally a case of superficial epithelioma may be cured, at least temporarily, by periodic exposure to the x-rays. Their action appears to consist in stimulating an over-production of fibrous tissue, by which the growth of the cellular elements is arrested or abolished. After operation for carcinoma, and in inoperable cases, systematic treatment with the x-rays may delay recurrence, diminish pain, and greatly promote the patient's comfort. Therapeutic Uses of Radium. — What was said of the use of the .r-rays applies also to that of radium; when used by the ignorant, in inefficient doses, radium emanations do more harm than good. When properly used, their effect in certain cases of sarcoma and car- cinoma, in Hodgkin's disease, and allied conditions, sometimes is marvellous. They may secure freedom from recurrence for a number of years, but rarely cure the disease definitely. As the same is the best that can be said of surgical operations in some cases, it is w r ell to consider treatment by radium when such is available; but the fact remains that in the majority of cases the results of operation are more certainly known in advance, and therefore usually to be preferred. GENERAL EFFECTS OF INJURIES. Shock. — The primary constitutional effect of injury is named shock. The term dates from 1795 (James Latta). Certain clinical states previously confused with shock were first clearly distinguished from it in 1871 by John Ashhurst, Jr. 1 Such especially were hemor- rhage, concussion of the brain, syncope, etc. Subsequent experi- mental studies, as Quenu points out, again served to confuse these various states, and for the last generation the utmost vagueness has existed in the ideas of many surgeons and physiologists as to what is and what is not shock. Crile (1899) attributed shock largely to interference with the vasomotor mechanism, from injury of peripheral nerves (see footnote, p. 149); but other investigators have found it difficult or impossible to produce symptoms of shock by injury to the nerves alone. Henderson (1908) proposed the theory that shock was due chiefly to loss of the carbon dioxide constituent of the blood, 1 I make this statement on the authority of Prof. Quenu, whose monograph on Traumatic Toxemia (1919) is the latest addition to the literature of shock. 182 TNJV R I ES AND THEl R EF F E( ' TS .1 state to which he applied the term acapnia; but, again, other physi- ologists claim that this is the result, not the cause of shock. Acidosis, which is, strictly speaking, only a lessened alkalinity of the blood, always results from hemorrhage, and usually is present in shock. Prince (1918) considers it to be compensatory in nature, due to the acapnia; but Cannon (1918) recognizes it as the result of destruction of muscle tissue at the wound site. Failure of the circulation is always present, but the accumulation of blood in the splanchnic area, of which so much was formerly said, is not regarded as of constant occurrence in pure shock. The blood-pressure falls, but the peri- pheral vessels are contracted (witness the blanching of the skin, the sweating, etc.), and it probably is in the capillaries that concentrated blood collects; its fluid constituents being largely expelled (Archibald, 1917). Quenu's own theory, which has most to support it, is that shock is a toxemia due to absorption of albuminoid poisons developed in the tissues which have been mechanically injured. Precisely similar symptoms develop in sudden and overwhelming toxemias due to other causes (intraperitoneal or intrapleural rupture of an abscess, intestinal perforation, cholera, anaphylaxis, etc.); Cannon and Bayliss (1918) have produced such symptoms experimentally by crushing muscular tissues, proving at the same time their independence of the nervous system and their dependence upon the circulation; and clinically the untimely removal of a tourniquet from a mangled limb, permitting sudden restoration of the circulation, has been known to cause the immediate development of profound shock (Estes, 1913; Quenu, 1919) » It is true that shock frequently accompanies concussion of the brain, syncope and hemorrhage; but it may and often does exist in marked degree when none of these factors is present. It is the prim- ary, constitutional effect of injury; it is neither immediate nor second- ary, it is primary. It may appear immediately, or it may be long delayed, but usually a distinct though comparatively short interval (one-half to three hours) elapses betw r een the occurrence of injury and development of the symptoms recognizable as those of shock. Usually the injury is extensive: crushes and mangling wounds of the extremities, especially muscular wounds, or multiple wounds even if each is unimportant, extensive burns and scalds, and other lesions without hemorrhage and without syncope or concussion of the brain produce the typical symptoms of shock. Predisposing Causes. — General debility, extreme youth and age, and organic diseases (heart, kidneys, liver, etc.) are among the pre- disposing causes. Exposure and chilling, if prolonged, will increase shock. Hemorrhage, by directly affecting the patient's vitality, and lowering blood-pressure, is probably the most important predispos- ing factor of all. Prolonged anesthetization acts in a similar manner, chloroform causing lowering of blood-pressure from the very first, ether only after long administration. Shock during or following surgical operations is rare unless there has been great traumatism 1 I observed such an occurrence in 1909. SHOCK 183 inflicted by the surgeon, or unless there has been hemorrhage or chilling and exposure during the operation. Symptoms. — The patient, if not stunned by the injury or suffering from cerebral concussion, is conscious, his mind sometimes being clear and alert, but more often semi-stuporous, as if the effort even to think were exhausting. The face is pale, the lips ashen or slightly blue; the entire body surface is pale, cold, and often clammy; the temperature is subnormal (Fig. 129); the eyes are staring or half- closed; there may be dimness of vision or actual blindness (from retinal anemia); the pupils are dilated, and react sluggishly to light; the respirations are shallow and rapid; the pulse is quick, fluttering, weak and frequently uncountable. Incontinence of feces is frequent, that of urine rare and usually portends a fatal issue. The patient lies motionless wherever placed. His sensibility is diminished. This torpid stage may last a few minutes or several days. Death may occur without reaction, in spite of energetic treatment. 1 Recovery may be apparently complete in a few minutes, or may occur gradually, especially when there is some severe injury present. When reaction occurs, it may be excessive, the patient be- coming mildly delirious, and exhibiting the condition described by Travers (1827) as prostration icith excitement (erethistic shock). This condition, which occasionally develops immediately after the injury, the torpid stage being extremely short or altogether absent, may pass into true traumatic delirium, an affection probably due to some form of toxemia. The patient is restless, talkative, with bright, roving eyes and incessant action ; he is really weak, though seemingly strong, and is liable to collapse at any time. He is pursued by frightful hallucinations, often acting over and over again in his delirium the drama of his injury. Traumatic delirium should always be regarded as a dangerous complication, being unus- ually serious when developing immediately after the accident. Collapse is not to be confused with shock; it is immediate in its appearance, and is due to inhibition of the heart's action through the nervous system. It occurs sometimes during operations on the larynx and thoracic organs. Diagnosis. — The essential symptoms of shock are tachycardia, tachy- pnea, hypoesthesia and torpidity of the body. In hemorrhage there is restlessness, not torpidity; the lips are blanched not livid; there is no hypoesthesia unless syncope occurs ; and infusion of saline solution and especially transfusion of blood are beneficial, but rest without effect in pure shock. Syncope may occur without history of injury, the patient 1 In shock alone, a blood-pressure below 80 mm. of mercury, and in shock com- bined with hemorrhage below 90 mm. of mercury, usually is fatal unless transfusion of blood is done. DAY OF MONTH 5 1 (5 [ 7 | 8 100 I » < 99 | 98 |w 96 95 z i -y\ - -e— \ ■ - A Fig. 129. — Shock and reac- tion. Case of multiple frac- tures; man, aged thirty years. Episcopal Hospital. IS I INJURIES AND THEIR EFFECTS becoming unconscious, and possibly being subject to fainting fits. Psychical shock (fright) should not be mistaken for surgical shock; it may result in death in the absence of all injury, especially in cardiac patients, but usually the mental trepidation soon passes ofT, having caused no more serious disturbance than a sinking feeling in the prccordiuni, slight qualmishness, and a temporarily accelerated pulse. Erethistic shock and traumatic delirium are to be distinguished from deli rin hi tremens and mania a potu. In these a history of chronic alcoholism usually can be obtained, and the delirium is somewhat different in character: in delirium tremens which may be regarded as the first stage of the affection, the patient is fearful and shrinking, the delirium is muttering, the hallucinations usually relate to insects, reptiles, etc., and the trembling of the hands is characteristic; in mania a potu, the second stage, he is violent, shouting, cursing and singing, with no fear of man or devil, breaking loose from the bed, attempting to climb out of the window, and having no sensations of the pains caused himself, grinding his broken bones together as if they were cobble-stones (Hunt, 1881), and sometimes wilfully mutilating his person. Yet as alcoholics are prone to severe injury, and therefore to shock, it is frequently impossible to say whether the ensuing delirium is alcoholic or purely traumatic. The delirium of uremic conditions (Chapter XXV) adds another confusing factor which is often present in injured alcoholics and others with diseased kidneys. Prevention of Shock. — Maintenance of body heat and prevention of further tissue destruction at the site of injury by proper splinting during transport (p. 204) are the most important measures for the prevention of shock. A full dose of morphin should be given as soon as possible; it checks cellular action and maintains a state of rest. The hypodermic use of atropin is valuable in two ways: it causes a rise of blood-pressure by central action, and by paralyzing the inhibi- tory fibers of the vagus prevents injurious impulses from reaching the heart and producing collapse. When an operation is to be undertaken and shock is feared, nitrous oxide and oxygen is the best anesthetic; ether is better than chloro- form both because less toxic and because for a tune at least it acts as a cardiac stimulant. During an operation the most important means of preventing shock are control of bleeding, gentle manipulation, and maintenance of bodily heat. Direct division by the scalpel should replace blunt dissection and tearing, dragging manipulations when- ever possible. Mechanical means for maintaining blood-pressure are discussed under Treatment. Treatment. — The indications are to restore the circulation, prevent the loss of body heat, and keep the patient alive (by artificial respi- ration if necessary) until the remedies used have time to act. If hemorrhage is present it must be checked (p. 260). Application of external heat is most important: cover the patient warmly, and sur- round him with hot water bottles, hot bricks, etc.; a current of hot air from an oil lamp may be conducted under the bed-clothes. Give CAUSES OF DEATH AFTER OPERATION 185 him camphorated oil (up to 4 to 5 c.c. may be given intravenously), atropin or digitalis hypodermically. It is improbable that saline solution intravenously or transfusion of blood will be of value unless there has been hemorrhage. The measures mentioned (heat, stimu- lants, transfusion) will be effective in an hour or so if hemorrhage is the main factor present. When there is a severe mangling injury no further delay, unless the patient is actually moribund, should be permitted, but prompt local treatment (excision, amputation) should be instituted, as it may be the only means of saving the patient's life. It is possible that antitoxic sera may some day be available for shock. It is important to determine whether serious symptoms occurring during an operation are from shock or from acute dilatation of the heart. In the latter condition, which may arise without any recogniz- able cause for shock, the head should be kept high, and, if this does not relieve, the patient should be bled, and in extreme cases the right ventricle may be punctured. Artificial respiration and massage of the heart (p. 269) should be persisted in for fifteen or twenty minutes. Treatment of Traumatic Delirium and Delirium Tremens. — If the patient is not too violent, attempts should be made to dilute the toxins in the blood by the use of saline solution, by rectum, hypoder- mically, or even intravenously. Lumbar puncture sometimes aborts the disease. In any case the patient should be isolated, to avoid the mutually exciting effect of other patients. Catharsis will aid elimi- nation of toxins. Sedatives and hypnotics should be freely employed, especially veronal, and paraldehyde. Sleep should be obtained at all hazards, but morphin, hyoscin, chloral, and the bromides increase the mortality, and are much less effective than veronal and paralde- hyde (Ranson and Scott, 1911). R. S. Hooker, however, gives chloral in large doses, hourly, until sleep is obtained. Measures must be taken to prevent the patient from injuring himself, strapping him to the bed if necessary, and never leaving him unguarded by a nurse or orderly strong enough to control his actions. Liquid diet should be taken in moderation, but the more water that can be absorbed the better. Ranson and Scott urge the use of ergot (4 c.c. of fluid- extract every four hours) as preventative of cerebral edema and as a general circulatory stimulant. No alcohol should be given to patients with alcoholic delirium; though Ranson and Scott urge its admini- stration at least in the first stage of the affection, and though it may be used as a prophylactic where the development of delirium tremens is feared, yet all surgeons of large experience in accident wards find that immediate and absolute withdraival of alcohol from patients with delirium tremens both shortens the disease and decreases the mortality. In traumatic delirium from burns, etc., in which there is clear evidence that no element of delirium tremens is present, but in which delirium is due chiefly to asthenia, the moderate use of alcohol frequently hastens convalescence. Causes of Death after Operation. — As operations always involve the infliction of wounds, this seems a suitable place to consider the causes 186 INJURIES AND THEIR EFFECTS of death after operation. Certain of these causes are more or less avoidable; such are shock, hemorrhage, pneumonia, acidosis and sepsis. Others usually seem unavoidable, especially myocarditis, embolism, status lymphaticus, heat prostration, and conditions previously present which the operation could not remove or which it has inevit- ably made worse. Among the latter may be mentioned various forms of sepsis (peritonitis, pyemia, etc.), curable only by removal of the original focus and the institution of drainage, but which these meas- ures, though judiciously and skilfully executed, nevertheless fail to relieve; asthenia from preexisting shock or hemorrhage, death being certain without operation, but a fighting chance of recovery existing after prompt operation; and preexisting disease of the kidneys or other organs when operation is undertaken as the only means of cure. The conscientious surgeon will never, therefore, blithely assure his patient that any operation is entirely devoid of risk, as these calamitous deaths frequently occur when least expected. Shock. — See p. 181. Hemorrhage. — The importance of preventing loss of blood during operations cannot be overestimated; and, fortunately, gross and sudden hemorrhages usually can be prevented, for it is these which are much more lethal than the slight ooze throughout the operation which sometimes is unavoidable. But even though quite large amounts of blood may be lost gradually without producing immediate and noticeable effects, it is much better for the surgeon to go about his work deliberately, clamping or tying bleeding vessels as he goes, than to try to hurry along and by his very haste making less speed from having continually to return and pick up vessels which might have been caught with more effect when first divided, and thus subject his patient not only to the unnecessary if gradual loss of blood, but also to a needlessly prolonged operation, and to unneces- sary tissue traumatism from repeated sponging and search for the bleeding points. In addition to this primary hemorrhage which occurs at the time of operation, surgeons recognize an intermediary, consecutive, or reac- tionary hemorrhage, which occurs after recovery from the anesthetic or the shock of operation, due to the reestablishment of the normal circulation and blood-pressure, causing bleeding from vessels which escaped notice at the time of operation owing to their collapsed condition; and a secondary hemorrhage, which occurs any time between the occurrence of reaction and the ultimate healing of the wound. Secondary hemorrhage is due usually to separation of ligatures (1) from their having been insecurely applied at first; (2) to their premature absorption; or (3) to ulceration of the vessel walls at the site of ligation; occasionally it is due (4) to sloughing of a vessel at another point in the wound. The treatment of hemorrhage is discussed at p. 260. Pneumonia. — Careful examination of the lungs always should be made before undertaking any operation, especially under a general CAUSES OF DEATH AFTER OPERATION 187 anesthetic. If bronchitis or pneumonia already exists and the oper- ation cannot possibly be postponed, as in the case of strangulated hernia, local or spinal anesthesia should be employed. To prevent the development of pulmonary complications, a general anesthetic must be given with care, guarding against choking, secretion of mucus, and inspiration of vomited particles; and pains must be taken not to expose the patient to chilling, draughts, etc., either during operation or while recovering from the anesthetic. After an operation, patients, especially if aged, should not be kept flat on the back long, being turned from side to side at suitable intervals to guard against the development of hypostatic congestion; deep breathing should be enjoined periodically; and they should be allowed to sit up or to leave the bed so soon as the condition of the wound permits. Under the term massive collapse of the lung, W. Pasteur (1911) describes a condition often mistaken for pneumonia, but due to inhibition of dia- phragmatic action from operations in the upper abdominal or renal regions. Sepsis. — In operations on previously aseptic structures, sepsis can and should be prevented. Whenever it occurs under such circum- stances, the surgeon should seriously endeavor to detect the fault in his technique, in order that a similar calamity may not occur again. In operations on already infected parts, it will not always be possible to prevent infection from spreading further, or from becoming more virulent even if still localized; but by strict adherence to antiseptic methods, unfavorable results might be made much less frequent than they are. Myocarditis. — "Heart failure" usually is an unavoidable cause of death; detection of the lesion before operation is frequently difficult, and even skilled physicians occasionally err in estimating the ability of an evidently diseased heart to withstand the strain of operation. The choice of anesthetic, the position of the patient during operation, avoidance of causes of cardiac collapse and of shock, the rapidity and extent of the operation itself, all deserve to be considered more attentively than usual in such patients. Embolism. — Under the term "secondary or insidious shock" (p. 273) was formerly described a condition which is now popularly known as "pulmonary embolism." From some chemical change (bacterial or aseptic) in the blood, it becomes more prone to clot, and at varying periods after operation, but usually not until con- valescence seems assured, a portion of a thrombus, formed at or near the seat of operation, is detached, is carried to the right heart, and thence to the pulmonary arteries, where it may lodge; or, passing through, may cause pulmonary infarction. The symptoms are sudden dyspnea, cyanosis, precordial pain, collapse, and rapid, perhaps immediate, death. Busch (1909) studied twenty-two deaths after operation, presenting symptoms usually ascribed to pulmonary embolism; twelve of these patients died with great suddenness, no preliminary symptoms of any kind existing; while in ten death 1SS INJURIES AND THEIR EFFECTS occurred at periods varying from ten minutes to three and one-half hours after onset of the symptoms. These ten patients all came to autopsy, and in only five was a pulmonary embolus or infarction found, the five others having died from myocarditis. The diagnosis, therefore, is not always easy. Treatment. -The treatment is purely symptomatic, including inhalations of ammonia, and the hypodermic use of atropin, oil of camphor, etc. Trendelenburg (1908) proposed arteriotomy of the pulmonary artery, by opening the pericardium, with removal of the clot; he adopted the operation in one case, his patient living until the next day, while Siever's patient (1908) lived fifteen hours. As death frequently occurs with great suddenness, giving no oppor- tunity for treatment of any kind; and as in other cases recovery under expectant treatment, though rare, is not unknown; and as the diagnosis between myocarditis and embolism is often impossible, I think Trendelenburg's operation should be regarded at present more in the light of a curiosity than as a practice for habitual employment. Fat-embolism. — Fat-embolism occasionally occurs after injuries of or operations on bones. The symptoms and treatment resemble those of ordinary pulmonary embolism; lipuria is not pathogno- monic, though suggestive, and it may exist in cases of simple fracture without evidence of embolism. Status Lymphaticus. — This term is used to describe a condition in which there exists widespread enlargement of lymphoid tissue in all portions of the body — naso-pharyngeal "adenoids," cervical "adenitis," hypertrophy or hyperplasia of the bronchial and mesen- teric lymph nodes, and of the thymus gland. It is most frequent in rachitic children, and subjects of it are liable to sudden death at any time, even during natural sleep (Blumer, 1903). The true cause of these deaths is not known, but is probably to be classed as an "auto-intoxication;" death almost certainly is not due to acute enlargement of the thymus gland causing asphyxia from pressure on the trachea. Unfortunately the existence of the condition is rarely if ever recognized until death occurs. Undoubtedly some deaths charged to the anesthetic really are due to the status lymph- aticus. Death may occur while the patient is under the anesthetic, or, as is more often the case, a few hours later, with symptoms of dyspnea, rapid, feeble pulse, high temperature, and restlessness, but with no evidence of traumatic delirium. Acidosis. — Acidosis is the name given to an acid intoxication similar to that which sometimes occurs in diabetics, and which may be a cause of death after operation. It is predisposed to by starvation, by deprivation of fluids and carbohydrates. Its development is to be feared in homesick children who cry all the time and will not eat after entering the hospital for operation; also in cases of advanced sepsis (peritonitis, puerperal septicemia). The anesthetic, not the operation, precipitates the attack. Chloroform is especially to be avoided. The symptoms resemble those enumerated above as occur- CAUSES OF DEATH AFTER OPERATION 189 ring in status lymphaticus; there is acetone and in advanced cases diacetic acid in the urine. Treatment consists in saturating the patient with alkalies. Sodium bicarbonate should be eaten liberally; if there is vomiting, wash the stomach and give the alkali intra- venously, one or two liters of a 3 per cent, solution. Sweating, as in diabetic or uremic coma, is indicated to aid elimination. Heat Prostration. — Heat prostration occasionally causes a post- operative death. The symptoms and treatment are the same as for heat prostration in other patients. It is well to postpone all operations but those of immediate necessity during the prevalence of extremely hot weather. CHAPTER VII. GUNSHOT WOUNDS. WnEN a soldier in the front lines is wounded, he is supposed to apply to his wound the dressing in his first aid packet; but in con- ditions of modern warfare this is not of much use except for bullet wounds; other wounds are too large, and even if smaller than the dressing, the latter does not remain aseptic during application; nor is the underlying wound aseptic even if covered. Then the soldier keeps under cover of the trenches or shell-holes, and if artillery fire is not too intense, and if he is able, finds his own way back to the First Aid Station (Post de Secours of the French). Otherwise he lies where he fell until found, usually the following night, by the litter-bearers who have come out for the purpose from the First Aid Station. On arrival at the latter (about 0.5 to 1 kilometer 1 distant), the clothing is cut away from the wound area, and this is cleansed with any available antiseptic, a dry dressing is applied, antitetanic serum, and, if indi- cated, morphin are given, and a diagnosis tag is attached. Trans- port splints for fractures are also applied here; indeed, in many cases these have been carried forward and applied in the trenches or over the top before evacuation is even commenced. At the First Aid Station also the patient is fed and rested. He may have to remain here until nightfall before the next step in evacuation. From the First Aid Station to the most advanced point that can be reached by motor ambulances (usually a distance of 4 to 8 kilometers), where the Field Hospital is established, the wounded are carried through the evacuation trench on hand litters, by relays of bearers. This journey may take from one to three hours. In some sectors it is possible to employ light motor ambulances for this journey. Field Hospital. — At the Field Hospital it is expected that the very seriously wounded (the worst head, thoracic and abdominal injuries and cases of acute hemorrhage which has been temporarily controlled by tourniquet or tampon) will be retained, and emergency operations done; but often it is impossible to keep such patients, and they have to be sent on with the main bulk of the wounded, by motor ambu- lances to the nearest railhead, where the Evacuation Hospital (the French H. O. E., the English C. C. S.) is established. Evacuation Hospital. — The Evacuation Hospital, of 500 to 1000 beds capacity, usually is established from 15 to 25 kilos back of the 1 A kilometer is about 0.6 mile; to reduce from kilometers to miles, multiply by 6 and move the decimal point one space to the left: 20 kilos = 12 miles; 2 kilos = 1.2 miles. (190) EVACUATION HOSPITAL 191 front trenches. 1 It is fully equipped to do all kinds of surgery. The wounded reach it from six to thirty hours after injury, and in quiet Fig. 130. — Diagram of battlefield and evacuation of wounded A. E. F. 1 Mobile Units, corresponding to the Auto. Chir. of the French (Ambulance Chirurgicale Automobile), which are in every way as well equipped as the Evacua- tion Hospitals, may be established temporarily even nearer the front. All these 192 GUNSHOT WOUNDS sectors may be hospitalized until nearly convalescent. In active sectors all who are not strictly intransportable are evacuated to the Bases as soon after operation as accommodations can be found for them on the Hospital Trains. The latter, well equipped for nursing and feeding the patients, reach their bases within twelve to forty-eight hours: thus in the most favorable contingencies a wounded soldier may reach the Base within twenty-four hours of the time of injury; but the average time required is three to four days. When possible the slightly wounded should be segregated at the Evacuation Hospital, and sent to a hospital center in the intermediate zone, whence they may be returned to the front when recovered without ever reaching the Base. Base Hospital. — The Base Hospitals, from 50 to 100 kilometers or more from the battle front, and with a capacity of from 1000 to 3000 beds each, are equipped, so far as exigencies of wartime permit, like the best metropolitan civilian hospitals, and the treatment is such as can be given under these circumstances. Missiles. — Gunshot wounds are those produced by missiles pro- jected by the explosive action of gunpowder. The missiles include the various projectiles from artillery (chiefly shells and shrapnel); bombs from airplanes; bullets from machine guns and from small arms (muskets, rifles, revolvers, pistols, etc.); hand grenade fragments; as well as small shot from shotguns. Shells and bombs are directed rather against defences, lines of communication, ammunition dumps, etc., than against the soldiers on guard, and these rarely are injured except by fragments of such large missiles. Cannister and shrapnel are much alike, being composed of a collection of small missiles within a steel casing; but cannister explodes as it is discharged from the gun, while shrapnel contains an explosive in its center, with a time fuse, and is exploded only when the time fuse is consumed. Both shrapnel (which is filled with round lead bullets), and cannister (filled with missiles of all shapes and sizes) are used only at close range, the latter scarcely ever, and the former very seldom, in modern warfare. A shell is a hollow steel cylinder with conoidal nose, from 75 to 150 or even 320 mm. in diameter, containing a charge of high explosive; it bursts on impact or by a time fuse, and each fragment may set in motion other missiles, by striking and shattering rocks, trees, houses, etc. Bombs dropped by avions are similar to shells in size and con- struction, and explode on impact; grenades, thrown by hand in close combat, resemble small shells. Gas shells are also employed in modern warfare ; there are mustard gas shells, which cause burns of the surfaces of the body (p. 178); and poison shells, which on bursting disperse poison gases acting chiefly on the respiratory tract, and cause, if not sanitary formations make use of existing buildings, when available. The First Aid Stations usually are in dug-outs, underground, or in the sides of hills, for protection from shell-fire. Auto. Chirs. and Evacuation Hospitals are not usually exposed to shell-fire, and depend for protection against bombs of avions on being distinctly marked as Hospitals by immense red crosses laid out in broken bricks, etc., in the surrounding fields. GENERAL NATURE OF GUNSHOT WOUNDS 193 immediate death from suffocation, at least very severe pulmonary complications. The modem conoidal bullets (Fig. 131) are projected from rifled barrels. The rifling imparts to the missile a rotatory motion or spin, which approximates 3000 revolutions per second on its discharge, at which instant its velocity is over 800 meters (nearly 2700 feet) per second (initial velocity). The Mauser bullet still in use in the U. S. Army is 30 caliber (i. e., 0.3 inch — about 8 mm. — in diameter) and 1.08 inch (about 28 mm.) long; it consists of a core of lead and tin composition inclosed in a jacket of copper and nickel, and weighs about 10 grams. The German Mauser bullet is 28 mm. long, 7 mm. in diameter, and weighs 10 grams. The high velocity imparted to the modern bullet tends to make its trajectory (line of flight) more nearly horizontal, thus increasing the danger zone. When fired horizontally ("point blank") the danger zone embraces the entire trajectory of the bullet, which under such circum stances is about 700 meters in 12 3 4 Fig. 131. — Evolution of the bullet. 1, old rounded musket ball; 2, Minie bullet; 3, 0.45-caliber Springfield; 4, 0.30-caliber jacketed Springfield, model 1905. All of natural size. (.Bryant and Buck.) length; when aimed at a greater distance, the shot is fired into the air, the trajectory is a parabolic curve, and the danger zone is removed to the area within which the bullet is liable to strike earth. The rotatory motion and high velocity combined, tend to lessen the bullet's dip, thus enabling it to strike more nearly end-on; while both factors markedly increase its penetrating power. The range of the bullet is nearly two miles, being fairly accurate up to one mile. At short range, and at long range, it wobbles, the period of steady flight being comparable to the period when a boy's spinning top is "asleep." General Nature of Gunshot Wounds. — Bullet wounds formerly comprised nearly 90 per cent, of those seen in war, and form almost the only variety of gunshot wounds encountered in civil life, with the exception of occasional wounds from small-shot or from wadding out of blank catridges. In the German War, however, bullet wounds formed less than half of those seen, the majority being due to shell fire. (Early in the war, before the complete development of the machine gun, bullet wounds formed only 15 per cent, of the total.) 13 104 GUNSHOT WOUNDS Missiles penetrate or perforate the body, or cause superficial "gutter" or tangential wounds. If they merely penetrate, there is only a wound of entrance; if they perforate there is also a wound of exit 1 (Fig. 1:12). But the wound of entrance may be within the mouth, or even within the anus or external auditory meatus. Bullet Wounds. — If the bullet is fired at close range (usually not over 1 meter) there will be powder marks around the wound of entrance. The wound of exit is usually, especially in civil life, larger than the wound of entrance, and its margins may be somewhat everted. If the bullet was fired at close range, or if nearly spent, or if deformed by striking elsewhere first (wound by ricochet), the w r ound of exit may be very ragged or even explosive, while even the wound of entrance may be gaping (Fig. 136). These characters of the wounds are due to the wobble of the bullet, to its carrying foreign par- ticles or pieces of flesh and bone before it into and out of the wound, to its deformed state, or to its emerging sideways (no longer end-on). The wound of entrance sometimes seems smaller than the missile by which it was pro- duced, from the elasticity of the skin. If two bullets enter by the same wound, one may pass through and the other lodge; or they may emerge by the same or by different wounds; and two bullets may enter by different wounds and emerge by the same wound of exit. One bullet may traverse successively various parts of the body, making wounds of entrance and exit in both lower or upper limbs, or in a limb and the trunk; or if the limb is acutely flexed, traversing the same limb twice. The tract of the bullet forms a sinus which heals by the ordinary processes of repair. The smaller the caliber of the bullet the less likely is sloughing to occur; wounds by bullets of 0.22 caliber frequently heal without infection evenin civil life; those by bullets of 0.35 caliber or over frequently suppurate throughout their extent. At close range (up to 400 meters) the modern military bullet has what is known as an explosive effect; that is to say, any marked resist- ance causes its energy to be transmitted into the surrounding tissues. The more resistant the tissues, the more marked is the explosive effect. This is particularly noticeable in bone: if the spongy, expanded epi- physes are struck, there is little resistance offered and a grooved or tunnelled wound will be produced (Fig. 133) ; w r hereas if the hard brittle 1 Abbreviated by the French as O.E. (orifice of entry) and O.S. (orifice of sortie, or exit). It ii w Fig. 132.— 0.38-caliber bullet wound in right calf. Wound of entrance on outer side; wound of exit on median side. Five days after injury. Episcopal Hospital. BULLET WOl'SDS 195 diaphysis is struck, the bone will be shattered (Fig. 134). Fluid saturated or fluid containing organs offer extreme resistance to bullets because of their lack of compressibility; the brain, the liver land the hollow viscera (if distended with liquid or semisolid food) afford notable examples of this explosive action, which is due to the missile's high initial velocity. Larger missiles (as the old round shot) with much lower velocity, even when almost spent, may have an equally de- structive action. 1 The bullet wounds encountered in civil life (suicide, homicide, etc.), as a rule, are not produced by modern military bullets, but by softer, unjacketed bullets (Minie or Springfield) of low velocity (about 220 meters per second) ; the caliber varies 1 These facts are concisely expressed in the physical formula M = mv; that is, the momen- tum equals the product of the mass by the velocity, and if either the mass (as in the larger missiles) or the velocity (as in the modern military bullet I lie sufficiently great, the mo- mentum of the projectile, -and hence its de- structive action, will be correspondingly great. Fig. 133. — Cancellous bone perforated l>v bullet. (After Helferich.) — Compact boneshat- bullet. 'After Hel- L96 GUNSHOT WOUNDS Fig. 135.— Soft bullet de- formed (mushroomed) by strik ing bone end-on. From i patient in the Episcopal Hos pital. from 0.22 to 0.40 or 0.45 (5.5 to 11.25 mm.) but is usually large. As in civil life the bullet is softer, larger, and slower, it is more easily deflected and deformed, and almost invari- ably lodges in the patient's body; the wound is less clean-cut, more lacerated and con- tused, than that produced by the military bullet (Fig. 135.) In war it is rather ex- ceptional for the bullet (unless nearly spent) to lodge in the patient's body; and owing to the greater velocity, the direct impact, and the rectilinear course of the bullet through the body, and its subsequent absence from the wound, infection is not usual. Wounds by Shell Fragments, as already noted, usually are very severe. In civil life such wounds are encountered only in blast- ing accidents, explosions, etc. The larger fragments of the shell, or the rocks, beams, trees, etc., projected by the explosion, may carry a limb completely away, blow the head off, or actually destroy a large portion of the trunk. In such cases death may be immediate or occur before aid can be rendered. Smaller fragments, the average size being about 10 to 15 mm. in diameter, may be driven into the tissues in all directions and to all depths, each one carrying along with it deadly germs ( Fig. 137.) These fragments are much more apt to lodge than are bullets. In the German War no such wounds could be considered clean, unless produced by fragments of ex- treme minuteness (2 or 3 mm. in diameter). In almost every instance foreign materials, especially fragments of clothing, are carried into the wound by the shell fragments, and are left in the tissues even when the shell fragment itself fails to lodge. In such cases, apparently innocent on the surface, debride- ment shows the muscular tissues pulpefied to an incredible extent, forming an excep- tionally favorable nidus for bacterial growth. Such closed wounds (Fig. 138) are in many respects more to be dreaded than the im- mense open wounds where the damage is clearly apparent. The tremendous concussion in the sur- rounding air produced by shell explosion may knock a group of soldiers down or even cause them to be projected into the air for some distance, resulting in wounds from their impact Fig. 136.— Bullet wound of left shoulder region, explosive exit. (Auto-Chir. 6, French Army.) SMALL-SHOT WOUNDS 197 against surrounding objects. It has even been held that the concussion alone without direct trauma may produce serious lesions of the internal organs, particularly of the brain and spinal cord; but this suppo- sition lacks confirmation. Fig. 137. — Multiple wounds by shell fragments. Gas gangrene of right leg and thigh; compound fracture of right fibula; amputation below hip. Compound fracture of left patella into knee-joint; excision of knee. Debridement of other wounds. Recovery. (Auto-Chir. 6, French Army.) Small-shot Wounds are occasionally seen in civil life. If fired at close range, small shot produces great damage, the wounds resembling those caused by artillery projectiles (Fig. 139). Fingers, toes and parts of the hand or foot are frequently blown off. If at longer range, the shot scatters, there is no powder burn, and comparatively little damage may be done, particularly in the case of bird-shot. Of course, if the eye be struck, or an important nerve or bloodvessel injured, the consequences may be very serious from the impact even of one or two shot. It is seldom necessary to extract all these small shot. If the part be treated as for a contused wound it usually does well. 1<)S GUNSHOT WOUNDS Wounds from Blank Cartridges scarcely require separate mention. Thev occur in this country chiefly about the Fourth of July. If the Fig. 138. — Subcutaneous pulpefaction of muscles in shell wound necessitating excision of entire thickness of the muscle for 15 to 25 cm. longitudinally. Fig. 139. — -V-ray of small shot fracture of femur. Death from shock five hours after admission. Esmarch band in place. Episcopal Hospital. TREATMENT OF SMALL-SHOT WOUNDS 199 wadding has lodged, it should be extracted, devitalized tissue should be cut away, the raw surface swabbed with iodin (3 per cent.), and the wound dressed antiseptically. Symptoms. — These are general and local. Shod: seldom is marked immediately after the injury; it develops only after exposure, unless a vital organ is wounded or unless the wound is very extensive. In the heat of battle a soldier may be scarcely aware that he is wounded until he feels the trickling blood. Traumatic delirium is rare and usually not marked, being manifested by extreme talkativeness and sometimes by hilarity. Pain from bullet wounds rarely is great, usually being merely a stinging sensation, as if from a smart blow with a whip. Hemorrhage seldom is profuse, unless from a bullet wound of a large bloodvessel, and it is more likely that a hematoma will form than that there will be continued external bleeding. Shell frag- ments, even when large bloodvessels are implicated, very seldom cause much hemorrhage, owing to the contused nature of the wound. Secondary hemorrhage (p. 2(U) is liable to occur at any time until sloughs separate. Prognosis. — In warfare there is one soldier killed for every four, five, or six wounded and this proportion has been very little altered by the changes in military equipment. A large proportion of gunshot wounds therefore, seems to be necessarily fatal; but in the remaining cases the prognosis depends almost entirely upon the treatment. By modern methods the death-rate has been reduced to 5 or 10 per cent. The bullet wounds of war are not seriously infected of themselves, and if kept clean the resistance of the patients usually is sufficient to ensure a good result, at least as regards life. Wounds by shell fragments, however, have been uniformly infected, and therefore are more disabling than those by bullets. Injuries of the trunk are more serious than those of the extremities, because of damage to viscera; but they are also less frequent. Injuries to the extremities involving bones, joints or bloodvessels are more serious than mere flesh wounds. The positions of the wounds of entrance and exit frequently will enable the surgeon to exclude injury of important structures. Mul- tiple wounds, even when each wound appears insignificant, usually prove very serious. Treatment. — As soon as possible after injury the patient should receive hypodermically 500 units (U. S.) of antitetanic serum. 1 If the wound is extensive or painful, especially if there is a fracture, a large dose of morphin (16 to 32 mg.) should be given. This is done at the First Aid Station. The wound area is also exposed, cleansed mechanically so far as possible without a general anesthetic, its edges wiped with any available antiseptic, and it is covered with dry sterile gauze. Transport splints (p. 204) are also applied. Then the 1 It is probable that in future wars this may be combined with a serum prophy- lactic against gas gangrene. The dose of antitetanic serum should be repeated at the time of any secondary operation. 200 GUNSHOT WOUNDS patienl is fed and allowed to rest and if possible to sleep until evacua- tion to ilif Field Hospital becomes possible. At the Field Hospital soiled dressings are renewed, splints arc read- justed, and the patients arc \\-(\. Occasional emergency operations m;i\ be demanded. But so Par as possible all patients are evacuated by ambulance as speedily as possible to the Mobile Units or Evacua- tion Hospitals. Here again it is important to provide for the patients' general condition, as well as to care for the wounds. The patients must be bathed, fed, and allowed to. sleep. This usually is possible while awaiting admission to the operating room. Serious cases must have precedence. Badly shocked patients are sent at once to the heating room, where necessary measures are carried out by shock teams. Unfortunately this delays resort to operation and increases the chances of infect ion. A general sponge hath should be given to all patients if at all possible; at least the area surrounding the wounds should be well cleansed mechanically and dry shaved. Soap and water should not be used on the wound nor on adjacent skin. Splints should not be removed until the patient is on the operating table and anesthetized. In the preparation room, or elsewhere, the slightly wounded should be segregated and sent to the minor operating room, where most of the treatments can be done without any anesthetic or under primary (p. 151) or local anesthesia. Such operations fall under the heading of what the French describe as Nettoyage, which implies mechanical cleansing alone, and Epluchage, which means the plucking from the wound of all foreign substances. 1 After leaving the preparation room all patients except those in whom such an examina- tion is manifestly superfluous, should pass through the fluoroscopic room; here the radiologists localize foreign bodies — shell fragments, bullets, shrapnel balls. By all means the most satisfactory localiza- tions for the surgeon as well as most rapidly done by the radiologist, are those where the foreign body is indicated as being of certain dimensions, at a certain depth under a near point marked indelibly on the skin. This localization is found both more accurate and convenient than that by two or more axes intersecting at the site of the foreign body. From the fluoroscopic room the patients are taken to the operating rooms, where the surgical teams (surgeon, assistant, anesthetist, nurse and two orderlies) work in shifts from eight to twelve hours at a time. Here the operations consist mostly in those succinctly described by the French as Debridement, Excision and Extraction. Ether is the most satisfactory anesthetic; chloroform is particularly dangerous in those who have been "gassed." 1 Many wounds of large extent and deep, if tangential in nature, may be satis- factorily treated by nettoyage and epluchage if they have arrived at or passed the period of infection when first seen. If suppuration is already established and the original missile has already procured debridement of the wound, excision usually is unnecessary. DEBRIDEMENT 201 Debridement. — This term actually means the relief of tension by incision — the unhridling of the wound. The method has been used in surgery for generations for infected wounds, but as applied to war wounds was developed into a definite technique by the teachings of Lemaitre (1915). It is to be applied to all war wounds which show, or which may conceivably develop subsequently, infection. It is especially necessary therefore, in shell wounds, less so in those by bullets; but even in the latter, if the tissues are at all tense or pain- ful on gentle palpation, and in almost every case where the bullet has lodged, debridement should be done. The wounds of entrance and exit are widely opened by incisions, when possible in the longi- tudinal axis of the limb, or parallel to the main muscular masses; these debridements are frequently 25 to 30 cm. (10 to 15 inches) in length, the usual error being to make them too small. The wound area being thus slit open and freely exposed to view, the next step is excision: first the devitalized skin immediately surrounding the wounds is cut away (no more than is absolutely devitalized should be sacri- ficed) ; and then the entire mass of contused and lacerated subcutan- eous tissues and muscle is cut bodily away with scissors. Accurate anatomical knowledge is requisite to avoid damage to important bloodvessels and nerves. All the devitalized and hemorrhagically infiltrated muscle must be excised; though it may not be actually invaded by bacteria at the time of operation (and probably is not until eight to twelve hours have elapsed since injury), yet if left it is certain to become infected. The surgeon should proceed methodic- ally, excising piecemeal these tissues until he reaches muscle which when cut reacts promptly by contraction. Usually in the course of the debridement and excision he comes upon the shell fragments or other foreign bodies (clothing, mud, wood, leaves of trees, etc.), and at once does extraction, which is the third stage of the operation. In exceptional cases the missile enters without causing much laceration, and its tract has to be followed by dissection, layer by layer, until the missile is found. When the tract no longer can be followed by the eye, it is justifiable to insert the finger for palpation. Usually if the missile is less than 0.5 cm. in diameter it is useless to make prolonged search for it, the missile itself being comparatively harmless after removal of all tissues liable to infection. But in every case clothing or other foreign bodies should be removed. Frequently the missile can be extracted more easily by a counterincision than through the wound of entrance. 1 Finally hemostasis must be secured, and all complications (fractures, severed bloodvessels, tendons and nerves) must be treated as will be presently described. 1 When difficulty is experienced in finding a missile which requires removal, extraction usually may be accomplished under the fluoroscopic screen; or if an electro-vibrator is at hand, this may indicate the location of a steel fragment by causing it to vibrate in the wound, the vibration being palpable to the finger and sometimes visible. 202 GUNSHOT WOUNDS Drainage is very important. Most of the tedious healing of wounds is due to pocketing of infection, and this cannot he prevented unless there is dependent drainage. A counterincision made to,- extraction may be used for drainage; hut it' not in a suitable situation for secur- ing dependent drainage, another counterincision should be made where indicated. It should he amply large, and a rubber tube (1 to l.o em. in diameter) should then he passed from one wound to the other; unless this tube rides easily through the wound, without any binding whatever, the wound should be more widely opened. The entire wound surfaces are then swabbed with iodin (3 per cent.), flavin (1 to 2000), picric acid (2 per cent.), or Menciere's solution (p. 172). If nothing else is available ether alone may be used, but this, as well as Menciere's solution, is apt to increase dozing of blood. Dressing the Wound. — If debridement has been adequately done, and all the devitalized tissues have been excised, it is thus sufficient to provide a sewer (rubber tube) which will carry off the unavoidable wound secretions, which, if dammed up in puddles, would encourage the growth of bacteria. When drainage is provided, it is unnecessary and harmful to stuff the entire wound with gauze. Sterile gauze and cotton in abundant quantities should be applied to the surfaces of the wound area, and securely bandaged in place. Fixation by splints is of great value for transportation even in the absence of a fracture. Primary and Delayed Primary Suture. — If debridement is properly done within twelve or eighteen hours of injury, and the wounds are completely sutured (providing for drainage) at once, and if the patients are not evacuated but kept absolutely quiet, about 85 per cent, of such wounds will heal without further trouble; the remainder will require opening for infection. On the other hand, if these patients, after suture of the wounds, are evacuated at any time within a period of ten days or two weeks, at least 90 per cent, of such wounds will break down or require to be opened for infection, and only 10 per cent, will heal without further trouble. Hence the absolute rule in periods of great activity, when immediate evacuation after operation is necessary, that no wounds shall be sutured. But when these patients, after proper debridement, reach the Bases where they may be kept permanently, delayed primary suture is very successful. If all the wounds not involving bone are sutured immediately upon arrival at the Base, approximately 85 per cent, of such wounds will heal without further difficulty, and only 15 per cent, of them will require reopening for infection, and this is so regardless of the number or kind of bacteria present in the wounds, with the exception of the streptococcus: almost without exception wounds infected by the streptococcus will require reopening; and if the presence of the strep- tococcus can be ascertained beforehand (there is not always time or personnel for the bacteriological examination of all wounds within a few hours of their arrival at the Base), it will be useless to attempt suture. GUNSHOT WOUNDS OF SPECIAL STRUCTURES AND REGIONS 203 Secondary Suture. — Many wounds, which for some reason have not been treated by primary or delayed primary suture, may be sterilized while granulating, and then secondary suture will prove successful. 1 The best methods of chemical sterilization have already been dis- cussed in Chapter VI (p. 169). It should never be overlooked that they are efficient only when the wounds are mechanically prepared in advance; this often requires a secondary operation (debridement, sequestrotomy) ; and as such operations in the presence of streptococcic infection frequently cause further spread of the infection, it can be readily understood how difficult the sterilization of such wounds may prove. The motto qiiieta non movere surely applies to such wounds, and if they continue to heal, even if slowly, it is best to pursue a conservative course. Fig. 140. — Mounted needle for secondary suture. To perform secondary suture, it usually is sufficient to freshen the skin edges, undermining them if necessary, and to close the wound not too tightly by deep sutures (Fig. 140.) It always is important not to leave any dead spaces, and for this purpose buried sutures sometimes may be necessary; but their use, as well as that of drainage, should be avoided when possible. GUNSHOT WOUNDS OF SPECIAL STRUCTURES AND REGIONS. Bloodvessels. — For primary hemorrhage the same rules apply here as in civil life (p. 262): (a) Usually the bloodvessels are more or less contused by shell fragments, and thrombosis is sufficient to prevent free bleeding, producing what are called by the French dry lesions (lesions seches; Fiolle, 1916); hence it is important to explore the condition of the main bloodvessels if they are in the tract of the missile, whether or not there is any evidence of injury; if the lesion passes undiscovered, secondary hemorrhage is the rule. The danger of gas gangrene in such cases has already been noted (p. 89). A wound of the main artery, complicating a gunshot fracture, usually demands amputation, (b) Military bullets, however, groove or cut across large vessels, and hemorrhage is profuse, large pulsating hemato- mas developing if death does not occur from external hemorrhage. Sec- ondary hemorrhage is a frequent sequel, especially in the presence of 1 A second injection of 500 units of antitetanic serum always is to be administered when an operation is done on parts which have been wounded in battle. 204 GUNSHOT WOUNDS infection; its treatment is described at p. 204. False aneurysm (p. 265) <>r arteriovenous aneurysms (p. 267) are remote consequences. The general mortality from wounds of large vessels is nearly 25 per cent., and oxer 10 per cent, of the patients finally come to amputation. Nerves, Tendons. In warfare these are riot deflected by the bullet, but are cut through. Nerves may be seriously injured also by being grazed by a bullet, causing what the Germans call an " Frschutterung" of the nerve, which England's great lexicographer might have trans- lated by the term "tremef action." Severed nerves and tendons should be sutured at the time of the debridement, and nerves espe- cially should be covered up inside the muscles, and not left exposed in the wound. Fig. 141. — Thomas knee splint for transport of fractures of the lower extremity (Keller's half-ring modification.) Fig. 142. — Same in use, on stretcher. Fig. 143. — Hinged Thomas traction arm splint for transport. Bones. — Transportation of fracture cases is much facilitated by the use of the transport splints adopted during the German War, especially the modifications of the Thomas knee splint for fractures of the lower extremity (Figs. 141 and 142), and of the Thomas humerus splint for those of the upper extremity (Fig. 143). They should be applied so as to secure extension as well as fixation. In the trenches or First Aid Station extension may be secured by an anklet applied over the shoe, or a wristlet applied over much padding; but at the Field Hospital, or earlier if possible, these must be replaced by adhe- sive extension 1 applied to the sides of the leg and to the flexor and 1 This glue is used: resin, 50; alcohol, 50; benzin (pure), 25; Venice turpentine, 5. It does not require heating, and may be removed with alcohol or ether. BONES 20" extensor surfaces of the forearm. Too long application of the anklet and wristlet has caused many sloughs. Extension during transport is secured only by counter-extension against the tuber ischii or the axillary folds, and cannot be maintained efficiently for more than a few hours without causing pain and perhaps producing sloughs. When apparatus of this kind is used as a permanent splint, exten- sion is secured by tying the splints to fixed points, and (the foot of the bed being elevated) letting the weight of the limb or body act as counter-extension, thus pulling the tuber ischii or the chest away from the splint. Fig. 144. — Hodgen splint for femur. Gunshot fractures usually are compound, but may be incidental to a non-communicating wound of the soft parts. In the latter case it is not necessary to expose the fracture at the debridement. Frac- tures caused by perforating bullet wounds without serious damage to the soft parts resemble simple fractures; other gunshot fractures resemble the worst kind of compound fractures and are treated accord- ingly (p. 347): during the debridement the fractured ends should be exposed, curetted and swabbed with iodin or other antiseptic; reduc- tion is then secured, the soft parts dressed, and the splints re-applied. Removal of fragments (esquillectomy) should be parsimonious: only those actually detached should be removed, and whenever pos- sible subperiosteal extraction should be practised. It is true that wide esquillectomy may favor rapid healing of the wound, but it usually leaves a flail-like limb. Fractures of the femur should be drained by an incision 15 to 20 206 aixsiior wor.xDs cm. long, at the posterior border of the vastus externus, just proximal to the site of fracture. Fractures of the tibia should he drained by an incision posterior to the fibula. In only one of the fractures I have seen unhealed after many months, had dependent drainage been provided. Fracture cases bear evacuation better immediately after operation or not for eight or ten days. Treatment of fractures at the Base is best done in suspension: the Thomas splints may be used for this purpose, rendering the wounds accessible without removal of the splint; but neither the knee nor the elbow should be kept in full extension long (Figs. 144 and 1 15). Fig. 145. — Fracture of the humerus in suspension and traction. Joints. — In all joint wounds the soft parts are treated as if no com- plicating joint lesion existed, but extraction, by arthrotomy when indicated, should precede the operation on the septic soft parts. 1. Clean perforating wounds of joints, as by the modern military bullet, are to be treated by aseptic occlusion of the orifices and immo- bilization until the soft parts have healed. Then active movement is encouraged. 2. Penetrating wounds with slight fracture are to be treated by arthrotomy, extraction and primary suture at least of the joint cap- sule; it is doubtful whether irrigation of any kind is of value, but many surgeons employ it (saline solution, ether, Dakin solution, JOINTS 207 etc.). The overlying soft parts are left open and drained it* the patient must be evacuated, but wounds of the knee at least are considered Fig. 146. — Bullet lodged in knee-joint, localized by skiagraphy; compare Figs. 147, 148, 149. Episcopal Hospital. Fig. 147. — Lateral view (skiagraph) of bullet lodged in knee-joint. Epis- copal Hospital. Fig. 14S. — Result of arthrotomy and extraction of bullet from knee-joint ; recent accident. Episcopal Hospital. Fig. 149. — Result of arthrotomy and extraction of bullet from knee-joint. Same patient as Figs. 146, 147, and 148. ■ Epis- copal Hospital. intransportable. In many cases extraction may be done by enlarg- ing the wound of entrance; in the knee, however, longitudinal section of the patella (Fig. 473) gives better exposure and the operation may be 208 GUNSHOT WOUNDS concluded more rapidly and with less damage to the joint. In such cases, of course, the arthrotomy wound is completely closed, only the septic wound of entrance being drained down to the joint capsule. If, as is often the case in civil life, the bullet traverses the joint and is lodged extra-articularly, it is not necessary to open the joint to extract it. After arthrotomy, most surgeons practise immobilization, and for the larger joints extension also is maintained. Some follow the teaching and practice of Willems of Gand (1917) who makes the patient keep up active movement in the joint as often and as long as possible; he claims that the more the patient moves the joint (after the first painful efforts) the better it feels. If suppuration follows the primary opera- tion, or occurs before the patient is seen: (a) reopen the joint, and try chemical sterilization; if this does not immediately succeed, aban- don it, and (b) trust to active movements to secure drainage: this is the plan Willems has adopted in many cases, and he claims it secures adequate drainage, the movements forcing the pus out from all crevices of the articulation; I never saw this method successful, and it is clear that it will not always succeed, as even Willems himself acknowledges. The next step then (c) is icicle arthrotomy, with chemical disinfection. When even this fails, one resorts to (d) excision of the joint, and finally (c) to amputation. 1 3. Penetrating or Perforating Wounds- with Notable Fracture. — If removal of detached or nearly detached fragments will leave the bone ends in proper shape for joint function, esquillectomy (p. 205) is suffi- cient; if this procedure utterly destroys the joint contour, a formal excision (p. 510) is preferable. After excision of a joint in military surgery, the wound should be left open, and chemical disinfection employed. Amputation is most often requisite for wounds of the knee. Head. — In civil life these injuries frequently are the result of sui- cidal attempts, the wound of entrance being in the temple, forehead, or within the mouth. Even if the brain is injured there may be no localizing symptoms (p. 628). The only indications for operative treatment are (1) to disinfect the wound of entrance; (2) to arrest hemorrhage ; (3) to repair damage to the cranium ; and (4) to remove a lodged missile if it is producing symptoms. If the wound of entrance is small, not liable to cause further trouble from infection; if the fracture of the skull is a mere puncture, without comminution or Assuring; if there are no symptoms of internal hemorrhage or com- pression of the brain; and if the patient does not grow progressively Avorse, no operation should be done. If the wound of entrance is lacerated, contused, filthy, and splintering of the skull is evident, operation should be undertaken as in any case of fracture of the skull whether there are cerebral symptoms or not. In warfare most wounds of the head resemble the type just described; but in every case, no matter how insignificant the scalp wound appears, 1 The average mortality of infected gunshot wounds of the knee-joint is about 2") per cent. By early arthrotomy as indicated above it has been reduced to less than 1 per cent., but recovery of satisfactory function is exceptional. THORAX 209 the cranium should be exposed. Local anesthesia should be used if possible. The scalp wound should be excised, dirty or depressed bone removed, and the dura, unless normal, should be opened. A hernia cerebri (p. 635), which often presents in the scalp wound, should be gently cleansed; and if the operation is done under local anesthesia the patient may be directed to cough, or to strain, as this may force out of the tract in the brain pulpefied cerebral tissue, and fragments of bone or shell. This is preferable to introducing a catheter and attempting evacuation by suction, as advised by Gushing (1918). Unless fluoroscopy shows foreign bodies are very accessible no attempt should be made to extract them unless they are causing symptoms. It is best not to attempt reduction of the hernia cerebri by means of lumbar puncture, as this is apt to rupture limiting adhesions and to be followed by meningitis; but merely to suture the scalp over the protruding brain, disregarding the dura. In all cases it is important to close the wound completely, and to do so may necessitate a rather elaborate plastic operation on the scalp; but the results fully justify such an operation. These patients are intrans portable. Secondary operation may be required for removal of a lodged missile which is causing symptoms. Most patients with lodged missiles die suddenly when apparently convalescent, or after developing a brain abscess or meningitis. Removal should be attempted by the nearest approach, sometimes along the original tract, but often by a counter- opening. Spine. — The mortality from gunshot wounds of the spine in war is about 66 per cent. Nearly every case is complicated by cord lesion, which may be direct, or merely an "Erschiitterung" without rupture of the dura, and even in these cases a complete transverse lesion may result. In civil life the slowly moving bullet usually is arrested by the spine, and fracture without injury of the cord is the rule. In military practice early operation is indicated only for proper treat- ment of the soft parts, and extraction of easily accessible missiles. The modern teaching is that no catheter should be passed for reten- tion of urine (for fear of infection), but that the distended bladder should be emptied by gentle pressure above the pubes, repeating this maneuver until the sphincter gives away and retention is relieved. The question is not settled, however (see p. 645). These patients should be evacuated immediately to the Base, where they may be hospitalized indefinitely. Thorax. — Gunshot wounds of the thorax rarely are serious unless they penetrate and wound the viscera, but shell fragments may cause very severe damage to the chest wall, fracturing ribs or scapula, opening the pleura widely (the so-called sucking wounds), and produc- ing death from shock without any damage to the viscera. On the other hand, bullet wounds may result in instant or rapid death from injury to the heart or great bloodvessels, with insignificant injury to the chest wall. In warfare a bullet seldom lodges; in civil life it nearly invariably is arrested, frequently being found beneath the skin 14 210 GUNSHOT WOUNDS on the opposite side of the body. It is important to look for it care- fully beneath the skin, if there is no wound of exit, so as to determine its course through the thorax. A bullet may seem to traverse the thorax, and yet wound no viseus; while a wound which does not pene- trate far may cause alarming hemorrhage from the internal mammary or an intercostal artery. Symptoms. In sucking wounds there is great dyspnea, and shock often is pronounced. In penetrating or perforating bullet wounds, with punctiform orifices, and if the course of the bullet is above the level of the anterior end of the fifth rib, and there arc no signs of serious internal hemorrhage (p. 259), it is probable that the upper part of the lung has been wounded at its periphery. If the bullet is of small caliber, pulmonary tissue expands and occludes the wounds of entrance and exit in the lung, and little bleeding occurs into the pleural cavity. A larger bullet, and most shell fragments, will produce more of a lacerated wound, and the signs of hemothorax (sometimes pneumo- hemothorax) quickly develop. Subcutaneous emphysema (p. 77(5) is not infrequent. In nearly every case the physical signs of a more or less diffuse bronchitis appear; bloody mucus is expectorated; moderate fever occurs; and the patient passes through an atypical attack of pneumonia. Dyspnea rarely is severe unless from internal hemorrhage or from pneumothorax. If the bullet passes below the level of the fifth rib, it may involve the diaphragm, or pierce this, and entering the abdomen wound the subdiaphragmatic viscera. Treatment. — 1 . Wounds by Shell Fragments. — Sucking wounds should be tamponed with gauze as soon as the wounded man is found, and morphin administered. At the Evacuation Hospital the soft parts of the chest wall, and fractures of ribs or scapula, are to be treated as if no visceral lesion existed (debridement, excision, extraction), and the pleural cavity is to be closed by suture of the muscles across the opening with only superficial drainage. Only if a shell fragment is easily accessible should attempts be made to remove it from the lung; then the lung should be grasped in the fingers or volsellum forceps, the missile located by palpation, an incision made in the visceral pleura over it where most accessible, and extraction done. If the pleural incision is small, no suture is needed. The chest is closed without drainage. The operation has been systematized by P. Duval (1915). In the majority of cases the missile is small and provocative of no symptoms if allowed to remain, and pulmonary complications are unusual. If extraction is subsequently required, it is better to do open thoracotomy, according to Duval's plan; though Petit de la Villeon (1916) has practised in a large number of cases with great success, under fluoroscopy, extraction by a long forceps introduced through a buttonhole intercostal incision. Most of his operations were done weeks or months after injury. 2. Bullet Wounds. — Wounds above the level of the fifth rib seldom require operation; the orifices should be cleansed and occluded with sterile dressings, and the affected side of the chest strapped, as for ABDOMEN . 211 fractured ribs (p. 359). Dyspnea is to be controlled by opiates. In any case where the abdominal contents may have been wounded exploratory laparotomy is indicated. When dyspnea is extreme, and the pleura is filled with fluid, it is better to evacuate this through an incision in the ninth or tenth intercostal space, posteriorly. This should also be done when an infected hemothorax is encountered. If there is persistent internal hemorrhage, open thoracotomy (p. 785) is indicated. It is best not to drain the thorax, unless already infected. Abdomen. — Gunshot wounds of the abdomen may involve only the parietes, and in a patient with a very fat or pendulous abdomen the bullet may enter in front and lodge in the groin or flank without penetrating the peritoneum. Every case, however, should be sub- jected to exploratory operation, whether in military or civil practice, provided ample facilities exist; and patients should not be moved for two weeks after operation. If abstention from operation is uniformly practised in war, the mortality is considerably higher than when imme- diate operation is done in all cases. Bullet wounds are less dangerous than those from shell fragments, the respective mortality, according to Chalier and Glenard (1917), being 42 and 68 per cent. The surgeon should abstain from operation only when the patient is first seen from twenty-four to forty-eight hours after injury, and if there are no abdominal symptoms. If no operation can be done, for any cause, the non-operative treatment for peritonitis (p. 862) should be adopted. Such patients sometimes live to develop a localized abscess, a fecal fistula, or even intestinal obstruction, which may be treated success- fully by a late operation. In civil life, nearly half the patients recover if operation is done within tAvelve hours; after that time only one out of four recovers. Though the mortality in civil practice, even after prompt operation, is thus seen to be nearly as high as in military surgery, it must be remembered many patients who die on the field or in advanced posts are not included in the military statistics. The diagnosis and operative treatment of penetrating wounds of the abdomen are discussed in Chapter XXII. CHAPTER VIII AMPUTATIONS. Amputation, derived from the Latin word meaning to lop off, to prime, etc., is by surgeons usually confined in its application to the removal of a limb, or part of a limb. If the member is removed at a joint, the operation may be termed an exartieidation, or a dis- articulation; if through the bones, the operation is an amputation in continuity. Conditions Requiring Amputation. — Among the most frequent and important are: (1) Avulsion, or traumatic amputation, of a limb; here there is no alternative but to trim up the stump that is left so as to hasten healing and secure good functional result. (2) Compound fractures and luxations, which sometimes leave the limb attached only by a few shreds of muscle or a strip of skin. (3) Lacerated and contused wounds, even without fracture, sometimes exhibit such extensive destruction of the soft parts as to demand the removal of the limb. In general, if the limb is sure to be useless if retained, or if it is sure to become gangrenous, it should be re- moved. (4) Injury of the main artery of a limb, when it occurs at a site which habitually results in gangrene, usually is a cause for amputation ( p . 6 1 ) . ( 5 ) Gan gren e , when con st itut i n g m ore than a superficial slough, usually is a cause for amputation. The special varieties of gangrene, and the proper time for amputation, as w r ell as the level where this should be done, have been considered in Chapter II. Gas gangrene is discussed at p. 88. (6) Septic wounds, espe- cially if complicated by lesions of bone or joints, come to amputation as a life-saving measure. (7) Diseases of bones and joints ; these are much less often a cause for amputation now than formerly. (8) Malignant tumors frequently necessitate amputation. (9) Deformity, including also certain non-malignant tumors, may very occasionally be a cause for amputation. Instruments. — These include a tourniquet (Fig. 150), or an Esmarclis band (Fig. 151) for controlling the circulation; amputating knives for dividing the soft parts; periosteotome, or raspatory; retractors to guard the soft parts from the saw; bone forceps, to steady the bone as it is (212) Fig. 150. — Screw tourni- quet applied to thigh. INSTRUMENTS 213 sawed, in cases of avulsion or traumatic amputation, and~J>one nippers to trim rough edges off the bone after it has been sawed; hemostatic Fig. 151. — Esmarch band, showing proper method of its application. Fig. 152. — Amputating instruments. 1. Large amputating knife. 2. Catlin (double- edged knife). 3. Small amputating knife. 4. Metacarpal knife. 5. Periosteotome or raspatory. 6. Phalangeal saw. 7. Metacarpal saw. 8. Large amputating saw. forcejjs, as well as ligatures, sutures, needles, and scissors. These instruments are illustrated in Figs. 152 and 153. 21 I AMPUTATIONS Tourniquet. — The screw tourniquet (Petit, L690) is seldom employed now, Esmarch's elastic hand (1873) having largely superseded it. Before applying either, especially in shocked or anemic patients, the limb should be elevated for a few moments, so as to empty it of venous blood. The tourniquet, when used, should be placed upon the limb so that the screw is either directly over the main vessels, or at a point diametrically opposite to them, compressing them against bone; and a compress (as a roller bandage) should be placed between the tourniquet and the main vessels, so that greater pressure will be brought to bear on them than on the surrounding soft parts. After fixing the tourniquet in place by buckling the strap tight, the plates Fig. 153. — Amputating instruments. 1. Hemostatic foceps. 2. Curved hemostatic forceps. 3. Fergusson's "lion-jawed" bone-holding forceps. 4. Liston's bone-cutting forceps ("nippers"). 5. Farabeuf's bone-holding forceps. are separated by turning the screw, thus drawing the encircling strap tighter and forcing the compress against the vessels until distal pulsation is arrested. Esmarch's elastic band is wrapped around the limb three or four times, each turn being directly superposed upon, and being drawn a little tighter than the previous one, until the circulation is arrested. If not drawn tight enough, it will increase venous bleeding; if drawn too tight, it may cause local sloughing and subsequent gangrene of the entire limb; or paralysis from pressure on the nerves, especially above the elbow, when the ulnar or musculo- spiral nerve may be injured. In emergencies the "Spanish windlass" (Morel, 1674) may be used (Fig. 154), or even Momburg's method of hemostasis (p. 235). OPERATIVE PROCEDURES 215 Amputating Knives. — The length should be about one and a half times the diameter of the limb to be removed, and the blade should be from 1 to 2 cm. wide; one of 20 or 25 cm. is suitable for the thigh or hip; one of 15 cm. for the forearm, arm or leg; while for the hand or foot a metacarpal amputating knife (Fig. 152, 4), with a blade 7.5 cm. long and 0.5 cm. wide, is preferable. Double edged catlins occasionally are used for the forearm or leg, to aid in clearing the interosseous space. The raspatory is used to separate the periosteum before apply- ing the saw, thus avoiding ragged division of the periosteum by the saw. The retractor is made of muslin, being two-tailed for the humerus and femur ( Fig. 155), and three-tailed for the forearm and leg (Fig. 150 1 . gSfe Fig. 155.- -Two-tailcd muslin retractor, for amputations of the arm and thigh. Fig. 154. — The "Spanish windlass." Fig. 156.- -Three-tailed retractor applied for an amputation of the leg. The amputating saw is about 25 cm. long by 5 cm. wide; strong- backed, and with widely set teeth. A smaller saw is used for the hand and foot. Bone-nippers are sometimes used for amputating phalanges, though they are apt to splinter the bone; and if larger bones are properly sawed, there should be no rough edges to trim off. Ligatures are of absorbable material, as are the buried sutures; skin sutures usually are of silkworm gut. Operative Procedures. — A patient who is to have a limb removed usually is in a weakened and precarious state, either from shock and hemorrhage following an accident, or from the cachexia of chronic disease. Hence it is the surgeon's duty to take special pains to 216 AMPUTATIONS prevent loss of bodily heat, and needless waste of time. In cases of accident it frequently is necessary to prepare the limb for ampu- tation after the patient is on the table, while the anesthetic is being administered. The surgeon and his first assistant should be ready to commence the operation the instant that the patient is under the anesthetic, and the preparation of the limb should be complete at the same time. While one assistant raises the limb, the surgeon applies the tourniquet, or if he entrusts this important duty to an assistant, he should make sure before commencing his operation that the circulation is properly arrested and that there is no danger of the tourniquet slipping. One assistant should give his entire attention to the tourniquet throughout the operation. Another assistant holds the limb in a convenient position, clear of the table, and the surgeon, standing with his left hand to the patient's trunk, 1 so as to be able to control the main artery should the tourniquet slip, divides the soft parts and the periosteum, as will be presently directed; and, while the soft parts are drawn out of the way and protected by the retractor, saws the bone, his assistant guarding against binding of the saw by the manner in which he holds the limb. As soon as the limb has been removed, the surgeon applies to the face of the stump a folded towel, lightly wrung out of very hot antiseptic solution; this checks the slight venous ooze, and as it is gradually withdrawn, the surgeon catches with hemostats all the vessels large enough to have names, and ties them all. The main artery and vein of the arm or thigh should be tied separately; smaller arteries may be included in one ligature with their accom- panying veins. Then another hot antiseptic towel is applied to the face of the stump, and, the limb being held as nearly vertical as possible, the tourniquet is completely removed. If it is only partially loosened, venous bleeding is increased. If the surgeon has done the operation with due care, there should now remain only a few oozing points in the muscular masses, which can be controlled by sutures. If the soft parts have been cut dexterously, with long sweeps of a sharp knife, the tendons and nerves are cut cleanly across, will not be redundant, and will not require to be retrenched. Hemorrhage from the medulla, which is unusual, should be controlled by plugging with muscle tissue, by packing with Horsley's wax, or in emergency with gauze. Finally, the stump is closed, with a few buried mattress sutures of chromic catgut approximating the ends of opposing sets of muscles. A rubber drainage tube is placed across the face of the stump, just beneath the skin, and the skin is closed with interrupted sutures of silkworm gut. Dressing the Stump. — Moderate pressure, rest, and mechanical protection are necessary. Abundant sterile gauze dressings are applied, and in a certain definite manner. Ruffled gauze is placed around each end of the tube, one end of which may be left long and brought out of the deep into the superficial dressings, as described 1 In amputating the left lower extremity he stands between the patient's legs. GUILLOTINE AMPUTATION 21* at p. 166. The special amputation dressing is cut as shown in Fig. 157; the transverse portion is placed beneath the limb, and folded around it, the longitudinal portion being then folded up over the end of the stump. Over the gauze dressings an abundant amount of sterile absorbent cotton is arranged, burying the end of the tube, and the whole is band- aged snugly on to the stump. It is surprising how much diminution in size an apparently bulky dressing undergoes when it is properly bandged. Next the limb is bandaged firmly to a splint, which projects some inches beyond the end of the stump. It is never safe to as- sume that cases of amputation, especially recent accidents, will be free from traumatic delirium, and the proper time to protect the limb from injury is before the delirium develops. The stump should be kept as nearly vertical as pos- sible for twelve hours. Usually the drainage tube may be removed at the end of twenty- four to thirty-six hours ; and the stump need not be dressed, if all goes well, until time to remove the skin sutures. Methods of Operating. — Every method of amputating may be considered a variety either of the circular or the flap method. The circular method is to be preferred whenever a choice is possible; it is suited for all limbs where the bones are approximately in the center of the soft parts (lower forearm, arm, thigh), provided the limb is not conical in shape. It is not desirable in amputations at joints, nor in the leg, where a weight-bearing stump is sought, since the cicatrix always falls across the face of the stump. Fig. 157.— Method of cutting and applying gauze for dressing an am- putation stump. Fig. 158. — Traction on guillotine stump. Guillotine Amputation {Amputation en Saucisse). — This primitive method has been revived during the German War, as a preventative 218 AMPUTATIONS of septic complications (Pauchet, 1914) : all the tissues are divided at the same level; the skin and muscles retract, leaving an exposed conical stump, open to antiseptic treatment. When granulations commence, traction should he applied (Fig. 158) and in a few cases healing will occur without further operation. In most cases, how- ever, it is necessary eventually to trim off the bone and do secondary FlG. 159. — Guillotine amputation of the thigh, after extension had been applied for weeks. Ready for secondary suture. Re-amputation not necessary. Walter Reed General Hospital. suture (Fig. 159.) This is the form of amputation to be preferred in exceedingly septic cases, as an emergency method; it exposes the least possible area to infection and leaves the least possible surface to heal. Esmarch, over thirty years ago, employed what he called the Einschnitt Method, which was in all respects similar to the guillotine method, except that Esmarch applied one or two sutures to the center of the skin incision, letting the sides gape for drainage. Fig. 160. — Circular amputation of the forearm, showing method of holding the knife as the first incision is started. Circular Amputation. — In this method all the tissues of the limb are severed by circular incisions, the skin at the lowest, the muscles at an intermediate, and the bone at the highest point ("triple in- cision" method of Hey and Bell, about 1800). The surgeon passes CIRCULAR AMPUTATION 210 the knife under, around, and over the limb, so that its point is down, and its back toward his own face (Fig. 160); then, pressing the heel of the knife well into the flesh, with one long steady sweep he divides the skin and subcutaneous tissues down to the deep fascia, the blade ending with its point exactly in the place where its heel began the incision. The surgeon now dissects the skin up, with the same knife, for a distance equal to half the diameter of the limb, taking care always to direct his blade toward the deeper structures so as to leave uninjured the cutaneous vessels, and thus ensure the vitality of the skin. Then the muscles are similarly divided down to the bone, with the same knife, by a circular cut at the point of reflection Fig. 161. — Skiagraph of stump resulting from amputation of leg by modified Sedillot method. Episcopal Hospital. of the skin. The muscles are not separated from the periosteum further than is necessary, but this is cut through by a sharp knife and scraped upward for 2 or 3 cm. In the forearm and leg the interosseous space must be cleared also; in doing this the surgeon should studiously avoid turning the edge of his knife upward, toward the patient's trunk, for fear of nicking bloodvessels higher than they can be conveniently tied. When the bone has been cleared, the muslin retractor is applied, each end overlapping the other, and all being drawn upward by an assistant. The bone is then sawed, at right angles to its long axis, without injury to the periosteum. In the forearm both bones are sawed at the same level, and simulta- 220 AMPUTATIONS neously; in the leg, the fibula is sawed first and at least 2 cm. higher than the tibia (Fig. l(il). After suturing the muscles, the skin incision may be closed transversely or anteroposterior^' as seems best. Sometimes in a conical limb there is difficulty in dissecting back the circular cuff of skin, as above described; then it may be slit at one or two points. If slit at only one point, and the angles rounded off, this constitutes the Racket Method, named from its resemblance to a tennis racket, and habitually employed in many disarticulations. The Oval or Elliptical Method, a modification of the racket method, is employed in many amputations without the formality of commencing it as a circular amputation, by making the first skin incision in the form of an ellipse. If the cuff of skin is slit at two points, and the angles rounded off, the amputation becomes one by skin flaps, commonly called the Modified Circular Method. Flap Amputation. — The flaps may include the skin and superficial muscles, or the entire muscular mass with the skin. The flaps may be rectangular or curved in outline, and may be cut from without inward or by transfixion. They always should be of equal breadth at their base, whether they are of equal or unequal length. Their combined length should equal one and a half times the diameter of the limb. Care should be exercised to have the main bloodvessels in one flap or the other (usually in the shorter), and not at a point where they may be slit up as the flaps are being formed. In amputating by transfixion the surgeon raises the tissues to be cut with his left hand, and entering the point of the knife at the side of the limb nearest himself, pushes it across and around the bone, and brings its point out diametrically opposite its place of entrance. The flap is then formed by cutting first downward and then rapidly outward, with a vigorous sawing motion. The knife is then reentered as before, pass- ing on the opposite side of the bone, and the second flap is cut. The remaining fibers are then divided by a circular sweep, and the opera- tion terminated as already described. The flap which contains the principal bloodvessels should be cut last. Usually it is more conven- ient to form the flaps by cutting from without inward; or the second flap only may be cut by transfixion. Though an amputation may be performed more rapidly by transfixion, this method has lost in favor since the introduction of anesthesia; since by cutting from without inward the flaps may be more accurately shaped, and the main bloodvessels may be severed transversely, instead of obliquely as frequently happened in cutting flaps by transfixion. Multiple Amputations.— It is occasionally necessary to remove two or more limbs at the same time. Under such circumstances it is best to do the amputation of greatest magnitude and severity first; and for the same surgeon to proceed immediately afterward to remove the second and third limb, if the patient's condition warrants the continuance of the operation. If it does not, hemorrhage from the remaining limb or limbs must be temporarily controlled, and further operation postponed. For two or more surgeons to operate DISEASES OF STUMPS 221 on different limbs simultaneously usually increases the shock to the patient. Multiple amputations for gangrene following frostbite are much less serious than those for traumatic cases. Structure and Diseases of Stumps. — A stump not only goes through the processes of inflammatory reaction, cicatrization and contrac- tion; but there also occurs actual atrophy of the muscular tissues from disuse; the bone becomes rounded off and atrophies; the nerves degenerate, and usually become bulbous, but will not be painful unless caught in the cicatrix. The muscles occa- sionally become unduly atrophied and re- tracted, leaving the ends of the bone covered only by skin, or even causing the incision to break open, and producing a painful ulcer. Sometimes, from continued growth of bone, a conical stump is formed (Fig. 163). This usually is due to the natural develop- ment of the bone, being seen oftenest in amputations of the upper arm in children, as the growth of the humerus takes place chiefly at the upper epiphysis. Sometimes a conical stump forms in the leg in child- hood, the growth occurring from the upper epiphysis of the tibia; whereas in the fore- arm and thigh, the greater part of the growth comes from the lower epiphyses. For conical stumps, and for intractable ulcers, adherent to the bone, which cannot be cured by palliative means, there is no remedy short of re-amputation, which, fortunately, is a much less serious operation than amputa- tion. It sometimes is possible to resect the end of the bone, without doing a formal amputation again. In cases which have been septic it is best to remove sequestra first, and not to do secondary suture until a later occasion, after all swelling has subsided. By a plastic operation it may be possible to secure closure without removal of more bone. Stumps must have a certain length to be useful with artificial limbs: too short stumps are a hindrance. At least 4 cm. on the flexor side of the bent knee, enough of the femur to project well beyond the level of the tuber ischii, and of the humerus to clear the axillary folds, are required to keep the stump from riding out of the socket of the prosthesis. A good stump is one which is painless and which, in the lower extremity, can be used to support the weight of the body through an artificial limb. The bones should be well covered with soft parts, and these soft parts should not be adherent to the ends of the bone; if there are no such adhesions it makes no particular difference whether Fig. 162. — Double amputa- tion, circular of thigh and Cho- part's of foot. Episcopal Hos- pital. 9.9.9 AMPUTATIONS the cutaneous cicatrix lies across the end of the stump or at one side; but there are much less apt to be adhesions to the bone if the cicatrix Fig. 103. — Conical or sugar-loaf stump from continued growth of bone after ampu- tation in early youth. From a patient in the Pennsylvania Hospital under the care of the late Prof. Ashhurst. of skin as well as of muscle lies to one side of, rather than directly over, the end of the bone. Few stumps will bear, by direct pressure on their ends, the entire weight of the body, and most artificial limbs are made to obtain their chief support from surrounding bony points (head of the tibia, tuberosity of the ischium). But Bier (1895) advocated an osteo- plastic method of amputating, after the Pirogoff principle, by means of which end-bearing stumps may be obtained (Fig. 164). Bunge (1905) found that by sawing the bone 2 mm. Fig. 164. — Bier's osteoplastic method of amputation. The bones are sawed at two levels, and a flap of the tibia turned across the ends at the last section. Fig. 105.— Amputation of leg by aperiosteal method of Bunge. MORTALITY AFTER AMPUTATION 223 below the level at which the periosteum is divided, and scraping out the marrow cavity for the same distance, end-bearing stumps may be obtained without any osteoplastic oper- ation. He makes his flaps of skin only (Fig. 165). The oval method is suitable for such cases. I have used this method with perfect success (1911) (Fig. 166). After-treatment of Stumps. — It is im- portant to prevent contractures of neighboring joints, especially flexion of the knee, flexion and adduction of the hip, and loss of supination in the fore- arm and of abduction at the shoulder. Active exercises for this purpose should be instituted so soon as the condition of the stump permits, usually within ten days or two weeks; and so soon as the stump is healed it should be fitted with a temporary prosthesis and active use encouraged. This develops the muscles which move the stump and greatly hastens the return of function. In the lower extremity a bucket of plaster of Paris, moulded to the stump, may be attached to a peg-leg for tem- porary use. The permanent prosthesis may then be fitted as soon as the stump ceases to shrink. Cinematoplastic Amputations. — (See p. 256.) Mortality after Amputation. — Although this depends much more on the condition of the patient than on any other single factor, it is nevertheless proper for the surgeon to be familiar with the relative mortality of amputations for injury and for disease; and, in cases of injury, with that which accompanies primary, intermediate, and secondary operation; as well as the average mortality which attends amputation in different regions of the body. Primary amputations are those done before the inflammatory process has had time to develop — generally speaking, those done within twelve hours of injury; intermediate amputations are those done during the height of the inflammatory process; and secondary amputations are those performed after its subsidence, when the operation resembles that done for disease. As a rule, the lowest mortality attends primary amputations; and though since the introduction of antiseptic methods there is less inflammatory reaction than formerly, nevertheless intermediary amputations still give the highest mortality. In the case of secondary amputation the results are not so good as they seem, many patients being too shocked for primary amputation, and dying before secondary amputation can be attempted. It has usually been taught, and it is still stated by many surgeons, Fig. 166. — End-bearing stump (aperiosteal method of Bunge). Patient bearing all his weight on the stump twenty-five days after amputation. Episcopal Hospital. 224 AMPUTATIONS that amputations tor disease are attended by a much lower death rate than those for injury. While this was perfectly true before the general adoption of antiseptic methods and modern methods of treating shock and hemorrhage, I believe the relation is now reversed. Treatment of Crushed Limbs. — The first thing to do is to control hemorrhage and combat shock. The limb should be held vertically, and an Esmarch band applied as near to the crushed area as practicable; the foot of the bed should be raised, and in cases of grave anemia the other extremities should be bandaged from the periphery toward the trunk (auto-transfusion). The application of external heat, and other methods detailed at p. 184, should be employed for shock. If any vessels can be recognized in the wound they should be ligated. Amputation should be done as soon as the -patient reacts, or at once if the shock is not marked. If reaction once occurs no delay in ampu- tating should be allowed, as the improvement frequently is only fleeting, unless the mangled limb is removed. The Esmarch band should not be left in one place more than four or five hours; sometimes, on removing it, no further bleeding will occur; but usually a little ooze persists, and the band should be re-applied higher on the limb. In a few hours its position should again be shifted (applying a second before removing the first, if necessary), since in this way it is possible to keep the bleeding checked without endangering the vitality of the parts above the wound. If the patient does not react, or if, in spite of the skilful application of the Esmarch band, oozing of blood persists, and seems to prolong shock, the surgeon must consider whether the mere presence of the mangled extremity is not detrimental, and whether by resorting to amputation at once he will not obviate the tendency to death better than by delay. These are the cases which suffer from true toxemic shock (p. 181). In such cases delay is fatal with extremely few excep- tions; but by prompt operation, even under desperate circumstances, a life is occasionally saved. SPECIAL AMPUTATIONS. Amputations of the Hand. — Though removal of a portion of the hand is required frequently, the surgeon should exercise the utmost conservatism; no artificial contrivance can be as useful as the human hand, and though amputation of a portion of it is often a less tedious and more brillant operation than partial excision and careful suture, yet judicious attempts at the latter are not seldom attended by gratifying results (Figs. 120 and 121). Amputation of the Fingers. — No tourniquet is required, and local anesthesia usually is sufficient. This is secured by injections at four points around the base of the finger, blocking the digital nerves. It is best to remove the fingers at a joint, but amputation is fre- quently done through the proximal or middle phalanx of the index and fifth fingers; this is then divided with a small saw or cutting SPECIAL AMPUTATIONS 225 forceps. The middle and ring fingers are of comparatively little use, unless part of the middle phalanx is retained (Fig. 167); hence it is better to amputate at the metacarpal joint than to save only part of the proximal phalanx, unless the tendons can be sutured to each other over the end of the stump. The position of the joints Fig. 167. — Tendinous insertions in the middle finger: a, deep flexor; 6, superficial flexor; c, extensor; d, lumbrical; c, extensor carpi radialis brevior. Note the uselessness of the proximal phalanx (2), unless the insertion of the superficial flexor tendon is retained in the middle phalanx (3), or unless b is sutured to c over the end of 2. (After Waring.) must be borne in mind (Fig. 168), the usual error being to expect to find them too high. In amputation by the racket-shaped incision (Fig. 169), the first incision, on the dorsum, opens the joint, and as the finger is sharply flexed the lateral ligaments are divided, and the palmar flap is formed by passing the narrow-bladed knife between the ends of the bones and cutting from within outward. It is easier / p^ £ to preserve the tendons if a short extensor and long flexor flap are employed. The digital arteries are ligated, the flexor and extensor tendons sutured to each other by buried sutures; and the stump Fig. 168. — The finger-joints. Fig. 169. — Amputation of the fingers by the racket-shaped incision and by antero- posterior flaps. is closed by bringing up the palmar flap and suturing it transversely. This is known as the "poor man's amputation" because the scar is carried away from the palmar surface and the stump is covered with the tough palmar skin. If the palmar surface is destroyed by disease or injury, a dorsal flap may be used ("rich man's amputation"). Two lateral flaps are sometimes employed. 15 226 AMPUTATIONS In amputation at the metacarpo-phalangeal joints the racket method is to be preferred; in the case of the index and fifth fingers, the handle of the racket is placed on the radial and ulnar borders of the joint, instead of on the dorsum. The head of the metacarpal bone of the two middle fingers sometimes is removed for cosmetic reasons. Am- putation of the thumb is done by making a palmar flap whenever pos- Fig. 170. — Partial amputation of right hand for crush. Everything but the thumb removed. Episcopal Hospital. sible. Amputations through the metacarpal bones are done by antero- posterior flaps, saving as much of the palm as possible, and making the necessary incisions on the back of the hand. Owing to the variety and irregularity of the injuries to the soft parts and bones in such cases, each one is a rule to itself, and the surgeon must exercise his ingenuity in saving whatever may prove useful, and securing skin flaps in any way possible (Fig. 170). Fiu. 171. — Anterior-posterior skin flaps, two inches below elbow. Episcopal Hospital. Amputations through the Wrist-joint are seldom employed; a long palmar flap should be cut, and the triangular cartilage should be retained, so as to aid in the preservation of rotation. Amputations of the Forearm. — In the lower half of the forearm I think the circular method is the best form of amputation, while below the elbow the modified circular, with antero-posterior skin flaps is quite satisfactory (Fig. 171). Some surgeons employ Teale's method above the wrist: in this two rectangular flaps are formed, the width of each being half the circumference of the limb ; the longer flap (formed from the flexor surface) is exactly square, while the shorter flap is only one-fourth as long (Fig. 172). SPECIAL AMPUTATIONS 227 Amputation at the Elbow. — This may be done by the oval method, taking a long skin flap from the thick skin covering the upper part of the ulna; or by antero-posterior flaps, the anterior being longer and including the muscular masses arising from the condyles as well as the brachialis anticus. The joint is entered just above the head of the radius. Amputation through the Arm. — The circular method is suitable for any level up to the insertion of the deltoid; above this point lateral flaps are to be preferred. Injury by the saw to the musculo-spiral nerve is to be avoided in amputations of the middle third; and the incisions in the upper third should respect the circumflex nerve as it enters the posterior surface of the deltoid. In cases of high ampu- tation of the arm the tourniquet is applied with the screw over the acromion and a large pad in the axilla over the vessels which are thus compressed against the head of the humerus as the arm is well abducted; or the bloodless method of Wyeth for amputation at the shoulder-joint may be adopted. Fig. 172. — Teale's method of amputation. Amputation at the Shoulder- joint. — (Morand, before 1715.) Hemos- tasis is best secured by Wyeth's method (1889) : two long steel pins are used, one entering in front of the acromion and travers- ing the anterior axillary fold, to emerge close to the chest; while the other passes from behind the acromion to the border of the posterior axillary fold, also close to the chest. The points of these pins should be guarded by sterile corks. An Esmarch band is then wrapped tightly three or four times around the shoulder, passing from above the acromion around the armpit between the pins and the chest (Fig. 173). This band is effectually pre- vented from slipping down by the steel pins, and the surgeon can form his flaps in any fashion below them. If these pins are not available, the surgeon may have the subclavian artery compressed; or, which is better, may cut down in the axilla and do a preliminary ligation of the axillary artery in its third portion. The only form of amputation habitually practised at the shoulder- joint is the racket method, though it has many modifications, known by various names. The operation of Larrey (1817), (external racket method), is now very seldom employed (Fig. 174). In Spence's ampu- tation (1807), (anterior racket method) the incision begins midway 228 AMPUTATIONS between the acromion and the coracoid, where the point of an oval is formed, then passes down nearly to the insertion of the deltoid, and there encircles the arm transversely (Fig. 175). Dupuytren's ampu- Fig. 173. — Wyeth's pins applied for amputation at the shoulder. Fig. 174. — Incisions for amputation at the shoulder by Larrey's method (external racket). tation (1812), by a large deltoid flap, originally was performed by transfixion: the knife entered at the front, just within the acromion, and its point emerged behind at the level of the spine of the scapula; the flap extended down almost to the insertion of the deltoid. After dis- Fig. 175. — Incisions for amputation at the shoulder by Spence's method (ante- rior racket). Fig. 176. — Incisions for amputation at the shoulder by Dupuytren's method (external flap). articulation a short internal flap was cut from within outward (Fig. 176) . A form of amputation midway between these two extremes (Spence and Dupuytren) may be termed the lateral flap method, the internal SPECIAL AMPUTATIONS 229 flap being very short, and the external being formed by an incision beginning as in Dupuytren's and Spence's methods, but not extending so high posteriorly as the former. Lateral Flap Method. — The knife is entered between the eoracoid and acromion processes, and cutting through all the tissues down to the muscle is carried downward in a broad sweep, nearly to the insertion of the deltoid, and up again as far as the posterior axillary fold. The flap thus marked out is deepened to the bone, and raised so as to expose the tuberosities of the humerus. With the arm of the patient held close against his chest, and rotated out as far as it will go, the point of the amputating knife opens the capsule by following the long tendon of the biceps into the joint, and then detaches the subscapularis, attached to the lesser tuberosity, and severs the long head of the bi- ceps. The arm is then forcibly rotated inward, and the muscles attached to the greater tuber- osity are severed. The head of the bone then drops from the glenoid cavity, and may be fur- ther freed by cutting the mus- cles attached to the bicipital groove. The amputating knife is then passed across the joint between the upper end of the humerus and the axilla, and the axillary tissues are cut from within outward. After ligating the vessels the Esmarch band and the pins are removed, the muscles of the two flaps are sutured to each other, and the skin closed, with provision for drainage from the two ends of the incision. This form of amputation may be very quickly performed, and it leaves a very excellent stump (Fig. 177). Its advantages are (1) the first incision is the same as that used for excision of the shoulder- joint, and permits inspection of the parts before the amputation is performed; (2) the posterior circumflex artery and circumflex nerve are not divided, if the knife is kept close to the bone in detaching the deltoid flap; (3) either the external or internal flap may be re- trenched at the expense of the other, in case of injury or disease invading one; (4) in emergencies the entire operation, up to the division of the inner flap, may be completed almost bloodlessly without the use of a tourniquet; and the main vessels can readily be controlled by the fingers of an assistant before the inner flap is severed; or the third portion of the axillary artery may be ligated through the first incision, before raising the external flap or dis- articulating; finally (5) it is more nearly universally applicable than any other method of shoulder- joint amputation. Fig. 177. — Stump resulting from latera flap method of shoulder amputation (modi- fied Dupuytren's). Episcopal Hospital. 230 AMPUTATIONS Amputation above the Shoulder. — The interscaputo-thoradc ampu- tation (Berger's operation, 1SS7) comprising removal of the entire upper extremity, is employed usually for disease, especially sarcomas of the shoulder or scapula, though it is occa- sionally required for injury. The oper- ation is best performed by opening the sterno-clavicular joint, raising the clavi- cle (Le Conte, 1899), and detaching the pectoralis minor from the coracoid; then the subclavian artery and vein are doubly ligated outside of the scalenus anticus, and divided; the brachial plexus is next cut; the transversus colli and supra- scapular arteries are ligated and divided, and finally the scapula is dissected away from the chest. The incisions used are shown in Fig. 178. Berger (1905) col- lected ninety-four cases of this operation, with eight deaths, a mortality of 8.5 per cent.; in the twenty-five cases in which the tumor originated in the scapula there were five deaths, and only three deaths among the sixty-nine cases of sarcoma of the humerus. Amputations of the Foot. — The yhalanges may be amputated by an oval incision, with a plantar flap; or, preferably, by antero- posterior flaps. The heads of the metatarsal bones should be retained whenever possible, as they afford great support in walk- Fig. 17S. — Incisions for intersca pulo-thoracic amputation. Fig. 179. — The tarsal joints: A, astragalus; Ca, calcaneum; S, scaphoid; C, cuboid; 1, 2, 3, cuneiform bones. Note the irregularity of Lisfranc's joint (between the tarsus and metatarsus). Chopart's joint is between the astragalus and calcaneum posteriorly, and the scaphoid and cuboid anteriorly. The subastragalar joint includes the astragalo- scaphoid joint as well as the astragalo-calcanean. ing. A single metatarsal bone, with its annexed digit, may be removed by a dorsal incision. Amputations through the metatarsal bones are sometimes performed for gangrene following frost-bite; a long plantar and short dorsal flap are used. Amputation at the tarso- metatarsal joint (Lisfranc, 1815) is difficult to perform, and is seldom employed (Fig. 179). To avoid the difficulties of dis- articulation Hey (1799) sawed off the projecting internal cuneiform, while Skey (1850) removed the base of the second metatarsal by SPECIAL AMPUTATIONS 231 cutting forceps. It is better to saw through the foot at any level required by the length of available skin flaps (Hancock). Ampu- tation at the medio-tarsal joint (Chopart, 1792) is performed thus: a transverse incision, convex forward, is made across the dorsum of the foot, from a point midway between the external malleolus and the tuberosity of the fifth metatarsal, to a point half an inch behind the tubercle of the scaphoid; the plantar flap extends from the same points as far forward as the line of the metatarso-phalangeal joints. The usual error is to make this flap too short. By for- cing the foot downward, after making the dorsal flap, the joint between the calcaneum and cuboid is easily opened on the outer side; and the disarticulation is completed by pass- ing between the astragalus and scaphoid. Though the scaphoid has repeatedly been left, unintentionally, it has not interfered with the result. The tibialis anticus tendon should be sutured over the end of the stump to the plantar tissues. Careful dressing and after-treatment are required to keep the calf muscles from drawing the cicatrix on to the sole of the foot. The patient walks with the ankle-joint in slight plantar flexion (Fig. 180). Amputation at the Ankle-joint (Syme, 1843), including removal of the malleoli, is performed by making a heel flap by cutting across the sole from one malleolus to the other. Subastragalar amputation (Textor, 1841) retains the motions of the ankle-joint, and greater length of limb. Pirogoff's Amputation (1854). — In this operation all the foot is removed, except the posterior part of the calcaneum, which, still attached to the tendo Achillis and covered by the tissues of the heel, is brought up and applied to the sawn surfaces of the tibia and fibula (Fig. 181). The plantar flap is formed by cutting across the sole from just in front of the external malleolus to just below the internal malleolus; the dorsal flap is slightly convex forward across the front of the ankle-joint (Fig. 182). The malleoli are cleared, carefully pre- serving the calcaneal branches of the posterior tibial artery, and the leg bones are sawed just above the articular surface. The calcis is sawed obliquely from above downward and forward. This amputa- tion preserves almost the normal length of the extremity (lost in Syme's amputation), but is difficult to perform, and makes a less useful stump than Chopart's. None of these foot amputations are in very good repute in this country, where both patient and surgeon usually prefer amputation Fig. 180.— Stump thirty- two years after Chopart amputation (in 1877) by the late Prof. Ashhurst. Episcopal Hospital. 232 AMPUTATIONS about the middle of the leg, since a better prosthesis is available. The English think highly of Syme's, and the French of Chopart's amputation; my own experience inclines me to prefer Chopart's to any amputation of the foot posterior to one through the metatarsals; rather than do a Pirogoff or Syme, I would amputate the leg. Amputation of the Leg. — In the lower third of the leg, antero-pos- terior flaps are to be preferred. Teale's method (1858) produces an excellent stump (Fig. 172). In the middle and upper leg the lat- eral flap method of Sedillot (1840) as modified by J. Ashhurst, Jr. (1889), is better: The knife is entered on the inner side of the spine of the tibia, and passes down- ward for about three inches, then curves backward, outlining a long flap and terminates diametrically opposite the point of beginning; a Fig. 181. — Skiagraph of stump of Piro- goff operation. (Case of Dr. H. C. Deaver.) Episcopal Hospital. Fig. 182. — Skin incision for Syme's and Pirogoff 's amputations. short internal flap is then formed (Fig. 183). The cicatrix is carried to the inner side of the stump, and the outer flap covers the spine of the tibia (Fig. 184). If the skin on the front of the leg is deficient, a long posterior flap may be used (Henry Lee, 1865), preferably includ- ing only the gastrocnemius muscle (J. Ashhurst, Jr., 1881). Amputation at the Knee. — A distinction is made between amputa- tions at the knee-joint, which are pure disarticulations, and ampu- tations at the knee, in which a section is removed from the femoral condyles. Amputations at the knee-joint are prone to infection, and leave a bulky stump, difficult to fit with an artificial limb. Two methods are in use, a long anterior flap method, and a lateral flap method; the latter is more applicable to disarticulations, when the cicatrix falls between the condyles (Stephen Smith, 1870). But the anterior flap method is. better even in such cases. If the patella is retained its articular surface may be removed by a saw, and applied SPECIAL AMPUTATIONS 233 to the sawn surface of the femoral condyles (transcondylar ampu- tation of Gritti, 1857); or to that of the femoral shaft {supracondylar amputation of Stokes, 1870) (Fig. 185). Fig. 184. — Stump of leg eight weeks after amputation by Ashhurst's modifica- tion of Sedillot's method. Episcopal Hospital. Fig. 183. — Amputation of leg by long external and short internal flaps. (J. Ashhurst, Jr.'s method.) Fig. 185. — Stokes' osteoplastic supra- condylar knee amputation, patella utilized : shaded parts are those brought in apposi- tion. (Farabeuf.) Amputation of the Thigh. — The circular, modified circular, and flap methods all produce an excellent stump in the thigh. The circular is best whenever there is a choice. If flaps are used, the posterior should be cut sufficiently long. The greater retraction of muscles in the posterior flap carries the cicatrix away from the face of the stump (Fig. 186). Amputation at the Hip-joint (H. Thomson before 1777). — Hemo- stasis is secured by Wyeth's method (1890): Two steel pins are used, each T 3 g- of an inch in diameter, and ten inches long; one pin is introduced close to the spine of the pubis, and after traversing the adductor tendons emerges just below the tuberosity of the ischium; the other pin enters below and within the anterior superior spine of the ilium, traverses the gluteal muscles for about 8 cm., and emerges 234 AMPUTATIONS well above the level of the great trochanter; the points of the pins are immediately shielded by corks. A compress of gauze, two inches thick and four inches square, is laid over the femoral vessels at the brim of the pelvis, and an Esmarch hand is wrapped very tightly two or three times around the hip between the steel pins and the pelvis (Fig. 1ST). B "y^^Hi^ Fig. 1S6. — Amputation of right thigh (anterior-posterior flaps). Episcopal Hospital. Fig. 187. — Wyeth's pins, and Esmarch band, for hemostasis during amputation at the hip-joint. Antero-posterior Flap Method (Guthrie, 1815). — The flaps are cut from without inward, 1 with a moderately short knife; the posterior is formed first, the incision commencing above the trochanter, and crossing the back of the thigh in a curved line convex downward, to a point in front of the tuber ischii; the anterior flap is then outlined, extending at least five inches below the joint (Fig. 188). These flaps being dissected up and the joint exposed, it is opened in front, the femur being forcibly abducted and hyper-extended, bringing the ligamentum teres into view; when this has been cut and the remainder of the capsule divided, any fibers on the back of the joint are severed, and the limb removed. In cases where Wyeth's method of hemostasis is not available, and where Momburg's method (p. 235) is not employed, the sur- geon may adopt either preliminary ligation of the femoral vessels, by an anterior racket incision (Larrey, 1817), opening the joint from the front and dividing the remaining tissues posteriorly from within outward; 2 or he may adopt DiefTenbach's method (1827), consisting of circular amputation of the thigh followed by excision of the head of the femur through an outer longitudinal incision; or following Brashear's (1806) and Fourneaux-Jordan's (1879) method 1 Guthrie cut them by transfixion. 2 This is the "extirpation method" of Kocher, permitting careful dissection of malignant disease, and clamping and ligating every vessel as it is cut. It was used habitually by Verneuil (1877) in all large amputations. SPECIAL AMPUTATIONS 235 as modified by Senn (1893) may first disarticulate through an external incision and then, puncturing the tissues on the inner side of the thigh, introduce a double elastic tube, and compress in this way the tissues of both anterior and posterior flaps before removing the limb. Compression by a forceps tourniquet, somewhat like the forceps used for intestinal anastomosis, may also be employed (Lynn Thomas, 1898). The mortality of hip-joint amputation is now about 8 per cent, in disease, and 16 per cent, in traumatic cases (Wyeth, 1910), this vast improvement in the results being due chiefly to improve- ments in methods of hemostasis. Fig. 188. — Incisions for amputation at the hip-joint by antero-posterior flaps. (Guthrie's method.) Fig. 189. — Incision for interilio-abdominal amputation. (Babcock.) Interilio-abdominal Amputation (Billroth, 1885). — The incisions used by Babcock (1918) are shown in Fig. 189. The horizontal and descending rami of the pubes are divided, and the ilium is sawed through just in front of the sacro-iliac joint, the entire intervening portion of the pelvis being removed. Pringle (1916) has collected 43 cases, with a death-rate of 58 per cent. He has done 5 such operations himself, only 1 patient dying (shock) ; he prefers to clamp and cut the vessels as they are encountered. Pagenstecher (1909) and Bier have used successfully Momburg's method of hemostasis (1908) : This had been employed up to 1909 with success in over thirty oper- ations of various kinds. It consists in applying an Esmarch band or thick rubber tube (size of the finger) four' or five times so tightly around the waist, between costal arch and iliac crests, as to stop pulsation in both femoral arteries; the band is applied only after the patient is anesthetized, and before it is removed the patient is inverted and an elastic band applied around the base of each lower extremity, so as to prevent sudden anemia of the heart when the waist band is removed. CHAPTER IX. RE< '( INSTRUCTIVE SURGERY. The term Reconstructive, or Plastic Surgery, covers a wide range of surgical procedures designed to restore or improve the function or appearance of a part, deficient congenitally or through disease or injury. Until within a few years its field w r as limited to the skin and subcutaneous tissues (including mucous membrane), and to this department the name Plastic Surgery (anaplasty) strictly applies. But recently the formation of new joints (arthroplasty), transplanta- tion of bone, cartilage, fascia, tendon, etc., and cinematoplastic amputations have been done. These various operations may be classified as follows: 1. Anaplasty by .simple approximation as after excision of any tumor in which the wound edges can be brought together, if necessary by undermining; in the operation for hare-lip, etc. 2. Anaplasty by transfer of flaps from the immediate neighborhood, by gliding, stretching, etc., as in operations for deforming cicatrices from burns, and in the Indian method of rhinoplasty (p. 667), in muscle transplantation, etc. 3. Anaplasty by transfer of flaps from a distance: (a) By one migration, as in the Italian method of rhinoplasty (p. 668). (b) By successive migrations (method of Roux), as from the abdomen to the arm, and then from the arm to the face. 4. Anaplasty by readjustment of totally severed parts, including skin- grafting, transplantation of fascia, bones, joints, etc. SKIN-GRAFTING. This, which is the simplest form of plastic surgery, will be con- sidered first. In cases of extensive granulating areas resulting from burns or other causes, this plan often not only accelerates healing, but may be absolutely necessary to bring it about. For the grafts to "take" well it is essential that the granulating surface approach in type to that of the "healthy ulcer" (p. 53). There are three principal methods of skin-grafting, known by the names of Reverdin (1869), Thiersch (1874), and Wolfe (1875) or Krause (1893). In all of these methods the granulating surfaces must first be prepared for the reception of the grafts. If the surface is suppurating, it is useless to attempt grafting. When it has been rendered aseptic and there is no discharge, the area is ready for grafting. Needless to say syphilitic, malignant or other ulcerating surfaces are not suitable for (236) SKIN-GRAFTING 237 skin-grafting, nor is any surface which must bear weight, such as the end of an amputation stump. Boykin (1916) reports success from prepara ion for two days with dressings kept constantly moist with warm sodium bicarbonate solution (2 per cent.). The best sites from which to obtain grafts are the adductor surfaces of the thighs, the inner surfaces of the arms, and the lateral abdominal and thoracic walls; hairy skin is not suitable for grafting, as apart from the deformity which might result from reproduction of the hair, it is difficult to sterilize, and less apt to grow successfully than more delicately formed skin. The region from which the grafts are taken also must be prepared as for an aseptic operation. Antiseptic methods are not successful. Whenever possible autografts (from the patient's own body) should be employed. Homografts (from another's body) are much less likely to grow, and should be used only when the recipient is so extensively affected as to render any additional tax on his healing powers unwise. Fig. 190. — Skin-grafting by Reverdin's method, in a case of burns of leg. The white spots on the surfaces of the ulcers are islets of new-formed skin. Episcopal Hospital. Reverdin's Method. — Minute particles of the cuticle are raised on the point of a needle, cut off with a sharp scalpel, and at once trans- ferred to the granulating surface, previously prepared. As many such grafts as may be required (a score or more) are applied with the epidermic side upward, at close intervals; gently pressed down on the granulations, and held in place by covering the entire area with wide meshed paraffined gauze, over which in turn may be placed gauze moistened in saline or 2 per cent, sodium bicarbonate solution. The part is suitably splinted, and need not be dressed for four or five days, when it will be found that many of the grafts have taken, and may be recognized as minute islets of bluish-white epiderm growing in the center of the granulating area (Fig. 190). In time these islets coalesce, and a number of small granulating areas surrounded by epiderm replace the one large surface. This method is suitable when only small areas are to be covered. The donor does not require an anesthetic. Thiersch's Method. — Long strips of epiderm, with only the most superficial layer of the cutis, are cut by means of a very sharp razor, with a short rapid sawing motion, while the skin is held taut. The skin and the razor may be moistened with saline solution, to facilitate j:;s RECONSTRUCTIVE SURGERY the process. The long grafts arc then at once transfer red to the granulating surface, previously prepared, and spread in place, covering nearly its entire area (Fig. 191). Dressing is similar to that for the Reverdin method. Fig. 191. — Eight days after Thiersch grafts (from father) were applied to abdomen and groin. The white areas are the grafts. Episcopal Hospital. Thiersch grafts are more difficult to cut, require a general anesthetic, and are less apt to grow than the smaller grafts of Reverdin; but if they do grow, the healing of the ulcer is very much more rapid and the resulting scar less conspicuous. Fig. 192. — Epithelioma of temple. See Fig. 193. — Same patient nine days after Fig. 193. Episcopal Hospital. excision of epithelioma and implantation of Wolfe graft. Episcopal Hospital. Wolfe-Krause Method. — The entire thickness of the skin is trans- planted, but without any subcutaneous tissue. The graft is dis- SKIN-GRAFTING 239 sected free by an extremely sharp scalpel, and is sutured in the defect, being closely applied throughout its extent to the underlying tissue (Figs. 192 and 193). The entire operation should be dry and abso- lutely aseptic. The graft is dressed as in other methods, and should be kept constantly warm by hot water bottles. This is the best method to fill in a recently made wound, provided this may be com- pletely filled by a single graft; one with a diameter of more than 7 cm. is not apt to prove successful. For granulating surfaces Boykin's Fig. 194. -Small deep grafts ten days after application to granulating area resulting from excision of a carbuncle. Episcopal Hospital. method (1916) of Wolfe grafting is preferable; here numerous grafts are cut in the same manner as described for Reverdin's grafts, but each is from 1 to 2 cm. in diameter, and includes the entire thickness of the skin. They are placed not more than 1.5 cm. distant from each other, and are dressed as already described, being kept warm for about a week by hot water bags. Figs. 194 and 195 are from a patient in my service on whom Dr. Boykin operated. The operation may be done under local anesthesia. 240 RECONSTRUCTIVE SURGERY Fig. 195. — The same patient twenty-seven days after skin grafting. Episcopal Hospital. PLASTIC SURGERY. The form of plastic surgery most often employed is that by transfer of flaps from the immediate neighborhood. The simpler the opera- tion, the more successful it is likely to be; hence the simpler methods always should be tried first, unless manifestly inadequate. Even such operations will not succeed unless infection is absent, and unless no active disease exists in the parts on which the operation is done. Lupus and syphilitic ulcerations must be healed, and the disintegrat- ing process at a standstill before any plastic surgery is attempted. Another maxim of extreme importance in plastic surgery is to do too little rather than too much at each stage of the operation, which is often thus better divided into several sittings. Cicatricial tissue usually should be excised and not employed in plastic surgery as it is very apt to slough. This applies more particularly to the subcu- taneous tissues, cicatricial skin acting very well when freed from the underlying scars. When a defect already exists or is made by excision at the time of operation, it usually is in one of the forms shown in the annexed dia- PLASTIC SURGERY 241 grams (Fig. 196); and the various methods currently employed for closing such gaps are indicated. The special method chosen depends on the tissues available. «% f f f ¥- Y y ytk^y y f Fig. 196. — Typical plastic operations. In all plastic operations great gentleness should be used in manipu- lation; strict hemostasis by the finest catgut ligatures must be secured, and accurate, but not too tight approximation must be obtained. 16 242 RECONS TR UC TI VE S URGER Y Relaxation sutures (p. 104) often are essential. The flaps should contain a moderate amount of subeutaneous tissue, and their bases should be broad and should contain the main vascular supply; and the Haps should be made of sufficient size to allow for inevitable shrink- age, especially when cut from tissues naturally lax (neck, scrotum), as in them retraction is greatest. If the base of the flap is much twisted in adjustment, it must be divided (to restore contour) in from two to three weeks after the first stage of the operation. Fig. 197. — Ulcers resulting from exten- sive burns received three months pre- viously. Episcopal Hospital. Fig. 198. — Same patient, two months later, after complete cicatrization. Epis- copal Hospital. When a fold of cicatricial tissue exists, as in the axilla or elbow, what is known as Z-plasty is very satisfactory : the tense edge of the flap is split, and from each end of this first incision is carried another diverging at an acute angle on opposite sides of the web; the entire incision is thus Z-shaped. The two triangles thus outlined are dis- sected up, the subcutaneous scar tissue is excised, and the joint fully extended, when two lax triangular flaps will be available for covering the flexure of the joint, the upper triangle filling the distal portion of the defect, and the lower triangle the proximal portion (Figs. 197 to 205). In this way the only cicatrix left in the flexure of the joint runs transversely and cannot reform a web. When a flap is to be transferred from a distance, a site of the body PLASTIC SURGERY 243 must be selected which can be easily brought into contact with the affected region; and the skin to be transplanted should resemble as closely as possible that of the part to which it is to be transferred. In defects of the back of the hand a pocket may be made in the oppo- site side of the chest, to which the hand is sutured for a couple of weeks. For the palm of the hand the buttock of the same side has been employed, but the skin is too dissimilar to give a good cosmetic result. A flap from one shin may be easily attached to the other. Fig. 199. — Same patient as Fig. 197, one year later, after extensive plastic operations. Episcopal Hospital. Fig. 200. — Same patient one year after complete cicatrization, showing result of extensive plastic operations. Episcopal Hospital. Gillies (1918) has developed a method of transplants with tubular pedicles, by which skin areas from a considerable distance may be successfully transplanted. A large area of the skin of the forehead or neck or chest, attached at each side by long pedicles (the free margins of which are sutured to each other, converting each pedicle into a tube, thus ensuring better nutrition) may by this means be used to restore defects of the face; after the parts have united, the tubular pedicles are detached from the face, and the tubes are unfolded and restored to their original situation. The method of transferring a flap by successive migrations is very seldom employed. Unhealed cavities following operations for osteomyelitis, empyema, 211 RECONSTRUCTIVE SURGERY Fig. 201. — Fingers amputated and t luunl) useless from contractures, as result of injury by hand grenade. Walter Reed General Hospital. Fig. 202. — Same patient as Fig. 201, one month after Z-plasty for web of thumb. Can now oppose thumb to stumps of fingers. Walter Reed General Hospital. Fig. 203. — Incurvation of the penis from congenital shortness of frsenum. Episcopal Hospital. Fig. 204. — Diagram of Z-plasty for shortened frsenum. Fig. 205. — Method of suture of the flaps outlined in Fig. 204, restor- ing meatus to norma' site at apex of glans. FREE TRANSPLANTS 245 etc., may be covered in by skin flaps, derived from the immediate neighborhood or transferred from a distance. E. G. Beck (1918) has recently done much work of this kino!. Compound Flaps, containing fat, fascia, muscle or even bone, are occasionally used, the pedicle consisting only of skin and subcutaneous tissues. Or a flap may be used having only an island of skin on its surface, the pedicle consisting of subcutaneous tissue only, as in cases reported by Monks (1898) and Horsley (1915) in which defects of the face were repaired by the transfer of an island of skin from the temple, containing the temporal artery in the pedicle. Fig. 206. — Transplantation of the pectoralis maior muscle to supplant the deltoid. The origin of the muscle is detached from the clavicle and upper ribs, and with nerve supply intact is re-attached to the acromion and outer end of the clavicle. This boy was unable to execute the movement of propulsion of the shoulder before operation, but regained it after operation. Episcopal Hospital. Transfer of Muscles. — Muscles may have their origins shifted, so as to substitute other muscles which have been paralyzed or destroyed by injury. It has been shown that a muscle may be almost severed from its blood supply, yet retain its functions so long as its nerve supply is intact. Thus the origin of the pectoralis major may be divided, and the muscle may be shifted so as partially to supplant the deltoid (Fig. 206) (Hildebrand, 1905). FREE TRANSPLANTS. Argument still continues among experimental surgeons as to whether a free transplant, especially of bone, continues to live as an entity in its new site, or whether it becomes disintegrated and is replaced by permeation of surrounding tissues. It is fairly certain that free transplants of skin (skin-grafts) continue their individual existence, and not improbable that transplants of fat, fascia, tendon and carti- 24f> RECONSTRUCTIVE SURGERY lage do; and while it is improbable that an entire transplant of bone, unless very minute, continues to live as a whole, it is highly probable if not certain that portions of it live, and that for this reason it is better tolerated than foreign substances. Therefore an auto-trans- plant, even of bone, is preferable to a homotransplant, and still more so to the use of silk for ligaments or tendons, of animal membranes for fascia, of silver or celluloid plates for cartilage or bone in skull defects, or to that of ivory pegs or ox-bone inlays in the long bones. In all operations involving free transplantation of tissue, asepsis (better than antisepsis) and strict hemostasis are necessary. The transplants should not be cut until their bed has been prepared, and when cut, should be transferred without unnecessary delay. In all except bone and some cartilage transplants, which usually may be wedged into position, or retained by suturing an overlying layer of fascia, it is well to fix the transplant in place with buried catgut sutures. No drainage should be employed. Fat. — Fat is admirably adapted for transplantation; it is obtained from the buttocks when coarse fat is desired, or from the flexor sur- faces of the upper limb or from around the tendon of Achilles when fat of finer texture is needed. The former serves merely to fill in hollows for cosmetic purposes, while the finer texture is better for preventing injurious adhesions. For the latter purpose it has largely superseded the use of Cargile membrane. Transplants of fat should be cut about one-third larger than the size actually needed, as they shrink when cut, and may grow smaller during the process of repair. A slight discharge of disintegrated fat, which sometimes occurs between the sutures does not necessarily mean than the entire transplant is sloughing; and even when a considerable amount is discharged the result may be satisfactory. Tendons.- — Transfer of the insertion of tendons, the tendons them- selves remaining attached to their respective muscles, is discussed sufficiently in connection w 7 ith infantile paralysis (p. 568). Here attention is called to the substitution of tendons destroyed by slough- ing or otherwise by the total transplantation of portions of other tendons. For instance the tendon of the palmaris longus, which is not of much use, has been excised and inserted in the finger, being sutured at the proximal end to the stump of the lost tendon in the palm, and at the distal end attached to bone. As it is difficult to construct vincula to hold the tendon in contact with the phalanges, Lexer (1914) adopted the expedient of having the patient wear a ring on the affected finger, which prevents the new tendon from pulling aw>ay from the phalanges during attempts at flexion. Fascia. — Fascia, usually obtained from the fascia lata, may be used for many purposes: (1) Cut into strips and doubled, it becomes strong enough to act as a tendon or ligament. (2) Rolled into a tube it has been used to surround nerve and tendon anastomoses in the expectation (which has not always been fulfilled) that its presence would prevent development of injurious adhesions; its use for this purpose FREE TRANSPLANTS 247 has been abandoned by many surgeons, who find free transplants of fat more satisfactory. (3) As an insertion after an economical resec- tion of joints, to prevent reunion; it is questionable whether this is as apt to be successful as the use of pedunculated flaps (see Arthro- plasty, p. 252). (4) As an insertion between the skin and brain, to replace the dura in cases of adherent cicatrices, in an effort to obviate symptoms considered due to the superficial scar. Fig. 207. — Dental engine and circular saw used in operations for bone transplantation. Orthopaedic Hospital. Cartilage. — Cartilage, usually costal in origin (sixth to eighth ribs), has been used to form a bridge for the nose, to fill defects in the skull, to bridge gaps in the mandible, etc About two-thirds of the thickness of the costal cartilage is included in the transplant. It has the advan- tage over bone that it is more easily cut and shaped, and that it appears to endure indefinitely in its new site as cartilage even when not attached to other cartilage or bone (J. Staige Davis, 1917). When 248 RE( 'ONSTRUCTIVE SI ' RGERY used for filling a skull defect too large to be covered by one piece, the cartilage is applied in strips, each of which must be in contact with the freshened skull edges at both ends. "Since the grafts take on a pounded shape with the convexity toward the cut surface, the smooth perichondria! side is placed next the brain" (Wilson, L919). Bone.— Bone is the most widely used of all free transplants, the usual source being the subcuta- neous surface of the tibia. Its main uses arc: 1. For defects of the long bones, due to their congenital absence or to their operative removal (Figs. 208 to 213). Fig. 208. — Six weeks after excision of metacarpal shaft for necrosis following lacerated wound from human teeth. Episcopal Hospital. Fig. 209. — Same patient as in Fig. 208, three weeks after bone transplantation. Normal length of finger, restored. Epis- copal Hospital. 2. For ununited fractures, thetransplant bridging the gap, large or small, and acting as an osteoinductive tract promoting bonv union (p. 354). _ 3. For immobilization of the spine in eases of tuberculosis, according to Albee's method (p. 659). For the operation of transplanting bone the use of a motor-driven circular saw is almost indispensable. Many types are on the market, that of Albee being most popular; in this, as in certain other types, the motor is held in the hands, and the saw is attached directly to a short shaft. Personally I have always employed a dental engine, FREE TRANSPLANTS 249 which obviates the necessity of holding the heavy motor in the hands, as the power is transmitted by a cord and pulleys to a light shaft which is readily controlled by the surgeon (Fig. 207). In cutting- slots for the reception of a transplant, as well as in outlining the transplant itself, a twin circular saw is a convenience but not a neces- sity. The surgeon first prepares the site which is to receive the bone. If the transplant is to be used to span a gap in a long bone, it may be placed as an inlay in slots cut in each fragment to receive it, or as is less often done, it mav be driven into the medullary canal of Fig. 210. — Myeloma of radius before operation. Duration one year. See Figs. 63 and 211. Orthopaedic Hospital. each fragment as a peg. Usually when the latter plan is adopted the medulla must be reamed out to receive the bone peg. In opera- tion for ununited fracture of the hip, it is convenient to ream out a hole through the neck and head from the outer surface of the femur below the trochanter (Fig. 343). If the defect is not very great it may be possible to cut the transplant from another portion of the same bone, as in Buchanan's original method (1912), which Albee terms the sliding inlay (Fig. 340). If it is considered important to have the transplant as large as the bone to which it is to become attached, it 2")0 RECONSTRUCTIVE SURGERY may be fastened end-to-end by a steel plate (Fig. 211), or it may be mortised into the medulla of the receiving bone In cutting the transplant the periosteum usually is left attached, so far as possible. I believe this is of value only when the transplant is not to be embedded in bone; if it is used as an intramedullary peg, or if buried in bone as when inserted in the spinous processes of the vertebra? in cases of Pott's disease (p. 059), retention of the perios- teum is a detriment, hindering rather than promoting permeation of the transplant by the surrounding bone cells. If, however, the transplant is to span a gap (Figs. 211 and 212), and is exposed to the action of for- eign connective-tissue cells, it is well to leave the periosteum intact, to act as a limiting membrane and protect the trans- planted bone from absorption. There is much contradictory experimental evidence on the role of the periosteum in bone growth, but from clinical experience the advice above seems to be just. 1 After trans- plantation, bone will become hypertrophied to meet the requirements of its new duties; disuse causes it to atrophy. In removing bone from the tibia, the subcutaneous surface is exposed by a curved incision, turning aside a flap so that the skin scar will not fall directly over the bone defect. The transplant is cut from the antero-internal face of the tibia, leaving the crest intact, as on this the strength of the tibia largely depends, and fractures have occurred in some cases during con- valescence where it has been sacrificed. If the saw is made to sink at once into the medulla, enough bleeding will occur to keep the bone moist, and there will be little danger of the heat generated by the saw injuring the bone. The transplant being outlined by the saw, is raised from its bed by osteotome or chisel, and at once transferred to its new site. During any delay it should be wrapped in dry sterile gauze; putting it into saline solution may wash away some of the bone cells. Both wounds are closed without drainage, 1 Oilier (1867) taught that periosteum was the chief factor in new bone forma- tion, especially its deep or cambium layer. Experiments by Axhausen (1907-1911) and others supported this view. Macewen (1912) held the theory that the peri- osteum was only a limiting membrane, and that bone itself was chiefly responsible for its own reproduction. But as Ely (1919) very justly points out periosteum and its cells extend into the cortex (Sharpey's fibers) while marrow cells may exist in the periosteum. Fig. 211. — Same case as Figs. 63 and 210 after bone trans- plant. Excellent function and no recurrence after five years. FREE TRANSPLAXTS 251 and the parts properly immobilized until union occurs, usually in the course of ten or twelve weeks. If the transplant must bear much weight (leg, thigh, spine), suitable apparatus should be worn for a number of months. Fig. 212. — Same patient as in Figs. 68 and 69. Spindle-cell sarcoma of periosteum of tibia, seven months after excision of tibia and implantation of fibula and transplant from other tibia (20 cm. long) into condyles of femur. Episcopal Hospital. Fig. 213. — Side new of leg shown in Fig. 212. The fibula has slipped from its socket in the external condyle, but the tibial trans- plant remains firm. Useful leg with nearly stiff knee. No recurrence three and one- half years later. Transplantation of Entire Bone Ends, with cartilage and ligaments attached has been done by Lexer (1908) and others, from amputated limbs or cadavers, implanting them into the space left by excision of the diseased bone (chiefly tibia or femur at knee). Though fair function was obtained at least for a time in some cases, one patient 252 R /••'' VNS TR rem 7<: S I ' RGE R Y became melancholy from the consideration of the fact that he was host to a dead man's knee, and subsequently demanded to have his thigh amputated. Transplantation of Entire Bones, as the astragalus to form a new head for the femur (Roberts, 1912), has also been practised in a few cases. ARTHROPLASTY. This is an operation designed to substitute a joint which is stiff by one which is movable but stable, with the minimum amount of bone resection, by interposition between the bone ends of pedicled flaps of fat, fascia or muscle. Free transplants of fascia lata may be used when flaps cannot be obtained from the neighborhood. But it seems advantageous to have the flaps thicker than fascia alone. Baer (1909) uses a prepared animal membrane (pig's bladder). Murphy (1904) did much to systematize the technique. It may prove a difficult operation, requires special training and experience in joint surgery, and is not always successful. At the shoulder and elbow-joints it is not much preferable to typical excision, since great stability is not required; at the hip and knee where stability is important, the result of an arthroplasty may be more disabling than an absolutely stiff joint. At the wrist and ankle it has seldom been employed. In exceptional cases it is of utility in the finger-joints, though many patients will prefer amputation. But in any strong and healthy patient its merits deserve serious consideration, especially in those with ankylosis in bad position, or with more than one joint ankylosed (Fig. 221). Its best field is in cases of bony ankylosis following metastatic arth- ritis (p. 515) where little bone destruction has occurred, since in these the original form of the joint may be largely restored. Its use in cases of tuberculous ankylosis, which is never very firm (unless at the knee, following excision), is not yet on a solid foundation; and in my opinion is not to be recommended. Nor should it be employed in any other case where the disease is still active or has only recently become quiescent. A period of several months at least should elapse after a bacterial infection of the joint, and if the infection is known to have been streptococcic (as in a case of gunshot fracture) a longer period still is required. Nor is the operation suitable for cases of fibrous ankylosis seen in joint dystrophies. In performing the operation, exposure of the joint should be free, important ligaments should be preserved, and the flaps (of ample size) should have their pedicles close to the joint and of sufficient thickness to ensure their vitality. It is best, when possible, to complete the resection of the bones before cutting the flaps. The latter are attached by catgut sutures in their new situation, and what remains of the joint capsule is sutured around them. Hemostasis should be com- plete, and no drainage should be used. The limb is put up in the most stable position, with sufficient traction to prevent pressure on the flaps, and the joint is kept quiet until the soft parts have healed, ARTHROPLASTY 253 when active motion is encouraged, and passive movements, within the range of painlessness, are daily employed. Long and persistent after-treatment with gymnastics, massage, etc., usually is necessary to secure the full benefit from the operation. Arthroplasty of Temporo-mandibular Joint. — See p. 709. Arthroplasty of the Shoulder. — The joint is exposed by a curved incision around the acromion from coracoid process to the spine of the scapula (Senn, 1901); the acromion is cut through at its base with osteotome (Kocher, 1894), guarding the suprascapular artery and nerve (Fig. 214); the acromion with attached deltoid is then turned down exposing the shoulder-joint which is economically resected, by gouge and gouge forceps, until free motion is secured. A flap of fascia and muscle is then detached from the deep surface of the del- toid, from the coracobrachialis or short head of the biceps, or even from the pectoralis minor. The arm is put up in abduction and slight external rotation. Fig. 214. — Arthroplasty of the Shoulder. Spine of scapula exposed and retractor passed under base of acromion. Arthroplasty of the Elbow. — An incision along the external supra-con- dylar ridge exposes the external condyle, which is detached, and turned down (Fig. 215), carrying with it the external lateral ligament and origin of the supinator and extensor muscles. The union between ulna and humerus having been divided, the forearm is strongly adducted around the internal lateral ligament as a hinge, thoroughly expos- ing the bone ends (Fig. 216); these are then shaped, enough bone being removed to leave at least 2 cm. interval when the elbow is extended under moderate traction. A flap is then cut from the dorsal surface of the triceps, with pedicle near the olecranon, is turned across the humerus and is stitched in place. The elbow is then reduced, and the external condyle reattached by sutures or screw (Ashhurst, 1915). Arthroplasty of the Wrist. — Through a long dorsal incision between the tendon of the extensor indicis and the extensor pollicis longus, enough bone is gouged out to allow very free motion, and a free transplant of fat or fascia lata is inserted. 254 UFA 'ONSTRUCTI VE SURGER Y Arthroplasty of the Fingers. — Lateral incisions should be used, and free fat transplants inserted (Payr, 1914). Fig. 215. — Elbow exposed for arthro- plasty. Fig. 216. — Joint luxated around internal lateral ligament as a hinge. Arthroplasty of the Hip. — A curved incision passes from the anterior superior spine of the ilium, down below the great trochanter, and up posteriorly in the direction of the fibers of the gluteus maximus; and Fig. 217. — Reaming the acetabulum in the arthroplasty of the hip. the flap thus outlined, including the facia lata, is turned upward. The great trochanter is cut off by osteotome, carrying with it the attachment of the gluteus medius (Oilier, 1879). The capsule of ARTHROPLASTY 255 the joint is incised along its upper border, and the Y-ligament is detached from the anterior intertrochanteric line, the flap of capsule thus made being turned in and down. With large gouge the femur is cut from the pelvis, and is luxated anteriorly by external rotation and adduction of the limb, exposing the acetabulum, which is deep- ened with gouge. The head of the femur and its socket may be rounded off with Murphy's end-mill and reamer (Fig. 217). A flap of fascia lata and fat is then dissected off, the skin flap turned up at the beginning of the operation, the pedicle of the fascia being well pos- terior; the flap is inserted across the acetabulum, and properly fixed by sutures. Next the head of the femur is replaced against the flap, and the capsule sutured over it. Then the great trochanter, with attached gluteus medius is brought down, anterior to the pedicle of the fascia flap, and is held in place with sutures or screws. Finally the skin flap is replaced, and weight extension (15 to 20 pounds) applied. Fig. 218 Fig. 219 Fig. 220 Figs. 218, 219 and 220. — Result of arthroplasty of hip for bony ankylosis. Orthopsedic Hospital. Arthroplasty of the Knee. — Two long lateral incisions (15 to 20 cm.) are employed, converging below in the region of the tibial tubercle, where they are about 4 cm. apart, while their upper ends are about 10 or 12 cm. apart. Open the joint on each side of the patella, chisel the latter free from the femur, and remove most of its under surface, leaving little more than its anterior fibrous surface. Then divide the femur from the tibia, luxating the patella first to one side and then to the other until the knee can be fully flexed, and the bone ends properly shaped. Cut an intercondylar groove in the femur both on its end and its extensor surface, and remodel a spine on the end of the tibia. Cut one long flap on the outer side from the fascia lata 256 RK( 'OSSTRVCTl VE SURGERY and muscle above the external condyle; or two short flaps, one from each side may he used. Turn the flap across the femoral condyles and attach it by sutures. Next fold around the under surface of the patella the lateral expansions of the quadriceps tendon and attach them to each other by sutures (G. (i. Davis), or if the extensor apparatus is too long, owing to excision of the joint, the patella may be rotated on its long axis, bringing the upper surface of the patella against the condyles (Murphy). The soft parts are then closed and weight extension (10 to 15 pounds) applied. Arthroplasty of the Ankle. — Make an ante- rior transverse incision through the skin, passing between the anterior tibial artery and the tendon of the extensor longus hallu- cis to expose the joint. After this has been excised, insert a free transplant of fat and fascia lata. Fig. 221. — Bony ankylosis of elbow and knee. Orthopaedic Hospital. CINEMATOPLASTIC AMPUTATIONS. Vanghetti (1906), Ceci and other surgeons have devised and practised methods of Fig. 222. — Result of arthroplasties of elbow Fig. 223. — Same patient, showing nor- and knee, showing limits of flexion. mal extension of elbow and knee. CINEMATOPLASTIC AMPUTATIONS 257 amputating which provide for voluntary motion in the prosthesis. It is of no value in the lower extremity, and unless some satisfactory prosthesis can be invented will prove useless in the upper limb in the future as it has in the past. In cases of recent accidents the limb is amputated in the ordinary manner, 1 and when the patient has recovered his normal health the stump is reopened, and the flexor and extensor muscles are sutured to each other in the form of a loop, over the end of the bone, which is resected if too long; the loop so formed is covered on all sides by flaps of skin. When healing is complete, a stout cord is passed through this tendinous loop, and each end of the cord is attached to the mech- anism of the prosthesis. The patient can then, by drawing on this loop, flex the fingers of his artificial hand, which may be opened again by action of a spring. I have adopted this method in some cases, but so far have not found any manufacturer in this country who will furnish the desired cinematic prosthesis (Figs. 224 and 225). Fig. 224. ■ — Cinematoplastic amputation; five months after operation. Episcopal Hospital. Fig. 225. — Cinematoplastic amputation; temporary prosthesis. Episcopal Hospital. Another method, practised by Francesco (1908), is to detach the end of the bone from its diaphysis, still leaving it buried in the muscu- lar mass at the end of the stump. When healing is complete, a ring of iron is applied around the stump between the knob of bone and the diaphysis from which it has been detached. As this detached knob of bone is voluntarily movable, the ring above it can be inclined in any direction, and through attached cords transmits the movements to the prosthesis. In amputations of the forearm, where free rotation is preserved, it has been proposed to attach a ring to the surface of the stump, and 1 The guillotine amputation (p. 217) has the advantage of preserving the greatest length of limb if a reamputation is contemplated. 17 258 RECONSTRUCTIVE SURGERY connect it to the mechanism of the Hand, so that supination move- ments might close the fingers and pronation open them. In Germany, according to Primer (1918), a modification of Yang- hetti's procedure, which was introduced by Sauerbruch, has been used almost to the exclusion of the original Vanghetti method. In this a tunnel is constructed merely in a muscle belly near the end of the stnmp, and to the rod passed through this tunnel the cords moving the hand are attached. The patients seen by Druner were not satisfied with their prostheses and proposed to abandon them as soon as discharged from the hospital. Moreover, the tunnels through the muscle remained tender and irritable. CHAPTER X. SURGERY OF THE BLOOD VASCULAR SYSTEM. Hemorrhage. — This is the natural consequence of injuries which sever the walls of bloodvessels. Hemorrhage may be apparent, when it occurs in an open wound; or concealed {internal), when it takes place into one of the natural cavities of the body. Subcutaneous hemorrhage, attended by extravasation or formation of a hematoma, has been mentioned at p. 160. The signs of hemorrhage are both local and constitutional. The local signs of venous and arterial hemorrhage are different, but the constitutional signs are identical. Venous hemorrhage is characterized by the darker, bluish color of the blood; by its flowing in a steady stream, not in spurts; and in most cases of wounds of the extremities by the ease with which it is arrested simply by elevation of the part. Arterial hemorrhage occurs in rhythmic jets, and the blood usually is of a distinctly redder tinge. Constitutional Signs of Hemorrhage. — As the volume of blood within the vascular channels is rapidly lessened by hemorrhage, the heart begins automatically to pulsate more quickly. A steady rise in the pulse rate is one of the surest signs of hemorrhage. As the quantity of blood in the system decreases, faintness comes on: there is thirst, rapid and sighing respiration {air-hunger) ; the skin becomes blanched and clammy; the lips and conjunctivae are pale; the ears ring; vision fails; specks and blackness float before the eyes; restlessness and delirium come on; involuntary dejections may occur; and with one or two gasps the patient may seem dead. At this stage bleeding may cease spontaneously, owing to the diminished force of the circula- tion which permits thrombosis; but it may begin again when reaction sets in. After very severe or repeated hemorrhages, faintness is prone to recur; and the patient may be feverish and delirious for several days. Slow hemorrhage is much less serious than profuse, sudden bleeding. Patients in early adult life bear hemorrhage better than infants or the very old; and, as a rule, women bear it better than men. Hemophilia is the name given to an obscure condition affecting males almost exclusively, and seemingly transmitted from one gener- ation to another only through the female sex. It is characterized by an abnormal and inveterate tendency to hemorrhage even from the most trifling injuries. Mere scratches, the extraction of a tooth, etc., frequently have caused such persons to bleed to death. The vice appears to reside in a loss of coagulability of the blood, though (259) 200 SURGERY OF THE BLOOD VASCULAR SYSTEM it was long held that the bloodvessel walls were at fault. Blood oozes in profusion from the capillaries, and no local remedies are of much avail. The internal administration of calcium chloride may be tried; and the hypodermic injection of horse or rabbit serum, and even of diphtheria antitoxin has been used in some cases with benefit. Nolf and Kerry (1910) secured arrest of the bleeding in nine cases by a single hypodermic injection of 10 c.c. of a 5 per cent, solution of peptone in 0.5 per cent, sodium chloride solution. Hypodermoc- lysis, intravenous injections of saline solution, and even direct transfusion of blood may be tried. Plate II, Fig. 2, shows the sub- cutaneous hemorrhages which followed the insertion of needles for hypodermoclysis in a patient with hemophilia following circumci- sion; in this case recovery occurred after the direct transfusion of blood and use of diphtheria antitoxin. Yet a year later the patient was again in the ward with hemarthrosis (p. 424) following a trifling contusion of the knee. Spontaneous Arrest of Hemorrhage. — As mentioned above, bleeding sometimes ceases spontaneously. Most very small vessels cease to bleed in a few minutes. In the case of capillaries, swelling of the endothelium occludes the lumen; in larger vessels there occur in addition contraction and retraction of the vessel walls. Contraction of a divided vessel is said to be an effort to restore the blood pres- sure to normal. Retraction results from the natural elasticity of the vessel, its ends being drawn back among the tissues, and its walls curling upon themselves so as to diminish the lumen, thus favoring coagulation. Treatment of Hemorrhage. — Temporary control of hemorrhage usually can be secured by direct pressure against the bleeding point, or on the main artery of the part close above the wound, with eleva- tion of the wounded part. When possible a tourniquet or Esmarch band (p. 214) may be applied. For permanent control of hemorrhage the surgeon has many means at his command. 1. Position. — Elevation of the part has been mentioned already, and should never be neglected. It is a remedy so simple that it often is overlooked. Hold the wounded extremity up in the air until help arrives, if you can't do anything else. 2. Pressure. — Direct pressure on the wounded vessel always can be relied on to check hemorrhage. Use your finger if you have noth- ing else. A graduated compress may be held against the w T ounded vessel: this is made of pieces of gauze so cut as to form a pyramid when placed one on the other; the apex of the pyramid is placed against the wounded vessel, and the compress is held in place by a tight bandage. Hyperflexion of the elbow or knee over a compress will control bleeding below. Hemostatic forceps (Fig. 153) or other form of clamp may be applied directly to the wounded vessel, and in emergency the forceps may be left in place thirty-six to forty- eight hours. If the wound in the vessel cannot be found, com- press the main artery, when possible, at a higher point. This, and PLATE II Fig. 1. — Multiple nevi, affecting scalp, forehead, left foot, etc., in a baby aged two and one-half months. Episcopal Hospital. Fig. 2. — Hemophilia, two days after circumcision, in a boy aged eight years; show- ing subcutaneous hemorrhages; that in right thigh followed an attempt to give hypo- dermoelysis. Episcopal Hospital. TREATMENT OF HEMORRHAGE 261 elevation of the part, will arrest, temporarily, any hemorrhage. Or the wound may be packed with gauze or lint. Acupressure (Sir J. Y. Simpson, 1859) is seldom employed at present. A long and strong steel pin is passed under the vessel, occluding it against the overlying tissues, as the stem of a flower is pinned against the coat lapel; or a ligature in figure-of-eight fashion may be wound around the two ends of the pin, compressing the vessel between the pin and the intervening tissues. Forcipressure or angeiotripsy consists in occluding the bleeding vessels by powerful clamps which are removed at once; they cause a reactive inflammation which will occlude the lumen. Skene (1897) and A. J. Downes (1902) used an electro-thermic angeiotribe. 3. Heat and Cold are efficient in hemorrhage of mild degree. Cloths wrung out of very hot water (120° F.) applied to the face of an oozing wound (p. 216) usually check all capillary bleeding. Cold, in the form of ice caps, frequently is employed in gastric and intestinal hemorrhage; and often is of value in checking extravasation in the subcutaneous tissues. The actual cautery, heated to a black heat only, is very efficient when other methods are not available. 4. Styptics are seldom used except for oozing. Alcohol is not very active. Alum, tannic acid, the perchloride and persulphate of iron, etc., are more valuable, especially when applied on a graduated compress. Cocain and epinephrin are employed on mucous mem- branes. 5. Torsion. — A bleeding vessel may be caught in forceps and twisted on itself until the forceps is twisted off ("free torsion";; or, being caught higher up by one forceps, may be twisted by another ("limited torsion"). In either case the manoeuvre succeeds in ap- proximating the walls of the vessel and in arousing sufficient reaction on the part of the intima to favor permanent occlusion. Vessels of moderate size only should be treated by torsion; usually from five to six turns are sufficient. 6. Ligation. — Ligatures, like sutures, are of absorbable or non- absorbable material. Usually catgut ligatures are preferred, and for large vessels chromicized catgut is used, though some surgeons prefer silk or linen. When a ligature is applied to a vessel it constricts it concentrically, crumpling its coats more or less, and bringing intima into contact with intima; owing to the properties of this serous surface, like that of the peritoneum, pleura, etc., prolonged contact after very moderate injury is sufficient to secure firm adhesion. It is not usually necessary to draw the ligature so tight as to rupture the inner and middle coats; it is sufficient to occlude the vessel. The method of union after firm apposition of the intima is patholog- ically identical with that already described in connection with the repair of wounds as union by adhesion. The walls of the vessel, with their endothelial cells, play a more important part in the process than the contained blood; indeed, it is denied by some pathologists that the blood takes any part in the process. The formation of a clot is not a necessary phenomenon, and if infection be absent firm 262 SURGERY OF THE BLOOD VASCULAR SYSTEM occlusion of vessels will occur without any thrombosis; this renders it sale (Guyon, 1868; Wyeth, 1876), though not always expedient, to Iigate large trunks close to the origin of branches, or vice versa. Usually, however, a clot forms proximal to the ligature, and, if the vessel has been tied in its continuity (i. e., in cases where the vessel has not been divided), a smaller clot usually forms on its distal side. These clots lie rather loosely in the channel, and are gradually con- verted into fibrous connective tissue by organization (p. 30). Should such a clot extend from the point of ligation past the origin of a large branch, there might be danger of emboli being carried away from it; hence it usually is considered proper not to apply a ligature within 1 or 2 cm. of a large branch. Rules for Ligation of Wounded Arteries. — These rules are now classic in surgery, and even today admit of very few exceptions: 1 . In cases of primary hemorrhage do not Iigate the vessel unless it is actually bleeding at the time. This rule applies to primary, not to secondary hemorrhage, and should be observed because: (a) bleeding may never recur; (6) it is difficult to know which artery to tie unless the surgeon sees it bleed; and (c) search for the artery may cause unnecessary damage and lead to infection. Exceptions: (a) if the artery is seen pulsating in the wound it should be tied whether it bleeds or not: the operation is easy, harmless, and the remedy sure; (6) if the patient has to be transported a long distance or will be out of reach of a skilful surgeon, it will be proper to make a search for the vessel even if it is not bleeding nor easily found. 2. The vessel should be ligated where it bleeds and not elsewhere, no matter what the condition of the wound. Because: (a) unless the wounded vessel itself is seen, the surgeon may Iigate the wrong vessel and fail to check the bleeding; (6) ligation even of the proper vessel at a higher point will not prevent recurrence of bleeding from the distal end, nor from the proximal end if a large branch intervenes, so soon as the collateral circulation is established. There are no exceptions to this rule (Guthrie, 1815; Matas, 1909). But in certain regions (floor of the mouth, pelvis) it may be necessary to expose the bleeding point by a counter-incision, instead of through the original wound. 3. Both ends of the wounded vessel should be ligated; and if it is only partly severed a ligature should be applied each side of the wound and the artery then divided between them. Because: when collateral circulation develops bleeding from the distal end will occur even if this is not bleeding when the proximal is ligated. Exceptions: (a) when the distal end cannot be found, the wound should be packed after ligation of the proximal end; and (6) where both ends are easily found, where the injury was a clean incised w r ound, and where occlu- sion of the the vessel might cause gangrene, an attempt at circular arteriorrhaphy (p. 266) should be made. 4. Wound of a large vessel near its origin requires ligation of the wounded vessel beloiv the icound, and of the parent trunk above and TREATMENT OF HEMORRHAGE 263 below the origin of the wounded branch (Fig. 226); and wound of a main trunk near the origin of a large branch requires ligation of the wounded vessel above and below the wound and ligation of the large branch (Fig. 227). Because: in the former case the end of the bleeding vessel next the main trunk is too short to hold a ligature; and in the second case the establishment of collateral circulation will cause the branch to bleed through the wound of the main trunk unless the branch is ligated. Exception: in case of the main vessels (carotid, iliac, femoral, popliteal), occlusion of which may cause gangrene, the wound in the main trunk should be sutured, and only the collateral should be ligated. Fig. 226. — Wound of a large branch near its parent trunk requires ligation of the trunk above and below the branch as well as of the branch. Fig. 227. — Wound of a main trunk near the origin of a large branch requires ligation of the branch as well as of the trunk. Method of Ligating Arteries. — Arteries (and veins) may be ligated in continuity or at the seat of the lesion. In the latter case, the cut end is grasped with a hemostat, drawn slightly out of its sheath and the ligature applied well above the forceps. When ligation is done in continuity, an incision is made slightly oblique to the known course of the vessel, the proper muscular interspace is found, and when the sheath of the artery is exposed, it is picked up by forceps and cautiously divided by the edge of the knife cutting toward the forceps (Fig. 22S). The threaded aneurysm needle is then gently insinuated between the artery and its sheath (entering on the side where lies the most dangerous structure, usually a vein), 1 and is gradually teased around the artery, great care being exercised not to separate the sheath more extensively from the vessel than is absolutely necessary and not to include a neighboring nerve in the ligature. When the point of the aneurysm needle emerges on the opposite side of the artery, the loop of the ligature lying in the con- cavity of the needle is caught in forceps and pulled through (Fig. 228). Then the aneurysm needle is withdrawn. An assistant then feels for the pulsation of the artery or its main branches below, and the surgeon temporarily constricts the artery between the ligature and 1 Vense comites may be tied in with their artery. 261 SURGERY OF THE BLOOD VASCULAR SYSTEM his finger, determining whether he is about to tie the proper vessel by its effect on the pulse below. In the ease of anomalous high division of the brachial artery, for instance, he might be tying only one branch instead of the main trunk, as desired; and unless obliter- ation of the radial and ulnar pulse was sought for, his error might pass undis- covered at the time. Arteries of ordi- nary size are to be tied with the square knot (Fig. 116); very large arteries (innominate, iliac, femoral) or those which are atheromatous, are more safely secured by the stay knot of Ballance and Edmunds (Fig. 229). Fig. 228. — Ligation of an artery; above, the sheath is being opened ; in the centre, the ligature is being passed; below, it is being tied. Fig. 229. — The stay-knot. A, double ligature passed and each end tied separately; B, all four ends tied as if they formed one ligature. Secondary Hemorrhage. — This was defined and its causes stated at p. 186. It is apt to come from the distal stump of a vessel ligated in con- tinuity, and is frequently ushered in by slight blood-stained discharges, premonitory of the violent gush when the vessel finally gives way. Treatment. — The treatment differs in some respects from that proper for primary hemorrhage. The first rule given above does not apply, because hemorrhage having once recurred is extremely liable to do so again unless active measures are instituted. The surgeon may after the first, and must after the second bleeding adopt determined measures to prevent a return of the hemorrhage (Erich- sen, 1861), and should ligate both ends of the abounded artery in the wound, no matter what the condition of that wound, whether or not active bleeding is present when the operation is undertaken. Should re-ligation be impossible (as in vessels at the root of the neck, or in the pelvis), a graduated compress may be applied; or neighboring collaterals may be ligated, to check the return circulation {e. g., the vertebral in secondary hemorrhage after ligation of innominate.) 1 If secondary hemorrhage recurs after re-ligation in continuity, amputation should be done at the site of ligature in the lower extremity; while in the upper extremity this final step sometimes may be obviated by ligating 1 Secondary hemorrhage recurring from an amputation stump requires re-ampu- tation if ligation of the main trunk, of the limb has failed. SUBCUTANEOUS INJURIES OF BLOODVESSELS 265 the main vessel (brachial, axillary, or subclavian) at a higher point. In the lower extremity such a course would surely cause gangrene, so amputation is better. Constitutional Treatment of Hemorrhage. — This is very much the same as that for shock (p. 1S4), especially valuable being elevation of the pelvis and lower extremities, autotransfusion, intravenous saline infusion, direct transfusion of blood, and the administration of cardiac stimulants. According to Depage (1917), recovery without transfusion of blood will not occur if the number of erythrocytes has fallen below 4,000,000 in the first six hours after injury. Subcutaneous Injuries of Bloodvessels. — Injuries of either arteries or veins are attended by reactive phenomena which correspond pathologically to the inflammatory process. In cases of contusion this reaction may cause thrombosis of the blood within the vessels; but far more frequently the vessel is ruptured subcutaneously, caus- ing the formation of a hematoma (p. 160). This may be absorbed if small, but sometimes remains fluid, may become infected (through Fig. 230. — Gangrene following ligation of both ends of ruptured femoral artery and vein, in Hunter's canal. Amputation. Recovery. Episcopal Hospital. the blood-stream, from a neighboring viscus, or from the deeper skin cocci), and require opening and drainage. If a hematoma pro- gressively increases in size after its formation, it is probable that a large vessel is ruptured ; it will then be proper to open the hematoma and check the hemorrhage. A hematoma due to rupture of a large vessel may cease to grow and finally become encysted, still being in communication with the source of hemorrhage: if this was a vein, a so-called venous aneurysm is formed; if an artery, a circumscribed traumatic aneurysm. A diffused traumatic aneurysm is more frequent in the axilla or groin, where the tissues are more readily separated by the extravasated blood; the blood in such cases is more apt to become clotted, and may very seriously compromise the circulation of the limb. The semi-clotted mass should be evacuated, and the ruptured vessels ligated. Fig. 230 shows gangrene following ligation of both ends of a ruptured femoral artery and vein, due to contusion by a heavy steel plate, and accompanied by the formation of an immense diffuse traumatic aneurvsm. 266 SURGERY OF THE BLOOD VASCULAR SYSTEM Open Wounds of Bloodvessels. These may be incised, punctured, etc., or due to gunshot injury. If smaller vessels have not been divided completely by the original injury, the surgeon should cut them entirely across, and li^ate both ends. For punctured wounds of the larger veins a lateral ligature should be applied (Fig. 231); by bringing Ultima into contact with intima, firm union without thrombosis may be expected. If a large vessel, artery or vein, presents an incised wound, and obliteration of the circulation by ligature is Fig. 231. — Application of a lateral ligature for punctured wound of vein. Fig. 232. — -Circular arteriorrhaphy by Carrel's method : when the three stay sutures are pulled taut, the introduction of the sutures is much facilitated. likely to result in gangrene (as is especially the case in the popliteal, femoral, and axillary arteries), attempt should be made to suture the wound in such a way as to evert its edges, thus apposing serous surfaces. Should such a vessel, especially an artery, be completely divided, circular arteriorrhaphy should be done (Fig. 232), using a very fine round-pointed needle and No. 500 silk, soaked in sterile vaselin (Carrel, 1902). The circulation is controlled by Crile's clamps (Fig.233), Fig. 233. — Crile's clamp for temporary occlusion of bloodvessels, blades covered with rubber. applied directly to the w T ounded vessel. Even if thrombosis follows the attempt, occlusion of the artery will be so gradual that gangrene will be much less apt to ensue than after ligation. Should ligation of the main vein of a limb be necessary, the main artery should not be ligated also; to do so increases the risk of gangrene (p. 273). Gunshot and other contused wounds rarely admit of suture. Entrance of air into veins is no longer regarded as a frightful calamity, presaging immediate death. In operating at the root of OPEN WOUNDS OF BLOODVESSELS 267 the neck, where negative pressure in the veins during inspiration is most marked, air may be sucked into the circulation, and when in large quantity has, in a few instances, been productive of serious consequences. A sucking, lapping, or gurgling sound is heard, closely following a gush of blood from the wounded vein, and sometimes followed by the appearance of frothy blood in the wound. 1 Pale- ness and lividity, failure of the circulation and collapse may ensue. In operations in the "danger zone" the surgeon, if possible, should apply a compress to the region where the internal jugular and subclavian veins unite, thus causing back pressure on the main trunks above; this facilitates dissection. When the accident occurs, plug the open- ing with the finger until other means of arresting the hemorrhage can be applied. Fig. 234. — Direct arteriovenous fistula (aneurysmal varix) . Fig. 235. — Indirect arteriovenous fistula (varicose aneurysm). Arterio-venous- wounds occasionally occur from puncture, stab, or gunshot injury involving both artery and vein. The superficial parts may heal, leaving a form of traumatic arterio-venous aneurysm: if the artery and vein are in direct communication, the condition is known as aneurysmal varix (Fig. 234); if a sac intervenes, it is a varicose aneurysm (Fig. 235) . 2 The diagnosis in either case depends on the history of injury, and the rather tardy development of signs of a traumatic aneurysm, accompanied by a susurrus, or purring thrill, and in the case of a varicose aneurysm by a distinct impulse and aneurysmal whirr. The buzzing is continuous, not disappear- ing entirely during diastole (except sometimes when the limb is elevated — Nelaton), but being accentuated during systole; the murmur is transmitted centrifugally, sometimes centripetally, and the superficial veins may pulsate (Matas). An aneurysmal varix rarely gives much distress, except for the buzzing sensation on palpa- 1 A somewhat similar sound, but no bleeding, follows injury of the pleura. 2 The terminology of John B. Roberts (arterio-venous fistula, director indirect) is preferable. 268 SURGERY OF THE BLOOD VASCULAR SYSTEM tion; this may be audible to the patient; but the tumor seldom enlarges, and, as a rule, only palliative treatment is required. If necessary, however, the surgeon may attempt separation of the vessels and suture or ligation of the defeets. A varicose aneurysm, on the other hand, is prone to grow larger progressively, and, though rarely reaching very large size, in many respects resembles an ordinary aneurysm. Operation generally is indicated; this may consist merely in ligation of the more accessible vessel (preferably the artery) above and below the sac, or in extirpation of the sac and suture of the venous and arterial orifices; better still (Bickham, 1904) would be oblitera- tion of the sac by endo-aneurysmorrhaphy (p. 288). Conners (1918) sacrifices the vein, using it as a patch to repair the arterial defect. For the success of most of these methods, preliminary control of the circulation is necessary; where this is impossible, even by the use of ( 'rile's (Fig. 233) or some similar clamp, the surgeon must open the sac, plug the arterial orifice with his finger, and apply a suture to occlude the orifice as quickly as possible; the venous opening is next closed. Injuries of the Heart.- Rupture. — Rupture of the heart may be due to injury or disease. Blood is pumped into the pericardium, causing embarrassment of cardiac action, with dyspnea, cyanosis, collapse, and death, before suture of the rent, which is indicated, can be attempted. Wounds. — Wounds of the heart are usually stab or gunshot wounds. In cases coming to operation, the left ventricle is most often wounded, generally on the left of the sternum. The symptoms are much the same as those of rupture of the heart, though somewhat less severe; if the patient does not die within a few minutes, he usually survives several hours, affording opportunity for rational treatment. Wounds of the pleura (40 to 70 per cent.) and of the lung (30 to 50 per cent.), may coexist, and pericardial hemorrhage may come from this source, and not from a wound of the heart itself. In all cases in which car- diac injury is suspected, however, exploratory pericardiotomy should be done. Where no precordial wound exists, Matas (1909) advises an oblique incision, from the mid sternum opposite the fourth inter- space, downward and toward the left, dividing the fifth or sixth costal cartilage, which is excised. When an external wound makes the diagnosis more certain, Spangaro's incision (1906) in the fourth intercostal space is preferable; this extends from the left margin of the sternum out as far as necessary, the pleura being opened if already wounded. If sufficient exposure is not obtained by forcible retraction of the ribs, the costal cartilages above and below may be divided close to the sternum. The pericardium being opened and clots evacuated, the slippery heart is grasped in the left hand, and the wound sutured with a continuous chromic gut suture, hemorrhage being intermittently controlled by pressure on the vena? cavae at their entrance into the right auricle (Rehn, 1907). Drainage should be avoided until subsequently required for infection. Simon collected (up to 1912) 241 operations for gunshot wounds, with 124 deaths THROMBOSIS AND EMBOLISM 269 (51 per cent, mortality) ; and 200 operations for stab wounds, with 99 deaths (49 per cent.). Foreign Bodies. — Foreign bodies in the heart have been recorded in over 100 cases. Most have been portions of needles or encysted bullets. The diagnosis and localization are aided by radiography; and extraction by cardiotomy is indicated if any symptoms are present. Cardiolysis is an operation proposed by Brauer (1902), and employed by Petersen, Simon, Morison, and others, consisting in excision of portions of the fifth and sixth left ribs to allow more room for expan- sion of a heart hypertrophied from aortic disease; much improvement in symptoms is said to have resulted. Haberer (1910) employed a similar operation for chronic adhesive pericarditis; while others have gone further, opening the pericardium and freeing its adhesions. Leriche and Cotte (1909) refer to 18 operations of the latter type, with marked improvement in all cases. Pericardiotomy may be required for serous or purulent effusion in the pericardium. A trocar may be introduced for diagnosis close to the sternum in the fourth, fifth or sixth left interspace, according to the physical signs, or, which is preferred by Matas, at the left side of the base of the ensiform. If pus is found a formal incision is made, dividing the sixth and seventh left costal cartilages close to the ster- num, and a drain tube is introduced. A series of 22 cases of pericardi- otomy gave a mortality of 32 per cent. (Elliott, 1909). Massage of the heart should be employed in cases of sudden arrest of its action during surgical operations. Through an epigastric inci- sion the hand grasps the heart from beneath the diaphragm. Jurasz (1911) referred to 64 recorded cases, with 13 permanent and 15 tem- porary recoveries. DISEASES OF THE BLOOD VASCULAR SYSTEM. Thrombosis and Embolism. — When blood coagulates within the vessels during life, the process is called thrombosis, and the resulting clot a thrombus. It is recognized clinically that there may be an aseptic as well as a septic thrombosis, though the former becomes rarer the more we learn of the subject. Infection may reach the region of thrombosis through the blood-stream, or by contiguity from neighboring parts; in the latter case it is customary to incrimi- nate the perivascular lymphatics and the vasa vasorum as the avenue of approach. Accepting, then, infection as the exciting cause of thrombosis, we admit as predisposing causes anything which sloivs the blood-stream, which produces changes in the vessel walls, or in the com- position of the circulating blood. The most important of these three doubtless is changes in the vessel walls; and these changes in most instances are due to bacteria or their toxins. Aseptic injury seldom is a cause of thrombosis (p. 261). Moreover, changes in the vessel walls, as in atheroma, phlebectasis, etc., also act by obstructing the blood-current; and when the composition of the blood is altered by disease {e. g., infections such as typhoid fever, appendicitis, sup- 270 SURGERY OF THE BLOOD VASCULAR SYSTEM putative inflammations; metabolic poisons, as in eclampsia, after burns, etc.), or by injury (as after profuse hemorrhages), very slight retardation may be sufficient to cause thrombosis. The thrombus formed of circulating blood, within the vessels, is either of the white or mixed variety: that is, it contains relatively few erythrocytes, as these flow in the axial blood-stream furthest from the vessel walls where thrombosis is inaugurated by depositon of blood-platelets, destruction of leukocytes, and formation of fibrin ferment. The thrombus thus formed may be a parietal thrombus only, not occlud- ing the entire vascular lumen, or it may be a complete or obstructing thrombus. In either case portions may be broken off by external injury or simply by force of the circulation; and such an embolus, being carried away in the blood-stream, ma}', when it is arrested {embolism), produce a secondary thrombus, so named in contradistinc- tion to the original primary thrombus. The thrombus, whether primary or secondary, undergoes in time certain changes analogous to organiza- tion, cicatrization, and contraction, as studied in Chapter I; by these processes the vessel affected becomes converted into a solid fibrous cord of connective tissue. Occasionally small parietal thrombi are absorbed; rarely obstructing thrombi become canalized by the gradual development in them of capillaries which subsequently dilate and re-establish permeability for the blood-stream; not seldom infective thrombi disintegrate by suppuration, and then the emboli derived from such a thrombus may cause metastatic abscesses (p. 70). Finally, thrombi may become calcified, especially in veins, where they are converted into phleboliths. Phlebitis. — Phlebitis, or inflammation of a vein, is due in general to the same factors mentioned above as causing thrombosis; and, as may readily be understood from w T hat was there said, thrombosis is a much more frequent occurrence in veins than in arteries. Venous blood normally clots more quickly than arterial; the normal venous current is slow, is opposed by the force of gravity and by the valves in the veins; superficial veins are not supported by the muscles, and thus liable to trauma and to extension of infection from the skin and its lesions; and their walls are thin, and liable to be varicose, thus forming pouches where the blood eddies and stagnates. In spite of all these factors which predispose to primary thrombosis, it is not impossible for phlebitis to exist, at least for a time, without thrombus formation. Thus in many cases of varicose veins (p. 274) there is chronic phlebitis {phlebosclerosis) , with marked thickening of the venous w r alls, yet without thrombosis. Such cases probably are due to the action of metabolic poisons, not to septic infection, unless this is extremely attenuated. Surgeons thus distinguish clinically between plastic and infective or septic phlebitis, the latter being accompanied in practically all cases by thrombosis, and running a much more acute course. The thrombus which forms in a vein as a ride extends rather rapidly in the direction of the blood-current, invading not infrequently the THROMBOSIS AND EMBOLISM 271 nearest branches in the thrombotic process; the clot extends also but to a less degree on the distal side of the obstruction. Thus throm- bosis beginning in the long saphenous vein behind the internal malleo- lus, or in the lower leg, may extend to the femoral; and from this the iliac veins and even the vena cava may become thrombosed. Thrombosis commencing in the appendicular veins may extend to the portal vein and into the liver. Thrombosis commencing in the facial or angular vein may extend to the cerebral sinuses; and throm- bosis commencing in the lateral sinus frequently extends into the internal jugular vein. Symptoms. — These are the usual symptoms of inflammation, more or less localized to the known course of a vein. Pain frequently is the first symptom to attract attention; examination soon after discloses heat, a dusky redness in the line of the veins ; and often the thickened, tender, cord-like vein can be palpated through the over- lying tissues. Great gentleness must be used in examination, for fear of detaching an embolus. Sometimes the position of the valves can be recognized by the presence of knobby protuberances. Very rarely suppuration occurs, multiple abscesses forming along the course of the vein. There is moderate swelling from the first, and if thrombosis is complete, and especially if a main trunk is involved, there is a certain amount of edema in the parts beyond. In advanced cases there is total disability of the affected extremity. The disease lasts from one to three or four weeks. Per- manent occlusion of the affected veins results in compensatory dilatation of collaterals, which may themselves be the cause of annoyance or disability (Fig. 236). Diagnosis. — Predisposing causes must be considered (infections, injury), and the physical signs must be accurately noted. By the latter means phlebitis may be distinguished from (1) Lymphanc/eitis (p. 299), where the redness is more flame colored, where the inflam- mation seems more superficial, where it does not follow the known course of a vein, where a thickened knobby cord cannot be palpated, and where lymphadenitis is a frequent accompaniment; from (2) Periosteitis and Osteomyelitis, where the superficial veins are not Fig. 236. — Epigastric varicosities fol- lowing typhoid thrombosis of iliac veins. Episcopal Hospital. 272 SURGERY OF THE BLOOD VASCULAR SYSTEM affected, where tenderness and pain are limited to the bone affected, not extending past the nearest joint; where history of direet trauma is frequent; and where tapping the suspected bone almost at any part of its shaft is productive of pain at the seat of greatest disease; and from (3) Neuralgia and Neuritis, where the symptoms are localized to the known course of a nerve, and where no physical signs of inflammation are present. Post-operative Phlebitis has laparotomy as its most frequent cause, and usually affects the veins of the left lower extremity. It not infrequently occurs after apparently aseptic operations, and it runs a comparatively mild course. Phlegmasia Alba Dolens is a term used to describe inflammation of the veins and lymphatics, usually of the left lower extremity, and generally due to puerperal sepsis ("milk leg"). The usual signs of phlebitis are present, but the disease is characterized especially by the marked edema, rendering the skin tense and shiny, probably due to coincident diffuse angeioleucitis; and by the pallor of the affected extremity. Treatment. — Phlebitis is a serious disease, and requires efficient treatment. Local rest, which usually implies confinement to bed, and elevation of the limb, should be insisted on. Gentle support, as by flannel bandages, aids elevation in preventing excessive edema. Local applications have little appreciable effect, but the use of ice bags in the early stages, and of heat later, usually is grateful to the patient. Ichthyol or mercury and belladonna ointment may be applied to the seat of greatest inflammation. The skin should be kept clean, and well dried, by washing gently with alcohol once every other day or so; but under no circumstances should massage be attempted, and none but the very gentlest passive movement of the extremity should be allowed. Absolute rest of the affected part should be maintained for at least one week after all symptoms have subsided. If the leg is affected there will be persistent edema for many w r eeks or months after the patient gets about, and an elastic stocking or firm bandaging will be necessary to promote ease in locomotion. General treatment is the same as in any acute infection. The treatment above described is sufficient in the immense majority of cases of plastic phlebitis; but in some cases of septic phlebitis it is proper to attempt to prevent the further spread of the thrombotic process by excising a portion of the main venous trunk some distance on the cardiac side of the furthest limits of inflammation. Thus for thrombosis extending up the long saphenous vein, this trunk may be doubly ligated and a section excised (Fig. 237), or the vein simply divided, at the saphenous opening. In thrombosis of the lateral sinus, following otitis media, it is the rule to divide the internal jugular, where healthy, between two ligatures; and some surgeons advise ligating all branches and excising as much as possible of the thrombosed venous channels. In septic thrombosis of the ovarian veins, following puerperal metritis, many surgeons have attempted to ARTERIAL EMBOLISM 273 prevent propagation of the thrombus by ligation above the limit of disease (Chapter XXIX). The operation of phlebotomy, with extrac- tion of the clot and suture of the vein is not so promising as arteriotomy for arterial embolism (p. 274), as the intima of the thrombosed vein is so diseased as almost necessarily to ensure recurrence of thrombosis; nor is the operation so desirable, since gangrene is less to be feared than from arterial occlusion. Wolff (1908) showed that in the lower extremity operative occlu- sion of the main arteries (137 cases) caused gangrene in 20 per cent, of cases; while occlusion of the femoral vein alone (3b cases) resulted in gan- grene in less than (i per cent. *In the upper extremity arterial occlusion (153 cases) caused gangrene in about 8 per cent.; only one case of ligation of the (axillary) vein was recorded, which did not result in gangrene. Pulmonary Embolism. — Pulmonary embolism, sometimes an alarming con- sequence of venous thrombosis, and often occurring at the onset of post- operative convalescence, has been considered at p. 187. Other forms of venous embolism, affecting the viscera (especially the liver), are of comparatively little surgical interest, except when occurring in pyemia. Arterial Thrombosis. — Arterial thrombosis occurs as a complication of wounds, compound fractures, cellulitis, etc.; but unless affecting the main artery of a limb, which is rare, its symptoms usually are overshadowed by those of the causative condition. When the main artery of a limb is affected, the symptoms differ only in the less sudden onset from those of arterial embolism, presently to be described. F. T. Stewart (1908) refers to 35 cases of traumatic arterial thrombosis, 31 of which terminated in gangrene. The treatment is the same as for embolism. Arterial Embolism. — Arterial embolism, when affecting the main artery of a limb, is a condition of great gravity. The clot usually is derived from one of the cardiac valves in a patient with ulcera- tive endocarditis; it is detached from no apparent exciting cause, is carried away in the blood-stream, and, if lodging so as to plug an artery of considerable size, presents characteristic and well-marked symptoms. The patient suffers a sudden, acute, stinging pain below the site of embolism, in the distribution of the affected artery; the limb below becomes tingling, numb, or for a time the seat of burning pain; pulsation is absent below the site of embolism; and the limb IS Fig. 237. — -Portion of thrombosed internal saphenous vein, excised at its juncture with the femoral. Episcopal Hospital. 271 SI HUKHY OF THE BLOOD VASCULAR SYSTEM gradually grows cold, bluish, livid, and the signs of oncoming gan- grene appear (p. 60). Fig. 20 (p. 61) shows gangrene due to lodgment three weeks previously of an embolus in the popliteal artery, in a patient who three months before had embolism of a cerebral artery. Treatment. — When the embolus lodges in an accessible situation, and in one where sudden complete arterial occlusion habitually results in gangrene (especially the brachial at the elbow, the femoral and popliteal arteries), the surgeon should lose no time in resorting to arteriotomy and extraction of the clot (F. T. Stewart, 1908). This is a more promising procedure for embolism with secondary thrombosis, than for primary thrombosis, since the healthier con- dition of the arterial coats in the former condition makes recurrence of thrombosis less likely. A number of unsuccessful operations are on record, but one successful case of arteriotomy for femoral embolism (aseptic) has been reported by Mosny and Dumont (1911). Varix, Phlebectasis, or Varicose Veins, describes a condition in which the veins become elongated, dilated, tortuous, and pouched. Any veins may be affected, even those of bone; but superficial veins, especially the veins of the spermatic cord and the saphenous veins of the lower ex- tremities, are most noticeably diseased (Fig. 238). The chief cause is gravi- tation, aided by obstruction to the normal venous current. Occupation (barbers, waiters, motormen, or others who stand for hours at a time), tumors, pregnancy, thrombosis (Fig. 236), or other factors producing obstruction, are all predisposing causes. Usually no one well defined cause can be found. The valves become incompetent, the blood stagnates, hypertrophy and scle- rosis of the vessel walls occur, phle- boliths may develop, and thrombosis may finally cause obliteration of the diseased veins. The symptoms of pain, fulness, weight, etc., are fre- quently disabling; in the lower extremities the perivascular tissues become thickened, hard edema develops, the nutrition of the skin suffers; trifling trauma produces an abrasion which fails to heal, and varicose ulcer results (p. 57). Profuse hemorrhage may occur from spontaneous rupture of a varix. Rupture of a deep varicose vein is attended by sudden stinging pain ("coup de fouet") and subsequent appearance of ecchymosis. Treatment may be palliative or radical. The former includes application of elastic bandages or stockings, after emptying the veins and reducing edema by elevation of the limb; the use of stimulating liniments, etc.; and attention to hygiene. Such treatment always should be tried first, and usually is efficient Fig. 238. — Varicose internal saphenous vein, aged sixty-three years; duration over forty years. VARICOSE VEINS 275 when the cause of the obstruction is temporary (pregnancy), or remov- able (tumor, etc.). In other cases, or when palliative measures fail to relieve symptoms, operation is indicated. If the superficial veins are varicose as a result of thrombotic obstruction of the deep veins, no operation should be attempted unless elastic support with temporary obliteration of the varicosities produces relief and demonstrates the efficiency of the collateral circulation. Very occa- sionally varicosities due to this cause disappear spontaneously after a few vears, owing to the development of collateral circulation (Skillern, 1913). Operative Treatment. — Operative treatment consists in obliteration of the varicose channels at one or several points. Scheie's operation (1877) is done by making a circular incision below the knee down to the deep fascia, thus dividing all the superficial veins; both ends of each divided vessel are then ligated, and the skin sutured. This operation also divides the superficial lymphatics and sensory nerves; sometimes is followed by edema, paresthesias, neuralgias, or trophic disturbances in the skin below; and, according to Matas, is followed by permanent cure in only one-third of the cases. Spiral division of the skin enables the surgeon to obliterate all the venous channels without severing all the lymphatics, thus rendering edema less likely; but section of the nerves can scarcely be avoided. Tren- delenburg's operation (1S90) consists in division of the main varicose trunk (usually the long saphenous above the knee) between two ligatures, the object being to break the column of blood, thus relieving pressure symptoms. It is suitable for those cases where only the main trunk, not its collaterals, is varicose; and is not suitable even for those cases if the saphenous vein is the seat of chronic phlebitis. According to Matas, 79 per cent, of patients treated by Trendelen- burg's operation have been cured or greatly improved. Multiple Phlebectomy, associated with the names of Madelung (1884) and Schwartz (1888), is, I believe, the best operation in the vast major- ity of cases. Sections of the diseased veins, 7 to 10 cm. long, are removed at the saphenous opening and in other parts of the thigh and leg, wherever the main trunks or their branches are most dilated; the intervening portions become thrombosed, contract, and produce no further symptoms; and the greater portion of the diseased tissue is completely removed from the body, which is not accomplished by either Schede's or Trendelenburg's operation. If the surgeon wishes, he can remove the entire saphenous vein through one long incision; or the entire vein may be removed through three or four small inci- sions by subcutaneous tunneling: Keller (1905) passed a probe into the lumen of the vessel, attached the sectioned end of the vein to the probe, and applied traction "until the vein is completely extirpated by being turned inside out and withdrawn from its sheath." C. H. Mayo (1906) accomplishes the same result by passing a curette over the ligated end of the main trunk, and thus ripping off its attachments. These methods, though more spectacular than multiple phlebectomy, 276 SURGERY OF THE BLOOD \ASCl LAR SYSTEM which is a tedious procedure, are less sure, since the diseased collaterals are left behind. In many cases, moreover, the veins are calcareous, and so densely adherent to the perivascular tissues and even to the skin, that only a formal dissection can free them. I have always employed multiple phlebectomy, except in cases due to thrombosis of the dee]) veins; in these I have adopted a spiral incision for Schede's operation, thus avoiding excision of the only veins the patient possessed. Operations for varicose veins are not entirely devoid of danger: in large series of operations death from pulmonary embolism has occurred in 1 or 2 per cent, of cases; the skin frequently is difficult to sterilize, and in spite of care infection of the incisions may occur; occasionally phlebitis is a sequel. Hemangiomas; Telangiectases. — Under these terms are included various affections of the vascular system, whose proper classification has not been determined by pathologists. In the vast majority of cases they are congenital, or at least are noticed first in early infancy; the lesions usually enlarge more rapidly than the part in which they are situated, and from being insignificant specks at birth may become growths of alarming size in childhood or early adult life. Sometimes they assume the character of tumors, as described in Chapter IV, very occasionally seeming to possess malignant characteristics (in- filtration, recurrence). Nevus Vasculosus. — This may affect either capillaries or venules, its. color (bluish, purplish, or red) depending upon the proportion of venous blood present. Capillary Nevi (Plate II, Fig. 1, p. 260) .—Capillary nevi occur in the skin, rarely in mucous membranes; they do not involve the subcutaneous tissues; they are red, or reddish blue ("mother's mark," "birth-mark," "port-wine stain"); they may be elevated above the surface of the surrounding skin,or may lie perfectly flat beneath a seemingly normal epi- derm. They vary greatly in size. Elevation of the affected part does not cause them to shrink or become pale; nor does pressure blanch them, unless very small, and then only momentarily. Usually they are multiple, are most frequent on the face and neck (perhaps branchio- genic) ; tend to grow larger; and may ulcerate and cause alarming hemor- rhage. Sometimes they blend into cavernous angeiomas, described be- low. The pigmented mole may be considered a variety of capillary nevus: frequently it is hairy {ncru.s yilosus, Fig. 239); usually remains of insignificant size; but occasionally Fig. 239. — Nevus pilosus (hairy mole). Age nineteen years, growing slowly since birth. Episcopal Hospital. HEM ANGEIOMA AM) XEVUS 2/i Fig. 240. — Cavernous angcioma of palm, hand dependent. See Fig. 241. From a patient under Dr. Frazier's care in the Episcopal Hospital. about puberty, or in adult life, from trifling or no apparent cause, begins to enlarge, assumes tumor-like characteristics, and may develop into or be inexplicably associated with melanotic sarcoma (p. 130). Treatment. — The treatment of capillary nevi should be undertaken within the first few months of life. The application of carbon dioxide snow (Pusey, 1907), for a half minute or so, every third or fourth day, probably is the most satisfactory treatment for the port-wine stains or other nevi not raised above the surface of the surround- ing skin. This "cold caus- tic," as it has been called, produces sloughing of the diseased skin, resulting in an ulcer which heals with the minimal amount of scarring. The earlier the nevus is cured, the more inconspicu- ous will the scar be. Fuming nitric acid is more effectual for raised capillary nevi than for port-wine stains. Electrolysis may also be employed. Moles are best treated by excision. Venous Nevi. — Venous nevi may occur in the skin or subcutaneously, in the latter case usually being described as cavernous angeiomas, their structure resembling the cavernous tissues of the penis. They form prominent lobulated tumors, easily compressible, sometimes becoming tense when the child cries or strains, emptying more or less completely when the affected part is ele- vated and pressure is applied, and rapidly refilling when the part is dependent (Figs. 240, 241). In the subcutaneous variety discoloration of the skin may not be present. The growths may be circumscribed or diffuse; the former some- times is mistaken for a cold abscess; while the diffuse sub- cutaneous cavernous angeioma may involve an entire extremity and neighboring portions of the trunk, the entire limb being deformed, flabby, pudgy, and sponge-like to the touch (pseudo-elephantiasis) ; the muscles may be wasted, and the bones atrophic (Plate III). Muscle tissue itself may be invaded by the angeiomatous growth. Similar angeiomas occasionally are found in the viscera, notably the liver. Subcutaneous cavernous angeiomas usually are associated with lipomatous growths (nevoid 241. — Cavernous angeioma of palm, hand elevated. Episcopal Hospital. 278 SURGERY OF THE BLOOD VASCULAR SYSTEM lipoma). They seldom cause hemorrhage but may undergo throm- bosis; ami formation of phleboliths is not uncommon. Treatment. — Treatment consists in excision whenever this is practicable; and in circumscribed angeiomas it usually is not very difficult. If excision be refused by the parents, the surgeon may strangulate the tumor by ligating it in sections, leaving the pro- truding masses to be separated as sloughs. In cases where an elastic tourniquet or other means of controlling the circulation can be applied above the seat of operation, Wyeth's method (1903) may be adopted: this consists in the repeated injection of boiling water (1 to 2 c.c), at intervals of several days; if the water is actually boiling, thrombosis of the blood in the angeioma will be immediate and the clot so firm that theoretically no fear of embolism need occur; but though no such result has been reported, so far as I am aware, the surgeon should be extremely cautious in employing this method about the face, where cerebral embolism might occur, or at the root of the neck or in the axilla, where pulmonary embolism might be caused. Diffuse subcutaneous cavernous angeiomas usually can be treated only by palliation. Arterial Varix. — Arterial varix, known also by the name of Cirsoid Aneurysm (Fig. 242), and, when capillaries are involved, by the terms Racemose Aneurysm and Aneurysm by Anastomosis, is an affection of the arterial system somewhat analogous to varicose veins, but present- ing in many cases neoplastic characteristics by which it is allied to angeiomas. The arterial distribution affected (most frequently on the scalp) becomes dilated, elongated, tortuous, and pouched, forming a vari- cose pulsating tumor often of considerable size. It occurs usually in early adult life, from no well defined cause, though history of trauma may be obtainable, and cases have developed from congenital nevi. The tumor presents a characteristic varicose appearance, is compressible, and may be reduced in size by pressure on the main afferent arterial trunks; when this pressure is removed, the tumor again increases in size, by expansile pulsation, perhaps several cardiac impulses being required before it regains full size. Palpation and auscultation detect a systolic thrill. Treatment. — Treatment is sought by the patient for relief from the constant murmur or whirr within the tumor, as well as on account of the deformity. Excision should be done when practicable; some- times it becomes possible only after preliminary circumferential ligation of the main arterial channels entering the tumor (Fig. 242). In rare cases such ligation alone is sufficient to cause disappearance of the tumor. Aneurysm. — An aneurysm is a hollow sac, filled with normal or altered blood, in communication with the lumen of an artery, and developed wholly or in part by progressive dilatation of the arterial walls. A traumatic aneurysm (p. 265) properly is not an aneurysm at all, but a pulsating hematoma, since the sac is formed not of arterial wall, but by condensation of surrounding tissues. Arterial aneurysms w < Oh ANEURYSM 270 are classified as true and false; formerly the term "true" was applied only to those aneurysms composed of all the arterial coats; but as this condition was found to exist only in an extremely limited number of cases of very minute (miliary) aneurysms, it has now been trans- ferred to all aneurysms developed wholly or in part by progressive dilatation of the arterial walls; while the term " false aneurysm" is now applied only to pulsating hematomas, etc. When a true aneurysm ruptures subcutaneously it is better to call it a "ruptured aneurysm," than a diffused or consecutive aneurysm (Fig. 243). Fig. 242. — -Cirsoid aneurysm, arterial varix, or aneurysm by anastomosis of right ear, treated by a series of operations by the late Prof. Ashhurst: 1. Ligation of temporal and common carotid arteries. 2. Strangulation of growth by multiple ligatures. 3. Amputation of ear, excision of tumor, and ligation of cut vessels separately. University Hospital. Fig. 243. — Ruptured aneurysm of left femoral artery; ligation in Scarpa's triangle thirteen years ago for popliteal aneurysm. Rupture two weeks ago. Episcopal Hospital. Aneurysm develops by the gradual dilatation of a portion of the arterial wall previously diseased. At this earliest stage the term arteriectasis is applicable. As the dilatation proceeds, the middle tunic gives way, and the aneurysmal wall is formed only of the adventitia with such clots as may be deposited from the swirling blood within the sac upon the surface of the intima. The walls of an aneurysmal sac in contact with circulating blood always are lined by endothelial cells, which are proliferated with great readiness either by extension from the intima of the parent artery, or possibly through the medium of angeioblasts of the vasa vasorum (Matas, 1910). This endothelial lining may itself become atheromatous and calcareous. 280 si RGBRY OF THE lU.ooD VASCULAR SYSTEM Aneurysms are further classified as to their form, into (1) Tubular or Fusiform (Fig. 244); (2) Saccular (Fig. 245); and (3) Dissecting Aneurysms. Tubular or fusiform aneurysms are those which involve the entire circumference of an artery, and are rare even in the larger Fig. 244. — Fusiform aneurysm. Fig. 245. — Saccular aneurysm, with small mouth. internal vessels. Dissecting aneurysms are those in which the blood makes a channel for itself between the coats of the arterial wall for a variable distance, and again enters the arterial lumen; they are seen almost exclusively in the tho- racic or abdominal aorta. The saccular aneurysm, in which the dilatation involves a portion only of the arterial circumfer- ence, communicates with the vessel by a comparatively small orifice called the mouth of the sac; by progressive growth of a saccular aneurysm its mouth may become so lengthened as to cause the aneurysm to re- semble at first glance one of tubular or fusiform variety, especially on laying open the sac, when it will appear that there are two mouths present (Fig. 246, B). Though aneu- rysms usually are single, they may be multiple; and after cure by obliteration of one sac others may develop (Fig. 243). The sac of an aneurysm when first formed contains fluid blood; the eddying and partial stagnation to which this is constantly sub- Fig. 246. — Saccular aneu^'sm with large mouth; when opened it appears as if there were two orifices. CAUSES OF ANEURYSM 281 jected leads in time to the deposition of fibrinous dots on the interior of the sac wall. These are deposited in successive layers, constituting the laminated clot. This rarely becomes firmly adherent in all spots to the sac wall, but is dissected loose by the eddying currents, thus preventing its organization. Should such firm adhesion and organiza- tion occur, and should concentric laminations be formed continuously, spontaneous cure of the aneurysm eventually might ensue by oblit- eration of its sac; but this is extremely rare. Causes. — The chief underlying cause of aneurysm is precedent disease of the vascular system; aneurysm is but a symptom of this disease; and in the immense majority of cases the vascular degenera- tion is a sequel of syphilis, 1 though chronic alcoholism, even without syphilitic affection, is said sometimes to be a cause. The immediately apparent cause, in most cases, is some sudden strain, exertion, or accident, which causes rup- ture of the diseased media at its most susceptible point; the vis a tergo of the blood- stream then causes progres- sive dilatation of the artery until a well defined aneurysm exists. Constantly recurring slight trauma is recognized as a predisposing cause in that it causes localization of arterial lesions where aneurysms later develop. Thus is explained the preponderance of aneu- rysm in the aortic arch and at the root of the neck, where not only is the cardiac im- pulse strongest, but where the arteries lie against bone (vertebra?, first rib, clavicle) and where each pulsation tends to bruise the arteries against this unyielding structure; the latter explanation is adduced by Barwell (1882) to account for the frequency of popliteal (Fig. 247) as compared with brachial aneurysm. Localization. — In general terms, the aorta is affected in 42 per cent., the popliteal artery in 24 per cent., the femoral in 12 per cent., and the carotid, subclavian, axillary, and innominate in about 3 per cent, each — leaving the smaller arteries of the extremities to form about 10 per cent, of cases (Crisp, 1847). Popliteal aneurysm forms from 55 to 60 per cent, of those occurring in the limbs (Matas, 1910). Age.— Aneurysm occurs mostly in patients in active adult life; about two-thirds of cases are seen between the ages of thirty and fifty years, after arterial lesions have had a chance to develop, Fig. 247. — Popliteal aneurysm, right leg. Dr. Harte's case. Pennsylvania Hospital. 1 This was strenuously denied by Barwell (1882). 282 SURGERY OF THE BLOOD VASCULAR SYSTEM and while sudden strains are still frequent. Sex: It is seen in men about six or seven times as frequently as in women, owing to the greater liability of the male sex to atheroma, and to their more labori- ous life. Occupations attended by violent exertion (porters, teamsters, soldiers, sailors) are regarded as p^disposing to the development of aneurysm, as are diseases of the heart and kidneys, chronic, gout, rheumatism, etc., causing arterial hypertension and calcification. Symptoms. — These usually are of slow development, though occa- sionally the patient is aware that "something has given way," expe- riences a sudden stinging pain, as the "coup de fouet" in rupture of deep varicose veins (p. 274), and on examination at once finds a pulsating tumor has formed. The symptoms of aneurysm may be considered as those peculiar to the aneurysm itself, and those due to its pressure on surrounding parts. There is present a rounded or oval tumor, either apparent to the eye or appreciable to the touch; it is situated along the course of an artery; it is movable laterally but not longitudinally on the artery; and it is somewhat compressible and elastic (depending on the amount of laminated clot). An aneurysm becomes more or less flaccid by pressure on the artery above, and harder and more tense by pressure on the artery below the tumor. It is covered by healthy, non-adherent skin, unless in the last stages when rupture is about to occur. The affected part is more or less disabled, with muscular weakness, paresthesia, numbness, or edema (pressure effects) : pressure on nerves causes neuralgic pain or paralysis (of pupil, of vocal cord, etc.) ; on neighboring veins causes varicosities and edema; on arteries (perhaps the parent trunk) causes gangrene; on bones causes erosion, with intense boring pain; on neighboring viscera (trachea, esophagus, bile ducts, etc.), may cause serious disturbance in their functions. Aneurysms pulsate, synchronously with the heart: they are not merely lifted by the pulsation of the underlying artery, but as the blood enters the sac and swirls around in its interior the sac walls dilate, causing an extremely character- istic pulsation which is both eccentric and expansile. The degree of aneurysmal pulsation depends on the size of the sac and of its mouth, and on the thickness of its walls; a small aneurysm with much thick- ened walls and a small mouth connecting w r ith the artery will pulsate much less than one which is large, thin walled, and possessed of a large mouth. Pulsation becomes more pronounced when the part is depend- ent and when pressure is made on the artery below the sac, and may almost disappear when the limb is elevated and the artery occluded above the sac. When pulsation has been made to cease by the latter method, application of the hands over the sac will enable the surgeon to detect the entering blood when pressure is removed, and will make him appreciate the facts that the sac does not always become fully distended with the first impulse from the heart, and that the pulsation is eccentric and expansile, driving the hands not only further away from the underlying artery, but also further apart from each other. Pulsation in the artery below the aneurysm may be blAGNOSIS OF ANEURYSM 283 much diminished, as compared with corresponding pulsation on the other side of the body; this phenomenon is due to pressure on the artery by the overlying aneurysm ; while the fact that the pulse below the aneurysm may be delayed is explicable on mechanical grounds, the aneurysm acting as the air-chamber of an hydraulic ram. More- over, the arterial pressure distal to the aneurysm is less than in the corresponding healthy artery. Bruit, which is the peculiar whirring or rasping noise made by blood entering the sac, is present with very few exceptions (old thick-walled aneurysms almost full of clot); it occurs during cardiac systole, is therefore intermittent, and is loudest in aneurysms with large sac mouths; it may be made to cease by obliteration of the artery above the aneurysm, unless large collaterals empty into the sac; and in aneurysms of the extremities sometimes becomes louder when the limb is elevated. It may be transmitted centrifugally along the diseased artery. Its conduction by bone has been noted" by Godfrey (1914). Thrill is to the hand what bruit is to the ear; but is much less marked than in arteriovenous aneurysms. Course and Termination. — Aneurysm is an incurable disease, and if left to itself first disables and then kills the patient within com- paratively few years. Apparent cure is only temporary, as other aneurysms may develop or the first recur. By proper treatment, however, symptoms may be relieved, individual aneurysms may be temporarily cured, and the life of the patient may be prolonged indefinitely (perhaps fifteen to twenty years) in comfort and reasonable usefulness (Fig. 243). Death finally comes slowly (from exhaustion, inanition, gangrene, etc.), rapidly (from pressure on trachea or larynx, on phrenic or pneumogastric nerve, from rupture and hemorrhage, etc.), or suddenly from syncope even without rupture. Diagnosis. — This is made by attention to the history and physical signs. Arterio-renous aneurysms usually follow penetrating wounds; other signs of vascular disease may be wanting; bruit is continuous (not intermittent except sometimes when the limb is elevated — Xelaton), is transmitted both centrifugally and centripetally; thrill is marked; and compression on the afferent or efferent arterial trunk does not cause such characteristic changes in the sac. Other vascular pulsating tumors are less well defined in outline, do not present eccentric pulsation, have little or no bruit, and are not neces- sarily placed in the course of a large artery. Other tumors may pulsate because they overlie an artery, but the pulsation is neither expansile nor eccentric, there is neither bruit nor thrill, and obliteration of the afferent or efferent arterial trunk, while it may cause cessation of pulsation, yet produces no other change in the tumor. Non-pulsating tumors may be mistaken for an aneurysm with contents clotted; such growths may be movable longitudinally as well as laterally, and present a different clinical history. An aneurysm which has become diffused or inflamed may be mistaken for an abscess (p. 48), but attention to the history, and a careful physical examination will almost surely prevent any confusion. 284 SURGERY OF THE BLOOD VASCULAR SYSTEM Treatment. This may be operative <>r non-operative. Under the hitter heading arc included hygienic and dietetic measures, such as alone are applicable to certain forms of internal aneurysm. 1 All other aneurysms should be operated upon, and nothing is gained by delay. The end sought by operation is to prevent blood from entering the sac, thus allowing its obliteration. Tins may be attempted in various ways. The methods still in most general use endeavor to secure coagulation of the blood within the sac; these may be regarded as palliative operations. Most of them act by retarding the current of blood passing through the parent artery; others act directly on the contents of the sac itself. They include pressure on the afferent artery; compression of the sac itself (as by flexing the knee for pop- liteal, or the hi]) for inguinal aneurysm), ligation of the afferent artery, or of the efferent artery or one of its branches; injection of coagulating fluids; insertion of needles with irritation of the intima to favor throm- bosis; and introduction of metallic wire with electrolysis. Manipula- tion of the sac (Fergusson, 1857), in an effort to detach a clot which shall plug the efferent artery, should be mentioned only to be con- demned. Radical operations comprise extirpation of the sac, with suture or ligation of the orifice or orifices into the parent artery; and Endo-aneurysmorrhaphy, which is the best method whenever applicable. Pressure. — The patient should be confined to bed, and kept on a low diet with very little fluid; this slows the circulation and favors thrombosis (Tufnell, 1864). The pressure may be either instrumental (by various forms of tourniquets), or digital (Knight, 1844), which is preferable. The afferent artery is compressed until the sac ceases to pulsate. Relays of assistants are required, each one keeping up pressure for from three to five minutes, being then relieved by another who compresses the artery above or below T the first point of compression before this is released by the fingers of the former assistant. In this way the circulation of blood in the sac is much diminished, favoring the formation of a laminated coagulum. Treat- ment is to be kept up for from two to four days, in sittings of about four hours once daily. After thirty-six hours hope of cure is much less, and continuation of pressure dangerous (sloughing, etc.). The method is most easily applicable to the femoral artery, for aneurysm of the popliteal. It should be employed only when endo-aneurysmorrhaphy or ligation are contraindicated, as in the very old and feeble, in those with serious visceral disease, etc., in whom the dangers of a cutting operation are excessive. The method is successful in perhaps half the cases treated. G. Fischer (1869), found that among 188 cases of aneurysm treated by digital compression, cure resulted in 121 (over 64 per cent.), and 38 of these patients were cured in less than three days; of 90 cases of popliteal aneurysm, 72, or 79 per cent., were cured by digital compression. 1 In all syphilitic cases proper constitutional treatment is indicated. TREATMENT OF ANEURYSM 285 Ligation. — This may be done on the proximal side of the aneurysm, or the distal, or on both sides. Proximal Ligation. — The method of Hunter (1785) consists in applying a ligature some distance above the aneurysm, allowing small branches to convey blood from above the ligature through collateral circulation, into the sac of the aneurysm (Fig. 248). The advantages claimed for the Hunterian method are: (1) accessibility of the artery; (2) healthier condition of the arterial walls; (3) gradual obliteration of the sac by formation of laminated clot. But modern aseptic oper- ating renders the artery easily accessible at any site, and even if the arterial wall be diseased close to the sac (which is not certain), application of a ligature will strengthen it, and healing will occur Fig. 218. — Hunter's method of liga- tion for aneurysm: collateral circula- tion from above the ligature into the sac. Fig. 249. — Anel's method of ligation for aneurysm: circulation through the sac com- pletely arrested. normally. Objections to Hunter's operations are: (1) the existence of collateral circulation through the sac really is unfavorable to its complete obliteration; (2) interposition of two obstacles to the circu- lation (ligature and aneurysm) renders gangrene more likely, as does the exclusion from the circulation of collaterals arising between the ligature and the sac; (3) if the collateral circulation is successfully established through the main trunk, recurrence of the aneurysm is likely. The method of Anel (1710), revived in 1856 by Broca, con- sists in the application of a ligature close to the sac (Fig. 249) ; until recent years it was considered inferior to Hunter's operation, but aseptic technique has shown it to be quite as safe and but slightly more difficult; and its manifest advantages are that the circulation through the sac is completely suppressed and yet no additional 286 Sl'HUKIiY OF THE BLOOD VASCULAR SYSTEM obstacle is erected to the circulation, only one set of anastomosing vessels being required, instead of two, as in Hunter's operation. Matas, Delbet, Weber, Kohler, LeConte and Stewart all prefer Anel's method to that of Hunter. Distal ligation also depends for its curative effect on retardation of the circulation within the artery, with consequent thrombosis in the aneurysmal sac. Brasdor's method ( 179N) consists in ligation of the main trunk immediately distal to the aneurysm, no branch intervening (Hodgson, 1815) (Fig. 250); while the "new operation " of Wardrop (1828) involves ligation of one of the main branches below the sac, or of the parent trunk below the origin of a branch (Fig. 251). These Fig. 250. — Brasdor's method of liga- tion for aneurysm, applied for aneurysm of the common carotid artery (C). /, innominate; S, subclavian artery. Fig. 251. — Wardrop's method of liga- tion for aneurysm, applied for aneurysm of the innominate (/). The common carotid (C), and the subclavian (S) in its third portion have been ligated, permit- ting slight circulation through the thy- roid axis. methods are inferior to proximal ligation, because less certain; but are still employed in places where the proximal side of the artery is inaccessible, as in Innominate Aneurysm, or large aneurysms of the first part of the Subclavian. For innominate aneurysm simulta- neous ligation of the common carotid and subclavian arteries is preferred; this constitutes Wardrop's method, since the subclavian is tied in its third portion below the origin of the thyroid axis and vertebral. Double Ligation, Above and Below the Sac. — When this is immedi- ately followed by incision of the aneurysm, evacuation of the clots, and packing of the sac, to control hemorrhage from collaterals entering TREATMENT OF ANEURYSM 287 the sac, it constitutes the operation of Antyllus (third century, a.d.); if the sac is opened first, the clots evacuated, the mouth of the sac sought with the finger, and a probe passed up and down the parent trunk as a guide to the application of ligatures above and below the tumor, it constitutes the "old operation," which was temporarily revived by Syme (1857). At the present time the mortality from ligation is about 8 per cent. ; there is, however, also the risk of gangrene, requiring amputation, which occurs in an additional 8 per cent, of cases (Delbet, 1907). Gangrene is due not only to sudden arrest of the circulation, but also to pressure on surrounding tissues by the thrombosed sac, and some- times to embolism of the artery below the sac. Even if a patient recovers and escapes gangrene, the symptoms from pressure (neuritis, edema, etc.), may be not only unrelieved but even aggravated by solidification of the sac. Fig. 252. — Aneurysm of abdominal aorta. Death from internal rupture. Deaver's case. Episcopal Hospital. Dr. H. C. FlLIPUNCTURE AND ELECTROLYSIS; WlRING OF ANEURYSMS. — Wiring was introduced by Moore (1864), and modified by Corradi (1879) who passed an electric current through the wire coil. Fine gold or silver wire (No. 28 gauge) is used, being inserted through a cannula which is plunged into the aneurysmal sac; from 3 to 30 meters of wire are introduced; the positive pole is attached to the wire entering the aneurysm (Hare, 1908), the negative pole being placed elsewhere on the patient's body, and the current (70 to 80 milliamperes) is allowed to run for nearly an hour. This method may be attempted in certain cases of internal aneurysm in which death is imminent from rupture, or in which Tufnell's treatment (p. 284) (perhaps combined with repeated venesection — Valsalva's method) fails to relieve urgent pressure symptoms, but in which liga- tion or endo-aneurysmorrhaphy are impossible. Thoracic aneurysms 288 SURGERY OF THE BLOOD VASCULAR SYSTEM (aortic arch, low innominate) are to be localized by physical exami- nation and the x-ray, and the cannula plunged directly into the sac; abdominal aneurysm is treated after exposing the sac by laparotomy. For thoracic aneurysm no other surgical treatment is possible, except in the case of innominate aneurysm, when simultaneous double distal ligation is preferable. In some cases of abdominal aneurysm endo- aneurysmorrhaphy can be performed, and is preferable if temporary control of the circulation can be secured. Matas (1000) found that wiring and electrolysis resulted in apparent recovery in less than 20 per cent, of cases; in 1910 he condemns the method as a "pure ex- periment, which is justified solely by the imminent and unavoidable danger of death from the progress of the disease itself." Eshner (1910) has analyzed 36 cases of aneurysm, mostly aortic, treated by wiring; 9 patients died within ten days, 22 lived less than one year, and 5 survived for periods ranging from fourteen months to over eleven years. Extirpation of the Sac, known by the names of Philagrius (third century A. I).), and Purmann (1685), now finds an ardent supporter in Delbet. It removes the danger of gangrene due to pres- sure on surrounding parts by the clot-filled sac, as also the danger of embolism. For its successful performance it is necessary to secure preliminary control of the circulation, when possible by application of an elastic band at the root of the limb, or even by direct clamp- ing of the afferent and efferent artery. This latter method, however, may not prevent profuse recurrent hemorrhage from collaterals emptying into the sac. The vein should be preserved, and if impor- tant structures are adherent to the sac that portion of the sac should be left behind. According to Delbet (1907), among 86 patients treated by extirpation of the sac there were no deaths, and gangrene followed in less than 3 per cent. Endo-aneurysmorriiaphy, introduced by Matas in 1888. After controlling the circulation, the sac is opened: (1) If a fusiform aneurysm, or a saccular aneurysm with very large mouth (Fig. 246), is found, the sac is obliterated by a series of fine chromic catgut or silk sutures, approximating its walls, and occluding the lumen of the artery adjacent to the mouth of the sac (Obliterative Endo-aneurysmor- raphy (Fig. 253). (2) If a saccular aneurysm with small mouth is found, it may be possible to suture the margins of the sac mouth with- out occluding the lumen of the parent artery (Fig. 254). Orifices of collaterals are then sutured, and the sac walls approximated as before (Restorative Endo-aneurysmorrhaphy). (3) In rare cases the form of the aneurysm may be such that it will be possible to reconstruct by suture a channel to represent the lumen of the parent artery, though little or no evidence of such a channel exists when the sac is opened ; a soft catheter may be used as a guide (Fig. 255) (Reconstructive Endo- aneurysmorrhaphy or Ajieurysmoplasty.) The methods of Matas possess over ligation all the advantages of extirpation (less mortality and diminished risk of gangrene) while at TREATMENT OF ANEURYSM 289 the same time they entail less trauma than extirpation, and in the restorative and reconstructive methods afford the possibility of preserving the circulation through the parent artery; and even if this circulation is preserved only temporarily, gangrene is less likely than if the circulation is occluded immediately as in extirpation. If endo-aneurysmorrhaphy is applied to cases of traumatic aneurysm, Fig. 253. — Obliterative endo-aneurys- morrhaphy. Fig. 254. — Restorative endo-aneurys- morrhaphy. Fig. 255. — Reconstructive endo-aneurysmorrhaphy. this should not be until a firm-walled adventitious sac has formed. Matas in 1910 collected reports'of 110 cases of endo-aneurysmorrhaphy (including 07 aneurysms of the lower extremity), with only two deaths (1.8 per cent.) attributable to the operation, and 4 cases of gangrene (3.0 per cent.), 3 of which were chargeable to complications, not to the operation itself. 19 CHAPTER XI. SURGERY OF THE SKIN, BURS/E, LYMPHATICS, MUSCLES, TENDONS, AND NERVES. SURGERY OF THE SKIN. Verruca or Wart. This is a localized hyperplasia of the epidermis, and theoretically may be distinguished from a papilloma, which, as noted at p. 119 is a neoplasm. The favorite sites for warts are the hands, face, scalp, and neck. They usually appear to grow spon- taneously, but in a few cases a suspicion of contagion exists; trauma followed by moisture seems a predisposing cause. They show little tendency to enlarge, scarcely ever become malignant, and occasionally disappear from no apparent cause. Treatment is sought for dis- figurement, sometimes for pain. Removal is accomplished easily by snipping off the warts with scissors, after spraying w r ith ethyl chloride; the base is then cauterized with silver nitrate. Or by apply- ing a drop or so of fuming nitric acid every few days, the warts will in time shrivel up and fall off painlessly. Recurrence is rare after thorough removal. ' J'cnereal warts are those growing upon the genitals or around the anus; they are due to irritation from uncleanliness, and have no necessary connection with any venereal disease. Callositas or Tyloma is a diffuse hypertrophic condition of the skin, normally present to a slight degree in the palms and soles, and due to intermittent pressure. It becomes of surgical interest when the hypertrophy is so great as to cause the lesion to approach to that of Clarus or Corn: in this lesion (which frequently develops in the center of a callosity, or may arise independently, especially on the toes) the intermittent pressure causes a pyramidal shaped up-growth of epithelial cells, which presses upon and finally separates the papillae of the skin, and causes exquisite pain from pressure on the highly sensitive nerve-endings found in this layer. A soft corn is distinguished from a hard corn by the fact that the former is placed where its surface is kept warm and moist, as between the toes; while the hard corn develops on an exposed surface. When of long duration a bursa may be formed beneath the corn, constituting a bunion; this is most often the case over the metatarso-phalangeal articulation of the great toe, often being combined w T ith hallux valgus (p. 592). Treatment. — Treatment of corns consists in removal of the cause; in frequent bathing; application of such plasters as will relieve the corn from pressure; use of salicylic acid ointment (5 to 10 per cent.); (290) FURUNCLE OR BOIL 291 paring the surface of the corn (a frequent cause of cellulitis, angeio- leucitis, and sepsis, if carelessly done); and sometimes in formal excision. Cornu Cutaneum or Horn, is a rare affection of the skin, most frequent in old age, and about the face; it may follow the spontaneous evacuation ■ of a wen. Closely analogous to it is the condition of hypertrophy of toe-nails or onychauxis (Fig. 25G). Excision is the best treatment. Keratosis Senilis. — See p. 669. Ingrowing Toe-nail. — Ingrowing toe-liail, Seen almost exclusively Fig. 256.— Hypertrophy of toe-nail, or in the great toe, USUally is due to onychauxis one year's growth since the ... „ . ° , , . , " , nail was last cut off . Episcopal Hospital. ill-nttmg shoes, which produce a degree of hallux valgus (p. 592) : in the early stages the form of the nail is unaltered, but the soft parts of the pulp are crowded over on its edge, and injudicious trimming of the nail down this chink predisposes to ulceration. Later, the edge of the nail becomes folded under, and by pressure on the pulp, aggravates the condition. If palliative treatment be persisted in long enough, a cure usually may be produced by keeping the parts free from pressure, and separating the overhanging skin from the nail either by antiseptic cotton stuffed into the chink, or by drawing the skin aside by adhesive plaster, while the ulcer is treated by desiccating powders after cauterizing its base. The nail should be cut square across the top, and never trimmed down at the sides. If a rapid cure is demanded, it is best to avulse the side of the nail affected (both sides if necessary) by splitting the nail down the center with strong scissors, and grasping the portion to be removed in forceps. Local anesthesia is sufficient. As the new nail grows, properly fitting shoes must be worn to prevent recurrence. Perforating Ulcer. — Perforating ulcer, usually seen in the sole of the foot or under the great toe, occurs in those past middle life, and is connected with arteriosclerosis or trophic disturbances. It occurs in diabetes, and in locomotor ataxia, and probably is not a specific disease, but merely an evidence of tissue destruction due to malnutrition. It is not attended by much pain, may follow slight injury, frost-bite, etc., and frequently originates in a small slough in the center of a callosity or corn. If untreated, the ulceration steadily progresses, eating through the foot, involving muscles, tendon, and bone; is attended by a stench, and in advanced stages perforates the dorsum of the foot. Under hygienic measures, internal administration of potassium iodide, rest in bed, and active local treatment (cleansing, curetting, etc.), temporary cure sometimes is obtained. Furuncle or Boil. — Furuncle or boil is an infection of a hair follicle or sebaceous gland, confined to the deeper layers of the true skin, 292 SURGERY OF THE SKIN usually terminating in suppuration, with the extrusion of a central slough called the core. The usual cause is Staphylococcus aureus, which gains entrance through a minute abrasion, as from a rough edged collar or cuff. Persons with disordered metabolism (diabetes, gout, nephritis, scrofula, eczema, etc.), are especially predisposed to furunculosis. The classical symptoms of inflammation are present — a red, extremely tender and painful swelling, attended by local heat, in the true skin and subcutaneous tissues. Boils vary much in size, but seldom appear over 5 cm. in diameter; they usually are multiple, sometimes appearing in successive crops. Boils usually have a marked tendency to point; those that do not, are called "blind boils." Treatment. — Treatment includes such general hygienic and tonic measures as will prevent a continuance or recurrence of the boils; frequent bathing, with the use of alkalies (sodium carbonate) in the bath and by mouth, is important. By local treatment in the very early stages it sometimes is possible to abort a boil by pouring pure ichthyol over its surface, and making a scab with a film of absorbent cotton. In most cases, however, early incision, besides relieving pain, will accelerate extrusion of the slough, and prevent formation of neighboring boils, which are encouraged by poulticing. After extract- ing the core, pure ichthyol may be poured into the crater of the furuncle, or a drop of carbolic acid may be introduced on a match- stick. The surrounding skin must be kept clean and stimulated with astringent washes. In cases of persistent furunculosis, benefit has been derived from the administration of autogenous vaccines. Skil- lern highly recommends sulphurous acid, in doses of one or two tea- spoonsful well diluted; this should be taken through a tube and an alkaline wash (milk of magnesia) used afterward to preserve the teeth. Baker's yeast has also proved beneficial. Carbuncle. — Carbuncle may be regarded as an aggravated form of boil (Fig. 257). The infection spreads more widely in the subcutaneous tissues, there is phlegmonous inflammation, and the pus tends to evacuate itself through manifold orifices, by following the course of the columns adiposes (Warren, 1881). Carbuncles are most common on the nucha, and may extend almost from the vertex to the shoulder. In the old, the diabetic, the subjects of advanced Bright's disease, etc., it forms a very serious malady, often endangering life. There is no clear limit to the inflammation, which usually is more wide- spread than is apparent on the surface. Treatment. — Hygienic and constitutional treatment is even of more value than in furunculosis. (1) Small carbuncles should be treated as boils, by early incision which may be crucial if necessary, to facili- tate extrusion of the sloughs. (2) Medium-sized carbuncles should be incised as above, and then strapped with adhesive plaster applied concentrically, until only a small orifice is left for the discharge of pus (Fig. 258); this strapping, suggested by O'Ferral (1858) and emphasized as particularly valuable by J. Ashhurst, Jr. (1869), acts mechanically by limiting the spread of the phlegmon by erecting an TREATMENT OF CARBUNCLE m impassable barrier around the base, and forcing the discharge of sloughs through the central opening; it secures local rest; and also, I believe, creates a certain de- gree of passive hyperemia in the diseased area, thus increas- ing the phagocytic and opsonic powers of the patient. The strapping checks almost at once the excessive pain caused by the carbuncle, and as it may be left in place for several days at a time, considerably simpli- fies the treatment. The gauze which receives the discharge through the central opening should be changed daily. The diminution in size of the car- buncle (Fig. 259) , evident when the strapping is removed, is as remarkable as it is gratifying. Seldom more than two or at most three strappings are re- quired to convert an angry volcano into a superficial ulcer, which readily heals under bland ointments. (3) Very large carbuncles sometimes may be excised, with benefit: the patient being anesthetized, a circular incision is Fig. 257. — Carbuncle of neck; duration, two weeks; incised a few days ago; no im- provement. Episcopal Hospital. Fig. 258.— Carbuncle of neck strapped with adhesive plaster. Epis- copal Hospital. _ Fig. 259. — Carbuncle of neck after strap- ping for one week. Only a superficial ulcer remains. Episcopal Hospital. made at the apparent outer border of the carbuncle; this incision is carried down to the deep fascia and muscles, which rarely are 294 SIVWKHY OF THE SKIN involved, and the entire sloughing mass is cut away; bleeding, which may be profuse, is checked by pressure with absorbent gauze, which may be held in place by sutures, and which should not he removed for four or five days. Free stimulation is required after the operation, and skin-grafting may be necessary to secure final cicatrization (Figs. 195, 196.) Tuberculosis Cutis.— The tuberculous lesions of the skin of most interest to surgeons are Lupus Vulgaris, Scrofuloderma, and Erythema Induratum. Fig. 200. — Lupus vulgaris in a girl, aged sixteen years. Four years ago the first lymph node swelling appeared under the chin. There followed tuberculous lym- phangeitis, which involved the skin. Two years ago invasion of nasal mucosa oc- curred, and this led to involvement of the skin over the nose. (Philippson.) 1 — A _^yg ' ,V- * v| ' .':/ mk _*s~ . ■ m A zt& Fig. 201. — Lupus vulgaris of face, in a woman, aged thirty-eight years.; the disease began twenty-three years ago in the left cervical lymph nodes. (Phil- ippson,) Lupus Vulgaris. — The tuberculous lesions are seated in the corium, and usually are secondary to an insignificant focus elsewhere. The disease occurs in young persons of scrofulous tendencies, is most frequent in the face, and appears as one or several minute red papules, tender but not appreciable to touch, which on examination are found to be covered by a thin pellicle of altered skin, giving them, when the blood is pressed out by application of a glass slide, a close resem- blance to drops of apple-jelly. The overlying pellicle is soft and easily punctured, the probe or scalpel sinking for some millimeters into the diseased area. These nodules may coalesce, the patch spread- ing eccentrically and healing in the middle, and thus bearing some resemblance to certain of the syphilodermas; but the apple-jelly nodules can be seen in the advancing border of the lupus patch. BR Y THE MA NO DOS I LM 295 When lupus ulcerates (lupus exedens, as distinguished from simple lupus, or lupus non-exedens) , the surrounding tissues may be widely destroyed, but the ulcer always remains superficial; its outline is rounded, its edges are not indurated, and its course is very slow (Figs. 260 and 201). Diagnosis. — This must be made by careful examination to detect the apple-jelly nodules, by attention to the clinical history of the patient, and by exclusion of syphilis, epithelioma, or other rarer ulcerations of the skin, all of which usually occur in older patients. Lupus erythematosis, thought by many to be due to toxins of tubercle bacilli lodged elsewhere in the body, is sufficiently characterized by its usual butterfly outline, its persistent redness, the absence of the apple-jelly nodules, and its unulcerated condition. Treatment. — The treatment includes constitutional anti-tuberculous measures (p. SO), and local remedies. The latter, whenever possible, should consist of excision, replacing the loss of tissue by skin-grafting or a plastic operation (p. 240). If excision cannot be done, the diseased spots should be gouged out with a sharp spoon, and the cavities left treated with strong antiseptics or caustics. Radiography is of value in some mild cases, as is the use of radium, Finsen light, etc. Scrofuloderma. — Scrofuloderma is the name given to the tuberculous lesion of the skin which results when this is invaded by a tuberculous pro- cess in an underlying structure, as a caseous lymph node. The condition was referred to at p. 78, Fig. .36. Erythema Induratum or Bazin's Dis- ease (1855) is a paratuberculous affec- tion usually of the calves of the legs of growing girls with a scrofulous taint ; it appears as multiple bluish-red indu- rations, resembling somewhat both furuncles and syphilitic gummas, which tend to soften and discharge, leaving indolent and very painful ulcers. These can be made to heal only by improv- ing the general health. Erythema Nodosum. — Erythema no- dosum is mentioned merely to warn the student not to mistake its lesions for contusions or abscesses. The affec- tion usually is bilateral, occurs in chil- dren, and in most cases the shins are affected (Fig. 262), though sometimes the lesions appear over the subcutaneous surfaces of the ulnae. There is no history of trauma; there is more constitutional disturbance than from bruises; and often Fig. 262. — Erythema nodosum. One week's duration, following staphylococcic infection of finger and complicated by endocarditis. Temperature, 100.4° F. Episcopal Hospital. 296 SVRGMRV OF THE SKI \ the disease is one manifestation of an infection (perhaps some atten- uated form of tuberculosis) which canses endocarditis, pleurisy, multiple arthritis, etc. Acne Rosacea. Sec p. 667. Epithelioma. Sec p, 670. Fig. 263. — Sebaceous cyst of scalp; duration thirty years. Epis- copal Hospital. Fig. 264. — Sebaceous cyst of ear. Episcopal Eospital. Sebaceous Cyst (Steatoma, Wen).— This is a retention cyst, due to occlusion of the orifice of a sebaceous duct. The cysts, which may be multiple, occur mostly in the scalp and face (Figs. 263 and 264); Fig. 265. — Sebaceous cyst of ear excised. (See Fig. 264.) Fig. 266. — Dermoid cyst of scalp. Children's Hospital. on the extremities, and especially below the level of the umbilicus they are extremely rare. The skin is adherent to the cyst at one point, the orifice of the duct, sometimes visible as a black dot; the cheesy, malo- dorous sebum usually can be squeezed out, after inserting a probe into WOUNDS OF BURS.K 297 the duct. These cysts frequently become inflamed and suppurate; when they discharge spontaneously, a bleeding fungous mass protrudes which may be mistaken for a malignant papilloma; and carcinomatous changes are not unknown (p. 597). If the discharge of sebum crusts on the surface, a cutaneous horn (p. 291) may develop. Some seques- tration cysts (p. 131) are clinically indistinguishable from sebaceous cysts (Fig. 266). Treatment. — Wens are removed easily, under local anesthesia, by dividing the overlying skin and dissecting the unruptured sac from the subcutaneous tissues, to which its adhesions are light. Recurrence is frequent unless all the cyst wall is removed. If of large size some of the overlying skin may be excised. Pilo-nidal Cysts and Fistulse. — These are a form of sequestration cysts, mentioned at p. 131. They occur most often in the region of the anus, and may be congenital or acquired. According to Hodges (1880) only the sinus is congenital, and the hairs work their way in during post-natal life, finally occluding the orifice of the sinus and forming a cyst. Suppuration is frequent. Excision is the proper treatment (Klemm, 1909). INJURIES AND DISEASES OF BURS^I. Wounds of Bursse. — If the bursa opened communicates with a joint, serious consequences may follow; and as, in the case of a bursa which sometimes communicates with a joint, the fact of its non- communication can never be known a priori, all such cases should Fig. 267. — Prepatellar bursitis; two months' duration; subacute onset. Epis- copal Hospital. Fig. 26S. — Olecranon bursitis, two months' duration; no acute trauma. Epis- copal Hospital. be treated as if a joint were involved (p. 423). If the wound is a puncture, it should be enlarged, after suitably cleansing the part; and foreign matter should be extracted, the bursa drained, and local and constitutional rest provided. If no infection follows, the bursa will heal with partial or complete obliteration of its cavity. If suppu- ration occurs, antiseptic applications or irrigations should be adopted so 298 IXJl /,'//<> AM) hlSKASKS OF Blh'S.F soon as it is evident that no progress toward healing is being made merely by drainage. Finally, the bursa may be excised it' continuance in conservative treatment is ineffectual. Bursitis. Bursitis, or inflammation of a bursa, usually follows contusions, and may be acute or chronic. Acute bursitis follows slight continuous, or frequently intermitted trauma, as in the retro- calcaneal bursa (Achillobursitis or Albert's disease, 1893), or in the olecranon bursa in those confined to bed, with gouty tendency. Relief of pressure, evaporating lotions, and rest, usually cause subsidence of the inflammation in a few hours. If suppuration occurs, early free incision should be made. Chronic Bur- sitis, which follows slight but continually repeated trauma, may be a sequel of acute bursitis or may be chronic from the start. The bursse most often af- fected are: (1) Prepatellar ("Housemaid's Knee," Fig. 267); (2) Olecranon ("Miner's Elbow," Fig. 268); or (3) the bursa over the Tuber Ischii ("Weaver's Bottom"). Fig. 269. — Inflammation of bursa beneath tendo patella?, bulging on inner side of tendon. Acute onset three days ago, from acute flexion of knee. "Dis- persed" by a blow. Episcopal Hospital. Fig. 270. — Ganglion in bursa of biceps brachii at insertion. Episcopal Hospital. Other bursa? sometimes affected are: (4) Subacromial Bursa (see Periarthritis, p. 507); (5) that beneath the Tendo Patellae (Fig. 269) ; (6) those over the Femoral Condyles (see Ganglion of Popliteal Space, p. 314); (7) Subgluteal Bursa; (8) that over the head of the first metatarsal bone (see Bunion, p. 290, and Hallux Valgus, p. 592) ; (9) between the tendon of the Biceps and tuberosity of the Radius (Fig. 270). By coagulation of the effused fluid, solid enlargement of a bursa may occur. Treatment. — Treatment of chronic bursitis consists in removal of the cause, application of sorbefacient ointments, painting with tincture of iodin, etc.; and, these failing, in tapping and injection of 2 per cent, formalin-glycerin solution or dilute alcohol (never when joint-communication may exist), in incision and drainage (when healing will occur by obliteration of the sac), or in excision which is best in most cases, especially those of long duration with thick sac walls. LYMPHADENITIS 299 INJURIES AND DISEASES OF THE LYMPHATICS. Wounds. — Wounds of the lymphatics are of little moment except when the thoracic duct is injured, as it may be in operations on the neck. If this accident is discovered when the wound is inflicted (by a discharge of milky fluid in the wound — lymphorrhea), an attempt should be made to apply a lateral suture. If this is impossible, both ends of the duct should be ligated; and this failing, the wound should be tamponed. If the injury is not discovered at the time of operation, it soon makes itself manifest by a discharge of chyle from the wound, and by rapid and progressive emaciation. There should be no delay in reopening the wound and suturing or ligating the duct. Fredet (1910) collected 58 cases of injury to the thoracic duct, with five deaths. Lymphorrhea. — Lymphorrhea may also occur from wounds of lymphangiectases (p. 300). Chylothorax and Chylous Ascites occasionally follow rupture from contusion of the thoracic or abdominal portions of the thoracic duct. Repeated tapping of the thoracic or abdominal fluid has resulted in cure in a few cases. Certain chylous cysts of the mesentery (Chapter XXIII) have a similar origin. Chyluria may result from communica- tion with the urinary tract. Lymphangeitis or Angeioleucitis, inflammation of lymphatic vessels, usually is due to spread of infection from a wound. It is seen most often on the extremities, but I have seen it on the abdomen as a result of omphalitis. There are one or several flame red, irregular streaks running from the site of infection (felon, lacerated wound, etc.) up to the axillary or inguinal lymph nodes; these streaks coalesce here and there to form broader red bands, and may again separate before reaching their terminus (Plate I, Fig. 1, p. 66). They are not particu- larly painful or tender, seldom are palpable, and are redder and less reg- ular in their course than veins in cases of phlebitis (p. 270). There is considerable fever, chills may occur, and lymphadenitis usually co-exists. Treatment consists in cure of the focus of infection; in local rest by splints, confinement to bed, etc., and in applications of silver nitrate, dilute iodin, ichthyol, etc., along the course of the inflamed lymphatics. Suppuration frequently occurs in the lymph nodes, but seldom along the lymph vessels. Lymphadenitis. — Lymphadenitis, or simply "adenitis," occurs as an incident in cases of lymphangeitis, but may also occur when no evidences of superficial lymphangeitis exist. Thus femoral or inguinal adenitis (bubo) frequently follows a blister of the foot, or venereal or other infection of the genitals, when no sign of lymphangeitis can be detected (Fig. 271). Epitrochlear or axillary adenitis may arise from a slight abrasion or punctured wound of the hand which healed before the secondary lesion was noticed. The symptoms are those usual in inflammation, and the tender, enlarged lymph nodes are distinctly palpable. Suppuration is not unusual. Secondary invasion by specific 300 l\.n /,•//•> AND DISEASES OF THE LYMPHATICS microbes (chancroidal, tuberculous) may occur, and somewhal changes the character of the lesion. Any lymphadenh is which assume- a sub- acute or chronic course is liable to infection with tubercle bacilli through the blood- stream. This is especially true of cervical adenitis (p. 725). Chancroidal bubo is discussed in Chapter XXVI. Treatment. Treatment of adenitis im- plies cure of the source of infection; anti- phlogistic applications to the seat of adenitis; early incision in case of suppura- tion; and finally formal excision of the diseased mass of lymph nodes if the re- sulting sinus fails to close under conserva- tive treatment or if the lymph nodes remain enlarged and tender without the occurrence of suppuration. Lymphangiectasis. — Lymphangiectasis, or dilatation of lymph channels, results from obstruction to the flow of lymph. This may be due to external pressure (as from tumors or cicatrices); to operative removal of the nodes draining the part; or it may be caused by chronic lymphan- geitis, causing obliteration of the main lymph vessels, often following repeated attacks of erysipelas, etc. It is much rarer as a consequence of external pressure than is phlebectasis (p. 274), because the lymphatic collateral circulation as much freer. Sometimes it affects the spermatic cord, constituting a lymphatic varicocele. When a distinctly localized swelling is formed, it is known as lymphangeioma; this occurs oftenest as a congenital condition in the face or neck, but may develop in adult life (Fig. 272). It forms a soft fluctuating swelling, covered by healthy skin. Excision is the proper treatment, but if complete extirpation is im- possible, a partial operation entails great risk of lymphorrhagia, with malnutrition; in such cases galvano-puncture may be tried. Macromelia, or giant growth of a part, usually is a lymphangei- omatous condition; one finger, the lips, the tongue, etc., may be affected. Lymphedema results from lymphangiectasis and consists of thick- ening of the subcutaneous tissues from the effused fluid with cellular reaction. The superficial and deep lymphatics have no communi- cation except through the lymph nodes; at all other sites the deep fascia is an impermeable barrier (Kondoleon, 1912). The edema thus is limited by the ski i abow and deep fascia beneath. It occurs principally in the lower extremity (Fig. 273), often associated with chronic ulcer (Fig. 274), or in the upper extremity following ablation Fig. 271. — Femoral lymph- adenitis; duration, two days; from infected wound of left foot two weeks ago. Episcopal Hospital. /. YMPHAXGIECTASIS 301 of mammary carcinoma and axillary lymphatics (Fig. 824). Heredi- tary persistent edema of the legs (Fig. 275), which has been studied by Fig. 272. — Lymphangioma of right foot, aged seventy-five years; duration, seven years. Orthopaedic Hospital. i 1 f[ f Fi( 273. — Lymphedema; duration, one year. Episcopal Hospital. Jopson (1898), is believed by Hope and French (1908) to be a vascular neurosis, causing hard edema, which terminates abruptly at the knee or groin, there being no evidence of venous or lymphatic obstruction; but the result is very like lymphedema. If palliative treatment (bandaging, mas- sage, administration of thyroid extract, etc.) fails, various operative measures may be undertaken. Excision of strips of deep fascia (7 by 15 cm.) was successful in 7 patients under the care of Kondoleon. Lymphangeioplasty (Handley, 1908) consists in inserting long strands of silk in the subcuta- neous tissues from the hand or foot to the axilla or groin; these act as capillary drains and rapidly reduce the edema. But many recurrences have been reported. Lanz (1911) drilled holes into the medulla of the femur and inserted into them strips of fascia lata still attached by one end, thus creating new channels of drainage through the marrow cavity tation is the last resort. Fig. 274. — Lymphedema with decubitus in a woman twenty-three years of age; unable to stand. Ulcer healed and patient walking after tak- ing thyroid extract for two weeks. Episcopal Hospital. Ampu- 302 INJURIES AND DISEASES OF THE LYMPHATICS Elephantiasis Arabum is a form of lymphedema due to obstruction of lymph channels by filaria sanguinis hominis, the disease being called filariasis. The parasite is transferred from patient to patient through a mosquito as intermediary host. In the patient the half grown parasites lodge in the peripheral lymphatics, there become mature and produce offspring. The embryos enter the blood-stream, but appear in the peripheral circulation only at night; when the patient is at rest they are readily abstracted thence by the mosquito. Elephantiasis affects the lower extremities and the scrotum more often than other parts of the body. It is rare in this country, except Fig. 275. — Persistent hereditary edema af- fecting two brothers. (See Fig. 276.) (Dr. Jopson's cases). Children's Hospital. Fig. 276. — Persistent hereditary edema, in two brothers. (See Fig. 275.) (Dr. Jopson's cases). Chil- dren's Hospital. in persons recently returned from the tropics. Treatment: Palliation is secured by support, bandaging, etc., but excision usually is indi- cated. Amputation may be necessary. Hodgkin's Disease (1832) (Malignant Lymphoma, Lymphomatosis, etc.). This, according to Adami, is a condition 01 the lymph nodes comparable to keloid in the skin — "an excessive overgrowth of the lymphoid stroma secondary to a minimal or unrecognized irritation." The disease was referred to in the chapter on Tumors (p. 115); it appears to occupy a place midway between the infectious granu- lomas and pure tumors. Yates and Bunting (1915) believe it is an HODGKIN'S DISEASE 303 infectious granuloma, developing first in related lymph nodes (espe- cially those of neck, groin, axilla) from some slight lesion of skin or mucous membrane. It presents what some consider a typical histo- logical picture — endothelial proliferation, giant and eosinophile cells. It is permissible to excise some tissue for diagnosis. Sometimes it resembles tuberculosis of lymph nodes (tuberculous infection may be secondary), at others it approaches lymphosarcoma in type. A number of observers have found in the affected lymph nodes a Gram- staining, non-acid-fast, polymorphous diphtheroid bacillus. Symptoms and Treatment. — It affects young adults, especially males, the cervical lymph nodes usually, those of groin or axilla rarely, being first enlarged (Fig. 277) . The axillary, inguinal, abdominal, and thoracic nodes are subsequently affected; even the spleen becomes enlarged. The masses are not inflammatory in character; do not adhere to the skin; the individual nodes remain discrete a long time; suppuration is unknown; enlargement is progressive, though temporary remissions may occur. Severe anemia accompanies the disease; the patient is feverish, listless, becomes dyspneic, weak, emaciated, and dropsical. There is no hyperleukocytosis in early cases, the only marked blood change being reduction in the amount of hemoglobin. 1 The most distressing symptoms are those due to pressure of the immense masses in the neck and mediasti- num, and it is usually for such effects only that surgical treatment, consisting in excision, has been recommended. Yates, however, advocates early block dissection, as for cancer, of the primary group of lymph nodes affected. After the removal of the main bulk of diseased tissue, he finds that .r-ray treatment may improve other groups of enlarged nodes; and he reports some patients apparently well after intervals of five years. Burnham (1919) finds radium very useful, even without operation. Treatment by vaccines made from the bacillus mentioned above has been attempted by Billings and Rosenow (1913) with rather encouraging results. Untreated, and in many cases in spite of all treatment, the disease tends toward a fatal termination, its duration being measured by months rather than by years. Fig. 277. — Hodgkin's disease affecting the neck and both axillse. (Dr. J. Ashhurst, Jr.'s case.) Uni- versity Hospital. 1 Yates and Bunting, however, recognize typical blood changes: always an increase in the number of blood platelets (unless exhaustion of bone marrow occurs), with forms which are abnormally large; and either a relative or absolute increase in the so-called transitional cells. In advanced cases they assert the leukocytes may be increased even to 100,000; and that the transitionals always outnumber the lymphocytes, being more than 8 per cent, of the differential count except in cases of very high leukocytosis. 304 INJURIES AND DISEASES OF MUSCLES Lymphosarcoma. — Lymphosarcoma was referred to at p. 11"). Theoretically we may distinguish (1) True Lymphosarcoma, from sarcomatous proliferation of the connective tissue cells of a lymph node; (2) Malignant Lymphoma, from malignant proliferation of lymphocytes in the lymph node; and (3) Lymphoma Sarcomatodes, indicating secondary (anaplastic) sarcomatous change in the lympho- cytes of a benign lymphoma (p. 115). The distinction is difficult histologically and impossible clinically. The disease may occur in the mediastinum or neck; tends to spread locally, to ulcerate, and to produce death by pressure, hemorrhage 1 or cachexia; internal metastases (liver, lung) may occur early, due to the invasion of veins by the original tumor; involvement of other groups of superficial lymph nodes is very unusual. Diagnosis. — Diagnosis is difficult: it may be distinguished from Hodgkin's disease by the rapid growth (weeks rather than months), the unilateral rather than bilateral involvement, the tendency to ulceration, and the persistently local character until the last stages; from tuberculosis of lymph nodes by the greater firmness, and absence of caseation and suppuration even when ulceration has occurred. Treatment is of little avail; excision should be attempted, especially to relieve pressure effects; but complete removal is difficult and recur- rence usually is prompt. Radium and .r-ray therapy find here their legitimate field. Carcinoma of Lymph Nodes is secondary to a primary focus else- where. In the neck, it should not be confused with a branchiogenic carcinoma (p. 731), which is primary in epithelial rests which may be scattered among lymph nodes and may invade them very early. So-called primary carcinoma of lymph nodes really is an endothelioma. INJURIES AND DISEASES OF MUSCLES. Wounds of Muscles —Little more need be said of these than what is contained in the discussion of wounds in general (p. 102). Sutures do not hold very firmly in muscular tissue alone; therefore mattress sutures are used, and in the case of transverse division of the muscular fibers the overlying fascia (muscular sheath) is included in the sutures when possible. The cicatrix formed in a muscle may somewhat impair its contractility, but the disability is slight unless the scar is adherent to the skin or bone or unless the motor nerve has been severed. The sheath of a muscle may be ruptured by external injury (con- tusion) or possibly by violent muscular contraction; the belly of the muscle, when relaxed, may then protrude through the rupture, con- stituting a muscular hernia. Such a protrusion is made to disappear by passive elongation of the muscle or by its active contraction (Fara- beuf, ISM i. Some forms of ventral hernia (Fig. 857) are of this 1 The hemorrhagic sloughing ulceration constitutes one form of the Fungus Hematodes of the older writers. MYOSITIS 305 nature. The diagnosis is based on the history of trauma and the appearance of an abnormal protrusion only when the muscle is relaxed; sometimes when the muscle is relaxed, the aperture in its sheath is palpable. Most cases so diag- nosed are some other condition, such as rupture of the muscle as well as of its sheath (see be- low) or the presence of an intra- muscular lipoma. In both these cases, contraction of the muscles produces a swelling, while its relaxation causes the swelling .© Fig. 278. — Diagram representing a cube of extensive rupture of the abdominal wall com- plicated by fracture of the iliac crest. The shaded area indicates the extent of the re- sulting hematoma. (See Fig. 279.) Episcopal Hospital. Fig. 279. — Rupture of abdominal wall and fracture of pelvis, after opera- tion. (See Fig. 278.) Episcopal Hos- pital. almost if not altogether to disappear. Treatment consists in suture of the rent. Rupture of a Muscle, much rarer than rupture of its tendon (p. 809), usually results from violent muscular contraction, without external injury. The abdominal muscles, however, may be ruptured sub- cutaneously by a crushing accident (Fig. 278). The lesion is sub- cutaneous, and when due to muscular action alone occurs oftenest in patients with rheumatic or fibrotic tendencies. When a long muscle, such as the biceps brachii or quadriceps femoris, is affected, there is a distinct hollow perceptible between the retracted ends, and this becomes more evident during voluntary contraction. Func- tional impairment may be marked. Treatment. — Treatment consists in suture of the muscle and its sheath. Myositis. — Myositis, or inflammation of a muscle, is frequent in rheumatism and as the result of contusions. Septic myositis occurs 20 300 INJURIES AND DISEASES OF MUSCLES becomes swollen, of almost wooden Suppuration is un- Fig. 280.— Myositis of left quadriceps femoris; unknown cause; duration, five weeks. Aged fifty-three years. Epis- copal Hospital. by invasion from a neighboring focus (bone, joint, lymph node), or as a metastatic infection in pneumonia, typhoid fever, etc. In such cases the ordinary symptoms of inflammation are present, and suppura- tion, with extrusion of sloughs (necrotic masses, p. 58), is the rule. In traumatic myositis the muscle painful, tender, and hardness (Fig. 280). usual. Treatment. — Treatment comprises rest, with application of sorbefacient ointments; anti-rheumatic remedies internally may relieve pain. Acupuncture and wet cup- ping may be tried. Massage is beneficial when acute symptoms subside. Meta- static abscesses in muscle require prompt evacuation. Myositis Ossificans occurs in two forms, the stationary and the progressive. 1. Myositis Ossificans Traumatica, the stationary form, is due to injury, usually following sprains, luxations, repeated slight contusions, etc. If small fragments of periosteum have been detached, it is possible that these may cause bony grow r th in the muscles or tendons surrounding a joint; but it is held by some that the muscle cells themselves or those of the perimysium may produce bone. The disease occurs in the adductor muscle of the thigh ("rider's bone"), in the deltoid from shouldering a musket, in the brachialis anticus (Fig. 281) following dislocation of the elbow, in the tendo Achillis following sprains, etc. The diagnosis rests on a history of injury, and on the existence of a localized, tender, hard, more or less movable mass in the body of a muscle or tendon. The x-ray usually is necessary to confirm the diagnosis. Proper treatment is excision of the bony mass, unless this shows a tendency to retrogress spontaneously when the part is put at rest. 2. Myositis Ossificans Progressiva is an obscure affection, perhaps due to auto-intoxication, beginning in the first ten years of life and progressing slowly "with intervals of quiet, death occurring in ten or twelve years — either from some intercurrent disease, especially bronchopneumonia, or from inanition due to involvement of the masseter muscles." (W. Walker, 1908.) The thumbs and great toes usually have a congenital deformity (microdactylia) consisting in shortening of the metacarpal or metatarsal bones, sometimes with ankylosis of the phalanges (Fig. 282). The muscles oftenest affected are in the trunk, the upper extremity, and the neck, especially the tra- pezius, latissimus dorsi, sterno-mastoid, and shoulder muscles (Fig. 283) . The disease begins with soreness and stiffness in the affected muscles, CONTRACTURES OF MUSCLES 307 Fig. 281. — Skiagraph of myositis ossificans traumatica. New-formed bone in brachialis anticus muscle. Aged twenty-one years. Episcopal Hospital. attended by local cyanosis and doughiness. After weeks or months another exacerbation occurs, and finally bony masses become palpable and demonstrable by the x-ray. No treatment has been of any avail. Contractures of Muscles resulting in limitation of articular motion (false ankylosis), follow rheumatic, gouty, or other inflammations, but are of special interest to surgeons in cases of infantile palsy or patients with bone and joint disease. Weight ex- tension, the use of a Stromeyer splint (for making graduated flexion or exten- sion by means of a double-threaded screw), elastic traction, massage, pas- sive motion, etc., sometimes are efficient in overcoming the deformity, but not infrequently mobilization under anes- thesia, or myotomy and tenotomy are required. If the joint capsule is the FlG . 2 82. — Microdactylia in a Seat of contracture, it mav have to be case of myositis ossificans progres- , , /n tt r>oj i nrx- \ siva. (Dr. Warren Walkers case.) incised also. (See Ings. 284 and 285.; children's Hospital. :;os I \. I DRIES AX l> DISEASES OF MUSCLES Ischemic Contracture (see p. 583). Trichuriasis. — Ingestion of the embryos of trichina spiralis, a parasite infesting uncooked pork, is followed by their migration to and development in the muscular tissues. Within a week or ten Fig. 283. — Myositis ossificans progressiva showing deposits in muscles of back. (Dr. Warren Walker's case.) Children's Hospital. Fig. '-'84. — Contractures of ilio-psoas muscles following neglected case of Pott's disease of spine. Children's Hospital. Fig. 285. — Contractures of feet, following paralysis of extensor muscles from fracture of tenth and eleventh thoracic vertebrae, five years previously. Episcopal Hospital. days after eating the contaminated food, the patient is attacked with muscular soreness, widely distributed, which frequently is regarded as rheumatic. Diarrhea often is present, and fever is usual. Examination of the blood shows eosinophilia (even as high as 50 SUBCUTANEOUS RUPTURE OF TENDONS 300 per cent.)- Microscopical examination of excised muscular tissue confirms the diagnosis. Beyond purgation, treatment is of little value; and the duration of the disease appears to be self limited to a few weeks. Tumors of Muscles. — Rhabdomyoma and leiomyoma have been discussed at p. 115. Desmoids are tumors growing from muscle or fascia, usually of the abdominal wall, analogous to keloids in the skin. They usually are single, oftenest arise after pregnancy or in an operative cicatrix, and sometimes recur after extirpation, assuming sarcomatous characteristics. INJURIES AND DISEASES OF TENDONS. Wounds of Tendons. — Wounds of tendons are of frequent occur- rence, and often are followed by marked disability, owing to adhesion of the tendons to their sheaths, to each other, to the skin, to bone, etc., even if careful primary suture has been done. Tendons retract when divided, and the surgeon must not hesitate to enlarge the original wound to find the divided ends. Usually it is better to administer a general anesthetic, especially in wounds of the flexor tendons above the wrist. Mattress sutures are preferable, and if the ends cannot be made to meet, tendon lengthening ma}' be employed (Fig. 308). Free transplants of tendons (p. 240) are not often suc- cessful in recent injuries. Fig. 286. — Rupture of long head of biceps brachii, forty-eight hours after accident, from violent contraction while leading unruly horse by halter. Dr. G. G. Davis's case. Orthopaedic Hospital. Subcutaneous Rupture of Tendons is more frequent than that of their muscular bellies. Usually it occurs only in already slightly diseased tissues, especially in cases of periarthritis (p. 507), dystrophic arthritis, etc. Following a sudden strain, the patient is conscious of something giving way, perhaps with an audible snap; severe stinging pain occurs, and the part is disabled. Ecchymosis appears subsequently, and when the affected muscle is voluntarily contracted, a characteristic deformity is seen, owing to the loss of attachment of the tendon. The biceps brachii, especially its long scapular head, (Fig. 280), and the quadriceps femoris are often affected; rupture of one of the tendons of the extensor longus digitorum near its insertion 310 tNJURlES AND DISEASES OF TENDONS in the finger is not unusual (Fig. 287). So-called rupture of the plan- taris probably is not as frequent as supposed (p.274). [n the pha- langes, firm bandaging on a splint for several weeks may prevent permanent deformity or disability; in other eases the affected tendon should be sutured. Dislocation of Tendons may be patho- logical or traumatic. The former is more frequent, and is secondary to changes in the contour of the neigh- boring joints, or to peri-arthritic lesions causing obliteration of the natural Fig. 287. — Rupture of tendon of extensor longus digitorum to fifth finger; from fall on hand two months ago. Episcopal Hospital. Fig. 288. — Luxation of pero- neal tendons in front of external malleolus of left foot, following paralytic calcaneus. Orthopaedic Hospital. groove in which the tendon lies. In cases of infantile paralysis with marked calcaneus deformity the peroneal tendons may be luxated anterior to the external malleolus (Fig. 288); in cases of knock-knee or simple relaxation of tissues around the knee- joint, outward luxation of the patella may occur (p. 448); in peri- arthritis of the shoulder, inward dislocation of the long head of the biceps sometimes is seen, allowing a subluxation forward of the head of the humerus. These deformities may be remedied by operation if dis- ability is marked. Correction of any predisposing deformity is the first step. In the case of the patella a suitable knee-cap may give relief, or the inner portion of the capsule may be pleated on itself, or the point of insertion of the tendo patellae may be shifted inward. The capsule of the shoulder may be pleated, and the biceps tendon shortened. Strains of Tendons are of frequent occurrence. Minute extrava- sations occur among the ruptured fibers, and the tendon is swollen, painful, and tender. Schanz (1905) has called particular attention to traumatic inflammation of the tendo Achillis, which often is mistaken for achillodynia (p. 298). Some cases of "trigger finger" (p. 586) may have a similar origin. The treatment is rest during the acute stage, followed by massage. Tenosynovitis or Thecitis is the name given to a form of inflam- mation of tendon sheaths usually caused by repeated trauma (strains), PARONYCHIA OR PANARIS 311 in those predisposed to rheumatic conditions. It occurs oftenest in the extensor tendons at the wrist, but is also seen at the ankle, and elsewhere. There is a fine crackling and creaking, appreciable on palpation and sometimes audible, whenever the affected tendons are moved; this is caused by effusion of plastic lymph between the tendon and its sheath. The disease never progresses to the stage of suppuration. Poncet considered it of tuberculous origin. Treatment. — Treatment consists in splinting the part and applying ointments - of ichthyol or of belladonna and mercury, iodin, etc. Local rest should be insisted on until physical signs have been absent for a week at least; otherwise recurrence is usual. With prompt treatment work generally may be resumed in a few weeks. Tuberculosis of Tendon Sheaths usually is secondary to tuber- culous synovitis or arthritis (p. 519). See also Tuberculous Ganglion, p. 315. Paronychia or Panaris. — This is a rather vague term, denoting a septic inflammation about the finger tips (very rarely of the toes). (1) Properly speaking, it implies an inflammation about the matrix of the nail, usually starting in children from a hang-nail (agnail), and appearing as a red, tender, swollen, semicircle around the base of the nail. Hot boric acid fomentations may arrest the inflammation if applied early. As soon as suppuration is suspected, a longitudinal incision should be made on one or both sides of the nail (Fig. 289), involving neither the nail itself nor the cuticle at its base. The flap so outlined is raised from the nail, discovering the sup- puration around the matrix, under the nail. The latter must now be raised and partly excised. The distal part of the nail may be left intact, and will be pushed gradually out by the new-formed nail growing as the suppu- FlG - 289- — incisions for ...,1,1 , • . • , • /r4N paronychia (index fin DISEASES OF TEXDO.XS of these fingers, and infection may travel along them to the web of the fingers, the pus pointing here on the dorsal aspeet. This is almost the only lesion which causes bulging or even merely obliteration of the palmar concavity. It is best drained by an incision in the palm from the web between the third and fourth ringers up about 4 cm.; the space (lying- deeper than the tendons) is then opened by Hilton's method (p. 50). (c) Envel- oping the ulnar side of the -flexor tendons Fig. 29G. — Bilocular ganglion Fig. 295. — Ganglion on extensor surface of wrist (see excised from wrist (see Fig. Fig. 296). Episcopal Hospital. 295). Episcopal Hospital. is the ulnar bursa, commonly involved by extension from the fifth finger, (d) On the dorsum of the hand is the subaponeurotic space, lying between the extensor tendons and the bones, and continuous distally with corresponding spaces in the fingers, and connecting also w T ith the palmar spaces along the lumbrical muscles. (5) Necrosis of the distal phalanx (usually not extending to its base) often com- plicates a neglected paronychia or digital abscess, and requires ampu- tation. Necrosis of other phalanges or metacarpals is rare unless the infection originated in a compound fracture. Fig. 297. — Tuberculous ganglion of right wrist and palm (hour-glass swelling). Aged forty-two years; duration, five years. Orthopaedic Hospital. Ganglion. — A ganglion is a cyst developed in connection with a tendon sheath, or from the subsynovial tissues of a joint capsule. Its pathogenesis is not well understood, but probably is a degenerative change (Clarke, 1908). Frequently slight trauma has occurred, but often no such history can be obtained. Ganglia occur oftenest in GANGLION 315 women, being especially frequent on the extensor surface of the wrist (Fig. 295) ; they are seen less often at the ankle or in the palm of the hand (Fig. 297) and certain bursal enlargements seem clini- cally identical with ganglia (Figs. 270 and 298). Occasionally a ganglion con- tains rice-like bodies, similar to "joint- mice" (p. 502, 520); and sometimes a ganglion is frankly tuberculous; this is especially apt to be the case in "com- pound ganglia," where the cystic mass is more or less lobulated, possibly as the result of the coalescence of several distinct ganglia. Syphilis, usually in the secondary stage (Verneuil, 1868), rarely congenital, may also cause bursal or ten- osynovial disease (Coues, 1915). Treatment. — A small ganglion may be dispersed by a smart blow with a heavy book, the part being splinted subse- quently for a week or so; recurrences may be expected in over half the cases so treated. Safer and better treatment is formal excision of the ganglion or aspira- tion and injection of 2 per cent, formalin in glycerin, dilute iodin or alcohol. Tuberculous ganglia never should be treated by attempts at rupture. Syphi- fig. 298.— Ganglia in popliteal litic ganglia usually disappear under space; aged eighteen years ;dura- ■ •? ,• i , i , , tion, over one year. Episcopal constitutional treatment and local rest. Hospital. INJURIES AND DISEASES OF NERVES. Contusion. — Contusion of a nerve produces tingling and perhaps numbness or paralysis in its distribution. A frequent lesion is paralysis Fig. 299. — Paralysis of musculo-spiral nerve from overlying. of the musculospiral nerve (less often of the circumflex) from pressure during sleep {overlying) — most seen after a debauch, the patient having 316 INJURIES AND DISEASES OF NERVES lain stuporous for many hours (Fig. 299). In other cases the lesion results from a sudden blow or fall, perhaps from sudden abduction of the humerus (Fig. 300). Crutch-palsy, affecting the axil- lary nerves, especially the mus- culospiral, is caused by the patient bearing most of his weight on the axilla instead of on his hands, usually because the hand- bars of the crutches are placed too low. Post-anesthetic palsy is due to direct pressure, the arm hav- ing been allowed to hang over the edge of the table (museulospiral, ulnar); or from pressure on the peroneal nerve below the head of the fibula. This latter form of paralysis may result from im- proper application of a gypsum case. As a rule, the only treatment required is rest upon a splint, sup- porting the paralyzed muscles ;with massage, electricity, etc. Subcu- taneous rupture is extremely rare, but in compound fractures or similar accidents a nerve ma}- be crushed, complete destruction of the nerve fibers occurring, and only the sheath remaining to connect the bruised ends of the nerve. The signs of loss of function due to such nerve injuries usually are subordinate to those due to the lesions of the muscles, tendons, and bones; but in all such accidents the surgeon should make tests for sensation and motion in the part supplied by any nerves which possibly might have been injured. Resection of the damaged portion, with end-to-end union of the nerve stumps should be done, as described under Wounds of Nerves (p. 318). Dislocation. — Dislocation of a nerve is rare. Occasionally the ulnar nerve slips in front of the internal condyle, and causes moderate disability. Operation generally is necessary to replace such nerves and consists in restoring normal relations and suturing a layer of fascia over the nerve to hold it in place. Stretching or Laceration. — Stretching or laceration of nerves may occur as a subcutaneous injury. In dislocations or sprains of the shoulder the circumflex, and more rarely the museulospiral nerve, may thus be damaged; or rarely the cords of the brachial plexus may be injured. (See also Neuritis, p. 320, Periarthritis, p. 507, and Birth Injuries of the Shoulder, p. 556.) According to Vandenbossche (1910) it is probable that in most of these latter cases the lesion is in the nerve roots rather than in the brachial plexus. Duval and Quillain Fig. 300. — Paralysis of left circumflex nerve with atrophy of deltoid muscle, from sprain of shoulder five months ago. Patient, aged sixty years, fell twenty-seven feet. Episcopal Hospital. s a !- 6. A/" STRETCHING OR LACERATION 317 (1898) maintained that there were no such clinical entities as paralyses due to lesions of the plexus, only two types existing, radicular and terminal, affecting either the spinal motor roots or the nerve trunks below the plexus. Rupture of the nerve sheaths occurs first, and there is more or less laceration of the nerve fibers themselves; intra- and perineural hemorrhage occurs, with marked cicatricial changes in the surrounding fascia. If no improvement occurs after proper splinting (to take all strain off paralyzed muscles) and persistence in use of massage and electricity for several months; or at once, if complete rupture is believed to exist, the nerves should be exposed by incision, and treated as may be indicated: Neurolysis (dissection from adhesions), neurectomy (when a scar exists which will not transmit the Faradic current) and resuture, or simple suture of the ruptured ends may be required. After-treat- ment is the same as after-operations for wounds of nerves (p. 319). Fig. 3 J I. — Deformity following Volkmann's ischemic contracture and paralysis of ulnar nerve after fracture of elbow. Orthopaedic Hospital. When the motor roots in the neck (above the brachial plexus) are ruptured, Alexinsky (1899) proposed transplanting the peripheral ends of the damaged nerve roots to the opposite side of the neck, and uniting them to the central ends on the other side; a similar operation has been done by Babcock (1907), in a case of anterior poliomyelitis. Muscle and tendon transplantation often will give better results than any operations on the nerves. Wounds of Nerves — These may bean incident in extensive lacerated wounds involving muscles, tendons, and bloodvessels; or isolated injuries due to stab wounds (Fig. 302). The symptoms are complete loss of function in the distribution of the injured nerve; usually this implies loss of both motion and sensation. If only a peripheral sen- sory nerve is divided, sensation may return in time, even if the ends of the nerve are not sutured; this is due in part to regeneration, and in part to collateral circulation, as it were, in surrounding nerve filaments. But unless the ends of a motor nerve are brought into accurate apposition by suture, paralysis of motion will be permanent. After suture, the prognosis is uncertain, though if suture is done soon 318 INJURIES AND DISEASES OF NERVES after the accident {primary suture) more or less complete recovery is the rule (Figs. 303 and 304) ; after secondary suture the results are very uncertain (Figs. 305 and 300). Howell (1S92) collected 84 cases of prim- IB^^^^k] ary nerve suture in civil life, with 12 per cent, successful results, and 40 per cent, improved; and 80 cases of secondary suture, with 38 per cent, successful, and 50 per cent, improved. Souttar and Twining (1918) found among 61 cases of secondary suture for war wounds, 14 per cent, were traced to recovery, 68 per cent, were re- covering, 14 per cent, were doubtful, and only 4 per cent, were failures. Treatment. — A recently wounded nerve should be exposed, and all damaged tissue excised with a sharp knife. Scissors bruise nerves, and never should be used. The ends are then united (neurorrhaphy) with very fine silk or chromic catgut threaded in fine round needles. One suture at least should be passed directly through the nerve, and Fig. 302. — Paralysis of pero- neal nerve following injury of cauda equina in spinal anes- 1 hesia ; seventeen months' dura- tion. Orthopaedic Hospital. Fig. 303. — Recovery after primary suture of musculospiral nerve, for stab wound. Episcopal Hospital. Fig. 304. — Recovery of function after primary suture of musculospiral nerve for stab wound. Episcopal Hospital. tied just tight enough to approximate without constricting the ends; other sutures of chromic gut should then be applied merely through the WOUNDS OF NERVES 319 nerve sheath, to relieve strain, and prevent adhesions of the nerve fibers to surrounding structures (Fig. 307). If for any reason, the ends of the nerves cannot be made to meet (even by free dissection of the nerve trunk above and below the lesion, and by flexing neighboring joints), both ends may be very cautiously stretched, or neuroplasty may Fig. 305. — Stab wound of median nerve just after operation of secondary suture (three months after injury) ; showing inability to flex wrist, index finger, and thumb (see Fig. 306). (Dr. Harte's case.) Orthopedic Hospital. be done (Fig. 308). It is in cases of secondary suture that the largest gaps may have to be spanned, as it is necessary to excise all scar tissue until projecting ends of nerve fibers can be seen in cross-section. 1 A layer of muscle or a free transplant of fascia lata, should then be sutured over the nerve, to protect it; the wound should be closed; and the limb kept at rest for two or three weeks, when light massage, electrotherapy, etc., may be com- menced. Sensation returns long before motion, sometimes within a few days ; but hope of motion should not be abandoned for about a year after suture, unless, of course, it can be shown that the sutures have given way. Under such circumstances the operation may be done over again. In all cases development of deformity must be prevented by splints, braces, passive motion, etc. Re- generation of sutured nerves de- pends on the formation of new axones, which some hold develop from proliferation of neurilemma cells in the peripheral segment, while others maintain that in all cases the axones grow out from the central segment, and have to penetrate the distal segment to its various terminations before function 1 I have had a brilliant result of secondary neurorrhaphy of both median and ulnar nerves by making traction on the bulbous ends until they overlapped (thus spanning a gap of more than 5 cm.), denuding the nerves laterally, and making a lateral anastomosis in healthy nerve tissue. In two cases of neuroplasty (one median and one ulnar), nearly complete function has been restored. Fig. 306. — Recovery of function eight months after secondary suture of median nerve (see Fig. 305) Note power of flexing wrist, index finger, and thumb. (Dr. Harte's case.) Orthopaedic Hospital. )20 INJURIES AND DISEASES OF NEW ES is restored. At present very little credence is given to the former view, but all authorities agree that the proper paths persist in the distal segment waiting to be penetrated by axones from the central segment; and it is this teaching which justifies us in urging late secondary suture. So long as the muscles have not become hopelessly Fig. 307. — Netve suture: one suture passes completely through the nerve; the others pass through the sheath only. degenerated, nerve suture may be successful (after fourteen years, Jacobson). Nerves which have no neurilemma do not regenerate; the nerves of special sense have no neurilemma; nor have the spinal nerves, except peripheral to the spinal ganglia. Neuritis. — Neuritis, as the term usu- ally is understood, implies not a reac- tion to septic infection, but a form of subacute or chronic inflammation due to contusion, to pressure (from cicatrices, callus, exostoses, tumors, etc.), to recurrent trauma (occupation neuritis), to toxic infections (influenza, typhoid fever, etc.), intoxicants (alcohol, lead, etc.), and other less well defined causes. The pathological change is proliferation of the nerve sheath (epi- neurium, perineurium, and endoneu- rium), which compresses the nerve fibers (axones), leading to pain, impairment of function, and various trophic dis- turbances in the distribution of the affected nerve. The nerve trunk is hyperemic, perhaps edematous, swollen, and bulbous. Perineural adhesions are frequently present. Symptoms. — The onset may be sudden, after exposure to cold, after violent exer- tions, or any factor w T hich reduces the patient's vitality. Pain is present in the portion of the nerve diseased, and also shoots along the course of this nerve, usually in a peripheral but sometimes in a central direction. There is tenderness along the course of the nerve, and cutaneous hyperesthesia may be very marked; numbness and a sense of swelling (vaso-motor or trophic disturbances) may be present in the area of distribution. The skin Fig. 308. — Neuroplasty. The proximal segment is split and a flap is turned down and sutured to the distal segment. (Tendon length- ening may be done in similar man- ner. See p. 309.) NEURITIS 321 becomes glossy, appears tense and hyperemia; sweating usually is diminished; incurvation or shedding of the nails may occur (Fig. 309) ; the muscles become atrophic and contractures and reactions of degeneration may develop. The nerve trunks most often affected are those of the brachial plexus, the masculospiral, ulnar, and median, and the sciatic. It must be remembered that the neuritis may be only a symptom of another affection (periarthritis of the shoulder, p. 507; ischemic contracture, p. 583; sacro-iliac or hip-joint disease, p. 57S; etc.). Fig. 309. — Photograph showing trophic changes in finger nails as a result of neuritis of median nerve. January 31, 1907. Episcopal Hos- pital. Fig. 310. — Photograph made eight weeks after neurolysis (from callus at elbow), to show improvement in finger nails. (See Fig. 309). Episcopal Hospital. Treatment. — Treatment comprises, first and foremost, removal of the cause, whenever this can be discovered (callus, tumor, cicatrix, etc.). In all cases rest is of utmost importance, and should always be the first step when no obvious cause exists. Counter-irritation sometimes is of value. The patient's general health should be im- proved. Antiseptics may be administered internally, especially the salicylates. Electrotherapeusis, massage, and baking, are suitable only for the chronic stages, after rest has allayed the acuter symp- toms. In many cases operation is of benefit (Fig. 310), especially neurolysis (dissection of the nerve trunk and even dissociation of its fibers); neurectasy (nerve-stretching) is a less certain operation, though 21 322 INJURIES AND DISEASES OF NERVES aiming to accomplish the same results; neurotomy and neurectomy (except when purely sensory branches are involved) seldom arc justi- fiable until other operations have failed. Neuralgia. — Neuralgia, signifying pain in a nerve for which no pathological lesion can be held accountable, remains an inscrutable problem; and to state, as is often done, that such changes as may be found on microscopical examination of the affected nerve are the result, not the cause of the disease, in no way renders the subject easier to understand. In a word, neuralgia is held to be a functional neurosis. Many cases of supposed neuralgia, however, will be found on careful investigation to be due to referred pain from definite lesions elsewhere. Many are really cases of neuritis. Symptoms. — Its symptoms differ somewhat from those of neuritis; the pain is equally great, but may come and go without apparent cause; it is more burning and aching than sharp and shooting in character; is more influenced by damp weather and exposure to cold; and is unattended with actual changes in the overlying tissues, which are common in neuritis. The tenderness does not extend over the entire course of the affected nerve, but is most intense at certain points ("points douloureux,") especially where the nerve passes through a foramen (intervertebral, supraorbital, mental, etc.), or through the deep fascia; and pressure on the nerve with the palm of the hand relieves rather than aggravates the pain, though pressure by the finger tip or pointed instrument may bring on an exacerbation of pain. Treatment. — Treatment is much the same as for neuritis, which often can be excluded from the diagnosis only after prolonged rest has failed to give relief. Injections of alcohol, osmic acid (1 per cent.), and other substances into or around the nerve have been adopted in many cases with varying results (p. 323). Neurectasis, neurolysis, and even neurotomy and neurectomy may be done. The forms of neuralgia most important to the surgeon are: Neuralgia of the fifth cranial nerve; Brachial Neuralgia (which has been sufficiently discussed under the heading Neuritis); and Sciatic Neuralgia. Neuralgia of the Fifth Cranial Nerve; Tri-Facial Neuralgia or Tic Douloureux. — The pathology of this affection is very little under- stood. Two types are recognized: the minor neuralgia, and the major or epileptiform neuralgia. In the former, which probably is a true neuralgia, there is more or less continuous pain, but it is not exces- sively severe; usually some local or constitutional cause can be found, and on remedying this the neuralgia may stop for a time or permanently. Among such causes are caries of the teeth, sinus diseases, malaria, lead poisoning, chronic nephritis, gout, etc. The major neuralgias, on the contrary, appear to be due to some central lesion which involves the Gasserian ganglion either primarily or by extension from disease of its branches, or possibly by pressure from some intracranial growth. This form of the disease is characterized by progressively severer NEURALGIA OF THE FIFTH CRANIAL NERVE 323 attacks of neuralgic pain, extending over months or years and affect- ing one or more branches of the fifth cranial nerve, with no discover- able cause. The mandibular and maxillary divisions are affected in most cases; the supraorbital branch rarely is affected alone. The attacks may be brought on by a draft of air, by touching the side of the face affected, by putting food into the mouth, etc. The skin may become so hyperesthetic that for weeks or months the patient may be unable to wash his face; he may be unable to eat because of pain aroused in the lingual and inferior dental nerves; and a state bordering on insanity may ensue finally unless relief is obtained. Treatment. — It should be ascertained whether any local or con- stitutional cause for the neuralgia exists; and such conditions should receive appropriate treatment. If the disease belongs to the major neuralgia type no treatment will be of long avail unless it acts directly on the nerves or ganglion itself. The administration of salicylates, quinin, opium, or other drugs may be useful to allay the pain "tem- porarily and thus improve the general health before surgical treat- ment is undertaken. This treatment implies destruction of the nerves or the ganglion, or both. The operations are divided into extracranial or peripheral operations and intracranial operations. Peripheral Operations. — Injection of the nerve trunks with alcohol (Schlosser, 1907) has entirely superseded injections with osmic acid, as originally advocated by Bennet in 1897. These substances, especially alcohol, destroy the nerve at the point of injection, and though regeneration may take place relief is secured for from six to eighteen months, rarely for longer periods. The longest period of relief secured in my own cases was twenty-seven months. Patrick, of Chicago, has had large experience with alcohol injections, which he makes into the second and third branches where they emerge from the base of the skull, and into the first branch at the supra-orbital foramen. He does not attempt to make deep injections into the first branch because of danger to other structures in the orbit. The internal maxillary artery with its branches, including the middle meningeal, is directly in the field of operation and renders deep injec- tions hazardous. But Patrick has had no bad results on this score in 150 cases. The needle is 12 cm. long, 1.75 mm. thick, is not acutely sharp, and is provided with a stylet. To inject the second branch, the needle is inserted at the lower border of the zygoma just in front of the coronoid process of the mandible (0.5 cm. behind a perpendicular let fall from the posterior edge of the orbital pro- cess of the malar bone); it points upward at an angle of about 30 degrees with the horizontal plane (the patient being erect) and at a right angle with the sagittal plane; while the third division is reached from a point at the lower border of the zygoma 2.5 cm. in front of its anterior root, the needle entering in the horizontal plane and pointing backward at an angle of 60 degrees with the frontal plane. A tingling sensation in the distribution of the nerve indicates that it has been reached. Usually the nerves must be sought for cautiously by inserting the point of the needle in different directions. 324 INJURIES AND DISEASES OF NERVES The foramen rotundum lies about 5 em., and the foramen ovale about 4 cm. from the surface About 2 c.c. of the solution are injected into each nerve. " If the operator feels satisfied that the needle is in the nerve (he never knows it)," writes Patrick, "less is enough." A local anesthetic is desirable. The injection may be repeated in a few days if the first attempt proves unsuccessful. If bleeding occurs through the needle, the stylet should be replaced and the needle left in situ until clotting occurs. Hartel worked out a method of injecting the Gasserian ganglion, which has been employed in this country by Martin (1915). Avulsion of the Peripheral Nerves (Thiersch, 1889) is a more formidable procedure, and usually secures no longer freedom from pain. The nerves are very slowly avulsed by wrapping them around a forceps, after adequate exposure. The second and third branches of the fifth nerve may also be approached extracranially, at the base of the skull, by various routes, involving more or less tedious and delicate operations. These methods were employed chiefly before the general adoption of alcoholic injections; they are now, I believe, very properly abandoned. Intracranial Operations. — Extirpation of the Gasserian ganglion was proposed by Mears, of Philadelphia, in 1884, and first per- formed by E. Rose in 1890. Rose employed the pterygoid ronte, trephining the base of the skull. Hartley, of New York, and Krause, of Altoona, independently, in 1892, proposed the temporal route, and most surgeons now employ some modification of the Hartley- Krause method. Owing to the difficulty of removing the entire ganglion from the presence of adhesions and its intimate relation with the cavernous sinus, sixth nerve, etc., many of the earlier operations were only partial excisions. To simplify the operation, Abbe (1903), merely divided the second and third branches before they left the skull, and interposed a strip of rubber tissue to prevent their reunion. Spiller (1901) by a happy inspiration suggested to Frazier that section of the sensory root of the ganglion would amount to a physiological extirpation of it, since this root, which is devoid of neurilemma, could not on that account regenerate. This operation, as pointed out by Frazier, is easier, is attended by less hemorrhage, does not expose the cavernous sinus or sixth nerve to injury, leaves the motor root (and consequently the muscles of mastication) intact, and, finally, involves a diminished risk of keratitis, which was so prone to follow removal of the entire ganglion. Frazier-Spiller Operation.- — A flap of soft parts is turned down, care being exercised not to injure the upper branches of the facial nerve. A sufficient amount of bone is then removed from the temporal fossa, with trephine and rongeur, and the dura is raised from the base of the skull.- Frazier always ligates and divides the middle meningeal artery, as it leaves the foramen spinosum. The dura covering the mandibular division of the nerve is then incised, and the ganglion exposed. If the motor root is seen, it should be separated from the sensory; this latter is then divided or avulsed. The brain NEURALGIA OF THE SCIATIC NERVE 325 is then allowed to fall back on the base of the skull, and the soft parts are closed with drainage. The mortality following the operation in the hands of skilled operators is less than 4 per cent. The chief dangers are shock, hemorrhage, and infection. After-care. — For weeks or months after operation the eye of the same side should be most carefully protected by a shield (an automo- bile goggle is suggested by Frazier), as destruction of its protecting nerve supply renders the cornea exceedingly prone to trauma and infection, and many patients have lost their sight from this cause. Sciatic Neuralgia or Sciatica. — This is not regarded as so frequent a lesion now as formerly, since it has been shown that in most cases the disease really is a neuritis, or is merely referred pain due to pelvic Fig. 311. — Sacro-iliac sprain, with relaxation (left side). For eight months pain in left hip, back, and down sciatic. Diagnosed Pott's disease, elsewhere. Orthopaedic Hospital. (Fig. 311) or hip disorders. If no cause of referred pain can be dis- covered, and if rest, antirheumatic drugs, counter-irritation (blistering, cauterization), and other palliative methods are ineffectual, the surgeon may be tempted to adopt operative measures, on the theory that the affection really is a neuritis, from infection or trauma, with perineural adhesions. Neurectasis may be secured without incision by forcibly flexing the thigh on the abdomen with the knee fully extended (the patient being anesthetized); or by exposing the sciatic nerve below the gluteus maximus, either on the inner or outer side of the biceps muscle, and stretching it over the finger both centrally and peripherally; the patient lying on his face it is safe usually to employ traction sufficient just to raise the limb from the table. Neurolysis is a safer and more 326 INJURIES AND DISEASES OF NERVES certain operation; the sheath is opened and the nerve fibers separated from it and from each other for a distance of several inches; Pers (1908) adopted this method 47 times, and among 42 uncompli- cated cases there were only three recurrences. In many cases the adhesions extend up into the sciatic notch, and the completion of the operation may be difficult. Best exposure is secured by splitting the fibers of the gluteus maximus at the level of the great sacrosciatic foramen. Tic Convulsif or Spasmodic Tic is a form of neuralgia, usually not painful, characterized by constant and often severe twitching in the muscles supplied by the affected nerves. In the neck, which is its most frequent seat, it produces spasmodic torticollis (Fig. 653); it also occurs in the face, the shoulder, and very rarely in other parts of the body. Myotomy, neurectasis, neurotomy, and neurectomy have been employed, but the disease always recurs in other muscles, no matter how wide the primary nerve excision may have been. Some neurolo- gists go so far as to maintain that even were the cortical centers governing the region to be excised, neighboring centers would take on diseased action. At present cure of the disease seems hopeless by operation, though the temporary improvement usually secured is not to be despised. Tumors of Nerves. — Fibrous out-growths occur on the ends of nerves in an amputation stump ("amputation neuromas"), appar- ently due to attempts at regeneration: the nerve fibers turn back upon themselves, being unable to make headway forward, and form bulbous masses; if these are caught in the scar they are painful, and usually have a strong tendency to recur if excised, or even after formal re-amputation. Such growths are rare except where the amputation was a bungling operation. Multiple tumors occasionally are formed along nerve trunks or at the terminations of nerve fibrils in the skin (Fig. 58) . This disease is variously known as multiple neuro-fibromutosis (when confined to nerve trunks); von Recklinghausen's disease (1881) or molluscum fibrosum (when occurring in the skin); and Rankenneurom or plexijorm neuroma, which occurs in the form of a circumscribed thick- ening of the skin, due to out-growth of nerve fibrils — a condition most often found in the neck or scalp, sometimes pigmented, and usually congenital. Da Costa (1910) compares the condition of nerves in a plexiform neuroma to that of the arteries in a cirsoid aneurysm. This disease, in its various forms, usually has been considered a form of dif- fuse fibromatosis, blastomatoid in character; but in the second edition of his Pathology (1910) Adami returned to v. Recklinghausen's original theory, and to that of Klebs (1889), which lately has received support from other observers, that these growths originate in the nerve fibrils themselves, and should be classed as Neurinomas. Excision of one or several of the multiple growths may be required for pain or deformity: those on the nerves sometimes may be shelled out with- out destroying the continuity of the nerve trunk. The "plexiform neuroma" sometimes recurs after removal; sarcomatous changes may occur, though they are not very frequent. CHAPTER XII. FRACTURES. The study of fractures is one of the most important subjects which can engage a surgeon's attention; they are injuries which occur constantly, in all classes of life, and under all circumstances. Even a general practitioner cannot avoid having a number of cases under his care every year; and no cases contribute as much to the fame or discredit of the man who treats them. And while it is well recog- nized that the most skilful and assiduous treatment cannot in all cases succeed in giving the patient a useful and comely limb, yet it is sadly true that many of the bad results con- stantly seen are due to sheer ignorance and neglect on the part of the practitioner. Classification. — Fracture of a bone may be complete or incom- plete. The latter form (green- stick fracture) occurs almost exclusively in young children, the bone fibers in the line of extension (convexity) being com- pletely ruptured, while those in the line of flexion (concavity) maintain their continuity (Fig. 312). Fractures may be subcuta- neous (simple) or open (com- pound), the latter term implying that the seat of fracture com- municates with the external air through a wound of the soft parts. Comminuted fractures are those with more than two fragments, the lines of fracture intercommunicating (Fig. 313). They are to be dis- tinguished from double (triple, quadruple, etc.) fractures in which two (or more) separate and distinct breaks are present in the same bone. (327) Fig. 312. — Green-stick fracture of radius and ulna with extreme deformity. Penn- sylvania Hospital. 328 FRAcrr/.-i-s Multiple fracture (Fig. 314) is a term which should be reserved for cases with breaks in more than one bone, the bones ail'eeted not being parallel (like the ribs, those of the forearm, the leg, hand, etc.). Complicated fractures are those attended by some other serious injury of the .same pari, as rupture of the main bloodvessels, crushing of nerves, dislocation of neighbor- ing joint, etc. A fracture of the lower end of the femur may be com- plicated by a fracture of the skull, or by a stab wound of the lung, but such a fracture is not a "compli- cated fracture of the femur" un- less the popliteal artery is ruptured, the knee-joint dislocated, or some other serious injury exists in the immediate neighborhood of the fracture. Fig. 313. — Comminuted fracture of tibia and fibula, a few hours after in- jury. Episcopal Hospital. Fig. 314. — Multiple fracture of upper extremity. Episcopal Hospital. Direction. — Fractures are further classified as longitudinal, trans- verse, oblique, spiral, etc. These terms are self-explanatory and are illustrated in the accompanying skiagraphs (Figs. 315, 316, 317). Transverse fractures are more frequent in cancellous bone, and are CLASSIFICATION :il»'.i often due to avulsion of the bone end by hyperextension of the joint; occurring in the shafts of long bones they are due usually to direct violence; whereas oblique and spiral fractures, seen almost exclusively in the shafts of the long bones, generally are due to a twisting force transmitted ^from a distance; and longitudinal fractures, frequently extending into a joint, usually are caused by a splitting action. They are seen oftenest in the head of the radius or tibia. A depressed fracture is one seen almost exclusively in the skull, in which the fragments are displaced by the vulnerating force below the level of the surrounding bone. An impacted fracture is one in which one fragment is driven into the other, and remains fixed (Fig. 412). Subperios- teal fracture is one in which the periosteum wholly or in great part remains unrup- tured. Epiphyseal Separations. — The epiphyses, or articular ex- tremities of the long bones, may be detached from the shafts (diaphyses) by separa- tion along the epiphyseal line until the age when ossifica- tion is complete in the car- tilage which unites epiphysis with diaphysis. The injury is most common at the lower ends of the humerus, radius, and femur; it is seen also, but more rarely, at the upper ends of the humerus, femur, and tibia, and at the lower end of the tibia. The injury, in all its aspects, so closely resembles a fracture, as to be considered by common consent along with such in- juries. Mechanism. — Bones may be broken in four different ways: (1) by torsion; (2) by flexion; (3) by distraction, and (4) by compression. For a bone to be broken by torsion, it is necessary for one of its ends to be free, while the other is fixed; the injury always is indirect, and the line of fracture usually oblique or spiral. When a bone is broken by flexion, the force may be either direct or indirect. All fractures by distraction are due Fig. 315. — Longitudinal (splitting) fracture of tibia and fibula (involving knee-joint). Age, forty years. Episcopal Hospital. 330 FRACTURES to indirect violence, and practically all produced by compression result from direct violence. Causes of Fracture. — Predisposing Causes. — These arise either from the condition of the patient or that of the bone affected. Bones of the aged are more liable to fracture, because more brittle, than those of young persons; but as the latter lead more active lives, and are more exposed to exciting causes, the number of fractures actually occurring in the aged is less than in the young. Likewise the male Fig. 316. — Transverse serrated fracture of humerus. Episcopal Hospital. Fig. 317. — Oblique and spiral frac- ture of femur. Age three years. Episcopal Hospital. sex, from its greater exposure, is more liable to fracture than the female. Certain diseases of bones render them more liable to be broken, especially osteopsathyrosis and malignant growths. The situation of a bone may predispose it to fracture, the clavicle being more often broken than the scapula, the lower than the upper jaw T , etc. ; and the function of a bone has a predisposing influence, the bones of the extremities being broken more often than those of the trunk. Exciting Causes. — Fractures may occur at the point of impact, from direct violence (gunshot, cart wheel, falling brick, etc.); or may SYMPTOMS OF FRACTURES 331 be due to transmitted force {indirect violence), as fracture of the elbow from falls on the hand. Fracture by muscular action usually is a variety of fracture from indirect violence, one end of a long bone being twisted violently by the muscles attached to it, and being wrenched loose, as it were, from the other end, which opposes its inertia to the sudden muscular impulse; this is the explanation of fractures of the humeral shaft from throwing a ball (Ashhurst, 1905). Muscular action may tear off an apophysis (coracoid process, greater tuberosity of humerus, anterior superior iliac spine, etc.), or may break the patella or olecranon by sudden flexion over their neighboring condyles, as an over-bent lever. Sprain fracture (Callender, 1870) is due to separation of a ligament from its point of insertion, with detachment of a small shell of bone. Spontaneous or Pathological Fractures are those due to preexisting bone disease, where trauma is minimal, as in fragilitas ossium, secondary carcinoma of bone, etc. . Symptoms of Fractures. — In addition to a history of injury, which exists in all cases except some pathological fractures, there are both symptoms and physical signs by which a diagnosis of fracture can be made clinically, with very few exceptions; in such exceptional cases the use of the a>ray nearly invariably will reveal the true nature of the lesion. Pain and Tenderness.- — These are present in practically every case and are by no means proportionate to the apparent degree of injury, some very severe compound comminuted fractures causing the patient less discomfort than a single subcutaneous break. When no other physical signs are present, the surgeon should always suspect a fracture when there exists persistent localized tenderness of a bone, following injury; such a fracture may be subperiosteal or impacted, and the surgeon should treat such a case as one of fracture until the incorrect- ness of his diagnosis has been proved. Swelling, Ecchymosis, etc., are present to some degree in nearly all cases of fracture (Fig. 318), owing to coincident injury of the soft parts; but they have no special significance. Abrasion over the seat of fracture usually shows that the break is due to direct violence. Deformity or Displacement. — This is one of the most constant and valuable signs of fracture. It may be due either (1) to the fracturing force, or may occur subsequently (2) from muscular action; both these factors may be operative; or finally it may be caused simply (3) by the weight of the limb. 1 . Deformity from the fracturing force is seen best in impacted and in depressed fractures. In fractures with great displacement other factors as well usually are at work. 2. Deformity from muscular action is seen especially in the long bones of the extremities, and occurs most markedly when the fracture is close above or below the attachment of powerful muscles — as above or below the insertion of the deltoid, below the insertion of the iliopsoas tendon, above the origin of the gastrocnemius, etc. In 332 FRACTURES fractures of the patella and olecranon it is almost the only cause of deformity. It is responsible both for the shortening, and for the angular deformity, as well as for many cases of rotatory displacement. Deformity from muscular action is dependent in part on the natural tension of the muscles, in part on involuntary contraction (spasmodic) from reflex nervous action, and in part on voluntary action by the patient. o. Deformity from the force of gravity is seen in the outward rotation of the leg which occurs in fractures of the femur; in the deformity known as "loss of the carrying angle" in supracondylar fractures of the humerus; in the dropping of the shoulder in fractures of the clavicle, etc. Fig. 31S. — Ecchymosis twenty-four hours after fracture of surgical neck of humerus, extravasation occurring in course of long tendon of biceps. Episcopal Hospital. Direction of Displacement. — This may be longitudinal, lateral, angular, or rotatory. 1. Longitudinal displacement almost always consists in shortening; lengthening is seen only in fractures of the olecranon and patella, and in some of the calcaneum; in fracture of the lower end of the fibula, lengthening of this bone may occur from inward rotation of the foot (Malgaigne, 1841). If the fracture is transverse, there can be no marked shortening unless there has first been lateral displacement, as the amount of shortening which occurs in an impacted fracture rarely exceeds one or two centimeters; oblique fractures, however, permit of great shortening without much lateral displacement. If the ends of the fragments are displaced so far as to pass by one another, overlapping is said to exist, the more prominent fragment overriding SYMPTOMS OF FRACTURES 333 the less prominent. In fractures of the femur the shortening from overlapping may be from 5 to 10 centimeters. In many fractures it is requisite, and in most it is highly desirable, to take the actual measurements of the sound and injured limb between known fixed points to determine whether or not there is shortening, and not to rely on the evidence of the eyes alone to determine this point. 2. Lateral or transverse displacement has been mentioned already; it occurs mostly in transverse fractures, and when marked allows overlapping. 3. Angular deformity usually results from the fracturing force. This is well seen in cases of green-stick fracture (Fig. 312); but it may be originally caused by muscular action, and usually is maintained by this or by the force of gravity. 4. Rotatory displacement consists in the fragments being twisted on their own axis in opposite directions, either from muscular action or the force of gravity. In fractures of the radius above the insertion of the pronator radii teres the upper fragment is snpinated by the biceps, while the lower is pronated by the pronator teres; in fractures of the neck of the femur the lower fragment is rotated outward by the force of gravity and the external rotator muscles, which are more powerful than the internal rotators. Displacement may not be due to fracture, but to some other lesion. Dislocations, old joint-diseases, exostoses, as well as other affections, may cause deformity with shortening, angularity, or rotation; so the surgeon must not place reliance upon deformity alone in the diagnosis of fracture. Mobility. — Preternatural mobility in a bone, following recent injury, implying as it does motion at some point other than the joints, is almost pathognomonic of fracture; but the normal flexibility of some bones (ribs, fibula, rachitic bones) should not be mistaken for abnormal mobility. In some cases mobility is so great that it is evident at a glance, the limb swinging flail-like at the site of fracture; in others, especially where only one of two or more parallel bones is broken (ribs, metacarpals, etc.), mobility may be difficult to detect. In subperiosteal and impacted fractures it is entirely absent; and in other forms of fracture it may be impossible to detect it owing to the depth at which the bone lies, existence of swelling, etc. In fractures close to a joint, and in those in which the line of fracture is wholly or in part intra-articular, no mobility may be demonstrable. While in a fracture a false point of motion exists, in a dislocation the mobility of the affected joint is diminished. Crepitus. — Crepitus is a term used to describe the grating sensation appreciable by palpation and frequently also by auscultation (a stethoscope may be used), when the ends of the fragments are moved against each other. When present in connection with mobility, the diagnosis may be considered established. Crepitus should not be mistaken for the creaking of tenosynovitis, nor for the similar sound produced by motion of some diseased joints; nor yet for the crackling 334 FRACTURES of subcutaneous emphysema. Crepitus may be absent, owing to the ends of the fragments not being in contact (overlapping, separa- tion), or to muscular or fibrous tissues intervening; in green-stick, impacted, and subperiosteal fractures, there is no crepitus. Loss of Function is another valuable sign of fracture, though it is by no means universally present. Patients with fracture of the fibula may continue at work, and apply for treatment only because of deformity or persistent disability; the same is true of fractures of the ribs; and of some fractures in which pain is absent owing to nerve lesions, or in which it is not appreciated owing to the develop- ment of mania a potu, etc. Circumstantial Evidence of fracture, in addition to the above men- tioned direct signs, is afforded by various occurrences: subcutaneous emphysema corroborates a diagnosis of fracture of the nasal bones, discharge of cerebrospinal fluid from the ear indicates a fracture of the middle fossa of the skull, etc. Diagnosis of Fracture. — If a surgeon conscientiously and system- atically examines the patient there should be very few cases in which the existence or non-existence of fracture remains doubtful. Inquiry should be made as to the history of the accident, including the mode of injury, the position of the patient, whether the lesion is due to a fall of the patient, or to his being struck by another body. If he fell, it should be ascertained, if possible, how he landed — whether on the outstretched hand, whether his foot turned in or out, whether his knee suddenly flexed or became hyperextended, whether his arm was abducted or lay across the thorax, etc. Occasionally when a bone breaks a crack is heard. Inspection. — Inspection may show the patient supporting or pro- tecting the injured part, may reveal evident deformity, shortening, abrasion, swelling, etc. Palpation. — Running the fingers lightly along the surface of the suspected bone, the point of greatest tenderness, nearly always corresponding to the site of fracture, can soon be determined. Sup- porting one end of the injured bone gently but firmly in each hand, test is then made for abnormal mobility, by attempting to increase or decrease angular deviation of the fragment, or to rotate one fragment on the other. In fractures near joints, lateral mobility, where none is normally present (elbow, knee) may thus be detected (in dislocations there is immobility rather than abnormal mobility). In most cases crepitus will be elicited during the manoeuvres advised for detection of mobility, but where overlapping exists it may be necessary first to bring the fractured ends into apposition; when crepitus once has been detected it is reprehensible to make attempts at reproducing it merely for the edification of bystanders. Mensuration. — Mensuration has been mentioned already as a valuable means of detecting shortening. In the upper extremity the fixed points employed are the tip of the acromion or the met- acromial tubercle, the condyles of the humerus, and the styloid proc- SKIAGRAPHY 335 esses of the radius and ulna; in the lower extremity measurements are made from the anterior superior iliac spine or symphysis pubis to either of the malleoli; or to the lower border of the patella, head of the fibula, etc. By placing the corresponding limbs in similar attitudes and taking repeated and accurate measurements, the pres- ence of shortening usually can be ascertained. It should not be forgotten, however, that in many persons the two lower extremities normally are not of equal length. It is important to make a correct diagnosis and to institute proper treatment as soon as possible after the injury is received; deformity at first easily appreciable may soon be obscured by swelling, and not only will the diagnosis then be more difficult than if made at first, but reduction of the deformity and other proper treatment will be less effectual or even impossible if the case is not seen early. In all cases, moreover, in which fracture is suspected, the case should be treated as if fracture were present until the contrary is proved. Skiagraphy. — Skiagraphy is a great aid in confirming a diagnosis of fracture tentatively made, or in disproving its existence when one is suspected. Whenever possible a skiagraph should be made before the patient is examined, as a matter of record; and usually it is desirable for the surgeon to examine the plate before treatment is instituted. Certainly after reduction has been attempted it is w T ell for him to have ocular evidence of what he has accomplished; and if reduction is not satisfactory he can try again. In making radio- graphs the film side of the plate is placed next the patient's limb, and the picture etched on the plate is the shadow of those parts impervious to the .r-rays. In looking at the developed plate, if it is held with the film side toward the observer, he is in the position occupied by the Crookes tube when the exposure was made, and, therefore, is looking at the shadows of the bones from the side of exposure. In taking lateral views of the limbs, that bone or portion of bone nearest the plate when the exposure was made, will be most clearly defined. Skiagraphs often are very deceptive. For instance, if the bones overlap, and lie in the same axis, a skiagraph which superposes one shadow on the other may show no fracture; one which is taken in the same plane as that in which angular displacement occurs, may show no deformity. Hence it is a good rule always to have two plates made, exposure being in planes at right angles to each other. If the Crookes tube is too close to the limb its rays will be quite divergent when impinging on the skiagraphic plate, and all the shadows will be exaggerated; and the further a bone lies from the plate the more rays it will intercept and the larger its shadow will appear. If the Crookes tube is not accurately centered over the fracture, the shadows cast by the fractured ends will be much distorted, perhaps markedly exaggerating the deformity, amount of callus, etc. In passing judg- ment upon a skiagraph, therefore, it is important to take these points into consideration, and not to regard as evidence of malpractice phenomena which may be quite easily explained in other ways. 336 FRACTURES Prognosis of Fracture. — Prognosis as to life is good. In large scries of statistics the general mortality from fractures is about 2.5 per cent. Compound and complicated fractures have a higher mortality. .Multiple fractures, as I pointed out in 1907, in studying 240 cases, give a mortality of about 25 per cent., even when deaths occurring soon after the injury from hemorrhage, shock, visceral injuries, etc., are excluded. In general it may be said that the chief causes of death in fractures of any variety are visceral diseases (pneumonia, uremia), delirium tremens, and, in the aged, exhaustion. The prognosis as to the function of the fractured part depends more upon treatment than any other single factor. As a rule, function is more quickly and completely restored in children and young adults than in the aged; and in those of sound constitu- tion than those with rheumatic or gouty tendencies. Process of Union in Fractured Bones. — It has been entirely too much the custom to regard bones as so many sticks or pieces of stone em- bedded in the soft tissues. The stu- dent should disabuse himself of this idea, and should aim constantly to remember that bone is a living tissue, composed of cells and intercellular substance, and differing chiefly in the composition of the latter from other tissues such as muscle or epithelium. Bone reacts to injury or disease in very much the same way as other tissues; the phenomena of inflamma- tion and repair may appear less active and slower than in the soft tissues, but they are none the less present. A glacier is a fluid body, though it looks solid ; it flows slowly and invisibly, but none the less surely; so with bone: processes measured by minutes or hours in soft structures may take days or weeks in bone, but they are the same in kind. \\ hen a bone is broken, the surrounding soft parts are more or less damaged, and themselves react to the injury by the process of inflam- mation as described in Chapter I. A certain amount of blood is extravasated between the ends of the broken bone, and the various cellular elements of the tissues in the injured area (bone cells from the marrow and periosteum, muscle cells, connective tissue cells, Fig. 319. ■ — Skiagraph showing callus several weeks after fracture of radius. Episcopal Hospital. PROCESS OF UNION IN FRACTURED BONES 661 leukocytes, etc.), proliferate, and aid in removing debris and causing organization in the mass of inflammatory lymph which is formed. The intercellular substance of the bone is temporarily absorbed or removed from the fractured ends by osteoclasts, and the exudate forming between the fragments, which is known as callus, is strictly analogous to the inflammatory lymph which surrounds it and with which it is continuous. The ends of the fragments thus become soft and sticky, and may be compared to the ends of a broken stick of scaling wax which one seeks to weld together again after heating in a flame. This callus is derived largely from the medulla of bono, by proliferation of osteoblasts. This portion of it is known as interior Fig. 320. — Skiagraph of exuberant callus from fractures of elbow and forearm. or pin-callus, while that portion formed from the periosteum is known as ensheathing or ring-callus; the material lying between the ends of the compact substance of the bone is known as the permanent or definitive callus as distinguished from the pin- and ring-callus, which is called provisional or temporary callus. In the course of ten days or two weeks the callus becomes impreg- nated with lime salts, often passing through a cartilaginous stage; and the bone can no longer be freely bent at the seat of union (Fig. 319). The callus gradually becomes condensed as organization pro- ceeds and remains only as a slight thickening at the site of previous fracture; but the pin-callus usually is not entirely absorbed, and complete restoration of the medullary canal is rare. If there has been 22 338 FRACTURES exuberant outpouring of callus (Fig. 320), it may cause union between adjoining bones, may interfere with full flexion or extension of a joint, may limit rotation in the forearm, may grow around nerves or tendons, or cause injurious pressure on them or on vascular channels, resulting in trophic changes, edema, etc. If the fracture is subperiosteal the amount of ring-callus formed will be inappreciable; and the less the primary displacement and the more accurate the reduction of the fractured ends, the less will be the amount of the ring-callus. In fractures of the skull or ribs, and in impacted fractures, where displacement is slight, no appreci- Fig. 321. — Skiagraph of supracondylar fracture of humerus, showing new-formed bone beneath bridge of periosteum, three weeks after injury. Episcopal Hospital. able callus is formed. If the periosteum is stripped up from the shaft of a bone blood-clot will form beneath it, as well as between the broken ends, and becoming organized will cause thickening of the shaft, as the periosteum will be unable to fall back into its normal position (Fig. 321). The periosteum is rarely completely detached from the broken ends, usually remaining at least on one side as a periosteal bridge (Oilier, 1867), which may secure firm bony union even in cases where marked displacement persists. The process described above usually does not make its beginning manifest for several days after the occurrence of fracture, and is TREATMENT OF SIMPLE FRACTURES 339 longer delayed in comminuted and in compound than in simple fractures. In multiple fractures it is a very usual thing for one or two fractures to unite in the ordinary time, and for the other fractures to remain ununited until those first uniting are quite firm, when union may commence in the remaining fractures. In simple fractures fairly firm union is present at the end of two weeks, though at this time, and in larger bones for some weeks afterward, bending at the seat of fracture still may occur. An adult's femur requires usually eight or ten weeks for absolutely firm union to occur. It is said that in no fracture is the structure of the bone entirely restored until a year after the accident. Delayed union is a relative term, since no fixed limits can be set within which union should be firm. If union has not occurred at the end of ten or twelve weeks, it is usual to regard the case as one of Non-union or Ununited Fracture. In these cases the tissue between the fragments remains in a fibrous condition, no bone salts being deposited. Treatment of Fractures. — The general principles already inculcated as proper in the treatment of inflammation guide the surgeon in the treatment of fractures. The indications are to replace the broken bones in proper position, with due regard for the condition of the soft parts, to maintain the fragments in proper position, and to dress the injured part at suitable intervals until cure is complete. Treatment of Simple Fractures. — Fractures often are received at a distance from the patient's home or a surgeon, and it becomes necessary to transport the patient to a place where the injury can be treated. The fractured limb should be rendered as immobile as possible; this may be accomplished by the temporary application of any available support (shingles, canes, umbrella ribs, bark of trees, twigs, etc.), applied over the clothing or suitable padding, or even by wrapping the limb firmly in clothing, without constriction; if the patient is unable to walk, he is carried on a shutter or on a stretcher improvised from poles and clothing, to his home or the nearest hospital. Transport splints have been mentioned in connec- tion with gunshot wounds (p. 204). 1. Reducing the Fracture. This, which often is expressed by the term "setting the bone," is a relative term, since comparatively few broken bones can be accurately restored to their original form; and in the case of shafts of long bones it is not always necessary that reduction should be accurate. Nevertheless, the aim must be to secure as accurate reduction as possible, and in the case of fractures near joints (especially the elbow and ankle) it is extremely important to do so; but in the middle of the shaft of a long bone it is sufficient to secure firm bony union, with no appreciable shortening, with preser- vation of the normal axis of the limb, and without rotation of one frag- ment on the other. For the first and second results to be obtained it is necessary for the fragments to be in contact "end-on," not only by lateral contact; and for the lateral displacement not to exceed 340 FR ACT IRES two-thirds of the diameter of the bone (Figs. 322 and 323). The axis of the limb sometimes may be preserved without end-to-end contact of the fragments, but it is very rare for firm union to be seemed (except in children), and shortening never will be absent unless overlapping is reduced. The methods of securing reduction arc many, and will be described when the injuries of the individual bones are discussed. Jt is sufficient to point out here that other than manual force seldom is necessary, it' the surgeon takes advantage of the relaxation of die muscles which may be secured by position of the limb; sometimes anesthesia will be necessary, and less often operative intervention (p. 343). Secur- ing muscular relaxation by position, the surgeon with his hands Fig. 322. — Showing fragments of broken bone in contact "end-on," and with not too much lateral displacement or firm union. Fig. 323. — Fragments displaced later- ally and with angular deformity; contact not sufficient for firm union. makes extension and counter-extension on the broken bone, and, by gently but firmly applied direct pressure, pushes the ends of the fragments into contact: if reduction has been properly secured, there will be distinct crepitus as the broken ends come together, the normal length of the limb will be restored, and bony deformity will disappear. It then becomes necessary merely to maintain reduc- tion until union is sufficiently firm. In many cases (femur, tibia) gradual reduction may be secured by means of weight extension in the course of a few days, without an anesthetic, even when primary efforts to secure reduction have failed. In muscular adults some form of skeletal traction may be advisable; this is traction fixed directly to the skeleton at some point below the fracture. The principle, which appears to have been introduced by Codivilla (1904), was popularized TREATMENT OF SIMPLE FRACTrh'ES m by Steinmann I LOO'S I, whose "pins" arc passed (by boring by hand) through the femoral condyles, the head of the tibia, or the calcaneum (Fig. 324). RansohofT ( L912) and Besley (1918) have adapted appa- ratus like ordinary ice-tongs for the same purpose. 2. Maintaining the Fragments in Apposition. For this purpose it is usual to employ splints or other external support, held in place by bandages, plasters, etc. Splints are made of various materials (wood, tin, wire, gypsum, etc.), and of various special forms. These will be described when discussing fractures of the several bones. It is above all things important to recognize the fact that splints are not used for the purpose of overcoming deformity, but merely to maintain the limb in correct position after the deformity has been reduced. The action of splints in this regard may be much assisted by the position in which the limb is dressed, and by the use of weight Fig. 324. — Steinmann nail extension in calcaneum. Episcopal Hospital. extension to overcome spasmodic muscular contraction. If a fracture is close to a joint it is necessary to immobilize the joint also; in general terms, it is desirable to immobilize so much of the limb as will prevent any lever action being transmitted to the site of fracture by movement of the portions of the limb left free. Before a splint is applied it should be covered smoothly with raw- cotton, oakum, or some similar material in sufficient amount to pre- vent painful pressure on the limb, special care being taken to protect bony prominences, superficial nerves, bloodvessels, etc. It often is well to apply between the splint and its padding, and over the ends of the fragments, pads suitable to prevent recurrence of deformity, provided no pressure is exercised which might injure the soft parts. An excellent rule is never to apply a bandage beneath the splints around the fractured region: in all fractures there is more or less injury of 342 FRACTURES the soft parts, ami the reactive swelling which occurs in these, has demonstrated on numerous occasions the danger to which the patient is subjected by neglect to observe this rule; a bandage which seems loose enough when first applied may in a very few hours become so tight as to cause serious constriction, perhaps resulting in gangrene of the extremity. Under all circumstances it is well to leave exposed the tips of the fingers or toes, and to direct the nurse or the members Fig. 325. — Compound comminuted fracture of tibia and fibula (bones pro- truded through skin on each side of leg, and were "reduced" by family physician after applying iodin before admission to hospital) . On admission in fracture box, shortening 3 . 5 cm. Fig. 326. — Two weeks after nail extens- ion (16 pounds). Overlapping reduced. Firm union secured. Out of work four months. Episcopal Hospital. of the patient's family to examine their condition at frequent intervals; should any interference with the circulation become evident the dress- ings must be removed at once and be re-applied more circumspectly. At the first visit, the surgeon should proceed to examine the injured member as described at p. 334; but he should not attempt to reduce the fracture until he has all his dressings prepared for application. 3. The after-care of a fractured bone involves" removal of the dressing frequently enough to make sure that the soft parts are in OPERATIVE TREATMENT OF SIMPLE FRACTURES 343 good condition, and that reduction is maintained by the dressing employed. The surgeon never should neglect to see the patient on the day after the dressing is first applied, and to ascertain for him- self that the limb is in good condition, and that the dressing is com- fortable; an uncomfortable dressing always is inefficient even if not positively harmful; but if the dressing is comfortable it is not desirable to re-dress the limb more than two or three times weekly at first, and less often as union progresses. As the splints and bandages are being removed for re-dressing, the surgeon should support the fractured part in such a way as to substitute his support for the splints, preventing dislocation of the fragments, and rendering dress- ing of the fracture entirely painless. While this support is main- tained, the patient's skin should be sponged off gently with dilute alcohol, employing such gentle friction as will stimulate the circula- tion. I do not approve of massage or mobilization in the treatment of fractures, except in so far as they are unavoidable in procuring proper care of the soft parts; and while I acknowledge the truth of the dictum (Lucas-Championniere, 1910) that "a certain amount of motion between the fragments encourages the formation of callus," I am firmly of the opinion that even the most careful immobilization by splints allows, and proper care of the soft parts, as above indicated, provides that "certain amount" of motion which is desirable, and that any surgeon who attempts more, in the vain idea that he is following modern teaching, will succeed either in stirring up such an amount of callus (especially in children) as to cause deformity and injurious pressure on the soft parts, or will (in most adults) leave his patient with an ununited fracture. When the ends of the bones become "sticky," and no tendency to displacement exists, the surgeon may then begin at each dressing to make very limited degrees of passive motion in the neighboring joints, meanwhile maintaining support at the seat of fracture. Under no circumstances should the passive motion cause pain. When union is firm enough for all external support to be discontinued, function usually will be more comfort- ably and quickly recovered by active movements by the patient himself, than by further attempts at passive motion; and if a fracture has been treated properly in the first place, massage rarely will be necessary to accelerate the cure. The average period of disability following simple fractures, according to the statistics of the Fracture Committee of the American Surgical Association (1915) is as follows: humerus, eight to twelve weeks; radius and ulna, over ten weeks; femur, six and a half months; tibia and fibula, four and a quarter months; ankle, four and a quarter months. Operative Treatment of Simple Fractures. — There are only two indications for the "open method" of treating simple fractures, so strenuously advocated by Lane (1905) and other surgeons: (1) If the fracture cannot be reduced properly without operation. (2) If proper reduction cannot be maintained without direct fixation of the fragments. :;ll FRACTURES I. When Proper Reduction is Impossible, Impossibility is here ;i relative term, since what is impossible for one surgeon may not be so for another; and I use the qualification "proper" reduction, because I do not wish to imply that operation is indicated whenever accurate, exact, perfect anatomical replacement is impossible, but only when such degree of reduction as is described at p. 339, as requisite for proper function, cannot be secured without open opera- tion. The chief causes of irreducibilit y are muscular spasm (usually this can be overcome by general anesthesia, weight extension, or sometimes by tenotomy), interposition of muscle, fascia, etc., between the fragments (sometimes this can be overcome by manipulation under an anesthetic), buttonholing of one fragment in the deep fascia, joint-capsule, etc. (this usually requires incision), complete rotation of a detached fragment (apophysis, condyle, etc.), and im- paction of Hie fragments (if desirable, which is not always the case, this usually may be overcome by manipulation with or without an anesthetic.) '2. When Subsequent Displacement Cannot be Prevented.- This also is a relative condition, depending upon the skill of the surgeon in devising and applying efficient retentive apparatus, and upon the extent to which displacement occurs. In the aged or feeble it may be wiser to permit recovery with considerable deformity than to undertake an inexpedient operation. Uncontrollable displacement generally is due to the nature of the fracture itself (marked obliquity, much comminution, etc.), to muscular action, or to the refractor;/ conduct of the patient. Apart from fractures of the patella, which are conceded to require operation (because of irreducibility) unless positive contraindications exist, the two forms of injury in which operation is most often urged, are fractures of both bones of the forearm, and those of the femur; so far as I am aware, however, it has yet to be shown that operative methods in these instances can be safely applied by the average surgeon, or that he can secure by uniform resort to operation as satisfactory results in as large scries of consecutive cases as he can obtain by conservative treatment. If operation is decided upon, it is best done either on the day of injury or not until about the end of the first week, or early in the second week after the injury, since at this time the primary swelling, etc., will have subsided, and any callus that may have formed still will be soft and easily removed; moreover, infection is less likely to follow than if early operation is attempted. The operation, which should be strictly aseptic, consists in exposing the fracture through the proper muscular interspace, excising exuberant callus, removing interposed soft tissues, and in securing reduction (which is not always easy) if possible without resection of bone. Then if very slight tendency to dislocation of the fragments exists it is not necessary to use mechanical means to hold the ends in apposition, provided the surgeon feels capable of maintaining reduction by his external OPERATIVE TREATMENT OF SIMPLE FRACTURES 345 dressings. It' there is still ;t tendency to displacement, the fragments (in the case of small hones) should be sutured with heavy chromic catgut, which will not be absorbed until union is so firm as to prevent subsequent displacement; in the shafts of the long bones it is safer to use a metal plate, since maintenance of reduction by external dressings alone usually is difficult. My own preference is for the form of plates used by Lambotte (1907); these are of steel, of various sizes, shaped to fit the bone and are applied to the bone beneath the Fig. 327. — X-ray of re-fracture of humerus through old fibrous union, two years and six months after original injury. See Fig. 328. Walter Reed General Hos- pital. Fig. 32s. — X-ray of fracture of humerus with Lambotte plate in place after resec- tion of the sclerosed ends of bono as a mortise and tenon joint. Perfect function recovered. Same case as Fijr. 327. periosteum (Figs. 327 and 328). Three or four screws are inserted in each fragment; the holes are bored by a suitable drill (Fig. 329) or dental engine, should extend into the medulla and should be slightly less in dia- meter than the screws; the screws should have round heads, should have the thread carried up to their heads and should be just long enough to enter the medullary cavity. The use of plates has almost super- seded wire sutures since even in smaller bones (clavicle, ulna, fibula) plates are efficient and may be easily applied. Occasionally the mandible requires direct fixation, and here a wire suture is usually 246 Fit ACT l ■/.'/•> preferable to a plate. A plate should not be applied in a subcutaneous situation, as it will there be exposed to injury and may require sub- sequenl removal. In the tibia the plate is to be applied to the fibular surface. II' wire is \\>v<\ phosphor bronze wire, which is much more pliable and stronger, is preferable to silver wire which breaks easily. Lambotte uses copper wire. In the ease of oblique fractures, where the obliquity exceeds twice the diameter of the bone, cerclage is prefer- able to plating: The wire is simply wrapped around the seat of fracture, tightened by twisting, and the ends hammered down against the bone. Two wires should be used, one at each end of the fracture, for better security. The wire should be heavy — 2 mm. in diameter for the femur. Milne, Parham (1913) and others have devised bands of flexible steel for the same purpose which have been used with satisfaction by many surgeons (Fig. 330). Frag- ments of cancellous bone are best fixed bv Lambotte's self-boring screws (Figs. 331, 332). After open operation the process of union sometimes is delayed, and in a fair proportion of cases operated on by the average surgeon, a mild degree of infection occurs and only fibrous union results. When the operative treatment of simple frac- tures is confined, as it should be, to skilful surgeons with all the facilities afforded by the best modern hos- pitals, better results are obtained. Treatment of Complicated Frac- tures. — Rupture of the main artery or vein of a limb complicating a frac- ture of the part requires the same treatment as when no fracture is present (p. 265) ; if gangrene follows, amputation should be done at the site of rupture; but if the axillary artery is ruptured in a case of fracture of the upper part of the humerus, it usually is sufficient to amputate through the seat of fracture ; and if the popliteal artery is ruptured, to amputate at the knee if the fracture is below the knee, and through the seat of fracture if this is in the femur. Injuries of nerves require immediate suture, if it is evident that function is completely destroyed; otherwise oper- ation should be delayed until after consolidation of the fracture, since recovery from contusion may be nearly complete. A severe ivound of the soft parts usually takes precedence over the fracture, and must be treated suitably irrespective of the latter; if sufficient to render certain the occurrence of gangrene, amputate at the point Fig. 329.— Hamilton's drill. TREATMENT OF COMPOUND FRACTURES Ul of injury to the soft parts. Dislocation of the neighboring joint, most often encountered at the shoulder, usually requires incision and direct replacement of the luxated fragment; though sometimes it is possible to secure reduction by manipulation after putting up the fracture in splints; operation is best postponed until seven or eight days after the injury. Fig. 330. — Parham bands on oblique fracture of humerus. Irreducible under ether (upper fragment entangled in biceps). Operation ten days after injury. Was out of work only ten weeks. Episcopal Hospital. Treatment of Compound Fractures. — If the limb is so severely injured that gangrene is sure to occur, or if it would prove useless even if it could be saved, it is best to amputate at once; the site of section of the bones in such cases is determined by the condition of the soft parts available for making flaps. A fracture which is made compound merely by the protrusion of the bones through the soft parts is much less dangerous than one in which the soft parts have been crushed or pulpefied by the same force which produced the fracture; because in the latter case there is much greater devitalization of tissue, infection is carried deeply into the soft parts, and comminution of the bones is the rule. 348 fractures A compound Fracture in itself requiring amputation, and compli- cated by ;i simple fracture higher in the same limb, usually will require amputation ;it the highest point of injury. Fig. 331. — Woman, fifty-six years old, with extension-abduction fracture at ankle. Failure of accurate reduction would have entailed persistent disability. Fig. 332. — Absolute anatomical reposi- tion secured by open operation, and main- tained by screw fixation. Episcopal Hos- pital. A compound fracture involving a joint sometimes requires ampu- tation (almost always at the knee), but conservative treatment with strict antiseptic methods often will secure a useful limb even if motion is limited. Fig. 333. — Compound fracture of humerus, bone protruding. Photographed just before operation. (See Fig. 334.) Episcopal Hospital. If it appears in any way likely that a useful limb can be saved, especially in the upper extremity, the surgeon must undertake repair of the soft parts and reduction of the fragments with antiseptic methods as detailed at p. 1 07 . In almost every ease the patient should TREATMENT OF COMPOUND FRACTURES 549 be anesthetized, and the primary dressing made to assume the character of a formal operation. If the ends of the bones project through the soft parts, they should not be reduced until alter the entire Fig 334 —Silver plate on compound fracture of humerus. (See Figs. 333 and 335.) Episcopal Hospital. wounded area has been surgically cleansed. The wound in the soft parts frequently has to be enlarged, to permit of reduction and repair of the deeper tissues (Fig. 333). It seldom is necessary to resect the 350 FRACTURES ends of the bones, reduction usually being possible by relaxing the muscles by the position of the limb, and bending the bones at an angle until their ends meet, then using the apposed fragments as a fulcrum on which to straighten the limb out again. Where the bones are much comminuted, such fragments as are entirely detached should be removed, while those that are partly adher- ent should be replaced, in the hope that they will aid in procuring union. Often the soft parts are stripped SO widely from the bones that it is impossible to prevent recurrence of displacement even when reduc- tion is easy. Under these circumstances the bones maybe fixed by some form of internal splint (Fig. 334); usually it is better not to plate a recent compound fracture (since bony union seldom follows such a course), but to postpone the plating until the soft parts have healed and asepsis can be assured. Particular attention should be paid to suture of nerves, muscles, and tendons. The wound, unless very slight, should be drained for about forty-eight hours; by arranging the dressings as described at p. 1G0, the drainage tube may be removed Fig. 335. — Fibrous union following plated compound fracture of left humerus. (See Figs. 333 and 334.) Episcopal Hospital. without disturbing the fracture. In the lower extremity, a gypsum splint, trapped over the seat of injury, makes a very good appliance for the treatment of compound fractures; but in the upper extremity ordinary splints used in cases of simple fracture are quite satisfactory. It is very seldom in civil life that injury to the soft parts is seen corn- comparable to wounds encountered habitually in the German War. For such cases the splints described in Chapter VII (p. 204) are well adapted. Frequently irrigation (p. 168) must be employed for several days to ensure vitality of the limb; and the frequency of dressings must be determined by the condition of the soft parts. Union is much more delayed than in simple fractures; and though fibrous union often is the best that can be secured, it may furnish the patient with a useful limb (Fig. 335). Treatment of Badly United Fractures. — If the case is seen before firm union has occurred, the position usually may be improved by judicious application of pads under the splints, or even by refractur- ing the bones manually and dressing them in the improved position. TREATMENT OF M ALU N ION 351 The question whether impacted fractures should be reduced is discussed under the lesions of the various bones. If the case is seen first after bony union has occurred, it is not always advisable to attempt reduction of the deformity if function is good, since non-union may result, or, even if firm union is secured, loss of function may accompany it. Shortening, as such, unless due to angular deformity, scarcely ever can be remedied; indeed, to secure end-to-end apposition of the fragments it often is necessary to resect their ends, thus increasing shortening; and attempts to lengthen a bone by oblique division usually are nulli- fied by contractures in the sur- rounding soft parts. On these accounts, operative measures are directed toward overcoming lateral displacement, rotatory and angular deformity, or to the re- moval of exuberant callus. Careful skiagraphic studies should be made of the fractured region, so that the surgeon may plan his method of operation in advance. In some cases simple refrachire, by the hands or osteoclast (p. 458), will be sufficient; in others (Fig. 336) it is necessary to cut down on the fragments and resect, treating the case then as one of recent fracture or as an ununited fracture (p. 353); Fig. 336. — Vicious union following frac- ture of forearm; angular deformity and loss of rotation. Suitable for operation. Epis- copal Hospital. Fig. 337. — Deformity from separation of lower radial epiphysis. Reduction by linear osteotomy. Episcopal Hospital. while in still others, linear or cuneiform osteotomy (p. 458) will give the best results (Fig. 337). F/iAC'l I ■/.'/■>• Ununited Fractures. The distinction between delayed union and ununited fracture, as was pointed out at p. 339, is difficult to draw; save that in the former condition union frequently occurs under conservative treatment, while in ununited fracture it rarely does. The most marked degree of non-union, constituting pseudarthrosis, is that in which a bursa tonus between the ends of the fragments, there being almost a Bail-like joint present (Fig. 338). In ordinary cases there is rather dense fibrous tissue between the ends of the bones, which are pointed and atrophic; and while this may prevent lateral displacement of the fragments, it' allows angulation at the seat of fracture. Causes. — The chief causes of non-union in fractures are : (1) Failure to secure end-to- end apposition of fragments. (2) Com- minution of the fragments especially in compound fractures where there may be marked loss of substance. (3) Interposition of soft tissues. (4) Imperfect immobilization soon after the accident. (5) Constitutional condition of the patient, rendering his pro- cesses of repair ineffectual. These factors, several of which may co-exist, are men- tioned in what I believe is their order of Fig. 33S. — Pseudai- throsis of humerus with ankylosis of elbow, follow- ing compound comminu- ted fracture. Episcopal Hospital. Fig. 339. — Moulded binder's-board splint, for delayed union after fracture of both bones of forearm. Epis- copal Hospital. frequency, with the possible exception of the patient's constitutional condition, which in many cases undoubtedly is the chief cause of non-union. But it should be noted that interposition of soft tissues, though comparatively infrequent, always results in non-union when present . Diagnosis. — The diagnosis rarely presents difficulties, if the seat of injury is carefully and repeatedly examined; it is a truism to state that the firmer the union the more difficult it is to detect motion. A skiagraph may aid, since it will show absence of bony structure between the fragments. TREATMENT OF NONUNION 353 J -. -^» — .~- Treatment. — The treatment depends upon whether the patient is seen during the stage of delayed union, or whether he first comes under the surgeon's observation when non-union has existed for months or years. The surgeon should endeavor to ascertain the cause of the condition, and should attend to the patient's general health, administering cod liver oil, phosphates, thyroid extract, etc. If separation of fragments can be excluded, conservative measures should be tried first. In the case of delayed union, the first thing to do is to try what strict immobilization for a period of four to six weeks will accomplish: this frequently secures firm union; but if it fails, trial should be made of functional use of the part, with the fracture supported in splints, braces, etc.; and of rather vigorous massage of the affected limb. A fracture of the leg bones with delayed union frequently will grow firm when the patient begins to walk around in his gypsum case; for delayed union of the femur a well fitting walking brace is more efficient; while for the humerus or forearm a light splint of binder's-board to support the seat of fracture will allow free use of the hand and elbow. The patient (Fig. 339), a skiagraph of whose forearm is shown in Fig. 402, cured his own delayed union by returning to his black-smithing work, securing perfect functional use in spite of the bony deformity, which, however, was not appreciable through the thick mass of muscles. Should this degree of stimulation fail to develop osseous union, the patient may be anesthetized, and the ends of the bones vigorously rubbed together, and then immobilized for a few weeks; this procedure often arouses osteogenetic processes and secures firm union when milder methods are ineffectual. Bier (1905) advocated stimulation of osteogenesis by injecting around the ends of the fragments 30 to 40 c.c. of venous blood freshly drawn from the patient. If conservative measures fail, the question of operation rises; but in every case the surgeon should stop to consider whether any operation is apt to improve matters, or whether the patient has not a sufficiently useful limb as it is. The mere doing of an operation does not ensure the occurrence of bony union; it may leave the patient with non-union, and with increased shortening, since resec- tion of the fragments may be necessary. But where deformity can be decreased, and disability lessened, operation is indicated. Fig. 340. — A form of mortise and tenon joint useful in opera- tions for ununited fracture. (See Fig. 328.) 23 354 FRACTURES Operation. — The fracture being exposed through the proper muscular interspace, it is found cither in good alignment or not. (1) In the former case no reduction is required and the best treatment consists in Fig. 341. — Sliding bone inlay after Buchanan's method. Fig. 342. — Non-union of radius and ulna, sixteen months after compound fracture. See Fig. 343. Episcopal Hospital. Fig. 343. — One year after bone trans- plant for non-union of radius. Five weeks after same (sliding) for non-union of ulna. See Figs. 341 and 342. Episcopal Hospital. implanting a bone transplant (p. 248) : with circular saw a gutter is cut in the fragments for 7 to 10 cm. each side of the fracture, and the transplant wedged into place; this opens up healthy bone above and TREATMENT OF NONUNION 355 below the sclerosed ends, and the bone transplant which acts as an osteo- conductive bridge is sufficiently strong, in combination with external dressings and splints, to secure immobilization of the fracture (Figs. 342, 343). In cases of loss of bone substance, also, a free transplant of bone is used to bridge the gap. (2) If, on the other hand, the fragments are not in good apposition, it is necessary first to secure reduction: exuberant callus is removed with gouge, chisel, and Volkmann's sharp spoon, and the ends of the fragments are freshened with the saw, the least possible amount of bone being removed which exposes heal hy Fig. 344. — Ununited fracture of the neck of the femur treated hy bone transplan- tation. Bony union; free motion. Episcopal Hospital. osseous structure and allows proper apposition. In some cases simple end-to-end approximation is sufficient; in others a form of mortise and tenon joint is preferable (Fig. 340). In either case it is desir- able to fix the fragments, and while the use of a bone transplant is preferable in most cases, there may be such tendency to displace- ment of the fragments that fixation by plating or cerclage may be required; either alone, or in addition to the insertion of a bone transplant. The wound should not be drained, if strict hemostasis has been 356 FRACTURES secured before closing it, hut in doubtful cases it is safer to leave a tube in place for thirty-six to forty-eight hours. If a sinus persists after recovery, as sometimes is the case when the plate or wire suture has been used, the foreign body should be removed, otherwise it may be allowed to remain indefinitely. ] )r. Edward Martin removed a silver plate inserted by my father, which only at the expiration of seventeen years began to work loose and produced a sinus. SPECIAL FRACTURES. The general subject of fractures and their treatment has been so fully discussed in the preceding pages, and so many excellent monographs on the subject are readily obtainable, that in speaking of the injuries of the several bones I shall be as brief as possible. As fractures of the skull and of the spine are of interest chiefly in connection with injuries to their contained structures, their con- sideration is postponed to Chapter XVI and XYII respectively. FRACTURES OF THE FACE BONES. Injuries of the face bones are due almost without exception to direct violence; edema and ecchymosis often are marked, owing to the abundance of loose cellular tissue overlying the bones, and hemorrhage into the nasal or oral cavities is quite frequent, the fractures being compound on the mucous surface. Antiseptic sprays, mouth washes, etc., are indicated under such circumstances. Union occurs rapidly. Nasal Bones. — These may be crushed directly inward, or as is more often the case, may suffer lateral deviation. The epistaxis fol- lowing the injury usually subsides in a few minutes. The deformity is characteristic, and the diagnosis usually is made by inspection (Fig. 345), and is confirmed by crepitus as the displacement is corrected. This often may be accomplished by external pressure, but in some cases is more effectually secured by leverage from within by a bone elevator. There is no marked tendency for recurrence of deformity, and retentive appliances generally are useless save to protect the part from injury. A strip of adhesive plaster may be carried across both cheeks and the bridge of the nose, as a precaution. As swelling subsides, deformity may appear more evident, and often it is desirable to mould the nose into shape by pressure every day or so during the first week. Rarely can complete symmetry be restored. Union is firm in ten days or two weeks. Malar Bone. — This is rarely fractured. Usually there is depression, (Fig. 346) which is best overcome by early incision under an anesthetic and direct elevation of the fragment. Fractures of the zygoma often are comminuted, and require the same treatment. Maxilla. — Fractures of this bone are not frequent, but sometimes occur with multiple fractures of the face. They are often compound FRACTURES OF THE FACE BONES 357 into the nose or mouth. Asymmetry of the alveolar process is the main diagnostic point. Impaction is usual, and must be reduced to restore symmetry. If maintenance of reduction proves difficult, it is well to have a special splint constructed bv a competent dentist (Aller, 1914). Fig. 345. — Fracture of nose, eighteen hours after injury. Episcopal Hospital. Fig. 346. — Fracture of right malar bone, from pressure by elbow in playing basket ball. Episcopal Hospital. Mandible. — Fracture of the lower jaw is the most important, and, with exception of the nasal bones, probably the most frequent of those of the face. It is due frequently to a blow from the fist, some- times to the kick of a horse, to sudden jerking upward of a mule's head, or to a fall. Fracture involves the ramus, the body of the bone, the condyle, or the coronoid process. Fracture of the body of the mandible occurs either near the symphysis, or, most often, anterior to the insertion of the masseter muscle. A rare fracture is detachment of the mental eminence, carrying the genial tubercles, and (by relaxation of the geniohyoid and geniohyo- glossus muscles) permitting the tongue to fall backward, perhaps suffocating the patient; this fracture requires immediate operation with suture of the fragment (G. G. Davis, 1894). A similar condition may exist in a double fracture of the jaw, on each side of the symphysis. Fracture in front of the masseter muscle, or posterior to the mental foramen, is the most frequent injury: the line of fracture usually is bevelled, permitting separation of the fragments as the posterior is drawn toward the middle line by the mylohyoid and internal pterygoid muscles; the corresponding muscles of the uninjured side increase the deformity by acting similarly on the unbroken side of the jaw (Fig. 347). In most cases good results follow immobilization for three or four weeks by a modified Barton bandage using the 358 Fh'.\< I l Kk'S upper jaw as a splint; tendency to displacement becomes less a lew days alter the injury. Fixation by a special interdental splint of gutta-percha, such as is made by dentists, though it may be un- necessary, undoubtedly promotes the patient's comfort, and recovery ensues with little or no deformity. Double or compound fractures, or fractures of the ramus to which no dental prosthesis can be applied, frequently require operation, with wiring of the fragments. Fig. 347. -Skiagrai i of fracture of mandible in front of angle, seven years. Episcopal Hospital. Age twenty- Fracture through the neck of the condyle is a serious injury, often leading to ankylosis (p. 709) : the external ptyergoid muscle, attached to the condyle, rotates its broken surface forward, and as it is very difficult to replace this by manipulation, operation is indicated. If the fracture is overlooked in children, disuse of the jaw following ankylosis may result in marked retrognathism. Fracture of the coronoid process, a very rare accident, is difficult to detect, as separation of the fragment is prevented by attachment of the temporal muscle far down the inner side of the ramus. Treat- ment consists in procuring rest by bandages until acute symptoms subside. FRACTURES OF THE BONES OF THE TRUNK. Sternum. — This is an unusual fracture, generally due to direct violence, the patient being crushed beneath a fall of earth, etc.; FRACTURES OF THE BONES OF THE TRUNK 359 some cases are due to muscular action, such as violent lifting effort, parturition, etc. Visceral injury is to be feared, especially in cases caused by direct violence; it is manifested by hemoptysis, dyspnea, cyanosis, subcutaneous emphysema, etc. The line of fracture usually is transverse, and sometimes consists in a diastasis between the manubrium and gladiolus; more often a true fracture exists above or below this joint, the lower fragment projecting in front of the upper. Attempts, not always successful, are made to reduce the deformity by hyperextension of the spine over a small pillow, and drawing the arms backward. Crepitus may be detected during this manoeuvre. The sternal region is then immobilized by broad strips of adhesive plaster, passed from axilla to axilla, while the chest is collapsed in expiration. In uncomplicated cases recovery is rapid, union being firm in three or four weeks. Suppuration may follow in case of extravasation into the anterior mediastinum, and is to be treated by intercostal incision or trephining the sternum. Fracture of the ensiform process may unite with deformity, the xiphoid being turned backward and causing gastric distress (xipho- dynia). This is best relieved by excision of the xiphoid. Ribs. — Fractures of the ribs dispute with those of the clavicle the first place in frequency among all fractures. The injury, commonest in male adults, may be caused by direct or indirect violence; in the latter case the force usually is applied antero-posteriorly, and the ribs break at their weakest point when the limit of elasticity has been reached. The ribs most often broken (usually two or more [at once) are those from the fifth to the ninth, usually in the axillary or posterior axillary line. There is great pain on forced inspiration, and on sudden motion; localized tenderness, sometimes distinct mobility and crepitus. By using a stethoscope crepitus can be detected in almost all cases, and may be traced up to its origin even from a distance. Vis- ceral complications are unusual but serious; they should be looked for: subcu- taneous emphysema indicates partial rup- ture of the lung; hemothorax is a grave complication, and traumatic pneumonia very fatal. Treatment. — Treatment comprises immobilization, but rarely con- finement to bed. Broad strips of adhesive plaster are applied, at the end of each forced expiration and with the arm on the affected side dependent ; they run from below upward, beginning at the spine, Fig. 348. — Adhesive plaster- strapping for fracture of ribs, applied with arm dependent; arm raised before photograph was taken. Episcopal Hospital. 360 FRACTURES and extending just to beyond the midline in front (Fig. 348). Im- mobilization of both sides of the chest is undesirable. This st nip- ping should be renewed as often as it comes loose, every five or six days; and should be continued for four or five weeks. For the persistent pain and neuralgia which sometimes follow these injuries, massage and antirheumatic remedies may be tried; the disability seldom persists long, but may eventually demand excision of callus for its relief. In one such patient sent to me with the diagnosis of cholelithiasis, the rib was found ununited one year after injury; symp- toms were relieved by excising the affected portion. Costal Cartilages.— These sometimes become detached at their junction with the ribs. Treatment is similar to that for fracture of the ribs. Fig. 349. — Fracture of pelvis, from antero-posterior force. Note diastasis of sym- physis; fracture through innominate bone from iliac crest to sacrosciatic notch; separation of sacro-iliac joint. Recovery. Episcopal Hospital. Pelvic Bones. — These fractures usually are caused by direct violence, and are of interest chiefly from their visceral complica- tions, which are met with in about one-sixth of the cases (Ash- hurst, 1909), the general mortality being over 30 per cent. The most important are those fractures which break the ring of the pelvis: FRACTURES OF THE BONES OF THE TRUNK 361 when the force is received antero-posteriorly, as when a heavy weight knocks a man down and lands on his symphysis pubis, the anterior part of the pelvis is crushed inward, fracturing the rami of the pubes and ischium on one or both sides or bursting the symphysis pubis, and spreading the halves of the pelvis apart, perhaps causing diastasis of the sacro-iliac joints, or fracture of the ilium through the sacro-sciatic notch (Fig. 349). When the force is received laterally, the most frequent frac- ture which involves the ring of the pelvis is a vertical fracture in the neighborhood of the symphysis pubis, and one of the ilium behind the acetabulum; but force transmitted through the femur may cause comminuted fracture of the acetabular region, not involving the pelvic ring. Of fractures which do not involve the pelvic ring those detaching one of the iliac crests are most frequent, usually being due to lateral force (Fig. 278), though the anterior superior spine alone has been detached by muscular action. The various fractures are not difficult to diagnose, as displacement usually is quite appreciable to palpation, which should always include rectal or vaginal examination. If displacement is slight, persistent localized tenderness, especially of one of the pubic rami, is a valuable sign; and a skiagraph may aid. Crepitus often is evident on attempts at motion; pain is experienced when the trochanteric regions are crowded together, or when attempts are made to move one innominate bone on the other. While operation may be required for visceral complications (rupture of urethra, bladder, abdominal wall, internal hemorrhage, etc.), the fractures themselves generally unite with little difficulty. The pelvis should be immobilized by a broad canvas belt or strips of adhesive plaster; and it often is well to secure relaxation of the adductors, sartorius and rectus muscles by keeping the thighs moderately flexed. Some disability may persist from shortening of one lower extremity, due to imperfect replacement of the fragments, or from mobility due to diastasis of one of the pelvic joints. Fracture of the Acetabular Rim is a rare injury due to force trans- mitted through the femur, which may become subluxated upward and backward. The diagnosis is difficult without a skiagraph. Treat- ment consists in applying w r eight extension to the femur in the abducted position, after replacing the head in its socket, and main- taining this position for three or four weeks. Use of the limb should not be allowed for ten or twelve weeks after injury. Under the name Central Dislocation of the Hip is described a stellate fracture of the acetabulum caused by the head of the femur being driven through it into the pelvis by direct violence acting in the axis of the femoral neck; pregnancy seems to be a predisposing cause. Henschen (1909) collected 139 cases. Skillern (1911) classifies the lesions as "fractura perforans" (Fig. 349) and "perforata," according to the degree of intrapelvic displacement. The diagnosis is made from flattening of the trochanter and relaxation of the supratrochan- teric structures; by palpating the luxated head in the pelvis by a finger in the vagina or rectum; and by recurrence of deformity, with crepitus, after reduction. The intrapelvic spicules of bone should not .;i,j /■•/.'.I ( r /■/,•/•>■ l>c replaced until the head of the femur has Keen withdrawn. The thigh should be dressed in plaster of Paris in a flexed and adducted position, and the patient should bear no weight on the limb for two or three months. Fractures of the Sacrum and Ischium are rare. The tuber isch.il has been detached 1>y niuseillar violence. Fig. 350.— Centra dislocation of right hip from fall from aeroplane. Fractura perforans. Walter Reed General Hospital. Fractures of the Coccyx follow falls or kicks or parturition, and may readily be diagnosed by inserting the index finger into the rectum and grasping the coccyx between this and the thumb, when abnormal mobility and perhaps crepitus will be detected. If forward displacement is persistent, it is best to excise the coccyx at once, since if the bone unites in bad position, or if non-union results, there often ensues in women a train of neurasthenic symptoms constituting the affection known as coccygodynia. This is characterized by local pain, interference w T ith defecation, vesical irritability, and sometimes a life of invalidism; all of wmich may be cured by removal of the entire coccyx at the sacrococcygeal articulation. FRACTURES OF THE UPPER EXTREMITY 363 FRACTURES OF THE UPPER EXTREMITY. Clavicle. — The entire upper extremity depends on the clavicle for its bony connection with the trunk, and this bone, therefore, is exposed to all manner of strains transmitted from the periphery. The patient falls on the hand, or on the point of the shoulder, or rarely receives a blow directly on the clavicle, which gives way usually at its weakest part, between the at- tachments of the sternomastoid and trapezius on its upper surface, and those of the pectoralis major and deltoid on its lower surface, ap- proximately at its middle, where the two curves of the bone meet. The line of fracture nearly in- variably is oblique from before backward and from without inward ; and as the main function of the bone is to prop the shoulder away from the trunk, giving the humerus a greater range of motion, the main deformity consists in the shoulder falling inward and forward, Fig. 351. — Deformity following frac- ture of left clavicle, much more notice- able than the average case. Episcopal Hospital. Fig. 352. — Skiagraph of fracture of clavicle, with slight comminution, from direct violence. Age twenty-three years. Episcopal Hospital. toward the trunk, by contraction of the muscles of the axillary folds, while the weight of the upper extremity causes slight dropping of :;iil FRACTURES the shoulder. The inner end of the clavicle remains in its normal position, or possibly is raised a little by the sternomastoid ; and at the outer end of this fragment a depression can be felt, owing to the displacement inward and backward of the outer fragment (Figs. 351 and 352). In rare eases this presses on the subclavian vessels or the brachial plexus, but in the vasl majority of cases the fracture is entirely uncomplicated. Owing to the inward rotation of the shoulder, the vertebral border of the scapula may become prominent. The diagnosis sometimes is difficult in cases of green-stick fracture, and in fat, chubby children, in whom the outlines of the bones may be hard to detect; but even in cases where deformity is absent, there will be persistent localized tenderness at the seat of fracture. In cases with deformity, the diagnosis is easy, even the attitude of the patient being more or less characteristic; he carries his head bent toward the affected side, supports the injured limb with his other hand, and is unwilling or unable to raise the arm from the side. Fracture of the Outer End of the Clavicle, a much rarer injury, generally is due to direct violence; if the fracture occurs through the coraco-clavicular ligaments there is little displacement, but if external to them, the outer fragment is carried downward and inward, a displacement which, owing to the posterior convexity of the curve at this point, causes the inner fragment to protrude posteriorly, and produces a characteristic deformity. Treatment of Fractured Clavicle. — Reduction of the deformity is difficult, and accurate retention of the fragments nearly impossible; nevertheless, such good functional results follow 7 conservative treat- ment that operation is very rarely performed, especially as a scar would be more conspicuous than the moderate amount of deformity which usually follows conservative treatment. By placing the patient flat on the back, on a hard bed, and with a folded sheet or firm, flat pillow across the bodies of the scapulae, this will act as a fulcrum and the force of gravity will carry the shoulder backward, rotating the outer fragment out into its normal relation with the inner. If now r a small bag of shot were placed over the inner fragment, to press it dow-n against the outer, and the head raised on a pillow- to relax the sternomastoid, and the upper extremity immobilized by proper bandages; and if the patient could be induced to remain in this position for two or three weeks until union was fairly firm, then recovery without deformity probably would be assured. Cou- teaud (1909) induced 24 patients to submit to bed treatment, and secured excellent results by letting the arm hang down over the side of the bed for the first two days, thus approximating the fragments by keeping the pectoralis major tense. But even a young girl anxious to preserve her neck from trifling deformity rarely will endure such confinement, and it becomes necessary to devise some means of ambulatory treatment; and though by such treatment entire absence of deformity rarely can be secured, yet recovery of function usually is perfect. The indications are to keep the scapula flat Fh'AcTCKES OF THE CLAVICLE 365 against the chest, thus rotating the shoulder and outer fragment away from the chest; to steady the inner fragment by a compress; Fig. 353. — Dressing for fracture of clav- icle: compress over inner fragment; arm in Velpeau position; fold of elbow and chest protected by lint. Episcopal Hos- pital. Fig. 354. — Dressing for fracture of clavicle: arm fixed by adhesive plas- ter. Episcopal Hospital. and to support the weight of the upper extremity. The fact that myriad dressings have been devised to meet these points sufficiently indicates that none of them is entirely efficient. In children a pos- terior figure-of-eight bandage (Fig. 92), drawing the shoulders back- Fig. 355. — Dressing for fracture of clavicle: application of Velpeau ban- dage. Episcopal Hospital. Fig. 356. — Dressing for fracture of clavicle: Velpeau bandage reinforced by figure-of-eight turns around elbow, shoul- der and axilla. Episcopal Hospital. ward, with a compress over the inner fragment, and with the arm supported in a sling, usually gives very satisfactory results. In adults, 366 FRACTURES in whom the parts are more difficult to fix, I prefer to use the dressing indicated in the accompanying illustrations. After strapping a com- press over the inner fragment, and fixing the scapula by a broad strap of adhesive plaster passing across the back to the axilla of the sound side, a piece of lint is placed in the elbow, the axilla is dusted with Fig. 357. — Fracture of scapula through body and near angle. Age twenty-four years. Episcopal Hospital. boric acid powder, and a large fold of lint is fastened across the chest (Fig. 353); the arm is then slung to the chest by a board band of adhesive plaster (Fig. 354) ; a Velpeau bandage is then applied, fixing the arm to the chest (Fig. 355); this is reinforced by turns of the bandage beneath the elbow, crossing each other over the injured FRACTURES OF THE SCAPULA 367 shoulder, and passing beneath the axilla of the opposite side (Fig. 356) . The last turns support the upper extremity and pull the inner frag- ment down, forming a valuable addition to the Velpeau bandage. This dressing need not be renewed until it comes loose — usually not for six or seven days; and at the end of four weeks may be discontinued, and the arm merely carried in a sling, its active use being prohibited until six weeks from the time of the accident. Rarely is any after- treatment required, normal use restoring function in a short time. Scapula. — This generally is broken by direct violence. Fractures of the body of the scapula (Fig. 357) usually are more or less transverse, and the fragments are not much separated: but by fixing the angle with one hand, and manipulating the shoulder with the other, both crepitus and mobility may be detected in most cases. Disability rarely is marked. Treatment consists in immobilizing the upper extremity for four or five weeks. Fractures of the acromion process are more frequent than those of the body of the bone, and are to be diagnosed by persistent localized tenderness following direct injury, sometimes by crepitus, but rarely by distinct mobility unless the line of fracture is distinctly posterior to the acromio-clavicular joint. Skiagraphic confirmation is desirable, and will serve to dis- tinguish this injury from separation of the epiphysis, which probably is a more frequent injury, but clinically indistinguishable from frac- ture. Immobilization for about four weeks is sufficient. Fracture of the coracoid process may occur from muscular action, or rarely from direct violence. It is a rare injury, but usually may be detected by painstaking examination, unless the patient is very muscular or fat. The process is pulled downward into the axilla by the muscles attached to it, and often may be felt here, while it is absent from its normal site just below the outer third of the clavicle. If crepitus cannot be obtained in confirmation of apparent displacement and mobility, a skiagraph must be relied on for diagnosis. Fracture through the surgical neck of the scapula, the line of fracture passing through the suprascapular notch and detaching both the coracoid and glenoid processes, is a rare injury which may be mistaken for dislocation of the shoulder; in dislocation, however, the arm hangs away from the side, mobility is decreased or even absent, and no crepitus can be obtained; in fracture, though the humerus is carried downward and inward with the detached fragment by the pull of the axillary muscles and those attached to the coracoid, thus pro- ducing a hollow beneath the acromion, yet attentive examination will show that there is in the axilla not the isolated head of the humerus, but a bony mass composed of coracoid, glenoid, and humerus, and that the coracoid moves with the humerus and is detached from the scapula. Moreover, there is crepitus and abnormal mobility; and when the deformity is reduced, it recurs at once; none •of which phenomena are present in dislocation. Finally, skiagraphic evidence may be called in aid, and usually will determine the matter without doubt. Treatment consists in reducing the deformity as 368 l I; ACT U RES far as possible, and immobilizing the upper extremity as in fractures of the clavicle; a folded towel or other flat support should be placed in the axilla io aid in retaining the fragment in place. Reduction usually is imperfect, callus may be exuberant, and the restoration of function may be much delayed, perhaps from involvement of the suprascapular nerve. Humerus. — It is customary to divide these injuries into fractures of the upper cud, those of the shaft, and those of the lower end of the bone. Fig. 358. — Fracture of anatomical neck of humerus. Age fifty-four years. Episcopal Hospital. Fractures of the Upper End of the Humerus. — Fracture of the anatomical neck is a rare injury; the detached hemispherical frag- ment is wholly or largely intra-articular, and is displaced toward the axilla, turning at right angles to the shaft (Fig. 358). Sometimes the fragment is forced through the capsule of the shoulder-joint, and< lies almost subcutaneously in the axilla. Palpation then detects the head in its abnormal position, while the tuberosities retain their FRACTURES OF THE HUMERUS 369 normal relations to the shaft of the humerus and to the acromion. Crepitus may be elicited by pressing the detached head outward against the shaft; but unless the head is clearly palpable a positive diagnosis is very difficult without a skiagraph. Most cases so diag- nosed turn out to be high fractures of the surgical neck. If the head is displaced so far as to be almost subcutaneous, it is best to remove it by incision; function will be much better than if the fragment Fig. 359. — Separation of upper epiphysis of humerus. Typical displacement. Note pyramidal shape of upper end of diaphysis, and new formed bone beneath periosteal bridge on inner side of fracture, which has not been reduced. Age nine years. remains as a foreign body to excite periarthritis. In cases where displacement is slight, the treatment described below for fracture of the surgical neck is efficient. Fracture of the greater tuberosity occasionally occurs from muscular action, and more rarely still from direct violence; a sprain fracture is a frequent lesion accompanying dislocation of the shoulder. The fragment is drawn outward, upward, and backward by the external rotator muscles. Reduction may be easy, but usually is very difficult to maintain even if the humerus is 24 370 FRACTURES dressed in adduction. Hence operative fixation by periosteal suture of chromic catgut or by screw may be advisable. In other cases, firm bandaging over a shoulder-cap may keep the fragments in place. Sep- aration of the upper epiphysis of the humerus: This epiphysis may be separated at any age until it unites with the diaphysis, not later than twenty-five years. The injury is commonest, however, at or about fifteen years of age, though sometimes it occurs as an obstetrical injury. The upper end of the diaphysis is pyramidal in shape (Fig. 359), and the epiphysis fits over it like a cap. The epiphyseal line passes on the surface of the bone just beneath the greater tuberosity, irregularly inward, being intra- articular on the inner side of the humerus, so that the detached frag- ment (the epiphysis) is somewhat larger than that in fracture of the anatomical neck, but smaller than that in fracture of the surgical neck. The displacement of the epiphysis depends largely on muscular ac- tion: the subscapularis in front and the infraspinatus and teres minor behind draw the epiphysis directly inward, while the supraspinatus, being unopposed, tilts its outer margin (the greater tuberosity) upward; the diaphysis usually, but not always, is drawn inward and forward, by the muscles of the axillary folds, and in typical cases is prominent beneath the anterior fibers of the deltoid. Fracture of the surgical neck of the humerus is the most frequent injury of the humerus in adults, and is produced usually by a fall or blow on the outer surface of the shoulder. The region included in the surgical neck is that from the epiphyseal line above, to the upper border of the insertions of the pectoralis and teres major muscles below. "High fractures of the surgical neck," some- times called "fractures through the tuberosities," are in all respects similar to epiphyseal separations, but occur after ossification in the epiphyseal line. The typical displacement in ordinary fracture of the surgical neck consists in the lower fragment being drawn inward by the axillary muscles, and somewhat upward by the deltoid, triceps, and muscles running from the humerus to the coracoid process. Unless impaction is present the diagnosis is not difficult; the tuberosities do Fig. 360. — Skiagraph of impacted fracture of surgical neck of humerus. (See Fig. 361.) Episcopal Hospital. FRACTURES OF THE HUMERUS 371 not rotate with the shaft, and deformity, mobility, and crepitus are easily detected. Treatment of Fractures of the Upper End of the Humerus. — After washing the parts in alcohol, a modified Fergusson's dressing (1842) is applied as follows: a primary roller is applied from the metacarpus up to the site of fracture, with the elbow flexed; this prevents swelling of the hand and forearm and adds much to the patient's comfort. The fracture is then reduced, by traction downward in the axis of the body, manipulating the upper end of the shaft so as to push Fig. 361. — Impacted fracture of surgical neck of humerus after reduction under an anesthetic. Compare Fig. 360. Episcopal Hospital. it out and bring it into contact with the upper fragment. Then a moulded shoulder-cap of binder's-board, well padded, is placed over the shoulder, reaching almost to the elbow, and is held in place by a spica bandage of the shoulder (see Fig. 365). A sufficient amount of raw cotton is then placed between the arm and chest to fill up the natural hollow, and to keep the shaft of the humerus from being dis- placed inward. The arm is then bandaged to the thorax, and a sling- is applied to support the wrist. By leaving the elbow unsupported, thus gaining the advantage of extension by the weight of the limb, 372 FRACTURES there is less danger of displacement of the fragments. This dressing should be renewed about twice weekly for five weeks. Occasionally it Fig. 362.— Fracture of humerus above insertion of deltoid, lower fragment displaced outward and upward by that muscle. Episcopal Hospital. will be necessary to dress the arm in abduction in order to secure better apposition of the fragments. FRACTURES OF THE HUMERUS 373 In cases of fracture of the surgical neck impacled with deformity I believe it usually is better, except in the very old or feeble, to anesthetize the patient, free the impaction (usually easy) by forced rotation, and reduce the deformity as far as possible (Figs. 360 and 361). Fractures of the Shaft of the Humerus. — These may occur at any level, usually from direct violence, but occasionally from muscular action. In 190G I found references to 96 such cases, mostly due to Fig. 363. — Fracture of lower third of shaft of humerus. Episcopal Hospital. throwing a ball, the two ends of the humerus apparently being twisted apart by violent rotation of the upper end, opposed by the inertia of the rest of the limb. Fractures from direct violence are more apt to be transverse and comminuted, than those caused by indirect vio- lence, which are more or less oblique or spiral. If the fracture is above the insertion of the deltoid, there is a tendency for the lower fragment to be carried up and out by this muscle; while the upper fragment is pulled inward by the axillary muscles (Fig. 362); but if the fracture is below the insertion of the deltoid, the reverse is ::7I I i; [CTURES the case, the uppe/ fragmenl being displaced outward by 1 1 1< • deltoid, while the lower is drawn up toward the axilla by the biceps, triceps, ob lialis Fig. 364. — Dressing for fracture of shaft of humerus: coaptation splints around seat of frac- ture. Episcopal Hospital. and coracooracniaiis. in fractures of the lower third of the shaft, which are rarer, there i- angular deformity forwards, owing to the action of the muscles arising from the condyles of the humerus which keep the elbow flexed, and thus bring the upper end of the lower fragment forward, as the arm falls by the side (Fig 363). In all fractures of the shaft the diagnosis is easily made, and reduction is not difficult to secure nor to maintain if an efficient dressing is applied. That which I have used with perfect satisfaction is shown in the accompanying illus- trations. A primary roller is applied up to the elbow; the arm is surrounded by raw cotton; three coaptation splints of binder's-board are adjusted around the arm, one anteriorly, one posteriorly, and one externally (Fig. 364), and are secured by continuing the bandage up to the axilla; over this a shoulder-cap is next adjusted (Fig. 365), and fixed by a spica of the shoulder (Fig. 366); the arm is finally bandaged to the chest and a wrist sling applied leaving the elbow unsup- ported to give extension to the seat of fracture (Fig. 367) . In rare cases with overlapping of very oblique fractures, weight extension can be ap- plied as an ambulatory dress- ing (Fig. 368). If the fracture is in the lower third of the humerus an anterior angular splint (Fig. 369) may be used, either alone, or in addition to the use of a shoulder-cap; but in fractures above this region any attempt to im- mobilize the elbow will result in transferring every motion of the forearm to the seat of fracture in the humerus, and delayed union frequently will result. Fig. 365.— Dressing for fracture of shaft of humerus: shoulder-cap applied. Episcopal Hospital. FRACTURES OF THE HUMERUS 375 Fractures of the Lower End of the Humerus. — These are much more frequent in children than in adults. The usual cause in children Fig. 366. — Dressing for fracture of shaft of humerus, shoulder-cap secured by spica bandage of shoulder. Episcopal Hospital. Fig. 367. — Dressing for fracture of shaft of humerus completed and wrist sling applied. Episcopal Hospital. is a fall on the outstretched hand; in adults such an accident is more apt to cause dislocation if the lesion occurs at the elbow. Direct Fig. 368. — Weight extension for frac- ture of shaft of humerus. Episcopal Hospital. Fig. 369. — Anterior angular splint applied to elbow. Episcopal Hospital. injury, often resulting in compound or comminuted fractures, is a more frequent cause of elbow fractures in adults. There are several 376 FRACTURES These are the most frequent varieties. distinct types of fracture here, which may be conveniently classified thus (Fig. 370): 1. Supracondylar Fractures 1 2. Diacondylar Fractures 3. External Condyle 4. Epiphyseal Separation. 5. Internal Condyle. (). Intercondylar, T or Y. 7. Epitrochlea. The lower epiphysis of the humerus is developed from a number of centres, and is best studied in a series of skiagraphs of normal elbows: the center for the capitellum of the humerus appears during the first year of life, that for the head of the radius becoming visible in the sixth year, closely followed by that for the epitrochlea of the humerus. These centers are well shown in Fig. Fig. 370. — Diagram to show classification of fractures of the lower end of humerus. Fig. 371. — Skiagraph showing lower epiphysis of humerus at five years and eleven months (antero-posterior). Episcopal Hospital. 371. The center for the trochlea appears at eleven years, and that for the olecranon a little later. Fig. 372 is a lateral view of the normal elbow at eleven years. 1. Supracondylar Fractures usually are due to a fall on the out- stretched hand, the elbow being suddenly hyperextended, and the lower end of the humerus torn off partly by ligamentous distraction, partly by the force of the blow, which generally displaces the fragment posteriorly. The line of fracture is oblique from above downward and forward (Fig. 373). Impaction is unusual. When the elbow 7 is extended it is found that lateral motion is possible between the forearm and FRACTURES OF THE ELBOW 377 arm, the "carrying angle" is lost, anteroposterior movements give crepitus, and often the lower end of the upper fragment can be felt Fig. 372. — Skiagraph of lower epiphysis of humerus at eleven years (lateral). Episcopal Hospital. Fig. 373. — Skiagraph of supracondylar fracture of humerus; before reduction, elbow dressed on anterior right-angled splint. Episcopal Hospital. 378 PUACTVRE& in the bend of the elbow. The condyles retain their normal relation with the olecranon, which is not the ease in posterior dislocation at the elbow, for which the deformity of fracture sometimes is mis- taken. L'. Diacondylar Fractures are transverse fractures between the level of supracondylar fractures and that of the epiphyseal line. They usually follow a fall on the extensor surface of the forearm, the elbow being flexed, and often are impacted. The line of fracture traverses the thin layer of bone separating the olecranon and coro- noid fossa\ Diagnosis is based on the history, the signs of elbow Fig. 374. — Supracondylar fracture of humerus shown in Fig. 373, after reduction dressed in position of hyperflexion. Episcopal Hospital. injury, and skiagraphic examination. A rare form described by Posadas (1901) consists in forward displacement of the lower fragment and posterior dislocation of the bones of the forearm. 3. Fractures of the External Condyle usually follow falls on the out- stretched hand; as the ulna does not articulate with the hand, the force is transmitted through the radius directly to the external con- dyle, thus explaining the greater rarity of fractures of the internal condyle. The line of fracture extends into the joint, somewhere between the capitellar and trochlear surfaces (Fig. 375); lateral FRACTURES OF THE ELBOW 379 mobility usually is present, and crepitus can be detected cither in this way or by moving the external condyle with thumb and finger directly Fig. 375. — Skiagraph of fracture of external condyle of humerus. upon the shaft. Under the name epicondylitis, Franke and Momburg (1910) described what corresponds to a sprain-fracture of the external epicondyle. I have seen several cases appparently of this nature. 4. Separation of the Entire Lower Epiphysis may occur until its union with the diaphysis, from fifteen to seventeen years, but usually occurs before thirteen years of age. The epiphyseal line is largely intra-articular, pass- ing beloiv the coronoid fossa. A small shell of bone often is de- tached from the diaphysis also (Fig. 376) ; if this is not the case, and the line of fracture passes directly along the epiphyseal line (cartilage), it will not be visible in a skiagraph. Many epiphyseal separations are wrongly classed as mere sprains, because the skia- graph shows nothing abnormal. The trauma producing the injury often is slight, and deformity . . ° i c m Fig. 3/6. — Skiagraph of epiphyseal rarelv IS present; but tailure to separation of left humerus. 380 FRACTURES recognize the lesion may be disastrous. The diagnosis is based on a his- tory of injury, on indistinct, muffled crepitus, extreme pain on forced extension and persistent localized tenderness in the flexure of the elbow. Fig. 377. — Skiagraph of fracture of internal condyle of humerus. Hospital. Episcopal 5. Fractures of the Internal Condyle. — These are rare in children, but being caused usually by direct violence (falls on the acutely flexed elbow) are relatively more frequent in adults. The usual line of fracture is shown in Fig. 377. The disability is extreme, the support of the ulna being destroyed: the forearm falls against the side, causing loss of the carrying angle, and the internal condyle may be moved antero-posteriorly on the shaft. 6. Intercondylar Fractures are very rare, especially in children. They are caused by great violence, almost always direct, the ulna being driven up between the condyles and separating them from each other and from the shaft (Madelung), resulting in a Y-fracture; or the diaphysis splitting into halves the fragment due to a supracondylar fracture (Gurlt, 1862), resulting in a T-fracture. The diagnosis rests on the independent mobility of the condyles on each other and on the shaft. FRACTURES OF THE ELBOW 381 7. Fractures of the Epitrochlea (Fig. 378) often are epiphyseal sepa- rations of this center, as it does not unite with the diaphysis until the Fig. 378. — Skiagraph of fracture of epitrochlea of humerus. Episcopal Hospital. eighteenth year. The injury usually is due to muscular or ligament- ous action, and is a frequent accompaniment of posterior dislocation of the elbow. Fig. 379. — Fracture of capitellum of humerus, from fall on elbow. Age thirty-eight years. Patient under care of Dr. Jopson in University Hospital. Fragment replaced by arthrotomy. Excellent result. Of other rarer fractures of the lower end of the humerus, those of the capitellum (Fig. 379) are of most importance; the fragment usually 382 Fli.-U'TURES is displaced into the bend of the elbow, and seldom can be replaced without incision. Treatment of Fractures of the Lower End <>f the Humerus. As these fractures arc all close to the joint, and many of them wholly or in part intra-artieular, it is extremely important to secure early and accurate reduction of the fragments, in order to lessen the amount of callus formed, and thus permit restoration of perfect function. Intelligent manoeuvres of reduction can be undertaken only after a correct diagnosis has been made, and I have dwelt upon the indi- vidual lesions so fully not because their treatment is materially different, but because accurate reduction must be secured at the earliest possible moment; only in this way can surgeons hope to remove the opprobrium which has long attached to these injuries and which 1 believe is quite unnecessary. a Fig. 380. — Diagram of carrying angle. (After Potter.) Fig. 381. — Patient showing normal earrying-angle on right and gunstock deformity on left. Children's Hospital. Supracondylar fractures form the large proportion of these injuries, and I shall discuss the treatment of this variety at greatest length. The muscles arising from the condyles of the humerus are the only muscles attached to the fragment, and they tend to keep it flexed on the forearm. Motion transmitted from the forearm takes place between the fragment and the shaft of the humerus, not in the elbow- joint. The fragment usually is displaced posteriorly. All these considerations, as well as clinical experience, teach that it is better to dress these injuries with the elbow flexed. The fracture is reduced, by hyperextension of the elbow to relax the triceps, then by extension FRACTURES OF THE ELBOW 3S3 and counter-extension to bring the fragment forward into its normal relation with the shaft. It is kept reduced by hyperflexion of the elbow (flexion as acute as possible), thus bringing the insertion of the triceps anterior to the humerus, and making this muscle act as a sling in holding the fragment in place. In order to preserve the "carrying angle," which is formed by an equal obliquity of the articular surfaces of the humerus and the bones of the forearm (Fig. 380), it is extremely important to flex the forearm upon the arm directly in the sagittal plane, and to keep it in that position, thus avoiding internal rotation of the lower fragment. When there is loss of the "carrying-angle" (cubitus varus, Fig. 381) the forearm falls to the outer side of the arm when the elbow is hyperflexed. Increase of the "carrying angle" (cubitus valgus) is a less conspicuous and much less disabling deformity (Fig. 382). Fig. 382. — Patient showing cubitus valgus after recovery from fracture of internal condyle. Episcopal Hospital. Other fractures of the lower end of the humerus must all be reduced accurately by suitable manipulations, which cannot be described at length here. All may be kept reduced by dressing the elbow in hyperflexion. 1 The method in which this is to be done is sufficiently indicated in the accompanying illustrations: the arm and forearm act as splints to each other, and when they are bound to each other they may be rotated inward as one bone, and the hand slung around the neck (Figs. 383, 384, 385). The elbow is dressed 1 In the very rare cases in which hyperflexion does not maintain reduction, the elbow should be dressed in the most stable position: occasionally this will require confinement to bed with weight traction in the extended position. :;si FRACTURES Fig. 383. — Dressing to maintain elbow in hyperflexion, first stage. Episcopal Hospital. Fig. 384. — Dressing to maintain elbow Fig. 385. — Dressing to maintain elbow in hyperflexion, second stage. Episcopal in hyperflexion, completed. Episcopal Hospital. Hospital. FRACTURES OF THE ELBOW 385 about twice weekly, the hyperflexion being reduced at each dressing only enough to permit washing the flexure of the elbow, and re-inser- tion of a fold of lint. At the end of the second week the elbow may be dressed in less acute flexion, and at the end of four weeks may be carried in a sling for a week or ten days. No massage or passive motion is necessary to restore function if accurate reduction has been secured; but full extension may not be secured for several months. Ulna. — Fractures of this bone are caused mostly by direct violence. Fractures of the olecranon, however, may occur from muscular action in sudden flexion, or as a "compression" fracture in hyperextension of the elbow; unless the aponeurotic insertion of the triceps is torn widely there is not much separation, but mobility and crepitus usually are distinct. In simple fractures operation rarely is indicated, as by strapping the fragment on to an obtuse angled splint (Fig. 386) reduction usually is easy: even if accurate reduction is not secured Fig. 386. — Dressing fracture of olecranon on anterior obtuse angled splint, omitted to show splint better. Episcopal Hospital. Padding at the first attempt, it is remarkable how much improvement in position is obtained in a few days. This is one of the few fractures which prove an exception to the general rule that prompt reduction is necessary for recovery of good function. But in cases where reduc- tion cannot be secured within a few days, and in compound fractures, operation is preferable (Figs. 387 and 388). Separation of the olecranon epiphysis, which appears first in a skiagraph from ten to eleven years, is a rare injury, requiring the same treatment as fracture. Fracture of the coronoid process is a rare accompaniment of posterior dis- location of the elbow, and is to be suspected when it is difficult to maintain reduction of this lesion. The fragment, which is partly intra-articular, and which has the brachialis anticus attached only to its base, seldom is much displaced. Treatment consists in dressing the elbow in hyperflexion for a couple of weeks, and then allowing gradual extension. Fractures of the shaft of the ulna are very dis- abling, as the ulna forms the main part of the elbow-joint, and through 25 386 FRACTURES the interosseous ligament supports the radius and hand. Patients with complete fracture of the ulna rarely can hold the forearm out for an examination without support from the other hand. In the upper part of the shaft the displacement often is backward, owing to the Fig. 387. — Skiagraph of compound fracture of olecranon. Treated by operation. (See Fig. 388.) Episcopal Hospital. pull of the triceps (Fig. 390) ; but when the trauma has been great, the ulna may be displaced anteriorly, the continuation of the force causing forward dislocation of the head of the radius (Fig. 457). In Fig. 388. — Skiagraph of compound fracture of olecranon, after suture of aponeurosis of triceps with chromic catgut. Age twenty-five years. Episcopal Hospital. the lower part of the shaft, the pronator quadratus draws the lower fragment against the radius, producing a deformity very difficult to overcome, though sometimes extreme abduction of the hand, by the use of a reverse Bond splint (one made for the other hand), may FRACTURES OF THE ULNA 387 succeed (Skillern, 1910). Green-stick fractures of the ulna are frequent, but these, as well as complete breaks of the middle and lower thirds, are frequently accompanied by fracture of the radius. Fracture of the styloid process of the ulna often accompanies fractures of the lower end of the radius. Owing to the subcutaneous position of the ulna the diagnosis of these various fractures presents few difficulties; and all may be treated by immobilizing the fore- arm on a straight splint, with pads so adjusted as to overcome the tendency to displacement. Radius. — Fractures of the head of the radius usually are caused by a fall on the over-extended palm, the force transmitted through the radius making it impinge with great force on the external condyle, and splitting the head of the radius into two or more parts (Fig. 3S9). The symptoms are persistent localized pain and tenderness, indistinct crepitus on rotation, but rarely appreciable mobility or displace- ment. A skiagraph usually is necessary for confirmation, but unless several are taken in differ- ent planes, the- line of fracture may not be visible. If there is a loose fragment it is better to excise it, as malunion or non-union is fre- quent. In most cases, however, it is sufficient to immobilize the fore- arm for about four weeks in full supination on an anterior angular splint (Fig. 369). Fractures of the neck of the radius result from much the same causes as those of its head, but may accompany fractures of the olecranon from a fall on the flexed forearm; or may be accom- panied by a fracture of the shaft of the ulna (Fig. 390). These fractures are apt to be impacted, and it is not desirable to disturb the impaction lest non-union result, the upper fragment being so small as to be uncontrollable. The forearm should be dressed in full supination. Fractures of the shaft of the radius are unusual except when accompanied by fracture of the ulna. If the fracture is above the insertion of the pronator radii teres, this muscle will pronate the lower fragment while the upper will be supinated and flexed by the biceps; to reduce the deformity the forearm should be dressed in full Fig. 389. — Fracture of head of radius Age twenty-six years. Episcopal Hospital :;ss FRACTURES supination (Lonsdale, 1 838) , on an anterior splint, with the elbow flexed. If the fracture occurs below the insertion of the pronator radii teres this muscle will keep the upper fragment semi-pronated, and the lower fragment should be brought into that position before the splint is applied, and so dressed. Fig. 390. — Fracture of neck of radius complicating fracture of upper half of ulna. Episcopal Hospital. Fractures of the Lower End of the Radius. — The typical fracture in this region, one of the most frequent in the entire body, is known by the name of Colles (1814). Colles's Fracture results almost invari- ably from a fall on the over-extended palm, and the break occurs about 1 or 2 cm. above the wrist-joint; the lower fragment is dis- placed toward the extensor surface, often being impacted into the posterior surface of the shaft, the lower end of which protrudes Fig. 391. — Colles's fracture of radius, showing silver-fork deformity; recent accident in patient of sixteen years. Episcopal Hospital. beneath the flexor tendons. This typical displacement is known as the "silver-fork deformity," and Fig. 391 shows that the term is well merited; often, however, deformity is much less evident. In addition to the antero-posterior displacement (Fig. 392) , there usually is mod- erate radial deviation of the hand, rendering the head of the ulna prominent (Fig. 393). A fracture of the ulnar styloid is a frequent accompaniment. Crepitus and mobility seldom are present, and the FRACTURES OF THE RADIUS 389 diagnosis usually is made from the deformity and localized pain and tenderness; but even in cases without visible deformity the lesion should be suspected from the nature of the injury. If un- recognized as a recent injury the deformity may become much more evident in the next twenty-four hours, and the patient and the surgeon whom he consults then, 'are apt to blame one who failed to recognize a fracture the day before. Treatment consists in reduction as soon Fig. 392. — Skiagraph (lateral view) of unreduced Colles's fracture of radius, slight silver-fork deform- ity; duration three weeks. (See Fig. 393.) Episcopal Hospital. Fig. 393. — Skiagraph (antero-posterior view) of unreduced Colles's fracture of radius, with radial displacement of lower fragment, and fracture of the styloid process of the ulna. (See Fig. 392.) Episcopal Hospital. as possible after the injury (Fig. 394) : this is accomplished by hyperex- tension and forced adduction of the lower fragment (Fig. 395), followed by direct pressure forward on it, with counter-pressure backward on the lower end of the upper fragment. If impaction is very firm, an anesthetic may be required. Usually more force is necessary even in cases of slight impaction than the inexperienced surgeon expects; and though failure to secure accurate reduction may not materially interfere with use of the hand, some deformity will remain, and :;:iii FRACTURES in many cases the hand is permanently weakened. Any dressing which will hold the fragments in place may then be applied, the Fig. 394. — Skiagraph of recent Colles's fracture of radius and fracture of styloid process of ulna, after reduction. Episcopal Hospital. forearm being in semi-pronation or full supination, never in complete pronation. Supination is the movement which is most difficult Fig. 395. — Reduction of Colles's fracture, of left radius. Episcopal Hospital. to regain, and if the hand is dressed in pronation, it may never be regained; whereas if the fracture is put up in full supination, all FRACTURES OF THE RADIUS :;;)[ subsequent activities of the hand will be such as to encourage return of pronation. In cases where no tendency exists for recurrence of dis- placement, a straight posterior splint (Fig. 396) makes a comfortable Fig. 396, -Posterior splint for Colles's fracture. Padding omitted for photograph. Episcopal Hospital. dressing; for the first week this should extend to the proximal inter- phalangeal joints, but may then be shortened to the metacarpo- phalangeal articulations. In cases where reduction is difficult to Fig. 397.— Bond's splint. maintain, I prefer to use a Bond splint"" (Fig. 397), on the flexor surface, with two compresses, one on the dorsal surface over the lower fragment, and the other on the flexor, to fill up the natural concavity Fig. 398. — Bond's splint for Colles's fracture. Padding omitted from splint, and leather guard removed to show compresses; note their form and position. Episcopal Hospital. of the forearm above the wrist, and to retain the upper fragment in proper position (Fig. 398). Splint support should be continued for three or four weeks. 392 FRACTURES Other Fractures of the Lower End of the Radius.— Barton's Fracture. (lS.'JS) is the inime given to detachment of the dorsal portion of the articular surface of the radius; diagnosis without a skiagraph is difficult. Reversed Colles's Fracture, in which the lower fragment is displaced toward the flexor surface, was described in 1 5 by Cal- lender; the displacement was named "gardener's spade deformity" by Roberts ( L897). Chauffeur's Fracture, so named because often received while "cranking" an automobile, may be of various types, the most frequent of which is one splitting off the outer surface of the articular surface of the radius through the base of the styloid process (Fig. 399). Separation of the lower radial epiphysis (Fig. 337) can be certainly distinguished from Colles's fracture only by radiography. All these lesions should be treated by reduction of deformity, when present, and immobilization for about four weeks. Fig. 399. — Unreduced "chauffeur's fracture" of right radius, caused by kick of handle while cranking. Walter Reed General Hospital. Both Bones of the Forearm. — These fractures are frequent, either from a fall on the hand, or from direct violence. The forearm is the most frequent site of green-stick fractures (Fig. 312); the deformity usually is very apparent (Fig. 400), and the treatment consists in reduc- ing this, which usually involves making the fracture complete; but as this frequently is accomplished without much rupture of the periosteum, there is little or no tendency for the fragments to be displaced subsequently. The forearm is dressed as in complete fractures. In these the radius usually is broken a little higher than the ulna, and one FRACTURES OF THE FOREARM 393 or both bones may be comminuted (Figs. 401 and 402). The diagnosis is easy, owing to the extreme mobility. Reduction should be attempted Fig. 400.— Green-stick fracture of both bones of forearm one month after injury which was untreated. Reduced under anesthetic. Children's Hospital. by fully supinating the forearm, and making extension and counter- extension so as to overcome any overlapping. Correct replacement Figs. 401 and 402. — Skiagraphs of comminuted fracture of both bones of forearm; delayed union at end of ten weeks. Patient, aged fifty-three years, then returned to work as blacksmith, and two months later union was firm. Episcopal Hospital. of the ulnar fracture usually can be determined clinically, as this bone is subcutaneous; but the radius is buried among so many muscles 394 FRAC1 i UE& that a skiagraph frequently is necessary to ascertain the position of the fragments if the fracture is above the middle of the bone. The forearm is then dressed in full supination between two straight splints, that on the flexor surface extending from the bend of the elbow to the tips of the fingers, while the dorsal splint extends from tli.' olecranon to the wrist (Fig. 403). These splints should be a little wider than the forearm, so as to prevent crowding the bones together laterally, and they should be smoothly but thickly padded. Apply the splints with the elbow flexed to a right angle, and make sure that the palmar splint does not compress the veins in the bend of the elbow and that the dorsal splint does not cause a slough at the back of the wrist. A longitudinal pad placed between the bones, in the effort to wedge them apart is not only useless but harmful. Extra com- presses, however, may well be placed over any of the fragments that tend to project. The splints are then strapped snugly around the forearm and held securely in place by a roller bandage. A large "handkerchief" or "triangular" sling is applied, and the forearm Fig. 403. — Dressing for fracture of both bones of forearm. Padding omitted. Note length of splints. Forearm in full supination. Episcopal Hospital. carried against the chest, but always in full supination. I urge the employment of this position not only because supination is the most difficult part of rotation to regain, and because the upper fragment of the radius usually is kept in supination by the biceps, but because I have found, if the forearm is dressed in mid-pronation, as is com- monly advised now, that the fragments sag by the force of gravity, and the patient recovers not only with lost supination, but with angular deformity of both bones toward the ulnar side. If attempt is made to correct this deformity by adjusting a coaptation splint over the angular projection of the ulna, this may be overcome, but the surgeon will succeed merely in forcing the ulna nearer the radius, which cannot be influenced by such an appliance, and the disability as regards rotation will be increased. It often is exceedingly difficult to keep these fractures even approximately reduced during the first week; but usually a little better position can be secured at each dressing, and when the ends of the bones begin to become sticky, during the second week, it will be found that deformity daily becomes less, and what looked at first like a hopeless case, will result in a very FRACTURES OF THE FOREARM 395 useful arm, and one with slight or no visible deformity. Skiagraphs are valuable and interesting, but I advise the inexperienced not to be terrified by the appearance of the bones in a skiagraph into Fig. 404. — Fracture of both bones of forearm. Lateral and antero-posterior views after first dressing. See Fig. 405. Episcopal Hospital. thinking that only operative treatment can give his patient a good result. If he uses the eyes in the ends of his fingers, he will secure by conservative means quite as good, and in many cases a Fig. 405. — Same case as Fig. 404. Lateral and antero-posterior views four months after injury Slight callus palpable. No visible deformity. Perfect function. much better result than by operation, and in a shorter time (Figs. 404 and 405). 396 FRACTURES Carpus. — Of these fractures, that of the scaphoid is least unusual, resulting usually from a fall on the thenar eminence; the diagnosis is made from tenderness in the "anatomical snuffbox," sometimes by dorsal displacement of one of the fragments, and effusion in the radio-carpal joint. Confirmation by a skiagraph is advisable (Figs. 4(H) and 407). Treatment consists in excision of an irreducible frag- ment, and in immobilization on a palmar splint for three or four weeks for those cases without deformity. In cases of non-union with disa- bility excision of one or both fragments gives good results. Fig. 406 — Fracture of carpal scaphoid from fall on hand from a height of several feet. Orthopaedic Hospital. Fig 407. — Same case as Fig. 406; six weeks later, fracture united. Metacarpus. — Fractures of the metacarpals result usually from direct violence (prize-fighting, etc.); the displacement is angular, toward the extensor surface, and may be difficult to keep reduced. The hand may be dressed on a palmar splint, the palm being well padded; or may be bandaged over a firm roller, the tension on the extensor tendons preventing deformity (Fig. 408). Fracture of the base of the thumb metacarpal (Bennett, 1886), may resemble a subluxation of that bone (Fig. 409). Phalanges. — Fractures of these usually are caused by direct violence, often being compound and requiring amputation. Simple fractures are dressed on antero-posterior splints (Fig. 410) for about FRACTURES OF THE PHALANGES 397 Fig. 408. — Dressing for fracture of metacarpals. Hand bandaged over a roller. Episcopal Hospital. Fig. 409.— Fracture of base of thumb metacarpal. Episcopal Hospital. 398 FRACTURES three weeks. If angular deformity toward the flexor surface persists, due to the pull of the interossei, the fingers may be dressed in flexion over a roller bandage. Fig. 410. -Dressing for fracture of the phalanges. Episcopal Hospital. FRACTURES OF THE LOWER EXTREMITY. Femur. -This is the most serious fracture of the extremities that a patient can suffer, but fortunately it is less serious in children, in whom it is more frequent, than in adults. In adults fractures of the leg are much more frequent than in children. The fractures of the femur may be grouped into those of the upper end, those of the shaftj and those of the lower end. Fig. 411. — Fracture of neck of femur close to its head. Episcopal Hospital. Fractures of the Upper End of the Femur. — Fractures of the neck of the femur ("fracture of the hip") are more common in adults, FRACTURES OF THE FEMUR 399 especially those past sixty-five years of age, than in children. The trauma in the aged often is trivial as their bones are more brittle; some cases are caused by a mere twist of the leg, catching it in a fold of the carpet, on an uneven paving stone, etc., or by sitting down suddenly. Such injuries usually produce a fracture of the neck close to the head (intracapsular), and seldom are impacted (Fig. 411). Falls on the great trochanter, especially in patients under seventy years of age, are more apt to result in an impacted fracture close to the trochan- ter (Fig. 412), which is at least partly extracapsular. In children, also, fractures of the neck of the femur usually are impacted, or Fig. 412. — Impacted fracture at base of neck of femur. Episcopal Hospital. Age sixty-five years. partial; or an epiphyseal separation of the head may occur. In impacted fractures, the impaction occurs chiefly at the expense of the posterior part of the neck, the shaft of the femur being rotated outward as the posterior margins of the fragments are driven together. Symptoms. — Muscular spasm is prominent, and this, with local- ized pain and tenderness, sometimes are alone sufficient to warrant the diagnosis in the aged. In unimpacted fractures the patient usually is unable to raise the limb from the bed; deformity is char- acteristic, consisting in eversion of the lower extremity, the fibular side of the foot lying on the bed; and there is moderate shortening (2 to 4 cm.), which frequently increases during the second day. In 101) FRACTURES impacted fractures the shortening may not exceed 1 cm. Normally when the thigh is flexed the great trochanter lies on a line drawn from the anterior superior spine of the ilium to the tuber ischii (Nilaton's line, IN 17); hut when there is fracture of the neck of the femur the muscles (ilio-psoas, adductors, hamstrings, glutei) passing from the pelvis to the shaft pull the lower fragment up, so that the trochanter lies above this line, and approaches or even ascends above a plumb line dropped from the anterior superior spine when the patient is lying supine (Bryant's line, 1879); the relation of the trochanter to Xelaton's and Bryant's lines on the two sides should be compared (Figs. 413 and 414). The trochanter is less prominent on the injured side owing to the loss of support from the neck of the bone, and by placing the tips of the fingers between the trochanter and iliac crest it will be found that the fascia lata on the injured side is relaxed (Allis's sign, 1877). Sometimes from the shortening a fold or wrinkle is formed over the tendo patella?, and can be smoothed out by making Fig. 413. — Nelaton's line; passes from anterior superior spine of ilium to tuber ischii and crosses tip of great trochanter of femur, when thigh is partly flexed. Fig. 414.— Bryant's line, a plumb line from anterior superior spine of ilium, patient supine. Orthopaedic Hospital. extension (Cleemann, 1876). In cases without impaction, mobility is present: this may be detected by rotating the entire limb, when it will be found to have a greater range of motion than the uninjured limb; and by pushing upward and pulling downward in the axis of the limb, the greater trochanter will be found to slide up and down on the pelvis; During these manoeuvres crepitus usually is elicited. By palpating the trochanter as the limb is rotated, it will be found to rotate in the arc of a smaller circle than the trochanter on the uninjured side; this is because the center of motion is trans- ferred from the acetabulum to the seat of fracture. Usually there is an abnormal fulness over the head of the femur (just below Poupart's ligament, beneath or immediately external to the femoral artery) owing to effusion in the joint and the external rotation of the outer fragment. Diagnosis rarely is difficult in the adult, attention being paid to the history of injury, even if slight, and to the cardinal physical signs, shortening, eversion, and crepitus. In cases with impaction, FRACTURES OF THE FEMUR 401 where mobility and crepitus are absent, and where eversion and shortening are slight, the diagnosis is less certain; but the cautious surgeon will treat all suspected injuries of the hip in the aged as if they were fractures until the contrary is proved. The impaction may be slight, and is apt to be released spontaneously. A skiagraph is very useful in such cases, and as well in children, in whom green-stick fracture, epiphyseal separation, or fracture with impaction, are the usual lesions. Frequently the true nature of the case is not recognized in children, and the surgeon sees the patient first when traumatic coxa vara (p. 586) has developed. Prognosis. — In the aged, death occurs from shock, pneumonia, bed-sores, exhaustion, etc., in about one out of four cases during the first year after injury; in those who recover, a useful limb results in about 60 per cent, of cases; nearly all of these will have a limp and slight eversion (Ashhurst and Newell, 1908). In children there is little disability though marked degrees of coxa vara may require subsequent treatment. Treatment. — In the aged, constitutional treatment often is more important than the local; these patients should not be kept in bed after the first shock of the accident and the acutest symptoms have subsided, unless they continue to improve. Get them up in a chair a few hours each day so soon as they seem to be losing ground. Watch for and guard against hypostatic congestion of the lungs and bed- sores. Keep the bowels open and the kidneys active. Stimulate the appetite. The usual teaching is not to disturb an impaction if one is present; and a very good rule it is in many cases; but in children this does not hold good if there is deformity, and in such cases even in robust adults (even up to sixty-five years), it is a question whether a more useful limb might not be secured by breaking up the impaction and dressing the limb in extreme abduction as described below. Impaction is usual in fractures near the trochanters, and non- union would not be apt to occur if the impaction were reduced in vigorous adults. But in aged persons, or speaking generally, in those past seventy years, it is far better to let the fracture stay impacted, even if there is deformity, since it is better to have them walking about with a limp and shortening and eversion, than to have them dependent on crutches or even a cane, as is almost always the case if non-union is present. Delbet (1908) suggested producing artificial impaction in recent fractures, and Cotton (1910) has secured it in a number of cases by hammering on the trochanter with a mallet. I find it sufficient to abduct the limb until a crunch is heard, evidencing the occurrence of impaction. Unimpacted fractures may be reduced by flexing the thigh on the pelvis to a right angle (to relax the iliopsoas which may press the capsule between the fragments), then making vertical traction upward on the thigh, and finally bringing the thigh down to the plane of the bed in moderate internal rotation and abduction as great as 26 Ii 12 FRACTURES possible. This last manoeuvre makes the anterior portion of the capsule tense, and wedges the outer fragment against the detached head lying loose in the acetabulum by keeping the iliopsoas tense across the anterior part of the joint. Whitman, who since 1897 has advocated the abduction treat- ment of fractures of the femoral neck, encases the entire lower extremity and pelvis in plaster of Paris (Fig. 415); this is usually well borne by old people, and their bed care is much sim- plified by the ease with which they may be turned. The head of the bed should be kept ele- vated to guard against hypo- static pneumonia. A method of lateral and longitudinal trac- tion, was described accurately in 1869 by Phillips, was taught for many years by Maxwell, and has been revived, system- atized, and popularized, by Ruth (1899). It is substantially iden- tical with Bardenheuer's method (1889), and will give good results in cases of fracture at the base of the neck, whether impacted or not. The fracture is reduced as described above, and in addition to the longitudinal extension (Fig. Fig. 415. — Abduction cast for separation of epiphysis of head of femur; age fourteen years. Cast has been cut off foot recently to facilitate walking. Episcopal Hospital. Fig. 416. — Applying Buck's adhesive plaster extension apparatus for fracture of femur. Orthopaedic Hospital. 410) lateral traction also is made on the upper part of the thigh. The longitudinal traction should be strong enough to overcome shortening, and about two-thirds as much weight should be used in FRACTURES OF THE FEMUR 403 lateral traction (Fig. 417). The lateral traction, which should draw the femur slightly away from the plane of the bed as well as laterally, overcomes outward rotation and keeps the capsule of the hip-joint Fig. 417. — Longitudinal and lateral traction for fracture of neck of femur. Note also use of Volkmann's sliding foot splint to prevent rotation of limb and to diminish friction. Episcopal Hospital. Fig. 418. — Fracture through trochanters of femur; rare and atypical line of fracture. Episcopal Hospital. 101 FRACTURES tense, preventing it from falling in between the fragments. Every two or three days the longitudinal traction should be substituted by traction with the hands upon the thigh, and the knee should be flexed gently through about 30 degrees to prevent stiffness. Union is good at the end of four weeks. Ruth found in 1907 that among a total of 72 cases treated by this method there had been no failure of union in patients under eighty years, no failure to secure a useful limb under seventy years of age, and in those past eighty years of age, success was obtained in over GO per cent, of cases. Impacted fractures are treated in the same way, but less weight is required. Fractures through the trochanters of the femur are not very rare, usually are due to great direct violence, and often are impacted. Three grades of this injury may be recognized (Ashhurst, 1913): the first is little more than an impacted fracture at the base of the neck; in the next, the neck penetrates the trochanteric region further, and a splitting fracture occurs; and in the severest grade the trochanteric region is entirely shattered. A linear fracture between the level of the trochan- ters is quite rare (Fig. 418). In most cases the lesser trochanter is fractured (Fig. 419). Metcalf (1915) collected 17 cases of isolated fracture of the lesser trochanter. Isolated fracture of the great trochanter occurs, and may require perios- teal suture to maintain reduction. Fractures of the Shaft of the Femur. — These are much more common in children and young adults than in old people, and usually are due to direct violence. There are three main types : (1) Fracture below the trochanters. The upper fragment is flexed by the iliopsoas; and rotated outward by the gluteus maximus and the short external rotators. The lower end of the upper fragment often is felt as a sharp projection in Scarpa's triangle; while the low r er fragment is drawn upward and inward by the adductors (Fig. 317). The leg rolls out- ward from its own weight, and shortening is marked. Crepitus and abnormal mobility are easily detected. (2) Fracture of the middle of the shaft, often oblique (Fig. 317), is attended by more shortening than any fracture in the body, sometimes as much as 12 cm. (five inches); the leg rolls outward, there is flail-like motion and marked crepitus at the seat of fracture; the lower fragment is drawn up and in by the adductors and hamstrings, and the upper fragment projects anteriorly (Fig. 421). (3) Supracondylar fractures are characterized by posterior displacement of the lower fragment which is kept flexed at the knee by the gastrocnemius (Fig. 423); and by anterior projection of the Fig. 419. — A common type of fracture through the trochanters: fracture at base of neck of femur (impacted) ; with separation of lesser trochanter. Age forty-five years. Episcopal Hospital. FRACTURES OF THE FEMUR 405 upper fragment, which may be embedded in the rectus muscle. The diagnosis of these various types of fracture of the shaft is riot difficult, since the displacement is fairly constant, and if deformity is great the ends of the fragments usually can be palpated even in very muscular limbs. Prognosis. — The general mortality is about 15 per cent.; 90 per cent, of those who recover under conservative treatment secure entirely useful limbs, but about one out of three of these will have a limp, Fig. 420. — Fracture of femur below trochanters. Episcopal Hospital. and only about one patient out of four will have no shortening (Ash- hurst and Newell, 1908). Though many surgeons urge the operative treatment of recent fractures of the femur as a routine, I am not aware that they have published figures demonstrating even as good results as the above. Treatment. — Reduction of the fracture is difficult, but probably could be more often obtained if the patient was anesthetized. Weight extension sheuld be applied in sufficient amount to overcome shorten- ing. Ochsner has found that if the adhesive plaster is carried up to 106 FRACTURES the groin, irrespective of the height of the fracture, weight extension is much more efficacious. The full amount of weight necessary should be applied during the first day or two after the accident, since shorten- ing becomes more difficult to overcome the longer it lasts. By raising the foot of the bed from 4 to <> inches, counter-extension is provided by the weight of the patient's body. A sling around the perineum attached Fig. 421. — Skiagraph of transverse fracture of shaft of femur. Best posi- tion obtainable after etherization and attempts at reduction with extension by compound pulley. Femur plated. (See Fig. 422.) Age twenty-three years. Episcopal Hospital. Fig. 422. — Skiagraph of patient shown in Fig. 421, three months after fracture of femur was plated. Excellent result, with no limitat- ion of motion. Plate still in place nine years after operation. Episcopal Hospital. to the head of the bed often is desirable for counter-traction. If neces- sary the patient is anesthetized {usually on the second day) and, short- ening being -overcome by the weights, the fragments are manipu- lated into as accurate apposition as possible. Extension by means of the compound pulley may be necessary in very muscular adults, the extension being made by means of a clove hitch applied above the knee (Fig. 424). Sometimes angulation of the fragments over the FRACTURES OF THE FEMlll 407 forearm will enable the surgeon to secure end-to-end apposition. Absolute reposition rarely can be obtained, and is not necessary to secure a useful limb. In subtrochanteric fractures it may be necessary to raise the lower fragment on a double-inclined plane, in order to approximate it to the upper (Fig. 425); and in supracondylar fractures it always is advisable to flex the knee (rarely to divide the tendo Achillis) so as to relax the gas- trocnemius muscle. In fracture of the middle of the shaft the thigh is dressed in the extended position, and the seat of fracture always should be supported by coaptation splints. Rotation outward of the lower fragment is prevented by the use of Volk- mann's sliding splint (1882) or similar device (Fig. 417). A long external splint (Liston, 1837), well padded, extending from the axilla to below the foot, and bandaged firmly to the entire lower extremity and pelvis, will prevent outward angulation of the fracture; and the use of a shot bag will Over- FlG . 423.— Skiagraph of fracture above Come anterior displacement. condyles of femur. Lower fragment drawn o e e i 7 j 7 j .«• / backward bv action of gastrocnemius. Epis- .Some torm of skeletal traction (p. cop ai Hospital. Fig. 424. — Clove hitch and compound pulley for reduction of fractures of the femur under anesthesia. Counter-extension by a sheet tied to the head of the bed. Episcopal Hospital. IDS FRACTURES 340) may be advisable. In children, Hamilton's splint (1860) facili- tates moving the patient, as it fixes hot h lower extremities by long external splints fastened together by a eross-har below the feet, through which passes the cord carrying the weighl extension. Immobilization in adults should be continued for six to eight weeks, but after the first four weeks very light massage is permissible, above and below the fracture. Weight-bearing should not be at- tempted for eight or ten weeks after the injury — in general, not until four weeks after union seems solid, as subsequent shortening with angular deformity is a sad consequence of too early efforts to walk. In very young children weight-bearing may be resumed in six or seven weeks. Fig. 425. — Double inclined plane, with weight extension for fracture of femur below the lesser trochanter. Episcopal Hospital. Fractures of the Lower End of the Femur. — Epiphyseal separation occurs oftenest from six to ten years of age, usually from hyper- extension or a twisting injury, as from having the leg caught in a revolving wheel. The epiphysis usually is displaced forward (Fig. 426). Reduction may be difficult, and is best maintained by dressing the knee in flexion. Fracture of one or other condyle, usually the external, is more frequent in children than adults, and occurs mostly from direct violence. There is mobility of the fragment, and lateral mobility in the knee, in addition to crepitus, localized pain, etc. Effusion, perhaps bloody, often occurs into the joint. Treatment consists in immobilization with weight-extension or gypsum case, in good position, for four or five weeks. Use of the limb should be gradually resumed. Patella. — If these fractures occur from direct violence there may be comminution, but there seldom is much separation of the frag- ments unless the lateral expansions of the quadriceps tendon are ruptured; in fracture from muscular action, however, which is the FRACTURES OF THE PATELLA 409 usual form, this fibrous expansion is widely torn, as the fracture takes place by sudden flexion of the knee, and the tense quadriceps breaks the patella over the condyles as an over-bent lever. The bone usually gives way more or less transversely, the lower fragment being smaller. Diagnosis. — Diagnosis is easy, owing to separation between the fragments, free mobility, and crepi- tus. If the quadriceps expansion is not torn, the patient may still be able to walk; usually he is entirely disabled. I have seen, however, a few cases of subperiosteal fracture, demonstrated by skiagraphs, in which there was no disability. Treatment. — Treatment in most cases is operative, as it is difficult to secure good apposition without suture of the fragments. But in the aged, or those with visceral disease, operation is much more of a risk, and conservative treatment may se- cure a very useful leg. The limb is dressed on an inclined plane (Fig. 427), thus relaxing the quadriceps muscle, and the fragments are ap- proximated by straps of adhesive , , " . , p £ Iig. 42o. — Separation of lower epi- plaster, much as in the Case Ot trac- p h ys i s of femur. Reduced under ether tUred Olecranon; the plaster should and knee dressed in flexion on double ' r . . inclined plane. Dr. H. ( . Dearer s be readjusted every tew days to case. Episcopal Hospital. Fig. 427. — Fracture of patella, dressed on inclined plane. Episcopal Hospital. Ill) FRACTURES keep the fragments as close together as possible, and to avoid everting them. This dressing is continued for six weeks. Even if only fibrous FlQ. 428. — Fracture of patella with wide separation of fragments, showing power of full extension six years after injury. No operation was done. Episcopal Hospital. union results, and if after getting about the bond of union stretches, as it frequently does, the power of extension of the knee may be retained Fig. 429. — Fracture of patella before operation. Episcopal Hospital. Age twenty-eight years. (Fig. 428) ; but in almost all cases there will be slight limp, and some disability in going up stairs. Operation is best done between the fifth FRACTURES OF THE PATELLA 411 and tenth days after injury; earlier intervention sometimes is followed by infection, and infection in a knee-joint of this kind usually requires amputation, and may result in the patient's death. The mortality of operation even under the best conditions may reach 4 per cent. (E. G. Alexander, 1911). The strictest aseptic technique is impera- tive. A semilunar flap is turned down or up, exposing the seat of fracture. The knee-joint is widely opened, and clots are removed by forceps or sponging with moist gauze. Any fringes of the quadri- ceps aponeurosis turned down between the fragments are everted, Fig. 430. — Fracture of patella after suture with chromic catgut. Episcopal Hospital. the quadriceps expansion and capsule are sutured with chromic gut; and the skin with interrupted silkworm gut (Figs. 429 and 430). In most cases it is sufficient to suture the fibrous tissues alone, without direct suture of the bone (Blake, Gibbon, 1904). Few surgeons any more employ a wire suture. If all oozing has been checked, and the skin is not sutured too tightly, it is not necessary to drain the wound; otherwise a small drain should be left beneath the skin for forty-eight hours. The limb is dressed on a posterior splint, which may be removed in a few days and the limb laid on a pillow, with the knee Ill' FRACTURES slightly flexed. Mosl surgeons now recommend beginning very gentle passive motion four or five days after operation, by raising the knee a few inches from the pillow once daily. No active motion should he allowed for at least two weeks, and not then unless the bone has been sutured with wire. If wire has been used, the frag- ments depend on it for their apposition and not on the newly formed callus. The patient may he out of bed in the third or fourth week but the knee should be supported by a posterior gypsum splint, or light brace, to prevent excessive flexion for about six weeks after operation. With non-absorbable suture the patient may begin to walk without support in three or four weeks. If wire has been used it may require to be removed. Kefracture is not very rare. Fig. 431. -Skiagraph of partial separation of upper epiphysis of tibia. (Schlatter's disease.) Episcopal Hospital. Tibia. — These fractures frequently are caused by direct violence, except those of spiral type following twists of the foot, and those of the internal malleolus accompanying fracture of the lower end of the fibula. The subcutaneous position of the tibia, and the fact that it supports the main weight of the body, render it much more FRACTURES OF THE TIBIA 413 liable to injury than the fibula, fractures of the shaft of which rarely occur except as secondary lesions in fractures of the tibia. The fractures from direct violence often are compound or comminuted. Fractures of the upper end of the tibia frequently run into the knee- joint (Fig. 315), and synovitis may result; as the fracture may be subperiosteal or impacted, involve- ment of the knee-joint with pain and tenderness over the head of the tibia, should make one suspect such a frac- ture. Complete separation of the upper epiphysis of the tibia is rare, but " start- ing of the epiphysis," sometimes known as Schlatter's disease (1903), is a not infrequent accompaniment of sprains of the knee in adolescents; the tibial tubercle, which forms part of the epiphysis, is partially loosened by the pull of the tendo patellae, and peri- osteal thickening results (Fig. 431). A comparison of skiagraphs of both knees is necessary for diagnosis. Most cases resemble "sprain-frac- tures" (p. 331), but in some the tibial tubercle is broken loose and is pal- pable as a distinct fragment. Treat- ment consists in rest until acute symptoms subside; immobilization of the knee should be continued for several weeks. Fractures of the shaft of the tibia gen- erally are oblique, and deformity may be great, owing to the pull of the calf muscles on the foot which causes shortening, and angular projection forward of the upper fragment. If this is pointed, as it usually is, there is danger of its causing a slough in the skin (Fig. 432). There also is a ten- dency to external rotation of the upper fragment from the weight of the thigh. Owing to the deformity, mobility, and crepitus, diagnosis is easy. The fibula very frequently is broken also, usually at a higher level, and impaction of the fibula may prevent reduction of the tibial fracture. Treatment consists in reduction of the deformity by extension, counter-extension, and manipulation; it may be assisted by placing the leg in Pott's position (1769) — lying on its fibular side with the knee flexed nearly to a right angle. Where posterior displacement of the lower fragment is very persistent, it may Fig. 432. — Skiagraph of fracture of both bones of leg; foot displaced back- ward by gravity and contraction of calf muscles; lower pointed end of upper tibial fragment protruding subcu- taneously on front of leg. Fracture of fibula comminuted and typically higher than that of tibia. Episcopal Hospital. Ill FRACTURES be advisable to divide the tendo Achillis. The leg may be put up in plaster of Paris at once, in cases where the condition of the soft parts will admit of this procedure, and in which reduction can be surely maintained while the plaster is setting; in this case the dressing must extend from the toes to above the knee, and it is very Fig. 433. — Long fracture box, for fracture of bones of leg. Note dry dressing over wound of compound fracture of tibia and foot bandaged to foot piece. Episcopal Hospital. important to keep the foot at a right angle with the leg. The gypsum case must be renewed at the end of a week or ten days, as subsidence of the primary swelling will have rendered it loose and hence useless in keeping the fragments in good position. Better than the circular case is the use of moulded splints of plaster of Paris; these are made by Fig. 434. — Long fracture box for fracture of bones of leg, sides raised and fastened around leg. Episcopal Hospital. folding the wet bandage backward and forward on itself until splints of the desired length and thickness are obtained, which are applied to the leg over a flannel bandage, and moulded around the limb as the plaster sets. If one such splint is applied along the back of the leg and foot, and one along each side, overlapping beneath the sole, FRACTURES OF THE FIBULA 415 very excellent fixation is secured and the splints may be removed to permit proper care of the soft parts once or twice weekly. In cases where the primary swelling is great, with bulla 3 , ecchymoses, etc., it is better to postpone the application of a plaster-of-Paris dressing for a week or ten days, keeping the leg meantime in a fracture box (Figs. 433 and 434), securely packed into a pillow which fills up all irregularities and keeps the leg straight ; a small shot-bag may be laid over the pro- jecting fragment. While in the fracture box great care must be exer- cised to protect the heel and malleoli from pressure by "floating" the former on a compress placed under the tendo Achillis, and by suitably padding the malleoli; and the heel should be kept down against the foot-piece of the fracture box, to prevent equinus deformity. Rotatory displacement of either the upper or lower fragment must be guarded against. Fig. 435.- -Skiagraph of Pott's fracture of left leg. Episcopal Hospital. Age forty-two years. Fractures of the Fibula. — Fracture of the shaft of this bone is rare, except when accompanied by fracture of the tibia, to which it usually is secondary. In such cases the treatment described above for fracture of the tibia is to be employed. Isolated fracture of the upper part of the shaft of the fibula often results in delayed union or non-union, 416 FRACTURES as it is very difficult to secure apposition of the ends of fragments buried in such a mass of muscular tissue. Fracture of the lower fifth of the fibula is a very frequent injury, resulting from indirect violence, the foot, as a rule, being turned violently outward (abduction frac- ture); as the astragalus forces the external malleolus outward, the tibio-fibular ligaments act as a fulcrum, so that the fibula is bent in against the tibia above the attachment of these ligaments, and finally breaks at this point, 5 to 8 cm. above the ankle-joint; the internal malleolus often is avulsed from the tibia, at the same time (Fig. 435); and to this combined lesion the name of Pott's Fracture is given, it Fig. 436. — Skiagraph of fracture of lower fifth of fibula, internal malleolus and posterior articular surface of tibia, with posterior dislocation of the foot. Episcopal Hospital. having been studied carefully and graphically described by Pott in 1771. A somewhat similar lesion may result from adduction of the foot, but then usually the fracture of the fibula detaches merely the external malleolus, and the tibial fracture enters the ankle-joint. No accurate description can be given of the lines of fracture in these various injuries, as they vary greatly in different cases. Other lesions, which may or may not be present, are rupture of the tibio-fibular ligament, rupture of the internal lateral ligament of the ankle without fracture of the internal malleolus, fracture of the posterior border of the articulating surface of the tibia, separation of the lower tibial epiphysis, or posterior dislocation of the ankle-joint (Fig. 436). FRACTURES OF THE FIBULA 417 Symptoms. — Symptoms of Pott's fracture are a well-marked and characteristic deformity, consisting in abduction of the foot, and marked prominence of the internal malleolus or of the lower end of the tibia when the malleolus is avulsed. If the posterior articular surface of the tibia is broken also, there is a tendency for the foot to slide backward, causing elongation of the heel and prominence of the tibia anteriorly. As a rule, lateral mobility is marked, and crepitus easily detected. But since fracture in this region occa- sionally exists without displacement, being subperiosteal or impacted, the surgeon always should treat a suspected case as one of fracture until this can be disproved by skiagraphy or otherwise. Treatment. — Accurate reduction is im- perative if a good result is to be obtained : imperfect reduction in an antero-posterior direction will limit dorsal flexion of the ankle, and imperfect correction of the abduction will render the patient liable to develop static flat-foot, and will cause last- ing disability in locomotion (Fig. 437). Sometimes general anesthesia is necessary to secure reduction. Grasp- ing the heel in one hand, and the leg in the other, the surgeon brings the foot forward until the astragalus bears its normal relation to the tibia, and then adducts the foot, so as to replace the internal malleolus and overcome the internal bowing of the fibula. Do not rotate the foot Fig. 437. — Deformity follow- ing unreduced Pott's fracture of left foot, two months after in- jury. Episcopal Hospital. Fig. 438. — Dupuytren's splint for Pott's fracture. Note pads along tibial surface of leg, allowing inversion of foot. Episcopal Hospital. inward on the long axis of the leg. If there is little reaction in the soft parts, plaster-of-Paris splints, from toes to knee, may be applied at once, to be renewed in a week or ten days. In many cases, however, it is safer to dress the leg temporarily in a fracture box, with a pad below the external malleolus and one above the internal malleolus to over- come eversion, and with careful support to the heel, keeping this w T ell down against the footboard so as to prevent the development of the pointed-toe deformity; or the leg may be dressed in Pott's position on a Dupuytren splint (1819) (Fig. 438). Weight should 27 418 FRACTURES not be borne on the foot for at least eight weeks. In many cases, where reduction has been imperfect, stiffness and edema may persist for some months, and may require massage, passive motion, baking, or eventually operative reduction (Fig. 332) for their relief. Frc 439. — Impacted fracture of neck of right astragalus. Episcopal Hospital. Fig. 44Q. — Skiagraph of fracture of calcaneum, comminuted and impacted. Episcopal Hospital, FRACTURES OF THE FOOT 419 FRACTURES OF THE FOOT. Fractures of the Tarsus usually result from direct violence or falls on the feet, and often are impacted. Localized tenderness following severe injury is the most valuable symptom, since swelling of the soft parts may obscure deformity, and since mobility and crepitus frequently are absent. Corresponding injuries often exist in both feet, and two or more bones often are fractured in the same foot. The astragalus most frequently is broken through its neck (Fig. 439; see also p. 451). Fractures of the calcaheum are more frequent, and often may be diagnosed clinically from the Fig. 441. — Fracture of second, third, fourth, and fifth metatarsal bones. Heavy stone fell on foot. Age twenty-three years. Episcopal Hospital. flattening of the heel and prominence of the calcaneum below the external malleolus; if the fracture detaches the posterior half this may be considerably displaced upward by the tendo Achillis; more often there is a general crush of the bone (Fig. 440). These fractures are best treated by immobilization in good position in plaster of Paris for three or four weeks; but weight-bearing should not be allowed for 420 FRACTURES several months. Traumatic flat-foot should be Immediately corrected by moulding the foot over the surgeon's knee or a sand pillow, as the plaster sets; division of the tendo Achillis may be necessary; the ever- sion of the heel should be corrected also. If impaction of the cal- caneum with deformity cannot be overcome without incision, it will be proper to do osteotomy of the heel portion so as to restore the normal weight-bearing surfaces. This has been done by Chutro (1909) as a secondary operation. Fig. 442. — Fracture of tuberosity of fifth metatarsal bone; patient had been treated for "sprain of foot." Age twenty-three years. Episcopal Hospital. Fractures of the Metatarsus. — The metatarsal bones usually are fractured by direct violence, usually two or three at once (Figs. 441) . Deformity is slight, but disability may be great. Diagnosis is based on persistent localized tenderness usually with mobility, and some- times crepitus. Fracture of the base of the fifth metatarsal bone (Fig. 442), or epiphyseal separation at this point, which is a less frequent injury, sometimes occurs from direct injury in stepping on the outer side of the foot. Fractures of the Phalanges are rare, even from direct violence, and then usually are compound and require amputation. CHAPTER XIII. INJURIES OF JOINTS. SPRAINS AND CONTUSIONS. A sprain is an injury to the ligamentous structures surrounding a joint, caused by a wrench or a twist; there may be a subluxation or actual dislocation of the bones composing the joint, spontaneously reduced. Ross and Stewart (1911) maintain that every sprain is a sprain-fracture (p. 331), the ligament giving way at its bony attach- ment. 1 Contusions are rarer than sprains, and are due to direct injury, the blow being received over the joint or being transferred to it through the bones; by the latter mechanism may be explained frac- ture or displacement of intra-articular cartilages (p. 448). The joints most often sprained are those of the foot, wrist, shoulder and elbow. Symptoms. — The symptoms of the two conditions are those of inflammation in general, with perhaps the added special symptoms of synovitis (p. 503), thecitis (p. 310), or sprain-fracture (p. 331). The joint assumes that position in which tension is least, the ankle being in slight plantar flexion and adduction, the wrist in flexion, etc. The swelling, heat, redness, etc., may appear in a few moments, but if the joint is well supported (e. g., by a shoe), and its use is per- sisted in, they may not manifest themselves until after support is removed. In the foot the subastragalar joint is that most frequently sprained, the lesion being referred to popularly as "sprained ankle'; the normal range of its lateral motion is suddenly exceeded either in abduction or adduction, with laceration or complete rupture of the internal or external lateral ligaments at the ankle; and in some cases there is a diastasis of the tibio-fibular joint. There commonly is effusion around both malleoli (Fig. 443). Distinction from fracture usually is possible after careful examination, by excluding abnormal mobility or localized tenderness of the bones around the affected joint, the signs in sprains pointing to the soft structures as the seat of lesion. Prognosis. — The prognosis is good, though in some rheumatic patients slight disability may persist for months; and in a few cases, especially sprains of the shoulder, periarthritis may ensue (p. 507). Treatment. — When seen early, it is best to strap the ankle with adhesive plaster (Fig. 444), applying a firm bandage over this. In 1 By a "strain" usually is understood a sprain of slight degree, in which the tendinous rather than the ligamentous structures are injured. (421) 122 INJURIES OF JOINTS mild sprains, limited use of the joint may be allowed when thus sup- ported, but in severe cases the foot should be elevated, and kept at rest for several days. This strapping should be renewed every third or fourth day, and may well be continued until function of the joint can be resumed. In cases not seen until marked swelling has developed, it is safer to treat the joint with anodyne or evaporating lotions until tenderness and swelling begin to abate. Sprains of the joints of the upper extremity may be dressed with ichthyol or belladonna and mercury ointment, and the limb carried in a sling. Absolute immobilization (plaster of Paris, etc.) rarely is advisable, as tending to promote stiffness by interference with the circulation of blood and lymph. In later stages much benefit is derived from alternate hot and cold douches, massage, and gentle passive motion. Fig. 443. — Sprained right ankle (recent accident). Episcopal Hospital. Fig. 444. — Adhesive plaster strapping for ankle. Episcopal Hospital. WOUNDS OF JOINTS. Open wounds of joints usually are very serious lesions, since joints are very susceptible to infection. They may be incised, lacerated, punctured, etc. Gunshot wounds of joints have been considered in Chapter VII. Diagnosis. — The diagnosis usually can be made by noting the situation and depth of the wound, or by observing the escape of synovial fluid, and the increase in its flow on manipulation or pressure of the joint; under no circumstances should a joint wound be probed with finger or instrument until all proper aseptic preparations have been made. Prognosis. — The prognosis depends on the joint injured, on the nature of the injury, on the constitutional state of the patient, and WOUNDS OF JOINTS 423 On the treatment employed. Except the vertebral joints, the knee is the most dangerous joint in the body, but no joint wound can be regarded as trivial: even those of the phalanges may require ampu- tation, or at least result in ankylosis. Infection is the great danger, and even supposedly aseptic operations occasionally terminate fatally when the knee is involved (p. 411). If proper treatment is not undertaken promptly, pyarthrosis may result, followed by septi- cemia and death, in spite of all the resources of surgery. Treatment.— If seen before these complications have arisen, the wound should be packed with sterile gauze, and the limb surrounding it prepared as for an aseptic operation; then any foreign bodies remaining in the wound (cinders, clothing, glass, needle, etc.), should be extracted, enlarging the wound if necessary, and evacuating blood and clots from the interior of the joint; this should then be gently irrigated (not sponged) with warm saline solution, and the capsule should be sutured with provision for drainage of the overlying soft parts. The joint is then immobilized by splint or plaster of Paris, elevated, and surrounded by ice-bags. In the case of large joints weight-extension should be applied. 1 Constitutional treat- ment (purge, diuretic, sedative) should not be neglected. If the joint does well, as shown by the absence of pain and fever, the drain may be removed on the second day, and immobilization continued for one or two weeks, when function should be very gradually resumed. If the signs of infection arise (pain, fever, leukocytosis), indicating the development of septic arthritis, the dressing must be removed promptly, and drainage instituted; this may be accomplished by reopening the original incision, by a counter-opening, or by numerous openings, with saline irrigation once or twice daily, or in desperate cases by wide incision of the joint (in the knee by dividing the tendo patellae and acutely flexing the knee — Dudley Allen, 1906). Instilla- tions of Dakin's solution may be adopted, as described at p. 170; or, as advised by Churchman (1918), a solution of gentian violet may be used. One thorough application to the opened joint of a strong, hot antiseptic sometimes will check the infection, usually with anky- losis as a result, and, as already mentioned (p. 172), Menciere reports good results from his method of embalming. But if septicemic symptoms continue in spite of this heroic treatment, the surgeon has only two resources left: these are excision and amputation. In the upper extremity the former usually is successful, as it sometimes is in the ankle-joint; but for the knee-joint amputation usually is required, and, of course, should be resorted to in the case of other joints, where excision has failed. Nor should these radical operations be postponed too long, as, when adopted late in the disease, even they may fail to save the patient's life. 1 Willems' plan (p. 208) of treating joint wounds and cases of suppurative arthritis by active mobilization, has not been generally adopted. 121 INJURIES OF JOINTS HEMARTHROSIS. Hemarthrosis may follow subcutaneous wounds of joints, espe- cially gunshot; it also is more frequent than is commonly supposed in severe sprains, especially of the knee. The symptoms are those of acute synovitis (p. 504); if distention is marked and the joint very painful, it should be relieved by puncture or arthrotomy, the joint in the latter instance being closed without drainage. But hemarthro- sis may follow slight contusion in cases of hemophilia , and in such patients may be a very serious malady. 1 nder no circumstances should such a joint be opened for exploration or drainage. It should be put at rest, ice should be applied, and the hemophilia treated as already advised (p. 259). DISLOCATIONS. Dislocation or luxation of a joint is a condition in which the articular surfaces of the bones forming the joint are no longer in contact. Dislocations, however, may be complete or incomplete (subluxation), the articular surfaces in the latter form retaining a partial contact with each other. It is usual to classify dislocations as traumatic, congenital, and spontaneous or pathological : traumatic dislocations are those resulting from the application of force; congenital dislocations are those present at birth; and spontaneous or pathological dislocations are those due to malformation of the joint surfaces from disease, or to laxness of the periarticular structures. Dislocations may be simple, compound, or complicated, these terms having the same sig- nificance as when applied to fractures; they may be recent or old, terms of relative meaning, and which sufficiently explain themselves; and they may be primitive, when the displaced bone remains where originally placed by the injury, or consecutive, when it assumes another position owing to manipulations by bystanders, the surgeon, etc. The direction of the dislocation is described as it regards the distal bone or bones forming the joint: thus posterior dislocation of the elbow means that the forearm (not the humerus) is displaced back- ward; but there are a few exceptions to this rule, which will be noted later. In the present chapter only traumatic dislocations are considered, pathological dislocations being discussed with diseases of the joints, in Chapter XV, and congenital dislocations in connection with orthopedic surgery, in Chapter XVI. Causes. — As in the case of fractures, the male sex and active adult life act as predisposing causes of luxation. Certain joints are dis- located much more commonly than others: the shoulder contributes about 50 per cent, of all dislocations, while the elbow, the clavicle, and the phalanges contribute only about 5 to 10 per cent, each; the hip, ankle, and lower jaw contribute from 3 to 5 per cent, each; while the wrist, knee, etc., are very rarely dislocated. DISLOCATIONS 425 Dislocations are caused much more often by indirect than direct violence. Usually the motion of the joint is forced beyond its normal limit, the distal bone impinging against a fulcrum formed by a neigh- boring bone; the capsular ligament is thus ruptured at its weakest point, and the head of the dislocated bone is forced through this opening either by continuation of the original force, or rarely by secondary muscular contraction. It thus happens that in each joint there is a more or less typical primitive dislocation, because the head of the bone habitually emerges at the weakest part of the capsule. If direct violence is the cause, the capsule and accessory band-like ligaments are widely ruptured, and the head of the bone may pass almost in any direction. In luxations caused by leverage (the usual mechanism), the tear in the capsule always is sufficient to allow passage of the head; but it is the capsule which offers the main obstacle to reduction since by secondary displacement of the luxated bone, and by its rotation on its long axis, the tear in the capsule becomes converted into a slit with tense margins. But though this slit-like opening in the capsule is the main obstacle to reduction further difficulty is afforded by muscular contraction and resiliency, which keep the bone in its abnormal position. Symptoms. — There are three cardinal symptoms of dislocation. (1) Alteration in contour of the affected joint, the head of the luxated bone being absent from its socket and palpable elsewhere. (2) Change in length of the affected extremity — either shortening or lengthening. (3) Immobility or loss of normal mobility. In many dislocations there also is evident (4) Change in the axis of the dislocated bone. The only pathognomonic sign, however, is the first, absence of the head of the dislocated bone from its socket and its presence elsewhere; and even here confusion may arise, if, as in cases of fracture of the surgical neck of the scapula (p. 367), the socket as well as the head of the bone is displaced. In general, however, a dislocation may be distinguished from a fracture near a joint, by the facts that in a fracture there is abnormal mobility and bony crepitus; and that when deformity is reduced it frequently recurs; whereas in dislocation the normal mobility is decreased or entirely lost, there is no true crep- itus, and deformity does not recur when the dislocation is reduced. But in dislocation caused by direct violence the periarticular struc- tures are so widely disrupted that abnormal mobility may exist, and deformity may persistently recur; and in some cases there may be an indistinct moist crepitus due to contrition of the luxated bone with the side of the socket; moreover, dislocation and fracture may be present in the same joint, symptoms of both conditions being evident. The skiagraph offers a controlling test by which almost always it is possible to ascertain the true lesion. Damage to periarticular structures — nerves, bloodvessels, tendons — may occur in dislocation, as in fracture, and always should be looked for before attempts at reduction are made. Other evidences of local injury, such as pain, swelling,ecchymosis, etc., do not require special description. 426 INJURIES OF JOINTS Changes in the Joint Surfaces occur within a comparatively short time, if the dislocation is not reduced. There always is a certain amount of blood extravasated, filling the capsule; and as this organizes the socket becomes shallower, the capsular tear cicatrizes and con- tracts, the surrounding ligaments, tendons, bloodvessels, and nerves become adherent in the newly formed scar-tissue; and the longer the dislocation remains unreduced, the more difficult is it to secure reposition. In the course of time the luxated bone forms for itself a new socket, which will furnish a certain degree of solidity and permit a moderate amount of motion. Prognosis. Prognosis is good in the majority of cases as to both lite and function. Dislocations very rarely are fatal injuries unless compound or complicated. Beyond a weakness or stiffness lasting some weeks or possibly months, most patients whose dislocations have been promptly and skilfully reduced suffer no further incon- venience; but where reduction is delayed, or where unusual force has been employed in securing reduction, a certain amount of disability may persist for years or throughout life. Treatment. — In recent dislocations efforts at reduction should be made at once, unless the patient is profoundly shocked. In many cases general anesthesia is desirable to relieve the pain and abolish muscular contraction, which is aroused anew T at every attempt to manipulate the limb. Dislocations are reduced by two methods, which may be classed, in the terminology of G. G. Davis (1910), as the direct and the indirect: in the former the limb is first placed in the attitude in which it was when the dislocated bone burst through its capsule, and the head of the bone is then pushed or pulled directly back through the rent in the capsule into its socket; in the indirect method the limb is manipulated in such a way as to bring into use the capsule itself and surrounding ligaments as a series of sliding fulcra, by means of w T hich the dislocated bone is levered into its socket. If an anesthetic is administered, completely abolishing muscular contraction, no obstacle to reduction remains except the joint capsule, and it depends on the skill, patience, and dexterity of the surgeon to insinuate the head of the dislocated bone through the capsular opening into the socket; for this to be accomplished, no force is required beyond what may be exerted by the surgeon's hands. The capsule is an inelastic structure, and the tear through which the dislocated bone emerges always is as large as and sometimes larger than the head of the bone itself. If no anesthetic is given, it may be necessary to supplement the surgeon's own power by weight-extension, gravity, etc., especially if the patient has a highly developed muscular system; in other cases it will be easy to reduce the luxation by taking the muscles by surprise, as it w r ere, and replacing the bone while the patient thinks a mere preliminary examination is being conducted. All efforts at reduction by conservative means having failed, the surgeon may resort to arthrotomy, by which he will be enabled to enlarge the rent in the capsule, and to displace tendons, ligaments, DISLOCATIONS 427 etc., caught around the head of the bone, this latter condition being almost the sole factor which renders a recent dislocation really irre- ducible. Usually operation is not undertaken until several days after the injury, different surgeons having meantime maltreated the limb by applying excessive force in attempts at reduction; this renders the operation more difficult and less likely to be successful than if done before such unskilful attempts have been made. Reduction having been secured, the joint should be kept at rest, in such a position as to prevent re-dislocation, for a period of ten days or two weeks; and for several weeks longer all violent motions, or even gentle motions of wide range, should be prohibited. Massage often is beneficial. Compound Dislocations are to be treated according to the principles inculcated when speaking of wounds of joints. Owing to the great force necessary for their production, and the wide laceration of the soft parts, reduction usually is easy. They are most frequent at the elbow and ankle. Complicated Dislocations. — Fractures complicating dislocations are discussed at p. 347. Rupture of the main vessels at a dislocated joint is to be treated as a wound of the vessels under other circumstances. Lesions of nerves accompanying dislocation should be treated con- servatively until no further improvement can be expected; unless, of course, it is evident that complete rupture of a nerve trunk has occurred, when primary suture should be done. Old Dislocations. — Some dislocations become "old" much sooner than others, and it is not always advisable to attempt reduction. Sir Astley Cooper (1822) set three months as the limit for the shoulder, and eight weeks for the hip, not because reduction could not sometimes be obtained after the lapse of a longer time, but because it was secured at the expense of such damage to the soft parts that the remedy was worse than the disease. The first question, therefore, which arises in a case of old dislocation, is whether or not reduction shall be at- tempted. And it may be answered affirmatively in almost every case, since even though the attempt prove a failure a skilful surgeon by judicious and gentle manipulation of a dislocated joint almost invariably will be able to improve the function of the part. But as to whether attempts at reduction will be .successful, it is much more difficult to formulate an answer, much depending on the duration of the condition, the age of the patient, and the joint involved. At the present day mere duration of the condition is very little con- sidered, since should reduction fail by manipulation, it may succeed by arthrotomy; and as a last resort the surgeon may have recourse to excision of the joint or of the head of the dislocated bone, an operation which generally will improve function, though not restoring it to normal. But the age of the patient is an important consideration; in the very old, while manipulation might succeed in securing reduc- tion more easily than in those of active middle life, yet the risk of producing fracture would be so great, and the advantages to be gained 1JS INJURIES OF JOINTS so temporary, that as a rule it is better to leave the joint alone unless the condition is very disabling. The hip-joint is that in which dislocation becomes irreducible most rapidly; the knee probably is second, the elbow third, and the shoulder fourth. But in the hip and the shoulder, especially the latter, if massage and passive motion are persisted in long enough, a fair range of motion may be secured without reduction. In the elbow arthrotomy usually will be successful in securing reduction and a useful limb; while in the knee excision may be required. Recurrent Dislocations are commonest at the shoulder, and may require pleating of the capsule by suture as practised by T. T. Thomas (1909). He employs an axillary incision. SPECIAL DISLOCATIONS. Mandible. — Usually this is produced through muscular action in yawning, though it may follow a downward blow on the chin. The luxation may be unilateral or bilateral, and the displacement nearly invariably occurs foricard: the condyle ruptures the weak anterior portion of the capsular ligament, rides forward on the eminentia articularis beyond its normal limit, and is held there by spasmodic contraction of the external pterygoid muscle, assisted by the tem- poral and masseter. The mouth remains open, and if only one side of the jaw r is dislocated, the chin is displaced to the other side. Treatment. — Reduction is secured by forcibly opening the mouth further, at the same time depressing the body of the bone by placing the thumbs (carefully guarded by adhesive plaster, gauze, etc.) over the back molar teeth, and finally raising the chin by the dis- engaged fingers. Recurrence, not very rare, should be prevented by application of a bandage, such as Barton's, for about ten days. Subluxation of the jaw is a term employed by Sir Astley Cooper (1822) to describe a frequently repeated, usually self-reduced, uni- lateral displacement of the mandibular condyle, due to looseness of the intra-articular cartilage. Probably it is more often the carti- lage that is displaced than the condyle; the cartilage has the external pterygoid muscle attached to it anteriorly, and the displacement is forward. In case the displacement is not self-reduced, Pringle (1919) advises its replacement "by keeping up hard pressure at the back of the condyle with the mouth open, and slowly closing the jaw." In mild cases it constitutes the condition known as "clacking jaw;" aside from the noise of the cartilage slipping around, which is audible to the patient and occasionally to those close to him, little inconven- ience is experienced. Treatment, when any is required, consists in administration of tonics, use of counter-irritants, injection of formalin or alcohol, and, as a last resort, excision of the cartilage. Central dislocation of the jaw is a very rare lesion, usually fatal, in wmich the condyle is driven through the base of the skull. Vertebrae.— See Chapter XVII. DISLOCATION OF THE CLAVICLE 429 Clavicle. — This bone may be dislocated at either end, dislocation at the acromio-clavicular joint forming an exception to the rule for nomenclature of luxations formulated at p. 424. Fig. 445. — Mechanism of dislocation of right sterno-clavicular joint. See text. Fig. 446. — Mechanism of dislocation of right acromio-clavicular joint. See text. Dislocation of the Sterno-clavicular Joint. — The clavicle usually is displaced upward and forward. The injury is produced by falls or blows causing sudden depression of the shoulder, the clavicle coming into contact with the first rib close to the sternum ; as the costo-clavicular ligament prevents the clavicle from giving at the point of attachment, the inner ex- tremity is pried out of its socket over the first rib as a fulcrum (G. G. Davis, 1910) (Fig. 445). The intra-articular cartilage usually is displaced with the clavicle. Symp- toms are self-evident (Fig. 417), and reduction is easy to secure by raising the outer end of the clavi- cle and drawing the shoulder back- ward; but it is difficult to prevent recurrence. The arm may be carried in a sling, and a firm spica of the shoulder applied (Fig. 89) with a pad over the inner end of the clavi- cle. Some deformity almost always persists, but function is good. In some cases the joint may be opened and the bones sutured in place. Backward dislocation at the sternal end is rare, and may be accom- panied by dyspnea, dysphagia, etc. In the only patient I have seen, under the care of Dr. F. T. Stewart in the Pennsylvania Hospital, Fig. 447. — Recurrent dislocation of sternal end of right clavicle. Ortho- paedic Hospital. 430 INJURIES OF JOINTS the only pressure effects were due to compression of the subclavian vein, and were promptly relieved by drawing the shoulder back- ward. A posterior figure-of-eight bandage (Fig. 92) makes a good dressing. Downward dislocation at this joint may occur when frac- ture of the first rib coexists; it is a serious injury, the result of great direct violence. Dislocation of the Acromioclavicular Joint usually results from depression and inward rotation of the scapula, from falls or blows on the point of the shoulder. This carries the base of the coracoid up against the clavicle, and as the clavicle is fastened to this by the strong coraco-clavicular ligaments, the only motion possible is an upward dis- placement of the acromial end of the clavicle, the coracoid acting as a fulcrum (G. G. Davis, 1910) (Fig. 446). The deformity is self-evident, and like that at the inner end is easy to overcome but difficult to keep reduced. However, by fixing the upper extremity in the Velpeau position, with the dressing advised for fracture of the clavicle, the turns of the bandage over the shoulder and under the flexed elbow (Fig. 356) will keep the bones in place as long as the bandages remain firm. This dressing should be continued two weeks or more. As in luxation of the sternal end, suture may be adopted for persistent deformity if it entails disability, which is rare. Downward and back- ward dislocations occur, but are very unusual. Scapula. — The only dislocation of this bone recognized by system- atic writers consists in displacement of its lower vertebral border from beneath the fibers of the latissimus dorsi, usually from indirect violence or muscular strain. If firm bandaging is not sufficient, the muscle may be re-attached by suture. The deformity seen in some cases of phthisis (winged scapula), and after paralysis of the serratus magnus muscle, closely simulates this "dislocation" of the scapula. Shoulder. — Dislocations of the head of the humerus may occur anterior or posterior to the glenoid cavity, the posterior variety being exceedingly rare. There are many reasons for this: the shoulder usually is dislocated by injuries which produce extreme abduction of the arm, and as the force generally acts from the front, the arm is carried backward as it is abducted. As the glenoid process looks more forward than outward, such a motion throws most strain on the anterior part of the capsule of the shoulder-joint; and if while the arm is abducted slightly posteriorly an inward thrust or a pull by the axillary muscles is added, this portion of the capsule will be ruptured; or if abduction continues until the humerus strikes against the acromion, after all possible leeway has been gained by rotation of the scapula, then the head of the humerus will be pried out of the capsule over the acromion as a fulcrum. The capsule is torn loose from the glenoid, from the base of the coracoid above to the attachment of the triceps below; and through this rent, which may be increased by rotation of the humerus, the humeral head emerges in the axilla, in front of the triceps. If the arm remains in the position of extreme abduction, which is extremely rare, the condition is de- DISLOCATION OF THE SHOULDER 431 scribed as luxatio erecta; usually, by the force of gravity or the assist- ance of bystanders, the patient's arm is brought down to his side, and the head of the bone passes beneath the coracoid [sub-coracoid dislocation) where it usually remains, or may be displaced further inward, into a subclavicular position. All these (axillary, subcoracoid, subclavicular) are varieties of anterior dislocations. Posterior dis- locations, unless congenital, usually result only from extreme direct violence, tearing loose ligaments and tendons on all sides; or some- times by inward rotation and adduction, with a backward thrust, the lesser tuberosity impinging on the coracoid process. Sometimes they are consecutive displacements, the primitive dislocation having been anterior. The head of the bone may be displaced only slightly backward (subacromial), or so far as to merit the term subspinous. Fig. 448. — Recent subcoracoid luxation of left humerus, patient aged seventy years. Reduced without anesthetic by Kocher's method. Episcopal Hospital. In anterior dislocations the subscapularis muscle, stretched over the capsule at the point of rupture, may itself be perforated by the head of the humerus, though usually this emerges below the sub- scapularis. The circumflex or musculospiral nerve may be stretched or lacerated, though recent observations seem to show that the lesions if permanent more often are in the spinal roots forming the outer cord of the brachial plexus (p. 316). 1 In most cases there is tingling and numbness in the fingers, and some distention of the veins, from pressure on the axillary vessels. Symptoms. — The appearance of patients with dislocation of the shoulder is characteristic (Fig. 448) : the arm hangs a little away from the side, there is a hollow under the acromion, and the head of the bone may be seen beneath the coracoid. As the head of the humerus 1 Delbet and Cauchoix (1910) collected 36 cases of paralyses complicating dis- locations of the shoulder: 25 of these were terminal paralyses, and were produced by the dislocation itself; the remaining 11 lesions all were radicular and were due not to the dislocation but to the cause which produced the dislocation. 432 INJURIES OF JOINTS has been displaced from its pedestal, and has been drawn against the side of the thorax, and as the thoracic cage is convex, it is impossible to bring the elbow against the side of the chest at the same time that the hand is placed on the uninjured shoulder (Dugas's sign, 1856). In recent cases, and in not very obese patients, the diagnosis is easy; but when swelling has occurred, and after much manipulation by others, it may be quite difficult; and it is in such circumstances that Dugas's sign and the x-ray (Fig. 449) become valuable aids. Fig. 449. — Subcoracoid dislocation of humerus. Episcopal Hospital. In posterior dislocation the head of the bone is palpable beneath the infraspinous muscles, the glenoid cavity is empty, the coracoid process is unusually prominent, and the other usual symptoms of dislocation are present. Treatment. — The indirect method of reduction, or that by manipu- lation, is preferable. This was proposed in 1858 by H. H. Smith, Professor of Surgery in the University of Pennsylvania, and later (1863) systematized by him; he thought muscular contraction, especially that of the supraspinatus, as taught by Sir Astley Cooper, was the main obstacle to reduction. Kocher, later Professor of DISLOCATION OF THE SHOULDER 433 Surgery in Bern, in 1870 adopted a similar method, founded on that of Schinzinger (1862); he recognized the capsule as the chief obstacle to and best aid in securing reduction. H. H. Smith's Method of Reduction. — The patient being on his back, (1) elevate the arm in the sagittal plane until it is nearly vertical (step two, of Kocher's method) ; this relaxes the supraspinatus muscle, as well as the coraco-brachialis and short head of the biceps, per- mitting step two to be more effectually executed. (2) Keeping the arm vertical, and using the bent forearm as a lever, rotate the humerus outward; by doing this the untorn posterior portion of the capsule is wound around the head and upper part of the neck of the humerus (Farabeuf, 1885), and acting as a sliding fulcrum draws the head of the bone away from the chest, until the subscapulars becomes tense and resists further rotation. (3) Then slowly adduct the arm across the chest, still maintaining outward rotation of the humerus; when the elbow touches the chest, the hand is brought down to the opposite shoulder, and the bone usually will be replaced. T. Kocher's Method of Reduction. — (1) Bring the elbow against the chest, and rotate the humerus outward as far as it will go, using the bent forearm as a lever (Fig. 450) ; do not push this outward rotation too far, and do it with a very gradual and gentle but persistent motion; force is very liable to fracture the humerus; Kocher himself broke it three times in reducing twenty-eight luxations. During this out- ward rotation of the humerus the same phenomena occur as during step two of Smith's method, but the lesser tuberosity may catch under the tense coraco-brachialis, and this is one cause of the frequency of fracture of the humerus (G. G. Davis, 1910). (2) Raise the elbow in the sagittal plane, or in slight adduction, until the arm is as nearly vertical as possible (Fig. 451); this relaxes the anterior border of the rent in the capsule (coraco-humeral ligament) and the coraco- brachialis and short head of the biceps, which hinder the ascent of the head on to the glenoid process. (3) Rotate the arm inward, using the bent forearm as a lever, until the hand touches the sound shoulder, then quickly bring the elbow to the side of the chest (Fig. 452). This last step slides the head of the bone back through the rent in the capsule, whose posterior untorn part is now on the inner instead of the outer side of the humerus, and again acts as a fulcrum to lever the head upward; but reduction often is accomplished at the conclusion of the second step. Of these two methods, Smith's undoubtedly is the better, though neither of them rests on the anatomo-pathological basis which was erected for them by their authors; Smith thought the muscles the all important factor, while Kocher thought success depended on the gleno-humeral ligament, which was shown by Farabeuf to be of no consequence. The great advantage of these methods of manipulation is that an anesthetic usually is not required in recent cases, and that they can be applied by the surgeon without other assistance than the inertia of the patient's body. They depend for their efficiency, 28 i:u INJURIES OF JOINTS however, on the untom >tate of the posterior part of the capsule; if this portion also is torn, the head of the humerus will not be pulled FlG. 450. — Kochcr's method of reducing dislocation of shoulder, first step: outward rotation. Episcopal Hospital. Fig. 451. — Reduction of dislocation of shoulder by Kocher's method; second step: elevation of arm in sagittal plane. Episcopal Hospital. Fig. 452. — Reduction of dislocation of shoulder by Kocher's method; third step: hand brought to shoulder and elbow to chest. Episcopal Hospital. away from the chest during outward rotation, but will rotate in situ. Under such circumstances the rent in the capsule will be so large DISLOCATION OF THE SHOULDER 435 that no difficulty should be experienced in replacing the head of the bone by direct pressure, after it has been drawn away from the chest by extension and counter-extension. The methods of direct reposition are many; all of them depend first on bringing the head of the bone opposite the tear in the capsule, and consequently aivay from the chest wall and out to the neighborhood of the glenoid -process; and then on pushing or pulling it into its socket. The head can be brought away from the side of the thorax only by eliminating or overcoming the muscular contraction which holds it there, either by continuous traction or a general anesthetic. 1. Sir Astley Coopers Method (1822): With the patient supine, place the heel of the unbooted foot in the patient's axilla, against the chest, and make traction downward and slightly outward on the upper extremity; the traction pulls the head free from the coracoid, and by slight leverage over the foot, the head is pushed directly into its socket. A little rotation in and out may assist. This is a very efficient method, really combining all others (extension and counter-extension, leverage, and manipulation), but it is very painful and usually requires anesthesia; and the inexpert or brutal may cause serious injury to the axillary tissues. 2. Stimson's Method (1900): The patient is laid on a canvas sling, with the dislocated extremity passed through a hole in the canvas and hanging free of the floor; a weight of about ten pounds is attached to the wrist or elbow. The limb is kept thus in abduction, and in a few minutes (never more than six, Stimson) reduction of the dis- location takes place quietly and without pain. No anesthetic is required, as the weight tires out the muscles which hold the head of the humerus against the chest; and as soon as it is drawn out to the region of the glenoid process, it slips into its socket spontaneously. 3. Malgaigne's Method (1855) is the reverse of Stimson's: The patient lies on the sound side on the floor, and a robust assistant pulls vertically upward on the dislocated extremity, till the shoulders just clear the floor, and maintains this traction till the patient's axillary muscles are exhausted; the surgeon then pushes the head of the bone into place. Many other modifications of this principle have been devised, and constantly are being reinvented by ingenious surgeons. In posterior dislocations upon the cadaver I have succeeded in securing reduction by reversing the manipulations of Kocher's and Smith's methods; but usually in life the capsule is so widely torn that the luxation is easily reduced by direct pressure forward or very slight manipulation. After reduction, the arm is dressed in the Velpeau position and guarded use may be permitted after two weeks. It is possible that if reduction were accomplished more often by manipulation and less often by brute force less disability as the result of periarthritis would follow this [injury. Yvert (1911) studied the statistics of various surgeons and found that Go per cent, of the patients had persistent 436 I.X.Ilh'll'S OF JOINTS disability, 22 per cent, had fairly satisfactory function, and only 13 per cent, had excellent results. Elbow. — The typical dislocation at the elbow consists in backward displacement of both bones of the forearm; anterior dislocation of both bones is rare; and lateral dislocations usually are incomplete and often accompanied by fracture of one or other of the humeral condyles. Posterior Dislocation. — Posterior dislocation is most frequent from fifteen to thirty years of age, and results almost invariably from a fall on the out-stretched hand causing hyperextension of the elbow, the olecranon acting as a fulcrum and prying the bones apart; the anterior capsule is ruptured, and the internal lateral ligament more or less lacerated, and detachment of the epitrochlea of the humerus often occurs. Fracture of the olecranon by compression sometimes is seen, and occasionally the coronoid process is broken off. Fig. 453. — Old unreduced posterior dislocation of elbow, with evidences of hypertrophic arthritis. Episcopal Hospital. Symptoms.— The deformity usually is quite apparent. The fore- arm, usually pronated, is carried at an obtuse angle with the arm, and motion is painful and restricted. The radius and ulna may be displaced directly backward, but often there is also slight lateral displacement. The olecranon is found displaced posteriorly and upward in relation to the condyles, and the greater sigmoid fossa of the ulna often can be felt between the tense triceps and posterior surface of the humerus (Fig. 453). The head of the radius is absent from its normal place just in front of the external condyle and can DISLOCATION OF THE ELBOW 437 be felt posteriorly. Anteriorly the lower extremity of the humerus fills the flexure of the elbow. The diagnosis from supracondylar fracture, referred to at p. 37(>, should present no difficulties, and in case of doubt, the lesion is much more likely to be a fracture than a dis- location. If the lesion is recognized, and the luxation promptly reduced, recovery is rapid, and in most cases nearly perfect function is secured. Treatment. — In recent cases, especially in children, reduction without an anesthetic is easy, by reversing the steps by which the lesion was produced: first hyperextend the elbow, until the tip of the olecranon strikes the humerus, and the coronoid is freed from the trochlea; then make extension and counter-extension in the axis of the arm, pushing the lower end of the humerus backward; and finally acutely flex the elbow, when the bones will be replaced with a snap. Often the pressure of the thumbs over the lower end of the ^~^- "~--— ?v~v^ humerus, and that of the clasped ( 4^=^=i======^ fingers over the posterior surface / j/^~~T\ \ ^ of the olecranon, is sufficient to r. / /I £ ' \ \ , secure reduction (direct method) '{ rf / / -^ \ or the knee may be placed in the p>\ / § \ bend of the elbow and used as a f ' "« / / & \ « fulcrum to lever the bones of the Av -** \ S L forearm away from the humerus V* \\ by traction on the wrist with one > % hand, while the humerus is pushed backward with the Other hand FlG -. 454 —Mechanism of reduction of ,„ At-*\ rm n • i i posterior dislocation of elbow by aid of (rig. 4o4). Ihe elbow is dressed the knee. in hyperflexion (p. 384), for a week, and then carried in a sling for another, and after two weeks guarded active use is encouraged. Lateral Dislocation.— External dislocation often is due to direct violence, usually is incomplete and complicated by fracture of the external condyle, and extensive rupture of the internal lateral ligament (Fig. 455). Internal dislocation is rarer than external, and fracture is a less usual complication (Fig. 456). In both forms the deformity is so extreme and the bony processes so easily palpable that, if careful examination is made before swelling obscures the landmarks, the diagnosis should not be difficult. Reduction is easier to secure than to maintain, especially if fracture exists. The elbow should be dressed in hyperflexion and treated as if fractured. Forward Dislocation. — Forward dislocation of both bones at the elbow is very rare; even including seven cases in which the olecranon was broken off and remained in place, the total number on record, according to Stimson (1917), is less than twenty-five. Fracture of the epitrochlea is a frequent accompaniment. Reduction is not difficult, as both lateral ligaments are lacerated. 138 / VJURIES OF JOINTS Dislocation of the Ulna Alone from the humerus is most often pos- terior; the symptoms and treatment arc much the same as when both bones are so displaced. Fig. 455. External lateral disloca- Fig. 4.16. — Inward dislocation of ulna and tion of elbow, with fracture of external radius. Dr. De Tar's case. Patient fell and condyle, and rupture of internal lateral while lying on left elbow train struck him ligament and fracture of epitrochlea. upon buttocks. Reduction easy under anes- Dr. W. Walker's case. Episcopal thetic. Hospital. Dislocation of the Head of the Radius usually occurs in an anterior direction. The orbicular ligament may remain intact, the radius slipping out of its grasp, and subsequently being displaced forward by the pull of the biceps; often it is the result of a fracture of the upper part of the shaft of the ulna, from direct violence, the continuance of the fractur- ing force driving the head of the radius forward (Figs. 457 and 458). This combined lesion is so frequent that the recognition of either a dislocation of the radial head or a fracture of the upper end of the ulna should make the surgeon suspect the existence of the complicating lesion (Ashhurst, 1912). Examination may detect a hollow in front of the external condyle, and the head of the radius a little forward from its normal position ; flexion of the elbow beyond a right angle may be prevented by contact of the radius with the humerus. Reduction sometimes may be secured by full supination and direct pressure upon the displaced bone; and flexion will then become possible. Reduction should be obtained at all hazards, by arthrotomy if neces- sary. Only after reduction of the radial dislocation has been secured can the fracture of the ulna be reduced. If re-dislocation of the radial head occurs after keeping the elbow hyperflexed (p. 347) for several weeks, it may be assumed that the radial head had not been replaced within the orbicular ligament; and an operation may be necessary to hold it in place. In cases of complete dislocation it is very unlikely that reduction can be secured without operation. In old unreduced luxation, excision of the radial head may be done to permit flexion dislocation of the radws 439 of the elbow, but in children this should be avoided if possible, since removal of the epiphysis will interfere with development. In young children a .subluxation known as "pulled elbow" occurs: this is due to vertical traction on the forearm, often produced as the caretaker helps or lifts the child across an obstruction in the street. If Fig. 457. — Anterior and outward dislocation of head of radius, with fracture of shaft of ulna. Four months after injury. Episcopal Hospital. Fig 458. — Anterior and outward dislocation of head of radius, three months after reduction by arthrotomy and capsulorrhaphy. Episcopal Hospital. the forearm is supinated the vertical traction tends to bring the fore- arm and arm into a straight line, causing momentary loss of the carry- ing angle; or forced pronation may pry the radius forward over the ulna as a fulcrum. C. A. Stone (1916) thinks this is always the mechanism, since in pronation the lesser diameter of the oval lit) INJURIES OF JOINTS head presents. Symptoms of "pulled elbow' 5 are rather indefinite, and in many cases no definite history of trauma can be obtained; it is merely noticed that the arm is not used properly, and that there is tenderness around the elbow. Treatment of "pulled elbow" consists in securing reduction of the subluxated bone by the same methods employed in cases of complete dislocation, and in preventing recurrence (which is not very rare) by keeping the elbow at rest for a week. Sometimes a lesion of the lower radio-wlnar joint co-exists. Wrist. — Dislocation of the radio-carpal joint, usually consisting in dorsal displacement of the carpus, is very rare; Stimson classes Barton's fracture (p. 392) more as a complication of this dislocation than as an independent lesion. It is produced usually by the same injuries as Colles's fracture, and the differential diagnosis is not always easy; but if it is possible to feel the styloid processes of the radius and ulna still attached to their respective bones, and to ascertain that the length of the bones of the forearm remains the same on both sides of the body and to feel the very abrupt eminence on the dorsum caused by the displaced carpal bones, confusion between fracture and dislocation is not apt to occur. Besides, the luxation is reduced by an elastic snap, without crepitus, and without tendency to recurrence. I have seen one case myself, easily diagnosed clinically by attention to these details. The diagnosis may be confirmed by a skiagraph. Spontaneous Subluxation of the Wrist (Madelung's Disease). — See p. 585. Dislocations of the carpal bones are not very uncommon, particularly forward dis- location of the semilunar, associated or not with fracture of the scaphoid. The bone is palpable under the flexor tendons, and there is a gap on the extensor surface be- tween the os magnum and radius. The other carpal bones, most often scaphoid or os magnum, usually are dislocated back- ward. If reduction is not easily secured, the displaced bone should be excised. Metacarpus. — The metacarpal bones rarely are luxated, the displacement usually being posterior. Phalanges. — The proximal phalanx of the thumb not infrequently is dislocated poste- riorly on the head of its metacarpal bone by hyperextension, some- times in a fight, a fall, or in the effort to push a tight stocking off the heel of the foot. The deformity is quite characteristic (Fig. 459), the phalanx in well-marked cases making a distinct angle with the meta- carpal bone, the head of which is easily palpable in front; the distal phalanx remains flexed, owing to tension on the flexor longus pollieis, which is displaced to one side or other, usually the Fig. 459. — Dislocation of metacarpophalangeal joint of thumb. Reduced by arthro- tomy. Episcopal Hospital. DISLOCATION OF THE HIP 441 ulnar side of the metacarpal. The head of the metacarpal is "button-holed" through the anterior ligament; the tendons of the flexor brevis blend with the lateral ligaments, and it is the tension of these lateral ligaments, which fit like a collar around the neck of the metacarpal, that may render reduction impossible. In some cases reduction can be effected without anesthesia, (1) by pressing the metacarpal bone toward the palm, so as to relax the short thumb muscles; (2) by sliding the base of the phalanx over the head of the metacarpal, keeping the phalanx in hyperextemion until the head of the metacarpal has been cleared. If reduction is impossible, an incision is made along the radial border of the flexor surface of the prominent head of the thumb metacarpal, and the external lateral ligament is divided close to the phalanx. Dislocations of the interphalangeal joints of the fingers almost always takes place posteriorly, from hyperextension, in falls or blows on the finger tips (Fig. 460). Reduction •usually is easy, but a joint fracture of the proximal bone may exist, and some deformity may result. Treatment is the same as for fracture of a phalanx. Lateral dislocation usually is incomplete (Fig. 461). Fig. 460. — Posterior dislocation of middle phalanx on proximal of fifth finger. Episcopal Hospital. Fig. 461. — Lateral dislocation of mid- dle on proximal phalanx. Episcopal Hospital. Sacro-iliac Joints. — Complete luxation is rare, but subluxation, from sprain or long-continued strain may take place. Motion occurs antero-posteriorly around a transverse axis, and the usual displace- ment is of the upper end of the sacrum backward. Cricks and stitches in the small of the back, or severe backache may follow strain on these joint ligaments from stooping, from malposition in sitting or standing, or simply from lying long flat on the back, when the mus- cular support is weakened by anesthesia or constitutional disease. Relaxation of these joints sometimes is seen, and is best treated by orthopedic apparatus, gymnastics, etc. (p. 57S). Hip. — Dislocation of the hip is a rare and rather a serious injury. The head of the femur is held in the acetabulum by a capsular ligament which is reinforced above and below by band-like ligaments, leaving the capsule weak anteriorly and posteriorly. The upper band-like ligament (ilio-femoral ligament of Bertin, 1754) is especially strong, and is known as the Y-ligament of Bigelow (1869); it is scarcely 442 INJURIES OF JOINTS Fig. 462. — Innominate hone showing the anterior and posterior planes. University of Pennsylvania. ever ruptured, no matter what the force thai produces the luxation. Indirect violence is the usual cause, the femur being forced beyond its normal range cither in flexion and adduction, or in extension and abduction, and the head of the hone being pried out of the acetabulum by leverage. In the cadaver luxations are most easily produced by hyperabduction, forcing the ureal trochanter against the posterior lip of the acetabulum, and using it as a fulcrum by which the head is lifted out of its socket; the capsule is then ruptured anteriorly below the ilio-femoral ligament, and the head of the bone passes on to the anterior plane 1 of the innominate bone (Fig. 4('i2). In patients, how- ever, the history of the injury generally indicates another me- chanism, the femur having been in flexon and adduction, and the force having been received through an upward thrust in the long axis of the femur, or by a heavy weight falling on the pelvis from behind. In such cases it is probable that the strong ilio- femoral ligament has been wound around the neck of the femur (inwardly rotated), acting as a sliding fulcrum; or possibly that the neck of the femur has been forced against the horizontal ramus of the pubis, and that the head has been pried out of the acetabulum over this as a fulcrum. The capsule here is ruptured posteriorly, and the fe- moral' head passes on to the posterior plane of the innominate bone. Owing to the immense length of the distal arm of the lever (the whole lower ex- tremity), it is not at all unusual for a dislocation primitively anterior to be converted' into one of the posterior variety consecutively ; in such cases the capsule may be widely lacerated, but in almost every case the ilio- femoral ligament remains intact, and the lower extremity is circum- ducted and rotated on it as a pivot. In general, then, two main types of dislocation at the hip may be Fig. 463. — Usual sites of dislocation at the hip. A to B, Negation's line. Posterior dislocations are (1) low; (2) high. Anterior dislocations are: (3) low; (4) high. See text. Nekton's line divides the innominate bone into two planes (Allis, 1896). DISLOCATION OF THE 11 W li:; recognized, anterior and posterior; and of each type there are several varieties, according as the head of the femur rests high or low on the anterior or posterior plane of the pelvis (Fig. 463). Posterior Dislocations of the Hip, more frequent than anterior, are classed as high (" dislocation on the dorsum ilii," or " above the tendon" Fig. 464. — Posterior (dorsal) dislocation of the hip. (Stimson.) of the obturator interims), and low (" dislocation into the sciatic notch" of Sir Astley Cooper, 1822; or "below the tendon" of Bigelow 1869); and of these two the high luxation is much more frequent, though this may be only a consecutive displacement, the head of the femur having emerged from the capsule lower than the sciatic notch, and having been displaced upward when the limb was extended. •II! INJURIES OF JOINTS Symptoms. There is loss of normal mobility; there is shortening, with flexion, adduction and internal rotation at the hip; and in stand- ing the toes of the injured side rest on the dorsum of the other foot i Fig. 164). The lower the position of the femoral head on the posterior plane, the more marked will be the shortening, flexion, adduction, and inward rotation. The head of the femnr 1 can no longer be felt below Poupart's ligament, beneath the femoral artery, but sometimes can be detected posteriorly under the gluteal muscles; the trochanter is unduly prominent, is rotated forward, and is above Nelaton's line. _^^ Anterior Dislocations of the Hip are > classed as high ("pubic"), or low ("thyroid"), the latter, in which the head rests in the obturator foramen, probably being the primitive form in most cases; in the pubic form, the head rests against the horizontal ramus of the pubis; an exaggerated form of the high dislocation is the "suprapubic," and an exaggerated form of the low dislocation is the "perineal," the head of the bone passing inward beyond the thyroid foramen and across the ischium into the perineum. Symptoms. — All these anterior dis- locations are characterized by im- mobility, flexion, abduction, and eversion of the limb (Fig. 405); in the low forms there may be apparent lengthening, but in the high cases there usually is actual shortening. The head of the femur generally can be felt beneath the pectineus or ad- ductor muscles, and often forms a visible prominence; the trochanter is rotated backward, and is less promi- nent than normally. Other Atypical or "Irregular" Dislocations of the Hip occur, but are extremely rare, and are either secondary modifications of those de- scribed above, or are caused by such violent trauma as frequently to cost the patient his life. The so-called "central dislocation of the hip" is discussed at p. 301. Prognosis. — If reduction is effected promptly, and without additional trauma, restoration of function is rapid, and generally complete; but the longer reduction is delayed, and the greater the force required 1 A good working rule to remember is that the position of the internal condyle corresponds to that of the head of the femur, while that of the external condyle corresponds to that of the great trochanter (G. G. Davis, 1910). Fig. 465. — Anterior (thyroid) dis location of hip. Episcopal Hospital DISLOCATION OF THE HIP 445 in accomplishing it, the more unfavorable the outlook. But even in some cases of irreducible luxation, especially of the thyroid type, very fair use of the limb may be secured. Treatment. — Reduction of dislocation of the hip is accomplished either by the direct or indirect method. Direct Method. — In this, systematized by Allis (1896), the head of the femur is first brought into the position in which it burst through the capsule, and is then pushed or pulled into the acetabulum. As in both anterior and posterior dislocations the head leaves the acetabulum in its lower part, and as the capsule probably is widely torn below, the method of direct reposition is nearly the same for both varieties. The patient should be anesthetized and laid on his back Fig. 466. — Position of bones in reduction of posterior dislocation of hip by direct method. University of Pennsylvania. on a mattress on the floor, with the pelvis firmly fixed : flex the thigh on the pelvis to a right angle, thus bring'ng the head of the femur toward the lower part of the acetabulum; flex the knee to a right angle, to relax the hamstring muscles and sciatic nerve, and to aid in rotating the thigh. Hold the ankle with one hand, and pass the other hand beneath the flexed knee or sling a towel under the knee and over your own shoulders, to aid in the upward traction required. In backward dislocation have the thigh slightly addicted, to free the head from the rim of the acetabulum and to relax the anterior branch of the Y-ligament; then make vertical traction on the thigh upward and a little inward, and the head may jump into the acetabulum (Fig. 400). If it does not, rotate the thigh gently in and out (do not circumduct it), to make the capsule gape widest, and try to pull 1 16 l\.ll HIES OF JOISTS the head over the rim of the acetabulum in the various positions of rotation. An assistant may help by direct pressure upward and inward on the great trochanter. The head usually will jump into the acetabulum with an audible snap. In forward dislocation, have the thigh slightly abducted, to free the head from the antero- inferior margin of the acetabulum, and to relax the posterior branch of the Y-ligament; then make vertical traction upward and slightly outward, and the head often will jump into the acetabulum (Fig. 467). If not, gentle rotation may be tried, until the capsule gapes its widest; and an assistant may aid by pushing the trochanter upward and slightly outward. Fig. 467.- -Position of bones in reduction of anterior dislocation of hip by direct method. University of Pennsylvania. In Stimson's application of the direct method (1889) for posterior dislocation, the patient lies prone, with the affected thigh hanging vertically downward: the knee of the dislocated side is flexed, and the ankle held by the surgeon; in most cases the weight of the limb is sufficient to reduce the dislocation within a few minutes without pain and almost imperceptibly; if necessary, weight may be added to the knee, and gentle rotation practiced, as when the patient lies on his back. Indirect Method. — Reduction by manipulation alone was taught and practised by Hippocrates, N. R. Smith (1831), and Despres (1835), and was systematized by W. W. Reid (1851); they regarded the muscles as the chief obstacles to reduction; but it remained for Moses Gunn (1853) and especially for Bigelow (1869) to demonstrate DISLOCATION OF THE HIP 44; that even with muscular contraction abolished by anesthesia, the capsule still remained the supreme obstacle, and that manipulation was successful only when the action of the Y-ligament was appreciated and employed as an aid. It is used as a sliding fulcrum over which the head of the femur rides into the acetabulum. The patient is anesthetized, and laid on his back on a mattress on the floor; with the pelvis firmly fixed, the thigh is flexed on the pelvis to relax the Y-ligament and to bring the head of the bone down to the lower part of the acetabulum near the rent in the capsule; and the leg is flexed on the thigh to aid in the manipulation, and to relax the ham- strings and sciatic nerve. In posterior dislocations the limb is brought up in the position in which it is found (adduction), and is gently circum- ducted and rotated outward after the thigh has been flexed to more than a right angle with the pelvis; as outward circumduction is con- tinued (Fig. 4GS), the head of the bone is swung downward and inward by tension on the posterior branch of the Y-ligament, and finally Fig. 468. — Reduction of backward dis- location of femur. (Bigelow.) Fig. 469. — Reduction of downward and forward dislocation of femur. (Bigelow.) as the limb is brought down to the position of full extension and very slight abduction, the head rides over the rim of the acetabulum and sinks into its socket. 7/ the abduction is too great as the thigh is brought down to extension, the head will slide across to the anterior plane of the pelvis, and a consecutive thyroid luxation will be produced. Rarely in this excursion the sciatic nerve may be caught up over the neck of the femur. If abduction is not great enough, the head will slide up again on the outer side of the acetabulum, and the high posterior luxation will be reproduced. Rarely as it slides up it may catch under the tendon of the obturator internus. In anterior dis- locations the limb is brought up in the position in which it is found (abduction), and is gently circumducted and rotated inward after the thigh has been flexed to more than a right angle with the pelvis; as inward circumduction is continued (Fig. 469), the head of the bone is swung downward and outward by tension on the anterior branch of the Y-ligament; and finally as the limb ig brought down to the 448 INJURIES OF JOINTS position of full extension and very slight adduction, the head rides over the rim of the acetabulum into its socket. // the add net ion is too gnat, a consecutive posterior dislocation may be produced; and if it is not great enough, the head will slide up the inner side of the acetabulum to a pubic position. Reduction is known to have been accomplished when the head of the bone is felt to snap into place, and it can be felt rotating in its socket by the fingers below Poupart's ligament; when normal extension of the hip is possible, and when a skiagraph shows the bones in place. After-treatment. — The patient should be kept in bed with moderate weight-extension for a couple of weeks, and should resume use of the limb with caution. Patella. Outward luxation of the patella was mentioned at p. 310 as a rare complication of marked knock-knee deformity, and of some paralytic conditions when it is a recurrent or habitual dislocation; it is also seen very occasionally as a traumatic lesion. Rotatory forms of luxation of the patella also occur, usually from injury; these almost invariably occur outward, that is, the anterior surface of the patella faces first outward, and, if the luxation is complete, then it turns completely over until the joint surface presents subcutaneously. A downward luxation, associated with rupture of the quadriceps, also has occurred, the patella being wedged between femur and tibia. If reduction by manipulation fails, arthrotomy should be done. Knee.— Traumatic luxations of the knee are extremely rare, and usually caused by very severe injuries. The displacement of the head of the tibia may be backward, forward, lateral, or rotatory. Wise (1909) refers to 270 cases of dislocation of the knee, 114 of which were anterior. Most of the displacements are incomplete, the lateral almost invariably. Forward dislocation is caused by sudden violent hyperextension, by indirect or direct violence; the tibia slides up on the front of the condyles, but usually maintains the same axis as the femur, not being flexed or hyperextended. Backward dis- location usually follows direct force applied to the front of the tibia, and the leg becomes hyperextended on the thigh. In many of these luxations injuries to the popliteal vessels or nerves are present, and the intra-articular cartilages and ligaments may be ruptured. Usually reduction is not very difficult, owing to stretching or laceration of the lateral ligaments. Prognosis as to function is not very good even in uncomplicated cases, some deformity (flexion, valgus, etc.), generally persisting through life; and for complications, amputation may be required. Internal Derangement of the Knee-joint (I ley, 1803).— Several lesions are grouped under this heading : Fracture or Subluxation of the Semilunar Cartilages-, usually the internal, has as its most frequent cause a fall with the knee in flexion and the tibia in outward rotation; if this process increases, the anterior crucial ligament may be ruptured; if the fall occurs when the knee is INTERNAL DERANGEMENT OF THE KNEE-JOINT 449 flexed and the tibia in internal rotation, avulsion of the tibial spine may result (Figs. 471 and 472). The patients often are not seen until some time after the original accident, and demand relief from recurrent disability: thus there may be repeated locking of the knee in flexion from slight sprain. This may be due to dislocation of a semi- lunar cartilage (Fig. 470), to the presence of joint mice (p. 502), or a loose fragment of bone. Sometimes the lump becomes palpable. According to Alwyn Smith (1918) when the knee is in full extension, the possibility of anterior displacement of the tibia on the femoral condyles indicates rupture of the anterior crucial ligament, while backward displacement indicates the posterior crucial is ruptured. With the former lesion relaxation of the internal lateral ligament is frequent, causing a ten- dency toward genu valgum. Fig. 470. — External semilunar cartilage removed from knee, for dislocation. Episcopal Hospital. Fj<;. 471. — Fracture nf spine of tibia. Episcopal Hospita 29 450 INJURIES OF JOINTS Treatment. — As a rule gentle manipulation and gradual passive extension so far as possible, followed by sudden acute flexion of the Fig. 472. — Same as Fig. 471. Patient completely relieved by excision of detached fragment and suture of anterior crucial ligaments. Fig. 473. — Arthrotomy of knee. Exposure secured by longitudinal section of patella. University of Pennsylvania. knee will reduce the deformity, and restore the movements of the joint. After reduction of the displacement, some appliance must DISLOCATION OF THE ANKLE 451 be worn to limit motion in the knee and prevent rotation of the tibia. If the patient is anxious for a radical 'cure, arthrotomy may be done, preferably by longitudinal section of the patella (Jones and Smith, 1913), which gives the best possible exposure for any procedure that may be indicated (Fig. 473). A luxated or fractured cartilage should be excised; attempts to suture it in place are not advisable. Function nearly always is completely restored. Hey Groves (1917) and Ahvyn Smith (1918) have used strips of fascia lata to replace the anterior crucial ligament. Fig. 474. — Skiagraph of fracture-dislocation of astragalus. Age forty-five years. From fall of eight feet, landing on feet. Irreducible. Both fragments excised. Excel- lent result. Episcopal Hospital. Ankle. (Tibio-tarsal Joint). — Except in connection with fracture of the leg bones, dislocations at the ankle-joint are exceedingly rare. Wendel (1898) collected 108 cases without fracture. Posterior luxa- tion usually follows forced plantar flexion of the foot, with rupture of the lateral ligaments of the ankle, the astragalus sliding backward off the tibio-fibular mortise as dorsal flexion is regained. Anterior luxation, much rarer, usually occurs when the foot is in extreme dorsal flexion, the leg bones being forced backward against the tense tendo Achillis either by a blow from above or by a fall on the heel. Lateral dislocation is that in which the astragalus and with it the foot, leaves the tibio-fibular mortise, and is displaced externally or internally, there being little or no rotation of the foot. A less unusual displacement is that in which the astragalus rotates around an antero- posterior axis, so that the sole of the foot looks either inward (sicpina- 452 INJURIES OF JOINTS Hon dislocation) or outward {pronation dislocation). If, on the other hand, the astragalus rotates around a vertical axis, it may remain in the tibio-fibular mortise, but the entire foot may rotate with it the toes looking inward and the heel outward in dislocation by inver- sion, and the opposite being the case in dislocation by eversion. Dis- location upward (the astragalus separating the tibia and fibula) is known by Nelaton's name, though his case was complicated by fracture. Unless swelling obscures bony landmarks, these various forms can be distinguished clinically; but in all cases it is desirable to have skiagraphs made in at least two planes. These dislocations about the ankle-joint frequently are compound, and as already remarked, fracture of some of the bones involved very rarely is absent (Fig. 436). Reduction is not always possible without incision, and should be accomplished on the day of injury if possible. The longer the bones remain out of place, the less favorable will be the prognosis for function. Fig. 41 -Skiagraph of upward dislocation of tarsal scaphoid. Age fifty-four years. Episcopal Hospital. Tarsus. — The astragalus may be the subject of an isolated dis- location forward or backward, the latter being much rarer, and the forward displacement usually being somewhat inward or outward as well; or the astragalus may be rotated in any axis, remaining in situ. If reduction is not possible by manipulation, aided perhaps by tenotomy of the tendo Achillis, arthrotomy should be done, and DISLOCATION OF THE FOOT 453 the astragalus removed unless reduction is easy. Isolated disloca- tion of the other tarsal bones may occur (Fig. 475) ; unless reduction is easy, the displaced bone should be excised. Subastragalar dis- location of the foot, of which Wise (1909) collected 87 examples (50 inward, 21 outward, 8 anterior, and 8 posterior), consists of displace- ment of the entire foot from the astragalus, which remains in the tibio-fibular mortise. Reduction usually is possible by manipulation, and may be aided by tenotomy of the tibialis anticus, or by incision, if necessary. For compound dislocations amputation may be required. Dislocation at the medio-tarsal joint is rare. Skillern (1913) reported what he considered the thirteenth authentic case on record. The anterior tarsus may be displaced toward the flexor or extensor surface. Reduction usually is possible by manipulation under an anesthetic. Metatarsus. — Dislocations of the meta- tarsals have been studied at length by Quenu and Kiiss (1909); they collected 35 cases, and believe that systematic radiographic study will show it to be rather a frequent lesion of the foot. It frequently is complicated by fracture, and usually is due to direct violence or to falls on the toes. They show that the foot may be divided into two structural parts, as in Fig. 476, of which the main weight-bearing part is composed of the tarsus and the first metatarsal with its phalanges, while the four outer meta- tarsals serve as a balance. The most frequent luxations are (1) one in which the balancing portion is displaced exter- nally and toward the dorsum of the foot (external dorso-lateral dislocation) , and (2) one in which there is a dis- placement of the balancing portion outward and of the first meta- tarsal inward (divergent dislocation). Diagnosis depends largely on radiography. If reduction is impossible by manipulation, operation may be done ; this cannot be made to conform to any type, but may involve tenotomy, arthrodesis, removal of fragments, etc. But even in cases not reduced, fair use of the foot may be regained after several months or a year. Phalanges. — Dislocations of the phalanges of the toes are rare, usually due to direct violence, and hence often compound. Reduction and treatment are the same as in the fingers. Fig. 476. — The structural por- tions of the foot concerned in metatarsal dislocations. (Quenu and Kiiss.) CHAPTER XIV. DISEASES OF BONE. DYSTROPHIES OF BONE. There are numerous affections of bone of whose nature patholo- gists are still in ignorance. Some of them are known to be associated with changes in the organs of internal secretion; some of them may be due to remote infections, to chronic toxemias or intoxications; but all that is certain is that they depend on disturbances of nutri- tion, and for that reason it is convenient to group them together as dystrophics. In most cases the osseous system alone is not affected, but is more conspicuously diseased than the soft tissues. The diseases in question range from atrophic to hypertrophic forms, but in many both atrophy (softening) and hypertrophy (hardening) are present coincidently, or at different stages of the same disease. Atrophy of Bone. — This.may be concentric or eccentric (Fig. 477). In the former variety, which begins at the periosteal surface, the size of the bone decreases, but its length (due to cartilaginous growth) is little affected, and what once was a strong shaft becomes a mere spindle. In eccentric atrophy the changes begin in the marrow, and, though the bone may not change in size, it becomes weaker and more porous. In both forms the pathological changes consist in absorption of the bony trabecular by giant cells (osteoclasts), with the deposit of fat in the lacunae (lacunar resorption). If the bone becomes fragile and brittle, there is said to be osteopsathyrosis (Lobstein, 1833), or fragilitas ossium; if it merely becomes light and porous, without tendency to fracture, the condition is known as osteoporosis. Causes. — Causes of bone atrophy are disuse (as in amputation stumps, paralyzed limbs, etc.); chronic disease, especially of the nervous system; and old age. In most cases disuse is the paramount cause. Atrophy from pressure is also seen, as in tumors, aneurysms, etc. Osteogenesis Imperfecta (Vrolik, 1849). — Osteogenesis imperfecta, the so-called "idiopathic fragilitas ossium," is considered a definite disease; it is congenital, may be hereditary, and patients seldom reach adult life. Lovett and Nicholls found it associated with changes in the adrenals (1906). Naturally the long bones of the limbs are those most often fractured, usually from no recognizable injury; union occurs without difficulty, but usually with deformity owing to the frequent lack of splinting. The calvaria may remain membranous throughout, or scattered bone islets may develop. The subject has been carefullly studied by E. Bronson (1917) 1 1 Cretinism was separated from osteogenesis imperfecta by Heckel in 1861. (454) DYSTROPHIES OF BONE 455 Achondroplasia. — Achondroplasia (Parrot, 1878), known also as ckondrodystrophia foBtalis (Kauffman, 1892) is a congenital affection in which the epiphyses of the long bones become ossified abnormally early, preventing growth of these bones in length, and giving these patients a typical appearance: normal sized body with dwarf-like extremities. Characteristic deformities are the trident hand, all the Fig. 477. — Extreme bone atrophy, occurring in hereditary syphilis, in a girl, aged eighteen years, who had not walked for five years. The continuity of the tibia is lost, that of the fibula preserved (concentric atrophy). The tarsal bones and articular extremities of the tibia and fibula show eccentric atrophy. Episcopal Hospital. fingers being of the same length, with a tendency toward bifurcation of the hand; and the fibula may extend to the level of the knee-joint. Cartilaginous exostoses (p. 485) may co-exist. The calvaria (of mem- branous development) usually is unaffected. Shattuck classes it as a paracretinous condition, and found it associated with changes in the thyroid. Rachitis. — This is a disease apparently dependent on malnutrition, and having its chief manifestations in the osseous system. It begins 456 DISK AS US OF HONK almost exclusively in young children (under three years of age), but seems never to be congenital. The patients usually are not breast-fed, but have been brought up on improper milk mixtures. The osseous changes occur chiefly in the epiphyseal cartilages, and consist in irregular over-growth of cartilage cells; some of these car- tilaginous islets may be displaced into the metaphysis, and cause subsequent trouble (see Multiple Cartilaginous Exostoses, p. 485). Though the cartilage cells form osteoid tissue, there is deficient depo- sition of lime salts, and such as are deposited may be removed by lacunar resorption, resulting in marked osteoporosis. When the disease passes off, after lasting from three to five years, the bone becomes hard, dense, and eburnated, and deformities developed during the earlier period become permanent. Symptoms. — Early in the disease, attention may be drawn to the infant on account of constant fretfulness, sweating about the head, backwardness in walking or even crawling, inability to sit up alone, delayed dentition, etc. In extreme cases the limbs are very painful, and pseudo-paralysis may be present. When physical signs begin to develop, among the most constant and conspicuous is enlargement of the epiphyseal cartilages (Fig. 478), ap- preciable especially at the wrist, ankle- and costo-sternal joints, the deformity in the last named situation being Fig. 478. — Rachitis. Age five years. Scarcely able to walk alone. Children's Hospital. Fig. 479. — Rachitis. Age two years. Showing how bow-legs develop from persist- ent malposition. Children's Hospital. called the "rachitic rosary." The head appears square, the forehead is high, and the fontanelles remain open to the third or fourth year. The thorax may present a transverse depression (Harrison's groove, 1820) from the constant tug of the diaphragm on the softened ribs. RACHITIS 457 The child is "pot bellied," and there may be a long, rounded kyphosis of the spine, which disappears completely on hyperextension; the spine is nowhere rigid. Various deformities of the extremities develop, due to malposition and pressure (Fig. 479). " Knock-knee" or genu valgum usually is due to changes in the lower femoral epiphysis, with over- growth of the internal condyle, increasing the normal outward deviation of the leg; "out-knee" or genu varum is a less usual deformity than "bow-legs," in which the main deformity is in the leg bones. Knock- knee and bow-leg may coexist (Fig. 480) , generally due to the mother carrying the child constantly on the same arm (that side on which knock-knee develops) instead of alternating on the right and left. Anterior curvature of the tibia' is a conspicuous deformity, but very slightly disabling. Rachitic coxa vara is one of the less usual deformities. Rachitic deformity of the pelvis may in- terfere with parturition. Treatment. — In early stages constitu- tional treatment is most important, and may be successful in preventing develop- ment of deformities. The diet must be regulated, and as soon as the child can be weaned, a generous mixed diet, with plenty of vegetables, is preferable to continuance with milk; of all tonics, exclusive of fresh air, cleanliness, and sunlight, which of course must be pro- vided, none is so good as cod liver oil; this (not an emulsion, but the pure Norwegian oil) may be given three in doses from 2 or 3 c.c. quantity that can be ab- sorbed. In the very exceptional cases in which this is not tolerated, the syrup of the iodide of iron may be substituted ; and in many cases phosphates should be given in addition. Locally, begin- ning deformity in the limbs may be overcome by daily gentle manip- ulation in the mildest cases; or by splinting, or the use of gypsum cases renewed every few weeks with the legs in a corrected position. The use of braces, which is preferable when the patient can afford to purchase them, usually will overcome slight deformities within eighteen months or two years, if applied while the bones are still soft (before the age of two years and a half). Bow-legs show a greater tendency to spontaneous cure, and improve much more rapidly under treatment by braces than do knock-knees. Good types of braces are shown in the accompanying illustrations (Figs. 481 and 482); the times daih up to any Fig. 480. Rachitic legs: knock-knee on right, bow-leg on left, from being carried con- stantly on the mother's right arm. Orthopaedic Hospital. 458 DISEASES OF BONE modus operandi of braces is not to overcome the deformity forcibly, but to prevent growth in other than the proper direction; they require constant repair and readjustment, and the surgeon should see that they are in repair and properly adjusted every third or fourth week. Usually they need not be worn at night in bed. After the age of three years, and occasionally earlier, very little improvement can be expected from conservative measures, and an operation should be undertaken. Manual correction may be attempted by Anzoletti's method (1909): plaster of Paris is moulded very accurately to the extremity, from beyond the toes well up to the groin, so as to prevent all motion, and the patient is kept in bed on low diet for four or five weeks, so as to promote bone atrophy; at Fig. 481. — Bow-leg braces. Pads over internal condyles and internal malleoli, with leather apron over apex of de- formity. Orthopaedic Hospital. Fig. 482. — Knock-knee braces. Pads over internal condyles and internal malleoli. Orthopaedic Hospital. the end of this time the gypsum is removed, and the softened bones sometimes may be bent in the hands to the desired shape without anesthetizing the patient. Plaster of Paris is then applied in an over-corrected position, and the patient encouraged to walk about, being fed up, and given cod liver oil; at the end of four or five weeks the bones will be hard enough to go without support. I have tried the method several times, but think it suitable only for acute cases, especially those of bow-legs; in cases of long duration it is better to resort to osteoclasis or osteotomy. Osteoclasis, or breaking the bone, is accomplished by use of the osteoclast (Fig. 483), the patient being anesthetized; the limb is then put up in plaster of Paris in over-corrected position, and is treated as a fracture. Osteotomy, or RACHITIS 459 Fig. 483. — Hopkins's osteoclast. Orthopaedic Hospital. Fig. 484.— Results of osteotomies for knock-knees and bow-legs. Episcopal Hospital. 400 DISEASES OF BONE division of the bone by an osteotome (Fig. 509, 4), which may be described as a chisel bevelled on both edges, so as to cut straight ahead, is done through a minute incision which divides the peri- osteum. The osteotome is introduced through the periosteum, is turned transversely to the long axis of the limb, and is driven through the bone by a mallet in such a way as to divide it transversely all Fig. 485. — Skiagraphs made through the gypsum cases, showing osteotomies for bow-legs. Orthopredic Hospital. except a few fibers at the further side ; several cuts in the bone (all at the same level) may be necessary, but they are all made through the one skin incision, making practically a subcutaneous operation. The remaining bone fibers are then fractured by hand, the incision closed with one suture, and the limb is put up in plaster of Paris in an over- corrected position. For knock-knee the osteotomy is done a finger's OSTEOMALACIA 461 breadth above the epiphyseal line of the femur, usually on the outer side of the bone; for bow -legs it is done at the apex of the deformity, usually only the tibia being divided, the fibula bending or being broken by hand (Fig. 485). The correction of anterior curvature is more difficult (Figs. 486 and 487). The patient is not allowed to walk for six or eight weeks. Fig. 486. — Anterior curvature of tibiae Fig. 487. — Anterior curvature of tibia? in rachitis. (See Fig. 487.) Orthopaedic after osteotomy. Orthopaedic Hospital. Hospital. Scurvy. — Scurvy which may complicate rachitis or occur inde- pendently, should be borne in mind as a possible cause of symptoms of bone disease in infants. Tenderness of shafts of long bones, with skiagraphic evidences of subperiosteal hemorrhages (Fig. 488), in asso- ciation with other scorbutic symptoms, should make one suspicious of this condition. The diagnosis from tuberculous or subacute septic osteomyelitis is not always easy. Constitutional antiscorbutic treat- ment is indicated. Osteomalacia. — Osteomalacia, or softening of the bones, is an affection occurring mostly in women, often in those who have borne several children in rapid succession. It is believed to be associated with ovarian disease. Scarcely ever does it occur before puberty. Deformity is progressive and marked, involving the pelvis, the vertebral column, and later the extremities. "Spontaneous fracture" (Fig. 489) may occur, but is not frequent. The disease has been treated by oophorectomy; Schnell (1913), reviewing 334 cases reported during the previous fifteen years, found only 7 recurrences among 105 treated by oophorectomy; but some surgeons (Bastianelli) claim that the benefit from such operations has been due to the chloroform inha- lation used for anesthesia; and they now induce such anesthesia 462 DISEASES OF BONE without doing an operation (W. J. Mayo, 1910). According to Mayo, also, different [talian observers have found an identical and specific Fig. 488. — Scurvy, with subperiosteal hemorrhages in a child nine years of age, five or six weeks after first symptoms of scurvy. Patient of Dr. Githens. diplococcus in the periosteum in this disease, in rachitis, and in osteitis deformans; when a culture of this diplococcus was injected into rats Fig. 489. — Osteomalacia (five years' duration) in a man, aged seventy-eight years. Confined to bed for six months. Fracture of right femur occurred the day before the photograph was taken, and death from asthenia two days later. Dr. F. W. Sinkler's case. Episcopal Hospital. it produced rachitis in the very young animal, and osteomalacia in adult rats. The relation of thyroid and parathyroid diseases to FIBROCYSTIC OSTEITIS; BONE CYSTS 463 osteomalacia is not clear. The parathyroids are believed to control calcium metabolism. Osteitis Deformans (Paget's Disease of the Bones, 1876) occurs in adult life, patients usually not applying for treatment until well past forty years of age. It runs a very chronic course, lasting many years, and growing progressively worse, though intermissions and exacerbations may occur. It is characterized in its earlier stages by osteoporosis, causing flexibility and deformity of the bones; but later the bones hypertrophy and become markedly thickened. Fracture is rare. The lower extremities are affected earliest, re- sulting in general outward and anterior bowing of the knees and legs; the spine shows a long, rounded kyphosis, and the calvaria becomes very much thickened. At times the bones are very painful, but often progressive enlargement of the head is what first calls the patient's attention to his condi- tion. Eventually loss of height is observed, the attitude resembling that of anthropoid apes, with bowed head, disproportionately long arms, and a waddling gait (Fig. 490). Some weakness and stiffness usually exist, but death occurs only from intercurrent dis- ease, usually pulmonary, or from advanced arteriosclerosis which is a prominent feature of the malady. Treatment. — Treatment is chiefly hygienic and dietetic. Thymus or thyroid extract may be of value. Pain may be relieved by application of proper orthopedic appa- ratus. Fibrous Osteitis, or von Recklinghausen's Disease of the Bones (1891), was later (1910) assimilated by him to Paget's disease, just described. It is a generalized affection, at- tacking many of the long bones simulta- neously; may arise in childhood; is accom- panied by numerous pathological fractures, and entails great deformity (Figs. 491 and 492). Should the process become arrested the deformities may be corrected by operation. Fibrocystic Osteitis; Bone Cysts. — As already mentioned (p. 113), Barrie (1914) considers this lesion the result of attempts at repair in cases primarily resembling hemorrhagic osteomyelitis. The cyst usually is single, and contains thin, dark brown fluid, never distinctly hemorrhagic, and never under great tension; there usually is a distinct fibrous lining inside the bony shell, and even when this is absent Fig. 490.— Osteitis defor- mans (Paget's disease) in a patient, , aged seventy-two years. • Duration twelve years. Orthopaedic Hospital. If, I DISEASES OF BONE evidences of fibrous osteitis can be found microscopically. Unless the cysts are huge and of very long duration, or "there has been a Fig. 491. Diffuse fibrocystic osteitis in a lad aged seventeen. Onset from five to seven years of age. First fracture at nine years. Since then seven fractures. Ortho- paedic Hospital. Fig. 492.— Same case as Figs. 491 and 493. Multiple osteotomies and resections were done over a period of many months to correct deformities. Death from shock after last operation. pathological fracture (Fig. 494) there is no alteration in the over- lying periosteum. Small islets of cartilage may exist in the cyst FIBROCYSTIC OSTEITIS; BONE CYSTS 465 Fig. 493. -Fibrocystic osteitis. Section removed from right femur of patient shown in Figs. 491 and 492 Natural size. Orthopaedic Hospital. Fig. 494. — Bone cyst of humerus, duration fifteen months; recent fracture from slight injury. Cured by evacuation and scraping; and crushing in the thin wall of the cyst to obliterate the cavity. Episcopal Hospital. 30 166 DISEASES OF BONE wall, and a few giant cells may be present; but neither occurs in sufficient amount to render likely confusion with degenerated chon- dromas. It occurs in children, affects oftenest the humerus, femur, and tibia, and begins insidiously; in very many cases spontaneous fracture or the deformity resulting from such an unrecognized fracture is what first calls attention to the condition. There may be pain and increase in size of the bone, but the disease usually is easily distinguished from malignant neoplasms of bone by the long duration of symptoms. Unless the patient is seen for fracture, the swelling and pain, neither very marked, usually exist for a year or more before the surgeon is consulted. Routine examination by skiagraphy may detect cystic changes of slight degree in many bones not suspected of being diseased. The diagnosis from other forms of cyst (degenerated chondromas, echinococcus disease, etc.), which are rare, is not very important clinically, as the same treatment is required. In bone abscess there usually is a history of previous osteomyelitis, and the .r-ray shows the abscess surrounded by sclerosed bone. From myeloma, except in cases of very short duration, distinction usually may be made by study of skiagraphs; myeloma expands the bone rather abruptly, may cause periosteal proliferation, does not extend far up or down the medul- lary cavity, sometimes shows trabecule, and at operation no fibrous lining is found beneath the cortex; the benign bone cyst causes little expansion of bone, extends for some distance up and down the medulla, and usually a faint, fibrous lining can be detected. Mye- loma occurs in young adults past eighteen years of age; and sponta- neous fracture is rare. Bone cysts occur mostly in children, and spontaneous fracture is frequent. Subperiosteal hematoma may resemble a bone cyst if encapsulated by new-formed subperiosteal bone. The cortex may be slightly eroded, but the medulla never is involved. Such cysts are not uncommon in the cranial bones of infants, from obstetrical injury, but may arise elsewhere from con- tusion of bone Treatment. — This is the same as for myeloma (p. 114.) Hypertrophy of Bone. — This may be compensatory, as when one of two parallel bones is removed for disease, the other may become hyper- trophied. Or it may be the result of chronic irritation, as in thick- ening of a tibia underlying an old leg ulcer. Increase in thickness and weight is commoner than increase in length, though the latter occurs to a marked degree in some amputation stumps (p. 221); sometimes, too, after fracture or tuberculous or inflammatory lesion of bone, actual increase in length may occur, or at least the affected bone may grow faster than the corresponding bone on the other side of the body. Leontiasis Ossea (Virchow, 1865) is a disease usually arising in youth, characterized by hypertrophy of the face bones, giving the face a leonine expression, due to the gradual obliteration of its features. The foramina in the base of the skull may be narrowed, causing exophthalmos, blindness, and paralysis of the various cranial INFECTIONS OF BONE 467 nerves. Hypertrophy of the calvaria causes pressure on the brain, with headaches, convulsions, etc. No treatment is of avail. Acromegaly (P. Marie, 1886) is a disease of youth or early adult life, characterized by hypertrophy, enlargement and thickening of the apices and extremities of the skeleton — fingers, toes, chin, nose, etc. ; while similar soft tissues also may enlarge — lips, tongue, ears, and even penis and clitoris. Increase in size of the jaws results in abnormal spacing between the teeth. A rounded kyphos develops in the dorsal spine (Fig. 495). Headache is the chief subjective symptom. The disease may be of long duration and usually is caused by neoplas- tic changes in the hypophysis cerebri; a skia- graph may demonstrate enlargement of the sella turcica, and pressure symptoms from hypophy- seal growth may develop later. Treatment by pineal, thyroid, thymus, or other extracts may be tried, but the only hope of cure consists in operation on the hypophysis (see p. 631). INFECTIONS OF BONE. Infection of a bone usually occurs through the blood-stream, some locus minoris resistentice, generally due to injury, determining localization of the infection. Those who have a general blood-infection (furunculosis, typhoid fever, syphilis, tuberculosis, etc.), therefore, are pre- disposed to bone infection. Infection of bone also occurs in compound fractures, but as in these the products of inflammation are readily discharged from the broken surfaces and through the wound of the soft parts, the disease seldom assumes such serious proportions as when in- fection arises in the unbroken bone; in the latter instance the very structure of the bone prevents swelling, so that strangulation and necrosis occur very early. Acute Periosteitis. — Acute periosteitis rarely occurs as an isolated affection; in almost every case there are also osteitis and osteomye- litis, and it is probable that the infection is localized first in the medulla, and is propagated to the periosteal surface of the bone through the Haversian canals. In convalescence from typhoid fever, however, subperiosteal abscess may occur, and in most such cases there is no appreciable involvement of the medulla, and at most only a superficial caries of the cortex. The lesion occurs oftenest in the long bones and the ribs; relief of symptoms (pain, tenderness, swelling, fever, etc.), and rapid cure usually follow incision of the periosteum and scraping the carious bone (Fig. 496). Fig. 495. — Acromeg- aly. Dr. Hooker's case. Episcopal Hospital. 468 DISK \SKS OF BONE Chronic Periosteitis. — Chronic periosteitis is a frequent lesion, occurring in many of the dystrophies already described, or as the result of contusions of bone, from chronic inflammation of overlying soft tissues, and in chronic infections, especially syphilis (Fig. 518). The long bones are most often affected: the periosteum is raised from the shaft by the formation of new bone, and the resulting deformity may be very evident on inspection. Distinct periosteal nodes may form, or the thickening may be diffuse. Us- ually there is a good deal of aching, but no very acute pain; the osteocopic (bone-tiring) pains become worse after exertion and when the warmth of bed induces hyperemia of the diseased parts. The treatment is much the same as for syphilitic periosteitis (p. 4S2). Osteitis. — Osteitis scarcely ever oc- curs as a recognizable affection apart from accompanying osteomyelitis. Osteomyelitis. — This is an acute septic infection of bone marrow, usu- ally due to the Staphylococcus aureus, and affecting mostly the long bones of the extremities, especially the tibia, femur, and ulna, in their juxta-epiphy- seal portion , which was named by Kocher the metaphysis. It occurs almost exclusively in children from six to sixteen years of age, and often follows slight trauma, or exposure to cold and wet, as in frequent swimming expeditions. Predisposing causes are malnutrition, convalescence from the exanthemata or other general infections. Owing to the dense bony case in which the inflammation occurs, it is extremely rare for an abscess to form; instead a true phlegmon of bone results, infection spreading up and down the medulla. The cortex is affected secondarily, and in most cases periosteitis results from transmission of infection through the Haversian and Volkmann's canals. The process rarely extends into the joints, even in adults, and in children nearly invariably is arrested at the cartilage of the epiphyses. Swelling being impossible, the medullary tissues become strangulated, and death of the bone in large masses follows (necrosis), its extent depending on the destruction of the marrow cells within, and on the amount of separation of periosteum on the surface. Some- times the entire shaft of the bone becomes necrotic, is spontaneously detached at its epiphyses, and floats in pus beneath the unruptured periosteum. Usually, however, before this stage is reached, drainage Fig. 496. — Periosteitis of left tibia nine months after typhoid fever. Age nine years. Episcopal Hospital. OSTEOMYELITIS 469 is instituted by operation, or the periosteum is perforated by the pus with formation of a parosteal abscess in the soft tissues. The periosteum is raised from the cortex, and new subperiosteal bone is formed; this at first is plastic but later becomes sclerotic and is known as the involucrum; and such portions of the bone marrow as survive form new bone within, so that eventually the necrotic portion of bone, known as a sequestrum, is more or less completely surrounded by new-formed bone but still communicates with the surface through r >t. * * i unusual strain, as deep sensation is lost, and the patient is not aware of the injury he inflicts upon them in walking, pulling lvmself up stairs, etc.; the nutrition of the bones also is dis- turbed, predisposing them to distortion and fracture. So-called spontaneous fracture is not rare, and sometimes occurs some time before definite tabetic symptoms develop. As a rule only one joint is affected by the dystrophy, most often the knee; but the shoulder, elbow, ankle, hip, and even spine sometimes are affected. Painless effusion may be the first symptom, and this may exist so long as to induce relaxation of the ligaments, or even a flail-joint, before the patient realizes its condition (Fig. 540). The bone ends become dis- torted from pressure, and pieces may be broken off and lie free in the joint. Osteophytes frequently grow in the fibrous tissues surrounding the joint. Diagnosis. — The diagnosis depends on the detection of constitu- tional symptoms of tabes, associated with a nearly painless dystrophy of one of the larger joints, with effusion and abnormal mobility. In syringomyelia similar changes may occur, usually in the upper extremity. Treatment. — This consists in care of the general tabetic condition, and support to the diseased joint; massage may improve the con- dition of the surrounding muscles. In some cases arthrodesis may be done, in the endeavor to restore stability. Very rarely amputation may be required. LOOSE BODIES IN JOINTS. This condition has many of the same symptoms as internal derange- ment of the knee-joint, referred to at p. 448, but the pathogenesis is different. The knee is affected in the vast majority of cases. The loose bodies, or "joint mice" as they are called, may be entirely free, or may remain attached to the capsule by a pedicle. They may be derived from hypertrophied synovial fringes, from organized blood- clot, flakes of fibrin, etc.; from detached chips of bone or cartilage; or from ecchondroses, osteophytes, etc., developed in hypertrophic arthritis. One or an innumerable number of such bodies may be present. Symptoms. — The symptoms are those of the underlying disease (villous, or hypertrophic arthritis), or of old injury, with occasional locking of the joint from impaction of the loose body. This often is followed by an attack of acute synovitis. If the loose bodies are large, or present in sufficient numbers, they may be detected by palpation, and sometimes they are dense enough to be detected in a skiagraph. Care should be taken not to mistake a normal sesamoid bone or other extra-articular structure for a loose body. Treatment. — Usually nothing short of arthrotomy and removal of the bodies will give relief, unless the joint is kept immobilized; and even after such an operation the joint lesion which caused the formation of the loose bodies will require its appropriate treatment. INFECTIONS OF JOINTS 503 INFECTIONS OF JOINTS. Pathology. — Infection may reach a joint through external wound, directly through the blood-stream, or from a neighboring focus of inflammation, usually in bone. Wounds of joints have been considered in Chapter XIII. Most joint infections secondary to bone lesions are tuberculous in origin; these are discussed at p. 519. In this place it is desired merely to enumerate briefly the main pathological changes which occur in joints as the result of infection. Synovitis is the earliest stage; the synovial membrane is congested and swollen, and minute ecchymotic areas may be present in it; effusion into the joint cavity occurs, due both to increase in the natural synovial secretion and to the formation of inflammatory lymph. Fluid collects in the joint because it is a free surface, and wherever a free surface exists effusion predominates over edema. In mild infections, and in aseptic inflammations such as sprains, contusions, etc., the effused fluid usually remains serous in type; but infections due to pyogenic cocci usually, and those caused by the pneu- mococcus, gonococcus, etc., often end in suppuration, constituting Fig. 541. — Pyarthrosis of wrist. Residual abscess three months after complete healing of infected hand and forearm. Orthopaedic Hospital. the condition of pyarthrosis or empyema articuli (Fig. 541). Arthritis is a clinical term used, in contradistinction to synovitis, to imply predominant involvement of structures of the joint other than the synovial layer of the capsule; and osteoarthritis signifies involvement of the bone ends. In some cases of subacute infection no marked effusion occurs, but proliferation of the synovial villi is the main feature, producing villous arthritis; this is believed by some to be caused by a specific diplococcus, discovered in 1900 by Schiiller. If recovery ensues while the effusion is still serous, little subse- quent trouble may be experienced; often, however, the fluid is not entirely absorbed, and chronic serous synovitis (hydrops articuli, p. 505) develops. When the exudate has been sero-fibrinous some organiza- tion of the inflammatory material usually occurs, and the joint cavity is more or less obliterated by bands of adhesions, which may restrict motion. When suppuration has occurred, more or less destruction of the cartilages, ligaments, etc., is inevitable; complete disorganiza- tion of the joint may occur; and as gradual repair by organization and cicatrization sets in, the bones become welded together, more or less firmly, and frequently in bad position, in a condition of ankylosis 51 1 1 DISEASES OF JOINTS (p. 508). Ankylosis may be entirely bony, or due to fibrous adhesions allowing a very limited range of motion; limitation of motion due to periarticular changes (contraction of capsule, ligaments, tendons; locking of osteophytes, etc.) is not spoken of as ankylosis, which term always implies loss of motion from intra-articular adhesions, fibrous or osseous in character. Owing to the distention of the capsule during the stage of effusion, and to changes in the bone ends, pathological dislocation of the joint may occur, from muscular action, or the force of gravity. Symptoms. — Joint effusion is shown by increase in circumference, with bulging of the capsule at its weakest parts. In the knee the patella is floated up from the condyles, and when the quadriceps extensor is relaxed, the patella can be made to tap against the bone; the capsule bulges on each side of the quadriceps tendon, and the quad- riceps bursa is distended (Fig. 542). When much fluid is present fluctuation can be elicited. In the elbow the capsule bulges on both sides of the triceps tendon; in the ankle, beneath the tendo Achillis and anteriorly. In the wrist swelling is more marked on the dorsum; while in the hip and shoulder effusion is more difficult to appreciate. Any joint which is the seat of effusion tends to assume a position in which the capsule is most relaxed; this usually is in moderate flexion, and in the hip slight abduction as well as flexion is charac- teristic. Great pain is felt in the affected joint, and from pressure of the effusion on neighboring nerves referred pain may exist. Mus- cular spasm is present, and may cause starting or jumping pains in the joint, from time to time, especially during sleep. Joint motion is painful, and the joint itself is tender. As a rule, the bone ends are not tender in simple synovitis nor in arthritis not secondary to osseous disease; but crowding the bones together causes pain. The affected joint may be hot even in simple synovitis, but unless suppuration is present there is not much constitutional disturbance, nor is the affected joint red. Suppuration may be ushered in by a chill, or there may be no change except in the temperature. In pyarthrosis of the larger joints the patient becomes gravely ill, and all the constitutional signs of septicemia or pyemia develop. The joint becomes more tense and painful, exquisite tenderness develops, dusky redness with edema of the skin may be present, and unless the pus is evacuated it may perforate the capsule and invade the soft parts. Spontaneous dis- location is most frequent in the hip. If villous arthritis develops, the joint does not present fluctuation, but is doughy, and the capsule does not bulge but presents a more uniform enlargement, and it is evident that this is due partly to peri- articular thickening. The condition becomes subacute or chronic, and is then characterized by creaking and crackling on motion, slight permanent loss of full extension, and moderate disability. Treatment. — The treatment of acute synovitis consists in local rest of the joint, secured by proper splinting, and in the case of the lower extremity by rest in bed, usually with weight extension. If CHRONIC SEROUS SYNOVITIS 505 this treatment is instituted promptly, apparent recovery may ensue in a few days; but the joint, especially the knee, should be protected for several weeks by a light plaster case, as recurrence of effusion, and development of hydrops is much to be feared. Massage of the surrounding muscles, not of the joint itself, is of value for restoration of function after all inflammatory symptoms have been absent for several weeks. When the patient comes under observation at a later stage, with the joint in bad position, or suppuration threatening, weight extension should be applied as well as splinting; the latter alone sometimes is sufficient for the upper extremity. The joints should be kept in the position which will be least useless should ankylosis occur: the shoulder in slight abduction; the elbow and ankle at a right angle; the wrist and knee in full extension; and the hip in full extension and slight abduction, but without either external or internal rotation. The forearm should be kept nearly in full supination. Suppuration is treated by aspiration (which may be used as a diagnostic measure) and injection of a few cubic centimeters of a 2 per cent, formalin-glycerin solution, the joint meantime being kept at rest, and such constitutional measures being used as the patient's condition demands. Aspiration and formalin injection may be repeated a number of times, though the injection may be very painful; and usually the infection may be controlled in this way, the fluid grad- ually becoming serous, and the joint inflammation subsiding with preservation of a fair degree of motion. Should, however, improve- ment not be secured after two or three aspirations, and at once if pus has perforated the capsule and invaded the soft parts, the joint should be incised, and treated as detailed for septic arthritis following trauma (p. 423). Villous arthritis, when acute, is treated as synovitis, by rest, and antiphlogistic or sorbefacient applications. In its more usual sub- acute or chronic stage, benefit is derived" from massage, passive motion, baking, hot and cold douches, passive congestion, etc. Any source of infection (see p. 516) should be removed, and the patient's general health improved. Painful joints should be supported by suitable apparatus. Arthrotomy, with excision of hypertrophied synovia is most often required at the knee. Acute Arthritis of Infants (T. Smith, 1874). See footnote p. 479. Chronic Serous Synovitis, or Hydrops Articuli, occurs oftenest in the knee, usually the result originally of slight trauma causing acute synovitis with effusion, which has never entirely subsided, owing to inefficient treatment, for which the patient is more often to be blamed than the surgeon. The condition is maintained either by recurring slight trauma, or by some remote or attenuated infec- tion. Sometimes hydrops seems to be chronic from the start; in such cases careful search should be made for any site of infection which may maintain a toxemia and thus interfere with joint metab- olism. 506 DISEASES OF JOINTS The joint is distended, but rarely tense; floating of the patella mid fluctuation are detected easily; and no signs of acute inflammation or constitutional disturbance are present (Fig. 542). If pain is entirely absent, the existence of a Charcot joint should be suspected (p. 502). The patient complains of weakness and insecurity in the knee, of its tiring easily, of a feeling of fulness and discomfort on partial flexion, and of inability to flex the joint completely. He stands usually with the knee not quite fully extended, though passive extension may produce no discomfort. There may be a mod- erate degree of villous hypertrophy, and "joint mice" may develop; indeed such conditions themselves may maintain a state of chronic synovitis by the con- stant irritation they produce. Increase in the pads of subpatellar fat is not unusual (see Lipoma Arborescens, p. 545); and the neighboring bursa? may be chronically inflamed. Treatment. — Any source of infection which can be detected should be cured, and intestinal putrefaction and toxemia should be overcome if present. Locally, treatment should be instituted as for acute synovitis, by putting the joint at absolute rest for several weeks. This, with moderate uniform pressure by plaster of Paris or adhesive strap- ping, may cause the effusion to dis- appear. Counter-irritation may assist absorption. It may now be possible to detect a loose cartilage or other form of "joint mouse" which is partly responsible for continuance of the condi- tion. Rarely aspiration of the fluid may be employed for the same purpose, and to hasten absorption; it should be followed by injection of 2 per cent, formalin glycerin solution. I once did arthrotomy, finding the under surface of the patella and opposing femoral cartilage roughened, and placed a drainage tube across beneath the patella; the patient recovered perfect function in a few weeks, and in the eight years he was under observation there was no return of the condition, which had resisted conservative treatment for months. Such a plan rarely is proper, because the disability never is total, and the disease entails no risk to life. If rest and immobilization fail to secure absorption of the fluid, or if, as is usual, effusion recurs when joint function is resumed, the patient may be allowed to walk about in a gypsum case or brace; and hot and cold douches, vigorous massage of the joint and leg and Fig. 542. — Hydrops articuli of left knee, slight of right. Gono- coccic arthritis of left knee twelve years ago. Knee always swollen since. Orthopaedic Hospital. PERIARTHRITIS 507 thigh muscles during many months, and elastic compression may bring a certain measure of relief. When joint mice are present, they may be removed by arthrotomy, in the hope that they are the cause of the recurring effusion. It is rare for a permanent cure to be obtained. Intermittent Hydrarthrosis is a very obscure affection of joints, generally believed to be of vaso-motor origin. The effusion occurs suddenly, within a few hours, and subsides as rapidly, or within a day or two; the attacks occur at more or less regular intervals, perhaps daily for a certain portion of each year, or every few months. Almost any joint may be affected, and men as well as women are subject to the disease. Treatment is purely symptomatic. Periarthritis. — Periarthritis is a vague term under which it is convenient to group various subacute or chronic periarticular con- ditions until their true pathology can be determined. These lesions seem to be more frequently a cause for complaint around the shoulder than elsewhere, though they occur sometimes in other joints. They usually are caused primarily by trauma (sprains, subluxations, etc.), and are maintained either by static strain (especially in the sacro- iliac joint), or frequently recurring trauma. The condition was mentioned at p. 316 and 421. Codman (1906) drew attention to the subdeltoid bursa as the main factor in such disability; while T. T. Thomas (1911) thinks cicatricial contracture of the axillary portion of the capsule, resulting from sprain or self-reduced subluxation, is a more frequent, if not the only cause of the condition at the shoulder. The neighboring nerves (axillary plexus, sacral plexus and sciatic nerve) may be involved in periarticular adhesions, and thus complicate the case. Symptoms. — The symptoms are pain and disability, and in the shoulder especially limitation of abduction and external rotation. Tendinous or bursal crackling often is present. "Sprain fracture" of the greater tuberosity of the humerus sometimes exists. Each case requires careful individual study to determine the original cause, and if possible the pathological lesion present. Subdeltoid bursitis is characterized by tenderness below and in front of the acromion when the arm hangs by the side, this tenderness disappearing when the arm is abducted and the bursa disappears beneath the acromion; in chronic cases with adhesions abduction is impossible, and the diagnosis is more difficult, but usually there are no physical signs in the axilla. Implication of nerves is recognized by symptoms of neuritis, and sometimes trophic changes in the fingers. My own experience leads me to coincide with Thomas's views, that in most cases the main lesions are in the axillary region of the joint, and not in the subdeltoid bursa. Treatment. — Massage, passive motion, baking, hot air douche, etc., may all be tried. Improvement is slow. In resistant cases the patient should be etherized, the adhesions forcibly ruptured, and the arm dressed in abduction. Improvement in the nutrition of the 50S DISEASES OF JOINTS hand may follow such treatment. If it be certain that the sub- deltoid bursa is the seat of adhesions which cannot be ruptured by manipulation, the bursa may be opened and the adhesions cut or the bursa excised. Dissection may relieve an intractable neuritis, especially of the sciatic nerve. Ankylosis. — This is a fixation of joints by intra-articular adhesions. According to the character of these adhesions ankylosis is classed as fibrous or bony. It is worth while to repeat here again that limita- tion of motion from extra-articular causes is not ankylosis; it has been called "false ankylosis." Thus in the dystrophies of joints discussed in the opening paragraphs of this chapter, there is limitation of motion, but not ankylosis. True anky- ^Hl losis, whether fibrous or bony, probably m n^^v ■ ;t ' u;i . vs ' s the result of infectious arthritis or of trauma. Complete bony ankylosis rarely occurs except from trauma, most cases of bony ankylosis due to arthritis presenting only a few bands or processes of bone uniting the articulating surfaces, the remainder of the joint cavity being filled up by fibrous adhesions. If only fibrous ankylosis is present it usually is possible to detect a few degrees of motion if the joint is carefully examined under an anesthetic. It is important to remember the best positions for ankylosis, since when this is seen to be inevitable, the surgeon must enveavor to secure the least dis- abling posture for the patient before anky- losis becomes complete: for the shoulder the humerus should be in abduction about 70°, external rotation 25° to 30° beyond the sagittal plane and flexion 45°; the elbow should be at about 110°, unless both elbows are ankylosed, when one should be at 60° or less so that the patient may reach his mouth; the wrist should be in hyperextension (200° to 210°); the hip in abduction (10° to 15°), flexion (160° to 170°), and very slight external rotation; the knee straight or very slightly flexed (never hyperextended) ; and the ankle at 75° to 80°. Treatment. — The treatment of ankylosis in tuberculous arthritis is considered at p. 529. What is said here applies to ankylosis due to other forms of infection (pyogenic, pneumococcic, typhoid, etc.), or to trauma. If ankylosis occurs with the limb in good position, no treatment may be advisable, especially in the aged, those with visceral disease, etc. A stiff hip is largely compensated for by mobility in the lumbar spine; a stiff elbow may be useful enough; and movements of the scapula on the trunk largely compensate for ankylosis in the scapulo- Fig. 543. — Brace for knee with Stromeyer screw, to pro- duce gradual extension. Ortho- paedic Hospital. ANKYLOSIS 509 humeral joint; but almost any joint which is in bad position will be improved by treatment. With very few exceptions, however, no oper- ation should be undertaken until all signs of active disease have long since subsided. In cases of fibrous ankylosis, where the disease is still subsiding, the use of weight extension or of elastic compression against a splint, or of a splint with Stromeyer screw (Fig. 543), may secure im- proved position; and in cases of fibrous ankylosis and false ankylosis in which definitive healing has occurred, the surgeon may make attempts Fig. 544. — Instruments used in excision of joints: (1) Blunt-pointed resection knife (2) Periosteal elevator. (3) Guide for Gigli wire saw (4), and (5) handles. (6) Chain saw. (7) Butcher's saw (1851), the blade of which can be reversed, so as to cut upward. to secure improved position by rupture of adhesions under an anes- thetic (arthrolysis or brisement force), always making movements of flexion before those of extension (to avoid damage to the important periarticular structures in the flexures of joints), and seeking to rupture adhesions by abrupt movements of small excursion rather than by pro- longed or violent pressure. The joint should then be immobilized in improved position until inflammation subsides, when gentle passive movements should be begun and active use encouraged. While such 510 DISEASES OF JOINTS measures often secure improved position and sometimes a moderate range of motion in eases of false or fibrous ankylosis, in bony anky- losis open operation is required. If it is not desired to restore motion to the joint, simple osteotomy may suffice to secure good position. This is seldom employed except at the hip. Here the neck of the bone may be divided (Adams, 1871), but as this often is distorted by disease, subtrochanteric osteotomy of the femur (Gant, 1872), is preferable (pp. 51 5, 530). Excision of joints for ankylosis is employed to correct deformity where osteotomy will not suffice, as at the knee, shoulder, and elbow. In the latter situa- tions a movable joint is sought, but at the knee the object of excision is to secure ankylosis in full extension, the most useful position. Excision of the knee is done without an Esmarch band by a transverse Fig. 545. — Excision of the right knee-joint. The ligamentum mucosum has been divided, exposing the crucial ligaments. The saw is removing a section from the con- dyles. University of Pennsylvania. incision, across the front of the joint from the posterior edge of the base of one condyle to that of the other; the skin is dissected up until the upper border of the patella is exposed, and the quadriceps tendon is divided at its insertion into the patella; the knee-joint is acutely flexed, and the intra-articular ligaments are divided. The condyles of the femur being thus cleared, the saw is applied to them and a sec- tion about half an inch thick is removed, not at right angles to the long axis of the femur, but in such a manner that the posterior internal portion of the sawn surface shall be the longest, and the anterior external the shortest (Fig. 545). The tibial condyles are then sawed across at right angles to the long axis of the leg, but somewhat bevelled antero-posteriorly so as to correspond to the section of the femur. The tibial condyles with the attached patella are then removed in one mass. Barely enough of the femur and tibia are removed to allow the EXCISION OF JOINTS 511 limb to come straight; the posterior ligaments always, and the lateral ligaments whenever possible, are left intact. The periarticular tissues are sutured with chromic catgut, and the skin is closed with provision for drainage for twenty-four hours. The limb is dressed in plaster of Paris and immobilization continued for six or ten weeks until union is firm. If complete bony ankylosis (in bad position) is present already, it is sufficient to excise a wedge of bone to restore the axis of the limb (Figs. 546 and 547). In all cases of excision of the knee, Fig. 546. — Ankylosis of knee in flexion, in a girl of twelve years; result of arthrec- tomy for tuberculosis nine years pre- viously. (See Fig. 547.) Episcopal Hos- pital. Fig. 547. — Result of cuneiform resec- tion of the knee shown in Fig. 546. The epiphyseal lines have been carefully pre- served. Episcopal Hospital. the limb should be supported by a brace for a year afterwards. The elbow is excised through a straight posterior incision splitting the triceps muscle near the inner border of the olecranon, and carefully separating its tendinous expansion from the olecranon. Injur}' of the ulnar nerve should be avoided; it is most liable to injury just below the level of the joint close to the inner border of the olecranon. After the lateral ligaments have been divided (Fig. 548) the joint may be luxated. Enough bone is removed (leaving the radial insertion of the biceps) 512 DISEASES OF JOINTS to ensure a false joint being established; a space of at least four centimeters should exist between the humerus and bones of the fore- arm, to ensure free motion (Figs. 549 and 550.) The limb is im- Fig. 548. — Excision of the elbow-joint. The joint has been opened posteriorly and the condyles of the humerus exposed. Above is seen the olecranon; just below it the trochlear surface of the humerus. The retractors pull aside the split triceps and the scissors are cutting the internal lateral ligament. University of Pennnsylvania. Fig. 549. — Result of excision of elbow for anky losis following fracture. Episcopal Hospital. Fig. 550. — Same patient as F'n 549, elbow extended. EXCISION OF JOINTS 513 mobilized only until the soft parts heal; active use is then encouraged. Return of function depends largely on preservation of the periosteum into which the triceps inserts, and its fibrous expansion over the radius. The shoulder is excised through an anterior incision in the hollow be- tween the coracoid and acromion processes, thus avoiding injury to the branches of the circumflex nerve. The long tendon of the biceps is pushed to one side. The capsule is opened as in shoulder-joint amputations, and the muscles inserted into the tuberosities are divided as there described (Fig. 551.) Usually the section of the humerus is made through the surgical neck ; but it is better to remove more bone from the glenoid than from the humerus, since restoration of function Fig. 551. — Excision of shoulder by anterior longitudinal incision. After division of the capsule and the muscles attached to the tuberosities the arm is allowed to hang over the edge of the tab'e; this causes the head of the humerus to project from the wound. University of Pennsylvania. depends largely on the preservation of the muscular insertions in the latter. After-treatment is the same as in excision of the elbow. In all these excisions, it is well, if possible, to open up the line of the old articulation first, by breaking adhesions and sawing across bridges of bone, and then to remove from the bone ends so much as is necessary. Attempts to excise a joint in one block, except by experienced sur- geons, result in the removal of too much or too little bone. Excision of the wrist seldom is required ; in most cases an erasion (p. 529) suffices. If formal excision is done, the best incision is that of Mynter (1894), splitting the dorsum of the hand between the index and middle fingers. Ankylosis is the desired result. Arthroplasty is discussed at p. 252. 33 514 DISEASES OF JOINTS SPECIAL INFECTIONS OF THE JOINTS. The special infections of the joints usually can be differentiated clinically from pyemic infections, and from each other, but bacterio- logical study of the joint fluids or capsule may be necessary. Pyemic infections of joints are referred to at p. 71. Pneumococcic Infection usually is a complication of pneumonia (70 per cent, of cases), but may occur from other sources, especially otitis media. The knee and shoulder are most often attacked. There is purulent effusion, and the signs of acute arthritis are present. Treatment consists in aspiration of the fluid and injection of 2 per cent, formalin-glycerin solution, and use of weight extension. Arthrotomy and drainage should be done if symptoms are severe or persist. The mortality is about 33 per cent. (K. Bulkley, 1914). Ankylosis is not unusual, but formation of sinuses is rare. Gonococcic Infection usually is secondary to a gonococcic urethritis or its local complications. It occurs in less than 2 per cent, of cases, and mostly in the male sex; almost invariably the joint con- dition appears in the end of the third week (eighteenth to twenty- second day) after the onset of gonorrhea. Diagnosis in obscure cases may be aided by the complement-fixation test. The polyarticular form is rheumatic (i. e., synovial) in character, somewhat resembling acute rheumatic arthritis; but the monarticular form is more like a septic arthritis. In the former the small joints of the hands and feet are oftenest affected; sometimes the sterno-clavicular joint. In the monarticular form the knee, ankle, wrist, and elbow are oftenest invaded. The joints become extremely painful, swollen, red, and doughy to the touch. There is not much effusion. Endocarditis is an occasional complication. Spontaneous fistulization is rare. After gonococcic arthritis the joints are left in a more or less damaged and sometimes seriously deformed state. Bony ankylosis is not unusual. Treatment. — If rest of the affected joints (the patient always being confined to bed, and the primary infection receiving proper attention) does not secure marked improvement within forty-eight hours, the joints should be opened, and irrigated with saline or formalin-glycerin solution, and closed without drainage. There is too little effusion, as a rule, for mere aspiration and injection to be efficient. Usually the disease is much shortened by joint irrigation; under conservative measures the joints may remain acutely painful for weeks, and the patient's health often is gravely affected, hectic fever and emaciation developing. Vaccine therapy is of considerable value. Fuller (1905) has proposed and practised drainage or extirpation of the seminal vesicles which some regard as the focus which maintains the infection. They are accessible by the suprapubic extra-peritoneal route. Typhoid Arthritis occurs during or after convalescence from typhoid fever, usually about the third or fourth week of the disease. Its development may be overlooked, owing to the patient's apathetic SPECIAL INFECTIONS OF THE JOINTS 515 state. The hip is most often affected (Figs. 552 and 553); suppura- tion and sinus formation are not unusual (perhaps from mixed infec- tion), though as in pneumococcic and gonococcic arthritis ankylosis may follow without frank suppuration. Pathological luxation may occur. Typhoid spondylitis (p. 662) sometimes is seen, though a true inflammation of the vertebral joints is much rarer than a periarticular fibrosis. Fig. 552. — Post-typhoid ankylosis of left hip, in a lad of sixteen years. Dr. Harte's case. (See Fig. 553.) Ortho- paedic Hospital. Fig. 553. — Result of subtrochanteric osteotomy of left femur for bony ankylosis in bad position. (See Fig. 552.) Ortho- paedic Hospital. Metastatic Arthritis. — In addition to these special infections of joints, and to tuberculous and syphilitic joint diseases, which are con- sidered at p. 519 and 545, there are a number of other systemic infec- tions, the etiological organisms of which are not known in all cases, but which sometimes are accompanied or followed by inflammation of one or more joints, and in which it is very evident that the general infection is responsible for the local inflammation, either by direct action of its bacteria, or through the toxins derived from these microbes. 1. We may recognize acute or subpyemic infections, some of them 510 DISEASES OF JOINTS having a more or less evident etiology and symptomatology (arthritis and scarlet fever, influenza, dysentery, etc.); while in others, such as "acute articular rheumatism," the joint infection itself seems almost to constitute the disease. Acute rheumatic arthritis probably is a form of pyemia. Immediate removal of the pharyngeal tonsils, thought by some to be the portal of infection, has been adopted in a few cases. Or the surgeon may open, irrigate, and close the first joint affected; or aspiration and injection with formalin-glycerin solution (2 per cent.) may be done. Probably the form of acute metastatic arthritis most often encoun- tered is that following infections of the pharynx, naso-pharynx., or tonsils. The joint manifestations occur so long (several weeks) after the primary lesion has healed that their inter-relation usually is overlooked. The patients come to the surgeon with bony ankylosis, and tell him their physician has been treating them for rheumatism. The history is that very soon after exposure to cold or wet, 1 sudden pain developed in one or more joints; probably a chill occurred; the joint became swollen, red, and tender; the patients lay in bed a long time in one position; and finally when in the course of several weeks the acute symptoms subsided, one or more joints were found to be stiff, and have remained so since. A skiagraph will show bony ankylosis. Now, acute rheumatic arthritis does not cause ankylosis, its symptoms are rapidly relieved by salicylates, and the disease does not last more than two or three weeks. These acute metastatic joint infections should be treated by weight- extension (to prevent deformity and if possible ankylosis), by aspira- tion of the joint contents (to relieve pressure on the synovial mem- brane thus preventing its destruction), and by injection of 10 to 15 ex. of a 2 per cent, formalin-glycerin solution (to sterilize the joint). This injection may have to be repeated once or twice after intervals of a few days (Murphy, 191:;). 2. Chronic or Cryptogenous Infections. — There is, moreover, a still more obscure group of joint diseases, which clinically give every evi- dence of being infectious, but the true pathogenesis of which has not been established from a bacteriological standpoint. These may be called cryptogenous injections of joints, and include various "rheuma- toid" conditions, which clinically resemble infectious as distinguished from dystrophic arthritis (p. 493). Among these, chronic rheumatic arthritis, a disease whose existence I do not doubt, holds an important place; by it I understand the damaged condition of joints which may persist after one or several attacks of "acute articular rheumatism;" on such a joint may be grafted, as on to any joint or set of joints whose resistance is below par, dystrophic lesions. I believe Fig. 554 repre- sents such a condition. Stills Disease (1897), a chronic polyarticular affection of young childhood, resembling atrophic arthritis in many respects, and accompanied by enlargement of the lymph nodes and 1 This is to be regarded merely as the localizing cause of the joint lesions. The infection which occurred two or three weeks previously is the original cause. METASTATIC ARTHRITIS 517 spleen, and involvement of the cervical spine, probably belongs among the cryptogenous infections. So does the tuberculous rheumatism of Fig. 554. — Chronic rheumatic arthritis; age fifty years; had acute rheumatic arthritis as child and as girl. Orthopaedic Hospital. Fici. 555. — Tuberculous rheumatism in a girl of five years. Acute onset in left ankle, some weeks after an attack of scarlatina. Six months later left knee, wrist, and shoulder became similarly affected; reacted to tuberculin. Photographed one year after onset. (See Fig. 556.) Orthopaedic Hospital. 518 DISEASES OF JOINTS Poncet (1903), which is a subacute polyarticular infection, somewhat resembling in onset "acute articular rheumatism," but probably due to endogenous toxins of tubercle bacilli (Figs. 555 and 55G). In this group of cryptogenous infections also belong certain cases of arthritis Fig. 556. — Patient shown in Fig. 555, one year later. Normal extension in left wrist. Knee still in plaster of Paris, and four years later not yet quiet. Orthopaedic Hospital. which cease to trouble the patient when he is cured of some source of infection which may have been neglected for years; such are dental caries, pyorrhea alveolaris; sinus diseases; affections of the tonsils; empyema thoracis (Fig. 557); affections of the lungs (here belongs pulmonary osteo-arthropathy) , intestines, appendix; genito-urinary dis- Fio. 557. — Pulmonary osteoarthropathy. Clubbed fingers four years after operation for empyema (unhealed). Age ten years. Children's Hospital. eases in both sexes, especially chronic semino-vesiculitis or prostatitis in the male, and cervical lacerations in the female, etc. Cases of joint disease concerned with one or more of the above infections are constantly being seen, and are recognized by intelligent physicians. TUBERCULOSIS OF JOINTS 519 In many cases the infecting organism may be recovered from the urine; and treatment by vaccines may prove curative. In chronic rheumatoid conditions always look for a source of infection. Tuberculosis of Joints. 1 — Pathology. — In tuberculous arthritis the primary lesion in almost all cases, especially in children, is in the adjacent bone, and the synovial membrane lining the joint cavity is invaded only secondarily. This was first definitely shown by Nichols, of Boston, in 1898. The bacilli reach the bone ends through the blood-stream, presumably from a preexisting focus in the bronchial or mesenteric lymph nodes; and they lodge in the region of the epiphy- seal cartilage rather than in the diaphysis of the bone for the ana- tomical reasons stated at p. 480. The disease begins on one side or other of the epiphyseal cartilage. An additional, and perhaps a better reason for this localization of the bacilli is suggested by Ely (1911): he recalls the well known fact that tubercle bacilli flourish where red marrow exists (as in the epiphyses of growing bones), whereas bone which contains yellow marrow (adult bones throughout, and the diaphyses of juvenile bones) is almost immune to tuberculous invasion; he also suggests that the immunity of cartilage and fascia to tuberculous invasion is due to the fact that only in connective tissues which have epithelial, epithelioid, or lymphoid cells, do tubercle bacilli find a suitable soil for development, and that in this way the marked affinity of tuberculosis for synovial membrane is to be ex- plained. This theory of Ely's also explains why primary synovial tuberculosis is so much less unusual in adults than in children, since the bones of the former do not afford a suitable soil for the develop- ment of tuberculosis, owing to the absence of red marrow. In tuberculosis of an epiphysis the lesion exists in the marrow, the cells of this structure being grouped around the invading bacilli in the form of histological tubercles; the bony trabecular are then destroyed, the center of the tuberculous focus undergoes caseation, and caries of the bone is said to exist; if actual liquefaction occurs a cold abscess of bone is formed. The entire bone end is the seat of a rarefying osteitis, the bony trabecular being much decreased in size and strength, while the marrow spaces are increased. Formation of sequestra is rather unusual; when found they are small, and typic- ally worm-eaten in appearance. Often there is a zone of sclerosed bone immediately around the sequestrum or the central caseous area, while outside of the sclerotic bone the rarefying osteitis, above described, continues. Caries Sicca is a term used by Volkmann (1867) to describe a rare form of joint disease now recognized as tuberculous, which is seen oftenest in the shoulder and in which gradual, quiet, fibrous ankylosis occurs, without swelling or other evidences typical of tuberculous arthritis. x The tuberculous nature of these diseases was first clearly demonstrated by Volkmann, in a classical paper published in 1879. :>2o DISEASES OF JOINTS Fig. 558. — Head and neck of femur excised for tuberculosis. Note "pepper- pot" appearance of cartilage covering head of femur; pathological fracture of neck: and small sequestrum below. Children's Hos- pital. The articular cartilage resists for ;i long time invasion by the spreading tuberculous process, and when the joint finally is entered it is more often at the site of attachment of the capsule than in the center of the articular cartilage. But as the disease progresses the articular cartilage is gradually covered in by the tuberculous granulation tissue or "pannus," and is perforated in numerous places, giving it (Fig. 558) a typical sieve-like (Volk- mann, 1882) or "pepper-pot" ap- pearance; and in advanced cases the cartilage may be entirely de- stroyed. Before actual tuberculous inva- sion of the joint cavity, there may be slight serous synovitis with effusion, from irritation due to the focus in the neighboring bone end. When the synovia has once been invaded, or in the rare cases of primary synovial disease, the tuber- culous process spreads rapidly throughout the joint, attacking and perhaps destroying the ligaments, reach- ing out along adjacent tendon sheaths and bursa? , and causing a pulpy, gela- tinous hyperplasia of all the serous tissues attacked (gelatinous arthritis, J. Ashhurst, Jr. 1871). Usually there is very little effusion, though "tuber- culous hydrops" occasionally occurs | Fig. 559). Either by condensation of fibri- nous flakes, or by detachment of the tips of the villous synovial fringes, so- called "rice-bodies" or "melon-seed bodies" may develop in tuberculous joints. By most authorities these are regarded as highly characteristic of the tuberculous nature of the joint lesions: tubercle bacilli frequently have been found within the rice-bodies, and their inoculation into susceptible animals causes generalized tuberculosis. If the tuberculous process extends to the skin surface, and a cold abscess of bone discharges itself through a sinus, secondary infection with pyogenic cocci Fig. 559. — Tuberculous hydrops of right knee. Age eight years. Duration six months. For persist- ence of symptoms, excision of knee ' was done five years later. (Dr. Dickson's case.) Orthopaedic Hospital. CLINICAL COURSE OF TUBERCULOUS ARTHRITIS 521 is extremely apt to occur. Before such secondary invasion the walls of a sinus communicating with a tuberculous focus are not themselves the seat of tuberculosis; but when secondary infection is present the connective tissue which forms the walls of such a sinus are studded with tubercles (Ely, 1911). Secondary invasion with pyogenic cocci may occur through the blood-stream before any sinus forms; such a complication is apt to hasten the disintegrating process and encourage formation of sinuses. Healing occurs by the encapsulation of the tuberculous focus or its replacement by fibrous tissue. If the joint cavity has been invaded this implies more or less firm fibrous ankylosis. In most cases the tuberculous process merely becomes latent, and is prone to become active again if the joint is subjected to unusual strain, or if the gen- eral health becomes impaired, particularly by the development of pulmonary tuberculosis. Clinical Course and Symptoms. — Joint tuberculosis is much more frequent in children than in adults, arising especially during the first decade of life. The spinal joints are those most often affected; the knee and hip come next in order of frequency; while the joints of the foot, elbow, and wrist are more frequently diseased than the shoulder. In about one-third of the cases in children a history of traumatism can be obtained, two or three weeks previous to the onset of joint symptoms; and this generally is regarded as having a distinct etiological relation to the development of the disease. But it must be remembered that nearly all children sustain slight joint injuries, yet comparatively few develop tuberculous arthritis; so that it is necessary to assume a predisposition to tuberculosis and the existence of a primary focus elsewhere in the body. The injury which precedes the tuberculous joint symptoms rarely is severe; fractures scarcely ever are followed by tuberculosis, and fractures in the tuberculous heal normally. Two explanations are offered for this: one is that the more severe injury arouses better defensive action on the part of the patient; the other is that severe lesions require careful and prolonged treatment, and healing, therefore, is more apt to occur than after a trivial injury which often is neglected. Among the earliest subjective symptoms of tuberculous arthritis are disability and pain. The joint is used less, the joint is "favored," and it gives evidence of being more easily tired than the normal joint. Stiffness present on getting out of bed in the morning may wear away during the day; but toward evening the joint again becomes disabled, and this is evidenced by slight limp, and complaints of pain. Pain may be almost absent except when the joint is used; but frequently a joint which is painless when the child is awake will trouble it at night, causing restlessness, and on falling asleep and relaxing its muscles the child will experience "starting pains'' which will rouse it momentarily from sleep with a "night-cry." Instead of pain being felt at the diseased joint, it may be referred to the peripheral distribution of the nerve supplying the joint: thus in 522 DISEASES OF JOINTS tuberculous spondylitis pain frequently is present in the epigastrium (intercostal nerves), and in tuberculosis of the hip pain is referred to the knee (obturator nerve). Examination of the diseased joint at this early stage shows slight but persistent muscular spasm. The muscles surrounding a joint are supplied by the same nerve that supplies the joint, and irritation of the joint causes reflex irritation of the adjacent muscles (Hilton's law, 18G3). The joint may be held absolutely rigid by the patient, but in the earliest stages the most that can be detected is limitation of motion in all directions: there is neither full extension, flexion, abduction, adduction, nor rotation; and forcing any of these motions causes pain. Comparison with movements of the corresponding unaffected joint is imperative. The joint is held in the most com- fortable position and is consistently protected by the patient: a sore wrist or elbow is supported by the other hand, and if the hip or knee is involved the sound foot may be put under the ankle of the diseased limb and be used as a splint to prevent motion in the painful joint. There is tenderness to palpation directly over the joint, and per- sistent tenderness of a bone end with evidences of articular irritation is a valuable sign. Unless the disease is advanced, or primarily synovial in origin, there is rarely much thickening of the capsule or synovial effusion. In superficial joints (knee, elbow, ankle) more or less heat usually is appreciable, but in the hip this seldom can be detected. Muscular atrophy, an evidence of disuse, is a valuable confirmatory sign of tuberculous arthritis ; in early stages it sometimes can be detected only by measurement, but in later stages, where articular thickening is present and accentuates the atrophy, it is apparent at a glance (Fig. 586). With these local signs there is seldom much constitutional reaction. The temperature may be raised 1° or 2° in the evening, and loss of appetite and malaise may be present ; but there is no acute inflamma- tory state such as is seen in cases of septic arthritis. As the disease progresses, the joint thickening increases, being of a doughy, boggy consistency, and typically spindle-shaped in outline. The skin is pallid, and the affection well deserves the name "white swelling" first applied to it in 1734 by Wiseman. Spastic contraction of the surrounding muscles passes into true contractures, which will maintain deformity even if ankylosis is absent. Progressive joint dis- integration may lead to partial or complete dislocation; and this usually is attended by relief from pain. Finally, by rupture of cold abscesses, sinuses may develop, and usually this complication is quickly followed by secondary infection, resulting in hectic fever, and the gradual but progressive decline of the patient's general health. Diagnosis. — Symptoms of subacute arthritis in a child, from no apparent cause, or following slight injury, and without marked constitutional reaction, but persisting in spite of temporary rest, always should excite a suspicion of tuberculosis. This suspicion is SYMPTOMS OF TUBERCULOUS ARTHRITIS 523 strengthened by a family history of tuberculosis, either pulmonary or osseous, and is made nearly positive if there is persistent elevation of temperature of 1° or 2°, if the tuberculin tests (p. 79) are posi- tive, and if there is no leukocytosis. Skiagraphic examination rarely will reveal any bony focus so early in the disease as to be of much value in doubtful cases, but a squaring of the epiphyses, particularly at the knee, is regarded as characteristic of tuberculosis. A sprain will cease to cause acute symptoms if the joint is put to rest for two or three weeks; but a tuberculous arthritis always will be roused to activity if joint function is resumed in so short a time. A septic arthritis is more violent in its onset, is attended by much more constitutional disturbance, and progresses to early suppuration and joint disintegration; its course is run in days and weeks, while that of a tuberculous arthritis extends over months and years. Acute rheumatic arthritis is in most cases a polyarticular affection, is char- acterized by high temperature, cardiac or pleural complications, hyperleukocytosis, and marked local inflammatory reaction. It is rare in young children. In syphilitic arthritis other signs of syphilis nearly always can be detected. A positive diagnosis of tuberculosis always can be made if tubercle bacilli can be found in the synovial membrane, rice-bodies, joint- fluid, etc., or if inoculation with these substances causes tuberculosis in a susceptible animal. Prognosis. — The most favorable cases are those of apparent osseous origin in children, in which efficient treatment is instituted before evidences of invasion of the synovia are demonstrable, and in which the symptoms are so slight as scarcely to warrant a positive diagnosis. These are the cases in which patients recover with joints which are to all intents and purposes normal. After joint invasion is once demonstrable, and in cases primarily synovial, the most that can be hoped for is recovery with more or less impairment of motion; and the more firm the ankylosis the less apt will the patient be to have recurrence of the disease. After secondary infection the prognosis is gloomier both as to function and life; and in adults all forms of tuberculous arthritis are much more serious than in children. In general terms it may be stated that from one-third to one-half of patients with tuberculous arthritis die as a result of their joint lesions; few indeed as a direct consequence (then mostly from hectic, amyloid degeneration of the viscera, etc.), but many from tuberculous menin- gitis, phthisis, or some intercurrent malady from which healthier persons would have recovered. In cases ending in apparent recovery, which often is merely latency of the tuberculous process, the course of treatment must last from one to five years or longer; and other patients must continue treatment until death removes them from the surgeon's care. Treatment. — The constitutional treatment of surgical tuberculosis was discussed at p. 80; its value in tuberculous arthritis is inesti- mable, and never should be forgotten. The most efficient local treat- 524 DISEASES OF JOINTS mi nt frequently is powerless to check the disease; and sometimes constitutional treatment alone is able to restore a patient to health. The surgeon must not overlook the fact that it is better to have a healthy body with a stiff or deformed joint, than to have a straight and comely joint without a body capable of sustaining life. If the general health is good, joint function can be restored subsequently by an orthopedic operation. Every hospital should have an open air ward or at least a porch available for tuberculous joint cases, where the advantages of constitutional and local treatment may be combined for those most requiring such care. Local treatment may be summed up almost in one word: Rest. It is not known definitely how this acts, but a plausible theory is suggested by Ely (1911) : he contends that cure is effected by abolish- ing joint function, because thus both red marrow r and synovia become atrophic and in the case of ankylosis entirely disappear; and where they are not, tubercle bacilli cannot exist. There are two chief methods by which joint rest is obtained: fixation and traction. Fixation is secured by the use of splints, plaster cases, braces, etc., the sole object being to abolish motion at the diseased joint as effectually as possible; this not only relieves pain, but has direct influence in checking the tuberculous process. By traction is understood not so much actual extension on the limb sufficient to pull the joint surfaces apart, as cessation of weight- bearing and relief of pressure: it acts by relieving pain and securing rest, but also prevents deformity which is prone to occur w r hen the weight of the body is borne on the softened bone ends. Traction is applied chiefly to the knee, hip, and spine; fixation alone usually is sufficient for the upper extremity. Whenever possible in the spine and lower extremity the advantages of fixation and traction should be combined. This is best accomplished by bed-treatment, so long as acute symptoms persist, regardless of the stage of the disease. Recumbency at once removes the weight of the body from the diseased joints, and fixation is much more readily secured. In children, the use of a Bradford frame (1890) (Fig. 560) to which the body is strapped, provides fixation for spine, hip, or knee, in the most efficient manner. This frame is made of gas-pipe, and is covered with tightly stretched canvas; it should be a little longer than the patient and as wide as from one armpit to the other. The child is fastened to it by a broad canvas apron covering chest and abdomen, or by straps crossing the shoulders. 1 The frame thus becomes a part of the child, and the two together can be carried about from room to room, or from ward to roof garden (Fig. 561), thus preventing the painful and harmful joint-movements necessitated by carrying the child in the arms or transferring it to a stretcher and back again to the bed. Weight-extension usually is a desirable adjuvant in securing joint fixation, and is the most effectual method 1 G. G. Davis used also an upper frame, well padded and moulded to the body, to hold the child against the lower frame. TREATMENT OF TUBERCULOUS ARTHRITIS 525 of overcoming pain and muscular spasm, to which latter factor deformity in the earliest stages is due. Weight-extension always should be applied in the axis of the deformity (Fig. 575), and as spasm Fig. 560. — Bradford frame. See text. lessens the direction of the extension can be gradually changed until the normal position is secured. Great care must be exercised during recumbent treatment to keep the foot at a right angle with the leg, preventing the development of talipes equinus. Fig. 561. — On the roof garden of the Orthopaedic Hospital. Showing Bradford frames with head and foot extension. ^Vhen all symptoms of arthritis (limitation of motion from spasm, pain, fever, etc.) have been absent for a month or more, recumbent treatment may be discontinued. This stage is reached after two 526 DISEASES OF JOINTS to six months in cases coming under observation in the early stages of the disease. If local treatment (fixation and traction) are now recklessly discontinued in the erroneous idea that the joint is cured, and if the patient is allowed to resume joint function, it will be only a few weeks before all symptoms of arthritis return, and possibly in aggravated form. It is absolutely imperative to guard the joint against injury and strain by continuing for a long period fixation or traction, or both, during ambulatory treatment. By the use of plaster of Paris cases, braces, crutches, etc., both fixation and traction (in modified forms) can be continued; and this should be done until, by allowing gradual return of function (first limited motion, then weight-bearing), the surgeon proves that the joint lesion has become so thoroughly encapsulated as not to be liable to cause recrudescence of the disease. This period of ambulatory after-treatment extends always through several months, usually through a year or more, and often for many years. Only by making haste slowly can permanent good results be achieved. If there is any reason (there are few good reasons) why recumbent treatment is impossible when the patient first is seen, ambulatory treatment with fixation and traction may be employed from the start; but this is apt to promote ankylosis, and deformity is very difficult to prevent. Moreover, in many cases the symptoms are so acute that rest in bed is an absolute necessity. Yet I believe with Coudray (1911), that in no case should a manifest tendency toward ankylosis be hindered; the joint should be kept in good position, but attempts to preserve motion are extremely apt to keep the disease active. The surest and most lasting cures are those which follow ankylosis. Treatment of Cold Abscesses. — If the joint be put at rest, and the patient kept in the open air, the threatening abscess may cease to enlarge, and in not a few cases gradually will disappear. Hence these conservative measures should be given full trial. If the abscess continues to enlarge, and threatens to approach the skin, with the consequent danger of infection from the skin cocci, even before spontaneous rupture makes such an infection sure, I think it is best to expose the abscess wall by careful dissection through overlying healthy tissues, to incise the abscess, evacuate its contents, and wipe the abscess cavity gently but thoroughly with iodoform gauze. I cannot see that anything is to be gained by curetting the walls of the abscess cavity, nor by attempts to "excise the sac," which in many cases is an impossibility. The incision to reach the abscess is sutured in layers, without drainage. Children should be anesthetized, but in adults local anesthesia is sufficient. In most cases (fifty-one out of sixty, according to Starr, 1907), the incision heals without breaking down at any point, and in only a very few cases does the abscess refill and require a second evacuation. It is dangerous to leave a cold abscess to itself until the overlying skin has become adherent and reddened, since secondary infection from skin cocci is frequent, and rapid joint disintegration, hectic, amyloid disease, etc., follow; and TREATMENT OF TUBERCULOUS ARTHRITIS 527 it is still more dangerous to open a cold abscess without perfectly aseptic technique, or to drain it by tube or gauze after incision, or to allow it to discharge itself spontaneously. But sometimes the patient is not seen until spontaneous rupture threatens, and secondary infection already is present. Under such circumstances the abscess should be evacuated by a small incision where it is pointing, but should not be drained; the puncture should be occluded with aseptic gauze, and in many cases little or no subsequent discharge will occur, the "hot" will gradually resume its character of "cold" abscess, and eventually may be absorbed. Thus the formation of sinuses and prolonged suppuration may be prevented. Aspiration of a cold abscess is inferior to formal incision, because it cannot be done satisfactorily until the pus is very close to the surface and unless it is very fluid. A certain number of cures, however, will follow aspiration and injection of a 10 per cent, iodoform-glycerin emulsion. Treatment of Sinuses. — In tuberculous arthritis sinuses nearly invariably are an indication of secondary infection: if no secondary infection is present (a fact which bacteriological investigation will demonstrate), they usually will heal under rest and constitutional treatment. I have had exceptionally good results from helio- therapy: the sinuses are exposed to direct sunlight, beginning with periods of five minutes twice daily, and increasing the length of the exposures as rapidly as possible without producing sunburn. If the sinuses fail to heal, and if discharge of pus is not profuse, they may be filled with bismuth paste after the method of Beck (1905). This is heated in a water bath until fluid, and is injected into the sinuses by a syringe which after being boiled, is rinsed in alcohol and allowed to dry before it is filled with the liquid paste. The sinuses are filled as full as possible. A skiagraph, made after distending the sinuses with this paste, will show their origin and ramifications (Fig. 562). If pus should be dammed up behind the paste, the increased local heat will cause the paste to melt, and it will be extruded from the sinus spontaneously. The mode of action of bismuth paste is not certainly known, but it causes marked improvement, the dis- charge diminishing and the sinuses often closing in a comparatively short time. In most cases the strength should not exceed one part of bismuth subnitrate (arsenic free) to ten parts of sterile amber vaselin, Beck's original formula (33 per cent.) having been responsible for numerous cases of bismuth poisoning. If profuse suppuration persists in spite of conservative measures, it is probable that a sequestrum is present, and this may be removed by curette or gouge. Formal operation in children rarely is advisable. Injections of alcoholic solutions of iodin (2 to 10 per cent.) are useful in overcoming secondary infection. Operative Treatment in Tuberculous Arthritis. — It might be thought that early excision of the diseased area would abort the disease, but unfortunately it scarcely ever is possible to locate by skiagraphy ;.l's DISEASES OF JOINTS or otherwise an extra-articular focus; nor would what might be con- sidered total extirpation of the focus amount to much more than removal of the center of an area infected far beyond what is indicated by gross appearances. When once the joint itself is involved, only a Fig. 562. — Skiagraph of tuberculous arthritis of left hip, with sinus discharging on outer surface of thigh; sinus has been distended with Heck's bismuth paste. Boy, aged ten years; coxalgia for six years. Abscess punctured three months before skiagraph was made, because it was pointing and because there was secondary infection from skin cocci. Sinus soon closed and remained healed five years later. Orthopffidic Hospital. formal excision could remove all the disease, and in children such an operation, which implies removal of the epiphyses, is productive of such marked deformity and disability as to be generally condemned by intelligent surgeons. Moreover, in children, the results of con- servative treatment thoroughly carried out, as outlined above, are TREATMENT OF TUBERCULOUS ARTHRITIS 529 so satisfactory, that operation presents no advantages in the early stages of the disease. In advanced secondary infection in children, however, excision may be imperative as a means of joint disinfection; and in adults, the results of conservative treatment have proved so disheartening, chiefly through their inability to endure confinement to bed, and their tendency to develop phthisis, that joint excision or even amputation is the accepted form of treatment. Ely (1911) claims that an excision which will produce ankylosis and thus permanently abolish joint function is all that is necessary to effect a cure; he asserts that it matters not how little bone is removed, nor how much tuberculous material is left, so long as ankylosis is obtained, as this in itself will cause disappearance of synovia, which is the joint tissue on which in adults tubercle bacilli almost solely subsist. But hitherto it has been the habit of surgeons to remove as much diseased tissue as possible. In children, excisions, if done, should be limited to the epiphyses of the bones, the epiphyseal cartilages being rigorously respected, and any focus in the metaphysis should be evacuated by the curette through a perforation of the epiphyseal cartilage, and not by sawing off the bone end until all diseased tissue disappears. Arthrectomy or erasion of joints, adapted especially to the knee, was introduced by Wright, of Manchester (1881), and in this country by J. Ashhurst, Jr. (1889), as a substitute for excision in children; it aims to remove all the diseased soft tissues (synovia, ligaments, cartilages) without invading the bones; and may be employed for the purpose of effecting ankylosis when conservative measures fail to secure subsidence of symptoms. Treatment of Ankylosis from Tuberculous Arthritis. — As has already been indicated, ankylosis following tuberculous arthritis often implies merely a latency of the disease, though no doubt definitive cure sometimes occurs. But owing to the frequency with which slight trauma, even many years after ankylosis has occurred, may rouse the dormant lesion into activity, the surgeon should be extremely cautious in efforts to restore joint motion. If ankylosis has occurred in good position, especially in the joints of the lower extremity, no treatment should be adopted, as a rule. For deformity at the hip, subtrochanteric osteotomy (p. 510) is the best treatment, as it divides the bone where healthy (just below the lesser trochanter), and there is very little risk of rousing the old disease, especially if the bone section is made with a saw instead of by osteotome and mallet. A puncture is made about 4 cm. below the great trochanter, on the outer side of the femur, with Adams's knife; this is passed directly to the bone, and is then carried across its anterior surface, and along this knife as a guide, Adams's saw is passed; the knife is then withdrawn, and the femur is divided by very gentle sawing. The limb is then brought into a position of abduction and nearly full extension (Figs. 563 and 504). Tenotomy of the adductors may be necessary to secure abduction. The limb is then fixed in this position in plaster of Paris, and is treated as a recent fracture. At the knee, formal excision (p. 510) usually will secure a useful and 34 530 DISEASES OF JOINTS straight limb, though still ankylosed; attempts at arthroplasty in tuberculous knees are to be condemned. An ankylosed elbow causes great disability even if ankylosis has occurred at the best possible angle, and excision may properly be done with the aim of restoring motion. The same is true of the shoulder. Fig. 563. — Ankylosis of hip from old coxalgia, age thirteen years. Ortho- paedic Hospital. Fig. 564. — Same patient as Fig. 563; one year after subtrochanteric osteotomy of femur. Orthopaedic Hospital. Tuberculosis of the Hip. — Pathology — The primary lesion is in the neck or head of the femur in most cases, but occasionally the acetabulum or synovia is first involved. Acetabular and synovial disease are intra-articular from the beginning; and a femoral lesion very soon penetrates the joint, the epiphysis of the head being intra- articular. Thus in all cases invasion of synovia occurs early, and in many the acetabulum remains healthy for only a short period. There is marked rarefaction of the bone, nearly all calcareous matter dis- appearing; the skiagraphic picture (Fig. 565) is not unlike that of round-celled sarcoma of bone in the total obliteration of all land- marks. If weight-bearing is continued, the acetabulum may be enlarged upward and backward ("wandering acetabulum"), and Fig. 565. — Skiagraph of tuberculosis of left hip-joint. Boy, aged five years, duration five months. Note abduction and flexion of thigh; absorption of head of femur and involvement of acetabulum. Orthopaedic Hospital. Fig. 566.— Skiagraph of ankylosis of right hip following tuberculosis. Girl, aged thirteen years; coxalgia at nine years; no symptoms for two years; healed sinus present in groin. Note obliquely contracted pelvis. Orthopaedic Hospital. 532 DISEASES OF JOINTS pathological luxation may occur; if this is an early symptom in cases in which weight-bearing lias not been allowed, it generally is due to rupture of the capsule from intra-articular effusion. The head of the femur may become very much altered in shape, or entirely absorbed; and when secondary pyogenic infection is present, pathological fracture of the neck is not very rare (Fig. 558). The best result in such cases is firm ankylosis (Fig. 566). Symptoms and Clinical Course. — When early symptoms of tuber- culous joint disease (p. 521) point to the hip, the patient should be attentively examined after removal of all clothing. Nearly 90 per cent, of cases are in children under ten years of age. First the gait (bare-footed) should be studied: usually a slight limp will be noted; and in the early stages the thigh is held in slight flexion and abduction, causing flattening of the buttock and obliteration of the gluteal fold on the affected side (Fig. 5(57). The patient is then laid flat on his back on a firm table: measurements from the navel to the malleoli may show apparent lengthening of the affected extremity; this is due to its abduction, but if the healthy limb is placed in a similar degree of abduction the discrepancy will disappear. Unless there is marked bone deformation or dislocation there can be no actual change in the length of the limbs. Examination usually is best begun by testing the motions of the normal limb, making all the tests with extreme gentleness, and aiming to gain the child's confidence. Usually the affected thigh is kept slightly flexed (Fig. 508), and when an at- tempt is made to bring it out straight, the lumbar spine rises from the table (Fig. 569) because the hip is held rigidly in flexion, and motion is transferred to the spine. First rotate the lower extremity gently to and fro in its own axis, comparing the motion in the two limbs; there will be little or at least limited rota- tion on the diseased side, and it will be painful. Then try abduction of the thigh, still keeping the limb as fully extended as possible; on the diseased side abduction usually is markedly limited by the muscular spasm. The range of flexion is next investigated, first, by bringing the sound thigh up against the abdo- men, and then comparing this with flexion in the diseased joint; this usually is somewhat limited, but not so markedlv as rotation and abduction. Next, abduction Fig. 567. — Tuberculosis of the left hip. First stage: flexion and abduc- tion; flattening of buttock and oblit- eration of the gluteal fold. Age five years; duration two months. Ortho- paedic Hospital. TUBERCULOSIS OF THE HIP 533 Fig. 568. — Tuberculosis of right hip for nine months. Age three years. The hip is held in a flexed position by muscular spasm, and the lumbar spine lies flat on the table. (See Fig. 569.) Orthopaedic Hospital. Fig. 569. — Tuberculosis of right hip (see Fig. 568), showing arching of lumbar spine when attempt is made to bring the knee down on the table. Motion occurs in the lumbar spine, not in the hip-joint. Orthopaedic Hospital. Fig. 570. — Deformity, following tuber- culosis of hip: adduction and shortening (six inches). Age sixteen years; onset of disease at three years; healed sinuses. No symptoms for the last eight years. Orthopaedic Hospital. Fig. 571. — Extreme exterior rotation following tuberculosis of hip. Age twelve years. Duration four years; sinuses still open. (Dr. Alexander's case.) Episcopal Hospital. 534 DISEASES OF JOINTS with the thigh flexed to a right angle may be tested; this is always much decreased on the diseased side. Then the child is turned over on its stomach, and the range of hyperextension is tested iii each hip by raising the knee from the table; this movement always is limited on the diseased side, and where marked flexion deformity is present, it is manifestly unnecessary to test hyperextension. If any of these motions are persistently, even if only very slightly limited, and if there is a history typical of the onset of tuberculous arthritis, the diagnosis may be considered established; and if an exami- nation such as above indicated were systematically made by the physician first called to attend the patient, and if proper treatment were instituted, valuable time would be saved. Only too frequently the family physician makes no physical examination at all, or only a partial one, hampered by the patient's clothing; and treatment for a sprain or for rheumatism is pre- scribed, when a very little more trouble would have enabled a correct diagnosis to be made. In the rare cases where the signs are so slight as to render a positive diagnosis hazardous, the surgeon will consult his own and the patient's interests much better by enjoining recumbent treatment for a week or two, than by making light of the malady. At a later stage of the disease, the early deformity of abduction is replaced by adduction, possibly owing to atrophy of the iliopsoas which lies closest to the joint, and the unopposed action of the adductors. In efforts to walk the patient has to bring the lower extremities parallel, and as the dis- eased limb is fixed in adduction, the healthy limb must be abducted to correspond; this causes a descent of the pelvis on the unaffected side, and apparent shortening of the diseased extremity. But if the healthy limb is placed in a similar attitude of adduction, the measurements will be found the same, unless bone destruction or dislocation is present. The deformity of flexion and adduction, in this which is called the second stage of '"coxalgia," may be due in part to intra-articular changes, but most of it is due to muscular contractures which may be overcome by joint fixation and traction. At a still later stage of the disease the patient may come under observation with cold abscess or sinuses, and with ankylosis in almost Fig. 572. — Cold abscess of left thigh, from tuberculosis of hip. Sequestrum discharged later. Age four years; duration three years. Orthopaedic Hospital. TUBERCULOSIS OF THE HIP 535 any position (Figs. 570 and 571), or with pathological luxation. Cold abscesses and sinuses usually are in direct communication with the joint cavity, but occasionally are due to extra-articular perforation of the bone. The abscess may point at any part of the thigh, but the most frequent site is on the outer side (Fig. 572) ; or a gluteal abscess (Fig. 573) may occur, usually from perforation of the poste- Fig. 573. — Gluteal abscess in coxalgia. (Dr. Hodge's case.) Children's Hospital. rior capsule. Abscesses or sinuses in the adductor region (Fig. 574) usually are an evidence that the acetabulum is involved, as, accord- ing to Vincent (1895) is the occurrence of adduction as the primary deformity. Diagnosis. — Not every case of arthritis of the hip is tuberculous, even in children, and where doubt exists as to the etiological factor, other aids may be called in to assist the clinical diagnosis, such as the Fig. 574.- -Adductor abscess in coxalgia. Age six years. Coxalgia for one year. Abscess for four weeks. Orthopaedic Hospital. tuberculin tests, estimation of the leukocytes, and skiagraphy. Nor should the surgeon forget that other affections besides arthritis may cause rigidity, flexion, adduction, etc. Among such may be mentioned inguinal or femoral adenitis, osteochondritis (p. 588), psoas abscess (p. 661), and even appendicitis. Attention to the clinical history and physical signs will exclude such affections as fracture of the cervix :>:',<; DISEASES OF JOINTS femoris, congenital or traumatic dislocation of the hip, coxa vara, and deformity from infantile arthritis. Fig. 575. — Bed extension for coxalgia with flexion deformity. Note the high cradle to keep the bed-clothes off the foot. Episcopal Hospital. Fig. 576. — Thomas hip brace. Episcopal Hospital. Fig. 577. — Thomas hip brace rear view. Treatment. — Recumbency should be insisted on in all early cases, with weight extension of two or three pounds applied in the axis of TUBERCULOSIS OF THE HIP 537 the deformity (Fig. 575). Sufficient fixation usually is secured by strapping the body to a Bradford frame. If this cannot be procured, a binder's-board splint or light plaster case may be applied to the hip and pelvis, weight-extension being used in addition. In most cases, after a week or two, muscular spasm disappears and full ex- tension may be secured. The temperature should be recorded twice daily, in this as in all acute tuberculous conditions; it forms a valu- able guide as to the progress of the local lesion. After one or two months of recumbency examination may disclose an apparently nor- mal joint, and the temperature curve may be quite satisfactory; but this merely indicates that the disease is latent, not that it is cured. When symptoms have been absent for a month or more, ambula- tory treatment may be cautiously tried. In this, joint fixation may be gradually relaxed, but weight-bearing should be prevented for a long time to come. Various braces are in use for this stage of treat- ment: with all, a high shoe is worn on the healthy side, and crutches are used, allowing the diseased limb to swing free of the ground. The brace of H. O. Thomas (1875) (Figs. 576 and 577), provides fixation at the hip, and traction is secured by the weight of the limb ; but it is impossible for the patient to sit down with the brace on, and the limb may rotate within the brace, giving rise to unsuspected deformity. About 1855 H. G. Davis introduced the method of traction in an ambulatory splint; a modification of this, introduced in 1873 by C. F. Taylor (Fig. 578), consists of a pelvic band, passing around the pelvis between the anterior superior iliac spines and the level of the great trochanters, to which is attached a long outside iron extending below the foot beneath which it forms a stirrup; to the stirrup traction straps are fastened from the foot, counter-extension being provided by a perineal strap. Movements of flexion and extension are per- mitted at the hip, as the outside iron is jointed below the pelvic band; this allows a sitting posture to be assumed. A more efficient brace is that of G. G. Davis (Fig. 579), in which besides a perineal strap for counter-extension, as in the Taylor brace, an inside iron is added which supports a well-padded bar passing from one side iron to the other beneath the tuber ischii; on this bar the patient sits, absolutely preventing weight-bearing on the diseased joint, while the foot exten- sion keeps the lower extremity taut, aiding the weight of the limb in securing traction. If braces cannot be secured, a spica bandage of plaster of Paris may be applied to the thigh and pelvis, preferably fixing the knee and ankle also; and with a high shoe on the sound side, and crutches, the patient may do well, though a well-fitting brace is much more cleanly and comfortable. Usually it is well for the brace to be worn night and day at first, until it is certain that no recurrence of symptoms is to be feared, when it may be left off at night. While a patient is wearing a brace, he should be seen by the surgeon every two or three weeks; and the surgeon should himself see, personally, that the brace fits comfortably and is efficient. If he is unwilling :>:n DISEASES OF JOINTS or unable to undertake the responsibilities of mechanical treatment, he should retire from the case. If it is found that under ambulatory treatment symptoms of coxitis return, recumbent treatment should be resumed, and carried out as already indicated. When, however, ambulatory treatment succeeds, joint fixation may be gradually dispensed with. If eight months or a year are passed without any symptoms whatever of joint trouble, it probably will be safe to discard the brace, but a high shoe on the sound side and the use of crutches should be insisted on for a much longer period. Then the high shoe may be abandoned, and crutches alone used, until by very gradual stages weight-bearing is proved safe. 1 Fig. 578. -Taylor hip brace. Episcopal Hospital. Fig. 579. — G. G. Davis's brace for coxalgia. Orthopedic Hospital. I am well aware that some orthopedic surgeons at present are opposed to such conservative measures, and prefer to follow the example of Lorenz (1906), in treating all early cases of coxalgia by weight-bearing, fixing the joint in the attitude of deformity by a gypsum splint, and abolishing recumbency and traction entirely from their plan of treatment. But the plan here recommended seems to me the most rational when the pathology of the lesions is con- TUBERCULOSIS OF THE HIP 539 sidered, and is still employed by the majority of judicious surgeons in this country, Great Britain, and France; and I am convinced that if rigorously employed from the earliest stage, it will cure a much larger proportion of patients without ankylosis than will the method of Lorenz, though the course of treatment may be longer. Fig. 580. — Result of excision of hip for tuberculosis, in a boy of fourteen years, one year after operation. Still uses crutches. (Dr. H. C. Deaver's case.) (See Fig. 581.) Episcopal Hospital. Fig. 581.— Excision of left hip for coxalgia. (See Fig. 580). Left hip in slight adduction; apparent shortening three inches, actual shortening one and a half inches; wound dry but scabby. The treatment of cold abscess and sinuses, with secondary infection, has been so fully discussed at p. 520, that little need be said here. In almost all cases recumbent treatment, and heliotherapy, alone or with bismuth or iodin injections, will cause sinuses to close eventually. Very rarely it may be necessary to remove a sequestrum or some carious bone by the curette; then the cavity should be filled with iodoform bone-wax (p. 478). Almost never is formal excision necessary or desirable in children, and then only to avert death from sepsis, and as a less severe remedy than amputation. Excision of the hip for tuberculosis should be regarded merely as a method of joint dis- 540 DISEASES OF JOINTS infection (Coudray, L911), and should be as conservative in extent as is possible with such end in view. An anterior incision is best, as originally advocated by Hueter (1878), and later adopted by R. W. Parker; this incision is made on the outer side of the sartorius, displacing the rectus and ilio-psoas to the inner side (Barker, 1888); as much synovia should be removed as possible. In very septic cases the posterior longitudinal incision is preferable. This was used by C. White, of .Manchester ( L769), and was known during the nine- teenth century by Langen- beck's name. After detaching the muscles from the great tro- chanter the femur is divided below this process, the entire upper end being removed; the acetabulum also is gouged away if necrotic. Though the immediate mortality of the operation is only about 5 per cent., yet, when employed for the cases here described as suitable for such treatment, the ultimate death rate is from 20 to 25 per cent. If employed in less severe cases in which it is not necessary, the death rate will, of course, be less. Amputation occa- sionally may save a life after excision and re-excision have failed. After the operation recumbent treatment with fixation and traction is con- tinued until latency of symp- toms indicates the propriety of passing to ambulatory treatment. Ankylosis should be encouraged. Ely (1911) thinks the benefit of excision in hip disease is due to the luxation of the femur which often results, thus permanently abolishing the joint as such, as effect- ually as would ankylosis (p. 524). In long quiescent cases with anky- losis, deformity may be corrected by osteotomy (p. 529); without ankylosis, disability may be relieved by an operation replacing the upper end of the femur in the acetabulum. In adults, in whom tuberculosis of the hip is rare, excision is more often required, but, fortunately, the resulting disability is less. Fig. 582. — Skiagraph of tuberculous arthritis of knee; age thirty-seven years; duration seven years. Same patient as in Fig. 583. Episcopal Hospital. TUBERCULOSIS OF THE KNEE 541 Tuberculosis of the Knee. — This is the most frequent form of tuberculous joint disease in adults, in whom the primary lesion often is synovial; but the knee is often attacked in children also, and in them usually the femur, tibia, or patella is first involved. In the knee, as in the elbow, local signs of arthritis are much more marked than in the hip, consisting in heat, dusky redness, typical fusiform swelling, and occasionally in intra-articular effusion. Usually, however, enlarge- ment of the joint is due to fungus granulation tissue, and though it may seem as if fluctuation was present, aspiration will fail to de- monstrate fluid. The pa- tella does not float, but early becomes fixed more or less firmly to the con- dyles of the femur (Fig. 582). The knee is flexed, and contractures of the hamstrings develop. In ad- vanced cases posterior sub- luxation of the tibia occurs, usually accompanied also by rotation outward. Start- ing pains are very annoy- ing, and the patient lies curled up on the diseased side, his whole attention apparently concentrated in protecting the painful joint from injury or motion. Cold abscess is rarer than in hip disease, and sinuses more frequently are of extra-articular origin. Treatment. — The treat- ment consists in local rest, secured in acute cases by recumbency with splinting and weight-extension. In less severe cases the fixation by plaster of Paris without traction may suffice, and if the gypsum is renewed every four or five weeks gradual decrease of the deformity may be secured. Weight-bearing usually should be allowed before motion at the knee, but for some months after ambulatory treatment is com- menced it is safer to employ a traction brace, much the same as in hip disease, with a high shoe on the healthy foot, and crutches. If con- Fig. 583. — Skiagraph of tuberculous arthritis of knee, showing destruction of external condyle of femur, external tuberosity of tibia and perforation of cartilage of tibia. Age thirty-seven years; duration seven years. Probably synovial in origin. Treated by excision. Episcopal Hospital. 542 DISEASES OF JOINTS servative treatment is persisted in for a year, and the disease fails to become latent, the question of operative treatment may arise: in cliil- dren below the age of puberty all that should be attempted is erasion of the joint (arthreetomy, p. 529); and though by resort to this operation the disease may not be permanently cured, and though, as is frequent, flexion deformity develops after operation, it may be possible by its aid to tide the patient over the years of childhood until formal excision can be safely done. In adults the results of conservative treatment are very disappointing (Fig. 583) ; if, after judicious trial of this for some months, no improvement occurs, or if the disease constantly lights up afresh when ambulatory treatment is adopted, excision of the knee should be done; and in practically all cases in adults with sinuses or secondary infection, early excision will give the best results (Fig. 584). The operation Fig. 584. — Specimen from excision of left knee for tuberculosis. (See Figs. 582 and 583.) Episcopal Hospital. Fig. 585. — Tuberculosis of left ankle-joint. Episcopal Hospital. has been described at p. 510. Ankylosis should be firm in eight to ten weeks. Even if excision fails to cure the disease at once, which rarely is the case, the surgeon must not conclude that immediate amputation is necessary; by persistence in conservative measures, firm ankylosis and healing of sinuses may yet occur; or a re-excision may be more successful. Amputation should be regarded as the last resort, chiefly adapted to the very old. By excision the limb will be shortened from 1.5 to 5 cm. During convalescence from operation the tendency to development of genu varum must be guarded against, as well as the tendency of the femur to ride forward on the tibia. The patient should wear an orthopedic apparatus to fix the knee for a year. The immediate mortality of the operation is about 5 to 10 per cent. Tuberculosis of the Ankle and Tarsus.— The diagnosis sometimes is difficult in children or adolescents, in whom painful flat-foot (p. 591) may be the primary symptom. The astragalus and calcaneum are TUBERCULOSIS OF THE ELBOW 543 the bones most often affected, but owing to the proximity of so much synovial membrane (Fig. 179), early joint invasion occurs (Fig. 585), and fistulization with secondary infection is very common. Treatment. — Treatment, even when the diagnosis is only tentative, should be by rest and cessation of weight-bearing, secured by a gypsum case and use of crutches. This usually is sufficient in children, in whom sinuses soon close, and erasion rarely is required. If motion is prevented by a suitable brace, weight-bearing may be resumed a few months after cessation of active symptoms. In adults, on the other hand, time should not be lost in conservative treatment unless improvement is progressive; if the disease seems stationary, and especially if the foot grows worse, erasion or excision should be resorted to without delay. The entire astragalus should be removed, and as Fig. 586. — Tuberculosis of elbow in a child of four years, showing typical fusiform swelling; also tuberculous spon- dylitis, and tuberculous osteomyelitis of left forearm and hand with sinuses. This condition is euphoniously described as the "moist rot." Children's Hospital. Fig. 587. — Tuberculosis of elbow. Age seven years; duration four years; sinuses for four months. Also tuber- culous cervical adenitis. (See Fig. 588.) Orthopaedic Hospital. much of the tuberculous soft parts as possible. Usually the surgeon finds that he has delayed too long, and that while this con- servative operation may improve matters for a while, amputation eventually will be necessary. Tuberculosis of the Elbow is much more frequent in children than in adults. The primary lesion is more often in the ulna or humerus than in the radius. Joint invasion is rapid, and typical fusiform en- largement results (Fig. 586). Fistulization is difficult to prevent (Fig. 587), and cure seldom occurs except by ankylosis, and it is better, especially in children, to encourage ankylosis and closure of sinuses than to resort to precocious excision (Fig. 588). No effort should be made to restore motion until all symptoms have been absent for many months. Then excision may be done. 544 DISEASES OF JOINTS Tuberculosis of the Wrist. — This is rare in children; immobilization promptly employed and long continued usually produces a cure with only moderate limitation of motion. In adults sinuses are prone to form, and amputation is the usual termination, though erasion should he tried first. Formal excision of the wrist is very rarely advisable (p. 513); firm fibrous ankylosis is sought, and the hand seldom is very useful. Tuberculosis of the Sacro- iliac Joint is very rare, es- pecially in children. The symptoms are pain, some- times radiating down the sciatic nerve, localized ten- derness over the affected joint, and a peculiar feel- ing of insecurity in the pelvis on attempts to walk. When stand- ing, the body is inclined away from the diseased side, as in Fig. 588. — Tuberculous elbow, fibrous anky- losis, sinuses healed. Age ten years. Three and a half years after Fig. 587. Fig. 589. — Syphilitic arthritis of left elbow. Age fourteen years; duration two years. Also interstitial keratitis and slight sabre-blade tibia. Orthopsedic Hospital. Fig. 590. — Syphilitic arthritis of both knees. Age thirteen years; dura- tion five months. Orthopsedic Hos- pital. " sciatica. " Examination shows no involvement of the hip or vertebra? ; hyper-flexion of the hip on the diseased side occurs to the normal extent unless the knee is kept extended, when it will be impossible TUMORS OF JOINTS 545 to flex the hip as far on the diseased as on the healthy side, since muscular spasm will be roused by traction on the ischium through the tense hamstrings. Pressing the iliac crests together, and attempts at antero-posterior motion in the pelvic joints cause pain. In advanced cases swelling over the dorsal or pelvic surface of the joint occurs, and suppuration may develop, with sinuses posteriorly or in the inguinal or adductor regions. Treatment. — Recumbency, with weight-extension for many months, is required. No form of apparatus is satisfactory in preventing weight-bearing at the sacro-iliac joint, and recurrence of symptoms is not unusual when ambulatory treatment is attempted. A few recoveries have been reported after resection of the joint, but even in adults this should be reserved until conservative measures have proved ineffectual. Picque (1910) reported seven resections of the sacro-iliac joint for tuberculosis: two patients were cured, three were recovering ("nearly cured"), one died of cachexia, and the last had amyloid degeneration of the viscera and death was anticipated. Syphilis of the Joints. — Syphilitic arthritis is not very rare in cases of hereditary lues, but often, especially in the acquired form of the disease, is not recognized. It was first described by A. Richet (1853). In its clinical aspects the disease much resembles tuberculous arthritis, especially of the primary synovial type, but pain is less severe. The diagnosis usually is made from concomitant evidences of syphilis (Figs. 589 and 590) , and is confirmed by the Wassermann reaction and results of antisyphilitic treatment. If the joint is painful, suitable apparatus should be provided. TUMORS OF JOINTS. Tumors of the joints, except those developed from the neighboring bones, are quite rare. Lipoma Arborescens is the name given by Volkmann (1882) to a synovial or subsynovial growth in which fatty deposits occur. It is observed oftenest in the knee, along one side of the tendo patella?, but also occurs in the shoulder. It is regarded by Poncet, Marsh, Ely, and Whitman as tuberculous in nature, and there is no doubt that sometimes it is; but it is better to consider it, with Nichols (1907), a hypertrophic synovial change which may occur in various joint affections. The fatty out-growth is more or less pedunculated, is palpable through the skin as an ill-defined mass, and interferes with the functions of the joint without producing very acute symptoms. The best treatment is excision of the growth. Sarcoma. — Primary sarcoma (endothelioma) of joints is rare. It begins in the synovia or subsynovial connective tissue. Lejars and Rubens-Duval (1910) collected 16 cases, 13 of which occurred in the knee. This is one of those neoplasms where transition from epithe- lioid to sarcomatoid tissue is best observed. The clinical symptoms somewhat resemble a subacute infectious arthritis, and the diagnosis usually depends on microscopical examination of an excised specimen. If the tumor recurs after local extirpation, amputation should be done. 35 CHAPTER XVI. ORTHOPEDIC SURGERY. Orthopedics, from the Greek words dpOoz and ~«fC, meaning lit- erally a straight child, is that part of surgery which deals with the correction of deformities, either congenital or acquired. So many surgeons, during the last fifty years or more, have devoted their exclu- sive attention to this subject, that the practice of orthopedic surgery is now recognized as a specialty of equal rank with gynecology or genito-urinary surgery. In the limits of a text-book on general sur- gery, therefore, it is manifestly impossible to do more than provide an outline of the subject, and inculcate the general principles which underlie its practice. CONGENITAL DEFORMITIES. Congenital Absence of Bones is not very rare. Those most often deficient are the radius, and the tibia or fibula. Sometimes the outer portion of the foot is absent along with the fibula, or a portion of the hand absent with the radius. The exact diagnosis often depends on skiagraphy. The hand or foot de- viates toward the side where its support is lacking. In infancy malposition may be prevented or corrected by splints, or other ap- paratus. Often during childhood or adolescence it becomes neces- sary to operate for the correction of deformity, or to improve function. In the foot, some form of arthro- desis (p. 570) usually will be re- quired to give stability in walking, while in the upper extremity it may seem desirable to lengthen con- tracted muscles and tendons, and do osteotomy or resection of the existing bone for cosmetic effect, though function can seldom be improved. Bone transplants (p. 248) may be inserted in some cases. Congenital Absence of Muscles (Fig. 591), which is quite rare, seldom entails much disability; when it does, it usually is possible to improve function by tendon transplantation (p. 568). (546) Fig. 591. — Congenital absence of costal portion of right pectoralis major, in a girl of six years. No disability. Slight scoliosis. Ortho- paedic Hospital. CONGENITAL DEFORMITIES 547 Supernumerary Fingers or Toes (Polydactylism) (Fig. 592) usually require amputation; special care should be paid to hemostasis, as deaths in infants from secondary hemorrhage have been reported. Malformations involving the metacarpal or metatarsal bones seldom can be appreciated without a skiagraph (Fig. 593), and require special types of operation. Fig. 592. — Supernumerary digits, six toes on each foot. Age seven months. Also had six fingers on each hand, but the extra fingers were amputated at birth. Episcopal Hospital. Webbed Fingers (Syndactylism) (Fig. 594) may be treated by several forms of plastic operation. Didot's method (1850) is sufficiently indi- cated by the accompanying figure (Fig. 595) and is suitable for cases of syndactylism without any web. There is great tendency for the web to re-form, and it always is well to carry the incisions far down between the heads of the metacarpal bones. For this reason Agnew's operation (Fig. 596) is preferable, as it provides a flap of healthy skin over the web. Congenital Contraction of a Finger may require some form of plastic operation, after excision of dense bands of connective tissue. Intra-uterine Fractures. — Intra-uterine fractures are to be distin- guished from those occurring during birth. In the former union with deformity and callus are present at birth, and usually there is a dimple as of a healed wound in the skin over the fracture. Its true nature is not known. In both varieties of fractures union occurs without diffi- culty, and almost invariably even marked deformity becomes spon- taneously corrected within a year or two (Fig. 597). Immobilization is necessary only so long as the part is painful. Congenital Dislocations. — Congenital Dislocation of the Hip is the most frequent of these congenital luxations. Some authorities believe that the displacement of the bones may not always date from fetal existence, but may be produced by uterine contractions during birth (Allis, 1907), or after birth by injudicious attempts 548 ORTHOPEDIC SURGERY to extend the baby's thighs; however, it is very generally agreed that there is a congenital malformation of the acetabulum and of the head of the femur or both, possibly due to malposition within the uterus. The deformity is more common in female (85 per cent.) than in male (15 per cent.) children, and more often unilateral (63 per cent.) than bilateral (36 per cent.). The dislocation is posterior in Fig. 593. — Skiagraph of the left hand of a patient, aged nineteen years, showing poly- dactylism and syndactylism. The right hand was similarly affected. Episcopal Hospital. the overwhelming majority of cases. The longer the dislocation stays unreduced the more does the capsule contract around the acetab- ulum, forming an hour-glass-shaped channel through which it may become impossible to replace the head. The acetabulum, which is shallower than normal, becomes more so as life advances unless the femoral head is replaced in it and normal weight-bearing is restored. CONGENITAL DISLOCATIONS 549 Symptoms. — Frequently nothing abnormal about the child is noted until walking is attempted, when a limp is visible in the unilateral Fig. 594. — Webbed fingers; age fourteen Fig. 595. — Didot's operation for webbed years. Orthopaedic Hospital. fingers. Fig. 596. — Agnew's operation for webbed fingers. Fig. 597. — Intra-uterine fracture of the leg. The mother fell when five months pregnant. Baby now five months old. Dimple over site of fracture. Orthopaedic Hospital. cases (Fig. 598), and a characteristic waddle in the double dislocations. In the latter there also develops marked lordosis (Fig. 599), because the center of support is displaced posterior to the center of gravity. If 550 ORTHOPEDIC SURGERY the dislocation is not reduced, deformity and disability usually increase with age; and in most cases adolescents and adults must lead a semi- invalid existence. The diagnosis is made from the history, from the symptoms noted above, and from the physical examination. This shows moderate shortening of the extremity affected (Fig. GOO), eleva- tion of the trochanter above Nekton's line, and absence of the femoral head from its socket. By alternately pulling and pushing on the fully extended lower extremity, while the pelvis is fixed, the great trochan- ter will be found to slide up and down. When the two thighs are Fig. 598. — Congenital dislocation of left hip, in a boy of two years. Limp first noted on attempts to walk at the age of fifteen months. Episcopal Hospital. flexed to a right angle, with the knees bent, and the child on its back, the thigh on the affected side is found shorter. There is diminished abduction, especially when the thigh is flexed to a right angle. Flexion and extension are free and painless, facts which together with the history readily serve to distinguish this affection from traumatic dis- location. In coxa vara the head of the bone is in the acetabulum; and in coxalgia there is an acute arthritis, or its resultant deformity. Confirmation of the diagnosis of dislocation is obtained by skiagraphy, which usually shows more or less anteversion of the head of the femur: that is, instead of pointing inward toward the pelvis, the CONGE N I TA L DISLOCA TIONS 551 neck of the femur lies more nearly in the sagittal plane, the head point- ing forward even when the lower limb is not rotated outward. Treatment. — Reduction is best accomplished between the ages of three and five years. In very young children, reduction is not difficult to secure by the usual methods for dislocation of the hip (p. 445) ; but reduction before bony elements are present in the head of the femur may cause irreparable damage to the growing bone. In all cases reduction is very difficult to maintain owing to the shallowness of the acetabulum, the deformation and ante version of the head, and the resiliency of the soft parts. After the age of eight or nine years it is very difficult and sometimes impossible to obtain reduction without open operation, which is called by the Germans the "bloody" as dis- tinguished from the "bloodless" method of re- position. Paci, of Pisa (1888, 1894), was an early exponent of the bloodless method, which he sys- tematized, and Lorenz (1895) abandoned his bloody method to take up a modification of Paci's operation which he has popularized all over the world. The child being etherized and the pelvis fixed, the surgeon flexes and then ab- ducts the thigh until the adductor tendons become tense; these are then ruptured subcutaneously by blows from the ulnar side of the hand, or by violent massage. The limb is then forcibly hyper- flexed, with the knee extended, until it lies along- side the body, with the foot beside the patient's head. When all resisting soft structures on the anterior portion of the joint have been ruptured, reduction is attempted: the trochanter is placed over a wedge-shaped block, and by hyperabduc- tion of the flexed thigh the surgeon pries the head of the femur into its socket. The clenched fist may be used as a fulcrum instead of Lorenz's wedge; but either method is liable to fracture the cervix femoris (Fig. 602). According to Bade (1909), nerve injury, resulting in paralysis, has occurred in 67 out of 2204 cases of blood- less reposition; and many surgeons have produced one or more frac- tures of the femur, myself included (in a patient over eight years of age). A much safer and equally efficient method is that of G. G. Davis (1907), in which the patient is placed prone on the table, and the thigh is flexed until it lies alongside the chest, with the knee in the axilla; this brings the head of the femur below but still posterior to the acetabulum; then the adductors are gradually stretched by manual pressure downward on the great trochanter (Fig. 603); when these structures have been stretched enough to allow the groin to come in contact with the table, the head of the femur may jump from the Fig. 599. — Lordosis in congenital disloca- tion of both hips; age six years. Orthopaedic Hospital. 552 ORTHOPEDIC SURGERY posterior to the anterior plane of the pelvis with an audible and palpable click. If not, the flexion of the thigh is slightly diminished (i. e., it is drawn a little away from the chest) and its abduction is slightly increased, by raising the knee a short distance from the table. Pressure downward on the trochanter is continued until the head of the femur can be felt by the finger in the groin. If reduction cannot be secured at the first attempt without the use of unjustifiable force, it is better to dress the limb in the fullest abduction possible and make another attempt several weeks later if necessary, after sub- cutaneous division of the adductor muscles, close to the pubis. Fig. 600. — -Congenital dislocation of right hip, in a girl eight and a half years old. (See Fig. 601.) Orthopaedic Hospital. Fig. 601. — Congenital dislocation of right hip. Three and a half years after bloodless reduction. Same patient as Fig. 600. Orthopaedic Hospital. When reduction has been secured, this fact may be determined (1) by hearing or feeling the femoral head jump into the acetabulum; (2) by observing that the knee can no longer be fully extended, since the ascent of the femur from the posterior plane of the innominate bone to the acetabulum has caused a relative shortening of the ham- strings; (3) by palpating the head of the femur in its socket below Poupart's ligament; (4) by reproducing the luxation and again redu- CONGENITAL DISLOCATIONS 553 cing it; and (5) by skiagraphy. Sometimes an "anterior transposition" only is secured : in this the head, instead of jumping into the acetabu- lum, passes above it to a position just below the anterior superior spine of the ilium; of course this is not so favorable a result as an "anatomical reposition," but it is better than a persistence of the dislocation, since it transfers the weight-bearing point to the centre of gravity. Fig.^602. — Fracture of neck of femur when hyper-abduction is attempted according to Lorenz's method. After reduction the head of the femur is not at all stable in its ill- formed socket, and the chief difficulty and tedium in the care of these cases arises in the after-treatment, in efforts to prevent relapse. The limb should be dressed in plaster of Paris in the most stable position; Fig. 603. — G. G. Davis's method of reducing congenital dislocation of hip. Orthopaedic Hospital. usually this is with the thigh flexed to a right angle and abducted beyond the coronal plane; that is, so that the knee is in a plane pos- terior to the symphysis pubis (Fig. 604). This, the "primary position," called also the "frog position" when both hips are concerned (Fig. 605) , must be maintained for from four to six months. During this time the child must be encouraged to walk about, with support, as 554 ORTHOPEDIC SURGERY weight-bearing favors the deepening of the acetabulum. At the end of this time, unless reluxation has occurred or is imminent, the abduc- Fig. 604. — Congenital dislocation of right hip; primary dressing. Photographed two weeks after operation. Same patient as Figs. 600, 601. and 606. Orthopaedic Hospital. Fig. 605. — Frog position after reduction of congenital dislocation of both hips. Orthopaedic Hospital. CONGENITAL DISLOCATIONS 555 tion and flexion may be diminished gradually, and the thigh dressed in a less awkward position (Fig. 606), in which locomotion is easier. Sometimes greater stability is secured by dressing the limb with the patella looking directly forward, without any external rotation of the thigh (Fig. 607). Immobilization of the hip must be continued, except in very young children, for from nine to eighteen months after the primary reposition, and for a similar or longer period after any recurrence of dislocation and sec- ondary reposition. After this time ex- ternal support may be discontinued, and gentle passive motion and massage may be prescribed. The younger the child, the sooner, as a rule, can external support be dispensed with, and the sooner will function return. In older children prolonged traction, in gradually increasing abduction, should be employed for several weeks before attempts at reposition are made. Churchman (1919) has devised a cir- cular gas-pipe frame attached to the bedstead, which allows this method to be applied efficiently and sys- tematically; and by its aid has secured spontaneous reduction. If reluxation recurs persistently, and in cases where bloodless reposi- Fig. 606. — Congenital dislocation of right hip in walking cast. Same patient as Figs. 600, 601, and 604. Orthopaedic Hospital. Fig. 607. — Secondary position in congenital dislocation of the hip. Note the bed-pan in position beneath the frame. Episcopal Hospital. 556 ORTHOPEDIC SURGERY tion is impossible , a resort to open operation usually is proper. The best approach is by Lambotte's incision, from the anterior superior iliac spine to the great trochanter, thence downward and forward, turning the flap (formed of tensor fascise lata?) forward. In all cases the capsule is widely opened, preserving the Y-ligament; and the ace- tabulum is cleared out sufficiently to hold the head of the femur. Structures preventing reduction should be divided; but in adults, where utmost efforts sometimes fail to secure reduction, it may be sufficient to form a new socket above the acetabulum (G. G. Davis, 1908). A certain measure of relief will be secured if the head of the femur becomes more firmly fixed, in any position, than it was before operation Birth Injuries of the Shoulder. — These were formerly confused with congenital dislocations of the shoulder, which probably do not exist; and with brachial birth yahies which are probably only incidental not essential lesions. It was formerly held that the cause was direct pres- sure on the brachial plexus by for- ceps in delivery (which is admittedly rare), or stretching and laceration of the plexus from attempts to deliver a shoulder by injudicious traction on the head or in delivery of the aftercoming head. But T. T, Thomas (1910) proposed the theory that lesions of nerves were due to their being caught in effusion of blood and lymph and that the essen- tial lesion is injury to the shoulder^ joint, produced by direct pressure on the humerus and acromion by the maternal pelvis, the arms being flexed and adducted at the shoulder (1914). This produces a posterior subluxation or complete dislocation. The usual deformity is characteristic (Fig. 608), the arm being in internal rotation, and there being apparent paralysis of muscles sup- plied by the suprascapular, musculocutaneous, circumflex, and some- times radial nerves, all of which lie close to the joint; while the muscles supplied by the subscapular nerves, the median, ulnar, anterior thoracic nerves and others not lying close to the joint, escape (Ashhurst, 1917). The hand is little affected, but supination and flexion of the forearm are imperfect or entirely absent. This corresponds to the upper arm type of brachial paralysis described by Duchenne (1872) and Erb (1874), the lesion being in the outer cord (fifth and sixth cervical nerves) of the brachial plexus. The "lower arm" type (Dejerine-Klumpke), and paralysis of the entire extremity are rare. Treatment. — Treatment consists in rest in a sling until acute pain is absent, then in passive movements (active also so far as possible) to Fig. 608. — Birth injury of the left shoulder, in a boy aged seventeen months. Typical posture. Ortho- paedic Hospital. CONGENITAL DISLOCATIONS 557 overcome the tendency to contracture in adduction and internal rota- tion. If subspinous dislocation exists, it should be reduced at about six months of age by a method analogous to that of G. G. Davis for Fig. 609. — Birth injury to shoulder in a boy aged five and one-half years; the typica disability is that the patient cannot get his hand to his mouth, even with marked abduction of the shoulder joint. Episcopal Hospital. congenital dislocation of the hip, and the arm maintained in abduction and external rotation for three months. If the child does not come under observation until the age of three years or older, it usually is necessary to resort to arthrotomy to secure reduction (Figs. 609 and Fig. 610. — Birth injury to shoulder two years after open operation. The dislocation has been reduced, and external rotation has been restored, and the hand can now be put to the mouth. Episcopal Hospital. 610). This is best done through Senn's incision (p. 253). In late cases without dislocation much benefit may result from tenotomy of the con- tracted muscles, especially the subscapularis and pectoralis major. r,:,s ORTHOPEDIC SURGERY Congenital Elevation of the Scapula, Sprengel's Deformity (1891). — The upper extremity develops as an appendage of the cervical spine, and if normal descent of the scapula fails to occur, it remains in the cervico-dorsal region, more or less deformed, often being fixed to the vertebral spines by a process of bone or cartilage. A. E. Horwitz (1908) studied 136 cases. In a patient under my own care (Fig. Gil), who also presented congenital scoliosis and absence of several ribs, marked improvement resulted from open section of the muscles attached to the vertebral border of the scapula, depression of the scapula, and re-attachment of the rhomboids to the upper angle of the bone (Fig. 612). Fig. 611. — Congenital elevation of left scapula in a boy of three years; before operation. Orthopaedic Hospital. Fig. 612. — Congenital elevation of left scapula, three months after opera- tion. Orthopaedic Hospital. Congenital Dislocation of the Knee is quite rare, and usually is anterior in direction, the leg being hyperextended on the thigh. The patella may be absent. The use of splints or orthopedic apparatus usually secures a return to the normal position, with moderate range of flexion, before the age for walking arrives. Congenital Talipes. — The cause of congenital foot deformities is unknown, though they often are attributed to malposition in the CONGENITAL TALIPES 559 uterus. The hands sometimes are the seat of similar deformities (Club Hands) . The deformity may affect one or both feet. There are.several distinct types of deformity, though usually more than one is present. Talipes Equinus is"pointed toe" deform- ity in which the front of the foot is de- pressed and the heel elevated, the patient walking on the toes, as a horse, whence the name. In Talipes Calcaneus the heel is depressed and the toes elevated. In Talipes Varus the anterior part of the foot is adducted, and the foot is inverted (supinated); the inner border of the sole is shortened and elevated, and the patient walks on the outer border. In Talipes Valgus the anterior part of the foot is abducted, the foot is everted and pronated, the sole is flat, and the inner border of the foot is convex. In Talipes Cavus or Arcuatus .("hollow foot") the arch of the foot is high, and the foot is shortened antero-posteri- orly, without being either pronated or supinated. At birth, there seldom is appreciable bony deformity, but contractures of tendons and ligaments as well as of the skin and subcutaneous tissues are pres- ent. If the deformity is not overcome while the bones are soft, these will become deformed, adapting their form to the altered function required by weight-bearing and locomotion. Equino-varus. — The most frequent combination of congenital deformities is that of equinus and varus, forming the ordinary "club- foot" (Fig. 614) ; there often is slight earns as well. The feet turn in, the soles face each other, the tibial border of the sole is con- cave and shortened, and the heel is elevated. There is no natural tendency for the deformity to correct it- self; on the contrary, if pa- tients are neglected and allowed to walk, the deformity constantly increases until in extreme cases they may have to walk on the dorsum Fig. 613. — Congenital talipes equinus, with slight cavus deform- ity in a boy of thirteen years. Orthopaedic Hospital. Fig. 614. — Congenital equino-varus (bilateral), age seven months. (See Fig. 615.) Orthopaedic Hospita 5G0 ORTHOPEDIC SURGERY of the foot (Fig. 615). The tibialis anticus and posticus are short, and keep the foot inverted; the tendo Achillis raises the heel; the plantar fascia is contracted and arches the foot, and the flexors of the toes aid in causing cavus deformity. The calcaneum long remains small and ill-formed, and the calf muscles are poorly developed, because of disuse; and the extensors of the toes and the peronei, which work at marked disadvantage, are weak and totally unable to over- come the deformity. Treatment. — In earliest infancy manual correction alone may suffice, if it is applied intelligently and at least twice daily. Holding the leg bones at the malleoli in one hand, the other hand forcibly abducts the foot, so as to stretch the shortened tissues on the inner side of the sole. This is repeated from ten to twenty times, morning and night. When the adduction can be over- come, and the foot brought into a straight line with the leg, but not before, attempts are made to bring the heel down by dorsi-flexing the foot in the sagittal plane. By no means should the tendon of Achilles be divided so long as there remains the slightest tendency to varus; without the calcaneum as a fixed point (made so by the attachment of the Achilles tendon) it is impos- sible to overcome by manipulation the adduction of the foot. From the age of a few weeks until the child begins to stand, the foot should be held in the best position obtainable at each manipulation by being ban- daged to a posterior right-angled splint, or in plaster of Paris. If plas- ter of Paris is used, the case should be renewed every two or three weeks and the foot put up again in the improved position secured by renewed manipulation. Sometimes it is necessary to anesthetize the baby to apply manipulation effectively. If this treatment is faithfully carried out there are very few cases of club feet in which the feet will not be in sufficiently good position for weight-bearing when the age for walking arrives. At this stage braces may be applied, to be worn night as well as day, but removed daily for washing and manipulation; and these must be continued until there is no further tendency to relapse. The main factors in such apparatus are a strong laced shoe, open to the toe, so that the foot can be inserted easily; an instep strap to hold the foot against the sole, and keep the heel from rising; side irons to prevent inversion of the foot; and an elastic strap from the outer side of the foot to the Fig. 615. — -Inveterate varus. Same patient as Fig. 614, three years later. Has received no treatment; walks on the dorsum of his feet. Orthopaedic Hospital. CONGENITAL TALIPES 561 outer side iron, to keep the ankle dorsi-flexed and the foot everted. Apparatus is not designed to overcome deformity, but acts merely as do splints in the case of fractured bones, to maintain proper position after this has been secured by other means. These braces (as all Fig. 616. — Bilatera' equino-varus (congenital). Age seven years. Re- lapsed case, from neglect of treatment. Orthopaedic Hospital. Fig. 617. — Relapsed varus. Rear view of patient in Fig. 616. (See Fig. 622.) Orthopaedic Hospital. other orthopedic apparatus) will require constant oversight and adjustment, and this must not be shirked by the surgeon who under- takes the treatment of such cases. Braces present the great advan- tage over gypsum that thev permit muscular action, and so favor Fig. 618. — Club-foot wedge in use, overcoming varus. Orthopaedic Hospital. development of the limb. Usually they should extend to mid-thigh, for greater security; and where internal rotation of the foot is per- sistent, it may be necessary to add a pelvic band, so as to have some fixed point by which to evert the entire lower extremity. 36 562 ORTHOPEDIC SURGERY In cases in which proper treatment has been neglected, and in relapsed cases (Figs. 616 and 617), mere manipulation usually is Fig. 619. — G. G. Davis's tarsoclast in use. Orthopaedic Hospital. Fig. 620. — Use of G. G. Davis's lever to stretch tendo Achillis. Orthopaedic Hospital. powerless to overcome the deformity. Here the patient must be anesthetized, and more forcible stretching done, as indicated in the accompanying illustrations (Figs. 618, 619, 620 and 621). The foot is CONGENITAL TALIPES 563 dressed in over-corrected position in plaster of Paris and the patient stays in bed several days after the operation, and for the first twenty- ^m IS 4'jj fr ^^^w ' ^^ ^^^^^~*~ BBBpBW^^ . *~ i ■HI Fig. 621. — G. G. Davis's varus machine in use. Orthopaedic Hospital. four hours the foot is kept elevated to prevent edema. Walking in the gypsum case is then allowed. If the stretching (redressement force) is skilfully done, evil consequences are very unusual, though rarely a superficial slough may form over the dorsum of [the foot. The plantar fascia often is tense, and usually should be divided; but tenotomy of the tendo Achillis or other tendons seldom is advisable. Tenotomy usu- ally is done by the subcutaneous method (Stromeyer, 1831): a punc- ture is made by a sharp-pointed tenotome (Fig. 623) just to one side of the tense tendon and where it is most accessible; a blunt-pointed tenotome is then inserted beneath the tendon, and while this is kept taut, it is divided from within out- Fig. 622. — Bi'ateral equino-varus after use of instruments shown in Figs. 618 to 620. Same patient as Figs. 616 and 617. Orthopaedic Hospital. Fig. 623. — Sharp and blunt-pointed tenotomes. ward by a gentle sawing motion; any oozing of blood is checked by pressure and an aseptic dressing applied with the limb as much 564 ORTHOPEDIC SURGERY over-corrected in position as is possible; and this position is maintained by a fixed dressing for four to six weeks. The tendo Achillis is divided about an inch above its insertion; the tibialis anticus below the annular ligament; the tibialis posticus between the internal malleolus and its point of insertion; and the peroneal tendons behind and above the external malleolus. Fig. 624. — Inveterate equino-varus in a woman aged twenty-eight years. No treatment since birth. Ortho- paedic Hospital. Fig, 625. — Result of astragalectomy. Same patient as Fig. 624. In cases in which bony deformity has developed, which cannot be overcome by forcible manipulation as above indicated, it may be necessary to do some formal cutting operation. In most cases in children or adults, the best method of overcoming the deformity is to Fig. 626, -Bilateral congenital talipes valgus. Age two and a half years. Orthopaedic Hospital. do cuneiform tarsectomy, or wedge-shaped resection of the tarsus CR. Davy, 1881) : in this operation a wedge of bone (regardless of the outlines of the individual bones), with its base on the dorsum and its apex on the sole, is removed from across the tarsus; the portion excised being sufficiently large to allow over-correction of the deform- ity. It is often well to combine this with transplantation of the tibialis PARALYTIC DEFORMITIES 565 anticus to the outer side of the tarsus. Astragalectomy (Lund, of London, 1872), which is preferred by many surgeons, is more difficult of execution, and leaves a less shapely foot than does cuneiform tarsectomy but may be indicated by the nature of the deformity (Figs. 624 and 625). Other forms of congenital talipes (Fig. 626), as well as club-hand, contracted knee (Fig. 627), etc., are so rare that it seems unnecessary to discuss them here, as the prin- ciples of treatment are the same as in equino-varus. PARALYTIC DEFORMITIES. Acute Anterior Poliomyelitis. — Paralytic Talipes. — Most of the para- lytic deformities which require orthopedic treatment are the result of "infantile paralysis," though cases occasionally are encountered the effect of cerebrospinal menin- Fig. 627. — Congenital club-feet and contracture of knee. Age three years. Episcopal Hospital. gitis, diphtheria, or other rarer infections. The vast majority of cases of infantile palsy involve one or both lower extremities, espe- cially the feet. The extent of the paralysis is very variable; it may affect only one muscle group, or a single muscle; or it may affect both lower extremities in their entirety, forcing the child to walk on his hands, using the feet merely as props (Fig. 628), or occasionally inducing a quadrupedal gait; or the trunk also may be paralyzed, rendering the child helpless. In- fantile palsy affecting one side of the back, is an occasional cause of scoliosis (Fig. 645). In some cases there is only slight tendency to contractures of the unparalyzed muscles,the paralyzed part remain- ing entirely flaccid; while in others, contractures are an early and prom- inent symptom. In nearly every case deformity eventually develops. When it has been ascertained that paralysis exists, it is important to institute mechanical treatment at once, to prevent, so far as Fig. 628. — Infantile palsy of both lower extremities. Position assumed in walk- ing on hands. Age four years. Ortho- paedic Hospital. 566 ORTHOPEDIC SURGERY possible, the development of deformity, and to encourage return of function. Even the weight of the bed-clothes on the toes may be injurious, predisposing to equinus deformity. The foot should be supported at a right angle with the leg, and the knee and hip should be kept fully extended, by suitable splints or apparatus. Not until acute symptoms have been absent for some weeks, should massage and electric treatment be employed; use of the limb should now be encouraged, provided that proper posture is maintained. Usually after a month or two the extent of the paralysis will be fairly well defined, but under conserva- tive measures, further improvement may occur for two or three years. If proper treatment (orthopedic support, massage, electricity) has been insti- tuted promptly, and faithfully pur- sued, usually there will be no further improvement after the lapse of this time. But in all cases where such treatment has not been employed, the surgeon should delay resort to opera- tive methods until trial has been made of mechanical support, massage, etc., for at least one year. If deformity develops from neglect of, or in spite of, proper support by apparatus, various forms of paralytic talipes may be present. These are dis- tinguished from the deformities of congenital talipes by the history of their being acquired, usually during the second or third year of life, as the result of an acute, even if slight, febrile attack, after which the child began to limp; by their flaccid character, some muscles being notice- ably paralyzed, while others by overaction cause persistent deviation of the foot; by reactions of degeneration in the paralyzed muscles when their electrical con- tractility is investigated (these never exist in con- genital talipes) ; and by marked atrophy of the paralyzed limb. The most frequent de- formity is equino-varus, due to paralysis of the peroneal muscles, often associated With loss of power in the , f lG - 630.— Paralytic equinus, age twenty years, , * ,. ., deformity growing steadily worse since childhood, extensor longUS dlgltoriim Orthopedic Hospital. Fig. 629. — Paralytic foot-drop, in a girl of fourteen years. Orthopaedic Hospital. PARALYTIC DEFORMITIES 567 and extensor longus hallucis; the tibialis anticus and posticus act as strong inverters of the foot, and the unopposed flexors and calf muscles maintain foot-drop (Fig. 629), producing a potential Fig. 631. — Paralytic varus before operation. Age fifteen years; dura- tion eight years. (See Fig. 632.) Orthopaedic Hospital. Fig. 632.— Patient shown in Fig. 631, after transplantation of tibialis anticus to base of fifth metatarsal bone. Orthopaedic Hos- pital. Fig. 633. — Paralytic calcaneus, showing attitude assumed in walking. Aged twelve years; duration eight years. Left foot assumed similar attitude as soon as any attempt at motion was made, but patient could not balance himself long enough with both feet in action for a photograph to be taken. (See also Fig. 634.) Orthopaedic Hospital. ;,c„s ORTHOPEDIC SURGERY equinus which it' long uncorrected may become a fixed deformity (Fig. 0:>0). In other cases there is no marked contracture of the active muscles, but owing to the paralysis, the foot easily turns into a position of extreme deformity (Fig. 031), rendering locomotion almost impossible without apparatus. Paralytic Calcaneus (Fig. 033) is due to paralysis of the calf muscles; the unopposed extensors cause the toes to fly into the air at each step; sometimes there is dislocation of the peroneal tendons anterior to the external malleolus. Calcaneus deformity usually is combined with marked cavus (Fig. 034), though this may exist alone, from contracture of the plantar fascia and extensors of the toes, when the short foot muscles (interossei and lumbricals) have been paralyzed (Fig. 030). Para- lytic Valgus (Fig. 635) is much more common than a similar congenital de- formity; usually the two tibial muscles are paralyzed, and sometimes the flexors of the toes as well. Usually the peronei are contracted. In many cases correction of deformity, by forcible manipulation, tendon length- ening, etc., may enable weak but not completely powerless muscles to recover nearly normal strength. When it has been ascertained that no further recovery of power is to be ex- pected the aim of the surgeon should be to devise some means by which apparatus may be discarded. Whenever there are a sufficient number of healthy muscles for the purpose, it is possible, by changing the points of insertion of one or more, so to distrib- ute the muscular power which remains as to secure to the patient a well balanced foot. This operation is known as Tendon Transplantation. It seldom is advisable to employ it before the age of six years, since before this age it is very difficult to be certain which muscles are functionally active, because this is a point ascertained much more accurately by clinical observation than by investigation of the elec- trical reactions. Before tendon transplantation is attempted, it is important to overcome all deformity, and this may require repeated manipulation under an anesthetic, redressement force (as in congenital talipes, p. 502), or even tenotomies; only when the foot can be held in the over-corrected position by the pressure of one finger, will it be safe to resort to operation. The best method of tendon trans- plantation is the periosteal insertion of Lange (1898); this may be succinctly described by a concrete example, namely, the transplan- tation of the tibialis anticus to the base of the fifth metatarsal bone, for the relief of varus due to paralysis of the peroneal muscles. Fig. G34. — Paralytic calcaneus, showing secondary cavus, when toes were forcibly flexed. Same patient as Fig. 633. PARALYTIC DEFORMITIES 569 Under Esmarch anemia the tibialis anticus is divided at its insertion, and is drawn out of its sheath through a second incision made over its course above the annular ligament; a subcutaneous channel is then burrowed from above the annular ligament to the tuberosity of the fifth metatarsal bone, and through a third incision at the latter point the tendon of the tibialis anticus is drawn down, and under tension is sutured to the periosteum by several mattress sutures of strong chromic catgut. The foot is immobilized in over-corrected position (valgus), in gypsum, for eight weeks; function is then grad- ually resumed. The tibialis anticus being now inserted on the outer side of the foot will act as an everter, largely replacing the paralyzed peronei, and rendering the further use of apparatus unnecessary. Fig. 635. — Paralytic valgus, age seven years; treated by tendon transplantation. Orthopaedic Hospital. Fig. 636. — Paralytic cavus, age eleven years, showing over-action of the extensor longus hallucis. Ortho- paedic Hospital. In similar manner, for other deformities, various other tendons may be transplanted, as will occur to the mind of any ingenious surgeon. For paralytic valgus it is best to transplant the extensor longus hallucis to the insertion of the tibialis anticus; when the exten- sor longus hallucis is paralyzed also, one of the peronei may be trans- ferred to the insertion of the tibialis anticus, or if the extensor longus digitorum is active, the distal end of the tibialis anticus (divided above the annular ligament) may be sutured to this healthy ten- don. For paralytic cavus, the extensor longus hallucis, which is usually the deforming factor (Fig. 636), may be attached to the head of the first metatarsal. For paralytic calcaneus the peronei and tibialis posticus may be transplanted into the insertion of the tendo Achillis (Figs. 633 and 634), though in most cases transverse horizontal section of the tarsus (see p. 571) is preferable. For paralysis of the quadriceps femoris one or more of the hamstrings may be trans- 570 ORTHOPEDIC SURGERY planted into the patella; and for paralysis of the internal rotators of the thigh, the tensor fasciae femoris may be transplanted into the great trochanter (G. G. Davis, 1911). In many cases it is possible by shortening paralyzed tendo?is to enable them to act as ligaments in maintaining better position, or when slight power remains, to enable them to use it to better advan- tage. Or the proximal end of the tendon of an entirely paralyzed muscle may be attached to bone, thus converting the tendon into a ligament (Sangiorgi, 1901, Gallie, 1913). Fig. 637. — Paralytic flail-foot, age eighteen years; duration fourteen years. Orthopaedic Hospital. Nerve Anastomosis has been employed in some cases of paralytic deformities of the feet, but not with much success. It should be reserved for those cases in which the entire distribution of one nerve is paralyzed, but in which the entire distribution of a neighboring nerve is intact. Arthrodesis. — When so many muscles are paralyzed that none are available for transplantation, it is possible to convert a "dangle-foot" with flail-joints (Fig. 637) into a firm and useful support by pro- ducing an artificial ankylosis. This operation, known as arthrodesis (Fig. 638), should not be undertaken before the age of eight or nine years, since the bones of younger patients are still too cartilaginous for firm union to follow a joint resection. For "footdrop," arthrodesis of the ankle-joint is done; through a small transverse incision over the PARALYTIC DEFORMITIES 571 front of the joint, displacing the tendons, the articulating surfaces of the astragalus, tibia, and fibula are removed. For lateral mobility, subastragalar arthrodesis is done; in most cases a single external incision, above the peroneal tendons, is sufficient to remove the articu- lating surfaces of astragalus and calcaneum, as well as those of astrag- alus and scaphoid (Fig. 179). The wounds are closed without drainage, and the foot is fixed in gypsum for eight weeks, when walking may be resumed; but a light brace should be worn for a few months more. Fig. 638. — Result of arthrodesis of ankle and subastragalar joints. Orthopaedic Hospital. (See Fig. 637.) For cases of calcaneus, calcaneo-cavus, or calcaneo-valgus, no opera- tion is as satisfactory as the transverse horizontal section of the tarsus devised by G. G. Davis (1913); this combines a subastragalar arthro- desis with a shifting backward of the foot on the leg bones, the hori- zontal section passing through the subastragalar joint posteriorly and emerging on the dorsum of the tarsus beneath the extensor tendons. This displacement elongates the heel, and shifts the weight of the body forward to the apex of the hollow sole. Transplantation of the peroneal tendons into the calcaneum may be a useful addition. 572 ORTHOPEDIC SURGERY Fig. G39. — Infantile palsy of right arm. Children's Hospital. Infantile Paralysis of the Upper Extremity (Fig. 639), much rarer than paralytic affections of the lower limbs, is treated on the same general principles. Transplan- tation of muscles has been done chiefly at the shoulder where a portion of the trapezius or of the pectoralis major has been used to supplement the deltoid. Nerve anastomosis has given no better results than in the leg. Cerebral Palsies. — These re- sult from cortical or meningeal hemorrhages, or from congen- ital defects, such as poren- cephalon. Spasticity is their main characteristic, and by this factor it usually is possible to distinguish them from infantile paralysis, which is flaccid. In children they usually occur from injury at birth, and there often is mental impairment (p. 608); but they may follow cortical or meningeal lesions occurring in the exanthemata. In adults they may follow cranial injuries, apoplexy, etc. The paralysis is hemiplegic, paraplegic, diplegic, or monoplegic, according to the site of the cerebral lesion. The hemiplegic form is most frequent, the paraplegic next, while the monoplegic or diplegic types are quite rare. The flexor muscles are stronger than the extensors, and the deformity is quite characteristic: the arm is adducted, the elbow flexed, the forearm pronated, the wrist flexed and the hand clasped tight; the hip is flexed and adducted, the knee slightly flexed, and the foot in the equino-varus position, there being a tendency to walk on the toes (Fig. 640 and 641). By gradual steady pressure it usually is possible to cor- rect these contractures, but as soon as pres- sure is released they recur, the patient having very little if any voluntary control of the affected limbs. In the course of time the deformity becomes permanent, unless malposition is prevented by orthopedic means. Treatment.— The treatment consists in the use of massage and manipulation to prevent the contractures from becoming permanent. • Fig. 640. — Infantile spastic paraplegia, age three years. Attitude in attempting to walk. Orthopaedic Hospital. PARALYTIC DEFORMITIES 573 Malposition should be prevented by splints or braces. Tenotomy will improve position temporarily, but relapses are common. A longer intermission before relapse, and better prospects of permanent func- tional improvement are offered by Stoft'el's operation (1912) of multiple peripheral neurectomy: the nerve supply to the spastic muscles is damaged, one-fifth, one-fourth, one-third, or more, by excision of motor branches in the limbs; this secures better balance of power be- tween the spastic and the weaker antagonistic muscles (Figs. 641 and 642). Forster (1908) has practised intradural division of the sensory nerve roots (Rhizotomy) supplying the affected extremity, but the operation is dangerous and the results very uncertain. Xo treatment is of much value in cases of athetosis. Fig. 641. — Spastic hemiplegia. See Fig. 642. Episcopal Hospital. Fig. 642. — Same patient after operation by multiple neurectomy. Episcopal Hos- pital. LATERAL CURVATURE OF THE SPINE. Lateral Curvature of the Spine, or Scoliosis, is an affection of child- hood. It is convenient to distinguish between functional or postural lateral curvature and true organic or structural scoliosis. The former is due simply to malposition, and there is a general (single) curvature 574 ORTHOPEDIC SURGERY of the spinal column, usually convex to the left. Round shoulders often coexist. If neglected, these children may develop true structural scoliosis, as the bones still are soft and their shape is readily altered by long continued unequal pressure. The diagnosis of postural lateral curvature is easily made by dropping a plumb-line from the vertebra prominens, and noting the deviation of the spinous processes. The child may be brought for examination on account of stooping, round shoulders, or general relaxation of the joints. Proper gymnas- tics, attention to hygiene, manner of supporting the clothing, etc., usually effect a cure in from one to two years. The clothing should not be supported by the points of the shoulders, but as far as possible from the pelvis, or from the slope of the neck; any ordinary gym- nastic and calisthenic exercises are efficient; over-study and tire should be avoided, and an active out-of-door life encouraged. In organic or structural scoliosis there is, in addition to lateral devia- tion of the spinal column (Fig. 643), also rotation of the bodies of the vertebra?, the transverse processes of the vertebrae rotating backward on the convexity of the curve, and forward on its concavity. This rotation is best appreciated by having the patient bend the body horizontally from the hips (Fig. 644). Scoliosis may be due to a number of causes: (1) It may develop, as already mentioned, as a sequel of postural lateral curvature; this probably is the most frequent cause. Sometimes it is convenient to recognize as a predisposing cause, in cases beginning this way, a rachitic or other dystrophic softening of the bones, to account for the rapidity with which structural changes occur in the spinal column. (2) Congenital anomalies of the spine (studied at length by Mouchet and Rouget in 1910); there may be a supernumerary wedge-shaped vertebra; or a portion of one or more vertebras, with or without their attached ribs, may be absent. The deformity in these cases is recog- nized in early infancy, and the bony lesion usually can be detected in a skiagraph. (3) Infantile jxiralysis or other muscular lesion, allowing unopposed contraction of the muscles on the unaffected side (Fig. 645), is a more frequent cause than formerly recognized. (4) Empyema, causing collapse of the thorax on the affected side, is a fre- quent cause (Fig. 847). (5) Torticollis, and other deformities of neigh- boring parts, such as ankylosis of the hip in bad position, causing tilting of the pelvis, should also be remembered as occasional causes of this deformity. In most cases, as already mentioned, the deformity arises from faulty attitudes in sitting, standing, sleeping, etc. It develops most frequently between six and ten years of age, and occurs in girls in over 75 per cent, of cases. The child carries heavy books or a heavy baby habitually on one arm; sits at school or at home at a desk or table disproportionately high, requiring habitual undue elevation of the right shoulder; one leg may be a trifle shorter than the other, or the patient may sit on a cushion higher on one side than on the other, inducing obliquity of the pelvis — in short, from causes, which often LATERAL CURVATURE OF THE SPINE 575 cannot be defined , the patient is brought to the surgeon (unfortunately seldom until the deformity has existed for some years) complaining of asymmetry, with projection of one shoulder and one hip, usually the right. Such patients should be examined with the back bare from neck to pelvis, and without shoes on their feet. Even if no asym- metry is evident at a glance, it is extremely likely that after standing a few minutes the slouching attitude will come on, and reveal the deformity. In the immense majority of cases there is a curve convex Fig. 643. — Scoliosis, in a girl of sixteen years; left shoulder droops, right thorax (convex curve) is prominent. (See Fig. 644.) Orthopaedic Hospital. Fig. 644.— Patient in Fig. 643, stoop- ing to show posterior rotation at the side of the convexity of the curve. Ortho- p'cedic Hospital. to the right in the thoracic region, which compensates a curve convex to the left in the lumbar region, the latter being regarded as the primary curve. (If the case is one of postural scoliosis only, there seldom is more than one curve, which usually is convex to the left; placing a lift under the left foot usually causes the curve to disappear.) The line of the waist is more cut in on the left side, a distinct fold often existing (Fig. 643) ; and when the patient stoops forward at the hips the right thorax becomes prominent, the left loin projects, and the right loin falls away (Fig. 644). In extreme cases the anterior surface of the thorax is deformed also, the left lower ribs becoming very prominent, and the apex of the right lung being markedly com- 57(> ORTHOPEDIC SURGERY pressed ; sometimes the left. Valvular the liver is proptosed, and the heart displaeed to incompetency is frequent in cases of great de- formity. Besides the deformity, the patient complains of tiring easily, of weakness, or of marked disability. Diagnosis. — In cases of very slight degree it is difficult sometimes to be certain that the affection is scoliosis and not incipient tuberculosis of the spine. In the latter condition there may be lateral deviation of the spine without any kyphosis; but the lateral deviation is more abrupt than the gentle curve of scoliosis (Fig. 715); there is painful rigidity of the spine as detected by flexion, hyperextension, and lateral bending; there usually is tenderness localized to the seat of disease; there may be constant, slight, evening rise of temperature; and the tuberculin test probably will be posi- tive. A skiagraph may reveal a tuberculous lesion; but in cases of scoliosis, except those easily recog- nized as such clinically, will show no bony change. If the slightest doubt as to the nature of the trouble persists, treatment for Pott's disease (p. 659) should be instituted until its absence is proved. Treatment. — The mildest grades of rotatory scoliosis may be overcome by correction of habitual malposi- tion and special gymnastic exercises under the supervision of a competent orthopedic surgeon. The patient should sleep on a hard, flat bed, without a pillow, and either supine or prone; she should spend at least one hour each day lying flat on her back on a hard level couch or on the floor; and should give up habits of writing, reading, sewing, etc., which require a cramped posture. Where pain or disability is marked, recumbent treatment, with head and foot extension, as for Pott's disease should be instituted. The exercises prescribed for scoliosis cannot be detailed here; they form almost a sub-specialty in orthopedic practice, and are of a highly technical nature. They should be taken daily (at least three times weekly) for from one to three hours for a period of nine months up to one or two years. It is folly to expect per- manent improvement 1 sooner. In most cases, certainly in those in which noticeable rotation is present, the patient should be provided Fig. <>4.">. — Incipient scoliosis, fol- lowing infantile palsy one year ago. Age four years. Left side paralyzed. Orthopaedic Hospital. LATERAL CURVATURE OF THE SPINE 577 with some form of spinal support; for all severe grades of deformity this is more important than gymnastics, as it is futile to expect to correct bony deformity by muscular exercise. As H. Bigg (1905), Lovett and Sever (1911), and other recent writers, point out, the deformity should be treated on the same principles that guide us in treatment of other bony deformities, such as bow-legs and club feet. The most efficient corrective apparatus is a gypsum jacket, applied according to the method of Abbott (1912) with the patient lying supine on a canvas sling, attached at each end to a special frame (Fig. 646). This sling is cut on the bias at one end, so that when one side of the sling is pulled taut the other is relaxed. The taut side of the sling Fig. 646. — The Abbot frame in use. Episcopal Hospital. is placed under the prominent side of the thorax, and the patient's head and thighs are thoroughly flexed. Then bands are attached to the sides of the frame to assist over-correction of the deformity, and the plaster of Paris is applied and moulded carefully to the body, which has been padded with saddler's felt until approximately sym- metrical in form. When the plaster has set, large windows are cut over the compressed portions of the thorax (usually over the left scapula and lower ribs posteriorly, and the right mammary region anteriorly), and the pads over these compressed portions are removed, while increasing pressure is brought to bear on the prominent portions of the thorax by inserting, at intervals of a few days, broad felt pads 37 578 ORTHOPEDIC SURGERY between the thorax and jaeket (Fig. 647). The same jacket may be worn for a period of from two to three months. A new jacket then is applied for a month or six weeks longer; and this treatment is con- tinued until over-correction of the deformity has been obtained. This form of treatment is the most efficient yet devised, but is not applicable to cases of fixed bony deformity in adults. When overcorrection has been secured it should be maintained for a number of weeks. In less severe cases removable jackets or spinal braces may be used, con- structed to act on the same prin- ciples as above described; they are useful also after the fixed dressings have been discarded. STATIC DISORDERS OF THE LUM- BAR SPINE AND PELVIS. These were studied in 1901 by Goldthwait, and are frequent causes of neurasthenia, backache, and gen- eral disability, especially in women. After childbirth, or during conva- lescence from some wasting disease, or simply from malnutrition, over- work, etc., the tone of the pelvic and lumbar muscles is lowered, and undue strain is thrown on the ligaments. Similar symptoms may occur after prolonged anesthesia, during which the patient has lain on her back without support to the lumbar spine; some cases of "lumbago" are due to similar conditions; and most patients with w T hat has long been called "neurotic spine" have some static disturbance with ligamentous strain as the basis of their trouble. The most frequent condition is a loss of the normal lumbar lordosis; occasionally, however, somewhat similar symptoms follow increase of the lordosis, caused by wearing very high-heeled shoes, by anky- losis of the hip in a flexed position, etc. Flatness of the back often is associated with weak or pronated feet (p. 591), and is relieved by treatment of the foot condition. The normal lumbar lordosis disappears at first merely when the patient is supine; later it is absent also in the erect posture. The sacro-iliac joints and symphysis pubis may become relaxed, and pain may be referred down the sciatic nerves; while at each step the patient Fig. 647. — Plaster of Paris jacket applied according to Abbott's method for the treatment of scoliosis (curve convex to right in thoracic region). Large window cut over the hollow re- gion; the left shoulder held high and forward; the right shoulder forced down and backward ; the pelvis rotated forward toward the right. Orthopaedic Hospital. DEFORMITIES OF THE HEAD AND NECK 579 may feel discomfort and may obtain relief only by lying prone, or supine with the lumbar spine supported by a pillow. One sacro-iliac joint frequently is more relaxed than the other. By placing one hand over the joint while the other palpates the symphysis pubis, it usually is possible to detect abnormal mobility as the patient stands first on one foot then on the other. Or with the patient lying prone, the sacro-iliac joints may be made to move by hyperextending the thighs. Very severe cases, usually unilateral, resemble sciatica (p. 325), and frequently have an acute onset, following sudden or pro- longed strain on the lumbar or pelvic joints, perhaps followed by exposure to weather. Treatment. — The treatment in mild cases consists in massage of the lumbar muscles, with gymnastic exercises. In severe cases it may be necessary to put the patient to bed with weight extension to the lower extremities; in some imme- diate relief is secured by forcibly hyperextending the hip and sacro-iliac joints under general anesthesia, and applying a gypsum jacket to main- tain lordosis. Some form of spinal and pelvic support must be provided for weeks or months during conva- lescence. For sacro-iliac relaxation the application of a firm pelvic belt between trochanters and iliac crests often is all that is required (Fig. 648). Where the lumbar spine also is in- volved, it will be necessary to support this also, maintaining it in hyperex- tension. Spondylolisthesis is the term given to subluxation of the last lumbar vertebra forward on the sacrum; occasionally the fourth lumbar verte- bra is displaced forward on the fifth. The affection is commonest in young adult females, but occurs also in growing girls and in youths and young men. There is a depres- sion above the sacrum, over the last lumbar vertebra, and sometimes a prominence can be felt above the sacral eminence by a finger in the rectum or vagina. The symptoms and treatment are much the same as for static strains of the lumbar spine, of which, indeed, spondylolisthesis may be considered the terminal stage. Fig. 648.- ation. -Belt for sacro-iliac relax- Orthopsedic Hospital. DEFORMITIES OF THE HEAD AND NECK Torticollis, Caput Obstipum, or Wry-neck, sometimes is due to injury at birth, rupturing some of the fibers of the sternomastoid or 580 ORTHOPEDIC SURGERY Fig. 649. -Torticollis from cervical adenitis. Children's Hospital. other cervical muscle. It is uncertain whether the cases of hematoma of the sterno-masioid muscle sometimes seen in infants are a result of the rupture of the muscle because it was congenitally short, or are themselves the cause of wry-neck by causing subsequent cicatricial contracture of the muscle. Often the deformity is not noticed until the child is several months old, and then it is difficult to be certain whether the affection is congenital or acquired. As a rule, the congenital affection is painless, while the acquired form has a more or less acute onset. Torticollis may be symptomatic of certain other diseases, as astigmatism, or cervical Pott's disease (p. 649), fracture-dislo- cation of the cervical spine, cer- vical rib, cervical adenitis (Fig. 049), "rheumatic stiff neck," toothache, ear-ache, tonsillitis, or other affection which may irritate the spinal accessory or upper cervical nerves, causing spasticity of the muscles concerned in the production of the deform- ity. These are especially the sternomastoid, the trapezius, and the scalenus anticus, especially the sternomastoid. Symptoms. — The head is rotated to the opposite side, the chin point- ing to the unaffected shoulder, while the ear approaches the shoulder of the affected side (Fig. 050). If the deformity continues long uncor- rected, it may lead to facial asymmetry, scoliosis, or other secondary deformities which cannot be remedied. Treatment. — The surgeon should first ascertain that the deformity is not of the symptomatic variety; if it is, removal or proper treat- ment of the cause of irritation usually will cause the wry-neck to disappear. If no cause other than a shortening of the muscles can be found, attempts may be made by massage, gymnastics, or apparatus to overcome the deformity. If these fail, as in most cases they do, the surgeon may resort to division of the contracted structures. In cases of short duration this usually is quite efficient, but in many patients the most that can be expected is a lessening of deformity. It is better to divide all resisting structures by open section than to attempt a subcutaneous operation; very dense cicatricial bands, which may exist in the cervical fascia, should be excised, and the muscles divided transversely and left unsutured. The head is then dressed in an over-corrected position, maintained by a gypsum case (Fig. 651). Spasmodic Torticollis, a form of Tic Convnlsif. is an affection of obscure origin, consisting essentially in sudden tonic involuntary, DEFORMITIES OF THE HEAD AND NECK 581 and usually painful contraction of the neck muscles, momentarily turning the head into a wry-neck position (Fig. 653.) The extent of the spasm, and the number of muscles involved, varies greatly. Fig. 650. — Congenital torticollis in a boy aged ten years. Episcopal Hospital. Fig. 651. — Patient shown in Fig. 650, in plaster case after open tenotomy of the right sternomastoid. See Fig. 652. The disease usually begins insidiously, in young adult life, but pro- gresses without intermission until almost the entire body may be in- volved; any effort to move or speak, and especially any excitement, Fig. 652. — Same patient as Figs. 650 and 651, nine months after operation. Fig. 653. — Spasmodic torticollis. Orthopaedic Hospital. brings on a spasm, and the patient may curl up in a knot, as it were, on the side affected, being absolutely helpless and unable to straighten himself out. Many surgical measures have been tried, but none 582 ORTHOPEDIC SURGERY have had permanent good effect; but as the same can be said for medical measures, the temporary relief which follows operation should not be despised. J )ivision of the nerves supplying the cervical muscles most affected is the operation usually done, especially division of the spinal accessory or upper cervical nerves (Keen, 1891). Cervical Ribs. — On one or both sides of the neck a rudimentary rib may be formed, usually attached to the seventh cervical vertebra, but occasionally to the sixth. The affection is said to be bilateral in 75 per cent, of cases, and occurs in females three times as often as in males. If the rib is Aery short, no symptoms may be produced, but usually it is long enough to reach to the subclavian artery, which passes over the rib, and may be compressed, causing symptoms of Fig. 654. — Cervical rib (left); age eighteen years. Numbness, tingling, etc., for four months. (Dr. W. J. Taylor's case.) Orthopaedic Hospital. numbness, tingling, etc., in the extremity affected. Pressure on the brachial plexus, cervical sympathetic or pneumogastric nerves may also occur. Usually no trouble is experienced until adult life (Fig. 654). In most cases the rib is palpable in the neck; and the abnormal position of the artery, as well as changes in the radial pulse, may simulate aneurysm. Rest for a few weeks, with elevation of the arm, usually causes subsidence of acute symptoms. When these recur, and are disabling, excision of the abnormal rib should be done. The operation may be very difficult, from the altered relations of blood- vessels, nerves, and muscles, and from the proximity of the pleura. Complete recovery is the rule, even if temporary paralysis occurs from careless handling of the nerves. ACQUIRED DEFORMITIES OF THE UPPER EXTREMITY 583 ACQUIRED DEFORMITIES OF THE UPPER EXTREMITY. Cubitus Valgus, or increase of the normal "carrying angle" of the upper extremity, sometimes follows rachitis, but most often is the result of a fracture of the lower end of the humerus. It is less frequent and less disabling than cubitus varus, which almost always is due to fracture, especially supracondylar fractures of the humerus. Either deformity may be treated by supracondylar osteotomy of the humerus. Some surgeons prefer to dress the arm in full extension after the operation: if this is done, for valgus deformity the forearm should be kept in supination, which relaxes the muscles passing from the external supracondylar ridge; while for varus the forearm is dressed in full pronation, making these muscles tense, and, there- fore, restoring the carrying angle. If the elbow is dressed in hyperflexion, as in a recent supracondylar fracture, the precautions mentioned at page 383 against varus and valgus deformities should be observed. Ischemic Contracture (Stromeyer, 1838; Volkmann, 1869) is due to muscle and nerve degenerations following ischemia caused by pressure of splints or bandages applied for a fracture of the elbow or forearm. Very rarely it has followed injury in which no splint or dressing of any kind had been used. It has been reported as affecting the lower extremity also. Bardenheuer (1911) in an elaborate study of the question, concluded that the degenerative changes were due to venous stasis, the muscle cells being poisoned by metabolic products in the blood, and that the primary cause is not an anemia of the parts. Nerve involvement in cases of ischemic contracture was empha- sized by J. J. Thomas (1909). The hand swells and becomes cyanosed, and the parts are extremely painful; but the constriction is not suffi- cient to cause gangrene. After a few days the pain ceases, and swelling may subside. The damage is done within a few hours, and cannot be repaired merely by removal of the splints; it is far better to be sure in the first place that the dressing used does not interfere with the circulation. Usually the condition develops in what appears an insidious manner only because the surgeon is not on the lookout for it; if interference with the circulation persists for several hours there is already nerve and muscle degeneration, and if the surgeon was suf- ficiently attentive he would discover it at the next dressing, and not be surprised when subsequent deformity develops. The deformity is quite characteristic, resembling that of ulnar paralysis; nor is this resemblance surprising since the ulnar nerve often is involved (Fig. 655). But even if the symptoms of neu- ritis are present, and they are not in all cases, there are also symptoms of fibrous degeneration of the muscles on the flexor side of the forearm. The joints are not affected, motion being limited merely by muscular contracture: thus, when the wrist is fully flexed, extension of the fingers becomes possible (Fig. 656) ; but efforts to straighten the wrist at once cause flexion of the fingers (Fig. 655). ;,.s i ORTHOPEDIC SURGERY Frequently there are pressure sores in the skin, and the resulting cicatrices aid in fixing muscles, tendons, and nerves, in one almost inextricable mass of adhesions. Treatment. — Very little can be done until the ulcers have healed, except to prevent further deformity. No remedial treatment should be undertaken until acute symptoms have subsided. Then trial may Fig. 655 Fin. 656 Figs. 655 and 656. — Volkmann's contracture seven weeks after greenstick fracture of radius and ulna with compression of median and ulnar nerves. (See Figs. 657 and 658) . be made of massage and passive motion; but usually very slight if any improvement is secured. R. Jones (1908) applies a malleable metal splint to each ringer up to the carpal joints, first with the wrist in full flexion, a position which usually permits nearly full extension of the fingers (Fig. 656) ; the wrist flexion is gradually diminished and the finger extension progressively increased by changing the angle of the Fig. 657 Fig. 658 Figs. 657 and 658. — Eight weeks after operation (lengthening of all superficial and deep flexors, and neurolysis of median and ulnar nerves). Patient was able to play the piano just as well as before injury. Episcopal Hospital. finger splints; and in the course of several months the contracted tissues may be sufficiently relaxed to permit fair function. In most cases, however, especially in those complicated by nerve changes, operation is required. This consists in a free dissection of the muscles, tendons, and nerves; in muscle and tendon lengthening (Anderson, 1889; Littlewood and Page, 1898), and in preventing, so far as possible, formation of new adhesions, by interposing flaps of fat (free trans- ACQUIRED DEFORMITIES OF THE UPPER EXTREMITY 585 plants if necessary, p. 246) between the various structures (Figs. 657 and 658). Binet (1910) studied 141 cases of Volkmann's contracture, and prefers to treat them by resection of the radius and ulna, shortening the forearm until the tendons become relaxed sufficiently to straighten the fingers (Colzi, 1892; Henle, 1896; Froelich, 1909); but while good results have followed this method, it is better in every case to make sure that the nerves are freed from adhesions. Spontaneous Subluxation of the Wrist or Manus Valga (Made- lung's Disease, 1878). — The symptoms of this affection usually are manifested about the age of puberty; it affects particularly females; and involves both wrists in about 50 per cent, of cases. Especially characteristic in radiograms is the widening of the interosseous space, due to incurvation of the lower end of the radius, the normal flexor con- cavity of which becomes much exaggerated. The hand thus is carried forward with the articular surface of the radius, while the ulna, which is not displaced forward, appears to be unduly prominent (Fig. 659). Siegrist (1908) collected 62 cases, only 10 of which were in males. Fig. 659. — Madelung's disease; male, aged twenty-four years. Began about eight years of age. Episcopal Hospital. The affection has been attributed by some to adolescent rachitis; others are satisfied to describe it as an obscure form of osteitis affecting the radius. In the last few years there has been a tendency to regard it as a congenital deformity, to which attention is first directed at an age when local over-exertion and constitutional malnutrition exert their influence. In addition to the deformity there often is discom- fort from pain or ache, and some disability from loss of extension and circumduction at the wrist. Usually these are relieved by splinting, or orthopedic apparatus, with constitutional treatment. In severe cases osteotomy of the radius may be done to overcome deformity. Contracture of the Palmar Fascia (Dupuytren's Contracture, 1832). — This affection occurs in adults past middle life, particularly men, and in some cases seems to be caused by slight recurring trauma from the handles of tools, canes, etc. In about half the cases both hands are affected, usually the right before the left. The fascia is the seat of chronic inflammatory changes, 1 with secondary contracture; it 1 These are classed by the Lyons surgeons as a form of inflammatory tubercu- losis. 580 ORTHOPEDIC SURGERY becomes densely adherent to the skin; and the resulting deformity may totally disable the patient. The thumb and index finger are the last to succumb. Temporary relief may be secured by tenotomy of the tense fascial bands, introducing the tenotome between the skin and fascia and cut- ting downward (Adams, 1879); the fingers should be dressed on a splint in full extension for two weeks, and this splint should be worn at night for two weeks longer. But recurrence of the deformity is usual. Excision of the contracted bands was introduced by Kocher (1887), and Keen (1906) reflected a skin flap, including the adherent fascia, which was then dissected off the skin before this was replaced. Gill (1919) reports success from free fat transplants, following excision of the fascia through the distal palmar crease. The fascia is so densely adherent that some sloughing is liable to occur. Lexer and others have excised skin and fascia in one piece, and filled the gap by a flap of skin transplanted from elsewhere. Fig. 660. -Dupuytren's contracture of the palmar fascia; early stage, sixty-six years. Episcopal Hospital. Age Trigger Finger. — Trigger finger is a condition in which there is some obstacle to voluntary flexion or extension of the finger, which flies "shut" or "open" when passively moved past the position where it catches. The usual obstacle is a fusiform thickening of one of the flexor tendons, and the hitch occurs where the deep tendon perforates the superficial. If rest on a splint for some weeks, followed by massage, proves ineffectual in relieving the condition, the tendon sheath may be opened and the thickening of the tendon excised. Cotton (1911) referred to 160 cases, in about 40 of which operation was done. ACQUIRED DEFORMITIES OF THE LOWER EXTREMITY. Coxa Vara. — Normally the neck of the femur forms an angle of about 135 degrees with the shaft; when this angle is notably decreased (115 degrees or less) coxa vara is said to exist. The deformity con- ACQUIRED DEFORMITIES OF THE LOWER EXTREMITY 587 sists in elevation of the great trochanter and a relative depression of the femoral head, which, however, retains its position within the acetabulum. Coxa vara may result from trauma, especially epiphyseal separation of the head or fracture of the cervix in children; from rachitic softening of the bones, when the deformity usually is bilateral (Fig. 661); or from not very well defined causes, chiefly in adolescents. (See Rottenstein and Houzel, 1910; Perrin, 1912.) Fig. 661. — Skiagraph of bilateral coxa vara (rachitic). Note rachitic pelvis- acetabula pressed together. Orthopaedic Hospital. Symptoms. — The symptoms are those of the underlying or preceding condition; slight limp, limitation of abduction, because the trochanter strikes the pelvis; marked prominence of the trochanter when the thigh is flexed (Fig. 662); increased range of adduction, especially when the thigh is flexed; elevation of the trochanter above Nelaton's line; and, in cases due to trauma, usually external rotation of the lower extremity. There is moderate shortening, but seldom much pain, relief being sought for the limp and deformity. Treatment. — In many cases no treatment is required; in some, the addition of a lift to the heel brings relief by overcoming shortening. In cases with great deformity a cuneiform osteotomy of the femur may be done, as advised by Whitman (1901), removing a wedge with its apex at the lesser trochanter; or simple linear osteotomy may suffice. The thigh is dressed in extreme abduction, and when consolidation is complete, adduction will restore approximately the normal relations of neck and shaft (Figs. 663 and 664). In recent cases of impacted fracture of the head or neck in children or adolescents, the deformity may be overcome by forcible abduction under an anesthetic. f,ss ORTHOPEDIC SURGERY Legg's or Perthes's Disease. — A dystrophic condition of the hip- joint exists, known as Legg's or Perthes's Disease (osteochondritis deformans juvenilis); it was studied by Calve, by Legg and by Perthes in L910. By some it is considered traumatic in origin. It arises in childhood, the patient limping but making little complaint of pain. X-rays show irregularity in the head of the femur and in the neck near the cartilage. In time the head becomes flattened. Tuberculosis must be excluded. It may be syphilitic. Some disability may persist in adult life (Fig. 665). Treatment comprises rest during the active stage, with support from a gypsum case. Prognosis is good. Fig. 663. — Whitman's wedge-shaped oste- otomy of the femur for coxa vara. Fig. 662. — Coxa vara from fracture of cervix femoris as infant. Note prominence of great trochanter when thigh is flexed. Episcopal Hospital. Fig. 664.— Whitman's operation for coxa vara. Consolidation has occurred in the abducted position. Coxa Valga (Fig. 666) is a much rarer condition, in which the neck of the femur makes with the shaft an angle of more than 135 degrees. The trochanter is less prominent than normally, abduction is increased and adduction diminished. There usually is outward rotation of the lower extremity. The deformity may be congenital and usually is observed in limbs which never have borne any weight. Efforts may be made to increase the adduction by manipulation under an anesthetic. The best study of the subject is by Worms and Ham ant (1915). Snapping Hip (die schnellende Hiifte, la Hanche a Ressort). This affection was carefully studied by L. Heully (1911), wh collected ACQUIRED DEFORMITIES OF THE LOWER EXTREMITY 589 57 cases. He proposed the term "ressaut fascio-glvteal," as explain- ing what he believed to be the pathology of the condition which has been recognized since 1859, though dispute as to its nature has always existed. Perrin, who reported the first case, believed it to be a form of voluntary luxation of the hip; but the study of Heully confirms the opinion of Morel-Lavallee, Chassaignac, and others, that it is due to sudden slipping of the fascia lata (altered by injury or congenitally deformed) over the surface of the great trochanter. The phenomenon occurs especially during flexion and internal rota- Fig. 665. — Flat-headed femur in a lad aged eighteen years, following multiple arthritis at age of five years. Episcopal Hospital. tion of the thigh, but in some cases slight movements of the pelvis on the lower extremity are sufficient to produce it. In traumatic cases the lesion is separation of the upper part of the tendon of the gluteus maximus from its insertion in the linea aspera, and the snap occurs involuntarily and is painful; while in congenital cases it is not painful and usually is under voluntary control, possibly being due to abnormally low insertion of the gluteus tendon in the linea aspera (Heully). The defect may be repaired by suturing the tendon to the periosteum of the great trochanter and aponeurosis of the vastus externus. 590 ORTHOPEDIC SURGERY Anterior Metatarsalgia. — T. G. Morton in 1876 described a condition which was believed by him to be due to pinching of a nerve between the heads of the fourth and fifth metatarsal bones ("Morton's toe"). A sudden unendurable cramp in the anterior metatarsus occurs while the patient is walking, and he is forced to remove the shoe at once, rub and manipulate the foot, and flex and extend the toes, until the pain passes. This series of events may be repeated a number of times, but except in the most aggravated cases the attacks never Fig. 666. — Coxa valga, apparently congenital, in a girl of twelve years. Angle between neck and shaft is 165 degrees on the right; on the left (normal) it is 130 degrees. Episcopal Hospital. come on except when walking, and with a shoe on the foot. More recent observations, especially by Goldthwait and Whitman, have shown that weakness in the transverse arch of the foot is an important factor, and may cause various minor symptoms before metatarsalgia develops. Callosities may form on the sole over the heads of the metatarsals, especially the second and third; and pain may be caused by lateral compression by a shoe which would be comfortable if the normal convexity of the arch were maintained. Relief usually may be obtained by wearing broader shoes, and by applying a small longi- ACQUIRED DEFORMITIES OF THE LOWER EXTREMITY 591 tudinal pad of saddler's felt beneath the insole with its anterior rather abrupt edge just back of the heads of the metatarsals, thus relieving them from strain; or a similar appliance known as an anterior heel. The patient should actively exercise the toes in flexion, and may benefit from massage. Flat-foot (Pes Planus). — This very frequent affection is an evidence of weakness in the foot. In a foot that is merely weak, however, the antero-posterior arch may still be preserved, but a tendency to pronation exists: when weight is put on the foot the internal malleolus descends and rotates backward, causing a relative outward displacement of the anterior part of the foot; the patient walks with the toes well turned out, and to bring the two feet parallel it may be necessary to rotate both entire lower extremities inward, so that the patella? look toward each other rather than anteriorly. In truly flat Fig. 667. — Flat feet, in a boy of eight years. (See Fig. 668.) Orthopaedic Hos- pital. Fig. 668.— Flat feet foot-prints. Same patient as Fig. 667. Ortho- paedic Hospital. feet the arch is depressed, and in aggravated cases the scaphoid may rest on the floor (Fig. 667) . The affection is common at all ages, and may be very disabling. In adolescents painful flat-foot often is an early evidence of tuberculosis of the tarsus, and this diagnosis always should be carefully considered. In young children the foot remains perfectly flexible, but if the condition persists for years unrelieved, great rigidity may develop; and in adults more or less rigidity is the rule. In cases where rigidity is absent much may be done by proper exercises, even without mechanical support. The patient should rise on to the toes of both feet simultaneously, from ten to twenty times, morning and night; he should then attempt to supinate his feet the same number of times by flexing his toes and contracting the tibialis anticus and posticus muscles; and flexion exercises of the toes with the feet off the ground also should be prescribed. Walking on the toes, and on the outer side of the soles is another valuable 592 ORTHOPEDIC SURGERY exercise. In most cases, however, it is desirable to support the arch in walking: for this purpose the first thing is to secure a pair of strong shoes, made on a straight or nearly straight last, with broad toes, low heels and a wide shank; the shoes should be "high" shoes, laced. Many sole plates are sold in the stores for the purpose, but as they scarcely ever fit the foot to which they are applied, it rarely is proper to use them. If a sole plate is to be used it should be made for the individual patient, moulded on a cast of his foot taken in the resting position. An easier and as efficient method, I believe, is to have a shoemaker insert a steel strip in the shank of the shoe, and then to build up the arch, to any height desired, by properly cut felt pads placed beneath the inner sole. The height of this pad may be increased or decreased at will. In very rigid feet, benefit is derived from massage, passive movements, and baking. Sometimes "Mobilisierung" under an anesthetic, with tenotomy of the tendon of Achilles or of the pero- neal tendons, may be necessary; after such an operation the foot is dressed in plaster of Paris in the varus position for several weeks, when proper apparatus may be applied. Fig. 669. -Hammer toe in a man of twenty-six; duration since childhood. Episcopal Hospital. Hammer Toe. — Hammer toe (Digitus malleus) is a deformity of extension at the metatarso-phalangeal joint and flexion at the proximal interphalangeal joint (Fig. 669). It is commonest in the second toe, which, being the longest, suffers most from short and narrow shoes. The condition usually begins in childhood. A corn forms over the prominent phalangeal joint, and the end of the toe becomes club-shaped. If massage, application of adhesive plaster strapping, etc., do not relieve symptoms, tenotomy of the contracted tendons (extensor and flexor) may be done; the head of the metatarsal may be excised; and in relapsed cases the toe may be amputated. Hallux Valgus. — Hallux valgus is a deformity in which the great toe is abducted, often lying on the top of or under the other toes. This results'in marked prominence of the first metatarso-phalangeal joint; and over this a bursa is formed by friction of the shoe (Figs. ACQUIRED DEFORMITIES OF THE LOWER EXTREMITY 593 670 and 671). In some cases, the primary cause of the deformity is adduction of the first metatarsal bone, which may be a congenital deformity. If proper shoes which do not abduct the toes fail to secure Fig. 670. — Hallux valgus. Same pa- tient shown in Fig. 671. Episcopal Hos- pital. Fig. 671.— Hallux valgus. After operation. (Sesamoid bones restored to normal site beneath metatarsal.) Fig. 672. — Exostoses of calcaneum at attachments of plantar fascia and tendo Achillis, in a patient aged forty-four years. Duration of symptoms, over two months. Also has incipient hypertrophic arthritis of hip. Orthopaedic Hospital. 38 VII ORTHOPEDIC SURGERY relief, excision of the projecting head of the first metatarsal may be done (Fig. 671). C. II. Mayo (1908) preserves the bursa and inserts it between the bones. Painful Heel. — Painful heel may be due to a variety of causes. Trauma may cause rupture of some fibers of the tendo Achillis (Achillodynia), or produce inflammation in the retrocalcaneal bursa (Achillobursitis, p. 298), or in a bursa sometimes present between the Achilles tendon and the skin; or it may cause strain on the attach- ment of the plantar fascia, as is common in flat feet. Subsequently, exostoses may develop at these points of strain. Infections, especially gonococcic, and some forms of sub-pyemic or cryptogenous infection (Fig. G72) may cause exostoses to form on the calcaneum or other tarsal bones; or similar changes maybe an evidence of hypertrophic arthritis (p. 497). Treatment. — The treatment consists in care of the underlying condition (sprain, flat-foot, gonorrhea, etc.); local rest by proper orthopedic shoes, etc.; and, in cases which resist conservative measures, in excision of the exostoses. CHAPTER XVII. SURGERY OF THE HEAD. SURGICAL AFFECTIONS OF THE SCALP. Birth Injuries. — During parturition that portion of the scalp which protrudes into the birth canal may become edematous from pressure on surrounding parts; this condition, which is known as ccq)ut suecedanewn, may be recognized by the history of prolonged or difficult labor, by the facts that it is present at birth, that the affected area pits on pressure and presents no signs of inflammation; while it may be distinguished from cephalhematoma (see below) by the fact that the swelling is not limited to the outline of one bone. The swelling disappears in a few hours or days, and usually no treat- ment is necessary. Cephalhe- matoma is an extravasation of blood beneath the pericra- nium; it is encountered in about one labor out of two hundred. Usually the right parietal is the bone affected, and it is probable that in many cases the bone itself is directly injured, either bent or broken (p. 608). As the pericranium is attached at the sutures, the hemorrhage never passes the limits of the bone affected; generally the condition is not noticed for a day or two after birth, and at this time the blood at the periphery may have become clotted or organized, so that the scalp presents an indurated ring with a softened or fluctuating center. Occasionally thin plates of sub- periosteal bone develop, and the bone crackles on palpation. In most cases no treatment is required, but if no evidence of absorption is seen after two weeks the fluid may be evacuated by puncture; pressure should then be applied to prevent re-accumulation. Should infection of the hematoma occur, from the deep skin cocci or through the blood stream, it should be drained (Fig. 673). Contusions. — Contusions of the scalp are frequent at all ages. If the head is examined immediately after the injury, the impress of the vulnerating body may be detected; but swelling occurs very quickly, (595) Fig. 673. — Suppurating cephalhematoma in an infant of five weeks. Incised. Death in four days. Children's Hospital. 59G SURGERY OF THE HEAD and usually the only signs are those of edema, and possibly hematoma. The blood usually is extravasated in the subcutaneous tissues, super- ficial to the aponeurosis of the occipito-frontalis. It may be difficult to distinguish such cases, after the lapse of a few hours, from depressed fractures of the skull as the contusion presents a soft depressed center, surrounded by an indurated area due to inflammatory reaction and commencing organization; but firm pressure in the center detects solid bone at the same level as the surrounding cranial surfaces, and there is no irregular outline to the depressed area, such as is commonly present in fracture; moreover, the elevated margin moves with the scalp upon the bone beneath. In cases of doubt the scalp should be incised and the skull inspected. A hematoma beneath the occipito-frontalis is widely diffused, and may be of great size. In most cases hematomas of the scalp subside under pressure by bandages, application of cold, and rest in bed; if no diminution in size is evident after ten days, or if infection occurs, the hematoma should be incised, and pressure applied, when the cavity will heal by granulation. Wounds. — Wounds of the scalp may result from blunt force, as well as from cutting instruments, as the scalp is very readily split on the underlying bone. Bleeding is free, as the bloodvessels are unable to contract and retract, being enmeshed in the firm fibrous processes which bind the skin to the aponeurosis. This also renders it difficult to catch the bleeding points in hemostats, or to apply ligatures; the surgeon usually de- pends on sutures to arrest the bleeding. Temporary control of hemorrhage is easily secured by pressure on the margins of the wound ; and during an oper- ation hemostasis sometimes may be secured by applying an Esmarch band or other form of elastic tourniquet around the crown of the head. Wounds which divide the occipito-frontalis aponeurosis trans- versely gape much more than longitudinal wounds; and when the loose subaponeurotic areolar tissue is opened there is much greater danger of infection arising, especially if the wound is closed without drainage (Fig. 674). Owing to the great vascularity of the parts large portions of the scalp may be avulsed and yet retain their vitality when properly cleansed and sutured in place. When the skull has been denuded of its pericranium over large areas, some caries is very apt to occur, but if the soft parts are promptly replaced no such result need be anticipated unless infection is present. Fig. 674. — Lacerated wound of the scalp, with subaponeurotic cellulitis; the result of sealing the wound with a cotton and collodion dressing. Forty-eight hours after injury the cellular infiltrate had gravitated into the temporal region where it was arrested by the attachment of the temporal fascia to the zy- goma. Episcopal Hospital. SURGICAL AFFECTIONS OF THE SKULL 597 In all scalp wounds a large surrounding area should be shaved, all foreign bodies removed from the wound, and this should be cleaned with antiseptics. Silkworm gut sutures should be used, and if there is any risk of a hematoma forming, or if the subapon- eurotic space has been opened, the wound should be drained for a few days. Tumors. — Tumors of the scalp apart from sebaceous cysts( Fig. 2G3, p. 296) are not very frequent. In infancy dermoid cysts (Fig. 266, p. 296) sometimes are seen; these usually grow in the region of the embryonal clefts, occurring in or near the orbit, at the glabella, or over one of the fontanelles; usually they are more or less immobile, deep-seated, and are not attached to the epiderm, being thus easily distinguished from ordinary wens. If not removed in infancy, the underlying bone may be absorbed from pressure, and the growth may become adherent to the dura mater, making its removal more difficult. Papillomatous growths of the scalp should be eradicated by cauterization, or excised, as they are prone to undergo epitheliomatous change. Epithelioma often develops in scars from burns, syphilitic ulcers, etc. Sarcoma may arise in the scalp or the cranial bones, and the latter are rapidly invaded by tumors which at first were superficial (Fig. 675) . Usually no operation is of any use. Fig. 675. — Sarcoma of scalp. Death a few months after photograph was made. (Dr. W. L. Rodman's case.) Pres- byterian Hospital. SURGICAL AFFECTIONS OF THE SKULL Congenital Malformations. — Cephalocele. — Occasionally at or soon after birth a fluctuating tumor of the head is found which evidently protrudes through the skull and is composed of cranial contents. The growth occurs oftenest in the region of the posterior fontanelle (occipital cephalocele), though it may also protrude at the root of the nose (sincipital cephalocele), or very rarely at the anterior fontanelle or through one of the cranial sutures. The tumor usually is wholly or partly reducible by pressure, which if excessive may cause symptoms of cerebral compression (p. 617) ; and it becomes more prominent and tense when the child cries. It frequently is possible to detect the defect in the cranium through which the protrusion occurs. If the protrusion is composed solely of the meninges, with subarachnoid fluid, it is called a meningocele; an encephalocele contains also some brain substance; while a protrusion formed by a diver- ticulum of one of the ventricles is called a hydrencephalocele or an encephalocystocele. It formerly was believed that the most frequent form was the meningocele; but, though the protrusion resembles this macroscopically, histological study has proved that most cases 598 SURGERY OF THE HEAD really are encephalocystoceles, as the cavity of the cyst is lined by ependymal cells, which are directly continuous with those of the ventricles of the brain, while the cyst walls are formed by an attenuated layer of cerebral tissue. The diagnosis usually is not difficult, though deep lying dermoids, in contact with the dura mater, and having its motions transmitted to them, sometimes are mistaken for cephaloceles. The prognosis is poor, most infants either dying soon after birth, or presenting in later life evidences of cerebral defects (porencephalon, hydrocephalus, idiocy, etc.). Spina bifida often coexists. Treatment. — Protection should be afforded the tumor, to prevent excoriation and infection. In most cases little else can be done; but if there is only a small channel of communication with the cranial cavity, and if the child's mentality appears normal, removal of the tumor may be attempted, with closure of the skull defect by trans- plantation of bone or cartilage. Microcephalus. — Idiotic or feeble-minded children often have an ab- normally small skull. Keen (1890), Lannelongue (1891) and others adopted linear craniotomy for this condition, on the theory that premature ossification of the cranial sutures caused compression of the brain, and that division of the cranium in a line parallel with the sagittal suture would allow the brain to expand. But the modern belief is that the smallness of the skull is the result of lack of cerebral development, and is not the cause of it. Agnew said the operation was no more use than cutting a piece out of a turtle's shell, to make him grow larger; and this is the general belief of surgeons of today. There is no surgical treatment for idiocy. Hydrocephalus. — This is a symptom of some disease of the brain or its membranes, interfering with the normal circulation of the cerebrospinal fluid, and causing it to collect in abnormal amounts on the surface of the brain or within its ventricles. External Hydrocephalus, in which the fluid collects in the sub- arachnoid space, is very rare; many cases designated by this name really are. properly classed as other conditions. There may be acute edema of the subarachnoid tissues, as the result of trauma; the "acute serous meningitis" of Quincke (1893) belongs here, as also does "hydrops ex vacuo," in which fluid collects and fills the space left by shrinkage of the brain from injury or disease. Internal Hydrocephalus. — There are two principle forms of this, that due to obstruction (usually acquired) and that due to lack of absorption of the cerebrospinal fluid (usually congenital). Frazier (1916) employs the following tests to distinguish them: 1 . First examination (for delayed absorption) : (a) Lumbar puncture — withdraw 1 c.c. (b) Attach to puncture needle a 2 c.c. syringe containing 1 c.c. • neutral phenolsulphonephthalein solution, and withdraw piston until 1 c.c. spinal fluid enters. OBSTRUCTIVE HYDROCEPHALUS 599 (c) Slowly inject the 2 c.c. solution now conta'ned in syringe and withdraw needle. (d) Test urine every five minutes until phthalein is detected; normally it appears within ten minutes. (e) Estimate total amount of dye excreted in the first two- hour specimen of urine; normally this is from 30 to 60 per cent, of the amount injected. 2. Second examination (for obstruction) ; this is made after the dye is no longer found in the urine, usually twenty-four hours a ter the first examination. (a) Puncture of lateral ventricle and injection of 1 c.c. of the neutral dye. (b) Lumbar puncture, with examination of fluid for the dye every five minutes until it appears. (c) Test the urine every five minutes. {d) Estimate total amount of dye excreted in the first two- hour specimen of urine, allowing for that lost by lumbar puncture. In the obstructive type, absorption from subarachnoid space and excretion by the kidneys is practically normal; in the non-absorbed type, the appearance of the dye in the urine is delayed — it may not appear for an hour or more, and the two-hour amount is low. Obstructive Hydrocephalus. — Each lateral ventricle communicates with the third ventricle through an interventricular foramen; while in the roof of the fourth ventricle (which drains the third ventricle through the aqueduct of Sylvius) are found three apertures (one medial and two lateral) which are the channels of communication between the ventricular cavities and the subarachnoid space of the brain, this being continuous with the subarachnoid space of the chord. Occlusion of one interventricular foramen may cause unilateral hydro- cephalus (rare). Most cases of internal hydrocephalus are acquired, being acute or subacute rather than chronic (as in the congenital form), and are due to basal meningitis, especially tuberculous (p. 623), causing occlusion of these foramina; yet pressure of a brain tumor causing obstruction to the subarachnoid circulation anywhere between the posterior cranial fossa and the supratentorial subarachnoid space also results in internal hydrocephalus; and according to Frazier (1914) symptoms of intracranial pressure in brain tumor (p. 626) may be thus explained. The symptoms of the acquired form of internal hydro- cephalus are those of the causative condition complicated by cerebral compression (p. 617) ; and the treatment consists in relieving the com- pression, as removal of the cause of the obstruction usually is out of the question. Lumbar puncture (p. 158) is useless, as the occlusion of the basal foramina prevents evacuation of the ventricles by this route; and such treatment may prove quickly fatal by withdrawing the support of the cerebrospinal fluid from beneath the medulla, and allowing the superincumbent pressure to crowd this down into the foramen magnum (p. 619). But as a palliative measure subtemporal coo SURGERY OF THE HEAD decompression (p. 634) or repeated tapping of the lateral ventricles may be done (v. Bergmann, 1888) through a trephine opening at Keen's point (1S88): this is 3 cm. behind and an equal distance above the external auditory meatus; the needle is entered through the posterior part of the first temporal convolution, and is directed toward the summit of the opposite pinna; the ventricle should be reached at a depth of about 4 cm . Kocher's point (1894) is 2.5 cm. to 3 cm. from the median line and 3 cm. anterior to the precentral fissure (see Cranio-cerebralTopography, p. 612); the needle is directed downward and backward and enters the ventricle at a depth of 4 or 5 cm. Frazier prefers to tap the lateral ventricle by puncture of the corpus callosum (Anton and von Bramm, 1908) : a button of bone is removed by trephine 2 cm. from the midline, and 2 cm. anterior to the midpoint between glabella and inion; the dura is opened, and a blunt curved cannula is passed cautiously between the hemisphere and falx cerebri until the corpus callosum is reached; this is then punctured, and the fluid allowed to escape. There is little tendency for the opening to close, especially if the corpus be slightly lacerated as the cannula is withdrawn, and thus a more or less permanent new channel of communication is opened between the ventricular cavities and the subarachnoid space. Fig. 676 illustrates the relative position of the lateral ventricles to the surface of the brain. Fig. 676. — Shaded portion on surface of the brain indicating the position of the lateral ventricle within. (Campbell.) Fig. 677. — Congenital internal hydrocephalus in a baby aged three and one-half months. Children's Hospital. Non-absorbed Hydrocephalus is usually congenital. There is here no obstruction or obliteration of the foramina at the base of the brain, but the cerebrospinal fluid collects in excessive quantities, and as this condition supervenes in fetal existence, or soon after birth OXYCEPHALY 601 before the cranium is ossified, there are no symptoms of cerebral compression, but progressive enlargement of the cranium occurs and the typical hydrocephalic head is produced (Fig. 677). A fair degree of intelligence may be preserved, but in cases of extreme deform- ity the size and weight of the head may render the child helpless, and in most cases death from malnutrition occurs within the first two years of life. Spina bifida sometimes complicates the case, and paralyses of the limbs are not uncommon. Rarely is the disease arrested spontaneously. Treatment. — Intracranial (Keen, 1891), and subcutaneous drainage (N. Senn, 1903) of the ventricles was attended by an unduly high mortality and no permanent benefit was secured in those patients who survived. Cushing (1908) having due regard for the fact that in these congenital cases there rarely is any obstruction to the circula- tion of the cerebrospinal fluid at the base of the brain, inferred thence that the obstruction must be where the cerebrospinal fluid enters the blood vascular system (i. e., in the region of the longitudinal sinus) ; on this account he proposed, after ascertaining that the ven- tricles could be drained by puncture of the lumbar spine, to divert the fluid thence into the retro-peritoneal tissues by means of a silver tube passed through the body of one of the lumbar vertebra?. He has done this operation a considerable number of times " with a consider- able measure of success." Heile (1910), in an infant of two days old, successfully employed Handley's operation (p. 301), connecting the sac of a spina bifida with the peritoneal cavity by means of sub- cutaneous silk threads; a complicating hydrocephalus also disappeared. Frazier adopts Handley's method by connecting the cysterna magna with the pleura. Hypersecretory Hydrocephalus. — In this rather rare type, which is recognized by the exclusion of the two most common types just described, improvement may be derived from the administration of thyroid extracts. Stiles (1905) employed ligation of both common carotid arteries, at an interval of three weeks; but the improvement was only temporary and other surgeons have not adopted the operation. Oxycephaly. — This is a marked form of steeple-shaped skull ( Turm- schadel) occurring in childhood (second to sixth year), and manifesting itself by exophthalmos and impairment of vision in addition to the cranial deformity. Other congenital deformities may co-exist, and the disease may affect more than one child in the family. About 80 cases are now on record, but not more than 20 were really oxy- cephalic (Sharpe, 1916; Bedell, 1917). The cause is unknown. Intra- cranial pressure exists, and expands only the vault, especially the frontal region, giving a towering forehead and perhaps a sagittal crest. The orbits become shallow, explaining the exophthalmos (fre- quently accompanied by divergent strabismus), while the increased intracranial pressure is manifested by choked disks. X-rays show the sella turcica widened, the middle fossa being depressed almost to the level of the posterior, the frontal and ethmoidal sinuses becoming G02 SURGERY OF THE HEAD obliterated, and there being marked reduction of the sphenoidal angle (Bertolette, 1910), converting the normal basilar kyphosis into a lordosis. The most severe cases usually die before puberty. The symptoms, apart from those already mentioned, consist almost solely in paroxysmal headaches, the child burying its head in the pillow and crying out with the pain. Palliative treatment, consisting in subtemporal decompression, callosal puncture, or other measures advised for cases of hydrocephalus, should be undertaken as soon as the diagnosis is made. INJURIES OF THE SKULL. Wounds. — Occasionally one sees incised wounds of the cranial bones, without fracture; saber wounds sometimes occur in war, and in civil life a pen-knife or other sharp instrument may be stuck into the skull. Such injuries require no special treatment beyond removal of the foreign body, if still present, and antiseptic care of the wound. Fractures. — For practical purposes the skull may be considered a sphere, possessed of a considerable degree of elasticity. For it to be fractured, a good deal of force is necessary, and this acts in two main ways: (1) the skull may be compressed between two diametric- ally opposite forces, or (2) it may be struck a violent blow. In the latter case the effect is the same whether the head is struck, or whether it strikes against another object; the only counter-pressure when the head is struck is that offered by the inertia of the head and the resist- ance of its attachments to the trunk, while when the head strikes another object there is also the momentum of what Archibald happily terms the "after-coming head." Between the diffused crush and the localized blow, there may be all grades of violence, varying from the puncture made by a pick-axe, or the blow from a black-jack, to a knock-out by a sand-bag, or a crush between two heavy beams. When the cranium is compressed in one diameter it naturally expands in the diameter at right angles to the first (Saucerotte, 1769); Victor Bruns (1854) and Angus McLean (1912) measured this compensatory expansion experimentally, finding that it amounted to several millimeters. The first and most obvious result of this compression was illustrated by Ali Krogius (1907) by cracking a hazelnut by lateral compression (Fig. 678): fissures are produced which represent meridians of longitude in relation to the points of compression which are regarded as poles; these fissures gape widest in the equatorial region, and when compression is relaxed they may close again completely. In the skull such fissures are very frequently seen as the result of diffused violence, and in them may be caught, as in a vise, hairs from the scalp, portions of felt from a hat, and strangest of all, foreign bodies may even pass through the fissure while it momentarily gapes, and thus be entirely hidden from view inside INJURIES OF THE SKULL 603 the cranium when the closed fissure is examined by the surgeon. These are called bursting fractures (von Wahl, 1883). Another result of the compensatory expansion of the skull in the diameter at right angles to that in which it is compressed, is that at the poles there occurs an inbending of the skull (Figs. 679 and 680) ; that such should be the case at the point of impact of localized vio- lence, is not difficult to understand, but that a fracture from inbend- ing may occur at a point more or less remote would be unthinkable unless the elasticity of the skull and ordinary physical laws were kept in mind. This is the fracture by counter-stroke (contrecotip) , which formerly was explained solely on the basis of vibrations which were set up by the blow, and spreading in all directions from the Fig. 678. — Mechanism of fracture of the skull by lateral compression: a meridional bursting fracture. Fig. 679. — Diagram to illustrate the elas- ticity of the skull. When the skull is com- pressed between a and b, these points ap- proach each other while the points c and d become more widely separated. (See Fig. 680.) Fig. 680. — Mechanism of fracture of the skull by counter-stroke: when the skull is compressed at a, a and b approach each other, and a fracture by inbending may occur at b as well as at a; or fracture by outbending may occur at c or at d. point of impact met finally at the polar point and there disrupted the skull. Though the bursting theory, originated by Chopart and other French surgeons in the eighteenth century, and re-introduced and elaborated by Felizet in France (1873), by Messerer and von Wahl in Germany, and by Dulles in America, in the eighth decade of the last century, has largely superseded the vibratory theory as an explanation of fissured fractures and fractures by counter-stroke, there can be no doubt, as pointed out by Nancrede (1884), that vibrations do occur, and are most violent where the bone is thickest, that is, at the base of the skull, where most of the fractures by counter-stroke occur. W. S. Wadsworth claims that fractures at the base are usual results of blows upon the vault because vibrations meet at the base: the vibrations travel quickly across the vault C04 SURGERY OF THE HEAD (thin) and slowly across the base (thick), vibrations starting in oppo- site directions thus meeting at the same time at the base. When localized violence is applied to the skull the force of the blow expends itself mostly by depressing the bone at the point struck; this is the inbending fracture referred to above. Now, this point being regarded as a pole, there are produced in the surrounding inert but elastic skull, concentric areas of compression, or oidbendings , which represent parallels of latitude; and at the points where the inbending and outbending 1 areas meet, a circular fissure or ring fracture^ may [result (Fig. 681). Occasionally a long fissure oc- curs at the equatorial region when the skull is diffusely crushed, and, according to Archibald, this must be ex- plained as a fracture by out- bending, as must certain fis- sures which run at right angles to the meridional bursting fis- sures (Fig. 682). In addition to the usual clas- sification of fractures, as simple, compound, depressed, etc., there are important clinical dis- tinctions between fractures of the vault of the skull and those of its base. Fractures of the Vault of the Skull. — Most fractures of the vault are due to direct violence, the parietal and temporal bones being most often injured. Almost always the injury acts from outside the Fig. 681. — Ring fracture of skull. From a specimen in the Mutter Museum of the College of Physicians of Philadelphia. Fig. 682. — Bursting fracture of skull from diffused violence on vertex: fissure radiating to base and widest at equator (temporal region) ; with outbending fracture (just below parietal eminence) at right angles to main fissure. From a specimen in the Mutter Museum. 1 The Flachbiegung urid Krummbiegung of Treub (1884). INJURIES OF THE SKULL 605 Fig. 683. — Teevan's diagram to show that the inner table often is more exten- sively damaged than the external, because it is in the line of extension. skull, so that the inner table is in the line of extension (Fig. 683), and, therefore, is more widely fractured than the external table (Teevan, 1864). Indeed, so elastic is the skull that a fracture of the vitreous table may occur without any fracture of the outer table. In the rare cases, mostly suicidal pistol shots, in which the cranial vault is fractured from violence within the skull, the outer table is more widely fractured than the inner. It is very unusual for the external table to be fractured without injury of the internal; it is then depressed into the diploe. The amount of splinter- ing is in inverse ratio to the momentum of the body fractur- ing the skull; but in the case of gunshot wounds, as pointed out at p. 194, the "explosive action" is manifested at close range. Symptoms. — Apart from those due to intracranial complications (p. 614), there are no symptoms specially indicative of a fracture of the vault of the skull. The diag- nosis rests on the history of injury, on the symptoms due to complicating intracranial lesions, and on physical signs. A skiagraph may be of value. If there is no scalp wound, the entire calvaria must be palpated carefully and persistently to discover any evidence of fracture; if a mere fissure exists, without depression or separation, nothing will be detected beyond the signs of contusion of the scalp (p. 595). The error of mistaking a hema- toma for a depressed fracture must be guarded against. If there is a depressed fracture it usually is possible to feel it through the scalp, recognizing its jagged outline and its actual depression below the surrounding bony surfaces; the depressed fragments may not be impacted, and injudicious pressure may drive them against the brain. If the existence of a fracture remains in doubt, no hesitancy should be felt in making an incision down to the bone, under proper anti- septic precautions, and inspecting the bared cranium. In compound fractures it may be necessary to enlarge the existing wound for the same purpose. A normal suture may be distinguished from a fissured fracture by its anatomical position, its greater irregularity of outline, and by the fact that a fracture cannot be washed clean of blood. In children there may be diastasis of suture lines instead of, or in addition to, fissured or depressed fracture of the skull. 1 Prognosis. — This is good, so far as the fracture alone is con- cerned. It is only intracranial complications that render the outcome doubtful. Excessive loss of bone seldom occurs, and complications affecting the scalp (erysipelas, etc.) are very rare with antiseptic methods. 1 See footnote, p. 606. C0(> SURGERY OF THE HEAD Treatment. — Every case of head injury, no matter how trivial in appearance, should be treated with extreme circumspection. It is the custom of many cautious surgeons, and for years has been mine, to urge all patients with injuries of the head to remain under constant surgical observation, preferably in the hospital, for several days. It is most important to prevent infection; and, as a rule, it is well to shave the entire scalp, as this often renders diagnosis easier, and always promotes asepsis. Shaving the scalp, or at least a wide area around the injury, therefore, usually is the first step in treatment. 7/ only a simple fissured fracture exists, without depression, and without any evidence of intracranial mischief, it is sufficient to keep the patient in bed for six to eight days, with an ice bag to the head; the bowels should be well opened, preferably by calomel, as this has a specific action upon the meninges and brain, exerting what was known in the last century as an "anticipatory antiplastic action," that is, preventing excessive inflammatory reaction, probably by its antiseptic properties. Urotropin is used for the same purpose, as it has been found to circulate in the cerebrospinal fluid; it must be given in very large doses. If the simple fissured fracture was caused by localized violence, which is rarely the case, it will be safer to ascertain whether or not the inner table is splintered, by removing a button of bone with the trephine. If such splintering exists, the case is treated as a depressed fracture. If the fissured fracture is compound the surgeon should make very certain that no hair or other foreign body is caught in the fissure, or has passed through it, before he decides against operation. If there is any doubt as to the surgical cleanliness of the fissure, the surgeon must take means to render it aseptic. Sometimes little tufts of hair are found sticking up out of almost invisible fissures (G. G. Davis, 1910), and a gouge must be employed to remove them and their containing bone; in other cases a trephine may be used to per- forate the skull, and then the entire septic fissure is gnawed away into healthy bone by rongeur forceps. 1 If the fracture is depressed I believe operation always in indicated, to relieve pressure on the brain; and if it is compound, whether it is depressed or not, operation usually is necessary to secure asepsis of the wound. But operation has no virtue of its own, being only a mechanical means of fulfilling plain therapeutic indications. Loose fragments are removed, and the elevator (Fig. 684, 3) is passed under 1 In 1907 I operated on a boy of eleven years, at the Episcopal Hospital, Phila- delphia, for extensive bursting fracture due to crush; there were compound com- minuted depressed ring-fractures in the right parietal and the left temporal bones, the poles of impact; and these areas were connected across the vault by a meridi- onal fissure which was deflected into the suture lines, causing diastasis of the right temporo-parietal suture and the entire coronal suture, with rupture of the longi- tudinal sinus. The loose fragments were removed, the depressed fragments elevated, and the separated sutures cleaned of hairs and clot by gnawing away both margins of bone. From the left temporal region a fissure ran to the base, thus practically separating the skull into antero-posterior halves. There was no injury to the brain, and the boy recovered. INJURIES OF THE SKULL 607 the depressed fragments and these are pried up into place. Search is then made by Horsley's dural separator (Fig. 684, 2) for loose frag- ments which sometimes are driven under the neighboring intact por- tions of cranium, and these are removed. All fragments completely detached should be removed entirely unless certainly aseptic; if a very large gap would be left by their removal, they may be replaced after being boiled. If the fragments are impacted, so that none of them can be removed, and there is no crack into which the elevator can be insinuated, a button of bone must be removed by the crown trephine (Fig. 684, 1), and the remaining depressed fragments ele- vatedJ[through the opening thus made. Next, the bone must be Fig. 684. — Instruments used in operating for fracture of the skull: 1, Crown trephine; 2, Horsley's dural separator; 3, bone elevator; 4, Hopkins's rongeur forceps. disinfected. Usually this is best accomplished by biting off ragged edges of bone with the rongeur forceps (Fig. 684, 4), thus completely removing all suspicious areas in which foreign particles may have been caught. In fractures of the frontal sinuses the outer wall alone may be fractured; but as the sinuses are of uncertain extent, even when developed, and as the fracture always is compound, either from within or on the skin surface, it is proper to explore the region affected and to remove sufficient bone to render the wound surgically clean. After any operation for fracture of the skull, a copious dressing should be securely applied (Fig. 685), as the patient may be delirious, and requires mechanical protection to the site of operation. fiOS SURGERY OF THE HEAD Fig. 6S5. — Dressing for fracture of skull. Episcopal Hospital. Rupture of the longitudinal sinus is a not infrequent complication of fractures of the cranial vault. Bone fragments may be embedded in its walls, or it may be torn accident- ally in elevating or removing depressed fragments. Hemorrhage may be pro- fuse, but it is readily controlled by packing, as the blood-pressure is low. Attempts to suture the rent rarely are successful, the sutures tearing out; and the profuse hemorrhage may cost the patient his life before the attempts to suture are abandoned. Packing is quicker and safer. The gauze should be removed in three or four days. Trephining the Skull. — The trephine is applied first with the center- pin protruded; with this as a pivot a circular groove is cut by alter- nately supinating and pronating the hand, and when this groove is of sufficient depth to steady the trephine without the aid of the centerpin this is withdrawn, and the trephining is continued very cau- tiously, using scarcely any pressure for fear of plunging the instru- ment into the brain. The use of Gait's conical trephine 1 renders this accident unlikely, if ordinary prudence is exercised. When the diploe is reached, the trephine cuts more easily, and the bone bleeds more; as the vitreous is approached the surgeon, from time to time, should test the depth of his groove with the flat end of a probe, as the skull is not of uniform thickness and incautious trephining may rupture the dura at one side before the vitreous table is cut through on the other. If the button of bone does not come away in the crown of the trephine, it is pried out by the elevator. The trephine never should be applied on the depressed fragment, but on the surrounding intact cranium, so that no further impaction or cerebral injury may be produced. Nor should the trephine be applied directly over the longitudinal or lateral sinuses. Fractures of the Skull in the Newborn. — Indentations of the semi- membranous skull of the baby may occur from injury during labor, or at a later age from blows, falls, etc. The bone is so flexible that true fracture during labor is rarer than bending. The depression usually corrects itself within ten days; if it does not, and immediately if it produces symptoms of cerebral compression (p. 617), operation should be done. Nicoll's operation (1903) consists in excision of the cup-shaped depression, and its replacement with the dural (convex) surface beneath the skin. Usually it is sufficient to pry the bone up by an elevator introduced through a neighboring fontanelle or suture. The bone is soft and easily cut by scissors. The danger of 1 This was a revival of an old instrument. Gait's pattern was first used by Sayre in 1861: the spiral grooves on the periphery act as a screw so long as there is counter-pressure by bone on the oblique teeth of the crown; when resistance ceases, the conical trephine acts as a wedge, and binds. Hudson's trephine (p. 634) is constructed on the same principle. INJURIES OF THE SKULL 609 ^F* f-" ^ f^H Wyf&\ / ^i"" ' V V ■ i .^^^ t 9 ~*'jf fi ■ 1 / ■^k leaving such fractures untreated is that cortical lesions may result, leading to spastic paralysis, epilepsy, imbecility, etc. In older infants fracture may split the cranial bone radially in the usual line of ossification. Fractures of the Base of the Skull. — Most of these are the result of bursting force, a fissure extending from the point of injury on the vault to the base of the skull, usually along definite lines. The recognition of this fact is due chiefly to Aran (1844), who claimed that in every fracture of the base the fissure began in the vault. This, how- ever, is not literally true, as the fracture sometimes begins at the base and may or may not extend to the vault. Falls on the feet or on the buttocks may fracture the base by force applied through the condyles of the occipital bone. When fracture of the base occurs as part of a bursting fracture from diffused force applied to the calvaria, the fissure extends to the base by the shortest anatomical route, avoiding buttresses such as the mastoid, the external angular pro- cess of the frontal bone, etc. Thus it is found that in fractures from lateral compression, usually on the parietal bones, the fissure crosses the middle fossa of the skull in the majority of cases (23 out of 32 cases recorded by Archibald). From occipitofrontal compression, a fissure results which passes usually through one orbital plate of the frontal, through the body of the sphenoid, and the sella turcica, along the petro-occipital suture to the jugular foramen, and perhaps up again to the vault along the masto-occipital suture; or if the fissure passes down the occipital bone, it skirts the side of the foramen magnum, and so to the sella turcica (Fig. 686). Rawling found the sphenoidal sinus fractured in 70 per cent, of his cases. These basal fractures very often are com- pound, through the naso-pharynx or middle ear. Displacement is very slight. Punctured fractures of the base of the skull are exceedingly serious lesions; they occur from such implements as umbrella tips, pencils, pipe-stems, etc., which may penetrate the orbit or naso-pharynx, sometimes entering one of the fissures or foramina at the base of the brain with little damage to the surrounding bone. Symptoms. — These depend, as in fractures of the vault, much more upon cerebral injury than upon the mere existence of fracture. The diagnosis, therefore, depends in large measure on circumstantial 39 Fig. 686. — Diagram showing the usual course taken by fissured fractures of the base of the skull. (ill) SURGERY OF THE HEAD evidence derived from certain physical signs, and from a knowledge of the mode of injury. Fractures of the anterior fossa may be accom- panied by bleeding into the retrobulbar tissues of the orbit, sub- conjunctivaJ ecchymosis appearing some days after the injury, and spreading from behind forward; exophthalmos is a rare sign. Bleed- ing from the nose or mouth is as often due to extracranial as to cranial lesions. Brain substance or cerebrospinal fluid rarely is discharged. Blood may be swallowed and vomited. Fractures of the middle fossa frequently are compound through the middle ear, and though bleed- ing from the ear may be due merely to rupture of the tympanic mem- brane, when persistent or profuse it has usually an intracranial source; it may enter the throat through the Eustachian tube. A elear liquid discharge may occur from the mastoid cells or from the membranous labyrinth, but any such discharge in large amount is more apt to be cerebrospinal fluid. Paralysis of one or more of the cranial nerves is more frequent in fractures of the middle fossa than in those of the anterior or posterior fossae. (Fig. 687.) The seventh and eighth nerves are those most often injured, usually from lacer- ation or secondary edema. Ferron (1908) collected 339 instances of nerve lesion, with 33 deaths. Fractures of the posterior fossa frequently are not recognized, be- cause of lack of physical signs. Ecchy- mosis over the mastoid, appearing some days after the injury, is of some signifi- cance; as is the occasional involvement of the ninth, tenth, and eleventh nerves. Prognosis. — This depends upon the presence of intracranial lesions and upon the development of complications, es- pecially meningitis. Without these, the prognosis is no worse than in fracture of the vault. As a general rule, about one out of three or four patients with fracture of the base will die within a week or ten days. Treatment. — The general treatment is the same as in fractures of the vault : physical and mental rest, in a cool , darkened room ; and purgation to remove material which might cause toxemia or bac- teremia and hence increase the danger of sepsis. Urotropin should be administered (15 grains three times daily, with an interval of one day at the end of each three-day period), and liquid diet should be continued until danger of complications has passed. The naso-pharynx and external auditory meatus should be cleansed, but repeated irrigation is more apt to encourage sepsis than to prevent it. If bleeding is profuse it may be necessary to pack the naso-pharynx Fig. G87. — Fracture of base of skull, following a fall. On second day developed paralysis of third cranial nerve on left side, and seventh cranial nerve on right side. Recovery. No operation. Episcopal Hospital. INJURIES OF THE SKULL 611 or auditory meatus; in all cases it is well to keep a little sterile ab- sorbent cotton in the latter channel to absorb discharges. If bleeding is very persistent, and especially if packing produces symptoms of cerebral compression, attempt should be made, by trephining the skull low in the temporal region, to reach the source of hemorrhage and deal directly with it. If symptoms of compression arise, whether there is external hemorrhage or not, decompression should be done (p. 634). Lumbar puncture may be employed as a diagnostic measure to ascertain the presence of blood in the cerebrospinal fluid; occasion- ally it is curative also. Osteomyelitis. — Osteomyelitis of the cranial bones is rare, and extremely fatal ; usually it follows contusion of the bone, secondary infection occurring through the blood-stream or from an overlying hematoma. It is rarer still as a complication of compound fracture or a scalp wound, as in such cases drainage is free. The diagnosis rests on the appearance of septic symptoms, after injury to the skull, with the develop- ment locally of the "puffy tumor" of Percival Pott (1768), which is "a circum- scribed, flattened, elevated swelling," due to infiltration of the scalp with serum, and indicates "a subjacent sup- purative periosteitis, denuded bone, and in many instances subcranial suppura- tion with separation of the dura mater" (Nancrede, 1885). Treatment. — Treatment consists in removal of all diseased bone, by trephine and rongeur, with free drainage. Death is the usual outcome of the disease, from meningitis and encephalitis, except where very early operation is done. Repair of Cranial Defects. — Usually after operation for fracture or other lesion of the skull, in which a large area of bone is removed, the defect produces little inconvenience, being filled in by dense fibrous tissue. There is no tendency to hernia cerebri (Fig. 704) unless intracranial tension is increased; on the contrary, the area usually is depressed (Fig. 688). Sometimes, from dural adhesions, or other cause, this depressed area is a source of constant annoyance, and may subject the brain to slight injuries. If the symptoms are so severe as to demand relief, a free transplant, consisting of the outer table, may be removed from another portion of the skull; or a free transplant of cartilage may be employed (see p. 247). Fir,. 6S8. — Loss of bone after fractured skull: four months after operation. (Dr. Mutsehler's ease.) Episcopal Hospital. 612 SURGERY OF THE HEAD SURGICAL AFFECTIONS OF THE BRAIN AND MENINGES. Cranio-cerebral Topography, which implies a knowledge of the relation of intracranial structures (cerebral fissures and convolutions, blood-sinuses, meningeal vessels, etc.) to the overlying skull, is not now regarded as of so much importance as some years ago. This is so both because these relations exhibit variations in different persons, and because modern surgical technique enables the surgeon to raise a large bone flap from the cranium, and expose the underlying structures over a sufficiently wide area to permit of his recognizing them rather by their relations to each other than by their relations to the surface of the cranium. But there are a few landmarks which it is indispensable for the surgeon to know. The longitudinal sinus runs beneath the sagittal suture from the root of the nose to the inion; it lies within the falx cerebri, and extends, with its annexed blood-lakes, for about 2 cm. each side of the median line, being broader behind than anteriorly. Usually it extends further to the right than to the left of the median line. The lateral sinus runs on each side, along the attachment of the tentorium cerebelli, from the inion to the base of the mastoid; here it passes downward, following the petro-mastoid suture to the jugular foramen (Fig. 690). The anterior and upper margin of the curve where the horizontal and descending (sigmoid) portions of the lateral sinus meet, known as the knee (genu) of the lateral sinus, is about 2.5 cm. above and nearly 4 cm. behind the center of the external auditory meatus. The sinus is about 12 mm. or more broad, and the "dangerous area," over which a trephine or chisel should not be applied, includes a strip of bone nearly 2.5 cm. wide, overlying the course of the sinus. The upper limit of the cerebral hemispheres corresponds to the position of the superior longitudinal sinus. Their lower limit reaches, in front to the upper margin of the orbit; laterally it passes from a point 12 mm. above the external angular process of the frontal bone, to the upper margin of the external auditory meatus, and thence to the inion, along the upper border of the lateral sinus. The fissure of Rolando runs from a point about 12 mm. behind the mid-point between glabella and inion, forward for nearly 8.5 cm., at an angle of about 70° with the sagittal suture. If a square of paper (90°) is folded diagonally, so as to make two angles of 45° each, and one of these folds is again doubled on itself, so as to make two angles of 22.5° each, it will be possible, by adding one of these latter angles to the 45° angle, to construct off-hand an angle of 67.5°, or three-quarters of the original right angle. If, then, this angle (67.5°) is placed on the sagittal suture, so that its apex lies 12 mm. behind the mid-point between glabella and inion, the course of the Rolandic fissure will be approximately indicated (Chiene, 1888). The relation of the other chief fissures and convolutions is sufficiently indicated in Fig. 689. CRANIO-CEREBRAL TOPOGRAPHY 613 The middle meningeal artery, entering the skull by the foramen spinosum, divides almost immediately into two branches. The anterior Fig. 689. — Relation of the chief fissures and convolutions of the brain to the surface of the skull. The dotted line which is nearly horizontal indicates the fissure of Sylvius; this line runs from the external angular process of the frontal bone through a point 2 cm. below the parietal eminence (x), and its middle third corresponds roughly with the Sylvian fissure. Note the positions of the cranial sutures. branch runs forward and upward and crosses the anterior inferior angle of the parietal bone, near the pterion; thence it runs upward toward the sagittal suture, lying behind and more or less parallel Fig. 690. — Course of middle meningeal artery and lateral sinus, outlined upon the surface of the skull. to the coronal suture. Near the pterion it lies usually in a bony groove or canal, and is frequently torn by splinters of bone, or ruptured (ill SURGERY OF THE HEAD by inbending or bursting fractures at this point. It may also be injured at this point by a trephine, so it is safer to expose it by a trephine opening in the middle of the temporal fossa, say 4 cm. posterior to the external angular process of the frontal bone, and 2.5 cm. above the zygoma (Fig. 690). The posterior branch runs horizontally backward across the squamous plate of the temporal bone, and crosses the temporo-parietal suture within about 2 cm. of its pos- terior end; it may be exposed by a trephine opening about 2.5 cm. below the parietal eminence. Concussion and Contusion of the Brain. — The brain is an incom- pressible structure suspended within a bony case by fibrous partitions, chief of which are the falx and tentorium; it is held relatively immobile at its base by the cranial nerves, bloodvessels, and processes of dura mater, which pass through the base of the skull. It is surrounded by a small amount of cerebrospinal fluid, which is in greater quantity toward the base, especially around the medulla; and its ventricles, which are directly continuous with the subdural spaces (p. 599), are filled with the same fluid. A blow upon the head causes not so much a vibration or tremefaction of the brain substance, as a sudden displacement of the brain as a whole; it is flung, as it were, against the opposite side of the skull, and usually it is contused most at the point of impact, or the polar point, or at the base, where the greatest strain comes. The cerebellum is relatively little affected, because of its protected position beneath the tentorium, because it floats on a greater amount of cerebrospinal fluid, and because of the possi- bility of downward displacement by crowding the medulla into the foramen magnum. Some blows on the head, severe enough to cause symptoms, produce symptoms which are so momentary and fleeting that it always has been difficult to believe that they were attended by structural change. And until modern methods of histological study were developed, it happened not rarely that postmortem examination failed to disclose any lesion in the brains of those who had actually died with symptoms due to "concussion." But it has come to be recognized, largely through the investigations of Sir Prescott Hewett (1870), that the condition of these brains is not one of "concussion," as was formerly taught, but is the result of con- cussion, and is characterized by contusion, compression, extravasation, laceration, or inflammation in varying degrees. Of course, it cannot be asserted categorically that histological changes always are present in patients w^ho recover at once from the symptoms of concussion, because there is no opportunity of submitting their tissues to micro- scopical examination at the time of injury; but the belief is quite general, and I believe quite justified, that even when the symptoms produced are the most insignificant, definite lesions exist, and that these vary from temporary arrest of cell-action, with capillary stasis, or the slightest grades of contusion, with punctate hemorrhages, to distinct laceration, ecchymosis, exudation, and edema of the brain and pia-arachnoid. CONCUSSION AND CONTUSION OF THE BRAIN 615 Symptoms. — As in all cases of injury, some degree of shock is present, and it often is difficult to distinguish the symptoms of this condition from those due to concussion of the brain. After a blow on the head only such symptoms as dizziness, or disturbances of vision (sparks, specks, etc.), may be observed. In more marked cases there is momentary loss of consciousness, the patient falling as one dead; or, when striking the head in a fall, lying motionless for a few seconds, and then regaining consciousness and rising to his feet before assistance can reach him. In typical cases, two distinct stages may be recognized: 1 (1) The patient at first lies motionless, senseless, nearly pulseless, pale and cold, breathing feebly but natur- ally; the pupils dilated or contracted, fixed or acting freely; perhaps with involuntary discharge of feces and urine. He will swallow if food is put into his mouth. From this first stage, which may last many days, the patient may recover without further trouble, or he may gradually sink and die without reaction; or the first stage may last a few moments only, the patient having passed into the second stage before the surgeon sees him. The disappearance of the first stage, whether by passing into the second or by direct recovery, commonly is marked by vomiting. (2) In the second stage the patient is no longer unconscious, though much indisposed to speak or pay attention to surrounding objects. If roused by a question, he will answer, but peevishly or angrily, turning away as if displeased at the interruption. His posture is peculiar: he lies habitually on his side, curled up, with all his joints more or less flexed, and if a limb is touched he draws it away with an air of annoyance. The eyelids are kept firmly closed. The pulse, at first slow and weak, gradually becomes more frequent and stronger; the breathing is easier, and the surface regains its natural warmth and color. This stage gradually subsides, after several hours or days, and as the patient regains ability and willingness to communicate with those around him, he complains almost invariably of severe headache. If the cerebral lesions have been marked, they may leave the patient with his mental faculties permanently impaired; usually, however, in such an event, the earlier symptoms will have been those of compression of the brain rather than those recognized as due to concussion. Treatment. — The patient should be laid horizontal, with the head slightly elevated, in a darkened room; and throughout his illness he should be protected from all noise. During the first stage, stimu- lation for shock may be necessary. So soon as shock is recovered from, the bowels should be evacuated, the urine drawn if necessary; and moderate amounts of liquid nourishment should be administered. During the second stage, cold should be applied to the head, while restoration of cerebration may be hastened by the administration of calomel, 0.010 gramme every hour for six doses, for its "antici- patory antiplastic effect" (p. 606); and this may be continued every 1 This description is copied, almost verbatim, from the Principles and Practice of Surgery of John Ashhurst, Jr. 61G SURGERY OF THE HEAD third or fourth hour for several days, or until the patient is clear in his head. Should restlessness or delirium supervene, it is well to administer, with each dose of calomel, 0.15 to 0.20 gramme of Dover's powder. The use of the mind, in conversation, reading, etc., should be resumed very gradually, and convalescence should be prolonged, the patient living by rule for many months after apparent recovery, and remaining under surgical observation until by the lapse of time the absence of complications from unrecognized cerebral lesions is assured. Examination of the eye-grounds and the visual fields will aid in excluding serious organic changes. Compression of the Brain. — As already stated, the brain is an incompressible structure; its bulk can be reduced only by loss of its fluid constituents; if compressed in one direction it must expand in another. Experimental compression of the brain produces first a stasis in the smaller venous channels; the longitudinal sinus col- lapses; the blood cannot escape from the skull. If pressure increases the arterioles may be affected. Normally changes in intracranial vascular pressure are compensated for by the ebb and flow of the cerebrospinal fluid. This drains away into the veins, and these in turn empty mostly into the longitudinal sinus and certain emissary veins through the diploe. Increase in vascular pressure from the arte- rial side is easily and rapidly compensated for by venous absorption of cerebrospinal fluid; and obstruction to the venous outflow (often seen in cases of cervical or thoracic neoplasms) does not prove inju- rious so long as the collateral diploic veins are open, or so long as the cerebrospinal fluid can pass into the spinal canal and escape into the venous circulation by that channel. But if the pressure on the venous side becomes so great as to dam the blood back into the capillaries, these side escapes become blocked, the brain may be forced down until the medulla chokes off the outlet for cerebrospinal fluid through the foramen magnum, and symptoms of "compression" appear. It was shown experimentally by Althann, in 1871, and since his time by numerous other investigators, that "the effect of space diminution in the skull was identical with that of any other process which hindered cranial circulation" (Archibald, 1908); so that, as pointed out by von Bergmann (1880), the symptoms of "compression" are due not to actual compression of nerve elements, but to cerebral anemia. The maintenance of life depends on the functioning of the chief medullary centers, vasomotor, vagus, and respiratory; and it is to interference with the circulation of these centers that the most strik- ing symptoms of cerebral compression are due. Localized compression produces the so-called focal symptoms, i. e., paralysis; while general- ized compression, which may develop independently of, or may succeed, local compression, is particularly characterized by bulbar symptoms: interference with the centers already named; but in generalized compression there also usually is unconsciousness, from cortical compression. COMPRESSION OF THE BRAIN 617 So soon as anemia affects the medulla, the vasomotor center is stimulated, blood-pressure is raised higher than intracranial (extra- vascular) pressure, blood again reaches the medulla, and life is pro- longed, at least temporarily (von Schulten, 1885). But the stimulus of anemia then being removed, blood-pressure sinks somewhat, as intracranial pressure continues to increase, and anemia of the medulla again occurs; whence renewed stimulation of the vasomotor center, a further rise in blood pressure, and again a temporary relief of the medullary anemia. (Hushing (1902, 1903) followed these successive periods of anemia and return of circulation by observation of the cerebral cortex of monkeys through a trephine opening; and his experiments justify the conclusion that similar changes occur in the medulla. This alternate stimulation and depression of the medullary centers explains the more or less periodic phases observed in the blood- pressure and respiration curves obtained from such patients. They are known as Traube-Hering waves. The respiratory phases closely resemble the Cheyne-Stokes type, the stage of apnea occurring when the respiratory center is deprived of blood, and the hyperpnea develop- ing when circulation is restored by increase in blood-pressure. This "life and death struggle," as von Schulten termed it, may continue until blood-pressure reaches enormous heights; Cushing raised it experimentally to 290 mm. Hg.; but unless intracranial pressure is relieved, the medullary centers in time will cease to react, and sudden fall of blood-pressure will occur, followed by death. "Death probably always occurs from primary failure of the vasomotor center, rather than from that of the respiratory, as has been asserted by some. The vasomotor center holds the key to the position. Its defeat involves that of the respiratory and vagus centers; and with their defeat the whole army is devoted to slaughter." (Archibald, 1908.) Causes. — Anything which increases intracranial pressure may cause symptoms of compression of the brain. This includes: (1) Foreign bodies driven against or into the brain (bone fragments, bullets, etc.); (2) hemorrhage, subcranial, subdural, or intracerebral; (3) products of inflammation (serous effusion, lymph, pus); (4) tumors of the brain; (5) acquired internal hydrocephalus, etc. Symptoms. — Very slowly induced compression may not produce symptoms for a long period; and even in cases of rapid compression there often is a "stage of compensation" from rise in blood-pressure, during which no symptoms may be observed. During the stage of manifest compression two periods may be recognized: (1) Early symptoms: There is irritation of the cortical and medullary centers, due to venous stagnation; slight quickening of respiration, and rise in blood-pressure; headache, dizziness, restlessness, roaring in the ears, disturbed sleep; moaning and groaning; and at times delirium. Sometimes circulatory changes in the fundus oculi can be detected, but these disappear in a few hours. (2) Late symptoms: The gradual 618 SURGERY OF THE HEAD increase in the compressing force finally overcomes the blood-pressure, and cerebral anemia results. This stimulates the vasomotor center which raises blood-pressure yet higher by causing peripheral capillary constriction, especially in the splanchnic area. The patient lies somnolent, stuporous, even comatose; with slow, full, bounding pulse ; there is labored respiration, which in the last stages approaches the Cheyne-Stokes type; the cheeks are passively puffed out at each expiration ("smoking his pipe," the French call it); the pupils react sluggishly or not at all. The more dilated pupil usually is on the side of greatest compression. Sometimes the patient can be partially roused from his coma by pressure on the supraorbital nerve; then slight convulsive movements of the extremities may occur, and hemi- plegia, or localized paralysis may become evident. Irregularity of the respiration is one of the earliest and surest signs of approaching exhaustion of the medullary centers; and unless blood-pressure can be measured periodically by the manometer, respiration is a more reliable guide as to prognosis than the quality of the pulse; for the "vagus pulse," slow, regular, and strong, continues practically unchanged until very near the fatal ending. Diagnosis. — If the early symptoms of the stage of manifest com- pression were borne in mind, the condition often could be diagnosed and measures for relief instituted, before the later stage, complicated by unconsciousness, is reached. When an unconscious patient is examined, the existence of an adequate cause for cerebral compres- sion always should be excluded before dismissing this as the cause of the symptoms. Many a patient suffering from cerebral compression has been sent away from accident wards as "drunk," when a very little time spent in examination would have detected focal symptoms (pupillary, facial, or lingual paralysis; monoplegia, hemiplegia, etc.); while bulbar symptoms probably could have been discovered if they had been specifically looked for. In any case of doubt, keep the patient under observation; if the cause of symptoms is compression, this soon will become evident. Prognosis. — This depends very largely upon the cause of the com- pression, and the time at which treatment is instituted. In many cases of brain tumor, for instance, it may be impossible to remove the cause of compression, so that cure is out of the question; but symptoms may be relieved and life prolonged by removing the counter- pressure caused by the skull. But even in cases where the cause of compression can be removed, treatment may not be instituted until the last stages of compression, and the medullary centers may not recover; or even though they recover, the focal compression may have done so much damage to the cerebrum as to impair the patient's mental or physical ability throughout life. Treatment. — From what has been said above it is very evident that the two main indications are to maintain blood-pressure at a higher point than intracranial (extravascular) pressure, and to relieve COMPRESSION OF THE BRAIN 619 the compression by surgical means. The full, bounding pulse, the singing in the ears, etc., of the early stages, do not by any means indicate that the patient should be bled, or that aconite should be administered; they are an index of his compensatory powers and all that will save his life is to keep his blood-pressure high, and to relieve the intracranial pressure as quickly as possible. Theoretically the latter point may be gained by lumbar puncture of the subdural space of the cord; but draining away cerebrospinal fluid, by removing the brain's support from below, may serve only to allow the super- incumbent pressure to force the medulla down into the foramen magnum, thus strangulating it and causing instant death. The most imperative indication is to "decompress" the brain by removing some of the overlying cranium, on one or both sides. This may be done by the trephine, the opening being enlarged by rongeur forceps, or a bone-flap may be raised (p. 632). At the same time that decom- pression is done, the cause of compression, whenever possible, should be removed. The site of the cranial opening depends on the cause of compression and on the existence of focal symptoms; when not contraindicated the subtemporal operation of Cushing (p. 634) is very satisfactory. In the most advanced stages of cerebral compression emergency measures are necessary to raise the blood-pressure until operation can be undertaken; these are such methods as artificial respiration, lowering the patient's head, bandaging his extremities, compression of the abdomen, and the administration of strychnin, adrenalin, etc. After decompression it should be remembered that the stimulating effect of recurring anemia upon the vasomotor center is lost; and if this center shows signs of exhaustion, it must be stimulated by strychnin, or repeated doses of adrenalin. Subcranial or Extradural Hemorrhage may be due to bleeding from the diploe or cranial sinuses, in cases of fracture of the skull, but in the vast majority of cases it is due to rupture of the middle meningeal artery. Middle meningeal hemorrhage may occur with or without fracture of the skull, and upon the side of injury or on the opposite side (from "contre-coup"). The anterior branch of the artery is most often ruptured, usually near the pterion, where it passes through a bony groove or canal; but it may be torn off at its exit from the foramen spinosum (by concussion, or by a bursting fracture), or lacerated by bone fragments at other parts of its course. The bleeding which results slowly separates the dura from the cranium, and the resulting clot may spread over an entire hemisphere (Fig. 691). Diagnosis. — The usual history is that after an injury to the head the patient experiences momentary symptoms of concussion, then recovers more or less completely; but some hours or even days later signs of compression appear, sometimes gradually, sometimes with alarming suddenness. What is particularly characteristic is the so- called "free interval," between the injury, when rupture occurs, and 020 SURGERY OF THE HEAD the time when the accumulating clot brings on symptoms of com- pression. Treatment. — The treatment consists in exposing the artery (anterior or posterior branch, according to the site of injury and the symptoms, p. 613), removing the clot, tracing the bleeding to its source, and ligat- ing the artery by passing a fine suture around it by means of a round-pointed needle. If all focal signs are absent, and no cause for compression is found on the side of the skull first opened, it is justifiable to open the other side, as rupture may occur from counter-stroke. Intradural Hemorrhage. — Bleed- ing into the meshes of the pia- arachnoid, which is much more frequent than the extradural form, almost invariably is of traumatic origin, venous in character, and complicated by extensive cranial and cerebral injury (Fig. 692). Usually the blood is widely diffused, and the fluid removed by lumbar puncture may be blood-tinged. The symptoms are those of cerebral compression; "it is safe to say," writes Cushing, "that in any serious cranial injury in which unconsciousness has been present from the Fig. 691. — Subcranial hemorrhage from rupture of the posterior branch of the middle meningeal artery. No frac- ture of the cranium. Man, aged fifty- one years, was found lying on the street, unconscious. Taken to police station. Operation about forty hours after in- jury. Blood-pressure fell from 170 mm. before operation to 110 mm. a few hours later. Recovery. (See Fig. 703) Episcopal Hospital. Fig. 692. — Intradural hemorrhage. A boy of five years had a large flap of scalp torn loose. Parietal bone bent inward, but no fracture. Operation three hours later (for continued unconsciousness and left hemiplegia) showed extensive intradural hemor- rhage, the brain being 4 cm. distant from the dura. After removal of compression respira- tion improved, but death occurred in a few hours. Episcopal Hospital. first, subdural bleeding is taking place, either from the fracture itself or from some laceration of the brain." Treatment consists in SINUS THROMBOSIS 621 decompression if symptoms of compression continue for more than a few hours or are well marked at first. Seldom is it possible to find any distinct bleeding point, but exposure to the air, or gentle irriga- tion with very hot saline, may be sufficient to arrest the hemorrhage. Drainage is provided by strips of rubber tissue. The operation, unless another opening is indicated by cranial injury or focal symp- toms, should be by Cusbing's subtemporal route (p. 634) which gives ready access to the base of the brain whence the bleeding usually arises. Intracranial Hemorrhages in the Newborn. — These occur usually from a rupture of a vein in the pia-arachnoid, near the longitudinal sinus, as the result of trauma during birth. The diagnosis is not always easy, at least until signs of compression of the brain appear; lumbar puncture may show bloody cerebrospinal fluid; and cerebral irritability and irregularity of respiration are suggestive. The prog- nosis is bad; nearly 80 per cent, die from cerebral compression within a few days; while of those that recover most are mentally deficient or afflicted with spastic paralysis (p. 572), athetosis, nystagmus, etc. Treatment: Operative relief, proposed by Keen in 1901, was first employed in 1904 by Cushing, who reported (1908) nine operations, with four recoveries. A large osteoplastic flap, which can be cut out with strong scissors, is raised, the dura is opened, the clots removed by gentle irrigation, and the wound closed without drainage. Intracerebral Hemorrhage occurs chiefly as the result of vascular disease (ordinary "apoplexy"), or from degenerative changes in brain tumors. Wounds are occasionally causes of localized cortical hemorrhage. The suggestion by Leonard Hill (1896) that surgery by effecting decompression, or even by evacuation of the clot, might be of use in these cases, was acted upon with success by Borsuk and Wizel (1897) in a traumatic case. Cushing (1908) operated on four cases of spontaneous hemorrhage, one operation (subtemporal decompression and evacuation of the clot) being successful. Under expectant treatment the mortality is nearly 90 per cent., in these cases of acute severe apoplexy, in which alone is operation to be considered. Sinus Thrombosis. — This arises, in the vast majority of cases, by extension of septic inflammation from the air sinuses of the skull, especially the mastoid cells. Pyogenic inflammation of the scalp or erysipelas are rare causes, the infection spreading along the diploic emissary veins. The diagnosis depends on recognizing a focus from which septic inflammation may be derived, on local signs such as edema of the overlying scalp, and distention of its veins, together with evidences of constitutional sepsis, and perhaps cerebral com- pression. The longitudinal sinus may be thrombosed from frontal, ethmoidal, or sphenoidal sinusitis, or rarely from erysipelas of the scalp, etc. Thrombosis of the cavernous sinus, which is very rare, may arise from extension of inflammation along the facial and angular veins (carbuncle of upper lip, etc.), or along the petrosal sinuses 622 SURGERY OF THE HEM) (from the sigmoid sinus), and is particularly characterized by the resulting exophthalmos. The lateral sinus, especially its sigmoid portion, is that which is involved in by far the largest number of cases, and almost always as the result of middle-ear disease, the infection coming along the emissary veins or directly invading the sinus wall after destruction of the intervening bone. The symptoms are those of the preexisting disease (mastoiditis), of sepsis (repeated chills, sweating, hectic temperature), and cerebral irritation or compression (rare); but such symptoms often do not appear until the sinus thrombosis has been in existence for some days, and may indicate a softening of the clot and dissemination of emboli. Naturally the lungs are most often attacked in this way. Thrombosis is prone to extend to the internal jugular vein, and often this can be felt as a tender cord in the neck. The head may be tilted to the affected side. In meningitis, which is much commoner in infants than adults as a result of middle- ear disease, cerebral symptoms (vertigo, vomiting, hebetude, delirium) are more marked, there is retraction of the neck and paralysis of the ocular muscles, with choked disk; fever is higher and more regular; Kernig's sign is present; and lumbar puncture shows turbid cerebro- spinal fluid, from which organisms may be recovered. In brain abscess cerebral symptoms, without those of meningitis, predominate; temperature is subnormal; there is evidence of cerebral compression; and emaciation is rapid. In neither meningitis nor in uncomplicated cases of brain abscess is there thrombosis of the internal jugular vein. Treatment. — The first step is to clear out the mastoid, and this merely preliminary measure should not be done with too great delib- eration (see Chapter XIX). The shell of bone which overlies the sigmoid sinus is then removed by gouge or burr, and the sinus well exposed; plenty of room should be gained by use of the rongeur. The sinus is next incised: if bleeding occurs the sinus is compressed first on the torcular side; and, if it continues, also on the jugular side of the incision. Persistence in bleeding, when pressure is made at both these points, indicates a return flow from the mastoid emissary or superior petrosal sinus. These should be separately tested. If the petrosal is not thrombosed it is probable that the entire system is healthy. // no bleeding occurs when the sinus is opened, it should be slit up toward the torcula until a return flow is obtained; this is controlled by packing; the clot is then removed as far as the original incision, and, after temporary pressure has been made on both jugulars in the neck, a similar procedure is carried out at the bulbar end of the sinus. If no return flow can be obtained from this end of the sinus, it is a sign that the thrombus extends into the jugular, and resection of this vein should be done. It is to be performed as a primary oper- ation, before exposing the sinus, when a diagnosis of jugular thrombosis is made in advance. Resection of the Internal Jugular Vein: The vein is exposed and doubly ligated low in the neck; it is divided between these ligatures and dissected upward, clamping and tying LEPTOMENINGITIS 623 each branch encountered. Thrombosed branches should be excised. When the vein has been traced up as far as possible, it is ligated and cut across. The neck wound is tamponed with gauze and not closely sutured. If the jugular vein is too densely adherent to be removed safely, it should be slit open, and the wound packed with gauze. The general mortality of thrombosis of the lateral sinus is about 25 per cent. Meningitis. — External Pachymeningitis, usually purulent and local- ized {subcranial abscess), affects the external layer of the dura, and may result from osteomyelitis of the cranium (p. 611) with or without fracture of the skull, or from neighboring sinus thrombosis. Treatment consists in removal of the overlying bone, with drainage. External hemorrhagic pachymeningitis, usually the result of trauma (an organizing clot resulting from middle meningeal hemorrhage), gives symptoms of cerebral irritation more or less confined to the area immediately affected. The best treatment is thorough extirpation of the diseased tissues. Internal Pachymeningitis is a rare disease, of subacute or chronic character, in which membranous lymph, easily detachable, is deposited on the inner layer of the dura. It is microbic in origin, occurs some- times in general infections (typhoid fever, pneumonia), and some- times is hemorrhagic in type. The symptoms are not very character- istic, being those of slowly increasing cerebral irritation or compres- sion; and the diagnosis is difficult. Treatment: operation, comprising removal of the false membrane or hemorrhagic exudate, offers the only hope of cure or prevention of insanity (Munro, 1902). Leptomeningitis. — Inflammation affecting the pia-arachnoid may be due to various bacteria; the form known as epidemic cerebrospinal meningitis, caused by the Diplococcus intracellulars, is a specific contagious disease, usually coming under the physician's care. Early intraspinal use of Flexner's serum (1906) is most important. From 15 to 30 c.c. are given, according to the age, and repeated every twenty- four hours. If begun promptly enough, four injections usually suffice. The ultimate cause of death is purely mechanical, being due to cerebral compression from acute internal hydrocephalus (p. 599), and lumbar puncture, used for diagnosis, may be repeatedly employed with benefit, even when no serum is available for injection; but it is of no therapeutic value when hydrocephalus supervenes; the only remedy then is single or repeated puncture of the ventricles. Leptomeningitis also may be caused by ordinary pyogenic cocci, pneumococcus, B. tuberculosis, etc. Especially in tuberculous menin- gitis, which is so uniformly fatal under medical treatment, it seems as if almost any surgical risk were justifiable; and if repeated lumbar puncture proves ineffectual, puncture of the ventricles should be done (p. 600). Serous or Amicrobic Meningitis is a form of the affection in which clear, sterile serous fluid collects in the intradural spaces (Eichhorst, 1887). Some cases are traumatic in origin, but most are regarded 624 SURGERY OF THE HEAD as due to bacterial infection localized elsewhere in the body, thus being analogous, as pointed out by Archibald (1908), to the sterile serous effusion of pleurisy secondary to subphrenic abscess. Some- times this affection complicates sinus thrombosis or mastoiditis. Diagnosis. — The diagnosis is difficult, the serous character of the effusion being discovered first at operation undertaken to relieve pressure symptoms thought to be due to subcranial or intradural suppuration, or to brain abscess. Treatment. — In traumatic cases lumbar puncture may suffice to evacuate the fluid; in others craniotomy should be done. If serous meningitis is found, undue persistence should not be exercised in searching for a brain abscess which may not exist. Syphilis of the Leptomeninges. — Practically all the intracranial lesions of syphilis arise in the meninges and involve the brain only secondarily, by pressure. They are found most often in the arachnoid tissues, especially in the frontal region and at the base. The diagnosis from cerebral tumors is not easy, but the treatment is much the same (p. 030). Encephalitis or Cerebritis, except as it complicates traumatic lesions, concerns surgeons little, unless in localized form (Brain Abscess). There is an epidemic form, analogous to acute anterior poliomyelitis known as lethargic encephalitis; should patients survive and present paralysis, orthopedic treatment is indicated. Brain Abscess. — This is due in about equal proportions to trauma, especially penetrating and punctured wounds, and to suppurative disease of the mastoid cells, middle ear, or other air sinuses of the cranium. It occurs also in pyemia, but very much less frequently. The site of the abscess in the brain depends largely on the focus of infection. Frontal abscess results from disease of the frontal sinuses, ethmoid and sphenoid cells, cavernous sinus thrombosis, etc. Middle- ear disease is the chief cause of abscess in the temporo-sphenoidal lobe; while cerebellar abscess usually is secondary to mastoid disease or lateral sinus thrombosis. The causative condition frequently has been in existence for months or even years, before brain abscess develops. The cerebrum is affected more than twice as often as the cerebellum. The abscess almost always is in the subcortical area of the brain, and seldom has any macroscopical connection with the source of infection, having arisen from embolism (rare), or by pro- gressive thrombosis of minute venous channels. Usually, if not invariably, however, there exists a microscopic connection between the source of infection in the cranial bones and the abscess cavity; the abscess has been compared to a mushroom, growing by a stalk from the neighboring carious bone. Symptoms. — When the abscess follows middle-ear disease, which is its most frequent single cause, and may be taken as the type, it is usual for there to have been some recent exacerbation of the chronic symptoms. The course of a typical case is well sketched by Cushing : after the exacerbation of the old symptoms, arise those of the initial BRAIN ABSCESS 625 stage of brain abscess (headache, nausea, chilliness, and fever) (Fig. 693) ; these may subside, but rarely disappear entirely, for a period of a week or ten days {latent stage) ; then, with more or less sudden cessa- tion of discharge from the ear, symptoms of intracranial sepsis and pressure become evident (persistent headache, mental hebetude, vom- Fig. 693. — Cerebral abscess from mid- dle-ear disease; initial stage: headache, nausea, chilliness, and fever. (G. Laurens.) Fig. 694. — Cerebral abscess from middle-ear disease; manifest stage: per- sistent headache, mental hebetude, and other symptoms of compression. (G. Laurens.) iting, slow pulse, subnormal temperature, and leukocytosis (manifest stage) (Fig. 694). Usually there are no distinct focal symptoms, other than marked tenderness of the overlying skull, and sometimes facial paralysis. Rapid emaciation is a very significant sign. If the abscess is in the cerebellum, meningitis may be simulated (Fig. 695). The distinction between abscess and tumor of the brain seldom is difficult (p. 628). Fig. 695. — Cerebellar abscess from middle-ear disease, simulating meningitis (retraction of the head, occipital headache, etc.). (G. Laurens.) Treatment. — The abscess must be drained as early as possible. Do not delay overnight if you suspect an abscess. Some surgeons prefer to do a tympano-mastoid exenteration first, and then wait a few days, to see if the symptoms suggestive of brain abscess will subside; but if an abscess is present, any delay is dangerous. Many 40 626 SURGERY OF THE HEAD operators prefer to open the intact cranium (Macewen, 1893) over the supposed site of abscess, and to proceed to exenteration of the tympano-mastoid only after evacuating the abscess. For abscess in the temporo-sphenoidal lobe trephine at a point 2.5 cm. above the suprameatal spine. The cerebellum is exposed by trephining below the lateral sinus and posterior to its sigmoid portion. Most aurists think it safer to approach the brain abscess through the middle ear or mastoid, because by this avenue one is most certain to cross the meninges where adhesions exist, and can follow on to the abscess along its " stalk." When the cortex is exposed, in either case, measures should be taken to prevent contamination of the meninges, unless the diseased area is isolated already by adhesions. The brain is then explored by a grooved director, and when pus is found the overlying cortex is incised on the director, sufficiently to secure drainage. This is difficult to maintain, as the semifluid brain tends to block the tube. A glass tube should be used. Should damming up of pus be suspected, the wound must be reopened. Even in the hands of the most skilled and expert surgeons, operation for brain abscess is attended by a mortality of about 50 per cent.; but as all patients will die, and quite as soon, if no operation is done, this should not deter one from trying to save even moribund patients. Brain Tumor. — Any growth within the cranium, whether a true neoplasm or an infectious granuloma, is considered clinically "brain tumor," because productive of the same general signs. Tuber- culoma is the most frequent growth in childhood; these tumors occur with special frequency in the cerebellum, and often are multiple. Syphiloma is more common in adults, being usually a meningeal growth which compresses the brain secondarily. These two types of growth form a larger class of brain tumors than do the true neo- plasms. Of the latter, the most frequent are endothelioma and glioma. The former grows from the meninges, usually is encapsulated and easily enucleated from the cup-shaped depression it produces in the surface of the brain (Fig. 696) ; the glioma, on the other hand, usually is an infiltrating growth of the subcortical area (Fig. 697) and may be with difficulty distinguishable macroscopically from normal brain tissue. Sarcoma which is less usual, grows from the connective tissue of the meninges, frequently invading the bone; or may arise in the cortex, whence it sometimes can be shelled out, owing to peripheral degenera- tive changes. Often it is multiple, and is a more frequent form of metastatic growth than carcinoma. Fibroma is seldom seen except in the cerebellopontine angle. Cysts occur in the brain; some are of para- sitic origin (echinococcus, cysticercus), others are the result of hemor- rhages'into the brain substance, or arise as degenerative changes in a glioma. The latter is the usual cause of cerebellar cysts. Symptoms. — Tumors grow in the brain oftener than in any other part of the body. Hale White (1885) estimated that a tumor is found in the brain in one among every 59 autopsies. They may exist for years and cause no symptoms, if in a silent region or if of very slow BRAIN TUMOR 627 growth. They occur mostly between the ages of fifteen and fifty. In old age and infancy they are rare. It is usual to discuss the symp- toms of brain tumor under two headings, general symptoms, and localizing symptoms. Fig. 696. — Endothelioma of the left hemisphere of the brain in the post-central region. Episcopal Hospital. General Symptoms. — The syndrome of brain tumor comprises the three cardinal symptoms, headache, vomiting, and papilledema. Headache at first is intermittent, but when constant, and especially when referred persistently to one region, which is tender to percussion or pressure, must be regarded as highly significant; probably it is due, as pointed out by Cushing (1908), to pressure upon or distortion of the falx or tentorium, as the brain itself is insensitive. The vomiting, perhaps due to irritation of the pneumogastric nerve, is projectile in character, may occur independently of meals, and be unattended by nausea. Papilledema, optic neuritis, or choked disk, is a characteristic change Fig. 697. — Glioma of the left hemisphere of the brain in the pre-central region. Episcopal Hospital. in the eye-grounds, commonly believed to be due to damming up of the cerebrospinal fluid in the sheath of the optic nerve, as the result of increased intracranial tension. If this pressure is not relieved, hemorrhages may occur in the nerve head and retina, resulting in 628 SURGERY OF THE HEAD permanent blindness. Usually both optic nerves are affected, but unequal involvement of the two nerves does not indicate that the compressing lesion is on the side where papilledema is greatest, unless only one nerve is appreciably involved. Papilledema often is more marked in subtentorial lesions than others. The importance of examining the eye-grounds in all suspected cases of intracranial lesion cannot be too much emphasized, as acuity of vision may persist even when papilledema is moderately far advanced. On the other hand, this sign may be entirely absent throughout the course of the disease. Changes in the color fields, detected by expert ophthal- mological examination, may be one of the earliest of the general signs of brain tumor. No bulbar symptoms, such as occur in com- pression of the brain from trauma, are observed in cases of brain tumor, because the increase in pressure is so very gradual. Occasion- ally a brain tumor, previously unsuspected, makes its presence known first by the occurrence of a hemorrhage into the tumor, the symptoms resembling those of ordinary apoplexy; and in a young adult such an occurrence should rouse the suspicion of a brain tumor. Localizing Symptoms. — These are interpreted through anatomical knowledge of the seat of the cerebral functions. As the increase in pressure occurs very slowly, it is the ride for the development of paralytic symptoms to be delayed, usually being preceded by irritative symptoms (Jacksonian epilepsy, p. 636); and a very slowly growing tumor in a silent region of the brain may produce no localizing symptoms until by encroachment it involves the nearest physiologically recognizable centre, causing "neighborhood" as distinguished from true "focal" symptoms. Thus a tumor in the frontal lobe may make its presence known only by general symptoms (headache, vomiting, papilledema), until so large as to interfere with the motor functions; and when paralysis of motion at last occurs, the incautious observer may jump to the conclusion that the tumor is growing in the motor region; instead of recognizing the fact, as he would have done if an accurate history of the progress of the disease had been obtained, that the growth evidently was primary elsewhere, and had compressed the motor region only secondarily. Diagnosis. — This involves not only the determination whether a tumor exists at all, but also the recognition of the kind of tumor present, and its location. 1. Brain tumor may be closely simulated by the cerebral symptoms of chronic nephritis; the urinary changes in the latter condition are the chief distinction, but as a brain tumor may coexist, the patient should be watched for the development of localizing symptoms. Abscess of the brain usually may be distinguished from brain tumor by the history of trauma, bone disease, etc., which is absent in the latter affection; as well as by the more acute course of the disease in cases of brain abscess. Acquired internal hydrocephalus (p. 599) usually exists as a complication of brain tumor, and as already noted, this condition, rather than the actual bulk of the tumor may be BRAIN TUMOR 629 responsible for the symptoms of intracranial pressure. Increased pressure of the cerebrospinal fluid, as detected by a manometer attached to the lumbar puncture needle, may be another clue. The normal pressure is less than 12 mm. of mercury, and readings of 20 mm. or higher are distinctly pathological (Kolmer, 1918). Sometimes a brain tumor may be detected by aid of a skiagraph. 2. The kind of tumor is very difficult and usually impossible to determine. The existence elsewhere in the body of a tuberculous process naturally would suggest a tuberculoma as the cause of the symptoms; as would a history of syphilis or evidence of past or present syphilitic lesions the existence of a syphiloma. The tuber- culin tests and the Wasserman reaction are also available. The use of antisyphilitic remedies, as a method of exclusion, though quite habitual, should not be persisted in for more than six weeks (Horsley, 1890), unless relief of symptoms is secured sooner; because, in the first place, few intracranial syphilomas are permanently influenced by medication, and, secondly, other forms of tumor may undergo temporary regression under antisyphilitic treatment, only to cause renewed symptoms later. Moreover, it is quite characteristic of the intracranial lesions of syphilis to undergo spontaneous retro- gression and recrudescence, even in the absence of treatment. Lumbar puncture may aid the diagnosis by showing the constant lymphocy- tosis so characteristic of syphilis, or by revealing the tuberculous nature of the affection by appropriate pathological methods. Noth- ing certain can be said of the diagnosis of glioma, endothelioma, sarcoma, etc. 3. The Site of the Tumor. — If in the frontal lobe no localizing symp- toms will be recognized, but there may be certain alterations in intellect appreciable by the patient's family or intimates. Frontal lobe tumors often are found at autopsy on the insane. A certain degree of incoordination may be present, affecting the equilibrium in standing or walking, and causing resemblance to cerebellar tumors. A tumor in the motor area (anterior to the Rolandic fissure) will produce first Jacksonian epilepsy (p. 636), and later motor paralysis of the opposite side, first of the centers nearest the growth, and later of the entire motor cortex of the hemisphere involved. In the 'parietal lobe (just posterior to the fissure of Rolando) sensory disturbances (such as loss of muscle sense, posture sense, etc., or word blindness) will precede Jacksonian fits and loss of motion, which latter phenomena will result when the tumor reaches such a size as to press upon the cortex or subcortical fibers in front of the fissure of Rolando. A tumor in the superior parietal convolution may cause astereognosis. A tumor of the occipital lobe, or posterior part of the parietal lobe, should be suspected if vision is affected early (homonymous hemi- anopsia, sometimes preceded by visual hallucinations, such as flashes of light, seeing objects upside down, etc.). Tumors in the temporo- sphenoidal lobe give rise to deafness, loss of taste and smell, and the convulsions which occur often are preceded by a sensory aura. Tumors 030 SURGERY OF THE HEAD at the base of the brain are particularly' characterized by paralysis of the different cranial nerves, as well as by hemiplegia, hemianesthesia, etc. Tumors of the hypophysis cerebri may produce symptoms of hyperpituitarism (gigantism in infants, acromegaly in adults) or of hypopituitarism (adiposity, with infantilism in children, and loss of sexual characteristics in adults), according as the anterior or posterior portions of the hypophysis are involved; in either case, the general symptoms of brain tumor are present, together with bitemporal hemianopsia from pressure on the optic chiasm. A skiagraph may demonstrate increase in size of the sella turcica. Slibtentorial tumors may be within the cerebellum or may grow from the meninges. The general symptoms occur early, and are constant and severe; and in addition to the cardinal symptoms of brain tumor already mentioned, these subtentorial growths are characterized especially by vertigo, cerebellar ataxia, nystagmus, etc. Most symptoms occur on the same side as the lesion. Of the extracerebellar tumors those growing in the cerebellopontine angle are most frequent; usually they are fibromas, growing from the sheath of the eighth cranial nerve, and cause persistent tinnitus aurium, and deafness of the same side; while at a later stage they cause paralysis of the fifth, sixth, and seventh nerves, and may finally sim- ulate tumors within the cerebellum (Fig. 698). They are lightly attached by a small pedicle, and usually can be enu- cleated easily. Intracerebellar tumors are characterized by the early development of vertigo, changes in the eye-grounds (some- times blindness before papilledema), and sensations of motion of self or of surround- ing objects; the head is tilted, usually toward the side of the lesion, and there is staggering gait, with ten- dency to fall constantly in one direction, often toward the side of the lesion. The ataxia is not increased by shutting the eyes. It is more marked in tumors of the vermis than in those of the hemi- spheres. Tumors of the pons and medulla are rapidly fatal, are not amenable to operative treatment, and often cannot be distinguished from cerebellar growths. Treatment. — An untreated brain tumor uniformly leads to death. Purely medical treatment is ineffective even in controlling the most dis- tressing symptoms, pain and blindness. Operation, merely by relieving an internal hydrocephalus by means of callosal puncture (p. 600) or by removing the overlying cranium and thus relieving the brain of pressure Fig. 698. — Tumor in right cerebellopontine angle. Age forty-nine years. Symptoms began two or three years ago; worse for last six to eight months, since which time there have developed ataxia, deaf- ness, facial paralysis, and loss of eyesight. (Paralysis of sixth, seventh, eighth nerves, paresis of ninth, and double choked disk.) (Dr. F. W. Sinkler's patient.) Orthopaedic Hospital. BRAIN TUMOR 631 (decompression) may cause disappearance of all symptoms for an indefi- nite period, even restoring sight; and in some cases the tumor can be removed, effectually curing the patient. A radical operation, including removal of the tumor, of course, always is to be preferred; but when an unlocalized tumor exists, making its presence known only by the " syn- drome of brain tumor," the surgeon should not hesitate to relieve the headache, check the vomiting, and prevent the development of blindness or possibly to restore sight which has failed, by means of a palliative operation. After such an operation it sometimes happens that localizing symptoms will develop, and thus enable the surgeon to remove the tumor later. A tumor in one of the cerebral hemispheres is exposed by the formation of a bone-flap (p. 632), the bone being replaced after the removal of the tumor. If no tumor is found, or if it cannot be removed safely, the bone is removed from the flap, thus con- verting the operation into one of decompression. Indeed, Horsley never replaced the bone flap even after the tumor had been success- fully removed. But where decompression is planned in advance, the subtemporal operation of Cushing is to be preferred (p. 634). A tumor beneath the tentorium is exposed by removal of bone from one or both occipital fossae; and the bone is not replaced. A tumor of the hypophysis grows either toward the brain, or toward the vault of the pharynx; this usually may be determined by skiagraphy. If the tumor appears accessible from within the cranium, it is best approached across the anterior fossa of the skull, by means of a frontal bone-flap, according to Frazier's modification of McArthur's method (1912) : a large bone-flap with external base is elevated from the right frontal region, and the supraorbital margin and roof of the orbit are temporarily resected. The dura is opened and the frontal lobe is elevated from the base of the anterior fossa, and is incised directly over the pituitary body (1919). The sella turcica may also be approached by the naso-frontal route of Giordano, employed by Schloffer (1907), and von Eiselsberg (1910); or by the infranasal method of Kanavel (1909), employed by Halstead (1910) and by Mixter (1910). In Halstead's operations a preliminary tracheotomy was done, and the pharynx was tamponed. Raising the upper lip, an incision is made through the mucous membrane of the superior alveolus, and the cartilaginous septum of the nose is divided. The nose is then retracted upward. After the bony septum and turbinates have been excised, the anterior wall of the sphenoidal sinus is exposed at the bottom of the wound. This wall being broken through, the posterior wall is identified. This lies at a distance of from 70 to 83 mm. from the anterior nasal spine, and often is thinned by the growth of the tumor within the sella turcica. As soon as the latter cavity is opened, the tumor tissue, which usually is fluid, is evacuated and the cavity is lightly curetted. The tumor cavity and the entire wound are then packed with iodoform gauze, which emerges through the nostrils; the nose is replaced and retained by a suture or two, and finally the alveolar mucous membrane is sutured. 632 SURGERY OF THE HEAD Temporary Resection of the Skull for Brain Tumor. — A skin flap is outlined with ;i narrow base in the temporal region, the flap, which may be of any size, being so situated as to overlie the supposed site of the tumor. I lemorrhage from the scalp is most readily controlled by clamp- ing its whole thickness in numerous Kocher hemostats, at every bleed- ing-point. The "head-high" position lessens venous congestion. The tissues of the scalp are not separated from the underlying bone, which is cut through in the same lines as the skin incision. Various methods are employed for dividing the bone: Frazier cuts the margins of the bone-flap by Cryer's spiral osteotome (1897), which is a side-cutting rotatory f raise, propelled by a dental engine (Fig. (599) ; by this method a curved incision may be made in the skull, a trephine opening being made each side of the base of the flap to admit and to withdraw the osteotome. Most surgeons make a quadrilateral flap, boring holes f) cm. apart, and then connecting the holes by cutting instruments: the Gigli wire saw (1897) is employed for the top of the flap, where the bone is thick, and this portion is bevelled, so that the bone flap when replaced will not sink against the dura; while the thin sides of the flap, in the temporal region may be easily cut by a De Vilbiss cranial rongeur (Fig. 701). The easiest way to drill the holes is by means of Hudson's trephine (Fig. 702). In any case, after the top and two sides of the bone-flap have been cut through, its narrow base (com- posed of the thin bone of the temporal fossa) is fractured by prying up the bone-flap by two bone elevators (Figs. 684, 3). Bleeding from the diploe is controlled by application of minute slips of muscle tissue (cut from the temporal muscle) or by plugging with Horsley's wax: beesw r ax, 7 parts; almond oil, 1 part; salicylic acid, 1 part. Some surgeons prefer to do this operation in two stages, replacing the bone- flap and postponing exploration for the tumor until some days later; but unless unexpected difficulty or delay has attended the formation of the bone-flap, it is better to conclude the operation in one sitting. 1 The dura, being thus exposed over a wide area, is incised concentric- ally with the bone, leaving a sufficient margin to facilitate closing it again by suture. When the cerebral cortex is exposed, the tumor may be found on its surface; it then usually is lightly attached, and may be enucleated. If no tumor is visible, it is justifiable to explore the subcortical region. It is extremely important to control hemor- rhage from the pial vessels; any bleeding points should be caught in mosquito hemostats (Fig. 701) and ligated or sutured with very fine silk. Sometimes it is sufficient to apply minute slips of muscle tissue. To explore the subcortical region an incision with scalpel is made in the middle of a convolution free of vessels, and if an encap- sulated tumor is found it is shelled out by blunt dissection; a cyst should be evacuated and its lining wall removed if this is possible 1 Cushing found that the second stage of such an operation may be con- ducted without the use of any anesthetic, except "primary anesthesia" for suturing the skin-flap at the end of the operation, since the dura and cortex are totally insensitive to gentle manipulation. TEMPORARY RESECTION OF SKULL 633 Fig. 699.— Cutting the bone-flap by means of Oyer's spiral osteotome. Fig. 701. — Cutting the bone-flap by means of the Gigli wire saw. (See Fig. 544.) Fig. 701. — Instruments used in making a flap of the skull: 1, De Vilbiss's forceps; 2, mosquito hemostat; 3, ordinary hemostat; 4, Hudson's trephine (see p. 608, footnote), with four bits; 5, the perforator; 6, 7, 8, burrs to enlarge the original perforation. (See Fig. 702.) lip.l SURGERY OF THE HEAD without trauma. A diffusely infiltrating growth should not be removed. I have seen a surgeon scoop out spoonful after spoonful of tissue from one cerebral hemisphere which was pronounced by several distinguished neurologists who were present to be typically gliomatous in appearance; yet microscopical study proved the tissue removed to be normal cerebral substance, while at autopsy the tumor was found in a totally different part of the brain. Hemorrhage from the brain substance is controlled by extremely gentle irrigation with hot (115° to 120° F.) saline solution, or by light pressure with pledgets of dry absorbent cotton, or the application of muscle tissue. The dural flap is then sutured as accurately as possible; the bone-flap is replaced, and the skin is sutured tightly with closely set (0.5 cm. Fig. 702. — Hudson's trephine in use. apart) interrupted sutures of silkworm gut, which control all bleed- ing from the scalp. Never hurry, and use only extremely gentle manipulations in brain surgery. Keep the wound free from blood, and avoid drainage whenever possible. Decompressive Operation for Brain Tumor. — As stated already, temporary resection of the skull may be converted into a decompressive operation by removal of bone from the flap, replacing only the tissues of the scalp. A better operation, when decompression is planned in advance, is the subtemporal decompressive operation of Cushing: in this a flap of skin is turned down over the temporal fossa, exposing the temporal muscle covered by its aponeurosis; these structures are then divided down to the bone in a straight DECOMPRESSIVE OPERATION FOR BRAIN TUMOR 635 line parallel to the muscular fibres, from temporal ridge to zygoma; by retracting the muscle a fairly large area of cranium is exposed; this is trephined,- and the opening is enlarged by rongeur forceps and the dura is incised around the margin of the skull opening and is left unsutured. The muscle and the skin-flap are then sutured, without drainage. The hernia cerebri, which results, protrudes beneath the temporal muscle, which acts as support, rendering the deformity less conspicuous, but if the intracranial pressure continues to increase, the hernia may become immense (Fig. 704), and may even cause sloughing of the overlying scalp. A similar decompressive operation on the occipital bone may be employed in cases of inoper- able cerebellar tumors. It may be impossible to close the scalp, in Fig. 703. — Cicatrix of operation by bone flap for middle meningeal hemor- rhage. See Fig. 691. Episcopal Hos- pital. Fig. 704. — Hernia cerebri fol- lowing bilateral subtemporal de- compression for unlocalized tumor. Orthopaedic Hospital. some cases of inoperable brain tumor, after decompression has been accomplished, owing to the protrusion of the hernia cerebri; but if necessary this may be diminished by elevating the patient's head, or by lumbar or ventricular puncture. Patients may live for months or years after a decompressive opera- tion, being symptomatically relieved until rapid death results from some incurable complication. Fungus Cerebri should be distinguished from hernia cerebri, mentioned above. The former is an old term which it is convenient to retain to describe granulations ("proud flesh") springing from cerebral substance exposed in a wound, and developing as the result of infection. Fungus cerebri may occur in cases of compound frac- ture, with rupture of the dura and protrusion of brain substance; or in cases of hernia cerebri secondarily infected from sloughing of the overlying scalp. The treatment consists in antiseptic and astrin- gent applications, of which alcohol is the most effective. This grad- 630 SURGERY OF THE HEAD ually causes the granulations to shrivel up. If the fungus is cut off with scissors it will soon return unless the infection is controlled and the wound begins to cicatrize and contract. Focal or Jacksonian Epilepsy, named after Hughlings Jackson, who particularly studied the condition in 1873, was referred to at p. 628, as an occasional symptom of brain tumor. It is characterized by convulsive attacks beginning in one muscle or group of muscles, gradually spreading until finally a generalized convulsion ensues. Consciousness may persist until the convulsions become general, or it may not be lost at all. It is thus distinguished from ordinary ("idiopathic") epilepsy, in which the fits are general from the first and in which unconsciousness ushers in the attack. 1 Jacksonian epilepsy is believed to be due either to some localized cortical lesion, or, rarely (and then most often in children and women), to some peripheral sensory irritation, arising from a painful cicatrix or other lesion such as eye-strain, dental disorders, genital affections, etc. In cases due to cortical lesion the most frequent cause, apart from tumor, is the result of old trauma; this may have been a depressed fracture, or a meningeal hemorrhage producing a meningo-cortical adhesion, a cyst, or a cicatrix. Similar lesions may be the result of intracranial infections, especially in children, in whom focal epilepsy may develop after an attack of meningitis, encephalitis, etc. Treatment. — As there is no medical cure for these cases, it is per- fectly justifiable to consider what benefits may be gained from surgical intervention if a definite lesion can be located. Nor should the surgeon hesitate to operate for any surgical condition in another part of the body in an epileptic patient merely because occasional fits occur; for it happens occasionally that cure of a lesion not sus- pected of having any causal relation with the epilepsy results in freedom from, or at least in a lessening in frequency of the convulsions. If a meningeal or cortical lesion is suspected, the center controlling the muscle group first affected is exposed by a skull flap. Depressed bone is removed; adherent dura is excised, and the reformation of adhe- sion is prevented by the interposition of free transplants of fascia lata or fat. Little can be done for lesions in the cerebral substance. The proper center may be identified by faradization of the cortex. Kocher (1899) believed a decompression operation alone was of benefit. The sooner any operation is done after the development of focal epilepsy, the more apt is it to be curative; and if all head injuries received efficient treatment at the time of the original accident, the number of cases of Jacksonian epilepsy would be much decreased. 1 Advances in knowledge constantly are diminishing the number of cases of true "idiopathic" epilepsy, and it is not impossible that only our ignorance prevents a recognition of an organic lesion in all such cases. CHAPTER XVIII. SURGERY OF THE SPINE. Spina Bifida, or Hydrorrachis. — Under these names are included several forms of congenital malformation of the spine, due to failure of proper coalescence in the embryonal medullary plates. Myelocele, or Rachischisis, is the most complete form. In this the skin is defi- cient, and there is exposed on the back of the infant, usually in the lumbar region, a dark red area covered by endothelium, which is con- tinuous above and below with the central canal of the spinal cord. The infant often presents other serious malformations, and usually is stillborn or dies within a few days from continual leakage of cerebrospinal fluid, or from infection. Syringomyelocele: Here the central canal of the spinal cord is distended with fluid, the surround- ing cord is compressed and atrophic, and protrudes as a cystic tumor through a defect in the vertebral laminae. The protrusion, which is covered by skin, or membrane, usually occurs to one side, and not in the midline. Meningomyelocele is by far the commonest of these deformities, occurring in nearly two-thirds of all cases of spina bifida. The cystic protrusion is formed by fluid which collects in the meshes of the arachnoid, and the roots of the spinal nerves are spread out over the walls of the sac. If the sac presents a dimple or furrow on its surface it is probable that the cord itself is adherent. The laminae of one or several vertebrae may be deficient. Meningocele, in which the protrusion involves only the spinal membranes, and never the nerve roots or the cord itself, occurs only in about 8 per cent, of cases. The tumor is small, covered throughout with healthy skin, never presents a dimple or a furrow, and usually is more or less pedunculated, its orifice of communication with the spinal canal being small. In meningomyelocele, on the contrary, the protrusion is large, sessile, and communicates with the spinal canal through a large defect; and while healthy skin may extend upward from its base some distance, the summit of the protrusion usually is covered by membrane which easily becomes inflamed and sloughing is frequent. Paralysis of the parts below the tumor points to a condition of meningomyelocele rather than of pure meningocele, and it may develop only as growth of the child's body draws the spinal cord away from the skin covering the protrusion, to which it is usually adherent. If there is a defect in the bony wall of the vertebral canal, without the protrusion of any of its contents, the condition is known as Spina Bifida Occulta; this usually is accompanied by hypertrichosis of the region affected. 1 In 1 The only difference in pathogenesis between this and ordinary spina bifida is that in the latter there is abnormality in secretion or absorption of the cerebro- spinal fluid, in addition to the congenital deformity. (637) C38 SURGERY OF THE SPINE very rare cases there has been a defect in the anterior portions of the vertebral canal, constituting Spina Bifida Anterior. Symptoms. — Besides the presence of a cystic growth, usually in the lumbar or sacral regions of the spine, it may be possible to ascertain by palpation or skiagraphic examination that a defect exists in the vertebra?. Compression of the spina bifida usually causes increased tension in the cranial fontanelles, and may produce convulsions. Tension of the cyst is increased during expiration, and when the child is in the upright position. Treatment. — 1. // there are other serious malformations, or extensive I hi rah/si*, no radical treatment should be adopted, as most of these patients will die within the first year under any circumstances. Efforts to avoid infection should be made, by preventing excori- ation of the sac. If such patients survive more than five years, operative treatment, as detailed below, will be proper. 2. If there are no other serious malformations and no paralyses, the treatment to be adopted depends upon the con- dition of the coverings of the spina bifida: when these are healthy, as in most cases of pure meningocele, operation should be postponed until the child is five years of age; when the coverings are thin or membran- ous, the risk from delay is as great as, if not greater than that from early aseptic operation. Imme- diate operation may be required at any time for rupture of the sac, but when a choice is possible, operation during the second or third month of life is to be preferred (Lovett, 1907). Operation usually consists in excision of the sac, preserving healthy skin coverings, and carefully dissecting free adherent nerves, but cutting away those that cannot be preserved, as they probably are functionless (Carson). The sac walls are then overlapped, as in radical cure of umbilical hernia, and the muscles and skin are sutured in separate layers, and the wound is closed tightly without drainage. The death rate following operation is from 25 to 35 per cent., and hydrocephalus sometimes develops as a result. Heile (1910) employed drainage of the sac into the peritoneal cavity by means of subcutaneous silk threads, with coincident cure of a complicating hydrocephalus. In some cases, even of spina bifida occulta, disability may persist in later life from weakness of the spinal column. For such cases bone transplantation, as in tuberculosis of the spine, may secure relief. Sacro-coccygeal Tumors. — See Chapter IV. Fig. 705. — Spina bifida. Age eighteen months. Orthopaedic Hospital. INJURIES OF THE SPINE 639 INJURIES OF THE SPINE. Strains. — Strains of the back, affecting the muscular and aponeu- rotic structures, are much more frequent than true sprains affecting the spinal joints. According to the severity of the injury, these patients are to be treated by rest in bed, or as ambulatory cases, support being provided during the painful stages by adhesive plaster strapping or plaster of Paris jackets. Restoration of function may be aided later by massage. Sprain-fracture. — Sprain-fracture of the transverse processes of the lumbar vertebrse, unilateral, occasionally occurs from muscular action. Tanton (1910) collected 17 cases of this injury. Skillern (1913) reported a case of sprain-fracture of a spinous process. Static Lesions of the Lumbar Spine and Spondylolisthesis are discussed in Chapter XVI. Concussion of the Spinal Cord. — This term has been used to define a condition supposed to be more or less analogous to con- cussion of the brain (p. 614). It implies that there has been injury to the spinal cord without lesion of the vertebral column; and while some hold that the symptoms which follow a supposed injury have no pathological basis for their existence, being merely one form of neurosis, other authorities believe that actual changes in the cord have taken place, and have left more or less irreparable damage. Many of these patients receive their injury in railroad accidents, and the condition which ensues is popularly known as " Railway Spine," or, because of the improvement which usually follows the settlement of a suit for damages, as "Litigation Spine." As a matter of fact it is probable that most of these cases should be considered severe strains or sprains of the back, and the surgical treatment is the same. For the hysterical symptoms which sometimes ensue, the patients should be referred to a neurologist. Hematorrachis. — Hematorrachis or hemorrhage into the spinal canal, usually is extradural and seldom exists as an isolated lesion, but complicates fracture-dislocations of the vertebral column. It manifests its presence first by irritation then by pressure symptoms (p. 665), and, if intradural, is readily recognized by lumbar puncture. If this does not relieve the symptoms of compression, laminectomy is indicated. Hematomyelia. — Hematomyelia, or hemorrhage into the substance of the spinal cord, sometimes occurs from sudden twists or angula- tions of the vertebral column, perhaps from a self-reduced subluxation, without discoverable gross lesion of the spinal column. It is seen oftenest in the lower cervical region (Thorburn, 1889), and causes paralysis depending upon the extent of the lesion (Fig. 706). Usually the lower extremities recover from the paralysis more or less rapidly, though they may remain spastic, while the flaccid paralysis of the upper extremities continues longer and may be permanent. There is dissociated anesthesia below the level of the lesion; that is, while 640 SURGERY OF THE SPINE tactile sensation is preserved, temperature and pain sense are dimin- ished or lost. Lumbar puncture shows no blood in the cerebrospinal fluid. Stab Wounds. — Stab wounds in- volving the spinal cord are very rare. From unilateral lesion a monoplegia may result. It is best in civil life to explore such wounds by laminectomy (p. 647), as it may be possible to re- pair the injury. Fractures and Dislocations of the Spinal Column. — Fracture and dislo- cation occur as a combined lesion in about 60 per cent, of cases of injury of the spinal column, while isolated fractures and dislocations form each about 20 per cent, of these injuries. The spine is most subject to injury where its mobile and immobile por- tions meet, that is, in the lower cer- vical and the dorso-lumbar regions. Pure dislocations are very rare except in the cervical region, as the form of the articular processes renders fracture almost a necessary complica- tion in other portions of the vertebral column. Fractures of the laminae Fig. 706. — Hematoniyelia, showing residual paralyses. Patient fell from a height, acutely flexing his neck. For a week there was complete paralysis below the neck, then gradual recovery. Episcopal Hospital. Fig. 707. — Fracture dislocation of eleventh and twelfth thoracic vertebrae. From a specimen in the Mutter Museum of the College of Physicians of Philadelphia. or spinous processes usually occur from direct violence, as in gunshot wounds, or in falls from a height directly upon the back, impinging INJURIES OF THE SPINE 041 on a stone, fence rail, etc. The most common lesion is a crushing fracture of the bodies of one or more vertebrae, attended by forward dislocation of the vertebra next above, the disjunction of the articular processes taking place on one or both sides (Fig. 707). Such cases generally are caused by sudden hyperflexion, with twist, of the spinal column, as falls from a height on to the feet or the buttocks, crushing injuries from above acting upon the shoulders, or from a dive into shallow water. Violence acting upon the head or neck usually pro- duces a lesion in the lower cervical region, and that acting from below determines lesions in the dorso-lumbar portion of the spine. Symptoms. — These may be divided into those due to injury of the vertebral column, and those caused by accompanying lesions of the spinal cord. It is said that the cord escapes injury in about one-third of the cases. Symptoms from Injury of the Vertebral Column. — Of these, deformity is of most value. This may consist in a depression at the point of injury, especially when the fracture is from direct violence, the spines and laminae being driven forward; or it may indicate that there is a partial forward dislocation of the vertebra whose spine is depressed. Such a de- pression is most apt to be found in a dorso-lumbar injury. In some cases there is angular deformity, a well defined kyphos existing at the point of injury and indicating the collapse of a verte- bral body, causing separation of the spinous processes. Rotatory deformity is seen oftenest in the cervical region, in cases of unilateral dislocation: the head is twisted away from the side which is luxated, and this side may be unduly prominent; the sterno- mastoid muscle on the uninjured side is more tense than is that on the in- jured side. Other symptoms of frac- ture, such as mobility and crepitus, seldom are present ; but persistent localized tenderness is very suggestive of vertebral injury, and in the cervical region muscular spasm, producing rigidity of the neck, is a very usual symptom, especially in lesions of the vertebrae without injury of the cord. A good skiagraph may be necessary to assure the diagnosis in obscure cases. Symptoms from Injury of the Spinal Cord. Motor Symptoms. — Motor paralysis is the most striking and one of the most constant symptoms, and involves all the muscles below the seat of the lesion. Usually it follows the injury immediately, and then indicates extensive destruc- tion of the cord, as a rule from crush due to displaced bone (Fig. 70S). 41 Fig. 708. — Crushing fracture of first lumbar vertebra. Mutter Museum. 642 SURGERY OF THE SPINE If the onset of the paralysis is delayed, it probably is the result of hemorrhage either within the cord {hematomyelia) or in the arach- noid spaces (hematorrachis). In the latter, paralysis of motion usually is more marked f than is that of sensation, and gradually extends upward, perhaps in the course of a few hours. In all cases the primary paralysis is flaccid, and the patient is free from pain, at least in the early stages. If the paralysis becomes spastic very soon (twelve to twenty-four hours) after the injury, and if the reflexes are present, it usually indicates only partial destruction of the cord, from contu- sion, pressure from displaced bone, hematorrachis, etc. Paralysis which first develops some days after a spinal injury usually is due to inflammatory exudation or blood clot. But lumbar puncture rarely shows blood in the cerebrospinal fluid. Fig. 709. — Fracture of cervical vertebrae. Characteristic position of arms when the lesion is above the sixth cervical segment. The external rotators of the shoulder and flexors of the elbow escape. (See Fig. 711, and Plate IV, p. 316.) Episcopal Hospital. In the cervical region, symptoms of cord injury may be obscured at first by those due to cerebral concussion, caused by the same injury. If the lesion is above the fourth cervical segment, causing paralysis of the diaphragm, immediate or rapid death is usual. Symptoms from paralysis of the cervical sympathetic may be present. Char- acteristic attitudes may be assumed owing to unopposed action of intact muscles (Fig. 709), as noted in 1894 by Thorburn. If the lesion is below the second lumbar vertebra, paralysis may be absent or only partial, owing to the fact that the spinal cord itself does not extend beyond this level, and the injury may involve only some of the branches of the cauda equina (Fig. 710) . In rare cases only unilateral (homolateral) paralysis may exist; this is much more usual in stab and gunshot wounds than in cases of fracture-dislocation. INJURIES OF THE SPINE 643 At a later date (after a week or ten days) it is very usual for the patient to experience painful spasms in the paralyzed limbs; and as cicatricial changes in the cord progress the type of paralysis becomes spastic, and contractures develop (Fig. 285). Fig. 710. — ^Fracture-dislocation of the third and fourth lumbar vertebrae. Five months after injury the only residual effects were weakness of left peroneal muscles and some anesthetic areas on right thigh. Episcopal Hospital. Sensory Symptoms. — Sensation is lost over an area corresponding to that of paralysis of motion, and the upper limit of the motor and sensory paralysis is sharply defined, thus determining the level of the injury (Fig. 711). Pain rarely is severe, though a zone of hyperesthesia is not infrequent at the upper border of the anesthetic area. Shooting pains, from irritation of the sensory nerve roots, are more common in partial cord lesions, and often occur when recovery from severer lesions is beginning. Dissociated anesthesia, as already mentioned, is frequent in hematomyelia. lilt SURGERY OF THE SPINE _A 7 . to rectus lateralis _il(o rectus antic minor -Anastomosis with hypoglossal Anastomosis with pncnmogastrio .V. to rectus antic. major. _.N. to mastoid region. .^Oreat auricular n. • -Transverse cervical n. F=£ \N. to Trapezius, Ana. Scap. and Rhomboid. Supra'davieular n. Supra-acromial n. Phrenic n. N. to levator ang. scap. JV. to rhomboid Subscapular n. Subclavicular n. iV. to peetoralis major. .Circumflex n. Musculocutaneous n. Median n. Radial n. Ulnar n. Internal cutaneous n. Small internal cutaneous n. IUo-hypogastrtc n. llio-inguinal n. ..External cutaneous n, .Genito-crural n. Anterior crural it. Obturator n. N. to levator ant -.; SURGERY OF THE SPINE nurse trained especially in this work is desirable whenever her services ran he obtained. If recumbent treatment can be instituted before fixed deformity develops, it may be possible to overcome the deformity already present, to secure arrest of the disease, and to prevent the occurrence of sub- sequent deformity. As in the case of tuberculous coxitis, the only patients I have seen whom I could consider really cured of the disease, without impairment of function, were those in whom such treatment was adopted before the diagnosis was entirely certain. When once a fixed kyphos has developed, it is very seldom that surgery can do any- thing better than to prevent increase of deformity. Fig. 724. — Extension from head and both feet for Pott's disease. Orthopaedic Hospital. When all symptoms of the disease have been absent for two or three months at least, ambulatory treatment may be tried with great caution, and never without efficient support to the spine. The plaster jacket, when properly applied, is a most efficient support. It may be applied with the patient recumbent, or suspended by the head and shoulders, the heels just clearing the floor (Fig. 725). For most cases of thoracic and lumbar disease the prone position is preferable (Fig. 726) : the child lies on a sling attached at both ends, by a bar and ratchet, to a Bradford frame; the sling is left just lax enough to allow slight hyperextension of the spine, and is included in the plaster bandages, being slipped out after the plaster jacket has dried. With a seamless undershirt next the skin, and all bony promi- nences (pelvis, kyphos, axillse) well padded with saddler's felt, such a TUBERCULOSIS OF THE SPINE 657 jacket may be worn for several months in comfort. The surgeon should smell the cast all over every few weeks, and thus may detect very early any evidence of excoriation. As an additional guard against such an occurrence, "scratchers" may be inserted next the skin before the jacket is applied : these are long pieces of bandage, with their pro- truding ends sewed to each other, and are to be drawn up and down every day or so, to keep the skin in good condition. For high dorsal (above the eighth thoracic vertebra) or cervical disease the head and neck must be immobi- lized also; and in such cases it is more convenient to apply the jacket with the patient sus- pended. The front of the cast should be cut away to diminish its weight (Fig. 727). Celluloid jackets, though more difficult to construct, are lighter than those of gypsum, and as efficient. Braces. — These depend more on fixation (limitation of move- ment) than on support in the sense of relief of weight-bearing. Davis's brace (Fig. 728) (1898) takes a fixed point of support at the pelvis (between iliac crests and great trochanters) by means of a malleable steel band ; over the iliac crests pass well-padded straps, attached behind and in front to the pelvic band, which effectually prevent the brace from sliding down- ward. Up from the pelvic band on each side of the spine runs a Fig. 725. — Application of plaster jacket with patient suspended. Orthopaedic Hos- pital. Fig. 726. — Position for applying plaster jacket in Pott's disease. Hospital. Orthopaedic light steel bar, connecting through a cross-bar above with crutch pieces under the axillae; these are supported below by steels attached to the pelvic band in the mid-axillary line. Nothing passes over the shoulders, as the object is not to hang the apparatus from the shoulders, but to support the weakened spine from below. The brace is thus 42 658 SURGERY OF THE SPINE fixed below at the pelvis and above at the shoulders, and presses for- ward on the transverse processes at the level of the kyphos, thus tend- ing to hyperextend the spine and relieve pressure on the bodies of the vertebrae. If the lesion is above the eighth thoracic vertebra it is necessary to support the head also, by an attachment to the spinal uprights. When ambulatory treatment is first commenced, the apparatus should be worn at night as well as during the day, of course being removed once daily for bathing; but the patient never Fig. 727. — The plaster of Paris jacket for upper dorsal disease. The jacket is trimmed away above and below, and the large abdominal window is cut to allow free breath- ing and feeding. (Cheyne and Burghard.) Fig. 728. — Brace for cervical or high dorsal Pott's disease. Ortho- paedic Hospital. should be in any other than the recumbent position except when the sjrinal support is in place. It should be taken off only after he lies down and should be put on again before he even sits up. Some support of this kind scarcely ever can be dispensed with; when it is abandoned symptoms nearly invariably return. This has been demonstrated to be a fact in so many cases that it is almost foolhardy for a surgeon to tell a patient to throw away his braces and go without support. Only after many long months of freedom from symptoms is it desirable to dispense with the crutch pieces of TUBERCULOSIS OF THE SPINE 659 the apparatus, the brace then consisting merely of a pelvic band, spinal uprights, and shoulder-straps (C. F. Taylor's brace, 1863). Such an apparatus gives practically no support, but prevents dangerous degrees of movement in the spine. Operative fixation of the spine, in recent cases of Pott's disease, is now a recognized method of treatment. Albee (1911) splits the spinous processes of vertebrae over the seat of disease and of two more above and below, and inserts in the cleft a transplant from the patient's tibia (Figs. 729 to 731) ; when this grows fast, firm ankylosis is secured. Hibbs (1911) chisels partly through the spinous processes at their base, turns each one down until it comes into contact with the base of the spinous process next below, and thus covers the diseased region of the spine with a solid bridge Fig. 729 Fig. 730 Figs. 729 and 730. — Tuberculosis of vertebrae, in a child aged four years, duration several months. Kyphos disappeared after one month's recumbency. Result of bone transplantation shown in second figure. See Fig. 731. Episcopal Hospital. of bone. I believe Albee's operation of bone transplantation is the best except in adults with marked deformity; for these I prefer Hibbs's method. After operation the patient is confined to bed for about six weeks, and is then allowed to be about with a light brace, which usually may be discarded in the course of a few months. In children under six years the operation seldom is advisable, and in older patients it does not always arrest either the local disease or prevent the develop- ment of a kyphos at another level. I have seen both paraplegia and abscess develop months or years after the operation. Treatment of Abscess. — The general principles which should guide surgeons in the treatment of tuberculous abscesses and sinuses have been discussed in Chapter XV. If recumbency and immobility do 660 SURGERY OF THE SPINE not cause retrogression of the abscess, and still more so if it continues to enlarge, it should be incised through healthy overlying tissues, should be carefully evacuated, its cavity should be thoroughly wiped out with iodoform gauze, and the incision should be tightly closed by several layers of sutures (see Fig. 721). A retropharyngeal abscess requires early evacuation, to prevent rupture into the pharynx or secondary infection from the same source. In adults local anesthesia is sufficient. An incision is made, in the lines of the skin, at the pos- terior border of the sternomastoid muscle, and this is defined and Fig. 731. — Bone transplant in lumbar spine. Episcopal Hospital. drawn forward; usually the bulging abscess is found just beneath the muscle, and may be opened by Hilton's method (p. 50). The abscess wall, the muscle, the platysma, and the skin, should be sutured if possible in separate layers. An abscess in the posterior mediastinum rarely requires drainage; it is exposed by excision of the transverse proc- esses of the diseased vertebra? with the heads and necks of the corre- sponding ribs (costo-transversectomy) . These are approached by detach- ing the spinal muscles from one side of the spinal gutter (preferably on the right), as if a hemi-laminectomy were to be done (Fig. 732). Injury to the intercostal nerves, and especially to the pleura should be TUBERCULOSIS OF THE SPINE 661 avoided. A psoas abscess still within the abdomen may be opened by a small McBurney muscle-splitting incision as in appendicitis (p. 872), without fear of invading the peritoneum if the incision is made close to the ilium and the dissection keeps close to the iliac fossa. After evacua- tion, and thorough wiping of the abscess walls with iodo- form gauze, the wall of the abscess cavity and the struc- tures of the abdominal wall are sutured in layers. A 2)soas abscess presenting be- low Poupart's ligament does not admit of such secure closure, but the abscess wall, the fascia lata, and the skin usually can be closed in separate layers. A lumbar abscess is approached as in operations on the kidney, and usually the abscess wall, the lumbar fascia, and the skin, can be sutured separ- ately. If the abscess is giving no symptoms, does not tend to enlarge, and is not so near the skin as to make probable the occurrence of secondary infection from skin cocci, it should be left alone, and the patient should be treated as if it did not exist. Constant watch, however, should be kept, and proper treat- ment promptly adopted whenever required. It seems unnecessary to add anything as to the treatment of sinuses to what was said in Chapter XV. Treatment of Contractures. — Often recumbent treatment, with weight extension applied first in the axis of the deformity, will allow contractures gradually to be overcome. Occasionally tenotomies are required (adductors, psoas, rectus femoris, tensor fascise femoris, ham- strings, tendo Achillis, etc.). But in many cases which have been neglected, sinuses exist, with secondary infection; amyloid degener- ation of the viscera is present; and nothing remains but to alleviate the patient's miserable state until death ends the scene (Fig. 284). Treatment of Paraplegia. — In almost every case in childhood recum- bency will cause disappearance of paraplegia in the course of six months or a year. In such cases, then, it is only after the failure of such treatment that the question of operation need be raised. In adults, also, recumbency in most cases will cause return of power within that time. If after eight months or a year of recumbent treat- Fig. 732. — Costo-transversectomy. The trans- verse processes of two vertebra? have been excised, and the lines for sectioning two others, as well as the ribs, are indicated. 662 SURGERY OF THE SPINE ment in adults no improvement is noticed and spasticity still persists, I think laminectomy (p. 647) should be done, and the tuberculous granulation tissue excised; the dura should not be opened, as tuber- culous meningitis probably would ensue; and it is quite useless, and perhaps not always harmless, to curette away carious bone from the vertebral bodies. Only when the paraplegia is of sudden onset do I think laminectomy should be undertaken as an early operation. In ordinary cases the symptoms come on very gradually, and the ultimate complete or nearly complete recovery, even after many months of complete abolition of the motor functions, is due to this very feature, as the cord gradually accustoms itself to the condition of pressure. But when the onset is sudden or very rapid (complete paraplegia developing in a few days in a patient previously not even spastic), the cord has not the time to so accustom itself, and there is great danger that it may be damaged irretrievably unless the pressure is promptly relieved. In cases with such rapid onset, as already noted, it is probable that the cause is rupture of an abscess into the spinal canal. Other Forms of Infectious Spondylitis. — Typhoid Spondylitis was referred to at p. 515. When a patient has lain long in bed, with any wasting disease, his spine is apt to become affected from static strain; lying flat on the back, the normal lumbar lordosis may be lost, and the thoracic kyphosis may be increased. As a consequence, when he first assumes the erect posture, or even during convalescence in bed, complaints of stiff back may be made. This condition is not very infrequent after long and serious attacks of typhoid fever, but though it is called colloquially by the name of "typhoid spine," it should not be confused with true typhoid spondylitis. The latter condition is much rarer, and is due, as suggested in 18S9 by Gibney, and as demonstrated in 1906 by McCrae, to definite lesions in the vertebrae, similar to those occurring in the long bones as a sequel to typhoid fever (p. 467). Only a few vertebrae are involved, usually in the lower thoracic or lumbar region. The onset is very acute, resembling the most severe cases of Pott's disease, with great pain, which may radiate along the spinal nerves, and perhaps with cramps in the extremities. Any motion is painful. Sometimes a kyphos develops. Treatment is the same as for tuberculous spondylitis; though ankylosis may result, recovery usually is complete in a few months. The spine may be affected also by gonococcic and pneumococcic infection, as well as by that due to influenza, tonsillitis, etc. The symptoms are subacute in onset, are typical of an infectious as distinguished from a dystrophic process (p. 493); and the diagnosis depends on the recognition elsewhere in the body of the original infective focus. According to Painter, the entire vertebral column, or the greater part of it, is affected at once, the lesions not being con- fined to any one region, as is so frequently the case in hypertrophic arthritis of the spine. There is spinal rigidity, but not much deformity, DYSTROPHIES OF THE VERTEBRAL COLUMN 663 unless this be a slight lateral deviation, or inclination to round shoulders. From involvement of the costal articulations, respiration is hampered. Treatment implies cure of the infecting focus, whenever this can be discovered, with support to the spine during the period of acute symptoms, and counter-irritation, massage, and gymnastics at a later date. The spine may also be affected by what were described in Chapter XV as Acute and Chronic Metastatic Infections. (See below.) Dystrophies of the Vertebral Column. — These affections conform more or less closely to the two main types of dystrophic arthritis discussed in Chapter XV. The term Spondylitis Deformans is quite as indefinite as is arthritis deformans, since it may include both types, or be limited, as it is by some, to the hypertrophic form. According to Poncet and Leriche, as noted already (p. 497), these affections are to be classed as forms of tuberculous rheumatism. Fig. 733.— Atrophic arthritis of spine ; age sixteen years ; duration one year. Fingers, right knee, and left shoulder are involved also. Ortho- paedic Hospital. Fig. 734. — Hypertrophic spondylitis; in- volvement also of acetabulum and pelvis. From a specimen in the Mutter Museum of the College of Physicians of Philadelphia. In atrophic spondylitis the vertebras seldom if ever are affected unless the small peripheral joints have been attacked previously; the spinal changes, therefore, occur merely as an advanced stage of atrophic arthritis as described at p. 493. Fig. 733 depicts the typical attitude 664 SURGERY OF THE SPINE assumed by these patients. Great care should be exercised to exclude any infectious origin for stiffness of the spine, before presuming to make a diagnosis of atrophic spondylitis. In what have been described as the subpyemic and cryptogenous infections, the vertebral column, when affected, seldom presents the rounded kyphosis (Fig. 733) which characterizes the dystrophic conditions; usually it becomes abnormally straight, and the patient often has been described as having a " poker- back." The treatment of atrophic spondylitis has been discussed sufficiently in connection with atrophic arthritis (p. 497). In hypertrophic spondylitis, the spine may be affected alone, or in association with one or more of the larger joints of the extremities. As in hypertrophic arthritis affecting such joints alone, so in the vertebral disease, a history of previous trauma or of actual static strain usually may be obtained. As a rule only a limited portion of the vertebral column is affected, especially the lumbar region, frequently in conjunction with hypertrophic arthritis of the sacro-iliac or hip-joint of one side. The pathological changes closely resemble those encountered in the joints of the limbs, and exostoses or osteophytes frequently may be detected in skiagraphs. Early in the disease there is softening of the vertebral bodies (rarefying osteitis), and considerable deformity may occur, in the form of a more or less rounded kyphosis. As the affection progresses, however, the new-formed periosteal out- growths tend to cover the vertebral bodies with a more or less con- tinuous bridge of bone, rendering the spine absolutely immobile (Fig. 734). Usually this bony coating is situated to one or other side of the median line, and there may be a corresponding lateral deviation of the spinal column. If any of the spinal nerves are compressed there may be neuralgic pains in the parts supplied, and sometimes there are secondary muscular atrophies. This complication was described by Bechterew (1892) as a special type of the disease. When one or more of the "root joints" (i. e., hip, shoulder) of the limbs were involved in the hypertrophic changes, the affection was considered by Marie (1898) a separate disease, and was described by him as "spondylose rhizomelique." In many cases of hypertrophic spondy- litis the affection progresses so quietly that the patients never apply for treatment, and the deformity is discovered by incident or only at autopsy. In others, pain, stiffness, and considerable disability demand relief. Treatment is to be conducted as in cases where other joints are involved in hypertrophic arthritis (p. 501). Intraspinal Tumors. — Usually these are small, more or less encapsu- lated growths, springing from the meninges, and intradural in location nearly as often as extradural. Very rarely has an intramedullary tumor been found. In most of the reported cases the tumors were sarcomatous, but fibroma, endothelioma, echinococcus cysts, and other growths have been found; and it is not unlikely that in some of the cases classed as sarcomatous the microscopical diagnosis was in error. Symptoms. — Pain of a rheumatic or neuralgic character, localized to one limb or to one of the intercostal nerves, usually is the first CHRONIC SEROUS SPINAL MENINGITIS 665 symptom (root irritation). This pain may subside under treatment but is prone to recur, and after a few months or even years is accom- panied by a numbness or heaviness in the affected extremity. Though unilateral at first, the symptoms nearly invariably become bilateral before complete paralysis develops. The ensuing paraplegia conforms to the ordinary type due to "pressure myelitis;" there is spasticity at first, but later complete flaccidity develops. As physical signs of a tumor (deformity, rigidity of the spinal muscles, tenderness) usually are absent, the diagnosis depends largely on the history, on the slowly developing paralysis, and on exclusion of other forms of medullary compression. A neurological consultation is desirable to aid in deter- mining the spinal segment involved. It scarcely ever is possible to determine before operation the nature of the tumor, whether or not it is extradural, or even whether or not it is intramedullary. Treatment. — Immediate resort should be had to laminectomy when once the diagnosis is reasonably certain, as the prognosis is absolutely bad unless pressure on the cord is relieved. The usual mistake, on the part of both neurologists and surgeons, has been to expect to find the tumor at too low a level. Hence the surgeon should expose first that region of the cord which is supposed to be affected; and if the growth is not found there, he should search upward until the cause of compression is found. In 1905 I collected for Harte records of 92 operations for intraspinal tumor; in only 5 of these cases did the surgeon fail to find the tumor, and in three of these it was learned subsequently that it was situated only a very little higher than the region exposed at operation. Elsberg (1914) pointed out that in some cases where an intramedullary or subpial tumor cannot be removed at the primary operation, it will be found to have been spontaneously extruded a few days later. The mortality of the operation is about 40 per cent. Of 185 patients who survived, one-third were classed as cured; over half as improved; and^in only 10 per cent, was no improvement secured (Frazier, 1918). Chronic Serous Spinal Meningitis usually is a complication of chronic serous cerebral meningitis (p. 623), but may occur indepen- dently (Krause, 1906), as a localized collection of serous fluid, possibly the result of a previous infection which has caused adhesion of the pia to the dura over a limited area (Spiller, 1906). It produces symptoms closely resembling those of intraspinal tumor, and the treatment is the same. CHAPTER XIX. SURGERY OF THE FACE, MOUTH, AND NECK. SURGERY OF THE NOSE. Epistaxis or Nosebleed may occur spontaneously or from trauma. Probably many cases of nosebleed thought to be spontaneous really are due to slight trauma, in "blowing" or "picking" the nose. High arterial tension, from renal or cardiac disease, is a predisposing cause. The patient should lie flat with the head slightly elevated, and should refrain from blowing the nose. It should not be thought that hemorrhage has ceased merely because no blood runs out of the nostril, since the patient may be swallowing the blood as it runs backward into the pharynx. Later such blood may be vomited. Cold applications are efficient in checking the hemorrhage in most cases. Applying a small roll of gauze between the upper lip and the alveolar process, in the midline, and compressing the lip over this pad, sometimes will control the bleeding by pressure on the coronary vessels of the lip or the arteria septi nasi. In almost every case the bleeding comes from this artery as it travels upward along the cartilaginous septum just within the nostril. By raising the tip of the nose, and with light reflected from a head-mirror, it often is possible to see this bleed- ing-point, especially if the nostril is sprayed with cocain solution (2 per cent.) or swabbed with adrenalin (1 to 1000). These agents, or hydro- gen peroxide, frequently are effective in checking the hemorrhage. If bleeding persists, and as a last resort, the tampon must be resorted to. If a Simpson splint (made of Bernays's sponge, which when mois- tened swells to eight times its previous size) is available, it may be inserted within the nostril, and usually is very efficient. If bleeding occurs from further back in the nostril, it may be necessary to plug the posterior as well as the anterior nares. This is done by attaching a string to the end of a soft rubber catheter, and passing this (string end first) along the floor of the nostril until the catheter emerges in the pharynx; the string is then pulled out through the mouth, and is tied to a tampon of size sufficient to plug the posterior naris of the bleed- ing side (Fig. 735). As the catheter is withdrawn from the nose this tampon is pulled by the string into the mouth, around the posterior margin of the soft palate and into the posterior nasal opening. An end of string is left long, hanging from the mouth, to facilitate with- drawal. The anterior naris is then plugged from the front. These tampons should not be left in place more than twenty-four or thirty- six hours, as they are apt to excite suppuration, and perhaps maxillary or frontal sinusitis, or even otitis media. A cannula expressly for plug- (666) SURGERY OF THE NOSE 667 Fig. Plugging the posterior nares. ging the posterior nares was invented by Bellocq, and is useful if at hand. Foreign Bodies in the Nose usually may be extracted by fine for- ceps or scoop, under good illumination. If, however, the foreign body lie not on the floor of the nose, nor anteriorly, it will be easier and safer to dislodge it by syringing warm boric acid or saline solution through each nostril alter- nately. Acne Rosacea. — Acne rosacea in its early stages comes under the care of the dermatologist ; but when through long duration and neglect of proper treatment the skin and subcutaneous tissues of the nose have become hypertrophied (Acne Hypertrophiea, Rhinophyma) , then surgical treatment is necessary for a cure. The nose is now enlarged, erythematous, covered with dilated venules or arterioles; and nodules of various sizes and shapes make the patient conspicuous. Treatment: Frequent steaming of the parts, after application of green soap or a soap poultice, or ointments containing sulphur or salicylic acid, may somewhat improve the nutrition of the skin; but in most cases the over-growths require to be removed. Simply shaving oft' these excrescences may suffice, the denuded areas being left to heal by granulation; or excision may be done, and the wound covered with Wolfe skin grafts. Rhinoplasty. — The formation of a new nose, wholly or in part, may be required for various reasons. The deformity known as Saddle Nose (Fig. 1027), occurring as the result of syphilis, old fracture, or other lesion, maybe remedied by implantingbeneath the skin a suitably shaped bridge of bone or cartilage. Subcutaneous injections of paraffin have also been employed. Kolle (1908) uses paraffin with a melting-point of 102° to 115° F., and makes the injections (by means of a special syringe with a screw piston) with the paraffin cold; this obviates danger of embolism. No anesthetic is required if the injection is made slowly, and if only a small quantity is injected at any one time. If the nose is completely destroyed from injury, lupus, syphilis, etc., a new one may be constructed by plastic operations. In the Indian method of rhinoplasty, used by the native surgeons of India for many centuries, and introduced into England in 1816 by Carpue, a flap is taken from the forehead, and is twisted around a pedicle which contains the angular, frontal, and supraorbital arteries of one side (Fig. 736). The flap is made 0.5 cm. larger on all sides than desired, as it is sure to shrink. The edges of the nasal opening are then freshened, and all bleeding is controlled by very fine catgut liga- tures. The frontal flap is then rotated and is sutured in place. A 60S SURGERY OF THE FACE, MOUTH, AND NECK columna may be formed from the upper lip, if thought desirable, after a week or ten days, but usually the orifice of the new nose contracts so much that it is undesirable to subdivide it. The pedicle is not cut through for about a month after the primary operation. The denuded frontal area may be left to heal by gran- ulation or may be covered by Wolfe grafts. The Italian Method of Rhinoplasty, wide- ly employed by Taliacotius in the sixteenth century, consists in transferring a flap from the arm. At the first operation the flap is marked out and is partially de- tached ; when it is sufficiently vascularized and thickened, after the lapse of about ten days, this flap is stitched to the freshened edges of the remaining nasal structures, and the arm and head are securely bandaged together. A plaster-of-Paris dressing is desirable. About ten days or two weeks later the flap is cut away from Fig. 73G. — Outline of frontal flap for rhino- plasty by the Indian method. V 1 1 1 i jf L .. w «S m : , Fig. 737. — Patient with destruction of the nose. Before rhinoplasty. (See Fig. 738.) Fig. 738. — Same patient after rhino- plasty by the Indian method by the late Prof. Ashhurst, 1894. University Hos- pital. the arm; and a columna may be formed then, or subsequently. In all modern operations for rhinoplasty (Keegan, Gillies, 1919) a skin lining for the new nose is formed by inverting flaps which are subsequently SURGERY OF THE CHEEKS 669 covered by other skin flaps. Gillies often uses flaps attached by tubulized pedicles which contain the temporal artery; after the new nose has grown in place, the pedicles of the flaps are cut and restored to the forehead. SURGERY OF THE CHEEKS. Keratosis Senilis or Seborrheic Patch has been referred to in Chap- ter IV as a precancerous condition of the skin. The skin of the face of elderly persons, especially those who have been exposed much to the weather, may present a number of slightly raised, greasy, yellow- ish-brown patches, due to hypertrophy of the epidermal cells, and accumulation of sebaceous matter on the surface. If these patches Fig. 739. — Hotchkiss method of meloplasty. Episcopal Hospital. are picked off and a small bleeding erosion is revealed, this lesion probably is a superficial epithelioma; if no bleeding occurs the lesion may still be in its precancerous stage. Beyond recognizing this fact and acknowledging the possibility that proper treatment by a skilled dermatologist might prevent or at least delay the development of epithelioma, neither pathologist nor clinician can go. Before there is any suspicion of malignancy, careful treatment of the skin should be adopted. The face should be well steamed over a bucket of hot water, at least once daily; after thoroughly drying, a little salicylic acid ointment (10 grains to the ounce) should be rubbed into the seborrheic patches. Sometimes green soap (Tinctura Saponis Viridis, U. S. P.) should be used instead of ordinary toilet soap. D. W. Mont- G70 SURGERY OF THE FACE, MOUTH, AND NECK gomery, who has studied these cases most carefully, wipes off the skin with glacial acetic acid, ami in rebellious cases uses trichloracetic acid, after curetting the lesion; then the arrays are employed. He points out that when the cheeks or other portions of the face are widely affected radical excision is not to be considered even if the epitheliomatous nature of the lesions is recognized; and any flaps used to repair defects left by partial excision will themselves be the seat of these precancerous growths, which will in time develop into epithelioma, causing an apparent local recurrence. If only one or two patches exist, they should be treated by excision, as in fully developed epithelioma. Fig. 740. — Patient, aged fifty-seven years, four days after operation according to the method of Hotchkiss (Figs. 739, 741 and 742), for carcinoma of cheek (Plate viii). Death from secondary hemorrhage fifteen days after operation. Episcopal Hospital. Superficial Epithelioma or Rodent Ulcer occurs more often on the cheeks or forehead than any other part of the face, especially near the ala nasi, on the lower eyelid, or near the angle of the mouth. Some authorities claim that it owes its comparatively benign character to the poverty of these areas in lymphatic vessels. Its pathology and clinical course have been discussed in connection with tumors (p. 124). The question of diagnosis is important. It must be distinguished from deep-seated epithelioma, lupus, and syphilis. Deep-seated epithelioma rarely occurs on the face except on the lower lip; it may develop from a seborrheic patch, but it is much more rapid in growth than the superficial form (months instead of years), and invades the regional lymph nodes. Lupus usually affects young adult patients of scrofulous diathesis; it is very rare in those past middle life in whom epithelioma is common; it almost always presents evi- dence of having healed at some part, which is rarely the case in epithe- SURGERY OF THE CHEEKS 671 lioma; and the typical apple-jelly nodules usually can be discovered around the periphery of the ulcerated areas (p. 294). The facial lesions of syphilis, especially ulcerated gummas, sometimes are mistaken Fig. 741. — Von Eiselsberg's method of splitting the tongue to restore defect in cheek. See Figs. 739, 740 and 742. for epithelioma; but the previous history of the patient, the presence of syphilitic lesions or their traces elsewhere in the body, the cir- Fig. 742. — Von Eiselsberg's method of restoring a defect in the cheek by splitting the tongue. See Figs. 739, 740, and 741. cinate or reniform shape of the ulcers, their greater depth and much more rapid extension, as well as the result of antisyphilitic remedies, and the presence of the Wasserman reaction, will render the correct 672 SURGERY OF THE FACE, MOUTH, AND NECK diagnosis evident. It should not be forgotten, however, that malig- nant changes may develop in old syphilitic or lupous ulcers. Treatment. — Treatment of rodent ulcer consists in excision of the entire thickness of the cheek down to mucous membrane or bone. The wound is then repaired by sliding flap as indicated in Fig. 19G, or by Wolfe grafts. The operation of repairing a defect in the cheek is known as mehplasty. Carcinoma of Buccal Surface of Cheek. — This is an unusual but serious situation for cancer (Plate VIII). The best method of excision is that described by Hotchkiss (1908), which is sufficiently indicated by Figs. 739 and 740. The cervical lymphatics are first excised in one mass, the external carotid artery being ligated; and the mucous surface of the cheek is restored, after extraction of teeth if necessary, by von Eiselsberg's method (1906) of splitting the tongue (Figs. 741 and 742). SURGERY OF THE SALIVARY GLANDS. Infectious Parotitis, called also symptomatic parotitis, and parotid bubo, is an acute bacterial infection of the parotid gland occurring in the course of some general infection (typhoid fever, scarlatina, pyemia, etc.). In rare cases the submaxillary or sublingual glands are similarly affected. In contradistinction to epidemic parotitis (mumps), only one parotid usually is affected, and suppuration is frequent. Cases of this nature may also follow abdominal or other operations, but rarely, if ever, unless general anesthesia has been induced. In all such instances, as in typhoid fever and other wasting diseases, there is abundant opportunity for a direct ascending infection from the mouth along Stenson's duct; and while infection through the blood- stream cannot be denied, it probably is rare. In the substance of the parotid gland, between its lobules, there are numerous minute lymph nodes; and it is possible that some cases classed as parotitis really are instances of lymphadenitis of these nodes. Prophylaxis is important, and consists in measures to promote cleanliness of the mouth and prevent drying of the mucosa around the orifice of the parotid duct. Mechanical injury of the glands should be avoided during anesthe- tization. Treatment. — Local applications (ice bag, painting with iodin, mouth washes) may be useful before suppuration occurs. This should be treated promptly by incision parallel with the branches of the facial nerve. A probe is then inserted, and an endeavor made to secure drainage of all pockets of pus through the one opening; but owing to the dense fibrous stroma of the gland each suppurating lobule may have to be incised separately. Tuberculosis sometimes attacks the parotid lymph nodes, but very rarely affects the gland itself. Excision of these nodes is difficult without injuring the facial nerve. Tumors of the Parotid.- — The peculiarity of parotid tumors is that they usually are of the "mixed" variety (p. 106). This may be due PLATE VIII Carcinoma of Buccal Surface of Right Cheek. In December, 1915, he noticed a white spot where he carried his quid of tobacco. This spot ulcerated in February, 1916. Operation in August, 1916 (Fig. 740). Above is seen the cheek, with fibers of masseter at right. Below is mass of cervical lymph nodes. Episcopal Hospital. SURGERY OF THE SALIVARY GLANDS 673 to the situation of the parotid in the region of the first branchial cleft of fetal life. These tumos are very apt to contain cartilage, with areas of myxomatous degeneration; rarely cysts may form. They occur in young adults, and grow with extreme slowness; often no change is appreciable from year to year (Fig. 743) . At first they are fairly well encapsulated, but owing to the deep relations of portions of the parotid gland, they appear to be fixed at an early stage of development. Though the tumor may grow to an immense size, the facial nerve seldom is affected; but the lobe of the ear becomes dis- placed, outward and upward. If rapid growth develops, as it usually does in time, malignancy should be suspected (Fig. 744). In every advanced cases, secondary enlargement of the cervical lymph nodes may occur. Similar growths may occur in the submaxillary salivary glands, but are much rarer, and seldom are distinctly cartilaginous. Fig. 743. — Mixed tumor of parotid, age forty-two years; duration twenty-two years. Very_ slow growth. Patient de- clined operation. Episcopal Hospital. Fig. 744. — Mixed tumor of parotid (sarcomatous) ; twenty-one years' dura- tion. Weight of tumor two pounds. Re- moved by the late Prof. Ashhurst, 1896. University Hospital. Treatment. — If the patient is seen before the tumor is large, and before rapid growth has commenced, it often is possible to enucleate the growth from the substance of the parotid without injury to the facial nerve or Stenson's duct. Operation should be urged before the tumor grows very large. The incision should be made parallel with the branches of the facial nerve, nearly as high as the zygoma, and the knife should pass at once to the tumor, with no dissection of the superficial structures, as this is apt to injure the facial nerve. The growth is then enucleated, and the wound closed by buried and super- ficial sutures. In malignant cases wide-sweeping excision must be practised if any operation is undertaken, but an attempt should be made to preserve the facial nerve by exposing its main trunk before it enters the tumor. Preliminary ligation of the external carotid 43 674 SURGERY OF THE FACE, MOUTH, AND NECK artery is advantageous. Blunt dissection should be avoided. The parts should be freely exposed, and nothing should be cut that cannot be seen. The operation is tedious, difficult, and dangerous. If the tumor extends far into the retro-maxillary fossa and appears densely adherent there, as ascertained by preliminary examination through the mouth, usually no operation should be done. (See also remarks on Excision of Tumors, p. 132). Mikulicz's Disease (1892) is a rare affection characterized by pain- less, slowly developing, chronic, symmetrical enlargement of the parotid and lachrymal glands; sometimes the submaxillary and sub- lingual glands are involved also. In some cases there is general lym- phatic involvement and enlargement of the spleen. There may be fever. If such constitutional remedies as arsenic and iodide of potash are ineffectual, extirpation may be justifiable for cosmetic reasons, or to relieve pressure on neighboring structures. The cause of the disease is unknown. Salivary Fistula. — This usually arises in the parotid gland, especi- ally in its main duct, as the result of injury (operative or accidental) or suppuration. The secretion discharges on the cheek which is kept constantly moist, especially while food is being masticated. The skin may become very much irritated. The mouth feels dry. The patient is rendered both conspicuous and miserable. Treatment. — If the orifice is in front of the masseter muscle the fistula is not so difficult to cure. A cannula may be passed from the mucous surface of the cheek through the fistula on to the cheek, making two punctures of the mucosa, about one centimeter apart; a fine wire (of silver, iron, or bronze-aluminum) is then passed through these two artificially made mucous orifices (Fig. 745), and is tied on the mucous surface (Fig. 746). The edges of the cutaneous orifice are then fresh- ened, and it is closed by suture. The parotid secretions then find their way along the wire to the mouth, and by the time the wire cuts out and establishes an internal opening the cutaneous orifice has healed. If the fistula is situated over the masseter muscle, at- tempts should be made to con- struct a channel forward in the cheek to its anterior edge, either ^W^^^SA^lLsH';/ Salivary duct -^.Mucosa Cutaneous opening of fistula. Fig. 745. — Operation for salivary fistula: both ends of a wire are conducted to the Fig. 746.— Operation for salivary fis- raucous surface of the cheek through punc- tula: the wire is tied on the mucous sur- ture made by a cannula. face. by establishing a seton, as in the method just described, or by a formal plastic operation. Occasionally partial excision of the parotid SURGERY OF THE EAR 675 gland will be necessary to cause cessation of discharge. If no infection is present, simple ligation of the main duct on the central side of the fistula may result in atrophy of the gland. Sialo-lithiasis or Salivary Calculus is not a very uncommon condition. In 1908 Bendixen referred to 216 cases. The calculous formation is due to bacterial action on the secretion of the glands, as in the pathogenesis of biliary calculi. The calculus usually obstructs the excretory duct, causing secondary enlargement of the glands, with mild inflammatory symptoms. Occasionally recurrent attacks of colic occur. The affection is much more common in the submaxillary than in either the parotid or sublingual gland. Often the calcu- lus is palpable in the floor of the mouth, just beneath the mucosa. Treatment consists in removal of the stone by incision in the floor of the mouth; if the calculus is in the body of the gland, and especially if there is suppuration or a cutaneous fistula, it is better to excise the entire gland, by an incision beneath the mandible. Chronic Inflammation may affect the submaxillary and sublingual salivary glands. The affection may simulate a neoplasm in its gradual onset and indolent course. Usually the glands are found to contain minute abscesses, and there is increase in the connective tissue. Extir- pation is the proper treatment (Fig. 747) . ■ ■ •' g£ 1 /&> ,^> A- ^M wk * £%. .- i* * Fig. 747. — Chronic inflammation of submaxillary and sublingual sali- vary glands and of submaxillary lymph nodes. Episcopal Hospital. SURGERY OF THE EAR. Foreign Bodies. — It is necessary first to ascertain whether or not the foreign body still is present. In children the history is not always very clear, and much harm may be done by incautious exploration. If a probe or forceps is pushed blindly along the canal, the foreign body may be driven further in. Under good illumination from a head-mirror, and by drawing the pinna upward and backward to straighten the external auditory canal, the surgeon will be able to detect the presence of a foreign body (Fig. 748). In children the use of an ear speculum seldom is necessary, but where the canal is hairy, as in many adults, this is indispensable. In most cases persistent syringing with warm sterile saline solution or weak antiseptic will be successful in remov- ing the foreign body; but if this is a pea or bean the soaking may cause it to swell up and thus render its removal more difficult. For such bodies, therefore, and for all others where syringing has failed, delicate forceps or scoop should be employed. The same methods should be employed in cases of impacted cerumen. 67G SURGERY OF THE FACE, MOUTH, AND NECK Furuncle. Furuncle of the auditory canal is an exceedingly painful condition which requires prompt incision. Even though the sharpest knife is used, and the incision made with great delicacy, the pain is excruciating, but if the auriculo-temporal nerve, just in front of the tragus, is infiltrated with a few drops of a 2 per cent, novocain solution complete anesthesia is secured (Skillern, 1913). After opening, the ' ... ' I Fig. 748. — Examination of external auditory canal by light reflected from a head-mirror. crater of the furuncle should be touched with a drop of tincture of iodin or pure carbolic acid; and a small pledget of cotton should be introduced, and an aseptic dressing then bandaged to the auricle. Hematoma Auris or Othematoma usually is the result of a blow. It is not uncommon in patients in insane asylums, who can give no account of its appearance; and on this account it has been thought to have some occult connection with un- soundness of mind. If it ever develops spontaneously, it probably is to be attrib- uted to arteriosclerotic changes. The effused blood separates the skin from the cartilage, usually over the pinna; and unless proper treatment is instituted the auricle will become conspicuously deformed from organization and cicatrization of the thrombus. The blood may be aspirated by a hypodermic needle in very recent cases; but usually the blood is semi-clotted, and an incision is necessary. This should be made along the helix (Fig. 749), and after the blood is evacuated the skin should be reapplied very carefully to the underlying cartilage and should be held against it by accurate adjustment of small pads and a firm band- Fig. 749. — Proper incision to evacuate an othematoma. SURGERY OF THE EAR 677 age. Unless this coaptation is very firm and exact, re-accumulation of blood will occur. After a few days massage should be employed. Prominence of the Auricle, either congenital or acquired, may be remedied by suitable plastic operation. In the usual congenital form the pinna hangs down like a hood, and the condition is named "lop- ear." It may be sufficient to remove an ellipse of skin from the pos- terior surface of the auricle and adjoining scalp, and then to suture the ear against the head and keep it in place by a firm bandage. Some such support should be worn for several weeks. Usually it is neces- sary to excise some of the cartilage of the auricle also. Supernumerary Auricles are not very rare. Excision is the proper treatment. Otitis Media. — The middle ear is a mucous-lined cavity, draining into the pharynx through a long and narrow channel, the Eustachian tube. Infection usually ascends from the pharynx, which often is septic, especially if adenoids are present. Occlusion of the Eustachian tube or of either of its orifices renders the middle ear a closed chamber where microbes are prone to multiply and increase in virulence. The middle ear in these respects resembles the vermiform appendix. In cases of middle-ear disease or its complications, the services of an otologist are desirable; but as these cannot always be obtained in emergency, the general surgeon may be called upon to treat the acute stages of such lesions. Only emergency treatment, therefore, is considered in this work. Catarrhal inflammation of the middle ear frequently develops after an attack of measles, pneumonia, scarlatina, or other infectious disease. It is accompanied by ear-ache, slight deafness, a sense of fulness in the ear, slight feverishness, and probably some dysphagia. Inspection of the drum membrane, with reflected light, through a speculum, shows it reddened and swollen, and sometimes bulging, especially in the posterior part. By moving the patient's head back and forth it may be possible to see the undulation of fluid through the semi-transparent drum membrane. Later the membrane becomes opaque. In acute purulent inflammation of the middle ear the symptoms are the same in kind though usually more severe in degree. The affection usually is purulent from the first, and does not follow catarrhal inflammation. In children the affection may run its course almost without pain, although pressure on the tragus usually is painful, as the bony canal is still incomplete, and movements of the auricle are communicated to the middle ear. Often only a sudden rise of tempera- ture will show any deviation from the normal. This is so frequently the case in children that any sudden rise of temperature during con- valescence from the exanthemas, influenza, bronchitis, etc., demands examination of the ears. If such examination is neglected, the first thing to attract attention to the ear may be the discharge of pus following spontaneous perforation of the drum membrane. 678 SURGERY OF THE FACE, MOUTH, AND NECK Treatment. — Simple "ear-ache," which may be due to referred pain from pharyngeal or dental affections, or may be a mild form of catarrhal otitis media, usually may be relieved by instillation into the external auditory canal of a few drops of hot water. This is quite as efficient as hot laudanum or other drug. It is the heat rather than the drug that is effective. If there is evidence of accumulation of fluid within the tympanic cavity, especially if there is any bulging of the membrane, this should be incised (myringotomy): after suitable cleans- ing of the canal by dilute hydrogen peroxide and aseptic syringing, the incision is made in a curved line around the entire posterior cir- cumference of the drum membrane, thus forming a flap, which allows much more free and prolonged drainage than a mere puncture. The point of the knife should not do more than penetrate the membrane, as the tympanic cavity may be very shallow. The ear is drained by a small strip of gauze extending just as far as the drum membrane; this should be renewed as often as it becomes soaked with discharge — several times an hour if necessary. Several times daily, not oftener than every two or three hours, the canal should be irrigated gently with a weak antiseptic solution. Heat to the mastoid will be grateful, and sedatives may be requisite to allay the pain. The patient must be confined to bed for several days. The nasopharynx, whence the infection usually has come, should receive appropriate treatment. Acute Mastoiditis. — Invasion of the mastoid cells, by extension of inflammation from the middle ear through the aditus and the antrum, occurs in many cases of acute purulent otitis media. Prompt treatment of the middle-ear disease by myringotomy will permit recovery in many cases without permanent damage to the antrum or mas- toid. If the discharge of pus persists long, and is profuse, in spite of proper conserv- ative treatment of the middle ear, it us- ually indicates that there is involvement of the mastoid cells. This is a chronic condition, however, and does not concern us here. Not infrequently, shortly before symptoms of acute mastoiditis appear, an ear which had been "running" for months Fig. 750. — Mastoid abscess j j 1 a j* i_ (left) pointing through petro- or years suddenly ceases to discharge, mastoid suture. Age three and The patient has pain in and behind the a half years. (Dr. Gibbs s case.) 7, P , ■, .„. Episcopal Hospital. ear; there is fever, perhaps chilliness or an actual chill; headache and general malaise. The mastoid is tender, not only at its tip, as sometimes occurs in cases of simple otitis media, but especially over the emis- sary vein and the antrum; and in some cases there is evidence of periosteitis. In children pus often makes its way outward along the petro-mastoid suture, bulges beneath the periosteum, and causes the SURGERY OF THE EAR 679 auricle to stand away from the head in a very characteristic manner (Fig. 750). In rarer cases an abscess forms deep in the neck beneath the sternomastoid muscle (Bezold's abscess). In adults movement of the auricle is not painful; this is an important differential sign from furunculosis of the external auditory meatus. But in children, in whom the bony canal is less well developed, movement of the auricle is communicated to the middle ear and hence usually causes pain. Diagnosis. — This rests on the previous history of the case, namely, onset of ear trouble usually in convalescence from an acute infectious disease; on the existence, past or present, of chronic otitis media; and on physical examination of the ear, showing mastoid tenderness, redness, and edema, perhaps with protrusion of the auricle. Prognosis. — If the infecting organism is the staphylococcus or even the pneumococcus, recovery without operative treatment (other than myringotomy) may occur in a fair proportion of cases. Where the streptococcus or the Bacillus mucosus capsulatus is found, bone destruction is apt to be much greater, and very seldom can operation be avoided. Treatment. — In cases which develop soon or immediately after the first appearance of an otitis media, operation on the mastoid may be delayed one or two days, to ascertain what effect the myringotomy will have on the mastoid symptoms. But if the B. mucosus capsu- latus is found in the discharge from the middle ear no delay in operating should be permitted; operation should not be postponed even until the next day. When the streptococcus is found delay never should be longer than one week, even when clear signs of mastoiditis are lacking. Prompt drainage of the infected bone is demanded. There is great risk of sinus thrombosis (p. 621) or brain abscess (p. 624) if there is delay, especially in cases occurring as exacerbations of long standing middle-ear disease with inefficient drainage. Operation for Acute Mastoiditis. — An incision is made from the tip of the mastoid process upward, parallel with and about 5 mm. post- erior to the attachment of the auricle, for a distance of 5 to 8 cm. This incision passes directly to the bone, but as in children the bone is very soft, great care should be taken not to cut too deeply. If the posterior auricular artery is divided, it should be clamped and ligated at once. The periosteum is then separated from the bone throughout the length of the incision, for a space 2 to 3 cm. in width, exposing the posterior wall of the external auditory meatus, and the suprameatal spine ofHenle. The sternomastoid muscle is then detached from the mastoid tip, cutting it close to the bone. If more room is required at any stage of the operation an incision is carried backward from the center of the post-auricular incision, and the two triangular flaps so formed are elevated from the bone. The surgeon next identifies the triangle of Macewen (1893), which lies above and behind the external auditory meatus; it is bounded in front by the bony wall of this canal and the suprameatal spine, above by the posterior root of the zygoma, and posteriorly by a line joining these two (Fig. 751). This triangle is the GSO SURGERY OF THE FACE, MOUTH, AND NECK guide to the situation of the antrum, over which it lies. In children the antrum lies at a higher level than in adults, in whom it is more behind than above the meatus. Usually the bone directly covering the Fig. 751. — Macewen's triangle, outlined on the skull; and the suprameatal spine of Henle. antrum is perforated by minute venous channels, and the antrum may be located in this way. The antrum may be opened first (Fig. 752), as a b Fig. 752. — Operation upon the mastoid antrum. The antrum (a) has been laid open and gouged out, and the bridge of bone (6) between it and the external audi- tory meatus is seen. (Cheyne and Burg- hard.) Fig. 753. — Operation upon the mas- toid antrum. A bent probe has been introduced from the antrum to the middle ear. (Cheyne and Burghard.) advised by Mace wen; or the surgeon may first remove the cortex over- lying the mastoid cells, from the tip of the mastoid up to the antrum. If a dental engine is available, a rotary burr is a very satisfactory instru- SURGERY OF THE EAR 681 ment. Usually, however, a gouge and mallet are used to remove the cortex, and then the pneumatic cells are excavated by a bone curette or fine gouge forceps. In young children a strong curette will remove the cortex also. The instruments should be made to cut from within outward, unless the parts are fully exposed. The entire mastoid, including its tip, should be removed; and in most cases all the pneu- matic cells which are accessible, wherever situated, should be removed, including any in the posterior zygomatic root. As the pneumatic cells may extend along the petrous portion of the temporal bone even to its apex, it manifestly is impossible to remove all in every case, and in cases where the patient is extremely septic it undoubtedly is better merely to secure free drainage, and to leave the completion of a radical operation for another occasion. But in every case, without exception, it is necessary to open the antrum, and thus accomplish the purpose of the operation, the securing of free drainage of this region of the middle ear through the mastoid. As the bone is being removed it should be repeatedly examined by the probe; the antrum is recog- nized by the probe passing first upward, then forward and inward through the aditus into the middle ear (Fig. 753) . A probe introduced into the middle ear through the perforated tympanic membrane may be an aid in locating the antrum. The structures in most danger of injury are the sigmoid sinus, the facial nerve, and the horizontal semicircular canal. If a gouge is used, cutting from without inward, it should be bevelled on its con- vex surface, and should be applied very obliquely to the surface of the skull, so that if the lateral sinus (Fig. 690) is exposed it will be pushed ahead of the gouge and not wounded. Usually the inner (vitreous) layer of the mastoid process, which separates the sinus from the pneumatic cells, may be recognized when the latter have been cleared away. If there is reason to suspect sinus thrombosis, this bone must be removed also, and the sinus treated as recommended at page 622. The facial nerve is in most danger as it passes outward and slightly backward beneath the floor of the aditus ad antrum. The horizontal semicircular canal projects into the median wall of the aditus ad antrum. The curette should not be used in either of these situations. The roof of the antrum and the aditus is very thin, and the middle cranial fossa lies directly above it; but this will not be opened if no bone is removed above the line of the temporal ridge (continuation of the posterior root of the zygoma). The condition of the bone forming the tegmen antri should be ascertained by very gentle probing. If it is carious or perforated it should be removed gently with curette or gouge forceps, since there may be an extradural abscess above it requiring drainage. The treatment of intracranial abscess has been considered at page 625. When the operation is concluded the cavity is lightly tamponed with iodoform gauze, and the skin incision closed except at the lower angle. An aseptic dressing is applied, and the head bandaged. The 682 SURGERY OF THE FACE, MOUTH, AND NECK after-treatment requires great care. The patient is confined to bed for several days; and the wound is dressed on the third day, and the gauze packing renewed. Not until firm granulations have formed should syringing be employed, but the sinus left by the operation and the external auditory meatus may be gently cleansed with pledgets of absorbent COttOD moistened with dilute hydrogen peroxide. The subsequent care is that for any granulating surface. In the most favorable cases healing is complete in from four to six weeks. SURGERY OF THE LIPS AND PALATE. Hare-lip and Cleft Palate. — These, which are conveniently con- sidered together, are the most frequent congenital deformities of the face. They are best understood by reference to the accompanying dia- gram (Fig. 754), which represents an embryo of three weeks. The fronto- nasal process (a) is descending between the maxillary processes (b b). The eyes are represented by c C, and the mandibular processes by there i- no contra- indication to the use of ether or chloro- form. Ether is preferable in older chil- dren and in adults. It is administered in the "hanging head" position CE. Rose, 1874j, and the surgeon sits at the patient's head (Tig. 756; . The use of a tube for intrapharyngeal anestheti- zation is a great convenience (p. 156) . Hare-lip. — Single hare-lip varies from a mere notch to a fissure extending into the nostril, and perhaps continuous with a unilateral cleft of the palate. The prin- ciple of the operation consists in freshen- ing the edges of the fissure and suturing them together. If operation has been postponed until the age of one or two years, a formal plastic Fig. 7-"/j. — Hare-lip pins in use with twisted suture; points of pins cut off and wrapped in adhesive plaster. 684 SURGERY OF THE FACE, MOUTH, AND NECK operation is preferable to Lane's method already described. The lip is first freely separated from the upper jaw, by dividing the frenum or other adhesions. Bleeding should be controlled promptly by mos- quito hemostats. If there is a mere notch in the lip it is sufficient to employ Nelaton's operation, which consists in incising the lip in the transverse direction above the notch, and in suturing this incision in the longitudinal axis of the body, thus lengthening the lip at the expense of its width. Usually, however, it is better to pare both edges of the fissure in a line slightly concave toward the median line. The knife is entered at the apex of the fissure for denuding each margin; and care is taken that these incisions unite above the apex of the fissure and that enough of each flap is left at the free border of the lip to ensure a 'projection on the vermilion border when the edges are united; if the vermilion border is sutured flush, the contraction of the cicatrix soon will cause a depression. Interrupted sutures of fine silkworm gut or horsehair are used. They are introduced from the cutaneous surface down to but not through the mucous membrane. Or hare-lip pins and a twisted suture may be used for the main support, with superficial interrupted sutures to secure accurate coaptation (Fig. 759). To improve the nostril, a wire suture shotted at both ends may be passed as indicated in Figs. 760 and 761. Figs. 760 and 761. — Method of improving the shape of the nostril. (Stone.) Double Hare-lip. — The operation here is the same as in cases of single hare-lip, the margins of each fissure being freshened and sutured separately; but often it is well to bring a small flap from the larger side across beneath the intermaxillary bone, to form the prolabium; and if there is sufficient tissue a second still smaller flap from the other side may be introduced between this flap and the intermaxillary bone If the intermaxillary bone protrudes and cannot be pushed back into place even by division of its attachment to the septum, it may be excised; but as it bears the central incisor teeth this should not be done recklessly. After the operation the parts are painted with Whitehead's varnish, 1 and a long strip of adhesive plaster is applied from one ear to the other *I$ — Extr. fl. benzoin 12.5 c.c. Iodoform 12.5 gm. Ether 75.0 c.c. SURGERY OF THE LIPS AND PALATE 685 across the upper lip. The baby should be put to the breast or fed from a bottle as soon as convenient, as the motions involved in sucking tend to lessen tension on the sutures. Minute doses of paregoric may be required to check crying. Every alternate stitch may be removed about the fourth or sixth day, and the remainder from the eighth to the tenth day. Cleft Palate. — If the operation is done in early infancy the max- illary bones are cartilaginous, and may be brought into apposition by moderate pressure (Brophy 1900) ; but it is probable that the maxillae are not abnormally distant from each other, and that the defect is lack of tissue in the median line. Nevertheless Brophy's operation permits suture of the vivified margins of the cleft without tension, and restora- tion of normal relations of the parts concerned in phonation before the child begins to talk. Lane (1897) also operates at as early an age as possible. If the operation is not done until after the age of two years, and particularly in older children and adults, a much more difficult and tedious method will have to be employed, and the patient will have acquired improper habits of speaking which he never will be able com- pletely to abandon. When the operation for cleft palate is confined to the soft palate, it is known as staphylorrhaphy; if it involves the hard palate it is called uranoplasty. Before operation is undertaken it is important that the patient be free of coryza, pharyngitis, or other inflammatory conditions of the upper respiratory tract. The best age for operation, in the opinion of the majority of surgeons, is during the second year. Early operation. — This consists essentially in passing sutures of heavy wire across the cleft (above the horizontal process of the palate bone) from the buccal surface of one maxilla to that of the other (Fig. 762). These sutures are then twisted tightly together over perforated lead plates; and when the maxillae are thus approximated the margins of the palatal cleft (pre- viously denuded) are sutured together with interrupted sutures of silkworm gut. The wire sutures are removed after four to six weeks. Though some slight pres- sure ulceration may occur beneath the lead plates no permanent harm is done. Late Operation. — Here the maxilla; cannot be approximated, and it is necessary to close the cleft solely by means of the soft parts. Fergusson's Operation (1844).— The margins of the cleft are freshened first. If they cannot be made to meet, an incision is made through the mucous membrane and periosteum of the hard palate close to the alveolar process; this is not carried so far posteriorly as to divide the trunk of the descending palatine artery as it emerges from the Fig. 762. — Wire sutures passed for uranoplasty in infancy. 6SG SURGERY OF THE FACE, MOUTH, AND NECK posterior palatine foramen, and it is placed so close to the alveolus as to leave most of the branches of this artery on the median side of the incision. Bleed- ing, which usually is very free, is controlled by pack- ing the incision with gauze while a similar incision is made in the palate of the other side. The mucous membrane and periosteum are now separated from the hard palate by suitable peri- osteal elevators from these lateral incisions to the median cleft (Fig. 763). Even when these flaps have been thus freed, it may be impossible to make the edges of the cleft meet in the median line without undue tension. The higher the arch of the palate the easier will it be to make the flaps meet, when thus separated from the palate above. To overcome the remaining tension it may be Fig. 763. —Separating the muco-periosteal flap in the operation for cleft palate. Fig. 764. — Cutting the aponeurosis of the velum at its insertion in the hard palate. Fig. 765. — Introduction of sutures in the operation for cleft palate. necessary to divide the aponeurosis of the soft palate at its attachment to the hard palate. This is accomplished by use of scissors bent on the flat almost to a right angle; one blade is inserted between the detached mucoperiosteum and the under surface of the back of the hard palate, and the other along the nasal surface of the soft palate (Fig. 764) . The freshened edges of the cleft are finally united by inter- rupted sutures of silkworm gut, passed by means of small curved needles, as indicated in Fig. 765. The sutures may be secured by clamping perforated shot over their ends. The wound is then covered by Whitehead's paint. SURGERY OF THE LIPS AND PALATE 687 Lane's Operation. — In this, a flap of mucoperiosteum is detached, inverted, and fixed by sutures under the opposite edge of the cleft (Figs. 766 and 767). The raw surfaces exposed are left to heal by granulation. If the operation is done before eruption of the teeth a wider flap can be secured. Figs. 766 and 767. — Lane's operation for cleft palate. The flap a be is raised along the dotted line, is inverted along a c as el hinge, and its free edge is sutured to the fresh- ened margin def. In the after-treatment the patient, especially if an infant, must be kept with the head low, and so placed that vomited matters, mucus, blood, etc., find a ready exit. If no marked opposition is encountered it is well to spray the mouth and nasal cavities with some weak anti- septic solution every three or four hours. Speaking should not be permitted for a week at the least. Liquid diet (meat juices or broth being preferable to milk) should be employed until after removal of the sutures, when soft diet may be allowed. The sutures should not be removed for ten days unless they begin to cut out sooner. If the opera- tion is not a success, from partial or complete sloughing, another attempt should not be made for at least a month, so as to allow the inflammatory swelling to subside. After convalescence voice and speech training should be systemati- cally instituted. The usual defect in speech comes from the continued habit of speaking through the nose. Such exercises, therefore, are to be enjoined as cause the child to speak through the mouth, raising the palate high against the pharynx and depressing the larynx. Acquired Perforations of the Palate, the result of syphilis, of trauma, or of sloughing following infection, are very difficult to close by opera- tion, and none should be attempted until the parts are in healthy condition. Usually a flap of mucous membrane must be inverted from one or both sides of the perforation. These are sutured together and the denuded area left to heal by granulation. In cases not admit- ess SURGERY OF THE FACE, MOUTH, AND NECK Fig. 768. — Macrocheilia in a boy of seven and a half years; not congenital; followed cellu- litis from injury at eighteen months of age. Orthopedic Hospital. ting of operative relief some form of obturator should be worn in the form of a plate attached to the teeth. The obturator never should be introduced into the perforation itself, as this would surely cause it to grow larger by atrophy from pressure. Macrocheilia. — Abnormal size of the lips, usually the lower, may be due to a congenital condition of lymphangiectasis. This often does not cause marked deformity until the age of puberty. Or the condition may be acquired as the result of hyper- trophy following recurrent attacks of cellulitis (Fig. 768). It frequently is ac- companied by an adenomatous condition of the mucous glands of the lip which may be palpable as shot-like nodules beneath the mucous membrane. The treatment, if any is demanded, consists in excision of a wedge-shaped section all across the lip, with suture of the mucous to the cutaneous border. Cysts. — Cysts of the labial mucous glands form small, rounded, submucous tumors. They may follow biting the lip. If punctured the cysts are apt to refill, so it is better to excise the anterior wall and cauterize the lining membrane. Carbuncle. — Carbuncle, when it affects the upper lip, is an unusu- ally serious form of the disease, from the danger of intracranial com- plications by thrombosis and embolism through the facial and angular veins. Bullock (1912) collected notes of 27 cases, with six deaths, a mortality of 22 per cent. He advocates, and practised with success in one case, early ligation of the facial veins about half an inch below the inner canthus of each eye. Early and free incision of the carbuncle is important, regardless of apparent deformity, as this may be remedied later by skin-grafting or plastic operation. Epithelioma. — Epithelioma of the lip is a frequent condition, and for successful treatment requires early recognition. Frequently it follows chronic local irritation, notably the heat from a short-stemmed clay pipe; the explanation is that the moistened epithelium sticks to the absorbent clay and is peeled off the lip as the pipe is removed. An exfoliation results, with a tendency to keratosis. Less than 9 per cent, of cases of epithelioma of the lip occur in women; in men there is only one case in the upper lip to 45 in the lower, while in women there is one in the upper to every 7 in the lower lip (Butlin). The lesion usually begins to one side of the median line on the vermilion border of the lip (muco-cutaneous junction), and almost without exception is of the more malignant deep-seated type of epithelioma. An epithelioma beginning on the cutaneous surface of the lip often is of the less malignant superficial type (rodent ulcer). SURGERY OF THE LIPS 689 The deep-seated epithelioma growing on the vermilion border of the lip may arise in a seborrheic patch, or as a primary papilloma. The former is much commoner. The lip is supplied by a row of seba- ceous glands which often are visible in lips that appear to be normal, " as a slightly shaded or as a glittering band that stretches like a bow across the front of the lips between one corner of the mouth and the other," about half a centimeter above the cutaneous border (Mont- gomery). Somewhere on this line, crusts tend to form, and a typical seborrheic patch develops. Early invasion of the regional lymphatics occurs; but they are microscopically infected long before they become palpable. They should be searched for carefully, the finger of one hand being placed in the floor of the mouth, and the fingers of the other hand beneath the chin. The submental nodes are those first affected, then those around the submaxillary salivary glands (both sides), and finally the deep cervical lymph nodes along the great vessels. The nodes at first are indurated, and usually painless; but rarely are they distinctly palpable until the labial ulcer has existed for many months. As already remarked, long before they are palpable, probably within three or four months of the appearance of the lip lesion, microscopical examination of the submental nodes will show the presence of carcinoma cells. As time goes on, the labial ulcer becomes a foul, f ungating, stinking crater; the cervical lymphatics form conspicuous tumors; they adhere to the skin and form secondary ulcers of the same foul character as in the lip. The patient cannot eat; the stench renders him loathsome to himself and every one near him; strength gradually fails; hemor- rhages from the growth may occur; the trachea or esophagus may be compressed; and he dies a miserable and painful death, but not as rapidly as he could wish. Diagnosis. — The diagnosis seldom offers much difficulty. Epithe- lioma occurs very rarely in patients under middle age; it is predis- posed to by exposure to weather, by chronic local irritation of any kind; the area affected is covered with adherent crusts, which reveal a small bleeding ulcer when removed; from the surface of the ulcer it may be possible to squeeze out the epithelial pearls and columns of cancer cells lining the sebaceous ducts; the crusts soon form again; and the regional lymph nodes are not palpably enlarged until the lesion has existed for a number of months. A chancre of the lip (Eig. 1008) is of much more acute development; may occur at any age; is frequent on the upper lip; presents parchment-like induration; does not tend to scab but has a macerated or sloughy surface which is very little inclined to bleed; a history of contagion usually can be elicited; lymphatic enlarge- ments occurs within a few weeks, the nodes being soft and juicy on palpation; microscopic examination of smears from the lesion usually will reveal the presence of the Treponema pallidum; in due time skin lesions make their appearance; and antisyphilitic treatment is curative. A gumma of the lips is quite rare; it is painless; there is no lymphatic 44 GOO SURGERY OF THE FACE, MOUTH, AND NECK enlargemenl ; the history or evidence of other syphilitic lesions usually c;in be obtained; and antisyphilitic treatment is rapidly effective. Prognosis. — The expectation of life in cases in which no operation is done is from three to five years from the commencement of the disease, and about eighteen months from the time of diffuse lymphatic involvement. If radical operation is done before the lymphatics are perceptibly enlarged, from 50 to 60 per cent, of patients will be free from recurrence three years later; of those in whom recurrence takes place a small proportion can be permanently cured by a second opera- tion, and the others will have an expectation of life dating from the period of recurrence. Recurrence is much more apt to develop in the lymphatics than in the lip; and a growth which develops in the lip may not be a recurrence, strictly speaking, but a development of a new epithelioma from a seborrheic patch in the neighboring skin used in forming the new lip at the first operation. Treatment. — A lesion on the lower lip which is merely suspected of being carcinomatous should be excised, with a margin of at least 0.5 cm. on all sides, and subjected to microscopical examination. If there is no evidence of malignancy this operation may be regarded as sufficient. If the patient refuses to have the suspected patch excised, treatment as for keratosis senilis (page 669) may be in- stituted; but the surgeon should not forget that he is dealing in the lower lip with a very different form of epithelioma from the rodent ulcer where such treatment is in a few cases successful. There need be no anticipation of success if the growth on the lower lip is really an epithelioma. If such a lesion is either clinically or microscopically malignant, it is necessary to remove the adjacent lymph nodes also. The growth on the lower lip should then be excised with a margin of at least 1 cm. each side, by incisions at right angles to the line of the lip, not by a V-shaped incision. The operation introduced by Grant, of Denver (1899), usually is employed (Figs, 770 and 771). After excision of the lesion, usually including most of the lower lip, in form of a rectangle, incisions are carried downward and outward from the lower angles of this rectangle, so as to expose the submaxillary region on each side. These regions are then cleared of lymph nodes, ligating the facial vessels if necessary. Finally the submental lymph nodes are removed through a separate median incision. By drawing together in the median line the flaps outlined by the two lateral incisions, the lower lip is well restored without further plastic procedure. The other chief merit claimed for this operation is that it leaves the point of the chin untouched, and that this serves as a firm basis of support for the new lower lip. But it will be noted that this method of operation does not remove the labial growth in one mass with its related lymphatics, but extir- pates the diseased tissue in three or four separate sections. Moreover, the cavity of the mouth is opened as the first step in the operation, exposing the entire wound to contamination during the tedious dis- section of the submaxillary and submental regions. SURGERY OF THE LIPS 691 For these reasons I think it is better to commence the operation by the removal of the submental and submaxillary lymphatics (J. Clark Stewart, 1910). These regions are well exposed by making a long curved incision which corresponds to those incisions of Grant's operation Fig. 769. — Grant's operation for epithe- lioma of the lower lip. Fig. 770. — Grant's operation completed. which are represented by solid lines in Fig. 769. The skin over the point of the chin may be left attached by carrying this first incision a little lower than indicated. The flap thus outlined is dissected downward, including with the skin only the platysma, and leaving the fatty and lymphatic tissues in situ. When the submental and both submaxillary Fig. 771. — Epithelioma of lower lip. Above is seen the area of lip excised, and below the mass of tissue containing lymph nodes excised in one piece from submental and both submaxillary regions. Episcopal Hospital. regions have been exposed in this way, they are cleared of lymphatics and fat by dissection from below upward ; and the diseased structures are removed. Incisions are then made upward into the mouth on each side of the labial growth, and the lower lip is excised (Fig. 771). The 692 SURGERY OF THE FACE, MOUTH, AND NECK submental flap is then sutured to the point of the chin, and the Lateral flaps are united in the median line as in Grant's operation (Fig. 770). It is well to drain both submaxillary regions from the outer angles of the lateral incisions for several days. Where the dissection has been very extensive it is better to carry a tube from the submental region in the median line through the floor of the mouth, draining the buccal secretions directly into the dressings, and thus lessening the chance of infecting the suture lines. The portions of the skin incisions not drained should be painted with Whitehead's varnish (p. G84). SURGERY OF THE TONGUE. Tongue-tie. — It happens occasionally, though not so often as mothers believe, that an infant is born with congenital shortness of the fraenum Ungues. The tongue then is held against the floor of the mouth, cannot be protruded beyond the alveolar margin, and may occasion slight difficulty in suckling. The condition is easily remedied by snipping with scissors the tense band close to the floor of the mouth (to avoid the ranine vessels which run beneath the tongue), and then stripping the tongue upward by the fingers as far as needed. The bifid blade at one extremity of the grooved director (Fig. 789) is a convenient retractor to hold the tongue away from the floor of the mouth, while the frenum is being divided. If the separation of the tongue from the floor of the mouth is carried too far, there is danger of the baby being suffocated by "swallowing" the tongue. Macroglossia. — Abnormal enlargement of the tongue, when not dependent upon constitutional causes, such as cretinism, may be congenital or acquired, as in the pathologically analogous condition of macrocheilia (p. 688), and from similar causes. In congenital cases the patients usually are mentally deficient. The protruding tongue becomes inflamed and dry from exposure to the air, resulting in stomatitis, with collection of sordes, fetor of the breath, etc. In time the incisor teeth of both jaws are pressed forward and the alveolar processes are distorted; but this deformity rarely becomes permanent before the tenth year. Treatment. — Treatment consists in partial excision, usually of a wedged-shaped portion of the tip of the tongue, with suture of the remaining lateral flaps in the mid-line. Or, as the thickness of the tongue usually is more obnoxious than its breadth, a transverse resec- tion may be done, making superior and inferior flaps. Preliminary ligation of the lingual arteries may be advisable if the tongue is very large, and Armstrong recommends the use of silver wire instead of silkworm gut for suturing the tongue. The best time for operation is from the third to the sixth year. Ranula. — Ranula is a cystic tumor between the tongue and the floor of the mouth. It is a clinical term, possibly descriptive of the re- semblance of the cyst wall, when exposed at operation, to a frog's belly (Skillern, 1919). Though occasionally congenital, in the vast SURGERY OF THE TONGUE 693 majority of cases it is acquired; usually it is considered a retention cyst of one of the sublingual glands or its duct, but it may be a hydrops of the sublingual bursa of Fleischmann (1841). The cyst in most cases is of slow development and chronic in duration. It is unilocular. Conditions described as acute, and as intermittent ranula are also recognized, though very rare. In the acute cases a swelling suddenly appears beneath the tongue, the mucous mem- brane lining the floor of the mouth is raised above the dental border, salivation is profuse, speech, deglutition, and even respiration are interfered with, and suffocation may threaten. Astringent washes usually are sufficient to relieve the symp- toms, and the cystic swelling may disappear as rapidly as it came, as was the case in the only patient with this rare af- fection I have seen; but. some- times incision is required. In the chronic cases the cyst, though unilateral at first, may spread so as to involve the entire sublingual region; very seldom at the present day is it allowed to grow so large as to project in the submental region. The mucous membrane slides freely over it, and its surface often is covered with dilated and tortuous veins (Fig. 772) ; it is semi-trans- lucent, and the contents are a viscid, ropy fluid. Ranula is most likely to be confounded with dermoid cysts, which, however, are rare; a dermoid cyst has thicker walls, pits on pressure, and is not trans- lucent. Treatment. — Excision of the anterior wall of the cyst, and scraping or cauterizing the remaining portion of the lining membrane, and packing the cavity with gauze until healing by granulation takes place, usually effect a cure. But unless a thorough operation is done and the after-treatment efficiently conducted, recurrence will take place. The operation can be done under local anesthesia, through the mouth. Ludwig's Angina, or Angina Ludovici, is a condition first accurately described by Ludwig in 1834. It is an acute septic inflammatory process involving the cellular tissues of the floor of the mouth and the submaxillary region of one or both sides of the neck. It is important to note that in this definition the main clinical features of the disease are indicated. It affects the connective tissue spaces, being a cellulitis, as asserted by G. G. Davis (1906), not a lymphangitis; the lymph nodes and the submaxillary and sublingual salivary glands are not primarily diseased, but may be invaded secondarily. It involves both Fig. 772. — Ranula. Age eleven years; duration over one year. Projecting cyst is dark blue from overlying vein. Episcopal Hospital. 694 SURGERY OF THE FACE, MOUTH, AND NECK the floor of the mouth and the cervical tissues. It is not confined to either. Usually it owes its origin to infection from dental lesions, and often commences after the extraction of teeth; but it may begin in the tonsil or other intrabuccal structure. The cellulitis spreads with great rapidity from the floor of the mouth around the posterior border of the mylo-hyoid muscle, a route to which attention was called by T. T. Thomas in 1907. Both sides of the neck are affected. The submaxillary gland and lymph nodes usually are found more or less intact in the center of a necrotic area of cellular tissue. It is not unusual for groups of patients to be affected nearly simul- taneously, but the disease does not seem to be contagious. Symptoms. — The onset of the disease is marked usually by difficulty in talking and swallowing, pain in the floor of the mouth, salivation, and finally dyspnea. The patient becomes profoundly septic, but gives evidences of little or no constitutional reaction. The tempera- ture often is not very high, nor is there marked leukocytosis. Edema of the glottis may occur at any time, and T. T. Thomas believes this is the usual cause of death; but in many cases death seems to be due to toxemia, and suffocative symptoms are entirely absent. Diagnosis. — The diagnosis depends on recognizing a possible cause; on demonstrating a cellulitis both in the floor of the mouth and in the upper cervical regions, perhaps extending to the clavicle, and often more marked on one side; and on the rapid progress of the disease to a fatal termination unless relieved by efficient treatment. Treatment. — As soon as the diagnosis is made, and without waiting for the development of more serious symptoms, the parts should be incised. This may be done under local anesthesia; general anesthesia may be out of the question, owing to the suffocative symptoms. An incision is made directly in the median line in the submental region, between the geniohyoid muscles; the knife is pushed up into the floor of the mouth, emerging just behind the symphysis menti. There are no structures of importance in the median line. A drainage tube is then drawn through from the submental region to the floor of the mouth. An incision is then made in one or both submaxillary regions, and a tract is made by thrusting a hemostat into the mouth through the mylohyoid muscle or around its posterior border. Tubes are then inserted in these additional tracts; or one long tube may be made to pass from one submaxillary region to the other across the floor of the mouth above the mylohyoid muscle (Fig. 773). In addition, if the sublingual tissue is markedly edematous, it is well to incise the mucous membrane of the floor of the mouth from the midline to the second molar tooth, as advised by J. W. Price (1908), and gently to curette wherever a soft spot is found. Usually little or no pus is found, the infection being so severe that the tissues are unable to react. The parts are dressed with hot, moist antiseptic gauze, to form a poultice. Con- centrated nutriment and stimulants should be given. Tracheotomy is required when edema of the glottis occurs. The mortality of the affection has varied from 20 to 40 per cent, in different series of cases. SURGERY OF THE TONGUE 695 Fig. 773. — Ludwig's angina, in a patient of twenty-two years. After operation. (Dr. J. W. Price, Jr.'s case.) Episcopal Hospital. Glossitis. — Acute Superficial Glossitis may follow burns, scalds, or other injuries, and the lesion may be catarrhal in character, or associated with destruction of the mucous mem- brane and the formation of one or more ulcers. Stomatitis of similar form may coexist. Healing readily occurs, as a rule, under the influence of alkaline mouth washes. An indo- lent ulcer may be touched with a drop of pure carbolic acid. Acute Parenchymatous Glossitis, in which the tongue suddenly becomes immensely swollen, threatening suffo- cation, is described by systematic writers. It is an infectious process, analogous to but rarer than Lud- wig's angina, and not affecting the sublingual nor the cervical tissues. Treatment consists in incising the dor- sum of the tongue to the depth of 5 to 10 mm., each side of the median raphe, for a distance of about 5 cm. This rapidly relieves the swelling. Abscess of the Tongue may be acute or chronic. Either form is rare, and the chronic form may be indistinguishable from a deep gumma of the tongue. If fair trial of antisyphilitic treatment causes no improvement, an exploratory incision should be made. Incision is the proper treatment also for acute abscess. Chronic Superficial Glossitis is known by various other names, more or less descriptive of different stages of the disease. The best known and most used is Leukoplakia . Other names are Leukoma, Leuko- keratosis, Smokers' Patches, Psoriasis, and Ichthyosis of the Tongue. These conditions derive their surgical importance from the fact that they are recognized as precancerous diseases, analogous to the senile keratosis of the skin discussed at page 669. The pathological change in the tongue consists in a proliferation of the epithelial cells, col- lection of leukocytes, and scar formation immediately beneath the epithelial layer. The patches may occur on the tongue alone, on the cheeks and lips alone, or on both tongue and other buccal surfaces. They are seen oftenest on the dorsum of the tongue near its tip, but not in the median line. They never occur behind the circumvallate papillae. They may be small or large, irregular, circular, circinate, or "geographical" in outline; they always spread, and different patches frequently coalesce. Early in the disease the patches appear as red, shiny, smooth areas on the tongue, surrounded by a distinctly furred area of mucous membrane (Smokers' Patches). Later these patches become bluish white, but retain their characteristic smoothness (Leukoplakia). Still later some evidences of thickening and indura- 696 SURGERY OF THE FACE, MOUTH, AND NECK tion are present, the patches are furrowed, and the fissures may be ulcerated (Leukokeratosis). This stage borders on the development of carcinomatous changes. Cause. — The cause of this affection is not known, but is definitely related to several forms of chronic irritation. Of these the most impor- tant is smoking or the use of tobacco in any form; probably it is the chemicals in the tobacco, combined with the mechanical irritation, and, in the case of smoke, the heat, that renders its use so harmful. But many cases occur in those who have never used tobacco. Other predisposing causes are syphilis, when its tertiary stage is reached; psoriasis, or ichthyosis, elsewhere in the body; the presence of broken, or decayed teeth; irritation from baldy fitting dental plates, etc. Symptoms. — The earliest symptom, which may be overlooked for many months, is smarting in the tongue after excessive smoking or drinking; later, pain is felt whenever highly seasoned or hot food is taken. But the patient may discover the patches accidentally, on looking in the mirror; or they may be called to his attention by his dentist or physician before any definite symptoms have arisen. Treatment.— The use of tobacco in any form should be absolutely prohibited until entire disappearance of the lesions. Any other form of irritation, whether due to dental conditions or dietary indiscretions, should be remedied, and unirritating, preferably alkaline, mouth washes should be ordered. Cauterization of the lesions usually makes them worse. If there is a single, small, localized lesion, it may be excised. If epithelioma is suspected, a portion of the patch should be excised for microscopical examination. Tuberculosis.— Tuberculosis of the tongue is rare. Scott (1916) collected 231 cases, only 26 of which were primary. The lesion com- mences as a tuberculoma, but very seldom is it seen until this has broken down, leaving an ulcer. The primary lesion usually is in the lungs or larynx, and this gives the clue to the diagnosis. The tuber- culous ulcer appears at the tip or edges of the tongue, rarely on the dorsum; it is superficial and lies in the long axis of the tongue; it is not indurated; has not raised or thickened borders; secretes thick and yellowish pus; and may be surrounded by caseous foci. It is commonest in men and in adults (Plate IX, Fig. 1). The ulcer is very painful. Early invasion of the cervical lymph nodes is usual. Treatment. — In the very rare cases where tuberculosis is primary in the tongue it is proper to excise the lesion together with the enlarged lymph nodes. In most cases, however, nothing can be done save to relieve the pain by local use of cocain or other anesthetic. Armstrong says spraying the affected area with a 1 per cent, solution of carbolic acid, to which a little sodium bicarbonate has been added, sometimes is soothing. Syphilis. — Syphilis of the tongue is of most surgical interest in the gummatous stage. Chancre and mucous patches of the tongue and mouth present the same characteristics as these lesions elsewhere, and their diagnosis seldom is difficult. Gumma of the tongue may be >< < >-S a 03 fl a (U c > £tf O o3 o £ '- 03 c W fl CO d 03 CO 99 P CO o3 "5c -c CO CO ._ >. 3 CO Q h CD += 03 > 03 id >. >. a> £ - So« T3 fl £ , CO gH :_ f>5 +3 3 = o a CO - 3 -r _05 05 CO 3 SURGERY OF THE TONGUE 697 single or multiple, superficial or deep. The lesions occur chiefly on the dorsum of the organ; they soon break down, and are apt to coalesce, forming large irregular, nearly painless ulcers with overhanging edges and covered with an adherent slough. The ulcers do not tend to bleed when the slough is pulled away; they are not indurated; they are not accompanied or followed by enlargement of the cervical lymph nodes; a history of previous syphilitic lesions usually can be obtained; and they rapidly improve under the administration of the iodides. These features serve to distinguish them from carcinomatous ulcers (p. 698). Diffuse gummatous glossitis as it heals leaves a charac- teristically fissured and furrowed tongue (Plate IX, Fig. 2). Benign Tumors of the tongue occasionally arise in the lingual tonsil. They should be excised before malignancy develops. Sarcoma. — Sarcoma of the tongue is very rare. Coughlin (1915) collected 60 cases. Carcinoma. — In the tongue this occurs almost invariably in the form of epithelioma, though a few cylindrical-celled carcinomas have been recorded. It is much more common in men than in women (about 15 to 1), and quite unusual before middle life. Frequently it seems to be brought on by chronic irritation, such as that from a broken tooth, from tobacco smoke, or the stem of a pipe (Plate IX, Fig. 3) . The pre-cancerous lesions of the tongue already have been discussed (p. 695), and Butlin demonstrated not long ago that many lesions, previously considered by him and others as pre-cancerous, prove on microscopical examination to be actually malignant. Usually the epithelioma begins in a fissure, an ulcer, or a patch of leukoplakia. Sometimes, but rarely, it appears first as a wart or papilloma; and any such growth on the tongue which does not disap- pear very promptly after removal of a recognized source of irritation should be considered malignant. The epithelioma commonly appears on the lateral margin of the tongue, very rarely at the tip, and almost never on the dorsum. It begins occasionally as a submucous growth, but even in such cases it is very seldom seen until an ulcer has formed; and in the vast majority of instances it develops in a preexisting erosion or ulcer. It may begin in the floor of the mouth, but it is more usual for this to be invaded secondarily. A cancer in the ante- rior third of the tongue tends to spread to the floor of the mouth and mucous membrane covering the alveolus; it early invades the sub- mental and submaxillary lymph nodes, first those on the same side as the growth, but later the involvement is bilateral. Next the deep cervical chain is invaded. The submaxillary and sublingual salivary glands usually are not invaded. A cancer in the posterior two-thirds of the tongue tends to spread to the soft palate and pharynx; it invades the lymphatics of both sides very early; first the submaxillary, then the deep cervical. When the latter have been invaded by cancer arising in any part of the tongue, the growth spreads up their chain to the base of the skull and downward to the clavicle. Distant metastases occur very late and are quite unusual. In the vast cm SURGERY OF THE FACE, MOUTH, AND NECK majority of cases the disease is distinctly limited to the face and neck. When once the cervical lymph nodes are invaded, the tumor may grow in them with alarming rapidity, and these secondary growths may quite over-shadow the original trouble. The same progressively fatal course, but even more rapidly, is observed here as in the cervical growths following carcinoma of the lip (p. G89). Symptoms. Tain and smarting in the diseased area, especially on smoking, drinking alcoholic beverages, or eating hot or highly seasoned food, usually are the first things to attract the patient's attention. The tongue, or the whole mouth, may feel sore. There is difficulty and pain in swallowing, and the patient refrains from eating. Later even liquids can scarcely be taken. The tongue feels thick and clumsy. Speech becomes in- distinct. Salivation is increased. Pain may be referred to the ear if the growth is far back in the tongue. Very rarely is pain al- together absent; but occasionally the patient is unaware of his condition until the tumor is inoperable. From inability to eat, sleepless nights, and constant pain, the patient rapidly becomes emaciated. If secondary infection occurs, there will be added fever- ishness, chilliness, and increased secretion from the tumor, with hor- rible fetor of the breath. Hemorrhages may occur from the mouth or from secondary ulcers in the neck. Death may occur from such a complication or from septic inhalation pneumonia, but more often follows a short period of delirium due to toxic absorption. Diagnosis.— Carcinoma of the tongue must be distinguished chiefly from tuberculous and syphilitic ulcerations. The characteristics of these have been considered already (p. 696); but it should not be forgotten that carcinoma frequently develops in a syphilitic lesion. In carcinoma the main diagnostic points are the hardness of the ulcer's base; the thickness of its margins, the bleeding when the adher- ent slough is removed, exposing an uneven floor; the patient's age; and the existence of some chronic form of local irritation. Any ulcer even suspected of being carcinomatous should be subjected to micro- scopical study. A portion of the ulcer may be removed easily by pulling the tongue far out of the mouth and injecting some eucain solution beneath the ulcer; a 'portion of the indurated margin of the ulcer is then pinched up in forceps and cut off with scissors. Enlargement of the lymph nodes never should be depended upon for a clinical diagnosis. Long before they are palpable they are microscopically diseased. Yet Fig. 774. — Recurrent carcinoma of floor of mouth. Excision of tongue by intra- buccal method in September, 1909, three months after appearance of growth. Re- currence in November, 1909. Photograph February 14, 1910. (Dr. H: C. Deaver's case.) Episcopal Hospital. SURGERY OF THE TONGUE 699 the presence of enlarged lymph nodes points to carcinoma rather than to a tertiary syphilitic lesion. Prognosis. — In cases entirely untreated, the expectation of life is not more than eighteen months from the time the growth is recog- nized. In many cases death occurs in less than nine months. By radical surgical treatment the expectation of life is almost doubled, and a certain number of patients (25 per cent, in Butlin's statistics) , in whom early operation is done, remain free of recurrence for many years or until death from some other malady. Even in cases where recurrence takes place, this is almost always in the neck, and the patient is still able to take nourishment and does not suffer nearly so much pain as if the tumor was still growing in the mouth. The imme- diate mortality after radical operation is in general from 15 to 20 per cent. It is lower in uncomplicated cases, and much higher when part of the mandible or pharynx has to be removed. Treatment.— Owen well said (1908) that most of these patients come to the surgeon when the tumor is so far advanced, that if he considered only his own peace of mind he would decline to undertake any operation. But whenever it is not inoperable, radical removal of the growth and the related lymph nodes is the only rational treatment. In deciding for or against operability, the surgeon should examine especially the local extent of the disease, and the range of lymphatic involvement. A cancer of the tongue cannot be considered inoperable merely because it has invaded the floor of the mouth or has eaten into the mandible. But if the entire floor of the mouth, on both sides, is densely infiltrated, and especially if the growth has extended along the anterior pillar of the fauces to the soft palate or pharynx, it generally will be impos- sible to cut wide enough of the growth to ensure freedom from local recurrence. In regard to lymphatic involvement, the surgeon should examine carefully and repeatedly the deep cervical lymphatics extend- ing up to the base of the skull. If these are manifestly involved, and certainly if they are immovably adherent to the spinal muscles or the skull itself, he should decline to interfere with them. Involvement of the lymphatics downward is not so serious a matter, since it is very seldom that the disease process passes beyond the subclavian triangle; and the contents of this triangle and those above it can be removed with comparative facility by modern methods. Most surgeons prefer to do in two stages whatever form of^operation is undertaken and if the disease is advanced, this is the only safe plan. Usually the lingual growth is removed first; and after a week or ten days the cervical lymphatics are dissected out. In early cases (3 to 5 months' duration) it may be sufficient to remove the lymphatics only from the bifurcation of the carotid up to the tongue and base of the skull ; in more advanced cases the dissection must commence as low as the clavicle. If only the anterior third of the tongue is involved, most surgeons consider it sufficient to remove the submental nodes and the cervical nodes of the same side as the lingual lesion; but Da Costa (1908) urged that even in such cases the cervical lymphatics also on the other 700 SURGERY OF THE FACE, MOUTH, AND NECK side should be excised, as he had found them involved at a very early stage. Nearly all authorities are agreed that, when the tumor involves the posterior part of the tongue, the lymphatics from both sides of the neck ought to be removed. This may require the division of the opera- tion into three stages. Owen recommends, if the lymph nodes are increasing very rapidly in size, that the first operation should consist in extirpating them, since if the tongue is removed first, and the opera- tion on the lymph nodes postponed for a couple of weeks, they may have become inoperable by that time. The questions of the preparation of the patient and of the anesthetic are of importance. For several days previously special attention should be given to cleansing the patient's mouth, and improving so far as possible, his general health. No operation should be done while there is an acute bronchial or pulmonary lesion. The anesthetic, preferably ether, should be given by a skilled anesthetist; wherever possible (and this should be the case in every well appointed hospital) the method of intratracheal insufflation (p. 155) should be employed. This minimizes or altogether prevents the chance of pulmonary com- plications, and permits the operation to be done in the head-high position, which markedly decreases the quantity of blood lost. If this method cannot be used, one of the other methods recommended at p. 155 for operations on the head and neck should be employed. A hypodermic of morphin and atropin should be given shortly before beginning the operation. For early cases the operation I described in 1915, is suitable; it is based on Crespi and Bastianelli's modification (1890) of Langenbeck's method (1875): (a) The cervical lymphatics are first removed on the diseased side through an incision passing from the chin to the hyoid bone, and thence to the mastoid, well below the body of the mandible (Fig. 775) . By well undermining this incision a much larger area of fat and lymphatics can be reached. The branches of the external carotid are ligated, but the descendens hypoglossi, the hypoglossal, the superior laryngeal and spinal accessory nerves are carefully preserved. When the entire area has been cleared, the skin flap is turned over the cheek (Plate X, Fig. 1) and the mass of fat and lymphatics is removed. (6) A suture is passed through the tip of the tongue, and a mouth gag is inserted on the opposite side of the mouth. The original skin incision is then continued from the chin up through the lower lip; this is detached from the alveolus, and the cheek is turned aside. Another traction suture is now passed through the glosso-epiglottidean fold, and both this and the suture through the tongue are drawn taut. Next the frenum and the mucosa between tongue and alveolus, and the anterior pillars of the fauces are divided; the tongue can now be pulled far forward, and its base and the muscles still holding it to the hyoid bone, can be cut under full visual control (Plate X, Fig. 2). The lingual artery on the opposite side will bleed in the stump of the tongue, and require ligation (Fig. 776). Molar teeth on the diseased side are then extracted, and the corresponding alveolus is cleared of mucous mem- SURGERY OF THE TONGUE 701 Fig. 775. — Skin incision for excision of the tongue. University of Pennsylvania. Fig. 776. — After removal of tongue, the floor of the mouth is covered partially by suturing the mucosa of cheek across the alveolus to stump of tongue. A hemostat is on the right lingual artery in the floor of the mouth. University of Pennsylvania. 702 SURGERY OF THE FACE, MOUTH, AND NECK brane or excised; this permits the mucosa on the buccal surface of the cheek to be drawn in as a flap and sutured across the denuded alveolus Fig. 777. — Skin incision sutured; drainage tube in place. Suture through glosso- epiglottidean fold retained for first twenty-four to thirty-six hours. University of Pennsylvania. to the stump of the tongue (Fig. 776), thus rendering a bucco-cervical fistula less likely. The remaining portion of the stump of the tongue is Figs. 778 and 779. — Excision of tongue by method illustrated in Plate X, eight months after operation. Death from intercurrent disease, without recurrence, nearly four years after operation. Episcopal Hospital. sutured to whatever mucosa remains in the floor of the mouth; the cheek is reattached to the mandible, and the lip and neck wound are '■""**j>> H « <■ c3 o _rPM W < -J 1 1 1 " A 03 — '3 -3 03 a> -q fH ? rC +^ i M c3 "C h H 11 C ^ *s s '5 m Cfi a T3 O += S X -g ^ w J 1 -5 "rt g .2rfS > "^ ^ 02 0) • £ u >rl a> a -6 & 2^ o y — « S 0> c E-> o 8 d "" 03 « 03 S3 _ a a c'£ O tn '-5 o c •*» !0 o> § " 0) " ~ m c3 & SURGERY OF THE TONGUE 703 accurately sutured, with tube drainage from below the floor of the mouth to the most dependent portion of the incision (Fig. 777). The resulting scar is inconspicuous (Figs. 778 and 779) . If the lymph nodes re- moved are found to have been in- vaded by carcinoma, those on the opposite side of the neck are to be removed after two or three weeks' interval. For more advanced cases, the cervical lymph nodes must be re- moved all the way down to the clavicle, and always on both sides of the neck. The incisions shown in Fig. 780 are suitable for this purpose; the two sides should be operated on at an interval of three or four weeks; first the triangle a b c is turned up, and when, working from below upward, the submaxillary and submental regions are reached, the incisions a d and a e are added, and very full exposure secured by elevating the Fig. 780. — -Incisions for extirpation of the cervical lymphotics. See text. A B Fig. 781. — Inoperable carcinoma of floor of mouth, after its arrest by cauterization and by excision of both sternomastoid muscles and lymph nodes on both sides of neck, through incisions shown in Fig. 780. Death from exhaustion fifteen months after operation. Episcopal Hospital. large flap e ab c and the smaller flaps d a e and dab. In such cases all the fat and lymphatic tissues, in one mass with the sternomastoid muscle (Fig. 781), are excised, clamping temporarily the common 704 SURGERY OF THE FACE, MOUTH, AND NECK carotid artery low in the neck, and if necessary excising the internal jugular vein. Even the vagus nerve and the common carotid may be extirpated on one side if necessary;, but in those past fifty years of age loss of the common carotid is inadvisable on account of the danger of cerebral complications. The tongue may be removed at the same time that the first side of the neck is being cleared by extending the incision ad through the lower lip, and turning the cheek aside, as in the method just detailed. Other methods of excision of the tongue are in current use: 1. I iiira1>urc(il Method (Whitehead, 1881). — After dividing the frenum, the anterior pillars of the fauces, and the mucosa covering the floor of the mouth, the tongue can be pulled far out of the mouth (Roux, 1839); it is then cut away, wide of the growth, and the lingual arteries are caught by hemostats in the floor of the mouth, and the dorsales lingiue are caught in the stump. 2. Method by Division of the Symphysis Menti. — This operation was introduced by Sedillot (1844) and a few years later by Syme. Kocher adopted it as his normal method. It is used for removal of the entire tongue in cases where the floor of the mouth is involved. The lower lip is divided in the mid-line, and this incision is carried down to the hyoid bone. The mandible is then drilled in two places on each side of the mid-line, to facilitate its subsequent wiring. The symphysis is then sawed through, and the halves of the mandible are separated. Rough handling may cause a fracture. The mucous membrane on the floor of the mouth is then divided, the lingual arteries are caught and tied, and the tongue, with as much of the floor of the mouth as necessary, is removed in one mass. The stump, with the two spurting dorsales linguse arteries, is treated as in Whitehead's method, over which this operation presents few advantages. The exposure is not very much better, the wound left is very prone to infection, and the jaw frequently fails to unite solidly. When it is necessary to excise a portion of the mandible along with the tongue and the floor of the mouth, Crespi and Bastianelli's modifi- cation (1890) of Langenbeck's method (1875) is to be preferred. After clearing the cervical region, as already described, and turning aside the cheek, the mandible is divided well in front of and behind the growth, and the tongue and floor of the mouth are removed in one piece with it. For cancer arising in or involving secondarily the floor of the mouth, temporary division of the mandible between the second and third molar teeth, as in Langenbeck's original method, may be necessary, even when the bone itself is not invaded by cancer. To remedy the defect in the floor of the mouth, the mucous lining of the cheek should be turned inward across the denuded alveolus, as already advised (p. 700). After removal of the tongue the patient still can make himself understood, and swallowing is not interfered with. Palliative Operations sometimes are possible, even when the disease is too far advanced to afford hope of cure. The most important of OPERATIONS ON THE AIR SINUSES 705 these methods is extirpation of the external carotid arteries, on both sides, as introduced by Dawbarn (1903), to effect starvation of the lingual growth. Or they may be injected with paraffin. These methods are not applicable to cases where the lymphatic involve- ment over-shadows the original growth. Excision of, or alcohol injec- tions into, the lingual nerves may alleviate the pain; and repeated cauterization of the ulcer in the mouth may render life endurable (Fig. 781). Elect ro-dessication (for superficial growths) and electro- coagulation (for deep-seated neoplasms) are useful in similar circum- stances (W. L. Clark, 1912; Pfahler, 1914). OPERATIONS ON THE AIR SINUSES. The air sinuses are mucous-lined cavities draining into the nasal passages, and like the middle ear are prone to become infected when their drainage is obstructed. The cure of adenoids, deflected septum, hypertrophied turbinates, and other seemingly minor conditions, therefore, becomes important as a prophylactic against more serious ailments. Acute infections of these accessory sinuses usually are treated successfully by the rhinologist by the intranasal route, and are by no means so important surgically as chronic infections, which require radical operation for their relief. These chronic lesions may consist merely of empyema of the sinus affected, or there may be exuberant granulation tissue, or even mucous polypi. As all these affections are rightly considered a part of the specialty of nose and throat diseases, it seems inexpedient to do more here than outline in the briefest possible manner the nature of the operations at present employed in their treatment. An acute exacerbation of a chronic lesion may occur at any time, and. may be quickly fatal, especially in the case of the frontal, ethmoidal, and sphenoidal sinuses, unless immediate adequate drainage is provided. The diagnosis of chronic sinusitis is not always easy, but depends in large measure upon persistent discharge of pus, found by intranasal examination to enter the nasal passages in the region where the suspected sinus normally drains. There are in addition, when drain- age is inefficient, usually headache and localized tenderness. In ethmoidal disease the pain usually is referred to the bridge of the nose and the eyeball; in sphenoidal sinusitis it usually is between the eyes and in the occipital region; in frontal sinusitis the pain and tenderness are localized to the region above the root of the nose and the inner margin of the orbital cavity, and occasionally the pus perforates anteriorly and forms an abscess at the root of the nose; in maxillary sinusitis the pain may be referred to the teeth, the nose, or all over the head, but tenderness usually is localized to the maxillary bone. As a preliminary to all these operations, preparation of the nasal passages by a course of conservative treatment is essential to success. This usually comprises removal of the anterior portion of the middle turbinate bone which almost invariably is thickened and interferes 45 700 SURGERY OF THE FACE, MOUTH, AND NECK with intranasal drainage. In cases of patients acutely ill it often is better to do an operation which is incomplete from the specialist's standpoint, consisting merely in securing adequate drainage by the most accessible route, and to postpone the ideal radical operation to another occasion, as in the parallel cases of acute mastoiditis (p. 079). Drainage tubes or gauze, employed in these nasal operations never should be allowed to remain in place more than forty-eight hours. Careful after-treatment, preferably conducted by a rhinologist, is necessary to complete the cure. The maxillary antrum communicates with the nasal cavity through its middle meatus, and the opening is some distance above the floor of the sinus so that drainage is very imperfect. Infection may follow nasal disease or be due to extension upward from a carious tooth. When conservative measures fail, the surgeon may break through the outer wall of the nasal fossa, in the inferior meatus, thus establishing drainage at the level of the floor of the antrum. This may be done in emergency by firm pressure with the blunt ends of the blades of scissors curved on the flat. Usually it is preferable to open the maxillary sinus by gouge and mallet through the canine fossa, after incising and reflecting the mucous membrane and periosteum. A large opening in the outer wall of the sinus should be made, and its cavity should be cleared of polypi, necrotic bone, etc. Then the inner wall of the sinus is broken down as far as the level of its floor, working across its cavity. The nasal mucous membrane is preserved, is formed into a flap attached along the floor of the nose, and is turned outward to cover the floor of the maxillary sinus, which is thus freely drained into the inferior meatus of the nose. This mucous flap is held in place by packing introduced from the nasal cavity, and the incision in the alveolar tissues is closed by suture. The frontal sinus is readily exposed by applying a small trephine just to one side of the glabella. As the size of these sinuses is extremely variable, not only in different individuals, but also on the two sides of the same individual, the surgeon always should make an opening which is small and close to the root of the nose, so as to run no danger of entering the cranial cavity. This opening may then be enlarged with gouge or rongeur. A tract for drainage into the middle meatus of the nose can be made by enlarging the infundibulum with curette. Such drainage, by a tube passed from the inner angle of the frontal incision down into the nose, is sufficient in emergency. Lothrop (1915) to ensure free drainage and prevent secondary invasion of the other frontal sinus, opens this also into the nose, converting both sinuses into one large cavity. The anterior ethmoidal cells frequently are diseased along with the frontal sinus, as they usually drain into the upper part of the infun- dibulum; and they are best evacuated across the opened frontal sinus. The middle and posterior ethmoidal cells drain into the middle meatus and the superior meatus, respectively. They may be reached by resec- tion of the os planum, after exposing the inner wall of the orbit. SURGERY OF THE JAWS 707 There may be a fistula in this situation, or even an abscess between the os planum and the eye-ball. Drainage into the nasal cavity and from the external wound is provided for. For radical cure, Killian's operation is preferable. (See below.) The sphenoidal sinus seldom can be drained effectively by the intra- nasal route, and as the ethmoidal and frontal sinuses frequently are involved also, the method of treatment for radical cure usually employed now is that known as Killian's Operation (1902), which involves an approach across the frontal sinus. This includes removal of the anterior wall of the frontal sinus and of its floor (the roof of the inner part of the orbit), leaving a bridge of bone (supraorbital ridge) between these two openings to support the soft parts when sutured and thus prevent deformity. After evacuating the frontal sinus, and thoroughly exposing all its angles, the frontal process of the superior maxilla is removed. (This should be done without injury to the mucosa of the nasal cavity, which is to be preserved as a flap to line the excavated frontal sinus and establish a free communication between this cavity and the nose.) The ethmoid cells which are thus exposed are then cleaned away, and the anterior wall of the sphenoidal sinus is removed by gouge or gouge forceps. Removal of part of the nasal bone of the side affected may be necessary to secure better exposure. The flap of nasal mucosa finally is turned outward across the lower wall of the large cavity, and this is lightly packed with gauze which emerges into the nasal fossa. The external wound is then completely sutured. SURGERY OF THE JAWS. Alveolar Abscess. — Alveolar abscess almost always is secondary to dental disease. Before the stage of suppuration, peridental inflam- mation is denoted by tenderness, which usually is relieved by firm pressure on the gum, accompanied by moderate swelling. At this stage proper disinfection of the root canals of the teeth, which are infected from the cavity in the crown, usually causes arrest of the pro- cess. Later the entire side of the jaw may be swollen, and tenderness is exquisite. Sometimes the pus escapes at the side of the tooth, but in many cases it spreads beneath the periosteum of the jaw, and unless promptly evacuated, osteomyelitis and necrosis may result, or in the upper jaw, involvement of the maxillary sinus. Occasionally the pus breaks through the skin below the body of the mandible (Fig. 782), or will form an abscess in the cheek (Fig. 783). Secondary infection of the salivary glands or of the cervical lymph nodes ma3~ occur. Treatment. — -Early free incision of the alveolar border, down to the bone, followed by detergent mouth washes usually is promptly curative, and even if no pus is found this incision quickly relieves pain and markedly accelerates recovery. A diseased tooth should be extracted. Acute Osteomyelitis of the jaws is not common even in the mandible, and in the maxilla is decidedly rare. The general septic symptoms render differentiation from alveolar abscess easy. 708 SURGERY OF THE FACE, MOUTH, AM) NECK Treatment. — Treatment consists in free incision, both inside and outside the month. The inflammation may be confined to the alveolar border, but it is better to open the body of the jaw by trephine or gouge if there is any doubt as to the limits of the disease. Free drainage is the most essential factor. W' '" ^"S M« "^B 7^| i^| fv^ ^ ^Sa Fig. 782. — Alveolar abscess of lower jaw, pointing over body of mandible. Four days after extraction of tooth. Episcopal Hospital. Fig. 783. — Abscess of left cheek, fol- lowing pulling of teeth on upper and lower jaw, thirteen days previously. Episcopal Hospital. Necrosis of the Jaws affects the mandible in most cases, and follows acute osteomyelitis, or may be due to phosphorus poisoning, with subacute or chronic onset. In the latter instance the disease seldom appears until the patient has been working in phosphorus for several years, and it may not appear for several years after the patient has quit his work in phosphorus. Phosphorus poisoning produces changes of a chronic ossifying nature in the periosteum in all parts of the body, resulting in increased density of the bone, decrease in the size of the marrow cavity, and lessened circulation. These changes are particularly marked in the mandible. If secondary infection does not intervene, as in the mandible it usually does from carious teeth, the later stages of the process (rarefaction and pathological fracture) are seen. Workers in phosphorus should have their teeth inspected and cleaned by a competent dentist, at frequent intervals. Necrosis of the jaws occasionally results from the constitutional effects of arsenic -poisoning, or from mercurial stomatitis. Treatment. — Treatment consists in providing free drainage by incision of the soft parts and involucrum, when the latter is present. Great conservatism should be exercised in extraction of sequestra. It is best to wait until they are freely movable by probes introduced through neighboring cloacae, and until the involucrum has developed sufficiently to maintain the form of the jaw. Though the teeth SURGERY OF THE JAWS 709 usually are lost, the ultimate outcome as regards function usually is satisfactory. Ankylosis of the Temporo-maxillary Joint may be unilateral or bilateral, but even unilateral involvement renders the jaw immovable. The condition may result from various forms of arthritis or from fracture of the condyle; or false ankylosis may occur from peri- articular contractures, due to cicatrices from burns, etc. If the ankylosis occurs before full development of the mandible, retrog- nathism, or micrognathy is the result (Fig. 784), from loss of function. In unilateral ankylosis the affected side of the mandible seems smaller than the sound side, but stands out normally from the neck, whereas the healthy side appears flattened; the chin usually is deviated toward the affected side (Kirstein, 1910). Fig. 784. — Retrognathism from ankylosis of jaw, following arthritis in infancy. Now fifteen years old. Dr. Gill's patient. Orthopaedic Hospital. Treatment. — Some form of arthroplasty (p. 252) is necessary to re- store motion. The joint is best exposed by turning down from above a skin-flap with temporary resection of the zygoma (Lilienthal, 1911). The condyle of the mandible is then excised, and a flap turned in from the temporal muscle or masseter. By turning down the zygoma, with attached masseter muscle, any damage to the facial nerve, parotid gland, and duct, is avoided. The periosteal insertion of the external pterygoid muscle should be preserved. The older operations of resection of a wedge from the body of the mandible in front of the angle seldom succeeded in restoring permanent motion. For false ankylosis from cicatricial contractures a plastic operation is necessary. Murphy (1913) used a flap of mucous membrane from the hard palate. The mandible may be lengthened by osteoplastic operation on both sides, dividing the body in sigmoid fashion and sliding the lower segment forward; but if the ankylosis is overcome before adult life, some development of the mandible may occur before full growth of the bodv is attained. 710 SURGERY OF THE FACE, MOUTH, AND NECK Facial Hemiatrophy is a very rare condition of obscure origin, but one whose existence should be known to the surgeon, for diagnostic purposes (Fig. 785). The atrophy affects bones as well as soft parts. It may be associated with neuritis of the trigeminal nerve, but usually is not painful. Neurologists treat it by electric currents and general hygienic measures. Tumors of the Jaw. — These may arise from the alveolar border or from the body of the bone. Tumors of the Alveolar Border. — There are three of these alveolar growths of considerable frequency: Epulis, Ossifying Periosteitis, and Carcinoma. 1. Epulis. — Epulis, a connective tissue tumor, is the most frequent growth of the alveolus. Pathologic- ally it is either (a) a fibroma or an angeio-fibroma, or (b) a tumor con- taining giant cells, resembling a myeloma or myeloid sarcoma. This appears to be the only region in the body where giant cells spring from periosteum. EpuKs seems to be more nearly related to in- flammatory processes than to true neoplasms. The giant-celled form often arises above an old root or beside a decayed tooth, and is red- dish brown in color; but the fibrous form may occur where the teeth appear normal, and is whiter in color. Epulis is painless, but in spite of this fact often has been mistaken for an alveolar abscess. It occurs in children or young adults, is soft and elastic, but does not fluctuate. Ulceration may occur eventually, but is very long delayed. Treatment. — Treatment consists in local extirpation by knife and gouge forceps, through healthy tissues. The raw surface left should be seared with the actual cautery. Recurrence may take place if the surgeon is too conservative. Yet even after repeated recurrence no metastasis occurs. It never is necessary to excise the whole thick- ness of the bone; removal of the portion of the alveolus affected is sufficient. 2. Ossifying Periosteitis forms a diffuse bony enlargement of the alveolus. It may be due to chronic infection (as pyorrhea alveolaris). Subperiosteal resection may be done, without fear of recurrence. 3. Carcinoma. — Carcinoma is commoner on the upper (Fig. 786) than the lower jaw (Fig. 787). It is sufficiently distinguished from epulis by its occurrence only in older patients, by its early ulceration, the marked induration of the borders of the ulcer, and the ultimate Fig. 785. — Left facial hemiatrophy. Male twenty-six years old. Duration ten months. No injury, but he was a "boxer" and deformity was mistaken for that due to impacted and united fracture of ascending ramus of lower jaw. Notice over-lapping of teeth. Episcopal Hospital. SURGERY OF THE JAWS 711 involvement of the lymph nodes. Extirpation, together with wide excision of the lymphatics of the same side as the lesion, is the proper treatment. Fig. 786. — Carcinoma of upper jaw. Age seventy-three years; duration six months, now inoperable. Was struck on this side of mouth one year ago by handle of "release" while running engine. Episcopal Hospital. Fig. 787. — Recurrent carcinoma of inferior maxilla. Partial excision of mandible in September, 1906. Pho- tograph March 1908. Now inoperable. (Dr. H. C. Deaver's case.) Episcopal Hospital. Tumors of the Body of the Jaw.— Some of these are benign, and some are malignant. Among the former are dentigerous cysts, espe- cially the adamantinoma. These were discussed at p. 112. Of the malignant tumors (sarcomas) there are various forms. Until recently the giant-celled form of epulis, affecting the alveolus, was classed as a sarcoma. True sarcoma may affect the body of either the upper or lower jaw. Usually it is periosteal in origin, and grows as a firm or even a bony tumor. It does not present egg-shell crackling, which is common in the admantinoma, and occurs in older patients than those in whom dentigerous cysts usually are seen. According to Bloodgood sarcoma of the lower jaw in front of the angle usually is of a less malig- nant nature than the forms which occur at the angle and rapidly invade the ramus. The former (less malignant) growths are "mixed sar- comas," that is, partly bony, fibrous, or myxomatous, and are rare after the age of twenty-five years. The more malignant varieties, which are rare before the age of twenty-five years, are spindle- and round-celled sarcomas. These latter quickly invade the soft parts, extending in the upper jaw to the antrum (where, indeed, they may originate), to the orbit, and to the temporo-maxillary fossa; and in the lower jaw invading the pharynx and soft structures of the neck. The differential diagnosis is best made from an excised specimen. 712 SURGERY OF THE FACE, MOUTH, AND NECK Treatment. In the less malignant forms of sarcoma, the surgeon aims to remove the entire growth, with a small margin of healthy tissue on all sides. In the lower jaw this usually necessitates a resec- tion of the entire thickness of the hone, though very occasionally the alveolar border may he left as a splint to maintain the form of the bone. In the upper jaw it usually is possible to preserve the orbital plate, and often the hard palate also. It is doubtful whether any operation, even the most radical, is of any use whatever in the more malignant forms of sarcoma. Excision of the Superior Maxilla. — The typical operation, though seldom done at present for tumors arising in the maxilla itself, some- times is required as a preliminary to the removal of growths in the naso-pharynx. Preliminary ligation of the external carotid artery is advisable if the operation is for exposure of such a tumor. The incision shown in Fig. 788 enters the nostril and outlines a flap which is reflected outward, the knife being kept close to the peri- osteum. The mucous membrane of the hard palate is divided in the median line, and the attachment of the soft palate to the bone severed transversely. The mu- cous membrane of the gingivo-labial fold Fig. 788.— Fergusson's incision is divided clear of the disease, and that in for excision of upper jaw. the floor of the nose is divided in the median line. After extraction of the cen- tral incisor tooth on the involved side, the alveolus and palate are divided by a phalangeal saw (Fig. 152, 6), introduced through the nostril. The tissues of the orbit are then displaced upward, the spheno- maxillary fissure is identified, and the attachment of the maxilla to the malar bone is divided with saw. Then the nasal process of the maxilla is divided from orbital to nasal cavity by large bone-cutting forceps, and the bone is grasped in lion-jawed forceps and pulled down- ward, any remaining attachments, including the junction of the ptery- goid processes with the maxilla, being severed with bone-cutting forceps or chisel. Hemorrhage is then controlled, if necessary by the actual cautery. The mucosa of the cheek is then sutured to that of the palate, and the skin wound closed with interrupted sutures, after .packing the cavity loosely with iodoform gauze, which is made accessi- ble through the nostril. Frequent syringing through the nostril or any opening in the roof of the mouth is required during convalescence. Temporary resection of the superior maxilla is done by the same skin incision, but the flap is not separated from the bone; this is divided as above described except at its malar attachment, which is used as a hinge, after fracture by leverage outward. Excision of the Inferior Medulla. — The typical operation involves only half the mandible. After clearing the submaxillary and sub- SURGERY OF THE TONSIL AND PHARYNX 713 mental regions through the usual incision (Fig. 775), the soft parts are separated from the outer surface of the bone, respecting the branches of the facial nerve, but ligating the facial and the lingual arteries and veins. Most of the external surface of the ramus is thus exposed. The skin incision is then carried up through the lower lip, and the cheek turned aside. The symphysis is then divided with saw and the structures of the floor of the mouth cut with scissors, from before backward. An incision is then made along the mucous membrane on each side of the ascending ramus of the jaw; the bone is forcibly depressed, and the insertion of the temporal muscle into the coronoid process is divided with scissors. The jaw is then turned somewhat outward, and the pterygoid muscles cut close to their insertions. The lingual nerve should be preserved if possible, but, of course, the inferior dental must be sacrificed. The temporo-maxillary joint may then be opened, the few remaining attachments severed, and the bone removed. After careful control of all hemorrhage, the pterygoids are sutured to the masseter muscle, and the mucous membrane of the cheek united to that of the floor of the mouth. Finally the skin wound is closed, with provision for drainage externally. Partial excision involves removal only of the portion of bone affected, after its division in front of and behind the growth. Prosthesis after Excision of the Inferior Maxillary Bone. — If the periosteum can be preserved, a shell of bone sufficient to prevent exces- sive deformity may be formed in time. While the wound is healing the remaining portions of the bone should be held in proper position by stout silver wire, used as a bridge across the gap left by excision of the diseased portion. A sinus usually persists until the wire is removed, but by that time the bone may be sufficiently firm. Claude Martin, of Lyons, since 1878, has employed after excision of either upper or lower jaw, a temporary prosthesis made of hard rubber, pre- viously constructed to fit into the contemplated defect. This pros- thesis is riddled with channels, and though it is implanted into the wound through the buccal aspect (no attempt being made to close anything but the skin), the wound and the appliance may in almost all cases be kept clean by irrigation through its numerous channels until healing occurs. When healing is complete a permanent prosthesis is constructed. SURGERY OF THE TONSIL AND PHARYNX. Peritonsillar Abscess or Quinsy usually is a sequel of parenchy- matous amygdalitis. The systemic symptoms of sepsis may be marked. Locally, in addition to the signs of the preceding tonsillitis, may be observed a diffuse swelling of the soft palate at the upper border of the tonsil. At no time is a distinct sense of fluctuation obtainable. Early evacuation is the only satisfactory treatment. Thrust a grooved director through the most prominent part of the swelling (usually through the soft palate), after painting it with 10 per cent, cocain 714 SURGERY OF THE FACE, MOUTH, AND NECK Fig. 789. — Puncture of peritonsillar abscess through soft palate. (Fig. 789). The tract made by the grooved director may be enlarged by inserting the closed points of a pair of dressing forceps, and with- drawing the instrument with the blades opened. The relief is imme- diate, and under the use of simple alkaline mouth washes conva- lescence usually is established in twenty-four to thirty-six hours. If a peritonsillar abscess is left to burst of itself, it may do so during sleep, and has caused death from suffoca- tion. In very young children it is better to open it in the head-low position. Malignant Tumors of the Tonsil. — Either carcinoma or sarcoma may occur in the tonsil. Diagnosis is not easy. Any unilateral tonsillar en- largement in an adult should be regarded with suspicion. The possibility of syphilitic lesions of the tonsil (chan- cre and ulcerated gumma) should be kept in mind, and their presence excluded by the history of the case, the existence of evidences, past or present, of the disease elsewhere in the body; as well as by the use of laboratory and therapeutic tests. In most cases a specimen of the growth should be excised for microscopic study. In carcinoma the diagnosis usually is easily made by this means, but in sarcoma the histological picture may not be convincing. Symptoms. — The symptoms are chiefly those of obstruction, in sarcoma, with pain on deglutition; the lymph nodes seldom become enlarged until late in the disease, after ulceration has occurred. Local extension to the palate and pharynx is much more common in carcinoma, and in this affection the submaxillary and deep cervical lymph nodes are involved early, though not palpably so for a number of weeks. Treatment. — If the diagnosis is made very early in the disease, by means of microscopic study, it may be possible to enucleate the tonsil from within the mouth. Usually, however, and particularly in the case of carcinoma, the growth should be approached from the outside, as in the operation for excision of the tongue described at p. 700. In lateral yharyngotomy the growth is approached from the submaxillary region. It may also be approached by suprahyoid yharyngotomy (Jeremitsch, 1895; von Hacker, 1906). Subhyoid pharyngotomy (Vidal de Cassis, 1826; Sklifosovsky, 1892) is a somewhat similar operation, but there is more danger of injuring the superior laryngeal nerve, without compensating advantages. When the malig- nant growth has been excised, the severed cervical tissues are carefully SURGERY OF THE AIR PASSAGES 715 re-united by many rows of buried sutures, and the wound is freely drained. These pharyngotomies are dangerous, seldom employed, and difficult even for skilled operators with accurate anatomical knowledge. If the case is inoperable, palliative measures, such as the "starva- tion" method of Dawbarn (p. 705), may be tried, with the use of radium, the .r-ray, and, in the case of sarcoma, of Coley's fluid. Tumors of the Naso-pharynx. — These usually are soft fibromas, occur in young adults from fifteen to twenty -five years of age, and in many cases assume a character which clinically is malignant, though microscopical examination rarely shows a typical sarcoma. They spring from the submucous tissues at the base of the skull, and grow into the nasal passages, invade the maxillary sinus, the orbit, the temporal fossa, and may open even the cranial cavity. Occasionally they seem to spring from the antrum and grow backward into the naso-pharynx. Unless removed, death is practically certain from obstruction to respiration and deglutition. Moure and Canuyt (1914) point out that the growth usually is attached by a small pedicle, which often may be exposed by partial resection of the maxilla, opening simultaneously from the front the maxillary antrum and the nasal fossse. The growth is apt to recur after partial removal, and complete extirpation may demand excision of the superior maxilla (p. 712) to gain access to the growth, even if this bone is not itself invaded by the disease. Preliminary ligation of the external carotid artery is advisable, and the actual cautery may be required to check the bleeding even after this precaution. SURGERY OF THE AIR PASSAGES. Foreign Bodies. — Foreign bodies are especially apt to enter the larynx, trachea, or bronchial tubes in young children, who thoughtlessly place various objects in the mouth, and by a sudden act of inspiration, in laughing or coughing, draw them into the larynx. In anesthetized patients, or those in a drunken stupor, vomited matters may be simi- larly aspirated into the air passages. Severe paroxysms of choking ensue, but very rarely does rapid death from asphyxia occur. Apart from asphyxia, the chief danger is due to secondary pulmonary inflam- mation. Occasionally a foreign body is arrested in the larynx, but in most instances it passes down into the trachea, and thence usually into one or other bronchus. Symptoms. — Symptoms depend on the site of the foreign body, and on the time which has elapsed since the accident. The first symptoms, or those of obstruction, seldom last very long. They are succeeded by those of irritation, denoted by a short croupy cough, with retro- sternal pain, and later by mucous or bloody expectoration; paroxysms of dyspnea occur from time to time when the foreign body is forced upward into the larynx. If impacted in the larynx, symptoms of obstruction persist, and there usually is aphonia. If impacted in a bronchus, or if immovably fixed at any point by a sharp projection 716 SURGERY OF THE FACE, MOUTH, AND NECK catching in the mucous membrane, the symptoms of irritation are not very marked; and auscultation over the region of the lung obstructed usually detects very weak or absent respiratory murmur, but no dulness is found on percussion until inflammatory changes arise. If the for- eign body moves freely about in respiration, the symptoms of irritation are very pronounced, and occasionally the foreign body can be heard flapping about. Diagnosis. — The diagnosis in small children must be made from "croup" or diphtheria, and in the absence of a clear history, and where there is no evidence of diphtheritic membrane in the pharynx, this is difficult, without laryngoscopic examination. When a foreign body is present dyspnea occurs particularly in expiration, while in laryngeal obstruction from other causes, inspiratory dyspnea is found. More- over, if the foreign body is sufficiently dense (a pebble or some metallic toy), its presence will be revealed by the x-ray. In the case of foreign bodies impacted in the pharynx or esophagus there rarely is so much dyspnea, and swallowing will be difficult or impossible. A foreign body in the pharynx usually can be reached by a finger introduced into the mouth. Treatment. — 1. In emergencies, any physician may open the trachea and extract the foreign body if it can be found. If impacted in the larynx, high tracheotomy or crico-thyrotomy should be preferred. In other cases low tracheotomy is better. Even if the foreign body is not found it is more apt to be discharged spontaneously through a tracheotomy wound than by the natural passages. Fig. 790. — Upper bronchoscopy. 2. When there is no emergency, the services of a skilled laryngologist should be procured. He may be able, by means of a bronchoscope introduced through the mouth (upper bronchoscopy) to see and extract the foreign body (Fig. 790). If it is situated too low to be reached successfully from above, the same method may be employed, the instrument being introduced through a "low tracheotomy" wound (p. 719), the procedure then being known as lower bronchoscopy. This is very rarely employed. Bronchoscopy was introduced by Killian in 1897, and has been highly developed by Guisez in France, and by Chevalier Jackson in this country. SURGERY OF THE AIR PASSAGES 717 Fracture of the Larynx is rare. The thyroid is the cartilage most often involved. Michel (1910) studied 40 cases recently reported. Among these there were 17 deaths. Seven of these patients died suddenly, without operation, at periods varying from a few hours to six days after the accident. The mortality in non-operative cases is 42 per cent. In very severe injuries, where the fracture is compound internally (hemoptysis, threatening asphyxia from edema of the glottis) tracheotomy should be done, and the deformity corrected. In very mild cases, no operation is required, it being sufficient to apply a light immobilizing dressing. In intermediate cases, especially if there is any emphysema, tracheotomy should be done as a precautionary measure, since experience shows that in such cases sudden death is apt to occur from edema of the glottis. Edema of the Glottis. — Above the true vocal cords there is abun- dance of loose areolar submucous tissue, prone to edema from trauma or infection. Below the vocal cords the mucosa is tightly applied to the cartilage. The symptoms of edema of the glottis usually develop very suddenly and often quite unexpectedly. They are those of asphyxia. Treatment, which must be immediate, consists in crico- thyrotomy or high tracheotomy (p. 719). Tumors of the Larynx. — These belong rather to the province of the laryngologist than to that of the general surgeon, except when external operations are required. In any such case it is well for surgeon and laryngologist to act in consultation. The most frequent benign tumor is the papilloma. It may occur in patients of any age, but is most frequent in young adults. Early symptoms of hoarseness, with recurrent attacks of laryngitis, finally will be followed by those of respiratory obstruction. The diagnosis is confirmed by inspection of the larynx through a mirror introduced above its superior aperture (laryngoscopy). Benign growths usually are pedunculated; ulceration or bleeding points to malignancy. Pedunculated growths usually may be removed by intra-laryngeal methods, in the hands of a specialist. Papilloma is very apt to recur, but other forms of benign tumors rarely return. The performance of tracheotomy, with the use of a tracheal tube sometimes has served to prevent recurrence, by putting the larynx completely at rest. Carcinoma. — Carcinoma is the most frequent malignant tumor. It is said to be rare as a sequel of papilloma. Sarcoma is very rare. In many cases the growth involves the larynx secondarily, having originated in the tongue, pharynx, or esophagus; this form is described as extrinsic carcinoma of the larynx, as distinguished from intrinsic carcinoma, arising primarily within the larynx. The symptoms are the same as in benign growths, but the patients are older (it is rare before fifty years), there is more pain, and sometimes there is sponta- neous bleeding. The diagnosis is made by laryngoscopy, and if neces- sary by microscopical examination of an excised portion of the growth. The disease- usually is more extensive than it seems. Tuberculosis and syphilis have to be considered, but usually may be excluded by 718 SURGERY OF THE FACE, MOUTH, AND NECK the history of the case, by clinical examination, and by laboratory tests. The prognosis of carcinoma of the larynx is bad. Without operation death usually occurs within three years, and it is a very painful death. Treatment should be radical whenever possible, and it is best accomplished by external operation. OPERATIONS ON THE AIR PASSAGES. Intubation of the Larynx. — This operation, introduced by O'Dwyer in 1885, consists in the introduction into the larynx, by special instru- ments passed through the mouth, of a hollow tube which is allowed to remain, suspended from the false vocal cords, until the symptoms of laryngeal stenosis, for which the operation was done, have sub- sided. It is employed almost solely for laryngeal obstruction resulting from diphtheria. The armamentarium comprises a set of hollow hard rubber tubes of various sizes suitable for any age up to twelve years. The approximate size is determined beforehand by means of a scale. Each tube is provided with a hole at its upper end through which a long thread is passed; the thread is left hanging out of the patient's mouth and enables the tube to be quickly withdrawn if necessary. The tube is then fitted over the obturator, which is screwed securely to the introducer. A gag is placed in the left side of the mouth, and the child (not anesthetized) is held upright in the nurse's arms, with head steadied and slightly extended. The surgeon then introduces his left fore- finger and draws the tip of the epiglottis forward. The intro- ducer is then passed backward by the right hand and the tip of the tube is guided into the larynx by the finger of the left hand (Fig. 791). The tube is then quickly pushed off the obturator by means of the slid- ing shaft on the introducer, and the latter with the obtur- ator still attached is with- drawn. The thread fastened to the tube is left hanging out of the mouth, until it is certain that the tube will be well borne. If the tube has been passed into the esophagus by mistake, it should be withdrawn at once, cleansed, and properly reinserted. If dyspnea is not relieved when the tube is in the larynx, a larger tube should be inserted. If the tube is well borne, the thread may be removed after a few hours. When necessary the tube may then be removed by the extractor, reversing the steps employed in its intro- duction. Fig. 791. — Intubation of larynx. OPERATIONS ON THE AIR PASSAGES 719 The mortality due to the operation itself is very inconsiderable, but death may occur in spite of the operation. Intubation should be preferred to tracheotomy in all cases in which it is applicable. When it fails to relieve the obstruction, tracheotomy may still be done, and a tube inserted below the obstruction. In cutting operations upon the air passages the patient should be in the "hanging head position" (Fig. 756); this not only renders the parts more accessible, but avoids so far as possible aspiration of blood or gastric contents. In cases where partial asphyxia is present, no anesthetic is required; in others local anesthesia usually is sufficient except where the soft parts have been invaded by malignant disease. Shortly before extensive operations (thyrotomy, laryngectomy) a hypodermic injection should be given of morphin and atropin to diminish secretion and paralyze inhibitory impulses. Crico-thyrotomy, in which an incision is made in the cricothyroid membrane, occasionally is done for acute laryngeal obstruction in adults. The wind-pipe is here most accessible, and in emergencies there is no other method by which it may be so quickly opened. But there is some danger of injuring the recurrent laryngeal nerve, and as the larynx itself is opened it is not considered a proper operation for diphtheritic obstruction, as the false membrane may extend below the seat of operation. But in cases of edema of the glottis this objection does not apply. No anesthetic is required. The surgeon fixes the cricoid cartilage between the thumb and finger of his left hand, and makes a small transverse incision in the skin over the cricothyroid space. The sternohyoid muscles are then separated, and the blade of the knife is entered transversely through the cricothyroid mem- brane. If the cricothyroid artery is wounded, it should be clamped and tied before opening the larynx. Occasionally it is of large size. A tracheotomy tube is then introduced, and the after-treatment con- ducted as in a case of tracheotomy. Tracheotomy. — The trachea may be opened either above {high tracheotomy) or below the isthmus of the thyroid gland (low trache- otomy) . Usually two or three rings are accessible above, and as many below the isthmus. The high operation usually is to be preferred if the indication is laryngeal obstruction, but, as already mentioned, low tracheotomy is preferable for the removal of a foreign body in the bronchi. The higher the trachea is approached, the nearer does it lie to the surface of the neck; and in the suprasternal region access to it is obscured by numerous veins, which are markedly engorged in cases of respiratory obstruction, and render the operation much more difficult (Fig. 792). No anesthetic is required. Partial asphyxiation renders the patient almost insensible to pain, and the first incision cuts all the sensory nerves. Most surgeons still employ a longitudinal skin incision, but I believe with O. Franck a transverse one is better, as it is less liable to subsequent infection, gives better exposure and leaves an inconspicuous scar. If the skin is pinched up in the fingers, the anterior jugular veins do not come with it, and there is almost no bleeding. The interspace between the sternohyoid mus- 720 SURGERY OF THE FACE, MOUTH, AND NECK cles is identified, and these as well as the underlying sternothyroids are separated, exposing the trachea. This is then fixed in the wound by a sharp tenaculum. Unless this precaution is taken it may be very difficult to cut the cartilages, especially in an adult, as the knife is apt to push the trachea deeper into the neck or to one side. Two or possibly three cartilages are then divided, in the long axis of the trachea, strictly in the median line. Or the trachea may be opened transversely, between two rings; it will gape, owing to the hyperextension of the neck. In this way the operation may be com- pleted with no other instrument than the knife. The operator should take care, especially in cases of diphtheria, that the violent paroxysms of coughing, which follow opening the trachea, do not spatter his face with false membrane. Any membrane presenting in the wound should be carefully withdrawn. A tracheotomy tube (Fig. 793) is then inserted, and fastened in place by tapes tied behind the patient's neck. This tube is provided with an inner can- nula which is removed frequently and cleansed, without disturbing the outer tube. As long as the tube remains in place, the patient should be kept in a moist warm atmos- phere; this is best secured by em- ploying a croup tent, and by the use of a kettle of hot water, on the surface of which is floated a small quantity of compound tincture of benzoin. It is an advantage to have the outer tracheotomy tube con- structed with a window on its con- vex surface, so that wdien the inner Fig. 792. — Sagittal section of neck showing anatomical landmarks involved in operations on the larynx and trachea. Fig. 793.— Tracheotomy tube. tube is withdrawn, tests can be made from day to day of the possibility of laryngeal respiration. In emergencies, where a tracheotomy tube is not available, one may be constructed out of a soft catheter or rubber drainage tube. It rarely is possible to remove the tube permanently before the third or fourth day. In cases of stenosis from cicatrix or neoplasm it may be necessary to wear a tracheal cannula permanently. In these cases a tube with a ball valve, permitting inspiration but preventing expiration through the tube, may enable the patient to employ his larynx in speaking. OPERATIONS ON THE AIR PASSAGES 721 Thyrotomy or Laryngo-fissure consists in splitting the thyroid car- tilage in the mid-line, turning aside the halves, and exposing the interior of the larynx. It is used to remove sessile benign growths, and as an exploratory operation in cases not certainly malignant. When malignancy exists the exploration should be followed imme- diately by laryngectomy. Laryngectomy may be partial {Hemilaryngectomy) or complete (Extir- pation of the Larynx). In the latter operation Hartley, of New York, adopted (1908) a cross-bow incision, analogous to that used in opera- tions on the cerebullum. The transverse incision passes just below the level of the hyoid bone, and the longitudinal extends far enough downward to expose the isthmus of the thyroid gland. The platysma, sternohyoid and omohyoid muscles are turned down in the triangular flaps. All superficial veins and both superior thyroid arteries are ligated, the latter close to their origin; and the superior laryngeal nerves are cut. The trachea then is cut away from the cricoid, is turned forward, and is sutured end-on into the lower angle of the incision. Division of the thyroid isthmus and free separation of the trachea from the esophagus may be necessary. A tracheotomy tube is then intro- duced, and the anesthetic subsequently administered by this route. The sternothyroid muscles are then divided below the larynx. The pre-laryngeal and lateral laryngeal lymph nodes are then raised, together with the larynx and attached sternothyroid muscles, and the pharynx is incised transversely behind the larynx, and the larynx, including the epiglottis, is removed. All bleeding having been con- trolled, the pharynx is completely closed by sutures (over a stomach tube, passed through the nose, and used as a guide); 1 the musculo- cutaneous flaps are replaced and sutured, and the wound is drained from one or both lateral angles. After-treatment is conducted as in cases of tracheotomy. The patient should lie in the head-low position, and should not swallow anything for three days. Until then he may be fed liquids through the tube passed by the nose into the esophagus at the time of operation. Crile (1913) points out that the chance of infection may be lessened by a preliminary operation in which the suprasternal space is widely opened on both sides of the trachea and is packed with gauze. After several days when the wound is covered with firm granulations, the surgeon proceeds to extirpation of the larynx. The mortality of the operation is about 20 per cent. Nearly 50 per cent, of those who recover remain free of recurrence for one year or longer. About 20 per cent, of those who recover are permanently cured. Recurrence usually takes place, if at all, within one year. If the deep cervical lymphatics are involved, no radical operation is of any use. Hemilaryngectomy is done by turning down a triangular flap on one side only. A tube is inserted in the trachea well below the cricoid, and after preliminary laryngo-fissure, the diseased half of the thyroid cartilage is removed, with its related lymph nodes. 1 This tube should be allowed to remain. 46 722 SURGERY OF THE FACE, MOUTH, AND NECK SURGERY OF THE NECK. Wounds. — These may be incised, lacerated, gunshot, or stab wounds. The chief immediate danger is hemorrhage or edema of the glottis. Injuries of nerves, if undetected and not repaired, may lead to lasting disability. In suicidal cut-throat, the patient often loses his courage when blood begins to flow, and the damage may not be nearly so great as appears at first sight. If the trachea, larynx, or pharynx are wounded, it frequently is safer to insert a tracheotomy tube at once, to prevent asphyxia should edema of the glottis occur. Usually no anesthetic is necessary. Hemorrhage should be controlled by expos- ing, clamping, and ligating the bleeding points. Venous bleeding may cease after respiratory obstruction has been relieved by tracheotomy. The superior laryngeal and the hypoglossal nerves are those most frequently severed in suicidal at- tempts. No prolonged attempts should be made to repair the nerve injury unless the patient's condi- tion is favorable. A lodged bullet need not be removed unless very easily accessible. Severed muscles should be sutured. The wound should be drained freely, as it is in a region very prone to infec- tion. Woody or Ligneous Phlegmon of the Neck (Reclus, 1893).— This is a slow and indolent inflamma- tion, probably due to attenuated bacterial infection, the portal of entrance of the infection being un- certain. The inflammatory pro- cess is said usually to begin below the jaw in the submaxillary or submental region, and extends to the clavicle, usually on one side only. It converts the normally supple neck into a dense board- like structure, neither painful nor tender, and not attended by noticeable constitutional reac- tion. There may be an erythematous blush in the skin, and pos- sibly some pitting on very firm pressure, but there is no evidence of suppuration. The affection, which seems to be a cellulitis or possibly a myositis of the platysma, begins insiduously and may last for weeks before medical attention is sought (Fig. 794). Fig. 794. — Woody or ligneous phlegmon of neck. Struck by steel two months ago. Slow, painless onset of induration, which extends from mandible nearly to clavicle, and from larynx to anterior border of trapezius. Skin red, slight edema, and pitting on pressure. No tenderness. Poulticed for three days, then incised. Rapid recovery. Episcopal Hospital. SURGERY OF THE NECK 723 Treatment. — The board-like area should be incised in several places, and the neck should be poulticed. After suppuration is established, the indurated tissues quickly soften, and recovery usually is unevent- ful. This disease must not be confused with actinomycosis; the chief point of resemblance is the board-like induration. Lymphadenitis. — Inflammation of the lymph nodes probably occurs oftener in the neck than in any other portion of the body. The cavities of the nose, mouth, and pharynx constantly breed hordes of microbes, and whenever the virulence of these is increased, or the resistance of the patient lowered, they or their toxins are absorbed, largely through carious teeth or the tonsils, and secondary enlarge- ment of the cervical lymph nodes follows. The scalp also is a very prolific source of infection for the cervical lymph nodes. Every year I see a number of patients with cervical adenitis due to the infection instituted by head lice. It is of the utmost importance not to regard the lymphadenitis as the main feature of the disease. The focus of infection always should be looked for, and usually can be found if the examination is thorough. If it is found and properly cared for, the lymphadenitis may subside spontaneously. Examine the scalp, ear, teeth, lips, tonsils, nose, and naso-pharynx, and do not be satisfied until some source of infection has been discovered. The anatomical connections of the various groups of cervical lymph nodes should be re- membered. Around the upper part of the neck, as a collar, are arranged, from before backward, the submental, sub- maxillary, subparotid, post-auri- cular and occipital lymph nodes, draining corresponding areas of the face and head. The sub- maxillary nodes receive the drainage from all of the other groups mentioned except the occipital, and sometimes the submental ; and all these groups directly, or indirectly through the submaxillary, drain into the upper portion of the deep cer- vical lymph nodes, which form a chain along the internal jugular vein from mastoid nearly to clavicle. These deep cervical lymph nodes sometimes are infected directly from the primary focus of the teeth, tonsils, scalp, etc., without implication of the intermediary group, but in most cases the latter is infected first. The deep cervical lymph nodes are also connected with the supraclavicular lymph nodes, Fig. 795. — -Tuberculous cervical and axillary adenitis, in a girl of fifteen years; duration nearly one year. Has had two operations on neck, both probably incomplete; last, one year ago. Episcopal Hospital. 724 SURGERY OF THE FACE, MOUTH, AND NECK which drain the surfaces of the upper arm and axilla, and sometimes the occipital portion of the scalp and the mammary gland. These supraclavicular lymph nodes may be infected through the deep cervical lymph nodes, or may in turn infect them. The deep cervical and supraclavicular nodes are themselves drained into the subclavian vein at its junction with the internal jugular. The deep lymph nodes of the neck lie beneath the sternomastoid muscle, and upon the fascia which covers the prevertebral muscles (scaleni, levator anguli scapulae, etc.) ; their efferent vessels do not pass into the mediastinal nodes, but occasionally they receive afferent lymphatics from this source. Occasionally the axillary lymph nodes become involved by infections travelling down the neck and through the supraclavicular nodes (Fig. 795). Acute Lymphadenitis. — The affected nodes are swollen, tender, palpa- ble, and sometimes visible as a diffuse swelling (Fig. 796) . The more acute the process the less distinctly can the individual node be out- lined, and in many cases the affection is so acute that suppuration has occurred before the surgeon is consulted. In the earlier stages, attention to the focus of infection, and application of ichthyol, bella- donna and mercury, or compound iodin ointment to the side of the neck affected usually cause sub- sidence of acute symptoms, and the nodes cease to be palpable. ^■** * %2 * 1 I s\ Fig. 796. — Acute submental lymph- adenitis. Children's Hospital. Fig. 797. — Submaxillary abscess from acute lymphadenitis (not tuberculous), due to carious teeth. Age eleven years. Two months later other abscesses formed, were incised and curetted. One year later, formal operation for tuberculous lymph nodes, evidently secondary to previous inflammation. (See Fig. 36.) Episcopal Hospital. Abscess from cervical lymphadenitis (Fig. 797) requires the same treatment as an abscess elsewhere ; but as in many cases the abscess is quite deeply seated, it often is best to open it by Hilton's Method; a small superficial incision is made in the skin, under local anesthesia if necessary, and then a grooved director is cautiously insinuated through SURGERY OF THE NECK 725 the intervening structures until pus begins to flow; a pair of dressing forceps is then passed along the grooved director, with its blades closed; when it has entered the abscess cavity the blades are opened, and the forceps is withdrawn, thus dilating the tract previously made. In this way there is no danger of injuring important bloodvessels or nerves. Chronic Lymphadenitis. — Chronic lymphadenitis usually follows re- peated acute attacks, the nodes retaining some inflammatory hyper- plasia after each new infection. In the vast majority of cases, under these circumstances, the nodes become secondarily infected with tubercle bacilli. It is possible, of course, that the primary infection may have been tuberculous, since even in cases which clinically are thought not to be tuberculous microscopical study nearly always reveals the characteristic lesions of tuberculosis; and in some cases where no histological indication of tuberculosis was found, inoculation experiments have been positive. 1 Fig. 798. — Tuberculous cervical adenitis (submaxillary and subparotid). Duration six months. No softening yet. Children's Hospital. Fig. 799. — Tuberculous cervical adenitis. Age twenty-five years; duration three years, no sinus. From carious teeth. Orthopaedic Hospital. Tuberculous Lymphadenitis. — Tuberculous lymphadenitis in the neck is an exceedingly common affection. For anatomical reasons, the subparotid and submaxillary lymph nodes, draining the tonsils, teeth, and anterior portions of the scalp, are those most often primarily involved (Fig. 798) . Thence the disease spreads to the upper deep cer- vical lymph nodes, travels along those accompanying the internal jugu- lar vein to the clavicle, and often invades the supraclavicular group. 1 Such cases are one form of "inflammatory tuberculosis" described by Poncet and Leriche. 72G SURGERY OF THE FACE, MOUTH, AND NECK Tuberculous cervical adenitis occurs ol'tcncst in those from fifteen to twenty years of age, and is commoner in those under fifteen than in those past twenty-five years of age. It may affect one or both sides of the neck. Usually, as noted above, there have been one or more attacks of acute adenitis — seldom so acute as to lead to suppuration, and often so subacute as to have required no medical attention, the child being "doctored" at home with ham fat or goose grease. Such attacks often date from the period of convalescence following measles or other acute exanthem. Finally the nodes become so conspicuous, or so constantly tender, even if invisible to a casual glance, that medical attention is sought. The nodes are now more or less discrete, movable, elastic, but tender; they do not feel hot, and give no evidence of fluctuation. They vary from pea-size to that of a walnut, seldom larger. Almost always there are a great many more present than can be detected by clinical examination. When the affection is of still longer duration the sur- geon finds, instead of discrete, elastic, and movable nodes, that there are ill-defined, more or less immovable masses, evidently composed of several coalesced nodes (Fig. 799); in one or two places there may be evidence of softening. At a still later stage, cold abscesses form, spontaneous fistulization may occur, and the neck is riddled with sinuses, each separate and distinct node as it softens discharging through a new orifice (see Fig. 36). If secondary pyogenic infection occurs, a hectic state may develop. The diagjiosis must be made from Hodgkin's disease and from malignant or syphilitic enlargements. A differential diagnosis from chronic non-tuberculous inflammation usually is impossible, at least in the early stages of tuberculosis, except from the results of treat- ment, or by laboratory examination of an excised specimen. If cure of the infecting focus and non-operative care of the neck causes nodes to become no longer palpable, it may be assumed that the condition was not tuberculous, or only very slightly so. Hodgkin's disease usually is easily recognized by the firmness of the nodes, their tendency to enlarge without coalescing or softening, and by involvement of other groups of lymph nodes as well as the cervical. Carcinoma is secondary to a growth elsewhere, though this growth may have been excised many years previously, and there may be no local recurrence and an inconspicuous scar. Such lymph nodes are hard and not tender, and the patients are very rarely indeed of an age w T hen tuberculous adenitis is frequent. Sarcoma of the cervical lymph nodes is rare. In its early stages it resembles clinically a case of Hodgkin's disease, but affects only the cervical lymph nodes; it never suppurates, but tends to involve the skin, and to form a fungous ulcer. It is important to recognize the existence of syphilis, particularly the hereditary form, in cases of the cervical lymph nodes. It occurs about puberty, and its syphilitic nature should be suspected from the presence of other signs of the disease (Fig. 1028). Prognosis and Treatment. — -The prognosis of tuberculous cervical adenitis is bad, unless it is properly treated. Not only does the local SURGERY OF THE NECK 727 condition go from bad to worse, but the patient's general health steadily deteriorates. Statistics collected in 1905 by Dowd, and so far as I know not since contradicted, showed that without operation, but with medical treatment only, from 21 to 25 per cent, of these patients ultimately develop phthisis. This is small wonder, when the drainage of the cervical lymph nodes into the right heart is remem- bered. In 1909 Dowd traced ninety-six patients on whom he had operated more than three years previously. He found nearly 94 per cent, apparently cured; one death; and five patients with recurrence which could be cured by operation. No other form of treatment gives such satisfactory results. Even in children, in whom temporizing and medical methods often are regarded as more legitimate in this affection than in adults, the prognosis is better if the diseased lymph nodes are Fig. 800. — Tuberculous cervical lymph nodes; duration six months, following measles. (See Figs. 801, 802, and 803.) Children's Hospital. Fig. 801.— Same patient as Fig. 800, after operation, showing temporary para- lysis of depressor anguli oris. (See also Figs. 802 and 803.) Children's Hospital. removed by operation. But in every case the source of infection must be cured. No matter how thorough the operation, if the infecting focus remains in scalp, tonsil, pharynx, or elsewhere, other nodes not detected at the first operation will become diseased, and the patient will be no better off than before the first operation. If there are chronically enlarged lymph nodes in the neck, the first thing to do is to cure the source of infection; the lymph nodes may then cease to give symptoms. If they do not, they almost certainly are tuberculous, and should be removed. Occasionally the lymphatic invasion is so much more disabling than the source from which the infection is derived, that it is justifiable to do the operation on the cervical lymphatics first, and to postpone cure of the nasal or tonsillar or dental or scalp con- dition, until comparative health has been restored; but in many such cases a recurrence in the neck will take place because the infecting '2S SURGERY OF THE FACE, MOUTH, AND NECK focus is too long neglected. Seldom or never is it advisable to under- take a nose or throat operation at the same time that the neck opera- tion is done. If there are adenoids, enlarged tonsils, etc., it is better to attend to them one or two weeks before the neck operation is done; Fig. 802. — Same patient as Fig. 800, showing Dowel's incision for cervical adenitis. Children's Hospital. and a week or ten days usually should elapse between operations if both sides of the neck are involved. The neck operation frequently is one of great difficulty, and if properly done always is tedious and lengthy (Figs. 800, 801,' 802, and 803). Operation. — If the nodes only in the upper portion of the neck are involved, they may be reached conveniently through Dowd's upper Fig. 803. — Mass of tuberculous lymph nodes removed entire, showing groove for great vessels (three-fourths natural size). (See Figs. 800, 801, and 802.) Children's Hospital. incision, which runs in the direction of the folds of the neck about 3 cm. below the jaw (Fig. 802). Cut through the platysma and deep fascia before reflecting the margins of the wound, so as to avoid injury to the branch of the facial nerve which supplies the depressor labii SURGERY OF THE NECK 729 inferioris; this nerve runs between the deep fascia and platysma, about a finger's breadth below the mandible, and is the only branch of the facial nerve exposed to injury (Fig. 801). Then identify the anterior border of the sternornastoid muscle, and work under its margin until the carotid sheath is exposed below the enlarged lymph nodes. These should then be removed by careful dissection (not blunt tearing) from below upward, in one mass (Fig. 803). The chief dangers are hemor- rhage from large branches of the internal jugular vein, especially the facial and temporo-maxillary veins; and injury to important nerves, notably the hypoglossal and spinal accessory. If the lower deep cervical lymph nodes are involved, a second trans- verse incision, parallel to the first, and several inches lower, may be added. These nodes are most easily exposed along the posterior border of the sternornastoid muscle. As one works along this from below upward, the first nerves encountered are branches of the superficial cervical plexus, emerging about the middle of the posterior border of the sternornastoid ; and about 2 cm. higher up the spinal accessory is encountered as it leaves this muscle and crosses the posterior cervical triangle to the trapezius muscle. The sensory nerves may be sacri- ficed, but the spinal accessory should be preserved. In cases where there is very extensive involvement, including the supra- clavicular nodes, and where the tissues are densely adherent, it is better to use the incisions advised in operating for carcinoma (Fig. 780). The dissection is begun at the clavicle and proceeds upward, the diseased tissue being removed in one mass. If the surgeon can once lay bare- the prevertebral muscles he will be able to remove the entire lymphatic area of the neck. In exceptional cases trans- verse division of the sternornastoid muscle may be necessary. The existence of a cold abscess or even of a sinus, if uninfected, does not interfere with repair of the wound. The wound should be closed with two layers of sutures, the first to the platysma and fascia, and the second in the skin. Neglect to suture the platysma separately allows stretching even of a transverse scar. Drainage should be provided for by small tube, for the first few days; and after extensive operations the patient's head should be immobilized by sand-bags until healing is well under way. Tumors of the Carotid Body or Gland usually are clinically malig- nant. Pathologically they are peritheliomas or endotheliomas. The tumor occurs in young adults, and is slow-growing, painless, dense, and non-inflammatory. Its clinical course extends through many years, but sudden growth may develop at any time. Eventually the growth surrounds and compresses the carotid arteries, and causes symptoms from pressure, especially from pressure on the sympathetic, hypoglossal, and vagus nerves. The diagnosis is made chiefly by exclu- sion. The tumor is situated at the bifurcation of the common carotid artery, and receives transmitted pulsation; but this pulsation is not expansile, and there is no thrill nor bruit. Compression of the com- mon carotid artery does not affect the tumor. The absence of primary 730 SURGERY OF THE FACE, MOUTH, AND NECK growth elsewhere, the long duration, and the younger age of the patient, exclude carcinoma. Sarcoma grows much more rapidly, and tends to soften and ulcerate. Treatment. — If seen very early, extirpation may be undertaken; but very soon the operation becomes one of the utmost difficulty and great danger. The mortality thus far is about 25 per cent. Operation usually involves ligation of the common carotid artery below and of the external and internal carotids above the growth, for it cannot be separated from them safely. Other structures should be preserved if possible. In one case it was necessary to remove part of the base of the skull to secure the internal carotid above the growth; and irre- parable damage has been done to both recurrent and superior laryn- geal nerves, to the hypoglossal and even the facial nerve. If it appear improbable that the operation can be completed, it should not be attempted, or if begun, should be abandoned in good time. Fig. 804. — Thyroglossal cyst: at birth size of walnut; steady growth since. Age four years. Orthopaedic Hospital. Fig. 805. — Thyroglossal cyst; age four years. Orthopaedic Hospital. Thyroglossal Cysts and Fistulae. — The thyroglossal duct in the embryo runs from the foramen cecum of the tongue through or behind the hyoid bone, in the mid-line of the neck, to the thyroid gland. If the duct fails to be obliterated, any portion which remains may become dilated and form a cyst; and if the cyst ruptures externally a fistula will result. These cysts and fistula? always are in the median line of the neck. They may be above the hyoid bone, over it, below it, or the entire thyro-glossal duct may be persistent. Usually these cysts are noted in childhood (Figs. 804 and 805), but sometimes no trace of them is observed until puberty (Figs. 806 and 807). The cyst slowly and painlessly increases in size, and relief is sought for deformity or pressure effects. A thyroglossal fistula secretes a little mucoid matter ; pain may result from retention of its contents if the orifice becomes scabbed. Suprahyoid cysts are lined by stratified squamous epithe- SURGERY OF THE NECK 731 Hum; those arising lower in the thyroglossal tract are lined by columnar (sometimes ciliated) epithelium. Treatment.— Extirpation should be done, removing carefully every trace of the duct wall. Recurrence will take place if any portion remains. The dissection is difficult and should not be undertaken by an unskilled operator. Fig. 806. — Thyroglossal cyst, age fourteen years; duration one year. Episcopal Hospital. Fig. 807. — Thyroglossal cyst. Same patient as Fig. 806. Episcopal Hospital. Branchial Cysts and Fistulse. — These result from maldevelopment of the branchial arches and clefts of embryonic life. They are situated laterally in the neck, and thus are easily distinguished from the median thyroglossal remains. Branchial fistulse usually open along the anterior border of the sternomastoid muscle, and may extend as far as or even into the pharynx. The condition is congenital, but the patient may not seek relief until adult life, and the cysts may be of insignifi- cant size until the occurrence of some injury (Fig. 808). If the cyst lies near the pharynx it will have lymphoid tissue in its walls. Treatment. — Extirpation, which is the only successful treatment, involves a very much more delicate dissection than that of the median cysts already mentioned; and even skilled dissectors may have to repeat the operation a number of times. Distending the sinus with paraffin, which is injected hot and allowed to harden in situ, is a valuable aid. Branchiogenic Carcinoma (Langenbeck, 1861; Volkmann, 1882). — Occasionally a carcinoma develops in a branchial cleft (Fig. 809.) Diag- nosis before operation is difficult. It may resemble a tumor of the carotid body, but occurs in older persons, its duration is measured by weeks or months, seldom by years, and it may become adherent to the skin. Treatment involves extirpation of the tumor with the overlying skin. 732 SURGERY OF THE FACE, MOUTH, AND NECK In the aged it is well to test the collateral circulation by applying a temporary clamp to the common carotid artery for a few days before operation, since its extirpation may be required (p. 134). Fig. 808. — Branchial cyst of neck; age eighteen years; duration seven months; followed a fall. Orthopaedic Hospital. Fiu. 809. — Branchiogenic carcinoma. Age sixty-one years. Duration three years. Episcopal Hospital. Hygroma. — This is an old clinical term used to describe cervical cysts of different nature. The subject has been studied recently by Dowd (1913). Some are lymphangeiomatons in character: these are congenital, usually occupy the posterior triangle, seldom cause dis- ability, often grow smaller and may even disappear as the patients grow older. Their removal is difficult and dangerous, and should not be attempted unless pressure symptoms render relief imperative. Often the most that can be done is to excise the anterior and parts of the lateral walls of the cyst, and pack its cavity with gauze, looking for a cure by granulation, cicatrization, and contraction. Occasion- ally the cyst extends into the axilla. Hemorrhagic cysts may result from traumatic or spontaneous hemorrhage into a preexisting cyst. Bursal cysts, occurring in preexisting bursas around the hyoid bone or thyroid cartilage, result from effusion due to trauma or constitu- tional disease. (See also Ranula, p. 692). Lipoma is frequent in the neck. Fibroma is rather unusual; it gen- erally springs from the deep fascia, is slow growing; may in time undergo degenerative changes, and reach an immense size. SURGERY OF THE THYROID GLAND. Inflammation. — Inflammation of the normal thyroid gland is com- paratively rare. It is described as thyroiditis, and must be distin- SURGERY OF THE THYROID GLAND 733 guished from strumitis, or inflammation of a goitrous gland (p. 736). Acute thyroiditis, seldom leading to abscess, occurs by infection through the blood-stream in general infections such as typhoid fever, scarlatina, etc. The entire gland is enlarged and tender, and pressure symptoms are usual. If suppuration is suspected an incision should be made. If multiple abscesses exist, or if necrosis occurs, partial excision should be done. Chronic thyroiditis is much less unusual than the acute, and usually is chronic from the start, seldom following an acute attack. It occurs usually in alcoholic or arteriosclerotic adults, and may be caused by syphilis (gummatous form), tuberculosis, or prolonged use of iodin. Operation may be required for diagnosis in cases of asymmetrical involvement of the gland, or to relieve pres- sure. Ligneous or woody thyroiditis (Riedel, 1896) is believed by Delore and Alamartine (1911) at times to be one of the manifestations of what Poncet called inflammatory tuberculosis. Clinically the diagnosis from carcinoma is difficult, and pathologists interpret the histological pictures differently. Compression of the trachea is frequent, and demands intervention. This should consist merely in resection of the thyroid isthmus. Radical operation is nearly impossible and is not necessary. The use of the .x-ray may hasten regression of the disease. Goiter. — This is a clinical term used to describe an enlargement of the thyroid gland. It is derived from the Latin word for throat (guttur). The thyroid is an epithelial gland which in embryonic life had a duct, the thyroglossal duct. The presence or absence of a goiter, and the existence or non-existence of constitutional symptoms in con- nection with it, depend on the inter-relation of secretion and absorp- tion in the thyroid gland. In fetal life there is little or no evidence of secretion. At puberty the thyroid becomes more active, and, as noted below, sometimes enlarges. In adult life whatever secretion is pro- duced is normally absorbed by the body tissues. In abnormal states there is excess of secretion, and this is either not so absorbed, and accumulates in the thyroid ("cystic" goiter); or else is absorbed and produces toxemia (hyperthyroidism). Whenever hyperthyroidism exists there is an increase in the secreting surface of the thyroid; this results either in a parenchymatous hypertrophy (without cyst formation), or in intracystic papillomatous out-growths (if the change occurs in a thyroid previously cystic). When instead of paren- chymatous hypertrophy, there is marked increase in the interglandular connective tissue, the amount of secreting surface is relatively decreased ; this is the case in the thyroids of cretins (hypothyroidism) and the term hypertrophic fetal thyroid is applied. If in a fetal type of thyroid the epithelial (secreting) elements are in excess, we have an adenomatous thyroid, and symptoms of hyperthyroidism may or may not be present. Patients in whom atrophy of secreting cells has occurred, usually as the result of pressure from accumulated and not absorbed secretion (chiefly, therefore, in cases of cystic thyroid), are those who are spontaneously cured of their toxic symptoms; in some such cases the final state may be one of hypothyroidism (MacCarty, 1910). 734 SURGERY OF THE FACE, MOUTH, AND NECK Physiological enlargement of the thyroid gland often occurs in girls at puberty, the enlargement persisting for a year or more and then gradually subsiding. Sometimes enlargement recurs at every menstrual period or during pregnancy; and occasionally the enlargement which appeared at puberty never subsides. The gland is uniformly and symmetric- ally enlarged. No symptoms are present and the patient may not be aware of the existence of a goiter. No treatment is required. Pathological enlargement of the thyroid gland is endemic in certain regions, notably in Switzerland: it is frequent in French Canada, and in some other parts of North America. It is generally believed that this enlargement is associated in some way with the drinking water of the patients ; and it seems Fig. 8io— 'Nodular" goiter in a probable that the cause is some woman aged forty years. Duration five ... '. , ., . ,. years. Orthopedic Hospital. qualitative change 111 the lodin constituents of the drinking water. The enlargement may be diffuse or circumscribed (" nodular") (Fig. 810.) This classification of Kocher is in general use, and is very convenient for purposes of clinical study. Diffuse enlargement involves both lateral lobes and isthmus pro- portionately. It usually is due to more or less uniform increase in all the elements of the thyroid (follicular and 'parenchymatous goiter) or to disproportionate increase in the colloid material (colloid goiter). In the latter and more frequent form, the consistency of the swelling is harder, and the individual lobules appear larger and are more easily defined. A diffuse vascular goiter is one of any form in which vascularity is marked. A diffuse fibrous goiter is the result of inflam- mation and cicatricial changes in any of the forms mentioned, and is very rare. There is also a form of diffuse adenomatous goiter which it is better to classify among malignant growths. Circumscribed or nodular enlargement may occur in any of the prin- cipal forms already mentioned: follicular, colloid, or adenomatous. The colloid or " cystic" goiter is by far the most frequent form. Nodu- lar goiter is characterized (1) by the irregularity and inequality of the enlargements; and (2) by their tendency to undergo degenerative changes, such as colloid, hyaline, calcareous, etc., and to intra cystic hemorrhages. Single nodules are most common in one of the lower poles of the lateral lobes; occasionally they occur in one of the upper poles; and very rarely in the isthmus or in the pyriform lobe when SURGERY OF THE THYROID GLAND 735 the latter is present. Multiple nodules may exist. As the nodules increase in size they displace the remaining normal gland structure, and may become more or less encapsulated. Occasionally a diffuse colloid goiter is converted into a goiter with multiple cystic nodules; these have little tendency toward degeneration or internal hemor- rhages. Symptoms and Diagnosis. — Diffuse goiter retains the shape of the normal gland, and rarely attains very large size. The tumor, as in all thyroid affections, rises with the larynx in the act of swallowing and in coughing. It is movable laterally, but scarcely at all up and down. Pressure symptoms are rare. Sometimes venous engorgement is visible over the root of the neck or upper thorax. In nodular goiter the relation of the swelling to the thyroid is determined by its location in the neck over the normal site of the thyroid, and by its movement with the larynx in deep breathing, swallowing, and coughing. The swelling is close to the median line of the neck, but usually is distinctly lateral in its at- tachment. As it increases in size it may become pendulous (Fig. 811). It pushes forward the sub-hyoid muscles, and displaces the sternomastoid muscle and great vessels of the neck laterally, so that the vessels may be palpable at the posterior border of this muscle; it may distort or com- press the trachea and esophagus; and may cause symptoms from pressure on the sympathetic, recurrent, or superior laryngeal nerves. Rarely a goiter may grow down behind the ster- num, when its presence may be detected by percussion. Finally, a goiter may produce disturbance of the heart and circulation, either directly by pressure on the great vessels, or through interference with respira- tion; or in some instances from hyperthyroidism (p. 737). Intermit- tent pressure on the great vessels of the neck may produce giddiness and other evidences of disturbances in the intracranial circulation. In diffuse follicular and in parenchymatous goiters the diagnosis rests on the soft, flabby consistency, palpation of the small but rather distinct lobules, and the vascularity. Early symptoms of hyper- thyroidism may be present, and these usually will be increased by the administration of iodin. The diffuse colloid goiter is relatively firm, the lobules are much larger, and some are quite hard ; iodin causes no diminution in size. The diffuse fibrous goiter is harder, and there are symptoms of hypothyroidism. In nodular colloid goiter (cystic goiter) the diagnosis often is made at a glance. The surface of the cyst is smooth, its form is oval or rounded, Fig. 811.— Cystic goiter, of sixteen years' duration in a patient of thirty- seven years. Pennsylvania Hospital. 736 SURGERY OF THE FACE, MOUTH, AND NECK and its consistency elastic. The adenomatous goiter is recognized by its circumscribed character, and its soft and doughy feel. Treatment. — In many cases of diffuse goiter, judicious medical treat- ment, with attention to hygiene, will cause diminution or complete subsidence of the swelling. Operation is required only for cosmetic effect, to relieve pressure symptoms, or to check progressive growth or a tendency toward hyperthyroidism. In most cases of nodular goiter operation is indicated at an early stage, for the same reasons which render its adoption advisable at a later stage in the diffuse form. This is particularly true of nodules undergoing degenerative changes, and especially of the nodular adenomatous form, since in this the ten- dency to malignant change is well marked. Finally, it may be stated in general terms, that any goiter of rapid growth or tender on pressure should be referred to the surgeon. The operation consists in excision of the affected lobe; or in case of one or tw r o large nodules, in their enucleation; as the nodules usually are fairly well encapsulated the remainder of the gland may be left intact, to prevent development of symptoms of hypothyroidism. Enucleation is indicated especially where it is probable that very little healthy functionating gland tissue remains. In diffuse goiter it usually is found sufficient to excise one lobe, with a part of the isth- mus; the remaining lobe may then cease to cause symptoms. Should these continue, a part or whole of the second lobe may be removed subsequently. Rocker's incision is a transverse incision, slightly convex downward, crossing the neck over the prominence of the thyroid, from one sternomastoid muscle to the other. In operations on one lobe only, the incision need be only half as long. The flaps, including platysma and fascia, are then dissected upward and down- ward, exposing the pre-thyroid muscles. These may be divided near the hyoid bone, if necessary, thus preserving their nerve supply, and the tumor may then be dislocated into the wound. In all thyroid- ectomies, partial or complete, hemorrhage should be scrupulously avoided, by clamping and ligating veins as they are encountered, and securing the superior and inferior thyroid arteries of the affected lobe before its excision is begun. The superior pole should be delivered first, and the artery ligated close to the gland. In delivering the in- ferior pole, damage to the recurrent laryngeal nerve and the inferior parathyroid (p. 739) should be avoided. Then the capsule of the gland is split open along its lateral aspect, and the lobe is removed, leaving part of it adherent to the posterior portion of the capsule, so as to avoid injury to the parathyroid glandules and the recurrent laryngeal nerve. The occasional presence of a thyroidea ima artery should be remembered. The isthmus is clamped and is ligated, in the groove made by the clamp, before it is divided. Severed muscles are then sutured, and the wound is closed with ample drainage. Strumitis. — Inflammation of a goitrous thyroid is less unusual than that of the normal gland. The diagnosis rarely is difficult, and the treatment is the same as for corresponding forms of thyroiditis. SURGERY OF THE THYROID GLAND 737 Hypothyroidism. — In persons from whom the entire thyroid gland is removed there usually develops a condition of acquired cretinism, known as myxedema, or cachexia thyreopriva. The signs of this con- dition need not be detailed here. A knowledge of the condition is sufficient to warn the operator not to remove all the function- ating thyroid tissue. If this course has to be pursued in the eradi- cation of malignant disease, the patient should ingest daily a sufficient quantity of thyroid extract to keep the myxedematous symptoms in abeyance. Transplantation of thyroid tissue, from man and from some lower animals, has been tried in such cases, and in some instances with encouraging results. The portions of thyroid gland have been implanted subcutaneously, in the subserous tissues, in the splenic pulp, and in the bone marrow. In most cases, even if the graft functionates properly for a time, it eventually is absorbed, and myxedematous symptoms again develop. Hyperthyroidism (Exophthalmic Goiter, Graves's Disease (1835), Basedow's Disease (1840), Thyrotoxicosis). — Administration of thyroid extract in excess to normal persons causes the development of certain symptoms which are also present in some diseased states of the thyroid gland. These symptoms are the direct antithesis of those observed in myxedema. They may be grouped in four main categories: (1) Local changes in the thyroid. (2) General circulatory symptoms. (3) Nervous symptoms. (4) Metabolic changes. There should also be mentioned exophthalmos, which usually is present, but sometimes is not associated with other typical symptoms. The affection is much commoner in women than in men (about 6 to 1), and occurs usually between the ages of fifteen years and thirty- five years; it is less rare after thirty-five years than before puberty. It appears to be induced by physical or mental exhaustion, worry, anxiety, fright, fear, etc. Sometimes it develops very acutely; in others very rapidly, but not suddenly; at other times its onset is insidious. In the cases which develop rapidly, the goiter usually makes its first appearance at the time that the thyrotoxic symptoms develop; in the chronic cases, with slow onset, a goiter usually has been present for months or years before hyperthyroidism ensues. Local Changes. — The thyroid usually is enlarged symmetrically and diffusely. Its vascularity is increased, giving it a soft feel; but deep pressure detects a gland firmer than normal. Nodular goiter rarely is associated with thyro-toxic symptoms. The more acute the onset, the more marked are the local changes. In cases of long duration, especially when medical treatment has been prolonged, the gland becomes smaller and firmer, but the vascular phenomena may be demonstrated again after excitement. In some cases no local changes are perceptible, and the diagnosis depends on other signs. Circulatory Symptoms. — Tachycardia is the most prominent symp- tom: the pulse is abnormally frequent, quick, usually of high tension, and extremely irritable (A. Kocher). These changes may be acute in onset, or very gradually develop. Excitement always accentuates them. 47 ;:;s SURGERY OF THE FACE, MOUTH, AND NECK Nervous Symptoms. — Restlessness of mind and body is exceedingly characteristic. The patient inclines to be hysterical, and weeps with- out provocation; there is insomnia; tremor, especially marked in the hands, tongue, and lips; and various psychoses may develop. Metabolism. — In general terms, all metabolic activity is increased. The skin is warm and moist; the temperature slightly raised; the amount of urine increased; weight is lost, and in advanced stages emaciation may occur. Brown atrophy of the heart and degenerations of the other viscera develop eventually, and render recovery impossible. There is great weariness quite early in the disease. Frequent attacks of diarrhea may occur. Gastric indigestion may be a prominent symp- tom. Capillary hemorrhages are not infrequent. The blood-changes are said by Kocher to be characteristic, and almost pathognomonic: there is slight leukopenia, but marked increase in the actual and proportional number of lymphocytes, which may outnumber the neutro- phile leukocytes; the red blood cells and hemoglobin remain unaltered. Fig. 812. — Exophthalmic goiter. Duration seven years; twenty-eight years old. Has had seven children. Exophthalmos not noticed by pa- tient. Episcopal Hospital. Fig. 813. — Exophthalmic goiter. Goiter has grown rapidly during the last year. No tachycardia or nervousness. Same patient as Fig. 812. Episcopal Hospital. Exophthalmos is not a necessary feature of hyperthyroidism. It may be present, and associated with a goiter, without any of the cir- culatory, nervous, or metabolic symptoms which are characteristic of the disease (Fig. 812). Its pathogenesis is not understood. It may be absent when other symptoms of the disease are very pronounced. Diagnosis. — This depends on recognizing the circulatory, nervous, and metabolic symptoms which have been detailed above; and on the blood-changes, on which great stress is laid by Kocher. The existence of a palpable goiter and exophthalmos are confirmatory signs, but by no means necessary for a diagnosis. The histological diagnosis, as pointed out at p. 733, depends on the recognition of increase in the secreting surface of the gland, quite apart from other changes which may be present. SURGERY OF THE THYROID GLAND 739 Prognosis. — Theoretically, hyperthyroidism is a self-limited disease; but the disease may kill the patient before it burns itself out. In rare cases the thyrotoxic symptoms subside, perhaps aided by medical treatment, and those of hypothyroidism succeed. The thyroid thus may destroy itself by hypersecretion. But in most cases the disease grows progressively worse. The more acute its onset, the more rapid is its course. Acute exacerbations characterize some rather subacute cases. In these and in the hyperacute cases, death may occur in a paroxysm, with rapid cardiac exhaustion (delirium cordis), general edema, albuminuria, fever, dyspnea, etc. In other, more chronic, cases, death occurs from intercurrent maladies, such as influenza or tonsillitis; it may occur merely from administration of an anesthetic for operative purposes, since viscera damaged by the long continuance of intoxication cannot functionate under these additional demands. Treatment. — As the disease is due to intoxication from the thyroid gland, there are two logical remedies: one is removal of part of the gland, the other is the preparation and administration of an antitoxic serum. The latter has been tried by Beebe and Rogers, but not with the uniform success which has attended operative treatment, and must be continued indefinitely as the cause of the symptoms is not removed. In the hyperacute cases usually no treatment is of use, and death occurs in a short time. In the subacute cases, in which the thyrotoxic symptoms and the goiter appear simultaneously, medical treatment should be tried before resort to operation, as by procuring absolute rest for mind and body it is possible to ameliorate the patient's condition. In most cases confinement to bed is imperative, in isola- tion. Local cold is of great value in quieting the tachycardia. Kocher thinks iodin internally is of much value. The bowels and kidneys must be looked to, and a milk diet may be beneficial. Belladonna or atropin, with an occasional course of bromides, are useful in controlling circulatory disturbances. If no improvement is evident within a couple of weeks, it is useless to pursue this treatment further, and operation should be undertaken, as it should even earlier if the patient continues to grow worse, and in the more chronic cases where it may be employed safely without such careful preparative treatment. The Parathyroids. — In all operations injury of the parathyroids should be avoided; these little glands, of uncertain function, usually are four or more in number; they are situated two on each side of the neck behind the thyroid gland, and separated from it by the posterior portion of its capsule. The lower pair are in relation with the terminal branches of the inferior thyroid artery, and are the more constant in position. The upper parathyroids are supplied either from the superior thyroid artery or from communicating branches from the inferior thy- roid. Removal or destruction of all the parathyroids is supposed to be the cause of post-operative tetany, which has been seen in a few cases. As it is impossible to identify the parathyroids except by histological examination (macroscopically they cannot be distinguished from lymph nodes), the only safe course is to keep clear of the site 740 SURGERY OF THE FACE, MOUTH, AND NECK where they normally are found. This is best done in excisions by leaving the posterior portion of the capsule and, if necessary, a layer of thyroid tissue adherent to it. Operation. — Tn severe cases it is the custom first to diminish the thyrotoxic symptoms by injecting boiling water (5 to 20 c.c.) into several parts of one lobe (M. F. Porter, 1915), or by ligating one or more of the arteries supplying the gland; and to proceed to partial excision within a week or ten days, before the favorable effect of the preliminary opera- tion has passed away. Porter's injections of boiling water may be repeated every other day until the desired effect is produced. A local anesthetic is used. In very acute cases the patient will be so much worried and excited by the anticipation of any operation, that Crile has adopted the ingenious plan of instituting a course of very strict pre-operative treatment, repeated every morning, and embodying the essential steps in preparation for operation, as if in themselves they constituted the treatment. Every morning the patient's neck is washed as if for operation, and dressings are applied; every morning she inhales some essential oil, to simulate an anesthetic. Then some favorable morning, in the course of usual routine, a real anesthetic is given, and the operation is completed without the patient being aware of it. In Kocher's hands, the mortality of operation in 200 severe cases was 4.5 per cent.; and there were 85 per cent, of cures. In cases with advanced visceral degenerations operation is useless. Ligation. — Delore and Alamartine (1911) have pointed out that the circulation is best controlled if the superior and inferior thyroids on the same side are ligated. Halsted (1913) now ligates both inferior thyroids. The superior thyroid artery is exposed by a small transverse incision over the upper pole of the lateral lobe, which usually is palpable through the skin; the sternomastoid is drawn backward and the omo- hyoid forward, and the pole of the gland itself is ligated extracapsularly, in two places. This "polar ligation," introduced in 1909 by Jacobson and Stamm, and adopted by C. H. Mayo, is valuable as it does not interfere with the blood-supply to the superior parathyroids, which would be jeopardized if the main trunk was ligated; and because it controls the veins and lymphatics and also destroys most of the vaso- dilator nerves entering the lateral lobe. This polar ligation thus becomes what Delore and Alamartine call an angeio-neurectomy. The inferior thyroid artery is best ligated at its origin from the thyroid axis, since it divides into numerous branches before entering the gland, and separate ligation of these is difficult and exposes the recurrent laryngeal nerve and inferior parathyroid to injury. The artery is exposed by an incision parallel to the clavicle at the posterior border of the sterno- mastoid; the anterior scalene muscle is identified, and the thyroid axis found just to its median border. Thyroidectomy. — As in the case of simple goiter (p. 736) the entire gland is not removed, but only one lobe or one lobe and half the other. If symptoms persist, more gland tissue may be removed at a second operation. Great care in hemostasis must be exercised, and the wound must be freely drained. SURGERY OF THE THYMUS GLAND 741 Sympathectomy (Jaboulay, 1896). — Excision of both superior ganglia of the cervical sympathetic, effective in overcoming the exophthalmos, has been abandoned by most surgeons, because it has very little influ- ence on the other symptoms. Malignant Tumors of the thyroid are not very rare, especially in goitrous regions. Carcinoma is commoner than sarcoma; endothe- lioma also occurs. Clinically, the distinction is not of much impor- tance, since, as A. Kocher says, " By the time malignant goiter reveals its two chief characteristics it is too late for a radical cure." He adds that if the thyroid continues to enlarge after puberty, in spite of appropriate internal treatment, and in the case of any thyroid which begins to grow without any apparent cause after the thirty-fifth year of life, malignant change should be suspected. The two chief char- acteristics of these malignant tumors are irregular growth, and change in consistency. Instead of the nodules being more or less uniform in distribution and size, a few of them will begin to project to an abnormal degree beyond the others, and they will lose their elastic consistency and become firmer and more flesh-like. Pressure symptoms occur earlier than in benign enlargement, because of development of adhe- sions to surrounding structures. Spontaneous pain is not an early symptom, but occurs in malignant growths much sooner than in benign. Prognosis. — The prognosis is bad. Metastasis occurs early, and may be the first evidence of malignancy. In carcinoma, and even in histologically benign diffuse adenoma, metastasis to bones is frequent; and Shepherd has observed pulmonary invasion by carci- noma through the internal jugular veins. Treatment. — Very early extirpation is the only method that offers any hope of cure. Shepherd says he has completely excised over a dozen thyroids, and never save in one case (repeated operations for recurrence) has seen any evil effects attributable to injury of the para- thyroids though he has taken no care to preserve them. But the prophylactic administration of parathyroidin is recommended, and the use of thyroid extract may be necessary to prevent myxedema. Tracheotomy may be necessary in far advanced inoperable cases; it may prove a difficult operation. SURGERY OF THE THYMUS GLAND. In some infants acute or chronic dyspnea is due to enlargement of the thymus gland, which compresses the trachea. Usually the enlarged gland may be detected by percussion or skiagraphy, and its presence should be suspected when tracheotomy fails to relieve the dyspnea. Then the incision may be extended down to the episternal notch, when the thymus (much like an enlarged lymph node) will protrude from the anterior mediastinum, and may be drawn up into the neck. So much of it as is easily detachable should be enucleated from its capsule and removed. The wound should not be drained, for drainage 742 SURGERY OF THE FACE, MOUTH, AND NECK implies infection, and this means death. If the respiratory obstruction is relieved promptly, recovery follows. Olivier (1912) studied the results of 42 thymectomies; of the 15 deaths, 7 were not due to the operation, and 8 were attributed to the secondary tracheotomy. SURGERY OF THE ESOPHAGUS. Foreign Bodies.— There are three points at which a foreign body is apt to be arrested: (1) At the level of the cricoid cartilage; (2) where the left bronchus crosses the esophagus; (3) at the cardiac orifice of the stomach. All sorts of things may be swallowed: chil- dren's playthings, false teeth, pieces of bone, and in the insane, even spoons, forks, etc. Large bodies usually are arrested in the pharynx, and often may be extracted with the finger. Bodies with sharp prongs may catch in the esophageal wall at any point, and much damage may be done by forcible attempts at extraction. The diagnosis depends on the history, which in infants and the insane may be very uncertain; on the presence of dysphagia; and on the results of examination with esophageal instruments and the z-ray. It is important to make the diagnosis as soon as possible, before inflam- matory softening or perforation of the esophageal wall occurs. Do not postpone thorough examination until the next day, thinking the diagnosis will be easier then. It will not be. The esophagoscope should be employed whenever available, and if used early, before the mucous secretion is excessive, the foreign body usually can be seen. This is an instrument analogous to the bronchoscope and cystoscope. It is very much safer in skilled hands than the insertion of a bougie, but this may be the only instrument obtainable. Treatment. — By means of an esophagoscope and the special instru- ments employed with it, one skilled in the use of such apparatus frequently will be able to extract the foreign body under the control of the eye. If this is not possible, the surgeon must employ the older and less satisfactory method of introducing an esophageal forceps, probang, or coin-catcher and thus endeavoring to remove the foreign body by the sense of touch. A general anesthetic is required. A coin usually lies transversely in the esophagus, and may be caught by a forceps whose blades open in this direction (Fig. 814). If the coin lies very far down in the esophagus the old fashioned "coin-catcher" (Fig. 815) may be more useful. Occasionally a lodged foreign body may be advantageously pushed on into the stomach. It is not safe to make violent or too prolonged efforts at extraction, especially when more than thirty-six hours have elapsed. When all reasonable efforts have failed, or at once if the nature of the impacted body forbids attempts at extraction through the mouth, the surgeon should resort to external esophagotomy if the foreign body is well above the cardiac orifice; if impacted at the latter site, extraction should be attempted by gastrotomy (p. 928). Under the best modern methods it might be possible to perform transpleural esophagotomy. SURGERY OF THE ESOPHAGUS 743 External Esoyhagotomy . — Through an incision along the anterior border of the left sternomastoid, with division or downward dis- placement of the omohyoid, the esophagus is exposed behind the trachea and on the median side of the great vessels It should be freely separated from the surrounding tissues, and incised on a sound passed from the mouth, after pulling it up into the wound and isolating it with gauze. The foreign body is then extracted with finger or for- ceps. The incision in the esophagus is tightly sutured with at least Fig. 814. — Forceps for removing foreign bodies from the esophagus. two rows of chromic gut sutures, and a strip of rubber tissue is passed down to the site of suture, and is not removed for a week. The remain- der of the wound is closed in layers. No food should be swallowed for a week or ten days; rectal feeding should be employed, especially water as in peritonitis, but in the case of very weak patients liquid food may be introduced by a stomach or duodenal tube. The prognosis is good if the foreign body has been removed within the first thirty- six hours. gaesaaa Q=^* Fig. 815.— instruments: 1, Olive tipped bougie; 2, horse-hair probang; 3, coin-catcher; 4, esophageal forceps. Stricture of the Esophagus usually results from lye burns, and is especially frequent in small children who drink a cupful of the nice white fluid, mistaking it for milk. It may occur also in adults, from ingestion of corrosive poisons. Symptoms of stricture may not develop for several months after the accident. Sometimes they appear rather suddenly, but usually there is a gradual but progressive increase in dysphagia, at first for solids, then for liquids, and finally regurgitation occurs through the nostrils as soon as food is swallowed. In time a 744 SURGERY OF THE FACE, MOUTH, AND NECK pouch may form, and then regurgitation may not occur for half an hour or more after food is ingested. Any inflammatory attack is apt to produce complete obstruction. Weight is constantly lost, and emaciation may become extreme. There is a decided tendency to bronchial and pulmonary disease, owing to regurgitation of decaying food, and death may occur from such intercurrent malady. Diagnosis. The diagnosis is made from the history of the accident, from the symptoms, and from examination of the esophagus. This should be done by the esophagoscope; but if this is not available, an olive-tipped bougie (Fig. SI 5) may be passed very gently and cautiously; and the existence of a stricture and its site may be thus determined. The .r-ray will detect the existence of a pouch if this is filled with an opaque meal. Treatment. — 1. If the stricture is easily permeable to liquid food, it usually will be possible to secure passage of a bougie, especially if this is done under control of vision through the esophagoscope. Many strictures impermeable to blind instrumentation are not imper- meable with esophagoscopy. The danger of perforation, especially if there is a thin walled pouch, always should be kept in mind. Such an accident generally results fatally in a few days from septic pneu- monia or mediastinitis. If a bougie can be passed, gradual dilatation often is possible, as in the case of permeable urethral stricture; but hazardous as is the employment of any force in urethral instrumenta- tion, it is absolutely harmless compared to its use in esophageal work. The safest esophageal sound, when one is used without the esophago- scope, is the olive-tipped bougie, but it is relatively safe only because of its size. The smaller the stricture, the more flexible should be the instrument. Gradual dilatation may be aided by internal esopha- gotomy through the esophagoscope, the edge of the stricture being divided under full view. Subsequent dilatation always should be conducted under control of esophagoscopy. 2. If the stricture is impermeable to instruments, the treatment depends somewhat upon the amount of nourishment the patient can take. If sufficient nourishment is taken to maintain weight, various expedients may be tried to get through the stricture. The patient may be made to swallow a silver ball (Abercrombie, 1830) or per- forated shot (Socin, 1889) attached to a string; after resting on the stricture for some hours these may pass through, and thus from day to day larger balls may be used, until a bougie can be passed. These methods are not more effective than esophagoscopic instrumentation, but may be tried when this is not available. External esophagotomy rarely can be recommended, even when the upper end of the stricture is accessible through the neck. It is not likely that this method will be successful when esophagoscopy has failed, and it cannot be known that the stricture does not extend all the way down to the cardiac orifice. If weight is being lost, it is useless to postpone a resort to gastrostomy (p. 929). When the stomach is opened, attempts may be made to pass an instrument through the stricture from below, SURGERY OF THE ESOPHAGUS 745 and these occasionally are successful. But if the patient is very weak it is better not to prolong the operation, but merely to establish an opening in the stomach as rapidly as possible. Stamm's method is the best for these cases. It usually happens that the stricture becomes permeable after the esophagus has had a rest for some weeks, while food is being introduced through the gastric fistula. This is analogous to the usual course of impermeable urethral strictures after the per- formance of Cock's operation (p. 1081). When the stricture becomes permeable, a string may be passed through it from the mouth; then by extracting the other end through the gastric fistula, the stricture may be cut by a sawing motion, while the esophagus is kept taut to prevent damage to its walls (Abbe's method, 1893); or the surgeon may adopt von Hacker's method (1894) of retrograde dilatation by drawing through the stricture gradually increasing sizes of rubber tubing, at intervals of a few days ("Sondierung ohne Ende"). 3. If the stricture remains impermeable even after gastrostomy, there are still several plans of treatment which may be adopted. Maffei (1906) in two cases successfully exposed the esophagus by the transpleural route, and found that the stricture became permeable as soon as he had released the peri-esophageal adhesions; the esophagus was not opened at all. Roux (1907) and Herzen (1908) have formed an artificial esophagus by transplanting beneath the skin of the sternum a loop of the upper jejunum, excluded from the intestinal tract. This is to be attached above to the cervical esophagus, and below to the stomach. Herzen's name for this delicate procedure, which is completed in several sittings, is "ante-thoracic esophago- jejuno-gastrostomy." Willy Meyer (1913) has followed Jianu and Roepke in utilizing a flap from the greater curvature of the stomach, to construct a new pre-sternal esophagus. Congenital Imperforation of the Esophagus is a rare malformation in which the gastric end of the esophagus usually empties into a bronchus, and the pharyngeal end terminates in a blind pouch. The baby suffers from recurring attacks of suffocation due to regurgi- tation of gastric contents into the air passages; food swallowed is at once regurgitated. The best treatment is performance of jejunostomy (p. 929), for the purpose of introducing nourishment, as advised by Demoulin (1904). Should the infant survive (which is unusual) treatment as for impermeable stricture of the esophagus should be attempted later. Diverticula of the Esophagus may be congenital or acquired. The acquired diverticula are due either to traction from without (usually from adhesions to bronchial lymph nodes, etc.), or to pressure from within. The traction diverticula rarely produce symptoms, as their lumen is oblique or horizontal and the orifice is directed down- ward (Zenker, 1878); food is not apt to collect in them, and often they are found unexpectedly at autopsy. But occasionally during life perforation occurs. Pressure diverticula, well studied by Halstead in 1904, constantly produce symptoms during life, from accumula- 746 SURGERY OF THE FACE, MOUTH, AND NECK tion and regurgitation of food. Sometimes during meals a palpable tumor appears in the left side of the neck, and can be emptied by pressure. Often the earlier part of a meal will be swallowed more easily than the latter part, because gradual rilling of the pouch causes obstruction of the esophagus. The pouch is found most often to spring from the posterior wall of the esophagus in the median line, just below the pharynx. A bougie sometimes will be arrested in the pouch, and sometimes will pass on into the stomach, and thus the condition may simulate a spasmodic stricture. But if one bougie is arrested in the pouch, it may be possible to pass another alongside of it into the stomach. The diagnosis is aided by esophagoscopy and by the use of the a>ray after filling the pouch with an opaque meal. Treatment. — If the diverticulum is accessible from the neck, it should be exposed from the left side, and excised. The stump is treated as the appendix stump (p. 909), and the wound treated as in external esophagotomy (p. 743). Dilatation of the Esophagus, as a whole, usually is secondary to what has been described as cardiospasm, which is now believed to be not a spastic condition of the cardiac orifice of the stomach, but of the esophagus just above the cardia. The cause of the " cardiospasm" has not always been determined, but in some cases gross esophageal lesions (ulcer, carcinoma, etc.) have been found. Symptoms. — The symptoms are those of slowly oncoming and never entirely complete obstruction to food. In the early stages there is a feeling of fulness after eating, with an uneasy sensation in the epigastrium or behind the sternum; the patient eats very slowly, and requires much liquid to wash the food down; final entrance of food to the stomach may be accomplished only after the patient has retired to a corner and urged the food down by deep breathing, gulp- ing, or curious contortions of the arms and body. Later, regurgitation occurs immediately after swallowing; but when full dilatation has developed food may be retained for several hours. The regurgitated food is not sour, as it would be if vomited after lying in the stomach. Diagnosis. — Diagnosis is based on the symptoms, and on the exclu- sion of organic stricture by esophagoscopy or by passage of a bougie. A bougie may be arrested near the cardiac orifice, but usually passes through after temporary arrest. A skiagraph, made after ingestion of an opaque meal, also is helpful. Treatment. — The most satisfactory treatment is forcible divulsion of the cardia. This can be done by instruments passed by mouth, as in the methods of Sippy and of Plummer. The apparatus consists of a rubber bag about 10 cm. long, encased in a silk bag which limits the possible distention to a circumference of 15 cm. Dilatation is produced by an air-pump. The treatment usually must be repeated several times before complete relief is secured. No anesthetic is necessary. In some cases divulsion of the cardia may be done after gastrostomy. SURGERY OF THE ESOPHAGUS 747 Carcinoma. — Carcinoma is a very frequent disease of the esoph- agus. It occurs oftenest in males, in the decline of life. About 50 per cent, of cases are near the cardia, 40 per cent, at the bifurcation of the trachea, and only 10 per cent, at the cricoid cartilage. It probably often develops in an ulcer or erosion. Its onset is insidious, but when once symptoms develop, they progress rapidly. The chief characteristic is increasing difficulty in deglutition, for which no cause can be found in the patient's clinical history. Syphilitic stricture is rare but must be excluded. The diagnosis from aortic aneurysm often is exceedingly difficult. In carcinoma very early and great enlargement of the bronchial lymph nodes may occur; there often are pressure palsies of the recurrent laryngeal or sympathetic nerves; and dyspnea may exist. Referred pain is common, and erosion of the vertebrae and even paraplegia may develop before symptoms of esophageal obstruction are marked. Pulmonary complications are frequent. Passage of a bougie may provoke hemorrhage. Esopha- goscopy is important. The prognosis is very bad. Death usually occurs in a year from the date of diagnosis. Treatment. — When thoracic surgery becomes better developed, and especially by the use of anesthesia by intratracheal insufflation, it will be possible to explore the seat of disease, with the hope of doing a radical operation. This has. been accomplished once successfully, by Torek (1913). In most cases only the palliative operation of gas- trostomy is successful, but this should not be employed so long as liquids can be swallowed. Whenever possible, before this operation is done, the intestinal tract should be cleared of the masses of stagnant feces usually present. CHAPTER XX. SURGERY OF THE BREAST, THE CHEST WALL, THE LUNGS, AND THE DIAPHRAGM. SURGERY OF THE BREAST. Congenital Anomalies. — The only one of these that is of much surgical interest is the existence of supernumerary breasts, a con- dition known as polymastia. Either sex may be affected, but it is said to be slightly more common in males. The extra glands may be situated almost in any part of the trunk, most often near the axilla or groin (Fig. 81(5), or in a line joining these two sites. The accessory glands may be of various sizes. Sometimes only a supernumerary nipple is present {polythelia) (Fig. 817), and sometimes a mass of mammary tissue without a nipple exists in the subcutaneous tissues. In men this resembles a lipoma; but in women its true nature is revealed by its increase in size during menstruation, or pregnancy, or lactation. Any supernumerary mamma which causes annoyance should be excised. Fig. 816. — Supernumerary mamma (or lipoma?) in adult male. Since puberty has had this mass which at times used to discharge a little whitish fluid, Note the nipple- like projection, but absence of pigmentation. Episcopal Hospital. Affections of the Nipple. — Sometimes a nipple fails to develop properly, especially where tight underclothing is constantly worn. During pregnancy care should be taken to favor its development by drawing it out, gently; and it should be further prepared for suckling by frequent cleansing and application of astringent washes, of which none is better than dilute alcohol. During lactation, (748) TREATMENT OF ACUTE MASTITIS 749 not only should the condition of the infant's mouth be watched, but the nipple should be washed with warm water and castile soap before and after suckling, and if any tendency to irritation exists it should be dusted with boric acid or borated talcum powder after cleansing after each act of nursing. Fissures and excoriations of the nipple, which are extremely painful and interfere with suckling, should be treated by unremit- ting attention to cleanliness. The use of a nipple shield or breast pump, so as to prevent direct contact of the child's mouth, is necessary, and in most cases the act of suckling must be discontinued tempor- arily. The excoriations and fissures, after gentle cleansing, should be painted with tinc- ture of iodin or a weak glyce- rite of tannin, and then dusted with boric acid powder. The use of ointments is injurious. Acute Mastitis. — Though in- flammation of the breast occa- sonally develops in the newborn, and in boys and girls at puberty, it occurs oftenest in nursing women, being in most cases an ascending infection from the nipple by way of the ducts or the lymphatics. It is most frequent in primipara3, especially in those with poorly developed nipples, which have received insufficient attention during pregnancy. It occurs most often within a few days of delivery, or not until the end of lactation. Acute mastitis is characterized by the usual signs of inflammation, which are confined in almost all instances to one or more lobes of the gland. Diffuse inflammation is rare. The regions affected feel tough and doughy, and tenderness is not very marked. The skin is unaltered and moves freely over the breast. There is a heavy feel- ing, with dull pain, and occasionally shooting pains. In a puerperal woman this stage is described as "caked breast," because of the accu- mulation and inspissation of the milk owing to obstruction of the galactophorous ducts by the inflammatory changes. Treatment. — Treatment consists in attention to the nipple, which may be fissured or excoriated, and to the patient's general health. The child should not be allowed to suckle from the affected breast until resolution is complete. Daily light massage of the area affected usually is efficacious in overcoming the stagnation and promoting resolution without suppuration. Some ointment with lanolin as a basis should be used in connection with the massage. In the intervals the breast should be covered with belladonna and mercury or Fig. 817. — Polythelia; a supernumerary nipple near right nipple. Orthopedic Hos- pital. 750 SURGERY OF THE BREAST other sorbcfacient ointment, and well supported with a compressory bandage or binder. Meantime a breast pump must be employed. Another valuable aid in resolution is passive hyperemia, according to Bier's method, with a cupping glass applied over the nipple, as originally introduced by Chassaignac. Mammary Abscess. Mammary abscess usually develops as a sequel of stagnation mastitis (caked breast). The area affected becomes more tender; dusky redness appears in the skin; this becomes adherent to the deeper structures; and the abscess is ready to be opened (Fig. 818). Before this occurs, however, destruction of the mammary tissue may be very extensive, and it is very im- portant to recognize the onset of suppuration as early as pos- sible. The fluid expressed from the nipple by massage, in the stage of caked breast, should be collected from time to time on gauze. The milk will be ab- sorbed; but if there is any pus in the fluid, it will remain on the surface of the gauze and stain it yellow. This is known as Budin's sign. As soon as suppuration is suspected, the inflamed area should be incised. This incision should be made directly over the area affected, and in a line radiating from the nipple, so as to injure as few of the milk ducts as possible and thus decrease the chance of a lacteal fistula developing. The earlier and more freely this incision is made, the less danger there is of the pus burrowing among the glandular tissue. If delayed, various pockets of pus will be found, and these will have to be broken open to ensure free drainage. Tube drainage is desirable until the discharge of pus ceases. An abundant dressing of hot moist gauze (soaked in boric acid or normal saline solution) is required to absorb the discharge. After drainage is dis- continued the wound closes rapidly in most cases, if incision has been made early enough; if it has been delayed or not sufficiently free, second- ary abscesses may form. Very rarely, when the breast is riddled with abscesses and discharging sinuses, amputation is required. Chronic mammary abscess is not very rare; it may be subacute or frankly chronic. The former usually arises during lactation, as the result of an unresolved stagnation mastitis; or after an imperfectly drained acute abscess. Those which develop independently of lactation are much more unusual, and may be due to suppuration in Fig. 818. — Abscess of left breast in primipara. Age twenty years, nursing baby three months old. Duration mastitis ten days. Incised and drained by tube; in nine days only a granulating sur- face remained. Episcopal Hospital. of CHRONIC MASTITIS 751 a hematoma (from trauma), or to excoriations, patches of eczema, etc., on the nipple or in the inframammary fold. The symptoms are those of chronic mastitis (see below), but the physical signs resemble more those of a neoplasm (p. 759), and the diagnosis, which often is impossible, rests on the history of the case, and the detection of some source of infection. Treatment: Exploratory incision, best by the submammary incision (p. 760), usually is necessary for diagnosis; and the abscess wall which often is thick and indurated, should then be removed in entirety. Submammary Abscess. — Suppuration may occur in the cellular tissue between the pectoral muscle and the breast. Usually this is caused by an abscess in a deep lying lobe of the mammary gland, where pointing occurs through the deep layer of superficial fascia in which the gland lies, instead of through the overlying skin; indeed, prolongations of the gland may extend normally into the retro- mammary space. In a few cases, however, submammary abscess is secondary to axillary lymphadenitis or to diseases of the pleura, caries of the ribs, etc., which usually are tuberculous in nature. The diagnosis of submammary abscess is not always easy; the gland is prominent, raised away from the chest by the suppuration beneath; but owing to the deep seat of the suppuration the ordinary physical signs of an abscess may not be present. The abscess may simulate a small hard tumor, especially as axillary adenitis often is present. Treatment consists in evacuation of the pus by a curved incision beneath the breast, with free drainage until the discharge ceases. Subpectoral Abscess. — See p. 778. Chronic Mastitis. — In addition to the acute infectious mastitis, already described as most frequent in puerperal women, there occurs a form of circumscribed subacute or chronic mastitis, probably also infectious in origin, in women at almost any age, but usually in those between twenty and thirty, or in those approaching the menopause, and among the unmarried nearly as frequently as in those who have borne children. They come to the surgeon complaining of a painful and tender area in the breast, about which they not infrequently seem unduly alarmed. Examination shows slight or no enlargement of the breast, and palpation of the gland with the hand, pressing it flat against the chest wall, makes it clear that there is no tumor present. If the gland is examined between the thumb and fingers, one or more irregularly-shaped, ill defined masses may be felt; these usually seem to radiate from the nipple, and undoubtedly are in the glandular tissue. The overlying skin is unaltered, and the breast moves freely upon the chest wall. The mass may be exquisitely tender, and the seat of shooting or neuralgic pains. The overlying skin may be highly hyperesthetic. To such a condition in neurotic women, the term mastodynia or neuralgia of the breast has been applied. This is the "irritable tumor of the breast" of Sir Astley Cooper (1829), though it is also possible that such a condition might be caused by a false neuroma (p. 320) as in other portions of the body. Pain referred 752 SURGERY OF THE BREAST to the breast in cases of intercostal neuralgia should not be confused with true mastodynia. /// most cases of mastodynia both breasts are affected, but only one out of a number of such lumps may give symptoms. They may produce symptoms during menstruation or pregnancy, and not at other times. The cause of these changes is obscure, and the subject is not much clarified by the various hypotheses which have been advanced. If the woman has borne children, the natural assumption is that these masses are the result of changes occurring during lactation; they may be the remains of an area of stagnation mastitis (caked breast) wbjch was so slight as to have been overlooked at the time. In virgins, it may be assumed that the breast has been subject to forgotten trauma; or that its condition is connected with some functional derangement of the pelvic organs. The pathological anatomy of the condition is practically unknown, as operation has been undertaken very seldom. Lecene (1911) examined a fragment of tissue from such a specimen, and found lesions which corresponded to a functional hypertrophy of the acini, with lymphatic stasis, and slight degree of congestion; he concluded that they w r ere trophic or vasomotor in origin, and in no way truly inflammatory. The clinical course of the disease is various. Usually the symptoms subside under conservative treatment, and the masses do not enlarge or give any other evidence of their presence; in many cases they almost disappear. In some cases, however, a cystic transformation supervenes, the pathogenesis of which is uncertain; probably it is neoplastic in character, and not due to inflammatory compression of the gland ducts (p. 749). Treatment. — Firm support, by bandaging or binder, or even by adhesive plaster strapping, should be provided, unless the tenderness is so excessive as to render this impossible. Belladonna and mercury, compound iodin or ichthyol ointment, applied to the breast, leaving the nipple uncovered, is useful in relieving tenderness. When tender- ness subsides, gentle massage should be given. The condition of the pelvic organs should be determined, and suitable treatment insti- tuted. Tonics, good food, and general hygienic measures should not be neglected. In addition to this circumscribed form of chronic mastitis, some writers recognize a diffuse chronic mastitis. This subject is discussed at p. 7 .">('). Galactocele. — Closely related pathologically with chronic mastitis is the condition described as galactocele, formerly considered a retention cyst of the breast. The cyst wall, however, is not composed of secreting cells, but is formed by a condensation of surrounding connective tissues. Lecene (1911) holds that it is merely a chronic abscess into w r hich milk ducts have opened secondarily; others, with less probability as it seems to me, contend that the primary con- dition was dilatation of the lactiferous tubules, and that the cyst SYPHILIS 753 is formed by their rupture into the surrounding tissues. Galactocele is quite rare, and occurs most often during lactation. A small lump forms quite suddenly; usually it is in the region of the areola, but may be more deeply seated. Sometimes several cysts exist. The mass is not tender or painful, feels semi-cystic, and is quite movable beneath the skin and on the underlying pectoral fascia. In many cases pressure on the swelling causes milk to exude from the nipple, and the cyst may thus be emptied. In other cases its contents become inspissated, and resemble butter or cheese, when there may be pitting on pressure, which is a very characteristic sign. Lacteal calculi have been described in some of these cases, but modern writers consider the reports apocryphal. Treatment. — A galactocele should be excised, and the wound sutured. Incision, followed by packing, is followed by tedious cure, and the cicatrix is more conspicuous. Tuberculosis of the Breast is a rare affection. Deaver and McFar- land (1917) refer to 90 cases. It occurs almost solely in women from thirty to fifty years of age, usually those who have borne children. The infection may be an ascending one from the nipple, by way of the ducts or lymphatics; may be hematogenous; or may arise by extension from an adjacent focus in the ribs, submammary lymphatics, or pleura. Many scattered nodules may be found, or one or two large masses. The tendency toward the formation of cold abscess and toward spon- taneous fistulization is more common in the latter form. Until this stage is reached the diagnosis is nearly impossible clinically, and even after these developments it is not always easy. The axillary lymphatics usually are enlarged. If secondary infection follows fistulization, the general health rapidly deteriorates. Treatment. — The only satisfactory treatment is amputation of the breast, and extirpation of the axillary lymphatics. The operation resembles that for carcinoma, but it is not necessary to remove the pectoral muscles unless they are manifestly diseased. Syphilis. — Syphilis may affect the skin over the breast, or the mammary gland itself. A chancre presents the same characters here as elsewhere; it occurs almost exclusively in women who act as wet-nurses to foundlings or other infants with congenital syphilis; the lesions may be multiple and often both breasts are affected. Prophylaxis usually is possible, and a syphilitic child never should be nursed by another than its own mother, who is immune to infection in this way, according to Colles'slaw (p. 1053). Secondary lesions of syphilis, especially mucous patches, often may be found in the sub- mammary fold when not visible elsewhere. Sometimes in this stage of syphilis the mammary glands become swollen and painful, the condition being known as diffuse syphilitic mastitis. Gumma is the most frequent lesion of syphilis which affects the glandular tissue of the breast. It is quite rare, however, and is difficult to distinguish from some benign tumors unless a distinct history of syphilis can be obtained, or the Wassermann test is positive, or when the bene- 48 754 SURGERY OF THE BREAST ficial effect of antisyphilitic treatment becomes apparent. Fortunately the iodides are very rapidly curative. Tumors of the Breast. — The subject of tumors of the mammary gland usually is a difficult one for the student, because owing to the complexity of its structure the tumors growing in it are of many different kinds derived from epithelial or fibrous tissues. Thus there may be adenomatous, papillomatous, epitheliomatous, cystic, and even sarcomatous tumors. And as in most of these tumors both the epithelial and fibrous elements seem to participate almost equally in the blastomatous transformation, it is rare for a pure adenoma, or a pure fibroma to develop. Instead we find many combinations of fibrous, adenomatous, cystic, papillomatous, and other conditions. The following classification, based in part on that of J. Collins Warren (1905), seems to me the most satisfactory. The relative frequency of the different growths is indicated by the attached percentages. Blastomatoid Conditions (a) Fibro-adenomatosis, . 2 per cent. (b) Cyst-adenomatosis, 15.8 per cent. Benign Tumors 1 . Fibro-adenoma, 9 . 6 per cent. / \ -n -j x i cu / Intracanalicular (a) Periductal fibroma j Pericanalicu i ar (b) Periductal myxoma (c) Periductal sarcoma 2. CVst-adenoma, 2.4 per cent. (a) Fibro-cystadenoma (b) Papillary-cystadenoma Simple Adenoma 16 per cent. 4. Lipoma 5. Angeioma 6. Endothelioma 7. Enchondroma 1 per cent. 12 per cent. Malignant Tumors 1. Sarcoma, 1 per cent. 2. Carcinoma, 70 per cent, (a) Adenocarcinoma Solid-celled Carcinoma 1. Scirrhous Carcinoma 2. Carcinoma Simplex 3. Medullary Carcinoma Paget's Disease of the Nipple Carcinomatous Cyst (6) (c) (d) 71 per cent. Before discussing blastomas, or tumors proper, it is necessary to say something of certain blastomatoid conditions which occur in the breast. The general characters of these conditions were discussed in Chapter IV. In the mammary gland there occur lesions the true nature of which is still in much dispute. As to one condition especially, while it may be said that surgeons acknowledge its existence and are agreed on its clinical features; and while pathologists agree on the histological picture; yet the former cannot agree on a name which they consider TUMORS OF THE BREAST 755 descriptive, and the latter cannot agree on the interpretation of what they see under the microscope. This condition is known in some quarters by the name "chronic cystic mastitis." Another condition the classification of which is disputed, is described as "idiopathic hypertrophy" of the breasts. Now when one looks at the classification of tumors given above, he sees that under the benign growths the two main types, which are fibro-epithelial in character, are (1) Fibro-adenoma, and (2) Cystadenoma. Were he to look around for blastomatoid conditions in his patients corresponding to these tumors, he would find that such conditions actually occur; and it would be a matter of surprise that no one had previously recognized that idiopathic hypertrophy of the breasts corresponds to a fibro-adenomatosis, and that chronic cystic mastitis corresponds to a cystadenomatosis. Let us look then at these two conditions more narrowly, and see what they are: Fibro-adenomatosis. — Diffuse or "idiopathic hypertrophy" of the breasts may appear first during pregnancy; but the disease in most cases affects virgins soon after the age of puberty. Albert (1910) collected 18 cases of the former and 52 of the latter variety. It is doubtful whether the conditions are pathologically the same: in the cases which develop during pregnancy the glandular elements are markedly increased, whereas in the virginal form it is a pure fibromatous over-growth, the undeveloped glandular elements being practically unchanged. This difference may be due merely to the undeveloped condition of the virgin breast. Both breasts are enlarged in almost all cases (62 out of 70 cases collected by Albert), and they may reach an immense size. In Durs- ton's historic case, recorded in 1669, the weight of one breast, removed postmortem, was 64 pounds. Seldom, however, does the weight exceed 8 to 12 pounds. There are no symptoms other than dis- comfort from the size and weight, but the breasts may increase and decrease slightly in size from time to time. The form which arises during pregnancy sometimes subsides spontaneously when the pregnancy and lactation are ended; but the virginal form progres- sively increases. The growth is slow, and the disease extends over many years. Very rapid enlargement of one breast alone, though it bear the character of a simple hypertrophy, always should rouse suspicion of malignancy, especially sarcoma. Treatment. — Treatment of the condition which arises during preg- nancy always should be palliative; this consists in the recumbent position, with elevation and compression of the breasts; the use of sorbefacient ointments locally; the internal administration of potas- sium iodide or thyroid extract; repeated catharsis, and a dry diet. If no improvement is noted after pregnancy has terminated, and in the virginal cases as soon as the diagnosis is assured, one of the breasts should be amputated. In a few cases the remaining breast has then somewhat decreased in size. If it does not, it should be removed subsequently. 750 SURGERY OF THE BREAST Cystadenomatosis or Abnormal Involution of the Breast. — In 1883 Reclus described in detail a "cystic disease of the breast," which he had studied first over twenty years before, and which had been recognized by F. Konig (1875), by Brodie (1840), and by Sir Astley ( looper (1829). In more recent times it has been studied by Schimmel- busch (1890), who named it cystadenoma; by Konig (1893), who called it mastitis chronica cystica; by J. C. Warren (1905), for whom it was an abnormal involution of the breast; and by Bloodgood (1900), who called it senile parenchymatous hypertrophy. These are only a few of the names by which it is known. It matters little by what name it is called, so long as people understand what is referred to; and I have not had the temerity to select a new name for it, but have followed Warren, who restored it to the position in the nosology of breast lesions to which it w T as originally assigned by Sir Astley Cooper: a pathological change similar in nature to that of diffuse virginal "hypertrophy," though characterized by epithelial (cystic) growth, where the latter is characterized by fibrous. The disease is very frequent, but may exist for years without producing symptoms Though seen oftenest in women from thirty to fifty years of age, this is no proof that it has not had an obscure beginning at a much earlier age. Occasionally it comes under obser- vation shortly after puberty, when the mammary glands begin to develop; but is much more frequently seen when their functional activity is drawing to a close. It is rare after the menopause. In most cases both breasts are diseased, though only one may produce symptoms. The disease appears to be as common in the unmarried and in those who have borne no children as in those in whom the mammary glands have been functionally active. Symptoms and Clinical Course. — The woman consults a physician usually because she has an uncomfortable feeling in the breast, and perhaps because she has noticed that it has growm larger, or because by accident she has felt a lump in it. On examination the breast generally is found enlarged, but not unduly pendulous. No lump or tumor is visible. If the gland is picked up in the thumb and fingers, it may seem that there is a considerable tumor in it, but if the hand presses the gland flat against the chest it is evident that there is no tumor at all. There should now be undertaken what Astley Cooper calls a very careful and nice manipular examination. What is detected is very characteristic: seemingly each individual lobule can be felt distinctly, enlarged and hardened, and moving freely upon the other lobules. The breast feels as if it were full of lead shot, varying in size from pin-head to grape-size. Early in the disease no large masses are felt. These little, hard masses are mostly in the center of the gland, beneath the nipple and areola. Pressure on the breast causes no pain, but an occasional shooting pain occurs. The overlying skin is normal. There is no discharge from the nipple. The axillary nodes are not palpable. If now the other breast be examined, almost invariably a similar condition, perhaps not so pronounced, will be found in it. CYST ADENOMATOSIS 757 If such a breast is amputated, it is found that the shot-like particles which felt so hard, and which were distributed through all parts of the gland, are not solid at all, as one might imagine; they are minute cysts, tensely filled with clear or slightly yellow or even brownish fluid. The cyst walls are smooth; there are no intracystic growths. Microscopical examination shows that the cysts are lined with gland- ular epithelium, which shows little if any tendency to proliferation beyond the capacity of the basement membrane ; seldom in any place is there more than one row of cells on the basement membrane, and never is there any papillomatous out-growth into the cavity of the cyst. The stroma of the breast is a dense white mass of fibrous tissue, and there is no single area in the entire breast which can be said to be free of disease. The change is not one of tumor formation, but a general blastomatoid over-growth. If no treatment is instituted the disease may progress; or after a few years, a secondary atrophy may set in, the breast decreasing in size, all symptoms subsiding, and the patient remaining well. This, however, is rare; in most cases the disease is progressive. In one portion of the breast a larger, more clearly outlined mass may be felt, and sometimes there are two or three such masses. They may be visible as rounded projections beneath the skin. When very large they may give a sense of fluctuation. They are cysts; and have formed by the gradual distention of one or more of the small cysts which have been present for years. In other parts of the breast these small cysts may still be felt on "nice manipular examination." At this latter stage of the disease, there sometimes is a glairy or clear yellowish discharge from the nipple; pressure on the cysts may cause this fluid to appear. The cysts may oscillate in size from month to month, and at times the axillary lymph nodes may become palpable, and again this swelling may subside. Pathological examination at this stage may show the cysts still simple in nature, with smooth lining wall, but in the vast majority of cases the cysts, at least the larger ones, contain intracystic papillomatous out-growths. If still no treatment is instituted, some of the clinical characteristics of malignancy may be noted. The nipple may seem retracted into the gland, but usually can be drawn out easily; the skin may become adherent, not by cellular infiltration, but by condensation of the intervening tissues; and at last one of the cysts may grow so large as to cause pressure necrosis of the overlying skin. The contents of the cyst will then be discharged, and the cyst, if it contains no papillo- matous out-growths, may collapse, and in rare cases healing may occur. If the cyst contains papillomatous out-growths, these may protrude through the opening formed in the skin by sloughing, and a fungus growth will develop which it may be very difficult to distinguish from a malignant tumor. At the present day, however, it is almost an unknown thing for the disease to be allowed to reach this advanced stage, as the breast is removed at an earlier period. 75S SURGERY OF THE BREAST Another, and probably more frequent contingency may arise. Instead of the disease taking on a cystic type of development, which usually is quite benign, it may undergo an adenomatous transforma- tion, in-growths occurring from the ducts or cyst walls into the sur- rounding stroma; and in about 10 or 15 per cent, of cases the disease terminates as a carcinoma (Speese, 1910). It is on this account that its early recognition and proper treatment are so important. Diagnosis. — In its onset this affection of the breasts resembles chronic mastitis, and by many it is still considered infectious in origin. There seems to be no doubt that previous attacks of mastitis pre- dispose the patient to the development of this disease. And in some cases it is nearly impossible to say off-hand that this is a case of diffuse chronic mastitis and not one of "abnormal involution," or vice versa. I have preferred to discuss the disease entirely in one place, and for this reason have described only a localized and not a diffuse form of chronic mastitis (p. 751). From cystadenoma of the breast (p. 761) its differentiation also is difficult especially in the later stages; but as a rule even in such cases the diffuse nature of the process is evident. While the cystadenoma is at first a localized growth, it increases in size much more rapidly than does the breast which is the seat of diffuse cystadenomatosis; and only after the latter con- dition has existed for many years will cysts be present commensurate in size with those of a cystadenoma of some months' duration. As in this stage the treatment for both affections is the same (amputation of the breast), the distinction is not of great importance. Treatment. — 1. If the woman is young (under thirty-eight years), the cystadenomatoid change recently discovered and presumably of slow growth, she should be kept under strict surgical observation, a careful manipular examination of the breasts being made at monthly inter- vals. Meantime such general hygienic measures, changes in clothing and habits of life, and attention to menstrual derangements should be enforced as seem indicated. Local treatment has little value, but such as was recommended for chronic mastitis (p. 752) is at least harm- less. If the condition remains stationary, or, still better, if it seems to subside, well and good; no operation is required. If it continues to progress, the breast (often both of them) must be operated on. The operation may be begun by an exploratory incision, as in the method of "plastic resection" of the breast (p. 760); when the gland tissue is exposed and incised, the subsequent course of the operation will depend on what is found. If only one or two fairly large cysts are found, and no suspicion of malignancy exists, it is sufficient to excise the cysts and leave the greater portion of the gland intact. If a number of cysts are present the entire breast should be ampu- tated, as described below. If any suspicion of malignancy exists, the axilla should be exposed, cleared, and its contents should be removed in one mass with pectoral muscles, mammary, gland, and overlying skin. 2. If the woman is past the age of greatest functional activity of FIBRO-ADENOMATOUS TUMORS' 759 the mammary glands (and this age varies in individuals as in different races), it is better to remove the breasts at once, since the probability of actual or subsequent malignant change is much greater at this period of life. Whenever the breast is removed it should be most scrupulously examined macroscopically ; any and every area suggesting malignancy should then be studied microscopically by a competent pathologist. Such areas are intracystic papillomatous growths, or areas of greater density or of ulceration in the cyst walls. Only one very minute area such as this may be present in the entire gland, and it is very easily overlooked. The question of malignancy should be decided, as it is vital for prognosis and the patient's peace of mind. I place no reliance at all on diagnoses made during the progress of the operation from microscopical study of frozen sections; yet I know that some very experienced surgeons still deem this method of value. The macroscopical appearance of the breast should be a better guide to the surgeon, and my own judgment agrees with that of Bloodgood and others, that no surgeon should be satisfied to operate on these borderline cases unless he has the skill and knowledge to differentiate clinically at the time of operation between growths certainly benign and those possibly malignant. Amputation of the Breast.— An incision is made in the submammary crease, from the anterior axillary fold inward to the parasternal line. The lower edge of the pectoralis major is exposed, and the mammary gland thrown upward on the patient's chest. The gland can then be explored from the posterior surface. If amputation, instead of plastic resection or radical ablation, is determined upon, a curved incision is then made above the breast, joining the ends of that already made. The flaps are dissected up sufficiently to ensure complete removal of all glandular tissue. The wide area over which this may be spread should be remembered (p. 770). The surface of the pectoralis major is then exposed above and the fascia is dissected from it downward. Bleeding points, chiefly branches of the inter- costals, are clamped as severed. The superficial fibers of the muscle are removed, and the mammary gland is excised in one piece with the nipple and overlying skin, the surrounding fat, and the pectoral fascia. Hemorrhage being controlled by ligature, the wound is closed with interrupted sutures, and provision is made for drainage for a few days. Benign Tumors. — Benign tumors of the breast are rare. They occur mostly in young women, from fifteen to thirty years of age, and in almost all cases are fibro-epithelial in type (Ribbert, 1901). They are conveniently divided, as is done by Warren, into two subdivisions: (1) Those in which the fibrous element predominates — fibro-adenoma; and (2) those in which the epithelial element is conspicuous — cyst-adenoma. 1. Fibro- adenomatous Tumors. — These are particularly character- ized by neoplastic growth of the stroma which surrounds the gland ducts; hence they are all described as periductal tumors. If the tumor is mostly pure fibrous tissue, like that found in the virgin breast, 760 SURGERY OF THE BREAST it is called a periductal fibroma; and the fibromatous change may be either intracanalicular in type, or pericanalicular: in the former case the fibromatous tissue compresses and distorts the duets, so that these appear as curved slits or chinks in the microscopical field; while in the pericanalicular form the normal appearance of the ducts is largely preserved. In most cases, instead of a pure fibro- matous tumor, there is myxomatous degeneration of the fibroma, and the growth is known as a periductal myxoma; this is the form most frequently encountered, though probably at an earlier stage the tumor was more purely fibromatous. In rare cases, the stroma of the tumor instead of being fibromatous or myxomatous is sarcomatous, and the growth is called periductal sarcoma. Symptoms and Clinical Course. — Usually occurring in young unmarried women, these growths well deserve the name "chronic mammary tumor" bestowed upon them by Sir Astley Cooper. They present few symptoms other than the presence of a "lump in the breast," which usually is discovered accidentally, and may be attrib- uted to injury. When of long duration a visible swelling may exist. This swelling or lump is in the central portion of the gland, but not close to the nipple. It feels hard, is well defined from the rest of the gland, is not tender, and seldom is movable except in one mass with the breast. Palpation of the breast with the flat hand, pressing it against the chest, demonstrates the presence of an actual tumor; the lump does not vanish as does that due to chronic mastitis, when this manoeuvre is adopted. The overlying skin is not affected, nor are the axillary nodes enlarged. The tumor grows very slowly, and may remain for years in much the same condition. Occasionally, however, rapid growth occurs; this, of course, is a bad omen. But in most cases the prognosis is absolutely good. Treatment.- — The tumor should be removed. It is encapsulated, and by exposing the posterior surface of the mammary gland, as described below, the growth can be enucleated, the breast replaced, and no visible scar will remain. This method of plastic resection of the breast, introduced in 1882 by T. Gaillard Thomas, was revivified by J. Collins Warren. It is thus performed: An incision is made from the anterior axillary fold inward in the submammary crease, as far as the inner lower quadrant of the breast. This incision is deepened to expose the pectoralis major, and the mammary gland is dissected from its surface and is thrown upward on the patient's chest. As the main blood-supply of the gland enters it from its superficial surface, near its upper border, no fear of sloughing need be felt. The posterior surface of the gland being thus brought to view, the region of the tumor is exposed by an incision radiating from the center ; the tumor is enucleated and the cavity is obliterated by catgut sutures, thus restoring the contour of the breast. This is then replaced on the pectoral muscle, and the deep layer of the superficial fascia carefully sutured, so as to retain the breast in place; and the skin is closed with provision for drainage. CYSTADENOMATOUS TUMORS 761 2. Cystadenomatous Tumors. — These seem to represent a later development of the fibro-adenomatous tumors just described; and as nearly all growths in the breast at the present day are removed soon after their presence is discovered, it results that' cystadenomatous tumors are much more rare now than fifty or one hundred years ago. At that time the curious combination of fibrous and epithelial pro- liferation, resulting in solid (perhaps sarcomatous) tumors filled with cysts, was productive of great confusion as regards nomenclature. This class of tumor was described by Astley Cooper as hydatid disease of the breast; Brodie called it sero-cystic sarcoma; Paget named them proliferous mammary cysts; and Johannes Miiller used the term cysto-sarcoma phyllodes, both the latter observers laying special stress on the occurrence of intracystic papillary out-growths To the present day the French call it adeno-sarcoma. The growth consists, in fact, of a cystic tumor, with a more or less abundant fibrous stroma — a fibrocysiadenoma. The cysts are of various sizes, usually some of them quite large. Their lining membrane may be quite smooth, as if from pressure atrophy. Almost invariably from one or more areas of the cyst wall, papillomatous growths project — papillary cystadenoma. These intracystic growths have a solid core of fibrous tissue, and they may completely fill the cyst and even cause its distention. It seems as if the proliferation of the stroma had converted the semi-circular chinks or slits of the intracanalicular fibroma into actual cysts formed by the pressure of papillary out-growths into the duct lumen. This impression is con- firmed by the fact that the papillomas are covered with cells which present the characteristics of ductal rather than of acinal epithelium. The small amount of fluid which the cysts contain may be colorless, slightly tinged with yellow or green, but usually is brownish or hem- orrhagic in nature. Symptoms and Clinical Course. — These tumors occur in older women than do the fibro-adenomatous growths. The average age in Warren's patients was fifty-two years. Indeed, in most cases where cysts are found in the mammary gland it is an indication that this organ has reached its full maturity before the tumor began to grow. Cyst- adenoma grows more rapidly than the solid benign tumors, and if not removed, may reach a large size. The growth is situated in the central part of the breast, beneath the nipple or areola, and at first presents much the same features as the fibro-adenoma. In the course of a few years, however, the presence of cysts usually may be sus- pected from the lobulated nature of the tumor, and sometimes from distinct fluctuation. But the latter rarely occurs, since the cysts are apt to be filled with the papillary out-growths, which give them a solid feel. The overlying skin is not altered, the axillary nodes are not enlarged, and seldom is the general health affected. Very often there is a bloody discharge from the nipple. In very advanced cases the skin overlying one of the cysts may become thinned, and a semitranslucent appearance may be present. The breast may be 762 SURGERY OF THE BREAST covered with a network of distended veins. Finally, as in the most advanced stages of cystadenomatosis (p. 756) perforation of the skin may occur, with the protrusion of the intracystic papillomas as a fungus growth. At any stage of the disease malignant changes may occur. These may develop in the epithelial elements (carcinoma), or rarely in the stroma (sarcoma.) Diagnosis.- — The diagnosis must be made from fibro-adenoma, and from cystadenomatosis. From the former, cystadenoma usually may be distinguished by the greater age of the patient, by the less dense feel and less definite outline which the growth presents; as well as by its more rapid enlargement and its eventually cystic char- acter. From cystadenomatosis of the breast the distinction is difficult only in the later stages, when the primarily local tumor (cystadenoma) has grown so large as to occupy nearly the entire area of the mammary gland. Treatment. — Ablation of the breast, pectoral muscles, and axillary lymphatics, as for carcinoma, is the safest treatment in patients over thirty-eight or forty years of age. In younger patients, in whom malignant changes are less likely, amputation of the breast is sufficient. Other benign tumors occur in the breast, but are extremely rare, and present only pathological interest. A pure adenoma was described by S. W. Gross (1880) and by Rodman: it is a soft, succulent, nodular, rather rapidly growing tumor, not very well encapsulated, and affecting young women. Lipoma may occur in the interlobular tissues of the mammary gland, in the subcutaneous fat overlying it, or in the sub- mammary tissues. Cases of angeioma and endothelioma have also been recorded. Enchondroma is another rare grow r th, developing here, as in the salivary glands, in the form of a "mixed tumor," with areas of cartilage and calcareous matter. The diagnosis of these rare growths sometimes is not made until after removal, which is the proper treatment. Malignant Tumors of the Breast. — The general character of malignant as distinguished from benign tumors was indicated in Chapter IV, and it is not necessary to repeat this discussion here. It is enough to say that over 70 per cent, of tumors of the breast are malignant, and that in women approaching or past the menopause every tumor should be regarded as malignant, and should be treated accordingly. Sarcoma.— Sarcoma is very rare. It occurs in less than 3 per cent, of cases of mammary neoplasm. Reference was made at p. 760 to a form of periductal sarcoma, which is classed among the benign tumors. This forms about 80 per cent, of the cases of sarcoma of the breast on record, a fact which emphasizes the exceeding rarity of true mammary sarcoma. This truly malignant form of sarcoma which forms only 20 per cent, of the recorded cases of mammary sarcoma, is of the spindle- or round-celled type, and epithelial proliferation is scanty or absent. The tumor affects women at any age, probably most often those between forty and fifty years. At first it is a well defined, small, indolent mass, which may cause no symptoms for PLATE XI Adenocarcinoma of Left Breast. Patient aged sixty-nine years; duration unknown (patient was insane). Section shows a soft, well-defined tumor, with cystic areas. On account of patient's mental condition and physical incapacity, mere amputation of the breast was done. Three years later she was reported as confined to the house with "dropsy and an abdominal tumor" (evidently metastatic carcinoma). Episcopal Hospital. PLATE XII m V* Scirrhous Carcinoma of Breast. Specimen (half natural size) from excision of right breast for carcinoma. Aged forty- five years ; duration two and a half years, ulcerated six months. Tumor developed a few months after direct trauma. Xote the "rose ulcer" in the upper outer quadrant, measur- ing 8x5 cm. and covered with adherent gray-green slough; beneath this was a hard tumor the -ize of a goose egg (Plate XIII), not attached to chest wall. Visible mass in axilla. Tumor, pectoral muscles and axillary structures removed in one mass. (August, 1912). Patient in good health and free from recurrence or metastasis more than seven years after operation. Episcopal Hospital. CARCINOMA 763 years. Eventually, however, rapid growth sets in, the tumor breaks through its imperfect capsule, infiltrates the mammary gland, causes distention, redness, and sloughing of the overlying skin, and in a few months or even weeks there is a protruding, fungus, bleeding mass (fungus nematodes). The diagnosis is difficult in the early stages; when seen at this time the growth may be mistaken for a benign tumor. Treatment consists in early amputation of the breast; the axillary lymphatics very rarely are involved, but in patients past thirty-eight or forty years it is a wise precaution to substitute ablation for amputation, as in cases of carcinoma. Carcinoma. — Carcinoma is the most frequent affection of the breast. Only about 1 per cent, of cases occur in the male breast (Fig. 819). " Most tumors of the breast in women over forty years of age are carcinomatous, but the disease is not at all infrequent at an earlier age. The older the patient, the more apt is a tumor to be carcinomatous. The left and right breasts are affected with about equal frequency. Very rarely are both breasts simulta- neously attacked (in about 1 per cent, of cases), but the disease may spread from one gland to the other through the lymph- atics (Fig. 820). Heredity has little influence in the clinical etiology of the affection, nor has race. It is more frequent in married than unmarried women, particularly in those who have borne and suckled children. The influence of direct trauma seldom is noted (Plate XII). Pathology. — A tumor of the mammary gland may begin as a car- cinoma, or carcinoma may develop in a previously existing benign tumor. The latter is much the rarer; it oftenest succeeds the change described as abnormal involution of the breast (p. 756) and assumes the type of adeno-carcinoma, or "duct cancer" (p. 126). In this form the tumor lies near or beneath the nipple, which is not retracted (Plate XI) ; the growth is soft, shows little tendency to infiltrate, but early breaks through the skin, and appears as an ulcer without the hard and thickened margins so characteristic of the commoner types of carcinoma, and having its surface not depressed but rather ele- vated above the surrounding skin. Rarely does this growth long pre- serve the relatively benign character of an adeno-carcinoma; it soon proliferates in an atypical manner like the solid-celled carcinoma. Fig. 819. — Scirrhous carcinoma of male breast, age fifty-nine years; duration three years; rapid growth for one year. Axillary nodes palpable. (Dr. J. P. Hutchinson's case.) Pennsylvania Hospital. 764 SURGERY OF THE BREAST The latter, which is the usual form of carcinoma seen in the breast, arises in an atypical proliferation of the epithelial cells lining the acini of the gland, and thus is distinguished from the rarer and less malignant duct-cancer by the term acinous carcinoma. The microscopical features of adeno-carcinoma and solid-celled carcinoma were considered at p. 120. Clinically, the usual type of mammary carcinoma, that classed as solid-celled, is encountered in three varieties dependent upon the relative amount of stroma present: Scirrhous Carcinoma, in which stroma is very abundant and cellular elements scanty; Carcinoma Simplex, in which stroma and epithelial elements exist in equal amount; and Medullary Carcinoma, in which the epithelial elements are very abundant and the stroma is scanty. The clinical features of these three forms mav be now briefly considered. Fig. 820. — Carcinoma simplex of both breasts, age sixty-six years. Growth in left breast for five years, ulcerated five months; large sloughing ulcer; axillary nodes palpable. Growth in right breast for two years: skin red and adherent; nipple retracted; axillary nodes palpable. Palliative amputation of both breasts in October, 1909, with prolonged after-treatment by x-rays. (Dr. Thos. S. Stewart.) In September, 1911, a metastatic growth appeared in right thigh. In August, 1913, mediastinal and pulmonary metastases, but no local recurrence. In January, 1914, feeble, but little discomfort. Death in March, 1914. Episcopal Hospital. Scirrhous Carcinoma, or simply Scirrhus, is the most frequent form of mammary cancer. Owing to the abundance of the stroma the tumor is quite hard; it seems as if the surrounding tissues were endeavoring to stifle the growth of the epithelial elements. On section the tumor is found to be absolutely continuous with the surrounding tissues; there is not the slightest indication of a capsule; it is impossible to remove the tumor from the gland. It is hard, and creaks when cut by the knife. Usually both the cut surfaces are found to be concave; it is as if the tumor were too small for the tissues in which it grew, and tended to contract further at the first opportunity. The surface of the section often has been likened to that of an unripe pear (Plate XIII) : it is pale and shiny, grayish white at first, but becomes X < c o CO o CO O c- £. O d o o M S-d 111 dog ~ a o 5 ft ™ © r ulceration of the skin develops. Ulceration is a late stage of the disease, usually not appearing for one or two years after the development of the tumor. In some cases (atrophic scirrhus) ulceration may never occur. When it develops it is due to gradual invasion of the skin by the cancerous growth; a small ulcer first appears, and this gradually increases in size. The scirrhous ulcer is quite typical: it is more or less circular in outline, fixed to the chest wall, red, dry, and quite dense; colloqui- ally it is known as the "rose ulcer" (Fig. 822). Occasionally as a primary growth, but more often as a recurrence after operation, carcinoma grows either in many apparently isolated spots over the chest wall, or widely diffused in the skin; this is known as "squirrhe en cuirasse," as if the patient was covered with a "coat of mail" composed of carcinomatous nodules (Fig. 824). Fig. 822. — Scirrhous carcinoma of breast showing typical "rose ulcer." Age sixty- eight years; duration three years; ulcerated six months. Has had no treatment, and growth is now adherent to ribs and inoperable. Two years and six months later, there was a large stinking ulcer, patient was extremely emaciated, hardly able to stand, and suffered dreadful pain. Episcopal Hospital. Prognosis and Treatment. — Owing to the slow growth and few subjective symptoms produced by the tumor, the patient often does not seek surgical advice until fixation and perhaps ulceration have occurred. The average duration of life in untreated cases of scirrhus is from two and a half to three years. The more atrophic the type, the longer will death be delayed; sometimes the patient drags out a painful existence for twenty years. If radical operation is done before fixation of the tumor, so that it is possible to remove all of the disease, freedom from recurrence for three years or more (which is classed as "ultimate cure") will result in from 50 to 70 per cent, of cases so treated. The reasons why operation should be urged, even with no better prospects, are stated at p. 774; and the question of operability is discussed in the same place. In inoperable cases palliative treatment, as outlined in Chapter IV, is indicated. CARCINOMA SIMPLEX OR ACUTE SCIRRHUS 767 Carcinoma Simplex or Acute Scirrhus is an intermediate form between the scirrhous and medullary types. The tumor causes increase in Fig. S23. — Carcinoma simplex of left breast. Age forty-four years; duration seven months, from recurring trauma from work in mill. Note pig-skin dimpling, retraction of nipple, breast standing out from thorax; emaciated face, and anxious expression. (See Fig. 824.) Dr. C. H. Frazier's patient. Episcopal Hospital. Fig. 824. — Recurrent carcinoma of breast one year after excision. Note cancer en cuirasse, fatter face and less anxious expression since being under hospital care; edema of left arm ; involvement of right axilla. Two and a half years after operation, condition no worse, growth seemingly held in check by constant z-ray treatments. (Dr. Thos. S. Stewart.) No pain, less edema of arm. Episcopal Hospital. the size of the breast, and grows rapidly; the axillary lymphatics are palpably involved quite early in the disease, and all local symptoms 70S SURGERY OF THE BREAST (limitation of excursion of the breast, retraction of the nipple, orange skin dimpling) occur sooner than in the scirrhous form (Fig. 823). Ulceration also develops earlier and the ulcer is deeper but is not fixed to the chest wall; its surface is covered with sloughs, there is more discharge, and hemorrhages may occur (Fig. 820). Prognosis and Treatment. — On account of the more rapid growth of the tumor, the patient usually seeks advice sooner than in the scirrhous form, and therefore radical treatment more often can be undertaken with a hope of cure. Medullary Carcinoma is much rarer than either scirrhus or carcinoma simplex. The tumor occurs in younger women, and is of extremely rapid growth, often simulating a phlegmonous process. The over- lying skin is red and tense; the breast is covered with dilated veins, and feels hot on palpation; soft areas resembling suppurating cysts or abscesses may be felt; and in the course of a few weeks the whole surface of the tumor breaks down, and a foul, sloughing mass pro- trudes. Hemorrhages are frequent, and large clots may cover the surfaces of the mass (Fungus Hematodes). On section the tumor often resembles softened brain matter, whence it sometimes is called encephaloid; it is friable and pulpy. An extreme type of medullary carcinoma, with most alarmingly rapid growth, frequently developing during pregnancy, is described as carcinomatous mastitis. This often involves both breasts. Prognosis and Treatment. — Death usually occurs within a few months, even early radical operation proving ineffectual in preventing recurrence. Those tumors developing during pregnancy are the most malignant of all. Paget's Disease of the Nipple. — This was described by Sir James Paget, in 1874, as a form of dermatitis or eczema predisposing to carcinoma of the breast. It is a rare disease, and while almost all cases occur in the nipple of the female breast, a few have been recorded as occurring in other parts of the body. The exact nature of the affection is still disputed by pathologists. Most authorities consider it carcinomatous from the beginning, but its point of origin is un- determined. Some hold that it arises in the galactophorous ducts and invades the skin secondarily; others believe that it originates in the epidermis and invades the ducts secondarily. Microscopically the characteristic feature is the presence of large transparent multi- nucleated cells ("Paget cells") in the deeper layers of the epidermis. Clinically the disease affects women of the cancer age; it begins as a scaly affection of the nipple, typically eczematous in nature but totally uninfluenced by local remedies usually effectual in relieving eczema in other parts of the body. As the disease progresses, the areola is involved, and the erosion or excoriation continues to spread super- ficially for months before the glandular tissue is noticeably affected. The area usually is moist, but some psoriasis-like cases have been reported. The subjective symptoms are itching, tingling, and burning; but the general health is not impaired. EXTENSION OF MAMMARY CARCINOMA 769 Treatment. — Treatment consists in amputation of the breast as soon as the disease is recognized; if the disease is extensive or of long duration, it is safer to do a radical operation as for carcinoma. Cancer Cyst. — This is the rarest form in which malignant disease of the breast occurs. It has been studied by Bloodgood (1907). Usually occurring as a single cyst, it grows slowly, and presents few clinical signs of malignancy. Exploratory operation being under- taken, the cyst is found to contain bloody fluid, and there is no intra- cystic papillomatous out-growth to account for this fact; but usually an indurated or ulcerated area is found in the cyst wall. Any cyst which is opened at operation, and is found to contain hemorrhagic fluid, should be looked upon as carcinomatous unless there is an intracystic papilloma to account for the blood. Treatment consists in radical operation as for other forms of car- cinoma. Extension of Mammary Carcinoma. — Local extension occurs especially to the overlying skin, to all portions of the mammary gland and its ramifications, and to the sur- rounding adipose tissue. The deep fascia overlying the pec- toral muscles and as far down as the epigastrium is widely infiltrated, and early invasion of the pectoralis major muscle may occur, as demonstrated by Heidenhain (1889). Lymphatic extensions are di- rectly continuous with the main growth by fine columns of cancer cells. As the primary tumor in most cases is in the upper outer quadrant it is the axillary lym- phatics that are first invaded as a rule, and this invasion occurs long before the nodules are pal- pable. In most cases the nodes which first become palpable are those on the side of the thorax, about midway between the axillary folds. Let the patient's arm hang by her side, so as to relax the axillary fascia, and then palpate gently and attentively in this region. But in the case of a growth in the extreme upper and outer part of the gland, early extension may occur to the nodes highest in the axilla, and these rarely can be palpated. In time all the axillary lymphatics are involved, and even the supraclavicular nodes may become enlarged. In advanced cases lymphedema of the arm results from the axillary lymphatic obstruction; venous obstruction may also contribute to the edema; and pain from compression of the axillary nerves may be a very distressing symptom. Lymphatic extension 49 Fig. 825. — Lymphatics of the breast and axilla, involved in mammary carcinoma. Episcopal Hospital. 770 SURGERY OF THE BREAST may also occur to the mediastinum, especially if the tumor grows in one of the inner quadrants of the breast; or extension may occur across the middle line of the body to the other breast, or even to the other axilla. Both breasts and both axillae always should be examined attentively. Finally reference must be made again to cancer en cuirasse, due to widespread carcinomatous lymphangeitis of the skin. Distant metastases by way of the blood-stream are denied by modern pathologists. Cancer cells in the blood excite thrombosis, and the thrombus as it organizes usually destroys or renders them harmless (Handley). Handley has also indicated that bone lesions (confined to the bones of the trunk, the proximal ends of the limbs, and the skull) are or have been in direct continuity with the main growth; their site often is suggested by the presence of subcutaneous nodules over the affected bone, even before bone pains, or pathological fracture demonstrate their existence. In cases of scirrhus this sad event occa- sionally occurs before the local tumor is noted; and it is a rule always to consider the possibility of already present metastases before operating on a case of scirrhus, and always to inquire into the con- dition of the mammary gland in the case of obscure malignant growths in the bones or viscera. Radical Operation for Mammary Carcinoma. — Ablation of the Breast. — The general principles on which a radical operation for malignant disease is based were discussed in Chapter IV (p. 132). The develop- ment of the technique of the modern operation for carcinoma of the breast is due largely to the teaching of C. H. Moore, Volkmann, Heidenhain, Stiles, Halsted, and Handley. Moore (1867) was one of the earliest to discard the theory of a cancerous diathesis, and to look upon it as a disease of purely local origin; in consequence he urged wide excision of the breast and all involved structures (pectoral fascia and muscle and enlarged lymphatics) in one mass. Volkmann (1875) always excised the pectoral fascia and emphasized the necessity of removing the surface of the pectoral muscles when diseased, and established the "three year limit," all patients free from recurrence after this interval being reckoned as "cures." Though recurrences (or perhaps new carcinomas) may grow after intervals of ten and even twenty or more years, it is found by the best operators today that recurrence after a free interval of three years occurs in only about 20 per cent, of patients. Heidenhain (1889) urged removal of the surface of the pectoral is major muscle in all cases, even when not visibly diseased, as on microscopic examination he found it always invaded by cancer cells. Stiles (1892) called renewed attention to the importance of w r ide local excision, showing the great area over which the mammary gland was spread out- — sending processes to the clavicle above, to the axilla laterally, and well below the lower border of the pectoralis major, on to the serratus magnus, rectus, and external oblique muscles. Halsted (1894) introduced removal of the pectoralis major as a measure of routine, to facilitate clearing the axilla, in RADICAL OPERATION FOR MAMMARY CARCINOMA 771 every case, whether the axilla was manifestly diseased or not; and he also insisted that the supraclavicular lymph nodes should be excised, and that the entire diseased tissue should be removed in one piece. Willy Meyer in the same year urged removal of the pectoralis minor in every case, and renewed the advice of Gerster (1885), who had advocated commencing the operation by the axillary dissection, which was left by others for the last step, and usually was under- taken only after the main tumor mass had been cut away. Finally, Handley, in his Astley Cooper prize essay (1905), demonstrated anew the importance of the deep fascia as the main highway by which the carcinoma cells spread in all directions from the common center of disease, and should the necessity of removing it in a wide circle on all sides of the growth, which should be taken as a center. This excision extends laterally to the latissimus dorsi, medially well beyond the middle line, and inferiorly, at least two inches below the ensiform process. The operation thus comprises removal of a very wide area of skin, the mammary gland with surrounding fat, the deep fascia, both pectoral muscles, and axillary lymphatics, in one mass. If this diseased mass is cut into at any point the contained cancer cells will be given a chance to escape into the surrounding healthy tis- sues, and recurrence will be very apt to follow. For the same reason all rough handling and tear- ing the tissues apart by blunt dissection should be avoided. Skin Incision. — So long as this removes a sufficient area of skin, its particular form is immaterial. A wound which cannot be closed completely is less likely to be the seat of recurrence than one which can, because there is less likeli- hood of diseased tissue remaining. I prefer Jabez N. Jackson's (Fig. 826) incision (1906) for early cases with little apparent involvement of the skin. Rodman's incision is as good as any (Fig. 827) Fig. 826. — Jackson's incision for carci- noma of the breast, suitable for early cases. The rectangular flap is turned down- ward and the axillary flap upward in closing the wound. Episcopal Hospital. For the average case Only a portion of the incision is made at first, sufficient for the dissection of the axilla, which should constitute the first step in the operation. To postpone this to the last, as in Halsted's method, leaves the entire thoracic wound exposed during the most tedious part of the operation; whereas, if the axilla is cleared first (and this may require two hours or more in difficult cases) the remainder of the operation may be completed in about fifteen minutes. Moreover, the blood-supply is controlled 772 SURGERY OF THE BREAST much more effectively if each branch going to the tumor mass is secured at its origin. The pectoral is major muscle is exposed first, its upper border identified, clamping or protecting the cephalic vein. A finger is then passed beneath the muscle, and it is divided close to its humeral attachment. The cla- vicular fibers of the pectoralis major are next cut close to the bone. This exposes the pector- alis minor, which is similarly divided close to the coracoid process, and the axilla is fully exposed. If there are palpably enlarged lymph nodes at the apex of the axilla, the skin incision should be extended upward across the clavicle, and the supraclavicular nodes explored. If enlarged they should be re- moved. Unfortunately it is not feasible to remove them in one mass with the axillary lymph- atics, and they must be excised separately. Then the axilla is cleared from above downward, working along the axillary vessels to the lower border of the latis- simus dorsi. Arterial and venous branches are clamped and cut close to the main trunks. Whenever the supply of hemostats is exhausted, all clamped points should be ligated, thus releasing the hemostats for future use. The main nerve trunks are carefully preserved, as is the median (long) subscapular nerve which supplies the latissimus dorsi; injury to this will affect the usefulness of the arm. Sensory nerves may be cut without compunction. When the vessels once have been dissected free the operation may proceed with greater rapidity. The entire axillary contents are turned toward the chest, and the lateral thoracic wall, from behind forward, is denuded of fascia; here the long thoracic nerve (external respiratory) should be looked for and pre- served. The axillary wound is then filled with gauze. The skin incisions are gradually extended to outline the breast, and are extensively undermined, on all sides, leaving attached to them only enough superficial fat to prevent sloughing. The axillary contents and pectoral muscles are then turned toward the median line, and the dissection of the chest is continued from the lateral wall to the sternum. Here the perforating branches of the intercostals and internal mammary arteries will be encountered, and may cause troublesome bleeding if allowed to retract below the intercostal Fig. 827. — Rodman's incision for carci- noma of the breast, suitable for most cases. The triangular flap below the clavicle is pulled downward, and the under- mined skin on the lateral surface of the thorax is pulled upward, the wound being sutured in the form of the letter T, the long limb lying in the long axis of the breast. Episcopal Hospital. RADICAL OPERATION FOR MAMMARY CARCINOMA 773 muscles before being clamped. The tumor mass now being free above, the dissection is continued downward, removing the deep fascia over the upper portion of the rectus muscle in the epigastric region. The tumor being thus removed, a puncture for drainage is made in the skin of the axilla, and a tube introduced; which is allowed to remain four or five days. The skin is then sutured, closing the wound as far as can be done without undue tension. The arm is dressed in a fully abducted position; this permits more accurate apposition of the skin to the axilla, prevents accumulation of wound discharges here, and facilitates return of the function of the upper extremity. When the skin is accurately adjusted to support the axillary struc- tures, it is very seldom that disability follows from cicatricial con- Fig. 828. — Ablation of the breast: the pectoralis major has been cut near its humeral insertion, and its clavicular fibers have been divided, exposing the pectoralis minor. The entire skin incision (indicated in the drawing) is not made at one time, but only as the operation proceeds. traction. Lymphedema may develop after the operation, especially when a thorough removal of the axillary lymphatics has been accom- plished. It may be treated by Handley's operation (p. 301). Excel- lent motion is retained by the arm in spite of removal of both pectoral muscles, and the patient is little if at all inconvenienced by their loss. The immediate mortality of the extensive operation described above is very low — not more than 1 per cent, in skilled hands. Deaths are caused almost solely by visceral complications, such as pneumonia, cardiac disease, or uremia. After-treatment. — When the incision cannot be sutured completely, some surgeons prefer to do skin-grafting at the conclusion of the operation; while others postpone this until granulation has commenced. Personally I believe it is better to do neither, but to expose the granu- lating surface to the a>ray at suitable intervals. If this treatment is conducted by a skilled rontgenologist, there seems much less tendency to recurrence, and where inoperable recurrence takes place this treat- ment greatly relieves the pain, diminishes the discharge and fetor, and keeps the patients comfortable (Figs. 820 and 824). 774 SURGERY OF THE BREAST Examination of the wound for recurrence should be insisted upon, at first monthly; then every three or four months, until the three year period has elapsed. After this time the patient should report to her surgeon at least once a year, or immediately if any symptoms arise. End Results of the Radical Operation for Carcinoma of the Breast. — If the operation is done in favorable cases (before there is palpable axillary involvement and before the tumor is fixed or the overlying skin ulcerated), about 70 per cent, of patients will be "cured" in Volkmann's sense; that is, they will remain free of recurrence for a period of three years. And of these clinical "cures," only about one- fifth will have a recurrence at a later date. If axillary invasion has occurred before the operation is done, about 25 per cent, of patients will be in good health after three years. These figures are conserva- tive, as better results are reported by those who do most of these operations. But the advantages of the operation are great even if recurrence or metastasis eventually occurs. At the very worst, the patient will enjoy a number of months, perhaps several years, of good health, and will have hope of ultimate cure. Even if recurrence takes place a cure may still be possible by aid of a second or third operation. Finally, if metastasis occurs, and death results from this cause, it will be a very much less painful death than that from local recurrence, and the operation at least will have prolonged life and afforded an interval of comfort and of hope. Inoperable Cases. — Usually no operation should be undertaken in cases in which it is manifestly impossible to remove all of the disease. In most patients with the supraclavicular nodes palpably enlarged, no operation, however radical, will effect a cure; but if the tumor is not otherwise inoperable, the radical operation may be done, these nodes being removed at a second operation ten days or two weeks later. Only if they are very slightly involved is it safe to prolong the original operation for their immediate removal. Recurrences are to be treated on the same principles as the primary growth. Even fixation to the chest wall does not necessarily contra- indicate excision; the portions of ribs invaded may be removed. Palliative operations sometimes are done in inoperable cases. Very occasionally mere "amputation'" of the breast (p. 759), to remove a sloughing ulcer, followed by a;-ray treatment, will promote the patient's comfort and prolong life even when cure is out of the question (Fig. 820) . Cauterization with the actual cautery, or with chemicals, such as chloride of zinc solution (5 per cent.), sometimes will relieve discomfort by sterilizing the surface of a sloughing growth. Double oophorectomy, introduced by Beatson of Glasgow, in 1896, has been employed in a number of advanced cases, and in some patients shrink- age of the breast tumor and considerable relief has followed. Ampu- tation at the shoulder-joint was employed by Esmarch (1883) as a primary operation in one far advanced case, and has been practised INJURIES 775 a number of times since in cases of recurrence; and even interscapulo- thoracic amputation has been employed in cases of recurrence (Dent, in 1897, and later by others). Others have employed rhizotomy (p. 573), with marked relief of pain. SURGERY OF THE CHEST WALL. Congenital and Acquired Malformations. — These are of interest from a diagnostic point of view, but little can be done in the way of treatment. Birth injuries occasionally result in deformities which persist through adult life (Fig. 829), but seldom entail any disability. The diagnosis is made from the history. Rachitic deformities, reference Fig. 829. — Birth injury of thorax. Orthopaedic Hospital. Fig. 830. — Funnel breast (rachitic). Orthopaedic Hospital. to which was made at p. 456, develop during infancy or early child- hood, and are recognized by coincident symptoms of rachitis. The most frequent deformities are the "rachitic rosary," Harrison's groove, and pigeon breast; these seldom persist past the age of puberty. Funnel breast, however, may last through life (Fig. 830). Some of these deformities may be improved by gymnastic exercises, or by the use of orthopedic apparatus, if treatment is begun in early childhood; but the disability is so slight in adult life that no active interference is required. Injuries. — The most frequent injury is fracture of the ribs. This was considered at p. 359. Simple contusions require no special notice. Severe lacerated wounds, with compound fracture of the 77G SCL'dEh'Y OF THE CHEST WALL ribs, usually are attended by visceral injuries (for which see p. 783). They are caused by crushing injuries, explosions, etc., and often are fatal. If the patient survives, con- valescence is prolonged, and severe deformity may ensue (Fig. 831). In some cases a phenomenon known as traumatic asphyxia, or stasis cyanosis, follows sudden vio- lent compression of the chest (or abdomen) of short duration. This state is characterized by marked cyanosis of the head, face, and neck, usually sharply delimited a "THBHP \ *^M MM m ^*h^ Fig. 831. — Deformity of thorax following injury by explosion in coal mine. Episcopal Hospital. Fig. 832. — Traumatic asphyxia; oxygen in- halations. Death in twelve hours. Episcopal Hospital. short distance above the clavicle, apparently by the collar. The patient looks as if he had been strangled (Fig. 832): the eyes are bloodshot, and the eye-lids may become edematous; there may be hemorrhages from the naso-pharynx or ears; convulsion's or uncon- sciousness may occur. In addition to shock, there is irregularity or entire failure of respiration. The cyanosis, which is petechial in appearance, may be due to extravasation of blood (true traumatic asphyxia) or to dilatation of the capillaries with blood stasis (stasis cyanosis) . It is difficult to differentiate the conditions, which, indeed, often coexist. The mechanism by which this state is produced is believed to be sudden compression of the thorax with the glottis closed, causing violent reflux of blood from the right heart. There may be interstitial and subpleural hemorrhages in the lungs, with interstitial emphysema; and in some cases cerebral congestion and hemorrhages have been found postmortem. Treatment. — Treatment comprises measures to overcome shock, with artificial respiration, and inhalations of oxygen. Surgical Emphysema. — Surgical emphysema is a term used to describe the escape of air into the subcutaneous tissues. As previously noted (p. 334) it may occur in the face in connection with fractures AXILLARY ABSCESS 111 of the nose, etc. The most usual form, however, is that due to thoracic injury; and the air escapes across the pleura from the lungs which have been punctured by a broken rib or ruptured by the compressing force. If the emphysema appears first at the root of the neck, and not at the site of injury, it is probable that the rupture of the lung is entirely subpleural, and that the air has escaped into the loose cellular tissues surrounding the bronchi, and eventually reaches the neck by way of the mediastinum. This subcutaneous emphysema may occur without any clinical evidence of severe intra-thoracic injury, but as auscultation and percussion are much interfered with by its development, it is probable that the deeper lesions often are overlooked. Occasionally a wound of the pleura, without injury of the lung, may cause the development of emphysema, the outside air being sucked into the wound by the negative intra-thoracic pressure. The air may spread far over the body, up to the scalp, down to the groin, and even out along the limbs; the eyes may be closed up, and the patient may become so bloated that recognition will be impossible. Subjective symptoms, except those due to visceral lesions, are insignificant. Palpation of the areas affected produces typical crackling; the skin feels as if floated up from the muscles or bones by an effervescing liquid; the air may be driven from one place to another by the fingers, and pitting on pressure is apparent. The larger the source of supply, the more rapid will be the develop- ment and spread of the emphysema. In some cases only a very limited area is affected, and attentive examination is required to detect it; in others the emphysematous area increases rapidly in size as the patient is watched. Treatment. — Mild cases require no treatment; but usually, whether or not there is fracture of the ribs, the injured side of the thorax should be strapped, as limitation of the respiratory excursions will diminish the spread of the air. Where the emphysema is very marked, it has been recommended that multiple punctures be made with a fine pointed bistoury, or tenotome, whereupon air will escape with a hissing noise, and the swelling will partly subside. As a matter of fact, if any treatment is necessary, it is much better to aspirate the pneumothorax, since as long as this continues air will escape from it into the subcutaneous tissues. The chief danger is infection of the subcutaneous tissues, with widespread cellulitis. Apart from this and visceral lesions, the prognosis is good. Axillary Abscess. — This may be superficial or deep. The former, which is more frequent and less serious, arises in connection with the hair follicles or sebaceous glands, as a furunculosis; the process occurs superficially to the axillary fascia. Usually suppuration starts in several different points, but if incision is not made promptly these may coalesce to form one abscess (Fig. 833). Treatment consists in incision and drainage. Deep or True Axillary Abscess arises in the tissues of the axilla underneath the axillary fascia; it begins as lymphadenitis (Fig. 834), 77.s SURGERY OF THE CHEST WALL and usually is due to a primary infection in the hand, or rarely in the breast. Occasionally these deep axillary abscesses point through the thin (cribriform) portions of the axillary fascia and present beneath the skin. Rarely the pus may travel upward along the sheath of the axillary vessels and point at the root of the neck. Owing to the deep seat of the inflammation, and to the pus being covered by the dense axillary fascia, distinct evidences of suppuration often are absent. The surgeon should not wait for fluctuation, or even for redness and edema of the overlying skin, or other classical signs of abscess. The subjective symptoms, pain, tenderness, and loss of function of the arm, are so severe as to suggest serious trouble, and the constitutional evidences of infection may be marked. Therefore no time should be lost in draining the axilla. Usually an anesthetic is desirable. An incision is made from the outer border of the axilla Fig. 833.— Abscess superficial to deep fascia of axilla. Episcopal Hospital. Fig. 834. — Deep axillary abscess, following lymphadenitis; duration six weeks. Episcopal Hospital. inward to the chest wall, midway between the anterior and posterior axillary folds. After the skin is incised the knife should be kept fairly close to the thorax. When the axillary fascia has been incised, if pus does not flow, further exploration should be conducted accord- ing to Hilton's method (p. 50). The axilla is drained by a tube, and the arm is carried in a sling. Subpectoral Abscess. — This is an abscess between the pectoralis major muscle and the pectoralis minor, or one beneath the latter muscle, at the extreme apex of the axilla. Probably in most cases it is caused by direct contusion or strain of the pectoral muscle, producing a small hematoma which subsequently is infected through the blood-stream. It may arise in suppuration of the subclavian lymph nodes, which lie on the anterior surface of the pectoralis minor or clavipectoral fascia. Sometimes this follows infected wounds of SUBSCAPULAR ABSCESS 779 the extensor surfaces of the fingers or forearm, since the lymphatics from these regions may pass directly to these nodes along the cephalic vein; whereas the lymphatics from other regions of the hand and fore- arm enter the axilla with the brachial vessels. Rarely a subpectoral abscess is caused by caries of the ribs, or by bronchial or pleural infec- tion; in such cases the abscess often is chronic and is due to tuber- culosis (Fig. 841). Fig. 835. — Right subpectoral ab- scess; duration three weeks. No cause discoverable. Episcopal Hos- pital. Fig. 836. — Abscess in left supraspinous fossa; duration one week; cause unknown. Incision evacuated 200-250 c.c. of pus. Healed in six days. Episcopal Hospital. Symptoms. — A subpectoral abscess forms a rounded, tender, painful swelling below the inner part of the clavicle; it tends to point at the lower border of the pectoralis major (Fig. 835), or rarely may burrow through an intercostal space into the pleura. It is differentiated from axillary abscess by its position nearer the median line of the body, and by the relaxed condition of the axillary fascia and freedom of the axilla; and from arthritis of the shoulder by the slight impairment of the movements of the joint, which are quite free within a limited range. I have seen the condition mistaken for tuberculosis of the shoulder-joint. Treatment. — The abscess should be opened by an incision along the lower border of the pectoralis major, and should be drained with a tube. Musser collected 23 cases with 13 deaths. Subscapular Abscess. — This is quite rare. It may follow disease of the scapula or shoulder-joint. The pus forms in the space between the serratus magnus and the posterior thoracic wall. It cannot point anteriorly because of the attachment of the serratus magnus to the lateral aspect of the thorax; it cannot escape internally because of the 7S0 SURGERY OF THE CHEST WALL spinal connections of the scapula. The pus, therefore, spreads either upward, and points beneath the trapezius, which is unusual; or down- ward to the angle of the scapula. If the existence of this condition is remembered, the diagnosis rarely will be difficult. The abscess should be opened at the lower angle of the scapula, and drained. In some cases the body of the bone may be trephined. Suprascapular Abscess. — Suppuration in the supraspinous fossa is another unusual condition (Fig. 836). Unless the condition is borne in mind, the swelling may be mistaken for a sarcoma. The onset usually is subacute, and may follow the formation of a hematoma in the supraspinatus muscle as the result of trauma; or the lesion may be tuberculous and arise in the bone. The abscess should be opened and drained, unless it is thought to be tuberculous, when it should be treated as a tuberculous ab- scess elsewhere in the body (p. 526). Caries of the Ribs and Costal Cartilages. — This usually is tuberculous in nature. It may be due to extension from a focus in the vertebrae, or from a tuber- culous pleurisy; or the disease may be primary in the ribs. In the latter case development of the affection often follows in- jury. Usually the patients are adults, and there often is pul- monary tuberculosis or a tuber- culous lesion in the bones, joints, or lymph nodes. Early forma- tion of a cold abscess occurs, and this presents itself as a fusiform swelling along the course of one or more of the ribs. The ribs from the third to the eighth are oftenest affected, near the chondral or the vertebral joints. The disastrous results of spontaneous fistu- lization and secondary infection are as prominent here as elsewhere in the body where tuberculous disease is concerned; and owing to the susceptibility of cartilage to infection, owing to its lack of blood supply (Axhausen, 1913), interminable suppuration ensues, with numerous fistulse, and constant pocketing of "hot" pus, which requires evacua- tion (Fig. 837) . Permanent cure can be secured only by radical extir- pation of all cartilage which has been denuded of perichondrium (Moschcowitz, 1918) : though the tuberculous infection may be eradi- cated by the first operation, pyogenic cocci continue to invade damaged cartilage, which should be excised until cancellous bone is reached at Fig. 837. — Extensive scars of both hyper- chondriac regions from previous operations for necrosis of ribs. Episcopal Hospital. ACUTE MEDIASTINI TIS 781 both ends. If seen before rupture occurs, the abscess should receive the treatment advised for cold abscess in general (p. 526). Tuberculosis may also affect the joints of the sternum; at the junction of the manubrium and gladiolus its development has been mistaken for fracture (N. B. Carson). Acute septic osteomyelitis of the ribs may occur, but is rare; also rare is typhoid periosteitis of the ribs, which may not develop for months or years after the attack of typhoid fever. Osteomyelitis may result in necrosis of the ribs, and resection of the portions affected may be required; in cases of typhoid origin, however, curettement of the carious surfaces usually is sufficient. SURGERY OF THE ANTERIOR MEDIASTINUM. Acute Mediastinitis. — Acute mediastinitis is the term used for a cellulitis of the mediastinum. It may follow a stab or gunshot wound, or may result from extension downward of a cervical cellulitis or be secondary to a pulmonary lesion. I have seen a metastatic abscess in the mediastinum in a case of osteomye- litis of the femur. There are pain, tenderness on pressure over the sternum, and constitutional symp- toms of sepsis. Signs of cardiac, pulmonary, or tracheal compression may arise. Usually in the course of time pus is formed, and this seeks an exit for itself through an inter- costal space close to the sternum, or possibly by rupture into a bron- chial tube or the pleura. Subcuta- neous emphysema may be an early sign. Lymphadenitis of the medias- tinum usually is tuberculous. The onset of symptoms is less acute than in mediastinitis. Treatment. — When medical meas- ures, with cold locally, fail to relieve the symptoms, and especially when symptoms of respiratory obstruc- tion arise, surgical intervention is called for, even before pointing of an abscess occurs. The operation consists in trephining the sternum, enlarging the opening with rongeur forceps, and evacuating the pus by Hilton's method (p. 50). An ab- scess may be opened where it points, but even then it is usually necessary to cut away part of the sternum to secure free drainage. Fig. 838. — Abscess of the mediastinum in a patient aged fifty-two years. Dura- tion three weeks, following influenza. In- cision evacuated pus and air. Recovery. Episcopal Hospital. 782 SURGERY OF THE LUNGS AND PLEURA Mediastinal Tumors. — These give evidence of their presence by compression symptoms, and by an abnormal area of dulness on percussion. Tuberculous lymphadenitis is the most frequent non- neoplastic growth. The lymphadenoid enlargements of Hodgkin's disease and sarcoma are not so frequent as secondary deposits of carcinoma. Benign tumors, especially dermoids, also occur. As a rule no surgical treatment offers any prospect of cure; but palliation may be offered by splitting the sternum longitudinally to lessen the symptoms of compression. Should a benign tumor be found, it might be removed successfully. Friedrich recommends transverse section of the sternum above the third rib. Enlargement of the thymus gland is referred to at p. 741. SURGERY OF THE LUNGS AND PLEURA. Subcutaneous Injuries. — Subcutaneous injuries of the thoracic viscera usually are accompanied by fractures of the ribs or sternum; but sometimes the lung is ruptured without there being any coinci- dent injury of the elastic thoracic cage. In most cases the lung is directly crushed, but it is possible for it to be injured by wrenching from its pedicle, or by being torn loose from pleural adhesions. The extent of the lesion varies from mere bruising to extensive laceration, and the resulting hemorrhage may be slight or very severe. In the mildest cases the visceral pleura is not ruptured, and the symptoms are those of a localized pneumonia, possibly with the development of subcutaneous emphysema commencing at the root of the neck (p. 776). When the visceral pleura is ruptured, hemorrhage occurs into the pleural cavity, and the air also usually escapes from the lung, forming a pneumo-hemothorax. Diagnosis. — The diagnosis depends on ascertaining the history of an injury; on the symptoms, which do not differ from those of pene- trating wounds of the lung (see below); and on the physical signs of pneumothorax and surgical emphysema. The differential diagnosis from traumatic diaphragmatic hernia may be difficult; this is dis- cussed at p. 802. Treatment. — The treatment consists primarily and chiefly in rest, either in the recumbent or sitting posture, whichever is more comfortable to the patient. The administration of opium in some form is decidedly beneficial, allaying the annoying cough, slowing the respira- tion, and, therefore, diminishing the bleeding. In many cases the bleeding stops of itself. The blood-pressure in the pulmonary system is only one-third of that in the systemic. If bleeding does not cease, as indicated by persistent symptoms of internal hemorrhage, and by gradual increase in the amount of pleural effusion, it must be checked by operative means, as described below in connection with penetrating wounds of the lung. If the pneumothorax persists and causes dyspnea, the air may be aspirated ; for this a very fine needle should be used, as less liable to cause subcutaneous emphysema. The surgeon should not PENETRATING WOUNDS OF THE THORAX 783 resort to this measure unnecessarily, since relief of the pneumatic pressure on the lung may cause recurrence of bleeding. Prognosis. — The prognosis is grave except in the case of trivial lesions. Moller, in 1910, reported 23 cases from Korte's clinique; no operation was attempted in any case, and none would have been of any avail in the 9 fatal cases. Fig. 839. — Cross-section of thorax at level of eighth thoracic vertebra. Pleura cavities outlined in black. Penetrating Wounds of the Thorax. — These are chiefly gunshot or stab wounds. The former have been considered at p. 209. In most cases of stab wounds the lung is injured, but penetration of the parietal pleura without visceral injury is possible. In the latter case intrapleural hemorrhage (hemothorax) may occur from injury of a vessel in the thoracic wall; and there usually is pneumothorax, air being sucked into the pleural cavity at each inspiration. Com- plicating injuries of the diaphragm and abdominal viscera are fre- quent. If the lung has been wounded there may be considerable shock, with dyspnea, cough, and usually spitting of blood (hemoptysis). In many cases there are the symptoms of severe internal hemorrhage (p. 259). The physical signs are those of pneumothorax, or hemo- pneumothorax; sometimes there is hemorrhage from the wound. Escape of air from the wounded lung through the external wound occasionally occurs; it is known as traumatopnea, and should not be confused with the mere aspiration of air into the pleural cavity such as was described as occurring even when no pulmonary injury is present. Prolapse of the lung through the wound is a rare occur- rence; this should not be confused with subcutaneous hernia of the lung, which is described at p. 786. 784 SURGERY OF THE LUNGS AND PLEURA Diagnosis. — Usually this is not difficult. But it should be remem- bered that alarming intrapleural hemorrhage may occur from injuries of the internal mammary and intercostal arteries, without wound of the lung; and the possibility and extreme seriousness of complicating stab wounds of the diaphragm (p. 801) should be kept in mind. Treatment. — The constitutional treatment is the same as for gun- shot wounds or subcutaneous rupture of the lung. Under no cir- eunistances should the wound be explored with finger or probe. The surrounding skin should be painted with 3 per cent, alcoholic solution of iodin, the wound should be covered immediately with sterile gauze, and the side of the chest affected should be firmly strapped as in the case of fractured ribs. This materially alleviates the patient's pain, though probably it has little influence on the progress of the wound in the lung. The question of the propriety of early operative interference in thoracic injuries has been the subject of much discussion during the last few years; and some surgeons are very uncompromising in their attitude for or against intervention. The debate is waged chiefly over the subject of stab wounds, the propriety of non-interference in the case of bullet wounds in civil life, except for positive indications, being very generally recognized. In the case of subcutaneous injuries, also, a decision for or against operation is not very difficult, because the symptoms either are so trivial as never to raise the question, or the lesions are so manifestly lethal in extent as to render operation useless. But in the case of stab wounds there are those who teach that operation is never or hardly ever required; and there are others, equal in experience and authority, who maintain that evere patient with a stab wound of the thorax, seen within the first twelve hours, should be taken at once to the operating room, and that the question of operative or non-operative treatment should be decided only after an exploratory operation has been done to determine by inspection the extent of the lesions. Zeidler, of St. Petersburg, with an immense experience in this class of cases, takes the latter ground; and his assistant Lawrow (1911) has exposed his views very thoroughly. Other things being equal, this no doubt is the logical position to take; but the fact remains that if it is adhered to, a great many unnecessary operations will be done; and in many cases the patients will be made worse or will be killed by the exploration. Most surgeons recognize that stab wounds which might involve the diaphragm or abdominal viscera should be explored; and the fact that 55 out of 121 stab wounds of the thorax (Lawrow) came within this category should be borne in mind. It is recognized, moreover, that wounds which probably injure the heart should be explored (p. 268); according to Lawrow's figures only one out of ten stab wounds of the thorax implicates the heart. But when these two classes of stab wounds are excluded, there certainly remains a large number of cases in which it is at least extremely probable that only the lung has been injured, or that even though the pleura has PENETRATING WOUNDS OF THE THORAX 785 been penetrated there is no visceral injury whatever; and it is interest- ing to compare the results secured in the case of uncomplicated pulmonary wounds in Zeidler's service, where every patient who con- sented was subjected to early operation, with those reported (1910) by Moller from Korte's clinique, where no operations were done in such cases. According to Zeidler's immediate exploration plan the mor- tality in 52 uncomplicated cases was 27 per cent.; whereas Korte treated 19 such cases without one death. And the significance of this comparison I believe is not altered by the fact that in 78 per cent, of the cases explored by Zeidler and his assistants some visceral injury or bleeding from an intercostal vessel was found. From a consideration of these facts I think it is evident that no hard and fast rules can be laid down for treatment, but that each individual case must be treated on its own merits. In fully equipped hospitals, I believe exploratory operation for stab wounds of the thorax will be indicated more often in the future than in the past; certainly more often than in the case of gunshot wounds or crushes. But I cannot believe that exploration in every case is necessary or desirable. If there is a possibility of injury of the heart, or of the diaphragm or abdominal viscera, exploration is imperative; but if this possibility seems remote, it is better to treat the patient expectantly. As indications for operation, then, may be recognized the following factors : 1. Possibility of injury to the heart, to the diaphragm, or abdominal viscera. 2. Active hemorrhage from the wound. 3. Signs of internal hemorrhage, recognized by constitutional symptoms, and by steady increase in the amount of the hemothorax. It makes no difference whether this comes from the wounded lung or from a parietal vessel. The bleeding must be stopped. 4. Pneumothorax which develops suddenly some days after the injury. As pointed out by Moller this indicates sloughing or reopening of the wound in the lung; and immediate drainage of the pleura is required to prevent sepsis. Primary pneumothorax scarcely ever will be so severe as to demand relief; but if necessary the air may be aspirated through a fine needle. If this fails, the only relief lies in thoracotomy, by which the pressure within the pleura may be reduced to that of one atmosphere. Operation. — Usually a general anesthetic is required. Ether is the best, and if possible it should be administered by intratracheal insufflation (p. 154). The wound is carefully explored, cutting down layer by layer, until it is ascertained that the pleura has been entered. Then the incision is extended to a length of 15 to 20 cm. in the wounded interspace. By strong retraction of the ribs (for which a rib-spreader is convenient) it may be possible to complete the operation without resecting any of the ribs. Resection of one or both ribs bordering on the primary incision may be done later if necessary. A 50 786 SURGERY OF THE LUNGS AND PLEURA bleeding intercostal vessel, which may be the only source of hemor- rhage, should be looked for and ligated. The pleura having been widely opened, the thoracic cavity is tamponed by hot moist gauze, and the diaphragm is inspected, unless there is good reason to believe that it has not been injured. If a wound is found, it should be treated as described at p. 801. If bleeding continues, the lung is caught in volsellum forceps, and is drawn into the thoracic incision. This fixes the mediastinum, promotes cardiac action, and ventilates the other lung. The lung is then searched for wounds, and these are sutured with mattress sutures of fine chromic gut, introduced close to the border of the wound, passed deeply, but not drawn very tight. Round-pointed needles should be used. A wound of exit as well as one of entrance should be looked for. If the wounds cannot be sutured, they should be packed; or a very extensive wound may be "exteriorized" by suturing its margins to the edges of the parietal wound. After the pulmonary wound has been sutured the lung will expand if intratracheal insufflation is being employed, and the blood which has collected in the pleural cavity will be forced out of the thoracic incision. If it is not, the pleura should be wiped dry. No irrigation should be employed. The parietal wound is then closed in layers (pleura, intercostal muscles, and skin), without drainage. If the anesthetic has been administered in the usual way it will be safer to leave a drainage tube in the incision for a few days; this should be just long enough to enter the pleura. In 22 cases where the wound was closed without drainage, subsequent drainage for empyema or abscess was required only in 13 (Stuckey); the other 9 patients recovered without any complication, and if all had been drained, all would have had empyema. Hernia of the Lung is rare. When congenital it may be due to defect in the chest wall, or may develop at the root of the neck. Acquired cases usually follow some months or years after injury of the thorax, the lung bulging out beneath the cicatrix. The swelling is sponge-like in consistency, crepitates on pressure, and is reducible; it increases in size during forced expiration, may disappear spon- taneously during inspiration, and gives an impulse on coughing. Treatment. — Treatment seldom is required. If support by pads or adhesive plaster does not secure relief, an operation may be under- taken, dissecting out the cicatrix, and repairing the wound by over- lapping its edges in several layers. The pleural cavity need not be opened. Pneumothorax. — The presence of air in the pleural cavity as a complication of injuries of the thorax has been alluded to. Occa- sionally the condition arises from disease of the lung, usually tuber- culous; but such cases have little surgical importance. The pneumo- thorax may be open or closed: that is, there may or may not be a wound of the thoracic parietes producing a communication between the pleura and the outer atmosphere. If there is no external wound (when the pneumothorax is due to escape of air from the wounded HEMOTHORAX 787 or diseased lung), or if the thoracic wound is small or valvular, the pressure of the air in the pleura may be increased at each respiration, and a "tension pneumothorax" is said to exist. Symptoms. — The symptoms depend upon the rapidity with which the pneumothorax develops, and on the air pressure. A very suddenly produced pneumothorax may cause immediate death from distortion of the mediastinum, and interference with the action of the heart or the other lung. One of very slow onset may produce no appreciable symptoms. When traumatic in origin, the symptoms often are obscured by those of shock, internal hemorrhage, etc. Unless the lung is bound down by adhesions, the air fills the entire pleural cavity, and the entire side of the chest affected becomes tympanitic on percussion. There is absence of respiratory movements, no breath sounds are heard, and vocal fremitus is absent. If the air is under extremely high pressure a dull note may be obtained on percussion; this is rare. Almost always there is dyspnea; there may be cyanosis; the cardiac action may be embarrassed, and the pulse usually is weak, not very rapid, and may be irregular. Treatment. — In most cases of closed pneumothorax the air will be absorbed spontaneously within a few days, and no treatment is required. If dyspnea is severe the air may be aspirated. For this a very fine needle should be used, so as not to produce subcutaneous emphysema. In cases of open pneumothorax relief of symptoms usually follows closure of the external wound by suture or occlusive dressing. This restores the piston action of the diaphragm, ventilates the other lung, and facilitates heart action. If for any reason the wound cannot be closed, and the symptoms of a tension pneumothorax supervene, it is better to enlarge the parietal wound or to introduce a drainage tube, thus reducing the intrapleural pressure to that of one atmosphere. Hemothorax. — Blood in the pleural cavity almost invariably is the result of injury to the thorax, either subcutaneous or penetrat- ing. The hemorrhage may be derived from the lung or from the internal mammary or one of the intercostal vessels. Bleeding from parietal vessels is not likely to stop of its own accord, owing to the negative pressure within the pleural cavity. If the bleeding comes from the lung it will not cease until the intrapleural pressure equals the blood-pressure within the lung; but as this is only one-third as great as that in the systemic circulation, intrapleural hemorrhage from a lung wound will stop of itself much sooner than will bleeding from an intercostal artery. The physical signs are those of pleural effusion. The symptoms of internal hemorrhage indicate the nature of the effusion, and this may be proved by aspiration. The blood does not clot very readily, and forms an excellent culture medium for bacteria. Hence there is great danger of secondary empyema. If infection does not occur, and the blood finally clots and becomes organized, extensive and perhaps disabling pleural adhesions may develop. I have operated 7SS SURGERY OF THE LUNGS AND PLEURA on a patient with calcification of the entire pleura, the result of injury many years previously. Treatment.— This depends upon the rapidity of the hemorrhage as well as upon its extent. Rapid bleeding (indicated by the symptoms of internal hemorrhage and by rapid increase in the amount of fluid in the pleura) usually indicates an extensive pulmonary lesion, and demands operation, as described under stab wounds of the lung (p. 785). If the bleeding is slower, it is better not to interfere unless the upper level of the dulness (in the sitting posture) ascends as high as the spine of the scapula, or unless the symptoms of hemorrhage are very pronounced. Pneumo-hemothorax. — Pneumo-hemothorax is more frequent than either pneumothorax or hemothorax separately. The air rises to the upper part of the pleural cavity, and the blood gradually accumulates below. The physical signs are those of pyo-pneumothorax, which are described in every text-book of general medicine. The diagnosis depends on a recognition of these, and on a history of recent injury and on the symptoms of internal hemorrhage. Aspiration of the fluid proves its hemorrhagic nature. Differentiation from diaphrag- matic hernia (p. 802) may be difficult. Treatment has been discussed sufficiently under the separate headings pneumothorax and hemo- thorax. Chylothorax. — Chylothorax usually is due to rupture of the thoracic duct, which may occur as a complication in some cases of fracture of the spine. The effusion is left-sided, but owing to more serious injuries often is overlooked. Rapid emaciation is characteristic, but the diagnosis cannot be certain until some of the fluid has been withdrawn by aspiration; and microscopical and perhaps chemical study may be necessary then to determine its nature, as an effusion similar in macroscopical appearances sometimes occurs in cases of malignant disease of the pleura. Treatment is unsatisfactory. In some cases repeated aspiration has been followed by recovery. Hydrothorax. — Hydrothorax is the term used to describe a collec- tion of non-inflammatory fluid (transudate) in the pleural cavity. It presents little surgical interest. Pleurisy or Pleuritis is an inflammation of the pleura, almost invariably of bacterial origin, and in the vast majority of cases due to infection transmitted from the lung. It may result from hematogen- ous infection, but this is rare. It is always present in some degree in cases of penetrating wounds of the thorax. In the early stages of the inflammation a plastic exudate is formed, and if the process stops here, recovery with more or less extensive pleural adhesions may occur. Such cases form about one-fifth of the total cases of pleurisy (Fraley, 1907) and seldom come under surgical care. In about three- fifths of cases serous effusion occurs, and in about one-fifth more this effusion finally becomes purulent (pyo-thorax) . If adhesions have formed early, or in a previous attack of pleurisy, the effusion may be encapsulated; its site then may be between the lung and the parietal PYOTHORAX, OR EMPYEMA THORACIS 789 pleura, between two lobes of the lung, or between the lung and dia- phragm. In cases where there are no adhesions the fluid lies free in the pleural cavity and forces the lung upward and backward into the spinal gutter. The symptoms of pleurisy with effusion are detailed in every text-book on general medicine, and need not be recounted here. The diagnosis is confirmed by exploratory puncture with an aspirating syringe. Treatment. — If the effusion is large and if no tendency to reabsorp- tion is manifested, and particularly if the constitutional symptoms indicate suppuration, the fluid should be aspirated, as described at p. 149. The needle is passed close to the upper border of the rib, in the sixth, seventh, or eighth interspace, usually in the posterior axillary line or below the angle of the scapula. The site may be anesthetized by a hypodermic injection of novocain or by ethyl chloride spray. Seldom is it necessary to withdraw all the fluid, as the relief of tension secured by aspiration of a portion may hasten absorption of the remainder. Pyothorax, or Empyema Thoracis, is a collection of pus within the pleural cavity. Usually it results from rupture of a small sub- pleural pulmonary abscess (Moschcowitz, 1919). It is the suppurative stage of pleurisy with effusion; but in many cases suppuration occurs so rapidly that no anterior stage of serous effusion can be recognized. In no case is there any sharp line of distinction to be drawn between the two conditions, as the serous exudate (when one exists) gradually becomes sero-purulent, and this in turn assumes the usual character of pus; but in every case before true pus is formed, adhesions set certain limits, large or circumscribed, to the cavity in which the pus is found. The pus may sink to the bottom of the cavity as a heavy flocculent sediment, and the supernatant liquid may remain comparatively clear. Pyothorax is most frequent in children, especially as a complication or result of a lobar pneumonia, the infecting organism being the pneumococcus. Pneumonia is followed by empyema in from 5 to 10 per cent, of cases. In adults men are affected much oftener than women, and the empyema results less often from a frank pneumonia; in many cases the staphylococcus or streptococcus is the infecting organism, and these may appear as secondary infections in cases originally caused by the pneumococcus, which is a short-lived organism. Unless the pus is evacuated early, the parietal and visceral pleura? become thickened, and a fixed cavity is produced, which will hinder expansion of the lung even when the contained fluid has been removed. Adhesions always occur, within the pleura, and the empyema whether small or large is encapsulated either on the surface of the lung (Fig. 846), between its lobes (Fig. 840), or between the lung and diaphragm. In rare cases the pus may evacuate itself through one of the bronchial tubes (pleural vomica), or may perforate the diaphragm and form a subphrenic abscess. In children it is not unusual for a neglected empyema to break through an intercostal space and to point sub- cutaneously. In adults this is rare (Fig. 841). This condition is 790 SURGERY OF THE LUNGS AND PLEURA described as an empyema necessitatis. If the empyema ruptures externally, which is very unusual, a pleural fistula is left, and this scarcely ever heals spontaneously. Symptoms ond Diagnosis. -Usually the empyema is secondary to some thoracic condition (pneumonia, bronchitis, injury) for which the patient has been under treatment. /// children, in whom the condition is most frequent, an empyema very frequently is mis- taken for an unresolved pneumonia; but this condition is rare in children, and if an aspirating syringe is used, as it should be, for rwg) Fig. 840. — Interlobar empyema ruptured into a bronchus (pleural vomica). pleural effusion in costo-phrenic sinus. Episcopal Hospital. Note exploration in such cases, the diagnosis will be quickly cleared up. The physical signs in children may be very misleading, as the breath sounds may be quite clearly heard; this, with the persisting dulness on percussion, causes the resemblance to unresolved pneumonia. There may be Skodaic resonance above the dull area. But tactile fremitus is decreased, and the mere fact of a lingering pneumonia in a child should make one suspect an empyema. Nor should failure to draw pus at the first puncture make the physician conclude that it is absent, if the constitutional signs of sepsis persist. The pus may be too thick to run through the needle employed, or may not have PYOTHORAX, OR EMPYEMA THORACIS 791 been reached by the needle. In advanced cases, however, the diagnosis is easy ; the temperature continues elevated, and though remissions may occur daily or oftener, the normal is not reached. The apex beat of the heart may be displaced by large effusions; the interspaces of the affected side may bulge; dilated veins may cover this side of the thorax; and it may seem larger than the healthy side, though its respiratory excursions are less than normal or absent (Fig. 842). The diagnosis from subphrenic abscess is considered at p. 865. In adults the diagnosis of pleural effusion does not present the same difficulties, but the pres- ence of pus rarely can be asserted positively unless paracentesis is done. Fig. 841. — Empyema necessitatis pointing beneath left pectoral muscles. Age thirty-two years; phthisis for two years; pneumonia seven months ago. "Abscess in thorax" for five weeks. (Dr. Harte's case.) Pennsylvania Hospital. Fig. 842. — Pyothorax on the left, following pneumonia. Age seven years; duration two weeks. Note x on apex beat, displaced to right; dyspneic expression; bulging of left intercostal spaces, and well marked intercostal depressions on right. Children's Hospital. Treatment. — A child almost in articulo mortis may be saved by prompt evacuation of the pus, but the evacuation should not be too rapid in any case where there is marked dyspnea, cyanosis, etc., as abrupt change in the intrapleural pressure may cause sudden death. In any case of massive effusion (one extending as high as the spine of the scapula) it is well to withdraw half or three-fourths of the fluid by aspiration before proceeding to drain the chest. In very early cases of seropurulent effusion, and in many cases of tuberculous pyothorax, it may suffice to aspirate the fluid, and at once inject 50 to 100 c.c. of formalin-glycerin solution (2 per cent.), as advised by John B. Murphy. A week later the fluid is aspirated again, being 792 SURGERY OF THE LUNGS AND PLEURA found in favorable cases less purulent and more serous; another injec- tion of the formalin-glycerin solution is given, and at the third or fourth aspiration, when pure serum is found, the fluid is allowed to remain in the pleura, and is very gradually (months) absorbed, as the lung expands and the chest wall sinks in until the cavity is obliterated. In most cases of pyothorax, however, thoracotomy and drainage of the abscess is the best treatment. Thoracotomy or Pleurotomy. — This is the operation of opening the thoracic cavity for the purpose of draining an empyema; a portion of a rib is excised to ensure free drainage (Konig, 1878). The rib selected depends on the location of the pus, if this is encapsulated; if the empyema is massive, the ninth or tenth rib below the angle of the scapula is the best site for drainage (Fig. 844). If the cavity extends lower than the rib first resected, a counterincision (resecting another rib) should be made at the lowest level for dependent drainage (J. Ashhurst, Jr., 1894). T. T. Thomas (1913) advocates resection of the eleventh rib close to its angle. In children some surgeons prefer an intercostal incision, without resection of a rib, but I believe even in these cases convalescence is more rapid if a larger opening is made. Dyspnea should be relieved by aspirating most of the pus before beginning the operation. The patient is not to be turned over on the healthy side, as this may cause arrest of respiration or cardiac action. By bringing the body well over the side of the table the operation may be done without much difficulty, as the patient lies supine. But it is much more convenient to have the patient lie prone; respiration is perfectly easy in this position and the operative pneumothorax causes less pulmonary collapse than in the usual position. The operation usually may be done under local anesthesia (p. 157) : after anesthetizing the skin and subcutaneous tissues as usual, the needle is inserted in the intercostal space at the dorsal extremity of the proposed incision, and is pushed in until it strikes the rib next above that to be resected ; its point is then manipulated until the lower border of the rib is found, whereupon it passes through the elastic resistance offered by the external intercostal muscle; it is then pushed still a little further in, and about 2 c.c. of a 0.25 per cent, solution of novocain are injected around the intercostal nerve. This procedure is repeated in the interspace next below; and after a few minutes the intervening rib may be painlessly resected. In some cases, especially in children, a general anesthetic (ether) is to be preferred, though I have employed local anesthesia with satisfaction at the age of sixteen months. An incision of about 8 to 10 cm. is made along the rib selected, and the knife is carried directly down to the bone. Bleeding-points are clamped. The periosteum is incised and is stripped from the outer surface of the rib throughout the length of the incision, by means of a periosteal elevator. On the upper surface of the rib strip the periosteum from behind forward, and on the inferior surface strip it from before backward. Then the periosteum is also stripped from the deep (pleural) surface of the rib, keeping the instrument close PYOTHORAX, OR EMPYEMA THORACIS 793 Fig. 843. — Excision of a rib for empyema. to the bone. By this means the intercostal vessels, which are separated from the rib by its periosteum, are pushed aside with the soft parts. When the rib has been thus denuded throughout its entire circumfer- ence for a distance of about 5 cm., a bone-cutting forceps or a special costotome is used to divide the rib at one end of the incision. The portion of rib to be excised is then grasped in forceps, and the rib is divided at the other end of the incision (Fig. 843), and the intervening portion is removed. This should be at least 3 cm. long. The parietal pleura, still covered by the deep layer of the periosteum, then presents in the wound; these structures should be divided in the axis of the rib for an inch or more. In some cases of long standing empyema the parietal pleura may be very thick. There is little danger of wounding the lung, but it is well to take the same precautions as in opening the peritoneum (p. 873). The intercostal vessels often are thrombosed, and may not bleed if wounded; if the periosteum has been stripped carefully from the rib before this is excised, and if the deep incision is made nearer the upper than the lower border of the rib, these vessels will not be wounded. If they are wounded, bleeding from them is controlled more easily by a mass suture than by a ligature. As soon as the pleura is opened a general anesthetic if used should be stopped. The pus should be allowed to escape slowly. Violent paroxysms of coughing may occur. The surgeon should introduce his ringer from time to time, to assist the discharge of masses of lymph. If the empyema is of long duration, it is well to break up adhesions between the lung and chest wall, so as to facilitate its subsequent expansion. In such old cases the infection is not very virulent, and septic absorption is not to be feared. In acute cases, where the infec- tion is more active, the lung is not firmly bound down, and its release, therefore, is not necessary. A large rubber tube (at least 1.5 cm. in diameter) is then passed 5 to 10 cm. within the parietal pleura, and is fixed by a stitch to the margin of the skin wound. If not thus fixed it may fall into the pleural cavity or be pulled out of the wound accidentally. An extremely abundant dressing of gauze and absorbent cotton is applied, and the patient is returned to bed. After-treatment. — The dressing may require changing several times daily at first. Masses of lymph blocking the tube should be removed with forceps. No irrigation of the cavity should be employed. In some instances this has caused death. As soon as agreeable the patient should be propped up in bed, and measures must be adopted to promote expansion of the lung. Every time the clock strikes the hour the patient should be instructed to take a half dozen or more 794 SURGERY OF THE LUNGS AND PLEURA deep respirations, and several times daily he should blow water from one Wonlff's bottle to another (Fig. 845). Children may exercise their 46YRS a dys 8 DYS. Fig. 844. — Three patients with empyema. The upper figures indicate the ages, the lower figuies the intervals since operation. Uneventful recovery in all. Episcopal Hospital. Fig. 845. — Blowing through Woulff's bottles to expand lung after thoracotomy for empyema. Episcopal Hospital. lungs by blowing up toy balloons, sounding trumpets, etc. Patients should be got out of bed as soon as possible. ENCAPSULATED EMPYEMA 795 Convalescence often is tedious, and may be interrupted by pneu- monic or pleuritic attacks, with evidences of septic absorption. This usually is due to interference with drainage of the wound. In favorable cases the tube does not require to be replaced when once removed at the expiration of ten days or two weeks. As judged by the results of operation, the mortality from empyema is about 20 to 25 per cent.; but as practically all patients die unless operated on, and as the death rate from the primary pneumonia is very high, the operation must be regarded as a distinct life-saving measure. Fig. 846. — Large but distinctly encapsulated empyema. Episcopal Hospital. Encapsulated Empyema. — The situation of the interlobar fissures should be re-collected (Fig. 846), as they are frequently the starting- place of an empyema. If the symptoms and physical signs indicate the presence of pus within the chest, I believe exploratory thoracotomy is justified, even if pus cannot be located by repeated puncture. The operation, done under local anesthesia, consists in resecting 8 to 10 cm. of the eighth and ninth ribs below the angle of the scapula, in walling off the healthy pleural cavity with hot moist gauze, and in searching between lung and diaphragm, between lung and chest wall, and between 79G SURGERY OF THE LUNGS AND PLEURA the lobes of the lung, for the abscess. This is then drained by tube, across the pleural cavity. I reported a series of such operations in 1916. Bilateral Empyema. — Bilateral empyema is most frequent in children. Fabrikant (1911) collected 118 cases, with a mortality of 37 per cent. The second side should be operated on a few days after the first. Pleural Fistula. Pleural fistula may persist for years after the evac- uation of an empyema, unless properly treated, and may lead to death from exhaustion, amyloid degeneration of the viscera, secondary tuberculosis, or some intercurrent disease. If the empyema has been recognized early, and has been evacuated promptly by a large incision low enough to secure efficient drainage, the resulting sinus closes in a month or two. Sometimes the thoracic wound closes on a persist- ing pneumothorax; but if the latter is sterile or nearly so, the sinus may not have to be reopened, the lung gradually expanding against the chest wall. It is in cases of chronic empyema, where the lung is bound down by dense adhesions, that a large thoracic cavity remains. From such an incompletely drained cavity half a liter or more of pus may be discharged daily; and when sapro- phytic infection is added, the dis- charge is exceedingly putrid, and the patient is loathsome to himself and to all around him. The thorax be- comes deformed, curvature of the spine develops (Fig. 847), and the patient is a helpless cripple. Club- bing of the ringers is frequent (Fig. 557), and other joint changes may add to his misery (pulmonary osteoarthropathy, p. 518. Treatment. — Treatment depends upon the extent and duration of the sinus. A small and recent sinus, which does not discharge very much pus, often may be made to heal by bismuth paste injections (Ochsner, 1909), as used for tuberculous sinuses (p. 527). This method, with skiagraphy, is valuable in determining the size of the cavity within the thorax. If drainage is not free, the sinus should be enlarged, under an anesthetic, and the surgeon should break up with his finger the adhesions between the lung and parietal pleura; and if the cavity is large, he should resect another rib at its most dependent portion, and drain from the lower opening. Fig. 847. — Scoliosis, nine months after operation for empyema; fistula still discharges 250 c.c. of pus daily. Episcopal Hospital. PLEURAL FISTULA 797 Sometimes the sinus is kept from healing by the presence of a drainage tube which has been lost inside the wound. This may be detected by a skiagraph. Information derived from use of the a>ray may be an aid in the prognosis: if the collapsed lung is permeable to air the a>ray will show decreased density during forced expiration; and if the lung shows a tendency to expand during coughing, it is probable no further operation will be required (Destot and Violet, 1904). For cases in which the lung is permeable, but where no tendency to expansion is apparent, Carrel-Dakin treatment, or decortication or discission, as described below, should be adopted. If the lung neither shows a ten- dency to expand nor is permeable to air, the only way to efface the pleural cavity is to resect the bony thoracic cage overlying it, and thus to allow the soft parts to fall in against the lung (Estlander, Schede). Carrel-Dakin Treatment.— -If treatment as above indicated fails to bring about closure of the sinus, resort may be had to systematic use of the Carrel-Dakin technique (p. 170) for the chemical sterilization of the cavity. The hypochlorite solution thus employed will gradually destroy the exudate covering the visceral pleura, permitting progressive expansion of the lung; and when repeated cultures (not merely smears) indicate that sterility has been attained, the Carrel tubes may be entirely withdrawn, an occlusive dressing applied over the sinus, and this may be allowed to close upon the remaining pneumothorax, which in some cases will eventually be obliterated by the mutual approach of lung and chest wall. In many the sinus will re-open. Decortication of the Lung (Fowler, Delorme, 1893). — This consists in opening the old cavity of the empyema, obtaining sufficient exposure to enable the surgeon to explore the entire interior of the empyema cavity. Lilienthal (1919) employs division of the ribs between scapula and spinal column, combined with an intercostal incision in the seventh or eighth space. The most important step is to free the lung thoroughly from its attachments to the parietal pleura. This is best done by mak- ing an incision through the latter close to the outer or posterior margin of the lung along the spinal gutter. The fingers are then inserted between the posterior thoracic wall and the lung, and the latter is gradually freed. Its natural elasticity and tendency to expansion aid in this manoeuvre. When the lung is thus freed posteriorly it may be possible to peel the remains of the abscess wall off its surface. The thoracic wound is then closed with drainage, and the case is treated as one of recent empyema. The results are very satisfactory, the lung expanding and the abscess cavity becoming obliterated. Discission of the Pleura (Ransohoff, 1903) is adopted in cases where decortication proves difficult or impossible. If the dense membrane overlying and compressing the lung is scored by the knife, down to the lung tissue proper, the incision will gape widely; and if a number of such incisions are made in parallel and criss-cross lines, each inci- sion will gape so widely that the lung will expand to a very surprising degree. 798 SURGERY OF THE LUNGS AND PLEURA Thoracoplasty, Estlander's Operation (1877).— This consists in the resection of several ribs (three to five), for a considerable extent, directly over the old empyema cavity, in order to allow the soft parts of the thoracic wall to fall in against the collapsed and non- expansile lung. The cavity is thus wholly or in part obliterated. In very large cavities the operation may not effect a cure, but the result is "the difference between having a large abscess discharging a great quantity of pus, and a small sinus which weeps a little thin fluid." (J. Ashhurst, Jr., 1894.) The operation may well be combined with free separation of the lung from its parietal adhesions, especially posteriorly — a modified form of decortication. Schede's Operation (1890) consists in resection of nearly the entire bony wall of the side of the thorax affected. This is exposed by reflecting an immense flap extending from the second costal cartilage anteriorly, to the costal margin below, and to the spine of the scapula posteriorly. After removal of the ribs, this flap is applied against the exposed lung. This operation has a high mortality and is rarely done at the present day, when earlier and more thorough treatment of the acute empyema enables the patients to recover without such immense cavities. In no cases should it be attempted until decortication and Estlander's operation have failed. Tuberculosis of the Pleura, usually secondary to that of the lung or bronchial lymph nodes, presents little surgical interest except in cases with effusion. Most painless, slowly developed, and appar- ently causeless cases of pleural effusion in adults are tuberculous. The condition is recognized by the physical signs of pleural effusion, and the nature of the fluid may be suspected from the patient's history. Diagnostic puncture reveals straw-colored or slightly turbid fluid, rarely blood-tinged. Tubercle bacilli seldom can be discovered, but a high lymphocyte count may suggest the tuberculous nature of the fluid, and inoculation experiments usually will confirm the diagnosis. The condition is to be regarded as one of cold abscess. Secondary infection, from the perforation of a tuberculous cavity in the lung into the pleura, is not very uncommon, forming a pyo- pneumothorax. Secondary infection may also occur through the blood or from the unruptured lung. Treatment. — Local treatment is entirely secondary in importance to the general treatment of the tuberculous patient. Only if the effusion is massive, and causes dyspnea, should any of the fluid be withdrawn by aspiration. If much fluid is withdrawn damage may be done to the diseased lung, or a recently closed communication with the lung may be reopened. After some of the fluid is withdrawn the remainder may be gradually absorbed. If on aspiration the fluid is found to be verging on suppuration (from secondary infection), 50 c.c. of formalin-glycerin solution (2 per cent.), should be injected. Under no circumstances should the pleura be opened by incision, or drainage be established: such a course surely invites secondary infec- tion, with an external pyo-pneumothorax, and death usually occurs in ABSCESS AND GANGRENE OF THE LUNG 799 a few weeks. Secondary tuberculosis in an open empyema cavity may occur, but is not so quickly fatal as a primary tuberculous pleurisy secondarily infected. It should be treated as other cases of open pneumothorax following empyema, with special attention to the patient's general health. Tuberculosis of the Lungs. — Surgery of this condition may be said to be still in an experimental stage, and has been applied mostly to advanced stages of the disease otherwise incurable. In 1898 Murphy introduced to surgical notice in this country a plan of treatment, previously advocated (1882) by Forlanini, con- sisting in injections of nitrogen gas into the pleural cavity, to cause collapse of the lung and thus to induce rest and promote healing of the pulmonary lesions. Nitrogen is said to be more slowly absorbed than any other gaseous substance. The subject has been exten- sively studied by Morelli (1918). Pneumonotomy, to drain cavities in the lung, has been done on numerous occasions; the first formal operation is the historic one of Baglivi in 1643. It is conceivable that with the present improvements in the technique of pulmonary surgery such operation may find a legitimate field in the future for the rare cases in which an apical cavity is not draining well, and in which no other discoverable tuberculous lesions exist. Partial pneu- monectomy was done by Tuffier in 1891; he removed the apex of one lung, containing an early focus of tuberculosis. The patient recovered and was in good health four years later. Medical and hygienic treat- ment will cure such patients, and no operation should be done. Est- lander's Operation was suggested in 1891 by O. H. Allis as a means by which collapse of a pulmonary cavity might be secured, with improved chance of its healing; and this operation has been employed by Quincke and others. Friedrich (1909) has employed Schedcs method for the purpose of causing collapse of a tuberculous lung, the other lung being healthy, or exhibiting no evidence of active disease. W. Meyer (1920) refers to 150 such operations in patients with pulmonary tuberculosis. Freeman (1909) resected the upper ribs, and after the wound had healed adjusted a hernial truss over the apex of the lung to cause obliteration of a tuberculous cavity. Freund's operation of chondrectomy, as in cases of pulmonary emphysema, has also been employed in cases of pulmonary tuberculosis, to overcome the thoracic rigidity which prevents aeration of the lung. Pulmonary Emphysema.— W. A. Freund, having recognized since 1858 that some of these cases are caused by fixation of the chest wall due to ossification of the costal cartilages, proposed in 1906 the operation of chondrectomy for their treatment. The costal cartil- ages of the second, third, and fourth ribs on both sides of the thorax are excised with their perichondrium, so as to prevent their regenera- tion. The operation appears to have been employed in at least fifty cases, with a fair measure of success. Abscess and Gangrene of the Lung, which are not very frequent, may be regarded as different stages of the same affection. Most SOO SURGERY OF THE LUNGS AND PLEURA cases occur in adults, and follow the lodgement of foreign bodies. Numerous cases following inspiration of blood or pus during tonsil- lectomies under general anesthesia have been reported. Some follow a pulmonary infarct from a septic focus elsewhere in the body. Most cases of so-called abscess of the lung develop from encapsu- lated empyemas and follow pneumonia; they are pleural vomicas (Fig. 840). Symptoms.- — Usually these develop rather suddenly as a compli- cation of the preexisting disease. There is profound sepsis. Physical examination reveals a localized consolidation in the lung, which may give the signs of cavity after expectoration of its contained sputum. The sputum from an abscess is great in quantity, and consists of thick yellow pus, not malodorous at first. The older the abscess the more fetid does the pus become, owing to saprophytic infection. In cases of gangrene, which usually is a sequel to abscess formation, this fetid character of the pus is very pronounced. If there is elastic tissue in the sputum it is not probable that gangrene is present, since saprophytic bacteria soon destroy it. Pleurisy, with adhesions, frequently occurs and may prevent perforation of the abscess into the pleural cavity with development of a putrid empyema. The use of the .r-ray is of much value in localizing the abscess. If exploratory puncture is done, it should be followed at once by operation. Treatment. — Operation should not be delayed if gangrene is pres- ent. The patient gets no stronger by waiting even for one day. Without operation 80 per cent, of cases of gangrene of the lung die. In Korte's 28 operations for abscess or gangrene, the mor- tality was 28.5 per cent. (1908). In Lenhartz's 111 operations for gangrene the mortality varied from 27 to 38 per cent. (1909). If the abscess drains well through a bronchus, operation may be post- poned. Whenever possible the operation should be done under local anesthesia or by anesthesia by intratracheal insufflation. The ribs overlying the site of the abscess (which should be determined before- hand) are resected subperiosteally, for a distance of 8 to 10 cm. Some- times the site of the abscess can be detected by palpation, being denser than the surrounding lung tissue. If the patient is not in very serious condition, the second stage of the operation is postponed for a couple of days, the lung being sutured to the pleura by interrupted sutures of chromic gut, applied in a circle around the supposed site of the abscess. If the lung is already adherent to the parietal pleura, or if the patient's condition is precarious, the surgeon proceeds at once to open the lung. This is done by Hilton's method, first thrusting a grooved director into the lung, and when pus is found dilating the tract with dressing forceps. Some surgeons use the actual cautery for opening the abscess. Any loose necrotic masses of lung tissue should be removed, but if even lightly adherent they should not be disturbed The abscess is drained by a tube. Bronchiectasis. — Though this condition is not curable by medical means, the cure by surgery may be worse than the disease. The STAB WOUNDS OF THE DIAPHRAGM 801 persistence of the bronchiectatic cavity may not materially shorten the patient's life, and the risk of operation is great. The least dangerous and most promising form of surgical treatment consists in some form of extrapleural thoracoplasty, to cause collapse of the diseased lung. Tumors of the Pleura and Lung may be primary, or secondary to growths elsewhere. Primary growths are rare and very difficult to diagnose. Most of them are malignant in nature. Endothelioma and sarcoma occur in both lung and pleura, carcinoma only in the lung. Tumors of the pleura invade the lung, and those of the lung soon attack the pleura. Of the secondary growths carcinoma is more frequent than sarcoma. Symptoms. — The symptoms are not clearly defined. Some cases of primary carcinoma of the lung are mistaken for tuberculosis. There is dulness on percussion, and the breath sounds are absent or may be heard distantly. Exploratory puncture may reveal a bloody pleural effusion, or there may be a dry tap. Blood in a pleural effusion signi- fies either tuberculosis or malignant disease. There is no fever and no leukocytosis. The increase in the physical signs is rapid. Cachexia appears early and is pronounced. Treatment. — There is little to do. If the pleura fills with fluid, and this causes dyspnea, thoracentesis may be done. A few cases of excision of portions of the lung have been recorded, the patients surviving the operation (Lenhartz). SURGERY OF THE DIAPHRAGM. Stab Wounds of the Diaphragm. — In the majority of cases the stab wound is received in the thorax, by a downward thrust, and a complicating wound of the pleura exists. This is almost always the case in stab wounds inflicted by Slavs, but Italians frequently stab their antagonists by an upward thrust, the stiletto entering the abdomen first. The left side is more often injured than the right. There are no characteristic symptoms, and the diagnosis can be made with certainty only by exploratory operation, except in the rather unusual cases in which the omentum or one of the abdominal viscera protrudes through the thoracic wound. It is the frequency of injury to the abdominal contents which renders these wounds so serious. In 55 out of 121 consecutive stab wounds of the thorax, recorded by Lawrow (1911), the diaphragm and abdominal organs were involved. The wound usually is in one of the lower intercostal spaces, espe- cially between the seventh and tenth; but stab wounds as high as the second interspace have caused injury to the diaphragm. The liver is the most frequently injured of the abdominal viscera, then the stomach or spleen (Magula, 1910). Treatment. — Treatment is by immediate exploratory operation in every case in which a lesion of the diaphragm is suspected. The mortality without operation is nearly 90 per cent., and those patients who have survived the immediate injury have perished eventually 51 802 SURGERY OF THE DIAPHRAGM from strangulation of a diaphragmatic hernia or other lesion which a prompt operation could have prevented. Thoracotomy is the oper- ation of choice, because by laparotomy it is very difficult if not impos- sible (1) to reduce the herniated organs, owing to the negative pressure within the thorax, (2) to repair the wound of the diaphragm, (3) to suture wounds of the cardia or fundus of the stomach, or (4) to repair damage to the lung. The technique of the operation is much the same as that for diaphragmatic hernia (p. 803). If the stab wound is abdominal, and laparotomy is employed as the primary operation, secondary thoracotomy may be necessary before the herniated organs can be replaced or the diaphragm sutured; such an operation is described as thoracolaparotomy. By the term combined operation is understood one in which the thoracic and abdominal cavities are opened by the same incision: this is best made in the eighth inter- space, dividing the ninth costal cartilage and the diaphragm as far as necessary to secure free exposure. If the case is not complicated by injury to the viscera, the mortality with prompt operation is less than 20 per cent.; in complicated cases it is about 65 per cent. (Magula). Gunshot Wounds of the Diaphragm, except when complicated by injury to the viscera, are so rare as to have little surgical interest, unless strangulation of a hernia occurs subsequently through the opening in the diaphragm. In most cases injuries of the thoracic and abdominal organs exist, and the surgeon has to employ either thoracolaparotomy or the combined operation. Rupture. — Rupture of the diaphragm, a subcutaneous injury, is very rare. As extensive lesions of the abdominal organs are frequent, it is best to employ laparotomy as the primary operation, so that hemorrhage and intestinal leakage may be controlled. If it is diffi- cult to reduce the organs which have been herniated into the thorax, thoracotomy should be done also; this usually is required to facilitate repair of the diaphragm. Diaphragmatic Hernia may be due either to congenital or to trau- matic defect in the diaphragm. Owing to the negative pressure within the thorax, it is always the abdominal organs which prolapse through the opening. The most frequently herniated viscera are the stomach, colon, omentum, small intestine, liver, duodenum, and kidney — in the order named. Though a congenital defect may be present at birth, the hernia may not appear until adult life, and may produce no noteworthy symptoms until strangulation occurs. In over 90 per cent, of cases the hernia is on the left side, because the liver acts as a protection on the right. Most of the cases occur in the fetus, or in infants stillborn or dying soon after birth. In adult life sudden death from cardiac failure is a frequent termination, and the possibility of a diaphragmatic hernia always should be re- membered in considering the causes of sudden death. Symptoms. — Subjective symptoms often are lacking, the malfor- mation being found unexpectedly at autopsy. In the newborn, DIAPHRAGMATIC HERNIA 803 cyanosis and dyspnea are prominent, the left thorax does not expand properly, there is dextrocardia, and death usually results in a few hours. The adult patient may have suffered from mild indigestion, with distress after meals; but no alarming symptoms may arise until sudden cardiac failure or perhaps death occurs from acute over- distention of the herniated stomach. Strangulation is a frequent termination, being due to any sudden strain which forces a larger portion of the abdominal contents through the diaphragmatic opening. The physical signs of diaphragmatic hernia are much more precise in theory than in practice. Diagnosis of the condition in life, except by the aid of the z-ray, is exceptional. The lower chest on the affected side is tympanitic, the breath sounds are very feeble and distant, vocal fremitus is lost, expansion is decreased, and the heart is dislocated away from the affected side. The same signs exist in pneumothorax; but in diaphragmatic hernia the diaphragm does not descend on deep inspiration, and causes which may produce pneumothorax nearly always may be absolutely excluded. Moreover, distention of the stomach with liquid will change the physical signs in a case of diaphragmatic hernia; but in pneumothorax the thoracic tympany and other signs will not be affected. Aspiration is to be condemned as a method of diagnosis, owing to the great danger of septic pleuritis or peritonitis. A history of sudden onset following severe strain (sometimes childbirth) or crushing injury, or occurring some years after a stab or gunshot wound of the thorax, is highly characteristic of diaphragmatic hernia. Finally the relation of the stomach to the diaphragm may be determined by the use of skiagraphy after filling the stomach with an opaque meal or introducing a stomach tube filled with mercury. From the rare congenital con- dition known as eventration of the diaphragm, which is associated with hypoplasia of the left lung, diaphragmatic hernia sometimes may be distinguished by the history of the case, and by recognizing through skiagraphy that the diaphargm in the former condition remains still above the abdominal organs no matter how far upward into the thoracic cavity these may protrude. Treatment. — Immediate operation is required for recent diaphrag- matic hernia of sudden development, because the danger of strangu- lation is very great. Unfortunately most such cases are first seen by the surgeon after strangulation has developed, and the patient is too ill to justify the prolonged examination and numerous tests recom- mended in seeking to reach a correct diagnosis. But if the surgeon can ascertain that the patient has had a severe injury (crush, or pene- trating wound of the lower thorax or upper abdomen) even many years previously, the diagnosis and indications for treatment may become very apparent. If the true condition is recognized thoracotomy (Permann and Postempski, 1889) should be done. In many cases inci- sion in the eighth intercostal space, without resection of ribs, has given adequate exposure. After packing off the lung with gauze tampons, any rupture or perforation of the abdominal viscera should be repaired, 804 SURGERY OF THE DIAPHRAGM and they should be replaced within the abdominal cavity. Then the opening in the diaphragm should be sutured; when this is not possible the omentum may be stitched to its margins, or as a last resort the opening may be tamponed. If the operation has been done under differentia] pressure or with intratracheal insufflation anesthesia, the lung should be expanded at the close of the operation, and the pleura may be closed without drainage. In other cases a tube should be left in for a few days. If no diagnosis other than intestinal obstruction has been made, laparotomy will be the operation- employed; but if reduction of the hernia from below proves impossible, no hesitation should be felt in proceeding to thoracotomy. CHAPTER XXI. HERNIA. A hernia is a protrusion of a viscus through an abnormal opening in the walls of the cavity within which it is naturally contained. This is a general definition, and may be applied to a hernia of a muscle through a rupture in its sheath, to a hernia of the brain through an artificial opening in the skull, or to a hernia of an abdominal viscus through an abnormal opening in the abdominal walls. By long usage, however, the term hernia, when standing by itself, is applied only to protrusions of the abdominal viscera. This protrusion usually occurs through an aperture of the abdominal wall which transmits bloodvessels or nerves, through a congenital defect, or through one acquired as the result of operation or disease. If this protrusion occurs through a normal opening it is not called a hernia, but a prolapse; as a prolapse of the rectum through the anus, or of the uterus through the vagina. The term hernia also implies that the protruding struc- tures are still covered by skin : thus when omentum or other structure protrudes through an incised wound of the abdomen, it is not called a hernia but a prolapse. In the great majority of cases of abdominal hernia, the viscus which protrudes carries before it a pouch of the parietal peritoneum, which is called the sac of the hernia ; and since this sac may remain as a pro- trusion even when it contains none of the abdominal viscera, a hernia has been defined as "a protrusion of peritoneum liable to contain, containing at times, or permanently containing any viscus or part of a viscus from the abdominal cavity." (Da Costa.) But as the abdomi- nal organs sometimes protrude through a part of the abdominal wall which has no parietal peritoneum (e. g., a hernia of the bladder), or slide down behind the parietal peritoneum, instead of carrying it before them as a protrusion (e. g., sliding hernia of the colon), I think it is better to cling to the old definition. If the sac protrudes and is empty that patient has either a reduced or a 'potential hernia, accord- ing to whether or not the sac has before been the seat of a hernia. A sac may exist for many years without a hernia developing in it (p. 806). Nomenclature. — A hernia receives its name (1) from the region in which it appears, as epigastric, lumbar, umbilical, inguinal, etc.; (2) from its contents, as a hernia of intestine (enterocele) , of omentum (epiplocele), of bladder (cystocele), of rectum (rectocele), etc.; (3) from its condition, as reducible, irreducible, inflamed, strangulated, etc. ; and (4) from its mode of development, whether of sudden develop- (805) 800 HERNIA ment or slowly acquired. Various other terms, used in describing hernia, will be explained as they are encountered. Causes. — The predisposing causes of a hernia may be either general or local. General Predisposing Causes. — -(1) Age. Most hernise appear in infan- tile or early adult life; the longer one lives the less apt he is to have a hernia. But the number of old people alive is so much less than that of young adults and children, that among the aged hernia is relatively more common. (2) Sex. Men and boys are much oftener afflicted with hernia than women. There are two main reasons for this: first because of the weakness of the inguinal region in the male sex from the descent through it of the testicle; and, second, from the more active life men lead, and the greater frequency with which they are sub- jected to great abdominal strains. (3) A distinct hereditary tendency toward hernia is recognized, probably from the persistence of anatomi- cal defects at points of greatest strain. Local Predisposing Causes. — (1) Weakness of the abdominal wall. After an abdominal operation, a hernia may develop in the scar (incisional hernia, p. 824) ; or as a consequence of injury to the motor nerves of the inguinal region from an operation elsewhere, an inguinal hernia subsequently may develop (Figs. 859, 872, and 876). Some- times a hernia appears first after a debilitating illness or pregnancy. (2) Increased strain upon the parietes by the abdominal contents. The gradual deposition of fat in the omentum and mesentery increases the intra-abdominal tension, causes stretching of the parietal peritoneum, opens up the hernial orifices, and thus predisposes to the development of a hernia. The same train of events may occur in cases of ascites, of intra-abdominal tumors, of pregnancy, etc. (3) A hernia may be the effect of repeated efforts, in coughing, in straining at stool, in urinat- ing (when there is some urinary obstruction) (Fig. 882). (4) The existence of a congenital sac predisposes the patient to the develop- ment of a hernia, though observations in the dissecting room show that many patients with preformed sacs pass through life without any evidence of a hernia. Structures Composing a Hernia. — In a typical case a hernia is composed of a pouch of parietal peritoneum, called the sac; of the contents of the sac; and of its coverings, which are the structures of the abdominal wall, muscles, fascia, and skin (Fig. 848). Sac. — The sac, as noted already, sometimes is wholly or in part deficient. Typically it is composed of a neck (that part which com- municates with the peritoneal cavity), and a body (that part which surrounds the protruding viscera). The apex of the sac is its fundus. The sac may be congenital or acquired. I believe, with Russell and Murray (1899), that the sac is congenital in afar larger proportion of cases than is commonly thought. This preformed sac renders the pat- ient the potential possessor of a hernia; but until the hernia develops ("comes down" is the colloquial expression), the presence of the sac in most cases cannot be determined (p. 1115, congenital hydrocele). STRUCTURES COMPOSING A HERNIA 807 Peritoneum Transvtrsalis fascia Muscle Skin &. Sup. fascia. Fig. 848. — Diagram to show a hernial sac, its contents and coverings. The congenital sac is found oftenest in femoral hernia, but occurs frequently also in the inguinal form, and sometimes in umbilical hernia. It may be very large, but usually is quite small until distended by the protruding abdominal contents. The acquired sac usually is slowly developed from gradual stretching of the parietal peritoneum: at first the neck of the acquired sac is its widest part, but as the sac increases in size it becomes more or less pear-shaped, the neck being relatively narrow; then the sac continues to increase in size by the pressure of the contained structures, but, as a rule, the neck does not enlarge at the same rate but remains relatively small. The wall of the sac, at first like the neighboring parietal peritoneum may become much thickened from inflammation, and its neck may undergo cicatricial contraction. The sac usually becomes densely adherent to the surrounding parts, especially at its fundus; and though the contents of the sac may be returned to the abdomen, as long as the empty sac remains recurrence of the hernia is to be expected. In hernia of long duration the neck of the sac may be shifted, by the pull of its contents, downward and toward the median line of the body. The Contents of the Sac may be almost any of the abdominal viscera, but the most frequently herniated structures are the intes- tine (enterocele), and the omentum (epiplocele). In infancy and young childhood the omentum seldom is found in a hernia, owing to its undeveloped state; but in adults, particularly those who are obese, it is the most frequently found of all structures. The lower ileum is the portion of the bowel most often found in a hernia, because it has the longest mesentery and lies nearest the inguinal and femoral openings. Hernia of the large bowel is infre- quent, owing to its relatively short mesenteric attachments. The cecum may be drawn into a hernia by a coil of ileum already there; but the sigmoid is sufficiently mobile to find its own way into a hernia. A single coil or several coils of intestine may be found in the sac, or the hernia may be formed only by a portion of the wall of the intes- tine; this latter condition (Fig. 849) is described as liichters hernia (1778). A hernia of Meckel's diverticulum (Fig. 850) is known as Littres hernia (1700). When the hernial contents remain long in the sac, they usually become adherent to its walls and often are matted together. In this way a hernia may become irreducible. When both omentum and intestine are in the sac (entero-epiplocele), it usually is the omentum which enters it first. The omentum generally lies in 808 HERNIA front of, or even completely surrounds the bowel, and the bowel may be caught in apertures or depressions in the mass of omentum and thus may become strangulated. Unless the hernia is inflamed or strangulated there is little or no serum within the sac. Fig. S49. — Partial enterocele, or Richter's hernia. Drawing made from a case of strangulated hernia in the Episcopal Hospital. The Coverings of the sac will be described in connection with each particular form of hernia. Fig. 850. — Littre's hernia — a hernia of one of the intestinal diverticula (Meckel's diverticulum). Reducible Hernia. — This is one in which the contents can be replaced within the abdominal cavity. It is the most frequent variety, since almost every hernia is reducible when it first appears, and becomes irreducible only after the lapse of years. For months or years before the hernia appears the patient may have felt a weakness in the region where the protrusion afterward develops. If the hernia develops gradually, there may be at first the merest bulging of the parts during straining efforts; later a small rounded tumor may be seen. This can be reduced easily by the pressure of a finger, and usually disappears spontaneously when the patient lies down. In cases of hernia present at birth, or of sudden though later development, or of long duration before seen by the surgeon, the protrusion often is of considerable REDUCIBLE HERNIA 809 size. In time the greater part of the abdominal contents may descend into the sac. The outline of a hernia is more or less rounded or oval, usually being less broad at the neck of the sac than elsewhere. The hernia increases in size when the patient stands up, coughs, or strains; it disappears either spontaneously or by gentle pressure when he lies down; and in most cases it reappears again if he once more stands up and coughs. When he coughs there usually is a distinct impulse transmitted to the hernia, and this often can be seen and almost always can be felt. Enterocele. — If the sac contains intestine only, the hernia is smooth, feels elastic, often gurgles on palpation, and usually is resonant on percussion. The impulse is well marked. Reduction usually is accompanied by a distinct gurgle and by a characteristic sensation well described as a "flop." Epiplocele. — An omental hernia feels denser, more fibrous or doughy to the touch than an intestinal hernia; it is irregular in outline; gives little or no impulse on coughing; and is dull on percussion. Reduction is not accompanied by any gurgle, nor by the "flop" so characteristic of bowel slipping back into the abdomen. In the entero-epiplocele the symptoms of the two separate forms are combined. It seldom is possible to ascertain what portion of the gut forms the hernia. In umbilical hernia the transverse colon is most often found; and in inguinal and femoral hernia, the ileum. The cecum is much more frequent in right-sided inguinal hernia than elsewhere, but is not very unusual in a left inguinal hernia. In femoral hernia the omentum and small bowel are most often found. Treatment. — It is necessary for a hernia to be cured, whenever possible, because of the grave danger which may accrue to the patient from the occurrence of strangulation. A cure can be obtained only by an operation, by which the sac of the hernia is removed, its neck closed, and the structures of the abdominal wall repaired in such a manner as to prevent recurrence of a hernia. This is the best treat- ment in every case in which an operation is not contraindicated ; but the operation requires skill for its performance, and sometimes is very difficult. It should not be attempted by the occasional operator. Even if the best treatment (that which results in cure) is contra- indicated or is refused, it is still necessary that the hernia be treated. An untreated hernia tends constantly to grow larger and to become irreducible. It is possible to keep a hernia reduced by the use of apparatus (known as a truss) which exerts pressure over the neck of the empty sac, and prevents descent of the hernial contents. 1 It used to be taught that in some cases the prolonged use of a truss might cause obliteration of the hernial orifice by exciting adhesions of the 1 I mention only to condemn the attempts of some charlatans to cause closure of the neck of the hernial sac by injecting paraffin in the surrounding tissues (Fig. 851). 810 HERNIA opposing layers of peritoneum. This occasionally occurs in infants, but in the vast majority of cases, though a truss may keep the hernia reduced so long as the truss is in place, no obliteration in the neck of the sac is caused, and its contents tend to return at once when the truss is removed. If the neck of the sac becomes constricted from prolonged use of a truss (and this is not unusual), the hernia will be more apt to become strangulated, if it comes down, than if no truss had been worn. If no treat- ment at all is undertaken, the hernia constantly increases in size, is very apt to become irreducible, and the patient must endure the discomforts of this condition as well as run the added risk of stran- gulation which an irreducible hernia entails. The contraindications to operation in the case of a reducible hernia are only those which contraindicate any operation, however trivial (p. 812). There are no local con- ditions which contraindicate operation in cases of reduci- ble hernia. Even immense size of the hernial orifice, with excessively weak ab- dominal walls, is a condition that may be overcome by proper methods (p. 826). A truss is an apparatus designed to support a hernia. It should keep a reducible hernia reduced. It is applied around the body, and has a pad which makes pressure over the hernial orifice. Most trusses are for inguinal or femoral hernia, and are applied around the pelvis between the iliac crests and the trochanters of the femora (Fig. 876). A truss may be made of steel covered with leather or hard rubber, causing elastic pressure over the hernial orifice; or it may be made entirely of leather, and depend on the tension with which it is buckled in place to retain the hernia. Trusses are also used for umbilical hernia?; and the abdominal belts, used to support ventral and inci- sional hernia may be considered a form of truss. There are certain features which every truss should possess: it should retain its position without extraneous aid; it should keep the hernia reduced in all positions of the body, and during coughing, sneezing, defecation, etc.; it should not cause irritation of the skin overlying the hernia or elsewhere; and it should be easily kept clean. The patient must have at least two trusses, in case one of them is Fig. 851. — Masses of paraffin in inguinal canal and scrotum, injected on two occasions, several months ago, in an effort to cure a hernia of twelve years' duration. Patient aged thirty- eight years. Hernia now in scrotum. Epis- copal Hospital. IRREDUCIBLE HERNIA 811 broken. The trusses suitable for the different forms of hernia will be described under special herniae (p. 837). De Garmo (1907) says a patient who wears a truss is a chronic in- valid, and though this statement is somewhat of an exaggeration, it is absolutely true that such a patient must observe certain rules of con- duct if he wishes to continue in good health. He should be kept under his physician's observation. A truss requires as strict oversight as any other orthopedic appliance (p. 561). The truss must always be applied while the patient is recumbent, after reduction of the hernia; it need not be worn at night, but it should be reapplied every morning before the patient gets out of bed. It must never be taken off except when he is lying down. When he takes a bath he must wear the truss in the tub. He must not make any sudden exertion or strain at any time. He must lift no heavy weights. He must not go swimming. He should be debarred from all athletics except the lightest exercises. If he wants to be cured of his hernia, let him be operated on. Other- wise he must endure the limitations which truss-wearing requires. The possibility of strangulation of his hernia should be ever present in his mind. Should it occur it will force him almost always to an immediate operation to escape death; and he will be unable to choose either the time, or the place, or the surgeon for such an operation. Irreducible Hernia. — The commonest causes for irreducibility of a hernia are inflammatory adhesions affecting its contents. These may be between the sac and its contents, or adhesions of the coils of bowel to each other, to the omentum, etc. The most frequent cause is adhesion of the omentum to the sac. The bowel rarely becomes adherent to the sac. Intravisceral adhesions often prevent reduction even when no adhesions to the sac wall exist, because the contents are amal- gamated into a mass too large to pass through the neck of the sac. A hernia may be apparently irreducible, because manipulation cannot force back in a short time, through a small orifice, a large mass of intestines or omentum which have taken years to descend. There is no strangulation present in an irreducible hernia, though a strangulated hernia may be irreducible. The diagnosis of an irre- ducible hernia depends upon recognizing that the protrusion is at one of the usual hernial orifices, on ascertaining the history of its develop- ment, and on the physical signs, which are the same as in a reducible hernia, with a few self evident exceptions. An irreducible hernia presents an impulse on coughing; it constantly tends to become larger, and the patient suffers from a sense of dragging, from digestive dis- turbances, and often from intermittent attacks of constipation and diarrhea. Though a patient may live for many years with an irre- ducible hernia, he is in constant peril because the prolapsed viscera are exposed to trauma, and are liable to repeated attacks of inflam- mation or obstruction; and strangulation is much more apt to occur than in the case of a hernia which is retained by a truss. 812 HERNIA Treatment. — The cure of an irreducible hernia is more difficult and dangerous than that of a simple hernia, and can be secured only by operation. Except in the very old, or those with severe constitutional or organic disease, or those with most enormous hernise, operation always should be urged upon the patient. It is extremely desirable to reduce the size of these large hernise before any operation is under- taken, and even if no operation is done the patient may secure much relief from the preliminary treatment. This plan is to keep the patient in bed, on spare diet, with a course of mild purging, and frequent enemas, so as to secure complete evacuation of the bowels. Absti- nence and rest will reduce the amount of fat in the omentum and mesentery; and recumbency, combined with elevation of the foot of the bed, will bring the force of gravity to aid in securing reduction in the size of the hernia. This method appears first to have been advocated by Sir Astley Cooper in 1828. In most cases a partial reduc- tion at least can be secured by resort to taxis (p. 818) after a couple of weeks of this preparatory treatment, and sometimes the entire hernia can be reduced. In these cases of immense hernia, if the surgeon thoughtlessly undertakes an operation without such preparatory treatment, he may find it impossible to make the viscera enter the abdomen even after this has been opened. If the hernia can be reduced to ordinary size before operation is attempted, this should be as successful in obtaining a cure as in cases of reducible hernia. If the patient refuses operative treatment, the application of some form of support, in the nature of a "bag-truss" or suspensory may somewhat alleviate the symptoms. Inflamed and Obstructed Hernia. — These conditions are met with almost solely in cases of irreducible hernia. Inflammation may occur from accidental trauma, from unskilled or violent attempts at reduc- tion, from the pressure of an ill-fitting truss, or from changes in the contents of the sac. Among the latter attention may be called to the occasional presence of the vermiform appendix in the sac, with the possibility of appendicitis. Obstruction of a hernia is said to occur when the normal course of gas or feces through the herniated bowel is interrupted; this may result from intestinal indigestion with accumu- lation of flatus, or from fecal impaction (p. 942). The symptoms of inflamed and obstructed hernia are much the same, consisting in local pain, tenderness, nausea, and perhaps vomiting; the hernia still gives an impulse on coughing; and flatus is passed by the anus, though there may be constipation. The symptoms are decidedly less severe than in the case of strangulation. Treatment.— The patient should be put to bed, and should lie in a position which relaxes the hernial orifice; an ice bag should be applied locally; an enema should be administered; nothing whatever should be given by mouth; and if the symptoms are severe or if they do not subside in the course of three or four hours, operation, as in cases of strangulation, becomes imperative. In any case where the condition of strangulation cannot be positively excluded, immediate operation should be done. STRANGULATED HERNIA 813 Incarcerated Hernia. — This is one which, though ordinarily re- ducible, has for some reason become temporarily irreducible (De Garmo). This complication occurs most often in large hernise, and usually is due to unskilful attempts at reduction, resulting in some slight twist in the bowel which renders the hernial orifice relatively too small to allow reduction. While there may be some local pain and tenderness, there are no symptoms of strangulation present. Treatment. — Treatment consists in rest in bed, with the foot of the bed elevated and the patient so placed as to relax the hernial orifice. An ice bag or cold coil should be applied to the hernia, and the surgeon should not attempt to reduce the hernia until the acute symptoms have had a chance to subside; he may find then that the hernia has been spontaneously reduced, or that its reduction by taxis (p. 818) is easy. If the symptoms do not subside within a few hours, taxis should be tried, and if this fails, operation should be done as in cases of strangulated hernia. Strangulated Hernia. — This is one in which the circulation of blood is obstructed or entirely arrested. This serious occurrence is liable to bring on all the usual consequences of strangulation, which are studied at p. 814. The cause of strangulation of a hernia is not always evident. It is clear that a constriction exists, pressing upon the protruded struc- tures and interfering with their circulation. This constriction may be either in the sac wall, in the surrounding structures, or inside of the sac. Constriction by the sac itself is rare, especially in children; the site of constriction usually is at the neck of the sac, particularly in the case of patients who have long worn a truss and in whom the sac and its neck have undergone cicatricial contraction. In some cases of congenital sacs points of constriction may exist elsewhere than at the neck (Fig. 864) ; and in some cases constriction may occur from bands of inflammatory adhesions formed within the sac. Extra-saccular constriction is by far the most frequent form and usually occurs at the abdominal opening in fascial or tendinous tissue through which the sac and its contained viscera pass. Intra-saccular constriction, which is rarest of all, may be due to torsion of the contents of the sac, or to the bowel being caught in an aperture or pocket in the omentum. Mechanism of Strangulation. — As the neck of the sac and the abdomi- nal opening through which the hernia passes are not muscular, but fibrous, and hence have no power of active contraction, it is evident that in cases of extra-saccular as in those of intra-saccular constriction the prime cause of strangulation lies in the contents of the sac. If the hernia previously was reducible, these changes in the contents of the sac usually begin as the state already described as incarcera- tion of the hernia; in the case of irreducible hernia the first changes usually are those described as inflammation or obstruction of the hernia, and they may be brought on by the unwelcome intrusion into the sac of a coil of gut or a plug of omentum never before present. In some patients a hernia which is suddenly developed becomes stran- S 1 I HERNIA gulated immediately on its first appearance; such a strangulation is apt to cause rapid and very serious changes in the contents of the sac. A similar chain of events usually occurs when a hernia suddenly pro- trudes into a sac which has long been empty, especially if the use of a truss has caused cicatricial contraction in the neck of the sac. This form of strangulation may he described as acute to distinguish it from that of more chronic onset, which usually is preceded by incarceration, inflammation, or obstruction of the hernia. All irreducible hernias are more liable to strangulation than those which are reducible and are retained by a truss. An irreducible umbilical hernia is especially liable to strangulation; and, of all forms, a femoral hernia is most prone to strangulation. Ventral and inci- sional hernias very rarely become strangulated. Structural Changes Occurring in Strangulation. — Probably in every case the first change is obstruction of the venous circulation of the contents of the sac; the arterial circulation is less rapidly affected because of the higher blood-pressure in the arteries and their more resistant walls. Arrest of the venous circulation causes the blood to be dammed back into the capillaries while these are still receiving blood from the arterial side. The result is stagnation of the blood, and edema of the extra vascular tissues. Almost at once the hernia becomes too large to be returned through the orifice by which it had escaped. If intestine is strangulated, intestinal obstruction (p. 937) is present as well as strangulation, and usually precedes it. Strangulation of bowel causes the rapid outpouring of serum which may distend the sac; it will be greater in amount if the strangulation is very slow in onset than if the entire circulation is arrested immedi- ately. At first this fluid is pale yellow, clear, and sterile, and perhaps should be considered a transudate rather than an effusion; but very soon it becomes inflammatory in character, turning cloudy from the increase in the number of leukocytes present, and often is bloody, and in later stages of strangulation, brownish or black. Bacteria soon penetrate the walls of the obstructed bowel. If the strangulation is not promptly relieved, the bowel, which at first is congested, bright red, soggy, and with its natural luster but slightly impaired, becomes purplish or even black in color, and may be covered with patches of inflammatory lymph. Actual gangrene quickly follows: the intestine loses its luster entirely, and becomes soft, doughy, and grayish black; the peritoneal coat strips easily, the muscular coats are friable, and the bowel is very easily torn. In many cases definite rings of con- striction are found at the points of strangulation: usually the con- striction ring at the distal (anal) end of the strangulated loop is more pronounced than that at the proximal (gastric) end. The bowel below the constriction is nearly normal in appearance, or if anything rather paler than normal and collapsed; that proximal to the constric- tion is distended, congested, and more nearly resembles the gut which has occupied the hernial sac. When the bowel becomes necrotic, or even before, merely as the result of intestinal obstruction, death from STRANGULATED HERNIA 815 toxemia may occur. If life is prolonged, the slough may separate from the intestine, resulting in intestinal perforation into the hernial sac, which then becomes the seat of a fecal abscess. The overlying tissues may next become inflamed, and in rare instances this fecal abscess has opened spontaneously through the skin. In many cases septic inflammation spreads to the peritoneal cavity, and general peritonitis is the cause of death. This may occur from perforation of the bowel at the point of constriction (Fig. 852), with escape of fecal contents into the peritoneal cavity, or from propagation of inflam- mation along the coats of the bowel above the constriction. There may be a volvulus of the intestine leading up to the hernial ring, within the abdominal cavity. Fig. 852. — Specimen of gangrenous small intestine resected in a case of strangulated femoral hernia. Age seventy-one years; hernia strangulated for two weeks before operation. Fecal abscess in sac, bowel ruptured just above proximal constriction. Death twelve hours after operation (spinal anesthesia). Episcopal Hospital. If omentum is strangulated there is not much serum effused in the sac. The omental veins are found distended, dark blue or black, and perhaps thrombosed. The omental fat becomes pinkish red at first, feels denser than normal, and does not bleed readily if incised; later it becomes grayish white and perhaps necrotic. Symptoms of Strangulated Hernia. — In almost every case the patient has had a hernia for some time before it becomes strangulated. Usually following a muscular strain (perhaps merely a mis-step^ exuberant laughter, etc.) a sudden pain is felt at the site of the hernia. If the hernia was not down at the time of the accident, it slips out suddenly, even escaping from under a truss if one was worn. If the hernia was down already at the time of the accident, whether irreducible or not, it feels to the patient as if it had increased in size from the protrusion 816 HERNIA of additional bowel or omentum. If the pain is very severe the patient may fall to the ground in a state of shock. The pain is followed very soon by a general abdominal pain which at first is colicky, becomes progressively worse, and which later is constant, not intermittent. //' not checked by opiates this pain does not leave the patient until gan- grene has occurred or until the strangulation is relieved. Spontaneous cessation of pain therefore is a bad sign; it is accompanied by a false sense of security, and is soon followed by extreme prostration, and signs of impending death as in cases of intestinal strangulation from other causes. If the hernia is an enterocele, the usual symptoms of intestinal obstruction (p. 937) develop very soon after the occurrence of the strangulation. The initial colicky pain, in almost all cases but not always, is accompanied or followed by nausea and vomiting. The vomiting, which at first is the result of nausea, later becomes typically projectile in type, due not to nausea, but to reversed peristalsis. First the gastric contents are vomited; then bile-stained matter; later the contents of the upper intestine, which is brownish and sour- smelling; and in the final stages true fecal or stercoraceous vomiting may occur. Coincident with these symptoms there is absolute con- stipation, and no flatus is passed by the rectum. An enema may empty the rectum of what was already there or in the sigmoid; but after the lower bowel has been emptied, no further movement can be obtained, and in no case is there passage of flatus. In the case of an epiplocele the symptoms are the same though often less in degree, there being seldom absolute constipation or complete arrest of flatus. If the intestinal obstruction is not relieved, peritonitis will develop, with its characteristic symptoms and physical signs (p. 856). Until this event occurs the temperature is not elevated, though the pulse slowly but steadily increases in rapidity. Physical examination shows a tender, painful, and tense swelling at the site of the hernia. In the case of a large hernia long irreducible, these signs are not so apparent, but usually it is evident that the swelling is somewhat more tense and painful than before the onset of the symptoms of strangulation. In an omental hernia the swelling is boggy, rather than tense. There is no impulse in a strangulated hernia when the patient coughs. Palpation of the abdomen usually reveals rigidity of the abdominal muscles near the site of the hernia; it is a voluntary rigidity, not like that which results from peritonitis. Auscul- tation of the abdomen detects sounds of borborygmi characteristic of peristalsis; usually these peristaltic noises are exaggerated, and sometimes they may be traced up to the site of obstruction, where they are arrested with a distinct click. Diagnosis of Strangulated Hernia.— This depends on recognizing, in addition to the symptoms of intestinal obstruction, the existence of a hernia with the signs characteristic of strangulation. If the latter condition is present, it is not necessary to wait for full development of symptoms of intestinal obstruction before making a diagnosis. I STRANGULATED HERNIA 817 have several times found a gangrenous patch on the bowel in cases where neither nausea nor vomiting had been present, although the strangulation had lasted for from six to eight hours. In very fat patients it may be impossible to detect with certainty a very small hernia. All the usual sites of hernia should be carefully examined, and corresponding parts of the body should be compared most dili- gently in obscure cases. A feeling of greater resistance over one hernial ring than at the corresponding point on the other side of the body may be the only physical sign discernible in a case of partial enterocele (Richter's hernia); but such small hernise may become gangrenous much sooner than larger herniae. If two hernia, both irreducible, are present, it may be difficult to decide which of the two is strangulated ; usually the physical signs (absence of impulse on coughing, greater tension and tenderness in the neck of the strangulated hernia) will be of more aid in such cases than the history and subjective symptoms. An irreducible hernia may be present and there may be 'peritonitis from some other cause. The distinctions between intestinal obstruc- tion and peritonitis cannot be too often insisted upon; they are detailed at p. 860. In strangulated hernia peritonitis is a late symptom, all the early signs indicating intestinal obstruction. There may be an irreducible hernia and yet there may be some other cause for intestinal obstruction: here again physical examination will show an impulse on coughing unless the hernia is strangulated; while a careful history of the case may throw much light on the diagnosis as it may indicate previous attacks of peritonitis, leaving crippling bands or adhesions as the true cause of the symptoms. If no conclusion can be reached after careful study, the surgeon should expose the hernia before proceeding to exploratory laparotomy. The vomiting of pregnancy may be confusing, if an irreducible hernia is present; but the negative physical examination of the hernia, and the fact that there is no evidence of intestinal obstruction, should be sufficient evidence of the true condition. In some cases of inguinal hernia, confusion is caused by the presence of an inflamed lymph node in the groin, and in infants by an inflamed hydrocele of the cord. When, as often in these cases, physical examination is unsatisfactory, and the history is unknown or negative, a differentiation may be impossible. An undescended testicle need not be mistaken for a strangulated hernia if the surgeon is cautious enough to examine the scrotum before reaching a diagnosis. Treatment of Strangulated Hernia. — The object of treatment is to relieve the strangulation. This may be accomplished (1) by pushing the strangulated bowel or omentum back into the abdominal cavity by means of Taxis; or (2) by operation — dividing the constriction, inspecting the bowel, and treating it appropriately before restoring it to the abdomen. In most cases this operation may be completed by repair of the abdominal wall so as to prevent recurrence of the hernia. The physician never should leave his patient until the stran- gulation has been relieved, or until he has made arrangements for immediate surgical treatment. 818 HERNIA Taxis.— This is a term derived from the Greek, and implying arrangement or adjustment. It is used in surgery in a technical sense to describe various manipulations by which the surgeon seeks to secure reduction of a hernia. The patient should be placed on a bed, with his shoulders and pelvis raised, so as to relax the abdominal muscles. The surgeon then surrounds the hernial orifice with the thumb and fingers of his left hand, while with the right he endeavors by very gentle but persistent compression to empty the herniated bowel of some of its gaseous and fluid contents. When this has been accom- plished, he employs his right hand in the most gentle and patient kneading movements, in the attempt to make the bowel recede into the abdomen. The direction of pressure must correspond to that by which the bowel came down. Success is manifested by the bowel slipping back into the abdomen with an audible gurgle and a charac- teristic flop. If these signs are absent, even though the hernia appears to have been reduced, it is most probable that this is not really the case, but that reduction in mass has occurred. This term implies that the contents of the sac have been pushed upward until they lie on the inner aspect of the abdominal wall, but have carried before them the neck of the sac, which is the seat of constriction; and that the hernia, still strangulated, rests between the abdominal wall and parietal peritoneum. If the symptoms of strangulation persist, operation should be done immediately. Contraindications to the Taxis. — (1) Taxis never should be employed if anyone else already has attempted it; because there is no telling how much damage may have been done to the gut, and in its present state even the very gentlest manipulation may rupture it or cause other disastrous consequences. (2) Taxis never should be employed in very acute cases; it is suitable only to such as begin with symptoms of incarceration or obstruction of the hernia. (3) Taxis never should be employed while the patient is anesthetized, as there is too much risk of using unjustifiable force. (4) Taxis never should be persisted in for more than fifteen minutes. Operation. — The operation for strangulated hernia is one which any medical man may be called on to perform in emergency. It is not nearly so difficult as is the taxis, and is incomparably more efficient in securing the end in view — that of relief of strangulation. If opera- tion were resorted to in every case within the first twelve hours, and with modern aseptic methods, the mortality of strangulated hernia would be only from 3 to 5 per cent., or less than half that of typhoid fever; instead of as high as that of pneumonia, or fracture of the base of the skull, as it is now, when in many cases the obstinacy of the patient or still worse the ignorance of the family physician post- pones operation until gangrene and peritonitis have developed. The mortality when operation is employed under such circumstances varies from 10 to 50 per cent., according to the constitutional resist- ance of the patient. If no operation is done, spontaneous cure by sloughing and formation of a fecal fistula may result in as many as 2 per cent, of cases, while 98 per cent, will terminate in death. STRANGULATED HERNIA 819 The operation, which is known as herniotomy or kelotomy, consists essentially in making an incision through the overlying structures until the neck of the sac is exposed; then the sac is opened, and the constriction causing strangulation is divided. For this deep incision many surgeons still use Cooper's herniotome (Fig. 853) which has the advantages of a blunt point which can be slipped under the constriction and a short cutting edge. The contents of the sac are then replaced within the abdomen if they are in good condition, and the wound is repaired as in an operation undertaken for the "radical cure" of hernia. If the contents of the sac are not in good condition they are treated as described below (see Treatment of Complications). Fig. 853. — Cooper's herniotome. In former times, before the days of aseptic surgery, there was great danger of peritonitis developing after such an operation, and much more stress was laid upon the employment of taxis, and even in operating many surgeons followed the method of Petit (1760), who divided extra-saccular constrictions and then reduced the hernia without opening the sac. But for the last thirty years at least, the taxis has been falling increasingly into disfavor; and especially since the development of methods of inducing local anesthesia, and spinal analgesia, have surgeons been more ready to resort to operation. And I am convinced that it should be clearly understood that no patients however moribund in appearance (unless in articulo mortis) should be refused the hope of recovery which operation always affords. If the patient is too ill to endure a general anesthetic, and if no facili- ties exist for administering local or spinal anesthesia, there is no reason in the world why the operation should not be done without any anesthetic whatever. Our surgical ancestors operated thus for many generations, and in not an insignificant proportion of cases recovery followed. Treatment of Complications. — As the surgeon cuts through the overlying tissues he may find that they are edematous. This may be the result of trauma inflicted during attempts at taxis, or rarely may be due to inflammation spreading from a fecal abscess in the sac. The sac usually is recognized by its transulucent and bluish appearance. Usually it is impossible, and never is it requisite for the surgeon to recognize the various layers of tissue overlying the sac. Each of the deeper layers as it appears should be cut through cautiously, as one opens the peritoneum, after raising it in forceps from the underlying structures. In this way there is very little danger of injury to the contents of the hernial sac. In most cases there is some fluid in the sac; if it is clear and limpid, it is not likely that the condition of the bowel is very bad. When the sac is opened and the constriction relieved, more of the bowel should be drawn out of the abdomen, and 820 HERNIA its condition should be carefully observed. (In serious cases the anes- thetic, if given by inhalation, may be suspended at this point in the operation.) If the bowel was merely nipped in the hernial orifice, and has fallen back into the abdomen as soon as the constriction is relieved, the surgeon never should neglect to draw it out again into the wound to ascertain its condition. The next step is the application to the bowel of hot (115° F.) sterile water or saline solution. The hot fluid should not be poured over the bowel with any force, but should be allowed to flow gently over the bowel so as to avoid the trauma even of a current of water. Nor should the bowel be sub- jected to massage or to irritation by gauze sponges. The bowel should be examined for its luster, its color, and its elasticiiy. Though the color when first exposed may be bright red, bluish, dark blue, purple, or even black, it may return to normal after relief of the strangulation and application of hot solutions for a varying time up to half an hour. If the gut is entirely gangrenous when first seen, of course it is hope- less to expect its recuperation; but recovery may occur from any stage short of gangrene; and a patch of seeming gangrene which at first appears so large as to demand resection, may be so much dimin- ished in size by hot applications as to permit of retention of the bowel after inversion of the worst portions. If the luster of the peritoneal coat is preserved, as a rule the color will return to the normal and the bowel will survive. If the mesenteric vessels cannot be felt pulsating the bowel will not survive. If the bowel fills out with its contained air and retains its normal cylindrical form, it is more apt to be healthy than if it has lost its resiliency and retains any indentation or crease accidentally produced during manipulation. Careful inspection should be made also of the circular constrictions on the bowel at the points of strangulation, if such constrictions exist. There may be a threatening perforation here, while the intervening portion of bowel which was not directly compressed, but had its circulation impaired only by pressure on its mesentery, may be fairly normal. If the bowel returns to its normal condition, it should be replaced, and the wound should be closed. If a suspected spot remains, it often is possible to cover it in by inverting it and suturing neighboring healthy portions of bowel over it, as indicated in the accompanying diagrams. Even though the entire lumen of the gut appears to be obstructed by the amount of its wall inverted, recovery without any untoward symptom may occur (Fig. 854). The sero-serous suture is used, as in other intestinal operations (p. 880). If the circular constriction at the point of strangulation has been very tight, it will have crushed all the coats of the bowel except the peritoneum at this point, just as if a compression forceps had been applied to the gut previous to the application of a ligature. In such circumstances the ring of constriction sometimes may be covered in by producing a partial intussusception of the bowel (Fig. 855). Only if there is actual gangrene is resection desirable; and even in such cases, if the patient's condition is very bad, or if the operator is STRANGULATED HERNIA 821 inexperienced, it will be quite sufficient to leave the gangrenous coil of intestine lying in the sac, after relieving the constriction, and packing sterile gauze around the bowel, which should then be opened and drained. If the proximal (afferent) bowel is very much distended, or if the strangulation has existed a long time, it always is well to evacuate the contents of the proximal loop (which in such cases are regarded as highly toxic), instead of allowing these contents to pass on down through the intestinal canal, whence absorption may occur, causing increased toxemia. Fig. 854. — Gangrenous spot on bowel (a), inverted into lumen by sutures (6). From a patient in the Episcopal Hospital. Recovery. Fig. 855. — Gangrenous area involving nearly whole circumference of bowel (a), successfully treated by producing a partial intussusception (6). Episcopal Hospital. Where resection of the bowel is done the surgeon may terminate the operation either by establishing a false anus in the wound (p. 969), or by completing an intestinal anastomosis. The former should be selected in all cases where a prolongation of the operation is not desirable, unless the site of resection is very high in the intestinal canal. When an anastomosis is done it may be either an end-to-end anastomosis or a lateral anastomosis (p. 884). In these cases no fur- ther prolongation of the operation is desirable, so no attempt at a "radical cure" of the hernia should be made; it is sufficient to close the wound, usually with drainage, in the simplest and most expe- ditious manner. The treatment of omentum found in the sac demands a few words of explanation. If there is no serious change in this structure, it may be replaced; but if there is any doubt about its condition, it should be 822 HERNIA excised, after tying it off where normal by a series of interlocking ligatures, below which it is cut away, leaving a sufficient stump to ensure that the ligatures will not slip. Each ligature should include no more than a pencil's thickness of the omentum, and the omentum should be excised before the ligatures are cut short, so that the sur- geon may use them to hold the omental stump in the wound for careful inspection, to make sure that hemorrhage is controlled. The omental bloodvessels have no muscular coats, and do not retract or contract and allow spontaneous cessation of bleeding. Not unfrequently the omentum protrudes in a loop, into the hernial sac (Fig. 850), and unless Fig. 856. — Loop of omentum protruding into hernial sac, but having its free end within the abdominal cavity. Complications might ensue if this free end was not drawn out before ligating and cutting off the omentum. care is taken to pull the end of the loop out of the abdomen before its base is ligated there will be danger of its necrosing and causing peri- tonitis or obstruction later. The omentum is so seldom normal when it has been long in a hernial sac, even if not strangulated, that I believe it is much better to excise it under all circumstances, unless the con- dition of the patient is such as to render any prolongation of the operation unjustifiable. If it is restored to the abdomen it is quite likely to cause subsequent trouble either by adhesions or by favoring recurrence of the hernia (Lucas-Championniere) . The after-treatment is the same as after other operations for intestinal obstruction. If the wound has not been securely repaired, the patient should be operated on after complete recovery, to obtain a cure; or a truss should be worn to prevent reappearance of the hernia. SPECIAL HERNLffi. Classification. — There are only three forms of hernia of frequent occurrence; all the others are rare. The most frequent form is the inguinal, which occurs in about 73 per cent, of cases; then comes the femoral, in about 18 per cent, of cases; and lastly the umbilical, which occurs in about 8.5 per cent, of cases. This leaves about 1 per cent. VENTRAL HERNIA 823 for the rarer forms (lumbar, obturator, etc.). In this reckoning, however, incisional hernia is not included. To afford a perspectus of the subject to the student, there is no more serviceable classification of hernia than the following: Hernle of the Epigastric Region. 1. Diaphragmatic. 2. Epigastric. Hernia of the Mesogastric Region. 1. Ventral. 2. Incisional— These may occur also in other regions. 3. Umbilical. 4. Lumbar. Hernle of the Hypogastric Region. 1. Inguinal. 1. Indirect (or Oblique). 2. Direct. 2. Femoral or Crural. 3. Pelvic. 1. Anterior — obturator. f (1) Perineal. 2. Inferior (2) Pudendal. (3) Vaginal. 3 - PoSteriOT {SGSa1r- These various forms will now be discussed in turn. Diaphragmatic Hernia has already been considered (p. 802). Internal Hernia is discussed in Chapter XXII. Epigastric Hernia. — By this term is understood orie or more small protrusions, usually of omentum only, occurring in or near the median line of the abdomen (linea alba) between ensiform process and um- bilicus. It is a rare condition, first well studied by Terrier in 1886. A much more frequent abnormality, and one which often is mistaken for a true hernia, is the protrusion of small portions of the preperi- toneal fat through apertures between the transverse fibers of the sheaths of the recti muscles which go to form the linea alba. Accord- ing to Tillaux (1894) it is more frequent in men. The patient com- plains of pain, and on examination a small mass can be felt the size of a marble or thereabouts, and generally irreducible. It simulates an epiplocele. Treatment. — If a fatty tumor is found it may be excised, after exposing and ligating its pedicle. If the linea alba is carefully sutured there is not apt to be a recurrence. A true hernia should be treated by excision of the sac, and suture of parietal peritoneum and linea alba. Ventral Hernia. — This hernia may occur in any part of the abdomi- nal wall, but does not protrude through one of the usual apertures such as the umbilicus, the inguinal or femoral canals, etc. It is a very rare form of hernia, though by many surgeons it is not distin- guished from incisional hernia (see below). The usual cause is injury resulting in partial rupture of the abdominal muscles, from a direct blow or merely by muscular strain. In some cases no distinct history 824 HERNIA of injury can be obtained, the abdominal wall seeming to have yielded spontaneously at the site where the hernia appears (Fig. 857). No true sac exists, the parietal peritoneum merely bulging a little when the patient strains. Under the heading of ventral hernia may be included also protru- sion due to diastasis of the recti muscles in the mid-line. A slight degree of diastasis is normal above the umbilicus, but pathological diastasis usually is seen in the hypogastric region, and occurs in women who have borne many children and who are emaciated. A similar condition is frequently seen in infants and young children, as a congenital deformity. Fig. 857. — Ventral hernia through right oblique muscles. Episcopal Hospital. (Dr. Neilson's case.) Symptoms. — The symptoms of ventral hernia are a feeling of weak- ness at the site of the protrusion, and dragging sensations within the abdomen. The diagnosis is not difficult, if the possible existence of the condition is remembered. Treatment.— Usually symptomatic relief is secured by wearing a firm abdominal belt. In children with diastasis of the recti the use of adhesive plaster strapping as advised in cases of umbilical hernia usually effects a cure. Even in adults the hernia is not liable to com- plications, but if desired the patient can secure permanent relief by an operation as for incisional hernia. Incisional Hernia. — This is much more frequent than a true ventral hernia, and receives its name from its development in the cicatrix of an operative incision. One cannot too much insist upon the impor- tance of placing the incision so as to do as little damage as possible to the structures of the abdominal wall (see p. 870). Incisional hernia was much more frequent formerly when less care was taken in the repair of abdominal wounds. An incisional hernia is very rare in a clean wound which is closed completely by tier suture. If the wound is drained, a hernia is much more apt to develop. INCISIONAL HERNIA 825 This form of hernia may be of any size, and if large may cause very great disability. Usually there is no true peritoneal sac, but the abdominal viscera lie in direct contact with fascia or skin, and almost always are closely adherent to their coverings. Owing to this fact there is no chance for spontaneous cure even if the hernia is kept reduced by suitable appliances. As the abdominal opening is rela- tively large, strangulation or other lesser complication is rare; though incarceration may occur if the aperture is small. The 'symptoms are the same as in ventral hernia. Fig. 858. — Incisional hernia, in scar of operation for appendicitis seven years ago (incision in right semilunar line). Episcopal Hospital. Fig. 859. — Incisional hernia, in scar of operation for typhoid perforation of intes- tine nine years ago (right rectus incision). Two years ago a right inguinal hernia also developed. Age thirty-six years. (Dr. Harte's case.) Episcopal Hospital. Treatment. — If the patient is healthy, operation should be done. If this is contraindicated, an abdominal belt, as in cases of pendulous abdomen (Fig. 963), may relieve the worst symptoms. When operation is done it should be remembered that the cicatrix is usually very thin and the hernial contents adherent. The surgeon, therefore, begins by an incision at the periphery of the hernia, and opens the abdomen not directly through the old cicatrix, but through healthy tissues above or below or to one side of the hernia. Here there will be no adhe- sions to the parietal peritoneum. The hernial contents are then cautiously dissected free from the overlying abdominal wall, the cica- tricial tissue is excised, and the herniated structures reduced. In cases of very large hernia with many adhesions between the prolapsed intestines and omentum it is not desirable to separate these more than is required to free the different layers of the abdominal wall. Redundant or diseased omentum should be excised. The various layers of the abdominal wall, especially the aponeuroses, should be dissected free, exposing enough of each for accurate suture, and if possible for overlapping. Then the wound should be repaired as a recent abdominal incision (p. 873). The most important layer of the 82G HERNIA abdominal wall to suture accurately is the anterior sheath of the rectus or the aponeurosis of the external oblique. Ilemostasis should be absolute, and the wound should not be drained. The patient should remain in bed for at least three weeks, and if the hernia was large should wear an abdominal belt and avoid straining efforts for a year after operation. Bartlett (1903) and other surgeons have implanted silver wire filigree in these wounds, with a view of rendering them stronger. Recent experience has shown that free flaps of fascia lata can be transplanted to supply a defect. Umbilical Hernia. — This is a frequent affection, especially in infants and stout adults past middle life. Three forms are to be distinguished, the Congenital, the Infantile, and the Adult. Congenital Umbilical Hernia is rare, occurring once in five or six thousand births. It is classed as embryonic and fetal. The former is due to failure of development of the abdominal wall, and the hernia, or rather eventration, may be very extensive, containing beside intestine also stomach, liver, heart, etc. The fetal variety develops after the third month of intra-uterine life, and the sac is lined by peritoneum and seldom is very large. Infants with large embryonic hernia usually are stillborn, or die so soon after birth as to offer little chance for repair of the defect by surgical means. The smaller fetal hernia usually is covered only by a translucent membrane through which the herniated viscera can be seen. Other malformations, espe- cially of the bladder or rectum, may be present. Treatment. — The hernia should be repaired by operation so soon as possible. The general mortality is about 30 per cent., but is less after operation done on the first day of life than later. Umbilical Hernia in Infants and Children is very frequent. It develops at any time after complete cicatrization of the navel, and seldom appears first after the close of the second year of life. The hernia seldom is very large, is covered by normal skin, and usually appears not directly under the umbilical cicatrix, but slightly above and to one side. Pressure by a finger reduces the hernia easily, and when the child cries or strains it becomes larger and more tense (Fig. 860) . Treatment. — If the hernia is small and the child is young, there is some chance of cure without operation. With the child lying down, one end of a strip of adhesive plaster, about two inches wide is fixed in one lumbar region; then the surgeon draws the opposite side of the belly forward, so as to form a longitudinal fold in the region of the linea alba. The adhesive plaster is then drawn across the relaxed belly and is tightly applied to the loin on the other side. It is well to reinforce this first strip by one or two others. It is better not to place a button, or a coin, or pad, or anything else over the hernia, as these tend to keep open the hernial ring. The adhesive plaster should be renewed about once a week, or as often as it comes loose. Care must be taken to keep the hernia reduced by the finger while the plaster is being changed. Attention is necessary to prevent excoria- tions of the skin. If the plaster is applied too tightly it may encourage UMBILICAL HERNIA 827 the development of inguinal hernia. If this method of strapping an umbilical hernia is faithfully continued for a year, a cure will result in a large number of cases if the hernia is small and of short duration. If no improvement is apparent within four or six months, operation probably will be necessary. Operation for infantile umbilical hernia is best done after the child is two years old. This will allow a fair trial of conservative treatment. I think it is well in children, especially in boys who are exposed more than girls to ridicule for any abnormality, to do an operation which permits preservation of the navel, as advised by Stone. I make a semi- lunar incision, below the umbilicus, in the direction of the folds of the skin, and turn this skin flap upward, exposing the hernial ring, which is treated as in adults; when the skin flap is replaced, the patient's aspect is quite normal (Fig. 861). Fig. 860. — Umbilical hernia in a rachitic negro boy. Children's Hospital. Fig. 861. — -Result of operation for umbilica hernia with preservation of the navel. Children's Hospital. Umbilical Hernia in Adults. — This may be a sequel or recurrence of the infantile form, or may develop first in adult life. It is more fre- quent in women, being predisposed to by repeated pregnancies. As in infants and children, the protrusion usually occurs slightly above the umbilical cicatrix. Omentum is almost always present in the sac, and generally becomes adherent, rendering the hernia irreducible 828 HERNIA at least in part. When the hernia is allowed to grow large, it becomes pendulous (Fig. 862), and usually contains transverse colon and often small intestine also. Incarceration is frequent, and strangulation not unusual. Strangulation often is intra-saccular, a coil of gut being caught in the matted and hypertrophied omentum. The coverings of the hernia are skin, subcutaneous fat, a thin layer of fascia, pre- peritoneal fat, and peritoneum; the latter forms the sac, which is acquired, not congenital. The pressure of the hernia causes atrophy of the tissues overlying it, and the contents of the sac usually lie very close to the skin, at least over the fundus of the sac. In many cases there is also considerable diastasis of the recti muscles, both above and below the ring. Fig. 862. — Umbilical hernia in adult. Age fifty-two years; duration two years. Episcopal Hospital. Treatment. — The best treatment is by operation. Before this is attempted, however, it is very important to secure reduction of as much of the hernia as is possible, by the means described at p. 812. A transverse incision is made, outlining an ellipse of the redundant skin, including the umbilicus. This incision should extend from one semilunar line to the other, and in very fat patients may have to be even longer. This incision exposes the anterior sheaths of the recti muscles on all sides of the hernial ring, and at some distance from it. The fat is then dissected off the aponeurosis up to the borders of the ring, and at this point the sac is cautiously opened, with the usual precautions against wounding its contents. This is very hard to avoid, if an attempt is made to open the sac at its fundus. The sac is then cut away with scissors at the margins of the hernial ring, on the finger as a guide, and the parietal peritoneum as cut is caught in clamps to prevent it from retracting out of sight. The reducible con- tents of the sac are then replaced in the abdomen. Usually a good deal of omentum has to be excised; this should be done with the precau- tions recommended at p. 821. The skin containing the umbilicus, circumscribed by the original incision, is removed in one piece with the UMBILICAL HERNIA 829 hernial sac (Omphalectomy). When all the hernial contents have been replaced, a gauze pack is inserted to plug the opening and keep them from protruding again. The next step is closure of the hernial ring: a transverse incision is made outward for about 3 cm. from the hernial ring through the anterior sheath of each rectus muscle. Usually there is diastasis of these muscles, and for a distance of 2 cm. or more on each side of the mid-line the anterior and posterior sheaths of the recti may be in contact. The anterior sheaths alone are to be incised, and are dissected upward and downward until a flap of this strong aponeurosis is formed both above and below the hernial open- ing. The margins of the neck of the hernial sac (parietal peritoneum), still caught in forceps, are next to be closed with sutures. This may Fig. 863. — Radical repair of umbilical hernia. The parietal peritoneum has been sutured, and the lower aponeurotic flap (anterior sheaths of the recti muscles) is being drawn up underneath the upper flap by means of mattress sutures. be accomplished by applying a purse-string (p. 881) if the ring is small; but if it is large it is better to use interrupted sutures. The sutures should include also the transversalis fascia and the posterior sheaths of the recti muscles. Before the last suture is tied the gauze pack is removed. The peritoneal cavity being thus closed, the surgeon catches in Allis forceps the free margins of his aponeurotic flaps already formed from the anterior sheaths of the recti muscles. These flaps are then overlapped, the lower one being pulled up between the upper flap and the deeper structures, and they are sutured together by interrupted mattress sutures of chromic catgut, as indicated in Fig. 863. The free margin of the upper flap may then be sutured to the superficial surface of the anterior rectal sheaths. Transverse suture of the wound in repair of umbilical hernia is 830 HERNIA preferable to longitudinal suture because patients with umbilical hernia usually have quite a pendulous abdomen, and there is much more slack in the tissues and less tension on the sutures if transverse suture is adopted. Frequently it is very difficult if not impossible to bring together the edges of the recti by a longitudinal suture, because of their diastasis; but if the transverse suture with overlapping is employed the approximation of the recti is unnecessary. The principle of overlapping fascial layers in the repair of hernia, first introduced in 1881 by Lucas-Championniere, was adopted by W. J. Mayo (1899) in the case of umbilical hernia, and the operation as above described is known by his name. He has since adopted modifications of the technique introduced by Ochsner: no attempt is made to suture the neck of the sac separately, nor are transverse incisions made in the rectus sheaths for the purpose of forming fascial flaps. The opening in the abdomen is closed simply by three mattress sutures so intro- duced as to draw its lower margin well up beneath its upper. I have always used the original method, and believe it is preferable except where the hernial orifice is quite small. The patient should be confined to bed at least for three weeks ; and if the hernia was very large or the abdomen very pendulous, an abdominal belt should be w r orn for several months. Recurrence is very unusual. Strangulated Umbilical Hernia. — This is a very serious condition; the patient frequently is old, feeble, asthmatic, fat, and arterio- sclerotic. The hernia in most cases is already irreducible; strangula- tion usually begins with symptoms of incarceration, and the develop- ment of complete strangulation is difficult to recognize, owing to the frequency of intra-saccular strangulation. Taxis should not be per- sisted in unless the patient absolutely refuses operation. Operation usually is too long delayed. When done, no attempt should be made to complete the procedure by repair of the hernial orifice if the hernia has been long irreducible, or if the patient's condition is bad. It is sufficient to relieve the" strangulation, and the herniated structures may be left adherent to the sac, and should not be reduced. Lumbar Hernia. — This is quite rare. The protrusion occurs through a space bounded above by the twelfth rib, medially by the quadratus lumborum, laterally by the external oblique, and below by the internal oblique (Grynfeltt, 1866); this space transmits the last intercostal artery and nerve, which weaken it. Hernia in Petit's triangle is almost unknown. The coverings of the hernia are skin, superficial fascia, lumbar aponeurosis (or internal oblique), preperitoneal fat, and peri- toneum. Most of the cases of lumbar hernia on record have been either con- genital, or the result of trauma. Goodman and Speese (1916) collected 12 cases of the former and 33 of the acquired form. The condition presents the usual symptoms and physical signs of a reducible hernia (p. 808), and must be distinguished from a cold abscess, as well as from a lipoma. There is no distinct neck to the sac. Strangulation is unusual. INGUINAL HERNIA 831 Treatment. — If the patient wears a well-fitting truss for a year or more, there is fair probability that a small hernia may cease to pro- trude. In most cases, however, operative treatment is preferable. This consists in dissecting out the layers of the abdominal wall, and overlapping them by suture whenever this is possible. Inguinal Hernia. — Of the three usual forms of hernia, inguinal, femoral, and umbilical, inguinal hernia is by far the most frequent. It comprises about three-fourths of all cases of hernia, and is much more frequent in men than in women. In males, 96 per cent, of hernia? are inguinal, about 2.5 per cent, are femoral, and only 1 per cent, are umbilical. In females, 50 per cent, are inguinal, 33 per cent, are femoral, and 16 per cent, are umbilical (De Garmo). Nomenclature. — If the hernia emerges from the peritoneal cavity at the internal abdominal ring, traverses the inguinal canal, and ap- pears at the external abdominal ring, it is called an indirect or oblique inguinal hernia. If it passes directly through the abdominal wall on the median side of the deep epigastric artery, and thus appears at the external ring without traversing the inguinal canal, it is called a direct inguinal hernia. This is much rarer than the indirect form. If the hernia remains above the brim of the pelvis, it is called an incomplete inguinal hernia, or a bubonocele; if it descends beyond the brim of the pelvis it is called a complete inguinal hernia. A complete inguinal hernia in the male enters the scrotum and is termed a scrotal hernia; in the female it enters the labium majus and is called a labial hernia (this should not be confused with a pudendal hernia, p. 851). Oblique Inguinal Hernia. — Inguinal hernia is more frequent in the male because of the greater size of the inguinal canal and because of the existence of the vaginal process of peritoneum which accompanies the testicle in its descent into the scrotum. These facts account also for the greater frequency of oblique than of direct inguinal hernia. It is gradually coming to be recognized, largely owing to the teaching of Hamilton Russell (since 1899), and of R. W. Murray, that most cases of hernia are due to the existence of a preformed sac. The proba- bility of the existence of such a sac is greatest in the inguinal region; and formerly it was the custom in describing oblique inguinal hernia to lay great stress on the different varieties of sac which might be present, according to the stage of development which had been reached by the vaginal process of peritoneum during fetal life. These dis- tinctions have little more than academic interest; but a reference to the accompanying illustrations will explain the five forms which may be encountered. Occasionally incomplete obliteration of the funicular process occurs at one or more points, forming fibrous bands or strictures in the serous sac (Fig. 864) ; this accounts for cases of bilocular hydro- cele (p. 1116), and is of some importance because strangulation may occur at any of these points, as well as at the neck of the hernial sac. The fact of greatest importance to bear in mind is that it is the exist- ence of a preformed sac which predisposes to development of hernia, and that it is the extirpation of the sac which is the most important step 832 HERNIA (especially in children and young adults) in the operation for the cure of hernia. A. IT. Ferguson pointed out that in some patients the internal oblique muscle does not have an origin from Poupart's ligament, as is normally the case, and that this renders the region of Fig. 864. — Incomplete obliteration of the funicular process of peritoneum, just above the testicle. Found at operation on a patient aged thirty-two years; duration of hernia sixteen years. Episcopal Hos- pital. Fig. 865. — Ordinary adult type of in- guino-scrotal hernia: fundus of sac separate from testicle, and easily enu- cleated. Hernia usually slowly de- veloped. the internal abdominal ring very weak. Torek (1919) insists that a weak spot at the internal ring exists between the spermatic vessels above, and the vas below. Apart from these anatomical factors, the Fig. 866. — Hernia into patulous pro- cessus vaginalis: there is no separate tunica vaginalis. So-called "congenital hernia." A hernia of sudden formation. Fig. 867. — Hernia into funicular pro- cess: fundus of sac adherent to tunica vaginalis. So-called "infantile hernia." A hernia of sudden formation. predisposing and exciting causes of inguinal hernia are the same as those of hernia in general (p. 806). If the hernia is present at birth it is one usually described as congenital (Fig. 866); but of course a "congenital" sac may be present but no INGUINAL HERNIA 833 hernia develop until adult life. If the hernia appears at any time after birth, and is of sudden formation, it is probable that there was a preformed sac, and that the sudden appearance of the hernia is caused by muscular effort forcing some of the abdominal contents into this sac (Fig. 867.) If the hernia is of slow formation, which is rare except in adults, it is still possible that a small preformed sac may have existed. Fig. 868. — Hernia encysted into the tunica vaginalis. The "encysted hernia of Sir Astley Copper." Funicular process closed only at the internal ring. An ac- quired hernia of slow formation. Fig. 869. — Hernia encysted between tunica vaginalis and testicle. "Encysted hernia of Hey, of Leeds." Due to same congenital defect as Fig. 868, but parietal peritoneum has yielded just posterior to upper obliterated end of funicular process. If the hernia occurs into a sac formed by the patulous vaginal process of peritoneum (Fig. 866), whether the hernia is present at birth, appears during infancy or childhood, or does not appear until late adult life, the contents of the hernia will obscure the outline of the testicle (Fig. 870). If, however, the testicle has its own tunica vagi- nalis (Figs. 865 and 867), the hernia and the testicle can be perceived as separate swellings in the scrotum (Figs. 871 and 872). This distinction is of some clinical importance, when operative treatment is under- taken (p. 841). In all cases, with very few exceptions, the hernia lies in front of the spermatic cord, and even if the hernia is irreducible, the cord usually can be palpated behind it. Symptoms and Diagnosis. — An oblique inguinal hernia is more common on the right side. It appears first at the internal abdominal ring, and may or may not descend into the scrotum. In its descent it always passes through the inguinal canal. The longer its duration and the larger the hernia, the less oblique becomes its passage through the abdominal wall, as the internal ring gradually enlarges and shifts its position nearer to the spine of the pubis. When in the scrotum the hernia is not attached to the testicle, and in most cases can be reduced within the abdomen. This reduction is attended by characteristic signs (p. 809). If the hernia is irreducible the diagnosis may be more difficult; but always, unless strangulated, the hernia 53 834 HERNIA transmits an impulse when the patient coughs. The differential diag- nosis of direct inguinal hernia is considered at p. 843, and that of femoral hernia at p. S46. 1 VI Fig. s $ \ Y^^, i4 m. 1 Fig. 11. — Operation for light inguinal hernia: the aponeurosis of the external oblique is sutured over the cord. Direct Inguinal Hernia. — This hernia is one which protrudes through the abdominal wall on the median side of the deep epigastric artery, just to the outer side of the spine of the pubis, and directly behind the external abdominal ring. This is the space known as Hesselbach's triangle. Direct hernia is seen about once in every 30 to 40 cases of indirect inguinal hernia. It is least rare in adults and occurs oftener in men than in women. It is a hernia of slow formation, and there is no well defined neck to the sac. In most cases it may be recognized at a glance (Fig. 882). Strangulation is very unusual. It is distin- guished from oblique inguinal hernia by the fact that when it has been reduced, pressure over the internal abdominal ring does not prevent its reappearance. It should not be forgotten that a large indirect Nil HERNIA Fig. 882. — Double direct inguinal hernia, age sixty-eight years; duration thirty years. Of slow onset, from constant straining in urination. Has strictures of urethra, and enlarged prostate. Operation on hernise contraindicated until urinary obstruction is relieved. Episcopal Hospital. inguinoserotal hernia may cause the position of the internal abdominal ring to shift until it lies directly behind the external ring; but a direct hernia never descends far into the scrotum. Sometimes when the hernia is reduced, it is possible to palpate the deep epigastric artery on the lateral margin of the hernial orifice. If there is any doubt about the nature of the hernia, it probably is an indirect inguinal hernia. A direct hernia usually pro- trudes through the conjoined tendon, which is carried forward as one of its coverings. Occa- sionally, however, it passes to the outer side of the conjoined tendon. In most cases the sper- matic cord lies on the outer side of the sac. Rare Forms of Direct Inguinal Hernia. — Sometimes the sac of a direct inguinal hernia occupies (1) a properitoneal position near the bladder ; or after protruding through the conjoined tendon on the median side of the obliterated umbilical vein, it may lie (2) between the conjoined tendon and the external oblique aponeurosis, or (3) in a subcutaneous position in front of the external oblique aponeurosis. For these rare varieties of direct inguinal hernia Reich, in 1909, pro- posed the name of Supravesical Hernia. He collected 16 cases of the first variety, whieh he calls internal supravesical hernia; and 26 cases of the second and third varieties, which he terms external supravesical hernia. Treatment of Direct Inguinal Hernia. — If a truss is used, it must have a large pad, as the hernia is difficult to control. Repair of the defect by operation is also more difficult and is less sure in preventing recurrence than in indirect inguinal hernia. The parts are exposed in the same way, and the sac is isolated. In doing this the surgeon should remember that the bladder frequently protrudes into Hessel- bach's triangle, and that its extraperitoneal surface is with difficulty distinguished from preperitoneal fat. Any fatty mass toward the median side of the hernial orifice should be avoided. When the sac has been opened and its contents have been reduced, it will be found that an opening is left which it is difficult to suture firmly, owing to the relaxed and atrophied condition of the various layers of the abdomi- nal wall. After the parietal peritoneum has been sutured, the inter- nal oblique and conjoined tendon should be drawn down if possible and sutured to Poupart's ligament, underneath the spermatic cord, as in the Bassini operation (p. 839). In cases where the internal FEMORAL HERNIA 845 oblique and conjoined tendon are very weak, the median reflected flap of the external oblique aponeurosis may be included in the sutures with them, and be drawn down and sutured to Poupart's ligament beneath the spermatic cord; then the lateral reflected flap of the external oblique is sutured over the cord (E. Wyllys Andrews, 1895). If the cremaster is well developed it may be employed as an additional layer in suturing the canal. Another plan may be adopted where the conjoined tendon is so thin that it will not hold the sutures; an incision is made through the transversalis fascia along the lateral border of the conjoined tendon, raising it and the anterior sheath of the rectus off this muscle, whose fibers are then drawn over and sutured to Poupart's ligament (Bloodgood, 1898). When, as is often the case, the sac is blended with the much relaxed overlying structures, no attempt should be made to separate them, but G. G. Davis's operation (1905) should be employed: these blended tissues are divided trans- versely, and are overlapped from above downward, much as in Mayo's operation for umbilical hernia (p. 829). This gives very satisfactory closure. The use of a free fascial flap, as noted on p. 826 may be desirable in some cases. However the deeper structures are sutured, the skin is closed in the usual way, and after-treatment is conducted as after operations for indirect inguinal hernia. Femoral Hernia. — Femoral or Crural Hernia has also been termed merocele. The hernia protrudes through the femoral canal, beneath Poupart's ligament, on the median side of the femoral vein. As already noted, it is commoner in women than in men, especially in women after the menopause. In childhood it is rare. Though in most cases there is a preformed sac, this may not always be a congenital deformity, 1 but may be a traction diverticulum probably due to the fact that some of the preperitoneal fat is forced into the femoral canal and gradually draws the peritoneum after it. Such a sac may exist for many years before a hernia forms; Murray found this condition in 48 out of 200 cadavers. Most of the femoral hernia? I have seen have been of sudden formation, clearly indicating the previous existence of a sac. As the hernia develops, it carries before it preperitoneal fat (septum crurale) and transversalis fascia (crural sheath). While still in the femoral canal it is known as an incomplete femoral hernia. Increasing in size, it leaves the femoral canal, causes bulging of the cribriform fascia, and curves upward over the falciform process of fascia lata, and lies beneath the skin of the groin (complete femoral hernia). It seldom grows very large. The only contents of the sac often is omentum, but neither this nor intestine is likely to become irreducible without becoming at the same instant strangulated. Strangulation probably is more frequent in femoral than in any other form of hernia, and 1 According to Lockwood, a congenital sac in the femoral canal is to be attrib- uted to traction by aberrant strands of the gubernaculum testis. 846 HERNIA gangrene occurs more rapidly, owing to the sharp margins of the femoral canal. Small intestine is much more frequently present in the sac than the colon, but the cecum sometimes is found; A. C. Wood (1900) collected 100 cases in which the vermiform appendix was the only structure in the sac. Rare Forms of Femoral Hernia. — The sac of a femoral hernia may have one or more diverticula, and such cases have been described as sepa- rate forms of femoral hernia: there are recognized (1) a diverticulum through the cribriform fascia, or hernia of Ilesselbach (1816); (2) a diverticulum through the superficial fascia, or hernia of Cooper (1807); (3) a properitoneal diverticulum, or hernia of Tessier (1834). A more frequent, but still very rare variety, is called a pectineal hernia, or hernia of Cloquet (1814); in this the sac passes from the femoral ring between the pectineus muscle and its sheath, instead of anterior to the latter as in the usual form; if large the sac may extend outward beneath the femoral vessels. Ulrichs (191 1) referred to 15 cases of this variety of femoral hernia which was well studied in 1907, by Dege. This hernia is to be distinguished from another rare variety, in which the sac enters the sheath of the femoral vessels, and passes into the thigh behind them (hernia retrovascularis) . There have been recorded also a few cases of femoral hernia external to the femoral vessels, between the ilio-pectineal ligament and the femoral artery (hernia of Partridge, 1846). A hernia through an opening in Gimbernat's ligament was described first by Laugier (1833) and is known by his name; it is on the median side of the obliterated umbilical artery. Diagnosis. — A femoral hernia is to be distinguished from other forms of hernia, from enlarged lymph nodes, from subcutaneous lipoma, from varices of the saphenous vein, and from psoas abscess. 1. An inguinal hernia appears first above Poupart's ligament, and can be retained within the abdomen, after reduction, by pressure over the inguinal canal. A femoral hernia always makes its first appear- ance below Poupart's ligament, and it will not be retained within the abdomen if pressure is made only over the inguinal canal. If the hernia is irreducible the diagnosis is more difficult; but if an imaginary line is drawn from the spine of the pubis to the anterior superior spine of the ilium, it is safe to say that a hernia whose chief bulk lies below that line (which corresponds to Poupart's ligament) is a femoral hernia (Fig. 883). 2. If an obturator hernia is present, the femoral canal will be empty, which is never the case if a femoral hernia exists. 3. In femoral adenitis the swelling may occur over the femoral canal, but it transmits no impulse on coughing; moreover, it presents signs of inflammation and a primary source of infection usually can be found. But as a strangulated femoral hernia may be present behind inflamed lymph nodes, it is safer to operate in cases of doubt. The same is true in cases of fatty or other tumors overlying the femoral canal. 4. A varicosity of the long saphenous vein may protrude over the femoral canal. It transmits an impulse when the patient coughs, FEMORAL HERNIA 847 but though, like a hernia, it disappears when the patient lies down, its reduction is not attended by gurgling, nor when the patient stands up will its reappearance be prevented by pressure over the femoral canal. 5. A psoas abscess is secondary to tuberculosis of the spine, which usually may be detected by proper examination. When the abscess descends below Poupart's ligament it usually appears on the outer side of the femoral vessels. Though it may transmit an impulse on coughing, and may be reducible, this reduction is not attended by the gurgling so characteristic of hernia. Fig. 8S3. — Right femoral hernia. Episcopal Hospital. Treatment of Femoral Hernia. — The use of a truss is unsatisfactory even in retaining the hernia within the abdomen, as it is impossible to obliterate the femoral canal; the most that a truss can do is to close its lower (crural) opening. No cure without operation need be antici- pated; and in no form of hernia is a cure so necessary, owing to the great frequency with which strangulation occurs. 1. The usual operation is done by the femoral route. The skin incision may be straight, in the long axis of the body, directly over the femoral canal, or a flap may be outlined, convex outward, so that the line of skin sutures will be far removed from the genitalia (Fig. 884). The incision should commence well above Poupart's ligament, and should expose also the fascia lata and cribriform fascia over the upper part of Scarpa's triangle. Care should be taken not to wound the long saphenous vein. When the skin and subcutaneous tissues have been reflected, the sharp margin of the falciform process of the fascia lata is to be located. Beneath this the femoral artery will be felt pulsating, and to the median side of this is the femoral vein which is in constant danger of injury. On the median side of the wound the surgeon should identify the pectineus muscle and its fascia. Then the sac may be opened. If the hernia is large and irreducible, which is seldom the case, it may be impossible to identify these various structures until the sac has been opened and its contents reduced. Under such circumstances the operator must cut down layer by layer sis HERNIA until the sac is opened. It is seldom possible to identify the various coverings of the hernia. The omentum in an irreducible femoral hernia nearly always requires to be excised in entirety. When the contents of the sac have been reduced, the sac must be traced up into the femoral canal under Poupart's ligament until parietal peritoneum is reached. This is known by its being whiter, denser, and more fibrous than the walls of the hernial sac. The opening in the parietal peritoneum is then closed with a purse-string suture, and the sac is cut away, with the usual precautions against overlooking hemorrhage from the stump (p. 841). From recent observations (Ochsner) it seems probable in most cases of femoral hernia, except where the femoral canal is widely dilated, that accurate suture of the parietal peritoneum is a sufficient preventative of recurrence, even without any attempt to close Fig. 884. — Incisions for femoral hernia: a a', for the inguinal method; b b', longi- tudinal incision for the crural method; c c', flap incision for the crural method. the femoral canal by suture. But in most cases it is not very difficult to insert one or more sutures so as to obliterate the canal. The needle (curved and round pointed), threaded with chromic catgut, is entered on the superficial surface of Poupart's ligament, close to the femoral vein, and is made to emerge in the femoral canal, catching some of the fibers of the sheath of the femoral vein if possible to do this without puncturing the vein. The needle is again gripped in the needle-holder, and is passed transversely inward, taking a firm hold of the pectineal fascia and underlying muscle, and is again gripped in the needle-holder. The needle is then passed through Poupart's ligament from below upward, near its inner end, and emerges finally near its original point of entrance on the superficial aspect of Poupart's ligament. This completes the first purse-string suture of the femoral canal (Fig. 885) . If there is room, a second similar suture may be passed nearer the lower (crural) orifice of the femoral canal. When these sutures are tied, FEMORAL HERNIA 849 Poupart's ligament is pulled down against the pectineal fascia, and the femoral canal is closed. The needle always should be introduced first on the side of the canal where the femoral vein lies, as there is thus less danger of injury to this important structure. The skin wound is then closed in the usual way. 2. The inguinal route for operation in cases of femoral hernia, intro- duced, in 1892, by Ruggi, does not seem to have been employed much in this country, though it possesses many ad- vantages, which I shall mention after briefly describing the operation. The skin incision is the same as in the operation for inguinal hernia (Fig. 884, a a'), and the external oblique is divided, freely exposing the inguinal canal. The lower border of the internal oblique and the con- joined tendon (with the spermatic cord or round ligament) are then pulled upward and toward the median line by a retractor, drawing the transversalis fascia tense, and exposing the superficial aspect of Hesselbach's triangle — bounded below by Poupart's ligament, inter- nally by the conjoined tendon, and on the outer side by the deep epigastric artery (Fig. 886). The transversalis fascia is then incised on the inner side of, and parallel to, the deep epigastric vessels. This at once exposes the pouch of peritoneum, as it enters the upper (abdominal) orifice of the femoral canal, to form the femoral hernia. It lies just to the median side of the external iliac vein, in full view. The hernial sac is then drawn out of the femoral canal, and into the inguinal wound. It is opened and its contents are reduced. It is then easy to close by suture the opening in the parietal perito- neum well above the neck of the sac. These steps having been accomplished, the surgeon may insert a purse-string suture in the femoral canal, precisely as in the crural method of operation, except that the steps of this suturing are under better control of the eye. Poupart's ligament is pulled down by the sutures against Cooper's ligament, firmly closing the femoral canal at its abdominal opening (Fig. 887). Or, the internal oblique and conjoined tendon may be sutured beneath the cord to Cooper's ligament (Lotheisen, 1898). The operation is then concluded, as in cases of indirect inguinal hernia. I have employed this inguinal method for the treatment of femoral hernia for many years, and regard it as superior in every way to the femoral route. It is simpler, easier, and I believe also safer. In uncomplicated cases it enables the surgeon to excise all of the sac, the whole of which is readily drawn up into the inguinal wound; and it ensures closure of the parietal peritoneum without leaving a pouch which will predispose to recurrence. In complicated cases it gives 54 Fig. 885. — Crural oper- ation for right femoral hernia: closing the fem- oral canal. 850 HERNIA much freer exposure of the parts, and renders the surgeon master of the situation: if there is strangulation, the constriction is much more readily found and easily divided; if there is an anomalous distribution of the obturator artery, it is easily discovered, and accidental hemor- rhage may be promptly controlled; if the gut is gangrenous, and intestinal resection or anastomosis is required, these may be done much more rapidly and safely than by the femoral method. By the latter route Gimbernat's ligament, the usual point of constriction, cannot be divided under control of the eye; it may be impossible, owing to shortness of the mesentery, to draw down enough healthy bowel to perform a resection, and even when the anastomosis is accomplished, Fig. 886. — Inguinal operation for right femoral hernia: the aponeurosis of the external oblique has been divided, exposing the inguinal canal. Tin; transversalis fascia has been divided, exposing the sac of the hernia entering the femoral ring. Fig. 887. — Inguinal operation for right femoral hernia: the sac has been removed and the parietal peritoneum sutured; Poupart's ligament is now being sutured to Cooper's ligament. Gimbernat's liga- ment in full view. if one is required, it may be impossible to return the gut through the narrow femoral canal. The only alternative in such cases is to divide Poupart's ligament, a procedure which renders recurrence of the hernia almost certain, and in a form which it is extremely difficult to cure. Should there be a fecal abscess in the sac, however, it should be drained through a femoral incision before the inguinal operation is begun. The peritoneal cavity also should be well protected by gauze- packs before the gangrenous gut is reduced. If it proves impossible to draw the sac up into the inguinal canal, its neck should be opened and its contents should receive appropriate treatment. Under these circumstances the fundus of the sac may be allowed to remain in the femoral canal. PERINEAL, PUDENDAL AND VAGINAL HERNIA 851 Obturator Hernia. — This is very rare. Berger found it once among 10,000 cases of hernia. About 200 cases are on record. It is most fre- quent in elderly women. It is a hernia of slow formation. The sac leaves the pelvis through the obturator foramen, and protrudes in the upper inner part of Scarpa's triangle, underneath the pectineus muscle, where the hernia can be more easily felt than seen. The thigh should be flexed, adducted, and rotated slightly outward: then the surgeon places his finger against the descending ramus of the pubis behind the adductor longus, and palpates carefully for the swelling (Macready). The two limbs should be conipared. Sometimes both sides are affected. The sac usually contains bowel, but the tube and ovary have been present in a few cases. The existence of a hernia seldom is recognized until strangulation occurs, and even then the true cause of the symptoms may be overlooked. Diagnosis. — The diagnosis in a case of strangulation, apart from the symptoms of intestinal obstruction, would depend on the history of previous attacks of incarceration of the hernia, with relief of pain coincident with the sensation of something slipping back into the pelvis; the onset of the present symptoms with sudden pain in the region of the obturator foramen; on the radiation of pain in the dis- tribution of the obturator nerve; and on the discovery of a tender swelling beneath the pectineus muscle, by the mode of examination already indicated, together with palpation of the inner surface of the obturator foramen through the vagina or rectum. Treatment. — Treatment consists in laparotomy and reduction of the hernia, with closure of the obturator canal by suture. The mortality has been about 85 per cent., largely because the condition has not been recognized in time. Perineal, Pudendal and Vaginal Herniae. — Pelvic hernia is extremely rare. It is probable that congenital anomalies of the pelvic peri- toneum (possibly preformed pouches) predispose to its development. It occurs about six times as often in women as in men. In the male the protrusion occurs in the perineum {perineal hernia), between rectum and prostate, or rarely in the ischio-rectal fossa. It may be associated with prolapse of the rectum. In the female the hernia may leave the pelvis behind or in front of the broad ligament. In the former case he protrusion may occur in the perineum, in the ischio-rectal fossa, or in the posterior vaginal wall {vaginal hernia). Vaginal hernia u ually is associated with procidentia uteri. If the hernia leaves the pelvis in front of the broad ligament, as is more often the case, it enters the labium majus (pudendal hernia, Fig. 888), where it must be distinguished from (1) an inguino-labial hernia, which passes above the brim of the pelvis, through the inguinal canal; and from (2) a femoral hernia, which also leaves the abdomen above the brim of the pelvis, and which has the neck of its sac external, not internal, to the descending ramus of the pubis. Treatment. — Treatment usually is palliative, by the application of a suitable .pessary, T-bandage, or other appliance. Strangulation is 852 HERNIA rare. Operation is undertaken only when the hernia forms a com- plication of another condition, such as prolapse of the rectum, vagina, or uterus. Fig. 888. — Left pudendal hernia, containing ovary, in a woman of eighty years. Diag- nosis at operation (symptoms of strangulation). Recovery. Episcopal Hospital. Ischiatic Hernia. — These are also extremely rare forms of hernia. Koppl (1908) collected 23 cases. He prefers Waldeyer's classifica- tion: (1) Hernia Ischiadica Suprapyriformis. (2) Hernia Ischiadica Infrapyriformis. (3) Hernia Ischiadica Spinotuberosa. The first and second forms occur through the greater sacrosciatic foramen (11 cases above, and 7 below the pyriformis muscle) ; the third form (only one case recorded) occurs through the lesser sacrosciatic foramen. In four of the recorded cases the particular form was not described. These hernia? occur into a preformed sac, either congenital, or formed by the traction of a gluteal lipoma, myxoma, or other tumor. They make their external appearance along the perineal border of the gluteus maximus muscle, and it is difficult to distinguish them from perineal hernia. If strangulation occurs, the swelling should be explored and drained from below; then the abdomen should be opened, and the gut reduced. The general mortality of the reported cases is 34 per cent. CHAPTER XXII. ABDOMINAL SURGERY IN GENERAL, AND INJURIES OF THE ABDOMINAL VISCERA. THE PERITONEUM. The large serous sac known as the peritoneum is of immense impor- tance in surgery. It forms the omentum and mesenteries, and covers closely the gastro-intestinal tract, and less completely the liver, gall- bladder, and pancreas, as well as the spleen, kidneys, bladder, and female organs of generation. Its total area is said to exceed that of the skin which covers the surface of the body. There is present normally a small amount of fluid, just sufficient to lubricate the endo- thelial surfaces. This fluid or any extraneous material introduced into the peritoneal cavity is absorbed largely in the region of the upper abdomen, especially through the peritoneum lining the under surface of the diaphragm. It is believed that a constant upward current exists from the peritoneal cavity through the diaphragm to the mediastinal lymph nodes; and absorption of intraperitoneal exu- dates occur much more rapidly by this route than through the mesen- teric lymph nodes which drain the mucous surfaces of the abdominal viscera. Absorption from the peritoneal cavity is hindered largely by a faculty which the peritoneum possesses in common with all serous membranes — that of forming adhesions. In cases of infection of the peritoneum by bacteria and their toxins, the injury to the endothelial surface of the peritoneum is sufficient in most cases to cause adhesion between adjacent serous surfaces, and it is in this way that infectious processes are localized. While this results in encapsulation of an infecting focus, it also entails a certain amount of impairment of function in interference with peristalsis. Isohtion of an infected area is favored by the insertion of gauze packs, which will within a few days excite adhesions of sufficient strength to wall off the general peritoneal cavity. The slight mechanical trauma inflicted by the insertion of sutures arouses sufficient reaction in the apposed serous surfaces to ensure their adhesion if contact is maintained by the sutures for a week or ten days; hence such sutures always are inserted in such a manner as to bring serous surfaces into contact with each other. Peritonitis. — Inflammation of the peritoneum is one of the most frequent abdominal conditions met with in surgery. It is caused by bacterial infection. The existence of "idiopathic" peritonitis is no longer recognized. Even if we cannot find the portal of infection, (853) 854 ABDOMINAL SURGERY IN GENERAL we can at least identify the microorganisms which are the ultimate cause of the peritonitis; and it may be accepted as an axiomatic truth that in practice no peritonitis exists unless it has been caused by bacteria. Experimentally an aseptic peritonitis may be produced by the intraperitoneal injection of irritating but sterile chemicals; and theoretically when any incision into the peritoneal cavity is repaired the process of union which occurs is a form of peritonitis; but what is understood by the term peritonitis standing alone, is a bacterial infection of the peritoneum. Causes. — The bacteria and their toxins gain access to the peri- toneum in various ways. (1) In the immense majority of cases they come from the gastro-intestinal tract, which always is swarming with bacteria; these escape from the intestinal tract as the result of lesions which will be studied in the next chapter (appendicitis, intes- tinal obstruction, cholecystitis, etc.). (2) In a large proportion of cases in the female the infection comes from the internal genitalia. (3) In a few cases infection is carried from without by injury; but in these cases the infection which results from injury of the intraperi- toneal organs is much more serious than that which is carried into the wound by the vulnerating body. (4) In a small proportion of cases the infection is believed to be hematogenous in origin. (5) In excep- tional cases peritonitis develops from extension of inflammation from some focus in kidney, bladder, diaphragm, abdominal wall, or other neighboring structure. The microbes most frequently encountered are the staphylococcus, streptococcus, and colon bacillus, in enterogenous infections; the gonococcus and streptococcus in genital infections; and the tubercle bacillus or the pneumococcus in those apparently of hematogenous origin. Pathology. — As a rule, peritonitis begins as a more or less localized process in the immediate neighborhood of the atrium of infection whether this be the vermiform appendix, the gall-bladder, the Fallopian tube, an ulcer in the gastro-intestinal tract, or any other lesion (Plate XIV, Fig. 1). Peritonitis always is either increasing or decreasing; it does not remain stationary. It is not a state but a process; it runs a more or less definite course, sometimes of infinite complexity, owing to changes w r hich will be studied in detail later. The disease pro- gresses either to recovery or to death of the patient, as surely as does inflammation of any other structure in the body, as pointed out in Chapter I. Its course is so very markedly influenced by treatment that this important fact sometimes is overlooked. The omentum plays a much more conspicuous part in the process of peritonitis than is generally recognized. This structure may be regarded as an aggregation of phagocytes enmeshed in fat. The endothelial cells which cover its surface are highly phagocytic. The omentum is the chief source of the reactive processes which are aroused by peritoneal infection. By chemotactic attraction it is drawn to the point of attack, and it envelops the infecting lesion in the endeavor PERITONITIS 855 to localize it. Other adjacent structures also become adherent to each other. When the peritonitis has been thus localized the further progress of the inflammation is the same as that which occurs else- where when the protective forces are in the ascendant : the phagocytes accomplish their task, the bacteria are killed and their toxins neutral- ized, and the patient recovers from his attack of peritonitis. But the omentum remains adherent to the diseased area; and more or less extensive intestinal adhesions persist. There may or may not be the formation of an abscess beneath the omentum, or in the midst of intes- tinal adhesions (Plate XIV, Fig. 3). If one is formed, it will run the same pathological course as an abscess in other situations; it will tend to point and to rupture at the site of least resistance, and this may be into the surrounding peritoneal cavity, into the bowel, bladder, etc., or rarely through the overlying abdominal wall. The frequency and great danger of intraperitoneal rupture makes it incumbent on the surgeon to recognize and to drain such an abscess as soon as possible. If intraperitoneal rupture of such an abscess is followed by a slight attack of peritonitis only, which at once becomes localized in the form of a second abscess; and if this abscess ruptures in turn and a third abscess is formed, and so on until multiple abscesses exist, then the condition corresponds to the progressive fibrino- purulent peritonitis of Mikulicz (1889). A large part of the peritoneal cavity may be invaded in this way, the intestines, omentum, and neighboring structures being matted together in an inextricable mass of adhesions among which are found numerous minute abscesses. This occurrence is rare; the rupture of an abscess into the neighboring healthy peritoneal cavity usually is attended by profound shock (toxic absorption) and often is followed by death, no reaction occurring in the surrounding structures which are overwhelmed. If the primary infection is very severe the bacterial toxins may be diffused within the peritoneal cavity before the omentum has an opportunity to encapsulate the source of infection. Then you will find on opening the abdomen that the omentum appears to have dissolved itself into an exudate which is rich in anti-bodies and which on culture you will often find sterile. The bacteria are enclosed in phagocytes, or are adherent to the omentum, or to the parietal or vis- ceral peritoneum. The omentum, as I said, seems to be dissolving in fluid; it feels extremely slimy, and you cannot tell where omentum ceases and where the fluid begins; if you hold the omentum up it will almost drip this fluid from its meshes. There are no adhesions any- where. Everything is covered by serous slime. This is the stage of the process which is recognized as spreading or diffuse peritonitis (Plate XIV, Fig. 2). The bowels are not much altered: those nearest the seat of disease may be red, their luster may be slightly diminished, and they may even feel a little sticky; but that is all. The battle between the attacking and repelling forces is as yet undecided; the process is very acute, and it changes with alarming rapidity. This change may be either for the worse or the better. If the latter, then the 856 ABDOMINAL SURGERY IN GENERAL anti-bodies gradually overcome the toxins, evidences of systemic poisoning (toxemia) subside; the peritoneal exudate becomes thicker and more sticky; lymph covers the inflamed intestines where their endothelial covering has been destroyed; frank pus begins to collect in dependent situations and pockets of the peritoneal cavity; and as the reparative process continues the infectious material is localized in one or many regions, which are shut off from the rest of the peri- toneal cavity by adhesions between the coils of intestine, the omentum, the parietal peritoneum, and neighboring structures, such as bladder, uterus, stomach, gall-bladder, diaphragm, etc. The result of such an attack of peritonitis is the formation of multiple residual abscesses. Many surgeons confuse this condition, which is frequent, with that described by Mikulicz as progressive fibrino-purulent peritonitis. The pathogenesis of the latter form of peritonitis, which is rare, has been described above; I believe the idea that it is of frequent occurrence rests on faults of observation. Purulent exudates collect, and residual abscesses form chiefly in the dependent portions of the peritoneal cavity, especially the pelvis, the iliac fossa, the lumbar gutters, or in the subphrenic regions (Plate XIV, Fig. 5). If the resistive powers of the patient prove unequal to the task of localizing an attack of peritonitis after it has reached the diffuse stage, the infection continues to spread, until what may be called general peritonitis is present (Plate XIV, Fig. 4). From this patients seldom recover. They die of toxemia or septicemia before the invading forces have been overcome. And if the virulence of the infecting organisms is very high, or if the patient's resistance is very much below par, the peritoneal infection may spread with alarming rapidity from the very first. In such cases little or no exudate is formed, but, on the con- trary, the bacterial poisons are quickly absorbed, and the patient dies with a dry peritoneum, without adhesions, without exudate, but with the intestines red, friable, and on the verge of disintegration. This usually is described as septic peritonitis, though the term of A. O. J. Kelly (1896), toxic peritonitis, is preferable. When there is a tendency for minute hemorrhages to occur, either in the subserous tissues, or free into the peritoneal cavity, rendering the scanty exudate blood-tinged, the condition is sometimes called hemorrhagic peritonitis. Clinical Course and Diagnosis. — The symptoms of oncoming peri- tonitis are so inextricably bound up with those of the condition to which it is secondary, such as appendicitis, or intestinal perforation, that it is difficult to distinguish between the two, especially as peri- tonitis is rightly regarded not as a distinct disease, but as itself a com- plication of the underlying disease. However, it is convenient to describe the clinical picture which a patient with peritonitis presents to the observer, and then to study more in detail the physical signs on which a diagnosis of peritonitis is based. Acute Local Peritonitis. — The initial more or less diffuse and colicky pain of the primary lesion (in the appendix, Fallopian tube, gall- bladder, etc.) is succeeded within a few hours by a pain which is burn- PLATE XIV Peritonitis. 1. Acute local peritonitis, from appendicitis. 2. Acute diffuse peritonitis. 3. Single, primary abscess. 4. General peritonitis. .5. Multiple, residual abscesses. (After de Quer- vain.) PERITONITIS 857 ing, intense, and local. This is increased by movement, by pressure, by coughing, or deep breathing. The affected area of the abdomen becomes extremely tender, the muscles overlying it are rigid, peri- stalsis is arrested in the immediate vicinity of the lesion, and there is local tympany due to paresis and distention of the bowel most affected by the peritonitis. These factors account for the persistent consti- pation, and the nausea and vomiting. There is moderate elevation of temperature, leukocytosis, and a rapid, hard, wiry pulse. Acute Diffuse Peritonitis. — This usually is a sequal to the local form, but in cases of gastric or intestinal perforation may exist from the very first. All the symptoms are aggravated, and at the onset there often is marked shock. The pain is almost unendurable, con- stant, burning, or boring, and spreads widely over the abdomen. 1 The abdomen is of board-like rigidity throughout, and exquisitely tender. The patient's respiration is entirely thoracic, and the flat or even scaphoid abdomen moves not at all, even in deep inspiration. The patient lies on his back or side, with knees drawn up to relax the abdominal muscles. The constipation is absolute; no flatus is passed; peristalsis is entirely absent; vomiting is almost continuous, the patient regurgitating with little effort, every few minutes, small amounts of offensive prune-colored liquid. The symptoms of this stage pass almost imperceptibly into those of general peritonitis. The evidences of systemic poisoning become pronounced : there is more fever, greater leukocytosis, rapid, shallow respiration; the eye is bright, the expres- sion anxious, and the skin from being rough and dry becomes covered with a clammy moisture. The pulse grows very rapid, running, weak, and almost uncountable. The abdomen begins to become distended, rigidity lessens and then disappears; extreme distention finally develops. In the last stages tenderness and leukocytosis may be absent. Death is preceded by delirium, great restlessness, cyanosis, air hunger, sweating, subsultus tendinum, carphologia, and finally exhaustion. In rare cases of very severe infection, from the first, and not infrequently before death, the abdomen is soft, and there is diarrhea ("septic diarrhea"). The history of the case is of great value in diagnosing the primary lesion, but in peritonitis, as in most other acute lesions, much more reliance can be placed on physical signs than on the clinical history or the symptoms. It is well, therefore, to consider in more detail some of the physical signs which were enumerated above. Rigidity of. the Abdominal Wall. — This is due to reflex (involuntary) muscular contraction, brought about by stimulation of the spinal segments, whence arise both the nerves supplying the diseased abdomi- nal viscera (sympathetic fibers) and those which supply the over- lying muscles of the abdominal wall. So long as the peritonitis is 1 Peritonitis limited to the area occupied by the small intestine, and confined beneath the omentum, may run its course without any of the usual symptoms, so long as parietal peritoneum is nowhere affected; it is only the parietal peritoneum which has pain sense, according to Lennander, while that covering the viscera is insensitive. N.")S ABDOMINAL SURGERY IN GENERAL localized, the rigidity will remain local; spread of rigidity is an indica- tion that the peritonitis is spreading in a similar manner. In some cases the stimulus seems to alfeet the sensory as well as the motor nerve filaments of the abdominal wall, and hyperesthesia of the skin overlying the diseased viseus is present. Conversely, inexpert palpa- tion of the abdominal wall with a cold hand, or with fingers lacking in skill and gentleness, will stimulate these sensory cutaneous filaments, and will cause contraction of the abdominal muscles, and thus may make the careless examiner think that rigidity due to peritonitis is present, when he has himself caused this rigidity by his inexpert examination. The true reflex rigidity of the abdominal muscles can be recognized only by experience, and many physicians never learn to recognize it, owing to indifference and lack of practice. It is the tactus eruditus, the experienced touch, that counts, and the only way to gain this experience is to palpate with attention and care the abdomens of hundreds of patients with and without peritonitis. Palpation for muscular rigidity should be made with the finger tips, but with the utmost gentleness. Place the tips of all four fingers of both hands very lightly on the surface of the abdomen at some point far removed from the region suspected of disease and palpate the normal abdominal wall first. Do this gently and circumspectly in every case, and you will gain your patient's confidence, and further palpation will be easier. Having placed the fingers barely in contact with the abdomen, arrange them so that alternate pressure w T ith each hand will be in a direction parallel to the course of the fibers of the muscle you are about to palpate. Then, without at any time raising your fingers from the surface of the abdomen, and with extreme gentleness, bear down for a fraction of a second first with one hand and then with the other. Repeat this manipulation a number of times before passing to another region of the abdomen, and accom- plish this transfer of your hands without raising them from the abdomi- nal wall, so as to spare the patient the shock of a new contact. Having reached another region, repeat your manipulations here, and so on until the entire abdomen has been covered. This should include the rectus muscle of each side both above and below the umbilicus, and the oblique muscles not only in the iliac and hypogastric regions, but in the flanks and in the loins as well. In this way you will very quickly learn the different sensation conveyed to the palpating finger by a rigid or a normally relaxed muscle. Do not be in a hurry, and be more gentle than you think anyone else can be. • This is not at all the same kind of palpation that is desirable when one is seeking to discover a mass within the abdomen. It is this latter form of palpation that most physicians attempt when they seek for rigidity, with the result that they usually fail to recognize its presence. Here the hand is laid flat on the belly, and by gentle and rocking pressure alternately with the heel of the hand and the pulps of the fully extended fingers, the examiner seeks to depress the abdominal wall until the underlying structures can be palpated. PERITONITIS 859 If rigidity is present, it is a clear indication that some degree of peritonitis exists. Slight rigidity usually indicates a mild grade of peritonitis so long as the abdomen is not distended; and marked rigidity indicates peritonitis of much more serious import. So, too, the extent of the rigidity on the surface of the abdomen is a fair indi- cation of the area of peritoneum involved. But if the patient is excessively fat, or if the muscles are very much atrophied, no rigidity may be palpable. Tenderness on palpation is of almost equal importance with rigidity. Cutaneous hyperesthesia, which was referred to above, is described as superficial tenderness; what is to be studied now is known as deep tenderness. When this is exquisite it usually signifies pus under ten- sion, whether the pus is localized as an abscess or free in the belly as in diffuse peritonitis. Rigidity scarcely ever is present without tenderness, though the latter may not be elicited by very gentle palpation in the case of a very muscular or extremely rigid abdominal wall. But tenderness frequently persists after rigidity has given way, as in time it usually does, to abdominal distention. This per- sistence of tenderness is a very important sign, often indicating that gangrene has occurred in the organ diseased. Palpation through the rectum often is of great value, in discovering tenderness in the recto- vesical pouch. Percussion of the abdominal wall should succeed palpation. It should be done with the utmost gentleness, and not over any area which is very tender. It is possible by percussion, much more safely than by palpation, to determine the presence of an abscess, or of an inflammatory mass due to adherent omentum. These will give a dull note on percussion, and will be surrounded by areas of tympany. The existence of an effusion which is settling in the pelvis or the loins may also be ascertained by percussion. Finally, auscultation should not be neglected. In cases of diffuse peritonitis the abdomen is quiet; no peristaltic sounds are heard unless at a great distance from the focus of infection. Distention of the abdomen is a late sign of peritonitis, and of bad prognostic import. A diagnosis which is delayed until the abdomen is distended is of little use. The onset of distention occurs pari passu with the disappearance of abdominal rigidity. The distended abdomen may be tense from tympanites, but it never is rigid. The distention is the result of two factors : the first is paresis of the intes- tinal nerves and of those supplying the abdominal wall, as a result of poisoning by the absorption of toxins; this relaxes the muscular tunic of the intestines and makes the belly wall soft. The second factor causing distention is the occurrence of fermentative and putre- factive changes within the intestines, producing tympanites. The constipation which has already been noted, and the distention of the abdomen which is here discussed, are the consequence and not the cause of the patient's illness. He is not ill because his abdomen is distended, but his abdomen is distended because he is ill. 860 ABDOMINAL SURGERY IN GENERAL Differential Diagnosis.— Peritonitis must be distinguished from the colic of acute gastroenteritis, from pleurisy and pneumonia, and from intestinal obstruction. Other conditions with which it is sometimes confounded will be discussed in connection with the several lesions which may cause peritonitis. Acute G astro-enteritis. — In mild cases this is attended by sudden, sharp, stabbing pain, which varies in intensity from time to time — intestinal colic. The pain is relieved by pressure on the abdomen. There is no tenderness, no rigidity, no change in pulse or tempera- ture, and no leukocytosis. Vomiting is unusual, but if it occurs it is not repeated when the stomach has been emptied. In severer cases there is vomiting, and general abdominal pain and tenderness. There may be fever, with increase in the pulse rate, but there is no rigidity of the belly wall; and there is diarrhea, which is rare in peritonitis. In cases where doubt remains after a thorough examination, visit the patient again after an interval of three or four hours, and keep him in constant surveillance until the nature of the disease is manifest. Pleurisy and pneumonia often are attended by pain referred to the abdomen, and in children this may be the only complaint. There is no nausea or vomiting; only slight rigidity of the upper abdomen, and only superficial tenderness (cutaneous hyperesthesia) are present. There is no deep tenderness. If the chest were examined in all cases of acute abdominal disease, whether the presence of pulmonary complications be suspected or not, the surgeon would be saved many an error and the patient an unnecessary operation. Even if the pul- monary lesion is so deep-seated as to give no distinct physical signs, a diagnosis of peritonitis usually may be excluded by the absence of physical signs in the abdomen, and by the presence of symptoms, such as rapid respiration, dyspnea, slight cyanosis, etc., which are charac- teristic of thoracic disease. Intestinal Obstruction frequently is complicated by peritonitis in its later stages, just as peritonitis may be followed at any time by intestinal obstruction. A differential diagnosis often is impossible when either condition has existed for some days, because then both conditions may be present. But at the outset the two affections pre- sent very different symptoms and physical signs. In intestinal obstruction, attentive study of the patient's history usually will reveal a cause for the obstruction in some previous attack of peri- tonitis. The attack of intestinal obstruction begins with colicky pains, and these are more or less relieved by pressure on the abdomen. The pain is intermittent, and between the paroxysms the patient may feel quite comfortable and may appear very well. In peritonitis the patient is decidedly ill from the very commencement of the attack, and there are no remissions. In obstruction the intervals between the pains rapidly shorten, but the pain does not for a long time become constant; in peritonitis it is constant from the beginning. In obstruc- tion there is absolute constipation, as in peritonitis, and no flatus is passed by rectum; vomiting occurs early, is persistent, and soon PERITONITIS 861 becomes of the projectile type (p. 937), with rather long intervals between the attacks of vomiting. In peritonitis, on the contrary, the patient vomits oftener, the vomitus is small in quantity each time; and the vomiting is not projectile but regurgitant in type (p. 857). In obstruction, as in peritonitis, the contents of the upper bowel are vomited after the stomach has been emptied ; but in obstruc- tion the rejected matters finally become fecal, which never is the case in peritonitis. In obstruction there is no rigidity of the abdominal wall, and distention occurs early — often within a few hours. Rigidity is the most valuable early sign of peritonitis, but distention seldom occurs until after the lapse of eleven or twelve hours. The disten- tion of obstruction may at first be localized to the area immediately above the obstruction. Auscultation in obstruction detects extremely active and disordered peristalsis; sometimes peristaltic waves can be clearly seen through the distended belly wall. In peritonitis the abdomen is silent. In obstruction the temperature is not elevated, while in peritonitis it almost always is above normal. Leukocytosis is rare in obstruction, unless strangulation has occurred; but in peri- tonitis it is the rule. In both affections a steady increase in the pulse rate occurs, and is a most valuable sign. Treatment. — This is not the place to discuss the prevention of peri- tonitis; but that it may be prevented often by prompt operation will be pointed out time and again in the following pages. What concerns us here is how to treat the patient after peritonitis has devel- oped; and I here exclude from consideration pelvic peritonitis in connection with gynecological affections. 1. In the early stages, before the peritoneal inflammation has become diffuse, surgeons are in perfect accord in recommending immediate operation, to remove the source of infection, and thus prevent the development of diffuse peritonitis. This is a much surer and far safer course to pursue than to trust to the unaided powers of nature to isolate and overcome the infection. If the source of infection is the appendix, it can be entirely removed; if it is a perforation of the intestine, it can be sutured, and the further discharge of infectious material prevented; if there is a lesion which cannot be treated in either of these ways (as in acute pancreatitis) the surgeon can at least isolate the source of infection by gauze packs, providing drainage, and thus preventing further intra-abdominal contamination. The details of operation, which should be completed quickly, will be described in connection with the various lesions which cause peritonitis. 2. When the peritonitis is in the diffuse stage surgeons are divided into two camps. There are those who think, with Ochsner, that it is safer to undertake no operation in cases of spreading peritonitis, but to trust to such measures as are detailed below to aid nature in isolat- ing the infection, and to wait until a residual abscess has been formed before instituting drainage. Neither Ochsner nor anyone else, how- ever, ever claimed that the patient could be cured without any opera- tion; the only question is whether the operation shall be immediate 862 ABDOMINAL SURGERY IN GENERAL or postponed. Then there are other surgeons who believe, so long as the evidences of toxemia are not very marked, and so long as the degree of abdominal rigidity is greater than its distention, so long, in short, as it is evident that the patient is still reacting to, the infection, that throughout this period it will be more to the patient's ultimate advantage to institute drainage as soon as possible, and at the same time to treat the focus of infection by excision, suture, or tamponade, provided this secondary part of the operation can be carried through without unduly prolonging the procedure or entailing too great shock. My own belief and my practice, founded on a not very limited experience with all forms of peritonitis, is that operation under these circumstances is not only justifiable but imperative. Ochsner and others limit the time within which immediate operation is to be done to the first thirty-six hours from the beginning of the illness. No doubt this is a convenient rule of thumb, but one patient will reach at the end of twelve hours a stage of peritonitis which will not be reached by another for two or three days. So that I think it is safer to decide the question in favor of or against immediate operation not on the mere lapse of time, but, as I have done above, on the patient's physical condition. Especially valuable, I believe, is the persistence of rigidity or the onset of distention. Statistics might be quoted to support the views of surgeons on both sides of this question; but the fallacy of trusting to such figures is obvious. Only those who open the abdomen in all these cases know the state of affairs inside; those who do no operation give statistics founded on impressions, not on visual inspection of the peritoneum, and they are quite as likely to reckon as non-operative survivals, patients whose peritonitis never became widespread, as the really serious cases. 3. When diffuse peritonitis has so far advanced that rigidity has disappeared, and marked distention is present, the patient being very toxic and perhaps delirious, and constantly regurgitating the upper intestinal contents, almost all surgeons are in agreement with Ochsner that operation is more apt to hasten death than to give the patient a chance of recovery. In these cases, however, a well defined course of treatment must be pursued, and occasionally even a seemingly moribund patient will improve, one or more abscesses will form, and if these are drained at a propitious time recovery may yet ensue. This treatment, about to be described, is known as the Ochsner treat- ment of peritonitis, because so warmly espoused by this surgeon ever since 1900. It should be adopted in every case of peritonitis so soon as the diagnosis is made, whether or not operation is to be undertaken. If operation is to be done, this treatment will be of short duration, but it will aid materially in securing a good result; and the same treatment always is continued after operation until the peritonitis subsides. The most important features of this non-operative or preparatory treatment are: (1) abstinence from everything by mouth (hence it sometimes is called "starvation treatment"); (2) instillation of fluids by the rectum; and (3) the head high position. PERITONITIS 863 The patient is placed in bed either in Fowler's position (1900), lying flat on the back, and with the head of the bed raised twelve to fifteen inches from the floor; or else in the so-called exaggerated Fowler position, that is, in a semi-sitting posture in the bed (Fig. 889) . This aids the gravitation of fluids to the pelvis and keeps them away from the subphrenic region, whence absorption is so rapid, thus dimin- ishing toxemia; and it lessens the chances of pulmonary complications. The patient is very apt to slide down in the bed unless supported. A special chair-like bed frame is the best support, but in emergencies a sand-bag may be passed beneath the mattress below the buttocks, or the patient may sit in a sling formed by tying the ends of a sheet to the two upper posts of the bed. Fig. 889. — Exaggerated Fowler position. One week after suture of a duodenal per- foration. Note slight elevation of reservoir for enteroclysis solution. Episcopal Hospital. Nothing whatever is given by mouth, not food, not water, not ice; nothing is permitted. Anything taken into the stomach rouses peris- talsis, and this spreads infection more widely in the peritoneum. Moreover, it increases nausea and provokes vomiting. The only thing ever to be introduced into the stomach is a stomach tube, which should be used every six hours or less often, to relieve the stomach of regurgitated intestinal contents. A patient who has once experienced the relief which lavage of the stomach affords under these circum- stances is only too anxious to have the procedure repeated as soon as he feels his stomach refilling. To replace the fluids lost by intraperitoneal effusion, the patient is given saline solution or tap water by the rectum, as already described in Chapter V. This does not excite peristalsis, is quickly absorbed, allays thirst, restores blood-pressure, dilutes circulating toxins, and after operation seems to promote drainage from the wound. No drugs are required as a rule. Stimulants, such as camphorated oil, atropin, digitalis, or strychnin, seldom are indicated and do not seem to have much effect. Morphin very rarely is required; the pain soon ceases if nothing is taken by mouth and if nausea is controlled by lavage. Unless there is pain, sleep is not much interfered with. But I do not believe that morphin does any harm, and there is no reason why it should not be administered if it promotes the patient's comfort. 8G4 ABDOMINAL SURGERY IN GENERAL This treatment should be continued until the peritonitis subsides. This period seldom is longer than three days, but it may be a week. The more absolute the treatment from the first, the sooner will its effed become manifest. Under this form of treatment many patients who would die under any other form of treatment, or after operation, will survive the peritonitis, and as the abdomen gradually softens, the surgeon will find evidences of one or more collections of pus. Very rarely a patient will recover from what appears to have been a diffuse septic peritonitis without effusion; when the abdomen is opened later to remove the cause of the disease, few adhesions and no pus may be found. Other patients will die in spite of this treatment; but it is not too much to say that the Ochsner treatment is the only form of treatment which gives these bad cases of peritonitis even a fighting chance. After the peritonitis subsides the patient is still far from convalescent. As the abdomen becomes softer auscultation will detect commencing peristalsis, and it will be painless; flatus will be passed, and the bowels may move spontaneously or by simple enema. At this time small amounts of liquid food may be allowed by mouth; but if this is attempted too soon it will cause vomiting, rouse active peristalsis, break up newly formed adhesions, rupture an abscess which is just localizing, and perhaps cause intestinal obstruction. The patient must be very carefully nursed, and progress must be sure rather than rapid. When the abdomen has become entirely soft in parts removed from the seat of disease, when the bowels are acting normally, and the patient is approaching convalescence, then it is time to drain the abscesses which have formed. If these are neglected, and intraperi- toneal rupture occurs, the patient seldom survives even immediate drainage. Residual Peritoneal Abscesses. — So long as an intraperitoneal abscess is present, the patient is in constant danger. No delay should be permitted in instituting drainage when once it is ascertained that the patient can withstand the intervention. The abscess should be incised and drained, if possible without opening the uninvolved peritoneal cavity; nothing else should be attempted. Do not make any search for the cause of the peritonitis, but be content to secure drainage. Make sure, however, that you find all the abscesses. Plate XIV, Fig. 5, shows the most frequent sites in which residual abscesses form. In most cases a secondary and more formal operation is indicated some weeks or months later, to complete the cure by removal of the diseased organ (appendix, gall-bladder), closure of a fecal fistula, etc. Pelvic abscess sometimes may be drained by puncture through the rectum, or through the vagina. Unless the anterior rectal wall bulges and fluctuation is unmistakable it is safer usually to make a supra- pubic incision. This always should be preferred whe.i there is also an iliac abscess; and always after opening an iliac abscess the surgeon should make sure that a separate pelvic abscess is not overlooked. A lumbar abscess is drained by an incision in the flank or loin. PERITONEAL ADHESIONS 865 Subphrenic abscess is of great importance, because, though less frequent, it is so often overlooked. It may occur either (1) to the right or (2) to the left of the falciform ligament of the liver; or (3) behind the right coronary ligament; or (4) in the lesser peritoneal cavity. Abscesses on the extraperitoneal surfaces are rare, and usually are secondary to hepatic abscess, in connection with which they are dis- cussed (p. 991). Of the four sites of subphrenic abscess mentioned above, that most frequently the seat of suppuration is the space behind the right coronary ligament and extending around its free margin to the subhepatic space. Most abscesses in this situation are secondary to appendicitis; the abscess tends to point through the lower intercostal spaces, except when intraperitoneal or intrapleural rupture occurs. Most of the abscesses in association with the left lobe of the liver in front of the left coronary ligament are due to gastric or duodenal lesions; those in the lesser peritoneal cavity may follow gastric or pan- creatic lesions; while those far to the left are rare and generally sec- ondary to splenic affections or are the result of diffuse peritonitis. The diagnosis of subphrenic abscess is based: (1) On the history of the illness, indicating a possible cause for the formation of an abscess in the subphrenic region; perforated gastric or duodenal ulcers cause almost one-third of these cases, appendicitis over one-sixth, hepatic affections about one-sixth, and the remaining one-third are due to miscellaneous affections (Barnard, 1908). (2) On abdominal signs and symptoms of an abscess — dulness, tenderness, mass, possibly rigidity. (3) On thoracic signs and symptoms, especially slight pleural frictions or effusion, or upward displacement of the lung with increased dulness over the liver. (4) On general signs and symptoms of suppuration — fever, leukocytosis, chills and sweats, and especially progressive emaciation. X-ray study should not be neglected. In the differential diagnosis from thoracic affections, Hoover (1913) measures the respira- tory excursion at the epigastric angle: if the collection of pus is sub- phrenic, the excursion of the costal margin is increased on the affected side; while if the pus is above the diaphragm and the latter is depressed to a straight line (not beyond) the respiratory excursion is diminished, because then the diaphragm acts to better mechanical advan age against the intercostal and serratus muscles which tend to pull the ribs up and out. The treatment of subphrenic abscess involves drain- age by operation; nearly every patient not operated on dies. In most cases of right-sided abscess the operation is by thoracotomy, as in operations for abscess of the liver (p.. 992). Rarely an abdominal incision is proper. The general mortality is about 37 per cent. Peritoneal Adhesions. — This condition, which has been referred to (p. 853), often is described as chronic peritonitis; it is rather the result of a former peritonitis. There is no inflammatory process. The adhesions which developed during the existence of active inflam- mation remain, and by their interference with peristalsis cause symp- toms of which pain and obstipation are the most constant. The drag of adherent structures on the parietal peritoneum, the mesenteries 55 866 ABDOMINAL SURGERY IN GENERAL or the female genitalia may render life miserable, and the patient may become an invalid. Purgation is apt to rouse such active peristalsis as to increase pain, and sometimes causes intestinal obstruction; and mil ss the bowels are opened normally the usual symptoms of coprostasis are present. There are other cases in which peritoneal adhesions develop as the result of such an attenuated infection that the origin of the affection cannot be traced. Such, it is taught by some, are many cases of Lane's kink, of Jackson's membrane, and other forms of peritoneal disease which have been recognized only within recent years, (p. 951). The surgeon is powerless to prevent the formation of adhesions in cases of acute peritonitis, and, indeed, often hails them with delight as aids to the patient's immediate recovery; but he is careful when he opens the abdomen in other cases to avoid manipulations which will encourage the formation of useless and disabling adhesions. He does not handle the parts not concerned in the operation; he with- draws from the abdomen as little of the intestine as possible, and prevents it from becoming dried while it is exposed; he uses only hot moist gauze packs within the abdomen, and inserts and removes them with gentleness; and he is careful to cover all denuded serous surfaces by inversion with sero-serous sutures or by stitching the omentum over the defect. Various attempts have been made to prevent peri- toneal adhesions by the use of oily substances, but without much success. In laboratory work, however, Saxton Pope (1914) found that a 2 per cent, solution of sodium citrate in a 3 per cent, (hyper- tonic) sodium chloride solution possesses great power in preventing peritoneal adhesions. Treatment. — In the treatment of peritoneal adhesions, it is only by experience that a surgeon can learn when to let well-enough alone. If the adhesions are broken up the new adhesions that form may be still more disabling, in spite of patient suturing and omental grafting. Unless the adhesions produce symptoms it is better, as a rule, not to interfere with them. Of course, if intestinal obstruction occurs, this must be overcome. Pneumococcic Peritonitis. — This occurs oftenest in children, par- ticularly girls under the age of six years. Most cases are secondary to a pneumococcic infection of the lungs; but the primary focus may be situated elsewhere, as in the middle ear or the female genitalia. The infection probably is more often enterogenous than hematogenous. The physical signs are those of acute diffuse peritonitis (p. 857), but the patient's general condition is not so much affected as when the peritonitis is due to the ordinary organisms, and the death rate is much lower. In most cases there is a good deal of effusion, and this usually becomes encysted within the course of a few days or a week. It should then be opened and drained. Tuberculosis of the Peritoneum. — The tubercle bacilli may reach the peritoneum through the blood-stream, from the mesenteric lymph nodes, directly from the intestinal tract, or from the Fallopian tube. TUBERCULOSIS OF THE PERITONEUM 867 In almost all cases there are other tuberculous lesions elsewhere in the body. Tuberculosis of the lungs frequently preexists, and in a large proportion of adult patients this will develop later if not already present at the time the signs of peritoneal tuberculosis are noted. As a complication of Pott's disease of the spine, tuberculosis of the peritoneum is not very rare. As a part of a general miliary tuberculosis (blood infection), tuber- culosis of the peritoneum has no surgical interest. The cases of most surgical importance are those in which a removable focus of tuber- culosis exists in the abdominal cavity. This is most often the Fallo- pian tube in women, and the vermiform appendix in men. In children tuberculosis of the mesenteric lymph nodes is more frequent. In many cases a tuberculous ulcer of the small intestine is the point of peritoneal infection. Here, as in the appendix, the tubercle bacilli penetrate the thinned floor of the ulcer, and usually without a macroscopical perforation, escape into the peritoneal cavity, which becomes widely covered with miliary tubercles. These feel like minute shot or sand- like particles, projecting from the serous surfaces. They are yellowish- gray in color. The same course of events occurs when the infection arises in the Fallopian tube, whence it may escape through the abdomi- nal ostium, or by a minute perforation. It is not improbable (Baum- gartner) that the lesion is not really primary in the Fallopian tube, but that this has been infected from its peritoneal surface; but at all events, the tuberculous process is most active here for the time being, presumably because the bacilli have found a fertile soil for develop- ment. Tuberculosis of a hernial sac is not very rare. Usually it is secondary to some intra-abdominal focus. The changes in the peritoneum are those characteristic of other forms of peritonitis, only very much milder in degree. Usually there is a moderate amount of exudate formed. This may be clear, yellow- ish, greenish, turbid, or even purulent; not seldom it is bloody. When the disease has lasted for many months, adhesions form, and may be very extensive, causing kinks, and leading to intestinal obstruction. The omentum becomes thickened and forms lumpy masses which often can be felt through the abdominal wall. As the omentum and mesentery both may become retracted from thickening and tuberculous infiltration, these masses usually are situated in the left hypochon- drium. The intestines lie mostly below and to the right, and their tympanitic state adds to the distention of the abdomen. Among the adherent intestinal coils small collections of puruloid matter may occur. Rarely there is a large encysted collection of fluid. Caseous changes in the mesenteric lymph nodes are a late occurrence. The intestinal walls become very friable, and internal (entero-enteric) fistula may form; occasionally an external fecal fistula develops spontaneously. In infants a tuberculous abscess may discharge through the umbili- cus, as in a case under my care some years ago at the Children's Hospital. 868 ABDOMINAL SURGERY IN GENERAL Symptoms and Diagnosis. — The disease is one of early adult life, and of early childhood. Before five years of age it is not infrequent. It is rare after thirty-five or forty years. Most cases occur in women between eighteen and thirty years of age. Tuberculous peritonitis may begin rather acutely, or it may be chronic from the beginning. In the former case, after a few weeks of malaise and gastrointestinal derangements (colics, attacks of con- stipation and diarrhea, nausea) the first thing to attract the patient's attention is enlargement of the abdomen, due to serous effusion. This may persist unchanged for months, but usually there are times when the abdomen seems to become smaller. As time goes on, adhe- sions begin to form, and if spontaneous recovery takes place (and it is not unknown) the abdomen becomes softer, the bowels act normally, the general health improves, and the patient convalesces. Or an encysted collection of fluid may form, and be cured by evacuation. In cases which are chronic from the beginning the prodromal symptoms may have existed for many months; there rarely is much effusion; often none can be detected. Omental masses may be palpable, and they may change their site and their form from time to time, in the course of weeks or months, from no appreciable cause. Usually the subjective symptoms are slight, unless the adhesions cause intestinal obstruction, or secondary infection produces hectic fever. So long as the patients lie quiet in bed and are carefully nursed little change in their condition may be appreciable from month to month (Fig. 890). Fig. 890. — Tuberculosis of the peritoneum with effusion. Episcopal Hospital. The diagnosis of peritoneal tuberculosis will be strengthened by finding any tuberculous focus elsewhere in the body. Tuberculosis of the bones usually will be easily detected; but examination should also be made of the lungs, testicles, prostate, seminal vesicles, and kidneys, as incipient lesions in these structures often are overlooked. Treatment. — The general hygienic treatment already recommended (p. 80) for patients with tuberculosis is most important in cases of tuberculous peritonitis. A fair proportion of cases, as pointed out by Fenger (1901), tend toward spontaneous recovery. If improvement under general hygienic treatment is progressive, no operation is indi- cated. In other cases, however, effusion persists; the patient does not gain ground, and may grow progressively worse. In these patients, OPERATIONS ON THE ABDOMEN 869 the propriety of operative interference must be considered. Operation has been found, empirically, to be of most value in cases with effusion. Tapping and aspiration of the fluid never have produced as good results as formal incision and evacuation. Probably this is for the same reasons that incision and evacuation of cold abscesses in con- nection with joint tuberculosis are more successful than is aspiration; the peritoneal effusion of tuberculosis is similar to a cold abscess elsewhere, and it is important to prevent the occurrence of secondary infection, either from the surface of the body or from within the intestinal tract. The abdomen should be opened in women, as if for an operation on the uterine appendages; in men, over the appendicular region; as these are the most frequent sites of primary foci. When- ever possible, without inflicting damage on the intestines, a tuber- culous appendix in men should be removed ; in women not only should one or both tubes be removed if affected, but a diseased appendix also. If adhesions are present the utmost caution should be used if any attempts to separate them are made. It is very easy to tear a hole in the intestine, and very difficult to repair it. Even if the intes- tinal sutures can be made to hold, union very seldom occurs, and a fecal fistula is the nearly inevitable result. Only if the bowel has been torn should the abdomen be drained. In other cases it should be closed tightly, to prevent any possibility of secondary infection from the surface of the body. In general it may be said that the immediate mortality following operation is very small, if proper precautions are taken against injuring the intestines. The ultimate prognosis is better when some focus such as the appendix or tube has been removed. Cure occurs much oftener in the ascitic than in the dry cases. If the patients are traced, nearly half the number will be found to die within a few years, and there will be many recurrences. But the prognosis is better with than with- out operation, and even a few years of comparative freedom from discomfort are not to be despised. OPERATIONS ON THE ABDOMEN. Laparotomy, or Abdominal Section, is a general term used to describe any operation which involves opening the peritoneal cavity. 1 Definite operations are described more accurately by specific names, such as gastro-enterostomy , cholecystectomy, entero-anastomosis, etc. These terms will be defined in the proper place. They are sufficiently descriptive of the operation when they stand alone, and it is not necessary to complicate them by the prefix laparo- as is done by some surgeons ; though all such operations include that of laparotomy. 1 Laparotomy is derived from hanapa the Greek word for the soft parts between the ribs and pelvis. Celiotomy is used as an equivalent by some writers, but is considered less correct, as the Greek term itoiTda from which it is derived was used for a cavity of any kind— a joint, the heart, as well as the abdomen. 870 ABDOMINAL SURGERY IN GENERAL Abdominal Incisions. In planning an incision through the abdomi- nal wall, the surgeon must have in mind not only ready and sufficient exposure of the abdominal viscera concerned in the operation, but also must endeavor to inflict as little injury as possible on the structures through which he cuts. There are three things to be considered in this connection — the bloodvessels, the muscles with their aponeuroses, and the motor nerves. The bhodsupply is so free that injury or ligation of any one of the main arterial trunks entails no danger of sloughing; but such injury should be avoided whenever possible because time is lost in checking the hemorrhage, and the w r ound is more liable to become infected if not kept dry during the operation and if deprived of proper blood supply while healing. The deep epigastric artery is the most impor- tant; the superior epigastric is much smaller; and the deep circumflex iliac is not often encountered. Muscles should be split in the course of their fibers whenever possible. Transverse section of muscle fibers is to be avoided; when this is unavoidable, the muscle must be repaired by suture. The resulting cicatrix in the muscle will resemble one of the linese transversa? in the rectus abdominis muscle; this will not impair much the muscle's con- tractility, but it complicates the operation and is undesirable. The fibers of the three oblique muscles of the abdomen cross each other's course at various angles, and transverse division of one or two of these muscles can be avoided only in small incisions, such as the gridiron incision of McBurney (p. 872), where each muscular layer is split in the direction of its fibers. Incisions through the rectus muscle can be made of any length by splitting its fibers parallel to their course. An incision through muscular tissue is preferable to one through the linea alba or the linea semilunaris, because where several layers of tissue are traversed, as in cutting through a muscle and its sheath, much firmer union can be secured by suturing the wound in several layers, than where only one aponeurotic structure is avail- able. The motor nerves are the most important of all structures to preserve, since they are so small that they cannot be sutured if cut, and the muscles supplied by them are paralyzed, and permit marked bulging of the abdominal wall in spite of accurate repair of muscular and aponeurotic structures by suture. These nerves are branches of the lower intercostals (6th to 12th) and they run more or less transversely forward from the intercostal spaces between the transversalis and internal oblique muscles, giving off branches to these and the external oblique; finally they perforate the posterior sheath of the rectus muscle and supply it by numerous fine twigs. Any incision which will divide these nerves is to be avoided whenever possible. An incision through the semilunar line will cut the nerves supplying that portion of the rectus muscle between the incision and the linea alba. Hence any longitudinal incision, unless quite short, should be made as near the linea alba as possible. If an incision is planned for any other OPERATIONS ON THE ABDOMEN 871 part of the abdominal wall, it should, so far as possible, run parallel to and between two of the motor nerves. Section of nerves, as mentioned above, results in bulging of the abdominal wall from muscular paralysis (Fig. 891). This may entail great disability; and unlike incisional hernia (p. 824), with which it should not be confused, it cannot be cured by operation. All that can be done is to apply some form of abdominal support, as in cases of pendulous abdomen (p. 953). For operations on the stomach, intestines, and female generative organs surgeons usually employ a longitudinal incision splitting the fibers of the rectus muscle close to the linea alba on the right or left, » i I * • Fig. 891. — Bulging of right side of abdomen from paralysis of motor nerves as result of long incision in right] rectus muscle. Episcopal Hospital. Fig. 892. — Incision for perforated duo- denal ulcer. Cicatrix 8 cm. long. Supra- lj A pubic stab wound for drainage. Episcopal Hospital. whichever appears to give readiest access to the seat of disease. An epigastric incision of course is used in stomach operations (Fig. 892), and one in the hypogastrium for pelvic operations. For operations on the small intestines the incision usually is made to the left of the median line, just below the umbilicus; thus it may be extended upward past the umbilicus without injuring the round ligament of the liver, which lies to the right. For operations on the gall-bladder the usual incision is a longitudinal one through the outer third of the right rectus muscle, from the costal margin downward for four inches; if more room is needed the incision is extended obliquely upward along the costal border to the ensiform process (Mayo Robson's incision) (Fig. 982). Though this incision 872 ABDOMINAL SURGERY IN GENERAL necessarily divides a number of motor nerves the resulting disability is much less than when an incision of similar length is used in the lower abdomen, where the tension is greater. For operations on the appendix a lateral incision is employed. If only a small incision is required, the muscle-splitting or gridiron incision, introduced in 1893 by McBurney, is preferred by many operators. 1 It is centered over McBurney 's point, which is "from one and a half to two inches" (about 4 cm.) from the right anterior superior iliac spine, and on a line from that point to the umbilicus. The skin incision is made parallel to Poupart's ligament, and the aponeurosis of the external oblique is divided in the same direction, parallel to its fibers. The fibers of the internal oblique are thus exposed. They run nearly at right angles with the previous incision, and are split in this direction. The fibers of the transversalis at this point run in the same direction as those of the internal oblique, and are split with them in the direc- tion of their course. The peritoneum is opened by an incision parallel to that through the skin. This gridiron incision cannot well be made more than 8 to 10 cm. long. Many surgeons expose the appendix by a longitudinal incision splitting the outer fibers of the right rectus muscle; this has been called Deavers incision; he calls it the "simple incision." Or, after opening the anterior sheath of the rectus and displacing the fibers of this muscle toward the median line (passing around the lateral border of the muscle without splitting its fibers), the posterior sheath of the rectus, together with the trans- versalis fascia and peritoneum, may be incised, as proposed by Battle in 1895, by Jalaguier and by Kammerer in 1897, and by Lennander in 1898. Both this and Deaver's incision necessarily divide a number of nerves to the rectus muscle unless the incision is short. For this reason I prefer the transverse incision of G. G. Davis (1906), which is described at p. 906. Making the Abdominal Incision. — The skin and superficial fascia are divided down to the aponeurotic layer (external oblique aponeurosis, anterior sheath of rectus). Bleeding-points are clamped. The aponeu- rotic layer is then divided throughout the length of the incision. Do not forget that in the lower abdominal wall the aponeurosis of the external oblique does not blend with the rectus sheath at the semilunar line, but passes as a separate structure for some distance toward the median line before blending. Therefore an incision in the lower abdo- men just to the median side of the semilunar line must divide the exter- nal oblique aponeurosis and the rectus sheath as separate structures before the muscular fibers of the rectus will be exposed. When the muscular fibers are exposed they are to be split parallel to their course. This is best done by the handle of the scalpel, followed by the fingers of the surgeon. In the hypogastric region the rectus fibers should be split from below upward, and in the epigastric region from above downward, so as in each case to brush aside rather than break off the 1 It had been used previously by L. L. McArthur. OPERATIONS ON THE ABDOMEN 873 branches of the epigastric arteries which run in the directions named — from the epigastrium down, and from the hypogastrium up. When the transversalis fascia and peritoneum are exposed they should be caught up in two forceps, applied about a centimeter apart, and should be drawn away from the underlying viscera; then the surgeon should divide these structures cautiously, with the flat (not the point) of the knife, held sideways (Fig. 893) . If the peritoneal cavity is not opened at once, another hold should be taken of the intervening tissues, and thus the surgeon should cut down layer by layer until the peritoneum has been opened. As soon as this is accomplished, the scalpel is laid aside, and the peritoneal opening is enlarged by a blunt pointed scissors passed on the finger as a guide. The peritoneum is opened to the full length of the abdominal wound. Fig. 893.— Incising the parietal peritoneum. Fig. 894. — Suturing parietal peritoneum (Deaver and Ashhurst.) Closing the Abdominal Incision.— The cut margins of the peritoneum (including the transversalis fascia, and where present the posterior sheath of the rectus) are caught in hemostats, and drawn into the wound until visible. The abdominal viscera are kept from protruding by the insertion of a gauze pack. Then the peritoneum is closed with a continuous catgut suture, applied so as to evert the peritoneum into the wound (Fig. 894). This brings endothelial surfaces together, favors rapid union, and lessens the chances of omentum becoming adherent to the abdominal surface of the cicatrix. Before the last peritoneal suture is drawn tight, the gauze pack is removed. S7I BDOMINAL SURGERY tN GENERAL If the wound is large or if the patient is very fat, several "relaxa- tion" or "splint sutures" are next inserted; these are interrupted sutures of non-absorbable material, silkworm gut, linen, or wire. Each splint suture is passed from the skin surfaee down through all structures of the abdominal wall to the peritoneum (which has already been sutured) across the wound, and out through all structures of the abdominal wall on the other side, to the skin surface. None of these sutures is tied at this time. Fig. 895.— The "splint sutures" have been inserted, and their ends are clamped, anterior sheath of the rectus is being sutured. (Deaver and Ashhurst.) The Next the aponeurotic layer is sutured with a continuous stitch of chromic catgut (Fig. 895). The split muscle fibers fall together naturally and do not require a separate suture. If there is much subcutaneous fat, a continuous suture of plain catgut may be used to appose it. Finally the splint sutures are pulled taut and tied, not with very much tension, but just tight enough to obliterate all dead spaces in the wound. A few superficial skin sutures may be required to secure accurate closure. If the patient is not fat, and the wound small, the splint sutures may be omitted. In wounds which may become septic (many drained wounds) it is safer to use interrupted sutures throughout, so that should one stitch become infected it may be removed without destroying the entire row of sutures. General Technique of Abdominal Operations. — There are so many technical points that are common to different abdominal operations, OPERATIONS ON THE ABDOMEN 875 that it is convenient to describe them together. I shall consider here preparation for operation, and after care; as well as intestinal localization, methods of intestinal suture, intestinal resection, and entero-anastomosis. In all abdominal operations the parts especially concerned in the manipulations are walled off from the rest of the viscera by gauze "packs" or "pads." These are made by stitching together a number of layers of gauze (four to six thicknesses is sufficient) so as to give the packs a certain bulk, and prevent ravellings from escaping into the wound. These packs are made of convenient sizes; for a major laparotomy, they should be about 20 by 35 cm.; for a minor lapa- rotomy they may be much smaller. Most important is it not to allow one of the gauze packs, or a sponge, or an instrument, to become lost in the wound. Such accidents sometimes occur, but with care and system are avoidable in almost all cases. It is best to have a tape attached to one corner of each pack, and to leave this tape hanging out of the wound, clamped by a hemostat; if a piece of gauze never is placed entirely within the abdomen, it is not likely that it will slip in unper- ceived. Some operators employ a continuous roll of gauze, which is unrolled only as it is inserted into the abdomen. These packs, and all gauze employed within the abdomen, should be used only after they have been moistened in hot saline solution. Preparation of Patient for Abdominal Operation. — Unless immediate operation is demanded, as in emergency cases, the preparation of the patient should begin at least twenty-four hours before the time set for the operation. It is well that he should learn to pass his urine while lying on the flat of his back (Atlee); it may save him much dis- comfort after operation. Other general preparation is the same as for any major operation. The intestinal tract should be well cleared by a purge and this should be administered sufficiently early on the day before the operation for it to act before night, so that the patient's sleep may not be disturbed. On the day of operation, and at least two hours before the time set for operation, the patient should be given an enema of warm soapsuds. Even in emergency cases it often is well to administer an enema just before operation. The abdomen should be shaved, including the pubic hair, and should be washed with green soap, rubbed with alcohol (60 per cent.), and covered with a dry sterile dressing. This preparation is best done in the evening of the day before operation; unless done at least three or four hours before operation, the skin will not be sufficiently dry at the time of operation for the use of iodin to be effectual (p. 143). If iodin is not used, the entire abdomen should be washed again, after the patient is etherized, as at the first prepa- ration. In emergencies it is sufficient to paint the abdomen (pre- viously shaved dry) with 3 per cent, iodin twice, allowing the first coat of iodin solution to become thoroughly dried before the second is applied and waiting until the second has dried before making the incision. A 2 per cent, solution of picric acid is as good as iodin. On the evening before operation the patient should eat only a 87G ABDOMINAL SURGERY IN GENERAL light, semi-solid meal. Only cooked (sterile) food should be taken for at least two days before operation. The mouth and teeth should be carefully cleansed. On the day of operation nothing but water should be allowed, unless the operation is to be late in the afternoon. Then a little liquid, preferably not milk, should be given for breakfast. Water may be taken until two hours before operation, but not in excessive quantities. Fig. 896. — Gauze packs, for a major laparotomy; with "sponge forceps." After-treatment in Abdominal Operations. — Very little except careful nursing is required in uncomplicated cases. Immediately after opera- tion, before recovery from the anesthetic, a liter of hot water should be injected into the rectum and allowed to remain. If there is no vomiting, 5 c.c. of hot water (not luke-warm) may be given every few minutes after eight to twelve hours. I am quite convinced that really hot water is less apt to cause nausea than is ice or ice-water. After eighteen to twenty-four hours small quantities of liquid diet may be given; soft diet may be begun on the third or fourth day. If the stomach has been the seat of operation mouth-feeding should not be begun for from twenty-four to thirty-six hours after operation. Vomiting is treated by total abstinence from mouth-feeding; by sitting the patient up in bed; by the administration of a glass of hot water; and finally by lavage. The treatment of peritonitis has already been considered (p. 861). The surgeon should not be in too great a hurry to have the patient's bowels moved. Unless they move spontaneously, an enema may be given on the third or fourth day. Owing to the pre-operative catharsis, OPERATIONS ON THE ABDOMEN 877 and the abstinence from food after operation, it is futile to expect a free evacuation any sooner. Cathartics should not be given after operation unless the enema proves ineffectual. Calomel in divided doses, followed by a saline purge, usually is preferred. The patient may be turned on his side (this does not mean that he may turn himself) on the second day after operation if he desires it. He should be made comfortable. If there is peritonitis he will be in the sitting posture (Fig. 889) and will not need to be turned over to ease his back. It is not well for the patient to leave bed until several days after the sutures have been removed. Rarely should an abdominal patient spend less than two weeks in bed. If the incision was large, or the operation very extensive, it may be advisable for the patient to remain in bed three weeks or longer. Only the very old should be hurried out of bed ; and even they, if they can be made comfortable in a sitting position in bed, do just as well in bed as in a chair. Intestinal Localization. — Often during the course of an abdominal operation it becomes important to distinguish large from small bowel, or even to identify more or less accurately different areas of the latter as belonging to the upper jejunum, the middle of the small gut, or the lower ileum. In cases of peritonitis or intestinal obstruction, the small intestine may be so distended as to equal or exceed the size of the colon, so that mere size is no criterion. In many cases the longi- tudinal bands on the colon may be recognized, or even the sacculation of the large intestine; but inflammatory changes or distention may obscure such means of identification. The large intestine in fat adults is covered by epiploic appendages; but in children and emaciated adults these are absent. The safest and most constant distinction is the attachment of the intestine to the posterior abdominal wall by its mesenteries (Da Costa, 1894). The small intestine is attached by its mesentery obliquely across the lumbar spine: the coils of small bowel rarely can be brought very far laterally in the abdominal cavity, but usually occupy its middle portion. The large intestine is attached to the posterior abdominal wall on the right and left of the abdomen, and transversely above. If all the intra-abdominal structures are pushed away from the right side by the use of gauze pads, the bowel which it will be impossible to push away, will be the cecum and ascend- ing colon. In inserting the hand, if the fingers be made to follow the peritoneum on the right across the flank, into the loin, and toward the median line, the first bowel they encounter attached to the pos- terior abdominal wall, will be the ascending colon. The same con- dition of affairs exists on the left side : the descending colon and the sigmoid have their posterior attachments further to the left than any of the intestines, and after all the movable bowels have been packed away from the left side, the immovable intestine, which remains relatively fixed, will be the descending colon or sigmoid. The sigmoid often has a long mesentery, and the sigmoid loop may prolapse into a right inguinal incision. The same is true of the transverse colon, 878 ABDOMINAL SURGERY IN GENERAL which may be easily accessible from either iliac region or the hypo- chondrium. But the transverse colon is easily distinguished from other portions of the large bowel because it has the great omentum attached to it. The sigmoid and cecum are readily distinguished from each other by their mesenteric insertions. The mesentery of the small intestine, as already noted, crosses the lumbar spine obliquely, beginning above on the left, and ending at the cecal region on the right. The direction in which a coil of small bowel is running (i. e., which end is nearer the duodenojejunal junc- ture) can be ascertained by paying attention to the attachment of its mesentery. The coil of bowel to be investigated should be withdrawn from the abdomen, spread out, and untwisted, until the fingers can follow the mesentery down to its origin or root along the lumbar spine. If the bowel is not rotated on its mesentery, it is evident that it is running in the same direction as the root of the mesentery, and hence that its upper (duodenal) end is nearer the epigastrium than is its lower (cecal) end. The upper end of the jejunum is readily found by lifting the great omentum and with it the transverse colon out of the abdomen, and turning these structures upward on the patient's thorax. This makes the transverse mesocolon taut, and the jejunum is seen emerging from its lower layer just to the left of the spinal column. This is the duodeno-jejunal juncture. The duodenum here is retroperitoneal, and the first intraperitoneal coil of gut is the origin of the jejunum. This is an important landmark in gastrojejunostomy. The lower end of the ileum, or the ileo-cecal juncture, is readily found by running the fingers upward along the external iliac vessels as they lie at the brim of the true pelvis. The structure which arrests the fingers in the neighborhood of the right sacro-iliac joint, will be the termination of the mesentery of the ileum where this passes into the cecum. With a little practice it is not difficult to scoop up into the wound, on the finger tips, the ileo-cecal loop, and thus to bring the appendix vermiformis into view. Monks (1903) conducted studies in the hope of being able to differentiate at operation between dif- ferent portions of the jejuno-ileum, without the necessity of tracing the entire small intestine downward from its origin or upward from its termination. Chief reliance is placed on the arrangement of the mesenteric bloodvessels. High in the jejunum there are only primary vascular loops, with perhaps an occasional secondary loop, and the vasa recta are from 3 to 5 cm. long (Fig. 897). Midway, say at 3 meters from either end, the secondary loops are a prominent feature of the mesenteric vessels, and the vasa recta are shorter (Fig. 898). In the lower ileum the vessels are much less easily distinguished, owing to the deposition of fat in the mesentery; the loops, if visible, are much more complex, and the vasa recta are short and irregular (Fig. 899). The upper jejunum is larger in diameter, its walls are thicker, and often the valvulse conniventes are palpable, or they may be visible by transmitted light. The lower ileum is smaller, and its walls are thinner. INTESTINAL LOCALIZATION 879 Fig. 897. — The mesenteric arteries in the upper portion of the jejunum. There are only primary vascular loops, and the vasa recta are long. Fig. -The mesenteric arteries in the middle of the jejuno-ileum. Secondary loops are well-developed, and the vasa recta are shorter. Fig. 899. — In the lower ileum the mesenteric bloodvessels can hardly be distinguished, owing to the deposit of fat. The preparations shown in Figs. 897, 898, and 899 are from the Laboratory of Operative Surgery in the University of Pennsylvania. SSI) ABDOMINAL SURGERY IN GENERAL Intestinal Sutures. — The underlying principle in suture of organs covered with peritoneum is to bring serous surfaces into contact. This principle appears to have been introduced by Jobert de Lamballe in 1824. It is analogous to the principle adopted in surgery of the vascular system (Chapter X), always to bring intima into contact with intima. Such apposition, both of the intima which lines blood- vessels and of the peritoneum which covers the abdominal viscera, results in much more rapid and certain union than where the muscular or fibrous layers of these structures are sutured without bringing their serous surfaces into contact. Any suture which brings serosa into contact with serosa may be called a sero-serous suture. There are many varieties of this suture in use at the present day, to which the names of various surgeons have been attached. As already mentioned, this principle was used by Jobert in 1824; but in 1826 its application was simplified by Lem- bert, and to this day an interrupted sero-serous suture is known as a Lembert suture (Fig. 900). If the suture did not hold well he included Fig 900. — Perforation of the bowel, being closed by three Lembert sutures. Fig. 901. — a, Czerny-Lembert suture; b, Albert-Lembert suture not pulled tight. (.See the text.) tissues down to the mucous coat of the bowel, and Halsted, in 1887, renewed this injunction. It is easy to tell by the sensation imparted to the surgeon's hand, when the needle has caught up the tough submucous tissue. As a matter of fact the needle often, if not indeed usually, penetrates all the coats of the intestine; and this makes no difference so long as no fecal leakage occurs along the needle track. This is prevented by the use of (1) round-pointed needles, and (2) linen celluloid thread (Pagenstecher's suture, 1900), which possesses no capillarity. This suture material becomes encapsulated and may remain permanently. For additional security in intestinal wounds, and especially to check bleeding from the cut margins of the bowel, it is the rule to employ also a through-and-through suture, which passes through all the coats of the intestine. This is inserted before the sero-serous suture, is knotted within the lumen of the bowel, and should be of absorbable material so that it will ulcerate out into the intestinal canal when union is firm. Chromic catgut (No. or No. 1) is the best material. INTESTINAL SUTURES 881 The principle of the through-and-through suture knotted within the lumen of the bowel we owe to Albert. A diagram of the Albert- Lembert suture is shown in Fig. 901, b. Czerny's suture did not penetrate the mucosa, and was not knotted within the bowel (Fig. 901, a). Suture of Punctures and Perforations. — A mere puncture may be inverted by a couple of Lembert sutures (Fig. 900) or by the first points of a Gely suture (1844) (Fig. 902). A perforation usually may be closed by a purse-string suture (Fig. 903, 6), but if it is large it must be sutured as a wound in a direction either transverse or parallel to the long axis of the intestine, whichever puckers the bowel less. As there seldom is bleeding from the edges of a perforation it is not usually necessary to use a through-and-through suture, the sero-serous suture being sufficient. Fig. 902.— Gely 's suture. Fig. 903. — a, The first points of a Gely suture, used to close a puncture, b, a purse-string suture, used to close a per- foration. Suture of Incisions or Wounds. — Gunshot wounds resemble perfora- tions and require the same treatment. Ruptures, lacerated and incised wounds, especially operation wounds, usually require first a through-and-through suture to check hemorrhage. This may be either interrupted or continuous. The needle is entered at one end of the incision, from the mucous surface, emerges on the peritoneal surface, crosses to the opposite side of the incision, and there again penetrates all the coats of the bowel from the serous to the mucous surface. It is then knotted; the knot thus lies within the lumen of the bowel. If an interrupted suture is desired, both ends of the thread are cut short, and other sutures introduced about one-half a centi- meter apart until the wound is closed. If a continuous suture is pre- ferred, only the free end of the thread is cut short, and the needle is re-introduced on one side of the wound from its mucous surface, and traversing all the coats of the bowel, emerges on the peritoneal sur- face. The needle is then carried across the wound to its opposite lip; here enters the serous surface of the bowel, traverses all its coats, and emerges on the mucous surface. This completes the second stitch, and the thread is then drawn taut, carefully inverting the lips of the 56 SS2 AIWOMINAL SURGERY IN GENERAL wound ;is this is done. Each similar stitch is pulled taut until the other end of the wound is reached, when the suture is knotted and the knot is allowed to retract within the lumen of the bowel (Fig. 904). Fig. !>04. — Closure of an intestinal wound by a continuous through-and- through suture. The knots lie within the lumen of the gut. . Fig. 905.- — Continuous sero-serous suture (Dupuytren's suture). To reinforce this through-and-through suture, a continuous sero-serous suture (known also as Dupuytren's suture) is applied (Fig. 905). Any point which seems weak may be reinforced again by an interrupted Fig. 906. — Right-angled sero-serous suture of Cushing. suture. When there is much tension on the parts a sero-serous suture, inserted as shown in Fig. 906, usually holds better; it is known as the right-angled sero-serous suture (also by the name of Hayward W. Fig. 907. — Interrupted mattress suture. (Deaver and Ashhurst.) Fig. 908. — Continuous mattress suture. (Deaver and Ashhurst.) Cushing, 1889). Or a mattress suture, either interrupted (Fig. 907) or continuous (Fig. 908) may be employed; this is known by HalstecTs name (1887). Intestinal Resection. — When it is necessary to resect a portion of the intestinal canal, the mesentery is first tied off. This is done by a INTESTINAL RESECTION 883 series of interlocking ligatures applied 2 or 3 cm. from the intes- tinal attachment of the mesentery, and never over quite as wide an area as the length of gut to be removed, for fear of endangering its vitality. The gut above and below the diseased area is then double clamped : suitable clamps, with their blades covered by rubber tubing, introduced into surgery by Rydygier (1881), and popularized by Doyen (1900), may be applied to healthy bowel, and, if clamped only tight enough to appose the mucous surfaces, may remain in place a most an hour without inflicting any injury. These clamps should have light, elastic blades, which meet at their tips before the bodies of the blades come together (Fig. 909). They prevent fecal extrava- sation and also serve the purpose of temporary hemostasis, like the elastic band of Ej march used in amputating. In emergency pieces of tape jnay£be[tied^around the bowel. Fig. 909. — Clamps used in gastric and intestinal surgery. Note the form of the blades; [in the upper (three-bladed) forceps the rubber tubing is in place. Such clamps should be applied to the healthy bowel an inch or more above and below the proposed limits of resection. Any ordinary clamp forceps are then applied at the limits of the diseased area, which is thus cut at each end between two pairs of clamps (Fig. 910), so that no fecal extravasation occurs. The subsequent procedure depends upon whether it is desired to restore the continuity of the intestinal canal by anastomosis, or to establish a false anus in the wound. The best way to establish a false anus after intestinal resection is to suture the. two coils of bowel together like a double-barrelled shotgun — " en canon de fusil" as the French call it. This is easily accomplished by a few sero-serous sutures. Then the circumference of each intestinal coil is sutured to the parietal peritoneum, leaving about an inch of each gut pro- truding from the wound. The clamps used for resection may be left SSI ABDOMINAL SURGERY IN GENERAL on the protruding ends for a few days (or until the peritoneal cavity is shut off by adhesions), if there is no urgent need to secure a fecal evacuation; or the ends may be simply ligated and be left to open themselves when the slough separates. Other methods of forming a false anus are discussed at p. 9G9; and the treatment of this condition is considered at p. 946. Fig. 910. — Intestinal resection. After the mesentery has been ligated and cut close to the bowel, the resection clamps are applied, and the diseased bowel is cut away. Intestinal Anastomosis. — This may be accomplished by uniting the gut end-to-end (circular enterorrhaphy) ; or, after closing the open ends of the intestines, these may be placed side by side and a lateral anas- tomosis may be established (N. Senn, 1889). By an implantation is understood an operation in which the end of one bowel is sutured into the side of another, much as the ileum is implanted into the cecum. End-to end Anastomosis. — The rubber-covered clamps employed during the intestinal resection are left in place. By bringing them parallel to each other, the ends of the gut are approximated; these then look at the surgeon like a double-barrelled shot-gun. This brings four layers of intestinal wall to view, two of which are apposed. 1. First, a continuous through-and-through suture of chromic catgut is applied: this is begun by introducing the needle from the mucous surface of that coil of gut on the operator's right, at the anti- mesenteric point. The needle is pushed through the apposed intes- tinal walls from the lumen of one gut into that of the other, where it emerges on the mucous surface, having in its course traversed all intervening layers of both guts : of the first coil from the mucous to the serous, and of the second coil from the serous to the mucous surface. The first stitch is then tied, the knot coming within the lumen of the bowel. The end is left long. The suturing is then continued (Fig. 911) toward the mesenteric attachment, and when this is reached the suture is passed as indicated in Fig. 912. The suture is continued around the margin of the gut, always passing from the mucous to the serous surface of the first coil and from the serous to the mucous surface of INTESTINAL ANASTOMOSIS 885 the second coil of bowel. When the point of beginning is reached at last, the suture is terminated by knotting it to the original end, which was left long for this purpose. When both ends are cut short, the knot disappears into the lumen of the bowel. 2. The clamps may then be removed, and the operation is com- pleted by passing a continuous sero-serous suture around the entire anastomosis, thus reinforcing the through-and-through suture. 3. The mesentery will become redundant when the intestinal ends are approximated; its free border may be stitched to the anastomosis. Fig. 911. — End-to-end anastomosis. The through-and-through suture has been started. Fig. 912. — End-to-end anastomosis. Passing the through and through suture at the mesenteric attachment. Fig. 913. — Maunsell's method of circular enterorrhaphy. a, the incision in one coil of intestine; b, the open ends of both coils evaginated through this incision, to facilitate suturing; c, the operation completed. Maunsell (1892) thought it facilitated the operation of circular enterorrhaphy to evaginate the divided ends through a longitudinal incision in one of the coils of intestine. After suture of the divided ends has been thus completed, from their mucous surface, they are replaced, 886 ABDOMINAL SURGERY IN GENERAL and the intestinal incision through which they were withdrawn is closed. A partial intussusception of the sutured ends remains (Fig. 913). M. E. Connell (1892) advocated only interrupted- mattress sutures, penetrating all the coats of the bowel, and tied on their mucous surface. Lateral Anastomosis. — The open ends of the resected bowel must first be closed. If the lumen of the gut is small, it is sufficient to apply a ligature in the groove made by a crushing clamp, as in the operation of appendicectomy (p. 907) and to invert this ligature by a purse- string sero-serous suture. When the guts are to be left in or near the wound after the lateral anastomosis has been completed (as in some cases of resection for strangulated hernia), it is sufficient to apply a strong ligature, as above described, without a secondary inverting purse-string suture. Thus time is saved. In most instances, however, and especially where the lumen of the resected gut is of large size, it is safer to close the end of the bowel by two layers of sutures, the first being a continuous through -and-through suture of chromic catgut, and the second a linen sero-serous suture. Fig. 914. — Lateral anastomosis with intestinal coils in iso-peristaltic relation. ) Fig. 915. — Lateral anastomosis with intestinal coils in anti-peri- staltic relation. Lateral anastomosis should be made in an iso-peristaltic direction (Fig. 914); though where afferent and efferent loops are sutured together en canon de fusil, and an anastomosis is subsequently estab- lished, the antiperistaltic direction of the anastomosis appears to make little difference (Fig. 915). The formation of a lateral anastomosis is much facilitated by the use of rubber-covered intestinal clamps. The three-bladed clamp is very convenient (Fig. 909). The clamp shou'd be applied so as to embrace a considerably greater area of bowel than that concerned in the anastomosis. The anastomosis is made on the free (antimesenteric) border of the intestinal loops. 1. The first step consists in the insertion of a continuous linen sero- serous suture close to the median blade of the clamp, for a distance a little longer than the size of the proposed intestinal opening, say about 8 to 10 cm. This suture is begun at one end of the proposed intestinal opening, where it is knotted, the free end being left long; it is continued in a straight line to the other end of the proposed anas- tomosis, uniting the two coils of intestine, as indicated in Fig. 91G. LATERAL ANASTOMOSIS 887 When this point is reached the suture is not cut, but the needle, still threaded, is laid aside temporarily, to be used again before the close of the operation. This needle and thread will be referred to as the sero-serous suture. Fig. 916. — Lateral anastomosis: the clamp has been placed; the sero-serous suture has been inserted, close to the middle blade of the forceps; and the coils of intestine have been opened. At the near angle of the intestinal incisions the needle is entered for the commencement of the through-and-through suture. 2. The surgeon then makes a longitudinal incision in one of the coils of bowel, about one centimeter distant from and parallel to the sero-serous suture already applied, and about 6 to 8 cm. in length. This incision divides first the serous and muscular coats of the gut; as these retract the mucosa pouts into the incision. The mucosa is cautiously opened at one point, so as not to wound the opposite wall of the bowel. Any discharge from the lumen of the bowel is wiped sss ABDOMINAL SURGERY IN GENERAL carefully away. Then the opening in the mucosa is enlarged by scissors to the full extent of the intestinal incision. If the mucosa seems redundant, as is often the case in the small intestine, it should be excised. The other coil of gut is then opened in a similar way for an equal distance. There are now exposed in the wound two apposed loops of intestine, each with a longitudinal incision in its antimes- enteric border. Each of these incisions has two lips, an anterior and a posterior. The two posterior lips are fairly close together, while the anterior lips are some distance apart. For purposes of descrip- tion it is convenient to apply definite names to these structures: we may speak of the coil of bow r el on the operator's right as the first gut, and that on h : s left as the second gut (frequently it is impossible to know which of these is the afferent and w T hich is the efferent loop); each of these guts has an incision with an anterior and a -posterior lip; the posterior lips are closely apposed to each other. Where the anterior and posterior lip of each incision join, is found the angle of the incision; one angle is at the end of the intestinal incision away from the operator (the far angle of the incision) and the other is at the near end of the incision (the near angle of the incision). 3. A through-and-through continuous suture of chromic catgut is now to be inserted. The needle is entered at the near angle of the incision in the first gut, from its mucous surface, and traverses all its coats, emerging on its serous surface; it is then inserted at the near angle of the second gut, passing from its serous to its mucous surface. This stitch is then tied, the knot coming within the lumen of the bowel. The end of the suture is left long; it should not be confused w r ith the end of the sero-serous suture (linen), which also w r as left long. The through-and-through chromic catgut suture is continued away from the operator, uniting the posterior lips of the intestinal incisions, as shown in Fig. 917, until the far angles of the incisions are reached. During this time the needle is passed always from the mucous surface of the first gut through all its coats to its serous surface, and imme- diately into the serous surface of the second gut, emerging on the mucous surface of the second gut. Then the thread is drawn taut; the needle is carried back to the side from which it started, and again enters the mucous surface of the first gut, traverses all its coats to emerge on its serous surface, and at once enters the serous surface of the second gut, and, traversing all its coats, emerges on its mucous surface in the lumen of the second gut. This is accomplished each time by one push of the needle, which is enabled to pass through the walls of both guts "all at one bite," because the posterior lips of the intestinal incisions are so closely approximated. When, however, the far angles of the intestinal openings are reached, it is no longer possible for the needle to pass through the w^alls of both guts all at one bite, but it is necessary for it to be passed through each separately. But the same method of suturing may be continued: thus the needle always enters the first gut from its mucous surface and emerges on its serous surface; it then is carried across to the free margin of the LATERAL ANASTOMOSIS 889 second gut (at its far angle or on its anterior lip), and always enters its wall from the serous surface and emerges on its mucous surface. This is readily understood by reference to Fig. 917. This method of suturing is continued along the anterior lips of the intestinal incisions toward the operator until the near angles of the incisions are reached, when a complete circumference will have been traversed by the through-and-through chromic catgut suture, which is finally knotted to its original end, which was left long for this purpose at the starting- point, the near angles of the intestinal incisions. As this suture is being inserted in the anterior lips these should be carefully inverted Fig. 917. — Lateral anastomosis: the through-and-through suture has united the posterior lips of the intestinal inci- sions, and the far end of these incisions has been reached. Fig. 918. — Lateral anastomosis: the far angles of the intestinal incisions have been sutured, and the anterior lips of the incisions are now being united by the through-and- through suture which is passed in a manner similar to the sero-serous suture shown in Fig. 906. so as to ensure accurate contact of their serous surfaces. If there is difficulty in securing proper inversion of the anterior lips, it is a very good plan to use for this part of the operation a continuous right-angled suture similar to the sero-serous suture of Cushing (Fig. 906), except that here the right-angled suture should penetrate all the coats of the intestine, leaving the loop of the suture always on the mucous surface of the bowel (Fig. 918). This is known as C. H. Mayo's suture (1905). It is nothing else than a right-angled through- and-through suture. 4. When the application of the through-and-through suture has been completed, the rubber clamps may be released, but should not be 890 ABDOMINAL SURGERY IN GENERAL removed from their position, as they serve to keep the parts accessible for the application of the final suture. This is a continuation of the sero-serous suture first applied, the needle of which, still threaded, was laid aside temporarily before the application of the through-and- through suture was commenced. This sero-serous suture is now con- tinued over the inverted anterior lips of the intestinal anastomosis, further inverting them and burying from sight the through-and-through suture. The sero-serous suture is finally arrested at the near angle of the anastomosis, where it is knotted to its own original free end, which was left long for this purpose. The clamps are then entirely removed ; the anastomosis is inspected on all sides, any weak spot being reinforced by one or two additional interrupted sero-serous sutures. The intestines are then replaced within the abdomen. The advantages of lateral over end-to-end anastomosis are the follow- ing: the opening may be made of any desired size; there is no mesen- teric attachment to be included in the sutures, and no fear of leakage at this weak point. The chief disadvantage is the additional time required for its performance, when it is employed after intestinal re- section, because then it involves also closure of two ends of bowel. After lateral anastomosis following intestinal resection the coils of bowel involved tend to straighten out, so that after some years little or no trace of the anastomosis can be found, even when it was made in an antiperistaltic direction. Lateral anastomosis I believe should be preferred (1) whenever the large bowel (except perhaps the trans- verse colon or sigmoid) is concerned, as this has a relatively large extra- peritoneal surface and, therefore, usually is not well adapted for an end-to-end anastomosis ; (2) in cases where the two coils of gut to be anastomosed differ much in diameter, though by careful suture or by cutting the smaller intestinal loop obliquely it is possible to employ end-to-end anastomosis even under such circumstances; and (3) in cases where the intestinal walls are altered from inflammatory changes, as in most cases of acute intestinal obstruction, strangulated hernia, etc. End-to-end anastomosis I think is best limited to resections of small intestine not undertaken in the presence of acute disease. Mechanical devices for intestinal anastomosis are not much used by surgeons any more. The Murphy button, introduced by J. B. Murphy, in 1892, is still the most popular in this country, as is the somewhat similar contrivance of Jaboulay, in France, and Mayo Robson's bone bobbin, in England. The Murphy button is a very ingenious contriv- ance, made of metal, nickel-plated; it consists of two parts (Fig. 919), one of which is inserted through a small incision into each of the loops of bowel to be anastomosed, and is held in place by a purse-string suture which puckers the bowel around the half of the button inserted. The projecting shanks of each end of the button are then forced together, the male within the female; the two halves of the button are thus held together automatically by a spring. Serous surfaces are thus brought into broad apposition (Fig. 920). The union may be reinforced by a few interrupted sero-serous sutures. The button is provided with INJURIES OF THE ABDOMEN 891 a lumen in its center, and if all goes well, it ulcerates into the lumen of the intestine in ten days or two weeks and is passed by rectum. During the application of the button its lumen may be filled with cocoa butter, which will prevent fecal extravasation temporarily, but melts as soon as the intestines are returned to the abdomen. I have never used any mechanical device in effecting intestinal anastomosis, but believe the Murphy button better than any other such appliance. It is particularly indicated where the parts concerned in the operation cannot be brought into the wound so as to render accurate suture possible, or where very rapid conclusion of the operation becomes imperative. The chief danger from the use of the button is that its mechanism may be defective, so that it may ulcerate out too soon, allowing fecal extravasation and causing death from peritonitis. It should be an invariable rule for the surgeon himself personally to test _ Fig. 919. — The Murphy button for intes- tinal anastomosis; above, the female half; below, the male half of the button. Fig. 920. — Two coils of intestine anastomosed by means of the Murphy button. the mechanism of the button thoroughly and several times before the operation is commenced. Occasionally the button has caused intestinal obstruction. INJURIES OF THE ABDOMEN. Subcutaneous Injuries. — These may affect the abdominal wall only, or there may be visceral injury with or without injury of the overlying structures. In almost all cases the injury is by direct vio- lence, blunt force in the form of a blow, a kick, a fall, or a crush, being applied to the abdominal wall. If the abdominal muscles are rigidly contracted, the blow a glancing one, the force not very great, and the viscera not distended or weakened by disease, only a contusion of the abdominal wall may result. If the force is greater, rupture of the abdominal wall may occur; this was referred to at p. 305. Rupture 892 ABDOMINAL SURGERY IN GENERAL of one of the abdominal muscles from voluntary contraction sometimes occurs in cases of typhoid fever; I have seen one case, apparently of this nature, complicating pneumonia. In such cases there is metas- tatic infection. Traumatic Iliac Abscess deserves recognition as a clinical entity: an extraperitoneal abscess, right or left, forms as the result of trauma or sprain. Probably the injury causes a hematoma, which becomes infected through the blood stream. In some cases the abscess origin- ates in lymphadenitis of the nodes along the external iliac artery; there is no evidence that it results from vertebral osteomyelitis. The diagnosis must be made from appendicular abscess (p. 910), and from 2?50O5 abscess (p. 652). Treatment consists in opening and draining the abscess by an incision close to Poupart's ligament. When there is visceral injury it usually is because the abdominal muscles have been taken off their guard, or because they are very flabby and weak. Then the force need not be very great, especially if the hollow viscera are distended or the solid viscera enlarged by disease. In these cases no macroscopic evidence of injury to the abdominal wall may be found. Visceral injury without injury of the abdominal wall is much more frequent than rupture of the abdominal wall without visceral injury. The gravity of the injury, as pointed out at p. 195, depends largely upon the momentum of the vulnerating body : a mere tap on the abdomen from a heavy swinging crane, or block and tackle, will do much more damage than a smart blow with a stick. Sometimes a fall inflicts injury by indirect violence, one of the abdominal viscera being torn from its moorings by the jar when the patient lands on his buttocks or feet; but this is very rare. Most cases of abdominal injury occur in men during active adult life, or in children. An irreducible hernia is an important predisposing factor: not so much that the structures in the hernial sac are injured, but because the intra-abdominal organs are held taut, and thus are unable to escape from a crushing force. This was the case in two out of six adults upon whom I have operated for subcutaneous rupture of the abdominal viscera. The intestinal tract is most often injured. Its more fixed portions (duodeno- jejunal juncture, lower ileum and cecum) are most exposed to injury. The injury may be a mere contusion, which may or may not terminate in gangrene and perforation; rupture may occur; or the bowel may be torn loose from its mesentery. Ruptures usually occur on the antimesenteric border of the gut, and seem to be caused by over-distention of the intestine with a resulting explosive injury, a coil of gut being compressed so as to dam up its contents against an obstruction, such as the ileo-cecal valve or a kink between adjacent intestinal loops. A few cases of rupture of the large bowel have been reported from the injection of compressed air into the rectum. Rup- tures of the stomach have occurred from too forcible lavage, and from artificial distention with Seidlitz powders; this is especially to be feared in cases of gastric carcinoma, and in unconscious patients. Sponta- INJURIES OF THE ABDOMEN 893 neous rupture of the stomach has been reported as a result of vom- iting, fermentative distention, etc. Complete transverse ruptures occur oftenest at the duodeno-jejunal juncture. Crushes of the intes- tine result from pressure between the body which inflicts the injury and the sacral promontory or lumbar spine. In this way the lower ileum is often torn loose from its mesentery. The solid organs are less often the seat of injury than is the gastro- intestinal tract. The spleen and liver are much more frequently injured than is the pancreas, which is in a protected situation. The liver or spleen may be penetrated by the fragments of broken ribs, but usually the lesion is a rupture from diffuse compression. The rupture may be entirely subcapsular, or may extend to the surface of the organ. Symptoms and Diagnosis. — Often there is considerable shock; usually there is vomiting; local pain causes shallow and thoracic respiration. Pain is the most constant symptom, and where fecal extravasation occurs it may be agonizing. The abdominal wall is very rigid, and physical examination is unsatisfactory. If there is only a severe contusion of the abdominal wall, without vis- ceral injury, the general condition of the patient is not much affected, even at first, and it rapidly improves. The pain is not very great, but tenderness and rigidity usually are very pronounced. It is very difficult to exclude visceral injury certainly, and in most cases explora- tory laparotomy is indicated. If there is a large rupture of the gastro- intestinal tract, permitting fecal extravasation, the pain is extremely severe; but if the rupture is very small it may be occluded by the mucosa, 1 and there may be comparatively little pain. Serious symp- toms follow intra-abdominal hemorrhage even when there is no injury of the gastro-intestinal tube. A significant symptom in cases with visceral injury is a steady increase in the pulse rate; usually the temperature also rises, and leukocytosis develops. Later the signs of peritonitis develop. If there is a rupture of one of the solid organs, or of the omentum or mesentery, signs of internal hemorrhage usually precede the onset of peritonitis. Emphysema of the abdominal wall (a valuable but very rare sign), indicates rupture of a hollow viscus. The only certain way to exclude visceral injury is by exploratory laparotomy, and usually this is postponed too long. Ruptures of the gastro-intestinal tract almost always are due to injury from the front. Apart from the very severe pain, mentioned above, the occurrence of repeated vomiting, of widespread tenderness and rigidity, or of blood in the stools, indicates injury of a hollow viscus. Rupture of the liver is due to injury to the right hypochondriac region or lower thorax. As noted above, fracture of the ribs may be present, with puncture of the liver by a fragment. The rupture usually is in the right lobe, involves the capsule of Glisson, and permits intra- peritoneal hemorrhage. The chief symptoms are those of internal 1 In all injuries sustained during life the mucosa is everted into the rupture; this is not the case if the rupture takes place after death (Whitney). S<)1 ABDOMINAL SURGERY IN GENERAL hemorrhage. Jaundice may develop after several days. Rupture of the gall-bladder or bile-ducts allows extravasation of bile, and peri- tonitis develops early or late according to the infectiousness of the bile. Rupture of the spleen is most frequent in cases of malarial hyper- trophy, and under such circumstances may occur from very slight trauma, or even spontaneously. Other enlargements of the spleen also predispose it to rupture. This occurrence during typhoid fever is rare, and usually fatal. Rupture of the normal spleen usually is due to severe injury directly over the left hypochondriac region, lower thorax or loin; but if the spleen is enlarged it may be ruptured or torn loose from its supports by indirect violence. Rupture of the Kidney. — See p. 1039. Rupture of the Bladder. — See p. 102G. Treatment. — If there is reasonable doubt as to the presence of visceral injury, the patient should be carefully studied for three or four hours after the accident. If there is only contusion of the abdomi- nal wall, distinct improvement usually occurs within this time. If no improvement occurs, I believe exploration is imperative, even if the patient does not seem to be growing worse. The mortality without operation is 96 per cent. The earlier the operation the more chance there is of its being successful; isolated case reports show that the death rate after operation within twenty four hours of injury is about 55 per cent. The general mortality after operation, in consecutive series of cases, is about 85 per cent. (Meerwein, 1907). Until operation is done, the shock should be treated; and, after making a diagnosis, morphin may be administered to allay pain. In cases of mere con- tusion an ice bag or hot water bag locally may be soothing. After operation, treatment as for peritonitis is indicated (p. 861). Operation. — Unless there are definite indications of the seat of the lesion, a left paramedian incision should be made just below the umbilicus. Do not let the intestines escape from the wound. If there is free air in the peritoneal cavity, or if gastric or intestinal contents are found, it is clear that the gastro-intestinal tract is ruptured. If the abdomen is full of blood, it probably comes from a solid organ or from the omentum or mesenteries. If the operation has been delayed, the presence of recent adhesions, lymph, etc., will serve as a guide to the seat of rupture. If these are absent, the intes- tine must be examined in detail, beginning at the ileo-cecal juncture, and passing upward toward the duodenum. Not more than two or three feet of small intestine should be outside the abdomen at any one time. Most ruptures are in the lower ileum. If active hemor- rhage is found, this should be checked before anything else is done. For this purpose it is best to pack all the intestines away first to one side of the wound and then to the other and examine all structures in turn on the right and on the left, from the spinal gutter forward and from diaphragm to pelvis. Eventration of the intestinal tube does not facilitate the search; it is best to keep the intestines inside INJURIES OF THE ABDOMEN 895 the abdomen as much as possible. Do not hesitate to make your incision large enough to facilitate rapid operating. Intestinal Tract. — A rupture of the antimesenteric border usually can be repaired by suture, as described for perforations (p. 881); resection of the intestine should be avoided if possible. A complete transverse rupture should be treated by lateral anastomosis, or, as a last resort, and only when the rupture is low in the intestinal tract, by establishment of a false anus. At the duodeno-jejunal juncture, where lateral anastomosis is impossible, end-to-end union should be attempted; if this proves impossible, the duodenal end should be closed, and the upper end of the jejunum united to the stomach by lateral anastomosis (gastrojejunostomy, p. 930). In Moynihan's case the regurgitation of the bile and pancreatic juice into the stomach caused no disability. Meerwein successfully supplemented this operation by uniting a lower loop of the jejunum to the descending duodenum (anterior antecolic duodeno-jejunostomy). If the intestine is torn loose from its mesentery at any point, it should be resected; it will be best then to fix the intestinal loops in the wound, en canon de fusil (p. 886), after ligating their ends and establishing a lateral anasto- mosis, as advised in cases of resection for strangulated hernia. Irriga- tion should not be employed, even if there is fecal extravasation. A large rubber or glass drainage tube should be carried to the floor of the pelvis, and subsequent treatment should be conducted as in cases of peritonitis. Liver. — If injury of the liver is suspected, the incision should be made through the upper right rectus. As the blood-pressure in the liver is low, hemorrhage is not difficult to control if the site of rupture is accessible. If possible, the injury should be sutured. Mattress sutures of chromic catgut will hold in most cases, if they are not drawn too tightly. If tbey cut out, they should be tied over strands of catgut, used as the quills in the old-fashioned quill suture (Fig. 107). If direct suture proves impossible, the omentum may be sutured into the rupture, as a tampon, or gauze may be used. Blood-clots should be scooped out of the pelvis and spinal gutters, or wiped up with sponges; but irrigation is not advisable. The pelvis should be drained, and subsequent treatment conducted as in peritonitis. The mortality after operation is from 75 to 80 per cent. (Boljarski, 1911). Spleen. — The incision is best made in the upper left rectus muscle. The operative mortality is about 38 per cent., but many patients die before operation can be undertaken. If the spleen is not much dis- organized, it may be possible to suture the rent, or to tampon it, or even to compress the spleen against the diaphragm by firmly applied gauze packs; but suture is difficult, owing to the friability of the splenic pulp, and in many cases, especially if the lesion is at all extensive, splenectomy (p. 1011) should be done. Sheldon (1910), as the result of animal experimentation, advises clamping the pedicle of the spleen with rubber-covered forceps; these are loosened in four hours, and if ^hemorrhage does not recur they are subsequently removed. The 890 ABDOMINAL SURGERY IN GENERAL splenic wound itself is ignored. This method is more applicable to cases of stab wound than to rupture, since the spleen often is quite disorganized in the latter cases. Stab Wounds of the Abdomen. — The symptoms alone are not suffi- ciently characteristic to warrant a diagnosis. They are those of any abdominal injury: shock, vomiting, pain, and rigidity. The important question to decide in these cases is whether or not the abdominal cavity has been penetrated. Under no circumstances should this be left in doubt until the development of peritonitis renders it certain. The question as to which viscus is injured is of quite secondary impor- tance. If protrusion of omentum, prolapse of bowel, or escape of intes- tinal contents renders the fact of penetration certain, no hesitancy need be felt in freely opening the peritoneal cavity. This should be done by a para-median incision. If the external wound is small, and there is doubt as to whether the blade actually has entered the peritoneal cavity, cautious explora- tion should be undertaken. The wound should not be explored by sound or finger. It should be stuffed with gauze and the patient should be prepared as for an abdominal operation. The surgeon should then dissect down layer by layer and thus follow the tract of the wound. If difficulty is experienced in tracing a small stab wound, it is best first to lay bare the abdominal aponeurosis (sheath of rectus, aponeurosis of external oblique) over a wide area, and search it for the stab wound. If this cannot be found, and it is known that the blade was very short (that of a pen-knife, for example), and if there are no other symptoms of penetration, the skin incision may now be closed. If, however, it be ascertained that the blade has pene- trated the aponeurosis, the surgeon should next lay bare the trans- versalis fascia and peritoneum, but should not open the latter until he is sure it has been penetrated. I am thus insistent upon this cautious approach to the peritoneal cavity, when the fact of its penetration is in doubt, because it often happens on opening the abdomen widely in these cases that inspection shows no evidence of intra-abdominal lesion, and very extensive search becomes necessary to exclude the possibility of visceral injury; and if none be found to exist, and it is shown that the vulnerating weapon itself never had opened the peritoneal cavity, the surgeon will have subjected his patient to a quite unnecessary and by no means trivial operation. If, however, the fact of abdominal penetration has been determined by the method just described, the surgeon will be quite justified in his extensive intra-abdominal manipulations, even though no lesion be found more serious than hemorrhage from an omental vein (Deaver and Ashhurst). If some of the abdominal contents protrude through a wound their condition will determine their proper treatment. If viable, 1 they should be cleansed, any visceral wounds should be repaired, and the viscera should be replaced. For this purpose it may be neces- 1 See Strangulated Hernia, p. 829. INJURIES OF THE ABDOMEN 897 sary to enlarge the abdominal wound. Omentum which protrudes from an abdominal wound should be excised, as should portions of prolapsed intestine which appear certain to become gangrenous. The abdominal structures most often wounded are the following: small intestine, colon, omentum or mesenteries, liver, stomach, and diaphragm. After opening the abdomen, the first thing to do is to control hemor- rhage. Each intestinal lesion should be repaired as it is discovered, and should not be put aside with the idea of repairing it later in the operation. Careful search of the entire intestinal tract is necessary, as the lesions often are multiple, and in about one-third of the cases which terminate fatally postmortem examination shows this result to be due to the presence of one or more perforating wounds which were not discovered at operation. The general mortality after opera- tion is about 50 per cent.; it is much higher if no operation is done. When operation is done within the first twenty-four hours the mortality is less than 10 per cent. Gunshot Wounds of the Abdomen. — In addition to the general account of these injuries given in Chapter VII, some more particular account of the operative treatment may be given in this place. The probability of penetration is so great that every case should be subjected to exploratory laparotomy at as early an hour as possible. The incision should be made close to the median line, in that portion of the abdomen injured. The wound of entrance of the bullet may be disregarded, unless there is hemorrhage through it from a vessel in the abdominal wall ; then the wound of entrance should be opened and the bleeding arrested. But it is much better to enter the abdomen through healthy structures, and at the most convenient point, than to make the exploration through the infected bullet tract. The bullet wound, however, should be swabbed out with iodin (3 per cent.) and packed with gauze. In warfare the tract is debrided. Gunshot wounds of the intestinal tract usually are perforating, the bullet producing wounds of entrance and exit in each coil of intes- tine which it injures. Sometimes as many as four or six perforations will be found within a few centimeters of each other in one coil of bowel. In such cases it may be necessary to excise the segment of gut wounded ; but whenever possible suture should be preferred, and even if the repair of the perforations by suture seems to cause some obstruction to the lumen of the gut, I believe it is better to run this risk than to undertake resection. The omentum may be sutured over the damaged area, to reinforce the sutured perforations; or the damaged coil of bowel may be fixed in the wound, to preclude damage from intraperitoneal leakage of intestinal contents, if there is doubt about the sutures holding. If the mesentery is so much damaged as to impair the vitality of a segment of intestine, resection can hardly be avoided. Each lesion should be repaired as it is found ; it is only a waste of time to pass over a perforation thinking to find and repair it at a later stage of the operation. S<)S ABDOMINAL SURGERY IN GENERAL Gunshot wounds of the stomach require special mention. The "head-high" (reversed Trendelenburg) posture, with a sand bag under the patient's lower dorsal spine, is a great help in exposing the field of operation. The stomach is best found by identifying first the left lobe of the liver, and passing the fingers from its under surface over the gastro-hepatic omentum on to the anterior wall of the stomach. Usually there is both a wound of entrance and one of exit. The wound first found should be repaired at once. If no other wound is found on the anterior wall, the gastro-colic omentum should be divided, between hemostats, on the colonic side of the gastro-epiploic arteries, and for a distance at least of 8 cm. The existence of a per- foration on the posterior wall usually will be indicated by extrava- sation within the lesser peritoneal cavity. W. Martin (1907) found that among the cases he studied failure to suture the bullet-hole in the posterior gastric wall had not materially influenced the mortality. A perforation should be sutured if found; if inaccessible from the posterior wall of the stomach the surgeon may open the anterior wall of this organ and suture the posterior perforation from inside the stomach. If more room is required to expose a perforation in the cardiac region of the stomach, temporary resection of the costal margin may be adopted; if the line of section is kept in the cartilages (not invading the bony structure of the ribs) , the pleural cavity will not be opened (Auvray). Drainage of the lesser peritoneal cavity should be secured by a wick of gauze emerging through the gastro- colic omentum; hemorrhage from this structure, which has been con- trolled during operation by hemostats, is permanently arrested by suture. Drainage through the left loin seldom is required; but some form of drainage of the lesser peritoneal cavity never should be neglected, particularly in cases where the pancreas has been injured. Another drain should be placed anterior to the stomach, and in cases where gastric or intestinal contents have been diffused in the abdomen, the pelvis should be drained also through a suprapubic opening. Gunshot wounds of the duodenum are rare, scarcely ever uncompli- cated by other lesions, and usually fatal. Proper exposure is difficult and it may be impossible to suture or even to discover a perforation on the retroperitoneal surface. Usually it will be well to drain the sutured area, especially if it is retroperitoneal. Drainage always should be employed, preferably through the loin, if a retroperitoneal perfora- tion is suspected but not definitely located, or if one is located in an inaccessible position. Resection with end-to-end anastomosis may be required. In many instances it probably will be safer to close both ends of the duodenum, and do gastrojejunostomy or duodeno- jejunostomy (Deaver and Ashhurst, 1909). Gunshot wounds of the liver often bleed profusely. There usually is little difficulty in checking bleeding by suture or tampon, and if hemorrhage is arrested in good time, the immediate prognosis is reasonably good; though secondary complications, such as hepatic INJURIES OF THE ABDOMEN 899 or subphrenic abscess, empyema, or pneumonia, are much to be feared. The general mortality after operation is from 35 to 40 per cent.; in a series of 37 cases uncomplicated by injuries of other viscera, the mortality was only 16 per cent. (Patel and Loaec, 1912). Gunshot wounds of the spleen, as in the case of subcutaneous injuries, frequently cause so much disorganization as to require splenectomy. Gunshot wounds of the pancreas almost always are complicated by injuries of surrounding viscera. The best exposure is gained through the gastro-colic omentum, or between great omentum and transverse colon. Tamponade is more successful than attempts at suture. Drainage always should be employed. If the injury is undis- covered, death is practically certain. • The death rate after operation is about 43 per cent. (Diehl, 1911). CHAPTER XXIII. SURGERY OF THE GASTRO-INTESTINAL TRACT. SURGERY OF THE APPENDIX VERMIFORMIS. Appendicitis. — Inflammation of the vermiform appendix of the cecum is the most frequent form of abdominal disease seen by the surgeon. Its symptoms were described even by authors of classic times; but no one, except perhaps Melier, in 1827, considered disease of the vermiform process as the chief, if not the sole cause of these symptoms until it was proved, about thirty-five years ago, by Matter- stock in Germany that almost all abscesses in the right iliac fossa were associated with a perforated appendix; and by Fitz in America that in cases of so-called typhlitis (inflammation of the cecum) and in cases of appendicitis the symptoms were identical. The term appendicitis was introduced by Fitz in 1886. Pathogenesis. — The anatomy of the appendix predisposes it to inflammation. It is filled with fecal matter charged with bacteria; it contains a long mucous canal which opens by a narrow orifice into the cecum; usually it is more or less kinked or twisted, owing to the shape of its mesentery; and the slightest swelling of its walls at any point may cause complete obliteration of its lumen, converting its distal segment into a closed cavity whose naturally infectious con- tents are thus markedly increased in virulence. In addition to these factors, the appendix possesses a precarious blood-supply : it possesses no collateral circulation; its arteries are "end-arteries;" and the slightest swelling or constriction or kinking of the organ may cut off the blood-supply completely, resulting in partial or total necrosis. The infection, in the vast majority of cases, is enterogenous; but hematogenous infection sometimes occurs (p. 902). In enterogenous infection the bacteria swarming in the fecal contents of the appendix produce a sub-epithelial reaction, which is known as the primary focus (Primarinfekt) of Aschoff (1908). This occurs in the depths of one of the mucous crypts of the appendix, and consists of a collection of neutrophile leukocytes. The epithelium itself, which overlies the primary focus, may be destroyed very early in the process, its place being taken by a plug of fibrin. Usually a number of these primary foci develop simultaneously. The inflammatory reaction spreads very quickly toward the serous coat of the appendix, and peritonitis may develop before the mucous surface is seriously diseased. In almost every case, the primary infection is due to the streptococcus; but invariably the colon bacillus invades the walls of the organ secondarily, (900) APPENDICITIS 901 and soon over-grows the streptococcus, so that cultures of the latter are lost. If resolution does not occur at this very early stage of appendicitis, these intramural foci become confluent, and the condition is known as simple phlegmonous appendicitis. The existence of a primary catarrhal appendicitis, with ulceration as its result, is denied by Aschoff; what was formerly described as catarrhal appendicitis is now recognized as phlegmonous (intramural) in nature. This phlegmonous stage is present, with few exceptions, whenever the disease has lasted more than twelve hours. Even should resolution occur at this early stage of the disease, the appendix will not return to its normal state; cicatricial tissue remains, strictures may form, and the organ is more than ever predisposed to infection. If resolution does not occur early in the phlegmonous stage of the disease, intramural abscesses develop, miliary in size. These are prone to perforate the serous coat of the appendix (miliary perforations), causing peritonitis without macro- scopic perforation of the appendix. Or they may rupture into the lumen of the appendix, producing ulcers. Ulcerative appendicitis never is the primary stage; it follows the phlegmonous, whether or not this has progressed to the stage of suppuration. In this ulcerative stage the mucous membrane frequently is hemorrhagic; but the most serious complications of this stage are (1) ulcerative perforation (macro- scopic), which usually occurs on the antimesenteric border of the appendix; and (2) necrosis of the wall of the appendix. This necrosis may be the result of anemia from vascular thrombosis, or it may be due to the direct toxic influence of bacteria on the appendicular wall. In either case secondar}' invasion of the necrotic area b}^ putrefactive microbes (from the fecal contents of the appendix) leads to gangrene. Separation of the slough formed in this manner produces yet another variety of perforation. Every attach of appendicitis passes through all the stages described unless arrested spontaneously or unless the appendix is removed. If resolution occurs early in the phlegmonous stage of the disease, and if the appendix suffers a number of such mild attacks (which may be so mild as to pass unnoticed), a condition described as chronic appendicitis may develop. 1 This term implies not so much a chronic inflammation, as defined at p. 35, as it does the result of previous inflammatory attacks. The lesions are fibrotic and sclerotic in nature, and are most marked in the distal portion of the appendix, especially behind a stricture. In some cases repeated mild attacks lead to obliteration of the lumen of the organ, through the process of adhesion between its apposed granulating walls. This appendicitis obliterans (Senn, 1894) usually affects only the tip of the organ, but as the patient ages the entire lumen may be obliterated. 1 This is the teaching of Aschoff, whose studies of the pathology of appendicitis are the most recent and accurate. Other authorities have held that an acute attack seldom occurs except in an appendix already the seat of chronic appendicitis. Both views are harmonized if we admit that chronic appendicitis always begins with a definite attack which is acute pathologically, no matter how mild clinically. 902 SURGERY OF THE G ASTRO-INTESTINAL TRACT Strictures, or actual occlusion of the lumen of the appendix may occur at various points. If a stricture only is present, it is usual for a coprolith or fecal concretion to develop behind it (Fig. 921), or between two strictures. If complete occlusion exists the tip of the appendix beyond the occlusion or the segment lying between two occluded points may become the seat of an empyema, during an acute attack; or if the infection dies out a cyst may succeed the empyema. Not infrequently in an acute attack temporary occlusion (from edema or kinking) occurs close to the cecum and the whole appendix is con- verted into an abscess sac. Fecal concretions found in the appendix at operation almost surely are the result of a previous attack of appendicitis; after they are once formed they predispose, by their mechanical action, to further attacks and especially to perforation, which occurs oftenest behind the concretion. Foreign bodies which are rare in the appendix, act in much the same way as do the fecal concretions: they may lie in the lumen of the appendix for years without producing any symptoms. Fig. 921. — Gangrenous appendix with fecal concretion near tip. Note thickness of walls, indicating previous attacks; stricture on proximal side of concretion; and impending perforation near tip. Episcopal Hospital. Causes. — Appendicitis is commonest between the ages of ten and thirty years, when all infectious disorders are most prevalent. Strep- tococci, especially diplococci, are the bacteria most often directly responsible for an attack of the disease; but why it is that they produce the attack at any given time is a mystery. The great frequency of enterogenous infection has already been noted; and it is probable that stagnation of the contents of the appendix from kinking is the main predisposing cause. Digestive derangements increase the virulence of bacteria in the intestinal canal, or are the result of this increased virulence ; and disordered peristalsis may force fecal matter containing these highly virulent organisms into the appendix. There is no good proof that appendicitis arises as the extension into the appendix of a catarrhal inflammatory process in the cecum. It is probable that intes- tinal parasites found in the appendix (Fig. 922) have no etiological significance except as any other foreign bodies. In some cases it is possible that infection occurs through the blood- stream (hematogenous). In this connection attention has been called (by Kellynack, Kretz, and others) to the histological resemblance of the appendix to the faucial tonsils, both of them containing much lymphoid tissue ; and it has been held that appendicitis is an abdominal angina. But neither the clinical history of the patients, nor the histological examination of the diseased appendices supports the theory APPENDICITIS 903 of hematogenous infection, except in rare instances. Rosenow (1915) has shown, however, that certain strains of streptococci have an affinity for different organs; and it may well be that hematogenous infection of all organs is more frequent than generally recognized. One attack of appendicitis predisposes to another. Nearly 85 per cent, of 3000 patients under Deaver's care had had a previous attack. Fig. 922. — Acute appendicitis, appendix containing oxyuris vermicularis. (Natural size.) Episcopal Hospital. Acute Appendicitis. — Symptoms and Clinical Course. — Pain, nausea, and vomiting followed by tenderness and rigidity: These are the cardinal symptoms of acute appendicitis. Usually without previous warning the patient develops a sudden colicky pain, more or less diffused throughout the abdomen or localized to the umbilical region. This pain is due to the disordered peristaltic action of the appendix in attempts to empty itself against resistance. It is analogous to the pain of biliary, intestinal, or renal colic; like them it excites nausea and vomiting. The vomiting is reflex, and suffices only to empty the stomach. It is not repeated unless peritonitis develops, when it assumes the type already described at p. 857. This primary nausea and vomiting follows and does not precede the initial pain of appen- dicitis; to this rule there are very few exceptions. At this time there is no special tenderness in the abdomen; indeed, as in intestinal colic, pressure may relieve the pain. But usually within twelve hours the character of the pain changes; it is no longer diffuse and colicky, but becomes localized to the right iliac region, where the diseased appendix is found. The pain is now burning, constant, and intense. Simul- taneously with this localization of the pain to the right iliac fossa there develop both tenderness and rigidity, which also are confined to the region of the appendix. Palpation now reveals a normal abdomen elsewhere, but over the right iliac fossa the muscles (par- ticularly the right rectus) are rigid, and tenderness is so marked that even slight pressure causes extreme pain. This localized rigidity is the most important single symptom of appendicitis. Roughly speaking, all these symptoms of appendicitis are localized around McBurney's point, which was described by its author in 1891 as a point from one and a half to two inches (4 to 5 cm.) distant from the anterior superior spine of the right ilium on a line drawn between this spine and the umbilicus. When this stage of the disease has been reached, it is possible in all but the most exceptional cases to make an accurate diagnosis of appen- dicitis. The condition is clinically one of localized peritonitis, as '.Hi I SURGERY OF THE G ASTRO-INTESTINAL TRACT described at p. 857, and that this is the pathological state is evident from the account of the pathogenesis of appendicitis already given. Appendicitis is localized peritonitis; all the signs of this condition are present : tenderness and rigidity, arrest of peristalsis in the immediate vicinity of the lesion, local tympany from paresis and distention of the ileo-cecal coil of the intestinal canal; and persistent constipation. The development of complications should not he awaited before making an accurate diagnosis. In a small proportion of cases the attack does not begin with acute pain, but with a gradually increasing discomfort in the neighborhood of the appendix; and in such cases, the physical signs of appendicitis often develop without any nausea or vomiting. Hence it is, that in appendicitis as in all other acute abdominal lesions when the history of the case is atypical, it is safer to rely on the physical examination than on the history, in reaching a diagnosis. No mention has been made hitherto of the temperature, pulse, or leukocytosis, in connection with appendicitis. They are of quite secondary importance. Usually the temperature is slightly elevated from the first, and the pulse quickened, as in all febrile states. There also is leukocytosis in most cases, the white blood cells numbering anywhere from 10,000 to 40,000. The white-blood count is of more value in prognosis (p. 911) than in diagnosis. When the stage of localized symptoms described above has been reached, the disease pursues either one of two courses: It subsides, or complications develop. In the former case the pain gradually lessens; the tenderness changes to mere "soreness," rigidity disappears, flatus is passed normally, the temperature curve reaches the normal, and the leukocytosis gradually subsides. The course of such an attack lasts on the average from three days to a week. If the attack does not subside, complications develop; they are frequent and almost countless. Among the more important are perforation and gangrene of the appendix, and abscess formation or diffuse peritonitis with all its dire consequences. The symptoms, diagnosis, and treatment of these complications are considered at p. 909. Diagnosis. — The diagnosis of appendicitis usually is easy. It is the most frequent of all acute abdominal diseases, and should be ever in the surgeon's mind. In intestinal colic the pain is general and does not become localized to the region of the appendix; pressure relieves it; nausea and vomiting are by no means constant, and often precede the onset of the pain; active peristalsis is audible; and diarrhea is the usual outcome. At no period of the attack is there muscular rigidity. Fever is unusual. Leukocytosis is absent. In biliary colic the pain is situated in the right hypochondrium and often radiates to the right shoulder. A history of many previous attacks often is obtainable, and jaundice may have been present at some time. Tenderness and rigidity if present are confined to the gall-bladder area. If the patient is past forty years of age the attack probably is biliary, not appen- dicular. In acute cholecystitis the symptoms somewhat resemble those of biliary colic. Tenderness and rigidity are constant, but are con- APPENDICITIS 905 fined to the upper right abdominal quadrant, unless the gall-bladder is displaced. The characteristics by which an enlarged gall-bladder is recognized are stated at p. 976. In renal colic from disease of the right kidney, the symptoms may closely simulate those of appen- dicitis, particularly when a calculus is lodged in the ureter. Yet the radiation of the pain, the urinary findings, and the absence of gastro- intestinal symptoms suffice in most cases to make the diagnosis clear. Skiagraphy is a valuable aid. In acute salpingitis, especially affecting the right tube, the peritoneal symptoms are confined to the pelvis and gastro-intestinal symptoms are absent. Tenderness is too low and too near the median line, for appendicitis; it is not at McBurney's point, but about over the middle of Poupart's ligament. Vaginal examination confirms the diagnosis. Some cases of typhoid fever begin with rather acute abdominal pain, and this may be accompanied by nausea and vomiting. Usually, however, strict inquiry reveals that the actual onset of the disease occurred several days previously, with malaise, headache, feverishness, etc. The temperature is too high (103° F. or more) and the pulse too slow (100 or lower) for appendicitis; and there is leukopenia not leukocytosis. In none of the affections mentioned, nor in any of the score or more other diseases which may be exceptionally confused with appendicitis, is the clinical history typical of the latter: sudden pain, first diffuse, then settling to the right iliac fossa; followed by vomiting; and the extremely important localized tenderness and rigidity. Prognosis. — The appendix is the fons et origo mail, and if it is removed before complications develop, the prognosis is brilliant. The mortality of operation at this stage of the disease is so low that hundreds and hundreds of such simple cases are cured without a death. Once in several hundrecf operations it may happen that a patient dies of pneumonia or some other unforeseen complication; but this minimal risk stands in no sort of relation with the risk run by delaying operation to determine whether or not complications are about to develop. As a matter of fact, even under the most approved non-operative treat- ment, complications develop in at least 10 per cent, of cases. It was justifiable to delay operation only in the days before the develop- ment of aseptic surgery; until that time the only form of intra-abdomi- nal disease successfully amenable to surgical treatment was localized suppuration. It was then and it is now absolutely impossible to control the course of the disease in the appendix by any means known to medical science. 1 Unless the appendix is removed the patient is left to the unaided efforts of nature. Never should the surgeon call for aid from beneficent Nature until he has exhausted his own resources. Apollo would not help the teamster until the latter had whipped up his horses and put his own shoulder to the wheel. The mere diagnosis of appendicitis should be an indication for immediate operation. I am conceited enough to believe that I can recognize, as well as anyone else, the occurrence of perforation or suppuration 1 I am speaking of disease in the appendix, not of the peritoneal complications of this disease. 906 SURGERY OF THE GASTROINTESTINAL TRACT in appendicitis, but I frankly confess my utter inability to feel sure one hour that neither of these events will occur during the next, so long as an acutely inflamed appendix remains within a patient's belly. It is possible to argue on probabilities, and to defer operation in cases that appear mild; but sooner or later the surgeon will encounter a case which will make him regret his procrastination, and will convince him that he has lost the life of his patient through over-confidence in his own powers of prognostication. Even if life be not lost, it will be surely jeopardized by the development of peritonitis, localized or diffused, with the possibility of its lethal sequels, such as gangrene of the bowel, intestinal obstruction, pylephlebitis, etc. It is strange that well-meaning physicians, and even some apparently intelligent surgeons will delay operation, trusting to be warned of impending danger by well-defined symptoms in time to employ an operation, when the best time for operation is before alarming symptoms arise. Only in the very aged, or in those with extremely serious visceral lesions (cardiac or renal) is delay justifiable. Treatment. — The abdomen should be shaved and cleansed and the bladder emptied (by catheter if necessary) as before any abdominal operation. No other preparation is required, but in many cases it is well to empty the lower bowel by enema. Operation. — I prefer, and habitually employ, the transverse incision of G. G. Davis 1 (1906). Other incisions for appendectomy have been described in Chapter XXII. This transverse incision is so planned that its center lies over the right semilunar line, at the level of the anterior superior spine of the ilium. In simple acute cases the incision is from 4 to 5 cm. long (Fig. 923). The skin and subcutaneous tissues are divided, exposing the aponeurosis of the external oblique. This, and the anterior sheath of the rectus are incised in the same transverse direc- tion throughout the inner half of the wound. The muscle fibers of the rectus are thus exposed, and are to be retracted toward the midline. In this way the posterior sheath of the rectus and the transversalis fascia are exposed. The peritoneal cavity is next opened in the usual way, in a transverse direction. The left forefinger is then inserted into the peritoneal cavity, and hooks up the abdominal wall on the outer side of the opening already made. With closed blunt scissors the operator then splits the internal oblique 1 Similar incisions were described by J. W. Elliott (1896), A. E. Rockey (1905), and Chaput (1905). Fig. 923. — Transverse incision for appendectomy; two weeks after opera- tion. Episcopal Hospital. APPENDICITIS 907 and transversalis muscles outward in the direction of their fibers (which here run directly transversely), thus passing parallel to the motor nerves of the abdominal wall. The transversalis fascia and perito- neum are then cut in the same direction, throughout the whole extent of the wound. If more room is needed toward the median line, the anterior and posterior sheaths of the rectus may be incised as far as the linea alba, but the muscle itself need not be cut, as it can be drawn far to the left with a retractor. If more room is needed to the outer side, the oblique and transversalis muscles may be cut as far as the iliac spine, or further if necessary, without any damage to the abdominal nerves (Fig. 931). Some branches of the deep circumflex iliac artery may be cut if the wound is extended outward, but the only muscular fibers which will be cut across are those of the external oblique; but in most cases the incision involves only the aponeurosis of this muscle, not its muscular fibers. Locating the Appendix. — First Method: Place two fingers of the left hand inside the abdominal wound and follow the parietal peritoneum of the anterior abdominal wall downward to Poupart's ligament; then carry the fingers upward along the brim of the pelvis (recognized by the pulsations of the external iliac artery) until they are arrested. The structure which arrests them will be the mesentery of the ileo-cecal region. Usually the appendix can be recognized in this position by the sense of touch, and if not adherent can be drawn out of the abdominal wound between the index and middle fingers. Second method: Pass the fingers of the left hand along the parietal peritoneum on the outer side of the wound, and let them follow the parietal peritoneum inward across the iliac fossa. The structure which arrests them will be the cecum or ascending colon with its mesentery. Draw the cecum into the wound and trace its longitu- dinal bands downward until they converge at the base of the appendix which is then delivered. Third method: This is less brilliant than those just mentioned, but it is the surest method of all. Pack all the abdominal contents to the patient's left, by inserting gauze sponges. When all the movable structures have been thus carried away from the seat of operation, only the immovable will remain. This is the cecum, attached to the posterior abdominal wall by its short mesen- tery. When the cecum is thus found, draw it out of the wound, and trace it downward until the appendix is delivered. Removal of the Appendix. — (1) Pass an aneurysm needle, carrying No. 1 chromic catgut, through the meso-appendix close to the base of the appendix and tie this ligature around the free border of the meso- appendix as far away from -the appendix as possible. If the meso- appendix is very thick or long, it is safer to tie it in two or three sections. (2) Cut the meso-appendix as close to the appendix as pos- sible, thus leaving enough tissue beyond the ligature to prevent its slipping (Fig. 925). (3) Clamp the appendix at its juncture with the cecum, and clamp it again about a centimeter distant. Remove the first clamp and ligate the base of the appendix in the groove crushed 'IDS STRdERY OF THE CASTRO INTESTINAL TRACT by the clamp, using No. 1 chromic catgut (Fig. 920). (4) Cut the appendix between the ligature and the distal clamp. The stump of Fig. 924. — The blood-supply of the cecum and appendix. Fig. 925. — Appendectomy: the meso- appendix has been tied close to the base of the cecum, and then divided close to the appendix. Fig.' 926. — Appendectomy: the base of the appendix has been ligated in the groove made by clamping a hemostat; a second hemostat is left in place. the appendix may be touched with phenol and with alcohol, but this is unnecessary. (5) Insert a purse-string suture of linen thread in the cecum about 2 cm. away from the stump of the appendix (Fig. COMPLICATIONS OF APPENDICITIS 909 Fig. 927. — Appendectomy: the ap- pendix has been cut off, and a purse- string suture has been inserted in the cecum. 927); then cut the ends of the appendicular ligature short, and as the stump of the appendix is pushed inward, tie the purse-string suture, thus completely burying the stump. (6) Look at the meso-appendix to make sure that the ligature has not slipped, and then cut the ligature short. (7) Finally, close the abdominal wound, suturing (a) the peritoneum and posterior sheath of the rectus; (6) the anterior sheath of the rectus and the internal oblique and transversalis muscles; (c) the external oblique aponeurosis. Each layer is sutured with a continuous suture of chromic catgut. Tie any bleeding points in the superficial fascia; and then close the skin wound with a buttonhole suture (Fig. 109) of chromic gut (So. 0). In uncomplicated cases of appen- dicitis no drainage is required, and no special after-treatment is to be pursued. The patient may have hot water, in amounts of 15 c.c. or less, every fifteen to thirty minutes, by mouth, after twelve hours. Liquid diet is begun after twenty-four hours and is continued for three days, when soft diet is allowed. Full diet may be given after the tenth day, when the wound is first dressed and the skin sutures removed. If the bowels do not move spontaneously by the third or fourth day, an enema should be given, and only when this proves ineffectual is a purge required. I prefer to keep my patients in bed at least two weeks, but many surgeons allow them to be up in a week or ten days. If operation cannot be done, then, so soon as a diagnosis is made, treatment should be instituted as already advised for cases of diffuse peritonitis (p. 862). By adherence to the strictest code of the Ochsner treatment, it usually will be possible to prevent the development of widespread peritonitis; but even under the best circumstances, an abscess will form or some other complication develop in about 10 per cent, of cases. Nothing is so surely productive of complications as the administration of purgatives. Complications of Appendicitis. — From a clinical point of view the most frequent complications of appendicitis are abscess, diffuse peritonitis, and gangrene of the appendix. There is no greater fallacy than to suppose, as is done by many physicians, that neither abscess nor peritonitis can occur unless there is a macroscopical perforation of the appendix. Macroscopical perforations are comparatively rare, and even when present usually are of secondary importance to the abscess or the diffuse peritonitis which dominates the clinical picture. The complicated cases of appendicitis under my own care treated by operation may be classified thus: 910 SURGERY OF THE GASTRO-INTESTINAL TRACT Primary abscess in 36 per cent. Residual abscess 12 " Gangrene 17 " Diffuse peritonitis .... 34 " Mortality. 8.4 per cent. 30.0 11.1 12.7 The general mortality for the entire series of complicated cases of appendicitis is 13 per cent. Not one of these patients would have died if operation had been done within twenty-four hours of the onset of the disease, and even those patients among the com- plicated cases who recovered would have been saved the discomforts and prolonged con- valescence attending a drained wound. Primary Appendicular Ab- scess.— This is the least dan- gerous of the complications of appendicitis. The reaction of the peritoneum to the appen- dicular infection is adequate, and the infection remains local- ized to the immediate neigh- borhood of the appendix. The most frequent site of such ab- scess is in the right iliac fossa. Other frequent sites are the pelvis and the right flank or loin, depending upon the posi- tion of the appendix (Fig. 928). An abscess on the median side of the cecum, or among the coils of small intestines is unusual; one Fig. 928. — Usual sites of appendicular abscess: 1, in the right iliac fossa; 2, in the pelvis; 3, in the right kidney pouch. Fig. 929. — Perforated appendix, forming part of an abscess wall; perforation into adhesions. Episcopal Hospital. between the layers of the mesentery of the ileum, or elsewhere in the retroperitoneal tissues, is very rare. In most cases the wall of the abscess is formed by the parietal peritoneum of the iliac fossa, pelvis APPENDICULAR ABSCESS 911 or flank, on one side; by the cecum, adherent omentum or anterior abdominal wall, in front; while its medial wall is formed by omentum or coils of small intestine. The appendix usually forms a part of the abscess wall at some point (Fig. 929), but may lie entirely within the abscess cavity. It may or may not present a macroscopical perforation. Symptoms. — So long as the pus is under tension there are the usual symptoms of toxic absorption, such as elevation of temperature, increase in the pulse rate, and leukocytosis. If a differential count shows more than 90 per cent, of the white-blood cells are polynucleated, it usually indicates the presence of pus provided there is hyperleuko- cytosis. A high white count, with a low polynuclear percentage, indicates poor resistance on the part of the patient. If leukocytosis is not marked and the polynuclear percentage is low, it indicates either that the abscess is completely localized and that no absorption is occurring, or that the patient is overwhelmed by the infection. The clinical picture must be relied upon to distinguish between these two states. When only a small abscess has formed, and has become well localized so that no absorption is occurring, a careless observer may be led to think that the patient has entirely recovered. In such cases secondary leakage of the abscess may occur, resulting in diffuse peritonitis. Fig. 930.— Large appendicular abscess two weeks after onset. X on anterior superior spine of ilium. Outlines of abscess indicated by a drainage tube. Episcopal Hospital. The physical signs present depend upon the duration of the abscess and upon its size. Soon after the formation of an abscess, the rigidity and tenderness so characteristic of appendicitis in its earlier stages may persist to such a degree that recognition of a mass by palpation may be impossible. But by percussion it usually is possible to demon- strate an area of dulness in the right iliac fossa. Such dulness, however, frequently is due to a mass of adherent omentum; and it is not safe to assume that a mass, even if distinct and papable, contains much pus. The quantity of pus may vary from a few drops up to 500 c.c. or more. Seldom does the abscess contain more than 10 to 15 c.c. of pus. Palpation through the rectum may discover a bulging, tender mass in the rectovesical pouch, or in women behind the uterus. Rectal touch is particularly valuable in small children, for in them a large pelvic abscess may pass unnoticed if this examination is neglected. 912 SURGERY OF THE G ASTRO-INTESTINAL TRACT If the appendicular abscess lias been in existence for several days, it usually is possible to define its outlines by palpation, and in cases of very long duration the abscess may be visible at a glance as a large rounded tumor (Fig. 930). Residual Appendicular Abscess. — This is one which forms after the subsidence of diffuse peritonitis caused by appendicitis. It has also been termed a post-Ochsner abscess, because localization of the infection has been brought about by adherence to the" Ochsner treat- ment (p. 862). The pathogenesis, symptomatology, and treatment of these conditions have been discussed in Chapter XXII. Treatment of Appendicular Abscess. — An appendicular abscess should be evacuated, and unless the patient is very gravely ill the appendix should be removed at the same operation. But if it is very difficult to find the appendix, or if it is extremely adherent, it need not be removed. Deaver says it is better to have a live patient with his appendix still in, than a dead patient without one. Operation for abscess should be undertaken as soon as possible after the diagnosis is made. There is nothing to be gained by delay, and in many cases, especially of residual abscess, there is danger that the adhesions limiting the abscess may give aw T ay, and that diffuse peritonitis may follow the leakage of pus. It is the teaching of Deaver, and many surgeons are in accord with him, that it is best always to open the appendicular abscess at the place where it comes in contact with the parietal peritoneum. To my mind there are serious objections to this teaching: (1) in the vast majority of cases there is no way of telling beforehand whether or not the abscess is in direct contact with the abdominal wall, and as a matter of fact in a great many cases no such direct contact exists; (2) in cutting down upon the point where the abscess is supposed to be in contact with the abdominal wall, one cannot be sure that he will not extend his incision too far in one direction or the other and so trespass upon uninfected peritoneum at the same moment that he gives exit to the pus, thus running the grave risk of spreading infection within the peritoneum; (3) in an endeavor to prevent this error in tech- nique it is necessary to make a funnel-shaped wound in the abdominal wall — very large in its superficial part and very small in the depths; the surgeon has to work in a confined space at the bottom of a deep wound; often the appendix cannot be found, and a second operation is necessary to remove it; and in any event the large wound (made fortuitously according to the site of the abscess, and not with respect to the anatomy of the abdominal wall) must be left open almost in its whole extent, and post-operative hernia is the rule; (4) last, but by no means least, in evacuating an abscess in this way the surgeon cannot be sure that he has not ruptured the abscess wall on the opposite side — that toward the general peritoneal cavity — thus causing leakage of pus into uninfected areas. Only when the abscess is almost ready to burst through the abdominal wall, or rarely through the rectum, and the patient is gravely ill, am I in the habit of incising directly into the GANGRENOUS APPENDICITIS 913 abscess cavity. In such cases, which are mostly residual abscesses, I make no attempt to remove the appendix at the first operation, which need consume only about five minutes and may be done under local anesthesia or under nitrous oxide. In the ordinary cases of appendicular abscess I believe, with Murphy, that it is much safer first of all to open the healthy peritoneal cavity on the median or upper side of the abscess mass, and to isolate the entire diseased area by gauze packs. Then one may extend the incision to as great a length as seems desirable (Fig. 931); and, after evacuating the ab- scess at leisure and with perfect control of the infective material, may complete the operation by removal of the appendix, and may close the greater part of the abdominal wound, leaving only sufficient space unsutured for the emergence of the drains. With such treatment hernia is a very rare sequel, and no sec- ondary operation is required. In all operations for appendic- ular abscess the surgeon should make sure that no pelvic collec- tion of pus is overlooked. This is determined by passing a glass tube, along the fingers as a guide, to the bottom of the pelvis; through the lumen of the glass tube a rubber tube is then inserted to the floor of the pelvis, and by means of a syringe attached to its outer end suction is exerted, and any fluid in the pelvis will be drawn into the syringe. If the abscess occupies the iliac fossa or loin, and no pus is found in the pelvis when it is explored as just indicated, it will be safe usually to be content with drainage extending only to the base of the appendix and the site of the abscess cavity. In cases where pus has been found in the pelvis, or in other cases if there is any uncertainty as to the efficiency of the drainage, it is proper to drain the pelvis also. For this purpose a rubber tube suffices, and acts as a better drain than does a wick of gauze. The drain should emerge at the outer angle of the transverse incision, or at the lower angle of a longitudinal wound. The drain should not be removed for at least four days, and it is better then to siiorten it by degrees. Too early removal of the drainage frequently leads to the damming up of pus and the formation of a residual abscess. Though such collections usually can be opened by inserting a finger into the wound, without a general anesthetic, sometimes formal operation is necessary. Gangrenous Appendicitis. — Though an appendix associated with an abscess or with diffuse peritonitis frequently is necrotic wholly 58 Fig. 931. — -Very large transverse incision in a case of appendicular abscess, drained from its outer end. Two months after opera- tion. Episcopal Hospital. 014 SURGE in' OF THE G ASTRO-INTESTINAL TRACT or in part, there is a clinical distinction between such cases and those classed as gangrenous appendicitis. In the latter class, necrosis of the appendix occurs with such rapidity, usually as the result of vascular thrombosis, that no adequate peritoneal reaction develops, and the necrotic organ lies free from limiting adhesions or protecting omentum in an almost normal abdomen. Unless such an appendix is removed promptly, it will separate as a slough from the cecum and fecal extravasation will cause very severe septic (toxic) peritonitis, often costing the patient his life. There are no certain symptoms by which the occurrence of gangrene may be recognized; but sudden cessation of pain, especially if extreme tenderness persists, should make one suspect the occurrence of gan- grene. The fact that gangrene has occurred, thus checking absorption of toxins, may also explain rather abrupt disappearance (unfortunately only temporary) of systemic symptoms of infection. The only efficient treatment is immediate removal of the appendix. It is wise to drain the wound in every case. Diffuse Peritonitis. — The pathogenesis, symptomatology, and indications for operation have been discussed at p. 857. In cases deemed suitable for operation, the surgeon must aim to make the operation as short as possible. After opening the peritoneum, the appendix is sought, and if readily found is brought into the wound and removed. Then a glass drainage tube is passed to the bottom of the pelvis, and any fluid which has collected there is removed by suction as described under the treatment of pelvic abscess (p. 913). If the head of the operating table is raised after evacuating the pelvis, the fluid which lay in the patient's flanks will trickle over the brim of the pelvis and may be removed thence by suction. A gauze wick is carried down to the pelvis behind the glass tube, and both the glass tube and the gauze wick are allowed to remain for drainage. The patient is returned to bed in the head high position, and the usual treatment for peritonitis (p. 862) is continued. The glass tube should be exhausted once or twice daily, and at each dressing should be rotated slightly so as to prevent its fixation by adhesions. When the discharge ceases to be purulent, usually about the third or fourth day, the glass tube should be substituted by one of rubber. The rubber tube should be inserted as far as the floor of the pelvis through the lumen of the glass tube, w T hich is then withdrawn over it ; if the glass tube is with- drawn before the rubber tube is in place, the drain tract will collapse and it will be impossible to insert the rubber tube. The gauze w T ick is removed from the fourth to the tenth day, and the rubber tube is gradually shortened, allowing the sinus to heal by granulation. If the appendix is not removed at the first operation, the patient should be strongly urged to have this done so soon as convalescence is complete. The frequency of second attacks of appendicitis is great, and they are attended by all the dangers of the first. Even should no such acute attacks occur, the presence of the diseased organ and of the adhesions which surround it often seriously impairs the patient's TUBERCULOSIS OF THE APPENDIX 915 comfort and may render him a semi-invalid; moreover, the appendix may undergo malignant change. Chronic Appendicitis. — The pathogenesis of this condition was dis- cussed at p. 901. The symptoms are many and various. Pain is the most constant symptom and is one without which the diagnosis cannot be made accurately. In most cases the pain is localized to the region affected, but it may be referred through the pull of adhesions to various parts of the abdomen. Gastric dyspepsia is frequent, and may be the predominant symptom. The stomach, as W. J. Mayo points out, is the mouth-piece of the gastro-intestinal tract. Disorders anywhere in this tract are constantly calling attention to their pres- ence through disorders of the stomach. This is true, of course, espe- cially of gastric and duodenal lesions; but it is equally true of gall- stones and of chronic appendicitis, as well perhaps as of other less frequent lesions. The characteristics of the dyspepsia due to chronic appendicitis are sufficiently distinct to enable a diagnosis to be made in most cases. The gastric symptoms occur with no regularity as regards ingestion of food, nor is relief obtained by eating. Indeed, eating usually aggravates the indigestion, but with no constancy or regularity. The patient complains of general abdominal pain, mostly below the umbilicus. The patient usually is about thirty years of age. Patients past thirty-five years much more often suffer from dyspepsia due to gall-stones, and those past forty years from that due to gastric ulcer or its sequels. Apart from the symptoms of chronic appendicitis, a good deal of reliance should be placed on the history of the case, and particularly on the physical examination. Usually there will have been one or two attacks of abdominal pain or distress sufficiently acute to have laid the patient up for a day or so, even if not so acute as to have been recognized at the time as attacks of appendicitis. Even when such a history is lacking, deep palpation of the abdomen over the right iliac fossa almost invariably detects marked localized tenderness even when none is complained of by the patient. Chronic appendicitis must also be differentiated from ureteral calculus (p. 1035). Treatment. ■ — The treatment of the disease consists in removal of the appendix. Often this contains a fecal concretion, and evi- dences may be found of past inflammation within the appendix (strictures, obliteration of its tip), or without it (peritoneal adhesions, kinks, etc.). Primary Carcinoma of the Appendix is found in less than 1 per cent, of cases which come to operation or necropsy. Without microscopical examination the lesion usually is overlooked. It causes no symptoms which suffice to distinguish it from chronic appendicitis, with which it often is associated. Its frequency is an argument for the removal of the appendix as an incident in the course of other abdominal operations. Tuberculosis of the Appendix is scarcely less frequent than carci- noma. If any symptoms are produced they are indistinguishable from 916 SURGERY OF THE GASTRO-INTESTINAL TRACT those of chronic appendicitis, except when the tuberculous infection has spread so far as to give rise to the clinical picture of tuberculosis of the peritoneum (p. 866). The appendix should be removed unless the disease is so widespread as to make this unusually difficult. Intussusception of the Appendix has been recorded in a few cases. The symptoms are those of acute appendicitis and the treatment is the same. SURGERY OF THE STOMACH AND DUODENUM. Gastric and Duodenal Ulcer. — It is probable that these ulcers, as well as others in the gastro-intestinal tract, are toxemic in origin. In practically all toxemias there are gastro-intestinal ulcers, and in practically all cases of gastro-intestinal ulceration there is present some form of toxemia (Dieulafoy, Gandy, 1899). The toxemia is of infectious origin, and the infection may arise in a chronically inflamed appendix, in the biliary tract, or in some other situation which is readily overlooked. Oral sepsis usually is present, and no doubt has etiological relation; constant swallowing of pathogenic microbes impairs the vitality of the stomach, and its acid secretions render it more vulnerable. Mechanical indigestion, from rapid eating ("bolting" unmasticated food), is another important cause. The earliest stage in these gastro-intestinal lesions is ecchymosis; then follow hemorrhagic infarct, slough, and hemorrhagic erosion; next is developed the "exulceratio simplex" of Dieulafoy; then comes the true ulceration with hemorrhagic borders; and then the final stages, perforation, chronic ulcer with thickened border and little tendency to heal, or a cicatrix. These local effects probably are due to the action of hemorrhagins , which erode the endothelial lining of the bloodvessels, and of mucolysins, which destroy the gastric mucosa. Ecchymosis, the first stage, is produced by hemorrhagins alone; when mucolysins also act an erosion is produced, and in time a fully developed ulcer will be formed, unless anti-bodies are formed by the organism to hold these cytolysins in check (Hort, 1908). These ulcers are not formed alone in the stomach and duodenum though they are most frequent here. Other similar lesions, not so apt to produce symptoms, may exist in the jejunum or ileum or large intes- tine, but they are comparatively rare. In the mucous membrane of the stomach there are small collections of lymphoid tissue, and these are in greatest number along the lesser curvature and in the pre- pyloric region. It seems not improbable that inflammation of these structures, occurring in general infections, may have an etiological relation to gastric and pyloric ulcer. An ulcer in the stomach or duodenum, when once formed, is diffi- cult to heal, partly owing to trauma from ingested food, and to want of rest due to constant peristalsis, but largely owing to chemical changes in the gastric secretions, producing hyperacidity} 1 Normally it requires from 55 to 65 c.c. of decinormal sodium hydroxide solu- tion to neutralize the acidity in 100 c.c. of gastric contents. A figure over 70 is indicative of hyperacidity, and one under 50 of hypoacidity. GASTRIC AND DUODENAL ULCER 917 Duodenal ulcers are more frequent than gastric (as 3 to 2), and of gastric ulcers those near the pylorus and along the lesser curvature of the stomach are much the most frequent. At first "acute," "round," or "open" in type, the ulcer through long duration becomes callous, with thickened borders; and if healing finally occurs, in part or wholly, the resulting cicatrix will distort the stomach, and perhaps cause pyloric stenosis. Acute Gastric Ulcer and Duodenal Ulcer, are rather frequent in this country. They affect especially anemic young people, especially women, from eighteen to twenty-five years of age, and are as much a symptom of their disease as the anemia itself. They are apt to give rise to hemorrhage and to 'perforation. The ulcers usually are multiple; are round; appear punched out of the gastric wall; and usually are from 0.5 to 1 cm. in diameter. Symptoms. — The characteristic symptoms are severe burning pain soon after eating, relieved by evacuation of the stomach either through the pylorus or by vomiting. The pain seems to be due to the increased acidity of the gastric juice caused by the process of digestion, as well as to peristaltic movements and mechanical trauma by the food. There is hyperacidity even of the empty stomach . Antacids thus relieve the pain. An area of tenderness in the epigastrium is commonly pres- ent, usually to the right of the median line; sometimes a similar tender area is found just to the left, more rarely the right of the last two dorsal vertebra?. Vomiting is frequent, often being self-induced to relieve pain. The vomitus often is streaked with blood, and quite independently of the ingestion of food hematemesis may occur. Pro- fuse and prostrating hemorrhage usually is due to an erosion or an exulceration ; more moderate bleeding, especially if frequently recur- rent, generally is due to the round open ulcer. Chronic Gastric and Duodenal Ulcer; Cicatrizing or Callous Ulcer. — This may be a later stage of the open ulcer already described, but it seems clinically often to have been chronic from its commencement, whatever its pathological origin. It is a much more frequent disease in this country. It is this type of ulcer which is more often duodenal than gastric. Mayo has established the position of the pyloric vein as the dividing line, and classes the portion of the duodenum above the bile papilla as gastric rather than intestinal in nature. The ulcer, which usually is single, has thickened borders, and is quite irregular in outline. Cicatrization leads to contraction, and pyloric stenosis (p. 922) is the most frequent result. If the ulcer is situated on the lesser curvature, it often extends on both anterior and posterior walls of the stomach (saddle ulcer) ; and its cicatrization may produce hour-glass stomach (p. 923). The chronic inflammatory changes around the periphery of the ulcer are thought by some to be forerunners of carcinoma of the stomach (p. 925). Symptoms. — These last a long time before relief is sought from surgery, so that the patients usually are thirty-five to forty years of age or older when first seen. The affection is commoner in men 918 SURGERY OF THE GASTRO-INTESTINAL TRACT than in women. Symptoms of dyspepsia overshadow everything else. These dyspeptic attacks, characterized by flatulence, pain, palpitations of the heart, epigastric distress, belching, sour eructa- tions, nausea and even vomiting, occur in periods which last several weeks at a time. During the intervals the patient suffers less, and is sometimes free from symptoms. The pain and distress do not begin until three or four hours after meals, and are relieved by ingestion of more food (hunger- pain of Mayo Robson). This is because the excess of acid is neutraliz.ed by food. Patients are unwilling to go without food for more than a few hours at a time. This constant and regular recurrence of gastric dyspepsia several hours after meals is particularly characteristic. The dyspepsia due to chronic appendi- citis (p. 915) is both inconstant and irregular in its occurrence, and is not relieved by eating. In chronic gastric or duodenal ulcer, how- ever, the distress from indigestion may finally become so extreme, that a patient will be unable to eat his full meals. He may be reduced to carrying a bottle of milk around with him, taking a sip every little while, to relieve the burning sensation in his stomach. Hemorrhage, as has been remarked, is less usual in chronic than in acute ulcer, and rarely is large in amount. If the ulcer is duodenal, blood in the stools (melena) is more frequent than hematemesis; the bleeding may be occult or visible to the naked eye. Physical examination is of much less assistance at this stage of the disease, than later, when pyloric obstruction has developed. Tender- ness is rather diffuse; and occasionally a mass may be felt in the pyloric region, and may be mistaken for carcinoma. Roentgenologists place much confidence in their ability to detect even minute ulcers by fluoroscopy or by innumerable plates taken in series. In the nor- mal stomach the peristaltic waves occur regularly and are not inter- rupted in their course. A lesion anywhere on the lesser curvature will interrupt these waves, because it produces a spastic contraction of the neighboring gastric wall. The crater of the ulcer may be visible as a niche in the gastric wall; and any distortion of the normal outline of the first portion of the duodenum should be regarded w r ith suspicion. But unless the surgeon has available the advice of a really expert roentgenologist, he will do well not to attach too much importance to gastric diagnoses based on the use of the .r-rays. Prognosis and Treatment of Gastric and Duodenal Ulcer. — Hemor- rhage kills about 5 per cent, of patients, and perforation about 15 per cent. Of the 80 per cent, which remain, prompt, efficient, and pro- longed medical treatment will cure perhaps three-fourths; but this cure seldom is permanent. From 30 to 50 per cent, of patients so cured have relapses, and though they may be "cured" a number of times by resort to medical treatment, the cure usually is attained with greater difficulty and is less lasting, after each new relapse. Mean- while the patient is subjected to the danger of hemorrhage and per- foration; and the development of pyloric stenosis, hour-glass stomach, or carcinoma is the usual termination in those patients who survive. GASTRIC AND DUODENAL ULCER 919 Medical treatment aims to encourage healing of the ulcer largely by reducing the acidity of the gastric juice. This is accomplished by regulation of the diet and the ingestion of antacids. Surgical treat- ment aims to effect a cure either by excision of the diseased structures, or by altering the composition of the gastric juice more or less per- manently by admitting the alkaline duodenal secretions (bile and pancreatic juice) into the stomach through a gastro-intestinal anasto- mosis. The latter method, which still is more widely employed than excision, and which is more widely applicable, is attended by an opera- tive mortality of 3 per cent., or less, in the hands of skilled abdominal surgeons; and from 75 to 80 per cent, of the patients who recover are permanently relieved of symptoms (Deaver and Ashhurst). It is generally conceded, therefore, in patients whose symptoms recur after one or several "medical cures," that surgical treatment is indi- cated; and especially is this true of patients with recurring hemor- rhage. Perforation of course calls for immediate operation. Operation. — If the stomach is not bound down by adhesions, removal of the entire ulcer-bearing area (Rodman, 1900), as in cases of car- cinoma, is preferred by many surgeons; this is especially desirable when there is much inflammatory thickening around the base of the ulcer. The technique of this operation (partial gastrectomy) is detailed at p. 933. Excision of an isolated ulcer may also be done. In both cases a complementary gastrojejunostomy is done. The mortality, even in skilful hands, is higher than that of simple gastro- jejunostomy (p. 930), and I believe in most cases the latter operation is to be preferred, unless the stomach is freely movable or unless carcinoma is suspected. If there is no pyloric stenosis Fin- ney's method of pyloroplasty (p. 930) will accomplish as much as gastrojejunostomy, and is to be preferred under these circumstances. It is well also to invert the ulcer by a few sutures, as a prophylactic against subsequent perforation. Perforation of Gastric or Duodenal Ulcer. — In most cases, unless the patient is too ill to talk, he gives a history characteristic of the disease. Perforation may be acute, subacute, or chronic. An acute perforation is one which occurs into the free peritoneal cavity, the base of the ulcer having been unprotected by adhesions. A subacute perforation is one which occurs into such protecting adhesions. A chronic per- foration occurs into an adherent viscus, such as pancreas, liver, colon, gall-bladder, etc. Acute perforation is characterized by very sudden, extremely severe epigastric pain, often attended by shock. The patient doubles up with pain, clutching at his abdomen, and even after being got to bed may be found rolling around in agony, groaning constantly and secur- ing no relief. Vomiting may or may not occur. Collapse is recognized by the anxiety of countenance, the cold and clammy surface, the sudden pallor and the guarded breathing. The pulse is feeble but may be either slow or rapid at first. The abdomen presents truly a " board-like" rigidity, and as a consequence deep palpation is valueless. 020 SURGERY OF THE G ASTRO-INTESTINAL TRACT If the patient is not seen soon after the occurrence of perforation, the effused gastric contents may have travelled down the right flank to the cecal region, and the case may be mistaken for appendicitis. After six or eight hours, the abdomen becomes distended, secondary vomiting commences, the pulse quickens and becomes more feeble, and other signs of diffuse peritonitis (p. 857) arise. Treatment consists in immediate laparotomy through the upper right rectus, and suture of the perforation, which usually is near the pylorus. If suture is impossible, the perforation should be tamponed with gauze. If operation is done within a few hours of perforation and especially if suture stenoses the pylorus, or if the sutures tear out, posterior gastrojejunostomy should be done at the same time. In many early cases the abdominal fluid is sterile, particularly if per- foration occurred in a fasting stomach, and perhaps because of the hyperacidity of the gastric juice; but in all cases the pelvis should be drained (through a suprapubic incision) as well as the upper abdominal wound. Subsequent treatment is the same as after any operation for diffuse peritonitis. If operation is done within the first few hours of perforation, the mortality is only about 15 per cent.; if postponed, the death rate rises to 33 and to 50 per cent. Subacute Perforation may be attended by the same type of symp- toms, though less severe, as in acute perforation; or the condition may be found unexpectedly at operation for the underlying disease. If a subacute perforation is suspected in such a case, it is safer to do gastrojejunostomy without disturbing the adhesions more than is necessary. It may be very difficult to secure efficient closure of such a perforation by suture. In chronic perforation no additional symptoms are produced at the actual moment when the gastric wall ceases to form the floor of the ulcer and its place is taken by pancreatic tissue or by firm fibrino- plastic material, so that the symptoms which first call attention to the changed condition are not those of perforation nor of peritonitis, but of sepsis due to some form of perigastric or subphrenic abscess, or to some internal fistula. Treatment involves drainage of such an abscess and operative cure of the gastric lesion. Hemorrhage in Gastric and Duodenal Ulcers. — The diagnosis usually is not difficult, but a diagnosis of gastric ulcer has been made in cases of bleeding from esophageal varices. Treatment during continu- ance of bleeding should be purely medical : morphin hypodermically, an ice bag to the epigastrium, and nothing whatever by mouth. Operation at this time is too dangerous to be recommended; the mor- tality is from 60 to 80 per cent. When the hemorrhage has ceased, however, and the patient has regained some measure of health, opera- tion should be done to cure the ulcer. Especially important is this when repeated hemorrhage occurs. Pyloric Obstruction. — This includes three distinct affections: Infantile Pyloric Stenosis; Pylorospasm; Gastric Dilatation. PYLORIC OBSTRUCTION 921 Infantile Stenosis of the Pylorus (Hirschsprung, 1888) .'—The baby usually is healthy at birth, but within a week or so develops the con- dition described as hyperemesi* lactantium. Unless arrested, the affection progresses until gastric peristalsis can be seen through the emaciated abdominal wall, and a pyloric tumor can be felt. The obstruction usually is due to excess of muscular tissue about the pylorus. The cause of this change is not certain, but probably is hypertrophic. In some cases medical treatment brings relief before complete obstruction develops; but unless loss of weight is checked very soon operation should be done. Rammstadt's 'pyloroplasty (1912) is the operation usually employed: an incision through the pyloric mass from stomach to duodenum is made down to but at no point opening the mucosa; the thickened muscular wall is gently pushed away from the mucosa by blunt dis- section, until the mucosa pouts into the incision, and the abdomen is closed. No sutures are employed in the pyloric incision. If injury to the mucosa is avoided, the mortality is very low (10 to 12 per cent, in the hands of Downes, Matthews and others) and uninterrupted recovery is the rule. Pylorospasm. — This is an intermittent or constant contraction of the pyloric sphincter, attended by more or less evident symptoms. It is itself only a symptom of a lesion which may be in the stomach or elsewhere. Pylorospasm not infrequently accompanies gallstone colic or appendicitis. In many cases the pain is not very great, amounting merely to a lively sense of discomfort in the epigastric region, and being overshadowed by symptoms of "peristaltic unrest of the stomach" (Kussmaul, 1880): when the pylorus contracts spasmodically the stomach meets with an insuperable obstacle to its evacuation; peristaltic unrest ensues, flatulence develops from fer- mentation and from swallowed air; and, finally, when the limit of endurance is reached, the pylorus relaxes and gastric contents pass out into the duodenum or the patient is relieved of his distress by vomiting. Secondary gastric dilatation may ensue. Treatment is that of the causative condition. Gastric Dilatation. — Acute Dilatation of the Stomach (Hilton Fagge, 1872) is met with as a complication in various infectious diseases, notably typhoid fever and pneumonia; as well as after some operations, not always involving the abdomen. Though not caused by pyloric obstruction, it seems best to mention the condition in this place. The stomach fills nearly the whole abdomen, and the site of apparent obstruction usually is found at or near the duodenojejunal angle. A physiological fact pointed out by Kelling (1900) may have some bearing on the condition: this is that so long as the duodenum is distended the stomach is unable to empty itself. Many surgeons still support the theory of Hanau-Albrecht (1899), that acute dilatation 1 In, 1917 I described an analogous condition occurring at the ileo-cecal valve. 922 SURGERY OF THE G ASTRO-INTESTINAL TRACT of the stomach is caused by constriction of the transverse duodenum by the superior mesenteric artery, from the drag of the small intestines (gastro-mesenteric ileus). Vomiting is profuse and repeated, and there is little nausea; immense quantities of fluid are brought up in this way, demonstrating hyper- secretion by the stomach. Gaseous distention is extreme, and the outlines of the stomach may be recognized through the abdominal wall. When the stomach tube is passed there is an abundant escape of odorless gas, with a gushing or gurgling sound, at times almost an explosion. Marked flattening of the abdomen follows this evacuation, but soon the stomach refills with fluid and air. Signs of collapse, largely due to deprivation of the tissues of so much liquid, quickly follow. Occasionally spontaneous relief occurs, and profuse diarrhea ushers in convalescence. Treatment. — Treatment consists in repeated use of the stomach tube ; and in placing the patient prone or on the left side, with the foot of the bed elevated, with a view to overcoming an obstruction at the duodenojejunal angle. Or the patient may assume the knee-chest posture. Operation to relieve a kink, or to perform gastrojejunostomy should be the last resort. Secondary Gastric Dilatation. — This is not a distinct disease, but is the terminal stage of some preexisting disease which causes pyloric obstruction. The most frequent causes are carcinoma, chronic gastric or duodenal ulcer, or perigastric adhesions usually due to disease of the biliary tract. Benign pyloric obstruction usually is due to contraction of ulcers near the pylorus. Occasionally in the earlier stages of ulceration such hyperplastic reaction occurs as to cause temporary obstruction of the pylorus; if gastrojejunostomy is done at this stage the pylorus may subsequently become patulous, just as it might have done if no operation had been employed. But when cicatricial stenosis once develops the prognosis is hopeless with- out operation. Symptoms. — Three stages are recognized: In the stage of compensa- tion it is only after an unusually heavy meal that distress is experi- enced; gaseous distention becomes oppressive, the clothing is perhaps unconsciously loosened, and relief eventually is obtained by the belching of gas and the eructation of a little sour fluid. Finally the wearied stomach empties itself into the duodenum. This stage may last for months or years, but eventually the stage of stagnation is developed: here the stomach is unable completely to evacuate its contents between meals, except in the long interval at night. A sense of fulness persists from one meal to the next, and anorexia develops. Weight may not be lost, but none is gained. In the stage of retention emaciation commences and may become extreme. The stomach is not emptied even during the night; lavage before breakfast will detect food particles still in the stomach, and the gastric contents will be sour, rancid, and usually very acid. The evidences of fermenta- tion are pronounced, and production of gas may continue after the HOUR-GLASS STOMACH 923 stomach contents have been removed, as is evidenced by their separa- tion into three typical layers on standing. Because fluids are not absorbed from the stomach, and because in this stage they are late in reaching the small intestine, if they reach it at all, there is more or less constant thirst. As retention becomes extreme, the stomach occasionally makes an attempt to empty itself by the act of vomiting; though generally incomplete evacuation is secured, temporary relief is obtained. Copious and cumulative vomiting which occurs every few days is very good evidence that the stomach is dilated. Occa- sionally tetany occurs. Constipation usually is marked. Physical Signs. — The capacity of the stomach is seen to be increased not only from the large amount of the vomitus, but by lavage. Skiag- raphy at various intervals after the ingestion of an opaque meal will demonstrate the gastric retention, and dilatation. The greater curvature almost always is below the umbilicus and may reach to the pelvis. The stomach may be cautiously distended with air by a hand bulb attached to the stomach tube. The outlines can then be deter- mined by percussion. Diagnosis. — The diagnosis is based on a history indicative of a previous disease which might cause pyloric obstruction, and upon the existence of the symptoms and physical signs mentioned above. In gasiroptosis , though the stomach may be dilated, there is no clinical history characteristic of gastric ulcer or gall-stones. Prognosis and Treatment. — This is the terminal stage of a serious disease. Gastric dilatation due to benign obstruction is less serious than gastric carcinoma only because patients with the former disease die more slowly than do those with cancer. Cancer usually kills in a shorter time, but death in benign dilatation is quite as sure even if longer delayed. The starvation is slow, and it is barely possible that the patient will not recognize the fact that he is starving to death; yet he should be told that surgery affords the only escape from death. A measure of comfort may be secured, in the earlier stages, by periodic gastric lavage and careful regulation of diet ; but no true improvement takes place. The choice of operation lies between gastrojejunostomy, which is preferable in most cases; partial gastrectomy, which is indi- cated if malignancy is suspected; and some form of pyloroplasty, which is not to be recommended except in patients whose pylorus is stenosed without marked thickening. Hour-glass Stomach. — As more than two pouches may exist, the term segmented stomach (Wolfler, 1895) is preferable, though little used. The deformity usually is the result of contraction of an ulcer, but perigastric adhesions may be the cause, or even carcinoma (Fig. 932). The pouches may be of various sizes, or diverticula may exist. The symptoms seldom can be distinguished from those of pyloric obstruction, which often is present as an additional complication; and the diagnosis depends chiefly on the use of fluoroscopy, by means of which a constant, persisting constriction can be recognized. Treat- ment consists in some form of operation to overcome the obstruction. 024 SURGERY OF THE G ASTRO-INTESTINAL TRACT In gastroplasty (Fig. 933) an incision is made through the constriction in the long axis of the stomach and is sutured transversely; the opera- Fig. 932. — Hour-glass stomach from carcinomatous "saddle" ulcer on lesser curvature, with perforation; death from peritonitis (half natural size). (Deaver and Ashhurst.) Episcopal Hospital. Fig. 933. — Gastroplasty. Ashhurst.) (Deaver and Fig. 934. -Gastro-gastrostomy. and Ashhurst.) (Deaver tion is analogous to pyloroplasty (p. 930). In gastro-gastrostomy (Fig. 934) a lateral anastomosis is made between the adjacent pouches. Gas- tro-anastomosis (Fig. 935) is anal- ogous to Finney's pyloroplasty (p. 930). In the majority of cases gastrojejunostomy in the cardiac pouch is to be preferred to the oper- ations just mentioned. As the car- diac pouch may be so small as to pass unperceived, the entire stom- ach should be examined before any operation is done. If pyloric stenosis also is present, it may be -Gastro-anastomosis. (Deaver . , , , . . and Ashhurst.) necessary to do pyloroplasty in Fig. 935. CARCINOMA OF THE STOMACH 925 addition, or even to make a second anastomosis, between the jejunum and the pyloric pouch. Plastic Linitis (Cirrhosis of the Stomach, Zuckergussmagen, Magen- schrumpfimg, etc.) — This is a diffuse sclerosis of the stomach, especially of the submucous tissues, leading to marked thickening of the gastric walls and diminution in the capacity of the stomach. It may be benign or malignant in nature, and probably may arise in several different diseases, such as carcinoma, syphilis, polyserositis, lymphatic obstruction, etc. Thomson and Graham (1913) reviewed the sub- ject at some length, and prefer to term the condition a "fibroma- tosis." If the change is recognized early enough, partial gastrectomy may be attempted; as a palliative measure gastroenterostomy may be done, or even duodenostomy or jejunostomy. Gastroptosis. — See Visceroptosis, p. 953. Carcinoma of the Stomach. — This is a very frequent disease, but it seldom is recognized in time to save the patient's life. Cancer of the stomach presents clinically two forms. In one a patient past middle life, without having suffered previously from indi- gestion, suddenly loses appetite, especially for meats, grows pro- gressively weaker and more emaciated, develops epigastric pain and possibly a palpable mass, becomes subject to vomiting spells every few days, which bring up a quantity of coffee-ground material, foul smelling and fermented; and quickly develops the cancerous cachexia. This is the classical picture of gastric carcinoma, and it is still that most frequently seen. It is less usual to find carcinoma in patients who have been long sufferers from dyspepsia. The studies recently announced by the pathologists of the Mayo Clinic, tending to show that in 75 per cent., or more, of cases of gastric carcinoma this lesion developed as a complication of a preexistant simple ulcer, have not been accepted by other pathologists; and Judd (1918) states that it is now generally accepted that nearly all gastric cancers have been malignant from the beginning. Pathology. — Carcinoma of the stomach occurs oftenest between the ages of forty and seventy years, and affects the sexes about equally. The growth occurs at the pylorus in about 60 per cent., and at the lesser curvature in about 10 per cent, of cases. Carcinoma of the body or fundus is rare. Histologically three types of gastric cancer are recognized: (1) Spheroidal-celled carcinoma, composed of cells like those normally lining the gastric tubules; (2) Cylindrical-celled or adeno-carcinoma, composed of cells similar to those normally lining the gastric glands; and (3) Colloid carcinoma, a tumor whose chief characteristic is myxomatous degeneration of epithelial cells and stroma, which may occur either in the spheroidal-celled or cylindrical-celled varieties. Clinically carcinoma may be classed as scirrhous or medullary. Lymphatic extension occurs early. The main paths invaded are indicated in Fig. 936. Our knowledge of these lymphatics is due almost entirely to Cuneo (1900), and to Jamieson and Dobson (1907). 926 SURGERY OF THE GASTRO-INTESTINAL TRACT ( larcinoma, beginning as it usually docs along the lesser curvature close to the pylorus, invades first the lymphatics along the lesser curvature, even up to the coronary artery close to the cardiac orifice of the stomach. Hence it is evident that every radical operation for gastric cancer must remove the entire lesser curvature of the stomach. More- over, so soon as the carcinoma is at all extensive, the lymph nodes in the gastro-colic omentum, for a variable distance away from the pylorus, are involved. Therefore Hartmann's line for gastrectomy (1901) was made to pass from the coronary artery to a point directly below it on the greater curvature (Fig. 941). A third point of the greatest importance is that whereas the carcinomatous invasion extends rapidly and for an indefinite distance away from the pyloric region of the stomach, it invades the duodenum only rarely. The removal Fig. 936. — Paths of lymphatic extension in carcinoma of the stomach. After Jamieson and Dobson. of the first 2.5 cm. of the duodenum nearly invariably enables the surgeon to get beyond the limits of the growth. Palpable indura- tion stops with the area of mucosa involved, but in the submucosa the invasion will have advanced considerably further. The resection must extend from 5 to 8 cm. away from the macroscopical tumor on the cardiac side of the growth, and from 1.5 to 2 cm. from it on the intestinal side. Early lymphatic extension, according to Jamieson and Dobson, also occurs along the pyloric and hepatic arteries to the suprapancreatic lymph nodes. Apart from the lymph nodes, gastric carcinoma extends oftenest to the liver, which is affected in one-third of the cases examined at autopsy. This invasion occurs along the radicles of the portal vein. In scirrhous carcinoma, and in all forms which cause marked pyloric stenosis, invasion of the liver is long delayed. Invasion of the great omentum may be followed by grafting of cancer cells on the pelvic CARCINOMA OF THE STOMACH 927 organs. Invasion of the left supraclavicular lymph nodes, by permea- tion along the thoracic duct, is a very late sign. Symptoms. — Early diagnosis from symptoms alone is so difficult as to be usually impossible. Almost always, by the time classical symptoms have developed, the disease has passed beyond the stage curable by excision, which is the only means of cure at present known. Pain, vomiting, and tumor; loss of weight, anemia, and changes in the gastric secretion are the classical symptoms. But their develop- ment is so late that they do not bring the patient to the surgeon in a curable stage. Carcinoma should be suspected when chronic gastric catarrh exists without any discoverable cause (such as abuse of food, of alcohol, or of drugs; circulatory disturbances of the heart or liver; or diseases such as cholelithiasis, gastric ulcer, etc., which cause definite lesions in the region of the stomach) ; especially if the chronic gastritis is in a patient over forty years of age, and if it is attended by loss of appetite for meats. If a tumor exists, the diagnosis is less difficult; but the tumor must be distinguished from a distended gall-bladder, from a growth of the colon, pancreas, etc. In obscure cases distention of the stomach with air should not be neglected; this may render a hidden tumor pal- pable, and the characteristic shape of a pyloric growth (apex toward the duodenum and indistinct base toward the body of the stomach) frequently can be recognized (Kocher). Occult blood in the stomach contents and feces is the most valuable of the laboratory findings. In non-malignant ulcerations of the stomach, rest in bed with milk diet will cause the disappearance of occult blood. In cancer no treat- ment has any effect (Deaver and Ashhurst). Especially characteristic of carcinoma, roentgenologically, is a "filling defect" in the outline of the stomach, but this also, when marked, is only a late sign. Yet W. J. Mayo writes (1918) "cancers of the stomach may be demon- strated in 95 per cent, of cases in this way by the time they give sufficient evidence of their presence to call the patient's attention to the fact that something is wrong." Inoperability may be as readily detected by the .r-ray as by an exploratory operation (Beckman, 1915). Diagnosis. — The diagnosis can be only surmised in most cases still in the operable stage; only when the abdomen has been opened (and not always then) can the surgeon be sure carcinoma is present. If a distinct tumor is present, it generally can be recognized as carcino- matous by its irregular shape, its "knotty" feel, and by diffused indura- tion into surrounding structures. Treatment. — ^Yhenever there is evidence of an anatomical lesion in the stomach which is not relieved by a few weeks of judicious medical treatment, exploratory operation should be undertaken even though an exact pathological diagnosis of the lesion has not been reached. Partial gastrectomy (p. 933) should be done even on sus- picion of malignancy. The immediate mortality of this operation is about 25 per cent, in the hands of the average surgeon; even in the hands of Robson, Mayo, Deaver, and other skilled abdominal surgeons 928 SURGERY OF THE G ASTRO-INTESTINAL TRACT the mortality is from 5 to 10 per cent. The remote results indicate that from 10 to 20 per cent, of patients with carcinoma of the stomach who survive radical operation are cured of the disease, passing the three and five year limits without recurrence. This is a creditable showing considering that no other form of treatment offers even the shadow of a chance for cure. Moreover, even if the patient ultimately dies from recurrence or internal metastasis, his life is prolonged on the average for eighteen months and most of this time is passed in comparative comfort, and death finally comes in less hideous form: the patient dies not of starvation but of cancerous cachexia. Even when removal of the entire disease by operation seems impossible, many abdominal surgeons think that life is prolonged and comfort promoted by removal of the foul sloughing mass, discharging into the stomach. It is well recognized that gastroenterostomy is not a good operation for such cases; the immediate mortality is very high (15 to 25 per cent.), and if the immediately fatal cases are included, the reckoning shows survival is shorter than if no operation had been employed, while the patients who survive suffer more than before the operation and may live a longer time than if the abdomen had been closed without doing gastro-enterostomy. Only in cases of pyloric obstruction does gastro- jejunostomy bring relief. Other palliative operations have been employed: in carcinoma of the cardiac orifice gastrostomy has been done, but I believe it is contra-indicated so long as the patient can swallow fluids. Jejunostomy and even duodenostomy (above the bile papilla) may be employed as euthanasial measures in cases where the body of the stomach is widely infiltrated and the patient is starving. In employing such operations the precarious state of the patient must be remembered; the surgeon should know before beginning the opera- tion just what he intends to do, and then should do it without any unnecessary intra-abdominal exploration. Carcinoma of the Duodenum, primary, and not arising in the bile papilla (for which see p. 997) is very rare. It has been carefully studied by Forgue and Chauvin (1915). OPERATIONS ON THE STOMACH. Gastrotomy. — The operation of opening the stomach may be required for the removal of foreign bodies within the stomach or impacted in the lower end of the esophagus; or for purposes of explora- tion. The abdominal incision is made through the upper left rectus muscle, close to the median line. The stomach is located by finding first the left lobe of the liver and tracing the gastro-hepatic omentum down to the lesser curvature of the stomach. If a foreign body is to be removed, it should be located if possible before opening the stomach. After isolating the stomach with gauze packs, hold the foreign body against the anterior wall of the stomach and cut directly down upon it, making the incision just long enough to remove the foreign body. Then repair the gastric incision with at least two rows of sutures (p. 880), and close the abdominal incision without drainage. OPERATIONS ON THE STOMACH 929 Gastrostomy. — The establishment of a gastric fistula, for the purpose of introducing food, is required most often in cases of impermeable stricture of the esophagus (p. 743). The fistula should be made in the pyloric antrum, and not in the fundus of the stomach. Several methods of operating are in common use. 1. Stamm's Method (1894). — The anterior gastric wall is drawn into the wound, and a small incision is made, just large enough to admit the end of a good-sized catheter (No. 26 French). The catheter (its outer end clamped) is inserted for about 2 or 3 cm. inside the cavity of the stomach, and is fixed to the gastric wall by a single catgut suture. Then a purse-string suture of linen is taken in the stomach wall, cir- cularly around the catheter and about 1 cm. distant from it; as this suture is tightened the cath- eter is pushed toward the cavity of the stomach and carries with it the gastric wall, which is thus inverted so that the catheter lies in a serous channel (Fig. 937). Two other purse-string sutures are similarly passed, and as each is tightened the inverted cone of gastric wall is lengthened, so that finally the catheter lies in a channel over 3 cm. in length. The stomach is then sutured to the parietal peritoneum on both sides of the abdominal wound, and this is closed around the catheter. 2. In WitzeVs method (1891) the tube is buried in an oblique manner in the gastric wall, by means of Lembert sutures. After these sutures are all tied, an opening is made in the gastric wall just large enough to admit the end of the tube; and after this has been introduced and fixed to the wall of the stomach with one catgut stitch, its point of entrance is covered by a few additional Lembert sutures of linen. The channel formed from the cavity of the stomach to the skin in these operations is absolutely continent so long as the catheter is in place; when it is removed leakage may occur, but if the catheter is left out for a long time the channel tends to close spontaneously, owing to the adhesion of its serous surfaces. Liquids may be intro- duced into the stomach through the tube at once if the patient is much emaciated. During the intervals between feedings the tube should be clamped, and it should be withdrawn for cleaning and the stomach should be irrigated at least once daily after the first few days. Jejunostomy (p. 928) sometimes is employed as a substitute for gastrostomy. Karewski (1896) adopted the technique employed by Witzel for gastrostomv, while Maydl (1898) emploved a Y-anastomosis (p. 932). 59 Fig. 937. — Gastrostomy by Stamm's method. 930 SURGERY OF THE CASTRO-INTESTINAL TRACT Pyloroplasty. — The operation for pyloric stenosis devised inde- pendently by Heinecke and Mikulicz is seldom employed at present. It consists in incising the pylorus in its long axis and then suturing this incision transversely. The incision should extend from the stomach clear through the pylorus into the duodenum. The opera- tion is inefficient in preventing recurrence of stenosis, and is undesir- able because it is necessary to work in diseased tissues. The latter objection applies also to Finney's pyloroplasty (1902) which is more efficient, however, because it approaches the type of a lateral anasto- mosis between stomach and duodenum (Fig. 938). Fig. 938. — Finney's method of pyloroplasty. Gastrojejunostomy. — An anastomosis between the stomach and small intestine was first made in 1S81 by Wolfler at the suggestion of his assistant Nicoladoni. The jejunum was anastomosed with the anterior wall of the stomach, for malignant obstruction of the pylorus. In 1885 von Hacker adopted a method of posterior gastrojejunostomy, by anastomosing a loop of the upper jejunum with the posterior gastric wall through an opening made in the transverse meso-colon. Most surgeons have now adopted posterior gastrojejunostomy as the method of choice, and use a jejunal loop as short as possible, as advised in 1901 by Petersen, the assistant of Czerny (Fig. 939). The indications for gastrojejunostomy have already been considered. The abdominal incision is made through the upper right or left rectus muscle close to the linea alba. After careful exploration, the great omentum and attached transverse colon are drawn out of the wound and pulled upward to the patient's right, thus putting transverse meso-colon on the stretch, and bringing the origin of the jejunum into sight. The jejunum, just below the duodeno-jejunal juncture, is brought forward, and grasped by the anastomosis forceps, for a distance of 10 cm. on its antimesenteric border. The transverse mesocolon is next cut through in a bloodless area, and the opening is enlarged in an antero-posterior direction until it is from 8 to 10 cm. in length. The posterior gastric wall is thus exposed and is made to protrude through OPERATIONS ON THE STOMACH 931 the mesocolon, whereupon it is grasped in the other portion of the anastomosis forceps. At least 8 cm. of the gastric wall should be grasped in this way. The portion grasped should be in the pyloric antrum, and the forceps should be applied more or less transversely to the long axis of the stomach. The jejunal loop should be applied to the stomach in such a way that its aboral end is next the greater curvature of the stomach, and its oral end next the lesser curvature. Moynihan prefers to have the jejunum slant toward the patient's right; while Mayo turns it toward the left. The gas- tric wall and jejunum being thus apposed, a typical lateral anasto- mosis (p. 886) is made between them with needle and thread. The clamps are then released, and the edges of the opening which was made in the transverse mesocolon are carefully sutured to the gastric wall just above the anastomosis by three or four interrupted sero- serous sutures. If this is ne- glected, a hernia of the small in- testine may occur alongside the anastomosis, into the lesser peri- toneal cavity. The abdominal contents are then replaced in proper position, and the abdom- inal wound closed without drain- age. Liquids may be given in small amounts in twelve hours, but even semi-solid food should be withheld for a week or ten days. Exclusion of the Pylorus. — This may be done as an accessory to gastrojejunostomy in cases where the pylorus is patulous. It- is probable that no method short of actual section and suture of both ends will permanently occlude the pylorus, but even temporary occlusion is believed by some surgeons to be beneficial in these cases. A stout linen thread may be passed clear around the pylorus as a purse-string, or the anterior wall may be plicated longitudinally by sero-serous sutures until obstruction is produced. Anterior Gastrojejunostomy may be required when the posterior wall of the stomach proves inaccessible on account of adhesions, etc. A loop of jejunum about 35 cm. long must be used, so as not Fig. 939. — Posterior retrocolic gastro- jejunostomy. Note the absence of a loop between the origin of the jejunum and the site of anastomosis and the slight distortion of the organs when the operation is com- pleted. 932 SURGERY OF THE G ASTRO-INTESTINAL TRACT to constrict the transverse colon. If the operation must be com- pleted with great speed, a Murphy button may be employed for the anastomosis. Posterior Gastrojejunostomy in Y. — This, which was adopted in 1897 by Roux of Lausanne, presents advantages in some cases: the jejunum is divided transversely about 35 cm. below its origin, and its aboral segment is implanted into the posterior wall of the stomach through an opening in the transverse meso-colon. Then the oral segment of the jejunum is implanted into the aboral segment about 15 cm. below the gastro-jejunal anastomosis (Fig. 940). In this way there is no chance for the duodenal secretions to reach the stomach, as they constantly do when the usual anastomosis is done. The principle of the Y-anastomosis is of value in certain other intestinal anastomoses. Fig. 940. — Diagram of posterior gastrojejunostomy in Y. The Vicious Circle after Gastrojejunostomy is rarely seen at present. When a long jejunal loop was used it was not infrequent. Probably the cause is obstruction of the duodeno-jejunal loop at the point of anastomosis. The patient vomits persistently after operation, and if repeated lavage proves ineffectual the abdomen may have to be re-opened to relieve the obstruction. The best treatment is an entero- OPERATIONS ON THE STOMACH 933 anastomosis between the afferent and efferent limbs of the jejunal loop. The pylorus also should be occluded by a purse-string suture, if still patulous. A peptic ulcer of the jejunum occasionally forms at or below the gastrojejunal anastomosis. It is seldom recognized except by hemor- rhage or perforation. Treatment of these complications is the same as that of gastric or duodenal ulcer. It may be necessary to make a new gastrojejunostomy opening. This complication is rare after the no-loop method of posterior gastroenterostomy. Wright (1919) has tabulated 145 proved cases of this complication: 82 patients recovered and were relieved of symptoms as a result of re-operation; 25 were no better; 19 died after the operation; and 19 died without operation. Fig. 941. — Stomach, showing the Hart- mann (H), Mikulicz (iif), and Mayo (M') lines. Fig. 942. — Partial gastrectomy by Bill- roth's first method. Gastrectomy. — A portion or the whole of the stomach may be removed. In pylorectomy the pylorus and some of the pyloric antrum are removed; this operation is employed only in cases of benign disease. In every case of malignant disease the whole of the lesser curvature ought to be removed, and the operation is called a partial gastrectomy, the stomach being divided at the Hartmann or Mikulicz line (Fig. 941). If the stomach is removed as far as the Mayo line, the operation is known as subtotal gastrectomy; while if the entire stomach is removed from esophagus to duodenum, the procedure is worthy the name of total gastrectomy. Circular or cylindrical gastrectomy desig- nates an operation by which the central portion of the stomach, including the entire circumference, is removed. Partial Gastrectomy. — Billroth' s First Method (1881). — This operation is very rarely employed. After removal of the diseased area, an end- 934 SURGERY OF THE G ASTRO-INTESTINAL TRACT to-end anastomosis is made between the duodenum and the remaining portion of the stomach (Fig. 942). As the circumference of the latter is much greater than that of the duodenum leakage is very apt to occur at the "angle" of the suture lines. Kocher (1891) modified the Billroth I technique by implanting the duodenum into the posterior wall of the stomach, thus avoiding the deadly angle, and completely closing the cut surface of the stomach. Billroth' 8 Second Method. — In this both the duodenum and stomach are closed completely, and the operation is terminated by a typical gastrojejunostomy. In Billroth's original technique an anterior gas- trojejunostomy was done; but whenever possible posterior gastro- jejunostomy is preferable. The stomach is exposed through the usual right rectus incision, and is isolated with gauze. The coronary artery is identified, doubly ligated and divided, close to the cardiac orifice of the stomach. The finger is passed through the gastrohepatic omentum into the lesser peritoneal cavity, and the gastrohepatic omentum is ligated in sections fairly close to the transverse fissure of the liver. By cutting through the gastro-hepatic omentum the surgeon reaches the pyloric artery, which is doubly ligated and cut. The finger is then passed down behind the pylorus, and the right gastro-epiploic artery is identified below the pylorus; this artery is doubly ligated and cut. Hemostatic forceps are then applied to the gastro-colic omentum between the gastro- epiploic arteries and the colon, and as they are applied the gastro-colic omentum is divided between them, beginning at the pylorus and passing along the upper border of the transverse colon until the point is reached at which it is proposed to divide the stomach. This point should be 5 cm. to the left of the visible malignant growth. When this point has been reached, the left gastro-epiploic artery is ligated just to the left of the proposed gastric incision. In plac- ing the hemostats on the gastro-colic omentum, great care is to be taken to avoid the middle colic artery and its branches. The portion of stomach to be removed is now completely freed along its curva- tures, and remains attached only to the duodenum and the body of the stomach. The lesser peritoneal cavity can now be protected thoroughly by sterile gauze compresses. A clamp with rubber- covered blades is now applied to the duodenum about one inch beyond the portion visibly diseased, and an ordinary clamp is applied just to the pyloric side of the first clamp. The duodenum is then divided between the two. The entire portion of the stomach to be excised can now be turned to the patient's left. The duodenal stump is closed first by a through-and-through chromic catgut suture; a purse-string suture of linen is applied and by catching the duodenal wall in two places with dissecting forceps the sutured end of the duodenum is inverted and the purse-string suture is drawn tight and tied (Fig. 943). The gastro-colic omentum is then ligated, and the hemostatic forceps removed. Rubber-covered gastrectomy clamps are then applied across the stomach from the greater to the lesser curvature, at least OPERATIONS ON THE STOMACH 935 5 cm. to the left of the visible malignant growth. ( lamps with a screw lock at the end of the blades are safest. About 2 cm. to the right of this occluding clamp an ordinary forceps is applied, and the stomach is divided between the two with the thermocautery. The excised portion being removed, a through-and-through suture of chromic cat- gut is inserted through the margins of the gastric walls which protrude from between the blades of the rubber-covered clamp. It is well to grasp these margins at one or more points with forceps to prevent their retracting. ^Yhen the through-and-through sutures have been completed, the clamp is removed, and a continuous sero-serous suture is applied burying the first row. A posterior gastrojejunostomy is then done, the viscera replaced, and the great omentum is drawn up to cover the space left by the removal of the stomach. Fig. 943. — Partial gastrectomy: the duodenum has been divided, and the clamps are in place for the gastric section. (Deaver and Ashhurst.) Subtotal Gastrectomy differs from the operation just described only in the greater amount of stomach removed. Sometimes this is so great that only an anterior gastrojejunostomy can be done to complete the operation. Polya's method (1911) of anastomosis (in which the open end of the stomach is implanted into the jejunum a convenient distance from its origin, the jejunum being brought up through the 930 SURGERY OF THE GASTRO-INTESTINAL TRACT mesocolon) is useful in such cases; Mayo and Balfour (1017) make an antecolic anastomosis according Fig. 944. — Polya's method of im- planting the stomach into the jejunum, after gastrectomy. to l'olya's technique. It is well to attach the jejunum to the stomach before cutting away the tumor (Fig. 944). Total Gastrectomy proceeds along the same linesas partial gastrectomy ; the duodenum should be sutured to the esophagus (end to end) before the stomach is completely cut away from the latter. If the duodenum, even after mobilization (p. 988) can- not be made to reach the esophagus without undue tension, a loop of the jejunum should be employed instead, being drawn through the transverse meso-colon. The Y-anastomosis of Roux is valuable under such circum- stances (p. 932). SURGERY OF THE INTESTINES. Intestinal Obstruction, or Ileus, may be caused by: 1 . Paralysis of the muscular tunic of the bowel {adynamic obstruc- tion) from bacterial toxins, as frequently seen in cases of peritonitis (p. 857), or from lesions of the spinal cord (p. 645). 2. Spasticity of the muscular tunic {dynamic obstruction) which is very rare, and occurs chiefly in cases of lead or tyrotoxicon poisoning. 3. Occlusion of the intestine by (a) Changes within the lumen of the bowel, such as impaction of feces, a gall-stone, or other foreign body {obturation), {b) Changes in the wall of the bowel, such as congenital malformations, or gradual occlusion by a tumor or contracting cicatrix, (c) Pressure from the outside, by tumors of neighboring organs. 4. Strangulation of the intestine by (a) Peritoneal bands or adhe- sions. (6) Intussusception, (c) Volvulus, {d) Internal Hernia. 1 Cases of intestinal obstruction are conveniently divided into two classes, acute and chronic. Though cases of chronic obstruction frequently become acute, and though acute cases very rarely may become chronic, there is in most cases no difficulty in distinguishing one from the other. Most of the acute cases are due to strangulation or to obturation from the sudden impaction of foreign bodies. The chronic cases are almost solely those due to gradual occlusion of the lumen of the bowel by a tumor or cicatrix or from pressure from with- out. Dynamic obstruction is scarcely a surgical affection, while ady- namic obstruction has been sufficiently discussed with the subject of peritonitis. Obstruction from congenital malformations usually 1 Strangulation of external hernia has been considered at p. 813. INTESTINAL OBSTRUCTION 937 occurs at the rectum or anus, and is discussed at p. 956. Affections of Meckel's diverticulum are discussed at p. 943. Acute Intestinal Obstruction. — The gravity of this condition depends not merely upon the arrest of the fecal current but upon constitutional symptoms. The higher the obstruction occurs in the intestinal tract the more quickly developed and the more pronounced are these constitutional symptoms. The collapse and other consti- tutional symptoms of acute dilatation of the stomach have already been noted (p. 921). The exact cause of such constitutional symptoms has not been determined, in spite of much recent experimental work by Draper, Hoguet, and others. Symptoms. — The local symptoms are well marked and easily recog- nized: they are pain; vomiting; obstipation, with no passage of flatus by the rectum; disordered peristalsis which is always audible when the ear is placed on the belly, and may be visible if the abdominal wall is thin; and finally distention of the abdomen. The pain is characteristic; it is sudden in onset, very severe, often causes the patient to cry out, and is intermittent. When it ceases the patient feels and may look perfectly well, but it returns unexpectedly and with great suddenness. In most cases, within a day or so, the pain becomes constant, and is more or less localized to the seat of obstruction. Sudden cessation of a fixed pain usually indicates the occurrence of gangrene. The vomiting is projectile in type: there is little or no nausea, and the patient, unprepared by previous nausea, suddenly and unexpectedly spues forth a quantity of vomitus all over everything. At first the vomiting is not very frequent; the gastric and duodenal contents are rejected first, later the upper intestinal contents, and shortly before death matter that appears fecal may be vomited. Though repeated enemas may secure an evacuation from the bowel below the obstruction, no normal move- ment occurs, and no flatus is passed by rectum at any time. Eventu- ally the abdomen becomes tympanitic and distended and the peris- taltic movements sometimes may be observed to be arrested at a fixed spot, where the obstruction is located. The bowel above the obstruction becomes much dilated and undergoes the changes already described in strangulated hernia; that below the obstruction is col- lapsed. The virulence of the bacteria above the obstruction is much increased, and the altered intestinal wall is more readily traversed by them, and thus peritonitis supervenes even before gangrene or per- foration of the strangulated bowel takes place. Not until this time is the temperature noticeably elevated, and though at this time also the pulse becomes rapid and wiry, in the early stages of intestinal obstruc- tion the pulse often is fuller and slower than normal. In this advanced stage the diagnosis is difficult between peritonitis with secondary obstruction, and primary obstruction terminating in peritonitis. The clinical picture is that of the late stages of peritonitis (p. 857). In cases of acute intestinal obstruction, unrelieved by operation, death usually occurs within a week. 938 SURGERY OF THE G ASTRO-INTESTINAL TRACT Diagnosis. — The impaction of a biliary calculus or other foreign body may be suspected from the history of the case, and from tlie inter- mittent character of the symptoms, since the obstruction seldom is absolute at first, the gall-stone shifting its position within the lumen of the gut from time to time. It is most apt to become impacted in the lower ileum. Obstruction from peritoneal adhesions, resulting in kinks of the intestine or constriction beneath a band of organized lymph is most frequent in children or young adults who give a history of one or more attacks of peritonitis or of an abdominal operation. The symptoms usually are very severe and collapse is marked. Intus- susception is rare in those more than two years of age; usually it results from violent peristalsis induced by enteritis; the presence of intestinal parasites, polypi, or enlarged mesenteric lymph nodes may act as predisposing causes. The most frequent form of invagination is the ileo-cecal. The portion of intestine which is sucked down into the lumen of that below is known as the intussusceptum, while that which receives it is called the intussuscipiens (Fig. 945). The apex of the intussusceptum is that part which leads the way in the lumen of the bowel (in an ileo-cecal intussusception the apex of the intussusceptum 4mmmwMmmm^ Fig. 945. — Diagram of an intussusception: A, A' the apex of the intussusceptum; C, C the collar of the intussuscipiens. is formed by the ileo-cecal valve) ; while the neck is the portion which enters the collar of the intussuscipiens. The characteristic symptom of this form of intestinal obstruction is the constant desire to defecate, with the passage of blood and mucus from the rectum. Occasionally the finger introduced into the rectum will feel the apex of the intus- susceptum; and in many cases it is possible to recognize a sausage- shaped tumor in the right or left hypochondrium, the right iliac region being flattened (Dance's sign, 1826), owing to the migration of the invaginated bowel along the course of the ascending and transverse colon. Volvulus is most frequent in adults, especially in the aged, and is said to occur oftenest in the sigmoid flexure; but in my own experience the small intestine has been oftenest involved. The obstruc- tion is due to twisting of the bowel around its mesentery; unless an arc of three-fifths of a circle is described strangulation does not occur. The twist usually takes place in contra-clockwise direction, the oral limb of the bowel passing above and to the right of the aboral limb. Volvulus is predisposed to by elongation of the mesentery or by fixa- tion of the intestine at any point by adhesions, thus permitting active peristalsis to throw the oral limb over the aboral portion which is INTESTINAL OBSTRUCTION 939 fixed. Rectal examination sometimes reveals a distended coil of bowel in the recto-vesical pouch; or the distended loop may be palpable through the abdominal wall. Internal hernia may occur in any of the recesses or pockets of the peritoneum, especially the duodeno-jejunal fossa? (Fig. 946) ; less often in the pericecal fossa? or the mesosigmoid fossa. Hernia through the foramen of Winslow is rare, as is a hernia through a congenital or acquired opening in the mesentery of the small intestine (Fig. 947). The possibility of a hernia through the transverse mesocolon after the operation of gastrojejunostomy has been mentioned (p. 931). The diagnosis of these internal hernias is difficult; usually the | Fig. 946. -Diagram of a case of strangulated retroperitoneal hernia into the paraduodenal fossa. Episcopal Hospital. symptoms are gradual in onset, and many cases belong to the category of chronic rather than to that of acute obstruction. Sometimes as the hernia increases in size it may be discovered on palpation, or borborygmi and subjective symptoms may point to the region of the abdomen involved. Treatment. — The first and most important item of treatment is to avoid purgatives. Even if the presence of obstruction is uncertain, the administration of any form of laxative or purge is absolutely con- traindicated, so long as the possibility of acute intestinal obstruction cannot be excluded. It is perfectly proper to use enemas, in order to 940 SURGERY OF THE G ASTRO-INTESTINAL TRACT secure an evacuation ; but purgatives are not only useless, in that they never relieve the obstruction, but they are intensely harmful. They arouse peristalsis, which results in increase of the strangulation, and they increase the amount of the intestinal contents above the obstruc- tion. Some surgeons recommend the use of eserin, in cases of obstruc- tion seen early; they argue that while it arouses peristalsis it does not cause an exudation into the intestinal canal as most other purga- tives do; and they believe that it will do good in cases of adynamic obstruction, and that where the nature of the obstruction is uncertain its use will aid the surgeon in reaching a diagnosis, since if nothing is accomplished or the patient is made worse it may be assumed that the obstruction is not adynamic but mechanical. This teaching I regard as pernicious. Though I have seen eserin blow the wind out Fig. 947. — Strangulation of a loop of ileum through a hole in its mesentery. A Meckel's diverticulum, adherent to the anterior abdominal wall prevented more intestine from passing through the mesentery. Episcopal Hospital. of a belly with great activity, I have failed to observe that such an occurrence hastens recovery; and I have also seen intestinal perfora- tion caused by the violent peristalsis induced by eserin. Pituitrin is highly commended by Gibson (1916) for adynamic obstruction: 1 c.c. is injected intramuscularly every hour for three doses, and then every two hours until effective. But it cannot be too strongly impressed upon the student that in cases of adynamic obstruction the patient is not ill because his abdomen is distended, but his abdomen is distended because he is ill. If there is any doubt as to the diagnosis, much less damage will be done the patient by resort to immediate laparotomy than by pro- crastination; and when operation is once seen to be indicated, there should be no delay. The patient will not get any better by waiting. INTESTINAL OBSTRUCTION 941 But it is always well to wash out the stomach before operation. This will prevent vomiting and perhaps aspiration of gastric contents into the lungs while the patient is under the anesthetic. Operation. — Unless the site of obstruction is definitely known, the incision should be median, below the umbilicus. Do not let the dis- tended intestines escape from the abdomen. Find the transverse colon; it is recognized by the attached omentum. If it is distended, the obstruction is lower, probably in the sigmoid or rectum, rarely at the splenic flexure; if it is collapsed, the obstruction probably is in the small intestine. Try to find some collapsed small intestine and trace it upward to the obstruction. If evisceration becomes necessary, the eviscerated intestines should be covered in hot wet towels, and these should be kept hot and wet by constant irrigation with saline solution at a temperature of about 115° F. If the bowel above the obstruction is very much distended it should be emptied of its highly infectious contents by aspiration or incision. Monks advocated passing a glass tube up the lumen of the distended intestine, and crowding as many coils of bowel upon it as possible, to aid in securing evacua- tion. I tried this method on several occasions, but did not find it effectual. If the condition of the patient is very bad, the operation may be terminated by establishing a false anus above the obstruction, as in cases of acute obstruction superimposed upon chronic obstruction (p. 942); and in almost moribund patients life is occasionally saved by opening the first distended coil of intestine which presents itself without making any search whatever for the obstruction; this consti- tutes the old operation of enterotomy. It was revived by Krogius (1911). If obstruction is due to the impaction of a foreign body, it should be dislodged if possible and removed through an incision in healthy intestine. If the obstruction is due to kinking from adhesions, these usually may be separated with the fingers or gauze dissection; distinct bands must be cut. The denuded areas on the intestines should be inverted by sero-serous sutures, or should be covered with omentum. If the adhesions are very widespread and the bowel very friable, a short- circuiting operation (p. 949) may be necessary. In cases of intussusception, efforts at reduction should be made by pushing the intussusceptum back, not by attempts to pull it out from above. The latter method rarely is successful, and may be pro- ductive of much damage. If reduction proves impossible, the intus- suscipiens may be incised longitudinally and the intussusceptum removed, the incision being closed and the neck and collar of the invag- inated bowel being sutured together. Enterectomy rarely is justi- fiable in this or any form of acute obstruction; the establishment of a false anus above the obstruction (if this is not too high in the intestinal tract) or a short-circuiting operation will be preferable. Occasionally the gangrenous intussusceptum separates as a slough and is discharged by rectum. The operative mortality is about 33 per cent. 942 SURGERY OF THE G ASTRO-INTESTINAL TRACT In cases of volvulus, the bowel should be untwisted, and if the condi- tion of the patient permits, it is well to take a reef in the redundant mesentery or to attach the sigmoid to the parietal peritoneum, so as to prevent recurrence. Chronic Intestinal Obstruction. — This is most often the result of fecal impaction, benign or malignant stricture, or widespread peri- toneal adhesions which interfere with peristalsis without causing strangulation. In fecal impaction, which occurs oftenest in the rectum or sigmoid, rarely in the transverse colon or cecum, there is obstinate constipa- tion, with slight intermittent colicky pains from disordered peristalsis; sometimes a mass can be felt through the abdominal wall, which is recognized as fecal from its doughy consistency. Vomiting (never Fig. 948. — Cecostomy, for acute intestinal obstruction, of one week's duration, super- vening on chronic obstruction of twelve years' standing. Paul's tube in cecum. Stricture of sigmoid, in woman of fifty-three years, following injury in childbirth thirteen years ago. (See page 966.) Episcopal Hospital. stercoraceous) may occur during an acute attack; and watery diarrhea often follows relief of the obstruction. Treatment comprises the use of repeated enemas, administered in the Trendelenburg or knee- chest posture, and evacuation of fecal masses from the rectal ampulla by the finger if necessary. When once the impaction is relieved, it is safe to give purges; as long as any acute symptoms persist opium and belladonna may be of use in relaxing intestinal spasm. In chronic obstruction from a cicatrix or tumor of the intestine, the symptoms are much the same as in fecal impaction, but as a rule no tumor can be felt. After many attacks of partial obstruction, this is prone to become acute and complete at the last. If palliative treat- ment (enemas) proves unavailing the surgeon should open the abdo- men, and in the presence of acute obstruction should content himself with making a false anus above the seat of the tumor; if there is no evidence of acute obstruction the tumor or cicatrix may be resected, but such a course almost always leads to death from peritonitis unless MECKEL'S DIVERTICULUM 943 the bowel above the tumor is unobstructed. If the tumor is in the rectum, a sigmoid anus may be made in the left iliac region (Littre's operation, 1710); but if the tumor is higher in the large intestine cecostomy (Fig. 948) should be done in the right iliac region (Pillore, 1776). For obstruction in the small intestine, which is rare, a short-circuiting operation is preferable (entero-enterostomy). Mesenteric Thrombosis and Embolism. — Thrombosis of the mesen- teric vessels occurs in many cases of intestinal obstruction, as the result of strangulation. But thrombosis, and rarely embolism, may occur as a primary condition, from the same causes which produce similar conditions in other parts of the body. The symptoms are not unlike those of acute intestinal obstruction, except that pain occasionally is inconspicuous in cases of thrombosis; peritonitis develops more rapidly than in intestinal obstruction; and there are evidences of hemorrhage into the intestinal tract, with bloody diarrhea or vomiting. Diagnosis is difficult. Trotter (1913) collected 366 cases, in only 13 of which was a correct diagnosis made. Treatment comprises immediate laparotomy and resection of the affected bowel, which quickly becomes gangrenous. The mortality is 36 per cent, in cases treated by resection (Trotter). If the condition of the patient renders resection impossible, the gut may be tamponed, or may be drained; but incomplete operations almost always terminate fatally. Meckel's diverticulum, the remains of the omphalo-mesenteric duct, is found in about 2 per cent, of bodies which come to autopsy. It is attached to the lower ileum, within a few feet of the cecum, and usually springs from the anti- mesenteric border of the gut. It is about the size of the finger, and may be unadherent, or may be at- tached to the umbilicus (see Um- bilical Fistula) or to some other point in the abdomen. It is most apt to cause trouble if adherent, acting as a band under or around which the intestine becomes stran- gulated. If adherent to the um- bilicus, volvulus of the small in- testine is frequent, causing torsion FlG 949 _ (t ran g ulation of Meckel's di- and perhaps Strangulation of the verticulum, adherent to umbilicus. Age ,. ;. , ,-,-,. ?nn\ th forty-six years; duration two days. Epis- diverticulum (Iig. 949). 11 unat- C o P ai Hospital. tached, its chief affection is acute inflammation, which in its pathogenesis, symptomatology and treat- ment resembles appendicitis. Diagnosis. — The presence of a Meckel's diverticulum may be sus- pected if the umbilical cicatrix is abnormal. I have twice been able to make the correct diagnosis before opening the abdomen, by heed- ing this maxim. 944 SURGERY OF THE GASTRO-INTESTINAL TRACT Treatment. — It is best to excise the diverticulum, at the same time (loins what is necessary to the strangulated intestine. Umbilical Fistula. — If the omphalo-mesenteric duct remains patu- lous, a fistula is present at the umbilicus. This may discharge feces, or if very small only mucus. In some cases the discharge resembles gastric juice and it is uncertain whether the mucosa from which the discharge comes is an excluded part of Meckel's diverticulum, or neoplastic (adenomatous) in nature (Denuce, 1908). The best treat- ment is extirpation of the diverticulum. Affections of the Urachus are discussed at p. 1017. Internal Fistulae of the Intestinal Tract usually are the result of peritonitis, malignant disease, or tuberculosis. Occasionally they result from injury. The existence of a fistula between the gall-bladder and the intestine may be inferred if a large gall-stone is passed by rec- tum or lodges in the intestine; such fistula? often close spontaneously and rarely cause symptoms. A gastro-colic fistula gives evidence of its presence chiefly by the development of lienteric diarrhea and fecal vomiting. Other forms of internal fistula are rare and do not cause characteristic symptoms. Gastro-colic fistula? scarcely ever close spontaneously, and early operation is indicated. Tbe best plan is to separate the stomach and colon and repair the perforation in each. But this is not always possible. Alternate methods are (1) section of the colon on each side of the fistula, and bilateral exclusion (p. 952) of the portion of bowel containing the fistula, leaving it as a pouch attached to the stomach, and reuniting the colon above and below the seat of disease ; (2) short-circuiting the fecal current by a colo-colostomy (above and below the fistula) or by ileo-sigmoidostomy ; but neither of these plans is very satisfactory. Intestinal Perforation in Typhoid Fever occurs in about 2.5 per cent, of cases. It is most frequent during the third or fourth weeks of the disease and is predisposed to by a mixed infection in the intestinal tract. The great majority of perforations occur in the ileum, within a few feet of the cecum. The important symptoms are abdominal pain, localized muscular rigidity, increase in the pulse rate, and often a fall in the temperature immediately after the perforation. But the patient may be too toxic to complain of pain, and the other symptoms may pass unnoticed unless the physician and nurse are constantly alert. Very soon rigidity is lost, distention commences, and often it is not until widespread peritonitis is developed that the surgeon is asked to see the patient. The sooner operation is done, the better the chance of recovery. Consent for immediate operation should be obtained before perforation occurs if its occurrence seems probable. If a pre- perforative stage (peritonitis without symptoms of perforation) can be recognized, it is proper to open the belly then, and to prevent perforation by inverting all ulcers w r hich threaten to perforate or by establishing a fecal fistula above the level of diseased bowel. Even if no lesion is found {laparotomie blanche) the patient is none the worse for the exploration. IN TES TINAL PER FOR A TION 945 The operation may be done under spinal or local anesthesia, but I prefer a general anesthetic (ether or gas). The incision, about 7 cm. long, is made through the right rectus muscle, below the umbili- cus (Fig. 950) ; and the lowest loop of ileum (located as described at p. 878) is pulled into the wound and traced upward until the per- foration (there may be more than one) is found or until healthy bowel is reached. When a perfor- ation is found it should be closed by a purse-string or other appropri- ate suture ( p. 881) in such a way as not to stenose the bowel. If the patient is desperately ill, it is suffi- cient to drain the intestine above the area of disease by a Paul's tube (p. 970), tamponing the necrotic bowel. Drainage to the pelvis always should be employed, but I consider irrigation of the peritoneal cavity harmful. Subsequent treat- ment is the same as for peritonitis. In collective statistics (Harte and Ashhurst, 1904) the mortality is nearly 75 per cent.; but a few individual operators report a death- rate well below 60 per cent. (Montreal General Hospital, Johns Hop- kins Hospital). In my own hands the mortality has been 61.5 per cent.; this includes one patient who recovered after cholecystectomy for perforation of the gall-bladder during typhoid fever (Fig. 951), and a case of recovery after removal of an acutely inflamed appendix during typhoid fever and a recovery after a laparotomie blanche. Fig. 950. — Scar four months after operation for intestinal perforation in typhoid fever. Episcopal Hospital. Fig. 951. — Gall-bladder removed by cholecystectomy, showing typhoid perforation. (Natural size.) Episcopal Hospital. Intestinal Hemorrhage in Typhoid Fever is of surgical interest, chiefly in connection with the diagnosis of perforation. In hemor- rhage, though there may be marked shock, increase of pulse rate and fall of temperature, there seldom is pain or marked abdominal rigidity; 60 946 SURGERY OF THE CASTRO-INTESTINAL TRACT and usually the blood appears in the stools within an hour or so. In severe recurring hemorrhages, which usually are fatal, Ilarte (1909) advocates laparotomy; he succeeded in finding the bleeding spot by the aid of transmitted light, and in checking the bleeding by suture. Though his patients eventually succumbed, he has indicated the proper course to pursue in such cases. Fig. 952. — Diagram of a fecal fistula. Fecal Fistula and False Anus. — If only a small portion of the intestinal contents (perhaps only flatus) is passed from the bowel through the opening in the abdominal wall, the patient is said to have a fecal fistula (Fig. 952); but if practically the entire intestinal con- tents are discharged in this way, a false anus (Fig. 953) is said to exist. Fig. 953. — Diagram of a false anus, with formation of a marked spur. A fecal fistula sometimes develops in a drained abdominal wound a few days after operation in cases where the bowel was gangrenous, but the fecal discharge usually ceases spontaneously after removal of the drainage, as the wound granulates. Its closure is aided by con- fining the patient to as dry a diet as possible, and by securing an evacuation through the rectum every day by means of an enema. Purges are contraindicated. To prevent excoriation of the skin around the fistula, it may be covered with zinc oxide ointment. Mineral bases should be used in all such ointments, as animal bases sometimes are digested by the intestinal juices. FECAL FISTULA 947 A false anus usually is an artefact, intentionally produced by the surgeon (Fig. 974) ; though it may also develop spontaneously, by the gradual formation of a spur in a case of fecal fistula. It shows no ten- dency to heal, owing to the presence of this firm spur between the affer- ent and efferent loops of bowel ; operation almost always is necessary to secure its closure. In some cases, where it is certain that the afferent and efferent loops of bowels are in close apposition, it is safe to destroy the spur by passing one blade of a clamp into each opening and gradu- K . v t: f J-., i \ Fig. 954. — Carcinoma of the ascending colon. (See also Figs. 955 and 956.) Stricture admitted goose-quill (0.5 cm. in diameter). Specimen excised included the ileocecal coil and entire ascending colon. Specimen has been slit down the anterior wall through the stricture. Patient died in two days. Episcopal Hospital. ally tightening the clamp throughout a period of several days until pressure has caused a slough to form, and converted the lumen of the two intestines into one. Dupuytren's enterotome is the type of instrument employed. If this can be satisfactorily accomplished the external opening of the fistula usually closes spontaneoulsy. In most cases, however, a radical operation must be done. This consists in dis- secting widely around the false anus, opening the healthy peritoneal cavity, which is well protected by gauze packs, and closing the open- ing in the bowel by inversion of its margins where this is possible; •IIS sriWKRY <>!■' THE G ASTRO-INTESTINAL TRACT and in other cases by resection of the affected bowel, and restoration of the continuity of the intestinal tract by end-to-end or lateral anas- tomosis. Fig. 955. — -Carcinoma of the ascending colon. Barium fills the small intestines but has not passed obstruction. Some is still in the stomach. (See Fig. 954) . Episcopal Hospital. Fig. 956. — Excision of the ascending colon with implantation of terminal ileum into transverse colon. (See Figs. 954 and 955). Tumors of the Intestine, except of the sigmoid and rectum (for which see page 968), are quite rare. Benign tumors are almost unknown OMENTAL CYSTS 949 with the exception of mesenteric cysts (see below). Hyperplastic tuberculosis and malignant tumors (sarcoma and carcinoma) produce symptoms by obstructing the bowel. Sometimes melena or enter- orrhagia occurs. If the tumor is recognized as soon as symptoms of chronic obstruction appear, it is usually possible to remove it by intes- tinal resection with fair prospect of ultimate recovery. Lymphatic extension generally occurs late. In malignant tumors of the small intestine resection with end-to-end or lateral anastomosis may be done. In carcinoma of the cecum (which sometimes gives a palpable tumor before obstructive symptoms arise) or of the ascending colon it is best to resect the entire ileocecal coil of intestine as high as the dis- tribution of the middle colic artery (Figs. 954, 955, 956). The con- tinuity of the intestinal tract is restored by implanting the ileum into the transverse colon or the sigmoid. If resection is impossible in any case (and it never should be attempted when acute obstruction has developed) a false anus may be established above the site of obstruc- tion; or a short-circuiting operation (Fig. 957) or an intestinal exclusion (Fig. 958) may be performed. The tumor is to be resected when convalescence is well established. Fig. 957. — Ileo-sigmoidostomy, a typical "short-circuiting" operation. Fig. 958. — Unilateral exclusion of the ascending colon, by implantation of the ileum into the transverse colon. Mesenteric Cysts usually are of embryonal origin, and are endo- theliomatous in nature. Hydatid cysts, and cystic degenerations of malignant tumors, also occur. Adhesions are common, but the tumor usually is movable laterally; it is surrounded by a tympanitic area, and may be crossed by a band of tympany. Its most frequent site is in the mesentery of the lower ileum. H. C. Deaver collected 40 cases in 1909. The proper treatment is extirpation, which often involves resection of the overlying intestine. Omental Cysts of the same nature occasionally occur. 950 SURGERY OF THE CASTRO-INTESTINAL TRACT SURGERY OF THE COLON AND SIGMOID. Colitis. — Three types of this disease may be recognized: (1) Ordi- nary "catarrhal" colitis or entero-colitis, without known specific cause, due originally to errors in diet, exposure, etc. (2) Bacillary dysentery, due to the B. dysenterise of Shiga, which usually is an acute disease and often rapidly fatal, and which is the common epidemic form of dysentery which devastates camps, prisons, etc. (3) Amebic dysentery caused by the amoeba dysenterise (A. coli), which even if acute or subacute at first almost always terminates as a chronic disease. It is almost solely with the latter group of cases that surgery is concerned, since except in the rare event of perforation or abscess formation the first and second are best treated medically. In amebic dysentery the entire colon or only parts of it may be affected. As the sloughs are cast off ulcers are left, and these may cicatrize or perforate, while new ulcers are forming in other parts of the colon. The sloughs may be passed by rectum in large masses (membranous dysentery). The amebse are carried quite constantly in the portal circulation to the liver, and hepatic abscess (p. 991) is a frequent sequel. Symptoms. — The disease may begin acutely or so insidiously that the patient is unaware of its existence and comes under the surgeon's care first for the liver complication. A history of residence in the tropics is then a great aid in diagnosis, though those who have never been in the tropics may suffer from the disease. Usually the ameba may be found in the stools, especially after purgation. The symptoms of the acute stages are frequent and copious watery and bloody dis- discharges from the bowel, with much pain and loss of weight and strength." Periods of remission are common, but recurrence of symp- toms is almost inevitable. Treatment. — The indications are (1) to destroy the parasites which infest the bowel, and (2) to procure healing of the intestinal lesions. Dieting, intestinal antiseptics, and rectal and colonic irrigations, which comprise the medical treatment, rarely succeed in meeting these indications, though they may secure alleviation or even latency of symptoms. If symptoms recur persistently, it is best to resort to the operation of cecostomy, or that of appendicostomy (Weir, 1902); when a fistula is thus established in the caput coli, irrigations can be much more effectively used, and thus the operation affords a means of killing the parasites and of curing the intestinal lesions. Cecostomy is done by the method of "Witzel, for gastrostomy (p. 929); appendicostomy is accomplished by detaching the meso-appendix in part, and suturing the appendix in the abdominal wound (Fig. 989). Pericolitis, etc. — Of late years numerous cases have been observed at operation in which there existed more or less definite symptoms of chronic intestinal obstruction, of chronic appendicitis, etc., but in which the main pathological changes consisted in the presence of broad PERICOLITIS 951 bands or membranes, binding the cecum to the parietal peritoneum, holding the lower ileum in a kinked position, causing excessive angu- lation at the hepatic or splenic flexures, or fixing the sigmoid so as greatly to interfere with its function. These membranes were well described by Jabez N. Jackson in 1909. The kink of the ileum (Fig. 959) is especially associated with the name of Lane (1908). It is usually assumed, rather by exclusion than from any definite reasons, that these membranes are the result of low grade infection. Some are thought to be congenital in origin. But their exact pathogenesis is not known. The subject has been studied by Pilcher (1912) and by Descomps (1916). Symptoms. — The symptoms are subacute or chronic in type, and, according to Jackson, consist essentially in pain and tenderness, con- stipation, mucous discharge from the bowel, meteorism, loss of weight, gastric symptoms, and "neurasthenia." Fig. 959. — Kink of the ileum due to membrane binding it to the cecum, and associated with chronic appendicitis. The appendix was much twisted and occupied a deep sub- cecal fossa. From a patient in the Episcopal Hospital. Treatment. — Treatment consists in division of the adhesions and careful peritonization of all denuded surfaces. A diseased appendix or gall-bladder, or other source of infection should be treated appro- priately at the same time. In cases of long duration, with thickened cecum and ascending colon, it is best to excise the entire affected area, implanting the ileum into the transverse colon (Fig. 956). 952 SURGERY OF THE OASTRO-IXTESTINAL TRACT Neither a short-circuiting operation (Fig. 957) nor unilateral exclu- sion of the ascending colon | Fig. 958) is satisfactory, as trouble develops subsequently from distention of the cecum, owing to the normal reversed peristalsis in the proximal colon; and bilateral exclusion of the affected bowel (Fig. 960), though it may prevent accumulation of secretions if a false anus is established at one or both ends of the excluded loop, is not much preferable. Pericolitis Sinistra. —When the sigmoid is affected the cause almost always is inflammation of one or more of the diverticula so commonly found there, and the pathological changes are somewhat different from those encountered about the cecum and ascending colon. The classification I suggested in 1907 includes: (1) Sigmoiditis, an inflam- matory hyperplasia of the walls of the sigmoid, converting it into a rigid tube, and usually causing a certain amount of obstruction. This Fig. 960. — Bilateral exclusion of the ascending colon, both ends of the excluded bowel being sutured to the skin and allowed to discharge. is comparatively rare. It may be caused by inflammation of a diver- ticulum buried in the intestinal wall or in an epiploic appendage. (2) Perisigmoiditis, which usually is the result of inflammation of a diverticulum projecting into the free peritoneal cavity. This may or may not lead to perforation or abscess formation. The symptoms resemble those of appendicitis, except that they occur on the left side, and the treatment is the same, viz., excision of the diverticulum and drainage of the abscess, or in rare cases resection of the diseased portion of the sigmoid, especially if there is any suspicion of malignancy. Sigmoid diverticulitis has been particularly studied by Mayo (1907) and by Brewer (1907). (3) Mesosigmoiditis : This again is most often due to inflammation of a diverticulum lying within the layers of the meso-sigmoid, or to an ulcer in the sigmoid. Sometimes a distinct tumor is formed by the secondarily enlarged lymph nodes (Fig. 961); VISCEROPTOSIS 953 and sometimes the meso-sigmoid becomes contracted and distorted, causing secondary obstructive symptoms (Ries, 1907). Cecum Mobile. — An unduly mov- able cecum may be the cause of many of the symptoms just de- scribed, according to Wilms (1908). This condition may be associated with Lane's kink or with Jackson's membrane, constricting the ascend- ing colon or hepatic flexure; and is to be treated by suspension of the cecum by suture to the parietal peritoneum after removal of the appendix and any adventitious membrane present. Fig. 962. — Pendulous abdomen; complaints of backache and invalidism for years. Episcopal Hospital. Fig. 961. — Meso-sigmoiditis, in a child of seven years. Recovery after exploratory laparotomy. Children's Hospital. Fig. 963. — Same patient as Fig. 962. All symptoms relieved by wearing suitable belt. Visceroptosis. — Glenard, in 1885, drew attention to general visceral prolapse, involving the hollow viscera, usually the right kidney, and sometimes the liver and spleen as well. The deformity is more common in women, and may or may not be associated with pendulous abdomen. It is recognized now as not very rare in children, and is often held responsible for chronic constipation. Gastroptosis, already mentioned at p. 923, usually is a part of general visceral prolapse. In cases of pendulous abdomen symptoms of sacroiliac relaxation (p. 578) may 954 SURGERY OF THE G 'ASTRO-INTESTINAL TRACT arise, and much comfort often be derived from the use of an abdominal belt (Fig. 9(>3) or properly fitting corset, though skiagraphs made (after the use of an opaque meal by mouth or enema) before and after the application of such a support do not show any noticeable change in the position of the hollow viscera. Relief probably is secured by over- coming static strain in the pelvic joints and lumbar spine or by the improvement in the circulation of the ptosed viscera. Chronic Constipation, which often is due to some mechanical factor, such as visceroptosis or one of the types of pericolitis above described, is treated by Lane by means of exclusion of the colon by ileo-sigmoidostomy. 1 Owing to the normal reversed peristalsis in the ascending colon, both it and the cecum soon become overfilled with feces after simple ileosigmoidostomy; so that it is the rule to excise the colon from the terminal ileum to a point beyond the obstruction, either primarily or subsequently. Codman warns against accepting without ques- tion the evidence of skiagraphs made after the ingestion of an opaque meal as indicating true obstructive kinks in the large intestine, since it has been found by Hertz that fluoroscopic ex- amination demonstrates no obstruction to the onward course of the intestinal contents even when the kinks appear very pronounced. 1 According to Lane's theory most human ailments are due to "chronic intestinal stasis:" the primary condition is some obstruction in the descending colon or sigmoid; this results in cecal dilatation, and in attempts to overcome the obstruc- tion adventitious attachments are formed around the cecum and lower ileum which should be regarded as nature's efforts to fix the bowel in a more effective position. Unfortunately this usually results in obstruction in the lower ileum; the weight of the retained secretions in the jejuno-ileum causes a kink at the duodeno-jejunal juncture, and again in an effort to overcome this nature produces adhesions around the origin of the jejunum which may increase the obstruction, and by leading to dilatation of the duodenum may be responsible for the development of duodenal ulcer. Gastro-enterostomy, Lane holds, is effective merely because suspension of the first jejunal loop to the stomach relieves obstruction at the duodeno-jejunal juncture; the gastro-jejunal anastomosis is of no use whatever. The only rational treatment for all these conditions, he contends, is section of the lower ileum and union of its proximal end with the sigmoid below the last obstruction. In this way he claims to have cured such diverse lesions as exophthalmic goiter, tuber- culosis of the hip, trifacial neuralgia, etc., all of which he attributes to a primary auto-intoxication from chronic intestinal stasis. Fig. 964. — Congenital megacolon. From a patient under the care of the late Prof. Ashhurst in the University Hospital. SURGERY OF THE RECTUM AND ANUS 955 In most cases of chronic constipation the delay occurs in the pelvic colon, and not at the hepatic or splenic flexures where kinks are most apparent. Congenital Megacolon. — This is believed by most pathologists to be really of congenital origin, as indicated by the name selected for it by Hirschsprung in 1886. It is also known as Hirschsprung's Disease. Whether or not there is always a mechanical obstruction, or whether the dilatation of the colon is of neuropathic origin, are questions still in dispute. The sigmoid flexure is usually, and the entire colon often, involved; while the rectum and the small intestine almost always escape the dilatation. Most patients come under observation between the ages of two and ten years. Obstinate con- stipation exists from very early life; the abdomen becomes immensely distended (Fig. 904); the colon is packed with feces; tympany may be extreme at times; and the usual symptoms of fecal impaction are present. The general health is impaired, and the child's growth may be arrested. Treatment. — Treatment in mild cases, and especially in very young patients, should be palliative, as for any ordinary case of chronic constipation. In others, operative treatment, which offers the only hope of permanent cure, should not be delayed too long. Cecostomy I believe is the operation of choice; this is to be followed by free irrigations of the bowel through the fistula, and when the colon has been well cleansed and the patient's health is improved, the entire portion of bowel affected is to be resected. Tumors of the Sigmoid and Pelvic Colon are considered in con- nection with those of the rectum (p. 968). SURGERY OF THE RECTUM AND ANUS. Examination of the Anus and Rectum. — Digital examination may be employed with the patient on his back with thighs flexed, or stand- ing in a stooping posture. The gloved finger, well lubricated with green soap, is gently insinuated until both sphincters are passed, when its tip will be in the rectum, which normally contains no feces. In men the prostate and seminal vesicles can be felt beneath the anterior rectal wall, and in women the cervix of the uterus usually can be felt. Most pathological changes occur in or near the anal canal, and they often are overlooked because the examiner expects to find them too high in the rectum. If visual inspection is desired, it is necessary to dilate the sphincter; this is best done under a general anesthetic. First one index finger then the other is introduced, and by gradually sepa- rating them in various diameters, the sphincter is dilated. Usually it is desirable to dilate it until the finger comes into contact with the tuberosity of the ischium on each side. The mere fact of dilatation renders the anal canal visible, but to inspect the rectum high up, a speculum (proctoscope) is necessary. Fig. 965 shows some conven- ient types. The patient should lie in the Sims position (Fig. 1084). 956 SURGERY OF THE G ASTRO-INTESTINAL TRACT The speculum is introduced gently, with the obturator in place, and when introduced to its full depth the obturator is removed, any fecal matter or mucus is sponged away, and as the speculum is slowly withdrawn the mucosa which prolapses into its end is care- fully inspected for ulcers, dilated hemorrhoidal veins, orifices of fistuhe, etc. A sigmoidoscope is similar to a proctoscope, but much longer (25 to 35 cm.): it is inserted with great care until its tip gets well beyond the hollow of the sacrum, and the bowel is examined (by light reflected from a head mirror, or preferably by means of an incandescent bulb at the point of the instrument) from above downward, as the instrument is withdrawn. In most cases the instru- ment does not really enter the sigmoid, but the entire rectal canal is readily seen, especially if the pelvis is raised so that the rectum balloons. Fig. 965. — Two forms of proctoscope, and a sigmoidoscope. Congenital Malformations. — These are due to failure of proper union between the primitive proctodeum and the rectum (Figs. 966, 967, and 968). The most important classification is into those infants with absolute occlusion of the rectal canal, and those in whom there exists some form of fistulous exit for the meconium. In these latter cases the rectum may empty into the urethra or the bladder, or in the female into the vagina. In all except the last mentioned variety the condition usually is recognized at birth, or within a few days, and demands immediate operation. When the opening is into the vagina no obstruction may occur, and the malformation may pass unnoticed until adult life. The proctodeum may be present, as a dimple or shallow sinus at the normal site of the anus, the occlusion being above; or there may be no evidence of an anus. The most serious cases are those in which the proctodeum is present and the occlusion so high in the SURGERY OF THE RECTUM AND ANUS 957 rectum or sigmoid that it cannot be recognized from below, but is only inferred when symptoms of obstruction have been present for a number of days. In such cases it is safer to open the cecum than the sigmoid, since the obstruction may be in the latter. Fig. 966. — Congenitally imperforate rectum, proctodeum absent. Fig. 967. — Congenitally imperforate rectum, proctodeum present. Fig. 968. -Congenitally imperforate rectum, the bowel opening into the urinary tract. I demonstrated in 1907 that there are exceedingly few of these cases in which the bowel cannot be reached by a perineal operation; and as the mortality of this operation is very much less than that of iliac colostomy (Littre's operation, p. 943) which is the usual sub- stitute, it cannot be too strongly emphasized that perineal proctoplasty almost always may be successfully accomplished. An antero-posterior incision is made in the pCrineum, over the normal site of the anus, from the base of the scrotum to the coccyx, and this is deepened, keeping in the median line and following the curve of the sacrum, 958 SURGERY OF THE GASTRO-INTESTINAL TRACT until the rectal pouch is found. (I may go further, and advise, with Stromeyer, even if the rectum cannot be found from below, that the peritoneal cavity be opened through the perineum and any distended loop of lx»\vel found.) When the bowel is found, it is opened, and its margins arc drawn down and sutured to the skin. In newborn infants the promontory of the sacrum is only 3 to 5 cm. distant from the anus, and I have on several occasions carried the dissec- tion as far as this and succeeded in finding the rectum; and none of the patients so treated (one of whom was two weeks old when brought for operation) has died. On the other hand, the only patient on whom I have been forced to do iliac colotomy (cecostomy) died of inanition; this was a case in which no obstruction could be felt from below, and where the autopsy showed there was agenesis of a portion of the sigmoid, producing obstruction. In cases where the bowel opens into the bladder or urethra it almost surely will be possible to reach the rectal ampulla from below. If nothing more radical can be done the surgeon can at least establish a common perineal opening for feces and uirne, thus preventing temporarily ascending infection of the urinary tract. When the child is older a more radical opera- tion may be attempted. When the bowel opens into the vagina, it is best to dissect the rectum free, transplant the fistulous opening in it to the normal site of the anus, and repair the vaginal opening (Rizzoli, 1856). Abscess Around the Rectum and Anus. — This is a frequent affection, and the abscess may occur in various situations (Fig. 969) : (1) Sub- tegumental or perianal, which is be- tween the skin and the external sphincter; (2) ischiorectal, the most frequent of all, which occupies the ischiorectal fossa, between the skin and the levator ani muscle; (3) sub- mucous between the mucous mem- brane of the rectum and the internal sphincter; (4) pelvi-rectal, which de- velops above the levator ani muscle, just outside the muscular wall of the bowel; and (5) retrorectal, which is similar to the last named, except that it develops in the hollow of the sacrum. As will be seen by reference to the diagram all of these abscesses have their origin in the region of the anus between the sphincters, and almost always they are the result of slight trauma, from hardened feces, perhaps combined with exposure to wet and cold. The patient complains of burning and scalding in the rectum and great pain on defecation; it pains bim to sit down; and he may have retention of urine. Ischio-rectal Abscess is most frequently seen (Fig. 971) . Examination in the earliest stages shows merely a sense of resistance close to the Fig. 969. — Perianal abscesses. (See text.) FISTULA IN ANO 959 sphincter ani, with extreme tenderness. Later the whole ischiorectal region on one side may be tumefied, red, edematous, and pitting on pressure- Occasionally the abscess bursts spontaneously into the rectum (between the external and internal sphincters) or on the surface; but usually it is so painful that surgical treatment is sought quite early. Treatment consists in opening the abscess by an incision radiating from the anus in the case of very small abscess; or by an anteroposterior incision if the abscess is large. The incision must be much longer than seems necessary, since it contracts very rapidly when the pus is discharged. The cavity is drained by a wick of gauze, and is allowed to heal by granulation. Great care in dressing is requisite to prevent damming up of pus. The affection is not usually a serious one, but I have seen a few fatal cases in alcoholics and patients otherwise unable to withstand infection. The sinus may be very slow in healing, and fistula in ano is a frequent result, especially if rupture into the bowel takes place. The other forms of abscess mentioned require the same treatment, but in those which lie above the external sphincter (submucous) it is desirable to divide this also, as in fistula in ano, to secure better drainage. A pelvi-rectal abscess should be opened by an incision in the ischio-rectal fossa, after which the abscess is freely opened and drained by puncturing the levator ani and then dilating it by Hilton's method (p. 50). Fig. 970. — Fistulae in ano: 1, complete fistula (usual form); 2, blind external fistula (usual form); 3, blind internal fistula; 4, blind external fistula with suppurat- ing tracts; 5, complete fistula entering the bowel above the internal sphincter. Fistula in Ano. — -The most frequent cause of a fistula about the anus is ischio-rectal abscess. The fistula may have two openings, one on the skin surface (usually over the ischio-rectal fossa) and the other on the mucous surface (usually between the external and internal sphincters) ; this is known as a complete fistula. Only one opening may exist, and this may be on the skin surface {blind external fistula), or on the mucous surface (blind internal fistula) . Sometimes there are two or more skin openings to the same fistula, which may then resemble a horseshoe in form. Occasionally several independent fistulse exist. 960 SURGERY OF THE G ASTRO-INTESTINAL TRACT Symptoms and Diagnosis. — The patient complains of a discharge of pus, or ;ni irritation of the skin around the anus. The external orifice of the fistula usually is easily detected when the buttocks are separated ; it may be marked by a granulation or a tab of skin. The internal orifice sometimes can be felt by a finger in the rectum as an indurated spot, or it may lie made visible by means of a rectal speculum. The suppurat- ing tract which connects the two may be very devious. If it is desired to probe the fistula without giving a general anesthetic, the finger should be introduced into the rectum before the probe is passed into the sinu<. Every fistula around the anus is not a fistula in ana; it may be a pilo-nidal sinus (p. 297) or the opening of a cold abscess in connection with disease of the pelvic bones or vertebral column; or, more probably, a fistula resulting from a peri-urethral abscess (p. 1082). Treatment. — If the fistula is of very recent formation, palliative treatment may be employed. Cauterization with silver nitrate or chloride of zinc, or injections of bismuth paste sometimes bring tem- porary relief, but permanent cure without operation is very rare. The classical operation consists in laying open the fistula from one orifice to the other, by division of the external anal sphincter. A grooved director is passed into the external opening of the fistula, is caught by a finger as it emerges in the anal canal or rectum, and its point is bent down and brought out of the anus, which is then slit up on the director as guide. In the case of external blind fistulas the director is passed into the sinus and is made to perforate the rectal mucous membrane where this seems thinnest. A blind internal fistula may be opened up in similar manner after exposing its internal orifice. When the fistula is once laid open, the cicatricial tissue lining it is cut or scraped away, and the raw surface is packed and allowed to heal by granulation. The sphincter should be cut transversely, not obliquely to its fibers, and in not more than one place at the same operation, even if several fistulas exist, for fear of producing inconti- nence of feces. Of late years many surgeons have had much success in curing fistula in ano by formal excision of the tract followed by immediate closure by buried absorbable sutures; but the practice is not yet very common. Some of these fistulas are tuberculous in nature; usually they develop very insidiously, and usually a tuberculous focus exists elsewhere in the body. Unless the other lesions are very far advanced, tuberculous fistulas should be treated by excision and suture, as those of simple inflammatory nature. Scraping and leaving the wound open is apt to result in recurrence. Fissure of the Anus. — If a lump of hardened feces tears down one of the anal valves, the trauma is very apt to result in an indolent ulcer, lying in the grasp of the external sphincter. The ulcer is placed longitudinally in the anal canal, almost always at its posterior mid- portion, and usually extends on to the skin surface. Almost unbearable burning pain at the anus, after every act of defecation, and lasting FISTULA AND FISSURE OF THE ANUS 961 for an hour or more, is a highly characteristic symptom; and inspection of the anus confirms the diagnosis. Digital examination of the anal canal should not be made until the surgeon is ready to treat the lesion. Very occasionally a recently formed fissure can be made to heal by cauterization, application of a stimulating ointment, and scrupulous cleanliness; but in most cases operation is required. This consists in division of the sphincter through the base of the ulcer, under a general anesthetic. Healing is then prompt under ordinary dressings. Hemorrhoids or Piles. — A varicose condition of the rectal veins is a very frequent affection. The inferior hemorrhoidal veins drain into the internal pudic; the middle hemorrhoidals into the internal iliac or one of its branches; while the superior hemorrhoidals are tributaries of the portal system through the inferior mesenteric vein. These veins lie beneath the mucosa in loose areolar tissue, possess no valves, and are therefore especially subject to the effects of gravity; there are free anastomoses between the superior and the middle and inferior hemorrhoidal veins, so that dilatation of one set is quickly succeeded by dilatation of the others. In addition to the effect of gravity, which is always acting, these veins are liable to distention from the pressure of the contents of the rectum and sigmoid, from disturbances in the portal circulation (which occur during every period of digestion, and which pathological states frequently render constant), and from pressure on the pelvic veins in cases of ovarian, uterine, or prostatic disease. Straining in urination (as from stricture) as well as that due to chronic constipation, is a frequent cause. Hemorrhoids are classed as internal (which are covered with mucous membrane) and external (covered by skin), or as inter o-external, according to their relation to the sphincters. Hemorrhoids are further classed as bleeding, inflamed, thrombosed , etc., terms which sufficiently explain themselves. The affection is commonest in adults, but is not very rare in the young and the aged. External piles appear as protrusions of small size, close around the anus; they are covered with normal skin, unless inflamed, when they become purplish or red, swollen and very tender (Fig. 971). Suppuration may occur, and clotting of the contained blood is not very unusual; in this way a phlebolith may develop. The skin around the anus may become much macerated, and at first glance the condition may be mistaken for mucous patches; but the latter usually are not the only signs of syphilis present, and frequently occur elsewhere as well as around the anus. Internal piles are arranged in a circle just within the sphincters. Three sites are constant: two on the right of the anus, and one on the left; and such piles are termed primary. Secondary piles, not always present, and never more than four in number (Miles, 1919) may develop at other points of the anal circumference. Piles are bluish-black protrusions beneath the mucous membrane, and are easily compressible unless partly organized or thrombosed from repeated attacks of inflammation. The piles become worse when the patient is constipated, and may protrude only when he strains at 61 962 SURGERY OF THE G ASTRO-INTESTINAL TRACT stool or may come down on the slightest effort (Fig. 972), leading eventually to prolapse of the rectum. There is a sense of fulness and discomfort in the rectum almost all the time, and during a "fit of the piles," when these structures become inflamed, the pain may be almost unendurable and may radiate in various directions. Free bleeding from the dilated veins usually brings relief, and is a rather frequent occurrence, es- pecially at the end of a bowel movement. The blood is bright red, and appears spread over the fecal masses, not mingled with them, as is blood which comes from higher up in the intestinal tract, and which is apt to be brown and clotted before it is passed. Treatment.- — Any cause which can be discovered should be re- moved if possible. In mild cases it is sufficient to attend to the state of the bowels, procuring at least two free and soft motions daily by means of dieting and mild laxatives, such as salines in the morning, senna, rhubarb, etc. Active purges have little therapeutic effect though they may be required to unload the rectum. Scrupulous cleanliness must be preserved by irrigation or injections of cold water; protruding Fig. 971. — Inflamed hemorrhoids and ischiorectal abscess. Episcopal Hospital. Fig. 972. — Internal hemorrhoids, protruding and bleeding. Episcopal Hospital. piles should be pushed back after defecation; and some astringent ointment (as one of equal parts of gall and stramonium ointment, U. S. P.) may be applied to the anus. Should inflammation occur, the patient should be confined to bed, with the pelvis slightly elevated ; HEMORRHOIDS 963 and an ice bag or dry hot cloths may be applied locally. Moist heat should be avoided. Much relief may be secured by the administration of the following: 1$ — Ext. rhamni pursh.fi., 15. c.c; ext. ergot.fi., 30 c.c. ext. hamamelis fl., 45 c.c. — M. S. — Teaspoonful in water three or four times daily. Sometimes suppositories of opium, with acetate of lead or tannic acid, prove useful. If thrombosis occurs and the pile is excessively painful, it may be punctured and the clot evacuated. Usually it is best to postpone more formal operative treatment until the inflammation has subsided. Some surgeons employ palliative operations, especially the injection of carbolic acid into the base of each of the piles (one or two at each sitting) which are thus thrombosed and may eventually shrivel up. I have no experience with this method myself, but believe that as commonly employed it is neither efficient nor entirely safe. Wallis prefers a 10 per cent, solution of carbolic acid in glycerin and water; 3 to 8 minims are injected into the pile, according to its size. He found his patients secured temporary relief. The operations in common use for cases of hemorrhoids are ligation and the clamp and cautery operation. For the average operator there is no doubt that the first of these is the method of choice both for safety and for certainty of cure. For internal hemorrhoids I think it is preferable to cauterization, though the latter is widely employed for these as well as for external piles. Excision (Whitehead, 1882) is a more formidable operation, is quite unnecessary as it is often a failure and the simpler operations are always curative if properly done. Ligation of Hemorrhoids. — The anus is dilated as described at p. 955, and each pile mass is caught in suitable forceps. Hemostatic forceps are not efficient, as they usually tear loose. The Allis forceps or a special ring forceps may be used. Unless all the piles are clamped in this way at one time, there will be danger of dislodging the ligatures already placed while the remaining piles are being sought for. If there is any pile which has a cutaneous margin (intero-external hemorrhoid) a groove should be cut around its base through the skin with scissors; this prevents the ligature from slipping, and by severing the skin nerves reduces the discomfort after operation. A groove may be cut also in the mucous membrane, all around the base of the pile, exposing its pedicle, but this is not necessary. Then a curved needle carrying a long, stout, linen thread is made to transfix the base of the pile, in the long axis of the rectum; the loop of the thread is cut and the pile is ligated in two sections, the ligatures interlocking and being tied in the groove already cut. The protruding portion of the hem- orrhoid is then cut away leaving enough stump to prevent slipping of the ligature. The ends of the latter should be left long until it has been ascertained that no bleeding occurs. Each pile mass (usually there are not more than five) is treated in the same way. Finally the surfaces of the amputated piles are dusted with iodoform powder, and a sterile pad is applied to the anus and held in place by a T-bandage. Usually the bowels move spontaneously by the fourth day. If they do not they should be opened by a dose of castor oil. An enema should 964 SURGERY OF THE GASTRO-INTESTINAL TRACT not be given. Particular attention to local cleanliness and efficient drying should be enforced for two weeks; usually the patient may leave bed in a week or ten days after operation. Clamp and Cautery for Hemorrhoids. — After dilating the sphincter and grasping all the piles in suitable forceps as already advised a special pile clamp is applied to one of the masses, in the long axis of the bowel, and is screwed so tight as to crush the base of the pile. The protruding tissue is not cut away but is cauterized with the cautery at a dull (cherry) red heat until destroyed. Though the pile-clamp usually has its under surface faced with ivory, to prevent radiation of the heat to the surrounding tissues, it is well as an additional safeguard to surround it with damp cloths while the cautery is in use. Each pile mass in turn is treated in similar fashion, and subsequent treat- ment is conducted as alreadv described. Fig. 973. — Prolapse of rectum. Children's Hospital Prolapse of the Rectum. — This develops as the result of repeated straining efforts, as in cases of hemorrhoids with constipation or in severe diarrhea with rectal tenesmus, or sometimes as the result of whooping-cough. A congenital malformation in the attachment of the rectum within the pelvis is also recognized as a cause, the recto- vesical or rectovaginal pouch of peritoneum being abnormally deep. The loose mucous membrane protrudes from the anus at first only during defecation, and may recede spontaneously when the patient stands up. Later, however, the bowel may protrude at other times and may require to be replaced manually. Occasionally reposition becomes impossible; in such cases usually the muscular wall of the rectum has prolapsed also {procidentia recti). The condition is most common in young children, but occurs also in adults, and sometimes during old age when it often seems to depend on loss of muscular tone. In every such case examination should be made to exclude the presence of polypus, stricture, or carcinoma higher up in the bowel. Symptoms. — In the ordinary form (prolapsus recti or partial prolapse) the mucous membrane of the rectum is seen protruding from the anus PROLAPSE OF THE RECTUM 965 as a red or purplish ring. Usually the condition is unmistakable (Fig. 973). In complete prolapse (procidentia) the protrusion may be 5 cm. or more in depth, and there is a clearly recognized groove between the mucous membrane and the anus. Prolapse causes a sense of weight and weakness, and often some disturbance of the urinary functions. Strangulation is rare, but is seen occasionally at the first onset of the prolapse; when the condition becomes chronic the sphincters are much relaxed. Treatment. — Reduction usually may be secured by moderate pressure with an oiled cloth or the gloved hand, while the patient is lying prone. In cases of strangulation it may be necessary to divide the sphincter. Recurrence often may be avoided by having the bowels opened only when the patient is lying down flat on his back. Moreover, the buttocks should be strapped together by adhesive plaster, which is removed only after the bowels have acted, and is at once replaced when the parts have been cleansed. In the case of most children, in whom the condition is not of very long standing, a cure results if the child is kept in bed with proper regulation of diet and bowels. Cod- liver oil is valuable as a tonic for these purposes. If operation is required, trial should first be made of cauterization as in the case of hemorrhoids, clamping, excising, and cauterizing longitudinal folds of mucous membrane down to within 1 or 2 cm. of the anal margin. Mummery's operation (1910) consists in opening the space between the rectum and sacrum by a transverse incision, packing it full of gauze, and allowing it to heal by granulation. The patient should remain in bed for a month. Sigmoidopexy , or suspension of the sigmoid to the anterior abdominal wall, was first employed in 1889 by Verneuil; it is wise to combine it with a plastic operation below, as recurrence has taken place in more than half the cases treated by sigmoidopexy alone (Pachinio, 1905). Obliteration of the rectovesical (rectovaginal) pouch of peritoneum is a more efficient procedure (Quenu and Duval, 1910; Moschcowitz, 1912). Fecal Incontinence. — Fecal incontinence is to be treated by removal of its cause when this is possible. Gersuny (1893) dissected the anal canal free of all attachments, and twisted it on itself until a feeling of resistance was encountered; the anus is then sutured in its new position. Even an iliac anus may be preferable to hopeless incontinence, because more cleanly. Proctitis. — Inflammation of the rectum may be traumatic (from impaction of feces, frequent use of enemas, foreign bodies, etc.) or infectious (dysenteric, septic, gonococcic, etc.). The symptoms are a sense of heat; tenesmus; frequent, small, watery stools, often with blood and mucus. There may be considerable fever and much con- stitutional disturbance. Examination through a speculum shows inflamed mucous membrane, and frequently patches of lymph covering ulcers which bleed readily when touched. Treatment involves removal of the cause when this is possible and known; also cleansing and anti- septic applications through a speculum. After an ordinary cleansing 966 SURGERY OF THE GASTRO-INTESTINAL TRACT enema, in severe cases, the patient may be etherized, and a 2 per cent, solution of silver nitrate swabbed all over the inflamed surfaces, through a speculum. Then the rectum is irrigated with boric acid solution (half saturated), and finally an injection is given of 50 to 75 c.c. of some demulcent solution (flaxseed or slippery elm), contain- ing 10 drops of laudanum (Abbe); this is to be retained as long as possible. In most cases two or three such treatments at intervals of a few days arrest the disease. But in cases where colitis also exists (dysenteric, tuberculous), recurrence is the rule unless the ulcers above can be made to heal by appropriate treatment (p. 950). Strictures of the Rectum. — These are a frequent result of dysenteric ulceration and of trauma in childbirth (Fig. 948). Malignant ulcera- tion causing obstruction is considered under the heading Tumors of the Rectum (p. 968). Inflammatory changes in neighboring structures (vagina, broad ligaments of uterus, pelvic connective tissue, prostate, etc.) frequently extend to the fibrous tissue in the layers of the rectal wall and they may cause a submucous or perirectal stricture which is the same in its effects as one which arises in ulceration of the mucous membrane, since no ulceration of the mucous membrane which does not involve the fibrous tissue can produce a stricture. Other causes than those already mentioned are rare, though tuberculous and syphilitic and other specific ulcerations and strictures do occur. Syphilitic stricture, formerly considered frequent, is now acknowl- edged to be quite rare. When these specific ulcerations occur their pathology is much the same as that of septic or traumatic ulceration, since secondary infection from the intestinal contents is the rule. Almost all strictures occur within 7 to 10 c.c. of the anus; those which occur higher, in the sigmoid or colon produce the symptoms of chronic intestinal obstruction (p. 942). The stricture may be single or multiple, marginal or annular, of large or small caliber. The simple inflammatory stricture, according to Tuttle, usually occupies only a portion of the circumference of the bowel, stands out abruptly from the rectal wall, usually is close to the anus, and has a smooth surface covered with epithelium. A syphilitic stricture presents a gradual funnel-shaped contraction, there is a bluish-white cicatrix around the edges of the ulcer, and the floor of the ulcer is excavated ; the edges of a tuberculous ulceration always are undermined and its base is elevated (Tuttle). Secondary ulceration, from fecal impaction, occurs above the stricture, so that when these patients come for treatment the rectum almost always is ulcerated as well as strictured, though the ulcers which were the original cause of the stricture may have healed long since. Symptoms. — These may not develop for years after the proctitis which is the original cause of the stricture. The patient may come complaining of frequency of urination with a sense of weight in the perineum, and the importance of thorough local examination cannot be too often emphasized. There is a history of the primary rectal condition, followed by a latent period, and then gradually developing STRICTURES OF THE RECTUM 967 but steadily increasing difficulty in obtaining complete evacuation of the rectum. As secondary ulceration develops, blood and mucus are discharged with the stools, or frequently alone, the stricture retaining the fecal mass above it. The diagnosis of simple from malignant stricture is made by observing the long duration of the simple stricture and the comparatively slight impairment of the general health; and by direct examination of the rectum, when the smooth, hard, but not nodular character of the stricture determines it to be non-malignant. Malignant stricture is very rare before thirty-five or forty years of age; its course is rapid and progressive (two to three years) ; loss of flesh and strength appears early ; the tumor is nodular to the touch and bulges into the lumen of the bowel as well as causes fibrous thickening of its coats; and the odor of the discharge is gangrenous, never simply fecal (Tuttle). Treatment. — Permanent cure cannot be hoped for from palliative treatment with rectal bougies; they are of benefit even temporarily only when the stricture is of recent formation; they must be passed at intervals throughout the patient's life; and in many cases serve only to aggravate the patient's discomfort by producing bleeding and further ulceration, even if skilfully and gently passed. An ordinary wax candle, molded by heat to suitable shape, makes as good a bougie as any, provided the stricture is not very small and is close to the anus. In other cases it is best to use the hollow bougie of Wales, which is introduced through a speculum passed up to the face of the stricture, and by means of which irrigation may be practised above the stricture. Before operative treatment is undertaken it is important to cleanse the bowel above the stricture. If this cannot be accomplished from below (by repeated enemas or colonic irrigations through a Wales's bougie, aided by the use of olive oil or gentle saline purges by mouth), it is necessary to do colostomy (sigmoidostomy). After the entire fecal current has been diverted in this manner, and the lower segment of the bowel thoroughly evacuated and brought into a healthy state by irrigations, direct treatment of the strictures may then be attempted. Posterior proctotomy (Verneuil), or incision of the posterior rectal wall, including the sphincters and everything down to the bone, is not to be recommended unless the stricture is close to the anus ; but it is a good operation in cases where septic proc- titis accompanies stricture, as it secures free drainage and relieves the acute symptoms though it does not produce a cure. The hemor- rhage is not alarming and may be controlled by packing gauze around a large rectal tube. It is necessary to continue the passage of bougies subsequently for an indefinite period. In the case of a single high stricture it may be possible to perform sigmoido-proctostomy, making an anastomosis by the Murphy button between the sigmoid and the rectum below the stricture; the spur between the strictured and the anastomotic opening may be removed later by Dupuytren's enterotome. In the worst cases of stricture formal excision of the rectum, as for malignant disease, is the most satisfactory treatment. 968 SURGERY OF THE GASTRO-INTESTINAL TRACT Recto-urinary and Recto-genital Fistulae. — Formerly these were frequent results of difficult parturition, following the separation of sloughs caused by pressure of the fetal head or by instruments; but owing to improvements in the obstetric art they are now comparatively rare. Occasionally they result from operative injury, or from the rupture of an abscess into both the intestinal and genito-urinary tract, or as the result of specific or malignant ulceration. The fistula may connect the intestinal tract with the bladder or urethra (recto-vesical and recto-urethral fistula) or with the vagina (recto-vaginal), rarely the uterus (recto-uterine fistula) . Vesico-vaginal and vesico-uterine fistula are results of similar causes and require similar treatment, though the intestinal tract is not involved. The diagnosis is made by observing the discharge of urine or feces (sometimes only of flatus) through an abnormal channel, and by direct examination with sound or endoscopic instrument (cystoscope, proctoscope) in the bladder or rectum. The only satisfactory treatment is by operation, which consists essentially in dissecting up the borders of the fistula and closing the opening in the wall of each viscus involved, by means of separate sutures. In the rare cases of recto-uterine or vesico-uterine fistulse hysterectomy may be necessary (Chapter XXIX). Tumors of the Rectum and Sigmoid. — Benign tumors are com- paratively rare. Adenoma is the least unusual. It occurs most often in children in the form of rectal polypus, and presents symptoms similar to those of hemorrhoids, for which or for prolapsus it is often mistaken. Usually when the child strains the polypus comes down in reach of the examining finger, or it may prolapse through the anus. Treatment consists in excision after transfixion and ligation of its base. In adults adenoma and papilloma are quite rare growths, and usually are pre-carcinomatous in nature. The tumor is rather soft, seldom is ulcerated, and is freely movable on the underlying rectal wall. It should be freely excised. In the disease known as multiple adenoma the entire colon may be invaded by small polypoid growths, though usually the rectum is the part most involved. The symptoms are persistent bloody diarrhea, with tenesmus, and gradual loss of flesh and strength. If removal of the numerous rectal growths is followed by their persistent recurrence, or if there is a suspicion of malignancy excision of the rectum should be done; or if the entire colon is diseased a false anus may be established in the cecum. Carcinoma.- — Carcinoma is the most frequent tumor of the rectum. It occurs (1) at the anus (squamous-celled carcinoma), which is rare; (2) just above the sphincters (adeno-carcinoma, often encephaloid), which is not unusual; or (3) above the reach of the examining finger in the upper rectum or pelvic colon, at the level of the promontory of the sacrum (adeno-carcinoma, often scirrhus); in this latter situation about two-thirds of rectal cancers are found. The rectum frequently is invaded by carcinoma originating elsewhere (prostate, cervix uteri) . Anal carcinoma causes secondary invasion of the inguinal lymphatics, and clinically resembles epithelioma of the lower lip. True rectal TUMORS OF THE RECTUM 969 carcinoma extends in the submucous tissues of the rectal wall rather than directly through it to neighboring structures; and invades the lymph nodes in the hollow of the sacrum, but seldom higher than the promontory of the sacrum. Except in the more highly malignant forms, death is more apt to occur from intestinal obstruction than from local extension or metastasis. Symptoms. — The symptoms are hemorrhage (especially in younger patients), alternating diarrhea and constipation, and eventually loss of weight and foul discharge with highly characteristic odor. These symptoms, however, may not appear for months after the development of the tumor, particularly if the latter is high in the rectum. Often the growth is found absolutely inoperable when no symptoms of note have ever existed. Diagnosis. — Diagnosis is not difficult at the stage when most patients consult a surgeon. The tumor is irregular in outline, nodular, with raised margins and ulcerated center; and it is fixed to the bowel wall if not to the surrounding structures. If any doubt exists, a piece should be excised from the base, for microscopical study. If the growth is too high to be accessible for diagnosis from below, lapar- otomy should be done. Treatment. — The first question to decide is whether or not radical operation can be done, and, if this is impossible, whether the establish- ment of a false anus will promote the patient's comfort. The growth may be considered inoperable (1) when the patient's condition forbids an operation with a mortality varying from 10 to 50 per cent.; (2) when the growth is found to be fixed even when examined under anesthesia; or (3) when distinct metastases exist. In such cases palliative treatment aims to reduce the amount of fecal discharge and decrease its irritating qualities by attention to diet and adminis- tration of intestinal antiseptics; to secure free evacuation of the bowels by gentle purging and by enemas administered if possible by a tube passed above the growth; by local treatment of the ulcerating area by irrigation with permanganate or creolin solution; and finally to keep the patient as comfortable as possible by administering plenty of opium. In rare instances advantage is to be derived from scraping and cauterizing the surface of a cauliflower-like growth. The degree of heat may be controlled by placing a finger within the bladder through an abdominal incision (D. F. Jones, 1915). If acute obstruc- tion occurs (it is rare except in carcinoma of the sigmoid), a false anus should be established in the sigmoid, or if the obstruction has existed very long, in the cecum, where the gut is healthier. Unless obstruction is present or death only a matter of a few months, many patients will prefer to suffer rather than be relieved at the expense of an iliac anus; but if the latter is properly constructured and cared for, it produces very little disability, and relieves the patient of untold discomfort by producing latency of rectal symptoms. Formation of a False Anus. — Through a left-sided McBurney incision a loop of sigmoid is drawn out, and its afferent limb drawn 070 SURGERY OF THE GASTRO-INTESTINAL TRACT taut. If this precaution is neglected prolapse of the descending colon may occur through the false anus. Then the afferent and efferent loops are stitched together along their mesenteric borders, for a dis- tance of about 10 cm., so as to form an efficient spur. The loop of bowel is then replaced and sutured in the abdominal wound at the level of the mesentery (Fig. 974), a rubber tube, transfixing the mesosigmoid at the apex of the loop, being left in place a few days to prevent the loop from retracting too far within the abdomen. If the operation is done for acute obstruction a Paul's tube should be fixed in the proximal loop immediately. Otherwise it is not necessary to open the gut for several days; the opening is then accomplished by a transverse incision by cautery. Subsequent treatment involves occasional irrigation of the rectal loop through the false anus, to clear it of discharges (which are much diminished after diversion of the feces from the ulcerating area) and regular daily irrigation of the colon through the upper opening. If the colon is thoroughly flushed out every morning, by 500 to 1000 c.c. of warm water, and if this injection is retained for about twenty minutes, free evacuation of the bowel is secured by turning face downward and exerting pressure over the cecum. "The patient is then quite comfortable and clean for the rest of the day" (Wallis, 1912). Fro. 974. — Establishment of a permanent false anus by suturing the afferent and efferent loops together "en canon de fusil." A Paul's tube has been tied in each end. Radical Operation. — About a week is required to get the intestinal tract in proper shape for operation, and commencing the night before large doses of deodorized tincture of opium should be given (Tuttle). In cases of acute obstruction, or if the sphincters will have to be removed, a preliminary colostomy (as above described) should have been done about two weeks before radical operation. Opportunity should also have been taken, when the abdomen was opened, to palpate the liver for metastatic growths. 1. Where the growth invades the sphincters, these and the rectum as high as the sacral promontory are removed; and the pelvic end of the CARCINOMA OF THE RECTUM 971 rectum is closed and allowed to drain through the previously estab- lished iliac anus. The perineal wound is completely closed, with drainage to the hollow of the sacrum. The inguinal lymphatics should be extirpated also. 2. For a growth just above the anus, in which the sphincters can be preserved, I think the perineal operation as modified by Peck (1909) should be done: The anus is closed by a purse-string suture; then an incision is made from coccyx to rectum and is carried forward on each side of the anus in Y-shape. The coccyx may be excised, but further removal of bone from the sacrum (Kraske, 1885) does not materially facilitate the operation. Both of the levator ani muscles are cut just above the anus; the rectum is separated all around its circumference and is doubly ligated below the growth, divided between the (linen) ligatures and the cut surfaces are seared with the actual cautery. The peritoneum is then opened, the rectum is freed anteriorly from bladder and prostate, as well as laterally and posteriorly, and is drawn down until an area well above the growth is exposed. It is here again doubly ligated, divided and cauterized, and the tumor is removed. The occluding suture is then removed from the anus, the sphincter is split posteriorly, and the anal mucous membrane is excised. The proximal segment of bowel, still closed by ligature, is then drawn down until it projects well beyond the sphincter, which is sutured around it. The peritoneum and levatores ani are then repaired, the hollow of the sacrum is drained, and the unopened bowel is left pro- truding from the anus. When several days have passed, and granula- tion has begun, so that little fear of infection remains, the redundant bowel (perhaps sloughing in parts) is cut away, and fecal discharge is allowed. Fair sphincter control is preserved; the immediate mortality of such an operation is from 10 to 20 per cent.; and from 20 to 60 per cent, of patients pass the three-year interval without recurrence. 3. For high rectal carcinoma (all tumors above easy reach of the finger), a combined abdominal and perineal extirpation is the accepted procedure, though the primary mortality even in skilled hands is very high (25 to 50 per cent.), and the permanent cures average only about 16 per cent. This method was first introduced by Maun- sell, and has been popularized in France by Quenu and Hartmann (1897), and in this country by Tuttle and the Mayos. I believe Weir's modification (1901) of the method in which the sphincter is preserved, and which since 1914 has been employed also by Quenu, is better than the original plan of Quenu in which the entire rectum is removed and an iliac anus established. Quenu and Schwartz (1917) have reported 7 radical operations by this method with only 1 death. The surgeon commences by opening the abdomen in the midline and examining the parts. If the tumor is high enough in the sigmoid an ordinary intestinal resection may be done, with end-to-end union, or where possible by lateral anastomosis, which is safer. If the tumor is too low to make this possible, the sigmoid is divided a safe distance (15 cm.) above the growth, both ends being closed at once 972 SURGERY OF THE CASTRO-INTESTINAL TRACT Fig. 975. — Abdomino-anal operation for carcinoma of the rectum: the sigmoid has been divided and both ends closed; the rectum has been freed from the hollow of the Fig. 976. — Blood-supply of the pelvic colon and rectum: 1, ligature on the superior hemorrhoidal artery; 2, ligature on the inferior mesenteric; 3, ligature on a descending branch of the left colic artery. CARCINOMA OF THE RECTUM 973 by suture. The mesorectum is then divided, and, after ligation of the superior hemorrhoidal artery, the rectum and fatty and lymphatic tissue behind it can be stripped off the sacrum quickly, and with very little hemorrhage (Fig. 975). The rectum is then doubly clamped below the growth, divided, cauterized, and the diseased bowel removed. Next the sigmoid and perhaps the descending colon must be freed sufficiently to enable the remaining bowel to be brought down to the anus. This is accomplished by mobilization of the sigmoid (P. Duval, 1902) : the outer leaf of the meso-sigmoid is divided, and the bowel is turned toward the median line by gauze dissection, restoring it to the condition which existed in intra-uterine life. By ligation and section of the sigmoid arteries, and if necessary of the inferior mesenteric itself, close to the root of the mesosigmoid (Fig. 976) sufficient circulation is preserved through the loops of communica- tion from the left colic or even from the middle colic artery (Archibald, 1908). Ample slack of sigmoid and descending colon having been secured in this manner, an assistant introduces forceps into the anus from the perineum, and evaginates the lower segment of the rectum; next he pulls down through its lumen the upper segment (sigmoid). The abdominal wound is then closed, after repair of the pelvic peri- toneum. The evaginated rectum and sigmoid are then securely sutured together, and are finally replaced in the pelvis by reducing the evagina- tion. Drainage of the pelvis is provided by an incision in front of the coccyx. If an iliac anus has been made previously, for obstruction or any other reason, it is better to excise the entire rectum, including the sphincters, and to close the perineum. CHAPTER XXIV. SURGERY OF THE GALL-BLADDER, LIVER, PANCREAS, AXI) SPLEEN. SURGERY OF THE GALL BLADDER AND BILE-DUCTS. Infections of the Gall-bladder and Bile-ducts. — It has been shown by Adami and others that bacteria are constantly being transmitted from the intestinal tract through the portal circulation to the liver. The liver is endowed with antibacterial and antitoxic properties, and under normal conditions the bacteria received in the way described are destroyed in the liver. But if the virulence of the bacteria is increased, or the destructive action of the liver lessened, then such bacteria are excreted from the liver with the bile. The gall-bladder is a suitable place for bacteria to multiply, both from its anatomy, and from certain characteristics which are easily acquired. The bile tends to stagnate in the gall-bladder because of the tortuosity of the cystic duct, because the fundus of the gall-bladder is lower than its outlet, and above all because persons of sedentary habits and those who wear tight corsets do not aid the expulsion of bile from the gall-bladder by active exercise of the diaphragm and abdominal muscles. It is possible also, and not very infrequent, for the gall-bladder to be infected by way of the systemic circulation, through the cystic artery. This is probably the case in typhoid fever, in which disease the infecting bacillus usually can be obtained in pure culture from the gall-bladder. An infection by way of the common bile-duct, ascending from the duodenum is rare. If the infection which reaches the gall-bladder either through its contained bile, or through the blood-stream, is very severe, the result- ing changes in the gall-bladder are acute in type. The pathology of acute inflammation of the gall-bladder (cholecystitis) corresponds to that already discussed in connection with the appendix. The walls of the gall-bladder are the seat of round-celled infiltration (phleg- monous inflammation) and this may lead to gangrene or to perforation of the organ. If the infection which reaches the gall-bladder is very mild, a slight catarrhal inflammation occurs, and the interaction of the cholesterin set free in this w T ay with the salts contained in the bile results in the formation of concretions known as gall-stones or biliary calculi. Cholecystitis. — The pathogenesis of this condition has been described It is rare except as a complication of gall-stone disease (cholelithiasis, p. 977). Swelling of the spiral folds of mucous membrane lining the (974) CHOLECYSTITIS 975 cystic duct converts the gall-bladder into a closed cavity, and the virulence of the infection is thus increased. If suppuration occurs within the gall-bladder the condition is described as empyema of the gall-bladder. If inflammation spreads to the surrounding peritoneal structures, pericholecystitis is said to exist. Even if the disease is arrested before gangrene or perforation occurs a return to normal does not ensue; pericholecystitis leaves as a legacy pericholecystic adhesions which bind the gall-bladder to the duodenum, pylorus, or omentum, and which may cause kinking of the bile-ducts; while changes in the wall of the gall-bladder and in the cystic duct impair still more its drainage facilities, and stricture or occlusion of the cystic duct may convert the gall-bladder into a permanently closed cavity with contents of very low infectious power, a condition described as hydrops of the gall-bladder. Chronic cholecystitis may occur as a sequel of an acute attack, or if the infection is mild the cholecystitis may be chronic from the beginning. It is very rare except in cases of cholelithiasis. Fig. 977. — Gall-bladder excised for acute calculous cholecystitis; gall-bladder was almost gangrenous, and ruptured near fundus during removal. Recovery. One-half natural size. Episcopal Hospital. Symptoms of Acute Cholecystitis. — The patient usually is an adult in early middle life. The affection is rare before thirty years of age, and not very frequent in those over forty years, unless previous attacks have occurred. The attack usually begins with biliary colic (p. 979) which may be mild or severe. It is a mistake to suppose that biliary colic occurs only when gall-stones are present; as in the case of the appendix, the intestine, and the kidney, the colic is a sign of disordered and violent peristalsis in an effort of the organ to empty itself against resistance. The resistance may be formed by a gall-stone impacted in the neck of the gall-bladder or in one of the ducts, but it often is formed by inflammatory occlusion of the cystic duct, or by an exceedingly viscid and tarry state of the bile which is a frequent condition in the stagnant gall-bladder. In many cases of cholecystitis the pain is not very severe at first, and is felt in the epigastrium, or is diffused through the abdomen; soon, however, it settles to the gall- bladder region, to the right of the epigastrium or in the right hypo- 976 SURGERY OF THE GALL-BLADDER AND BILE-DUCTS chondrium. Sometimes referred pain is felt in the right shoulder, under the scapula, or in the right iliac fossa. If the gall-bladder lies low in the abdomen the attack may be confused with appendicitis. Nausea and vomiting usually occur, but may be entirely absent. Muscular rigidity and tenderness over the site of the gall-bladder are constant and very valuable signs. The gall-bladder becomes enlarged and usually can be outlined by percussion, and if rigidity and tender- ness are not very great, it may be palpable as a smooth rounded tumor beneath the costal margin continuous with the liver dulness and moving in respiration unless fixed by adhesions from previous disease. Jaundice does not occur in uncomplicated cases of cholecystitis; it implies involvement of the common or hepatic ducts. There usually is fever, but the temperature seldom is very high; there is polynuclear leuko- cytosis. If there is much constitutional reaction, and if the elevation of temperature continues for several days and is high, empyema or threatening gangrene should be suspected. Perforation into the free peritoneal cavity is very rare (Fig. 951), and is unusual even into preformed pericholecystic adhesions. It may be recognized in some cases by sudden severe pain, perhaps with symptoms of shock, fall of temperature, rise of pulse rate, and occasionally by the sudden dis- appearance of a gall-bladder tumor previously palpable. Unless the upper abdomen is well protected by adhesions, spreading peritonitis ensues. In the former case a pericholecystic, subphrenic or, rarely, a perinephric abscess results. Spontaneous perforation through the abdominal wall {external biliary fistula), or into the gastro-intestinal tract {internal biliary fistula) is very rare. Diagnosis. — Acute cholecystitis must be distinguished from appen- dicitis (p. 900), gastric or duodenal perforation (p. 919), intestinal obstruction (p. 936), and acute pancreatitis (p. 999). In most cases the correct diagnosis is easy, owing to localization of the signs and symptoms to the gall-bladder region, and the recognition of the enlarged gall-bladder. Treatment. — The patient should be treated by rest in bed, in the semi-recumbent position; absolute prohibition of food or liquid by the mouth; hot or cold applications to the upper right quadrant of the abdomen; and proctoclysis of saline fluid or tap water. Most mild cases of cholecystitis will subside within a day or two under this treatment. If anything is taken into the stomach peristalsis is aroused, and there is danger of spreading the infection from the gall- bladder to the bile ducts or to the surrounding peritoneal structures. When all acute symptoms have been absent for a day or so, sodium phosphate in hot water may be given by mouth, and then feeding may be cautiously resumed. If the attack does not subside promptly, suggesting the probable occurrence of suppuration within the gall- bladder, the organ should be drained {cholecystostomy, p. 985). Cholangeitis. — Cholangeitis, or inflammation of the bile-ducts, is rare except as a complication of gall-stone disease, or as a sequel of catarrhal gastro-duodenitis ("catarrhal jaundice"). In this condition CHOLANGEITIS 977 the duodenal mucous membrane around the bile-papilla, and that in the lower end of the common duct, swell up and cause obstruc- tion of the biliary outlet, resulting in the development of jaundice. In many of these cases it is probable that swelling of the head of the pancreas also occurs and compresses the common bile duct, which is known to traverse its substance in two out of three cases. If the attack of jaundice occurs in the young, it usually is due to gastro- duodenal catarrh; jaundice in middle aged or old patients usually is due to gall-stone disease, pancreatitis, or malignancy. In the latter conditions pain is more marked (usually it is entirely absent in catarrhal jaundice); the jaundice is of longer duration (usually it subsides in a week or ten days in cases of gastro-duodenal catarrh); it varies in intensity unless there is obstruction by a malignant growth or pancre- atitis; and attacks of chills and fever are much more common than in attacks of catarrhal jaundice. Chronic catarrhal cholangeitis and suppurative cholangeitis are very rare except in connection with gall- stone disease. Treatment. — Cholangeitis due to gastro-duodenal catarrh subsides promptly under appropriate medical treatment. In other cases the treatment is that of the causative condition, and postoperative drain- age of the ducts should be continued until the bile becomes and remains free from virulent bacteria. Cholelithiasis. — The formation of gall-stones has already been alluded to. The chief predisposing condition is stagnation of bile in the gall-bladder. As the stagnant gall-bladder is more frequent in women than in men, so is the occurrence of gall-stone disease. The stagnated bile becomes viscid, ropy, and very dark in color. It invites infection, and when such infection occurs, in attenuated form, the union of cholesterin derived from the mucous membrane, with bile salts, results in the formation of concretions (gall-stones). Biliary sand, composed of minute cholesterin crystals, is found not very infrequently in such a gall-bladder, which is otherwise apparently normal. This sand clings to the mucosa of the gall-bladder and can- not be detected with the finger because so fine and so well covered by mucus; it can be seen glistening on the gauze which has wiped the gall-bladder cavity. It is held by AschofT and Bacmeister (1909) that a concretion composed of pure cholesterin may be formed in the gall-bladder without the presence of bacterial infection; they teach that this stone precedes the formation of all other varieties, which may be numerous. The following varieties of gall-stones may be recognized: (1) The pure cholesterin stone (Figs. 978 and 979) usually is of fairly large size and oval in shape; it is soft when first formed but becomes hard and brittle on drying; is white, yellowish, or brownish black on the surface, but white and crystalline on section. It is not stratified, but is composed of radiating crystals around a comparatively soft center, which in the dried specimen may be hollow. (2) Laminated cholesterin stone. Laminations indicate that secondary deposits of bile salts have 62 978 SURGERY OF THE GALL-BLADDER AND BILE-DUCTS occurred around the primary radial cholesterin stone. (3) The common gall-stones, or mixed cholesterin calculi, vary greatly in number and size Fig. 978. — Radial cholesterin stone; spontaneous fracture in gall-bladder. Female, aged fifty years, with empyema of gall-bladder. Recovery. Scale in inches. (See Fig. 979.) Episcopal Hospital. and usually are faceted; the surface color usually is yellowish. They are all formed at or about the same time, and are pressed into their Fig. 979. — Cholesterin gall-stone, with polished facet at each end. Same stone as Fig. 978, after fragments had been glued together. Scale in inches. Episcopal Hos- pital. faceted shape while still soft (Fig. 980). (4) Mixed bilirubin-calcium stones are less usual, generally occur singly, or in groups of three or Fig. 980. — Common gall-stones, from a gall-bladder removed for acute calculous cholecystitis, in a woman, aged thirty-seven years. Dyspepsia for years, and much belching after meals. Wakened one midnight by epigastric pain ; two days later enlarged gall-bladder palpated; admitted for operation on third day; cholecystectomy; recovery. Episcopal Hospital. four, on section show concentric layers of dark reddish-brown material ; and on drying usually contract with the formation of fissures. (5) Pure bilirubin-calcium stones also occur, as do certain still rarer forms. CHOLELITHIASIS 979 Gall-stones are the result of previous disease in the gall-bladder, and may form so silently that little indication of their presence is given until some acute infection arises, causing acute calculous cholecystitis, or cholangeitis. They are formed in the gall-bladder, not in the liver or bile ducts, and so long as they remain in a gall-bladder free from infection may produce no noteworthy symptoms. This state is described as Simple Cholelithiasis. But the presence of the concre- tions predisposes the gall-bladder to infection, and if one or more of the calculi wander from the gall-bladder and enter the cystic or the common duct, very serious symptoms may arise. At operation these ducts are found to have been invaded by one or more calculi in nearly 40 per cent, of cases (Deaver and Ashhurst). Simple Cholelithiasis. — This has been defined above. The gall- stones have remained quiescent in the gall-bladder since the time of their first formation, perhaps many years previously. The symp- toms are due to a chronic catarrhal cholecystitis, and the pathological changes in the gall-bladder are not very marked. The bile is thick and tarry, but so long as no acute infection occurs the patients are not much troubled. But certain symptoms are present by which the disease may be recognized, and they can be discovered by studying carefully the history of the case. These symptoms usually are con- sidered gastric in origin, and the patient attributes to "indigestion" fleeting attacks of pain, dull, boring, or grasping in character, which occur in the epigastrium, but which are irregular in their occurrence and are dependent on no recognized factor. Such symptoms are more or less constantly present; there are no free intervals such as usually occur in case of gastric or duodenal ulcer. Pylorospasm may occur, but vomiting is rare, as is acute pain. If slight pressure over the gall-bladder region relieves the discomfort it is probable that perichole- cystic adhesions are present. In cases of simple cholelithiasis there may be tenderness over the gall-bladder, and various special points of tenderness (corresponding to McBurney's point in appendicitis) have been described, but I have not found them of practical signifi- cance. With the patient sitting and leaning forward, the surgeon may stand behind him, with one hand hooked under each costal margin at the ninth costal cartilage. If at the end of deep inspiration, which forces the gall-bladder against the finger tips, the patient experiences a sudden severe pain, it is the opinion of some that gall-stones are present. This is known as Murphy's test for cholelithiasis; I have repeatedly found it unreliable. With the patient recumbent, the right loin may be supported with the left hand, while with the finger tips of the right the gall-bladder is palpated beneath the costal margin. Sometimes at the end of deep inspiration it can be felt and if diseased usually is tender and painful. There is also very commonly a tender spot to the right of the twelfth dorsal vertebra (Boas's area). Biliary Colic. — Biliary colic usually has occurred once or oftener before patients come to the surgeon for operation. As stated already, it may occur where no calculi are present. In the mildest cases the 980 SURGERY OF THE GALL-BLADDER AND BILE-DUCTS pain may be fleeting, and the patient may forget its occurrence unless closely questioned, especially as the earlier attacks of colic usually cause pain in the mid-epigastrium and not over the gall-bladder. In other cases, however, the initial attack is severe. A man, believing himself to be in the enjoyment of excellent health, except for slight gastric symptoms which have never incommoded him, may suddenly have a dreadful cramp in his upper abdomen; he bends forward press- ing his hands or the back of a chair into his belly; breaks out in a cold sweat; becomes deathly pale and feels faint; is nauseated; and sometimes his distress is relieved by vomiting. Or he may writhe around his bed, or even on the floor in utmost agony. When the obstruc- tion is relieved by the calculus fall- ing back into the gall-bladder or by the cystic duct becoming patulous, pain ceases instantly. If obstruction continues pain does not vanish, but continues for hours or days, but not so intense as at first. The pain now shifts to the gall-bladder region, and may be referred to the back or shoulder through filaments of the fourth cervical nerve, from which the phrenic is derived. When there is complete obstruction of the cystic duct, colicky pain quickly disap- pears. Acute Calculous Cholecystitis is a frequent occurrence in cases of simple cholelithiasis. The symp- toms do not differ from those of non-calculous cholecystitis (p. 975), and it is largely on the recurrence of symptoms that the diagnosis of gall-stones is based. Migrated Gall-stones. — In many cases of cholelithiasis it is possible to determine whether the calculi remain in the gall-bladder or have escaped into the bile ducts, and especially whether or not the common duct is involved. As only a few of the calculi usually leave the gall- bladder the clinical picture may be somewhat confusing. Stone in the Cystic Duct. — As soon as a stone enters the duct, typical gall-stone colic results and paroxysms of pain recur until the stone either passes through the duct, returns to the gall-bladder, or is arrested permanently in the duct. If in the latter case obstruction is com- plete, colic gradually ceases, and usually the gall-bladder becomes distended and enlarged, causing at first empyema, and later, if the Fig. 981. — Sites of lodgement of mi- grated biliary calculi: in the neck of the gall-bladder; in the cystic duct; in the hepatic duct; in the common duct (supra-duodenal, retro-duodenal, or pan- creatic portion), or at the papilla of Vater. MIGRATED GALL-STONES 981 infection becomes attenuated, hydrops. In many cases, however, when a stone is lodged in the cystic duct, it forms a diverticulum for itself and bile can still enter and leave the gall-bladder. Perfor- ation in cases of cholelithiasis occurs usually at or near the origin of the cystic duct; while in non-calculous cholecystitis it occurs oftenest at the fundus of the gall-bladder. Stone in the Common Duct. — It is rare for a stone to pass completely through the choledochus. The larger stones are arrested in its supra- duodenal portion, and the smaller in its retroduodenal or in the ampulla of Vater. Complete obstruction, when it occurs, seldom lasts more than a week or ten days, the acute attack then subsiding and perhaps not recurring again for weeks or months. Each attack of colic is characterized by jaundice, fever, and marked constitutional disturbance. These are absent in simple biliary colic. They are due to recurrent attacks of cholangeitis, causing temporary complete occlusion of the choledochus with damming up of bile and pus, very seriously threatening the integrity of the liver, and frequently bringing the patient to death's door. The calculus does not float around free in the bile-duct, acting as a ball-valve, as described by Fenger (1S96) : at operation it usually is found firmly fixed, sometimes in a divertic- ulum. The fever rises abruptly to 104° F. or higher, and falls again as rapidly to normal or subnormal. It is known as "Charcot's inter- mittent fever," and Moynihan described the temperature record as a "steeple" chart, from its sudden variations. The jaundice also is intermittent, or at least lessens from time to time, and stercobilin is never very long absent from the feces. Persistence of jaundice, with its accompanying constitutional condition, known as cholemia, is a very dangerous feature, and the tendency to hemorrhage becomes very marked, owing to the prolongation in the clotting time of the blood. When there is calculous obstruction of the common duct, the gall- bladder is found to be contracted in 80 per cent, of cases; and in 90 per cent, of cases where the gall-bladder is enlarged, the obstruction is due to causes other than stone, usually malignant disease. This is known as Courvoisier's Law (1890). The explanation is that the gall-bladder has been diseased so long before the stones migrate into the common duct, and has become so contracted and thickened as a result of disease, that it can no longer dilate under the influence of back pressure. Stone in the Hepatic Duct. — Calculi are found in the hepatic duct only when they have floated upward from the common duct, or when, the common duct being already full of stones, others descending from the gall-bladder have to pass into the hepaticus. Gall-stones (except biliary sand) are not formed in the liver except when the choledochus and common hepatic duct are already filled. The symptoms of stone in the hepatic duct cannot be distinguished from those due to common duct calculus. Treatment of Cholelithiasis. — In cases of simple cholelithiasis operative treatment should be urged, unless any operation is contraindicated 982 SURGERY OF THE GALL-BLADDER AND BILE-DUCTS by extreme age, or by visceral disease. There is no medicine which will cause the solution of the stones, though charlatans often deceive patients by administering olive oil in large quantities and telling them that the fecal concretions so produced are the biliary calculi. But it is possible by strict medical treatment, such as diet, hygiene, etc., to keep the disease latent for many years in some cases; and most patients who can afford such a life will be satisfied to adopt this procedure rather than operation. But they should be informed that, as Mayo writes, the danger of the development of carcinoma in such a gall- bladder (see p. 997) is five times as great as is the mortality following operation for the relief of simple gall-stone disease, when performed by a competent surgeon. And Kehr says "the slight dangers of early operation stand in no sort of a relation with the great dangers of the disease itself; even the latent cholelithiasis we should always regard with suspicious eyes, for the quiet work of gall-stones is often the most destructive. In malignancy and imidiousness," concludes Kehr, "no disease of man compares with choleliihiasis." If, after their attendant has stated the facts of the case, the patients still will not be operated on, that is their own concern. The mortality following operation in these simple cases, in competent hands, is less than 5 per cent. The proper operation in most cases of simple cholelithiasis is removal of the calculi and drainage of the gall-bladder (cholecystostomy, p. 985) ; if the gall-bladder is altered by disease it is desirable to remove it (cholecystectomy, p. 986). Recurrence of gall-stones after cholecyst- ostomy is very unusual, and generally the stones that are found subse- quently are not newly formed, but were overlooked at the first operation. The mortality of cholecystectomy is slightly higher than that of simple drainage, but in cases of acute calculous cholecystitis it is to be preferred, as also in every case where the gall-bladder is contracted or thickened or manifestly diseased. Cholecystectomy is also to be done in cases of obstruction of the cystic duct by a calculus, since stricture, with resulting hydrops, is the almost inevitable result of removal of such a stone. In cases of hydrops and gangrene always, and in. most cases of empyema or perforation removal of the gall-bladder is indicated. In cases of stone in the common duct the patients may come under observation either during an attack of obstruction with cholangeitis, or during a free interval. In the latter contingency there is no need to postpone operation, and removal of the stone or stones should be undertaken. In the presence of acute complete obstruction of the common duct, however, it is the teaching of nearly all surgeons that operation should be delayed until under medical treatment (as for acute cholecystitis, p. 976) complete obstruction has subsided. Deaver and Ashhurst contend, on the other hand, that by waiting the patient runs the risk of cholangeitis, cholemia, with the gravest form of sepsis ; not to mention perforation of the common duct or the formation of almost inoperable adhesions, or the indefinite persistence of chronic jaundice with its dangerous hemorrhagic tendencies. The fact that the mortality of operations during persistence of complete obstruction TYPHOID CARRIERS 983 is very much higher than that of interval operations is not a valid argument against immediate operation, since the question is not the death rate from operation, but the death rate from the disease. Deaver says "while many times there has been cause to regret not operating during the stage of acute obstruction, never yet has there been cause to regret prompt relief of the obstruction by operation." The operation consists in removal of the stones in the common duct (by choledochotomy, p. 987), thorough exploration of the common and hepatic as well as the cystic duct, and drainage of the common duct and the gall-bladder by separate tubes. Frequently the gall- bladder has to be removed. Obstruction of the Common Duct may result from stricture, the result of previous operative interference, or from tumor formation, as well as from lodgement of calculi. If the stricture is benign in nature, the bile should be short-circuited into the intestinal tract by an anas- tomosis between the gall-bladder and duodenum or stomach. If the gall-bladder has been removed, and cholecystenterostomy is therefore impossible, an anastomosis will have to be made between the dilated duct above the obstruction and the intestine (choledocho-enterostomy, hepatico-enterostomy) . If the obstruction is due to malignant disease, palliative operation may be done, but has a high mortality. Radical operation seldom is possible. Carcinoma of the gall-bladder and bile- ducts is considered at p. 997. In cases of postoperative external biliary fistula the- gall-bladder should be removed, if the common duct is patent; if the gall-bladder has already been removed there is almost certainly obstruction of the common duct. In either case obstruction of the common duct is to be treated as above indicated. But it should be remembered that in cases of pancreatitis the fistula may close spontaneously even after many months. Typhoid Carriers. — Individuals are so called who harbor in, and discharge from, their bodies typhoid bacilli. Not all such persons have had typhoid fever. The gall-bladder is the most frequent site where the bacteria continue to live, but the entire biliary tract may be infected; in rare cases only the intestinal tract is at fault, or the urin- ary tract. Diagnosis depends on the persistence and presence of the bacilli in the feces (perhaps only after purgation), duodenal contents or in the urine. As these people may cause epidemics of typhoid fever if turned loose on the community, they must either be quaran- tined or cured of their infective qualities. For the latter purpose operation is required, as no medicines are of any value: the gall- bladder should be removed, and the hepatic duct drained until the bile no longer shows typhoid bacilli. If the urinary tract is infected, removal of the diseased kidney is indicated. For the very rare cases where infection persists in the intestinal canal, after the bile has been rendered sterile, colostomy or ileostomy with intestinal irrigations may be required. 984 OPERATIONS ON THE GALL-BLADDER AND BILE-DUCTS OPERATIONS ON THE GALL BLADDER AND BILE DUCTS. The deeper structures may be made much more accessible by placing a sand-pillow (about 10 to 15 cm. in thickness) beneath the patient's spine, at the level of the liver, thus throwing the upper abdomen forward, and allowing the intestines to fall toward the pelvis. The head and shoulders should be suitably supported so as to facilitate administration of the anesthetic. In very difficult cases the foot of the table may be lowered (reversed Trendelenburg posture) as originally advised by Elliot, of Boston, who introduced in 1895 the position above described. Bi Fig. 982. — Mayo Robson incision for cholecystostoniy. Episcopal Hospital. The incision in common use for biliary operations is that known as Mayo Robson's (Fig. 982); in simple cases only the longitudinal incision through the rectus muscle is necessary. An oblique para- median epigastric incision, commencing at the ensiform, dividing only the anterior sheath of the rectus muscle from this point downward and outward until* the semilunar line is reached at or below the level of the umbilicus, displacing the rectus muscle laterally, and dividing its posterior sheath and peritoneum near the midline; gives as much room as Mayo Robson's incision, without injuring any of the motor nerves. If, as Collins (1908) advised, the linea alba is cut transversely at the upper limit, and the linea semilunaris at the lower limit of this inci- sion, ample exposure is secured. Sprengel's transverse incision (1910) which divides the right rectus muscle directly across at whatever level seems desirable, and which may be extended in the same direction if necessary, is gaining favor. Before suturing any of these incisions, the support should be removed from beneath the patient's spine. CHOLECYSTOSTOMY 985 After the abdomen has been opened, the parts concerned in the operation must be well protected by gauze pads. One presses the stomach out of the way toward the left, a second is packed down on the colon and a third is placed in the subhepatic space or right kidney pouch. Sometimes another pad is placed between the right lobe of the liver and the diaphragm. In many operations it is possible to draw the liver, and with it the gall-bladder partly out of the wound. If the lower border of the liver is drawn slightly downward and then lifted upward into the abdominal incision, slightly rotating the organ so as to turn its inferior surface toward the patient's left, it fully exposes the gall-bladder and brings the cystic and common ducts very near the surface. In this way the cystic duct forms almost a straight line with the common duct, which is therefore more easily found. An assistant should hold the liver in this position with the aid of gauze sponges. Too much force must not be used. I have torn the liver in trying to deliver it. Cholecystotomy and Cholecystostomy. — The former term implies merely opening the gall-bladder, while the latter indicates that it is left open for the purpose of drainage. The terms often are used synonymously. A gall-bladder which needs to be opened needs also to be drained. The gall-bladder is exposed and isolated by gauze packs. If distended the contained fluid is removed by trocar and cannula, taking care to prevent contamination of surrounding struc- tures or the abdominal wound. The gall-bladder is then pulled into the wound and opened at the fundus with scissors, and the finger is introduced for exploration. Gall-stones are removed with scoop, forceps, or spoon. Thick and tarry bile is wiped out, and the surgeon makes sure that no calculi remain in the neck of the gall-bladder or the cystic duct by palpation with a finger on the outside and a sound in the lumen of the duct. Unless the patient's condition forbids, the surgeon should then explore the common duct and the head of the pancreas, while the gall-bladder is temporarily plugged with gauze. These manipulations are described at p. 987 (Choledochotomy) . When it is certain that no stones remain, a drainage tube open on the side as well as at the end, or cut in fish-tail fashion, is passed into the gall-bladder for about 3 cm., and is stitched to the gall-bladder with catgut. Then a purse-string suture of catgut is inserted in the fundus of the gall-bladder about 2 cm. from the opening. The tube is then pushed into the gall-bladder, inverting its edges around the tube, and the purse-string suture is pulled taut and tied. With this valve-like closure of the opening the biliary fistula does not remain open long after the tube is re- moved. If the gall-bladder cannot be inverted in this manner the opening should be sutured tightly around the tube, and in such cases or whenever there is a possibility of leakage around the tube it is safer to insert also a small cigarette drain beside the gall-bladder (Fig. 983). The gauze pads are then removed and the abdominal wound is closed around the drainage. The tube in the gall-bladder remains until it comes away of itself, which is usually about the end 986 OPERATIONS ON THE GALL-BLADDER AND BILE-DUCTS of the second week. The fistula in such cases ceases to discharge bile very soon after the tube is removed. When prolonged drainage is desired, as in cases of cholangitis, pancreatic lymphangeitis, etc., the gall-bladder should not be in- verted around the tube, but should be closed tightly around it without inversion of its wall; then the gall- bladder should be sutured to the parietal peritoneum, or even to the anterior sheath of the rectus mus- cle; and biliary drainage should persist for from four to six weeks at the least. In some cases of pan- creatic disease many months are required before it will be safe to allow the fistula to close. Cholecystectomy. — After expos- ure and isolation of the parts in the usual way, the cystic duct is identified, and the peritoneum over- lying it is incised, and is separated from the cystic duct by gauze dis- section until the common duct is reached. The cystic duct is then grasped with two hemostatic for- ceps and is divided between them. The cystic artery and vein which lie above and to the inner side of the duct are then clamped with two hemostats and divided between. The cystic vessels may be ligated now or later. The gall-bladder is then enucleated from its attachments to the liver, leaving a peri- toneal fold on each side (Fig. 984). When the gall-bladder has been removed these peritoneal folds are sutured together; but if there is much bleeding from the denuded liver surface, or in cases of marked infection, it is safer to put a cigarette drain in the bed of the gall- bladder and suture the peritoneal folds over it. If on opening the abdomen the surgeon encounters very dense adhesions, it may not be practicable to proceed as above indicated. In such cases Terrier's operation (1905) is to be preferred: the anterior margin of the liver is identified, and the fundus of the gall-bladder found. The gall-bladder is opened at its fundus and its lower wall is cut open little by little by snipping with fine scissors. This incision is continued into and through the cysticus, right down to the chole- dochus. The splitting of the cystic duct is the most difficult part of the operation, because it cannot be distinguished from the outside, on account of adhesions, and it is only by following its lumen, as one follows the strictured lumen of the urethra in external perineal urethrotomy without a guide, that the choledochus can be reached. Before concluding the operation of cholecystectomy, the common and hepatic ducts should be sounded, through the stump of the Fig. 983. — Cholecystectomy : the gall- bladder tube is surrounded with gauze from a cigarette drain. (Deaver and Ashhurst.) CHOLEDOCHOTOMY 987 cystic duct, to make certain that no calculi have been overlooked. A drainage tube is then passed into the stump of the cysticus for about 1 cm., and is stitched in position with No. chromic catgut. The subhepatic space should also be drained by a tube, and these two tubes must be carefully distinguished (by color, by insertion of two safety pins instead of one, or in some other way), so that no sub- sequent confusion can arise. The abdominal wound is then closed around the drainage. The tube to the subhepatic space may be removed on the second or third day, but that which drains the ducts should be allowed to remain at least for two weeks. If there has Fig. 984. — Cholecystectomy: the cystic duct and the cystic vessels have been clamped and ligated, and the gall-bladder is being enucleated from its bed under the liver. The method of suturing the peritoneal folds is indicated. (Deaver and Ashhurst.) been much hemorrhage or escape of bile into the subhepatic space it is safer to use a glass tube for drainage of this region. This tube is replaced by a rubber tube within a few days, and the subsequent treatment conducted as when a glass tube has been used to drain the pelvis (p. 914). Choledochotomy and Choledochostomy are employed interchange- ably as are the corresponding terms relating to the gall-bladder, since at present almost every operation involving an incision into the chole- dochus is supplemented by drainage of that structure. When the gall-bladder is present it serves as a guide to the common duct, which 988 OPERATIONS ON THE GALL-BLADDER AND BILE-DUCTS is brought into the wound, when possible, by the method noted at p. 985, after the gall-bladder has been opened and cleared of stones as previously described. The common duct often is much dilated and it may be difficult to distinguish it from the portal vein. For this purpose a hypodermic needle may be used, as advised by Terrier and by Deaver. The index finger is passed into the foramen of Winslow, while the thumb is placed on the free border of the gastrohepatic omentum and the supraduodenal portion of the choledochus is pal- pated. If a stone is found it scarcely ever is possible to push it back through the cysticus into the gall-bladder, but sometimes the scoop or forceps may be passed down from the gall-bladder through the cysticus for removal of the stone. In most cases, however, it is neces- sary to incise the duct over the stone to extract it. This incision is made in the long axis of the duct and of convenient length. If the duct is large enough the finger makes the best probe to search for other stones. Any stones detected bv finger or scoop or sound, should be pushed toward the opening in the choledochus; if impacted in the retroduodenal portion of the duct a stone may be crushed between the fingers or broken up by the scoop, and the fragments extracted from the incision in the supraduodenal portion or pushed into the duodenum through the ampulla of Vater. As a last resort retroduodenal chole- dochotomy may be necessary; or if a calculus is impacted in the lower end of the common duct very close to the duodenum, transduodenal choledochotomy may be necessary. These operations are described below. When all stones have been removed, the common duct is drained by passing a rubber tube large enough to fill its lumen up toward the hepatic duct for 1 to 2 cm. (Hepaticus drainage.) The tube is fixed in the common duct, as described in connection with chole- cystectomy; and the gall-bladder is drained by a separate tube. (If cholecystectomy is necessary, the stump of the cysticus should be ligated.) The operation is concluded by drainage of the subhepatic space, as after cholecystectomy. In cases where the gall-bladder is absent, choledochotomy may be a very difficult operation if many adhesions are present, as there is no guide to its location. In such cases the surgeon commences by exposing the retroduodenal portion of the choledochus by mobilization of the duodenum as described below. Or the surgeon may open the duodenum antl identify the choledochus by retrograde catheterism through the ampulla of Vater. I believe the former method is prefer- able. Retroduodenal Choledochotomy. — If an incision is made through the parietal peritoneum on the right of the descending duodenum, this coil of intestine may be separated by blunt dissection from the posterior abdominal wall, and restored to the condition it occupied in fetal life. By turning the duodenal loop to the left (mobilization of the duodenum, Jourdan, 1895) the head of the pancreas and the retroduodenal por- tion of the common duct are brought into view (Fig. 985), and an impacted calculus may be removed by direct incision (Fig. 986). As CHOLEC YS TEN TEROS TOM Y 989 in most cases in which this operation is necessary the supraduodenal portion of the choledochus has already been opened, this may be used for drainage, and the incision in its retroduodenal portion sutured. It is wise, however, to leave a drain in the retroduodenal space, for fear of leakage. Fig. 985. — Retroduodenal choledochot- omy: after mobilization of the duodenum, a stone is exposed at the site of obstruc- tion to the sound. (Deaver and Ashhurst.) Fig 986. — Retroduodenal choledochot- omy: the choledochus is incised over the impacted calculus. (Deaver and Ash- hurst.) Transduodenal Choledochotomy (McBurney, 1891) is applicable to a calculus impacted in the ampulla of Vater or very close to the duo- denal wall. The duodenum is opened through its anterior wall, and the bile papilla identified. If a calculus is caught in the ampulla it usually is possible to extract it by dilating or incising the papilla. If it is impacted in the common duct just outside the duodenal wall, it is necessary to incise also the posterior wall of the duodenum over the calculus, and then to open the choledochus and remove the stone. The opening in the choledochus is then sutured to the incision in the posterior duodenal wall, to ensure adequate drainage of the chole- dochus; this is Kocher's operation of dnodeno-choledochostomy (1895). The incision in the anterior wall of the duodenum is then sutured as any intestinal wound, and the abdominal incision is closed in the usual way. Cholecystenterostomy. — The anastomosis may be made with the duodenum (cholecysto-duodenostomy) or with the stomach (chole- cysto-gastrostomy). A lateral anastomosis, about an inch long, by suture (p. 886), is the best method, but if it is impossible to apply 000 SURGERY OF THE LIVER rubber-covered clamps to prevent fecal extravasation during the operation, a small sized Murphy button may be used for the anasto- mosis. SURGERY OF THE LIVER. Anomalies of Shape and Position. — Except in rare cases of con- genital, diaphragmatic, or umbilical hernia the position of the liver seldom is altered unless hepatoptosis (falling of the liver) exists in con- nection with visceroptosis (p. 053). Apart from rather vague pains hepatoptosis produces no characteristic symptoms and the diagnosis must be made by recognition of the liver in its abnormal position. Usually it descends somewhat toward the median line, and is recognized as a large tumor to the right of the umbilicus of the size and con- sistency of the liver; often a notch can be felt. When displaced there is resonance over the normal site of the liver dulness, and pulmonary resonance and intestinal tympany may merge. It is distinguished from a movable or enlarged kidney by the absence of urinary symptoms, by the fact that the liver moves in respiration, while the kidney does not, and that it lies in front of the colon, not behind it. Treatment. — Treatment should consist in reposition of the liver, when this is possible, with the patient recumbent, and the applica- tion of an abdominal belt as in cases of pendulous abdomen (Fig. 063). If palliative treatment proves ineffective, the abdomen may be opened and the anterior margin of the liver stitched to the costal border, with mattress sutures of heavy chromic catgut. Changes in the Shape of the Liver usually are acquired, and are of two main varieties. In one, the so-called corset liver (Fig. 087), the plastic liver has become indented by compression through the costal margin. This tends to distort the cystic duct, caus- ing stagnation of bile, with its consequences already dis- cussed (p. 077). In the other form the anterior margin of the liver is drawn down in a tongue - shaped protrusion, known as linguiform or Riedel's lobe (1888). Usually disease of the biliary tract exists and has produced the deformity by gradual traction from ad- hesions or the weight of an enlarged gall-bladder. Treat- ment involves operative cure of the biliary lesion, after which the enlarged lobe usu- ally shrinks (Terrier) ; in rare instances amputation of the lobe may be desirable. Fig. 987. — Corset liver, from a patient aged fifty-seven years. Death from perforation of a malignant ulcer of the stomach. (See Fig. 932.) Episcopal Hospital. (Deaver and Ashhurst.) SUPPURATIVE HEPATITIS 991 Suppurative Hepatitis. — There are three main varieties of suppura- tion which occur in the liver: (1) Abscess the result of trauma; (2) pyemic or embolic abscess; and (3) tropical or amebic abscess. 1. Traumatic Abscess is rare; it may occur as the result of a pene- trating wound, or from secondary infection (through the blood or bile) of a hematoma which has resulted from subcapsular rupture (p. 893); usually is single and may be of large size. The diagnosis depends on the history of the case, and development of symp- toms of pus formation; and the treatment is the same as for tropical abscess. 2. Pyemic or Embolic Abscess, when of surgical interest, almost invariably is the result of infection through the portal circulation, and is termed suppurative pylephlebitis. Especially frequent as causes are appendicitis and typhoid fever, but any infection in the distribu- tion of the portal vein may be the cause; and cases of suppurative cholangeitis involving the finer intrahepatic bile-ducts often cannot be distinguished either during life or at autopsy from cases of suppu- rative hepatitis caused by hematogenous infection. When occurring from appendicitis or other acute infection the symptoms (pain, high but irregular fever, chills, sweats, tenderness, and enlargement of the liver, sometimes jaundice) usually develop within a week or two of the primary affection. In such cases the liver is riddled with abscesses of various size, and operative treatment is out of the question. Every such case is fatal. When resulting from typhoid fever, however, and, according to Quenu and Mathieu (1911), occasionally as the result of appendicitis, the symptoms do not appear until convalescence is established. The average fever-free interval in typhoid fever, according to Melchior (1910), is fourteen days. Such cases resemble somewhat amebic abscess, and treatment is the same. 3. Tropical or Amebic Abscess takes its name from its occurrence especially in the tropics, and as the result of infection with the Amoeba coli. The patient usually gives a history of residence in tropical or semi-tropical climes, and almost always has suffered from dysentery; but as the symptoms of amebic colitis sometimes are very insignificant (p. 950) too much faith should not be put in the patient's history. The hepatic abscess, which usually is single (in 60 per cent, of cases) and of large size, may not develop or at least may not begin to produce symptoms until man}' years after the occurrence of the primary infection. The ameba is transported to the liver through the portal circulation, and the destructive process begins in the hepatic cells. The abscess usually is in the right lobe of the liver, but even when the abscess is very large the shape of the liver may not be noticeably altered. The abscess develops silently, like a cold abscess, and it often produces no symptoms until secondary infection has occurred. When uninfected by pyogenic organisms the contents are reddish brown in color and vary in consistence from fluid to gelatinous. Amebae often cannot be found except in scrapings from the wall of the abscess, or after it has been discharging for several days. 992 SURGERY OF THE LIVER Symjrtoms. — In one-third of the cases, according to Rouis, there are no symptoms noticed by the patient until rupture occurs, usually into the lungs, pleura, or peritoneal cavity. When symptoms exist, they may not be referred to the liver for months after malaise, lassitude, and increasing weakness are noted. Jaundice is rare. When local symptoms are noted they frequently are referred to the base of the right lung or the pleura. Fever is another valuable sign, though the temperature may not be high except in the evening; in malaria the temperature usually rises in the daytime. Enlargement of the liver, and pain (local and referred to the right shoulder) may not occur until late. Diagnosis is aided by purging the patients with salines and searching the stools for amebse, which usually can be found in the third or fourth watery stool. A high leukocyte count in the afternoon is regarded as an indication of the presence of secondary infection. The most common mistakes in diagnosis are (1) failure to recognize the presence of disease of any description; (2) misinter- pretation of the significance and nature of basic pneumonia; (3) attributing the fever to malaria; and (4) mistaking other diseases for abscess of the liver, and vice versa (Manson, 1904). In tropical abscess the spleen is not enlarged. Fig. 988. — Transpleural operation for abscess of the liver: a portion of rib has been excised, subperiosteally; and the diaphragm is being sutured to the tissues or the costo- phrenic sinus. (Deaver and Ashhurst.) Treatment. — Treatment involves drainage of the abscess. At the same time proper treatment of the colitis (p. 950) must be instituted and emetin hydrochloride (0.04 to 0.08 gram daily) should be given. The operation of hepatotomy for drainage of a liver abscess resembles that for subphrenic abscess (p. 865). If the abscess cannot be localized by the physical signs, laparotomy should be done and its position determined. No attempt should be made to localize the abscess by aspiration, except after the liver has been exposed to view. If the abscess is found to be near the convex surface of the liver or if this fact can be determined without opening the abdomen, the abscess should be drained by the transpleural route (Knowsley Thornton, 1885) as in the operation for subphrenic abscess: Excise (subperi- osteally) 10 cm. of the eighth, ninth or tenth rib in the mid-axillary ECHINOCOCCUS CYST 993 line; then suture the diaphragm to the tissues of the costo-phrenic sinus (deep layer of costal periosteum, both layers of pleura), without opening the pleura, by three or four interrupted sutures of chromic catgut (Fig. 9S8). Then make an incision along the upper border of the next lower rib, through all structures, diaphragm included, until the liver is exposed. In acute cases the liver is bluish, soft and pulpy, and may bulge into the wound. Adhesions usually shut off the peri- toneal cavity, but it is well to isolate the parts with gauze. Where these adhesions are the densest, usually the abscess is found. It is opened by a grooved director, and the tract enlarged by dressing forceps followed by the finger. It is drained by a double tube of rubber, and not until four or five days at least have elapsed should irrigation be employed. The sinus may take many weeks to close. Fig. 989. — Hepatic abscess exposed by flap method. Appendicostomy for accom- panying colitis. Catheter in the appendix. Recovery. (Dr. C. H. Frazier's case.) Episcopal Hospital. Echinococcus Cyst. — Hydatid cyst is the result of infection by the Tenia echinococcus, a parasite found in the intestinal tract of dogs, sheep, and other animals. The ova enter the intestinal tract of man with food or drink, or possibly as the result of handling or being licked by an animal infested by the parasite. The capsule is digested in the intestinal tract of the patient, and the embryo is liberated. It bores into the intestinal wall, and in most cases is carried by the portal system to the liver. Hydatid cysts of other organs or tissues are rare and often secondary to a primary growth in the liver. After the para- site (in larval state) reaches the liver, it loses its hooklets and enters the immature or cysticercus stage. Inflammatory changes cause a connective tissue encapsulation, so that the cyst wall consists of two layers; an outer laminated layer or capsule, and an inner granular or germinal layer. The contents are clear, colorless fluid, unless sec- ondary infection occurs, when the fluid is purulent; sometimes it is bloody or bile-stained. Hydatid fluid contains a poisonous ptomain, 63 994 si i:<;ei;y of the LIVER which may cause convulsions, rapidity of the pulse and respirations, dilated pupils and collapse. Unless the parasite dies daughter cysts develop within the original parent cyst. The heads or scolices of the parasites cling to the germinal layer in pedunculated vesicles known as brood capsules. These are similar to the primary cyst. The scolices may become detached and lie free in the brood capsule, or if this ruptures they may float free in the parent cyst. Degeneration, calcification, and death of the parasites may occur. Hydatid cysts usually occur in the right lobe of the liver and in 90 per cent, of cases the cyst is solitary. Symptoms. — The clinical course of the disease much resembles that of tropical abscess of the liver. So long as secondary infection is absent, and until the cyst grows so large as to project from the surface of the liver, symptoms are inconspicuous. The average duration of the disease before treatment is sought is from five to seven years. Attacks of urticaria are not uncommon. There is danger of rupture (spontaneous or from trauma), into the bile passages, the peritoneal cavity, the gastro-intestinal tract, or the thorax; as well as from secondary infection. Diagnosis. — The diagnosis can be made only when a palpable cystic enlargement of the liver is detected. The condition must be dis- tinguished from carcinoma of the liver, which is a solid growth, and usually secondary to a tumor elsewhere; from tropical abscess (p. 991); from empyema thoracis and subphrenic abscess; and from gummatous growths (syphilitic) of the liver, which are much more common in this country than hydatid cysts. Treatment. — There is no cure without operation. Most cysts grow downward and are best exposed by laparotomy. The best plan is that of Quenu; after exposure of the cyst its contents are aspirated by means of a very fine trocar and cannula. It is well to insert the trocar through the rubber tube used to drain the fluid from the cannula (Fig. 990), as in this way no danger of leakage occurs. Then a solution of formalin (1 per cent.) is allowed to run into the cyst cavity and to distend it. This is permitted to remain for five minutes so as to sterilize its contents. It was demonstrated by Deve (1901) that each of the parasitic elements is capable of reproducing the primary lesion, and Quenu found (1902) that formolization as above described steril- ized the contents of the cyst absolutely. The cyst is then emptied, its wall is incised, and the germinal membrane is removed. Then the cyst may be obliterated by sutures, without drainage, but it should be attached to the abdominal wound so that an intracystic effusion of bile Fig. 990. — Quenu's method of formolization of hydatid cysts of the liver. CIRRHOSIS OF THE LIVER 995 or blood can be evacuated easily should either complication occur later. If the old plan of marsupialization (opening, packing with gauze, and suturing to the abdominal wound) is employed without formoliza- tion, the condition is analogous to that of a cold abscess opened and drained — secondary infection is almost unavoidable, biliary effusion is frequent, and the sinus takes very long (months) to close. Cirrhosis of the Liver. — Pathologists distinguish between portal cir- rhosis, in which the cause is transmitted by the portal circulation, and the obtrusive symptoms are those of portal obstruction; and biliary cirrhosis in which the essential lesion is a radicular cholangeitis, and the conspicuous clinical feature is jaundice (A. O. J. Kelly, 1908). The latter is not amenable to surgical treatment, though proper operative treatment of diseases of the gall-bladder and bile-products may often prevent its development; and in the former surgery is able only to modify or lessen the distressing symptoms, without in any way bringing about a cure of the underlying disease. The main symptoms of portal cirrhosis of the liver are (1) gastro- intestinal hemorrhages, from obstruction of the portal vein, and (2) ascites from peritoneal changes which accompany the disease. Pure portal obstruction is said not to produce ascites, which it is believed is caused almost solely by changes in the endothelium of the peri- toneum; it is in the nature of a chronic serositis, probably due to the toxemia of disordered hepatic function. Cases of portal cirrhosis sometimes are complicated by tuberculosis of the peritoneum, or by a chronic polyserositis associated with cardiac disease; and in such cases it may not be the hepatic toxemia, but the complicating disease which is responsible for the peritoneal effusion. Most of the operative methods proposed for the relief of ascites are based on the idea that this occurs as a direct transudate from the portal system. Such is not the case, and a rational operation must seek to alter the nutrition of the peritoneal endothelium; operations which seek to establish a collateral circulation for the obstructed portal system are rational only when gastro-intestinal hemorrhages are present or threaten. Paracentesis. — The ascitic fluid may be removed by repeated tap- pings, and in rare instances the fluid finally ceases to re-accumulate. The trocar and cannula should be thrust into the abdomen in the mid- line between umbilicus and pubes, after it has been ascertained that the bladder is empty. No anesthetic is necessary, though in nervous patients or when the abdominal wall is thick, a local anesthetic may be used. The patient should be in the semi-recumbent position, and as the fluid is evacuated concentric pressure should be made on the abdo- men by means of a many-tailed bandage, so as to prevent syncope by the sudden relief of pressure on the large abdominal bloodvessels. If the amount of fluid is very great, it is best not to remove all of it at once. The puncture is sealed with collodion, and the abdomen kept tightly bandaged, in an effort to prevent re-accumulation. Laparotomy with gauze abrasion of the serous surfaces of the liver, spleen, and diaphragm, in an effort to alter their nutrition, and check 990 SURGERY OF THE LIVER the formation of the ascitic fluid, which is simultaneously evacuated, is a more effectual method of treatment, and much of the good attrib- uted to epiplopexy (see below) is no doubt due to these steps which form an integral part of that operation. Epiplopexy, introduced by Talma (1889) and Morison (1894), con- sists in suturing the omentum to the parietal peritoneum on both sides of the abdominal incision, or between the peritoneum and the posterior sheath of the rectus muscle, in the effort to establish a collateral circulation. As already noted, abrasion of the serous surfaces of the liver, spleen, diaphragm, and of the parietal peritoneum forms an integral part of this operation, the idea being that a collateral circulation will be established in the adhesions thus produced. The surest maimer of establishing a collateral circulation for portal obstruc- tion is to make an anastomosis between the portal vein and vena cava (Eck's fistula); this was done by Vidal (1903) in a patient almost exsanguinated by gastro-intestinal hemorrhages; but though these were cured, the ascites was not, and death ensued four months later from acute general infection, evidently enterogenous; the portal blood-stream had been short-circuited and the liver was no longer interposed against the hordes of microbes constantly absorbed from the bowels. After epiplopexy the abdomen is not drained, though this formerly was considered essential. Symptomatic relief has been secured in from one-third to one-half the cases. Splenectomy is proposed by Mayo (1918) as a means of relieving the overburdened liver and affording it an opportunity to recuperate. Removal of the spleen may not only lessen the liver's work by cutting off much of the portal circulation, but may at the same time eliminate a constant stream of bacteria or their toxins strained out of the general circulation by the spleen and passed on to the liver for destruction. Tumors of the Liver, Gall-bladder, and Bile Ducts. — Benign tumors are very rare and have little surgical interest. Carcinoma of the Liver may be primary, but in almost all cases is secondary to a growth in the distribution of the portal system. The usual type, whether primary or secondary, is nodular or multiple carcinoma. If this is a primary growth most of the nodules are metas- tases from one original focus which usually is in or near the gall- bladder (Beadles, 1896); while in secondary carcinoma the nodules are scattered all over the liyer uniformly, and not massed about the fossa of the gall-bladder. The nodules are whitish, gray, or yellowish masses, from the size of a pinhead to that of an orange, but seldom larger than a walnut. They stand out from the surface of the liver, frequently cause perihepatitis with resulting adhesions ; and when large often become umbilicated as the result of interstitial hemorrhages. If the growth is primary, gall-stones usually are present. Symptoms are not characteristic, and the diagnosis rarely is made until enlargement of the liver, with palpable nodules, and the develop- ment of ascites and sometimes of jaundice, indicate that the disease TUMORS OF LIVER, GALL-BLADDER, AND BILE-DUCTS 997 has passed the operable stage. The symptoms of the secondary growth in the liver frequently overshadow those due to the primary focus in pancreas, stomach or intestinal tract, and even at autopsy it may be difficult to find the primary growth. Treatment in almost all cases must be palliative; very occasionally a primary growth may be excised, but in most patients the prognosis is hopeless, and death ensues in from five to seven months after recog- nition of the condition. Sarcoma of the Liver almost always is secondary, usually to a growth in the eye or the soft tissues of the limbs; but many years occasionally elapse between removal of the primary tumor and evidence of hepatic involvement. Carcinoma of the Gall-bladder and Bile-ducts is much more common than carcinoma of the liver. Secondary carcinoma is rare and of little surgical importance. Primary Carcinoma of the Gall-bladder is found in about 2 per cent, of specimens removed by cholecystectomy; and almost invariably gall-stones are present and are regarded as the predisposing cause. The growth begins at the fundus or near the neck of the gall-bladder, and extension occurs to the liver. The early symptoms are those of cholelithiasis; later a hard nodular tumor of the gall-bladder is rec- ognized, but by this time hepatic involvement frequently renders the case inoperable. The most favorable cases are those where a thick- walled gall-bladder removed at operation is discovered to be the seat of carcinoma only when microscopically examined. Such patients may survive several years, whereas those in whom the correct diagnosis is made before or during operation usually die within a year. Treatment consists in extirpation of the growth whenever possible. This always should include excision of the entire cystic duct with the gall-bladder and may necessitate removal of the adjoining liver tissue also. Methods of suture of the liver have already been considered (p. 895). Primary Carcinoma of the Bile Ducts presents much the same symp- toms as carcinoma of the head of the pancreas, notably obstructive jaundice, of slow or sudden but almost always painless onset, never remitting but gradually deepening to a bronze or almost black hue. If the growth is in the choledochus, the gall-bladder becomes dis- tended and enlarged, and is palpable through the abdominal wall in half of the cases. If the growth is in the hepaticus (which is rare), no enlargement of the gall-bladder occurs. Disturbance of the pancreatic functions indicates obstruction at the papilla of Vater. Treatment. — Exploratory operation is proper in all but manifestly hopeless cases. If a radical operation cannot be done, the gall- bladder may be drained into the duodenum or stomach (p. 989); but palliative operations in these conditions have a high mortality (hemorrhage from cholemia) and do not prolong the patient's life though they may promote his comfort. If complete extirpation can be 998 SURGERY OF THE PANCREAS dour, the drainage of bile into the intestine must be restored by some form of biliary-intestinal anastomosis (p. 983). Retroduodenal resec- tion of the choledochus (Oppenheimer L912) gives an immediate mortality of 50 per cent. Occasionally a growth at the papilla of Vater can be excised by a transduodenal operation (Czerny, L901). The immediate mortality of this operation, according to Oppenheimer, is 33 per cent. The most radical operation of all for growths at the lower end of the choledochus resembles that of cephalic pancreatectomy (p. 1005). SURGERY OF THE PANCREAS. Infections of the Pancreas. — Theoretically infection may reach the pancreas, as it may any other organ, (1) through the blood-stream ; (2) along its excretory ducts; (3) through its lymphatics; or (4) by contiguity, from neighboring structures. 1. Infection through the blood is comparatively rare. The pancreas is seldom affected in pyemia; but the occurrence of pancreatitis as a complication of acute parotitis (mumps), though unusual, is well recog- nized (Deaver and Ashhurst tabulated 01 cases in 1913); and a few cases of involvement of the pancreas have been reported in cases of scarlatina, influenza, and other acute infections. In chronic interaci- nar pancreatitis, also, which is a frecment accompaniment of arterio- sclerosis and which usually results in diabetes, the causative agent is conveyed to the pancreas in the blood-stream; and it is probable, as pointed out below, that acute pancreatitis is the result of some toxin which exerts its action first on the endothelial lining of the bloodvessels. 2. Infection through the ducts has been produced experimentally by injection of bile, gastric juice, and other irritants, resulting in acute inflammation. Opie (1901) recorded a case in which a small gall-stone blocked the orifice of the ampulla of Vater and allowed retrojection of bile into the pancreatic duct, and Archibald (1910) maintains that spasm of the sphincter of Oddi is a frequent cause of this occurrence, and that most cases of pancreatitis may be thus explained. 3. Infection through the Lymphatics. — The lymph nodes around the head of the pancreas drain the lymph from the gall-bladder and bile-ducts, as well as (more or less directly) from the pylorus, the appendix, and other common sites of intra-abdominal infection. The lymphatics from the remainder of the pancreas are more or less inde- pendent of those about its head, and do not drain such common sites of infection as those already mentioned. The chronic infections of the pancreas are almost always confined to the head of the gland, and the fibrous tissue which forms is interlobular in distribution, thus corresponding to the lymphatic tissue; it is true that the blood-chan- nels also are interlobular, but if in these cases of chronic pancreatitis the infection was conveyed by the blood-stream the entire gland should be involved, which is not the case in chronic interlobular pancreatitis, ACUTE PANCREATITIS 999 the common form; though it is the case in the rarer interacinar form, in which, as already indicated, the causative agent probably is blood- borne. That the infection does not originate in the excretory ducts, in cases of interlobular pancreatitis, is indicated by the local dis- tribution of the resulting fibrosis, which is neither scattered diffusely throughout the gland, as are the ducts, nor yet situated close about the parenchyma of the gland in the portion which is affected. It is thus evident, as pointed out by Maugeret (1908), that the condition commences as a pancreatic lymphangeitis, the term suggested by Arnsperger (1911), and adopted by Deaver and Pfeiffer (1912), who have been particularly instrumental in securing recognition of the disease in this country. 4. Infection by contiguity is rare, except when a gastric ulcer or carcinoma becomes adherent to or perforates into the pancreas. Acute Pancreatitis. — Acute catarrhal pancreatitis is of little impor- tance surgically; it may accompany acute gastroduodenitis, and catarrhal cholangeitis, aiding in producing the obstructive jaundice which is the common expression of these conditions. Acute 'paren- chymatous pancreatitis is classified as hemorrhagic, suppurative, and gangrenous (Fitz, 1S89), terms which indicate the stage of the disease. The suppurative and gangrenous stages frequently are classed as subacute pancreatitis. Acute Hemorrhagic Pancreatitis is the commonest form of acute pancreatitis. The adjective hemorrhagic is attributive, not qualify- ing; hemorrhagic inflammation may occur in any organ, but it is especially frequent, and the hemorrhagic tendency is especially marked in the case of the pancreas. It is probable, as long ago indicated by Truhart, that the process commences as an autodigestion of the pan- creas. It is true that under normal conditions the pancreatic juice is activated by a kinase with which it comes in contact only after leav- ing the pancreas; but under abnormal conditions, as pointed out by Carnot (190S), a kinase may be generated within the pancreas itself by the action of leukocytes or bacteria or toxins. These, probably, are conveyed to the organ through the blood-stream, for the lesions in acute pancreatitis are scattered here and there, and are not confined to any particular segment of the gland. The results of the infection are caused by extravasation of the pancreatic juice, whether this is con- fined to the pancreas itself or escapes into the retroperitoneal tissues or into the free peritoneal cavity: the trypsin causes hemorrhages and the steapsin causes areas of fat necrosis. The disease is more frequent in men than in women, and most patients are of middle or later life, and rather obese. Recurring slight attacks are not very rare, though the surgeon often is not consulted until a fulminating attack occurs, and so far the existence of the dis- ease in milder forms has scarcely ever been recognized. Trauma has in some cases seemed a predisposing cause; in them a hematoma probably had formed, and only when it ruptured and allowed extrava- sation of pancreatic juice, did the symptoms of acute pancreatitis I ray or after distending them with collargol. Anomalies of the blood-supply of the kidneys are frequent. The most important are extra arteries to the upper or lower pole of the kidney, or an artery which crosses in front of the ureter, and which may be a cause of hydronephrosis by intermittent pressure or by causing kinking of the ureter. The kidney may be congenitally misplaced in almost any posi- tion in the abdomen, but this is very rare Nephroptosis, or Movable Kidney may be congenital or acquired (repeated pregnancies, tight lacing), is more common in women than men, and on the right than the left side, but both kidneys often are affected. Symptoms. — The patients usually are thin, long-waisted, run-down women from thirty to fifty years of age. In most cases the condition is discovered as an incident in an abdominal examination. The chief complaint is weakness and dragging sensations in the loin; but acute attacks known as Dietl's crises (1864) may occur from torsion of the pedicle. The diagnosis depends on recognizing by palpation the movable kidney. Examination is conducted with the patient recum- bent, and the thighs flexed to relax the abdominal muscles. The surgeon places one hand beneath the loin, and presses downward firmly but gently with the other hand in the flank, until the two hands are approximated. Then, when the patient takes a long breath, the lower pole of the kidney, if it is palpable, is forced down against the examining hand. If the kidney is truly movable it can be felt also when the patient stands and leans forward, resting her hands on the edge of the bed. The examiner now stands behind her, and works his hand gently upward from the iliac fossa toward the flank; where- upon, during deep inspiration, a movable mass may be recognized, which slips back to the loin, during expiration. A floating kidney can almost be grasped in the fingers, and may be found in the iliac fossa or the pelvis. Fixation of such a floating kidney in abnormal position, by adhesions or otherwise, constitutes a dislocated kidney. This is a very rare condition. A Dietl's crisis is recognized by its occurrence in a patient with a floating or movable kidney, by the sudden increase in size of the tumor, by the attending constitutional disturbance (nausea, vomiting, shock, perhaps chills and fever), by the absence of intestinal or peritoneal symptoms, and by prompt sub- sidence of symptoms when the kidney becomes untwisted on lying down or by manipulation. Subsequently microscopical study of the urine may show blood. 1028 SURGERY OF THE BLADDER AND KIDNEYS Treatment. — If no symptoms exist, no treatment is indicated beyond building up the patient's general health. If symptoms are present they often are relieved by a rest-cure, with forced feeding, or by the application of an abdominal belt such as was advised for cases of pendulous abdomen. It rarely is desirable to use a special pad over the kidney. If recurrent attacks of torsion occur, or if palliative treatment fails to relieve chronic symptoms which are undoubtedly due to the mobility of the kidney, this organ may be fixed in its proper position by operation (nephropexy). Various methods are employed. In all it is important to secure the kidney in a position as nearly normal as possible, avoiding particularly excessive rotation of the organ in any direction. One of the most satisfactory operations is to incise the capsule along the convexity of the kidney, to peel the capsule back in two leaves, and to suture these to the lumbar aponeurosis (Edebohls, 1901). The lumbar wound is closed in layers without drainage. Infections of the Kidneys arise in most cases either from the blood- stream or as ascending infections from the bladder or genitalia. Hematogenous Infections. — The kidneys receive from the body and discharge through the urine great quantities of toxins, and in many cases large numbers of bacteria (bacteriuria, p. 1019). If the resistive power of the kidneys is weakened (previous renal disease, urinary obstruction, trauma, etc.) or if the toxins or bacteria are of extra- ordinary virulence, inflammation of the kidneys (nephritis) results. There are various forms of nephritis, which are best classed as acute and chronic. Only some of these need concern us here. Cases of toxic nephritis due to mineral poisons, and those cases due to toxemia (as in scarlatina, diphtheria, influenza, etc.) or auto- intoxication (as in chronic intestinal stasis, pregnancy, etc.), may be acute but frequently are chronic from the beginning, and usually are cared for by the physician. Of late years, however, it has become possible to relieve some of these patients by operative means. Punc- ture of the kidney or incision of its capsule was advocated by R. Harrison in 1897, by Ferguson and Edebohls in 1899, and the latter in 1901 reported a number of cases in which he had practised decap- sulation of the kidneys. By stripping the capsule from the contracted and sclerosed kidney its nutrition is improved by relief of tension and perhaps by development of collateral circulation. There is no doubt that in many cases vast improvement occurs: the amount of the urine increases, the edema and ascites vanish, casts disappear from the urine, and previously bed-ridden patients are enabled to resume a certain degree of activity. In favorable cases this improvement has lasted several years, though evidences of chronic nephritis persist. In other patients, however, no improvement occurs or the state is made worse. The operation is still on trial. The kidney is exposed as for other kidney operations (p. 1040), it is brought into the wound, and its capsule is incised along the convexity; the flaps of the capsule are then stripped off the organ to the hilum on each side, and are excised; SEPTIC NEPHRITIS 1029 the kidney is replaced and the wound closed without drainage, but not too tightly. It is better to postpone operation on the second kidney for a week or ten days. Brewer recommends the operation in cases of severe acute nephritis, following the exanthemas, etc. Septic Nephritis. — What are commonly recognized as surgical infections of the kidney, of hematogenous origin, are cases of acute nephritis due to septic embolism. In a large proportion of cases only one kidney (usually the right) is affected, and the lesions vary from hemorrhagic infarcts (which soon heal, leaving minute cicatrices) to diffuse suppuration. Several foci of suppuration may coalesce and form distinct abscesses. Extension to the pelvis of the kidney, causing pyelitis, is frequent; extension to the fatty capsule of the kidney and surrounding structures (perinephritis) is less usual. In cases where pelvis and kidney are diffusely involved (pyelo-nephritis) it may be impossible to distinguish the pathological changes from those caused by an ascending infection. Symptoms. — The recognition of acute unilateral hematogenous infec- tion of the kidney is due mainly to the work of Brewer (1906.) Over 80 per cent, of the cases occur in women, frequently as a sequel of some known general infection (pneumonia, tonsillitis, furunculosis, etc.). The onset and course of the disease may be very acute, sub- acute, or comparatively mild. The severe cases usually begin with a chill, temperature of 104° or 105° F., rapid pulse and high leukocytosis. From the first the symptoms of toxemia are marked, and the local condition may be overlooked, the disease resembling perhaps influenza, lobar pneumonia, or one of the exanthemas. Subsequently attention is directed to the kidney region by pain and discomfort in the abdomen or flank, and these may be mistaken for signs of cholecystitis or appendicitis. Compensatory action of the healthy kidney may obscure urinary changes (red-blood cells, albumin, pus) unless especially looked for. "The one pathognomonic sign present in all cases," adds Brewer, "is a marked unilateral costovertebral tenderness." Treatment. — In the severe cases, with high temperature and pro- gressive toxemia, nephrectomy should be done without unreasonable delay; death is the almost invariable result of such delay or of palliative operations. In the milder cases, which Brewer describes as those where the temperature begins to fall within forty-eight hours, decap- sulation of the kidney may be done, or nephrotomy if there is evidence of much tension or localized suppuration. In the mildest type, where the diagnosis may be uncertain, medical treatment may be persisted in, and any chronic pyelonephritis which remains may be subjected to appropriate surgical treatment subsequently. Ascending Infections. — Ascending as well as hematogenous infection is predisposed to by previous renal disease (especially renal calculus) or the occurrence of trauma; but even in such circumstances it rarely occurs unless there is obstruction to the urinary outflow. In women, pressure from pelvic tumors or the gravid uterus is a cause of urinary obstruction which leads not infrequently to ascending kidney infec- 1030 SURGERY OF THE BLADDER AND KIDNEYS tion. In men such obstruction is due in most instances to enlarge- ment of the prostate or stricture of the urethra. Back pressure of urine within the bladder first compresses the ureteral orifices, damming the urine back into the ureters and kidneys; inflammatory infiltration of the bladder wall from cystitis may impair the sphincteric action of the ureteral orifices; and if extreme dilatation of the bladder occurs the ureteral orifices may become constantly patulous, by the approxi- mation of their course through the bladder-walls to a straight line. It is probable also that infection extends up the walls of the ureters to the kidney pelvis, and thus produces pyelitis and pyelo-nephritis, which are the usual results of obstruction in the presence of infection. In some cases the ureters appear unaffected, but in most they are dilated, pouched and perhaps strictured. The pyelo-nephritis arising from ascending infection is commonly spoken of as surgical kidney. The renal cortex is thinned, the pelvis enlarged, and the kidney sub- stance is riddled with abscesses of various sizes. Symptoms. — Surgical kidney is more frequent in the aged than in the young, and occurs very much oftener in men than in women. It may be acute or chronic, but as acute attacks tend to be prolonged by chronic symptoms, and as the chronic condition frequently is interrupted by acute attacks, the symptomatology is best considered together. The onset usually is acute, and often follows exposure to cold or wet, the passage of a catheter, sounding for stone, or dilata- tion of a urethral stricture. The patient has a chill, is nauseated, his temperature rises, and for a few hours he may be very ill. In many cases these symptoms cannot be distinguished from those of so-called urethral fever (p. 1081), but the diagnosis of pyelitis is probable if fever continues, and becomes almost a certainty if there is a dull ache in one or both loins and if an enlarged, tender kidney can be palpated. The urine contains pus, sometimes blood, and usually is alkaline. The pus settles slowly to the bottom of the receptacle, whereas the pus of cystitis settles very quickly. One or both kidneys may be affected. If only one is affected and the ureter is completely blocked, the urine may be fairly normal, while the patient's condition will grow worse; on the other hand, if free drainage of the kidney is present the patient may feel quite comfortable in spite of the infected character of his urine. In the average chronic case, so long as the kidney drains freely, the patient may be little troubled by subjective symptoms unless an exacerbation occurs from renewed irritation of the urinary passages, or indiscretions in diet, etc. Recurrence of acute attacks is common, as the kidney, unlike the bladder, has no great tendency to sterilize itself spontaneously. Treatment. — In the acute cases put the patient to bed, and ensure free drainage of urine from the bladder by an inlying catheter if neces- sary. Keep the patient on a milk diet, and make him drink plenty of water. Give one gram of urotropin three times daily. Treat threatening uremia by diuretics, cathartics, sweating, and if necessary venesection. If the urine is nearly normal, or anuria is present, and PERINEPHRIC ABSCESS 1031 the kidney enlarged and tender, nephrotomy or rarely nephrectomy may be required; but whenever possible radical operation should be postponed until the acute attack subsides. When the chronic stage is reached, radical treatment of the obstructing cause (stricture, enlarged prostate, etc.) may succeed in curing the pyelitis. Before nephrectomy is done, in any case, the functional capacity of the other kidney must be proved adequate (p. 1016). Hydronephrosis. — This is hydrops of the kidney due to urinary obstruction, in the absence of infection. The condition may be unilat- eral or bilateral. Causes of unilateral hydronephrosis are recurrent torsion of the ureter by the vagaries of a movable kidney; impaction of a stone in the ureter without complete blocking of the canal; or stricture of the ureter. Bilateral hydronephrosis is due to obstruction of both ureters, either directly, as by a tumor of the bladder involving both ureteral orifices, pressure of a pelvic tumor, etc., or indirectly by en- largement of the prostate, stricture of the urethra, etc. The symptoms occur as a sequel to those due to the obstructing lesion; the kidney becomes enlarged and may reach an immense size. If temporary relief of the obstruction occurs, the accumulated urine is discharged, with polyuria and disappearance of the tumor. This, however, may soon refill {intermittent hydronephrosis). Treatment. — Treatment comprises removal of the obstruction when this is possible. A movable kidney may be fixed; a stone in the ureter removed; a stricture of the ureter treated by dilatation, ureteroplasty (analogous to pyloroplasty) or by resection and end-to-end suture; a pelvic tumor may be excised. Finally, if no obstruction can be found, or if it cannot be removed, and the kidney is functionless, nephrectomy may be done. Pyonephrosis. — Pyonephrosis occurs as the end-result of pyelo- nephritis, or it may be due to the infection of a preexisting hydro- nephrosis. If the other kidney is functionally sufficient, nephrectomy should be done. Nephrotomy with drainage rarely is beneficial, and in most cases nephrectomy and death are the only alternatives, and death may follow nephrectomy. Perinephric Abscess. — This is suppuration in the fatty capsule of the kidney. I have already mentioned the occurrence of perineph- ritis as a sequel of septic nephritis; and though perinephritis often results in suppuration there are many other causes for perinephric abscess; hence the term perinephritic abscess should not be used, the kidney being at fault only in about one-fifth of the cases (M. B. Miller, 1909). In most cases the source of infection is in the lower genito-urinary tract, and extension to the perirenal tissues occurs along the lymphatics. Trauma may be a predisposing cause. Pul- monary complications are frequent. Symptoms. — Symptoms often are subacute in onset, and the patient may not be laid up until a week or more has elapsed. He complains of local pain and tenderness, walks guardedly, with his body bent toward the affected side; and the hip is slightly flexed; there is local- L032 SURGERY OF THE BLADDER AND KIDNEYS ized muscular rigidity, and a tender spot between the twelfth rib and iliac crest posteriorly. Later there may be moderate or high elevation of temperature; leukocytosis usually is high (average is 25,000) ; and still later distinct evidences of suppuration develop. Sometimes, however, the onset is very acute, with chill, high fever, and extreme prostration. The diagnosis is not always easy, even if the condition is kept in mind. A source of infection should be looked for. Confusion with a lumbar abscess, due to Pott's disease of the spine, should not arise unless such a cold abscess is secondarily infected and signs of spinal involvement are absent. Treatment. — Treatment consists in evacuating the abscess by a lumbar incision; and this should not be postponed if the symptoms are acute, even if the diagnosis is uncertain. Nephrolithiasis or Renal Calculus. — The urine of many persons may contain crystalloids in abnormal amount, yet so long as they are held in solution by the action of colloids, no stone will be formed. If, however, the crystalloids are present in excess of the power of the colloids to hold them in solution by means of what is known as adsorp- tion, then the crystalloids (uric acid, acid urates, calcium oxalate, etc.) go out of solution and are deposited on the colloids as a matrix. If the colloids are what are known as reversible colloids, such as mucin, both they and the mineral deposited on them may be redissolved by more water. If, however, the colloid is irreversible, such as fibrin, it cannot be re-dissolved. The colloid mostly concerned in the forma- tion of urinary calculi is believed to be fibrin; and as this is a product of inflammation and infection, it is not unreasonable to suppose that calculi may form as the remote result of an attenuated infection of the urinary tract, much as gall-stones are formed in the biliary tract. But the influence of infection in these cases has not been proved, and it is customary to regard such calculi (uric acid, oxalate of lime; rarely cystin, etc.) as primary calculi, in contradistinction to those undoubtedly the result of bacterial infection of the urinary tract, which are termed secondary calculi. These latter usually are composed of triple phosphates and result from bacterial decomposition of the urine. Phosphatic deposits may occur as laminations on primary calculi, as concretions on the mucous membrane lining the urinary tract, or as distinct calculi. Renal calculus is most common between twenty and forty years of age, affects men somewhat oftener than women, and the right kidney a little oftener than the left. Both kidneys are involved in from 20 to 50 per cent, of cases. The prevention of calculus formation concerns the physicians; when stones have formed in the kidney the case becomes surgical. The classification of urinary concretions as sand, gravel, and calculi, is self-explanatory. Sand may be productive of no definite symptoms; gravel gives rise to repeated attacks of renal colic as the small stones pass into or through the ureter; while a calculus so large as to be relatively immovable may be symptomless. The smaller the calculi, NEPHROLITHIASIS 1033 as a general rule, the greater is their number and the more apt are they to produce symptoms. Symptoms. — These may be divided into those of simple nephro- lithiasis and those of complications of the disease, such as renal colic, hydronephrosis, pyelitis, and its sequels. In simple nephrolithiasis (which corresponds to simple cholelithiasis) the stones remain in the kidney and infection is absent. There may be no symptoms to call attention to the kidney. What symptoms the patient complains of usually are referred to the bladder, and are the effect of passage of urine altered in quality or quantity. Especially valuable as suggestive of renal disorder is the occurrence of blood in the urine, usually in microscopic amount. It may be present only after the patient has been up and about, and may disappear if he lies quiet in bed. Unless secondary infection occurs, or unless the kidney is unduly movable, and therefore liable to congestion or to hydro- nephrosis, it is unusual for much pain to be felt in the kidney region Fig. 1000. — Shadows cast in a radiogram by different renal calculi: on the left, phosphatic; in the centre, uric acid; on the right, oxalate of lime. (Rothschild.) itself or for macroscopical hematuria or pyuria to occur. But sometimes complaint is made of a dull ache in the lumbar region, and quite frequently there is tenderness on pressure here, or over the lower pole of the kidney in the flank. Sometimes the kidney is palpably enlarged. Murphy placed special reliance on fist percussion over the lower ribs, using one hand as plessimeter and thumping it with the other fist as plessor. He claimed that in the presence of a renal calculus this always produces severe pain. Subjective symptoms, such as pain over the kidney, frequently disappear as soon as the patient goes to bed; and after his admission to a hospital ward the diagnosis may seem doubtful. The x-ray is of inestimable value in the diagnosis of renal calculus, but unfortunately it may be difficult, or impossible, to secure a skiagraph which will show calculi of pure uric acid (Fig. 1000). Fortunately few calculi are composed of uric acid or urates without some admixtures of other salts. No plate should be considered satis- factory unless the shadow of the psoas muscle is clearly visible. Con- fusion arises from defects in the plate, shadows of fecal concretions, Ili:;i SURGERY OF THE BLADDER AND KIDNEYS and, in the case of ureteral stone, from those of phleboliths, calcifica- tion around ligatures left at previous pelvic operations, etc. The functional capacity of the other kidney (p. 1010) should be ascertained in every case of renal calculus. Renal colic is the most frequent symptom of complicated cases of nephrolithiasis, but it may be caused by other factors than the passage of a calculus through the ureter. The symptoms are the same as in cases of Dietl's crisis (p. 1027), but in the latter condition the kidney Fig. 1001. — Four stones in left kidney, removed at operation. Episcopal Hospital. always is movable, which is not often the case in nephrolithiasis. Pain is referred along the course of the ureter, into the testicle, and down the thigh, and sometimes to the end of the penis. The pain usually begins and ends suddenly; but if the stone is impacted in the ureter the pain ceases gradually and light attacks of colic recur often. There may be nausea and vomiting, but there seldom is much constitutional disturbance, unless the kidney is infected, when the symptoms of pyelitis, etc., arise. These have already been considered. During the continuance of the colic the urine may be diminished or entirely URETERAL CALCULUS 1035 suppressed; crebruria, with tenesmus, is frequent, and blood usually is found in the urine. Diagnosis of Nephrolithiasis. — This is not certain unless the stones are seen in a skiagraph (Fig. 1001); and even then, as noted above, sources of error are not infrequent. If gravel has been passed, and colic persists, it is a fair inference that other stones remain; and the diagnosis is very probable if repeated colic occurs, with hematuria and occasionally pyuria, with symptoms of pyelitis. The chief con- ditions from which renal calculus must be distinguished are biliary colic, appendicitis, and intestinal obstruction. The diagnosis of these has already been considered. Treatment. — If the stones are shown by skiagraphy to be merely gravel, and if such have already been passed successfully, it is sometimes advisable to trust to medical treatment to prevent the formation of other calculi, and to allow the patient to pass such as already exist per vias naturales (Fig. 1002). Any stone too large to be passed requires removal by operation ; especially is this true when pyelitis is present and fails to clear up under palliative treatment. Fig. 1002. — Renal calculus of uric acid passed by urethra. (Scale in inches.) Orthopaedic Hospital. If the stones lie loose in the kidney pelvis, a fact which cannot be determined before the kidney is exposed, they should be removed by pyelotomy; if they are fixed in the cortex, nephrotomy (nephrolith- otomy) should be done. These operations are described at p. 1041. If the presence of calculi is uncertain it is better to incise the kidney sufficiently to explore its interior than to endeavor to locate the stone by "needling" the kidney. In all cases a sound or ureteral catheter should be passed down the ureter to the bladder, to make certain that no obstruction has been overlooked. Ureteral Calculus. — The .r-ray has shown that calculus is more frequent in the ureter than in the kidney (C. L. Leonard). In nearly all cases the stone has descended from the kidney. It lodges by pref- erence (1) just below the renal pelvis; (2) at the brim of the true pelvis; or (3) just outside the bladder wall. Blockage of the ureter in the first position causes symptoms similar to those of renal calculus; in the last position, those resembling cystitis. Stones arrested at the brim of the pelvis frequently are mistaken for chronic appendicitis, and the appendix is removed in vain. Complete blockage of the ureter may bring on calculous anuria. This may be due to the functionally useless state of the second kidney; to blockage of both ureters at once; to the existence of only one kidney, 1030 SURGERY OF THE BLADDER AND KIDNEYS or of a horseshoe kidney with a single ureter; or to what is called "reflex inhibition" of the healthy kidney. Unless relieved by opera- tion, calculous anuria usually terminates in uremia and death; occa- sionally death occurs suddenly without uremic symptoms. The free interval varies from one to sixteen days, but rarely is it longer than three or four days. Treatment. — A stone in the upper part of the ureter often can be worked backward into the kidney pelvis; if not, it must be exposed by enlarging the lumbar wound, and removed by direct incision of the ureter (ureterolithotomy). If in the middle portion of the ureter, the stone is best exposed extraperitoneally through a McBurney or similar incision. As the peritoneum is stripped up from the iliac fossa, it carries the ureter with it. Gibbon (1908) placed a finger inside the peritoneal cavity to aid in bringing the ureter into the wound. A stone very near the bladder may be reached extraperitoneally by the suprapubic route (C. L. Gibson, 1910); vaginal and perineal opera- tions are less satisfactory. A calculus in the intramural part of the ureter may be extracted by suprapubic cystotomy, or even by means of the operating cystoscope. Calculous anuria requires active treatment to prevent uremia; hot baths, sweating (pilocarpin) ; morphin and atropin to allay pain and spasm. Unless the anuria is relieved within thirty-six or at the most forty-eight hours, operation should be done. There is no time to undertake an elaborate search for the site of obstruction in the ureter; so unless this is known (when ureterolithotomy by the proper route is indicated) the diseased kidney should be incised and drained, the radical operation being postponed until convalescence. Tuberculosis of the Kidney. — Tuberculosis of the genito-urinary tract usually develops first in the kidney (66 per cent, of cases), or the epididymis (30 per cent.) ; in a few cases it appears first in the Fallopian tubes, the prostate, testis, uterus or seminal vesicles (Watson and Cunningham). In nearly all cases the infection is blood-borne and is secondary to a focus elsewhere in the body (bronchial or mesenteric lymph nodes). The bladder, as pointed out at p. 10.10, scarcely ever is the first portion of the genito-urinary tract to be invaded, and as a consequence ascending tuberculous infection of the kidney is exceed- ingly rare. Secondary pyogenic infection, however, frequently ascends from the bladder and causes rapid disintegration of the tuberculous kidney. In most cases only one kidney (the right and left about equally) is affected at first, and the other kidney may remain intact for a long time. The lesions commence in the cortex, but the pelvis is invaded when rupture of the caseous foci occurs. The ureter may remain healthy long after the infection has secured a foothold in the bladder. The disease is most frequent in early adult life, and the sexes are about equally affected. At the time patients come to operation the disease is still confined to one kidney in more than half the cases, TUBERCULOSIS OF THE KIDNEY 1037 and even at autopsy the second kidney is free in about one out of three cases. In the large majority of cases of bilateral disease the second kidney is only very slightly involved. Symptoms. — There are both constitutional symptoms characteristic of a tuberculous lesion, and local symptoms referable to the urinary tract. Among the former may be mentioned afternoon pyrexia, nervousness, sleeplessness, anorexia, and loss of weight. Though the patient seems ill, no definite cause is apparent. After weeks or months, urinary symptoms appear. At first these are referred to the bladder; the urine is passed frequently; its quantity is increased, and its specific gravity lessened ; it contains pus and microscopical amounts of blood. Frank hematuria is rare. Vesical irritability may be extreme before the tuberculous lesion has spread to the bladder. Secondary pyogenic infection of the kidney causes hectic fever, night sweats, emaciation, and rapid loss of strength. Not until this stage is reached is the acidity of the urine lost. Diagnosis. — Vesical symptoms should not divert attention from the kidney. Pus in the urine does not necessarily mean cystitis. In cys- titis the urine almost always is alkaline; but in renal tuberculosis it remains acid until pyogenic infection is far advanced. Occurrence of remissions in the severity of the symptoms is highly characteristic of tuberculosis, but is unusual in renal calculus. In the latter, exacer- bation of symptoms usually follows exercise; but in renal tuberculosis this constant relation of cause and effect is not seen. Renal calculus usually may be excluded by skiagraphy. In tuberculosis the tempera- ture chart (even in the absence of pyogenic infection) should rouse suspicion of the nature of the infection. The hypodermic use of tuber- culin and inoculation experiments with the centrifugated urinary sediment, are valuable aids in diagnosis. Cystoscopy usually reveals appearances around the ureteral orifice on the diseased side which are considered by experts highly characteristic. Ureteral catheteri- zation is the surest way of determining the healthy condition of the second kidney. In many cases inoculations and examinations of the urine for tubercle bacilli have to be repeated on several occasions, as the results are not always constant. Treatment. — Most surgeons are in accord in recommending removal of the diseased kidney as the only hope of cure; even if the other kidney is slightly diseased, the tuberculous process may become latent in it after the more diseased organ has been removed. The excellent effect of nephrectomy on vesical tuberculosis has already been mentioned (p. 1020). The immediate mortality of nephrectomy for tuberculosis is from 5 to 10 per cent.; and about 26 per cent, of patients are cured of the disease and remain well for three years or longer. In most others great improvement occurs. But if the second kidney is incom- petent, nephrectomy should not be done, and hygienic treatment alone must be employed. If pyonephrosis is present, relief may be afforded by nephrotomy and drainage, if nephrectomy is contraindicated. 1038 SURGERY OF THE BLADDER AND KIDNEYS Tumors of the Kidney. — These are conveniently classed as solid tumors and cysts. Solid Tumors of the Kidney. — Hypernephroma is the commonest (p. 129). Other solid tumors are sarcoma and carcinoma. Benign solid tumors are very rare. Solid tumors occur oftenest in adult life, especially from forty to sixty years of age; but sarcomas, embryonic tumors and tumors of the adrenal gland are seen in children. The physical signs of all these solid tumors are much the same, and have been considered under the differential diagnosis of enlarge- ments of the spleen (p. 1007). Hypernephroma may grow to immense size, but the other malignant tumors kill before they reach great size. Symptomatic varicocele and severe referred pain are usual results, and ascites is an unusual result of pressure by kidney tumors. The chief characteristic, apart from the presence of a tumor, is hematuria, which often is painless, usually is profuse, and occurs without vesical symp- toms. Bright red blood is passed from the urethra when the patient ex- pects urine. Bleeding may be so profuse as to produce faintness, recurs at irregular intervals, and is not made worse by exercise as is the less marked bleeding which attends renal calculus. If the ureter is blocked by a clot the urine is clear, but diminished in amount, and severe pain may be felt in the loin. When hemorrhage occurs and back pressure on the kidney is relieved the patient may feel better. Tumor of the adrenal sometimes may be distinguished from tumors of the kidney proper by attention to certain details: it is most frequent in children, and anorexia, listlessness, loss of weight and strength may be noted weeks or months before the tumor is discovered; the tumor grows beneath the diaphragm, pushes the kidney down, causes early referred pain and paresthesia, and sometimes is accompanied by bronzing of the skin and precocious puberty; hematuria is very rare. The skeleton always should be examined for metastases. According to Symmers (1917), when the adrenal medulla is the seat of tumor formation in children (neuroblastoma; ganglioneuroma, p. 129) two distinct clinical types are recognizable: (1) Extensive metastases in cranium and regional lymph nodes attended by secondary exophthalmos and ecchy- mosis of lids; and (2) rapidly increasing distention of abdomen due to neoplastic infiltration of the liver, without ascites or jaundice. Prognosis. — Hypernephroma generally leads to death within three or four years. Sarcoma and carcinoma terminate fatally within a year or less, as do tumors of the adrenal in children. Treatment. — Nephrectomy should be done whenever possible. If the growth is large the transperitoneal route is the best. The immediate mortality of operation is about 25 per cent, and most patients who survive succumb to metastases within two years. Cystic Tumors of the Kidney are rare and of little surgical interest. Polycystic disease sometimes appears to be hereditary; it is seen oftenest in early infancy or in middle life and may be due to lack of proper fusion of the cortical with the pelvic portions of the kidney in the embryo; usually both kidneys are affected, and hence nephrec- OPERATIONS ON THE KIDNEY 1039 tomy which otherwise would be proper, is contra-indicated. Simple serous cysts of the kidney also occur, but are exceedingly rare. Injuries of the Kidney. — Rupture from falls, kicks, etc., is more frequent than stab or gunshot wounds. The latter are recognized by the course of the missile, bleeding into the bladder, and sometimes the discharge of urine from the wound, Subcutaneous injury varies from con- tusion, to fragmentation, or complete disruption (pulpefaction) of the kid- ney. There is hematuria, and in most cases a hematoma forms in the flank. Intraperitoneal hemorrhage is rare. There is much local pain and tender- ness, and if bleeding is profuse or long continued even in small amount the usual consequences ensue. Treatment. — In cases of gunshot or stab wound the kidney should be exposed and the wound tamponed or closed by suture. There is little prospect of spontaneous arrest of hemorrhage. In subcutaneous in- juries, on the other hand, bleeding frequently ceases when the patient is kept quiet in bed, with ice locally and morphin internally. Salol or uro- tropin should be given. If bleeding is very profuse, and particularly if the lumbar hematoma continues to increase in size, the kidney should be exposed and its wound tamponed, or, better, closed with mattress sutures of chromic gut, deeply inserted and including the fibrous capsule. Nephrectomy is to be avoided; even a portion of the kidney completely detached may be sutured in place (Fig. 1003), and if even only one-tenth of what is saved retains its functional activity, the patient is just so much better off than if it had been removed. Fig. 1003. — Rupture of right kidney (anterior view). Woman, aged thirty- two years, fell, striking loin on a step. Operation for increasing hematoma four hours after injury. Fragment sutured to kidney. Recovery. Epis- copal Hospital. OPERATIONS ON THE KIDNEY. Position of the Patient. — In lumbar operations the patient should lie prone, with a sand-bag or other support between the costal margin and pelvis. When the kidney has been exposed the patient may be drawn toward the foot of the table, while the sand-bag is kept immov- able. Thus it compresses the lower thorax, enforces abdominal breath- ing, and the kidney tends to prolapse into the wound (Edebohls). In the abdominal approach the position is similar to that employed in operations on the bile-ducts, but with the patient turned a little toward the healthy side. 1(110 SURGERY OF THE BLADDER AND KIDNEYS Incisions. — The usual incision for haiibar operations runs parallel to the last rib, and about 2 cm. below it, from the outer border of the erector spinas mass for 10 to 15 cm. downward and forward. This incision may be extended forward in the course of the motor nerves of the abdominal wall (Fig. 1004). The iliohypogastric and ilioinguinal nerves lie just below this incision between the transversalis fascia and the oblique muscles, and should not be injured. If more room is desired at the upper angle of the wound, the lateral arcuate ligament, which binds the twelfth rib to the transverse process of the first lumbar vertebra, and the quadratus lumborum may be cut and the rib thus mobilized. By keeping close to the rib there is not much danger of wounding the pleura. This oblique incision divides, at the spinal end, the latissimus dorsi; at the ab- dominal end, the oblique abdominal muscles at their origin from the lumbar aponeurosis. This aponeurosis itself is divided as far backward as the erector spinas mass. Then the transversalis fascia is divided. These struc- tures are shown diagrammatically in Fig. 1005. When they have been incised the peri-renal fat, enclosed in the fascia of Gerota, is Fig. 1004. — Incision for exposure of kidney by lumbar route. Fig. 1005. — Cross-section of left lumbar region, to show structures concerned in operations on the kidney (diagrammatic). 1. External oblique muscle. 2. Internal oblique and transversalis muscles. 3. Latissimus dorsi. 4. Lumbar aponeurosis. 5. Perirenal fascia. 6. Peritoneum. 7. Ureter. 8. Renal artery. 9. Renal vein. exposed. In infected cases this fatty capsule may be dense, but usually it is easily displaced by the finger, exposing the kidney covered by its true capsule. OPERATIONS ON THE KIDNEY 1041 In exposure of the kidney by the abdominal route, the best incision is one parallel to the motor nerves, beginning at the semilunar line at the level of the umbilicus and running back toward the flank as far as necessary. Nephrotomy. — After exposure of the kidney by a lumbar incision, as indicated above, proceed to enucleate it from its fatty capsule. Free both poles as well as the anterior and posterior surfaces by blunt dissection with the finger, and do not attempt to deliver the kidney into the wound until it has been thoroughly freed. In infected cases it may be impossible to free the kidney, on account of adhesions; hemor- rhage may then be controlled by clamping the pedicle with rubber- Fig. 1006. — Nephrotomy: The kidney drawn out on the back and its pedicle com- pressed with the fingers. The splitting of the kidney here shown illustrates the operation for removal of stones from the calices. (Watson and Cunningham.) covered forceps while the kidney is opened. If the kidney can be delivered, deliver the upper pole first and control the pedicle between the fingers (Fig. 1006). Incise it longitudinally a little posterior to the convex border, in the bloodless zone, so as to avoid Brodel's white line which overlies the principal vessels supplying the renal cortex. Brewer opens the exposed kidney by Hilton's method (p. 50), so as to avoid hemorrhage. If the operation is for the removal of calculi (nephrolithotomy) a largejcortical incision is desirable, so as to expose all the calices and thejpelvis and allow probing of the ureter. If the operation is 66 1042 SURGERY OF THE BLADDER AND KIDNEYS done merely for drainage, the opening need not be s<> large. At the conclusion of the operation, bleeding is arrested by mattress sutures of chromic gut through the kidney. The lumbar wound should be drained in all eases. Fig. 1007. — Nephrectomy: Manner of clamping and tying the pedicle of the kidney. (Watson and Cunningham.) If the stones are known to lie in the kidney pelvis, pyelotomy should be preferred to nephrolithotomy. The pelvis is exposed by turning the kidney forward and clearing off by gentle blunt dissection the fat which covers the posterior surface of the kidney pelvis. The pelvis is then incised a short distance from the kidney. After removal of calculi and probing of the ureter, the fatty tissue overlying the pelvis is sutured back in place, as this tends to prevent leakage. Drainage should be by rubber tissue, not by gauze. OPERATIONS ON THE KIDNEY 1043 Nephropexy has been sufficiently described (p. 1028). Nephrectomy. — The kidney is exposed, and, if possible, is delivered through the wound. The pedicle is attacked from below. Clamp the proximal and ligate the distal portion of the ureter, cut between, and leave the ligature long. Expose the renal arteries and vein by blunt dissection, from the front of the kidney; if not too bulky, ligate the pedicle en masse, or transfix and tie on both sides. Leave the liga- ture long. Then catch the pedicle between the kidney and the ligature in forceps, and cut between the kidney and the forceps, removing the kidney, but leaving the forceps on the pedicle. In case bleeding occurs (it may be profuse) the pedicle can be drawn into the wound, and another ligature applied. If it is impossible to expose the pedicle satisfactorily, it may be clamped and the kidney cut away. Never tie the ligature while the clamp is in place, since when the clamp is released and the pedicle retracts the ligature may be forced off. It is permissible to hold the pedicle in a clamp while the ligature is being passed (Fig. 1007), but before the ligature is tied the clamp must be released. If this is impossible, the clamp must be left in place for four or five days. The kidney being removed and all hemorrhage checked, the liga- ture on the ureter is pulled upon, and the ureter drawn into the wound. As much as possible of it should be resected, and the end securely ligated. In septic or tuberculous cases it is well to inject 10 drops of carbolic acid, thus ensuring obliteration of its lumen. In all cases temporary drainage of the wound is essential. Closure of the Wound. — In all operations on the kidney, whether drainage is employed or not, the same care in suturing the wound should be taken as in abdominal operations. Hernia is not very infrequent if suturing is carelessly done. CHAPTER XXVI. VENEREAL DISEASES. SYPHILIS. The pathology of syphilis is discussed in Chapter III. Contagion. — The disease may be inherited (congenital syphilis) as well as acquired. The only pathological difference between these two forms of the disease is that in the inherited form there is no primary lesion (chancre), the infecting organism having entered the infant's body through its mother's blood or with the semen of the father. 1 The lesions of syphilis from which the disease may be contracted are the primary lesion (chancre), and the secondary lesions (especially mucous patches). Tertiary lesions seldom if ever convey the con- tagion. In nearly all cases there is at the point of inoculation a pre- existing abrasion, crack, or fissure in the epithelium of the patient inoculated; inoculation through the intact skin is very rare. The occurrence of immediate and mediate contagion was also men- tioned in discussing the pathology of syphilis. In most cases syphilis is acquired by immediate con- tagion, during sexual intercourse. Hence it is classed as a venereal disease. 2 The sores from which the virus is derived being situated on the genitalia, the sore produced by inoculation likewise develops on the genitals. If the disease is not con- tracted during coitus, the primary lesion usually is not on the genitalia (though it may be), but on the lip (Fig. 1008), face or other exposed portion of the body; and is due to direct contact with contagious sores in another individual (immediate contagion) or to mediate contagion through infected towels, eating and drinking utensils, etc. Such patients being regarded as innocent, the disease in them is some- times termed syphilis insontium. In such cases mediate contagion may conceivably cause inoculation in the genitalia; but the presump- 1 It has not been found possible to produce a similar form of the disease experi- mentally (using monkeys), since the treponema is destroyed by phagocytosis when injected directly into the blood. According to Levaditi and Roche, however, syphilis without any primary lesion has been produced by injecting the organisms into the testicle where they are able to develop. In these cases the first manifes- tations of the disease corresponded to secondary syphilis, and in so far resembled the congenital form. 2 Until Ricord, in 1836, pointed out the clinical differences between chancre and gonorrhea, these two affections were not distinguished, both, as well as chancroid, being considered lesions of "the venereal disease" (syphilis). (1044) Fig. 1008. — Chancre of the lip ; duration three weeks. Age, eighteen years. Devel- oped two weeks after exposure. Dr. Alexander's patient. Episcopal Hospital. SYPHILIS 1045 Fig. 1009. — Multiple chancres (penis and abdomen), the result of simultaneous inocula- tion. Episcopal Hospital. tion is strong that a genital sore has been acquired during the venereal act. Yet it is well to remember that such occurrences are at least possible, and care should be taken not to wound the feelings of others and perhaps cause domestic unhappiness by expressing an unguarded opinion, which, after all, may prove erroneous (J. Ashhurst, Jr.). Symptoms and Diagnosis of Chancre. — A chancre develops from three to five weeks after exposure, and occurs first as a reddish-brown papule; but usually when first seen exfoliation of the overlying epithe- lium has occurred. The chancre appears as a superficial erosion, which is common, or as a deep excavated ulcer (Hunterian chancre), which is rare. In the male, chancre usually develops on the prepuce, fre- num, or glans penis; less often on the body of the penis, the abdomen, or elsewhere. In the female it occurs on the labia, within the vagina, or on the cer- vix uteri; occasionally around the anus or in the perineum. In men it usually attracts at- tention as soon as it develops, on account of its exposed posi- tion; in women, for the contrary reason, it is generally overlooked, and they come under treatment first when secondary lesions develop. In almost all cases the chan- cre is solitary; if more than one is present, all have been inocu- lated at the same time, usually from numerous secondary le- sions (Fig. 1009). The chancre is not auto-inoculable; a person who has a chancre has de- veloped a constitutional disease which runs a regular course, and he is immune to re-inocu- lation (from his own sores or sores of others) until the dis- ease is absolutely eradicated. In all cases the chancre is indurated, at some time in its development. Sometimes in- duration appears before erosion of the epithelium occurs, and usually it persists after the ulcer has cicatrized. The induration of a chancre causes it to feel like a piece of parchment or a split pea in the skin, and often the chancre can be picked up, as it Fig. 1010. — Chancre, duration one day; ex- posure two weeks ago. (Also left varicocele.) Age twenty-one years. Note induration. Ulcer can be picked up in forceps without folding on itself. Episcopal Hospital. lOlli VENEREAL DISEASES were, without causing it to fold on itself or wrinkle (Fig. 1010). In cases where induration is less evident, it is best detected by slight rigidity of the prepuce as this rolls back from the corona glandis (Fig. 1<)1.'5). This is not an inflammatory induration: the outlines of a chancre (almost invariably round or oval) are sharply defined; and there is no redness, heat, swelling, or abundant secretion from the eroded or ulcerated surface. The surface of a chancre on a mucous membrane may be moist, and covered with a thin pellicle of fibrin; but one on an exposed surface usually is covered with a dry brownish scab. The duration of a chancre is self-limited. It heals spontane- ously in a few weeks or months unless complications arise. It leaves a very characteristic cica- trix, which usually but not always, may be identified years later by its circular, shiny, slightly de- pressed appearance (Figs. 1011 and 1012). A mixed chancre is a sore in which both the syphilitic and chancroidal viruses have been inoculated. 1 Usually both poisons have been inocu- 1 . A A Fig. 1011. — Scar from chancre on glans penis, seven months previously. Age twenty-two years. (Note also small punched-out ulcer back of prepuce from a healed chancroid.) Episcopal Hospital. Fig. 1012. — Scar on body of penis from chancre two years previously, twenty-six years. Episcopal Hospital. Age 1 Until Bassereau in 1852 pointed out the clinical differences between chancre and chancroid, they were not distinguished, both being regarded as the initial lesion of syphilis. Rollet in 1866 was the first to explain the essential nature of "mixed chancre." SYPHILIS 104? lated at the same time, but this is not always the case. A chancre may be inoculated subsequently with chancroidal virus, or vice versa. Fig. 1013. — "Mixed chancre." Multiple chancroids, appeared four weeks ago, four days after coitus. Induration present for last week only. Note stiffness of prepuce as it is rolled back from corona glandis. Episcopal Hospital. In most cases the early symptoms and history indicate that the lesion is a chancroid; and it may be only when the ulcer fails to heal and in- duration commences (Figs. 1013 and 1014), or even not until symptoms of secondary syphilis appear, that the true condition is recognized. Syphilitic Bubo. — Very soon after the appearance of the chancre, the related lymph nodes (usually the inguinal) become enlarged and indurated. Many nodes are af- fected (poly 'ganglionic) , and if the Fig. 1014. — Mixed chancre. Lesion appeared five weeks ago, four days after coitus. Episcopal Hospital. Fig. liii.j.- -Syphilitic buboes. Age seven- teen years. Coitus January 15, chancre of glans penis developed February 7. Photo- graphed March 22, 1909. Episcopal Hos- pital. 104S VENEREAL DISEASES inguinal region is involved, almost invariably the affection is bilateral. Usually the enlargement is moderate (Fig. 1015), but occasionally I have seen great lumps the size of oranges develop. The individual nodes do not tend to coalesce, they remain discrete; their outlines are recognizable on palpation; they are neither especially painful nor very tender; they show no evidences of acute in/lamination, and never suppurate. These features serve to distinguish syphilitic from chan- croidal bubo, which is unilateral, inflammatory, very painful; and in which suppuration is frequent. Fig. 1016.- -Macular syphiloderm; duration seven days; chancre three months ago. Episcopal Hospital. Symptoms and Diagnosis of Secondary Lesions. — As noted in Chapter III, various prodromal symptoms (fever, malaise, headache, vague "rheumatic" pains) often occur during the period between the development of the chancre and the appearance of secondary lesions. This period lasts, on the average, about six weeks. At the end of this time, often before the chancre has healed, sometimes after its existence has been almost forgotten, and occasionally as the first recognized SYPHILIS 1049 symptom of syphilis (the chancre having passed unnoted) , there appear skin rashes which, though multiform and various, possess certain characteristics by means of which their syphilitic nature usually may be recognized. About this same time the lymph nodes all over the body become enlarged, especially the posterior cervical and epi- trochlear groups. This lymphatic involvement is very characteristic, and often can be relied on for diagnosis when the skin rashes are too faint or fleeting for recognition. There is also falling of the hair (alopecia syphilitica) ; and sore throat, from de- velopment in the pharynx of lesions which correspond to the skin rashes. Affec- tions of the eye, especially iritis, sometimes occur. Fig. 1017. — Papular syphiloderm, scaling (syphilitic psoriasis); duration one month; chancre three months ago. Episcopal Hos- pital. Fig. 1018. — ■ Papulosquamous syphiloderm ; chancre seven months ago. Episcopal Hospital. The occurrence in combination of skin rashes, lymphatic enlarge- ment, falling of the hair, and sore throat is almost pathognomonic of secondary syphilis. Syphilodermas.— The skin rashes of secondary syphilis require more extended description. They are characterized (1) by the so-called protean nature of the eruption, or the appearance simultaneously, or L050 VENEREAL DISEASES in quick succession, or more than one variety; (2) by their appearance symmetrically, all over the body; (3) by the absence of subjective symp- toms, the lesions causing no sensation of itching, burning, etc.; and (4) by the ham-red or coppery color of the lesions, especially as they fade away. They are distinguished from the skin lesions of tertiary syphilis: (1) by their appearance within a more or less definite interval after the primary lesion; this is not true of tertiary lesions; (2) by their general and symmetrical distribution; tertiary skin lesions are local and asymmetrical; (3) they do not spread centrifugally and hence do not assume the circinate and serpiginous character of tertiary lesions; (4) they tend to disappear spontaneously after lasting a few weeks or months, even without treatment; and their disappearance is markedly hastened by mercurial treatment. Macular rashes (erythema and roseola) usually are the first to appear (Fig. 1016); they may become apparent only after the patient's body has been exposed to the air. Examination in a good light is necessary. Fig. 1019. -Mucous patches around the labia and anus of a colored woman. Pennsylvania Hospital. Papular rashes also occur early. Papules which are exposed tend to scale, and the lesion may resemble psoriasis (Fig. 1017). A papular eruption which occurs late is more deeply situated in the skin, and bears a slight resemblance to tertiary lesions (Fig. 1018). Papules which occur in a group on the forehead, just below the hair line, tend to become confluent and are termed the corona Veneris. Papules which occur on mucous membranes, or on skin surfaces which are moist and w r arm (anus, scrotum, labia, infra-mammary folds) have their epithelial covering destroyed by maceration; they are known as mucous patches, or if confluent, as condylomata lata (Fig. 1019). l They 1 The condyloma latum, or flat wart, is so-called to distinguish it from the ordinary venereal wart or condyloma acuminatum (p. 1105). SYPHILIS 1051 should be looked for in the situations named, as well as in the buccal mucous membrane (cheeks, palate, fauces, tonsils, tongue). Pustular rashes occur later than the macular and papular, usually several months after the primary lesion. The chief varieties are ecthyma, acne, and impetigo. If deep ulcers are formed, character- istic round, white, shiny cicatrices are left. Symptoms and Diagnosis of Tertiary Syphilis. — Usually there is an interval of a few or many years between the disappearance of secondary symptoms and the occurrence of those of the tertiary stage. Occasionally, however, no interval elapses, tertiary symptoms appearing while the skin rashes of the second stage still are present. In many cases no tertiary symptoms ever appear, especially if active treatment has been persisted in throughout the secondary period. Tertiary lesions may affect almost any tissue in the body. Those which occur in the skin, mucous membranes, subcutaneous tissues, eye, nervous and vascular systems, muscles and fascia, bones and periosteum, and certain of the solid viscera, are of most importance in surgery. The skin lesions of tertiary syphilis are deep and destructive. They appear at no definite interval after the primary lesion, they are localized and not symmetrical in distribution, they tend to spread centrifu- gally and to assume a serpiginous form, they show no inclination toward spontaneous cure, and treatment by mercury alone rarely is very effective. Their chief forms are the tubercular (not tuberculous ; see p. 75), squamous, and rupial. Syphilitic tubercules are at first reddish or coppery papules, which tend to early ulceration; as those in the center heal, the tubercules at the periphery become ulcerated, producing a serpiginous lesion (Fig. 1020) which usually is easily recognized. Syphilitic tubercules occur frequently about the eye and nose; where it is important to distinguish them from lupus, and rodent ulcer. The scar which results from a tubercular ulceration is large and quite characteristic (Fig. 1021); it will be noted, in the patient represented in this photo- graph, that although both knees (symmetrical portions of the body) have been affected, the lesion on the left side developed seventeen years after that on the right. Squamous lesions often attack the palms and soles, where cracks and fissures are frequent, and may be very painful. Rupia may occur in one or many patches, following a bullous eruption (Fig. 1022). In the mucous membranes syphilitic ulceration may cause great destruction. Gummatous lesions of the tongue have been described in Chapter XIX. The palate, fauces, pharynx, etc., may suffer severely; perforation of the palate is not unusual; "falling in" of the nose is frequent; and sometimes the soft palate grows fast to the vault of the pharynx, completely shutting off the nasal passages from the oropharynx. Strictures of the esophagus, larynx, trachea, and occasionallv of the intestinal canal occur. 1052 VENEREAL DISEASES In the subcutaneous tissues the most frequent lesion is the syphilitic gumma (Fig. L023). Its clinical characters have been described in Chapter III. In the eye the most frequent lesion is syphilitic iritis. In the nervous system the lesions affect chiefly the brain and spinal cord, or their membranes. Lesions of the peripheral nerves are rare. Any lesion of the central nervous system which occurs in a patient who has had syphilis, even many years previously (Fig. 1024), should be regarded as syphilitic until the contrary can be proved. In the arterial system the in- fluence of syphilis in causing aneu- rysm has been pointed out in Chapter X. Fig. 1020. — Tuberculo-crustaceous lesion, in tertiary stage of syphilis. Duration nine months. Episcopal Hospital. Fig. 1021. — Left knee, active tubercular ulceration of tertiary syphilis in a woman aged fifty years, twenty years after the pri- mary lesion. Right knee and thigh show cicatrices of similar tubercu- lar lesions which developed seven- teen years previously and were three years in healing. Episcopal Hospital. Fig. 1022. — Syphilitic rupia. Age twenty-six years; duration five weeks. Chancre one year ago. Episcopal Hospital. In the muscles, bursse, tendons, and fascia gummatous tumors are not unusual, limiting function by their bulk, by ulceration, or by the cicatrices which are the result of healing. Syphilitic panaris and dactylitis (Fig. 1025) have been described in Chapter XIV. SYPHILIS 1053 Syphilis of the bones has been considered in Chapter XIV, and that of the joints in Chapter XV. Of the solid viscera, the lesions of tertiary syphilis affect particu- larly the liver, where gummas may simulate nodular carcinoma. The diagnosis depends on the history of the case, the recognition of other signs (past or present) of syphilis, the Wassermann test, and the result of medication. At operation gummas usually may be recognized by central softening, if recent, or by the stellate fibrous cicatrix which results when healing has been uninterrupted. Excision may be desirable if calcification occurs. Syphilis of the spleen is rare and of little surgical interest. Syphilis of the testicle is considered in Chapter XXVIII. Fig. 1023. — Gumma of neck and of lower eyelid, duration six weeks. Patient aged forty-five years, had gonorrhoea twenty- five years previously, no history of chan- cre. Rapid improvement under mixed treatment. Episcopal Hospital. Fig. 1024. — Paralysis of left facial nerve from intracranial lesion, thirty years after chancre. Paralysis of sudden onset ten days ago. Epis- copal Hospital. Hereditary Syphilis. — It has already been stated that this differs from the acquired form of the disease chiefly in having no primary lesion. It may be inherited (1) from both parents; (2) from the mother, infected either before conception or during pregnancy; or (3) from the father at the time of conception. As the mother in the latter circum- stances is able to suckle her syphilitic child without acquiring syphilis herself (Colles's law, 1837), it was formerly taught that she had ac- quired immunity from the fetus; but as such a mother reacts positively 1054 VENEREAL DISEASES to the Wassermann test, it is now taught that she has acquired syphilis from her fetus, and that her refractoriness to inoculation is due to the fact that she already has the disease, though in latent form. Prof eta's law (1805), to the effect that a healthy child of syphilitic parents is unable to contract syphilis, is now also explained by the child having the disease in latent form, since such children give a positive Wassermann reaction. Both Colles's and Profeta's laws are merely an expression of the fact stated at p. 1045, that any patient who has devel- oped syphilis is immune to re-inocu- lation until the disease is absolutely eradicated. Pregnancy, in the case of syphilis, usually terminates in abortion, in mis- carriage or in still-birth at term. The more attenuated the infection, the more probable is the birth of a living child at term. The child often shows no evidences of syphilis at birth; but if the disease is truly hereditary and not acquired after birth, lesions corresponding to those of the secondary stage almost invariably appear before the age of two w T eeks. Fig. 1025. — Syphilitic dactylitis, in a patient aged forty-one years, twelve years after chancre. Episcopal Hos- pital. Fig. 102G. — Hereditary syphilis; aged twelve years. Hutchinson teeth; interstitial keratitis; sabre-blade tibiae. Orthopaedic Hospital. SYPHILIS 1055 The earliest symptoms are bullous skin eruptions (pemphigus), mucous patches, and coryza ("the snuffles"). The baby suffers from Fig. 1027. — Saddle-nose in hereditary syphilis. Age twenty-four years. Also has genital infantilism and chronic otitis media. Episcopal Hospital. Fig. 102S. — Hereditary syphilis. Age fourteen years; superficial gummata wrongly diagnosed as tuberculosis and eight operations done during last five years. (Dr. W. Walker's case.) Epis- copal Hospital. malnutrition and looks wrinkled and prematurely aged. If the period of infancy is survived, further lesions seldom appear until the age of six years or older. The most characteristic of these lesions are interstitial keratitis, "Hutchinson's teeth" (Fig. 1026) (a peculiar notched and inverted wedged-shaped con- dition of the permanent upper cen- tral incisors, first recognized as syphilitic by Jonathan Hutchin- son, 1861), rhagades or linear cica- trices at the corners of the mouth, saddle-nose (Fig.1027), dactylitis, and sabre-blade tibia (Fig. 519). Super- ficial gummata may be mistaken for tuberculosis of the cervical lymph nodes (Figs. 102S and 1029). Syphilis of the joints (p. 545) is common in the hereditary form of the disease. In many cases genital infantilism may exist even if the f ig , 1029.— Hereditary syphilis, sane bodv is large and reasonably well P atient ^^ie- 1 ' ,2S ' V' 1 ,-' 1 ' m ° nth ? aft f . j a course of anti-syphilitic treatment. IOrmed. Episcopal Hospital. 1056 VENEREAL DISEASES Diagnosis of Syphilis. — This has been based for many years solely on the clinical findings, and as laboratory aids (particularly the com- plicated Wassermann test, 1906) may not be available immediately, it is very important for the surgeon to be able to recognize and attach due significance to the multiform symptoms of the disease, especially as these often arc developed without apparent regularity and are constantly modified by previous treatment or extraneous circum- stances. Often very little assistance can be obtained from the patients themselves, who may be wilfully deceptive in their answers or who may really have failed to notice symptoms sometimes trivial in them- selves and frequently spread over a long term of years. The distinction between chancre and chancroid is of great importance, and usually is possible clinically by attention to the points enumerated at p. 1062; but the existence of mixed chancres must be remembered, and also that both chancre and chancroid may be inoculated simul- taneously but in different parts of the body. Moreover, a person already having syphilis may subsequently acquire a chancroid, and this may be modified by the syphilitic soil in which it is planted. Valuable information may be derived from "confrontation," or the examination of the individual from whom the disease was contracted; but this is seldom possible in this country. The development in later life of lesions of tertiary syphilis and a positive Wassermann reaction in patients having had no known genital lesion, or only chancroids or gonorrhea, show how very difficult it may be to exclude a diagnosis of syphilis at the time of the original infection. Extragenital Chancre, particularly on the lips and tongue, must be distinguished from carcinoma. This usually may be done clinically by observing the early palpable enlargement of the neighboring lymph nodes in chancre, and the effect of antisyphilitic treatment. Microscopical study of a section of the suspected ulcer is a sure method, but like other laboratory aids is not always available. In the diagnosis of secondary and tertiary lesions the surgeon must rely not upon any one or two symptoms, but upon the coexistence of a number, and especially upon their course and order of development. A surgeon meeting with a case of iritis or of cutaneous eruption, or of periosteal "rheumatism," in a person of notoriously lax morality, should not at once jump to the conclusion that the disease is syphilitic; for to do so would be as unphilosophical as it might be unjust. If, on the other hand, a patient should suffer from frequent attacks of recurrent iritis, copper-colored eruptions of various forms, post-cervi- cal engorgement, alopecia, and occasional development of mucous patches; or from osteoscopic pains, indolent nodes and gummatous tumors of the areolar tissue — even though such a patient should appear as virtuous as Joseph or as wise as Penelope — the surgeon might reasonably conclude that he had to deal with a case of syphilis, and should direct his remedies accordingly (J. Ashhurst, Jr.). Laboratory Aids to Diagnosis. — In many of the ulcerated lesions of syphilis, especially the chancre and mucous patches, it is possible to SYPHILIS 1057 find the Treponema pallidum by microscopical study of smears with dark field illumination, or after proper staining. The Wassermann or complement-fixation test for syphilis is considered perfectly reliable within certain limits. The test is of highly technical nature, and requires long practice and vast experience for its proper performance; many of the tests are useless because these exacting conditions are not fulfilled. Then the test sometimes is not positive during the earliest stage of syphilis (chancre), nor as a rule during the second- ary stage if the patient has been under active antisyphilitic treat- ment. It is of greatest value in the third stage of the disease, and in parasyphilitic affections, since here the patient usually has not been under active treatment for a long time, and if the test is posi- tive it may be considered conclusive evidence that the patient is still suffering from syphilis. Even this does not prove, however, that the lesion in question is necessarily syphilitic. In the case of hereditary syphilis, also, a positive Wassermann reaction may indi- cate that a child of syphilitic parents is itself actively infected, or it may indicate merely that the child has syphilis in a latent form, in accordance with Profeta's law. Whether or not a positive Wasser- mann test may be obtained in the third or fourth generation of patients suffering frorrf latent syphilis is not certain; even in the second genera- tion it is nearly impossible to prove that the disease was not acquired in very early infancy. Certainly the fact that the test is positive often is the only evidence, however remote, which can be obtained to indicate that the patient or his ancestors ever were infected with syphilis. Clinical observation convinces me that a negative test is of very little value in excluding the presence of latent syphilis. The therapeutic test is more reliable. Treatment of Syphilis. 1 — As syphilis is a general infection, consti- tutional treatment is much more important than local. It has been found by several centuries of experience that the most useful internal remedies are mercury and the iodides. The first of these is antiseptic, and probably acts directly on the parasite which causes the disease, thus being specially indicated during the active stages of syphilis; while the iodides, which aid elimination, are chiefly beneficial (either alone or combined with mercury) in the tertiary stage. Since the dis- covery of the microbic cause of syphilis, renewed efforts have been made to secure some drug which shall once and for all destroy the para- sites which cause the disease and thus produce rapid cure. At first it was thought that this Sterilisatio Magna had been provided in the arsenical compound known as Salvarsan, the six hundred and sixth ("606") chemical synthetically prepared by Ehrlich, with this end in view, and furnished to the public in 1909. To this remedy have succeeded others more or less similar. But it has become evident that while these preparations are of exceedingly great efficacy in certain cases, their use only supplements and does not supplant that of mercury and the iodides. 1 The question of venereal prophylaxis is mentioned at p. 1066. 67 105S VENEREAL DISEASES Throughout the continuance of the disease, strict rules of hygiene must be observed. In alcoholics, nephritics, and the tuberculous, the prognosis is bad. In otherwise healthy patients the disease is not only curable, but often rapidly so. The patient must not drink any alcoholic liquors. He must not smoke nor chew tobacco, as these habits favor the development of mucous patches. He should have his teeth put into good order, and should keep them in good condition throughout the disease. He must take great care of his skin, bathing frequently and paying special attention to regions where mucous patches are apt to develop. He must be careful in his diet. He must not kiss any one on the lips; must sleep alone; must never use a common towel, drinking cup, or other utensil likely to spread contagion. Treatment of the First Stage. — Unless the diagnosis of chancre is positive, I believe it is improper to administer constitutional treat- ment until the appearance of secondary symptoms renders the exist- ence of syphilis certain. The reason for this is that, if the sore is not a chancre, no secondary symptoms will appear under any circumstances, and if the sore is wrongly suspected of being a chancre, and consti- tutional treatment is administered, the subsequent failure of secondary symptoms to appear may be attributed to the treatment employed, and both physician and patient will still entertain the erroneous opinion that syphilis is present. Hence is apparent the extreme importance of reaching an accurate diagnosis in the first stage of the disease, by careful clinical study and laboratory work. If in any manner the diagnosis of chancre is incontestable, then the patient should be put upon constitutional treatment at once, since there is very little doubt that this will render the subsequent course of the disease less severe. The best way to administer mercury internally is in the form of the protiodide (hydrargyri iodidum flavum) in doses of from 0.008 to 0.016 gram. The tolerance of the patient for this drug must be ascertained, and the dose must be kept just below this point. Usually it is well to combine a tonic, such as iron, with the mercury. Whenever mercury is being taken, the patient should be directed to snap his teeth together occasionally, to ascertain the first occurrence of tenderness of the gums; the dose is then reduced slightly. Should salivation, unfortunately, occur, the drug must be stopped at once, and cleansing mouth washes used. Locally, little need be done for the chancre, beyond keeping it clean and dusting it occasionally with some inert powder. Cauteriza- tion is not only useless but harmful; and the uselessness of excision with a view of arresting the disease, was pointed out in Chapter III. If the buboes which attend a chancre are painful, they may be covered with ichthyol or belladonna and mercury ointment, and slight pressure may be applied by a firm bandage. Treatment of the Second Stage. — If constitutional treatment has been begun in the first stage, no secondary manifestations may appear; but it will still be necessary to continue treatment since experience has shown that not only may its discontinuance be followed by the SYPHILIS 1059 appearance of secondary lesions, but that the occurrence of tertiary lesions is more certain and their character more severe, while after prolonged and proper treatment during the second stage they usually are mild if they appear at all. A continuation of the internal adminis- tration of mercury is the least distasteful treatment for the patient, and if the protiodide has been given successfully during the first stage it may be continued into the second ; or what is probably better, the bichloride or the biniodide of mercury (hydrargyri iodidum rubrum) may be given in doses of from 0.004 to 0.008 gram, three times daily in pill form. If a tonic seems indicated, a mixture may be made up with the compound tincture of gentian, the compound syrup of sarsaparilla, or the tincture of the chloride of iron. If the patient first comes under treatment when the second stage is fully developed, there is no better method to gain prompt control of the symptoms than by inunctions of mercury; indeed, I much prefer this method of administration in all cases, but patients often object to it as uncleanly. About 4 grams of the Unguentum Hydrargyri is to be rubbed into a non-hairy part of the body once daily. The same part of the body should not be employed again except after an interval of several days: this is accomplished by using in succession the two sides of the thorax, the two flanks, and the epigastrium. The patient should make the inunctions himself; if made by another, gloves should be worn to prevent absorption through the hands. The patient should wear the same underclothing for a week before bathing and removing the excess of mercury. When the symptoms are thoroughly under control (usually within a few weeks) inunctions may be dis- carded if the patient desires, and mercury may be administered by mouth, as above described. Should active symptoms recur, it is best to resume inunctions temporarily. The hypodermic administration of mercury salts has been found pain- ful, dangerous and unreliable. Intramuscular injections are hotly advocated by E. L. Keyes, Jr.; he prefers a mixture of the salicylate of mercury 3 parts, and alboline (or benzinol) 30 parts. From 0.05 to 0.10 gram are injected once or twice weekly into the gluteus maximus. Mercurial fumigations are used by some, but never have been widely adopted. Administration of mercury in some form should be continued at least for two years and a half after the initial lesion. Some follow the intermittent method: give mercury for six months, then stop for a month; then give it for three months, then stop for two months. This includes the first year. During the second year mercury is given for eight months at intervals. Continuous administration is prefer- able; and after cessation at the end of two and a half or three years, the administration of mercury should be resumed if symptoms recur, or if a positive Wassermann reaction develops; and should then be continued at intervals until this reaction remains constantly negative, even after treatment has been stopped for some months. 1060 VENEREAL DISEASES Treatment of the Third Stage. — Here the iodides should be taken, usually in combination with mercury (especially the red iodide, 0.002 to 0.004 gram), which markedly enhances their effectiveness. Potas- sium or sodium iodide may be given in doses beginning with 0.30 to 0.65 gram, thrice daily, and increased to a point just short of iodism. In deep lesions, especially of bone, immense doses are tolerated. Local treatment of external lesions in this stage is an important adjuvant to constitutional treatment, but without the latter is absolutely inefficient. Treatment of Hereditary Syphilis. — If either parent is syphilitic the mother should be treated during pregnancy. This reduces the chance of miscarriage, and favorably influences the course of the dis- ease in the child. Treatment of the mother should be continued throughout lactation for the infant's sake, quite apart from any indication for treatment on her own part. Inunction is the safest and surest method of administering mercury to the baby; half a gram of blue ointment may be spread on the infant's binder, daily, and allowed to work its way into the skin by the baby's movements. For later lesions (bones and joints) iodides also should be given. In most cases tonics are indicated, especially iron and quinine. Treatment of Syphilis by Salvarsan, Arsphenamin, etc. — These are powerful antiseptics, and rapidly kill any syphilitic parasites with which they are brought into direct contact. They have no eliminative action like the iodides, and are useless for lesions to which they cannot be conveyed directly through the blood stream. They are adminis- tered by intravenous injection. The usual dose of salvarsan is 0.6 gm., in 40 c.c. of freshly prepared and sterile physiological salt solu- tion. This mixture is rendered alkaline by adding, drop by drop, 1 c.c. of a 15 per cent, solution of sodium hydrate, constantly agitating the mixture. Then enough salt solution is added to make 300 c.c. Thus each 50 c.c. of the entire mixture contains 0.1 gm. of salvarsan. Though occasional deaths, and a few cases of blindness and serious lesions of the central nervous system have been recorded as following the use of these drugs, and presumably caused by them, no hesitation need be entertained in their employment in any case where a rapid amelioration of symptoms is imperative. That such treatment is absolutely curative in some cases is indicated not alone by the sudden and permanent disappearance of all symptoms, but also by the per- sistently negative Wassermann tests, and in a few instances by the fact that patients have lost their immunity to syphilis and have again acquired the disease. In most cases it is necessary to continue the use of mercury and the iodides after the injection of arsphenamin, even if this has been repeated one or more times, as it may be at intervals of not less than one week. CHANCROID. The Chancroid, or Ulcus Molle (to distinguish it from the syphilitic chancre or ulcus durum), is now generally believed to be caused by CHANCROID 1061 infection with the Bacillus of Ducrey (1889). According to Sovinsky (1904) a pure culture of this bacillus will produce chancroids in man and in animals. The infection is strictly local, and always is acquired by inoculation from a similar sore. Usually it is acquired in coitus, but mediate transmission is possible. The lesion is auto-inoculable; from its first appearance and so long as it remains unhealed, other chancroids may be inoculated from the pus which flows over the surrounding skin. Chancroid occurs oftenest on the genital organs — especially on the prepuce, corona glandis, frenum, and urinary meatus in the male; and in the female on the labia or os uteri. But any part of the body exposed to the contagion may be inoculated. It is not very rare for inoculation to occur through unbroken skin; but usually some minute abrasion or excoriation is already present. Clinical Course and Symptoms.— There is no distinct period of incubation. Usually the next day after exposure the patient feels an itching or tingling at the point of inoculation; a minute papule rapidly forms, and this in another day becomes a vesicle, then a pustule which either ruptures and exposes an ulcer, or becomes scabbed. Thus by the fourth to sixth day the lesion is fully developed. An ulcer which appears later than the tenth day after exposure is not a chan- croid. In about 80 per cent, of cases multiple chancroids are present. These may have been inoculated simultaneously, or may have been inoculated one after the other from the single original lesion. A chancroid appears as a rounded or oval ulcer, apparently punched out of the skin, with sharply defined and undermined margins (Fig. 1014). It varies in size from less than 0.5 cm. to 1.5 cm. in diameter; it is not adherent to the underhung tissues, is surrounded at first by a reddened area of inflammatory reaction, discharges profusely pus which is auto-inoculable, and is covered by an adherent grayish slough. There is a certain amount of inflammatory induration about the base of a chancroid, but it is not sharply limited and does not resemble the parchment -like induration so characteristic of true chancre. Chancroidal Bubo. — In many cases, but not in all, the related lymph nodes become inflamed, and suppuration is very frequent. This complication usually develops within the first two weeks, but occasion- ally not for several weeks after the chancroid has healed. Suppura- tion in the bubo may result from secondary infection of the chancroid with pyogenic microbes (the bubo being then similar to the ordinary bubon (Temblee, p. 299), or may de due to direct absorption through the lymphatics of the Bacillus of Ducrey. Absorption of toxins produced by this bacillus is not a sufficient explanation. It is believed, however, that the Bacillus of Ducrey is self -destroyed by the toxins it produces in the bubo, and this is held to explain the difficulty of obtaining cultures or smears of the organism from the abscess. A chancroidal bubo almost always is unilateral (Fig. 1030), usually on the same side of the body as the chancroid itself. It is distinctly inflammatory in character from the first, and in no way resembles 1062 VENEREAL DISEASES the indolent syphilitic bubo in which many separate lymph nodes are palpable. Phagedenic Ulceration occasionally occurs in chancroid, especially in patients who are in poor constitutional condition from alcoholic or venereal excesses, or who are tuberculous. Serpiginous ulceration also is rare; usually it is seen in the case of inguinal buboes which have been opened without due attention to cleanliness, and have become secondarily infected with the discharges from the original chancroid (Fig. 1032). Other complications are phimosis, para-phimosis, balano posthitis, coexistence of syphilis or of gonorrhea, etc. Fig. 1030. — Left inguinal bubo, one week after development of chancroid on frenum. No bacillus of Ducrey found in pus, and bubo healed promptly after incision. Episcopal Hospital. Diagnosis of Chancroid. — Herpetic eruptions on the genitalia develop almost immediately after coitus, do not form ulcers by the third or fourth day, but disappear spontaneously. They are not auto-inoculable. Yet a chancroid may develop in an herpetic vesicle, and therefore a distinction before the third or fourth day is not always possible. A chancre appears about three weeks after coitus, not within a few days; it is single, unless multiple from the first, whereas chan- croids usually are multiple even if single at first. A chancre is a super- ficial erosion or an ulcer with hard, elevated, sloping edges, not a punched-out ulcer with undermined edges; it presents a peculiar parchment-like induration and is not surrounded by a reddened inflammatory base; it is almost invariably accompanied by double inguinal bubo, which rarely if ever suppurates, while chancroid often has no bubo and if one occurs it is unilateral and almost always sup- purates; a chancre has an innate tendency to heal but is followed by constitutional symptoms of syphilis, while a chancroid has no innate tendency to heal and is never followed by syphilis unless a mixed chancre (p. 1046) is present. One attack of chancroid affords no pro- tection against subsequent attacks. CHANCROID 10G3 Treatment of Chancroid. — Some mild chancroids may heal under ordinary antiseptic dressings. It is possible , however, that such sores are not true chancroids but only herpetic ulcerations infected by pyogenic cocci. In most chancroids the surest and occasionally the only way to secure healing is to destroy the specific microbes by cauterization. For this purpose I have never found anything so efficient as fuming nitric acid. Some surgeons much prefer carbolic acid, or even the actual cautery. If the chancroid is large, or the patient very timid, it may be necessary to administer an anesthetic. But in the average dispensary case (and it is only in the lowest class of such patients that chancroids are seen — it is a disease of filth) no anesthetic is necessary. Cauterization should not be employed unless the diagnosis is certain; it produces induration and makes difficult a distinction from the initial lesion of syphilis. When it is employed, thoroughness is requisite. The best way to apply nitric acid is by means of a stick about the size of a pencil smoothly rounded off at one end. The surrounding healthy skin should be protected from the acid by smearing it with olive oil or vaselin, and the ulcer is dried. The stick is then dipped in the acid, and is vigorously rubbed into the ulcerated surface, overlooking no corner or cranny. This destroys the specific microbes, and when the resulting crusts separate it will be found that a healthy granulating surface is left which will soon heal under ordinary antiseptic dressings or ointments. If healing does not proceed normally, cauterization must be repeated, but this is very seldom necessary if it has been properly done in the first place. Fig. 1031. — Dorsal slit of prepuce to expose chancroids of mucous surface of prepuce. Note inflammatory thickening of prepuce. Episcopal Hospital. If the chancroid is inaccessible on account of phimosis, the foreskin should be slit up the dorsum (Fig. 1031), under procain; then the cut edges and the exposed chancroids are to be cauterized. I have never seen a case where an efficient dorsal slit did not give enough exposure. Treatment of Chancroidal Bubo. — It is useless to attempt to treat the bubo until the infecting focus (chancroid) has been cured, since 1004 VENEREAL DISEASES fresh inoculation will constantly occur through the lymphatics. Prompt treatment of the chancroid itself, as indicated above, fre- quently is sufficient to cause the bubo to disappear, even when suppuration appears to threaten. I do not think it is advisable to open a chancroidal bubo until suppuration is very evident; the longer the pus remains in the abscess, the more apt it is to sterilize itself of the chancroidal virus. Yet spontaneous rupture of the abscess is to be avoided at all hazards, especially if the chancroid itself is unhealed; since then the opened bubo will become infected by the discharges from the chancroid, and Fig. 1032.— Chancroidal ulcer. Age fifty-five years. Duration ten weeks. Bubo developed soon after chancroid of glans, and was allowed to rupture spontaneously; the ulcer then became infected with the chancroidal virus, and showed no tendency to heal. Treated by excision. Episcopal Hospital. will be converted into a chancroidal ulcer (Fig. 1032). When the bubo is to be opened, this should be done with careful antiseptic precautions. Where this precaution has been taken, and where the original chancroid was no longer a source of infection, I have never seen any bubo that did not heal promptly under ordinary antiseptic dressings. If the bubo after it is opened becomes converted into a chancroidal ulcer, as indicated above, it must itself be treated as the original chancroid; or the ulcer may be excised and the resulting wound cauterized. GONORRHEA. Gonorrhea is a local infection of mucous membranes caused by gono- coccus (Neisser, 1879; Bumm, 1887). This is a diplococcus which is a pure parasite, growing best at body temperature and soon perishing when discharged from the body. It is readily killed by heat, and does not survive long in dried secretions. Mucous membranes with cylin- drical-celled epithelium are much more easily infected by the gonococ- cus than are those covered with pavement epithelium. The gonococcus GONORRHEA 1065 is found in the purulent exudate, within the leukocytes, 1 and invades the submucous tissues easily; it spreads through the lymphatics, enters the blood stream, and may produce a general infection (a mild form of pyemia). In the latter circumstances secondary localizations in serous membranes are frequent. One such localization, gonococcic arthritis, has been studied in Chapter XVI ; gonococcic endocarditis is treated by the physician; and gonococcic iritis by the ophthalmologist. Whether or not gonococcic conjunctivitis (gonorrheal ophthalmia) ever occurs by infection through the blood-stream is disputed; cer- tainly in most cases infection occurs by mediate contagion through soiled towels, etc. Gonococcic Urethritis. — Urethral inflammation due to infection by the gonococcus is the commonest venereal disease. In the female the infection localizes itself especially in the vulvovaginal canal, not so much in the urethra. In man the infection, acquired in sexual intercourse, becomes localized in the anterior urethra, especially the fossa naviculars; unless there is phimosis, causing retention of secre- tions, the glans penis and prepuce usually escape infection owing to the character of their epithelial covering. From the anterior urethra the inflammation usually spreads throughout the entire canal, and is especially apt to remain localized, in chronic form, in the deep urethra and prostate. Throughout the urethra the submucous tissues are invaded, and inflammation of the glands of Littre is common; these may be converted into abscesses, which rupture into the urethra or rarely externally. Inflammation of Cowper's glands is more apt to result in external rupture, and is the chief cause of periurethral abscess (p. 1082) and periurethral urinary fistula?. The healing of these patches of inflammation or follicular abscesses may result in the formation of urethral strictures (p. 1074). Symptoms and Clinical Course. — 1. In Acute Gonococcic Urethritis, vulgarly known as the clap, the first symptoms usually appear on the third or fourth day after contagion, and consist in tingling and itching of the urinary meatus. On inspection the lips of the meatus are found swollen, and there is a slight glairy discharge which causes them to adhere between the acts of urination. A scalding sensation in passing water is very frequent. One or two days later a profuse purulent, sometimes blood-stained discharge appears; the ardor wince lessens; painful erections are frequent; and edema of the foreskin may occur with phimosis or paraphimosis (Fig. 1065) and resulting balano-posthitis. Later, during erection, the penis may be bent downward or laterally (chordee) ; this painful symptom is due to the inability of the spongy portion of the penis, which surrounds the inflamed urethra, to become elongated to the same extent as the cavernous bodies. Epididymitis (p. 1108) is another frequent complication. In almost all cases of gonorrhea the inflammation extends within a week or ten days to the 1 Some pathologists hold that unless the diplococci in question are intracellular they cannot be certainly classed as gonococci; legal proof requires the growth of a pure culture. 10(30 VENEREAL DISEASES posterior urethra. This event may pass unnoticed, or may be evi- denced by increasing frequency of micturition, vesical tenesmus, and sometimes by temporary lessening of the discharge. Then as these symptoms abate, the discharge may again increase. Even in severe cases, constitutional symptoms usually are absent. Acute gonococcic urethritis tends to run a self-limited course, almost all symptoms disappearing within six to ten weeks, no matter what treatment is employed, or even if no treatment is employed; but proper treatment usually hastens subsidence of symptoms. In almost all cases, however, subsidence of acute symptoms does not indicate that the disease is cured, but merely that it has become chronic or latent. The gonococci remain localized in the deep urethral crypts, in the prostatic utricle, prostate gland, or seminal vesicles, and after any excess in eating or drinking, after excessive coitus, and sometimes from no ascertainable cause, a urethral discharge containing gonococci will appear, may cause a temporary renewal of acute symptoms, and is capable of conveying contagion to another individual. 2. Chronic Gonococcic Urethritis, known also as the gleet, is a very frequent sequel of acute posterior urethritis. The symptoms are insignificant, the most constant being slight mucous or purulent dis- charge (perhaps only a drop or two) from the meatus, observed when the patient wakens in the morning. After defecation, or during sexual excitement, a similar slight discharge may occur. If a sound is passed into the penile urethra, the chronically inflamed urethral glands often may be detected as small nodules, by running the finger along the under surface of the penis. Sometimes vesical tenesmus is annoying at intervals. There may be frequent erections and nocturnal pollutions, and the seminal discharge sometimes is blood-stained. Diagnosis. — The diagnosis of acute gonorrhea usually may be made clinically, but it is always well to stain a smear of the discharge and examine it for gonococci. If the anterior urethra only is involved, and the patient's urine is collected in two glasses, the second portion will be clear, as the urine first passed will have washed away all the secretions. If, however, the posterior urethra is involved, the second glassful of urine will be cloudy or will contain shreds of mucus, since the pressure of accumulated secretions pent up in the deep urethra can force the vesical sphincter and allow the urethral discharge to mix with the urine in the bladder. In chronic gonorrhea it is indispensable to examine the urethral discharge for gonococci. If no secretion is readily available, the prostate and seminal vesicles should be given gentle massage, as indicated at p. 1069, to force their contents into the urethra. A number of laboratory examinations may be necessary before gonococci can be found. In chronic urethritis the second urine constantly contains shreds. Treatment. 1 — Certain general directions should be given a patient suffering from gonorrhea. He should be warned of the danger of con- 1 The prevention of venereal disease is to be regarded as a scientific and not simply a moral problem. It is self evident that the simplest means of prevention GONORRHEA 1067 tagion, especially of gonorrheal ophthalmia; the possibility of compli- cations, especially epididymitis, should be called to his attention; and he should be instructed as to precautions concerning diet, rest, hygiene, and cleanliness. He should drink plenty of water, and should take no alcoholic liquor at all, unless a confirmed drinker. He should wear a suspensory bandage, and if possible during the acutely inflam- matory stage he should remain in bed with the scrotum elevated. The discharge should not be kept dammed up in the urethra by dressings; but the lips of the meatus should be greased with vaselin and the discharge collected in loosely applied absorbent cotton which is changed frequently. The presence of phimosis may add the com- plication of balano-posthitis, and a dorsal slit of the foreskin may be advisable to secure free drainage, especially if chancroids are thought to coexist. Meatotomy should be done if drainage through the meatus is insufficient. Paraphimosis seldom requires treatment. Fig. 1033. — Urethral syringe. (Watson and Cunningham.) If the patient is seen in the earliest stages of the disease, before profuse discharge has commenced, it may be possible to secure prompt arrest of the disease by what is called abortive treatment. This consists in the use of antiseptic injections into the urethra, the usual substances employed being protargol (2 to 5 per cent.) or argyrol (5 to 10 per cent.) ; silver nitrate, in strength varying from 1 to 2000 up to 4 per cent., is also used. The patient should urinate before taking the injection, which is administered by means of a glass urethral syringe with blunt nozzle (Fig. 1033). Tins is carefully introduced into the meatus, and the lips of the meatus are closed tightly around the nozzle by the fingers of the left hand, as the piston of the syringe is pushed home with the right. From 2 to 5 c.c. of the solution is injected twice, the second injection being held in the urethra for several minutes. These injections are to be used three or four times daily, except in the case of the very (abstention from impure coitus) is the most efficient, but cannot always be enforced upon patients. In the case of enlisted men in the army and navy it has been found advisable to adopt definite rules of venereal prophylaxis since without it the per- centage of infection is verv high. Holcomb and Gather (1912) report the results in the United States Navy, where the following rule was enforced after every known exposure to venereal disease: (1) Wash the penis (head and shank and under frenum) with 1 to 5000 bichloride of mercury solution, using a cotton sponge. (2) Pass the urine; and take urethral injection of 2 per cent, protargol solution and hold it in the urethra until 60 has been counted. (3) Rub 50 per cent, calo- mel ointment well into foreskin, head and shank of penis, especially the frenum. They found that: 1385 exposures treated as above in the first eight hours, gave 19 infections, or 1.37 per cent.; 731 exposures treated as above in eight to twelve hours, gave 25 infections, or 3.4 per cent.; 920 exposures treated as above in twelve to twenty-four hours, gave 46 infections, or 5 per cent. 1068 VENEREAL DISEASES strong silver nitrate solutions, which should be used only once daily and by the surgeon himself, one or two injections often sufficing. In many cases in which this abortive treatment is promptly instituted, the results are excellent; though the urethral discharge may be tem- porarily increased, it soon decreases again, becoming glairy and per- haps blood-stained, and then ceasing entirely, within a week or ten days. In other cases some discharge persists, and further treatment, as in the chronic stage, must be instituted. If the patient is seen first during the inflammatory stage of gonorrhea, it is not advisable to use injections, and they should be discontinued if previously employed. In this stage the patient should remain in bed if possible, with the scrotum well elevated, especially avoiding sexual excitement. The penis should be immersed in hot water several times daily, as the heat not only allays the inflammation but is germicidal to the gonococci. Internally, capsules containing 01. copaibse (0.5 c.c.) and Oleores. cubeb. (0.2 c.c.) may be given, with or without methylene blue (0.125 gram) and sandalwood oil (0.125 c.c). Not until the decline of the inflammation should injections be resumed, and as the discharge loses its purulent character and becomes mucoid, the stronger antiseptics may be abandoned and astringents given by injection, such as zinc or copper sulphate, lead acetate, etc. The following is the formula of the remedy known as "brue:" 1$ — Plumbi acetat., 2 grams; Zinci sulphat., 1 gram; Ext. krameriae fl., 16 c.c; Tinct. opii, 12 c.c; Aquse destillat. q. s. ad 200 c.c Internally such drugs as salol or urotropin are indicated. As the discharge lessens the strength of the astringent injections should be gradually diminished. The treatment of chronic gonococcic urethritis involves discovery, if possible, of the habitat of the remaining germs, and their destruction. For this purpose examination with the endoscope often is advisable. Through this it may be possible to detect superficial ulcerations or erosions of the urethra, the orifices of inflamed urethral glands, etc; or by the use of bulbed sounds the presence of a stricture of large caliber (p. 1076) maybe determined; or with the cystoscope the pros- tatic utricle and orifices of the ejaculatory ducts may be investigated. Chronic prostatitis and seminovesiculitis are frequent complications, and it may be impossible to discover gonococci in a chronic urethral discharge until after massage of these structures, as described below. For lesions of the anterior urethra, it is best to give irrigations three times weekly. The solution (silver nitrate, 1 to 10,000; potassium permanganate, 1 to 10,000; protargol, 1 to 2000) is allowed to enter the urethra from a fountain syringe, by the force of gravity. After the urethra has been well cleansed in this manner, a soft catheter is passed into the bladder, and this is filled with the solution; the catheter is then withdrawn, and the patient allowed to empty his bladder, thus cleansing the entire lower urinary tract (Horwitz). Strong applica- tions are then made to the erosions through the endoscope. If there is much periurethral infiltration, the passage of large-sized sounds GONORRHEA 1069 twice weekly is of benefit. Stimulating ointments may be employed by smearing them over the sound and then gently rubbing the corpus spongiosum while the sound is in place. // lesions persist in the deep urethra it is well to make instillations of silver nitrate (0.5 per cent.) or protargol (0.25 to 2 per cent.) through a deep urethral syringe (Fig. 1034) after massage of the prostate, which is accomplished by introducing the index finger into the rectum, and gently stroking the vesicles and each lobe of the prostate downward toward the ejaculatory ducts. Too violent massage may set up a prostatitis or even a proctitis. It is usual to have the patient stand in a stooping posture for massage of the prostate, the surgeon standing behind him; but if the surgeon has a little practice and not too short Fig. 1034. — Keyes' deep urethral syringe. (Watson and Cunningham.) a finger, it is more convenient to have the patient lying supine. Any urethral discharge which follows massage of the prostate should be examined for gonococci, and if these are found persistently absent at a number of examinations made at intervals after stopping all treatment, the urethritis may be considered cured. Sometimes pro- longed treatment causes a non-gonococcic urethritis, and cessation of local treatment and attention to the patient's general health may be successful in stopping a discharge which seems otherwise incurable. Microscopical examination of the discharge in such cases may show the presence of staphylococci, streptococci, or colon bacilli. The use of autogenous vaccines may be of use in such cases, as well as in chronic gonococcic urethritis. CHAPTER XXVII. SURGERY OF THE URETHRA AND PROSTATE. SURGERY OF THE URETHRA. Bougies and Sounds (Fig. 1035) may be regarded as solid catheters (p. 1013). They are used in the diagnosis and treatment of urethral strictures. The bougie (so-called because originally made of wax) is flexible; the old French bougie a boule is inferior to the modern bul- bous-tipped French bougies made of webbing, like English catheters. The best have a core of lead which gives them sufficient weight to facilitate their introduction. Filiform bougies are made of whalebone, and should be perfectly flexible and highly polished. Sounds are metallic instruments; they should be highly polished or nickel-plated, of sufficient weight to sink into the urethra easily, and provided with Fig. 1035. — Urethral sounds and bougies: 1. Steel sound. 2. Bulbed sound. 3. Bougie a boule. 4. Olive tipped bougie, made of webbing, with a leaden core. 5, 6, 7, Filiform bougies, made of whalebone. a suitable handle, to prevent slipping. They are introduced in the same way as metal catheters (Figs. 1036 and 1037). Bulbed sounds cor- respond to the bougies a boule; they are of use in determining the extent and site of a stricture, by the sensation they impart to the examiner's hand when the bulb catches on the anterior or posterior face of the stricture. Retention of Urine. — Retention of urine is a condition which occurs so often in affections of the urethra, that it is convenient to enumerate its varieties at the outset. First there is (1) Acute Complete Retention: the patient, previously able to evacuate his urine wholly or in part, suddenly becomes unable to do so; all the urine is retained, and the ( 1070 ) FOREIGN BODIES 1071 Fig. 103G. — Passing a sound from the pa- tient's right side. Observe how the sound is held in the fingers, and note that no force can be used. Episcopal Hospital. condition is acute. (2) Acute Incomplete Retention occurs when the patient is just able to void a few drops, with much effort; the condi- tion is acute, but a little of the urine is passed. (3) Chronic Complete Retention, where the patient depends absolutely upon the catheter for emptying his bladder, though the condition is chronic, and the catheter has been required for months or years. (4) Chronic Incom- plete Retention without disten- tion of the bladder, where a certain portion of urine is constantly retained, but where the major portion is evacuated voluntarily; a chronic condi- tion, where, without the blad- der being over-filled, residual urine exists. Finally there is (5) Chronic Incomplete Reten- tion with distention of the blad- der, where so much of the urine is retained that the bladder has reached the limit of its capacity, and overflow from retention results. We may tabulate these conditions as follows: I. Acute Retention. 1. Acute Complete Re- tention. 2. Acute Incomplete Re- tention. Chronic Retention. 3. Chronic Complete Re- tention. 4. Chronic Incomplete Retention without dis- tention of the bladder. 5. Chronic Incomplete Retention with disten- tion of the bladder. The first of these conditions occurs oftenest as a complica- tion of stricture of the urethra; the second in cases of urethritis; the third, fourth, and fifth are seldom seen except in cases of enlargement of the prostate. Foreign Bodies. — Foreign bodies may enter the urethra from the bladder (calculi, etc.) or from without. The end of a catheter or filiform bougie occasionally breaks off; and sometimes a patient passes implements into the urethra to relieve some fancied obstruction, and the instrument breaks off or escapes from his fingers. There is danger II. Fig. 1037. — The urethral sound fully intro- duced. Note the angle it makes with the horizon. Episcopal Hospital. 1072 SURGERY OF THE URETHRA AND PROSTATE of such bodies escaping into the bladder, and they may seriously traumatize the urethra. It is very important not to introduce a sound incautiously for the purposes of diagnosis, since it is apt to push the foreign body up into the bladder, or to embed it in the ure- thral wall. It is better to make the diagnosis by means of the a>ray, whenever this is available. It is rare for foreign bodies to produce complete urinary obstruction, but they scarcely ever can be washed out by the stream of urine. Fortunately sufficient time usually is available to send the patient to a w r ell equipped hospital. There it may be possible to extract the foreign body by the aid of the endo- scope, or even by alligator forceps (Fig. 1038) introduced closed and opened when they are felt to come into contact with the foreign body. Occasionally a pencil or similar article may be worked out step by step by forcing the penis down over it as it is fixed with the fingers through the perineum or the penile urethra. A hat pin, introduced into the urethra head first may be extracted by protruding its point through the body of the penis, re- versing it, and pushing it out head first. If all other methods fail ex- ternal urethrotomy (p. 1078) should be done; an incision in the penile urethra should be sutured, but one in the perineum may be left to heal by granulation. If the foreign body has escaped into the blad- der it may be removed by suprapubic cystotomy, if extraction with the operating cystoscope is impossible. Fig. 1038. — Urethral forceps. Fig. 1039. — Extravasation of urine beneath Colles's fascia; duration, twenty-four hours; from spontaneous perforation of urethra behind a stricture. No injury had occurred and no instruments had been passed. Episcopal Hospital. Rupture of the Urethra usually is the result of direct injury (falls, kicks, etc.) to the perineum; occasionally it occurs as a complication of fracture of the pelvis or from pressure of urine behind a tight stricture, in which situation perforation of the urethra from ulceration may occur. The lesion almost always is in the subpubic urethra, at the bulbomembranous juncture. The diagnosis RUPTURE OF THE URETHRA 1073 depends on the history of traumatism, and the passage of bloody urine or on the symptom of "bloody anuria" (p. 1026). In most cases urinary extravasation occurs after twenty-four hours. If the rupture occurs anterior to the superficial layer of the triangular ligament, the urine passes first into the perineum and being confined by Colles's fascia rapidly forces its way through the cellular tissues of the scrotum on to the abdominal walls, through the abdomino-scrotal opening (Fig. 1039). If rupture occurs above the triangular ligament, the symptoms resemble those of extraperitoneal rupture of the bladder, but the history of injury to the perineum, with resulting ecchymosis, etc., points to the urethra as the seat of the lesion. If urinary extra- vasation is unrelieved, extensive sloughing will occur, especially if the urine was previously unhealthy ; constitutional symptoms of sepsis are frequent, and death may ensue from this cause. Treatment. — Treatment consists first in guarded attempts to enter the bladder with a soft catheter. If this succeeds, as it may very soon after the injury, before urinary extravasation has occurred, the catheter should be left in the bladder for four or five days, while urinary antiseptics are administered. If extravasation of urine is already present when the patient is seen, the urethra should be opened, immediately, in the perineum, with the aid of a sound passed down to the site of rupture. Numerous incisions in the perineum, scrotum, and skin of the abdominal wall may be necessary to secure free drain- age and avert threatening sepsis. Usually there need be no fear that the patient will be unable to empty the bladder through the wound, and it is not necessary to drain the bladder by a catheter; but if the vesical end of the urethra is readily found this may be done. In a case of rupture of the urethra above the triangular ligament Demar- quay's operation (1858) may be employed; this consists in dissect- ing down to the site of rupture through a curved incision (convexity forward) as in the modern operation of perineal prostatectomy (p. 1096). Some surgeons advocate suture of the ruptured urethra; but in all the cases which have come under my care, the local condi- tion precluded such a step. When the perineal wound begins to granulate, it is usually possible to pass a sound through the penis into the bladder, and if this is done once or twice weekly, the perineal wound soon closes. The danger of subsequent stricture formation, however, is very great. Traumatic stricture forms rapidly after injury and the palliative methods and even the usual operations employed for stricture the result of gonorrhea seldom prevent recurrence, owing to the dense nature of the scar and its extent. Unless the patient can have bougies passed at least once monthly for many years (perhaps throughout life), it is better to excise the strictured area and to unite the healthy urethra above and below by sutures, over a catheter which is left in place for several days or until the urethral wound is healed. I employed this method with most happy results in the case of the boy shown in Fig. 1044. Though only ten years old, his urethra easily admitted a No. 18 Fr. sound one year after operation. 68 1071 SURGERY OF THE URETHRA AND PROSTATE Non-gonococcic Urethritis occasionally occurs, the chief causes being instrumentation, stricture, ingestion of irritating drugs, excessive coitus, or masturbation, etc. If the condition is chronic it probably is kept up by a stricture or a focus of inflammation in the prostatic urethra or its adnexa. The acute form usually subsides so soon as the cause is removed. The treatment of the chronic form is the same as for chronic gonococcic urethritis (p. 1068). Prolapse of the Urethra is rare. It occurs oftenest in female children, from straining efforts (coughing, defecation, micturition). The protrusion, which seldom involves more than the mucosa, may be excised, and bleeding checked by pressure, cauterization, or suture. Stricture of the Urethra. — Several varieties of urethral stricture are recognized : I. Inorganic Strictures. — 1. Inflammatory Stricture, or obstruction of the urethra from acute inflammation. This is the form which occa- sionally occurs during the acute stage of gonorrhea, resulting in acute complete retention of urine; it also occurs from pressure outside the urethra, from an inflamed prostate, periurethral abscess, etc. It is to be treated by palliative measures such as indicated under spasmodic stricture, or incision and drainage through the perineum of prostatic or periurethral abscesses. Introduction of a catheter should be avoided whenever possible; if retention persists, the bladder may be aspirated above the pubis. (2) Spasmodic Stricture: This is no stricture at all, merely a spasm of the urethra, though it occurs most often in patients with organic stricture. It occurs also as the result of psychic influence (as where an individual cannot urinate in the presence of others), in cases of inflamed hemorrhoids or of semino- vesiculitis, after surgical operations, in the course of the infectious fevers, etc. Spasm usually occurs in the membranous urethra, from the contraction of the deep transversus perinei muscle. If retention is complete, and of eight hours or more duration, a catheter should be used; if incomplete or recent palliative measures may be tried for some hours. Among the most effective is a hot bath, the patient attempting to urinate in the bath ; enemas of laudanum, followed by a purge, may also be used. Recurrence of spasm must be prevented by attending to the condition of the urine, and relieving any local cause, especially organic stricture. II. Organic Strictures. — (1) Traumatic Stricture has been described at p. 1073. (2) Congenital Stricture is less rare than usually supposed, but may produce no symptoms until the age of puberty or later. (3) Stricture from Cicatrices folloiving Urethritis, almost always the result of gonorrhea, is the type most often seen, and what is said in the following pages refers especially to it. Strictures result from submucous round-celled infiltration, which passes through the usual stages of organization, cicatrization, and contraction. As gonococcic urethritis is most frequent about the age of twenty years, strictures are seen oftenest in early adult life; they STRICTURE OF THE URETHRA 1075 seldom present symptoms for the first time after forty years of age. They may occur in any portion of the urethra, but are most frequent in the subpubic portion, especially the bulbous urethra, but are not rare in the penile urethra. Stricture of the membranous and prostatic urethra is rare. Strictures usually are multiple (Fig. 1040), and may be of various forms (Fig. 1041). Their caliber varies from that which is impassable to the finest instrument, up to those which barely con- strict the urethral lumen and which may be detected only by the aid of a bulbed sound. The orifice of the stricture may be central or eccentric. Fig. 1040. — Strictures of the urethra. A probe has been passed through a false passage in the bulbous urethra. (After Albarran.) Fig. 1041. — Diagram of different forms of stricture: a, annular; b, linear; and c, tortuous stricture. Symptoms and Clinical Course of Stricture.— The early symptoms of stricture usually are insignificant, but occasionally acute retention of urine is the first indication of trouble. In most cases the patient complains first of slight gleety discharge, with pain in the deep urethra during and following urination; he finds the calls to urinate more frequent, the stream is diminished in size, and a longer time is required to empty the bladder. Attacks of acute retention are frequent, from inflammatory changes or plugging of the stricture by a pellet of mucus or pus. Retention with overflow is another frequent sequel. From straining in micturition, hemorrhoids or prolapse of the rectum may develop. The urethra immediately behind the stricture becomes dilated, and as backward pressure continues, changes occur in the L076 SURGERY OF THE URETHRA AND PROSTATE bladder. The bladder at first may hypertrophy, but in most cases a r<> i id it ion of atrophy (fibroid degeneration) sets in eventually, so that the bladder loses its power of contraction. This is predisposed to by cystitis, which is prone to develop (owing to stagnation of urine) as the result of instrumentation or as a descending infection from the kidney. Pressure diverticula may form in the bladder, and eventually dilatation of the ureters and renal pelves may occur, with hydrone- phrosis, pyonephrosis, or surgical kidneys. Other complications and sequels are frequent. The most important (Retention of Urine, Ure- thral Fever, Extravasation of Urine, Periurethral Abscess, Urinary Fistulse) are discussed in the following pages. Diagnosis of Stricture. — While the existence of stricture usually may be surmised from its symptoms enumerated above, or from its various sequels, verification of the diagnosis depends on instrumental examination of the urethra. The caliber of the normal urethra corre- sponds with the circumference of the penis: a circumference of 80 mm. implies a urethral caliber of 30 mm. of the French scale (p. 1014); 85 mm. corresponds to 32 Fr.; 90 mm. corresponds to 34 Fr., etc. The a re rage urethra admits a No. 32 Fr. sound, but the meatus usually is smaller than the urethra within. Strictures of large caliber are best detected by passage of a bulbed sound. Such strictures require treat- ment only if productive of definite symptoms. Strictures of medium or small caliber will cause the arrest of an ordinary steel sound of average size. It is always well to commence the examination by passing a full sized sound, and then to try smaller sizes in turn until one is passed into the bladder. It is not safe to use an inflexible sound smaller than No. 10 Fr., for fear of making a false passage. Treatment of Stricture. — There are two main classes of strictures, the treatment of which it is convenient to consider separately: these are permeable and impermeable strictures. By the former is meant a stricture through which an instrument can be passed; and by the latter one through which no instrument of any size or form whatever can be passed. This distinction is relative, since a stricture which a surgeon finds impermeable on one occasion may not be so on another occasion nor for another surgeon. I. Treatment of Permeable Stricture.— 1 . The best treatment is that by gradual dilatation. A sound just large enough to be grasped by the stricture is passed about twice weekly, and the size of the sounds passed is very gradually increased. Thus if No. 14 Fr. has been passed with a little difficulty on the first occasion, it is well to begin the second seance with No. 12 Fr., and not to push dilatation beyond No. 16 Fr. At the third sitting Nos. 14, 16, and 18 Fr., probably can be passed. It is then desirable in the average case to continue dilatation until a number on the scale is reached which is two or three points higher than that which is considered normal for that patient. But in the case of multiple or fibrous strictures, or in a patient who is old or feeble, or prone to urinary fever or other complication, it is best to be satisfied with keeping a canal patulous for No. 22 or 24 Fr. If TREATMENT OF STRICTURE OF THE URETHRA 1077 over-dilatation can be secured gradually, and if it can be maintained for several months, it is probable that no further trouble will be experi- enced. Absorption of the cicatricial tissue will have occurred, and unless a new stricture forms the patient may consider himself cured. In cases where it is impossible to push the dilatation up to normal and beyond, it is necessary for the patient to have a sound passed once monthly for the rest of his life. Neglect of this precaution will allow the stricture to recontract, and relief of the patient will then be more difficult. Fig. 1042. — Kollman's urethral dilator. (Watson and Cunningham.) 2. Treatment by rapid dilatation or rupture of the stricture is, I believe, best adapted to strictures of large caliber, such as sometimes cause persistence of a chronic urethritis; though even in these cases gradual dilatation often is sufficient. Rupture is accomplished by various forms of instruments which are first passed through the strictures and then expanded by some mechanical device (Fig. 1042). 3. Incision of the Stricture (Urethrotomy) is the best treatment for strictures too dense and fibrous to be treated successfully by gradual dilatation; or for those which tend persistently to recur, even after a long course of such treatment. But it should never be forgotten that it may be more judicious to persist in conservative treatment in the old and feeble, even if it be not curative, than to resort even to a trivial operation which may suddenly snuff out life. Fig. 1043. — 1. Civiale's urethrotome; a model which will cut the stricture from behind forward, or from before backward. 2. Syme's grooved staff for external perineal urethrot- omy. 3. Tunnelled catheter, threaded over a filiform bougie. (a) Internal Urethrotomy (Amussat, 1824) is especially applicable to strictures of the penile urethra: it is accomplished by introducing an instrument through the stricture and then withdrawing from the instrument a concealed blade (Fig. 1043, 1), which cuts the stricture on the roof of the canal from behind forward (Civiale's urethrotome, 107S SURGERY OF THE URETHRA AND PROSTATE L849)j or from before backward (Maisonneuve's urethrotome, 1855). The operation may he done under local anesthesia (10 per cent. eucain), but a general anesthetic is preferable. After either of these operations it is best to retain an inlying catheter for three or four days, the penis being bandaged to it if there is much hemorrhage (which is unusual); and after the catheter is removed, dilatation must be maintained by passage of sounds for several weeks, or longer if a tendency to recontraction is evident. (b) External Urethrotomy. — This operation is safer than internal urethrotomy for strictures in the deep urethra. It was popularized by Syme in 1843, and is commonly known as External Perineal Ure- throtomy with a Guide, or Sy??te , s operation: A guide is passed through the stricture from the meatus, and the bulbo-membranous urethra is then opened from the perineum upon the guide behind the stricture, and the stricture is divided from behind forward. Syme used a guide provided with a groove upon its convexity and a shoulder which rested against the face of the stricture (Fig. 1043, 2). After division the stricture should be fully dilated by passage of steel sounds and the bladder drained by a perineal tube for several days, when the passage of sounds may be commenced, and the perineal wound allowed to heal by granulation. II. Treatment of Impermeable Stricture. — Very few strictures are really impermeable; indeed, it has been asserted by several eminent authorities that any stricture which would permit urine to escape from above would also admit an instrument from below. But as their experience increased they were forced to acknowledge that they themselves had encountered strictures which remained impermeable to their best efforts. If the patient is able to pass his urine, there is plenty of time available for attempts to render the stricture permeable. Hence it is convenient to discuss the treatment of impermeable stricture according as it is not or is accompanied by retention of urine. 1. Impermeable Stricture unthoul Retention of Urine. — The first efforts of the surgeon should be devoted to rendering the stricture permeable. It is not safe to let a patient with impermeable stricture continue as he is; the risks of retention, urinary extravasation, etc., are too imminent. After trying the usual steel sounds, and finding it impossible to pass the stricture with any, down to No. 10 Fr. (no smaller inflexible instrument is safe) the surgeon should next try fine flexible bougies (those filled with a leaden core are best) which on account of their very flexibility may be enabled to pass through a tortuous stricture which is absolutely impermeable to a rigid instrument. 1 If such an instrument cannot be passed (even a No. 1 Fr. may be used without fear of damaging the urethra), filiform whalebone bougies should be employed. These should be sterilized in the same way as the flexible bougies and catheters, in a cold 5 per cent, formalin solution (p. 1 As noted at p. 1014, passage of a bougie usually is easier after distending the urethra with the lubricant by means of a syringe. TREATMENT OF IMPERMEABLE STRICTURE OF URETHRA 1079 1014). The filiform bougie is passed down to the face of the stricture, where it may be arrested, or may enter a false passage produced by previous instrumentation. In any event it should be left in place, and other filiforms should be passed down beside it, until all the false passages are filled and the face of the stricture is covered by the points of the bougies. Then as the last filiform is introduced it may slide at once through the stricture and into the bladder, the orifice of the stricture being the only point unoccupied. 1 Usually not more than six filiforms are introduced at once; by withdrawing each in turn about 2 cm. and again passing it down against the face of the stricture with a slight twist, the surgeon seeks to insinuate one of the filiforms into the orifice of the stricture. After working a while on one side of the patient's bed, it sometimes is possible to accomplish more by passing to the other side and commencing all over again, as the surgeon insensibly works the filiforms toward himself on whichever side he stands (J. H. Brinton). If a filiform finally is passed through the stricture, it should be allowed io remain in place. This applies to any instrument which has been passed through a stricture with great diffi- culty. The continuous dilatation of the stricture thus produced will render easier the later passage of a larger instrument (Fig. 1044). "When a filiform has been successfully passed through a stricture, all the other filiforms may be withdrawn; and a tunnelled catheter (popularized by Gouley about 1873) may be passed over the filiform into the bladder, and retained in place of the filiform; this acts as rapid dilatation or rupture of the stricture. Some filiforms are provided with a cap and screw thread at their outer ends, so that a larger bougie may be screwed on and pushed through the stricture as the filiform is pushed into the bladder where it curls up. In case a stricture remains impermeable in spite of repeated efforts to pass an instrument, resort must be had to operation. As in this operation no guide can be passed through the stricture (as is a pre- requisite for performing Syme's operation), it is known as External Perineal' 2 Urethrotomy without a Guide, or Perineal Section. 3 Here a sound is passed down to the face of the stricture, and the urethra is opened on this as a guide, in front of the stricture, by an incision through the perineum. The margins of the opened urethra are then caught in guy sutures and pulled taut, while the surgeon endeavors to pass a probe or filiform bougie through the stricture whose face is thus exposed to view (Arnott, 1822). By forcing a few drops of urine out of the bladder, the orifice of the stricture may become visible. If a probe can be passed through the stricture, the operation is com- 1 If an endoscope is available, it may be possible to pass a filiform through the stricture under control of direct vision. 2 External urethrotomy scarcely ever is necessary for strictures of the penile urethra because these very rarely are impermeable; but it may be employed if requisite, the bladder being drained by an inlying catheter, and the incision in the under surface of the penis being allowed to heal by granulation. 3 Or the "old operation," the "London operation" (as distinguished from the Edinburgh operation, or Syme's). 1080 SURGERY OF THE URETHRA AND PROSTATE pleted as in Syme's method, by dividing the stricture on the guide. But if the stricture cannot be entered, the surgeon proceeds to com- plete the perineal section, dissecting cautiously backward, strictly in the median line, until he has divided the stricture and opened the dilated urethra behind it. This is the part of the operation which gives it the name of perineal section. 1 It is an operation which may prove long and difficult, but with a good light and steady hand it is not dangerous. An alternative method is to open the bladder above the pubis, introduce a sound into the vesical orifice of the urethra and make it protrude in the perineum behind the stricture; the urethra is then opened on this guide, through the perineum, and the stricture is cut from behind forward. This method of "retrograde catheteriza- tion," I regard as an unnecessary complication; though it may shorten the operation, it does not lessen its mortality or improve its results, Fig. 1044. — Acute complete retention of urine from traumatic stricture of urethra. Filiform bougie tied in the urethra. Age nine years, injury six weeks previously. Bladder drained itself alongside filiform in forty-eight hours. Treated by excision of stricture (See p. 1073.) Episcopal Hospital. rather the reverse. It is also possible to open the urethra at the apex of the prostate (behind the stricture) by open dissection of the perineum (Guthrie, 1834; Demarquay, 1858) and then to divide the stricture from behind forward; or to perform Cock's operation (p. 1081) and com- plete it as did John Hunter (1788) and Guthrie (1834) by division of the stricture from behind forward. But the best operation in impermeable stricture without retention of urine, is the perineal section, as systematized by Arnott and Jameson. After the stricture has been cut (by whatever method) it should be fully dilated, and the bladder drained for a few days through the perineum. 2. Impermeable Stricture with Retention of Urine.— Here there is no time for long delay. There is danger of urinary extravasation, rupture of the bladder, etc., and uremia generally impends from 1 This method, according to Wiseman, was first employed in 1652 by Molins; according to Guthrie it was adopted by Sir Astley Cooper in 1793. The operation was systematized by Jameson, of Baltimore, in 1824. URETHRAL OR URINARY FEVER 1081 renal complications. Not more than thirty minutes should be spent in attempts to pass an instrument through the stricture; if a filiform can be passed, the bladder will drain itself alongside the bougie within twenty-four to forty-eight hours (Fig. 1044) and immediate operation is unnecessary. If no instrument can be passed, and if the bladder is much distended, temporary relief may be secured by tapping it suprapubically; and occasionally after the bladder is emptied the stricture becomes permeable. In many cases, however, the bladder is thickened and contracted from cystitis, and is not accessible above the pubis; and even if it is possible to aspirate it in this position, more permanent drainage is required than can be secured in this way. Hence relief of retention is best accomplished by Tapping the Urethra at the Apex of the Prostate, known as Cock's operation. 1 The surgeon intro- duces his gloved left forefinger into the rectum and places it upon the apex of the prostate. Then he cuts steadily but boldly through the median line of the perineum toward his finger as a guide; when the knife is felt to approach the finger, it is made to cut obliquely, opening the dilated urethra at the apex of the prostate, behind the stricture. The knife is then withdrawn, and a grooved director takes its place, the left forefinger being kept in the rectum to serve as a guide until the director is in the bladder. The finger is then withdrawn from the rectum, and the glove removed. The left hand then holds the grooved director while the right hand passes a catheter along it into the bladder, where it is retained for several days. After this lapse of time the stric- ture usually becomes permeable. The main object of the operation, as I recommend it, is to relieve acute complete urinary retention in cases of impermeable stricture. When the patient has been put out of jeop- ardy by this means, other suitable measures may be adopted to cure the stricture. In many cases it is feasible to follow Hunter's and Guth- rie's advice, and complete the primary operation by division of the stricture from behind forward. In other cases the patient is in such desperate condition when first seen that any prolongation of the operation is injudicious. Cock's operation has often been described as "dramatic in its simplicity," and it is its extreme simplicity and the rapidity with which it may be done that commend it. Urethral or Urinary Fever is a form of sepsis due to absorption of bacteria or their products from erosions or abrasions of the urethra. In some patients it is a frequent sequel to the passage of a sound or catheter. Symptoms usually do not appear until after the first act of urination, subsequent to the instrumentation. In most cases there is only a feeling of chilliness, with anorexia or nausea, and some eleva- tion of temperature; but there may be a frank chill. In rare cases true pyemic symptoms develop, with acute monarticular or polyarticular effusion. 1 This is a variety of the old bouttonniere operation, revived in 1856 by Mr. Cock, of Guy's Hospital, as a treatment for impermeable stricture complicated by urinary fistulce, and popularized by him in 1866; he found that when the urine was diverted from the strictured urethra through the perineum, the fistuke tended to heal spontaneously, and the stricture usually became permeable. 1 1 iv > SURGERY OF THE URETHRA AND PROSTATE Treatment. — Treatment consists in the internal use of urinary anti- septics for some time before urethral instrumentation, and the admin- istration of a full dose of quinine and opium as soon as the instrumen- tation is completed. In case of severe and recurrent attacks, it may be desirable to drain the bladder by the perineum, until the urethra becomes healthier. Extravasation of Urine lias been referred to (p. 1073) as a complica- tion of rupture of the urethra, and its clinical features were pointed out in that place. It occurs not infrequently, also, in cases of urethral stricture, either spontaneously, or as the result of false passages made •by careless instrumentation. That false passages are not more often accompanied by urinary extravasation is no doubt attributable to the fact that the false passages have their orifices directed away from the bladder. Extravasation of urine occurs sometimes in cases where no stricture exists. One of the worst cases I ever saw was in an old man of seventy-three years, in whom no urethral obstruction existed, and in whom no instruments had been passed. In such cases it is probable that perforation of the urethra occurs as the result of unrec- ognized ulceration or the rupture of a peri-urethral abscess. Treat- ment, as already advised, consists in perineal urethrotomy, and free incisions wherever required to drain the extravasated urine or remove sloughs. Peri-urethral Abscess. — Peri-urethral abscess was mentioned at p. 1005 as a complication of gonococcic urethritis. Usually one or both Cowper's glands are involved, and a tender swelling appears to one side or other of the median raphe of the scrotum at its junction with the perineum (Fig. 1045). The condition is distinguished from perianal or ischio-rectal abscess by its less acute symptoms, the history of urethral disease, and the location of the swelling in the perineum rather than close to the anus. Treatment. — Treatment consists in incising the abscess as soon as it is recognized, in the endeavor to prevent its rupture into the urethra, as^ this latter result almost invariably entails the sub- sequent formation of [alairinary fistula in the perineum. Urinary Fistulse. — Urinary fistulse usually are the remote result of gonococcic urethritis, or of neglected cases of extravasation of urine. Usually the fistula? occur in the perineum, but they may be located in the scrotum, in the penis (floor of the urethra), in the adductor region of the thighs, or in the buttocks. In almost all cases the com- Fig. 1045. — Peri-urethral abscess, on the patient's right. Episcopal Hospital. SURGERY OF THE PROSTATE 1083 munication with the urethra is on the vesical side of a stricture, and proper treatment of the stricture often allows the fistula? to close. In cases where no stricture exists, however, and especially where the fistula is indurated and lined with mucous membrane, it is necessary to do a formal operation. The use of an inlying catheter, and cauteriza- tion of the fistulous orifices seldom is efficient. The urethra should be drained behind the internal orifices of the fistulse by Cock's or by Syme's technique, according as there is or is not an impermeable stricture; a stricture if present should be cut; and the fistulous tracts should be excised, and if possible closed by suture. Perineal drainage of the bladder may be dispensed with after a week and full sized sounds should be passed regularly until the fistulse have healed. SURGERY OF THE PROSTATE. Acute Prostatitis and Abscess of the Prostate. — Usually this is a complication of posterior urethritis (gonococcic), involvement occur- ring by direct extension. In rare cases acute prostatitis may result from the trauma of frequent or careless instrumentation; and occa- sionally prostatic abscess occurs as a metastatic infection in the course of the exanthemas, typhoid fever, pneumonia, etc. Symptoms. — The symptoms are both general and local. General symptoms (high fever, typhoid state, muttering delirium) if severe, may completely mask the local condition, which causes intense burning pain in the rectum, with rectal tenesmus and usually reten- tion of urine. Examination by a finger in the rectum (extremely painful) detects the enlarged tender prostate. One or both lobes may be involved. Only if an abscess is very near the surface can a soft area or fluctuation be detected by rectal palpation. Treatment. — Treatment should be palliative at first. A brisk purge should be given, and the urine rendered alkaline (Watson). Some relief may be secured from hot rectal irrigations and sitz baths. Urinary antiseptics should be administered, and if there is urinary retention it is better to allow a soft catheter to remain constantly in the bladder than to pass it frequently. Operation should be done after twenty-four or forty-eight hours unless relief is obtained sooner; but if suppuration is suspected operation should be immediate. Only if the abscess is manifestly pointing in the rectum should it be opened by this route; in such cases a drainage tube should be passed within the sphincter ani, but need not enter the prostate. Whenever possible it is better to expose the prostate as in perineal prostatectomy, incis- ing one or both lobes and draining the retroprostatic space by tube or gauze. Even if pus is not found, relief is prompt and lasting. During convalescence it is well to resort to regular prostatic massage. Chronic Prostatitis — Chronic prostatitis is a still more frequent complication of posterior urethritis than is the acute form of the dis- ease. Usually it is gonococcic in origin, but as a rule secondary infec- tion has occurred, and only the pyogenic cocci or the colon bacillus KIM SURGERY OF THE URETHRA AND PROSTATE can he found. It is insidious in onset, and patients may not come under treatment until many years after the causative urethritis has ceased to cause annoyance. Symptoms. — The main local symptom is a chronic, gleety, urethral discharge. General neurasthenic symptoms are frequent, and referred pain may be felt in the back, thighs, buttocks, groins, etc. The diag- nosis is confirmed by examination of the rather abundant secretion obtained by massage of the prostate (p. 1069). Soon after the primary lesion gonococci or other bacteria are found; but at later periods the secretion is composed almost entirely of pus cells, and even these may not be found until after massage has been employed for the third or fourth time. Treatment. — The best treatment is regular prostatic massage, about three times weekly, followed by urethral and vesical irrigations, and occasionally by instillation of 5 per cent, silver nitrate or the application of stimulating ointments to the deep urethra. The use of the Kollman urethral dilator (Fig. 1042, p. 1077) may also prove of value. Fig. 1046. — Diagram of a sagittal sec- tion through the prostatic urethra: 1. Sphincter of bladder (internal) , posterior segment. 2. Pre-spermatic portion of prostate. 3. Ejaculatory ducts. 4. Retro-spermatic portion of prostate. 5. Urethra. 6. Vesical orifice of urethra. 7. Internal sphincter of bladder, anterior segment. 8. Suburethral or paraureth- ral glands (group of verumontanum) . 9. External sphincter of the bladder. (After Cuneo.) Fig. 1047. — Diagram of a sagittal section of the prostatic urethra, in a case of "en- largement of the prostate:" 1. Enlarge- ment (adenoma) of the suburethral glands (Fig. 1046, 8). 2. Internal sphincter of the bladder, posterior segment. 3. Retro- spermatic portion of the prostate. 4. Ejaculatory ducts. 5. Pre-spermatic por- tion of prostate. 6. Lateral lobes of tumor (adenoma of suburethral glands). 7 External sphincter of bladder. 8. In- ternal sphincter of bladder, anterior segment. 9. Neck of bladder. 10. Bladder. (After Cuneo.) Enlargement of the Prostate — This often is spoken of as hypertrophy of the prostate, but in a pathological sense there is no true hyper- trophy, and I prefer to retain the term enlargement simply because ENLARGEMENT OF THE PROSTATE 1085 the actual pathological process at work in these cases is still in dispute, and because it is the mechanical effect of the enlargement of the gland (urinary obstruction) which makes the condition important surgically. The modern hypothesis, put forward by Motz and Pere- arnau in 1905, and supported by researches of E. Marquis (1910) and Cuneo (1913), is to the effect that so-called enlargement of the prostate is not an affection of the prostate at all, but of the suburethral glands, lying beneath the urethra immediately on the vesical side of the ejaculatory ducts (Fig. 1046). According to this theory, the change is truly neoplastic (adenomyoma), and the tumor displaces and con- denses the prostate beneath and around it as a sort of capsule (Figs. 1047 and 1048). Though this is in accord with the facts that in "enlargement of the prostate" the ejaculatory ducts are depressed far toward the rectal aspect of the tumor, and that the lengthening of the urethra occurs solely in that portion between the verumontanum and the bladder (there is no lengthening of the segment of the pros- tatic urethra on the distal side of the verumontanum) and that a few years after "total enucleation of the prostate" by the suprapubic route palpation reveals what is apparently a normal prostate gland, nevertheless this theory has not yet gained very wide acceptance. Clinically there are two seemingly distinct forms of enlargement of the prostate: in one the change in the prostate appears to be adenomatous in character, and the prostate becomes large, soft, or of only moderate hardness; while in the other a sclerosis exists, as if caused by a chronic inflammatory process, and the prostate does not become very large. I believe there is no good evidence that this fibrous type of enlargement is a later stage of the adenomatous form, though this is the teaching of Moullin and some other author- ities on the subject. I believe it is much more probable that the adenomatous form of enlargement is an "adenomatosis''' 1 of the prostate (or rather of the suburethral glands), or even a true adenomyoma; while the small sclerotic prostate is the result of chronic infection, and should be classed entirely apart. Ciechanowski (1900) and others since his time have sought to show that all cases of enlargement of the prostate were originally inflammatory in origin, the main causative factor being the gonococcus. A prostate which is the seat of the adenomatous type of enlarge- ment usually presents on section numerous "prostatic tumors" which compress the surrounding stroma into a capsular envelope, and which Fig. 1048. — Diagram showing in transverse section the relation of the periurethral adenoma to the prostate: 1. Capsule of the prostate. 2. Urethra. 3. Prostate, com- pressed and pushed aside by the new growth. 4. Ejaculatory ducts. 5. Adenomyoma. (After Cuneo.) L086 SURGERY OF THE V RET II R A AND PROSTATE grow in the direction of least resistance (toward the bladder) ; here they often project beneath the mucous membrane posterior to the urethral orifice, and are termed (wrongly) "median lobe" enlargements. In some cases the enlarged prostate presents no such distinct tumor masses in its interior, but exhibits general glandular or fibrous enlargement, or a combination of the two forms. The small, hard, sclerotic prostate usually is densely adherent to surrounding struc- tures, and these evidences of former peri-prostatitis lend support to the view that such prostates have been altered by chronic inflammatory changes. Any prostate weighing more than 23 grams may be considered abnor- mal. From this size they range up to 400 grams or more. The average weight of prostates removed at operation is less than 100 grams. Enlargement occurs chiefly in an anteroposterior direction and, as the apex of the prostate is fixed against the triangular ligament, growth occurs chiefly toward the vesical cavity. The two lateral lobes usually are not equally enlarged, and this accounts for a rather constant deviation of the urethra to one or other side. The two lateral lobes may project into the bladder in such a form that the urethral orifice resembles the os uteri; or as already mentioned, a "prostatic tumor" may force its way through the capsule of the prostate and project beneath the vesical mucous membrane as a nipple-like obstruction or as a pedunculated out-growth behind the vesical orifice of the urethra. Clinical Pathology. — As the prostate gland enlarges, various changes are produced in the urethra, bladder and rectum; and less directly in the urine, kidneys, and general health. Changes in the Urethra. — The length of the normal urethra averages 20 cm.; but in enlargement of the prostate the length may be 35 or 40 cm., the increase occurring in the prostatic portion of the canal, especially in that portion on the vesical side of the ejaculatory ducts. This fact also explains the elevation of the vesical orifice of the urethra and the increased curve of the prostatic urethra, necessitating a special curve to inflexible instruments (Fig. 1049, 3 and 4). Lateral deviation of the urethra has been mentioned above. In some cases a peduncu- lated enlargement at the vesical orifice produces a Y-shaped channel. Increase in length of the posterior wall of the prostatic urethra may increase its antero-posterior diameter and consequently its capacity, so that it may hold 25 to 50 c.c. of urine; this is rare, but should be remembered as a possibility, since evacuation of a small amount of urine from the dilated prostatic urethra may lead the inexperienced to think the catheter has entered the bladder. The most important change in the bladder is the formation of a post-prostatic pouch, due to combined elevation of the urethral orifice and descent of the vesical floor. The greater the obstruction to the outflow of urine the larger this pouch becomes, and the more residual urine collects in it. Residual urine is that which remains in the bladder after the patient has expelled all he can. At first some hypertrophy ENLARGEMENT OF THE PROSTATE 1087 of the vesical walls may occur, but if obstruction is unrelieved dilata- tion and atrophy ensue, and the quantity of residual urine gradually increases. This state of chronic incomplete retention of urine without distention of the bladder (stage of residual urine) is finally succeeded by the same condition with distention of the bladder, and when the limit of the bladder's capacity has been reached, overflow occurs (retention with overflow). The distinction between the latter condition and true incontinence of urine has been explained at p. (345. But cystitis may occur, and then the bladder does not dilate; its walls become thickened and its capacity diminished. Vesical irritability demands frequent evacuation, and retention with overflow is rare. The adenomatous type of enlargement usually is associated with a dilated bladder; while where cystitis and contraction of the bladder are present the prostate usually is small and fibrous. The effects on the kidneys and ureters are those usual in other cases of urinary obstruction, with or without infection (p. 1029). The residual urine almost invariably becomes alkaline, and invites the occurrence of cystitis, but if acute retention does not occur, and catheterization is avoided, the occurrence of cystitis may be long postponed. Phosphatic calculi frequently form, but as they are more or less fixed in the retroprostatic pouch may cause no characteristic symptoms. Effects on Urination. — Residual urine diminishes the capacity of the bladder; hence urination must be more frequent. Frequent urination increases the existing congestion; this in turn may bring on retention of urine; catheterization is resorted to, once or oftener, and cystitis is the usual consequence. The retention and the infection produce nephritis, the quantity of urine is increased, and this causes still more frequent calls to evacuate the bladder. In this way a vicious circle is produced, and unless the original cause of all this woe, uri- nary obstruction, is removed, the patient's general health quickly deteriorates. Dilatation of the bladder and changes in its walls cause feeble power of expulsion, and slowness in completing the urinary act; while the inability of the vesical neck to act properly and the interference with the action of muscles around the membranous urethra cause the last portions of urine to be voided in dribbles, no power remaining of evacuating it in spurts. Effects on the Rectum. — The rectum may be obstructed by an enlarged prostate, causing increasing difficulty in defecation; and the constant straining in micturition is a frequent cause of hemorrhoids and prolapsus. Symptoms and Clinical Course. — Symptoms seldom are observed before the age of fifty years, but usually enlargement is present for some time before notable symptoms are produced. Usually the disease is insidious in onset, and the first abnormality noted is noc- turnal frequency of urination. Urination probably is as frequent by day, but does not arrest attention. Sometimes involuntary dribbling of urine is the first sign of trouble, usually due to retention with over- 1088 SURGERY OF THE URETHRA AND PROSTATE flow. Occasionally acute retention is the first symptom. Starting the stream is difficult, because there is both increased obstruction to be overcome, and decreased expulsive power; the stream tends to drop vertically from the meatus; a longer time than usual is required to pass the urine, though the amount evacuated each time may be small; and the urine dribbles at the end of the act of urination. Retention of urine is noticed by the patient only when acute, or when the chronic form is accompanied by overflow. The symptoms of cystitis and renal complications need not be detailed here. Hematuria seldom occurs spontaneously, but may follow the most gentle catheterization, from rupture of varicose urethral or vesical veins. Patients with enlarged prostates may be divided roughly into three classes (Deaver and Ashhurst, 1905) : in the earliest stage the chief complaint is nocturnal frequency of urination; in the second stage patients suffer occasionally from complete retention, but are not much troubled by cystitis and enjoy fairly good health; while in the third stage urinary retention is nearly absolute, the bladder cannot be evac- uated without a catheter, the kidneys are markedly diseased, and the patients are on the verge of the grave. Diagnosis. — Diagnosis of enlargement of the prostate cannot be made from the symptoms alone; physical examination is required. The first and most important sign to be looked for is a distended bladder; neglect to observe this sign, and the hasty and injudicious introduction of a catheter in cases of long standing retention with overflow may cause immediate syncope (from decrease of intra- abdominal pressure), and may lead in a few days to the patient's death from renal congestion and uremia. The proper treatment of retention with overflow is given at p. 1091. Having noted the absence of a distended bladder, request the patient to pass all the urine he can, and note the facility with which he starts the stream, the force with which it is expelled, and the presence or absence of dribbling at the end of urination. The amount of urine passed should be meas- ured, and the habitual frequency of urination noted. A patient who passes 100 c.c. of urine, more or less, every two hours, probably has no serious renal lesion. If he passes 100 c.c. only every three or four hours, either the normal amount is not excreted by the kid- neys or the quantity of residual urine is rapidly increasing. If, on the other hand, 15 or 30 c.c. is passed every ten or fifteen minutes, the kidneys will be excreting from 1£ to 4| liters of urine daily, and retention with overflow probably exists. If the bladder is not distended, the surgeon should next insert a catheter, to ascertain the quantity of residual urine. For diagnostic purposes (not for treat- ment by catheterism, p. 1089) I prefer a metallic instrument, since it acts also as an exploratory sound. As this is passed, note the presence or absence of strictures, any deviation of the subpubic urethra, the height to which the vesical orifice is raised, and the distance from the external urinary meatus at which urine begins to flow. The following facts favor the diagnosis of enlarged prostate: if the shaft has to be ENLARGEMENT OF THE PROSTATE 1089 depressed unduly between the patient's thighs before urine flows, indicating elevation of the vesical orifice of the urethra; if the urinary distance (that from the meatus to the point at which urine commences to flow) is increased above 20 cm.; if the catheter deviates laterally in the prostatic urethra; or if the catheter meets an obstruction more than 18 cm. from the meatus, showing the obstruction is further back than the usual site of strictures. A small amount of urine evacuated from the dilated prostatic urethra should not deceive the examiner into thinking the bladder has been reached. The amount and character if the residual urine are now noted; and finally a few ounces of saline solution are injected into the bladder, and the metal catheter is used very gently as a sound to explore the condition of the vesical walls and to search for calculi in the post- prostatic pouch. Before the catheter is removed, insert a finger into the rectum and palpate the prostate; the intravesical instrument can then be regarded as a very long finger, and the prostate can be palpated between this and the finger in the rectum. Treatment. — This may be discussed under the headings: (1) General treatment; (2) palliative treatment, which includes catheterism and cer- tain palliative operations; and (3) radical treatment by prostatectomy. 1. General Treatment is important. Especial attention should be paid to diet, to hygiene, and to securing free evacuation of the bowels. Cascara or some similar laxative is to be preferred. Atropin never should be given long at a time, for fear of increasing vesical atony; hence the popular A. B. & S. pills should be avoided. The urine should be kept acid, by administration of benzoic acid in 0.30 gram doses, with twice the quantity of sodium bicarbonate to ensure solution; and if the urine is not too acid urotropin is the best anti- septic. For excessively acid urine it is best to increase the ingested fluid, to decrease the sugars, and to administer alkaline salts of potassium or sodium. 2. Palliative Treatment. — Catheterism consists in periodical evac- uation of the residual urine by use of a catheter. This will cure no patients, but may promote their comfort, and in the very aged or feeble may even prolong life. As the expectation of life, however, in patients treated by catheterism is in the average no more than four or five years, it is clear that the life of the average patient is shortened by such treatment. I do not recommend it except when prostatectomy is contraindicated. The frequency of catheterization depends entirely upon the distress occasioned by residual urine, provided the latter is not increasing in quantity. As a general rule a patient with 125 c.c. of residual urine requires to be eatheterized once in twenty-four hours; the best time is just before going to bed. If 200 c.c. are present, use the catheter twice, night and morning, and add one more catheteri- zation for each additional GO c.c. of urine up to six times daily. When the required number of catheterizations exceeds this limit, some other form of treatment is urgently demanded, even though catheterism appears to maintain the patient's general health. 69 1090 SURGERY OF THE URETHRA AND PROSTATE Catheters for use in discs of enlarged prostate should be •'>."> to 40 cm. long. If there is difficulty in introducing the usual soft rubber catheter, it is possible usually to insert a Merrier catheter; this is one made of web- bing, like the English catheter (p. 1013), but having the point set at an angle of 1 10 degrees with the shaft (Fig. 1040, 1 ) . This elbow facilitates the point of the catheter riding over the prostatic obstruction, the point of the instrument being made to follow the roof of the urethra. A double elbowed catheter may be useful at times. If neither of these can be inserted, an English catheter, moulded to the proper "prostatic curve," as advised at p. 1014, may be used. If it will not pass without the stylet, it should be reintroduced with the over-curved stylet in its interior; when the obstruction is met, the stylet may be withdrawn about 2 cm., thus raising the point of the instrument over the ob- struction (Physick, 1818) (Fig. 1049, 3). A metal prostatic catheter is advisable only where the tissues are so hard and resistant from long-standing inflammation, that flexible instruments are not strong enough to push apart the sclerosed structures. If the patient has to catheterize himself a metal catheter never should be allowed; the best instrument is the soft rubber catheter, next the Mercier or the Eng- lish. The patient should be drilled frequently in the necessary aseptic technique, care of the catheters, and their introduction. Only intel- ligent and careful patients, willing to devote the necessary time to the matter, will succeed in avoiding the prompt occurrence of cystitis, which is eventuallv nearly inevitable. Fig. 1049. — Prostatic catheters: 1. Mercier's coude (elbowed) catheter. 2. Bi-coude, or double elbowed catheter. 3. English catheter mounted on an over-curved stylet; when the stylet is partly withdrawn the catheter assumes the form indicated by the dotted lines. 4. Metal catheter, with prostatic curve. Besides the occurrence of cystitis, the treatment of which is dis- cussed at p. 1018, certain other complications are not unusual. Acute complete retention of urine is treated by immediate catheterization. There is great danger in delay, and the chance of the retention being overcome by palliative measures is very much less than in cases of acute retention from stricture. In chronic complete retention of urine the bladder should be drained by a permanent catheter, in the hope that the cause is atony of the bladder, which may be relieved by con- stant drainage. If retention persists after atony has been relieved in this way, or if atony is not relieved by the drainage, it will be advisable ENLARGEMENT OF THE PROSTATE 1091 either to remove the prostate or to establish a suprapubic vesical fistula (see below). The treatment of residual urine (chronic incom- plete retention of urine, without distention of the bladder) has been considered at p. 1089. Finally there may be retention with overflow (chronic incomplete retention of urine with distention of the bladder) : here immediate and complete withdrawal of the urine from the bladder is considered inadvisable, since experience has shown that sudden relief of intravesical pressure usually is followed by hematuria from rupture of veins in the bladder walls, and is frequently followed by the development of surgical kidneys, uremia, coma, and death, within a few days. It is probable that the danger in such cases lies in the intermittent catheterization that has usually been employed, since this increases the chances of infection, and since Cabot (1903) showed that constant drainage by the use of an inlying catheter was able to avert threatening fatalities from such causes. Hence the surgeon either should adopt Cabot's plan or should adhere to the time-honcred custom of evacuating such over-distended bladders by degrees, with- drawing only about 100 c.c. at a time; or if all the urine is drawn at once, and an inlying catheter is not retained, he should replace most of the fluid withdrawn from the bladder by saline solution. Among palliative operations the formation of a suprapubic fistula holds first place. This was popularized in 1888 by Hunter McGuire; the operation resembles that of suprapubic cystotomy (p. 1025). Where urethral obstruction is marked, there is no likelihood of the suprapubic fistula closing, but when this tendency is observed a rubber tube should be worn constantly in the fistula. At the time of the operation any calculi present may be removed, but no attempt should be made to remove the prostate in such feeble patients as those for whom this palliative operation is advisable. Siter (1912), however, has found that dilatation of the vesical orifice of the urethra, by the insertion of the surgeon's finger through the suprapubic wound, may secure almost as much relief (even if only temporary) as a formal prostatectomy, and may be resorted to without materially prolonging the operation or increasing its gravity. If a pedunculated prostatic out-growth is found acting as a ball-valve against the vesical orifice of the urethra, it should be removed ; if no other urethral obstruction exists (a point readily determined by passing a soft catheter) this may effect permanent relief of all symptoms. In some cases where the prostate is small and atrophic, and the bladder thickened and contracted, much relief may be secured by median perineal cystotomy, with incision of the prostate and dilatation of the prostatic urethra (perineal prostatotomy) ; a perineal tube is retained until a permanent fistula is assured. After either suprapubic or perineal drainage a fair measure of continence is secured; and constant drainage by an in- lying catheter will be available whenever demanded by the occurrence of cystitis. The Bottini operation was introduced in 1874, but little used until popularized by Freudenberg in 1897. It consists in making incisions 1 1 !!>•_' SURGERY OF THE URETHRA AND PROSTATE in the prostate by a galvano-cautery introduced through the urethra. The subsequent cicatrization and contraction of these incisions may reduce the size of the prostate and thus overcome urinary obstruction; or they may fail to do so. The operation is uncertain in its results, the good effects sometimes secured are not permanent, and the mor- tality is no lower than that of prostatectomy in skilled hands. 3. Radical Treatment consists in removal of the prostate. It is the treatment of choice, and should be adopted in every case except where distinct contraindications exist. The chief contraindications are severe cystitis and renal insufficiency; and these usually may be Peritoneum oneurosis °//}enonvii/iers 0/) Prostate Ant. layer °f Triangular ligament Post, lai/er °J 'Triangular ligament Fig. 1050. — Sheath of prostate in sagittal section (diagrammatic). (Deaver and Ashhurst.) overcome by preliminary treatment, which may include some of the palliative operations already discussed, notably suprapubic drainage of the bladder. Extreme age is not a contraindication 1 , but if such patients can be kept comfortable by catheter life, it will not be advisable to resort to prostatectomy. Two methods of operation are in common use: the siqyrapubic, introduced in 1887 by McGill of Leeds, and improved and popularized in 1901 by Freyer, of London; and the perineal, which was a gradual 1 1 have resorted successfully to suprapubic prostatectomy in a patient in his eighty-ninth year. PROSTATECTOMY 1093 development of the practice of perineal prostatotomy (a common practice in the early part of the last century), and which was employed first in cases of malignant disease during the decade from 1870 to 1880. Its modern development is due largely to the labors of the French school, headed by Albarran, and to its exploitation in this country by Dr. H. H. Young, of Johns Hopkins University. jecto-vesica? fascia y the development of acute hy- drocele, and such a lesion may lay the foundation for the sub- sequent pathological change in the serous membrane which leads to chronic serous effusion. It is probable that many adult hydroceles are unrecognized manifestations of tuberculosis (Fig. 1071) or syphilis. In some cases rice. bodies are found, and the sac may become calcareous. Most of the adults affected are arteriosclerotic. Symptoms. — The swelling commences at the bottom of the scrotum, and gradually increases in size. At first it is soft and fluctuating, but eventually may become very tense and hard. The patient has little or no discomfort except from the size and weight of the swelling. Usually relief is sought before a very great size is attained. Rarely the sac extends into the inguinal canal, and from the existence of con- strictions (similar to those encountered in some cases of inguinal hernia — see p. 831) an hour-glass or bilocular hy- drocele may result (Fig. 1079). The same appearance may be caused by the coexistence of a vaginal hydrocele and a hydrocele of the cord. The diagnosis is made from the history of the case, and from observing that most hy- droceles are translucent when examined by transmitted light; old hydroceles, with thickened walls, and those into which hemorrhage has occurred, however, are opaque. The diagnosis from hernia was considered at p. 835. The best treatment is by operation; but in adults who refuse operation or in whom operation is contraindicated for any reason, it is sufficient to withdraw the fluid from time to time by tapping the hydrocele. The testicle almost always is at the back part of the swelling, but its position should be ascertained by palpation and by examination with Fig. 1078. — Hydrocele of tunica vaginalis. Age fifty-two years; duration nine years; tapped eight times. One liter withdrawn after making photograph. Episcopal Hospital. SPERMATOCELE 1117 -Bilocular hydrocele. Age twenty-three years; duration since infancy. (Dr. C. F. Mitchell's case.) Pennsylvania Hospital. transmitted light. The tumor is then grasped in the left hand, and the skin is drawn tightly over it, when with a quick thrust a trocar and cannula are pushed into the most prominent part of the swelling, avoid- ing large veins. The trocar is then withdrawn and the contents of the hydrocele allowed to flow. When all the fluid has been evacuated the can- nula is withdrawn and the puncture is sealed with cotton and collodion. No anesthetic is required and the patient need not be confined to bed. He should wear a close-fitting suspensory in an endeavor to prevent too rapid re-ac- cumulation of the fluid. It is well to examine the testicle carefully after the hydrocele fluid has been evacuated, as in many cases it is found diseased. Some surgeons recommend the injec- tion into the emptied sac of some irritating or caustic fluid in the hope of causing obliteration of the cavity; but the alleged advantages of this practice do not compensate for the dangers of uncontrollable inflammation and excessive pain. In most cases in which simple tap- ping is done, re-accumulation of the fluid occurs at progressively shorter intervals. Operation. — In most cases, especially in children and young adults, it is best to resort to operation. The incision should be made just below the external abdominal ring, not in the scrotum, as this is diffi- cult to sterilize. The operation of Jaboulay (1895) consists in evacu- ating the contents of the sac by incision, and everting the walls of the tunica vaginalis around the testicle so that the serous surface of the tunica vaginalis lies against the subcutaneous tissues. Recurrences are frequent after this operation; therefore excision of the sac (von Berg- mann) is preferable. It is well to scarify the testicular portion of the tunica vaginalis with the scalpel to destroy its secretory surface. Hydrocele of the Cord is a collection of serous fluid in an unoblit- erated portion of the funicular process of peritoneum. If the sac communicates with the peritoneal cavity, the condition is known as funicular hydrocele; if the sac is closed at both ends, it is an encysted hydrocele of the cord (Fig. 1080) . Hydrocele of the canal of Nuck is the corresponding condition in the female sex. If inflammation of the sac occurs from any cause, and no accurate history can be obtained, the condition may be readily mistaken for strangulated hernia. Treat- ment of hydrocele of the cord consists in excision of the sac. Spermatocele. — Spermatocele, known also as encysted hydrocele of the tunica vaginalis, is a cyst which develops about the globus major of the epididymis and contains spermatic fluid. Its pathogenesis is ins SURGERY OF THE MALE GENITAL ORGANS Fig. 1080. — Encysted hydrocele of the cord. Age two and a half years. ( 'hildren's Hospital. disputed (Crossan, 1920). It occurs oftenest in young adults, and forms a slowly growing but tense cystic tumor at the upper and back part of the testicle. It may project into the tunica vaginalis or grow be- hind it. The diagnosis often is not made until operation is done. Proper treatment is excision of the sac. Hematocele. — A collection of blood in the tunica vaginalis may result from injury or disease; there may or may not have been a preexisting hydrocele. In many cases seemingly of spontaneous origin, hematocele is symptomatic of malignant disease of the testicle. The physical signs are the same as those of vaginal hy- drocele, except that the swelling is opaque to transmitted light. Treatment. — In acute traumatic cases the blood should be with- drawn by tapping. In other cases the treatment is that of the underlying cause (hydrocele, sarcocele). Varicocele. — A varicose condition of the veins of the spermatic cord (the pampinniform plexus) occurs in about 10 per cent, of males, usually commencing about the age of puberty. In almost all cases the left side is affected, occasionally both sides, very seldom the right alone. This predilection for the left side is attributed (1) to the pres- sure of the sigmoid on the spermatic vein; (2) to the fact that the left spermatic vein enters the left renal at a right angle, while the right spermatic enters the vena cava obliquely; (3) to the absence of valves on the left side; (4) to the lower position of the left testicle in the scrotum; and (5) to the habit most men have of "dressing left." Seldom or never can any exciting cause be found. The rather rapid onset of a varicocele usually is symptomatic of some abdominal neoplasm obstructing the venous circulation. Symptoms. — Symptoms may be entirely absent even in cases where the varicocele is very large. Often, however, the patient complains of vague dragging pains and discomfort in the left side of the scrotum, and there may be occasional lancinating pains in the testicle and along the cord. Atrophy of the testicle is mentioned as a possible sequel, but I never observed it. In rare cases the patient may be "neuras- thenic." Examination show r s a relaxed state of the scrotum, with the left testicle hanging very low, and above it, extending up to the inguinal canal, a soft mass of dilated veins w T hich feel like a bunch of earthworms (Fig. 1081). These veins may be emptied by having the patient lie dow r n and elevating the scrotum; they will become distended again when he stands up, even if pressure is made over the inguinal canal. TUMORS OF THE SCROTUM 1119 Treatment. — Treatment seldom is required. There is nothing serious in the condition and it often disappears spontaneously later in life. If the patient is uncomfortable he will feel better for wearing a sus- pensory bandage, particularly in warm weather, and in "dressing right." Cold douches sometimes are soothing. If marked discomfort persists, the varicocele is easily cured by a simple operation. An incision is made at the external abdominal ring, and the cord is brought out of the wound. The dilated veins are separated from the vas deferens and its accompanying vessels, and the varicose veins are ligated close to the external ring, and again about 5 cm . lower. The ends of these ligatures are left long, and after the section of veins lying between the ligatures has been removed, the ligature on the proximal end is tied to that on the scrotal end of the cord, thus shortening the cord and elevating the testicle. The wound is closed without drainage (careful henio- stasis), and the patient stays in bed a week or ten days. Fig. 1081. — Varicocele, age thirty-six years. Episcopal Hospital Elephantiasis. — Elephantiasis occurs oftenest in the scrotum, as pointed out in Chapter XI, and the disease may spread thence to the penis. As the result of lymphatic obstruction and repeated attacks of dermatitis, the skin and subcutaneous tissues become enormously hypertrophied, deep creases and folds form, and in them dirt and macerated epithelial cells collect, emitting nauseating odors, and pre- disposing to ulceration and renewed attacks of dermatitis, eczema, erysipelas, etc. In tropical countries the scrotum may become so immense that the patient has to push it around before him on a wheel- barrow. In this latitude the disease is very seldom seen. The best treatment is excision. The operation may prove difficult, and bleed- ing usually is free; but if asepsis can be maintained, great relief is afforded. Tumors of the Scrotum are unusual. The occurrence of dermoids (sequestration cysts) was mentioned in Chapter IV (Fig. 81). Papillomas are more frequent, and often undergo malignant degen- eration (Fig. 1082). In former years epithelioma of the scrotum was 1120 Kl'KCKKY OF THE MALE GENITAL ORGANS frequently seen in chimney sweepers, from the irritation of the soot which accumulated on the scrotum in these persons of none too cleanly habits. At the present day workers in tar and paraffin are subject Fig. 1082. — Ulcerating papilloma of scrotum (epitheliomatous). Age thirty-six years; duration three and a half years. Episcopal Hospital. to the same affection. The proper treatment of these tumors is excision; this scarcely ever requires castration, as the malignant growth spreads widely in the skin before attacking the testicles. CHAPTER XXIX. SURGERY OF THE FEMALE GENITALS. General Remarks on Examination of the Female Pelvic Organs. — Position of the Patient. — The woman usually is examined in the "lithotomy position," that is, lying on her back, with knees and hips flexed, and the soles of the feet resting on the bed or table where she lies (Fig. 1083). Sometimes the "Sims position" is preferred: here the woman lies on her left side, with her left arm behind her back, thus throwing her right shoulder forward; her right thigh is flexed upon her abdomen as fully as possible, so that the right knee rests upon the table, while the left lower extremity is flexed only to a moderate Fig. 1083. — Lithotomy position. degree (Fig. 1084). Sometimes, but not very often, it is desirable to examine the patient in the standing position, or even in the knee- chest position (Fig. 1085). In a virgin, vaginal examination should be made only when the patient is under the influence of a general anesthetic. A rectal examination may suffice. An examination of the female pelvic organs should include (1) inspection of the external genitalia, (2) examination with the speculum, and (3) bimanual examination of the internal genital organs. The bladder and rectum should be empty. 71 (1121) 1122 SURGERY OF THE FEMALE GENITALS External Genitalia. — Note the condition of the labia: inflammatory changes, as in acute gonococcic vulvitis and vaginitis; the existence of a labial abscess; the presence or absence of mucous patches; edema from pregnancy or pelvic tumors; excoriations and hypertrophy in cases of pruritus. Observe the state of the hymen; the position of the Fig. 1084. — Sims's position. carunculse myrtiformes, if present; and the condition of the vulvar opening, whether normally closed or widely gaping as in multiparous patients with relaxed vaginal outlet. The position and condition of the urethral orifice should be noted, especially the presence of a gonorrheal discharge, or the existence of a caruncle. Fig. 1085. — Knee-chest position. Speculum Examination. — If the patient is in the Sims position, the duck-bill vaginal speculum of Sims (1845) should be used (Fig. 1086, 2). This is inserted with the blade in the sagittal plane, and as soon as the vagina is entered the blade is turned transversely, and is pushed forward until the stem catches on the fourchette; then the speculum is drawn backward, displacing the posterior vaginal wall and rectum into the hollow of the sacrum, and causing the vagina to be ballooned with air. This usually renders the cervix visible. In the dorsal and lithotomy EXAMINATION OF THE FEMALE PELVIC ORGANS 1123 positions it is more convenient to use a bivalve speculum (Fig. 1086, 1) : this is inserted closed, with the blades in the sagittal plane; as soon Fig. 1086. — 1, Bivalve vaginal speculum. 2, Sims's duck-bill speculum. 3, Speculum forceps. Fig. 1087. — 1, uterine sound. 2, sharp uterine curette. 3, dull uterine curette. 4, placental forceps. 5, double tenaculum forceps. 6, cervical dilator. 1124 Sl'RGERY OF THE FEMALE GENITALS as the vagina is entered the speculum is turned transversely, but the blades are not opened until the speculum has entered its full length. When the blades are finally separated, the surgeon endeavors to bring the cervix into view between them. If the speculum is too small or too short this may prove difficult. Several sizes should be available. When the cervix is exposed, examine its size, its shape, Fig. 1088. — Bimanual vaginal examination. (Dudley.) and its position; note the presence or absence of lacerations, erosions, ulcerations; observe the condition of the os, whether characteristic of a nulliparous or parous patient; and especially note the presence or absence of a cervical discharge and its character — mucous, purulent, bloody, etc. In suspicious cases smears should be taken from vagina, from urethra, and from cervix for microscopical examination. CONGENITAL MALFORMATIONS 1125 Bimanual Examination. — After withdrawing the speculum, insert two fingers of the gloved hand into the vagina. The beginner will do best to use both right and left hands, alternately, on the same patient; with the left hand he will be able to feel lesions on the left side of the pelvis which might easily escape detection if the right hand only was used. First examine the condition of the posterior vaginal wall and perineum. Then locate the cervix, and note its condition (soft and characteristic of pregnancy; hard, with scar tissue from previous pregnancies, lacerations, etc.), its size, its position (whether or not displaced by pelvic lesions), and its mobility, or fixation. With the aid of the other hand above the pubes (Fig. 10SS), then endeavor to palpate the fundus of the uterus, and note its position, whether or not it is displaced, whether movable or fixed, and finally the size and con- sistency of the uterus. Note the presence or absence of a mass in the pouch of Douglas; its consistency, fixation, and tenderness. Palpate in turn each tube and ovary by passing the vaginal fingers first to one side and then to the other side of the cervix, and endeavor to locate and outline, between these and the fingers of the abdominal hand, the uterine adnexa. No matter what the age, social condition, or history of your patient, always exclude pregnancy before reaching a final diagnosis. Preparation for Operation and After-care. — Enough has been said on this subject in Chapter XXII in reference to abdominal operations. But a few words are necessary in regard to vaginal operations. It is desirable to have all such patients in bed, and to have the parts thoroughly cleansed by douching twice daily for several days before operation. No operation should be done while the parts are acutely inflamed, nor during a menstrual period unless immediate operation is imperative. The bowels should be thoroughly opened by a purge given early in the day before that set for operation, and a cleansing enema should be given at least six hours before the time of operation (the previous evening if necessary). If a purge is not given until the night before operation, the bowels may be so loose as to move during the operation and soil the wound. The bladder should be emptied just before the operation. When the patient is in position on the table the vagina is thoroughly washed with soap and hot water, wiped out with alcohol, and douched with bichloride solution. After operation the patient should remain in bed for at least two weeks, often longer. The bowels should not be locked up by opiates, and if they do not move by the fourth day castor oil should be given; whenever possible an enema should be avoided. The urine should not be drawn by catheter unless retention occurs; after the patient has urinated the vulva should be gently douched with some hot antiseptic solution and gently dried and powdered. Congenital Malformations. — The vulva may be congenitally imper- forate, but the condition is more often due to adhesion of the labia minora as the result of vulvitis in childhood (Fig. 1089). In most cases, whether congenital or acquired, the occluding membrane is very thin, L126 SURGERY OF THE FEMALE GENITALS and is readily ruptured by pulling the labia apart or by rupturing adhesions with a grooved direetor; occasionally the use of scalpel or scissors is necessary. Reunion should be prevented by dressing the raw surfaces with boric acid ointment and the daily introduction of a fold of lint. Fig. 1089. — Adhesion of labia from vulvitis in infancy. Children's Hospital. Age three years. Imperforate Hymen. — Imperforate hymen seldom is recognized until after the age of puberty, when the non-appearance of the menstrual flow, and its ultimate damming up in the vagina (hematocolpos) and in the uterus (hematometra) cause a local examination to be made. If these conditions continue unrelieved for several years a large pelvic tumor may develop, and some danger exists of peritonitis from rupture of the uterus or tubes or from leakage of the uterine contents through the fimbriated extremity of the tubes. Treatment consists in incision through the hymen and drainage, and if necessary in some form of plastic operation to prevent cicatricial contraction. Absence of the Vagina. — Absence of the vagina usually is a congenital defect, but occasionally the vagina becomes obliterated by cicatricial contraction. If the presence of a uterus and adnexa can be demon- strated (exploratory laparotomy may be necessary), attempts may be made to construct a new vagina. Various external plastic operations have been employed, but usually without permanent success. The plan introduced by Baldwin (1907) though the mortality is higher, has given much better results: a loop of the small intestine is excluded from the intestinal tract, and still attached to its mesentery (which must be sufficiently long) is sutured in place between bladder and rectum, opening below at the vulvar orifice, and being closed above around the cervix uteri. The continuity of the intestinal tract is then restored by end-to-end or lateral anastomosis. Stenosis of the Cervix. — Stenosis of the cervix, usually from congenital hypoplasia and accompanied by anteflexion of the uterus, is a frequent cause of dysmenorrhea in girls and young women. The dysmenor- GONORRHEA IN THE FEMALE 1127 rhea is of the obstructive type, that is, it is greatest preceding the flow which often is delayed and usually is scanty. The patient usually is sterile, and proper treatment often is followed by conception. The kink in the uterus favors retention of secretions, and causes venous conges- tion, with resulting endometritis. Examination shows an undersized but lengthened (conical) cervix with pin-point os, firm and unyielding to the touch, and the fundus uteri close beneath the symphysis. Treatment. — Forcible dilatation, the patient being anesthetized, is seldom productive of permanent cure, even if the operation is many times repeated. It is better to incise the cervix posteriorly in the mid-line almost up to the internal os and recto-uterine fold of perito- neum; a small wedge of tissue is cut out on each side (Fig. 1090), and the cut surface on each side is then folded on itself so as to pull the anterior lip of the cervix backward {Dudley's operation, 1891). If the anterior lip is very long it may be excised. Or Pozzi's operation may be done: this consists in dividing the cervix bilaterally, hollowing out and infolding upon itself each of the four denuded surfaces. Fig. 1090. — Dudley's operation for anteflexion. Patient in the Sims position. (Findley. ) Malformations of the Uterus. — Malformations of the uterus are not very rare. Ectopic pregnancy may occur in one of the rudimentary horns of a uterus bicornis. In cases of double uterus (uterus didelphys) it is best, usually, to remove one uterus by hysterectomy, to prevent complications during a possible pregnancy. Gonorrhea in the Female. — As noted at p. 1128, the occurrence of gonococcic infection of the genito-urinary tract in the female often is not attended by very acute symptoms. The gonococci are deposited at the vulvar orifice or in the vagina by mediate or immediate con- tagion, and within a few days may produce acute urethritis, vulvitis, and vaginitis. Frequently, however, no acute symptoms develop, but the gonococci lodge and proliferate in the vulvo-vaginal glands (Bartholinitis) and in the cervical glands (endo-cervicitis) and are 1128 SURGERY OF THE FEMALE GENITALS exceedingly difficult to dislodge. When the disease reaches a chronic stage, it persists indefinitely, causing no particular disability at times, but at others producing local and distant disturbances which render life a burden. Moreover, the patient is a constant carrier of infection, and this may be conveyed to innocent persons, especially children, by mediate contagion. Recrudescences of the infection occur from time to time, and with each new attack the germs travel higher in the genital tract, spreading from the cervix to the uterus (endometritis), where the infection does not linger, to the tubes, ovaries, and peri- toneum; here occur acute and chronic salpingitis, pelvic peritonitis, pyosalpinx, tubo-ovarian abscess, etc. These complications frequently de- velop first in the puerperium, especially after miscarriages or abortions. Urethritis. — The urethra almost always is affected when gonorrhea attacks the female, but the course of the disease is much less acute in its symptomatology, and residual foci of infection are much less frequent than in the male. Occasionally a focus of infection remains in the suburethral glands of Skene, but abscess formation is extremely rare. These abscesses (one in each gland) protrude just below the external urinary meatus, and pressure on them will make pus exude from their orifices in the floor of the urethra, about 0.5 cm. within the meatus. They should not be confused with urethral caruncles, which are inflammatory hypertrophies or angeiomatous out-growths of the urethral mucous membrane, protruding from the urinary meatus, not beneath it through the anterior vaginal wall. Some caruncles bleed or are excessively painful; such should be excised, with a wide area of the mucosa from which they spring, as recurrence is frequent. Treatment. — The treatment of gonococcic urethritis in the female is subordinate to that of the vulvitis and vaginitis with which it is accompanied. Vulvitis and Vaginitis. — These are exceedingly common in infants and little girls, usually resulting from mediate contagion through soiled towels, etc. In them the symptoms may be very acute, as is also the case in the young nullipara, but in the case of women who have borne many children the vaginal mucous membrane is much less easily infected and gonococcic vaginitis is rarely seen. The patient complains of burning pain, worse during urination and defecation; the labia minora are red, edematous, and tender; there is a profuse purulent exudate, in which gonococci are readily found; the vaginal walls may be fiery red, and in rare instances exfoliation of epithelium and ulcer- ation may occur. The vulvo-vaginal glands of Bartholin are exceed- ingly prone to harbor the infection for a long time, and abscess forma- tion is very common (Fig. 1091); indeed it may be the first symptom to bring the patient to a physician. The vulvo-vaginal abscess points at the posterior part of the vulvar opening, between the labium ma jus and minus, and is to be treated by early and free incision, with excision of the anterior wall of the abscess sac, or if possible by extirpation of the entire gland, as recurrence is very common unless radical treatment is adopted at the first. Occasionally as the result of very VULVITIS AND VAGINITIS 1129 attenuated infection, or from cicatricial closure of the duct, a cyst of Bartholin's gland develops (Fig. 1092) ; this is to be treated by excision. Treatment.— The treatment of acute gonococcic vulvitis and vag- initis is best conducted with the patient in bed, until the most acute symptoms subside. Great care must be taken to prevent infection of the eyes, as well as conveyance of contagion to other patients by instruments, dressings, etc. There is very little use in local treatment, since injections, irrigations, etc., are very apt to spread the infection further up the genital tract. The patient should be confined to liquid diet at first, especially drinking plenty of water; urinary antiseptics should be administered; and the accumulation and crusting of the purulent discharge should be prevented by douching the vulva fre- quently with hot permanganate of potash solution, or some other antiseptic. The heat of the solution is beneficial in itself. It may be Fig. 1091. — Abscess of the vulvovaginal gland of Bartholin. Duration three days. Acute gonorrhea in a patient aged twenty-two years. Pennsylvania Hos- pital. Fig. 1092. — Cyst of vulvo-vaginal gland of Bartholin. Age thirty-six years ; dura- tion fourteen years. Attached by two pedicles to right labium minus. Episcopal Hospital. well to leave a rubber tube in the vagina, to promote drainage. As the discharge lessens and tenderness becomes less, the rubber tube may be substituted by a glycerin tampon, changed daily. When the chronic stage is reached the infection probably will be found to be localized in the cervix or the Fallopian tubes; the local treatment of these affections is discussed below. Chronic Gonococcic Vaginitis, especially in children, is most success- fully combated by the use of vaccines; without their use a leucor- rheal discharge may persist indefinitely, and though no gonococci may be found by microscopical examination on many occasions, any local irritation may bring them from their hiding places. In both children and adults a so-called "cure" of the disease usually means only latency of symptoms. Some authorities teach that a woman once infected with gonococci is always infected. In the use of vaccines for chronic gonococcic vaginitis in children, the 1130 Sl'h'CKUY OF THE FEMALE GENITALS directions of B. W. Hamilton (1910) may be followed: give 50,000,000 killed gonococci by hypodermic injection every fifth day, increasing the dose by 10,000,000 until five injections have been given, the last dose being 90,000,000 gonococci. After a ten-day interval repeat the same treatment if necessary. In recent cases Hamilton found that six injections usually cured. Endocervicitis. — This usually is gonorrheal in origin, mixed infec- tion occurring subsequently and aggravating the condition. The chief symptom is a leucorrheal discharge, thick and purulent. Men- struation occurs irregularly, and usually the flow is greater than normal. Examination through the speculum usually reveals a plug of tenacious muco-pus protruding from the os. Microscopically, the glands which line the cervical canal are seen to be swollen and cystic, and much increase in the stroma may occur, leading to hypertrophy or elonga- tion of the cervix. The cervix may have erosions or actual ulcerations on its vaginal surface. Treatment. — Treatment by palliative means (douches, tampons, local applications or argyrol, iodin, etc.) rarely is efficient. Even thorough scraping of the cervical canal, the patient being anesthe- tized, generally fails to effect a cure. The best treatment is formal excision of the diseased tissue, with plastic restoration of the cervical canal: the cervix is split bilaterally, and a wedge of tissue (including the cervical mucosa) is removed from each lip; then the cervical flaps are folded upon themselves and their free borders sutured to the mucosa at the internal os (Schroeder's operation, Figs. 1093 and 1094). Fig. 1093. — Schroeder's operation: the Fig. 1094. — Schroeder's operation: the shaded areas are excised. flap3 are sutured. Endometritis. — Endometritis is a much rarer affection than com- monly believed. Most patients said to have endometritis have an entirely different lesion as the main cause of their symptoms. The symptoms of which they complain are painful, prolonged and irregular menstruation, leucorrheal discharge between their periods, a certain amount of backache, etc. Examination shows the existence of endo- cervicitis, or salpingitis, or both; and it is some such lesion, and not a possibly accompanying but relatively insignificant endometritis, which is responsible for the symptoms. Endometritis which exists as the most important lesion usually results from infection following ENDOMETRITIS 1131 abortion, miscarriage, or labor. Occasionally the disease occurs in the nullipara or in the aged; in these instances it usually is caused by stenosis of the os, or displacements of the uterus which cause conges- tion or interfere with proper drainage. If the disease continues long untreated, the entire uterine body may become affected (metritis). The diagnosis of endometritis, except in the rare virginal and senile forms, depends upon the recognition of the symptoms mentioned above occurring after a miscarriage or a prolonged convalescence from labor. Fig. 1095. — Curettage of the uterus. (Findley.) Treatment. — Much can be done to prevent the development of endometritis by avoiding infection in the puerperium, but when the disease is fully established, treatment is not very satisfactory. The first essential is to secure free drainage, by dilatation of the os, main- tained by introduction of a glass drainage tube (Wy lie's drain); the hypertrophied and diseased endometrium should be removed at the same time by the dull curette (Fig. 1095), but this step is quite useless unless free drainage is provided after the operation. The tube should be retained for several weeks, and may be replaced later if necessary. If other lesions (endocervicitis, salpingitis) exist they should receive appropriate treatment. Acute Metritis. — Acute metritis is seldom seen except in cases of puerperal sepsis (p. 1150). 1132 SURGERY OF THE FEMALE GENITALS Chronic Metritis.— Chronic metritis, as noted above, usually is a sequel of neglected cases of endometritis. At first the uterus is large, soft and boggy, but later becomes sclerosed, though usually retaining some enlargement. Hyaline degeneration is not infrequent, and malig- nant changes may occur. The symptoms resemble those of chronic endometritis, but usually are more severe and often are accompanied by pseudo-hysterical phenomena. Menorrhagia is excessive, and the patients become chronic invalids. The diagnosis from small intersti- tial or submucous fibroids may be difficult. The only efficient treat- ment is hysterectomy. The condition is no more curable by medicine or palliative local treatment than sclerosis of any other organ. Salpingitis. — Inflammation of the Fallopian tubes usually is due to the local action of gonococci, the infection travelling upward by gradual steps from its resting places in the vulva and cervix. Tuber- culosis of the Fallopian tubes has been mentioned in Chapter XXII. Acute Salpingitis. — Acute salpingitis is most frequent in nulliparae; it may occur during an acute attack of gonorrhea (vulvo-vaginitis and urethritis) or may arise later as the result of some factor which lessens the resistance of the pelvic organs. There is always a certain amount of peri-salpingitis (pelvic peritonitis) accompanying acute inflammation of the tubes, and pathologically the condition is not unlike an attack of appendicitis, except that the infecting organism is the gonococcus and not the more deadly streptococcus or colon bacillus. The symptoms are those of peritonitis localized to the pelvic region, usually more marked on one side than on the other, and not attended by notable gastro-intestinal symptoms. The tenderness is close to Poupart's ligament, too low and too near the median line for typical appendicitis; and the history of the case and vaginal examination almost always indicate the true condition. Treatment. — Keep the patient in bed, and treat her as for diffuse peritonitis (p. 862); there is no fear of gangrene or perforation of the tube, as there is when the appendix is acutely inflamed ; and the acute attack subsides almost invariably within a few days. The exceptions are a few cases of salpingitis of puerperal origin; but most of these, even, subside under proper conservative treatment. The mortality following early operation is high; but if recurrent attacks of pelvic peritonitis occur in spite of conservative treatment it may become necessary to operate before the chronic stage has been reached. The operation consists in removal of the affected tube (salpingectomy, p. 1137) and of the ovary also if this is involved. But whenever possible no operation should be done for several months after the subsidence of an acute attack; after such an interval the virulence of the microbes is very much attenuated, and often the pus in the tube is found to be sterile. Chronic Salpingitis. — Chronic salpingitis is a term used to describe a condition which is not so much a chronic inflammation of the tubes, as it is the result of a previous acute inflammation. The tubes and ovaries are bound down in adhesions, often involving omentum, PYOSALPINX OR PUS-TUBE 1133 sigmoid, cecum and appendix, and less often the pelvic coils of small intestine. There is difficulty, and often pain, in securing evacuation of the bowels; an aching sensation, or dragging pain, is nearly constant in the lateral pelvic regions, especially when the patient is on her feet; referred pains (small of back, thighs, groins) are frequently present; there usually is leucorrhea, with painful, profuse, and irregular men- struation, and the woman becomes a chronic invalid. Examination shows the uterus and adnexa more or less fixed by adhesions; con- siderable tenderness is present; and the pelvic organs cannot be clearly outlined. Treatment consists in removal of the focus or rather foci of infection (salpingo-oophorectomy), releasing the adhesions, and covering denuded peritoneal surfaces by infolding or by omental grafts. The appendix usuallv should be removed also. Fig. 1096.- -Right pyosalpinx, seen from posterior aspect. The tube is distended, pouched, and surrounds the ovary. Episcopal Hospital. Pyosalpinx, or Pus-tube, results from accumulation of the products of inflammation within the lumen of the Fallopian tube, owing to inflammatory occlusion of the fimbriated and uterine extremities (Fig. 109(3). The exciting cause almost always is the gonococcus, and the condition usually is a remote sequel of acute salpingitis. It has been noted already that gonococcic infection of the tubes becomes attenuated soon, and that after several months the contents usually are sterile. A patient with pus-tubes (both sides usually are diseased) as a rule gives a history of having passed through several attacks of pelvic peritonitis; and in many cases a distinct history of the primary infection can be secured. A pus-tube often follows the first childbirth in cases where the patient has been inoculated with not very virulent gonococci; thereafter the woman usually is sterile. If the pus-tube in such a woman first begins to cause symptoms a number of years after the last childbirth, it may be mistaken for a case of ectopic gestation (p. 1147). Frequently pus-tubes exist for years without causing notable symptoms; but in most cases there is an annoying leucorrhea, and the patient may be completely disabled by painful 1134 SURGERY OF THE FEMALE GENITALS adhesions to the intestinal tract, by recurrent attacks of pelvic peri- tonitis from leakage of the contents of the sac, etc. On examination it is usual to find the cervix displaced, and a mass in the recto-uterine pouch, sometimes clearly demonstrable as springing from one side or other of the uterus; a similar but smaller mass, not large enough to occupy the pouch of Douglas, may be present on the other side of the uterus. Pus-tubes usually are fixed by adhesions, but they may be very movable, and their existence should not be ruled out on the ground of mobility alone. A low, immobile mass, especially if it results from puerperal infection, almost always is a pelvic abscess; pus-tubes form a high, not a low mass. Treatment. — If symptoms are present the diseased structures should be removed. If the woman is young and the ovary healthy, it should be left, only the tube being removed, but in many cases the ovary is degenerated ("cystic degeneration" from chronic oophor- itis, p. 1 135) and will prove useless or even harmful if preserved. The entire tube should be removed, excising its interstitial part from the uterine cornu; in some cases, in addition to the removal of both tubes and ovaries it is necessary to remove the uterus also, either to facili- tate the operation, or because this organ itself is diseased (chronic metritis). The operation of salpingo-oophorectomy is described at p. 1136. If the woman complains of no particular symptoms, it often is best to do no operation. I have known a woman with an undeniable pus-tube pass through a normal pregnancy and puerperium and give birth to a healthy child. Rupture of a pus-tube is rare while its contents are still highly infec- tious; when it occurs, it is followed by diffuse peritonitis, which is best treated not by immediate operation, but by strict adherence to the rules laid down in Chapter XXII for the non-operative treatment of diffuse peritonitis. Immediate operation has a very high mortality, but if the patient is treated expectantly the infection almost always becomes localized again, frequently in the form of a pelvic abscess. Tubo-ovarian Abscesses. — This is an abscess which involves both tube and ovary (Fig. 1097). Usually the primary condition is that of pyosalpinx, and the ovary becomes invaded by direct extension. It is rare for an ovarian abscess to exist alone, or for it to spread to the tube secondarily. But when a small ovarian cyst or corpus luteum bursts into an adherent pus-tube, infection of the whole ovary may result, the tube and ovary then forming one mass. Sometimes tube and ovary are in communication only through an intervening pelvic abscess. It is difficult to distinguish a tubo-ovarian abscess from an ordinary pus-tube before operation, as the symptoms and physical signs are almost identical. Treatment is the same as for pyosalpinx. Hydrosalpinx. — Hydrosalpinx, or a collection of serous fluid in the tube, sometimes develops as a terminal stage of pyosalpinx; often, however, the collection of fluid appears to have been serous from the beginning. Hydrosalpinx frequently develops on one or both sides OOPHORITIS OR OVARITIS 1135 in cases of uterine fibroids. Treatment is that of the complicating condition. Fig. 1097. — Left tubo-ovarian abscess, seen from posterior aspect. Ruptured before operation, causing fatal peritonitis (colon bacillus). Episcopal Hospital. Oophoritis or Ovaritis is much less frequent and produces much less conspicuous symptoms than salpingitis. Like the latter condition, of which it is almost always a direct sequel, it may be acute or chronic. The symptoms cannot well be differentiated from those of the compli- cating salpingitis. In acute vvaritis the ovary is swollen, tender, and often prolapsed into Douglas's pouch; abscess of the ovary is rare unless it is the result of secondary infection of a preexistent ovarian cyst, or occurs in the form of a tubo-ovarian abscess, already described. Fig. 1098. — Microcystic degeneration of the ovary; the ovary to the right shows numerous small cysts scattered over the surface; these are Graafian follicles which have undergone cystic degeneration, and which it is said may take on excessive growth and develop into large tumors, or may remain as here represented; on the other side is shown a similar condition of the ovary in section. (Dudley.) Treatment. — In acute ovaritis the treatment should be the same as in cases of acute salpingitis. If suppuration occurs, the proper treat- ment is oophorectomy. In chronic ovaritis the ovary is the seat of "cystic degeneration," and should be removed along with the tube if this is diseased (Fig. 1098); since both ovaries usually are affected, 1 130 SURGERY OF THE FEMALE GENITALS it is well, if the patient is a young woman, and a portion of the ovary remains healthy, to leave it as a transplant in the abdominal wound; there are fair prospects that it will possess sufficient function to prevent or delay an artificial menopause. Salpingo-obphorectomy. — The abdomen is opened by a paramedian incision about 10 to 15 cm. long, above the pubes. In any case in which there is any possibility of pus being present, the surgeon should wall off the small intestines with gauze packs as soon as the peri- toneum is opened, and before the pelvis is explored. Place the first gauze pack on the right or left side of the pelvic cavity, not in the 'A 'V '// Y. P. « Fig. 1099. — Isolating the pelvic cavity by the use of gauze packs. (See Fig. 896.) (Dudley.) mid-line; if the first pack is inserted in the mid-line the intestines will prolapse into the pelvis on both sides of it, and it will be more difficult to control them. The second gauze pack is placed in the mid-line, and the third on the left, thus pushing the troublesome small intestines completely out of harm's way (Fig. 1099). If it is known to be a clean case it will facilitate these manoeuvres to place the patient in the Tren- delenburg (high pelvic) position as soon as the abdomen has been opened; but if there is any danger of infection, it is safer to isolate the general peritoneal cavity by gauze while the patient's body is still horizontal, and then to raise it into the Trendelenburg position. SALPINGO-OOPHORECTOM Y 1137 If many adhesions are present it may be difficult at first to recog- nize anatomical landmarks. First locate the fundus of the uterus. Sometimes it is covered by omentum or sigmoid. Then cautiously and gently work your fingers down behind it until Douglas's cul-de-sac is reached. Then endeavor to isolate the tubes and ovaries by blunt dissection with the fingers, working from the mid-line outward and pushing the omentum and intestine away from the pelvic organs rather than enucleating the latter from the intestines. It is not very difficult to tear a hole in the intestines if undue haste or force is em- ployed. From time to time mop up the clotted blood which collects in the pelvis as the result of rupture of adhesions. When at last the posterior surfaces of the broad ligaments are outlined, turn your atten- tion to their anterior surfaces, beginning at the fundus of the uterus again, where the attachments of the tube and of the round ligament form valuable landmarks, and then work out toward the sides of the pelvis. Fig. 1100. — Sulpingo-oophorectomy: on the right the suturing has been completed; on the left the method of resecting the uterine cornu is indicated. (Dudlc.\ . I If few or no adhesions are present, the tube and ovary from each side can be brought into the wound without difficulty. If the tube only is diseased, it alone should be removed (salpingectomy); or if the tube is healthy and the ovary diseased, oophorectomy should be done. In most cases both tube and ovary are removed together. The blood supply is readily controlled by a ligature around the ovarian artery, at the lateral margin of the broad ligament, and another close 1138 SURGERY OF THE FEMALE GENITALS to the uterus, just below the tube, where the uterine and ovarian arteries anastomose. The tube and ovary are then cut free from the broad ligament and any oozing points temporarily clamped in hemo- stats. The tube should be removed by resecting a wedge-shaped piece of the uterine cornu, unless the uterine tissue is very friable, and will not hold sutures, when it is sufficient to ligate the uterine stump of the tube. The cut edges of the broad ligament are then sutured by a lock stitch of chromic catgut, controlling any venous oozing (Fig. 1 100). The ends of the ligatures on the ovarian, and uterine arteries are then tied together, thus shortening the broad ligament, and retain- ing the fundus in proper position. Usually it is well to invert the edges of the broad ligament by another row of sero-serous sutures, burying the first row and covering the uterine stump of the tube. This lessens the chance of post-operative adhesions. In some cases it is safer to leave a tube or gauze to drain the floor of the pelvis, but where there has not been much soiling of the pelvic structures, and no oozing persists, the abdominal wound may be closed without drainage. Birth Injuries. — Lacerations of the cervix and perineum are the most frequent obstetrical injuries, and often produce such distressing symptoms as to demand operative relief. Lacerations of the Cervix may be unilateral or bilateral; anterior or posterior lacerations are rare, as are stellate lacerations. When these patients reach the surgeon healing has occurred, but it is healing with deformity: the cervical mucosa becomes everted, and resembles an ulcerated surface; erosions frequently form on the vaginal portion of the cervix, and annoying leucorrhea frequently is present. If the lacerations are very wide and deep, subsequent pregnancies may ter- minate in miscarriages from very slight provocation, or conception may not occur at all. Moreover, carcinoma of the cervix seldom occurs except in the scar of an old laceration; and this is the chief argument in favor of habitual operative treatment. But before any operation is done for laceration of the cervix, it is important to remedy inflammatory conditions in the uterus and adnexa, since the inter- ference with free drainage which may result from repair of a cervical tear may cause retention of uterine secretions, thus aggravating a chronic endometritis and perhaps indirectly leading to the develop- ment of salpingitis. At the time of operation the uterine cavity should be cleansed by the curette, and immediately after repair of the cervix the tubal lesion, if any exists, should be treated by laparotomy. Treatment. — The operation for the repair of a lacerated cervix is known as trachelorrhaphy ("tracheloplasty," Emmett, 1869). It con- sists in denuding the torn surfaces, excising the cicatricial tissue, and restoring the cervix to normal shape by sutures. The technique is sufficiently indicated in the accompanying illustration (Fig. 1001). In some cases where the lacerations are very extensive, or the cervix BIRTH INJURIES 1139 hypertrophied, amputation of the cervix is required. Schroeder's method has already been illustrated (Figs. 1093 and 1094). Lacerations of the Perineum and Pelvic Floor usually produce more discomfort than lacerations of the cervix. The levator ani muscles are composed typically of three portions : a posterior portion, entirely beneath the rectum, which is not' of importance in the pres- ent connection; a middle por- tion, which is closely applied to the sides of the rectum; and an anterior portion, which meets with the corre- sponding fibers from the op- posite side, at the perineal center. In superficial tears little more is torn than the juncture of these anterior fibers, and some of the fibers of the transversus perinei, at the perineal center. In com- plete tears the rupture extends down through the perineal center and involves the sphinc- ter ani (Fig. 1102), almost al- ways entailing fecal incontin- ence. Neither a superficial nor a complete tear of the perineum necessarily involves the pelvic floor proper, so there is not much loss of support to the pelvic organs; it is only when the tear extends up one or both lateral sulci of the vagina, rupturing the middle fibers of the levator ani and detaching them from the sides of the rectum that there develops a tendency to hernia of the pelvic contents through the vulvar orifice. The symptoms due to this loss of support in the pelvic floor are chiefly a feeling of weakness in the pelvis when the patient stands or walks; and dragging sensations in the lower abdomen, with pains referred oftenest to the ovarian or lumbar regions. In typical cases the vulvar orifice gapes, the anus falls backward toward the coccyx, and descends to a lower plane, no longer being placed in a well marked cleft between the nates. In many cases the anterior wall of the rectum protrudes beneath the posterior vaginal wall, forming a rectocele (Fig. 1103); and in connection with this there often develops an anterior colpocele or a cystocele (p. 1145). If the condition is neglected it fre- quently leads to prolapse or to procidentia of the uterus. Fig. 1101.— -Trachelorrhaphy: after excision of the cicatricial tissue, sutures of No. 2 chromic catgut are passed, beginning at the apex. (Findley.) 1140 SURGERY OF THE FEMALE GENITALS Treatment. — The operation for the repair of a lacerated perineum is known as perineorrhaphy.' Its nature and extent depend on the character of the tear. If both lateral sulci of the vagina are involved, the best operation is of the type de- vised by Emmett (1883): this con- sists in denuding the relaxed areas, reuniting the levatores ani muscles to the lateral rectal and posterior vaginal walls, and restoring the external perineum by transverse sutures, known as "crown sut- ures." The manner in which the denudation is accomplished is of little moment; many surgeons follow Emmett in employing scis- sors. Personally, I prefer the scalpel, and I am in the habit of proceeding as follows: 1. Dmvdation. — A tenaculum is placed at the lowest myrtiform caruncle on each side, and these points are well retracted exposing the rectocele. A point on this is selected, which when drawm forward by tenaculum will reach almost but not quite to the urinary meatus Fig. 1102. — Complete Laceration of perineum. Note the gaping vulva, and the absence of the anal corrugations anteriorly. No rectocele. Episcopal 1 1< pital. Fig. 1103. — Rectocele and cystocele. P Hospital. 1 It was Parvin's teaching that the terms trachelorrhaphy and perineorrhaphy should be limited to immediate repair of birth injuries; and that the operations when done at later periods should be called tracheloplasty and perineoplasty. The usual operation for repair of a lacerated perineum involves also the vagina, whence the term posterior colporrhaphy or colpo-perineorrhaphy. PERINEORRHA PHY 1141 (Fig. 1104). When these three tenacula are plaeed in apposition the normal form of the vulvar opening is restored. A fourth tenaculum Fig. 1104. — Typical incomplete lacer- ation of the perineum. The tenaculum hooked into the crest of the rectocele at point b draws it slightly forward. The other two tenacula are hooked into the lowest remains of the hymen, points d and e (carunculse myrtiformes). The three tenacula if approximated would bring into coincidence points h, d, and e, and would show what surfaces should be united. (Dudley.) is then placed in the mid-line at the mucocutaneous juncture. Point b (Fig. 1104) is then drawn upward and point / downward, making the line b / taut. The* vaginal mucosa is incised from b to/, and the mucocutaneous border from / to e and from / to d. The flap b / e is then dissected up with scalpel until c, the apex of the lateral vaginal sulcus, is reached; this point becomes apparent when the points b and e are drawn widely apart, forming the lines b c and e c (Fig. 1105). When the dissection has been carried as high as these lines, the flap of mucous membrane is cut free by dividing it along e c and b c with straight scissors. The same procedure is then carried Fig. 1105.— Same as 1010. Tenacu- lum at d removed and placed at /. Tenacula b, e, and / make traction so as to render tense, lift up and expose for denudation the torn sulcus of the left side. The ridges formed by the structures drawn taut indicate the out- line of the surface to be denuded. (Dudley.) Fig. 1106. — This shows the surfaces denuded and ready for suturing. It is desirable to denude on each side some- what further back into the sulcus than is here shown. (Dudley.) I I !_' sriiCKHY OF THE FEMALE (1ENITALS out on the patient's right side, until the lines s SURGERY OF THE F E MALE GENITALS pedicle. I differential diagnosis from other tubo-ovarian lesions depends chiefly on the clinical history. // the fin/tor is of medium size (fetal to adult head) it usually rises out of the pelvis and is appreciated as an abdominal growth. The diagnosis nnisl be made from uterine fibroid and other pelvic tumors. The cyst lies posterior to the uterus (a distended bladder lies in front), and it often is possible to determine that the uterus is of normal size. In most cases the pedicle of an ovarian cyst can be detected, but this may require abdomino-rectal palpation, while one assistant draws the uterus down into the vagina by a tenaculum and another assistant draws the tumor as far as possible out of the pelvis into the abdomen. If a pedicle is absent (intraligamentary cyst) the distinction from a subperitoneal fibroid may be very difficult, depending chiefly on the clinical history. Fig. 1121. — Malignant suppurating ovarian cyst in a woman, aged fifty-seven years; duration of illness seven years. Was tapped for ascites several years ago. Tumor cystic with solid masses; abdominal circumference, with patient recumbent, was 125 cm. Weight 149 pounds (normal weight 126 pounds). Inoperable. Episcopal Hospital. When the tumor becomes very large, ascites is the chief condition which simulates it. But in ascites there usually is some organic cause for the condition, and the latter has developed suddenly; the abdomen is fiat on the top and bulging in the flanks; its outline does not rise abruptly from the pubis as is the case in ovarian cyst (Fig. 1121); the umbilical area is resonant, the navel pouts, and there is shifting dulness in the flanks. Dermoid Cysts (Teratomas) develop from the germinal cells of the ovary. Under this term are classed both simple dermoid cysts, which contain only normal skin products (secretions of sweat and sebaceous glands, hair, nails, and teeth), and complicated dermoid cysts, in which may be found also bones, cartilage, muscle, and other more or less fully formed structures (embryomas). Dermoid cysts frequently affect both ovaries, and may begin to grow at any age (often in children and young girls). When growth begins it usually is rapid; but if the OVARIOTOMY 1159 cyst remains small it may cause no symptoms unless it becomes infected or undergoes carcinomatous change (both are frequent complications) and may last for a lifetime. Usually the cysts are adherent and should be treated as if malignant. Solid Tumors of the Ovary are comparatively rare. They are frequently bilateral. The most important are the malignant tumors: the carcinomas clinically resemble the papilliferous cystadenomas; in many cases they are secondary to carcinoma elsewhere (stomach, 1 breast, uterus, liver, etc.) being grafted on the germinal epithelium of the ovary through the medium of the omentum. Both ovaries may be involved. Blood-stained ascitic fluid is frequently present. Sar- coma usually occurs at a younger age. Of the benign tumors, fibroma is most often encountered; it may occur at an early age (Fig. 1122), but seldom causes symptoms except from its weight or from pressure if impacted in the pelvis. Fig. 1122. — Fibroma of the ovary in a girl aged nineteen years. Diagnosis was subacute appendicitis, and the ovarian mass with an unruptured blood cyst was dis- covered on exploration. Episcopal Hospital. Treatment. — All such growths should be removed, unless clearly inoperable. Ovariotomy. — This is the classical operation for the removal of an ovarian cyst (Ephraim McDowell, 1809). If the cyst is so small as to be delivered easily through an ordinary abdominal incision, the operation resembles that described as oophorectomy 2 or salpingo- oophorectomy (p. 1136); the tube may or may not be removed with the diseased ovary. But in cases where the tumor is very large, the technique of the operation is different. A hypogastric paramedian in- 1 The so-called "Krukenberg tumor" of the ovary (1896) is believed by Symmera (1917) to be of this nature. 2 This of course is a more correct term etymologically, but long usage sanctions the use of the term ovariotomy for the typical operation for large ovarian cysts. L160 SURGERY OF THE FEMALE GENITALS cisioD is made, and the peritoneal cavity opened; if thecyst is thought to be malignant (papuliferous cystadenoma, dermoid) every effort should be made to prevent its rupture; these cysts seldom are immensely large, and usually may be delivered through an incision of moderate size. In every ease of malignancy both ovaries should be removed. In the ease of an immense cyst, however (usually a simple cystadenoma), it is best to tap the tumor so as to enable it to be removed through an incision of ordinary size. After the cyst wall is exposed, the pre- senting surface of the tumor is isolated by gauze packs, and a large blunt pointed cannula (at least 1 cm. in diameter) with rubber tube attached, is thrust into an avascular area of the cyst wall, and the contents are removed by syphonage. If the cyst is multilocular it may be necessary to tap several loculi; usually a sufficient number may be reached from the interior of that first emptied without with- drawing the cannula. As the cyst walls collapse they are to be drawn into the wound with volsellum forceps, and an assistant is to make pressure on the flanks, so as to prevent leakage into the abdominal cavity. When the entire tumor has been withdrawn the pedicle comes into view. If there are adhesions, the operation is much more difficult, and careful dissection may be required to free the tumor from omentum, mesentery, intestine, etc. When the pedicle has been brought into view, it should be caught in strong crushing forceps, and ligated by transfixion in the groove thus made. The pedicle usually is composed of broad and round ligaments, Fallopian tube, and infundibulo-pelvic ligament. Great care should be taken to see that hemostasis is complete; when they can be identified the ovarian and utero-ovarian arteries should be tied separately. Finally the stump of the infundibulo-pelvic ligament should be united to the stump of the tube, and denuded areas should be covered by peri- toneum. Before closing the abdomen always examine the other ovary. If the intestines are carefully protected from exposure and the patient's bodily heat maintained, the operation is attended by very little shock. The mortality in expert hands is below 5 per cent. Fibroids of the Uterus. — These tumors are fibro-myomas; those with an excess of fibrous tissue justly merit the term fibroids, but in general this term and myoma or fibromyoma are used indiscriminately, regardless of the amount of fibrous tissue present in the tumors. The tumors usually are multiple, and spring from the uterine wall, prob- ably, it is believed, from the walls of bloodvessels. They occur with greatest frequency in the body of the uterus, fibroids of the cervix being comparatively rare. By some the affection is considered a wide- spread disease, with one of its local manifestations in the uterus; and they explain the frequently accompanying myocardial changes in this way. Some authorities teach that the tumors always have a congenital origin; it is undisputed, however, that they seldom begin to produce symptoms or are discovered until well into the child-bearing period, from thirty-five to forty-five years of age. A woman with fibroids usually is sterile, and it is disputed whether sterility is to be regarded FIBROIDS OF THE UTERUS 1161 as a cause or a result of the existence of fibroids. If pregnancy occurs it is very apt to result in abortion or miscarriage. Fibroids are especially common in the negro race. Fig. 1123. — Fibroids of the uterus, subperitoneal and interstitial; age fifty-three years. (See Fig. 1124.) Episcopal Hospital. Fig. 1124. — Uterine fibroids, specimen shown in Fig. 1123 sectioned, exposing inter- stitial growths, one of which has undergone cystic degeneration. Note also carcinoma of the cervix, with its crater-like excavation; a rare complication of fibroid tumors. Episcopal Hospital. 1162 SURGERY OF THE FEMALE GENITALS The tumors begin as interstitial growths, within the walls of the uterus; they may remain in the uterine wall even when attaining very large size, but usually they tend to push their way through to the subperitoneal or the submucous surface of the uterus. In many cases tumors are found in all three locations. They may present beneath the peritoneum or mucosa as sessile growths, but not infrequently a pedicle forms. Then the tumor, if subperitoneal, may become adher- ent to neighboring abdominal structures, as the result of attacks of congestion and inflammation from torsion of the pedicle; and in rare instances these secondary adhesions may become so firm that the pedicle ruptures and the migrated fibroid continues to receive its nourishment through the adhesions alone. Submucous fibroids frequently develop pedicles, and present in the uterine cavity or pro- trude from the cervix in the form of polypi. Usually only one polypus is present, springing from the cervix or near it, and mostly fibrous in structure. If a polypus springs from the fundus of the uterus, the uterine wall becomes thinned at the point of attachment, and inversion of the uterus may occur. Symptoms. — In many cases no symptoms whatever are produced until the tumors become so large as to cause pressure effects. Among the most usual of these are vesical irritability, hemorrhoids and inter- ference with defecation, pain in the sacrum and coccyx, varicose veins or edema from interference with the circulation of the lower extremities, renal disturbances from pressure on the ureters, etc. Interstitial growths may cause no noticeable change in the form of the uterus, though it may be much larger than normal, and the depth of its cavity will be increased; but a sound should not be introduced without due consideration, particularly until the possibility of preg- nancy has been absolutely eliminated. Dysmenorrhea is present in some cases of interstitial growths. Subperitoneal groicths usually may be recognized by bimanual palpation; they may be of various sizes and shapes, but are attached to the uterus, move with it, and usually are high in the pelvis, not in the position where pus tubes are found; unless the tumor is very large, or impacted in the pelvis, the tumor is not fixed. Submucous groicths are particularly charac- terized by profuse and prolonged menstrual bleeding; intermenstrual hemorrhage is rare, though bleeding may last from one period to the next and continue through this; then an intermission may occur until the normal time for the occurrence of the next menstruation which will also be unduly prolonged. Anemia is a frequent result and may be severe. Sometimes submucous tumors may be detected by the introduction of a finger into the os, which frequently is patulous. Attacks of colicky pain may be caused by efforts of the uterus to force the tumor through the cervix. Complications: Occasionally a large submucous fibroid prolapses through the vagina, and may cause inversion of this structure or even of the uterus itself. Strangulation of the prolapsed fibroid may occur, resulting in gangrene, a very serious complication (Fig. 1125). Fibrous polypi are less serious than FIBROIDS OF THE UTERUS 1163 larger myomatous submucous tumors, rarely causing alarming bleed- ing. Yet the presence of any submucous growth predisposes to infec- tion of the endometrium, and this readily extends to the tubes, so that hydrosalpinx, as already noted (p. 1134), is a frequent complication, Or infection may spread directly to the tumor mass, causing a very serious form of septic metritis. Fig. 1125. — Prolapse of submucous fibroid (strangulated) with complete inversion of vagina — uterus not inverted. Age forty-three years. Had normal childbirth two years ago, and no symptoms from fibroid until prolapse occurred, twenty-three hours before operation (vaginal hysterectomy). Death from peritonitis five days after operation. Episcopal Hospital. Diagnosis. — This is made from attention to the history of the case, from observation of the symptoms, and, most important of all, from the physical examination. It is especially important in every case to exclude the presence of pregnancy: a large interstitial myoma, par- ticularly if softened as the result of passive congestion with edema, may so closely simulate pregnancy as to deceive even the elect. Too much reliance should not be placed on the history in such cases, if it is impossible to corroborate the patient's tale; many women would be pleased to be relieved of a pregnancy by hysterectomy, and are wilfully deceitful. Usually, however, in pregnancy the cervix is softer, the uterus feels more cystic, the menses are absent, and always (if the policy of "waiting and watching" is followed) indisputable signs of pregnancy will declare themselves in time. An ovarian cyst may closely resemble a fibroid of the uterus if it is very tense, and particu- larly if intraligamentary; in some cases nothing short of an exploratory operation will clear the diagnosis. In the case of pyosalpin.v the history is different; the mass usually is posterior to the uterus and fixed; there is more leucorrhea than in fibroids, and menstruation is irregular rather than prolonged or profuse. The diagnosis from carcinoma and other malignant tumors rarely is difficult. Adenomyoma of the uterus occurs in 5 per cent, or more of cases. The glandular elements are derived either from the endometrium (Cullen, 1903), or from remnants of the Wolffian body in the walls 11G4 SURGERY OF THE FEMALE GENITALS of the uterus (von Recklinghausen, 1896). The tumors frequently are infiltrating in character, but occasionally more or less encapsu- lated subperitoneal growths develop, or even polypi. Cyst formation is the only form of degeneration which is common. The symptoms are much the same as in cases of ordinary fibroids, and the diagnosis seldom is made except in the pathological laboratory. The existence of this variety of myoma may be suspected, however, if the tumor is very adherent, and particularly if it is cystic and the contents of the cysts are chocolate colored (menstrual Hind). The proper treat- ment is hysterectomy. Prognosis. — The prognosis of uterine fibroids is not good. Until some symptoms are produced, the growths often pass undiscovered. But, when symptoms of any kind once have appeared, it is rare for the patient ever again to be free from discomfort. The menopause is indefinitely deferred, and the tumor usually continues to grow. Not to mention various degenerations (calcareous, myxomatous, cystic, hyaline, malignant) of the tumors, which occur in about 20 per cent, of cases, and the ever-threatening degeneration of the cardiac muscle, which is almost inevitable, the woman is subject to the dangers of hemorrhage, miscarriage, sepsis, inversion of the uterus, etc. Treatment of Uterine Fibroids. — We hear reports lately of favorable results secured by a;-rays and radium treatment, just as some years ago much was heard of the electric treatment advocated by Apostoli, and even before that time of the curative value of ergot. Whether these new departures will prove more lasting than their predecessors time alone can show; but for the present and immediate future at least, the treatment advised and practised by rational surgeons is operative. 1 The tumors should be removed. In some comparatively young women who are anxious to bear children, it may be justifiable to remove the individual tumors, leaving the main bulk of the uterus intact. This is especially the case when a polypus is present, without other demon- strable growths. Polypi may be removed through the vagina after the division of the pedicle by scissors or by formal excision from the uterine wall. Temporary division of the cervix may be necessary. Bleeding from the stump of the polyp rarely is severe and may be controlled by packing if suture is impossible. Isolated subperitoneal growths may be removed by excision and enucleation through an abdominal wound; the operation is known as myomectomy. The objec- tions to it (largely theoretical) are that other tumors almost surely are overlooked and will subsequently give rise to trouble; that even should pregnancy follow it is very apt to be terminated prematurely; and that should pregnancy continue to term, grave complications may arise during parturition or the puerperium from other fibroids which have grown during the pregnancy. But in a small proportion of cases, carefully selected, the operation is of value. 1 G. E. Shoemaker (1915) reported a case of sarcomatous transformation five years after bleeding was checked by x-ray treatment. HYSTERECTOMY 116£ In the great majority of cases removal of the uterus {hysterectomy) is preferable. This may be accomplished by the vaginal route (vaginal hysterectomy) if the uterus is small; but in most cases the abdominal operation is required. If the uterus is amputated above the cervix the operation is known as supravaginal hysterectomy; if the cervix also is removed the proper term is pan-hysterectomy . In most cases the tubes and ovaries are removed also (complete supravaginal or pan- hysterectomy) . Fig. 1126. — Diagram to show technique of abdominal panhysterectomy: on the right of the picture the left ovary and tube are being removed with the uterus; the right ovary is not being removed. Ligatures have been placed on the ovarian and uterine arteries and on the round ligaments on both sides, and the tissues close to the uterus have been clamped. The anterior vaginal fornix has been opened exposing the Abdominal Hysterectomy. — The fundus of the uterus is drawn through the abdominal wound by volsellum forceps, and one broad ligament is exposed by drawing the tumor well to the other side. Clamps may then be applied to both sides of the proposed section, leaving the adnexa attached to the uterus if they are diseased (Fig. 1126). In many cases it is simpler to ligate the ovarian vessels at once, applying clamps only to the uterine side of the broad ^ ligament. Hemorrhage being thus controlled, the broad ligament is divided with scissors down to the level of the cervix, but not far enough to wound the uterine artery, which has not yet been secured. The round ligament is then ligated close to the uterus, and divided between the ligature and uterus. The tumor is then pulled to the patient's other side, and the broad and round ligaments are divided as on the first side. HOG SURGERY OF THE FEMALE GENITALS This frees the uterus so that in most cases the cervix can be drawn up into the abdominal wound. The tumor is then turned backward, and an incision is made from one round Ligament to the other some- what above the vesical reflection of peritoneum. The peritoneal flap thus formed is pushed away from the cervix by gauze dissection, until at the sides of the cervix the uterine vessels are exposed. These arc clamped close to the uterus and ligated not more than 1 cm. distant; the ureter crosses under the uterine artery about 2 cm. distant from the cervix. The uterine vessels are then divided on both sides, between clamp and ligature. The uterus is then turned well forward over the pubes, and an incision is made across its body above the pouch of Douglas, from one broad ligament attach- ment to the other; and the peritoneal flap thus formed is pushed downward by gauze dissection. Finally the cervix is cut through with scissors in funnel shape, and the uterus is removed. The cervical canal is then closed with catgut sutures, and the stumps of the round and broad ligaments are sutured to it, so as to support it in proper position. Then the peritoneal flaps front and back are united over the cervical stump, closing in all areas denuded of peri- toneum. In most cases the abdomen is closed without drainage. If it is desired to remove the cervix also, the dissection must be carried a little deeper; then the vaginal vault is divided. The surgeon must look for bleeding from the vaginal arteries and secure a dry field before proceeding. Finally, the stumps of the round and broad ligaments are implanted into the vaginal vault. Though removal of the cervix prolongs the operation somewhat, I believe it should always be done in the absence of distinct contra-indications. Vaginal Hysterectomy. — -This is suitable only in cases where the tumor is small, and the vagina sufficiently relaxed. A self-retaining speculum is used (Fig. 1095), and the cervix is closed by sutures or by a double tenaculum forceps, and drawn outside the vulva. An incision is next made all around the cervix, through the mucosa; the incision in the anterior cul-de-sac is deepened, pushing the bladder wall and with it the ureters well upward and forward, until the peritoneal cavity is opened. A finger is then inserted into the pelvic cavity and passed behind the cervix, and on this finger as a guide the posterior vaginal cul-de-sac is further incised until the peritoneal pouch of Douglas is opened. Gauze is then packed into this opening to keep the intestines from prolapsing into the w^ound. Any bleeding is easily controlled by hemostats. If the tumor is not too large, the fundus of the uterus may now be hooked down by the finger and brought out through the incision in the anterior vaginal cul-de-sac. If this can be accomplished the broad ligaments may then be ligated from their ovarian border dowmw r ard to the cervix, as in supravaginal hysterectomy. If the fundus of the uterus cannot be delivered in this way, the broad ligaments are clamped from below r upward, not more than 1 cm. distant from the cervix, removing the tubes and ovaries also if they are diseased (Fig. CARCINOMA OF THE UTERUS 1167 1127). The broad ligaments are then cut through between the clamps and the uterus; and the peritoneum is closed, the gauze pack being removed as the last peritoneal suture is tied. After carefully ligating the broad ligaments, their stumps are sutured to the vaginal vault. A gauze drain is left in the vagina. The operation may be done also without ligatures, leaving the clamps on the broad ligaments for several days. Special clamps, with detachable handles, have been devised for this purpose. Fig. 1127. — Diagram of vaginal hysterectomy, showing application of clamps to the broad ligaments. Carcinoma of the Uterus. — This is exceedingly common, especially in the cervix. Only about 5 to*10 per cent, of cases occur in the body of the uterus. In the cervix the growth almost always is a squamous- celled epithelioma, though carcinoma of the glandular type (adeno- carcinoma) sometimes occurs; while in the body of the uterus the tumor, with a very few rare exceptions, is an adenocarcinoma. Most patients are in the fourth decade of life, approaching or past the meno- pause ; almost all have borne children, and many have had lacerations of the cervix which have not received proper treatment. Carcinoma of the Cervix occurs in two forms: (1) as an everting, vege- tating, proliferating, or cauliflower-like growth; or (2) as an inverting, infiltrating, and contracting growth. At an early stage of the disease these two types are quite distinct, but later the carcinomatous tissue tends to become necrotic, and when sloughs have been shed the cervix is represented only by a crater-like cavity filled with purulent debris (Fig. 1124). The everting type is more easily recognized at an early date, owing to the papillary excrescences which form; whereas in the infiltrating type very extensive invasion of the cervical tissues may occur before there is much alteration in the appearance of its vaginal surface. Extension occurs to all surrounding tissues, but in no definite order. The bases of the broad ligaments frequently are invaded early, so that the uterus becomes fixed; the ureters are surrounded and may 1168 SlliCKRY OF THE FEMALE GENITALS become compressed by the growth; the pelvic lymphatics up to and even beyond the bifurcation of the aorta are invaded; sometimes exten- sion to the inguinal lymphatics occurs; the growth extends locally into the vaginal vault, and the bladder and even the rectum may be infiltrated, so that late in the disease distressing vesicovaginal fistula? (rarely rectovaginal) may form. In most cases the uterine body remains free of disease, the carcinomatous growth rarely extending above the level of the internal os. Symptoms. — These usually are absent or are overlooked until the disease is quite far advanced; only from 10 to 20 per cent, of patients applying for treatment are susceptible of cure. The most important symptom, and usually the earliest, is bleeding, especially intermenstrual or occurring after the menopause. Usually this bleeding occurs spon- taneously, and is moderate or apparently insignificant in amount; it may follow coitus or defecation; occasionally it is profuse and pros- trating. Such a sudden and alarming hemorrhage almost always is due to carcinoma and not to fibroids. The bleeding is painless as a rule, and unless the woman notes its occurrence and submits to vaginal examination, she may go along for months before anything further occurs to call attention to her condition. There may be, indeed there usually is, a certain amount of leucorrhea; and the serous, watery, or blood-stained character of this, and at a later period its fetor, may arrest her attention. Pain is a late and unimportant symptom; it rarely is severe until the sacral plexus is involved and the tumor entirely inoperable. The disease may thus be divided clinically into three stages: (1) the stage of occasional hemorrhage; (2) the stage of gradual decline of health, with fetid leucorrhea; and (3) the inoperable, hopeless stage, with excru- ciating pain, and disgusting odor, the patient's condition being loath- some to herself and all about her. The average duration of the disease from first symptoms to death averages from fifteen to twenty months. Carcinoma of the body of the uterus presents the same symptoms, but they develop at a much later period, and are not attended by any definite physical signs, except slight enlargement of the uterus. It is much more frequent in women who have borne no children than carcinoma of the cervix. Diagnosis. — Every woman whose symptoms suggest the mere pos- sibility of the disease should be submitted to a competent surgeon for a most painstaking vaginal examination; any alteration in the cervix, especially if bleeding is easily aroused, should be regarded as suspicious, and a section should be taken for microscopic study. This is easily done after swabbing the cervix inside and out with 10 per cent, eucain solution; the section (removed with knife or scissors) should extend from the cervical canal into apparently healthy tissue, and should be submitted to a pathologist for prompt report. If a carcinoma of the uterine body is suspected, the curette should be used, and the scrapings mounted and examined histologically. Treatment. — A radical operation, similar in scope to that practised in cases of carcinoma of the breast, and involving removal of the pelvic CHORIO-EPITHELIOMA MALIGNUM 1169 lymph nodes and connective tissues in one mass with the diseased uterus, was systematized in 1895 by Ries, elaborated by Sampson, and popularized by Mackenrodt, Wertheim, and others; but while in theory this procedure is correct, it is found that the immediate mortality even in the hands of skilled gynecological operators is about 25 per cent. 1 An inexperienced surgeon will not be able to do a com- plete operation, and in his attempt to be ultra-radical probably will do more harm than good. Many investigators claim that a truly radical operation is impossible, and point out that autopsies have shown that whenever carcinomatous lymph nodes were removed at operation, others were overlooked. It seems to me that we must look upon these radical methods as still upon trial, and only to be attempted by exceptionally skilled and experienced operators in carefully selected cases. When the uterus is not fixed its removal by the ordinary method of pan-hysterectomy (p. 1165), paying special attention to wide excision of the vaginal vault, but without attempts to dissect the pelvic lymph nodes, is an operation not attended by an unjustifiable primary mortality; and many patients so treated will be restored temporarily to health and enjoyment of life; and when recurrence or metastasis takes place, as it almost surely will, the condition will be much less distressing than if no operation had been performed. High amputation of the cervix by the electrocautery knife, may be used as a preliminary to dispose of the sloughing vaginal mass, the abdominal hysterectomy being postponed for ten days or two weeks. When the uterus is fixed, and its removal appears impossible, the patient's comfort may be greatly promoted and her life prolonged by cauterizing the growth thoroughly with the actual cautery. This palliative operation may be repeated every few months, and may be used in cases of recurrence after hysterectomy. It deserves to be employed with more enthusiasm than is usually accorded to palliative operations. 2 Chorio-epithelioma, or Deciduoma Malignum (Sanger, 1888), is an exceedingly malignant tumor growing in the body of the uterus after pregnancy. The pregnancy frequently is terminated before term, and the most favorable cases are those in which the diagnosis is made by the pathologist from examination of retained tissues removed in such cases (Fig. 1128). Such examination never should be neglected. The tumor probably arises from the chorionic and not from the decidual tissues; it behaves like the most malignant types of sarcoma, giving early venous metastasis, especially to the lungs (78 per cent.) and vagina (54 per cent.) (Dorland). Vaginal growths may be the only evidences of the disease. The chief symptoms resemble those of uterine carcinoma, namely bleeding, and watery leucorrhea. 1 Though Cobb (1920) reports a mortality of 11.6 per cent, in 60 cases, with 20 out of 50 patients free from recurrence after five years. 2 Systematic cauterization of cervical carcinomata was introduced by Byrne (1896), and has been revived by Percy (1914), who claims that the use of low grades of heat for prolonged periods (made possible by a water-cooled speculum) kills the carcinoma cells without destroying normal tissues. His views are not shared by most surgeons. 74 1170 SURGERY OF THE FEMALE CENITALS The proper treatment is pan-hysterectomy, if the diagnosis is made before distant metastases occur. Removal of vaginal growths in cases where the uterus appears free from the disease, has occasionally proved successful. ■ ^. ., v ■ Fig. 1128. — Chorio-epithelioma in a patient aged forty-two years. Diagnosis made from microscopical examination of scrapings from endometrium ten days after an abortion. Immediate hysterectomy. No recurrence after six years. Fig. 1129. -Carcinoma of vulva; age forty-five years; duration eight months. Pennsylvania Hospital. Carcinoma of the Vulva is not very rare (Fig. 1129). Extension occurs to the inguinal lymph nodes, and radical operation requires the extirpation of these on both sides, the technique being similar to that adopted in cases of carcinoma of the external genitals of the male. INDEX. Abdomen, distention, 859 gunshot wounds, 211, 897 treatment, 845 injuries, 891 operation, 894 operations, 869 pendulous, 953 stab wounds, 896 Abdominal incisions, 870 operation, after-treatment, 876 preparation of patient, 875 technique, 874 section, 869 tumors, diagnosis, 1007 wall, contusion, 891 rigidity, 857 rupture, 891 woimd, suture, 881 Ablation of breast, 770 Abortion, tubal, 1148 Abrasions, 159 Abscess, 26, 46 acute, 46 diagnosis, 48 dressing, 51 pathology, 46 treatment, 49 drainage, 50 Hilton's method, 50 alveolar, 707 appendicular, 910 axillary, 777 Bezokl's 679 bone, 479 brain, 624 breast, 750 Brodie's, 479 chronic, 46 cold, 46, 77, 519 treatment, 526 digital, 311 gluteal, 653 iliac, 864 traumatic, 892 ischiorectal, 958 liver, 991 lumbar, 653, 864 lung, 799 mammary, 750 metastatic, 71 neck, 724 Abscess, ovary, 1135 palmar, 313 pancreas, 1001 parosteal, 469 pelvic, 864, 1153 extraperitoneal incision, 1096 vaginal puncture, 1154 pelvi-rectal, 958 peri-anal, 958 perinephric, 1031 peritonsillar, 713 peri-urethral, 1082 phlegmonous, 46 pointing, 47 post-Ochsner, 912 prostate, 1083 psoas, 653 residual, 856 peritoneal, 864 retropharyngeal, 652 retrorectal, 958 scrofulous, 46 spinal, 652 diagnosis, 653 spleen, 1009 subcranial, 623 submammary, 751 submucous, 958 subpectoral, 778 subphrenic, 865 subscapular, 779 suprascapular, 780 tongue, 695 tubo-ovarian, 1134 vulvo-vaginal, 1128 Acapnia, 182 Acetabular rim, fracture, 361 Achillodynia, 298 Achondroplasia, 455 Acid burns, 178 Acidosis, 188 Acne rosacea, 667 Acromegaly, 467 Acromioclavicular dislocation, 430 Actinomycosis, 82 Acupressure, 261 Acupuncture, 144 Adamantinoma, 112 Adenitis, 299 cervical, 723 Adenocarcinoma, 126 breast, 763 Adenoma, 120 (1171) 1172 INDEX Adenoma of breast, 762 of rectum, '.Mis Adenosarcoma, 100 Adherent prepuce, I L02 Adhesions, peritoneal, 805 Adhesive glue, 204 Agnew's operation, webbed fingers, 549 Ainhum, 63 Air-hunger, 259 Air passages, foreign bodies, 715 operations, 718 surgery, 715 sinuses, operations, 705 Albee's bone saw, 248 operation, 059 Albert-Lemberl suture, 881 Albert's disease, 298 Alexander's operation, 1143 Alexins, 23 Alimentary glycosuria, 1003 Allis's sign, 400 Alveolar abscess, 707 Alveolus, periostitis, 710 tumors, 710 Ambulance chirurgieal automobile, 191 Amebic dysentery, 950 Amputating knives, 215 Amputations, 212 ankle-joint, 231 arm, 227 Ashhurst's, 232 Berger's, 230 Bier's osteoplastic, 222 Billroth's, 235 Brashear's, 234 breast, 759 cervix, 1139, 1109 Chopart's, 231 cinematoplastic, 250 circular method, 218 conditions requiring, 212 Dieffenbach's, 234 dressing, 216 Dupuytren's, 228 Einschnitt, 217 elbow, 227 elliptical method, 220 fingers, 224 flap method, 220 foot, 230 forearm, 226 Fourneaux-Jordan's, 234 in gangrene, 60 Gritti's, 233 guillotine, 217 Guthrie's, 234 Hancock's, 231 hand, 224 Hey's, 230 hip-joint, 233 instruments, 212 interilioabdominal, 235 intermediate, 223 interscapulo-thoracic, 230 knee-joint, 232 Larrey's 227, 234 Amputations, Lee's, 232 leg, 232 Lisfranc's, 230 medio-tarsal, 230 metacarpal, 226 methods, 217 modified circular method, 220 mortality, 223 multiple, 220 neuroma, 326 operative procedure, 215 oval method, 220 penis, 1106 phalanges, 230 Pirogoff's, 231 "poor man's," 225 primary, 223 racket method, 220 "rich man's," 225 en saucisse, 217 secondary, 223 Sddillot's, 704 Senn's, 235 shoulder-joint, 227 Skey's, 230 special, 224 Spence's, 227 spontaneous, 59 Stokes's, 233 subastragalar, 231 supracondylar, 233 Syme's, 231 Teale's, 232 Textor's, 231 thigh, 233 thumb, 226 transcondylar, 233 traumatic, 212 wrist-joint, 226 Anaplasty, 236 Anastomosis, intestinal, 884 end-to-end, 884 lateral, 886 Murphy button, 890 Anatomical tubercle, 74 Anemia, splenic, 1010 Anesthesia, 149 accidents, 152 chloroform, 153 ether, 150 ethyl chloride, 153 freezing, 157 general, 150 administration, 154 choice, 154 infiltration, 158 intratracheal insufflation, 155 local, 157 nitrous oxide, 153 primary, 151 spinal, 158 Anesthetics, 149 Aneurysm, 278 by anastomosis, 278 Anel's ligation, 285 arterio-venous, 207 INDEX 1173 Aneurysm, bone, 487 Brasdor's ligation, 286 causes, 287 cirsoid, 278 classification, 249 dissecting, 2S0 extirpation of sac, 288 false, 279 filipuncture, 287 fusiform, 280 Hunter's ligation, 285 ligation, 285 Matas's operation, 288 needle, 164 racemose, 278 saccular, 280 traumatic, 265, 278 treatment, 284 non-operative, 284 operative, 285 true, 279 tubular, 280 varicose, 267 venous, 265 Wardrop's ligation, 286 wiring, 287 Aneurysmal bruit, 283 varix, 267 Aneurysmoplasty, 288 Angeioleucitis, 299 Angeioma of breast, 762. See Hem- angeioma. cavernous, 277 Angeiotripsy, 261 Angina Ludovici, 693 Ankle, arthroplasty, 256 dislocation, 451 fractures, 416 sprained, 421 tuberculosis, 542 Ankle-joint amputation, 231 Ankylosis, 508 temporo-maxillary joint, 709 Anoci-association, 149 Anteflexion of uterus, 1143 Ante version of uterus, 1143 Anthrax, 85 Antisepsis, 36, 141 Antiseptic methods, 143 Antiseptics, 36 Antitoxic sera, 44 Antitoxins, 23 Antrum, maxillary, 706 Antyllus, operation of, 287 Anuria, calculous, 1036 Anus, carcinoma, 968 examination, 955 false, 947 formation of, 969 fissure, 960 imperforate, 956 surgery, 955 Apoplexy, 621 Appendicitis, 900 acute, 903 complications, 909 Appendicitis, acute, operation, 906 treatment, 906 causes, 902 chronic, 901, 915 gangrenous, 913 leukocytosis, 904 obliterans, 901 pathogenesis, 900 simple phlegmonous, 901 ulcerative, 901 Appendicostomy, 950 Appendicular abscess, 910 Appendix, carcinoma, 915 coprolith, 902 cyst, 902 empyema, 902 foreign bodies, 902 gangrene, 901 intussusception, 916 necrosis, 901 occlusion of lumen, 902 operation, incisions, 872 removal, 907 stricture, 902 surgery, 900 tuberculosis, 915 Arrow-wounds, 174 Arsphenamin, 1060 Arterial embolism, 273 thrombosis, 273 varix, 278 Arteriectasis, 279 Arteriorrhaphy, 266 Arteriovenous wounds, 267 Artery, ligation, 262 middle meningeal, 613 Arthrectomv, 529 Arthritis, 492 acute, of infants, 464 rheumatic, 473 atrophic, 493 deformans, 493 gelatinous, 520 gonococcic, 514 hypertrophic, 497 metastatic, 515 nodosa, 493 rheumatic, 516 senile, 498 tuberculous, 519 typhoid, 514 villous, 503 Arthrodesis, 570 Arthrolvsis, 509 Arthroplasty, 252 Ascites, 995 Asepsis, 36, 141 Aseptic fever, 68 methods, 144 Ashhurst's amputation, 232 Asphyxia, traumatic, 776 Aspiration, 149 Astragalectomy, 565 Astragalus, dislocation, 452 fracture, 419 Atrophic arthritis, 493 1174 INDEX At rophy, bone, l"> I prostate, 1097 Auricle, prominence of, 677 supernumerary, 077 Autotransfusion, '_'- 1 Axillary abscess, 777 infusion, 140 Azotorrhea, 1002 B Bacillary dysentery, 950 Bacteria in inflammation, 18 pathogenic, 18 pyogenic, 28 saprophytic, 19 Bacteriemia, 08 Bacteriolysins, 23 Bacteriuria, 1019 Balanitis, 1105 Balano-posthitis, 1105 Bandage, elastic webbing, 137 figure-of-eight, 137 flannel, 137 gauze, 137 many-tailed, 137 muslin, 135 plaster-of-Paris, 139 recurrent, 137 of Scultetus, 137 spica, 137 spiral, 137 reversed, 137 T-, 139 Bandaging, 135 Banti's disease, 1010 Bartholin's gland, cyst of, 1129 Bartholinitis, 1127 Barton's fracture, 392 Base hospital, 192 Basedow's disease, 737 Bassini's operation, 839 Battlefield, diagram, 191 Bayonet wounds, 174 Bazin's disease, 295 Beck's bismuth paste, 527 operation, 1100 Bed-sore, 61 Bed-sores in spinal injury, 045 Bezold's abscess, 079 Bier's hyperemia, 40 osteoplastic amputation, 222 Bile-ducts, carcinoma of, 997 operations, 984 surgery, 974 Biliary calculus, 977 colic, 975, 979 fistula, 983 sand, 977 Billroth's amputation, 235 gastrectomy, 933 powder, 178 Birth injuries, 1138 shoulder, 550 "Birth-mark," 270 Bismuth paste, 527 Bistoury, 48 Bites, 174 Bladder, calculus in, 1021 carcinoma, 1021 contracture, 1097 diverticulum, 1019 exstrophy, 1017 foreign bodies, 1020 injuries, 1020 irrigation, 1019 papilloma, 1021 rupture, 1020 surgery, 1013 tuberculosis, 1020 tumors, 1021 Blank cartridge wounds, 198 Blastoma, lOO Blastomatoid growths, 107 Blastomycosis, 84 Blood, transfusion, 147 Blood-vascular system, diseases, 209 surgery, 259 Bloodvessels, gunshot wounds, 203 subcutaneous injuries, 265 suture of, 200 wounds, 200 Boas's area, 979 Boil, 291 Bond splint, 391 Bone abscess, 479 aneurysm, 487 atrophy, 454 carcinoma, 491 caries, 475 congenital absence, 540 cysts, 403 diseases, 454 dystrophies, 454 felon, 317 fibromas, 487 gunshot wounds, 204 hypertrophy, 400 infections, 467 inlay, 249 necrosis, 474 osteomyelitis, 468 Paget's disease, 463 sarcoma, 487 syphilis, 482 transplant, 248 tuberculosis, 479 tumors, 485 wax, 478 Bottini operation, 1091 Bougie k boule, 1070 Bougies, 1070 filiform, 1070 Bow-legs, 457 Braces, 057 Brachial birth palsy, 550 Bradford frame, 524 Brain, abscess, 624 carcinoma, 626 compression, 610 concussion, 014 INDEX 1175 Brain, contusion, 614 cysts, 626 endothelioma, 626 fibroma, 626 glioma, 626 sarcoma, 626 surgical affections, 612 syphiloma, 626 tuberculoma, 626 tumor, 626 decompression, 634 resection of skull, 632 treatment, 636 Branchial cysts, 731 fistula, 731 Branchiogenic carcinoma, 731 Brasdor's ligation, 286 Brashear's amputation, 234 Breast, ablation of, 770 after-treatment, 773 abnormal involution, 756 abscess, 750 adenoma, 762 adeno-sarcoma, 763 amputation, 759 angeioma, 762 caked, 749 cancer cyst, 769 carcinoma, 763 cauterization, 774 extension, 769 inoperable, 774 medullary, 768 oophorectomy, 774 operation, 770 end-results, 778 palliative, 774 recurrence, 774 scirrhous, 764 simplex, 767 congenital anomalies, 748 cystadenomatosis, 756 cystic disease, 756 cystosarcoma phyllodes, 761 enchondroma, 762 endothelioma, 762 fibro-adenoma, 759 fibro-adenomatosis, 755 fibrocystadenoma, 761 gumma, 753 hydatid disease, 761 hypertrophy, idiopathic, 755 involution, 756 irritable tumor, 751 lipoma, 762 neuralgia, 751 periductal fibroma, 760 myxoma, 760 plastic resection, 760 proliferous cysts, 761 sarcoma, 762 scirrhus, 764 acute, 767 senile parenchymatous hypertrophy, 756 surgery, 748 Breast, syphilis, 753 tuberculosis, 753 tumors, 754 benign, 759 cystadenomatous, 761 malignant, 762 periductal, 759 Broad ligament cyst, 1157 Brodie's abscess, 479 Bronchiectasis, 800 Bronchoscopy, 716 Bryant's line, 400 Bubo, 299 chancroidal, 1061 parotid, 672 syphilitic, 1047 Bubonocele, 831 Buchanan s bone inlay, 249 Budin's sign, 750 Buerger's disease, 58 Bullet wounds, 194 Bunion, 290 Buried suture, 163 Burns, 176 acid, 178 electric, 180 mustard gas, 178 treatment, 177 x-ray, 180 Bursa, wound, 297 Bursitis, 298 subdeltoid, 507 Bursting fractures, 603 Button, Murphy, 890 Cachexia thyreopriva, 737 Caked breast, 749 Calcaneum, fracture, 419 Calcaneus, paralytic, 568 Calculous anuria, 1036 Calculus, biliary, 977 lacteal, 753 pancreatic, 1004 preputial, 1105 renal, 1032 salivary, 675 ureteral, 1035 vesical, 1021 Callositas, 290 Cailous ulcer, 54 Callus, 337 Calmette's serum, 176 Cammidge reaction, 1003 Cancer, mammary, 764 Cancrum oris, 63 Cantwell's operation, 1102 Capillary nevi, 276 Caput obstipum, 579 succedaneum, 595 Carbolic acid gangrene, 59 Carbuncle, 292 of lip, 688 Carcinoma, 121 1176 INDEX Carcinoma, anus, 968 appendix, 915 bile-ducts, 997 I .ladder, 1021 I e, 49 I brain, 026 branchiogenic, 731 breast, 763 cauterization, 774 extension, 796 inoperable, 774 medullary, 768 oophorectomy, 774 operation, 770 palliative, 774 radical, end-results, 774 recurrence, 774 cecum, 949 cervix, 1167 cheek, 672 columnar-celled, 126 cylindrical-celled, 126 duodenum, 928 encephaloid, 127 esophagus, 747 gall-bladder, 997 glandular, 126 jaw, 710 kidney, 1038 larynx, 717 liver, 996 lymph nodes, 304 medullary, 127 ovary, 1159 pancreas, 1004 penis, 1105 prostate, 1097 rectum, 968 radical operation, 970 scirrhous, 126 simplex, 127 solid-celled, 127 squamous-celied, 123 stomach, 925 thyroid, 741 tongue, 697 tonsil, 714 treatment, 128 uterus, 1167 vulva, 1170 Carcinomatous mastitis, 768 Cardiolysis, 269 Cardiospasm, 746 Caries, bone, 475 costal cartilage, 780 ribs, 780 sicca, 519 skull. 481 Carotid gland, tumors, 729 Carpus, dislocation, 440 fracture, 395 Carrel tubes, 170 Carrel's arteriorrhaphy, 266 Carrel-Dakin treatment, 170 pleural fistula, 797 Carrying angle, 383 ( iartilage transplants, 247 Castration, 1113 < 'atarrhal jaundice, 976 Catheter, 1013 Merrier, 1090 Catheterism, 1089 Catheterization, ureters, 1016 ( auterization, 144 Cavernous angeiomas, 277 Cecostomy, 950 Cecum, carcinoma, 949 mobile, 953 Celiotomy, 869 Cellulitis, 64 Celluloid jackets, 657 Cephalic pancreatectomy, 1005 Cephalhematoma, 595 Cephalocelc, 597 Cerebellum, tumor, 630 Cerebral palsies, 572 Cerebritis, 624 Cerumen, impacted, 675 Cervical adenitis, 723 ribs, 582 Cervix, amputation, 1139, 1169 carcinoma, 1167 laceration, 1138 stenosis, 1126 Chain suture, 163 Chancre, 81, 1045 mixed, 1046 of tongue, 696 Chancroid, 1060 bubo, 1061 treatment, 1063 Charbon, 85 Charcot's intermittent fever, 981 joint, 497 Chauffeur's fracture, 392 Cheek, carcinoma, 672 surgery, 669 Cheloid, 109 Chemotaxis, negative, 21 positive, 21 injuries, 775 Chest wall, surgery, -775 Chilblain, 180 Chloroform, 153 Chloroma, 114 Cholangeitis, 976 Cholecystectomy, 986 Cholecystenterostomy, 989 Cholecystoduodenostomy, 989 Cholecystitis, 974 calculous, 980 Cholecystostomy, 985 Cholecystotomy, 985 Choledochenterostomy, 983 Choledochostomy, 987 Choledochotomy, 987 retroduodenal, 988 transduodenal, 989 Cholelithiasis, 977 simple, 979 treatment, 981 Cholemia, 981 INDEX 1177 Cholesteatoma, 130 Chondrectomy, 799 Chondrodystrophia fcetalis, 455 Chondroma, 110 Chondrosarcoma, 117 Chopart's amputation, 231 Chordoma, 115 Chorio-epithelioma, 1169 Chromoureteroscopy, 1016 Chylothorax, 299, 788 Chylous ascites, 299 Cicatrization, 30, 52 Cigarette drain, 51 Cinematoplastic amputation, 256 Circular amputation, 218 Circumcision, 1103 Cirrhosis, liver, 995 stomach, 925 Cirsoid aneurysm, 278 Citrate method of transfusion, 147 "Clacking jaw, "428 Clamp and cautery for hemorrhoids, 964 Clap, 1065 Clavicle, dislocation, 429 fracture, 363 Clavus, 290 Cleft palate, 682 operation, 685 Cloacae, 469 Cloquet's hernia, 846 Club foot, 559 hands, 559 Coagulation, electric, 705 Coccygodynia, 362 Coccyx, fracture, 362 Cock's operation, 1Q80 Coin-catcher, 742 Cold abscess, 77, 519 effects of, 178 Coley's fluid, 118 Colic, biliary, 979 renal, 1034 Colitis, 950 Collapse, 183 Colles's fracture, 388 law, 1053 Colon, surgery of, 950 Colostomy, 969 Colpocele, 1139 Colpo-perineorrhaphy, 1140 Colporrhaphy, 1140 Common duct, gall-stone, 981 obstruction, 983 Complement-fixation test, 1057 Compression of brain, 616 Concussion of brain, 614 of spinal cord, 639 Condylomata lata, 1050 Congenital absence of bone, 546 contraction of fingers, 547 dislocations, 547 of knee, 558 hernia, 832 talipes, 558 Congestion, 20 Constipation, chronic, 954 Contracture, Dupuytren's, 585 ischemic, 583 muscles, 307 Contused wounds, 166 Contusion, 159 abdominal wall, 891 brain, 614 scalp, 595 Cooper's hernia, 846 Coprolith in appendix, 902 Cord, spinal. See Spinal cord. Corn, 290 Cornu cutaneum, 291 Corona veneris, 1050 Corpus luteum cyst, 1155 Corset liver, 990 Costal cartilage, canes, 780 Costo-transversectomy, 660 Counter-irritation, 144 Courvoisier's law, 981 Coxa valga, 588 vara, 457 Coxalgia, 530 Cranial defects, repair, 611 Craniocerebral topography, 612 Cricothyrotomy, 719 Critical discharges, 32 Crural hernia, 845 Crushed limbs, treatment, 224 Crutch-palsy, 316 Cryptogenous joint infection, 516 Cryptorchidism, 1107 Cubitus valgus, 583 varus, 583 Cuneiform tarsectomy, 564 Curvature of spine, 573 Cushing's decompressive operation, 634 suture, 882 Cut-throat, 722 Cylindroma, 130 Cyst or cysts, 130 ante-natal, 132 appendix. 902 Bartholin's gland, 1129 bone, 463 brain, 626 branchial, 731 broad ligament, 1157 cancer, 769 corpus luteum, 1155 dentigerous, 711 dermoid, ovary, 1158 scalp, 597 extravasation, 131 Graafian follicle, 1155 hydatid, liver, 993 kidney, 1038 labial, 688 fiver, echinococcus, 993 mesenteric, 949 omental, 949 ovarian, 1155 ovary, torsion, 1156 pancreas, 1006 parasitic, 132 parovarian, 1156 1178 i\i)i:\ Cyst or cysts, pilonidal, 297 post-natal, 131 proliferous mammary, 761 retention, 131 ovary, 1 154 sebaceous, 296 of scalp, 507 sequestration, 131 spleen, 1009 thyro-glossal, 730 tubo-ovarian, 1155 urachal, 1017 ( lystadeno-carcinoma, 126 ( lystadenoma, 120 breast, 756 papilliferum, 120 Cystadenomatosis of breast, 756 Cystic duct, gall-stone, 980 Cystitis, 1018 Cystocele, 1139 Cystoscope, 1015 Cystotomy, suprapubic, 1025 Czerny's suture, 881 Dactylitis, syphilitic, 483 tuberculous, 481 Dakin's solution, 171 Dance's sign, 938 Dangerous area, skull, 612 "Dangle-foot," 570 Davis's brace, 657 incision, 872 operation, tarsus, 571 reduction of hip, 551 Death after operation, 185 Deaver's incision, 872 Debridement, 201 Decapsulation of kidney, 1028 Deciduoma malignum, 1169 Decompressive operation, 634 Decortication of lung, 797 Decubitus, 61 Deformities, congenital, 558 paralytic, 565 Deformity, Sprengel's, 558 Delirium, traumatic, 183 tremens, 184 Demarquay's operation, 1073 Dentigerous cyst, 711 Dermatitis, x-ray, 180 Desmoids, 309 Dessication, electric, 705 Diabetic gangrene, 58 Diapedesis, 20 Diaphragm, eventration, 803 gunshot wounds, 802 hernia, 802 rupture, 802 stab wounds, 801 surgery, 801 Dichloramin-T, 172 Di dot's operation, 549 Dieffenbach's operation, 234 Dietl's crises, 1027 Digital abscess, 311 Digitus malleus, 592 Dilatation, esophagus, 746 stomach, 921 Discission of pleura, 797 I >isinfection, 142 Dislocated kidney, 1027 spleen, 1009 Dislocations, 424 acromio-clavicular, 430 ankle, 451 astragalus, 452 carpus, 440 clavicle, 429 complete, 424 complicated, 427 compound, 427 congenital, 424 elbow, 436 femur, 441 hip, 441 central, 361 congenital, 547 humerus, 430 interphalangeal, 441 knee, 445 congenital, 558 mandible, 428 mediotarsal, 453 metacarpus, 440 metatarsus, 453 Nelaton's, 452 nerve, 316 old, 427 patella, 448 pathological, 424 phalanx, toe, 453 thumb, 440 prognosis, 426 radiocarpal, 440 radius, 438 recurrent, 428 sacro-iliac, 441 scapula, 430 shoulder, 430 congenital, 556 simple, 424 special, 428 spinal column, 640 spontaneous, 424 sternoclavicular, 429 subastragalar, 453 symptoms, 425 tarsus, 452 tendon, 310 tibiotarsal, 451 traumatic, 424 treatment, 426 ulna, 438 wrist, 440 Dissecting aneurysm, 280 Distention of abdomen, 859 Diverticulitis, sigmoid, 952 Diverticulum, bladder, 1019 esophagus, 745 INDEX 1179 Diverticulum, Meckel's, 943 Drainage, 50 tube, 50 Dressings, fixed, 139 removal, 141 plaster-of-Paris, 139 silicate of sodium, 141 starch, 141 Duct cancer, 763 Dudley's operation, 1127 Dugas's sign, 432 Duodenocholedochostomy, 989 Duodenum, carcinoma, 928 gunshot wounds, 898 surgery, 916 ulcer, 916 chronic, 917 hemorrhage, 920 perforation, 919 treatment, 918 Dupuytren's contracture, 585 suture, 882 Dysentery, amebic, 950 bacillary, 950 Dystrophies, bone, 454 joints, 492 E Ear, foreign bodies, 675 furuncle, 676 impacted cerumen, 675 surgery of, 675 Ear-ache, 678 Eau de Javelle, 170 Ecchondroma, 110 Ecchymosis, 159 Echinococcus cyst, fiver, 993 Eck's fistula, 996 Ectopic gestation, 1147 Edebohls's operation, 1028 Edema of glottis, 717 Edematous ulcer, 53 Elbow, amputation, 227 arthroplasty, 253 dislocation, 436 excision, 510 fractures, 375 subluxation, 439 tuberculosis, 543 Electric burns, 180 Electro-coagulation, 705 Electro-dessication, 705 Elephantiasis Arabum, 302 of scrotum, 1119 Embalming solution, Menciere's, 172 Embolism, 269 arterial, 273 mesenteric, 943 pulmonary, 273 retrograde, 71 septic, 70 Embolus, 269 Embryoma, 106 ovary, 1158 Emphysema, pulmonary, 799 surgical, 776 Emphysematous gangrene, 59 Empyema, appendix, 902 articuli, 503 gall-bladder, 975 thoracis, 789 bilateral, 796 encapsulated, 795 necessitatis, 790 Encephalitis, 624 Encephalocystocele, 597 Enchondroma, 110 breast, 762 End-bearing stumps, 222 Endo-aneurysmorrhaphy, 288 Endocervicitis, 1130 Endometritis, 1130 Endoscope, 1016 Endosteoma, 111 Endostosis, 111 Endothelioma, 129 brain, 626 breast, 762 End-to-end anastomosis, 884 Enostosis, 111 Enterocele, 809 Entero-epiplocele, 807 Enterotomy, 941 Epidemic cerebrospinal meningitis, 623 Epididymitis, 1108 Epididymo-orchitis, 1108 Epididymo- vasostomy, 1110 Epigastric hernia, 823 Epilepsy, focal, 636 Jacksonian, 636 Epiphyseal separation, 329 Epiplocele, 809 Epiplopexy, 996 Epispadias, 1101 Epistaxis, 666 Epithelioma, 123 cheeks, 670 deep-seated, 123 lip, 688 papillary, 124 scalp, 597 scrotum, 1119 superficial, 124 Epluchage, 200 Epulis, 710 Equino-varus, congenital, 559 paralytic, 566 Erasion of joints, 529 Erethistic shock, 183 Erysipelas, 65 complications, 66 Erythema induratum, 295 nodosum, 295 Esmarch's elastic band, 213 Esophagoscopy, 742 Esophagotomy, 745 Esophagus, carcinoma, 747 congenital imperforation, 745 dilatation, 746 diverticulum, 745 1180 IXDKX Esophagus, foreign bodies, 742 stricture, 7 1"> surgery, 742 Esqiiillectomy, 205 EstJander's operation, 798 Ether anesthesia, 150 Ethmoidal disease, 705 Ethyl chloride, 153 Eucain anesthesia, 157 Eusol, 170 Evacuation hospital, 190 Eventration of diaphragm, 803 Evidement, 478 Excision, elbow, 510 hip, 539 knee, 510 shoulder, 513 superior maxilla, 712 tumor, 132 wrist, 513 Exclusion of pylorus, 931 Excoriation, 159 Exophthalmic goiter, 737 Exostoses, 111 cartilaginous, 485 fibrous, 486 subungual, 486 Exstrophy of bladder, 1017 Extirpation of penis, 1106 Extradural hemorrhage, 619 Extra-uterine pregnancy, 1147 Facial hemiatrophy, 710 False ankylosis, 508 anus, 947 formation, 969 Farcy, 87 Fascia transplants, 246 Fat transplants, 246 embolism, 188 Fecal fistula, 946 impaction, 942 incontinence, 965 Felon, 311 Female genitals, surgery of, 1121 Femoral hernia, 845 operation, 847 rare forms, 846 Femur, dislocation, 441 reduction, 445 fracture, 398 Ferguson's operation, 843 Fergusson's operation, 685 Fever, aseptic, 68 surgical, 69 Fibroadenoma, 120 Fibroadenomatosis of breast, 755 Fibrocystadenoma of breast, 761 Fibroid, recurrent, 116 uterus, 1160 Fibroma, 108 bone, 487 brain, 626 Fibroma, molluscum, 10S ueck, 732 ovary, 1159 Fibromyoma, uterus, 1160 Flbromyxoma, 109 Fibrosarcoma, 117 Fibrous exostosis, 486 osteitis, 163 Fibula, fracture, 415 field hospital, 190 Figure-of-eight bandage, 137 suture, 164 Filiform bougies, 1070 Filipuncture in aneurysm, 287 Finger, amputation, 224 arthroplasty, 254 contracture, 547 supernumerary, 547 trigger, 586 webbed, 547 Finney's pyloroplasty, 930 First aid station, 190 Fissure, anal, 960 nipple, 749 Rolando, 612 Fistula, 47, 51 in ano, 959 biliary, 983 blind, 51 branchial, 731 Eck's, 996 fecal, 946 gastro-colic, 944 genital, 1146 internal, 944 pancreatic, 1001 pilo-nidal, 297 pleural, 796 Carrel-Dakin treatment, 797 decortication of lung, 797 discission of pleura, 797 thoracoplasty, 798 recto-genital, 968 recto-urethral, 968 recto-urinary, 968 recto-uterine, 968 recto-vaginal, 968, 1146 recto- vesical, 968 salivary, 674 thyro-glossal, 730 treatment, 5i umbilical, 944 urachal, 1017 uretero-cervical, 1146 urinary, 1082 vesico-vaginal, 1146 Fixed dressings, 139 Flap amputation, 220 Flat-foot, 591 Floating kidney, 1027 Focal epilepsy, 636 Foot, amputations, 230 fractures, 419 Forearm, amputations, 226 fractures, 392 Foreign bodies in air passages, 715 INDEX 1181 Foreign bodies in appendix, 902 in bladder, 1026 in esophagus, 742 in inflammation, 18 in urethra, 1071 Forster's rhizotomy, 573 Fourneaux-Jordan's amputation, 234 Fowler's position, S63 Fractura perforans, 361 Fracture, acetabulum, 361 after-care, 342 astragalus, 419 Barton's, 392 bursting, 603 calcaneum, 419 callus, 337 carpus, 395 causes, 330 cerclage, 346 chauffeur's, 392 classification, 327 clavicle, 363 coccyx, 362 Colles's, 388 comminuted, 327 complete, 327 complicated, 328 treatment, 346 compound, 327 treatment, 347 by cont recoup, 603 costal cartilage, 360 by counter-stroke, 603 delayed union, 339 depressed, 328 diagnosis, 334 disability, period of, 343 displacement, 332 double, 327 elbow, 375 face bones, 356 femur, 398 fibula, 415 foot, 419 forearm, 392 green-stick, 327 gunshot, 204 hip, 39S humerus, 368 impacted, 329 incomplete, 327 intra-uterine, 547 ischium, 362 larynx, 717 longitudinal, 328 malar, 356 malunion, treatment, 350 mandible, 357 maxilla, 356 mechanism, 329 metacarpus, 396 metatarsus, 420 multiple, 328 by muscular action, 331 nasal, 356 non-union, 339, 352 Fracture, treatment, 353 oblique, 328 olecranon, 385 patella, 408 pathological, 331 pelvis, 360 phalanges, fingers, 396 toe, 420 plating, 344 Pott's, 416 prognosis, 336 radius, 387 ribs, 359 ring, 604 sacrum, 362 scapula, 367 semilunar cartilage, 448 simple, 327 operative treatment, 343 skeletal traction, 340 skiagraphy, 335 skull, 602 base, 609 newborn, 608 vault, 604 spiral, 328 splint, 341 spontaneous, 331 sprain, 331 sternum, 358 symptoms, 331 tarsus, 419 tibia, 412 transportation, 204 transverse, 328 treatment, 339 ulna, 385 union, process of, 336 ununited, 339, 352 treatment, 353 vertebra?, 640 zygoma, 356 Fragilitas ossium, 454 Frazier-Spiller operation, 324 Frontal sinus, 706 sinusitus, 705 Frost-bite, 179 Fungus cerebri, 635 Funnel breast, 775 Furuncle, 291 of ear, 676 Fusiform aneurysm, 280 G Galactocele, 752 Gall-bladder, carcinoma, 997 empyema, 975 hydrops, 975 operations, 984 incisions, 871 rupture, 894 surgery, 974 Gall-stones, 977 in common duct, 981 in cystic duct, 980 IIS'J IX !>!•:. X ( lalt's trephine, 608 ( langlion, 314 gasserian, extirpation, 324 Gangrene, 57 amputation, 60 spontaneous, 59 appendix, 901 carbolic acid, 59 causes, 58 diabetic, 58 amputation, GO dry, 59 emphysematous, 59 foudroyante, 88 gas, 89 sera, 91 lino of demarcation, 59 of separation, 59 lung, 799 moist, 59 pancreas, 1001 senile, 58 special forms, 61 symmetrical, 64 symptoms, 59 traumatic, 88 treatment, 60 Gangrenous stomatitis, 63 Gardener's spade deformity, 392 Gas gangrene, 89 Gasserian ganglion, extirpation of, 324 Gastrectomy, 933 Billroth's, 933 Hartmann's line, 926 partial, 933 subtotal, 935 total, 936 Gastric ulcer, 916 Gastro-anastomosis, 924 Gastro-colic fistula, 944 Gastrogastrostomy, 924 Gastro-intestinal tract, rupture of, 893 surgery, 900 Gastrojejunal ulcer, 933 Gastrojejunostomy, 930 Gastroplasty, 922 Gastrostomy, 929 Gastrotomy, 928 Gelatinous arthritis, 920 Gely suture, 881 Genital fistula, 1146 Genitalia, female, examination, 1122 Genitals, female, surgery, 1121 male, surgery, 1099 Genu varum, 57 Gestation, ectopic, 1147 Giant-cell myeloma, 112 sarcoma, 112 Gillies's transplants, 243 Glanders, 87 Gleet, 1066 Glioma, 115 brain, 626 Gliosarcoma, 117 Glossitis, 695 gummatous, 697 ( I lot 1 is, edema of, 717 ( Hue, adhesive, 201 Gluteal abscess, 653 Glycosuria, alimentary, 1003 Goiter, 733 adenomatous, 736 colloid, 734 cystic, 734 diffuse, 735 exophthalmic, 737 operation, 7 10 treatment, 739 nodular, 735 operation, 736 parenchymatous, 735 treatment, 736 Gonococcic joint infection, 514 urethritis, 1065 Gonorrhea, 1064 female, 1127 treatment, prophylactic, 1066 Graafian follicle cyst, 1 1 55 Grant's operation, lip, (590 Granulation, 52 tissue, 26, 30 Granuloma, infectious, 74 Graves's disease, 737 Gridiron incision, 872 Gritti's amputation, 233 Guillotine amputation, 217 Gumma, 82, 1052 of breast, 753 of tongue, 696 tuberculous, 76 Gunshot fractures, 205 wounds, 190 abdomen, 897 bloodvessels, 203 bones, 204 diaphragm, 802 duodenum, 898 head, 208 intestine, 211, 897 joints, 206 liver, 898 lungs, 209 nerves, 204 pancreas, 899 spine, 209 spleen, 899 stomach, 89S tendons, 204 thorax, 209 Guthrie's amputation, 234 Gypsum, 139 H Hallux valgus, 592 Halsted's suture, 882 Hammer toe, 592 Hancock's amputation, 231 Hand, amputation, 224 Handley's operation, 301 Hare-lip, 682 INDEX 1183 Hare-lip, double, 684 suture, 162 Harrison's groove, 456 Hartmann's line for gastrectomy, 826 Head, deformities, 579 gunshot wounds, 208 operations, anesthetic, 154 surgery of, 595 Heart, foreign bodies in, 269 injuries, 268 massage, 269 rupture, 268 wounds, 268 Heat, effects of, 38 prostration, postoperative, 1S9 Heberden's nodes, 497 Hectic fever, 73 Heel, painful, 594 Heliotherapy, 527 Hemangeio-endothelioma, 130 Hemangeioma, 276 Hemarthrosis, 424 Hematocele, 1118 Hematocolpos, 1126 Hematoma, 160 auris, 676 treatment, 265 Hematometra, 1126 Hematomyeha, 639 Hematorrachis, 639 Hemiatrophy, facial, 710 Hemilaryngectomy, 721 Hemophilia, 259 Hemoptysis, 783 Hemorrhage, 259 apparent, 259 arterial, 259 concealed, 259 constitutional signs, 259 extradural, 619 internal, 229 intestinal, in typhoid, 945 intracerebral, 621 intradural, 620 middle meningeal, 619 operative, 186 primary, 186 reactionary, 186 secondary, 186, 264 spinal canal, 639 spontaneous arrest, 260 subcranial, 619 subcutaneous, 259 treatment, 260 venous, 259 Hemorrhagic pancreatitis, 999 peritonitis, 856 Hemorrhoids, 961 clamp and cautery, 964 ligation, 963 Hemostasis, Wyeth's method, 227 Hemothorax, 787 Hepatic duct, gall-stone, 981 Hepatico-enterostomy, 983 Hepaticus drainage, 988 Hepatitis, suppurative, 991 Hcpatoptosis, 990 Hepatotomy, 992 Hereditary deforming chondrodysplasia, 485 syphilis, 1053 Hermaphrodism, 1102 Hernia, 805 causes, 806 cecal, sliding, 836 cerebri, 635 classification, 822 Cloquet's, 846 congenital, 832 Cooper's, 846 crural, 845 diaphragmatic, 802 epigastric, 823 femoral, 845 operation, 847 rare forms, 846 strangulated, 850 of Hesselbach, 846 incarcerated, 813 incisional, 824 inflamed, 812 inguinal, 831 direct, 843 rare forms, 844 treatment, 844 oblique, 831 operation, 839 rare forms, 836 recurrence, 837 strangulation, 835 preperitoneal, 836 trusses, 837 inguino- crural, 836 interna], 939 interparietal, 836 interstitial, 836 irreducible, 811 ischiatic, 852 labial, 831 Laugier's, 846 Littre's, 807 lumbar, 830 lung, 786 muscular, 304 nomenclature, 805 obstructed, 812 obturator, 851 operation, contraindications, 810 Partridge's, 846 pectineal, 846 perineal, 851 pudendal, 851 recurrence, 837 reducible, 808 retroperitoneal, 939 retrovascularis, 846 Richter's, 807 sac, 806 acquired, 807 congenital, 807 contents, 807 sliding, 836 MM INDEX Hernia, special, 822 strangulated, 813 diagnosis, 816 operation, SIS treatment, 817 structures, son supravesical, S I 1 taxis, Ms of Tessier, Sit! treatment, 809 truss, 810 umbilical, 826 adult, 827 congenital, 826 infantile, 826 strangulated, 830 vaginal, 851 ventral, 823 Ilerniotome, 819 Herniotomy, 819 Herpes progenitalis, 1105 Hesselbach's hernia, 846 Hey's amputation, 230 Hilton's law, 522 method of opening abscesses, 50, Hip, arthroplasty, 254 central dislocation, 361 dislocation, 441 congenital, 547 excision, 539 fracture, 398 snapping, 588 tuberculosis, 530 Hip-joint amputation, 233 Hirschsprung's disease, 955 Hodgen's splint, 205 Hodgkin's disease, 115, 302 Hood truss, 838 Horn, 291 Horse-shoe kidney, 1026 Horsley's dural separator, 607 wax, 632 Hospital, base, 192 evacuation, 190 field, 190 gangrene, 62 trains, 192 Hotchkiss's meloplasty, 669 Hour-glass stomach, 923 "Housemaid's knee," 298 Hudson's trephine, 633 Humerus, dislocation, 430 reduction, 433 fracture, 368 Hunger-pain, 918 Hunter's ligation, 285 Hutchinson's teeth, 1055 Hydatid cyst, liver, 993 disease, breast, 761 of Morgagni, 1157 Hydrarthrosis, 507 Hydrencephalocele, 597 Hydrocele, 1115 acquired, 1115 acute, 1109 canal of Nuck, 1117 Hydrocele, congenital, 111- - * cord, 1117 encysted, 1117 operation, 1117 tapping, 1117 Hydrocephalus, 59S congenital, 600 hypersecretory, 601 obstructive, 599 Hydronephrosis, 1031 Hydrophobia, 96 Hydrops articuli, 503 gall-bladder, 975 Hydrorrachis, 637 Hydrosalpinx, 1134 Hydrothorax, 788 Hygroma, 732 Hyloma, 106 Hymen, imperforate, 1126 Hyperemesis lactantium, 921 Hyperemia, active, 20 passive, 20 Bier's, 40 Hyperkeratosis, 123 724 Hypernephroma, 129 kidney, 1038 Hyperostosis, 111 Hyperthyroidism, 733, 737 Hypertrophic joint lesions, 497 Hypertrophy, bone, 466 prostate, 1084 Hypodermic injections, 145 Hypodermoclysis, 146 Hypoleukocytosis, 31 Hypophysis, tumors, 630 Hypospadias, 1099 Hypothyroidism, 733, 737 Hysterectomy, abdominal, 1165 vaginal, 1166 Hysteropexy, 1143 Ichthyosis of tongue, 695 Ileus, 936 Iliac, abscess, 864 traumatic, 892 Imperforate anus, 956 esophagus, 745 hymen, 1126 rectum, 957 vulva, 1125 Incarcerated hernia, 813 Incised wounds, 160 Incision, abdominal, 870 closure, 873 suture, 881 Davis's, 872 Deaver's, 872 gall-bladder, 984 gridiron, 872 kidney, 1040 McBurney's, 872 Mayo Robson's, 872 muscle-splitting, 872 INDEX 1185 Incision, simple, 872 Sprengel's, 984 transverse, 872, 984 Incisional hernia, 824 Indian rhinoplasty, 667 Indigo-carmine test, 1016 Indolent ulcer, 54 Infantile paralysis, 565 stenosis, pylorus, 921 Infectious granulomas, 74 Infiltration anesthesia, 158 Inflammation, 17 alexins, 23 antitoxins, 23 bacteriolysins, 23 causes, 18 bacteria, 18 endotoxins, 19 exciting, 18 predisposing, 18 toxins, 19 chronic, 35 cure, 37 diapedesis, 20 diseases resulting from, 46 extension, 27 fibroblasts, 22 foreign bodies, 18 general affections, 67 leukocytes, 22 leukocytosis, 31 lymphs 23 lymphization, 23 lymphocytes, 22 lymphogenesis, 23 margination, 20 migration, 20 nervous system, 27 pathology, 19 summary, 29 phagocytosis, 23 phlegmonous, 26 polyblasts, 22 pyrexia, 68 regeneration, 30 repair, 29 resolution, 27 resulting affections, 70 round-cell infitration, 23 symptoms, 31 constitutional, 31 heat, 33 impaired function, 34 local, 32 modification of nutrition, 35 muscular rigidity, 34 pain, 33 redness, 32 swelling, 33 tenderness on pressure, 34 terminations, 27 treatment, 35 alteratives, 43 Bier's congestion, 40 bleeding, 39 cathartics, 42 75 Inflammation, treatment, cold, 38 compression, 40 congestion, 40 constitutional, 41 counter-irritants, 39 diaphoretics, 42 diet, 41 diuretics, 42 douches, 39 heat, 38 hygiene, 41 incisions, 39 irrigation, 38 local, 37 massage, 40 narcotics, 39 operations, 40 position, 37 prophylaxis, 35 rest, 37 sedatives, 41 serum therapy, 44 stimulants, 42 stimulation of phagocytosis, 43 tonics, 43 vaccins, 44 venesection, 39 Inflammatory fever, 69 lymph, 23 Infusion, axillary, 146 intravenous, 146 Ingrowing toe-nail, 291 Inguinal hernia, 831 direct, 843 rare forms, 844 treatment, 844 oblique, 831 rare forms, 836 treatment, 837 recurrence, 837 strangulation, 835 trusses, 837 Inguino-crural hernia, 836 Injuries, general effects, 181 local effects, 159 Insect stings, 174 Interparietal hernia, 836 Interphalangeal dislocation, 441 Interrupted suture, 162 Interscapulo-thoracic amputation, 230 Interstitial hernia, 836 Intestinal anastomosis, 884 end-to-end, 885 lateral, 886 exclusion, 949 hemorrhage in typhoid, 945 injuries, 892, 897 localization, 877 obstruction, 936 acute, 937 chronic, 942 perforation in typhoid fever, 944 resection, 882 sutures, 880 tract, internal fistulsc, 944 Intestine, surgery, 936 use, /.\i)i:\ Intestine, tumors, 9 18 Intoxication, 68 Intracerebral hemorrhage, G21 Intracranial hemorrhage in m wborn, 621 [ntradural hemorrhage, 020 Intrathoracic op rations, anesthetic, 155 Intratracheal Insufflation, 155 Intravenous transfusion, 146 intubation, 718 Intussuseept ion, 93N appendix, 916 Involucrum, 469 Iodin disinfection, 143 Irreducible hernia, si 1 Irrigation, bladder, 1019 Petitgand's, 38 Irritable ulcer, 53 Ischemic contracture, 583 [schiatic hernia, 852 Ischiorectal abscess, 958 Ischium, fractures, 362 Italian rhinoplasty, 668 Jabotjlay's operation, 1117 Jacksonian epilepsy, 636 Jackson's membrane, 951 Jacob's ulcer, 124 Jaw, carcinoma, 710 fractures, 356, 357 necrosis, 708 osteomyelitis, 707 sarcoma, 711 subluxation, 428 surgery, 707 tumors, 710 Jejunostomy, 929 Jejunum, peptic ulcer, 933 Joint, ankylosis, 508 arthrectomy, 529 atrophy, 493 Charcot's, 497 contusion, 421 diseases, 429 dystrophy, 492 erasion, 529 gunshot wounds, 206 hypertrophic, 497 infection, 503 gonococcic, 514 metastatic, acute, 515 chronic, 516 pneumococcic, 514 injuries, 421 loose bodies in, 502 mice, 502 neuropathic, 502 sarcoma, 545 sprain, 421 syphilis, 545 tuberculosis, 519 tumors, 545 wounds, 422 treatment, 423 Jugular vein, resection, 622 Keen's point, cranium, 600 Kelly's cystoscopc, 1015 Keloid, 109 Kelotomy, 819 Keratosis senilis, 669 Kidney, anomalies, 1026 calculus, 1032 carcinoma, 1038 cysts, 1038 decapsulation, 1028 dislocated, 1027 floating, 1027 function, tests, 1016 gunshot wound, 1039 horseshoe, 1026 hydronephrosis, 1031 hypernephroma, 1038 infections, 1028 injuries, 1039 movable, 1027 needling, 1035 operations, 1039 rupture, 1039 sarcoma, 1038 stab wound, 1039 stone, 1032 surgery, 1013, 1026 surgical, 1030 tuberculosis, 1036 tumors, 1038 differential diagnosis, 1007 Killian's operation, 707 Kink of ileum, Lane's, 951 Knee amputation, 232 arthroplasty, 255 dislocation, 445 congenital, 558 excision, 510 synovitis, 505 tuberculosis, 541 Knee-joint, internal derangement, 445 Knock-knee, 457 Knots, 166 Kocher's incision for goiter, 736 point, cranium, 600 Kollman's urethral dilator, 1078 Kondoleon's operation, 301 Kraske's operation, 971 Labarraqtje's solution, 170 Labial cysts, 688 Lacerated wounds, 166 Laceration of cervix, 1138 of perineum, 1139 Lacteal calculi, 753 Lacunar resorption, 454 Laminectomy, 647 Lane's kink, 951 operation, cleft palate, 687 Laparotomy, 869 Larrey's amputation, 234 INDEX 1187 Laryngectomy, 721 Laryngo-fissure, 721 Laryngoscopy, 717 Larynx, carcinoma, 717 extirpation, 721 fracture, 717 intubation, 718 tumors, 717 Lateral anastomosis, 886 sinus, 612 ventricles, tapping, 600 Laugier's hernia, 846 Leeching, 148 Lee's amputation, 232 Leg, amputation, 232 ulcer, 55 Legg's disease, 588 Leiomyoma, 115 Leiter's coil, 38 Lembert suture, 880 Leontiasis ossea, 466 Lepidoma, 106 transitional, 128 Leptomeningitis, 623 Leukocytosis, 31 Leuko-keratosis, 695 Leukoplakia, 695 Ligation of arteries, 262 of hemorrhoids, 963 Lightning strokes, 180 Ligneous phlegmon, neck, 722 Line of demarcation, 59 of separation, 59 Linitis, plastic, 925 Lip, carbuncle, 688 epithelioma, 688 surgery, 682 Lipoma, 107 arborescens, 545 breast, 762 neck, 732 Liquor puris, 26 Lisfranc's amputation, 230 Lithectasv, 1025 Litholapaxy, 1023 Lithotomy, 1025 perineal, 1026 Lithotrity, 1023 Litigation spine, 639 Littre's hernia, 807 operation, colotomy, 943 Liver, abscess, 991 carcinoma, 996 cirrhosis, 995 corset, 990 cyst, echinococcus, 993 gumma, 1053 gunshot wounds, 898 rupture, 893 sarcoma, 997 surgery, 990 tumors, 996 Lockjaw, 91 Lock-stitch suture, 163 Longitudinal sinus, rupture, 608 thrombosis, 621 Ludwig's angina, 693 Lumbar abscess, 653, 864 hernia, 830 Lumpy jaw, 83 Lung, abscess, 799 decortication, 797 gangrene, 799 hernia, 786 subcutaneous injuries, 782 surgery, 782 tuberculosis, 799 tumors, 801 Lupus, 670 vulgaris, 294 Luxatio erecta, 431 Luxation, 424 Lymph, inflammatory, 23 Lymphadenitis, 299 mediastinum, 781 neck, 723 Lymphangeio-endothelioma, 130 Lymphangeioma, 300 Lymphangeioplasty, 301 Lymphangeitis, 299 Lymphangiectasis, 300 Lymphatic varicocele, 300 Lymphatics, diseases of, 299 injuries, 299 wounds, 299 Lymphedema, 300 Lymphization, 23 Lymphogenesis, 23 Lymphomatosis, 114, 302 Lymphorrhea, 299 Lymphosarcoma, 117, 304 Lyssa, 96 M McBurney's incision, 872 point, 903 Macrocheilia, 688 Microglossia, 692 Macromelia, 300 Madelung's deformity, 585 Madura foot, 84 Malar bone, fracture, 356 Malignant lymphoma, 302 myoma, 117 osteoma, 488 pustule, 85 Mallein test, 87 Mammary abscess, 750 cancer, 764 gland, 753. See Breast. Mandible, dislocation, 428 excision, 712 fracture, 357 Mania a potu, 184 Manus valga, 585 Margination, 20 Mar John's ulcer, 157 Mastitis, acute, 749 carcinomatous, 768 chronic, 751 cystic, 756 L188 l.XDKX Mastodynia, 751 Mastoiditis, acute, 678 d] eral ion, 679 M:it:is's operation, ruicurysin, 288 Mattress suture, L63, 882 Maunsell's operation, 885 Maxilla, fracture, :'>•"><> inferior, excision, 712 superior, excision, 712 Maxillary antrum, 700 sinusitis, 70") tumors, 000 Ma\o |{<)l)S(in's incision, S72 Meckel's diverticulum, 943 Mediastinitis, acute, 7S1 Mediastinum, surgery, 781 Mediotarsal, amputation, 231 dislocation, 453 Megacolon, 955 Melanoma, 130 Melon-seed bodies, 520 Meloplasty, 072 Membrane, Jackson's, 951 Menciere's solution, 172 technique, 172 Meningitis, 023 serous, chronic spinal, 005 tuberculous, 023 Meningocele, 597, 037 Meningomyelocele, 037 Mercier catheter, 1090 Merocele, 845 Mesenteric cysts, 949 embolism, 943 thrombosis, 943 Mesosigmoiditis, 952 Mesothelioma, 128, 129 Metacarpus, dislocation, 440 fracture, 390 Metastatic abscess, 71 arthritis, 515 Metatarsalgia, anterior, 590 Metatarsus, dislocation, 453 fracture, 420 Metritis, 1131 septic, 1151 Michel's clamps, 100 Microcephalia, 598 Microdactylia, 300 Micrognathy, 709 Middle meningeal artery, 019 Migration, 20 Mikulicz's disease, 074 "Miner's elbow," 298 Minor surgery, 144 Missiles, 192 Mobile units, 191 Mole, pigmented, 270 Molecular death, 58 Molluscum fibrosum, 320 Momburg's method of hemostasis, 235 Monorchidism, 1107 Morbus coxse senilis, 498 Morgagni, hydatid of, 1157 Mortification, 57 Morton's toe, 590 Mosetig-Moorhof wax, 478 " Mother's mark," 270 Movable kidney, L027 spleen, 1009 Mucous patches, 1050 tongue, 696 Multiple neurofibromatosis, 326 Mummery's operation, 905 Murphy button, 890 Muscle, congenital absence, 540 contracture, 307 disease of, 304 hernia, 304 rupture, 305 transplants, 245 tumors, 309 wounds, 304 Muscle-splitting incision, S72 Muscular rigidity, 34 Mustard-gas burns, 178 Myelocele, 037 Myelogenous leukemia, 114 Myeloid tumors of tendon sheath, 129 Myeloma, 112 giant-celled, 112 Myelomatosis, 114 Myoma, 115 malignant, 117 sarcomatodes, 117 of uterus, 1 100 Myomectomy, 1104 Myo-sarcoma, 117 Myositis, 305 ossificans, 306 Myringotomy, 078 Myxedema, 737 Myxo-lipoma, 107 Myxoma, 109 Myxo-sarcoma, 109 N Nasal bones, fracture, 350 Nasopharynx, tumors, 715 Neck, abscess, 724 cut -throat, 722 deformity, 579 fioroma, 732 ligneous phlegmon, 722 lipoma, 732 lymphadenitis, 723 tuberculous, 724 operations, anesthetic, 154 surgery, 722 wounds, 722 Necrosis, 57 appendix, 901 bone, 474 jaws, 708 Needles, 104 Needling kidney, 1035 Negri bodies, 97 Nekton's dislocation, 452 line, 400 operation, 083 INDEX 1189 Neoplasm. See Tumors. Nephrectomy, 1043 Nephritis, septic, 1029 toxic, 1028 Nephrolithiasis, 1032 Nephrolithotomy, 1035, 1041 Nephropexy, 1028 Nephroptosis, 1027 Nephrotomy, 1035, 1041 Nerve, blocking, 158 dislocation, 316 gunshot wounds, 204 injuries, 315 suture, 318 tumors, 326 wounds, 317 Neuralgia, 322 breast, 751 epileptiform, 322 minor, 322 sciatic, 325 testicle, 1110 trifacial, 322 Neuralgic ulcer, 53 Neurectasis, sciatic neuralgia, 325 Neurinoma, 326 Neuritis, 320 Neurofibromatosis, 326 Neurolysis, 317 Neuroma, 115 amputation, 326 plexiform, 326 Neuropathic joints, 502 Neuroplasty, 319 Neurorrhaphy, 318 Neurotic spine, 578 Neurotomy, 322 Nevoid lipoma, 277 Nevus, 276 Newborn, intracranial hemorrhage, 621 Nicoll's operation, cranium, 608 Nipple, affections, 748 excoriation, 749 fissure, 749 Paget's disease, 768 retraction, 765 Nitrous oxide, 153 Noma, 62 pudendi, 63 Non-union, fractures, 352 Nose, foreign body, 667 saddle, 1055 surgery of, 666 Nosebleed, 666 Novocain anesthesia, 157 Obstruction, common duct, 983 intestinal, 936 acute, 937 chronic, 942 operation, 941 pyloric, 920 Obturator hernia, 851 Ochsner treatment, 862 Odontoma, 112 Olecranon fracture, 385 Omental cysts, 949 Omphalectomy, 829 Onychauxis, 291 Onychia, 291 Oophorectomy, 1137 carcinoma, breast, 774 Oophoritis, 1135 Operation, abdominal, 869 after-treatment, 876 injuries, 894 preparation of patient, 875 section, 869 technique, 874 ablation of breast, 770 Agnew's, webbed fingers, 549 air passages, 718 sinuses, 705 Albee's, spinal, 659 Alexander's, round ligaments, 1143 amputation, 212 breast, 759 penis, 1106 Anel's ligation, 285 anesthesia, 149 aneurysm, 285 aneurysmoplasty, 288 Antyllus, aneurysm, 287 appendicectomy, 906 appendicostomy, 950 arteriorrhaphy, 266 arthrectomy, 529 arthrodesis, 570 arthrolysis, 509 arthroplasty, 252 Ashhurst's amputation, 232 astragalectomy, 565 Bassini's, hernia, 839 Beck's, hypospadias, 1100 Berger's amputation, 230 bile-duct, 984 Billroth's amputation, 235 gastrectomy, 933 Bottini's, prostatic, 1091 Brasdor's, for aneurysm, 286 Cantwell's, hypospadias, 1102 carcinoma of breast, 770 of tongue, 700 cardiolysis, 269 castration, 1113 cecostomy, 950 cholecystectomy, 986 cholecystenterostomy, 989 cholecysto-duodenostomy, 989 cholecystostomy, 985 cholecystotomy, 985 choledocho-enterostomy, 989 choledochostomy, 987 choledochotomy, 9S7 chondrectomy, 799 Chopart's amputation, 231 circumcision, 1103 cleft palate, 685 ' Cock's, urethrotomy, 1080 into INDEX Operation, colostomy, 969 colporrhaphy, 1 1 I" costo-transversectomy, 660 cricothyrotomy, 719 Cushing's decompressive, 634 cystocele, 1146 cystotomy, 1025 debridement, 201 decompressive, craniectomy, 634 decortication of lung, 797 Demarquay's urethrotomy, 1073 Didot's, webbed fingers, "> lit Dieffenbach's amputation, 234 discission of pleura, 797 Dudley's, anteflexion, 1127 Dupuytren's amputation, 228 duodeno-cholcdochostomy, 989 Edebohls's, kidney, 1028 endo-aneurysmorrhaphy, 288 enterotomy, 941 epiplopexy, 996 epluchage, 200 erasion of joints, 529 esopliagotomy, 743 esquillectomy, 205 Est lander's, thorax, 798 evidement, 478 excision, elbow, 510 hip, 539 knee, 510 maxilla, inferior, 712 superior, 712 rib, 792 shoulder, 513 tongue, 704 tumors, 132 wrist, 513 extirpation of aneurysm, 288 of Gasserian ganglion, 324 of penis, 1 106 Ferguson's, hernia, 843 Fergusson's, cleft palate, 685 Finney's pyloroplasty, 930 Forster's rhizotomy, 573 fractures, 344 ununited, 354 Frazier-Spiller, 324 gall-bladder, 984 gastrectomy, 933 gastro-anastomosis, 924 gastrogastrostomy, 924 gastrojejunostomy, 930 gastroplasty, 924 gastrostomy, 929 gastrotomy, 928 goiter, 736 exophthalmic, 740 Grant's, cancer of lip, 690 Gritti's amputation, 233 Guthrie's amputation, 234 Hancock's amputation, 231 Handley's, 301 hemi laryngectomy, 721 hepaticus-drainage, 988 hepatotomy, 992 hernia, 839, 847 Operation, hernia, strangulated, 818 herniotomy, 819 Hoy's amputation, 231 Hotchkiss's meloplasty, 669 Hunter's, aneurysm, 285 hydrocele, 1117 hysterectomy, abdominal, 1165 vaginal 1166 hysteropexy, 1143 intestinal anastomosis, 884 exclusion, 949 Jaboulay's, hydrocele, 1117 jejunostomy, 929 kelotomy, 819 kidney, 1039 Killian's, 707 Kraske's, 971' laminectomy, 647 Lane's, cleft palate, 687 laparotomy, 869 Larrey's amputation, 234 laryngectomy, 721 Lee's amputation, 232 ligation for aneurysm, 285 of arteries, 261 of hemorrhoids, 963 Lisfranc's amputation, 230 lithectasy, 1025 litholapaxy, 1023 lithotomy, 1025 lithotrity, 1023 Littre's, colotomy, 943 lymphangeioplasty, 301 mastoiditis, acute, 679 Matas's, aneurysm, 288 Maunsell's, intestinal resection, 885 Mayo's, umbilical hernia, 828 meloplasty, 672 Mummery's, prolapse of rectum, 965 myomectomy, 1164 myringotomy, 678 Nelaton's, hare4ip, 683 nephrectomy, 1043 nephrolithotomy, 1035 nephropexy, 1028 nephrotomy, 1035, 1041 nettoyage, 200 neurectomy, 288 neurolysis, 317 neuroplasty, 319 Nicoll's, cranium, 608 omphalectomy, 829 oophorectomy, 1137 orchidectomy, 1113 orchidopexy, 1108 osteotomy, 458 ovariotomy, 1159 pericardiotomy, 269 perineorrhaphy, 1140 pharyngotomy, 714 phlebectomy, 275 phlebotomy, 148 Pirogoff s amputation, 231 plastic, 240 pleurotomy, 792 plombage, 478 INDEX 1191 Operation, pneumonectomy, 799 pneumonotomy, 799 Pozzi's, cervix uteri, 1127 proctotomy, 967 prostatectomy, perineal, 1096 suprapubic, 1093 prostatotomy, perineal, 1091 pyelotomy, 1035 pylorectomy, 933 pyloroplasty, 930 Rammstedt's pyloroplasty, 921 resection, intestinal, 882 jugular vein, 622 skull, 632 rhinoplasty, 667 rhizotomy, 573 Ruggi's, femoral hernia, 849 salpingectomy, 1137 salpingo-oophorectomy, 1136 Scbede's, thoracoplasty, 798 varicose veins, 275 S'chroeder's, cervix uteri, 1130 Sedillot's amputation, 704 sequestrotomy, 475 short-circuiting, 949 sigmoido-proctostomy, 967 Skey's amputation, 230 skin-grafting, 236 Spence's amputation, 227 splenectomy, 1011 Stamm's gastrostomy, 929 staphylorrhaphy, 685 Stokes's amputation, 233 stomach, 928 Syme's amputation, 231 urethrotomy, 1078 sympathectomy, 741 tarsectomy, cuneiform, 564 Teale's amputation, 232 tendon transplantation, 568 tenotomy, 563 Terrier's, choledochotomy, 986 Textor's amputation, 231 thoraco-laparotomy, 802 thoracoplasty, 798 thoracotomy, 792 thyroidectomy, 740 thyrotomy, 731 tracheoplasty, 1138 trachelorrhaphy, 1138 tracheotomy, 719 Trendelenburg's, varicose veins, 275 trephining skull, 608 ureterolithotomy, 1036 ureteroplasty, 1037 urethrotomy, 1077 vaginal hysterectomy, 1 166 ventro-fixation of uterus, 1144 Wardrop's ligation, 286 Whitehead's, excision of tongue, 704 hemorrhoids, 963 wiring aneurysm, 287 Witzel's gastrostomy, 929 Opsonins, 23 Orchidectomy, 1113 Orchidopexy, 1108 Orchitis, 1108 Orthopedic surgery, 546 Osteitis, 468 deformans, 463 fibrocystic, 463 Osteo-arthritis, 493 Osteo-arthropathy, pulmonary, 518 Osteochondritis deformans juvenilis, 588 Osteoclasis, 458 Osteogenesis imperfecta, 454 Osteoid sarcoma, 488 Osteoma, 111 malignant, 488 sarcomatodes, 488 Osteomalacia, 461 Osteomyelitis, 468 albuminous, 471 chronic, 473 infancy, 479 jaw, 707 ribs, 781 skull, 611 vertebrae, 648 Osteophyte, 111 Osteoporosis, 454 Osteopsathyrosis, 454 Osteosarcoma, 117, 487 Osteotomy, 458 subtrochanteric, 529 Ostoses, 111 Othematoma, 676 Otitis media, 677 Ovariotomy, 1159 Ovaritis, 1135 Ovary, abscess, 1135 carcinoma, 1159 cyst, 1155 dermoid, 115S retention, 1154 cystadenoma, 1155 embryomas, 1158 fibroma, 1159 teratomas, 1158 tumors, 1155 Oxycephaly, 601 Pachymeningitis, 623 Paget's disease of bone, 463 of nipple, 768 Pain in inflammation, 33 referred, 33 Painful heel, 594 Palate, cleft, 682 perforation, 687 surgery, 682 Pahnar abscess, 313 fascia, contracture of, 585 Palsy, brachial birth, 556 cerebral, 572 crutch, 316 infantile, 5(15 1192 /\i)i:x Palsy, post-anesthetic, 310 Panaris, :'>1 1 Pancreas, abscess, 1001 carcinoma, L004 cysts, L006 gangrene, 1001 gunshot wounds, 899 infections, !)'.)S surgery, 90S Pancreatectomy, L005 Pancreatic calculi, 1004 fistula, 1007 insufficiency, 1002 lymphangeitis, 1001 Pancreatitis, acute, 999 chronic, 1001 hemorrhagic, 999 Pancreatoenterostomy, 1006 Pan-hysterectomy, 1166 Papilloma, 119 of bladder, 1021 intracystic, 120 of larynx, 717 Paralytic calcaneus, 568 deformities, 565 equino-varus, 566 talipes, 565 valgus, 565 Paraphimosis, 1104 Parasitic cysts, 132 Parathyroids, 739 Park's solution, 145 Paronychia, 311 Parosteal abscess, 469 Parotid bubo, 672 tumor, 672 Parotitis, infectious, 672 Parovarian cyst, 1156 Partridge's hernia, 846 Pasteur treatment for rabies, 99 Patella, dislocation, 448 fracture, 408 Pathology of inflammation, 19 Paul's tube, 942 Peck's operation, rectum, 971 Pectineal hernia, 846 Pelvic abscess, 864, 1153 Pelvis, fracture, 360 static disorders, 578 Pendulous abdomen, 953 Penis, amputation, 1106 carcinoma, 1105 congenital deformities, 1099 extirpation, 1106 surgery, 1099 Peptic ulcer of jejunum, 933 Perforating ulcer, 291 Perforations in typhoid, 944 of uterus, 1151 Perianal abscess, 958 Periarthritis, 507 Pericardiotomy, 269 Pericholecystitis, 975 Pericolitis, 950 sinistra, 952 Periductal fibroma, 760 Periductal myxoma, 760 Perimetritis, 1151 Perineal hernia, 851 lithotomy, 1026 prostatectomy, 1096 section, 1079 Perineoplasty, 1140 Perinephric abscess, 1031 Perineum, laceration, 1139 Perinorrhaphy, 1140 Periosteitis, acute, 467 alveolus, 710 chronic, His rib, 787 Perisigmoiditis, 952 Perithelioma, 130 Peritoneal adhesions, 865 Peritoneum, 853 tuberculosis, 866 Peritonitis, S.",.'J acute, 856 diffuse, 857 operation, 914 fibrino-purulent, 855 general, 856 hemorrhagic, 856 Ochsner treatment, 862 operation, indications, 861 technique, 914 pathology, 854 pelvic, 1132 pneumococcic, 866 septic, 856 spreading, 855 symptoms, 856 toxic, 856 treatment, 861 Ochsner, 862 starvation, 862 Peritonsillar abscess, 713 Peri-urethral abscess, 1082 Pernio, 180 Perthes's disease, 588 Pes planus, 591 Petechia, 159 Phagedenic ulcer, 53 Phagocytes, 23 * Phagocystosis, 23 Phalanx, finger, dislocation, 441 fracture, 396 toe, dislocation, 453 fracture, 420 Pharyngotomy, 714 Phenol-sulphonephthalein test, 1016 Phimosis, 1102 Phlebectasis, 274 Phlebectomy, 275 Phlebitis, 270 post-operative, 272 treatment, 272 Phleboliths, 270 Phlebosclerosis, 270 Phlebotomy, 148 Phlegmasia alba dolens, 272 Phlegmon, 26, 46 neck, 722 INDEX 1193 Picric acid disinfection, 143 dressing;, 178 Pigmented mole, 276 Piles, 961 Pilo-nidal cyst, 297 Pirogoff' s amputation, 231 v. Pirquet's test, 79 Plaster jacket, 656 Plaster of Paris, 139 Plastic linitis, 925 surgery, 236, 240 bone transplant, 248 cartilage transplant, 247 fascia transplantation, 246 fat transplantation, 246 free transplants, 285 Gillies's transplants, 243 tendon transplantation, 246 transfer of muscles, 245 Plating fracture, 384 Pleura, discission, 797 surgery, 782 tuberculosis, 798 tumors, 801 Pleural fistula, 796 Carrel-Dakin treatment, 797 Estlander's operation, 798 Schede's operation, 798 thoracoplasty, 798 vomica, 789 Pleurisy, 788 Pleuritis, 788 Pleurotomy, 792 Plexiform neuroma, 326 Plombage, 478 Pneumococcic joint infection, 514 peritonitis, 866 Pneumohemothorax, 788 Pneumonia, post operative, 185 Pneumonectomy, 799 Pneumonotomy, 799 Pneumothorax, 782, 786 tension, 787 Poisoned wounds, 174 Poliomyelitis, acute, anterior, 565 Polydactylism, 547 Polymastia, 748 Poly]), nasopharyngeal, 715 rectal, 968 uterine, 1162 Polythelia, 748 "Port-wine" stain, 276 Post-anesthetic palsy, 316 Post-operative deaths, 185 embolism, 272 phlebitis, 272 Posthitis, 1105 Pott's disease, 649 abscess, 652 treatment, 659 fixation of spine, 659 paraplegia, 655 treatment, 655 fracture, 416 Poultices, 38 Pourriture d'Hopital, 62 Pozzi's operation, cervix uteri, 1127 Pregnancy, extra-uterine, 1147 Prepuce, adherent, 1102 Preputial calculus, 1105 Procain anesthesia, 157 Procidentia recti, 961 uteri, 1145 Proctitis, 965 Proctoclysis, 146 Proctoscope, 955 Proctotomy, 967 Profeta's law, 1054 Prolapse, rectum, 964 urethra, 1074 uterus, 1145 Prostate, abscess, 1083 adenomatosis, 1085 atrophy, 1097 carcinoma, 1097 enlargement, 1084 treatment, 1089 hypertrophy, 1084 sarcoma, 1098 surgery, 1083 Prostatectomy, perineal, 1096 suprapubic, 1093 Prostatitis, 1083 Prostatotomy, perineal, 1091 "Proud flesh," 52 Psammoma, 130 Pseudoarthrosis, 352 Pseudoleukemia infantium, 1011 Pseudomyxoma peritonei, 1156 Psoas abscess, 653 Psychical shock, 184 Ptomains, 19 Pudendal hernia, 851 Puerperal pyemia, 1150 sepsis, 1150 "Pulled elbow," 439 Pulmonary embolism, 187 emphysema, 799 osteo-arthropathy, 518 Punctured wounds, 173 Pus, 24 Pus-tube, 1133 rupture, 1134 Pyarthrosis, 503 Pyelitis, 1029 Pyelonephritis, 1029 Pyelotomy, 1035, 1042 Pyemia, 70 puerperal, 1154 Pylephlebitis, 991 Pylorectomy, 933 Pyloric obstruction, 920 Pyloroplasty, 930 Pylorospasm, 921 Pylorus, exclusion, 931 infantile stenosis, 921 Pyogenesis, 24 Pyogenic bacteria, 28 membrane, 26 Pyonephrosis, 1031 Pyosalpinx, 1133 Pyothorax, 789 1194 INDEX Quilled suture, 163 Quill suture, 1G3 Quinsy, 713 Rabies, 96 treatment, 99 Racemose aneurysm, 278 Rachischisis, 637 Rachitic rosary, 450, 775 Rachitis, 455 Radio-carpal dislocation, 440 Radium, therapeutic uses, 181 Radius, dislocation, 438 fracture, 387 Railway spine, 639 Rammstedt's pyloroplasty, 921 Rankenneuroma, 326 Ranula, 692 Ray fungus, 82 Raynaud's disease, 64 v. Recklinghausen's disease of bone, of skin, 326 Reconstructive surgery, 236 Rectocele 1139 Recto-genital fistula, 968, 1146 Recto-urinary fistula, 968, 1146 Rectum, adenoma, 968 carcinoma, 968 false anus, 969 radical operation, 970 congenital malformations, 956 examination, 955 imperforate, 957 prolapse, 964 stricture, 966 surgery, 955 tumors, 968 Redressement force, 563 Regeneration, 30 Relaxation suture, 164 Renal calculus, 1032 colic, 1034 Repair, wound, 161 Resection, intestinal, 882 Residual abscess, 856, 864 urine, 1070 Retained secundines, 1150 Retention of urine, 1070 - Retraction of nipple, 765 Retroduodenal choledochotomy, 988 Retroflexion, uterus, 1143 Retrognathism, 709 Retroperitoneal hernia, 939 Retropharyngeal abscess, 652 Retroversion, uterus, 1143 Reverdin's skin-grafting, 237 Rhabdomyoma, 115 Rhagades, 1055 Rheumatism, tuberculous, 517 Rhinophyma, 667 Rhinoplasty, 667 Rhinoscleroma, 85 463 Rhizotomy, 573 Ribs, caries, 780 cervical, 582 excision, 792 fracture, 359 osteomyelitis, 781 periostitis, 781 Rice bodies, 520 Richter's hernia, S07 Riedel's lobe, 990 Rigidity of abdominal wall, 857 Ring fracture, 604 Rodent ulcer, 124, 670 Roller bandage, 137 Rose ulcer, 766 Ruggi's operation, femoral hernia, S49 Rupture, abdominal wall, /•:. v Skull, wounds, 602 Sliding hernia, 836 Sloughing, 57 phagedena, 62 ulcer, 53 Small-shot wounds, 197 Smoker's patches, 695 Snake bites, 174 venom, 175 Snapping hip, 588 Sounds, urethral, 1070 Spangaro's incision, 208 Spanish windlass, 215 Spasmodic tic, 326 Speculum, bivalve, 1123 examination, 1122 Silence's amputation, 227 Spermatic cord, surgery, 1107 Spermatocele, 1117 Spermato-cystitis, 1110 Sphacelus, 57 Sphenoidal sinus, 707 sinusitis, 705 Spina bifida, 637 ventosa, 113 Spinal anesthesia, 158 canal, hemorrhage, 639 cord, concussion, 639 stab wound, 640 tumors, 664 meningitis, serous, 665 tuberculous, 623 Spine, curvature, lateral, 573 dislocation, 640 fractures, 640 gunshot wounds, 209 infections, 662 injuries, 639 operation, 646 treatment, 645 sprain-fracture, 639 static disorders, 578 strains, 639 surgery, (537 tuberculosis, 649 tumors, 664 Spirocheta pallida, 80 Spleen, abscess, 1009 cysts, 1009 dislocated, 1009 gunshot wounds, 899 movable, 1009 rupture, 894 surgery, 1007 syphilis, 1053 tumors, 1007 Splenectomy, 1011 for cirrhosis of liver, 996 Splenic anemia, 1010 Splenomegaly, 1011 Splints, 341 Hodgen, 205 Thomas, 204 Spondylitis, atrophic, 663 deformans, 663 hypertrophic, 664 Spondylitis, traumatic, 648 typhoid, 662 Spondylolisthesis, 579 Spondylose rhizomelique, tiii I Sprain, 421 Sprain-fracture, 331 spine, 639 Sprained ankle, 421 Sprengel's deformity, 558 incision, 984 Squirrhe en cuirasse, 766 Stab wounds, 174 abdomen, 896 diaphragm, sol spinal cord, 040 thorax, 783 Stagnant gall-bladder, 977 Stamm's gastrostomy, 929 Staphylorrhaphy, 685 Starch dressing, 141 Stasis cyanosis, 776 Status lymphaticus, 188 Steatoma, 296 Steatorrhea, 1002 Stenosis of cervix, 1126 Sterilization, 142 Sterno-clavicular dislocation, 429 Sternum, fracture, 358 tuberculosis, 781 Still's disease, 516 Stokes's amputation, 233 Stomach, carcinoma, 925 treatment, 927 cirrhosis, 925 dilatation, 921 gunshot wounds, 898 hour-glass, 917, 923 operations, 928 segmented, 923 surgery, 916 ulcer, 916 hemorrhage, 920 perforation, 919 treatment, 918 Stomatitis, gangrenous, 63 Strain, 421 spine, 639 tendon, 310 Strangulated hernia, 813 Strangulation, 160 Strapping joints, 421 ulcers, 55 Stricture, appendix, 902 esophagus, 743 rectum, 966 urethra, 1074 Strumitis, 736 Stumps, after-treatment, 223 conical, 221 diseases, 221 dressing, 216 end-bearing, 222 structure, 221 Subastragalar amputation, 231 arthrodesis, 571 dislocation, 453 INDEX 1197 Subcranial abscess, 623 hemorrhage, 619 Subcuticular suture, 166 Subdeltoid bursitis, 507 Subinvolution, uterus, 1143 Subluxation, elbow, 439 jaw, 428 semilunar cartilage, 448 wrist, spontaneous, 585 Submammary abscess, 751 Subpectoral abscess, 778 Subphrenic abscess, 865 Subscapular abscess, 779 Subungual exostosis, 486 Supernumerary auricle, 677 fingers, 547 toes, 547 Suppuration, 24 without bacteria, 27 Suprapubic cystotomy, 1025 prostatectomy, 1093 Suprascapular abscess, 780 Supravesical hernia, 844 Surgical emphysema, 776 infections, 74 fever, 69 kidney, 1030 technique, 135 Sutures, 162 absorbable, 162 Albert-Lembert, 881 buried, 163 chain, 163 Connell's, 886 continuous, 163 Cushing's, 882 Czerny's, 881 deep, 163 Dupuytren's, 882 figure-of-eight, 164 Gely's, 881 Halsted's, 882 hare-lip, 162 interrupted, 162 intestinal, 880 knots, 166 Lembert, 880 lock-stitch, 163 mattress, 163, 882 Mayo's, C. H., 889 metal clamps, 166 nerve, 318 non-absorbable, 162 overhand, 163 quilled, 163 quilt, 163 relaxation, 164 sero-serous, 880 splint, 164 subcuticular, 166 superficial, 163 through-and-through, 880 twisted, 162 of wounds, 165 Syme's amputation, 231 urethrotomy, 1078 Symmetrical gangrene, 64 Sympathectomy, 741 Sympathetic fever, 69 Symptomatic fever, 69 Syndactylism, 547 Synovitis, 503 chronic serous, 505 knee, 505 Syphilis, 80, 1044 bone, 482 breast, 753 chancre, 81, 1045 contagion, 1044 diagnosis, 1056 gumma, 1052 hereditary, 1053 treatment, 1060 insontium, 1044 joint, 545 leptomeninges, 624 pathology, 80 secondary lesions, 1048 tertiary, 1051 testicle, 1113 tongue, 696 treatment, 1057 arsphenamin, 1060 treponema pallidum, 80 Wassermann test, 1057 Syphilitic bubo, 1047 tubercle, 1051 Syphiloderma, 81, 1049 Syphiloma, brain, 626 Syringomyelia, 502 Syringomyelocele, 637 Talipes, congenital, 558 paralytic, 565 Tapping hydrocele, 1117 lateral ventricles, 600 Tarsus, dislocation, 452 fracture, 419 transverse section, 571 tuberculosis, 542 Taxis, 818 Taylor's brace, 659 Teale's amputation, 232 Telangiectases, 276 Temporo-maxillary joint ankylosis, 709 Tenderness, abdominal, 859 on pressure, 34 Tendon transplants, 246 Tendon-sheaths, tuberculosis, 311 Tendons, dislocation, 310 gunshot wounds, 204 rupture, 309 strain, 3 10 transplantation, 568 wounds, 309 Tenosynovitis, 310 Tenotomy, 563 Tension pneumothorax, 787 Terato-blastomas, 106 1198 INDEX Teratoma, 105 ovary, 1158 Terrier's operation, bile-duets, 986 Tessier's hernia, 846 Testicle, inflammation, 1108 misplaced, 1107 neuralgia, 1110 non-descent, 1107 surgery, 1107 syphilis, 1053, 1113 torsion, 1108 tuberculosis, 1111 tumors, 1114 wandering, 1107 Tetanus, 91 antitoxin, 94 cephalic, 94 chronic, 94 treatment, 94 Textor's amputation, 231 Thecitis, 310 Thiersch's skin-grafting, 237 Thigh, amputation, 233 Thomas splint, 204 Thoraco-laparotomy, 802 Thoracoplasty, 798 Thoracotomy, 792 Thorax, wounds, bullet, 210 gunshot, 209 penetrating, 783 shell fragments, 210 stab, 783 operation, 785 Thrombo-angeitis obliterans, 58 Thrombosis, 269 arterial, 273 mesenteric, 943 sinus, 621 Thrombus, 160, 269 Thumb, amputation, 226 dislocation, 440 Thymus gland, surgery, 741 Thyro-glossal cyst and fistula, 730 Thyroid, carcinoma, 741 enlargement, 733 surgery, 732 Thyroidectomy, 740 Thyroiditis, 732 Thyrotomy, 721 Thyrotoxicosis, 737 Tibia, fracture of, 412 Tibio-tarsal dislocation, 451 Tic convulsif, 326 douloureux, 322 spasmodic, 326 Toe, supernumerary, 547 Toe-nail, ingrowing, 291 Tongue, abscess, 695 carcinoma, 697 operation, 700 chancre, 696 excision, 704 gumma, 696 ichthyosis, 695 sarcoma, 697 surgery, 692 Tongue, syphilis, 695 tuberculosis, 696 Tongue-tie, 692 Tonsil, carcinoma, 714 sarcoma, 714 surgery, 713 Tooth wounds, 174 Torsion of arteries, 261 Torticollis, 579 spasmodic, 326, 580 Tourniquet, 214 Toxemia, 69 Toxic nephritis, 1028 Toxic peritonitis, 856 Toxins, bacterial, 19 Tracheoplasty, 1138 Trachelorrhaphy, 1138 Tracheotomy, 719 tube, 720 Transduodenal choledochotomy, 989 Transfusion of blood, 147 Transplant, bone, 248 cartilage, 247 fascia, 246 fat, 246 free, 245 GiUies's, 243 tendon, 246 Traube-Hering waves, 617 Traumatic asphyxia, 776 delirium, 183 treatment, 185 fever, 69 gangrene, 88 spontaneous emphysema, 88 Traumatopnea, 783 Trench feet, 180 Trephine, Gait's, 608 Hudson's, 633 Trephining, skull, 608 Treponema pallidum, 80 Trichiniasis, 308 Trident hand, 455 Trifacial neuralgia, 322 Trigger finger, 586 Truss, 810 cross-body, 837 Hood, 838 Tubal abortion, 1148 Tubercle, anatomical, 74 syphilitic, 1051 Tuberculin, 75 old, 79 test, 79 Tuberculoma, brain, 626 Tuberculosis, 74 ankle, 542 appendix, 915 bladder, 1020 bone, 479 breast, 753 carpus, 544 costal cartilages, 780 cutis, 294 diagnosis, 78 elbow, 543 INDEX 1199 Tuberculosis, glands, neck, 724 hernial sac, 867 hip, 530 joint, 519 kidney, 1036 knee, 541 lungs, 799 lymph nodes, 300, 725 meninges, 623 parotid,. 672 pathology, 75 peritoneum, 866 v. Pirquet's test, 79 pleura, 798 ribs, 780 sacro-iliac, 544 salivary glands, 672 skin, 294 spine, 649 sternum, 781 tarsus, 542 tendon sheaths, 311 testicle, 1111 tongue, 696 treatment, 80 tuberculin test, 79 vertebrae, 649 wrist, 544 Tuberculous arthritis, operation, 527 dactylitis, 481 gumma, 76 rheumatism, 517 sinus, treatment, 527 Tubo-ovarian abscess, 1134 cysts, 1155 Tubular aneurysm, 280 Tufnell's treatment, aneurysm, 284 Tumors, 101 abdominal, diagnosis of, 1007 adenocarcinoma, 126 adenoma, 120 alveolus, 710 appendix, 915 bladder, 1021 blast oma, 106 bone, 485 brain, 626 treatment, 630 breast, 754 benign, 759 malignant, 762 capsule, 102 carcinoma, 121 glandular, 126 carotid gland, 729 cartilage, 110 cheloid, 109 chloroma, 114 cholesteatoma, 130 chondroma, 110 chondrosarcoma, 117 chordoma, 115 classification, 104 consistency, 102 cord, spinal, 664 cylindroma,} 130 Tumors, cyst formation, 130 parasitic, 132 «^ cystadeno-carcinoma, 126 cystadenoma, 120 cystoma, 131 definition, 101 desmoids, 309 embryoma, 106 endosteoma, 111 endothelioma, 129 enosteoma, 111 epithelioma, 123 epulis, 710 excision, 132 exostosis, 111 fibroadenoma, 120 fibroid, uterine, 1160 recurrent, 116 fibroma, 108 fibromyxoma, 109 fibrosarcoma, 117 form, 101 formation, Cohnheim's theory, 103 parasitic theory, 104 Ribbert's theory, 104 gall-bladder, 997 glioma, 115 gliosarcoma, 117 hemangeio-endothelioma, 130 hylic, 106 hypernephroma, 129 intestinal, 948 intraspinal, 664 irritable, of breast, 751 jaw, 710 joint, 545 keloid, 109 kidney, 1038 larynx, 717 leiomyoma, 115 lepidic, 106 lepidoma, transitional, 128 lipoma, 107 liver, 996 lung, 801 lymphangeio-endothelioma, 130 lymphoma, 115 lymphosarcoma, 117 malignancy, 102 mediastinal, 782 melanoma, 130 mesothelioma, 129 metastasis, 103 mixed, 106 muscle, 309 myeloma, 112 myoma, 115 sarcomatodes, 117 myosarcoma, 117 myxolipoma, 107 myxoma, 109 myxosarcoma, 109 naso-pharynx, 715 nerve, 326 neurinoma, 326 neuroma, 115 1200 INDEX Tumors, odontoma, 112 osteoma, 1 1 1 osteosarcoma, 117 ovary, 1154 pancreas, 1001 papilloma, 119 parotid, 672 periductal, 759 perithelioma, 130 pleura, S01 prostate, 1097 psammoma, 130 rate of growth, 102 rectum, 968 recurrence, 103 rhabdomyoma, 115 sarcoma, 115 scalp, 597 scrotum, 1119 sigmoid, 968 spinal, 664 spleen, 1007 stomach, 925 terato-blastoma, 106 teratoma, 105 testicle, 1114 thyroid, 741 xanthoma, 107 Twisted suture, 162 Tyloma, 290 Typhoid arthritis, 514 carriers, 983 hemorrhage, 945 perforation, 944 periosteitis, 467 spine, 662 spondylitis, 662 Ulcer, 52 callous, 54 duodenum, 916 chronic, 917 hemorrhage, 920 perforation, 919 treatment, 918 edematous, 53 gastric, 916 gastro-jejunal, 933 healthy, 53 indolent, 54 inflamed, 53 irritable, 53 Jacob's, 124 jejunum, peptic, 933 leg, 55 syphilitic, 56 Marjolin, 57 neuralgic, 53 perforating, 291 phagedenic, 53 repair, 52 rodent, 124, 670 rose, 766 I leer, simple, 53 skin-grafting, 56 sloughing, 53 stomach, 916 acute, 917 chronic, 917 hemorrhage, 920 perforation, 919 treatment, 918 strapping, 55 varicose, 57 warty, 57 weak, 53 Ulceration, 26, 52 Ulcus molle, 1060 Ulna, dislocation, 438 fracture, 385 Umbilical fistula, 944 hernia, 826 strangulated, 830 Union by first intention, 161 in fractures, 336 Urachal cysts, 1017 fistula?, 1017 Ureter, catheterization, 1016 Ureteral calculus, 1035 Ureterolithotomy, 1036 Ureteroplasty, 1031 Urethra, foreign bodies, 1071 prolapse, 1074 rupture, 1072 stricture, 1074 treatment, 1076 surgery, 1070 Urethral fever, 1080 Urethritis, gonococcic, 1065 in female, 1128 non-gonococcic, 1074 Urethrotome, 1078 Urethrotomy, 1077 perineal, 1079 Urinary disorders, diagnosis, 1013 extravasation, 1073 fever, 1080 fistula, 1082 Urine, residual, 1071 retention, 1070 Uterus, adenomyoma, 1163 anteflexion, 1143 carcinoma, 1167 chorio-epithelioma, 1169 displacements, 1143 fibroids, 1160 fibromyoma, 1160 hysteropexy, 1143 malformation, 1127 myoma, 1160 perforation, 1151 polypus, 1162 procidentia, 1145 prolapse, 1145 retroflexion, 1143 retroversion, 1143 subinvolution, 1143 ventro-fixation, 1144 ventro-suspension, 1 144 INDEX 1201 Vaccination, 145 Vaccins, 44 in inflammation, 44 Vagina, absence, 1126 Vaginal examination, 1122 hernia, 851 hysterectomy, 1166 puncture, 1154 Vaginitis, 1128 Vagus pulse, 618 Valgus, paralytic, 568 Valsalva's treatment for aneurysm, 287 Varicocele, 1118 lymphatic, 300 Varicose aneurysm, 267 ulcer, 57 veins, 274 Varix, 274 Vein, jugular, resection of, 622 Veins, entrance of air, 266 Venereal diseases, 1044 wart prevention, 1066 Venesection, 39 Venous aneurysm, 265 nevi, 277 Ventral hernia, 823 Ventricles, tapping, 600 Ventro-suspension of uterus, 1114 Verruca, 290 Verrucse acuminata 3 , 1105 Vertebra, dislocation, 640 fracture, 640 osteitis, 648 osteomyelitis, 648 tuberculosis, 649 Vertebral column, dystrophies, 663 Vesical calculus, 1021 Vicious circle, 931 Visceroptosis, 953 Volkmann's contracture, 583 Volvulus, 938 Vulva, carcinoma, 1170 imperforate, 1125 Vulvitis, 1128 Vulvo-vaginal abscess, 1128 W "Wardrop's ligation, 286 War hospital, 190 Wart, 290 venereal, 290, 1066 Warty ulcer, 57 Wassermann test, 1057 Wax. Horsley's, 632 Mosetig-Moorhof's, 478 Weaver's bottom, 298 Webbed fingers, 547 Wen, 296 Whitehead's operation, hemorrhoids, 963 tongue, 704 varnish, 684 White swelling, 522 Whitlow, 311 Wille's test, 1003 Wiring aneurysm, 287 Witzel's gastrostomy, 929 Wolfe-Krause skin-grafting, 238 Wool-sorter's disease, 85 Wounded, evacuation, 191 Wounds, 160 abdominal, suture, 881 arrow, 174 art erio- venous, 267 bavonet, 174 bites, 174 blank cartridge, 198 bloodvessels, 266 bullet, 194 bursa?, 297 chemical sterilization, 169 contused, 166 debridement, 201 drainage, 165 dressing, 166 gunshot, 190 abdomen, 211, 897 bloodvessels, 203 bones, 204 diaphragm, 802 drainage, 202 dressing, 202 duodenum, 898 general nature, 193 head, 208 intestine, 897 joints, 206 kidnev, 1039 liver, 898 lung, 209 missiles, 192 nature, 193 nerves, 204 pancreas, 899 spine, 209 spleen, 899 stomach, 898 suture, 202 tendon, 204 thorax, 209 treatment, 199 of heart, 268 incised, 160 dressing, 166 healing, 161 treatment, 162 union, 161 infected, 169 intestinal, suture, 881 joint, 422 lacerated, 166 muscle, 304 neck, 722 nerve, 317 poisoned, 174 punctured, 173 scalp, 596 septic, Carrel-Dakin treatment, 170 shell fragments, 196 1202 IXDEX Wounds of skull, 602 small shot, 197 stab, 174 abdomen, 896 diaphragm, sol kidney, 1039 spinal cord, 640 thorax, 783 suture, 165 tendons, 309 thorax, bullet, 210 penetrating, r83 shell fragments, 210 tooth, 171 unbridling, 201 Wrist, arthroplasty, 253 dislocation, 440 excision, 513 subluxation, spontaneous, 585 Wrist, tuberculosis, 544 Wrist-joint amputation, 226 Wry-neck, 579 Wyeth's hemostasis, 227, 233 Xanthoma, 107 Xiphodynia, 359 X-ray dermatitis, 180 in fractures, "35 therapeutic uses, 181 Zygoma, fracture, 356 COLUMBIA UNIVERSITY LIBRARY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28I239IM100 COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) Rd 31 As3 1920 C.I Surgery; its pnncip 2002104466 RD31 Ashhurst Aso 1920