Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseonsurgerOOholm A TREATISE SURGERY, ITS PRINCIPLES AND PRACTICE. BY T. HOLMES, M.A. Cantab., SURGEON TO ST. GEORGe's HOSPITAL. WITH FOUR HUNDRED AND ELEVEN ILLUSTRATIONS, CHIEFLY BY DR. WESTMACOTT. MILLE MALI SPECIESr PHILADELPHIA: HENRY C. LEA. 18 76. r I? 1 1. A n K r, p II I A : S III: KM A.N .1 < ".. I' n I N T i; If*. PREFACE. I NEED say little by way of preface to this volume, which, indeed, speaks for itself. It is an attempt to represent the present condition of Surgery, as it is practiced in this country, by a treatise which shall be not unworthy to rank with the other excellent text-books in use in our schools. I have intended this book to be to some extent an introduc- tion to the more elaborate System of Surgery of which I am the editor, and liave freely used the treatises of that System in' composing the various chapters ; and when any quotations are made, the source of which is not distinctly acknowledged, it will be understood that they are taken from thence. At the same time I have not servilely followed the teaching even of those authorities; and I hope the reader will find throughout the book sufficient evidence of that personal experience of the various exigencies of surgery which can alone justify an author in attempting the difficult task of writing on the general subject of sur- gical theory and practice. The task is indeed difficult. It is not only the immense number of topics, and the endless details of all of them — though necessarily some of these topics must be less familiar to any single surgeon (however wide his experience) than others are, and though it is hardly possible but that some of the details should escape the writer's attention — but, added to this, the necessary conditions of space press hardly on the writer of a surgical text-book. Though this volume extends to over 900 pages, the space allotted to each topic only permits of a brief and, I fear,, far too meagre account of each, and leaves hardly any room at all to discuss varying opinions and rival suggestions of practice. My endeavor has been to give a plain and practical account of each surgical injury and disease, and of the treat- ment which is most commonly advisable. For the minuter details of pathology I must refer the reader to some of the many admirable works on that subject; and for fuller disquisitions on treatment, either to the essays in the System of Surgery or to the authors quoted in the text and referred to in the index of authors. I have to acknowledge with grateful thanks the liberality with which the rich store of material contained in the Museum and case-books of St. George's Hospital has been put at my disposal. It is, of course, from the school of this hospital, in which I have studied and practiced VI PREFACE. snrgei'v for over a quarter of a oentiiry, that my illustrations and my teaching have been chiefly drawn; but I have not neglected the teaching of other British schools; nor, although I have intended this work to be an exposition especially of British surgery, have I failed to refer, as far as my information and my space allowed, to the works of American and Continental surgeons. For the illustrations I have been indebted mainly to Dr. Westmacott, to whom my warm thanks are due for the great interest he has taken in the work and the pains he has spent upon it. Many of the minor illustrations were, however, drawn by one of my pupils, Mr. F. D. Drewitt, whose intelligent and able assistance it is my duty to acknowl- edge as it deserves ; nor must I omit to thank Mr. Evans, the engraver of the woodcuts, for the great care which he has bestowed upon them, and for several of the diagrams which he has drawn under my direction. I have thought it necessary to comprise in this treatise all the diseases which are included under the title " surgical," so that chapters will be found on diseases of the eye, ear, and skin. In treating the first-men- tioned subject I have availed myself of the able assistance of my colleague Mr. Carter; as it is many years since I have personally engaged in ophthalmic practice, and it is only from recent practice that a branch of surgery can be taught which has been so greatly modified by recent discoveries. But I hold that a knowledge of the main principles of diagnosis and treatment ought to be possessed by every surgeon in the case of diseases of the organs of the special senses quite as much as those of the rest of the body. Among the many injuries which the curse of specialism has inflicted equally on the profession and the public, not the least has been the. neglect of the diseases of these organs which some practitioners and many students seem almost to regard as natural. I am happy to think that in the subject of oi)hthalmic surgery my readers will have the benefit of so competent a guide as Mr. Carter. The chapter on Diseases of the Ear is necessarily very short, and is intended only to point out the leading facts in Aural Surgery, and those methods of treatment with which every practitioner ought to be familiar. I must express ray obligation to Mr. Dalby, who has been so kind as to peruse it and correct some of its most obvious defects. I must now submit this book to the judgment of my professional brethren, though fully conscious of its many imiicrfcctidus. I fear that as we advance in life we feel more and more the dillicuity of coming up to our own expectations in any enterprise of importance, and the truth of the old saying, "Quid tain dcxiro pcdo concipis ut to conatus non peniteat votique peracti ?" Great Cumberland Tlack, October, 1875. CONTENTS. CHAPTER I. INFLAMMATION AND THE PROCESS OF UNION IN SOFT PARTS TRAUMATIC FEVER — -DRESSING OF WOUNDS. rAGK 33 33 36 36 The Process of Inflammation, . Chief Symptoms: Kednoss, Swollini;-, Heat, Pain, Fever, Pathology of Inflammation, Emigration of Leucocytes, Terminations of the Inflamma- tory Process, . . . .38 Wounds and Contusions, . . .38 Blood-tumor: Organization of Clot, . . "^ . . .39 Kinds of Wound, . . . .41 Processes of Union : 1. Primary Adhesion, . . 41 2. Primary Union, or Union by First Intention, . . .41 3. Union by Suppuration, or by Second Intention, . . 42 Ulceration, . . . .43 Processes of Union — coiitvnied. Granulation, . . . .44 Cicatrization, . . . .44 4. Union by Secondary Adhe- sion, or by Third Intention, 44 5. Union under a Scab, . . 45 Cicatrices, . . . . .45 Traumatic Fever, . . . .46 Condition of llie Blood in Inflam- mation, . . . .48 Symptoms of Traumatic Fever, . 48 Methods of Dressing Wounds, . . 49 Lister .< Antiseptic Method, . 50 Di'essing Wounds where Iia})id Union is not sought, . . 52 Irrigation, Sutures, Strapping, Bandages, . . . .53 CHAPTER II. THE COMPLICATIONS OF WOUNDS AND INJURIES. Abscess, ... Kinds of Pus and of Abscess Progress of Abscess, Diagnosis — Fluctuation, Trejitinent of Abscess, Residual Abscess, Sinus and Fistula, Pyjemia and Septicemia, . Symptoms of Pyaemia, Pathology of I'yiEmia, Pathological Anatomy of Pyos mia. Diagnosis and Treatment, Chronic Pyiemia, Hectic Fever, . Visceral Disease produced by continued Suppuration, Erj'sipelas and Erythema, Various Forms of Erythema, Cutaneous or simple. Erysipelas, Phlegmonous or Cellulo-cuta neous Erysipelas, Causes of Erysipelas, . Diagnosis and Treatment, . 54 55 55 56 57 58 59 59 61 62 64 64 65 66 67 67 68 70 70 72 Erysipelas and Erythema— continued. Local Treatment of Diffuse In- flammation, . . . . Gangrene, . . . . . Traumatic and Spontaneous Gan- grene, . . . . . Moist and Dry Gangrene, . Phenomena of Gangrene, . Amputation in Gangrene, . Local and General Treatment, . Special Forms : Bedsores, .... Frostbite, .... Hospital Gangrene, Phagedena, Senile Gangrene, Cancrum Oris and Noma Vulvfe Tetanus, ..... Trismus Nascentium, Diagnosis of Teianus, Pathology, .... Treatment, Delirium Ti'emens, ... 74 76 76 77 79 80 81 81 88 84 85 86 87 87 88 89 91 vin CONTENTS. CHAPTER III. POISONED WOUNDS AND ANIMAL POISONS. Dissertioii-woiinds, ... 93 Acute and Chronic Form ofDis- scclion-poison, . . . 9i TrcatnuMit of Dissection- wounds, .... 95 Wounds of Venomous Animals, . 90 Intravenous Injection in kSnaUe- bite, 97 Glanders, 98 Glanders — continued. Farcy, ... Equinia Mitis, . Hydrophobia, ... The Disease in the Dosi;, Question of the Existence Significance of " Lyssi,' Diagnosis of Treatment, and 99 100 100 101 103 103 CHAPTER IV. HjEMOrriiage and collapse. Haemorrhage, ..... Spontaneous Hasmorrhage, The Hicmorrhagic Diathesis, . General Symptoms of Acci- dental Hiemorrhage, Injuries of Arteries, . Contusion, .... Partial Laceration, Complete Laceration, Sub- cutaneous, .... Complete Laceration in an Exposed Artery, Incomplete Division, . Complete Division, Injuries of Veins, • Entrance of Air into Veins, . Diagnosis of the Sources of Ha^- morriiage, .... Treatment: Method of Tying Bleeding Arteries, Cases in which Wounded Art-'^ries should not be Tied, 105 105 105 IPfi 107 107 107 108 109 109 110 110 111 111 112 113 Hajmorrhage — continued. Cases in which the Artery above may be Tied, . Ligature of Arteries, Changes subsequent to Liga- ture, .... Secondary Hivmorrhago and its Treatment, Recurrent Haemorrhage, Gangrene, Recurrence of Pulsation, Ligature of Arteries witli Carbolizcd Catgut (the " Antiseptic Method "), . Acupressure, Torsion, .... Other Means of Stopping Ar- terial Hiemorrhage, Unci- pression,Foicipres8ion,etc., Treatment of ordinary Capil- lary Ha'morrhage: Styp- tics, . . . ' • Transfusi-n of Blood, Collapse, ...... 113 114 115 iii; 118 118 118 119 121 1-23 125 125 120 128 CHAPTER V. BURNS AND SCALDS. Classification of Burns, . Symptoms and Stages of Burn.-, Ulceration of the Duodenum, 132 I Local Treatment, 132 I General, . i:!3 I Litrhtning-stroke 134 135 13r, CHAJ'TKK VI. FRACTURES AND DISLOCATIONS — OENEUAL P.\TII(tI.OO V. Fractures : Definition and Classification, Scfiaration of ICpiph3'.-es. . Symptoms and Diagno.-is, Treatment, Treat iiKint — continued. 137 Setting the Fraclurt', . 139 Question of Amiiutaticm or i;]9 Exci.sion, .... 14U Treatment of C(>ni|tlieation.'(, 141 142 143 CONTENTS. IX Fractures — continued. Union of Fracture, Ui-ual Process in Simple Frac- ture (Primary Union, In- termediate Callus), . Union by Provisional Callus, Union of Inflamed Simple, and of Compound Frac- tures bv Granulation, 144 145 145 146 Union — continued. Defects of Union, Delayed Union, . Ununited Fracture, Vicious Union: Refracturc, Dislocation : General Pathology, Reduction, Injuries of Cartilage, 147 148 148 152 154 154 155 CHAPTER VII. INJURIES OF THE FIEAD. Classification, . . . . .157 Complications, .... 157 Surgical Anatomy of the Scalp, . 157 I. Contusions of the Soft Parts, . 157 Diagnosis between Extravasa- tion and Depressed Fracture, 157 II. Scalp-wounds and their Treat- ment, . . . . . 158 Complications of Scalp-wound: Erysipelas, .... 159 Suppuration beneath the Cra- nium, . . . .160 Trephining for Pus, . 161 III. Traumatic Extravasation bc^- tween the Bone and Dura Mater, 162 Trephining for "Wound of Mid- dle Meningeal Artery, . . 163 Extrava-sation in the Arachnoid Cavity, ..... 165 Organization of such Ex travasation, . . . 165 Symptoms: Diagnosis from Apoplexy, . . .166 IV. Fractures of the Skull, . . 167 Fractures of the Vault, . . 167 Depression of Outer Table only : Fractures of the Frontal Sinus, .... 168 Fractures of the Skull — continued. Depression of Inner Table only, Fracture with Elevation, Fracture by Contre-coup, Treatment of Simple and Compound Fracture, . Fractures of the Base of the Skull, .... In Wounds of the Orbit, Of the Anterior Fos.-a, . Of the Middle Fossa, . .\ Of the Posterior Fossa, Serous Discharge in Fracture of the Skull, Union of Fractures of the Base, ..... V. Lesions of the Brain, Concussion of the Brain, . Compression, .... Trephining for Fracture, Cases not classifiable as Concus- sion or Compression. Contu- sion and Laceration of the Brain, .... Traumatic Inflammation, Hernia Cerebri, Injuries of Cranial Nerves, The Operatii'n of Trephining, 168 168 169 169 170 171 173 173 173 174 174 176 177 178 179 180 181 182 183 184 CHAPTER VIII. INJURIES OF THE SPINE. Sprains of the Back, . . . 185 i Treatment : Trephining the Spine, 189 Fracture and Dislocation of the I Concussion and Railway Injury, . 192 Spine, 186 I CHAPTER IX. INJURIES OF THE FACE. Bruises and Wounds, . . . 195 Salivary Fistula, . . 195 Foreign Bodies in the Nostril and Ear, 196 Fractures : or Nasal Bones, . . .197 Fractures — continued. Of the Upper Jaw, . . .197 Of the Malar Bone and Zygoma, 197 Of the Lower .Jaw. . . .197 Dislocation of the Jaw, . . . 200 Subluxation of the Jaw, . . 203 CONTENTS. CHAPTER X. INJURIES OF THE NECK. Cut throat, 203 Contusions of the Larynx, . . 20(5 Dislocation of the Hyoid Bone, . '200 Fractures of the Hyoid Bone, . . 207 Of the Cartilages of the Larynx, 207 Rupture of the Trachea, . . .208 Foreign Bodies in the Air-passages, 208 Burn and Scald of the Larynx, . 214 Foreign Bodies in the (Esophagus, . 214 (Esophagotoniy, . . . 210 CHAPTER XI. INJURIES OF THE CITEST. Contusions and Wounds of the Pa- rietes, ..... Fractured Ribs, With Wound of Lung, Complications : Empiiysema, Pneumothorax, Hsemothorax, Hydrothorax etc., .... Fracture of Costal Cartilages, Fracture of the Sternum, 217 218 220 221 221 221 222 222 Dislocations of tiie Ribs, . Penetrating Wounds, Hernia of the Lung, . Foreign Bodices in the Chest, . Wounds of the Mediastinum, Peri- cardium, and Heart, Paracentesis of Pericardium, . Wounds of Internal Mammary and Intercostal Arteries, Rupture of Viscera without Wound, Thoracentesis, . . . . 223 223 224 22G 227 228 228 CHAPTER XII. INJURIES OF THE ABDOMEN. Contusions, ..... Contusion with Rupture of Intes- tine ; Rupture of the Stomach, . of the Intestines, of the Liver and Gall- bladder, . of the Spleen, of Kidney and Ureter, Wounds ; I. Superficial, II. Penetrating : a. Simple: Foreign Bodies in such Wounds, 230 231 231 233 234 234 235 235 Wou nd s — coil i'mned. b. With Wound of Viscera which do not f)rotrude, . c. With Protrusion of Unin- jured Viscera, d. With Protrusidn of the Wounded Viscera, Suture of the Intestine, Foreign Bodies in the Stomacii or Intestines, .... Gastrotomy and Gastrostomy, . 236 230 237 287 237 238 CHAPTER XIII. INJURIES OF THE PELVIS. Contusion and Wound of the But- tock, ...... Fractures of the Pelvis : Of the Ala of the Ilium, . Of the True Pelvis, . Of the Acetabulum, . Of the Coccyx, . . . . Rupture of the Bladder, . Rupture of the Urethra, . 240 241 L'41 243 244 244 240 Injuries of the ^lale Organs of Gen- eraliiui, . . . . . Tying a Ligature round llie Penis, Injuiii's of the Female Organs, Wounds of tlie Bladder, . Wounds of the Hccluiti. . Foreign Bodies in the Bhidder, Va giiia, or Rectum, . 247 248 248 240 24!l 24!) CONTENTS. XI CHAPTER XIY. INJURIES OP THE UPPER EXTREMITY. Considerations applicable to all In- juries of the Upper Extremity, . Foreign Bodies in the Palm, . Wounds of the Palm of the Hand, Fractures of the Clavicle : Of the Body of the Bone, Of the Sternal End, . Of the Acromial End, Fractures of the Scapula, Of the Neck of the Scapula, Of the Coracoid and Acromion Processes, . . . . Fractures of the Humerus: Fracture of the Anatomical Neck, .... Of the Surgical Neck, Of the Epiphysis, Of the Great Tuberosity, . Of the Shaft, . Of the Lower End, . Fractures in the Forearm : Of the Olecranon, Of the Coronoid Process, . Of both Bones of the Forearm Of one Bone alone, . Colles's Fracture of the Lower End of the Radius, Fractures of the Carpus, Fractures of the Metacarpus and Phalansres, . . . . . ^50 251 251 252 254 254 256 256 258 259 261 261 261 262 264 266 266 266 267 269 269 Compound Fractures in the Upper Extremity, 269 Dislocation of the Sternal End of the Clavicle, . . . .270 Dislocation of the Acromion, . . 271 Dislocation of the Shoulder, . . 271 Into the Axilla : Subcoracoid and Subglenoid, 272 Subclavicular, . . . 274 Subspinous, .... 274 Earer Dislocations upwards (su- pracoracoid), . . . 275 Dislocations complicatf^d with Fracture, .... 276 Reduction, .... 276 Compound and Partial Disloca- tion, 279 Dislocation of the Elbow: Of both Bones backwards, . 280 With Fracture of the Coronoid Process, . . . .281 Of the head of the Radius only, 283 Rarer Dislocations, . . . 283 Compound Dislocations, . . 283 Dislocations of the lower End of the Radius, 284 Dislocations of the Wrist, . . 284 Dislocations of the Carpus, . . 285 Dislocations of the Thumb, . . 285 Dislocations of the Fingers, . . 287 CHAPTER XY. INJURIES OF THE LOWER EXTREMITY. Sprains and Wounds, . . . 288 Wound of Knee-joint, . . 289 Fracture of Cervix Femoris : Extra and Inti'a-capsular Frac- ture, Impacted and Non-im- pactcd, 289 Du\gnosis, .... 291 Diagnosis between Extra and Intra-capsular Fracture, . 292 Method of Union and Treat- ment, ..... 294 Fractures of Trochanter and Separation of Upper Ejjiphy- .'^is 295 Fractui'e of the Body of the Femur : In the Upper Third, . . 296 In the Middle of the Bone, . 298 Near the Knee-joint, . . 302 Fracture of the Patella : Transverse, .... 306 Y-shaped, . . . .309 Compound, .... 309 Fractures of the Leg: Of both Bones, . . .310 Fractures of the Leg — continued. Of the Tibia only, . . .311 Of the Fibula only, • • • 311 Compound Fractures, . . 312 Fractures of the Bonos of the Foot, 314 Dislocations of the Hip: 1. Upwardson the Dorsum Ilii, 315 2. Backwards on the Sciatic Notch, . . . .318 3. Downwards on the Obturator Foramen, .... 322 4. Inwards on the Pubes, . 323 Anomalous Dislocations, . . 325 Dislocation of the Knee, . . 325 Patella, 326 Semilunar Cartilages, . . 327 Head of the Fibula, . . . 327 Dislocations of the Ankle, . . 328 Pott's Fracturi', . . .328 Compound Dislocation, . . 329 Dislocation of the Astragalus, . 330 Subastragaloid Dislocation, . . 331 Dislocations of the Tarsus, Metatar- sus, and Phalanges, . . . 333 Xll CONTENTS. CHAPTER XVI. GUNSHOT WOUNDS. I. Gansliot Wounds in General : Definition, . . . . Mode of Union, Wound of Entrance and Exit, " Wind Contusions," or Contu- sions from Oblique Impact, . Symptoms and Method of Ex- amination, . . . . Treatn)eiit, . . . . II. Gunshot Wounds in each Kegion of the Body : Of the Head, .... Of the Spine, .... Of the Face 334 3:^4 335 335 335 33G 338 339 339 II. Gunshot Woundsin each Region of the Body — continued. Of the Neck, . . . . Of the Chest, . . . . Diagnosis and Treatment of Gunshot AVounds of the Lung, ..... Of the Abdomen, Of the Hypogastrium, Peri- neum, and Genital Organs, . Of the Extremities, . Treatment of Gunshot Injury of the Upper and Lower Extremities, .... 340 340 340 342 343 343 344 CHAPTER XVII. TUMORS. Deiinition of a " Tumor, CI a.ssiti cation, . I. Innocent Tumors : Cysts : Serous, . Sanguineous, Compound Cysts ceous, Congenital Cutaneoi Dermal Cysts, Proliferous Cysts, Cystigerous Cysts, Solid Tumors : Fatty, Fibrous, . Fibroceilular, . Cartilaginous, . Bony, Vascular, . Aneurism by Anastc Nicvus, Treatment of Nsevus, Degeneration of Nsevus, Seba s Cysts, mosis. 347 348 349 350 351 352 ;-i53 353 353 354 355 356 3.57 358 359 359 3(;0 3G0 363 Solid Tumors — continued. II. Sarcomatous or semi-malignant Tumors, Round-celled Sarcoma, Spindle-celled Sarcoma, . Giant-celled Sarcoma (mye loid), .... Net-celled Sarcoma (myxoma) Alveolar Sarcoma, . Pigmentary Sarcoma (mela nosis), .... Diagnosis of Sarcoma from •Carcinoma, . III. Carcinoma, Scirrhus, .... Medullary, Melanotic, Osteoid, .... Epithelioma Colloid, .... Villous, .... 364 364 364 366 866 366 366 367 369 370 372 373 373 374 375 376 Struma and Scrofula, Tubercle, its Kinds and Manner of Formation, Connection between Scrofula and Ordinary Inflammation, CHAPTER XVIII SCROFULA. . 37 37" Struma and Scrofula— con<('H»«/. Kinds of VarietitiS of Scrofula, 379 Causes of Scrofula, . . . 380 Treatment, .... 380 Definition and Pathology, Nervous Mimicry or Nervous Affections, . • • CHAPTER XIX. HYSTERIA. . ;J82 I Dcflnition and Pathology— coui(tn«c^Z. 383 ' Symptoms and Diagnosis, Treatment, 383 3H5 CONTENTS. Xlll CHAPTER XX. GONORRH(EA AND SYPHILIS, Gonorrhoea in the Male, . . . 387 Symptoms of its Various Stages, . 387 Gleet, 388 Complications : Lacunar Abscess, . . . 388 Balanitis, 388 Phimosis 388 Paraphimosis, .... 388 Spasms and Hjematiiria, . . 389 Chordee, 389 Bnbo, 389 Gonorrhoeal and Capivi Ea«h, . 389 Gonorrhoea! Rheumatism, . 390 Other Complications, . . 391 Treatment of Gonorrhoea, . . 391 Gonorrhoea in the Female, . . 392 Leucorrhoea Infantum, . . 393 Complications of Female Gon- orrhoga, .... 393 Treatment, .... 393 Syphilis: Definition and Nomencla- ture, 394 The Local Forms of Syphilis, or the Non-infectinsr Sore. . 394 1. The Common Soft Chancre, 394 2. The Chancre with Suppu- rating Bubo, . . . 395 Syphilis — cotitinned. Svphilitic Phimosis, . "3. The Sloughing Sore, The Constitutional Form of Syphilis — the "Hard," " In- fecting, '^' or '■ Hunterian " Chancre, .... Diagnosis between the two Forms of Chancre, Treatment : the use of Mer- cury, Secondary Syphilis, Skin Eruptions, Mucous Tubercle, Alopecia, . Sore Throat, Affections of Glands, Inoculation of Secondary Syphilis, .... Treatment, .... Tertiary Syphilis, .... Infantile or Congenital Syphilis, . Non-congenital Syphilis in Infants, Vaccino-syphilis, .... Irregular Forms of Syphilis, . Syphilitic Inoculation and Syphili- zation, . 395 395 396 396 398 401 401 402 403 403 403 404 404 405 407 409 409 409 410 CHAPTER XXL ULCERS — CICATRICES, Classification of Ulcers, . 411 The Healthy Ulcer, . 412 Inflammatory Ulcer, 412 Eczematous Ulcer, . 412 Cold Ulcer, 413 Senile Ulcer, 413 Strumous Ulcer, 413 Scorbutic Ulcer, 414 Gouty Ulcer, 414 Syphilitic Ulcer, 414 Lupous Ulcer, . 415 Rodent Ulcer, . 416 Cancerous Ulcer, 417 Varicose Ulcer, 417 (Edematous or Weak Ulcer 418 AND THEIR DISEASES. Classification of Ulcers — continued. Exuberant Ulcer, Hajmorrhagic Ulcer, . Neuralgic Ulcer, Inflamed Ulcer, Callous or Indolent Ulcer Phagedenic Ulcer, Cicatrices antl their Diseases, . Ulceration of Scars, . Neuralgia of Scars, . Excessive Formation of Scars Keloid Tumor of Scars, Warty and Epithelial Tumors Contracted Cicatrix, Sl Ul- ceration of Cartilage," . . 466 Loose Cartilages, or Loose Bodies in Joints, 469 Chronic Rheumatic Arthritis, Anchylosis, .... Forcible Extension, . Subcutaneous Section of Bone Hysterical and Neuralgic AtFec tions, ..... Diseases of Particular Joint.s Of the Hip: "Morbus Coxa rius," .... Congenital Dislocation, Other Affections of the Hip, Of the Sacro-iliac Articulation, Of the Ankle and Tarsus, Of the Sterno-clavicular Joint, Of the Shoulder, Of the Elbow, .... Of tlie Wrist and Carpus, 471 472 473 473 474 475 478 480 480 481 482 482 483 483 CHAPTER XXIV. DISEASES OF THE SPINE. Caries of the Spine, Affection of the Cord, Spinal Abscess, Psoas Abscess, Treatment of Diseased Spine, Disease of Cervical Vertebra?, . 484 Lateral Curvature, . 491 . . 485 Kyphosis, Lordosis, and ilher Cnr- . 487 vatures, 494 . 487 Anchylosis of the Spine, 494 . 488 Cancer, . 494 . 489 Spina Bifida, . 495 CHAPTER XXV. DISEASES OF MUSCLES AND BURSyE. Rupture of Muscles and Tendons, . 496 Inflammation of Muscles: Gum- matous Tumors, .... 497 Inflammation of Tendons, . . 497 Whitlow, 497 Diseases of Burste : Housemaid's Knee, . . 498 Affections of other Bursa-, Natural or Acquired, . 600 Bunion, ..... 501 Ganglion, .... 501 Diseases of Bur.sffi — continued. Compound Palmar Ganglion, 502 Degeneration of Muscles : Simple Atri)|iii3', . . . 502 Progressive Muscular Atrophy, 502 Fatty and other Di'geiieralioiis, 503 Infantile I'aralysis, . . . .■)03 Hypertrophic Paralysis (of Du- chenne), ..... 504 Tumors in Muscles, . . 504 CONTENTS. XV CHAPTER XXVI. CLUBFOOT AND OTHER DEFORMITIES ORTHOP^TEDIC SURGERY. Pathology of Congenital Deformi- ties, . . " . . . .505 Tenotomy, ..... 505 Talipes Equinus, .... 507 Division of the Tendo Achillis, 508 Talipes Varus, . . . .509 Division of the Tibial Tendons, 510 Talipes Valgus and Equino-valgus, 51"2 Talipes Calcaneus, . . . .512 Flatfoot, or Spurious Valgus, . . 512 PAGE Talipes Cavus, .... 513 Relapsed Clubfoot, . . . .513 Irregular Deformities : Clubhand, 514 Contraction of Palmar Fascia, . 514 Knockknee, ..... 514 Wryneck, ..... 515 Division of the Sternomastoid Muscle, .... 515 Emotional and Hysterical Contrac- tion, ...... 616 Wounds of Nerves, Neuralgia, CHAPTER XXVII. AFFECTIONS OF NERVES. 517 I Neurotomy, . 518 I Neuroma, 519 520 CHAPTER XXVIII. DISEASES OP THE ARTERIES. Atheroma and Calcification, 521 Occlusion and Embolism, 522 Arteritis, 523 Aneurism, 523 Causes of Aneurism, 524 Classification, . 526 Dissecting Aneurism, 527 Cirsoid Aneurism, 527 Arteriovenous Aneurism, 527 Treatment of Arteriove- nous Aneurism, 528 Symptoms of Arterial Aneu- rism, 529 Diagnosis, 529 Relations between the S ac and Artery, . 530 Progress of Aneurism, 531 Symptoms of Rupture, 531 Spontaneous Cure, . 581 Teatment : Medical or Internal, 531 The Old Operation, . 532 Hunter's Operation, 532 Failures of Ligature, 534 Distal Ligature, 535 Compression, 535 " Rapid" Pressure, 637 Genuflexion, 537 Manipulation, . 538 Coagulating Injections, 538 Galvano-puncture, . 538 Introduction of Foreign Bodies, 538 The Chief Forms of Aneuris m and Operations on the Various Arte- ries: Thoracic Aneurism, . 539 Innominate Aneurism, 539 Carotid Aneurism, .... 540 Brasdor and Wardrop's Ope- rations, .... 540 Ligature of the Common Caro- tid Artery, . . . .641 Ligature of the External Caro- • tid, 543 Ligature of the Lingual and Thyroid Arteries, . . . 543 Orbital Aneurism, .... 544 Subclavian Aneurism, . . . 545 Ligature of the Innominate or First Part of Right Subcla- vian. ..... 546 Axillary Aneurism, . . . 546 Ligature of the Subclavian Ar- tery, 547 Aneurism below the Axilla, . . 548 Ligature of the Axillary Ar- tery, 548 Ligature of the Brachial Ar- tery, 549 Ligature of the Ulnar Artery, 649 Ligature of the Radial Artery, 550 Abdominal Aneurism, . . 550 Ligature of the Abdominal Aorta and of the Iliac Ar- teries, ..... 561 Gluteal Aneurism, .... 553 Femoral Aneurism, . . . 664 Ligature of the Common Femo- ral Artery, .... 566 Ligature of the Superficial Fe- moral Artery, . . . 656 Popliteal Aneurism, . . . 656 Aneurism below the Ham : Liga- ture of the Tibial Arteries, . . 668 XVI CONTENTS. CHAPTER XXIX. DISEASES OP THE VEINS AND ABSORBENTS. Phlebitis and Tlironibosis, Various Kinds of Phlebitis, Treatment of Phlebitis, . Varicose Veins, .... Treatment : Operations for Va- ricose Veins, Phlebolithes and other Affections of Veins, PAGE 560 562 563 563 564 565 Lymphatic Fistula, Inflammation of the Absorbent Ves- sels and Glands, .... Affections of Absorbents and Glands in Various Diseases, Lymphadenoma, . . . . PAGE 566 566 567 568 CHAPTER XXX. SURGICAL DISEASES OF THE HEAD AND PACE. Congenital Malformations. Harelip, . Incomplete Harelip, Double Harelip, Complicated Harelip, Fissured Palate, Staphyloraphy, Meningocele and Encephalocele, Tumors of the Cranium, . Disease of the Lips and Mout Herpes of the Lip, . Fissures of the Lip, Strumous Lip, Najvus of the Lip, . Cancer of the Lip, . Chancre of the Lip, Kanula, . Salivary Calculus, . Acute Tonsillitis or Quinsy, . Chronic Enlargeraentof the Tonsils, Relaxed Uvula, .... Alveolar Ab.scess, .... Necrosis of the Jaws, Phosphorus Necrosis, Exanthematous .Jaw Necrosis, Tooth Tumors, .... Tumors of the Jaw. Cysts, Cysts of the Antrum, Dropsy and Abscess of the Antrum, Operations for Cystic Tumors of the Jaw, .... 569 572 572 573 574 576 579 580 H. 581 581 582 582 582 582 583 583 583 584 585 686 586 586 587 587 588 588 389 Epulis, ...... Fibrous Tumor of the .Jaw, Enchondroma of the .Jaw, Exostosis of the Jaw, Cancer of the Jaw, .... Tumors of the Antrum, . Total removal of the Upper Jaw, ..... Partial removal of the Upper Jaw, ..... Osteoplastic Operation on Upper Jaw, ..... Operations on Lower Jaw, Closure of the Jaws, Diseases of the Nose. Acne Rosacea, Lipoma Nasi, .... Lupous, Rodent, and Epithelioma tons Ulceration, . Malformations, Rhinolithes, .... Epistaxis, .... Plugging thi- Nostril, Chronic Thickening of tiie Schnei derian Membrane, Ozasna, ..... Tluidichum's Nasal Douche, Tumors and Abscess of the Septum Nasal Polypus, ... Fibrous and Nasopharyngeal Poly P"s, Malignant Polypus, 590 590 591 591 591 591 592 502 593 593 593 594 594 595 595 595 596 596 597 598 598 .599 599 GO! 603 CHAPTER XXXI. SURGICAL DISEASES OP Diseases of the Tongue. Tongue-tic, 603 Ulceration an d Cancer of the Tongue, 604 Treatment of Cancer of the Tongue, 605 THE DIGESTIVE TRACT. j Ulceration and Cancer of Tongue — continued. Partial Remuvai of tlin Tongue, Total licmoval of the Tongue, Syphilitic Affection of the Tongue, 605 60i) 60H CONTENTS. XVll Glossitis, ..... Abscess of the Tongue, Macroglossifi, .... Congenital Tumor of the Tongue, Naevus of the Tongue, Ichthyosis of the Tongue, PAGE 608 609 609 609 609 609 Diseases of the Pharynx and (Esophagus. Pharyngitis, 577 Tumors of the Pharynx, . . 577 Malformation of the Pharynx, . 577 Strictures of the Oesophagus, Nervous 'Dysphagia, PAGE 610 611 Affections op the Intestinal Tube. Internal Strangulation, . Impaction of Faeces, Treatment of Obstruction Colotomy, Gastrotomy, . Littre's Operation, Intussusception, Umbilical Fistula, . Paracentesis Abdominis, . 612 613 613 614 614 614 614 616 616 CHAPTER XXXII. HERNIA. Congenital and Acquired Hernia General Symptoms of Hernia, Irreducible Hernia, Strangulated Hernia,. Inflamed Hernia, ... Gangrene, .... Ulceration and Perforation of thi Bowel, .... Treatment: Reduction by Taxis Dangers of Forcible Taxis, Question of Repetition o: Taxis, Treatment of Irreducible Her nia, .... Accidents in Taxis — Rupture of Bowel, Reduction en masse, Trusses, .... Radical Cure of Hernia, . Herniotomy, Extra and Intra-peritoneal Operation, . Seat of Stricture, . Inspection of Contents of Sac Omental Sacs, Treatment of Strangulated Bowel, .... Ulceration in the Course of the Stricture, . Treatment of Strangulated Omentum, 618 618 618 618 619 619 619 619 621 621 622 622 622 623 629 630 631 632 633 633 634 635 635 Herniotomy — continued. Operations in Cases of Reduc- tion en tnasse, After-treatment in Herniol- 636 omy, .... 636 SequeliB of Strangulation, 636 Peritonitis after Operation, 637 Fiscal Fistula and Artificial Anus after Operation, . 638 Various Forms of Hernia. Inguinal Hernia, 640 Oblique, .... 640 With Retained Testis, . 641 Various Forms of Obi ique Hernia, . 642 Bubonocele, 642 Operations for Oblique Her- nia, .... 645 Direct, .... 646 Inguinal Hernia in the Feir ale. 646 Femoral Hernia, 647 Irregular Distribution of Ves- sels in Femoral Hernia, 647 Umbilical Hernia, . 650 Obturator Hernia, . 651 Ventral Hernia, 652 Phrenic Hernia, 652 Vaginal Hernia, 653 Perineal, Pudendal, Ischiatic and Lumbar Hernia, . 653 CHAPTER XXXIII. DISEASES OF THE RECTUM. External Piles, 654 Internal Piles or Hemorrhoids, 654 Operations for Piles, 655 Prolapsus Ani, 657 Fistula in Ano, 657 Ischio-rectal Abscess, 658 Ulcer or Fissure of the Anus, . 660 Pruritus Ani, .... 661 Polypus of the Rectum, . 66] Villous Tumor, 661 Mucous Tubercles and Condylomata, 662 Stricture of the Rectum, . . 662 Colotomy in Disease of the Rec- tum, 665 Malformations : Imperforate Anus, 665 Imperforate Anus, with Facal Fistula, 666 Imperforate Anus, with Defi- ciency of the Bowel, . . 667 Imperforate Rectum, . . 668 xvin CONTENTS. CHAPTER XXXIV. DISEASES OP THE LARYNX. PAGE Laryngoscopy, .... 669 Rliinoscopy, . . . .671 Laryngitis, Acute, .... 672 Croup or Cynanche Trachealis, 673 Laryngismus Stridulus, . . 674 Chronic Laryngitis, . . G74 Syjihilitic Disease, . . 675 Follicular Laryngitis ; Dys- phonia Clericorum, . . 675 Tumors of the Lar3^nx, . Removal from the Mouth, Thyrotomj'-, Extirpation of the Larynx, Nervous and Hysterical A})honia, Aphonia from Paralysis, Spasm of the Glottis, Tracheotomy, .... CHAPTER XXXV. DISEASES AND INJURIES OF THE EYE (bY MR. CARTER) . 683 General Considerations, . Diseases of the Lids : Tarsal Tumors, Blepharitis, Styes, .... Malposition of Eyelashes, Redundancy of Eyelashes, Incurvation of Cartilage, Ectropium, Wounds of the Eyelids, . Ptosis, . . _. Diseases of the Conjunctiva : Simple or Catarrhal Conjunc- tivitis, . . . . . Infantile Purulent Ophthalmia, Implication of the Cornea, Gonorrhceal Ophthalmia, Ejiidcmic Ophthalmia, Follicular or " Sago-grain,' Granulations, Papilhiry Granulations, Diphtlicntic Conjunctivitis, Phlyctenular Conjunctivitis, Conjunctival Growths : Ptery gium, . Episcleritis, Diseases of the Cornea : Pannus, Corneal Phlyctenular, Recurrent Vascular Ulcer Photophobia, Iridectomy, . Keratitis, . Vascular, Interstitial, . Suppurative, . Acute Ulcer, . Cicatrices, Complete Staphyloma, Partial Stiiyphyloma, Ccmical Cornea, Diseases of ih*; Iris : Cysts, or Morbid Growths Coloboma, Iritis, Plastic, . Complications, Iridectomy, 684 685 686 686 686 686 687 687 687 689 690 690 690 693 693 695 696 69 J 697 697 698 699 699 699 701 701 701 704 705 707 708 709 710 710 711 711 711 711 715 Diseases of the Iris — conibiued. Serous Iritis. Iridochoroiditis, . Diseases of the Ijcns : Cataract, .... Congenital, . Removal by Solution, Laminar, Removal by Suction, . Senile, .... Removal by Extraction Cataract-glasses, . Diseases Posterior to the Lens — The Ophthalmoscope, Glauc(mia, Iridectomy, . Diseases of the Choroid, Diseases of the Vitreous Body, Morbid Eye, Growths within the Injuries of the Eye : Foreign Bodies, Wounds and Contusions. Sym- pathetic (.»phthalmia, . Operation of Enucleation, Contusions of the Eve, With Rupture of'the Glob Wounds oi' the Cornea, . Wounds of the Iris and Lens, Injuries from Corrosive Sub- stances, .... Affections of the External Muscles Doui)le Vision, . Squint, . . • Secondary Squint, Operation for Scpiint, . ]'aral.> li<; Strahi^riius, . Divergent Stral)ismu<, . Paralysis of Ocular Muscles, Disea.ses of the Lachrynuil Apparatu Obstruction of the Nasal Duct, The Use of Spectacles, Presl)yopia, Ilypermetropia, Myopia, .... Astigmatism, . CONTENTS. XIX CHAPTER XXXYL DISEASES OF THE EAR. Affections of the External Ear : Malformations of the Auricle, . 756 Htematoma Auris, . . . 756 Keloid and other Tumors of the Auricle, . . . 756 Eruptions, . . . . 756 Periostitis and Caries of the Ex- ternal Meatus, . . . 757 Examination of the External Meatus, .... 757 Accumulation of Wax, . 757 Otorrhcea, .... 757 Syphilitic Affections, . . 758 Tumors of the Meatus, . . 758 Exostosis, .... 758 Affections of the Middle Ear: Examination of the Membrana Tympani, .... 758 Perforation of the Membrana Tympani, .... 758 Affections of the Middle Ear — con- tini'.ed. Artificial Membrana Tympani, 759 Examination of the Eustachian Tube (Politzor'smeth<.d), . 760 Acute Inflammation of the Tym- panum, ..... 761 Moist and Dry Catarrh, . . 762 Accumulation of Mucus in the Tympanum, . . . 762 Incision of the Membrana Tympani, . . . .76^ Disease of the Tympanum in Scarlet Fever, . . .762 Disease of the Mastoid Cells, . 763 Polypi 763 Affections of the Internal Ear, . 764 Diseases implicating the Brain, 764 Meniere's Disease, . . 765 CHAPTER XXXVII. DISEASES OF THE URINARY ORGANS. Surgical Affections of the Ki: NEY. Acute Nephritis, .... 766 Affections simulating Nephrit- is : Calculous Nephralgia, . . 766 Calculous Pyelitis, . . 706 Pvheumatism, Spinal Abscess, Cystitis, etc., . . . 766 Nephrotomy, .... 767 Chronic Nephritis, .... 767 Hffiniaturia : its Various Sources, . 767 Diseases of the Bladder. Malformations, .... 768 Extroversion 768 Inversion of the Female Bladder, . 770 Hernia of the Bladder, . . . 770 Tumors: Villous, .... 770 Cancer, . . . .771 Cystitis, 778 Vesico-intestinal Fistula, . . 776 Diseases of the Prostate. Acute Pro>tatitis, .... 776 Abscess of the Prostate, . . 776 Chronic Prostatitis, . . .777 Enlarged Prostate, .... 779 Prostatic Hauiorrhage, . . 778 Puncture of the Bladder above the Puiies, . . . .780 Cancer of the Prostate, . . . 781 Diseases of the Urethra. Malformations : Hypospadias and ■ Epispadias, 781 Stricture : Causes of Stricture, . . . 782 Seat of Stricture, . . . 784 Forms of Stricture, . . . 784 Symptoms and Sequela^ of Stric- ture, 784 Com])lications : Fistula in Perinajo, . . 785 Urinary Abscess, . . . 785 Extravasaticm of Urine, . 785 Rupture of the Bladder, . 786 Treatment : Catheterization, . . . 787 Gradual and iiapid Dilata- tion, . . . .788 Method of Tying in the Catheter, / . .790 Treatment of Impassable Stric- ture : Puncture from the Rectum, . 791 Puncture with the Aspirator, 792 Perineal Section, . . .792 Treatment of Abscess in Peri- uieo, 793 Treatment of Fistula in Peri- nseo, ..... 794 Ante-scrotal Fistula, . . 794 XX CONTENTS. Strictures — continued. Treatment of Non-dilatable or Recurring Stricture : Syme's Operation, or Exter- nal Uretlirotomy, Rupture, or Forcible Dilata- tion, ..... Internal Urethrotomy, 795 796 797 " Spasmodic Stricture," . Various causes of Retention of Urine, Stricture of the Female Urethra, . Retention distinguished fi-om Pa- ral^'sis and Atony, Incontinence of Urine, . Juvenile Enuresis, . PAGE 798 799 799 799 799 800 CHAPTER XXXVIII. CALCULUS. Urinary Deposits, . 801 Kinds of Calculi : Litbate of Ammonia, 804 Lithic Acid, 804 Oxalate of Lime, 804 Xantbic and Cystic Oxide, 804 Pbosphate of Lime, . 804 Triple Phosphate, 805 Fusible Calculus, 805 Alternating Calculi, 805 Carbonate of Lime, . 805 Pseudo Calculi, 805 Chemical Tests for Calculi, 806 Calculus in the Bladder : Symptoms 806 Sounding for Stone, . 807 The Endoscope, 808 Termination of Stone, 808 Operations for Stone : Compari- son of Lithotomy and Lilbot- rity, 809 Lateral Lithotomy, . 809 Lateral Lithotomy — contimied. Accidents and Complication.s, After-treatment, . Dangers of the Operation, Rectovesical and Recto urethral Fistula, Median Lithotomy, . Other Methods of Perineal Lith otomy, .... Rectal Lithotomy, . The Hypogastric or High Opera tion, .... Perineal Lithotrity, . Lithotomy in the Female, Lithotrit}', Complications, Removal of Foreign Bodies from the Bladder, .... Prostatic Calculus, . Vesicoprostatic Calculus, . Stone in the Urethra, 812 813 814 814 814 815 815 816 816 81fi 817 821 823 824 824 824 CHAPTER XXXIX. DISEASES OF THE MALE ORGANS OF GENERATION. Affections of the Testicle AND ITS Appendages. Congenital Malformations: Retain- ed Testicle, 825 Hydrocele : Common or Vaginal, . . 826 Congenital, .... 829 Infantile, 829 Hydrocele of the Cord, . . 830 Encysted Hydrocele of the; Tes- ticle, 830 Loose Bodies i n the Tu n ica Vag- inalis, ..... 831 Hematocele, ..... 831 Acute Orchitis— Gonorrhccal Epi- didymitis, ..... 832 Chronic and Syphilitic Orcliitis, . 834 Strumous Orchitis, . . . 835 Hernia Testi.-, .... 835 Cystic Disease of the Testis, . . 835 Enchondroma of the Testis, Innocent Tumors in the Scrotum, Cancer of the Testis, Castration, Dermal and other Frctal Tumors, Functional Disorders : Spermator rhcva, ..... Affections of liie Cord : Varieocele Tumors in the Spermatic Canal, Affections of the Sckotum G5dema and Inflammation, Elephantiasis, ..... Chimney-sweep's Canci-r, A FF EC T IONS O F 'r 1 1 E V K N I S . Cancer of the Penis, Amputation of the Peni.s, Circumcision, ..... Persistent Priajiism — Gangrene of the Penis, ..... 830 836 8J7 837 838 838 839 841 841 811 8-12 842 843 848 814 CONTENTS. CHAPTER XL. SURGICAL DISEASES OF THE FEMALE ORGANS OF GENERATION, Malformations : Adhesion of the Labia, . . 844 Imperforate Hymen, . . 844 Imperforate Vagina, . . 845 Vascular Tumors of the Urethra, . 845 Tumors of the Vulva, . . .846 Hypertrophy of the Labia and Clit- oris, 846 Cancer of the External Parts, . 846 Accidents in Parturition : Ruptured Perineum, . . . 847 Prolapsus Uteri, . . . 848 Vaginal Cystocele, . . 849 Vesieo-vaginal Fistula, . . 849 Accidents in Parturition — continued. Recto-vaginal Fistula, . . 850 Surgical Operations for Uterine Polypi, 850 Hysterotomy, ..... 851 Exci.sion of "the Os Uteri, . . 852 Ovarian Tumors : Cysts of the Broad Ligament, 85"2 Suppuration in Ovarian C^'sts, 853 Termination of Ovarian Dropsy, 854 Diagnosis, .... 854 Treatment; Paracentesis, . 855 Ovariotomy, . . , 855 CHAPTER XLI. DISEASES OF THE BREAST. Hypertrophy, 858 Atrophy, 859 Inflammation, , . . , 859 Chronic Abscess, 859 Lacteal Abscess, 859 Lobular Induration ; Neuralgia and Hysterical Pain, , . . , 861 Functional Disorders, 861 Tumors of the Breast : Adenoma, . 861 Serocystic Tumor, . 862 Simple Cysts, . , , . 863 Milk Cysts, . . , , 864 Tumors of the Breast — continued. Rarer Forms of Innocent Tu- mors, . , . , . 864 Cancer, 864 Amputation of the Mamma, 866 Diseases of the Mammilla : Malfor- mations, .... 867 Cancer, 867 Eruptions, followed by Scirrhus of the Breast, . . .867 Diseases of the Male Breast, . . 867 CHAPTER XLII. DISEASES OF THE THYROID BODY. Endemic Goitre, .... 868 Sporadic or Common Bronchoeele, 868 Removal of Bronchoeele, . . 869 Exophthalmic Goitre, . . .869 Cancer of the Thyroid Body, . . 869 CHAPTER XLIII. DISEASES OF THE SKIN AND ITS APPENDAGES. SiviN Diseases. Exanthemata: Roseola. . Urticaria, Hiemorrhagia : Purpura, Scorbutus, Vesiculse : Sudamina and Miliaria Eczema, .... Herpes, .... Parasitae : Tinea Tonsurans, . Tinea Decalvans : Alopecia, Tinea Favosa or Favus, . Parasitae — continued. . 870 Tinea S_ycosis or Mentagra, . 871 Chloasma or Pityriasis Versi . 871 color, .... . 871 Scabies, .... 872 Bullae : Pemphigus, . 872 Rupia, . . ... . 873 Pustulas: Impetigo, . 874 Eczema Impetiginodes, . 875 Porrigo, . 875 876 876 877 878 878 878 879 879 CONTENTS. PAGE PustuliC — eonlbiued. EctliyiUii, . 879 rapiiUe : Strophulus, 880 Lichen, 880 Prurigo, . 881 Squam:¥: Pityriasis, 882 Psoriasis and Lepra, 882 TuberculaliiB : Acne, 882 Syphilitic Tubercle, 883 JMoliuscum, 888 Lupus, 883 Elephantiasis: Leprosy e'. Grie - corum. 884 Barbadoes leg, E A ■ah um, 885 Keloid, . 885 Framboesia, 886 Maculae, 88P, Ichthyosis, 886 Diseases of the Api'kndages of THE Skin: Plica Polonica Corns, Warts, Venereal Warts and Condy loniata. Verruca Necrogenica, Horns, ' Boils, Carbuncle, Facial Carbuncle, . Malignant Pustule, . Chilblains, Onychia, . Syphilitic Disease of the Nails, Psoriasis of the Nails, Ingrowing Toenail, . Avulsion of the Nail, PAGE 886 88G 887 887 888 888 888 889 890 891 891 892 892 892 892 893 CHAPTER XLIV. MINOR AND OPERATIVE SURGERY. Minor Surgery. Bandaging: Spiral Bandages, . . . 894 Figure of 8, or Spica Bandage, . 895 Four-tailed Bandage, . . 895 Scalp or Capelline Bandage, . 896 T-bandage 896 Suspensory Bandage, . . 896 Many-tailed Bandage, . . 896 Splints, and immovable Apparatus, 897 Plaster of Paris Splint, . . 898 Sutures, 898 Clove-hitch, . . . .900 Counter-irritants : Blisters, 900 Issues, 900 Moxa, 901 Setons, 901 Actual Cautery, ... . 901 Galvanic Cautery, . . . 901 Potential Cauteries, . . . 901 Cauterization en fl{;ches, . . 902 Bloodletting : Venesection, .... 902 Cupping, 903 Vaccination, ..... 903 Anaesthetics. Local Anaesthesia, .... 905 Ether and Chloroform, . . . 906 Bichloride of Methvlene, . . 908 Nitrous Oxide, \ . . . 908 Means of Re.strainino Haemorrhage. The Common Tourniquet, . . 909 Tlie Horseshoe Tourniquet, . . 909 Digital Pressure, . . . .909 Esrnarch's Bandage, . . . 909 Plastic Surcikry. Principles of Plastic Oj/crations, . 910 Rhinoplasty, 911 Operations for Contracted Cicatrix, 912 Cheiloplasty, .... 913 Operations for Webbed Fingers, 913 Amputations. General Observations, Circular anc Flap Amputations, 915 Instruments for Amputations, 915 Special Amputations : At the Shoulder-joint, 916 Of the Arm, . ' . 917 Through the Elbow, 918 Of the Forearm, 918 At the Wrist, . 919 Of the Fingers, 9 1 9 Of the Thumb, 920 At the Hip-joint, 921 Of the Thigh, . 923 At the Knee, . 923 Of the Leg, . 924 Teale's Amputation, 924 At the Ankle, Syme's, 955 Pirogofl' -, . 927 Subastragaloid Amputation, 927 Hancock's Amjiutation, . 927 Chopart's Amputation, 927 Lisfranc'sor Hey's Amputation , 928 Amputation of the Toes, . 928 Ex(;isions ok Bones and Joints. General Observations, 929 Excision of the Shoulder, 930 Scapula, .... 931 Clavicle, .... !I31 Elbow, .... 932 Wrist, .... 935 Hip, .... 937 Kricf^ .... 938 Ankle, .... 943 Os Caleis, 944 Astragalus, 945 Metatarsal Bonos, 946 LIST OF ILLUSTRATIONS. FIG. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19 '20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. iture Cohnheim's Experiment, sliowin<^ the Emigration of Leucocytes, Pi's-corpiiscles — (after Riiidfleiscli), Diagram of granulation — (after Riridfleisch), Thcrmograpli of Traumatic Fever, Syme's Abscess-knife, ..... Paget's or Pollock's ditto, .... Thermograph of Pypemia, .... Diagram of Thrombus in a Vein — (after Billroth Thermograph of Hectic Fever, Thermograph of Erysipelas, .... Obstruction of Artery from Embolus, . Thermograph of Tetanus, .... Laceration of the Inner Coats of an Artery, Diagram of complete Division of an Artery, Aneurism-needle, ...... Effects of Ligature on an Artery, . Obliteration of a very small part of the Artery by Lig Effects of Carbolized Catgut Ligature on Arteries, Liston's Tenaculum, ..... Assalini's Tenaculum, ..... Acupressure — Circumclusion — (after Pirrie), Acupressure — Torsoclusion — (after Pirrie), Acupressure — Retroclusion — (after Pirrie), Torsion of Artery, ..... Torsion-forceps, ...... Method of performing Direct Transfusion, . Ulceration of the Duodenum in Burn — (from Syst. of Sur " Greenstick " Fracture of the Clavicle — (from Syst. of Surg.), Separation of Epiphyses in Lower Limb, Union of Fracture with ends overlapping, . Union of Fracture by Periosteal Bridge — (from Syst. of Surg.), Union of Fracture by Provisional Callus — (from Syst. of Surg.), The same at an earlier stage, ...... Ununited Fracture — soft union, ...... Ununited Fracture — false joint, ...... Ununited Fracture — complete non-union, .... Extravasation of Blood beneath the Cranium — wound of middle artery, .......... Blood-membrane in Arachnoid Cavity, .... Blood-cyst in Arachnoid Cavity, ...... Blood-cyst in Arachnoid Cavity from disease. Fracture passing vertically round the Skull, Union of Old Depressed Fracture, ..... Fracture limited to the Base of the Skull, .... Hernia Cerebri into the Meatus Auditorius, .... ). XXIV LIST OF ILLUSTRATIONS. FIG. 45. Frju-tm-e through the Internal Auditory Meatus, 46. United Fracture of the Anterior Fossa of the Skull, . 47. United Fracture of the Posterior Fossa of the Skull, . 48. United Fracture of the Posterior and Middle Fossie of the Skull, 40. Depression in the Brain after Old Concussion — (from Syst. of Sur 50. Thermograph of Concussion, ..... 51. Result of Trephining for Depressed Fracture of Skull, . 52. Compound Fracture of the Skull, with depression, 53. Thermograph of Traumatic Encephalitis, 54. Extravasation in the Sheath of the Optic Nerve — (from Sy.^t. of Surg 55. Hey's Saw, ....... 56. Elevator, 57. Trephine, ....... 58. Trephining — unequal thickness of Skull, 59. United Fracture of the Spine, 60 Dislocation of the Spine, .... 61. Fracture of the Spine, showing the nature of the displacement, 62. Unilateral Dislocation of the Jaw— (from U. W. Smith), 63. Dislocation of the Jaw — (from Malgaigne), . 64. Fracture of the Larynx, ...... 65. Foreign Body in the Eight Bronchus, .... 66. View of the Bifurcation of the Trachea — (from Syst. of Surg.), 67. The Horsehair Probang, ..... 68. The Aspirator, 69. Diagram of Repair of Wound of Bowel, 70. United Fracture of False Pelvis, .... 71. Comminuted Fracture of the Pelvis, 72. Diagram of Fractures of the Clavicle, . 73. 74. Bandage for Fractured Clavicle, 75 Fracture of Sternal End of Clavicle, 76. Fracture of Acromial End of Clavicle, 77. Comminuted Intracapsular Fracture of the Humerus 78. Bony union of Impacted Intracapsular Fracture of the Hume R. W. Smith), 79. Fracture of the Surgical Neck of the Humerus, . 80. Separation of the Upper Epiphysis of the Humerus, 81. Diagrams of Dislocation of the Elbow backwards, and Fracture of End of the Humerus, to show their points of contrast, 82. Two figures, to show the position of the Lower Epiphysial L Humeru.s — (from Holmes's Surg. Dis. of Childhood), 83. Fracture of the Olecranon — bony union, 84. Colles's Fracture— (from R. W. Smith), 85. Gordon's Splint for Colles's Fracture, . 86. Dislocation of the Shoulder — general appearance, 87. Subcoracoid Dislocation — (after Flower), 88. Intracoracoid Dislocation — after Flower), 89. Subglenoid Dislocation — (after Flower), 90. Subclavicular Dislocation — (after Flower), . 91. Subspinous Dislocation — (after Flower), 92. Dislocation of the Elbow backwards, . 93. Dislocation of the Elbow backwards, with Fracture of the Coronoid Process, 94. Dislocation of the Head of the Radius backwards 95. Dislocation of the Head of the Radius forwards, 96. Dislocation of the Thumb — faft'T Fabbri), . 97. Reduction of this Dislocation — (after Fabbri), [ from the Lower ne of the LIST OF ILLUSTRATIONS. XXV FIG. PAGE 98. Non-impacted Intnicap?uliir Fracture of Cervix Femoris, . . . 290 99. Impacted Extracapsular Fracture of Cervix Femoris, .... 290 100. Comminuted Non-impacted Fracture of Cervix Femori.s, .... 290 lOL Gunshot Fracture (intracapsular) of Cervix Femoris, .... 290 102. Fracture of Neck of Thi^al Tumors, ......... 152. Blood-cyst of the Leii, 153. Sarcomatous Tissue from the Walls of this Cyst, 154. Lobulatod Fatty Tumor, 155 Encapsulated Fatty Tumor, 156. Fibroid Tumiu- of Iliac Fossa, ...... 157 Fibrocellular Growths of Labium, ..... 158. Aneurism by Anastomosis of Upper Lip, .... 159. Subcutaneous Lis^ature of Naevus, ..... 160. " Fergusson's Knot" for Strangulating Large Nsevi, . 161. Ligature for Piecemeal Strangulation of Large Na3vi, 162. Round or Oval-colled Sarcoma, ...... 163. Spindle-cellcd Sarcoma, ....... 164. Giant-celled Sarcoma, or Myeloid Tumor — (after Billroth), 165. M\-.\oma, or Net-celled Sarccjma, ..... 166 Alveolar Sarcoma — (after Billroth), ..... 167 Microscopical Appearances of Scirrhus — (after Arnott), 168. Cancer Stroma — (after Arnott), ...... 169. Medullary Carcinoma — (after Arnott), .... 170. Melanosis springing from Urethra, ..... 17L ^[icroscopical Appearances of the above — (from Path Trans.), 172 Epithelioma — (after Arnott), ...... 173. Colloid Cancer — (after Arnott), ...... 174. Microscopical Appearances of Tubercle — (after Rindfleisch), 175. Microscopical Appearances of the Secretion from the Local or Su anil the Indurated Venereal Sore — (after H. Lee), 176. Syphilitic Teeth— (from Path. Trans.), 177. Skin-grafting Scissors, ....... 178. Periostitis— (from Syst. of Surg.), ..... 179. The Entire Diaphysis of the Tibia removed in a Case of Acute — (from Holmes's Surg Dis. of Childhood), . 180. Osteomyelitis of the Femur, ...... 181. Inflammation of the Femoral Vein in Osteomyelitis, . 182. Chronic Osteomyelitis following Amputation — (after Longmorf 183. Chr(jnic Osteomyelitis of tiie Whole Shjift of a Bone from luju L(jngmore), ........ 184. Chronic Absoe.ss in Lower End of the Tibia, 185. Chronic Abscess making its way into the Knee-joint, 186. Uns'iccessful Trephining for Chronic Abscess — (from Syst 187. Caries of Humerus, ...... 188. Necrosis of the Tibia implicating the Ankle, 189. Extensive Ulceration nnd Necrosis of the Tibia, 190. Fracture from Necrosis of the FiMnur. 191 Necrosis ..f the Whole Shaft of the Tibia, . 192. Deposit of Tubercle in the Head of the P^miur, . 193 Deposit of Tubercle in the Head of the Femur, . 194. Periosteal Cancer of the Humerus, 195. Cancer of the Tibia, 196. Epithelioma of the Tibia, 197. Multiple Enchondroniata, 198. Enchondrr)ma of the Humerus, .... 199. Ivory Exostosis of the Lower .Jaw, 2U0. Ivory P^xostosis of the; Antrum, .... :;01. Result of operation for Ivory Exostosis of the Skul of S )pur ry— urg. iting. Periostitis after from Syst. of Surg.), LIST OF ILLUSTRATIONS. XXVll the Tran FIG. 202. Os.sifying Enchonflroma, 203. Exostosis of the Phalanx, 204. Diffused Bony Tumor of tlie Jaw, .... 205. Acute Inflammation of Cartihii^e— (after Redfcrn), . 206. Section of Inflamed Cartilage— (after Redfern), . 207. Dislocation of the Hip from Disease — (from Syst. of Suri:;.), 208. Congenital Dislocation of the Hip— (from Syst. of Surg), 209. Angular Curvature of the Spine, .... 210. Abscess from Caries of the Spine, .... 2U. Compression of the Spinal Cord by Carious Bone, 212. Apparatus for Angular Curvature, .... 213. Caries of the Cervical Vertebra? opening into the Pharynx 214. Back view of the same preparatit)n, .... 215. Disease of the Cervical VertebriB, Partial Destruction of Ligament, ........ 216. Dislocation of the Odontoid Process in Disease, . 217. Extreme Lateral Curvature, . . • . 218 Apparatus for Lateral Curvature, .... 219. Spina Bifida, 220. Division of Tendo Achillis, 221. The External Pvectus of the Eye after Division, . 222. Talipes Equinus — internal view, ..... 223. The same — external view, ...... 224. Shoe for Talipes Equinus— (from Holmes's Surg. Di:'. of Childhood), 225. Skeleton of Foot in Extreme Talipes Varus— (after Little), 22(5. Shoe for Talipes Varus — (from Holmes's Surg. Dis. of Childhood), 227. Talipes Calcaneo-Valgus — (from Holmes's Surg. Dis. of Childhood), 228. Flat-foot— (from Holmes's Surg. Dis. of Childhood), . 229. Neuroma, ......... 280. Diagram of True Aneurism, ..... 231. Diagram of False Aneurism, ..... 232. Diagram of Hernial Aneurism, ..... 233. Diagram of Traumatic Aneurism, .... 234. Diagram of Dissecting Aneurism, .... 235. Tubular Aneurism, ....... 236. Cirsoid Aneurism — (from Syst. of Surg.), ... 237. 238. Diagrams of the Relation between the Aneurismal Sac 239. Diagram of Anel's Operation, ..... 240. Diagram of Hunter's Operation, . .... 241. Cure of Aneurism, ....... 242. The Circulation after the Cure of Aneurism by the Ligatu of Surg.), ......... 243. Diagram of Wardrop's Operation by Distal Ligature, 244. Diagram of Brasdor's Operation by Distal Ligature, . 245. Ligature of the Carotid Artery, ..... 246. Ligature of the Sul)clavian Artery, .... 247. Ligature of the Brachial Artery, .... 248 Ligature of the Ulnar and Radial Arteries, 249. Ligature of the External Iliac Artery, 250. Ligature of the Femoral Artery, .... 251. Ligature of the Posterior Tibial Artery, 252. Ligature of the Anterior Tibial Artery, 253. Diagramof the Common Harelip — (from Holmes's Surg Di 254. Harelip with Unequal Sides— (from Holmes's Surg. Dis. of Childhood), . 255 Harelip with its Two Parts on Different Levels — (from Holmes's Surg. Dis. of Childhood) and the A from •lery, 59 Svst. of Childhood) 570 LIST OF ILLUSTRATIONS. FIG. 2-36. 2-'i8 259. 200. 2(;l 262. 203. 2(i4. 205. 260 267. 208. 260. 270. 271 272. 273. 274. 275. 276. 277. 278. 279, 281. 282. 283. 284. 285. 286. 287. 288. 289. 290. 291. 292. 293. 294. 295. 296. 297. 298 299. 300. 301. 302. 303. 304. 305. 306, 307. 308, from Ilolints's Surtr. Dis. of Di.s. of alat Jaw, se, Oppration for Harolip witli Unequal Side* Childho..d), . . . . Cleinot's Operation for Incomplete Harelip — (from Holmes's 8iir: Ciiildhood) " . Diagram of Double Harelip— (from Holmes's Surg. Dis. of Childhood), Front View of Double Harelip with Projection of Intermaxillnrj' Bone— (from Holmes's Surg. Dis. of Childhood), Side View of the same case— (from Holmes's Surg. Dis. of Childhood), Giraldes's Operation for Harelip— (from Holmes's Surg. Dis. of Childhood Hainsby's Truss, ......... Smith's Gag for Staphyloraphy, ilethod of Passing and Tying the Sutures in Staphyloraphy, Muscles of Soft Palate— Pollock's Method of Dividinix the Levator P Fibrous Tumor of the Skull, Bellocq's Sound, ..... Plugging the Nares, .... Polypus Nasi — (after Liston), Hilton's Snare for Polypus, Nasopharyngeal Polypus removed by Excision of the Mr. H. Lee's Clamp, ..... The Ecraseur, ...... Hutchinson's Gag, ..... Internal Strangulation, .... Intussusception, ...... Rupture of Hernial Sac by Taxis, Kujjture of the Mesentery from the same cause, 280. Diagrams of the Two Modes of Reduction en mas. Right Inguinal Truss, Left Inguinal Truss, ..... Left Scrotal Truss, Double Inguinal Truss, .... Spiral Sjiring Truss, ..... Salmon and Ody's Truss, .... The same, double, ..... Moc-main Lever Truss, .... Hernia Knife, ...... Strangulation by Ni-ck of Sac, Omental Sac, ...... Contraction of the Bowel after Strangulation Artificial Anus, ...... Dupuytren's Enterotome, .... Nonclosure of the Tunica Vaginalis, . Retained Testicle with Hernia, . . . Diagram of Congenital Inguinal Hernia, . Diagram of Infantile Inguinal Hernia, Diagram of Encysted Inguinal Hernia, Diagram of Common Inguinal Hernia, Diagram of Partial Obliteration of tin; Funicular Process, Diagram of Formation of Hernia into the Funicular Procos.s, Dis.section of Oblique Inguinal Hernia, .... A notiier view of the same preparation, .... Dissection of I'^-mural Hernia, ...... Irregular Distribution of Obturator Vessels in Fciiimal lli-rnia Obturator Vessels Encircling the Sac of a Femnral Hernia, Obturator Hernia, ........ 571 572 572 LIST OF ILLUSTRATIONS. XXIX FIG. 309. Mr. H. Smith's Clamp for Piles, .... 310. Fistiihi in Ano without any Internal Opening, . 311. Preparation showing the Ordinary Anatomy of Fistula in Ano, 312. Simple Stricture of the Koctum, ..... 313. Cancerous Stricture, ....... 314. Strumous Ulceration and Stricture of the Rectum, 315. Bistouri-caclie, ........ 316. Imperforate Anus with Scrotal Fistula — (after Larcher), 317. Dissection of the above case — (after Larcher), . 318. Imperforate Rectum — (after Girald^s), 319. Imperforate Rectum — Result of Paracenteses — (from Holmes's Surj of Childhood), 320. Fuller's Bivalve Traclieotomy Canula, 321. Durham's Canula with "Lobster-tail " Director, 322. Bryant's Tracheotomy Canula — (after Bryant), . 323. Needle for Paracentesis Corneaj, . . . ' . 324. Effects of Atropine in Iritis, ..... 325 Diagram to Illustrate the Position of Laminar Cataract, 326. Curette and Mouthpiece for Suction Operation for Cataract 327. Focal Illumination for the Detection of Cataract, 328. Linear Knife for E.xtraction of Cataract, . 329. Diagram showing the Incision for Linear E.xtraction, 330. Diagram of Correct and Faulty Section of Iris in Iridectomy, 331. Iridectomy Forceps, ....... 332. Diagram of Direct Ophthalmoscopic Examination, . 333. Diagram of Indirect Ophthalmoscopic Examination, . 334. Lance-knife for Iridectomy, . . . 335. Diagram to Illustrate the Formation of Double Images 336. Diagram to Elucidate the Mechanism of Squint, 337. Diagram to Illustrate the Ofieration for Squint, . 338. Diagram to Show the Method of E.stimating the Degree of Squint, 339. The Strabismus Hook, 340. Weber's Canaliculus Knife, 341. Slilling's Knife for Lachrymal Fistula, 342. Diagram of Emmetropia, Myopia, and Hypermetropia, 343. Aural Polypus, . . .' 344 Congenital" Cyst of the Bladder, 315. Cancer of the Bladder, covered tjy a Villous Growth, 346. Villous Tumor of the Bladder, 347. Difl"u..^ed Cancer of the Bladder, 348. Glandular Tumor of the Prostate, .... 349. Enlarged Prostate, 350. Forcible Catherization in Enlarged Prostate, 351. Stricture! in the Spongy Portion of the Urethra, 352. Stricture at the Meatus, ...... 353. Annular Stricture of the Un-thra, .... 354. Lithate of Ammonia deposit in Urine, 355. Uric Acid deposit in Urine, ..... 356. Oxalate of Lime deposit in Urine, .... 357. Phosphate of Lime deposit in Urine,. 358. Triple Phosphate deposit in Urine, .... 359. Urate of Ammonia Calculus (impure) — (after Poland), 360. Uric Acid Calculus— (after Poland), . . 361. Oxalate of Lime Calculus — external view, . 362. Oxalate of Lime Calculus in section — (after Poland), Dis. XXX LIST OF ILLUSTRATIONS. on), oil), FIG. 363. Pliospliatc of Lime Calculus with nucleus of Lithic Acid — (after Poland), 3G4. Alternating Calculus — (after Poland), .... 365. Dissection of the Perineum — (after Pirrie), 366. The Second Step of the Operation for Stone — (after Pirrie), 367. Median Lithotomy— Sacculated Bladder, .... 368. The common Screw Lithotrite, ...... 369. Civiale's Lithotrite, 370. Sir H. Thompson's Lithotrite, ...... 37L The English, or Brodie's, Method of Lithotrity— (after Sir H. Thomp 372. The French, or Civiale's, Method of Lithotrity— (after Sir H. Thomp: 373. Clover's Syringe for Lithotrity, ..... 374. Fasciculated Bladder with Adherent Calculi, . 375. Impaction of Fragments in a Pouch of the Bladder, . 376. Result of Lithotrity in a case of Enlarged Prostate, . 377. Calculus Impacted in the Neck of the Bladder, . 378. Tapping a Hydrocele — (after Liston), .... 379. Cystic Disease of the Testicle, 380. Watery Cy.st of the Broad Ligament, ... 38L The common Leg Bandage, 382. Bandage for the Hand and Forearm, .... 383. The Spica Bandage, 384. Four-tailed Bandage for the Knee, .... 385. The Scalp or Capelline Bandage, .... 386. T-bandage 387. The Continuous Suture, 388. The Tsvisted Suture, 889. The Clove-hitch, 390. Venesection — (after C. Heath), 391. Amputation of the Shoulder-joint, .... 392. 393. Diagram of the Front and Back of the Arm, siiowii for various Operations, ...... 394. Diagram of a Section of the Upper Arm, . 395. Diagram of a Section of the Forearm, 396. Diagram of the Incisions for various Operations on the Trunk, . 397. Diagram showing the Incisions for various Operations on the Low tremity, ........... 398. Lines of various Amputations at the Back of the Lower Extremity, 399. Flap of Amputation at the Hip, 400. Diagram of Circular Amputation of tlic Thigh, . 401. Tcale's Amputation of the Leg, 402. Syine's Amputation, 4(J8. Skeleton of the Foot, showing the lines for Chojiart's and putations, ........ 404. Method of Slinging the Arm after Excision of the Elbow, 405. Mr. Svme's case of Repair after Excision of the Elbow, 406. Diagram of the Excision of the Wrist — (after Lister), 407. Serforate anus, 6G7 Roberts: flatfoot, 513 Rochard : operation for imperforate anus, 667 Rodr/ers, J. K. : ligature of left subclavian (first ]>art), 546 Rokiiansky : hypertrophy of bone, 458 Roux : intracranial suppuration, 160; sta|)liyloraphy, 575 Rfiux, Jules : gunshot wounds of femur, 345 Saemisch: creeping ulcer of cornea, 672 ; treatment of cornenl ulcer, 708 Salter: swinging fracture, 143 ; alveolar abscess, 585; phosphorus necrosis, 587 ; exan- thematous tooth-tumors, 587 ; jaw necrosis, 687 ; abscess of antrum, 589; epulis, 590. INDEX OF AUTHORS. XXXIX Sanderson : migration of IcucocytciS, "O ; inflamrnation, cli. i, pnsfihn ; 1 yiiiphadenoma, 5G8 Sanson: fracture of coronoid process of jaw, 198 Savory: scrofula, ch. xviii ; hysteria, eh. xix, pff.s.sim ; wounds of vessel, 109: col- lapse, 108; concussion, 176; pathology of tumors, 139; kinds of scrofula, 378; incision in enlarged bursa, 499 ; rapid dilatation of stricture, 789 Sayre: excision of hip, 937 Scnn : bilateral lithotomy, 815 Shaw: injuries of spine, ch. vu\, passim. ; recovery after fracture of cervical sj>ine, 187; fracture of leg, 311 ; rickets, 45G SiMcy : colloid and villous tumors, 37G Sedilloi : evidenient des os, 43'J ; incision in harelip, 574 Simon., John: heat in inflammation, 34; inllammation, cli. \, passim; loose bodies in joints, 470 Simon, of Rostock : primary union in gunshot wounds, 334 Simpson, Sir J. : sulphate of zinc as a caustic, 901 Skry : refracture of bone, 153; dislocation of shoulder, 270; rhinoplasty, 912 Smith, H.: diseases of rectum, ch. xxiii, /jassiwi. Smit/i., li. W. : dislocation of jaw, 201 ; fracture of sternal end of clavicle, 254 ; frac- ture of neck of humerus, 259 ; separation of upper epiphysis of humerus, 251 ; injuries near the elbow, 2G3 ; Colles's fracture, 267; dislocation of acromion, 271 ; extracapsular fracture of femur, 294 ; dislocation of metatarsus, 333 ; rheu- matic arthritis, 471 Smith, S. : dislocation of semilunar cartilages, 327 Smith, T. : congenital tumor, 496; harelip foi'ceps, 570; staphyluraphy, 575; affec- tions of cutaneous system, 892 et seq. Smyth: successful ligature of innominate, 545 Soden : partial dislocation of shoulder, 279 Solly: cyst of back (meningocele?), 495 South: fracture of neck of scapula, 256; fracture of coracoid iirocess, 257; jiartial dislocation of shoulder, 279; removal of scapula, 504 Souitiam: cure of aneurism by anastomosis, 360 /S/JC/<6'e .-'treatment of arteriovenous aneurism, 528; amputation at shoulder for sub- clavian aneurism, 545; elevation of shoulder in axillary aneurism, 547 Stanley: rupture of ureter, 234 ; phagedenic ulceration of bone, 433; ulcers of bone, 441 ; cystic tumors of bone, 451; hypertrophy of bone, 458 Startin : impetiginous lupus, 884 Stolies : gunshot wound of spine, 339 Stromeyer : subcutaneous surgery, 505 Sivayne : diagnosis of dissecting aneurism, 527 Syme: injury to vein in tying artery. 111 ; wound of artery, 113; torsion, 123; ojso- phagotomy, 216 ; caries, 440; old operation for aneurism, 532 ; old ojieration for axillary aneurism, 546; ligature of internal iliac, 553; external urethrotomy, 795; amputation of foot, 926; excision of elbow, 935 Tatiim : whitlow, 498 Taylor, A. S. : tetanus, 86 Taylor : extension in hip disease, 479 Tcnle : loose cartilage, 470 ; macroglossia, 609 ; rectangular amputation, 924 Teale, Jr.: injection of perchloride of iron in nsevus, 361; enucleation of nasvus, 361 ; suction operation for cataract, 719; operation for symblepharon, 741 Thotnas : fracture of jaw, 199 Tliornpson, Sir H. : urinary diseases, ch. xxxvii, passiwt; division of the entire pros- tate in lithotomy, 813; lithotrity, 822 Thudiclaiin : nasal douche, 599 xl INDEX OF AUTHORS. Tourdes: wound of internal mammary artery, 227 Toynbee : treatment of nervous deafness, 7G4 Travel- s : gangrene, 70; collapse, 128; cysts of bone, 452; orbital aneurism, 544; excision of clavicle, 9o2 Travers, Jr. : absorption of neck of femur, 244 Trousseau: hydrophobia, 101 Tufnell: medical treatment of aneurism, 531 Vanzetti : uncipression, 125; digital pressure in aneurism, 536 Velpeau : foreign body in chest, 225 ; injection of spina bifida, 49() Venning : treatment of gonorrhoea, 392; diagnosis of syphilis, 398; cancer of upper lip, 582 Veimeu'd : foreipressitin, 125; varicose veins, 564 V'idal dc Cassis : bilateral lithotomj', 815 Virchow : glanders, 99 ; nomenclature of tumors, 348 ; ulceration of cartilage, 468 Vulkmann : antiseptic surgery, 52 Wagstaffe : transfusion, 127 ; sarcoma of jaw, 591 Walker, of Liverpool: compression in popliteal aneurism, 537 Waller: migration of leucocytes, 36 Walton, Hagnes: orbital aneurism, 544 Wardrop : anastomotic circulation, 116; distal ligature, 540 Watso7i, P. H. : aneurism of profunda, 554; excision of knee, 939 Watson, Sir T. : foreign bod}' in bronchus, 213 Weber: ulceration of cartilage, 468; nasal douche, 598 Wells, Spencer: ovariotomy, 857 Willan : porrigo, 879 Williams: migration of leucocytes, 36 Wilson: removal of spina bifida, 496 Wilson, Erasmus: treatment of urticaria, 871 Wolfe: transplantation of excised portions of skin, 912 Wood: trusses, 629; radical cure of hernia, 630 ; extroversion of bladder, 770 Wormald: dissection of dislocation of hip, 319; reduction of dislocation of hip, 320 ; treatment of varicocele, 840 Wunderlich: temperature in injury of the spine, 187 h- Yuuatt : hydrojjhobia, 101 SURGERY: ITS PRINCIPLES AND PRACTICE. CHAPTER I. INFLAMMATION AND THE PROCESS OF UNION IN SOFT PARTS- TRAUMATIC FEVER— DRESSING OF WOUNDS. Inflammation is the name given to a perverted vital action, one of the leading features of which, as the name implies, is the production of unnatural heat in the part. Although the researches of modern pathol- ogists have greatly advanced our knowledge of the essential phenomena of the process of inflammation, yet, for practical purposes, I think it is better to commence the study of inflammation from the old definition ol it by its four great s_ymptoms, " redness, swelling, heat, and pain.'" Redneas. — The redness depends on cungedion, or the loading of the inflamed part with blood ; and this congestion is spoken of in surgical language as active^ i.e.^ due to an increased supply, or passive, i.e., due to diminished power of circulation or impeded return of blood. Conges- tion is best studied, either in a superficial part of the human body, or in the web of a frog's foot, or otlier transparent part, spread out under the microscope. Thus, in the ocular conjunctiva, after the lodgment of a grain of dust in the eye, red vessels will be seen shooting over parts which before were perfectly white, and soon the membrane, which in its natural state was transparent and imperceptible, is converted at the part injured into a pulpy mass of dilated vessels, from which a copious dis- charge of fluid exudes. In the frog's foot, on the application of an irri- tant, the small arteries dilate, the stream of blood flows more rapidly, the dilatation extends to the capillaries and then to the veins; next the stream of blood moves more slowly, and finally it oscillates and stops entirely. The period of dilated arteries and increased stream is that of "active congestion ;" that of dilated veins and diminished movement, " passive congestion ;"'^ The stoppage of the stream receives the name of " the inflammatory stasis." 1 This is Celsus's definition : " Nota3 inflammationis sunt quatuor, rubor et tumor, cum calore et dolore." 2 Passive congestion, however, is not always, nor indeed usually, an inflammatory symptom. Any cause which prevents the return of the venous blood — a lifi^ature round the limb, a tumor in the course of the vein, even prolonged standing or exposure to heat, besides innumerable other similar conditions — may determine pas- sive congestion. 34 INFLAMMATION. Swelling. — The increased supply of blood in the part must necessarily cause siceUiug., but another and the main cause of swelling is the extrav- asation which takes place in the parenchyma of the inflamed part as the impediment to the blood-stream increases. When the blood is flowing naturally, through a transparent web, there will always be seen around the central column of the blood-corpuscles an external part of the ves- sel's area, which looks as if it were empt}' — z.e., where only the trans-, parent serum is circulating — and, if the individual blood disks can be seen, they will be observed to be separate from each other. On what cause this mutual repulsion between the blood-corpuscles and the wall of the vessel depends we do not know, but it is abolished by inflamma- tion. The corpuscles adhere to each other and to the wall of the vessel, and soon the white corpuscles of the l)lood are seen to have passed through the membrane and to have moved into the parenchymatous tissue. The serum also transudes, and the red globules are here and there found to be cxtravasated. The name of lymph is given to this inflammatory exu- dation, consisting mainly of the cells which are formed out of the leuco- cytes in their various stages of development, and partly of serous fluid. Red blood-globules ma}' be intermingled, but this is accidental. The terra "fibrin" is also often employed as synonymous with lymph. Tem2:)erature. — The temperature of an inflamed part is raised, to the sensations of the patient himself generally, and always to the thermometer. This is familiar to everybody from his own experience, and some increase of temperature must evidently be caused by the mere loading of the part witli blood. But it seems, from recent experiments, that not only is the part more richly supplied with blood at the usual temperature of healthy blood, but that lieat is generated in the inflamed part, and thus the tem- perature of the blood at the focus of inflammation is raised above that of the rest of the blood. John Hunter taught the reverse of this doc- trine. He quotes some experiments which he made' to prove that the temperature of an inflamed part never raises above tiiat of the blood in the heart ; but these experiments were not made with sufficiently delicate means of observation ; and Mi*. Simon'' has put on record a series of thermo-electrical observations of inflamed parts, wherel\y he has proved: " 1. That the arterial blood supplied to an inflamed limb is less warm tlian the focus of inflammation itself. 2. That tlie Lienou.H blood returning from an inflamed limb, though less warm than the focus of inflammation, is warmer than the arterial blood supplied to the limb ; and, 8, that the venous blood returning from an inflamed limb is warmer than the cor- responding current on the o])posite side of the body;" that is to say, that the lieat generated at the inflamed part raises the blood returned IVom that part above the usual tem))eratnre of the mass of the blood. Wlien this increase of heat is so considerable that the natural loss of tempera- ture b}' perspiration, etc., is insufficient to counteract it, the temperature of the whole body rises, and tlie other phenomena of " inflammatory fever" ensue.'' Fain. — The pain of inflammation varies very considerablj'. Even in ' See Hunter's works, l)y Palmer, vol. iii, pp. 388-340. In the hist cxpfriinent there detiiiled, however, the reader will observe that Hunter noticed an increase of the tri'ueral temperature of the hody in inflammation. '■^ Holmes's .System of Suri^ery, "Ad (;d., vol. i, p 18, ' I do not mean that all tlie phenomena of inllainmalory oi- traumatic fevei- depend on th(! n)ere rise; of tcmipcirature of the blood, but as the inllammatory heat rises so arc these phenomena developed. Whether they depend on the rise of temperature, or whether they and it have a common cause, is another question. INFLAMMATORY FEVER. 35 inflammation of the largest and the most vital organs there may be little or no j)ain, while in some of the smallest (such as the fingers) tlie i)ain may be intolerable. Much depends on the extensibility of the inflamed part; thus the acute pain in wliitlow and in orchitis is explained by tlie resistance offered to the increase of swelling by the sheath of tlie tendon, and by the tunica albuginea respectively. Still more depends on the peculiar sensibility of tlic organ. The physical cause of pain it is often impossible to ascertain. Pain is often greater in diseases when there is no evidence of inflammation (as in neuralgia) than when inflammation is not only dangerou'^ but even fatal (as in gangrene of the lung); and most severe pain may be experienced, as every one knows, in conditions of the body which are compatible with perfect health. Yet this does not destroy the great importance of pain as a symptom of disease in general, and of inflammation in particular. It only shows tliat in clinical investi- gations it is necessary to take account of all the circumstances of the case, not of one only. The persistence of pain in any given part ought to induce tlie surgeon to examine closely the condition of the general system (pulse, tongue, temperature, and secretions) and of the part itself (as to redness, swelling, heat, and the functions of the organ), and on such an examination a secure diagnosis can almost always be founded. InJlaDLmcUory Fever. — Inflammation, when extensive or very violent, is accompanied by general fever, which is variously designated as " in- flammatory," "traumatic," "surgical," "irritative," etc. The condition necessary for its production appears to be the overheating of the blood, as stated above, and its leading symptom, therefore, is the rise of tem- perature of the whole body. Hence the importance of the thermomet- rical observations which are now so generally taken in surgical as well as in medical cases. As typical of inflammatory fever, for surgical purposes, I shall select that form which follows on a severe wound. ^ Traumalic fever commences usually within twenty-four hours of the receipt of the injury, and sometimes dates almost from the moment of its receipt. The jiatient feels hot and uncomfortable, with occasional intervals of chilliness, sometimes amounting to definite rigor. He is thirsty and reslless, with a rapid and perhaps hard and bounding pulse, furred tongue, hot and dr}' skin, scanty and high-colored urine, consti- pated bowels, flushed face, headache, and loss of appetite. The symp- toms are aggravated towards night, when a definite rise of temperature can usually be noted. Coincident with any abrupt and very considerable elevation (say more than 2" F.) of the heat of the blood there is almost certain to be a rigor. In uncomplicated cases of traumatic fever the symptoms will probably begin to decline from about the second day after its commencement, and will have entirely subsided by the fifth, sixth, or seventh day; l)ut there is much variety both as to the period at which it attains its climax (or "fastigium," as it is technicallj^ called) and as to its total duration. The first appearance of decrease is very generally coincident with the occurrence of supi)uration. After the subsidence of the primary attack of fever a secou(lary attack sometimes occurs, apart 1 A good opportunity of watching tlie phenomena of traumatic fever is furnished by any great operation, such as an amputation, undertaken for the removal of a chronic disease on a person previously in good general health. The state of the pulse, tongue, and secretions, and the normal temperature, should be carefully noted for the two or three days preceding the operation ; and morning and evening obser- vations should be regularly taken after it until the temperature and all other matters, observed have returned to the condition of health. 36 INFLAMMATION. from a.uy other complication, but iisuall}' the reappearance of fever de- notes the occurrence of some of the comi)lications of wounds, as deep- seated abscess, erysipelas, phagedrena, or pyiemia. When the fever does not subside at the ordinary time the presence of some concealed source of irritation, such as lodged foreign body or obstructed discharge, is probable, and should be carefully sought for. We shall consider this subject of traumatic fever more fully in its sur- gical bearings presently. Pathology of Inflammation. — The above is intended for a rough sketch of the leading symptoms of inflammation as seen in practice. The pa- thology or essential nature of the process must next be briefly discussed. It has long been a controversy whether the phenomena which we term inflammation are due to changes in the nervous s^'stem, the vessels, the blood, or the tissues ; nor is the question one which seems to admit of any conlident answer. Bnt the first changes which are perceptil)le to the eye utfect the vessels and their contents at once. The arteries dilate;^ the blood-stream moves with greater rapidity ; the red and white blood- corpuscles, which in the natural state are quite separate from each otlier as well as from the wall of the vessel, begin to adhere together and to stick to the arterial wall. As the dilatation extends, first to the capil- laries and then to the veins, the blood-stream moves more and more slowly, the vessels becoming more obstructed by blood-globules. Next, a very remarkable phenomenon is noticed, i.e., the "-emigration " of tlie white corpuscles, or "leucocytes," as they are now usually called. The experiment bj?^ whicli this emigration may be actually rendered visible is very difficult to carry out successfully.- It leaves no doubt that the white corpuscles begin to adhere to the wall of the vessel before the axial current (i.e., the current of red l)lood-globules along the centre of the vessel) stops ; that the wall of the vessel then exhibits buds or pro- jections, as if the leucocyte were pushing its way through ; that these buds or projections become connected with the wall of the vessel l\y a sort of tongue or string, which then gives wa}-, and leaves a body exactly similar to a leucocyte in the parenchyma external to the vessel; and that the vvallof the vessel shows no alteration at the part where the leucocyte has thus passed through it. In what precise manner this may take place it is needless here to discuss. We may suppose, even if only for the sake of hypothesis and to render the thing conceivable, that the leucocyte, which is a mass of prot()i)lasm, rebuilds the wall of tlie vessel that it is perforating (which is also a mass of proto[)hism; as fast as it destroys it.^ The leucocytes display the same amoeboid ujovements after their emigra- tion which the}' are known to do within the vessels, and which seem to be connected witii their further development. (See Fig. I.) 1 It seems doubtful whether or not this dih^tation is preceded by ii period of active contraction or spasm of the vessel. If it be so, that jieriod is so transient that it has not been found possible as yet to afBrm its constant occurrence. 2 Tills cxiicrinicnt was prohahly first performed by Dr. Waller, before 18-JG; but his observations did not attract the attention they deserved. Coiinheiin devised a more |)erfi'Ct form of tin; exiieriinent, on a frog paralyzed by curare. It will be found ver}' clearly described by Dr. Sanderson, in Holmes's System of Surs^ery, p. 751, 2d ed. At pp. 741-2 of the same volume will be found an account of the re- searches and leaching of our distinguislied countrymen, Dr. C. J. H. Williams and Dr. Addison, who so nearly anticipated Cohnheim's discovery, in spite of tin; im- perfection of the instruments with which at that lime they were obliged to work. ' Some authors teach that there are openings or "stomala" in the capillary wall, throui;h which the corpuscles pass. It this is tlie case, the corpuscles must, " emi- grate " al.«o in the healthy processes of nutrition. PATHOLOGY. 37 So far the changes observed refer wholly to the vessels and their contents. But that the tissues around the ves- sels have an independent and most important part in the process cannot be doubted. Professor Lister^ has observed changes going on in the pigment-cells lying in the intervascular spaces of the frog's web which testify to an ac- tion entirely indepen- dent of that in the blood or the vessels ; and the action of irri- tants on the non-vascu- lar tissues, such as the cartilages, will be found illustrated in subse- quent pages. Again, as the blood - stream becomes retarded, the blood begins to oscillate backwards and forwards in the vessels, and finally stops. This inflamma- tory stasis can be pro- duced even when the vessels have been en- tirely emptied of blood and filled with milk in place of blood. It can- not, therefore, entirely depend upon, though it must doubtless be influ- enced by, the qualities of the blood. Nor can we imagine that the mere vascular wall can be the sole cause of so remarkable a phenome- non. It must, there- fore, be caused in some measure by the vital ac- tions which are going on in the part generally. And the same conclu- sion results from many of the other recorded facts, for which I must \ V. C^JES^J^ Cohnheim's experiment showing the emigration of the leuco- cytes out of a vein in the mesentery of a frog. The times of the successive observations are marked on each figure, and the indi- vidual leucocytes are distinguished by different letters, r and g denote two leucocytes which were external to the vein at the com- mencement of the observation, a was only just attached to the outside of the wall of the vein at the commencement, and was free from it at the second observation, c had almost passed through tlif wall at the first observation, was only just attached at the sec- ond, and was free at the third. 6 had commenced to adhere to the interior of the wall of the vein at tlje first observation, had par- tially penetrated.it at the second, was adhering to its outer wall at the third, and was becoming pedunculated and preparing to detach itself at the fourth.— From an experiment made for me by my friend and pupil, Mr. J. R. W. Webb. 1 Pbil. Trans , 1858, p. 678. 38 INFLAMMATION. refer to works of more detail. The latest researches seem to show that irritants which do not affect the walls of the vessels, though they may cause dilatation of the capillaries and stagnation of the blood-current, are not followed b}^ emigration of leucocytes, or by transudation of the colored blood-disks ; while if an irritant be applied which acts so deeply and so continuously as to affect the wall of the vessel itself an abundant emigration of colorless and colored blood-disks ensues — the former pass- ing chiefly out of the veins and the latter from the capillaries.^ The question therefore above alluded to would be answered by saying tliat the essential phenomena of inflammation depend on changes in all the structures — the blood, the bloodvessels, and the parenchyma of the part simultaneously. Terminations of the Inflamniatory Process. — The process of inflam- mation maj^ be regarded as destructive or constructive, according to its terminations. If the process above described should cease at the point to which the description has just been carried, the blood-stream will re- sume its movement, the vessels their normal size, the effused serum and the leucocytes will disappear from the intervascular spaces, and the part will resume in all respects the functions and appearance of health. This termination is known in surgical language as '^ Resolution." But if this does not occur, the inflammatory exudation may become organized into new tissue forganization, adhesion), or it maj^ break down into pus (sup- puration, abscess), or the tissue of the part may become softened and disintegi'ated (ulceration), or the whole part may die (gangrene). Effusion and Organization. — The production of new tissue may be re- garded as the curative termination of inflammation. It is true that in many instances this newly formed tissue impairs the functions of the part and constitutes in itself a kind of disease. Thus the utility of joints is destroyed by soft anchylosis, the result of inflammatory adhesions ; or bands of adhesion are formed in the peritoneum which may fatally inter- fere with the movements of the Intestines. But it is none the less true also that it is upon such reproductive properties that all the repair of wounds and fractures depends, and that the greater part of the practice of surgery is directed to the production and regulation of this repro- ductive process. It will he most convenient, I think, to study here this curative termi- nation of inflammation as it is seen in the soft parts ; while the chapter on the union of fractures will contain a description of inflammatory or- ganization in the hard tissues. I therefore turn to the general subject of wounds and the process of their union, in order to illustrate the re- sults of inflammation. Wounds and Contusions. — A forcible solution of continuity in the soft tissues of the body is called a wound ; but, in ordinary language, the ex- posure of the injured part to the air is implied, and the action of some weapon is also understood. When the subcutaneous tissues are merely bruised, i.e.., more or less lacerated without the skin being divided, the injury is called a " Contusion." In a contusion there is pro1)ably always some laceration of the fibres of the cellular tissue, tiie vessels are more or less ruptured, and blood is extravasated proportionally into the subcuta- neous or parenchymatous tissue, or into any of the neighboring cavities of ^ See Dr. Klein's account of Cohnhoim's Ifxtest rosearchos in the London Mod. Record, December 31st, 1873, and January 7th, 1874. ORGANIZATION OF CI.OT. 39 the body. In very severe contusions, such as are produced by re])eated injuries, the skin is very extensively separated from the subjacent fascia,' and is consequently liable to perish for want of blood-supi)ly. Into this space blood is effused, which, showinj}; through the skin, gives the familiar black and blue appearance of a bruise, the color varying witli the deli- cacy of the skin, the quantity of blood effused, and the structure of the part. Thus, in the eyelids, s(;rotum, and vulva a bruise is black ; on the scalp, where the skin is strengthened by the tendon of the occipito-fron- talis, it shows hardly any color at all ; on the globe of the eye, where the conjunctiva allows the free passage of the air, it is scarlet. The black color of an ordinary bruise on the surface of the bod}^ fades away into green or yellow as the blood is absorbed. Very frequently, when the laceration has been great, the blood remains for an indefinite time collected in a cavity, the walls of which are formed of blood-clot and con- densed tissues, while its contents consist of serum mixed with more or less of the coloring matter and broken-down corpuscles. To such a col- lection the name Hematoma, or "blood-tumor," is given. Blood-tumors are distinguished from abscess by the history, appearing as they do at once after the contusion ; by the thinner character of the fluid, contained in a wall of solidified, but not inflamed, tissues ; and by the uninflamed and unengorged condition of the integuments. They are comparatively common on the scalp in infancy and childhood, sometimes extending over half or the whole head. They usually subside spontaneously, even when of very large size, though their absorption is generally considered to be accelerated by some of the stimulating lotions or embrocations usually ordered, among which arnica is perhaps the most in favor.'^ But such stimulating applications should not be made use of immediately after the injury. The application of cold is indicated at first, so long as it seems probable that fresh blood is being effused ; unless the skin is so ex- tensively separated that gangrene is to be feared, in which case moderate warmth (as b}^ water-dressing or warm opiate lotion) is more advisable. In some cases, when the effused blood shows no tendency to disappear, it has been removed by puncture with impunity ; but as this is usually unnecessary, it should not be done except in the last resort, and then the "aspirator" of Dieulafoy, or some such invention for avoiding the en- trance of air, should be employed. If the tissue around inflames, form- ing pus, the bloody fluid becomes decomposed and a serious form of fever may be generated. In such a case, as in that of inflammation of the sac of an abscess, it becomes necessary to lay open the cavity freely, wash it out with carbolic lotion daily, and support the patient's strength through the ensuing fever. Thus we see that, as a rule, contusions do not require any inflammatory process for their cure; and that when inflammation follows on a contusion it is usually as a complication, and one which, when it reaches the stage of suppuration, may prove a formidable one. But the hardening which sometimes remains permanently in a contused part is also very probably in many cases the result of chronic inflamma- tion, leading to the formation of a low form of fibrous tissue. The question as to the organization of blood-clots is one of much inter- 1 In examining the body of a schoolboj' who had been beaten to death by his schoolmaster, Mr. Prescott Hewett and I found the skin so extensively separated from the fascia lata that a common walking-stick could easily be laid between them. ^ The applications in common use in cases of contusion are: Tincture of arnica, gently rubbed in, either pure or diluted with its own bulk of water, or as a lotion •with five to ten parts of water; or poultices of black briony-root (much valued by pugilists) ; or Friar's balsam or soap and opium liniment. 40 INFLAMMATION. est, both in a pathological and a practical point of view. John Hunter tauglit unreservedl}' that coagulated blood "either forms vessels in itself, or vessels shoot out from the original surface of contact into it, forming an elongation of tliemselves, as we have reason to suppose they do in granulations;" and in order to define his meaning more precisely, he im- mediately adds, "I have reason, howcA'er, to believe that the coagulura has the power, under ordinary circumstances, to form vessels in and out of itself;" and of this supposition he proceeds to give proofs, for which I must refer the reader to the original.^ On this supposed property of extravasated blood to take on active processes of organization in its own substance, independent of the structures amongst which it was lying, depended, amongst many other surgical doctrines and precepts, the treatment so much recommended by Sir A. Cooper, and still occasion- ally practiced, of laying a piece of lint steeped in the blood of the part over the wound of a compound fracture, in order that the blood might form a bond of union, and convert the compound into a simple fracture. It seems, however, to say the least, highly dubious whether any such self-organization of clots is possible. The practical result is doubtless the same, viz., that in the substance of the clot vessels are formed, and ultimately the coagulum is replaced by a membrane or fibrous tissue more or less complete, and including in its substance the remains of the blood-corpuscles. But it seems more probable, as Rindfieisch has pointed out,^ that the efficient agents in this organization are leucoc^'tes, whicli are derived, not from the white corpuscles of the clot itself, but by immigration from the neighboring tissues. "Artificial thrombi," says this author, " have been produced by tying arteries in the lower animals ; cinnabar has then been injected into the blood, and its leu- cocytes impregnated with this fine granular material, which is easil}'' recognizable under the microscope. It was found that those cells from which, on the second or third day after the occurrence of coagulation, the organizing process appeared to set out, contained cinnabar — the inevitable inference being that they had emigrated into the clot from without." He then describes the branching out and communication of the leucocytes to form " a delicate protoplasmic network with nuclei in its nodal points," through which capillary cliannels are afterwards opened out, these channels ultimately anastomosing with the vasa vasorum ; while in the interspaces a connective tissue is formed from the fibrin of the clot, involving in its meshes the remains of the blood-corpuscles, wiiich at first entirely obscure it ; and then, a> the clot shrinks and hardens, they wither away, lose their coloring matter, and there remains instead of every red corpuscle a flake of colorless protoplasm. All tliis applies to the organization of non-laminated thrombi contained within the vessels. Of tlie minute phenomena of organization in extra- vascular and laminated coagula nothing is known. More will be found on the changes which intervascular thrombi undergo in the chapters treating of the diseases of the Arteries and Veins. Treatment. — The treatment whicli is to l)e selected in any case of con- tusion depends on tiie severity of tlie injury. When the blow (as is often the case) entails much loss of power and pain in attempted movement, it is obvious that rest is the main recpiisite. Warmth sliould be ai)plied, as by a piece of heated spongio-piline, or warm lotion, covered with oiled ' On tho Blood, Inflamrniilion, hihI (Jiiiisliot Wounds. Works, by PahiK;!-, iii, ^ Piithological Histology, trans, for tho New Syd. Soc, vol. i, p. 225. UNION BY FIRST INTENTION. 41 silk. In smaller and less disabling injuries some active movement is desirable, and gentle rubbing will relieve the pain and promote absorp- tion of the effused blood. Wounds are divided for purposes of description into incised, i. 6., simple cuts in whicli the length bears a considerable proportion to the depth ; jjuncfured, in which the deptli much exceeds the length, the latter being- more of the nature of a prick than a cut; subcutaneous, which are surgi- cal wounds in which a considerable extent of tissue (generally including one or more large tendons or muscles) is divided through a mere punc- ture of the skin, and which are therefore examples of one kind of punc- tured wounds ; contused, in which tlie divided tissues and those around are contused as well as cut ; and lacerated, in which the whole or a por- tion of the solution of continuity is caused by tearing and not by cutting. The incised are the most common, and those from which the process of union is best studied. Tlie processes by which wounds are united illustrate very aptly the various events of inflammation, regarded both in its curative and in its destructive aspect. 1. Immediate Union. — When the surfaces of a clean-cut wound, such as that made in the operation for harelip, are careful!}^ adapted to each other, and supported for a sufficient lengtli of time in apposition, they will probably be found to present no sign of inflammation appreciable by the senses, and in the course of from twenty-four to forty-eight hours the wound will be so soundly united as to require no further attention, nothing being left except a linear mark, which at first looks more or less red, but gradually fades awa}', and in the case of small cuts disappears altogether. This metliod of union is called immediate union or primary adhesion. In this form there is little or no evidence of inflammatory eftusion, and some pathologists have tauglit that the tissues merel}' adhere and grow togetlier. Tliis, however, is hardly an intelligible account of the action of living tissues, and it seems more probable that the process difers in no respect from that to be next described, except in that the symptoms are less obvious. 2. Union by First Intention. — Tlie next process is that of union by first intention, or primary union. In this the cut surfaces pour out a certain quantity of blood which, if in small quantit}^ is probably entirely ab- sorbed, although it is a very common opinion that a portion of it becomes organized, i. e., that the leucocytes become developed into permanent tissue in the extravasated blood, as they do in the inflammatory effusion. In the latter the process of development goes on by the amoeboid leuco- cytes attracting to themselves and absorbing into their tissue the pabulum appropriate for their nutrition from the neighboring plasma. Thus masses of protoplasm are formed, around which a cell-wall is developed. The nuclei of these cells divide and multiply to form new cells, of " prolife- rate," as it is called. The rounded cells then elongate into fibre-cells, out of which are formed the fibrous elements of the connective and vas- cular tissues ; the neighboring vessels shoot out processes into the grow- ing tissue, the unused serum, etc., is reabsorbed, and thus the wound is closed by new material, with no formation of pus. For the minute details of this process I must refer the reader to the works which treat specially of pathology. It will be sufficient here to say that as far as is known at present both the vessels and the connective tissue are formed out of leucocytes, and that the latter may be furnished 42 INFLAMMATION. either by emigration out of the vessels, or from the connective tissue of the part; that some of these leucocytes are converted into cells which communicatini); with each other form vascular channels, wiiile others are elongated into si)indle-shaped cells, the rudiment of libres ; and that the vessels are formed in one of two ways, either by channels (as above) formed out of leucocytes and afterwards opening into the capillary tube, and receiving a layer of endothelium from it, oi" by. a budding out of the endothelial tube of the capillaiT, which i)ud elongates into a loop and opens into another part of the capillary tube. The former is called by Billroth necondari/ and the latter tertiary vascularization, in contradis- tinction to the primari/ vascularization seen in the embryo, in whicli the vessels are directly formed by the differentiation of previously indifferent cells, others of which are developed into blood-corpuscles. Lymphatic vessels are observed in the cicatrix after the formation of the fibres of which it is composed, and nerves are also probabl}' produced in it. Muscular tissue is never reproduced, but the interspace caused in a muscle by a wound is filled up with fibrous tissue. 3. Union by Second Intention. — If the infiammation passes this point, then we have the phenomena of iii(ppu7-ation, one of the destructive ter- minations of the inflammntory action, and the method of union is that M-hich is known b}' the technical name of union by the second intention. The inflammatory leucocytes instead of developing into fibre-cells and forming tissue become developed into pia^-globules, and the exudation breaks down more or less completely into a creamy ttuid called pus, which consists of these globules floating in serum, the liquor puris. Pus- globules, as seen out of the bod\', are but little different in appearance from leucocytes. The leucocyte when treated with acetic acid displays the appearance of a nucleus in its interior, that appearance being usually regarded as the result of a shrinking of the i)rotoplasm of which it is composed. The pus-globule shows more distinct trace of a membrane, and is fre- quently many-nucleated when treated with acid, a condition which Kindfleisch regards as indicating a tendency to degenerate and break down. But tiie same author says that many of the corpuscles of pus displa}' no difierence whatever in character from the blood leucocytes, having only single nuclei^ showing the same auKcboid movements, and being in fact obviously the same things, both in structure and function. This should be borne in mind in connection with the fact that suppuration is not in most cases wholly a destructive process, but serves also as one of the usual modes of repair. The result then of the process of suppuration is twofold. Tiie greater part of the pus is sooner or later cast out of the body. When the suppu- ration is in tiie interior of tin! body this is effected usually by the forma- tion of an abscess ; the pus-globules make their way to a common centre, and the matter becomes inclosed in a cyst or cavity formed by inflamed tissue. As the inflammation progresses the tissues soften and break down in some definite direction, usually towards the surface of the skin or one of the cavities of the body, and the pus shows tiirough the thin tissue which is raised up by the fluid underneath it, allowing perhaps even the P'IG. 2. Pus-corpusoles. a. From a lioaltliy graDuhitins woniiil. 6. From an »]>- scess in tlie areolar tissue, c. The same treated with dilute acetic acid. tl. From a sinus in bone (necrosis), e. Migratory pns-corpiiseles. From Rind- flei-sch's Pathological Histology. INFLAMMATORY SOFTENING. 43 color of the pus to be distinguished. Then the abscess is said to point, and will shortly burst, if not opened by the surgeon. In some cases, however, no such collection of the pus takes place, the matter is difi'used with no definite limit through the interstices of the part — cliffiixe injiam- matiim. When suppuration occurs on the internal surface of one of the cavities of the body, as in i)urulent inflammation of a synovial membrane, it forms what is often spoken of as abscess of the cavity, altliough the matter is really contained, not in a cyst formed by the inflamed tissues, but in the natural bag of the serous or synovial membrane, which in some cases may be free from inflammation at the part where the pus is found. In flammatory Softening. — As the tissues inflame, and as the leucocytes multiply, the normal cells of the part proliferate, that is to say, they give rise to fresh cells by the multiplication of their nuclei, while they themselves become indistinguishable. Coincidently with this the fibres Vertical section through the edge of a gnuuilating surface in process of repair (after Rindfleisch). a. Secretioii of pus. 6. Granulation-tissue (embryonic tissue) with capillary loops, whose walls consist of a layer of cells longitudinally disposed ; their thickness decreases as we approach the surface, c. Cica- trization beginning at the base (spindle-cell tissue), d. Cicatricial tissue, e. Fully formed cuticle, its middle layer consisting of grooved cells. /. Young epithelial cells, g. Zone of ditferentiation. of which the part is composed soften, and in many parts a considerable amount of oil is produced in their interior. All this is quite consistent with absence of suppuration, and the inflammatory softening may be re- placed, or succeeded. b>Mnflammatoi'y organization, and the part become much more dense and solid than natural, as we constantly see in inflam- mation of bones. But if it proceeds a step further the softened and de- 44 I N F L A ]\r M A T I O N. generated tissues begin to melt away in suppuration, and the condition of uhrrafion ensues, denominated by Hunter " molecular gangrene," in which minute, imi)erceptible portions of the tissues die, and are either carried ott" with the discharges or removed by the absorbent vessels (the veins or lymphatics), causing a breach of surface, which when on a free surface is filled up by granulation and cieatrizaHon. GranulaUom^. — When the pus is formed on a free surface much of it is merely discharged, but the surface of the wound is all the time under- going a process of organization called granulatiun. To the naked eye, or under a lens of low power, the surface of a wound or ulcer covered with granulations ("a granulating surface," as it is usually called) looks something like coarse red velvet, that is, it is studded with innumerable small red projections which are concealed by the pus and serous fluid ex- uding from the wound, but are brought into sight by gently drying it. If one of these granulations be examined in tlie microscope, after having been artificially hardened, it will be seen to be composed chiefly of a col- lection of large granular cells (exudation-cells, as they used to be called) with pus-cells on the surface and fibre-cells at the deeper parts; intermin- gled with these cells there are new vessels which shoot into tiie granula- tions from the capillaries of the wounded or inflamed surface, and the whole is permeated by fluid. The cells on the surface may occasionally be seen to be developed into epithelium. The cavity of the wound is closed by the constant organization of the deep parts of these granulations, as the superficial parts melt away into pus, and ultimately by the forma- tion of epithelium over their surface, " skinning over," as it is popularly called. Cicalrization. — The cuticle is formed mainly by the differentiation of the outermost cells of the granulating surface; l)ut it seems probable that the proximity of the natural epithelium of the edge of the ulcer or wound has, to say the least, a considerable effect in producing or disposing to the production of this new epithelium. For though in an ulcer new for- mations of epithelium may often be seen far away from the edges, yet the skinning over far more commonly spreads from the edge, i.e.^ from the old e[)idermis; and the piienomena of skin-grafting also show how much the production of epidermis is hastened b}' applying a healthy epidermal tissue on healthy granulations. The formation, then, of the cicatrix in union by second intention differs veiy widely in its external phenomena from that which is seen in union by first intention, and alltlie differences are in favor of the latter process. In the su])purative union there is greatly more destruction of tissue, much more time is required, all the symptoms afl'ecting tiie palient's health are far more severe; and the newly formed bond of union is more lowly or- ganized, more prone to various degenerations, and more inadequate to replace the tissue in whose place it has been deposited. Yet, as will be seen from the above sketch, the essence of botli processes is the-same. 'Both depend on the organization of leucocytes into cellular tissue, and the development of new vessels; and the essential features, both of vas- cularization and of organization, are similar, only that in the secondary union nu\ny of the leucocytes lie too far from the vessels to obtain the nourisliment which is necessary for their growth, and therefore break down into pus. 4. Union by ^^ Secondary Adhesion.'''' — Besides the common process of repair l)y supi)uration, i.e., union by granulati'ju, or liy second intention, tliere are two other pi'ocesses dcscrilied by Paget analogous tf) and in lact to a great extent identical with it essentially', Ijiit dillering in some ini- CICATRICES. 45 povtant practical details ; they are union l)y s^econdary adhesion ^ or by the third intention., and union under a scab. The former process is best illustrated by the wound of an operation for harelip in which the attempt to obtain primary union has failed, and the surfaces of the wound have begun to granulate. If the ordinary process of union by second intention were allowed to go on to its termination, these granulations would grad- ually fill the wound up until the whole cavity was closed more or less Imperfectly by a dense cicatrix ; or, as would most likely be the case in the instance supposed, the two surfaces of the lip would scar over, and the cavity would not be filled at all. But sometimes, when the granula- tions are perfectly healtliy, if the surfaces be brought evenly together throughout, they will adhere without any further suppuration, the grow- ing tissue at the base of one set of granulations coalescing witli tliat at the base of those on the opposite side, and thus the wound will be closed perfectly and at once. The advantages of this process are that it leaves ranch less scar beliind ; that the scar is much more nearly equal in size to the cavity wliich it fills, and that it is completed in a very short space of time, so that any bone or otlier important part which has been exposed in the wound gets rai)idly covered over and defended from the inflammatory action. The two former points are of interest in wounds of the face or other exposed part ; the last is of great importance in scalp wound, where exposed bone can often be rapidly covered by bringing the granulating edges (if perfectly healthy) into contact by means of one or two silver sutures, and thus all risk of necrosis, or inflammation of the exi)osed cranium, will be avoided. 5. Union under a svab.i or union by scabbing, takes place either in fresh wounds or in those wliich have Iteen previously grautdating. In fresh wounds the surface is covered by a laj'er of dried l)lood, or of the inspis- sated secretion (serum and lymph), which will ooze from the divided vessels just after the bleeding has ceased; and when this comes away the surface is found to be skinned over. The exact nature of this process does not seem to be altogether understood. It is constant in animals, but very rare in man, though Sir J. Paget relates two instances in which even so large a surface as that left after removal of the breast has been thus healed. In the case of a granulating wound the surface of the granulations is coated over either naturally with inspissated secretion (pus and serum), or ai'tificially with some semi-fluid substance which excludes the air ; the superflcial portion of the granulations is then at once converted into epi- thelium, and the cicatrization is completed without further su})puration. When the scab falls off a scar is found below it. Cicatricex. — The material by which a wound is united is called a cica- trix. It differs from the normal tissue which it has replaced in man}' important particulars. As Rindfleisch says: "The cicatricial tissue is far from being a connective tissue of ideally high quality. On the con- trary, its fibres are stiff, inelastic, and misshapen ; its cells are represented b}' shrunken, staff-shaped nuclei, and its vital capacity is proportionally reduced. Moreover, the cicatricial tissue exhibits an extreme proneness to contract in all its dimensions. ... It need hardly be said that this general diminution in bulk is a physical rather than a vital phenomenon. The removal of water has a great deal to do with it, for the white glis- tening tissue of a cicatrix is dry, compact, and harder to cut than any other variety of connective tissue." These remarks of Rindfleisch are applied by him to the cicatrix produced by primary union ; but they 46 INFLAMMATION. apply still more forcibly to that of tiie union by second intention ; and generally it may be said that the longer a cicatrix is in forming, the more imperfect will be its organization, the more will it be likely to fall short in bulk of the parts which it replaces, and the more liable will it be to all the various diseases which affect scars, sucii as contraction, ulceration, cheloid, and cancerous degeneration. All these diseases will be Ibund treated in the chapter on Ulcers. Traumatic Fever. — We have spoken incidentally of traumatic fever as one of the occasional phenomena of inflammation, but this subject is so important in |)ractical surgery that it demands a very careful study. The inflammatory process involves, as we have seen (p. iU), as one of its necessary results, the generation of heat in the blood of the inflamed part. When that part is small and insignificant the slight additional heat thus imparted to the total mass of the blood is easil_y got rid of by the natural processes of transpiration through the skin and lungs. But if the inflammation is very extensive the bodily powers may not be suHfi- cient to clisi)os.e of the excess of heat — the whole mass of blood then rises in temperature, and the phenomena of fever result. This is the simplest theory which can be formed of the causation of fever, and that it is true in part, I think, can be hardly douI)ted, though it is far too simple to be acce[)ted as a solution of all the complicated facts of inflammatory fever. Besides this mere increase of heat from simple inflammation, it seems necessary to admit tliat the blood is also poisoned by the imbibition of some product of inflammation ; and hence the intimate, not to say indissol- nble, connection between traumatic fever and that constitutional infec- tion now commonly called septicaemia. That traumautic fever ma_y originate independently of absorption of any of the products of decomposition, or even of inflammation, is proved by the fact that it arises occasionally almost immediately alter the injury, and nearlj" as soon as tlie inflammation itself does. Since, in these cases, there has been no time for the imbibition of decomposing matters into the blood, there are, as far as I can see, only two hypotheses l)y which the occurrence of fever can be explained, viz., either tiie simple one of increase in the heat of the blood, or the supposition (which is onl^^ slightly different) that such overheated blood, circulating through the nervous centres, disturbs the chief functions of respiration, circulation, etc. But since, commonly speaking, fever does not set in till a period at which the products of inflammation have formed and have had time to decompose or ferment,' since similar phenomena niay doubtless be excited, in a pre- viously healthy animal, l>y the injection into the circulating blood of va- rious putrefying matters ; and since the gravity of the traumatic fever seems often to bear a proportion to the amount of decomposition present in tlie wound, it appears, to say tiie least, probable in the highest degree that tiie ellicient cause of the fever is in most cases, tliougli not in all, the imbiitition of some of the pioducts of inflammation into tlie blood. On this point Billroth speaks as follows : " .Since, from the nature of the process in the inflamed part, some of the tissue is destroyed, while some new tissue is formed, it is notiraprob- 1 Billroth SHys that in hi.* numerous observations the fever has usually been found to coiTim(;noe before tlie end of the >coond day. Mr. Pick (St. George's Ho.spital Reports, vol. iii) says that out of 108 cases " in no single instance did it occur after the fifth day, and in some cases it occurred within the first twenty-four or forty- eiirht hours." TRAUMATIC FEVER. 47 able tliat some of the products of this ; the size of the wick the supply of fluid can be almost exactly i)roportioned to the evaporation, and a gutter made in a macintosh siieet laid under the wound will convey away any super- fluity. It would be endless if I were to endeavor to discuss all the details of dressing wounds, as to every one of which the widest diflference of opinion prevails, even among surgeons of tlie same school. But a few words on some of the chief ])oints may be useful. Thus with regard to sutures. Some surgeons insist on the supposed necessity for withdrawing them very early after the operation ; others, of whom I am one, believe that if an adequate exit has been provided /"rom Ihe first for the discharges (for which purpose a drainage tube, laid in the wound during tlie operation, is very convenient) the sutures can hardly be retained too long — they keep the parts in easy contact, and obviate the necessity for the constant reapplication of strapping, whicii is in general very painful and irritating to the patient, especially to children. 1 have often treated cases of ampu- tation to the end without removing the sutures till the patient left the hospital; and the stumps so formed have generally been the most satis- factorj'. This, of course, does not apply to wounds of the f[\ce, or any other part where the marks of the suture would be objectionable. Again, with respect to the material and kind of the suture. The silver sutures are now in universal use, and are incontestably superior to any other, if they are to be allowed to remain long in ; but if the sutures are to be re- moved soon after tlie operation, silk is better, since it can be removed without any pain or difficulty, whereas the withdrawal of a metal suture, whatever care be used, must as a general rule give a little pain. That pain, however, may be reduced to a minimum by carefully straightening the suture after it is cut, and flattening ;ind other experiments that the pus-iilubules pass from the supfiurating surface up the veins in the same way as thiis globuhi of mercury did, and are detained in the capillaries of remote organs, generally the lung. 62 COMPLICATIONS OF WOUNDS. Fio. 8. out any known injury or anj' ulcerating surface, symptoms of blood poi- soning come on, followed by secondary abscesses in various parts. On this subject Billroth speaks as follows: " At present there is probably no doubt that it is usuall}' due to reabsorption of putrid fluid or pus ; that it is always so is, indeed, disputed. Man}^ surgeons assert that pyaemia very fre- quently results from miasma, especiall}^ from a miasma which develops from the wounds of many patients lying together. This view is based chiefly on the fact that where many severe surgical cases lie together (as in large hospitals, especially army hospitals), many of them die of pysemia, and that even mild cases, patients with cicatriz- ing granulating wounds, become pysemic under such circumstances. This is no place for po- lemics, hence I must be content with giving you my own views on the subject. I can entirely agree to the miasmatic origin of pj'aemia, if by miasma is understood what I understand by it in the present and some other cases, namely, dustlike, dried constituents of pus, and possibly also accompanying minute, living, very small or- ganisms, which in badly ventilated sick-rooms are suspended in the air or adhere to the walls, bedclothes, dressings, or carelessly cleaned in- struments. These bodies, which are in some respects of difl:'erent nature, are usually phlogo- genous, all pyrogenous,^ when they enter the blood. Of course they will collect chiefly where there is the best opportunity for their develop- ment and attachment, that is, in badly ventilated sick-rooms, where the patients are carelessly at- tended, where there is deficient cleanliness, and the patients remain some time in the same apartments. It is impossible to say whether all pus, moist or dr}', is alike injurious; experiments on animals give us no in- formation on this point. It is possible that dry pus, as well as moist, acquires peculiarly injurious qualities from certain minute organisms, animal or vegetable " We are here floating entirely in the region of hypothesis : even as- suming the action of these small organisms in the development of pysemia, the question as to the mode of their action arises. Possibly they induce a sort of fermentation in the pus of the wound, inflammation and destruc- tion of the granulations; possibly they force their way into the granula- tions ; possibly, also, as previously mentioned, they enter the blood through the lungs; possibly even when in the blood they are not alike dangerous to all persons — all these things are unknown.'" The pathological analonnj of septicaemia and pyaemia maj' be thus very summarily described : 1. In some cases (septicseraia) no distinctly local- ized appearances are discovered; the spleen, the solitarj^ glands of the intestine, and the lymphatic glands may be found swollen, the blood Diagram of a thrombus in a vein. From Billroth, Surg. Path., p. 337. a. Central end of a venous thrombus project- ing into a large trunk. 6. A branch without thrombus ; the blood flowing through it may detach and carry into the cir- culation the end of the throm- bus a. 1 By " plilogogenous " is meant "capable of exciting local inflammation;" pyrogenou.s," "CMpable of exciting general fovor." See pp. 47, 48. * Billroth. Surgical Pathology, trans, by Hackloy, pp. 358-9. by PYEMIA. 63 hardly coagulated, and the tissues prone to rapid decomposition, and thereby somewhat altered in microscopic appearance. 2. In other cases (more distinctly pyiiemic) the appearances are localized in the synovial and serous cavities, as diffuse sero-purulent inflammation of the pleura, pericardium, peritoneum, or endocardium, without any perceptible in- flammation of the organs which they cover, or as similar affections of the joints. Heiberg notices that when tlie pysemia follows on childbirth (puerperal fever) sucli inflammation may be found in the peritoneum "without an}' aff'ection of the walls or lining of the uterus. 3. In the third form the morbid material shows its aflinity for the mucous membranes, and chiefly that of the alimentary' canal, by which it seems, as it were, to seek for elimination. The appearances are those of catarrh of the mem- brane, with swelling of the solitary and agminate glands. This is the form which is usually seen in animals after the injection of putrid matter into the blood. 4. The fourth form is tliat in which numerous metastatic abscesses are formed, such metastatic abscesses being usually, but not always, preceded by embolic clots in the minute vessels. Bacteria in Blood Poisoning. — The above is summarized from a very able tract by Heiberg, of Christiania,^ which may also be consulted for a demonstration of the presence of bacteria in these p3'ffimic deposits and in all the parts where the pyfemic or septicaemic process is perceptible. He appears to regard these bacteria as in some way an integral part of the matter (the "materia peccans," as he terms it) which sets up the fermen- tative action in the blood ; and he endeavors to trace the bacteria along the venous and the lymphatic system from the point of inoculation into the general mass of the blood, i. e., to the great veins and the heart. This view would explain the cases of apparently spontaneous pyaemia as being instauces where the morbid matter was accidentally implanted on some part of the external integument, or alimentary mucous membrane, or respiratory tract accidentally denuded of its normal epithelium ; so that the "peccant substance" (the presence of which is indicated by the bac- teria) is allowed to find its way into the lymph-channels, and so into the blood. At the same time it must be admitted that our knowledge of the con- nection which may exist between the bacteria which are found extensively in decomposing fluids and tissues, and the symptoms (called septicaemia, pyaemia, etc.) which ma\' be caused by the absorption of putrefying pro- ducts, is at present very limited. An interesting article recently pub- lished by Panum, of Copenhagen,^ may be referred to as showing that such putrid fluids retain their poisonous properties after undergoing pro- cesses by which all bacteria must be destroyed, and that the mode of their action is much more analogous to that of some compound chemical pro- duct than to the propagation of an animal or vegetable parasite. But even if the bacteria themselves be not the vehicles of the poison, there remains the possibilitj' that the bacteria may have been in some way the cause of the poisonous property of the matter. And this possibility Panum ad- mits, representing it hypothetically by the assumption that the "• putrid poison " may be the secretion of the bacteria ; and he points to the prac- tical fact, which is alone of extreme importance, that the same precau- tions which will prevent the development of bacteria will hinder the forma- tion of the poison. 1 Die Puerperalen und Pyamischen Processe. Leipzig, 1873. * Das putride Gift, die Bakteiien, die putride Infection und die Septicsemie. — Lan- enbeck's Archiv, vol. xvi, 1874. 64 COMPLICATIONS OF WOUNDS. The reader who wishes to see the opposite views as to the connection between the lowest forms of animal life and the development of inflamma- tory disorders ably and fully stated may be referred to the discussion re- cently held at the Pathological Societ}-^, and reported in the British Medical Journal^ for April 10, 24, and May 8, 1875, or in tlie other medi- cal papers of similar dates. The diagnosis of pyaemia is not by any means easy in all cases, or even possil)le at lirst, since its early symptoms are identical or near!}' so with those of the severer forms of traumatic fever. Indeed, tliere can be little doubt that since they are due to simiUir causes there is no essential differ- ence between a case of acute traumatic fever and one of the so-called septiciemia, nor does post-mortem examiuation detect an\' difference in their effects. But the characteristic difference between these three forms of wound fever is this, that in the simple traumatic fever there is a distinct rise up to the climax and a distinct defervescence and return to health. Recurring traumatic fever is onl}' a repetition of this process usually due to a repetition of the irritation, as from retained matter or impacted foreign bod^'. In the constitutional infections, on the other hand, to which the names of septicaemia and pysiemia have been given, there is no such definite course of the fever. The temperature maintains itself above the normal and is exacerbated from time to time when the I'igors take place, falling again as tlie sweating goes on.^ It is, tlien, by tliis course of the temperature, or by the recurring rigors and sweats wliicli are its more palpal)le indications, that we diagnose p^'a^uiia previous to the occurrence of visible deposits or internal inflammations, recognizable by their symptoms. Prognosis. — The prognosis of pygemia is, as a general rule, very bad ; that recovery does ensue, however, we have the most ample proof, and it appears to occur more frequently in cases of spontaneous pysemia than in those of traumatic origin, and is always more probable the more chronic is the course of the symptoms. Causes. — In surgical practice p,y?eraia is usually caused by severe in- juries to bones, and especially in surgical operations and compound frac- tures, or by inflammation of veins. Parturition is a frequent cause. All visceral diseases and exliaustiug maladies, as well as atmosplieric impuri- ties, act as predisposing causes. Treatment. — Tlie treatment of py.Temia, like that of traumatic fever, really resolves itself into propiiylaxis, as to which enougii has been said above. None of tlie various plans of specific treatment wiiich have been proposed, as by quinine, mercury, alcohol, or opium, appears to exert the least real influence on the disease itself. All that can l)e done is to sup- port the patient's strength, and treat the symptoms as they occur. When abscess forms in an accessible situation it should be opened, but not by too free an incision. Chronic Pyaemia. — The above description applies to acute i)y,Tmia as we ordinai'ily see it, especially in surgical practice, as occurring after severe injuries, particular!}' tiiose in wliicii bones are involved. It is an acute disease, and its course is usually to be reckoned liy days, rarely extending to some weeks. But pyjemia occurs also in a clironic form, of which Sir J. Paget has given, in the paper which commences the first volume of the St. Bartholomew's Hospital Brports, an excellent descrip- tion, and some very striking instances, in one of which the symptoms ' iSee the thermograph of pyaemia, nup. p. 60; and of traumatic fever, p. 49. HECTIC FEVER. 65 were protracted over three years. The essential features of this form are similar to those of acute pynemia, and with proper attention the diagnosis can usually be estal»lished ; but tiie resemblance both to rheu- matism and to hectic fever is much greater than in the acute disease, especially to hectic, which in fact may sn{)ei'vene. The disease is not so dangerous as the acute affection, and it is frequently s[)ontanoous, or at least independent of any traumatic cause. Sir J. I'aget has noticed that "■the local evidences of chronic are more frequently than those of acute pyaemia seated exclusively or chiefly in different parts of the same tissues [as, for instance, if occurring as a consecjuence of disease of a bone, all the secondary inflammations may affect tiie osseous system only] ; that they are more frequent in the trunk and limbs than in internal organs, and when seated in tiie veins are most frequently found towards tlie close of the disease." And he adds a most important practical point, in which chronic pyjemia agrees with hectic, viz., that in this as in hectic tiie re- moval by operation of the seat of the original disease is frequently so beneficial that it becomes the surgeon's duty to perform the operation, whilst in acute pyaemia operations almost always deprive the patient of the faint chance of life he might otherwise have. Hectic Fever. — Clear which all run a definite or "suppurative" feve death by exhaustion tinned suppuration, bu greater ex[)enditure of the blood. Its symptoms are ar stages, between which. ly distinguished from the previous forms of fever, course, is tiie feverisli condition called " hectic" r,^ which runs no definite course, and tends to It is generally caused by profuse and long-con- t may be occasioned l)y anything which causes a the elements of nutrition than can be supplied to ranged for convenience of description into three however, there is no exact separation : Thermograijli of hectic lever. From a case, recently under niy care, of pelvic inflammation after parturition, which ultimately ended in recovery. In the first stage there is loss of flesh, varying and feeble pulse, the skin is dry and becomes hot towards evening, when the patient feels chilly, and the general temperature rises ; there are profuse night-sweats with morning remissions ; the tongue is clean and red. In tile second stage the emaciation is greater, the hectic flush begins to appear (that is to say, a circumscribed red blush on the cheek strongly contrasted with the clear pallor of the complexion, and lasting so long as the hot state continues), the night-sweats are much more profuse — "col- liquative," as they are termed — and there is often diarrhoea; the rise of temperature at night is more marked to the thermometer; "the urine Billroth has applied the term " suppurative fever," also to pvfemia. 66 COMPLICATIONS OF WOUNDS. after the sweating will be found to contain increased quantities of urea, chloride of sodium, sulphuric acid, and water." (Croft.) The third stage is one of still more marked exhaustion and failing powers; the pulse feebler and more rapid, the skin dry and scaling, the motions loose and sometimes passed involantaril3', the urine offensive, the mouth aphthous ; the cliills and sweats are more frequent, occurring sometimes twice in the twenty-four hours; the legs become oedematous, bedsores are apt to form. In some cases consciousness gradually de- parts before death. The patient dies very graduall}', sometimes almost imperceptibly. This condition differs entirely from traumatic fever, since it does not depend on any definite irritation, and runs no definite course ; and from pyasmia in the same particulars, and also in the absence of any imbibition of poisonous materials by the blood. The treatment of hectic must generally be directed merely to keeping the patient alive, in the hope that the source of suppui'ation will dry up, and on the cessation of the cause the hectic fever will sul)side. But there are a few cases, mainly those of suppurating joints and bones of the limbs, in wliich the source of suppuration can he removed by operation, and if this is to be done, it should always be done as early as possible in the disease. At later stages the patient is too weak to bear the shock of an operation. In the majority of cases where the source of this disease cannot be removed (of wliich the hectic ensuing on psoas abscess is a familiar example) the patient's strength must be supported, and albuminous ma- terials supplied to the blood while the disease is passing over. Small quantities of nourishing food, wine or beer, repeated as often as the patient can bear it without making too strong calls on his digestion, quinine, sulphuric acid, and iron to check the feverish exacerbations and the sweats, and opium to stop the diarrhoea and procure sleep, are the chief indications of treatment. Suppurative Degeneration of Viscera. — Long-continued suppuration may also prove fatal by inducing disease of the alidominal viscera, chiefly the kidneys, liver, and spleen. It is now universally admitted that the condition which was originally described as "waxy," or "lardaceous" disease af tiiese viscera, and afterwards, not very correctly, as " amyloid degeneration," is often caused by long-continued suppuration, and this degeneration of the liver and kidneys is a frequent cause of droiisy and thereby of death in patients laboring under exliausting suppuration, whether with or without hectic fever. Dr. Dickinson, to whoni we owe, I believe, our first accurate statement of the cause of this degeneration,' traces its production to the great loss of the alkaline salts of potasli and soda from the blood in order to form [)us. He points out that the alka- linity of pus is due to its containing about twice the quantity of the salts of potash and soda which are contained in the sei'um of blood ; that the wax}' or lardaceous viscera always contain a decidedl}' smaller quantity of such salts than are contained in the iieallhy viscera, and that the so- called "am3"loile, or in the groins of infants. The scorch of a sunburn or other irritant is somewhat of the same kind. Cleanliness, the avoidance of friction, powdering the part, and brushing it with nitrate of silver lotion or some other astringent, will relieve it. Erythema Fugax. — There are many other forms of erythema which, thougli they are in themselves local, yet own a general cause. The most obvious and familiar instance of tliis is the "chloroform rash," which is so often seen on the chest and other parts in young jjeople of delicate skin — a slight erythematous eruption which very quickly fades away. The late Dr. Murray observed often a swollen condition of the thyroid gland during its appearance. This of course requires no treatment. In other cases erythema fugax appears as a consequence of indigestion, especially from eating shellfish or pork, in persons to whom such food acts in a poisonous manner, or as a complication of various diseases in which the digestive system is disturbed. The knowledge of the cause points out the treatment. There are other special forms of erythema which are more persistent, and which more nearly approach the characters of the definite skin erup- tions, especially roseola. Such are the Erythema circinatum and mar- 68 COMPLICATIONS OF WOUNDS. ginatnm — definite rings, patclies, or spots of redness, very hardly if at all distinguished from roseola when occurring in a similar form ; Ery- thema papulalum, in which the spots are raised up into a sort of pimple; Erythema tuberculatum, in which the prominence of the spots is greater, and in which they are more persistent. This form is usually seen as a symptom in the debility of fevers. It forms the transition to the Erythema nodosum, which is not uncommon as a substantive disease. Erythema nodosum ditlers so much from the usgal forms of erythema that it is doubtftd whether it ought to be included among them or classed with afiections of the lymphatic system. It occurs in the form of raised patches or tubercles of a red or reddish-yellow color, and somewhat ten- der to tlie touch, sometimes accompanied with a good deal of smarting pain. The patches are generally about the size of half a nut, sometimes as large as the fist. They are seated most commonly on the legs, but they may affect an}^ other part; and Hebra speaks of cases in which as they disappear at one part they occur at another till the whole body has been implicated. They never suppurate, and the redness of the indi- vidual tubercles never spreads to the skin around them, a character which is peculiarly distinctive of erythema nodosum. "It is ver}' probable," says Hebra, ^ "tliat in its pathological anatomy E. nodosum is allied to absorbent inflammation, and likewise to the erysipelatous diseases,'' and the same thing may periiaps be said also of the other erythemata. Indeed, it admits of no doubt whatever that the morbid process concerned in some cases of Erythema nodosum is essentially an inflammation of the lym- phatic vessels." The disease more often aff'ects young women suffering from menstrual irregularities than any other class of persons, though men suffer from it also. I never saw a case in childhood. It is usually con- nected with some obvious disturbance of health, and may be accompanied with more or less symptomatic fever. The treatment consists in the res- toration of the general health, and in alleviating the pain by position and Ijy mild soothing vvarm applications. We must now turn to the varieties of erysipelas, which are distin- gui^shed from these various forms of erythema both by the local characters of the eruption and by the presence of a definite form of general fever. The cutaneous or simple erysipelas is a spreading inflammation of the surface of the skin, with thickening of its tissue, and sometimes consid- erable pulfiness of the subcutaneous parts. This puffiness is especially marked in erysipelas of the face, where the features swell so much and so rapidly that tlie patient is quite irrecognizable in a few hours, and loses all power of vision from the swelling of his eyelids. The redness of er}'- sipelas is usually of a bright tint, often mottled, disappearing on pres- sure; it has a defined border, wiiicli, however, shifts continually as the eruption advances or recedes, and the surface, especially on the face, is often studded with vesicles or blebs. There is often a good deal of ting- ling pain in the part, and swelling of the absorbent glands is a very com- mon plicuomenon. In fact, the glands have often been found enlarged before the eruption shows itself; and if these enlarged glands be more carefully examined, tenderness will often be detected in the course of the lymphatics which lead to them. These symptoms are only the local man- ifestations of a general disorder of the system shown by fever. There is 1 Diseases of the Skin, Iransliitod for the New Syd. Soc, vol. i, p. 291. 2 We chilli see iiri'seiilly how close is tlie connection between erysipelas and influtn- mation of the absorbents. ERYSIPELAS. 69 Fig. K). Tlu'riiiogra|jli of erysipelas. almost always a ri<^or, often several, at the commencement of an erysipel- atous attack ; the tongue is usually coated and often dry, the pulse rapid, the patient restless and feverish, ap- petite bad, bowels consti|)ated, urine hioh colored and often slightly all)u- minous. The rise in temperature, as seen in the annexed thermograph, is often very abrupt, and the defervescence frecpiently as rapid. The course of the teni|)erature in uncomplicated ery- sipelas (such as is siiown in tiie chart) differs from that in traumatic fever in running a much less regular course, and usually subsiding more rapidly and al>ruptly ; and from tliat in pyie- mia in not presenting those constant exacerbations and depressions which mark the rigors and sweats of pyHemia. But erysipelas so frequently supervenes on traumatic fever, and is so frequently complicated with local and general disturbances (notably with the formation of abscess and with the transition to pyaemia), that its tem[)erature curves vary very con- siderably. There is an interval between the first feverish symptoms and the appear- ance of the rash which is said sometimes to be as long as four days, but which I think is rarely more than twenty-four hours. The fever ought to subside considerably in a few days. If the pulse and temperature keep up beyond about ten days, and particularly if there is a rapid and con- siderable rise after a week, the case may be expected to terminate fatally, though I have seen exceptions to this rule. Disturbances of digestion are very common in erysipelas, so that sometimes the rash is mixed more or less with the color of bile, and the conjunctivae are slightly jaundiced, and this is sometimes descril)ed as "bilious erysipelas," though it hardly seems to require a separate name. Conversely, bilious disturbance is occasionally an exciting cause of erysipelas, so that persons j)redisposed are very liable to have an attack of erysipelas from disturbance of the liver. Erysipelas lasts an uncertain time, generally fading gradually and disappearing with desquamation of the epidermis ; but sometimes vanish- ing suddenly in one part of the body to appear in another — erratic ery- sipelas. Suppuration often follows in the cellular tissue, or in the glands which were originally inflamed. There are, again, cases in which no preliminary affection of the lymphatics or of the glands precedes the attack of erysipelas, but in which the erysipelas itself originates the in- flammation of the absorbents. In fact, the connection between spreading erysipelatous inflammation of the skin and the similar inflammation of the absorbents is, as might have been anticipated, an extremely close one; and this illustrates what was said above of the close connection between erythema nodosum, erysipelas, and absorbent inflammation. As the case progresses the constipation often passes into diarrhoea, the feverishness gives way to lassitude and exhaustion, and death by asthenia is threatened. Kinds of Cutaneous Erysipelas. — Numerous varieties have been de- scribed by authors, more indeed than there is any practical necessity for distinguishing. I see no oliject in describing as distinct varieties more than the E. ambulans, in which the rash spreads rapidly over the greater part of the whole body ; the E. erraticum,, in which it leaves one part to 70 rOMPT^ICATIONS OF WOUNDS. appear in another; and the E. metastaticum, in which after the subsidence of erysipelas of tiie skin, an affection, presumed to be of an erysipelatous nature, is developed in internal organs, which, however, is certainly very rare, if indeed it has any existence apart from general pyaemia. In phlegmonous erysipelas the skin is less, and the subjacent cellular tissue much more, atlected than in the simple cutaneous form, not that in the latter the cellular tissue is usually quite unaffected, as the swollen features of erysipelas of the face show. The general symptoms of phleg- monous erysipelas or ''diffuse inflammation" are much tlie same as those of cutaneous erysipelas, but more intense; the redness is usually deeper in color, the skin more brawny, alid the part is oedematous and some- times very tense. In a few days it becomes boggy, from the formation of matter. This is often accompanied by renevved rigors, and the skin frequently sloughs, sometimes to a very great extent Thus I have seen the whole scalp perish, exposing the entire vertex of the cranium in a case of diffuse inllammation of the head. The destruction from suppura- tion and sloughing often extends very deeply and very far, opening into the joints, destroying muscles, exposing I)ones, etc. Diffuse cellulitis is a variety of this, in which the skin is almost or entirely exempt, or which attacks the cellular tissue in a part where there is no skin. In some forms, especially in those rapidly fatal cases which have been known to follow dissection-wounds, the disease evidently has a very close relaiionship to pyremia, and the rapid occurrence of death shows that the general mass of the blood is affected. In such cases it does not necessarily spread from the wound, Init appears at a remote part of the limb, or even on the opposite side of the body. And in other cases diffuse cellulitis accompanies or precedes traumatic gangrene, the limb being mottled with patclies of a dark-red color, which, when cut into (in amputation, for example), are seen to consist of patches of cellular tissue loaded with serum and a dark-colored sanious lymph. The inflamed cel- lular tissue in such cases rapidly sloughs, involving the skin in its destruc- tion. The causes of erysipelas may be separated into ihe predisposing and the exciting. The most common predisposing cause seems to be bad air. Hence the great prevalence of the disease in ill-ventilated hosi)itals, and to a less extent even in those whose ventilation and other arrangements are as good as our present knowledge enables us to make them.' Habitual intemperance, bad diet, visceral disease — especially, as it ap|)ears, disease of the kidneys — are all undoubted predisposing causes. And many peo- ple, without any such definite predisi)Osing causes, have a constitutional predisposition to erysipelas ( particularly of the head and face), wliich will show itself in them on the slightest exciting cause, or even with no obvious cause whatever. ' 1 cannot but protest at:;!iin?t the n?sumption involved in thct terms " hos)iitiil ery- sipelas " and " hospital diseases " as descriptive of tlio complications of wounds. Such com]ili('ations are met with, it is true, most commonly in hospitals, for the simple reason that wounds are also met with most commonly there; but they occur very frequently in private practice, even under the most favorable circumstances, and they have never really bi'cn jn-oved to be relaiiv(dy more frcfjuent in good liosjiitals than in pri\'ate practice, in similar cases. There is much need ibr us all to do our best to im- prove in every way theair, the treatm<-nt, thedressing, and all the other circumstances of tlie wounded in our hospitals — and thereby, doubtless, the jirevalencc of these complications will be lessened — but it is n sad error to impair the re))utation and thus diminish the usefulness of our hosjiitals by reckless aspersions on their salubrity. ERYSIPELAS. 71 The exciting cause of erysipelas is very commonly a wounrl, and it is especially common after lacerated vvoiiiids of the lower extremities and scali), ill the latter case almost always in the pldegmonous form (see Injuries of the Head).' It is very liable to occur after puncturin*if or scarilyini^ dropsical parts. A current of cold air on the head, cold to the loins during menstruation, any sudden chill, overexertion or errors in diet, will sometimes be followed by an attack of erysipelas in tiiose predisposed to it. Tliere are also causes which are sometimes classed separately as efficient causes, inasmuch as they are looked on as really producing the disease, while the others only prej)are the system for it. Such are poisoned states of the atmosphere, of the precise nature of which we are ignorant, but where, as is believed by some, germs are conveyed by the air, which sow the disease, as it were, on wounds in persons pre- dis[)osed to it, or where some material passes into the blood which ex- cites the disease during its elimination. Many authors have believed that the etticient cause of erysipelas is the contagion of bacteria, and their passage into tiie blood, and it seems at least certain that very fre- quently bacteria may be found both in the blood and in the tissues. They are found also in the discharges, but this may be accounted for in various ways. A very interesting i)aper by Dr. Lukomsky, a pupil of von Kech- lingsliausen, may be found in the sixteenth volume of Langenbeck's Archives^ in which it is sought to be proved (1) that bacteria may be found in the bloodvessels, the lympliatics, and the lymph-cliannels of the skin, the cellular tissue, and the internal organs in the human subject, when deatli takes place during the advance of the attack of erysi[)elas; (2) tiiat the bacteria are no longer found in cases of death during the retrocession of the disease; (3) that an affection exactly similar to, if not identical with, cutaneous erysipelas can be excited in the lower ani- mals, not only by the injection into the veins or under the skin of matter containing bacteria, but also by the application of such matter to a raw surface. If tliis should be confirmed it would afford an easy interpreta- tion of the spontaneous, the traumatic, and the contagious origin of ery- 8i[)elas-, but a perusal of the recent debate at the Pathological Society, above referred to, will show how very far we are at present from any trustwortliy knowledge as to the universaiit}' and the significance of the presence of these minute organisms. ' But erysipoliis wiien excited by a wound does not always attai-k the wounded part. I may mention a striking case. I amputated the f(>ot of a man in perfectly good general liealth t occurred a few daj's after the operation and proved rapidly fatal. The other case of amputation (which was certainly an un- promising one) proved fatal also, from pyaemia. I have seen many other cases in which a wound has been the exciting cause; but as the disease has appeared in a remote part we must seek elsewhere for the efBcvent cause. A very natural expla- nation (though hitherto conjectural only) would be that some morbid product is generated in tlie wound, and passes along the channels of absorption (veins or lym- phatics) to the heart, and thence to the part affected. 72 COMPLICATIONS OF WOUNDS. Contagwusness of Erysipelas. — Direct infection from putrefvin;? dis- charges of any kind ma^' produce erysipelas. Hence tiie proliil)ition of the use of sponges in liospital wards, since after being infected by the discharge from one wound, they may be employed to cleanse another ; and hence also tiie necessity for very great care in washing the hands after dressing each case before another patient is handled. It seems also un- deniable that erysipelas has been propagated by contagion — that is to say, that some material may be given off from the body of a patient suf- fering from erysipelas which will excite the disease in a person in health, and still more in a wounded or sick person — of course, supposing in either cass a previous predisposition. Too numerous instances of this have been recorded by writers of experience and credit to leave any rea- sonable doubt that erysipelas is occasionally contagious. Yet, as pa- tients are constantly received into our ordinary surgical and medical wards without any spread of the disease, its contagiousness must be very trifling, and in a well-ventilated and well-managed hospital there is no practical danger in so placing the patients, whilst the collecting of all the patients into special "erysipelas wards'' seems to concentrate the poison and increase the I'isk of contagion, unless such wards and all their attend- ants are absolutely separated from the rest of the hospital, M'hich in prac- tice it is A'ery difficult to do. The diagnosis of the disease is usually obvious. In some few cases there may be a little difficulty in distinguishing diffuse inflammation from phlebitis or from inflamed absorbents, and I have seen a more fatal error committed in treating. a case of deepseated abscess below the fascia, accompanied by oedema and inflammation of the cellular tissue above it, as one of diffuse inflammation merely. The patient died, with numerous incisions into the subcutaneous tissue, but with the abscess unopened below; and I have seen the same error committed with less serious re- sults, as the diagnosis has been corrected afterwards. When any reason exists for believing that matter is situated below the fascia, an explor- atory puncture should not be neglected. 2'he prognosis of the disease depends on a great number of different considerations. Gseteris paribus., the different forms of erysipelas are dangerous in proportion as they are deepseated — the cutaneous, cellulo- cutaneous, and cellular, in that order. But the prognosis varies also with the condition of the patient, being bad in the intemperate and bloated, and especially in those with diseased kidneys or liver; with the patient's age, being bad in the aged and in the very young, though good in cliildhood; with the exciting cause, being worse in epidemics; with the form of the disease, l>eing worse in erratic erysipelas and in recurrent attacks; with its course, being worse when the disease does not subside at the usual period, and particularly if the fever is liglited up again after partial subsidence about the first week; with the situation, being worse in erysipelas of the head and face, and peculiarly so in diffuse inflamma- tion of tiic neck, and especially if in either case the erysipelas spreads inlernall}'' to the mouth and fauces. These are tiie main prognostic con- siderations, tliough many others might be added And it should not be omitted that erysipelas is sometimes salutar}-, ushering in a better state of health, and preceding the definite healing of wounds and ulcers which iiad lieen long open and sluggish. The treatment of erysii)elas resolves itself naturally into general and local. The former is the same for all forms of the disease, and is regu- lated by the general symptoms present in each i)articular case, i. e., it consists in the treatment of the accompanying fover. In the present day ERYSIPELAS. 73 the old antiplilogistic or depletory treatment of fever has been practically abandoned ; yet there are cases of eiysipelas in which, if I can trust my own observation, the indiscriminately stimulant treatment (vvliich has so generally superseded that of indiscriminate depletion), is very ill l)orne, and has a direct influence in prolonging the disease. The strength of the pulse, the general appearance of the ])atient, and his apparent vital power must be the surgeon's guide. In the plethoric and strong, after the bowels have been freely evacuated with a mercurial purge (which should be done in every case of erysipelas, even when diarrhoea is present, for the diari'hoea often depends on loaded bowels), salines with small doses of antimony, and light fluid diet without stimulants should be oi'dered. But there are very few cases (if any) which will not be benefited by the administration of wine or beer carefully at some period of the attack; and if there are any which I'equire bleeding or leeching at first, I have not met with them, although I am piei)ared to admit the advisal>ility of taking blood either from the arm, or better from the temples by leeches, in cases of erysipelas of the head accompanied by sthenic inflammation of the membranes of the brain. In almost all the cases of difluse inflam- mation (cellulo-cutaneous) which we see after injuries, no judicious prac- titioner can hesitate as to the desirability of at any rate avoiding depletion, and a resort to free stimulation is generally followed by amendment. The diet must be regulated by the state of the appetite and tongue. It can do nothing but harm to load a man's stomach with food which he cannot digest, but when meat and other nourishing diet can be borne it should be given along with the stimulants. The kind and quantity of the latter must depend on the patient's previous habits to some extent, but nothing seems in general more grateful to the patient and more supporting than good porter. When there is much nervous excitement and restlessness opium should be carefully administered ; but as a rule opiates are to be avoided in erysipelas, except in the phlegmonous form after injuries. Cam|)hor, ammonia, and light tonics are generally well borne after the bowels have been regulated. Iron, particularly in the form of the Tinct. Ferri Perchloridi, is undoubtedly useful in many cases, and it is believed by some surgeons to have a direct influence on the blood, and thus to act as a specific on the disease. This idea depends on an assumed condition of the blood in life something similar if not identical with the state in which the blood is found after death. There is no doubt that in many post-mortem examinations of persons dying with erysipelas nothing ab- normal has been found except a thick, tarry, uncoagulated condition of the blood, staining the vessels, soon putrefying, and leading to a diffluent condition of the spleen and other viscera which contain much blood. On microscopic examination of the blood the corpuscles are found irregular and broken. It is assumed with great probabilit}' that this testifies to a previous disorganization of the l)lood during life. And it may be that iron, if it can be assimilated, will cf)rrect this; and certainly the free exhibition of iron is very beneficial in many cases. But then it must be given very freely (say xv to xx drops every three hours) in order to produce any such specific effect. And it will not agree with the j^atient if given when the tongue is foul and the general fever is rising. When iron has been prescribed in such cases I have often seen marked benefit from discontinuing it, and prescribing salines, with small doses of anti- mony, if the strength admits of the latter drug being borne; or if there is much prostration, combined with tincture of bark and ammonia. The local treatment differs according to the form of the disease. In the cutaneous form the exclusion of the air is often very soothing. Thus 74 COMPLICATIONS OF WOUNDS. in erysipelas of the face a mask is made for the ])atient, smeared with some ointment (a favorite one for the pur|)ose at St. George's Hospital is an equal mixture of Uncr. Phinibi and Ung. Calaminaj), or the part is defended witli a layer of <.'otton-\vool, or some bland warm lotion is used, such as Lotio Plumbi, a lotion of sulpliate of iron 5J to Oj, or of the Tinct. Ferri Perchlor. 5'j t<> o^'i'j <>f water. Diluted tincture of iodine is recommended l>y some. Nitrate of silver in a strong solution (about grs. .XV to' the oz.) ai)pears to me often Aery useful; and many surgeons are fond of drawing a ring round the erysipelatous rash or round the limb above it with a stick of caustic, a practice to which there is certaiidy uo objection, though I cannot speak positivel}' from my own experience of its utility. In diffuse inflammation and in cellulitis more decisive measures are necessary. In the early stage, when there is only a little oedema around the wound, the discharge of inflammatory products is to be insured by laying the wound freely open with the finger or director. If, notwith- standing this, the inflammation spreads and tlie tension increases, it becomes a question wiietlier or no incisions should be made, not in order to evacuate matter — for as yet no matter will have been formed — but to relieve the tension of the parts, and to avert the gangrene which is threat- ened, as well as to provide free exit for the matter when it does form. For there can be no doubt that the pressure caused by the exudation of serum and lymph on the capillaries which pass through the cellular tissue, and the stretching of these vessels as the skin is pushed away from the fascia, are potent causes of gangrene. When, therefore, the local symp- toms arc marked enough, in the surgeon's judgment, to require such severe measures, incisions ought to be made freely and boldly into the cellular tissue. Kach incision should he of no great length (say two or three inclies), but they should together embrace the whole extent of the tense parts; and if the tension affects fresh parts afterwards they should be rej)eated. A good proof of their necessity, and a good augury for their beneficial influence, is the free gaping of each cut as it is made. If any cousidei'able vessel is wounded it must be secured either by torsion or ligature, but a certain amount of bleeding is rather to be encouiaged. If the luemorrhage be alarming, but its source cannot l>e detected, in consequence of tl)e cut vessel having retracted into the oedematous tissue, the bleeding can be rei)ressed by stuffing the wound with lint for a few hours and making pressure over it. After four or six hours this may be witlidrawn without fear of renewed bleeding. In cases not severe enough to demand incision the parts should be relaxed with warm lotions or poultices. Many surgeons speak favorably of the apparentl}' less severe measure of multiple punctures with a lancet as a substitute for incisi(ms, but they generall}' give a good deal of pain, and are insufficient to afford relief. In making the incisions it is often advisable to administer an anaes- tlietic, more especially in view of the very probable necessity of the repetition of tiie operation ; and if the same indications call for it no hesitation should be felt in repeating the incisions again and again. I have often seen a case terminate happily willi a dozen or more incisions, emf)racing every pai't of the liml), and have often seen occasion to regret that incisi(jns had not been made freely enough where tiie patient lias either sunk under the irritation of constantly advancing erysipelas, or has recovered, but with much loss of function of the liml) from sloughing of skin, fascia, or tendons. In cases where this has unluckily occurred, leading to stiffness and loss of motion of the joints, and particularly the GANGRENE. 75 fingers, careful and clilioent passive motion after the wounds are healed wiil often l)e rewarded with great success. Tlie part should he well steamed, and each of the affected joints severally attended to, hy gentle, cautious, and gradually increasing passive motion, while tiie patient is encouraged to use tlie part as much as he can without great pain or sub- sequent swelling. By gangrene is understood the death of a visible portion of the soft parts and its removal in a niasfj, which is called a slough. Tlie terms Hphaccliis and mortification are also sometimes used to express the pro- cess of gangrene.^ Gangrene may be tlie result of mere spontaneous inflammation, but as a general rule this is not so. The great majority of the cases which we see in i)raclice own some definite cause, although in most of them in- flammation has played an important part in completing the death of the tissues. Traumatic and Spontaneous Gangrene. — Gangrene is divided (a), ac- cording to its exciting causes, into traumatic and spontaneous, and (6), according to its form, into moist and dry. The usual causes which produce traumatic gangrene are mechanical injuries, chemical injuries, local poisons, heat or cold, and arrest of cir- culation. The first cause is too familiar to need any illustration. Of chemical injuries the ordinary caustic issue is a common example, where the skin is destroyed by the desiccating action of the potassa fusa, and is cast off as a slough, the result being a healthy granulatiug ulcer. Closely analo- gous to such cases are those which result from tlie local action of poisons, such as putrefying urine. Such urine escaping through a rui)tured ure- thra kills the cellular tissue into which it is extravasated. producing secondai-ilv the death of the skin which receives its nutrition through this cellular tissue. Gangrene from burns is unhappily only too common, and that from frostbite is toleraltly familiar to most surgeons. Gangrene from arrest of circulation may arise from obliteration of the main artery atone spot, as when the femoral is tied, or from general pressure, as when a liml) is destroyed by tight bandaging. Spontaneous gangrene occurs sometimes as tlie direct result of idiopathic inflammation, as the slough- ing which follows a carbuncle; or it may be caused by degeneration of the vessels in old age (senile gaugrene), by impaction of a plug of fibrin in a large vessel (gangrene from embolism), by inflammation of arteries leading to their obliteration, by loss of nervous power, and by impaired nutrition. The sloughing of the cornea which follows on injury of the fifth nerve is usuall_y quoted as an illustration of gangrene produced by loss of nervous power, and the gangrene which used to be produced bj' eating cock-spurred rye, of gangrene from imi)aired nutrition ; but the two causes seem identical, for loss of nervous power appears to produce gangrene merely b}' impairing the nutrition of the part. We see, then, one main distinction between the two classes of cases, which is of the highest importance in their surgical treatment, viz. : that the causes of the former are local, and therefore often susceptible of me- 1 " Gnngrene proporly sisjnifies the state whicli immediately precedes mortification, while the complete mortification, or absolute death of a part, is called sp/incetus." — Hooper's Med. Diet. But the distinction is not a very obvious one, and the term sphacelus is superfluous, and is now almost disused. When mortification is spoken of as distinct from gangrene, the former means the process, the latter the result. 76 COMPLICATIONS OF WOUNDS. chanical removal ; while those of the latter are mostly (general; so that even if the atlected part of the Iiody could be i-emoved without any injury to the i)atient, the same general cause would in all prohahilitv reproduce tiie jrangrene elsewiiere. Jlloist and !)/•)/ Gangrene. — The division of gangrene into moist and dry is a classical, and in the extreme cases a very well-marked one, hut in ordinary instances it is not very easy to refer the case to one or the other foi'm. The best examples of dry gangrene are sometimes seen in the lingers or toes of very old persons, where tlie arteries become entirely impei'vious, the part tui-ns dry and white (sometimes yellow or brown or black), shrivels up. witii little pain or inflammation, and thus separates from the body.^ The purely inflammatory forms of gangrene, on the other hand, are always moist, much fluid and much gas. the result of pu- trefaction, ai'e efl'used into the cellular tissue, and the affection is accom- panied usually by a great deal of pain. So that it is clear enough tliat gangrene dei)en(is in the former class of cases on deficient supply, and in the lalteron ol>structed return of blood. But in most cases the two causes act together. Thus in senile gangrene the main cause is indisputalUy the delicient snpi)ly of Itlood. and it is therefore usually classed as a form of dry gangrene, yet obstruction of the cai)illary and venous circulation also plays a prominent part, and in many cases there is the inflammatory pain and the loading of the part with the products of inflammation which are characteristic of moist gansrene. Phenomena of Gangrene. — Taking an ordinary example of gangrene, in which the part has been previously inflamed, its red color becomes livid or mottled, blebs or liulkie form, i.e.., the cuticle separates from the cutis, and fluid, generally blood-tinged, is efl^used between them ; the tempera- ture of the part falls, it loses its sensibility, then the part turns black and decomposes, so that it crackles with emphysema. If cut into it is found sodden with foul serum ; in extreme cases all the tissues of the limb are softened and separated fi'om the bone. This is mortificalion. Tlie next step is sloughing — tiiat is. the separation of the dead parts — a purely inflammatoi-y process, exactly analogous to that by which a foreign body, such as a dart, if fixed in the living parts, is loosened and thrust out. The living (i)erhai)s better called half-dead) tissues adjoining the gan- grenous part liecome inflamed, and thus a red line is traced around the slough, which is called the line of demarcation.^ and the formation of which proves that the gangrene has stopped, at least at the part where the line is found. Next the inflamed parts suppurate, and thus a trench is dug around the dead part; granulations spring up and push off the slough, which is novv loose and can l)e picked off. Very commonly one or two strings of cellular tissue resist longer the process of inflammation, and the slough requires to be cut away with a pair of scissors ; and in the case of a limb the bone takes far longer to separate than the soft parts, and it is often necessary to divide it in order to rid the patient of the offensive putrefying mass. When the process of casting off the slough is completed the result is an ordinary granulating ulcer. The genei'al symptoms caused by an attack of gangrene are usually of a low or "typhoid" character. The pulse is small, weak, and frequent, ' This is f;omi'tim(!s callod "chronic" gsintjrcne, as by Travers, who saj's : "The main distinction between this and acute gangrene is, that from the; first the part thus affected, losing its temperature and color, becomes dry, tougli, and slirunketi, instead of moist, soft, and swollen, and takes on a j'ellow or blackish-brown color, nearly resembling that of a mummy." I have seen the color in the fingers perl'eclly dead- white. GANGRENE. 77 the tongue dry and brown, the appetite bad, and tlie strength failing. Death occurs from asthenia, and often ver_y rapidly and unexpectedly. Treatment. — In the treatment of gangrene the first question is, whether or not the part can be removed. Speaking generally this is only advisa- ble in cases of traumatic gangrene, although in some of the more favor- able examples of the spontaneous form it may be done after the line of demarcation has formed. In the case of a purely localized cause, such as ligature of the main artery, there can be no question that as soon as gangrene is once de- clared tile surgeon may amputate if he thinks it necessary, for in such cases there is not usually much general fever. But in severe and exten- sive injuries, such as the passagi3 of a cart-wheel over a limb, the prac- tice of surgeons diflers. When the patient is first seen, directly after the accident, if the injury is obviously incompatible with the mainte- nance of the life of the member, it is better to amputate at once, before the traumatic fever which will follow has had time to set in, and if pos- sible to amputate through healthy unl)rnised tissues. Otherwise, if the surgeon delays the amputation, fever will ensue, and will probably pre- clude successful amputation (for amputation in conditions of acute fever is usually fatal), and diffuse inflammation often accompanies this fever, and spreads the gangrene rapidl}' beyond the range of the original injury,' so that the patient sinks before an}^ second opportunity of removing the limb occurs. Therefore some surgeons, looking to these unfavorable cases, teach that it is better to wait for the line of demarcation in cases of traumatic gangrene before performing amputation, while others say that such delay is unnecessary. It appears to me that the surgeon's choice must be regulated by the amount of fever ar.d by the progress of the gangrene. If the liml) is so far mortified as to be useless, yet a stump can be formed in tolerably healthy parts, and the general condi- tion admits of it, there is no motive for waiting. On the other hand, when the fever is extreme and the gangrene is spreading very rapidly, amputation is useless and often immediately fatal. Such cases, in fact, are well nigh hopeless; but if the patient has any chance of recovery it is in waiting till the gangrene has stopped. But the not infrequent occurrence after injuries of this frightful form of spreading gangrene, accompanied as it is by such profound fever, shovvs that the surgeon has not accurately judged the nature of the injury at the time of its occur- rence, or he would have amputated at once. Yet it must be admitted that the error is one which it is difilcult to avoid. 'We are all desirous rather to save liml)s than to amputate them. We can all look back on cases where the patient's obstinacy has triumphed over the surgeon's urgency, and has been justified by his preserving both life and limb. And it can hardly be doubted that formerly amputation was somewhat too frequently performed. We have lately had many cases published of the preservation of limbs (whether b}' '' antiseptic " dressing or otl)er- wise) which would some years ago have been sacrificed ; and in endeav- 1 The process is tlius graphically described by Mr. Hotmts C'uolc : "Nature en- deavors to cast ofl' the dead from the living tissues by an inflamuialory process in the latter, whicii speedily lose their vitality from inability to support this action towards repair. According to Hunter, a diminution of power, when joined to an increased action, becomes a cause of nn)rtitication, by destroying the bahmce whicli ouglit to subsist between the power and action of every part. Thus the mortification spreads towards the trunk, preceded by a blush of dusky red, marking its onward course." I may add that in many cases tiiere will be found a diffused or phlegmonous inflam- mation of the cellular tissue, spreading along the course of the lymphatics. 78 COMPLICATIONS OF WOUNDS. oring to carry o\it such truly conservative surgery mistakes are inevitable. I will relate two cases. A man was brought to St. George's Hospital, of large frame, healthy appearance and history, who had sustained a severe injury to the el))ow-joint. j\o case could seem more decidedly suitable for excision of the joint and preservation of the limb. I performed the operation with the sanction of my colleagues. The main nerves and vessels were perfectly intact. A day or two after the operation, rapidly spreading gangrene attacked the forearm. One of my colleagues in iny absence am[)utated tiiearni near the shoulder ; gangrene rapiclly attacked the stump, and death followed in a few days. The i)ost-mortem appear- ances threw no light on the cause of this fatal tendency. Another man, also of robust appearance. ;iet. 80, was admitted under my care from the country. A few days previously a charge of small shot had lodged in the calf of each leg from a distance of about twelve paces. On admission there were found numerous shot-holes in both calves, with consideralile bruising and swelling. On the third day gangrene of one leg had set in and spread rapidity. The patient when seen appeared to be sinking; and although tiiere seemed little prospect of recovery, it was judged right to give him the small chance that amputation might afford him. He died, however, almost immediately after the operation. On examination of the limb no artery of consequence was found wounded, nor was there very much extravasation of ]>lood. In both these cases it is clear enough that i)i"imary amputation as soon as practicable after the accident would have given tlie jjatient the best chance for his life : but I do not know how tlie cases could have been distinguished IVom a multi- tude of similar injuries in which the limb has been preserved. I allude to sucli cases in order to impress on the mind of the reader the vital im})ortance of early interference where amputation is necessary, if the operation is to have a fair chance of preserving lil'e. But if the attempt to save the limb has been made, and gangrene sets in in a severe and rapidly spreading form, it appears to be of little use to amputate — at least 1 have not seen any successful cases. And if the gangrene does not spread rapidly and is not accompanied bv the severe constitutional symptoms which always accompany the acute form, it is questionable whether under ordinary circumstances amputation is necessary. The exjiectant treatment may succeed in [(reserving part or the whole of the limb. Thei-e are many other exceptions to the rule usually laid down, that amputation may lie 'performed in traumatic gangrene. Thus in the gan- grene which is caused either by heat or cold it is very rarely that ampu- tation is successfully performed ; for in burns the limb is generally scorched and partially disintegrated far beyond the part at which it is totally destroyed; and in frostbite, though the disintegration is less vis- ible, yet it is so real, that in the Crimean cam[)aign, where this injury was fatally prevalent, the surgeons at last gave up every form of opera- tive interference, so uniform was the bad success — due no doubt in part to the general exhaustion of the patients, but partly also to the local elfects of cold, extending beyond the frozen toes or fingers, and indis- posing the tissues oi' which the stump is formed to take on rei)arative action. Gangrene from emlujlism might be tliought to be a favoral)le case for amputation, and so it would be were it not for the concomitant heart disease. In gangrene after ligature of the u)ain artery we have perhaps the most appropriate example of the use of amputation in trau- matic gangrene. S'ow, gangrene from embolism resembles this in many respects. The obstruction to the circulation is limited and definite; and GANGRENE. 79 the condition can frequently be diagnosed, as it was in the instance here figured ; hnt as it is ustially only a feature of a general disease whicli is necessarily fatal, and which would usually preclude recover}^ from a seri- ous operation, we luxi'dly ever see amputation practiced in such cases. On tlie whole, therefore, ampu- tation on account of gangi'ene is more often practiced before gan- grene has set in, Init when it is judged to Ije inevitable; and when amputation is performed later on, the successful cases are gener- ally those in which the surgeon has waited until tlie process has stopped. If the surgeon has decided to save the limb, or if the gangrene is in a part which cannot be re- moved, tlie first indication is to wraj) it up as completely as possi- ble in some application which will deodorize the dead parts and stim- ulate the living to cast them oft'. For the latter purpose uniform gentle heat is very desirable, and the two indications may be com- bined by a charcoal poultice ; or some tarry preparation, such as carbolic acid or creasote, ma}' be applied to the sloughing part, and the whole wrapped up in a thick layer of cotton-wool. Some of the balsams, such as balsam of Peru or Friar's Balsam (Tr. Benzoin Co.), poured into a poultice, or resinous substances, are also much in use. An old and ver}' useful application is the ''green ointment" of the St. George's Hospital Pharmaco- pojia.' Many other local applica- tions to gangrenous parts might be mentioned, but I think the principle of all of them is the same, — to keep up the heat of the parts equal to or a little above the natural heat of the body; to stimulate the living parts and to deodorize the dead. The general treatment of gangrene rests also on simple principles — difficult as it may be to apply .them in practice — viz., to clear the alimen- An embolic clot, lodged in and completely ob- structing tbe superficial femoral artery, just as it springs f'i-ouithe bifurcation of theconnnon femoral trunk. The Clot was irregularly adlierent to the wall of the vessel, which had a slightly roughened appearance at the point of contact. Elsewhere the lining membrane was natural and the vessel quite empty. At the upper end, corresponding to the deep femoral (which was unobstructed), the clot was scooped out by the action of the blood p-issing into that artery. The patient was admitted with dis- eased heart and dropsy, and in the course of that disease gangrene of the foot supervened. The na- ture and seat of the obstruction could be quite easily recognized during life. Blocks of librin were found in the spleen and kidney. — St. George's Hospital Museum, Ser. vi, No. 199. 1 The formula for this is — R. Ung. Elcmi, lb. j, Uiig. Sambiici, ^iij, Bal.'^. Copaib., ^^iij. The oinlments to bo melted together and the Cojiaibu added to them after they have been removed from the fire, before they cool. Ung. Sambuci is made with the fresh leaves of the elder (lb. ij), prepared lard (lb. ijss.j, and as much water as required. 80 COMPLICATIONS OF WOUNDS. tary canal and improve the digestion, so that the patient may be able to take such nntiinient and stimulants as will keep him alive through the process; and to calm Hie nervous system and procuie sleep b}' means of opium or some of its preparations; or if these are not tolerated, b^' some otlier narcotic. Tiiere are few cases of gangrene in which opium is not indicated, and this is e.s|)ecially the case tiie older the patient is; and tliere are perhaps none (at least none in which tlie gangrene is extensive enough to produce constitutional symptoms) where alcoholic stimulants are not required. But it is a great error to "^ i)our in " stimulants and narcotics without any refei'ence to the condition ol" the tongue, pulse, and temperature. Nar- cotics are used cliietly to calm the patient nnd to avoid the exhaustion which excitement and pain produce; but opium when ill-borne will often make the patient semi-delirious, and will cause excitement and loathing for food, and so increase the exliaustion. In such cases the narcotic must be used cautiously and administei'ed hypodermically or by the rectum, for many patients can tolerate moi'phia or opium in tliis manner who can- not take it by the stomaclu But in some persons all opiates disagree, in whatever form or in whatever way they are given. Chloral, in full doses, (say 9j), should be tried in such persons, or hyoscyamus, or the Indian hemj) (in doses of gr. i-ij of the extract or n^x-xx of the tincture, cau- tiously' increased if it seems to agree). But no narcotic is nearly so cer- tain as opium or morphia; and this is usually not merely tolerated in cases of gangrene, but the patient's general condition improves under its use, visil)l\- and at once. Stimulants are used to procure sleep, to assist appetite, to steady the pulse, and to lower the temperature ; buttliey will not do tliis unless tlie}^ are digested. Tlie judicious use of purgatives and the apportionment of the needful stimulant, both as to quantity and quality, to tlie patient's powers of digestion, will tax all the experience and resources of the surgeon, especially when the patient is somewhat advanced in life and has already ruined his digestion and health by the abuse of fermented liquors. It remains to speak of some of the s[)ecial forms of gangrene. Traumatic Gangrene. — Enough perhaps has ali'eady been said about traumatic gangrene as far as concerns tlie question of amputation. It may be useful just to remind the reader that the limb may be hopelessly dis- organized, both in military practice by spent shot, and in the injuries of civil life by extensive crushes, without the skin being very much injured; the soft [jarts are separated from the bone, the pulse in the main vessels is stopped, and an attentive examination will leave no doubt of the neces- sity for amputation. I ought also to add that the indications for the removal of the limb are quite ditferent in early and in late life. Injuries which alter middle life call iuqjeratively for amputation may in childhood or about the age of |)ul)erty be most reasonably treated on the expectant plan, the surgeon feeling conlident that if gangrene sets in and anqjuta- tion becomes necessary there will be no sucli prolbuiid traumatic fever as that which, in later life, almost precludes the hope of success. lU'xhoreti. — A form of gangrene which niny be regarded as to a certain extent traumatic is that iV(;m pressure — bedsores, or "gangrjtMia ex decu- V)itu." They are usually found in debilitated and emaciated persons who have lain long in bed, and whose weakness ])revents them from shifting their position often or much. They form usually on the sacrum, buttocks, hips, and heels. The skin begins to look red and thin, and then a circular black slough forms. The jjarts may slough so deeply as to open the ver- tebral canal, and the sl(Mighiiig is often the proximate cause of death in HOSPITAL GANGRENE. 81 cases which might otherwise get well. Hence the greatest care should he exercised in all chronic cases to watch the state of the parts on which bedsores usually form, and no doubt careful and dexterous nursing will prevent their foimation in nian}^ cases, though it is most unjust and untrue to say, as is sometimes said, that the occurrence of bedsores proves careless nursing. In order to obviate their formation the first thing is to contrive frequent slight changes in the patient's position, to pad the parts where the bones press on tlie skin with air or water pillows, elei)hant-plaster cut into a ring, or some such contrivance, and to harden the skin by painting it with camphorated spirit or weak solution of nitrate of silver. If the redness still persists a soft poultice is, I think, the best application ; and when gangrene is absolutely declared it must be treated locally like any other form of sloughing. A kind of bedsore is formed in fracture of the spine in which the slough- ing is partly produced ity loss of nervous influence. This will be spoken of under tiie head of Injuries of the Back. Tlie sloughing which is caused by tight bandaging is an illustration of gangrene from pressure with which we are happily unfamiliar in these days of iin|)roved medical education. Occasionally the formation of a small limited slough can hardly be avoided, but the mortification of the whole or great })art of the skin of a limb is justl}' regarded as a proof of crimi- nal negligence, and punished accordingly. In the unhappy cases where this has occurred amputation is often necessary. Ill fro.Htbite the symptouis seen immediately after the injury are usually rather in excess of the real amount of destruction. Parts are cold, white, destitute of sensation and of circulation, and seem condemned to inev- itable death, which really will recover if they are patiently and gradually restored to the natural warmth. This is best done by rubbing the part gently with snow, and bringing the patient by degrees into a warmer atmosphere. If the circulation be too abruptly stimulated the frozen parts will probably slougli. On the other hand, some time afterwards, the apparent is less than the real injuiy, since the parts whicli a{)pear to be perfectly nourished are really incapable of sustaining the reparative process, and if operations be performed through them renewed sloughing or tedious ulceration will ensue. In the cases where gangrene sets in immediately it is of the dry form ; the parts shrivel up at once, and never regain the warmth or color of life. In other cases they perisli from low infiamuiatiou, being unable to support the reaction which ensues on the return of the circulation. The treatment of frostbite, beyond the means required to restore warmth at first, involves no peculiarity except that the atlected parts should long be kept warmly wrapped in wool. UospHal gangrene is an extreme form of sloughing phagedsena. The term '• |)haged!ena" has been applied to a combination of ulceration and gangrene in which as the ulcer spreads its surface sloughs more or less deeply. Tv^o forms of this atiection are recognized, viz., spreading pha,- ged;ena, where ulceration is the prominent symptom, the sloughing being only sui)erficial, and ploughing phagedaena, where the slough which forms on the surface of the ulcer is thick, black, and round in shape, and ap- pears to involve a considerable depth of tissue, so that the sloughing is the prominent symptom; but underneath tliis slough ulceration is going on, and these ulcerating tissues will themselves rapidly perish. The disease which has been clescribed to us by military surgeons' as 1 As for example, in Henncn's Military Surgery, from the outbreaks of this disease during the Peninsular war; or Macleod's Surgery of the Crimean War. 6 82 COMPLICATIONS OF WOUNDS. " hospital o;angrene," and of which we have been fortunate enough not to have seen any instances in the hospitals of this country,' is a severe form of sloughing piiagedfena, accompanied by a constitutional affection which is usually', in fact almost always, fatal. Its cause. api)ears to he general, i. e., to be contained in the atmosphere of the chamber in which it origi- nates, and this seems to be usually the result of overcrowding, deficient ventilation, and uncleanliness, acting on men depressed by wounds and possibly by defeat. The condition of the general atmospliere of the place may favor its develo})ment, but cannot induce it, for it is almost alvva3S observed that scattering the sick into the neighborhood, even putting them into the open air under canvas, stops the outbreak. Direct conta- gion, there can be little doubt, acts powerfully as an exciting cause, and very probably the flies which generally abound in such places convey the poison from one wound to another. From this contagious property, of which many striking examples are given, the disease is sometimes de- nominated " Gangnena contagiosa." The disease commences with pain and tightness across the forehead, small, quick pulse, anxious countenance, stinging pain in the wound, swelling and hardness around its edges. The discharge becomes tliin, gleety, and blood-tinged, with masses like gruel suspended in it. In a few hours the limb becomes greatly swollen, with blue congested veins; if cut into, the cut edges look like raw pork, from the oedematous condi- tion of all the parts. The wound assumes a circular form, and is covered with a thick black slough, or its surface turns white or ashy gray. The affection is attended by constitutional or traumatic fever in its sevei'est form, from which the patient often sinks in a few hours, and which in gen- eral goes on to a fatal termination. The awful mortality attending on this disease is attested by many sad histories of overcrowded militai-y hospi- tals and transport ships, as in an instance recorded by Mi". Holmes Coote of a French Crimean transport, from which sixty dead bodies were thrown overl)oard in a passage of thirty-eight hours. Wlien this formidable disease has invaded a hospital there seems no question that the first thing which should be done is to empty the build- ing of all the sick and wounded which it contains, isolating them if pos- sible ; and if that is not possible putting them under canvas in the open air. The most minute attention must also be paid to the cleanliness of the dressings, ever}' material with which the wounds are touched being burnt at once ;'^ the gangrenous surfaces should also be covered over with thick layers of charcoal, creasote, carbolic acid, or some other disinfect- ant, so that there can be no possibility of the convej'ance of matter from one sore to another. The sloughing surfaces should be destroyed by means of an active caustic, of which, perhaps, fuming nitric acid is the best; opium should be freely given, and the patient's strength sui)p()rted by lilieral quantities of nutriment and stimulants. The cauterization should be repeated as often as ma^' be judged necessary, the patient being under ana^stliesia. Phagedsena. — The disease to which the name of hospital gangrene has 1 In Soutli's Ch«lius, i, 08, may bo seen an account by Li-ton of a severe outbreak of i-loughini; pluiL^edicrui in University Collei^c Hospital in the year 1841, wbicli at- taciic'd a hirge nuniluM- of patients sinuiltaneou!-!}', and wliicii lie classed as •' liD.-pital gani^ronc," but no case proved fatal. » ^ It is not cnoui^h merely to scald or boil sp()nc;cs. Mr. Coote relates tbat in an outbreak of pliagcdscna in St. Bartholomew's Hospital the extension of the disease in two instances was clearly traced to the use of a sponu;e which had first beitn ap- plied to a gangrenous sore, then boiled, and afterwards ap|)lied to a healthy wound. PHAGED.ENA. 83 been given, I think erroneously, and which has been seen of late years occasionally in our London hospitals, differs from the formidal)le affection above described in tiie essential particulars that little or no constitu- tional fever accompanies it, and that it involves very little danger to life. I make bold also to say that it differs in another respect, viz., that it has not been proved to originate from any hospital influence. We have had several outbreaks of this disease at St. George's Hospital, and have always found that it has been prevailing at the same time in the neighborhood of the hospital, and has attacked persons who have had no connection whatever with the latter, so that the influences, whatever they were, which generated the disease could not have been confined to the iiospital. It is, of course, theoretically possible that dirt and overcrowding might have generated the gangrenous affection both in private houses and in the hospital simultaneousl>'. All that I can say is that the efforts of nu- merous skilled inquirers, most ardently interested in discovering any such cause acting in the hospital, have hitherto failed entirely to detect it, and it seems to me both incorrect as a matter of science and unfair (I had almost used a stronger word) to call it by a name which implies that there is some proved and admitted unhealthiness in our hospital wards, when no such thing has ever been shown to be true. I prefer, therefore, to denominate this affection simply Phaged^ena, and to confess that though tliere is a good deal of reason to suspect that it owes its origin, at least very frequently, to carelessness in hospital management, and particularly in the matters used for dressing wounds, yet that in very many cases it has been found hitherto impossible to verify this suspicion, and therefore impossible to explain the causation of the disease. It occurs in two forms: the ploughing phagedaena, the severer forms of which approach the local character of hospital gangrene, and whicii are characterized by the round black slough and its thickened border ; and the iipreading pJiogedasna, in which the wound spreads with an ii'regular edge and a foul, sloughy surface. The depth of this sloughing from the surface of the ulcer is hardly ever considerable, though sometimes from the swelling in and around the sore it appears so. In the limbs it seldom extends below the deep fascia, though I have known it to do so, and for the same reason haemorrhage is very rare.' Mr. Pick'"' has noticed an interesting fact, which is sometimes to be ob- served in phagedsena, viz., that the pain of the wound ceases about twenty- four hours before the commencement of the sloughing, and that, coin,ci- dent with this cessation of pain, tliere is a well-marked and vei-y striking fall of the thermometer. The traumatic fever is usually high in cases which are attacked by phagedaiua, so that the temperature will prol)ably have ranged up to 105^ or 106*^ F. From this there will be a sudden fall down to, or even below, DS*^, and twenty-four hours afterwards the phage- dfena will show itself Frotn these phenomena Mr. Pick has been able to prognosticate the occurrence of phagedsena in a case of amputation, where the surgeon in attendance was perfectly satisfied that the wound was going on quite well. But this phenomenon is not a constant one, nor is its cause obvious. The pain in phagedaena varies much. Sometimes wounds may spread ' It is as well, perhaps, to point out that this remark does not apply to cases in which (iis in sloughing after hubo affecting the deepseated ghindsj the fascia may have been perforated before the |)hagedifcna set in. In such cases the vessels are often exposed and occasionally give way. ^ St. George's Hospital lieports, vol. iii, p. 81. 84 COMPLICATIONS OF WOUNDS. to a very considerable extent with bnt little suffering, at others very large doses of opium are required to quell the pain. The treatment of phageda?na should, I think, be mainly local; the sur- geon should endeavor to procure a more healthy surface to the wound, by applications of which energetic caustics appear to me the best. If the sultject be young and healthy, steeping the attected surface in nitric acid, the patient being under chloroform, almost always stops the phageditna. If this should fail, or if the surgeon be unwilling to employ so strong a measure, the sore must be dressed with some detergent and stimulating application, such as those used in other forms of gangrene (see page 79). With regard to internal treatment, some persons believe tiiat opium exerts a specific influence on the spread of phagedaena. Having had a large experience of opium so given, I am convinced that it has no such influence. Opium is very useful, indeed necessary, in such doses as are required to procure sleep and allay pain, and its good effects are indis- putable in elderly persons of broken health and dissipated habits, but if given, as I have seen it, in enormous quantities frequently repeated, it seems to me to do harm, and I have seen phagedsena go on while the patient was being poisoned by opium — indeed, in one case up to the pa- tient's death from the latter cause merely. If this man had not been treated at all I have no doubt that he would have got well. Such gross instances of malpraxis are, no doubt, rare, but I have equally little doubt that the error of giving opium beyond what is necessary, under the idea that it is specific in sloughing, is common. There ai'e many cases wliich do well witli no opium at all. It is always well, I tliink, to evacuate the bowels, and stimulants with nourishing food are usually indicated. Bark, quinine, and ammonia also seem to accelerate convalescence. Senile gangrene is the indirect result of the ossification or atheroma- tous condition of the arteries common in old age. It occurs in two forms, the dry and the moist. In the former the disease is purely one of ob- structed blood supply, and the arteries will sometimes be found filled with clot for a very considerable distance. Billrotli points out that in senile gangrene it is not merely the anatomical condition of tlie arterial wall that is at fault, but that tiiere is IVequently also disease of the heart, and a tendency to embolism or arterial tliroml)Us, so that the gradual spi'ead of obstruction up the tube of the main arteiy can be verified l»y exami- nation during life. Cases of si)OutMneous gangrene are on record at all periods of life, even in childhood, though but rarely, and usually after acute blood diseases, as fever, iiut it will be sufficient to describe here the two forms of senile gangrene, leaving the lare cases of spontaneous gangrene at other ages to be dealt with on the same i)rinciplcs. The purely dry form, which in my own experience has been decidedly the ex- ception, is the result of mere obstruction ; the toes (in some very rare cases the fingers) turn black and shrivel, usually without much pain or constitutional disturbance; then a line of demarcation forms, and the pa- tient may recover. In rai'er cases a finger may sim[jly shrivel up, without any discoloration. In the other form there is consideralile pain and mu(;h redness around the black parts, together with (edematous swelling of the j)art, and all the evidences of inflammation ; and it is clear that the gangrene is i)artly inflammatory, i)eing caused probably by some irrita- tion making a call on the powei's of tlie part which the deficiency of its circulation renders it unal)le to snppl}'. In many instances the outbreak of the disease is referred with great probability to some trifiing injury, often a cut received in cutting the toenails. This form tends far less to limitation and therefore to recovery than the dry form. The disease is XOMA. 85 far more common in the male than in the female sex, and appears often to depend partly on visceral degeneration, the resnlt of overfeeding, and which is freqnently marked also by a gouty tendency. In the treatment of senile gangrene the fii'st point is to support the pa- tient's strength, and the second to support the warmth of the part, in hopes that the gangrene may stop. Opium must be given to allay pain, and it seems always to be well borne ; tlie part must l)e wrapped in cotton-wool and well deodorized. Amputation as a lule is to be deprecated, and the few cases in which it has been successfully practiced afford to my mind no argument against this rule, since we know that recoveries also occur with- out amputation. Possil)ly there may be exceptions in cases where the surgeon can clearly detect the limit of the arterial affection, but such cases must be very rare, and the few amputations which I have seen practiced for senile gangrene have not predisposed me in favor of the idea. There are two forms of gangrene which, singularly'' enough, are peculiar to childhood, viz., cancrum oris and noma vulvtie. The two names have been confused, since some surgeons call cancrum oris also by the name of noma, but it seems to me better to keej) the terms separate. Cancrum Oris. — The former, cancrum oris, is a very formidable disease in its worst forms. It is due to some profound exhaustion of the whole system, and usually follows on one of the eruptive fevers (measles most commonly) in children wiio have previously been ill-fed, ill-nourished, and brought np in bad air — at least, I am not aware that it occurs in others— and in these it does sometimes, though not often, occur without any feverish attack acting as a predisposing cause. The cheek swells, turns red and hard, and then a black spot shows itself either on the cheek or on the gums; ulceration takes place, the gangrene extends itself to a variable distance in the soft parts, the breath becomes horribly foul, the gums are exposed, the bone crumbles away, and the teeth drop out. The child is usually very feverish and depressed. Death is very common, though not universal, even in severe cases. Noma vulvae is a similar affection of the external organs of generation in little girls ; sometimes it seems to be merely the result of dirt and neglect, and then usuall}^ moie curable; at other times owing to the same general causes as cancrum oris, and in such cases much more dangerous. It begins either on the mucous or cutaneous surface of the vulva, some- times, indeed, at a distance from it in the skin of the groin. The ulcera- tion speedily assumes the sloughing form of phagedaena, and occasionally extends to a considerable distance, so as to cause great loss of tissue, and in some cases greatly to narrow the opening of the vagina after recovery. This, however, seldom takes place.; more commonly after recovery the destruction is found to have been much more superficial than it seemed at first. Both in cancrum oris and in noma vulvae death often takes place very unexpectedly, and without any post-mortem appearances to account for it. This has sometimes been explained in the case of the mouth aflec- tion as being the result of poisoning from the imbibition of tiie foul gas generated by the gangrene, and it may sometimes be so, but such ex- planation is not applicable to the case of noma. The treatment of these diseases is similar to that of other forms of gan- grene, but here it is still more essential to destroy the sloughing parts completely, which is best done, I think, by soaking them with strong nitric acid. The French surgeons, however, prefer the actual cautery. Chloroform must be administered, the cheek thoroughly exposed, and the acid applied slowly and carel'ully to every part of the sloughing sur- 86 COMPLICATIONS OF WOUNDS. face. When the disease does not commence in the mouth it is most im- portant to stop its spread before it has extended into that cavity. Free stimulation with wine is almost always necessary, and the exhibi- tion of tonics with diffusible stimulants. Chlorate of potash enjo3's a great reputation, and may be given in any dose up to a scruple, but I cannot say that I am convinced of its efficacy, and should be sorry to trust to it without the other and more powerful means of treatment. TetanuH is defined as "a tonic spasm of the voluntary muscles, with exacerbations;" that is to say, the muscles affected are in a constant condition of spasmodic tension, and this is exaggerated from time to time into violent convulsive action. Tetanus is divided into traumatic and spontaneous. In this country it is almost always caused by an injury, and the most various, and some- times the most trivial injuries have been known to cause it ; but even in this country, though rarely, and more commonly in the tropics, it occurs spontaneousl3^^ Tetanus is also divided, according to its course, into acute, subacute, and chronic, and varieties of the disease are named from the muscles implicated, viz., trismus or lockjaw, when the muscles around the jaw are alone or chiefly affected ; oi)isthotonos, when (as not uncom- monly occurs in the spasms of acute tetanus) the muscles of the back draw the patient's body into the form of a bow, the body resting on the head and heels ; emprosthotonos, when the abdominal muscles bend the body in the opposite direction; and pleurosthotonos, when it is bent to one side. The two latter are very rare; at least, in this country. I have never spoken to any one who has seen an example of either. Trismus exists more or less at the commencement of all attacks of acute traumatic tetanus.- The symptoms of tetanus are usually as follows : At any period after the receipt of an injury or after a surgical operation, with no especial pre- monition, the patient begins to complain of an uneasy feeling of stiffness about the neck and lower jaw — " stiff neck," as he probably terms it. After this there is difficulty in swallowing and chewing, and then com- plete fixedness of the jaws, the masseters and muscles about the upper part of the neck being felt firmly co'ntracted. There is also commonly at an earl}' period pain in the epigastrium, referred to affection of the dia- phragm. Convulsive cramps now occur at any attempt to open the jaws or to swallow. There are sudden and violent cramps in the region of tiie diaphragm. The muscles of the abdomen and then those of^ nearly all the body are rigidly contracted, so that the abdomen feels like a lioard, and on handling the limbs they may be as stiff as in death, but the mus- cles of the wrists and fingers are usually exempt from spasm. Tlie con- traction of the facial muscles gives asardonic grin to the features, " the tetanic grin." The tetanic state is now fully estal)lished. The pulse is usually unaffected, except during the spasms, when it is quickened. In the acutest cases, however, there is often great general fever, as the thermograph from a rapidly fatal case, on page 90, will show. Tlie bowels are generally constipated and the motions scybalous. The spasms vary much in severity. They are sometimes so severe as to jerk the patient out of bed, and even to rupture the muscles.^ Occasionally the tongue ' Tho fipontiinfous origin of tlie disease should not be admitted in any civen case without inquiry. I have known a case rei^arded as spontaneous in wiiich after death a wound was found whioii tlie patient liad forirotten. ■^ See Sir B. Brf)die's evidence on Palmer's trial in the newspapers of the time, or Dr. A. S. Taylor's paper in the Guy's Hospital Reports for 1850, pp. 29(5, 297. 3 Most museums contain specimens of one of the long muscles ruptured in tetanus. TETANUS. 87 is protruded from the month, and being canght by tlie ch)sing jaws, is severely lacerated. . The spasms are liable to be brought on by any sud- den impression — a noise, the slamming of a door, a draught of air. Sleep is rare and short in acute cases. The contraction of the muscles either ceases altogether or is greatly relaxed in sleep. The intellect is not atfected. Death seems to be caused sometimes by spasm of the glottis ; but usually occurs from suffocation during a spasm produced by the stiff- ness of the muscles of respiration, or from exhaustion. All this applies to the acute form of the disease; the subacute and chronic differ from the acute only in the course and severity, not in the character or order of succession of the sym|)toms. Speaking generally, the later after the injury the symptoms come on, the more chronic is the course of the disease, and therefore the greater chance is there of the pa- tient's recovery. There is a form of tetanus, called trismus nascentium, which affects in- fants in the first or second week of life, and which has been connected by some authors with the section of the umbilical cord. It is very fatal, though instances of recovery are not unknown. Generally, however, this infantile tetanus ends in death much more speedily than the adult dis- ease. Tetanus has also been kuovvn to be caused by parturition. Nothing, or next to nothing, is known as to the predisposing causes of tetanus. It is much more common in hot countries than in cold, and it attacks personsof the negro race much more commonly tiian whiles. Bad hygienic conditions seem to favor its development, as malaria, and pos- sibly bad ventilation. The idiopathic form of the disease seems far more common in the tropics than in this country. It has been referred to various causes, of which the best authenticated seems to be the sndden suppression of per- spiration by exposure to cold and damp; and it appears that a loaded state of the bowels is at any rate a predisposing, and. it has been looked upon as an exciting, cause of idiopathic tetanus. Diagnosis. — Tetanus requires to be diagnosed from hysterical affec- tions, from the convulsions produced by strychnia poisoning, from epi- lepsy, and from hydrophobia. As above stated, the symptoms, in the early stage, are those of f)rdinary stiff neck (rheumatic affection of the muscles of the jaw and neck), l)ut the progress of the case prevents any permanent confusion. The diagnosis from hysteria is not always perfectly easy, and this will be evident from the simple consideration that tetanus may attack an h3's- terical person, and may be complicated with hysterical fits. But, ordi- narily, hysterical lockjaw or any other tetanic symptom simulated by hysteria may be distinguished from the real disease by the patient's gen- eral condition and appearance, by the complete relaxation of the spasms from time to time, and by the fact that sooner or later the patient is sure to be able to eat. From strychnia poisoning the diagnosis may also for' a time be very difficult, as the celebrated trial of the surgeon Palmer for the murder of a man named Cook by strychnia shows, in which many medical men swore that in their opinion the man died of tetanus, or of epilepsy with tetanic complications. But the same trial brought out very clearly the differences, viz., that the spasm from strychnia poisoning commences and culminates with great rapidity, and without any previous stiffness about Thus, in St. George's Museum, Sec. iv, No. 1, is the rectus abdominis muscle torn across in a tetanic spasm. SS COMPLICATIONS OF WOUNDS. the jaws and neck; and that if the dose is insufficient to cause death the symptcMns subside with equal rapidity, leaving the patient in perfect liealth, but for the exlianstion following the spasms ; tiiat there is notliing of the tonic spasm with convulsive exacerl^ations which characterizes true tetanus. The spasms nlso of strychnia ditler from those usually seen in tetanus in that they affect tiic muscles of tlie trunk and limbs only, and not the jaw, and that they affect tiie muscles of the wrists and fingers, which, as above noted, are usually unaffected in tetanus. These minor differences, however, could hardly be alone relied on. From hydrophobia the differences are these: in hydrophobia the spasms are clonic — that is, the jaw may be spasmodically closed, but it will drop into complete lelaxation — which is not the case in tetanus. In tetnnus there is no dread of water, no aversion to it, thougli the attempt to drink may cause spasm, as any other excitement may ; the countenance in tetanus thongh distorted is calm, unlike the glowing eyes and excited face of hydrophobia; and the state of the mind corresponds, being calm and collected in tetanus, wild and often sulyect to delusions in hydro- phobia. From epilepsy there are numerous distinctions. An}' case of epilepsy likely to be mistaken for tetanus will in all prol)ability be accompanied by insensibility, which is never the case in tetanus, and by blueness of the surface. And then there is the great distinction that epileptic seizures have complete remissions, ?'. e., the spasms are clonic, while tetanic con- vulsions are connected together by the tonic spasm. Palhologij. — Nothing is really known of the pathology of tetanus. Tlieie have been cases in which a morbid condition of nerves has been found at the seat of the injury, and where the removal of the nerve so injured has been followed by immediate recovery. There have also been cases in which after death distinct evidence of inflammation of the trunk of the nerve has been found, extending to some distance, and others in which the spinal cord has been found inflamed. From which the inference has been drawn that the pathology of the disease consists essentially in inflammation propagated through the nerve or nerves injured to the spinal cord, thus exciting the general spasmodic condition. This explanation, though the most logical which has as 3'et been offered, is a|)parently con- tradicted by the anatomy of many cases in which the nerves have been found to all appearance healthy, and by the course of others, in which tlie injui-ed part has been removed, with no benefit. Though, dou])tless, in the latter cases the ill success might be explained b}' supposing that the morbid condition of the medulla was already generated ; and in the former it may l)e said with much plausibility that morbid conditions really existing may have been overlooked in consequence of the method of re- search not having been sufficiently delicate. Dr. Lockhart Clarke' has described altei'ations in the minute structure of tlie spinal cord in tetanus, which may very probably have existed in many cases where the cord was put down as " healthy," since such changes would not bo detected by an ordinary nakcil-e^'e examination of the cord, such as is usually made. To the same effect are Dr. Dickinson's observations,'^ and other i)atholo- gists have published similar cases. It is unnecessary to describe these changes minutely. Accurate plates frfun Dr. Dickinson's prei)arations are to be found in the Si/st. of Hurg., vol. i, p. 330. Suffice it to say that they show inflammatory exudation and extravasation of blood in the white columns and softening of the central gray matter of the cord. IJut I Med.-Chir. Trans., vol. xlviii. * lb., vol. li. TETANUS. 89 Other investigators, of undoubted skill, liave failed to find those changes;' and even allowing them to be constant, it would still remain a question whether they are the cause of the disease or its consequence. However, if we do not regard the tetanic condition as being due to irritation of the spinal cord propagated to it tiirough the injured nerves, we must take refuge in the vague theory " that it results from poisoning with some peculiar substanc^es which possibly are very rarely formed in wounds, and thence absorbed" (Billroth). Suc^h a theory leaves onr knowledge of the i)athology and treatment of the disease just where it found it. But if we admit that the disease starts from irritation of the injured nerve, one practical conclusion of great importance would follow, viz., that the nerve or the part should be removed at the first definite symptom of tetanus, and I must say that such a rule seems to me a good one. Mr. Bryant'- mentions a case in which *•' Mr. Key amputated a leg on account of tetanus, which had appeared six days after an unreduced dislocation of the astragalus. The symptoms disappeared at once after the operation. On dissecting the foot the posterior til)ial nerve was found to have been put violently on the stretch by the projecting astragalus." I have seen at least one similar case. That amputation usually fails, however, is quite true ; and this we might expect, since the S3^mptoms show that the irritation has already reached the central organ. Yet the chance that it may not have gone so far as not to be capable of recovery, if only the peripheral excitement is removed, justifies amputation, in my opinion, in appropriate cases. To be of any service it must be done early. The same end ma}' possibly in some instances be effected by excision of a portion of the nerve, luit it is rarely that the precise nerve can be isolated. Irrespective of these surgical measures the treatment of tetanus is entirely empirical, and completely unsuccessful. Possibly we ought to except from this sweeping condemnation the application of ice to the spine, which has, indeed, some logical basis, inasmuch as it seeks to re- duce the temperature, and tlius to combat the inflammation of the part whose irritation is believed to generate the disease, and in that sense may be said not to be empirical, but it seems entirely unsuccessful. Nearly every drug in the Pliarmacopoeia has been tried with occasional successes ; but these successes have been obtained mainly in the sub- acute form of the disease. Acute tetanus, though not uniformly fatal, is very generally so, and the few patients who have survived appear to have recovered under quite different kinds of treatment. If life can be pro- longed beyond the third week recovery becomes probable, though in- stances of death up to the thirty-ninth day are recorded by Mr. Poland.^ Therefore, in our present ignorance of the real pathology of the disease, and consequently of the effect of medicines on it, our great object is to keep the patient alive till the time when, as experience teaches, the irrita- tion may have worn out, and his powers ma}' suffice to carry him through. ' Billroth says: " Koki tan sky claims to have seen a developnnent of young con- nective tissue in tlie spinal medulla, which would make it appear that there was an inflammatory affection of this nerve centre. My examination of the spine and nerves in tetanus have thus far given only negative results." — Surg. Path., translated by Hackley, p. 3()5. ^ Practice of Surgery, p. 36. 3 Out of 327 fatal cases, 79 died within 2 days. 104 " in from 2 to 5 days. 90 " "5 to 10 days. 43 " " 10 to 22 days. 11 " beyond the 22d day. Syst. of Surg., vol i, p. 328. 90 COMPLICATIONS OF WOUNDS. Fig. 12. mkW" Chloroform may be cautiously tried, and if it can be borne it will relax the spasms and permit the introduction of food into the stomach; but its exhibition often sets up an amount of spasm which threatens to prove fatal. Most patients can get enouoh fluid nourislunent through the closed teeth to keep tliemselves alive, or they can be fed by a tulie passed through the nostrils. If this is not the case life cannot be long supported by enemata. and under tliese circumstances I entertain no doubt that it is justifiable to induce anoesthesia at any risk in order to feed the patient. And in such circumstances the larynx may be opened, in order to obviate death from spasm while the patient is being narcotized. Also if death is threatened from spasm of the glottis, tracheotomy may be performed. In one such case I saw much difficulty, from the neck being twisted, in keeping the incision near the middle line. Sleep is alwaj's to be procured by chloral or by morphia, which may be injected subcutaneously. The bowels ought, no doubt, to be unloaded at the commencement of the disease, and the purgation should be frequently repeated; the patient ought always to be kept in a cool, quiet, darkened room, and carefully defended from draughts and noises. As to the internal treatment, it is undoubtedly justifiable to use some of tlie medicines which have proved successful in other hands, or to try any new plan of treatment which affords a rational prospect of success. Of the former class, the ad- ministration of the tincture of aconite is, I think, on the whole tlie most promising. Five minims of the Pliarmacopoeia tincture may be admin- istered in a small quantity of any convenient vehicle every two hours until some definite im- pression is produced on the pulse and tempera- ture. In acute tetanus the temperature sometimes rises abruptly and continuously till the time of death, as in the case from which the annexed thermograph was taken ; and it is in these cases that large doses of alcohol may be expected to prove advantageous; but the use of alcohol as a specific, the patient being kept in a state of constant intoxication or semi-intoxication, seems to me not only useless but in- jurious. It would be vain to enumerate all the specifics which have at various times l)een recommended. They have all obtained their reputa- tion from their success in a few cases, which were in all probability of the subacute form — a form in which recovery is common under any treat- ment, or under no definite treatment, if the bowels be kept free and the patient's strength supported by such food as he can easily take and assimilate. Opium, chloral, Calabar bean, nicotin, turpentine, camphor, quinine, strychnia, curara, are the chief among the many remedies which have obtained some reputation, and some of these substances have been injected into the veins, as chloral. I will onl}' say that tliosc medicines which tend to constipation (as opium) seem to be mischievous ; those which are highly poisonous, as nicotin, curara, strychnia, appear to add a new danger to tlie disease, without any reasonable hope of benefit ; and the same appears to be true of intravenous injection. Quinine is, I have no doubt, cotnpletely inert; chloral, camphor, and turpentine are doubt- less useful in subacute tetanus, and the first may aff'ord some relief in the spasms of the acute disease ; but none of tliese, nor, as far as 1 know, any other medicine seems to have any curative virtue in acute tetanus. Thermograph of tetanus. From a case under my own care, which proved fatal ISJ/^ hours after the first decided symptoms of the disease. The case is recorded in Dr. Dick- inson's paper in Med.-Chir. Trans., li, where the post- mortem appearances are de- scribed and figured. DELIRIUM TREMENS, 9] Delirium tremens, the delirious excitement whicli depends on chronic intoxication, is a disease which we have only too frequent opportunity of seeing in our hospital patients, lioth as a spontaneous affection (in which respect it falls within the care of the physician) and as a complication of surgical injury, in which latter respect alone I shall here speak of it. The delirium which is excited in a patient laboring under chronic intoxi- cation — that is to say, in one whose blood and tissues, especially those of the brain, are deteriorated by the too free use of alcohol — is marked by several peculiarities which distinguish it from the delirium of ordinary fever, as well as from any other form of aberration of mind. The main peculiarity of the delirium is its buny character, and the prevalence of one dominant idea which is generally distressing or alarming to the patient.' The delirium is not usually violent, and any person who is not afraid of the patient, and who can speak to him with authority, can generally con- trol him. The next, and perhaps the most characteristic, feature of the disease is the tremor from which it takes its name, and which is generally seen in all the muscles, those of ihe tongue and face as well as the extremi- ties, though it is most marked in the hands. Another and most painful symptom is the want of sleep, and indeed of any rest either of body or mind; and this sleeplessness will usually l)e found to precede the delirium. A restless, tremulous, feverish, half rational condition commonly ushers in the defined attack of delirium. The general condition is also most unlike that of the delirium of either traumatic or any other fever. Trau- matic fever may of course accomi)any the attack of delirium tremens in surgical cases, but apart from this there is little evidence of general fever. The temperature is not high, the skin is usually bathed in a profuse sweat, the tongue instead of being dry and brown is moist, white, and oedema- tous, the pulse is small and quick, but not hard. There is almost always a loathing for food, and the patient often vomits. Evidences of visceral disease will often be discovered, especially in the kidneys and liver. The treatment of delirium tremens used to be conducted on the anti- phlogistic plan, the disease being confounded with inflammation of the inain, and this treatment was very fatal. In the reaction from this error it became usual to treat the disease with enormous quantities of stimulants and of opium ; and I cannot but think that this treatment, if pursued on a merely routine plan, is also unsuccessful, i. e., that it aggravates instead of diminishing the danger of the disease, though not to so great a degree as tie depleting plan. In fact, every case of delirium tremens should be treated on its own indications. In the premonitory stage, when the occur- rence of tremor, with some restlessness, in a patient known or reasonably suspected to be of drunken habits, gives fair cause for believing that an attack of delirium tremens is imminent, it is only too common to ply the patient with more stimulants, probalily on the principle contained in the old proverb, " A hair of the dog that l)it you." No treatment can have less support from logic, nor do I think that experience lends it any sup- port either. In patients of drunken habits adn)itted into the hospital I make it a rule to give them no more stimulant than to a healthy and sober person, to purge them freely, supplying them with a good supporting diet, and procure sleep by the subcutaneous injection of morphia if nec- essary ; and under this regimen the threatening symptoms almost uni- formly disappear. When the delirium is fully developed the same line of treatment should be pursued. The chief indications are to soothe the patient as much as possible, to procure sleep, and to enable him to take ^ See Barclay, Syst. of Surg., vol i, 342. 92 COMPLICATIONS OF WOUNDS. food. For the first purpose it is most essential to use no mechanical re- straint if it can be avoided. In public institutions, where separate rooms can be obtained for the treatment of the case, and the services of a num- ber of men can be procured if required, it ought to be very rarely neces- sary to tie down a patient sutfering from delirium tremens ; and if unnec- essary it cannot but be prejudicial to the case. In order to procure sleep opium or morphia must generally be given. The slighter cases may recover the power of sleep under free purging, as they regain that of taking food ; but in almost all traumatic cases it is advisable to procure sleep at once, as the restlessness of the patient renders him liable to dis- turb the injured parts. Chloral may procure sleep in the slighter cases; but speaking generally tlie best agent for this purpose is morphia, which ought to be injected under the skin in a tolerably large dose (gr. ^), and repeated in about half an hour, if sleep is not ol)tained, and so on until the patient does go to sleep. At the same time the bowels should be kept very freely open, and it may be necessary to give some tonic, quinine, ammonia, or bark with mineral acid. The use of stimulants in delirium tremens will need all the care and all the experience of the surgeon. In most cases I believe some amount of stimulant must be given, since the patient is weakened both by the shock of the injury and by the restlessness and agitation of the delirium, and cannot bear the deprivation of his accustomed drink. But I am in the habit of limiting that quantity as much as the state of the pulse per- mits while the patient remains unable to take food, and diminishing it rapidly as soon as nutrition can be procured otherwise. And when the patient is once out of serious danger I am quite sure that the enforce- ment of total abstinence is as good for his physical as for his moral health. In other cases, as it seems to me, in which the symptoms are not urgent and the pulse is strong, there is no need for the administration of any stimulant or tonic ; but on the contrary, along with the free administration of purgatives the cautious use of antimony seems to assist in getting rid of the poison and restoring the appetite. As to the alleged benefits to be derived from the administration of very large doses of digitalis, I have no experience. Generally when the patient can once be got to take food, and particulaily solid food, with a relish, sleep will return, and he will soon be well ; and, conversely, if sound sleep can be procured, generally tiie appetite will return and the case will do well. But this is only generally true. In some cases the patient will sink, although the insomnia has been conquered. A man was very lately under my care with compound fracture of the leg in whom a severe attack of delirium tremens came on shortly after the injury. After two days of restlessness a sound and natural sleep of several hours was procured by the subcuta- neous use of moiphia. He awoke refreshed and free from any signs of the constitutional effect of opium, l)ut soon began to sink, and died rapidly. Extensive disease of the liver and other viscera was the cause of death in this instance. And our prognosis in cases of delirium tremens must always be a cautious one, since latent visceral disease, such as fatt}' heart, may very possibly l)e present. I would, however, again urge on the reader the great importance of avoiding over-narcotism or over-stimulation in tliis disease. Great as the virtue of opium and morphia is when judiciously employed, we must not forget that when not well borne they constantly produce delirium, and that a form of delirium tiemens has sometimes been known to be pro- duced by opium-eating. Nor can I see on what ground of reason or of therapeutical experience we can expect a cessation of the effect from a DISSECTION-WOUJS'DS. 93 continu.ince of the very irritation wliich produced it. Yet tins is exactly what is implied in the routine treatment of delirium tremens with stimu- lants. We find a patient who has soddened his brains witli gin and beer, and probably has already suffered from previous attacks of delirium, and we think we shall cure him with more ^in and beer. CHAPTER III. POISONED WOUNDS AND ANIMAL POISONS. The inflammatory complications which we have been studying hitherto attack wounds of all kinds, irrespective, as far as we know, of anything special in the nature of the injury ; but there is a large class of wounds in which the inoculation of some detinite poison produces symptoms more or less peculiar. It would be endless to enumerate all the varieties of poison which may be conveyed into wounds, or all the various ways in whicii such convey- ance may be effected. It will be enough for our present purpose to divide poisoned wounds into the three following kinds : (1) wounds inoculated with matters which produce only ordinary traumatic fever and its compli- cations ; (2) wounds inoculated with matters which produce symptoms of specific general poisoning; (o) wounds inoculated with matters which produce definite diseases. The first class of cases is only separated from those which have been described in the previous chapters by the fact that in these a maferies morbi is known to have been inoculated, whilst in those nothing of the kind is known to have taken place, though there can belittle doubt that in many instances the wound has really been poisoned at the time of its infliction ; and in many of the cases of secondary com- plications (erysipelas, pysemia, etc.) the symptoms are so exactly similar to those of poisoned wounds as to leave no reasonable doubt that they depend on the imbibition into the blood of morbid poisons developed spontaneously in the wound, exactly similar to, if not identical with, those which are inoculated in cases of poisoned wound (see p. 46). The first class of poisoned wounds is best illustrated by dissection-wounds — injuries which display the phenomena of such wounds in their most ciiar- acteristic form, with the exact circumstances of which we are acquainted from the moment of their infliction, and with which few of us are not familiar from painful experience. The very same injuries are suffered, in the course of their business, \\y cooks, butchers, fishmongers, etc.; and similar symptoms ma}' be elicited l»y inoculation with various other sub- stances, both vegetable and mineral, though these, especially mineral matters, do not often occasion more than mere local inflammation. The phenomena ot dissection-wounds occur in an acute or chronic form. The former is perhnps the most formidable and the most rapidly fatal of all the forms of septicaemia. I have spoken of them as '' wounds," 94 ANIMAL POISONS. but the inoculation may pass through the unbroken skin, and has done so in many recorded instances — notably that of Sir J. Paget. ^ It seems universally admitted that '* the most dangerous postmortem examina- tions are those of women who have died with puerperal peritonitis; and that the intlammatory products of pycemial disease are especially virulent after death." Tliey are also especially virulent before death. Thus, Sir J. Paget tells us.tliat both his own nurse and the nurse of a friend of his who was suffering at the same time from dissection-wound ha(i their fingers poisoned by the matter. The danger seems only present during life or for a short time after death; when advanced putrefaction comes on no such special poisonous property is observed. Wounds poisoned in the dissecting-room hardly ever develop more than the milder or chronic symptoms. The nature of the virus is not known, nor is it known what makes a man liable to it; but it seems as if an immunity could be ac- quired by constant exposure, exactly as one can be acclimatized to an}' other form of morbid influence. " They who are day after day engaged in dissections or in post-mortem examinations," sa^'s Sir J. Paget, " usu- ally acquire a complete immunity from the worse influences of the virus. They ma}- sutier local troubles from it, or they may lose health through the influence of bad air or overwork, but they do not suffer with any infec- tion of tl)e lymph or blood." Though spoken of for convenience as dis- section-wounds or dissection-poisons, the affection is one which ma}' result also from the inoculation of matters from living bodies, as many cases show — notably that which deprived the profession some years ago of the rising talent of Mr. Maurice Collis, who died from inoculation received in an operation for the removal of a tumor of the jaw. Sir J. Paget has noticed a fact which, if it be confirmed by subsequent expe- rience, will be of the highest importance, viz., that one attack serves to give an imuuinity for a considerable time from renewed infection, though this immunity is not permanent. The most acute cases are well described in the words of Mr. Callender, quoted on i)age 59, as a description of septicaemia in its severest and most rapidly fatal form; and, as far as I know, the occurrence of such symptoms precludes all hope of recovery, though we must, of course, try to support the patient and relieve tension in any parts which may be inflamed by tiinel}' incisions. But fi'equently the fatal issue occurs before any local inflammation shows itself. Happily, however, such cases are very rare. The only one which has lately occurred in this city was that which led to the lamented death of Dr. Anstie. The subacute form, such as that which is illustrated by Sir J. Paget's illness, of which he has given so graphic and practical an ac- count in his recently published volume, is much more common. The channel of infection seems in tliese and the chronic cases usually to be the lymphatic vessels, whilst there is reason to believe that in some at least of tlie acute cases the poison passes directly into the mass of the blood thiough the veins. The first symptom, therefore, in most of the subacute cases is inflammation of the glands, with or without inflamed absorbents; and as the seat of inoculation is almost always the hand or forearm, the glands affected are the axillary. Frequently the inflamma- tion and resulting suppuration is confined to these glantls or the tissues which envelop them. At other times diffuse inflammation attacks the whole of the cellular tissue of the chest or back, leading to extensive suppuration. But the measure of the acuteness of the process and of the ' Cliniial Lectures and Essays, p. 322. DISSECTION-WOUNDS. 95 danger is given by that of the fever w^hich accompanies these local lesions. However severe the latter may be, we expect the patient to recover so long as tlie pulse is fairly good, the temperature not excessive, the appe- tite tolerable, and the internal organs unaffected. But a patient in this state is always hanging on the verge of erysipelas or pyjemia; and when a recurrence of rigors, or any symptom of mischief in the chest or joints, shows that the local poison has or may have passed into the mass of the blood, the prognosis becomes much more anxious.^ Yet in many cases during the course of the hjcal inflammation we see a low form of bron- chopneumonia come on and pass off harmlessly. It is difficult to account for this otherwise than as the result of pya^mic poisoning, except in cases where (as in Sir J. Paget's) there may have been some previous illness which has left a predisposition to pneumonic inflammation. But I have seen the same event where no such predisposition existed ; and it has seemed to me that the prognosis depends mainly on the time of occur- rence of the chest symptoms, being more favorable the longer after the injury they occur. There are other cases in which the disease begins, not in the glands, but as phlegmonous erysipelas of the limb, not neces- sarily starting from the wound, and other rarer cases of common cuta- neous erysipelas occur ; but these cases do not offer any other noticeable peculiarity. The danger is the same, the course of the constitutional infection is the same, and the treatment must be the same in whatever part the erysipelatous inflammation commences — whether in the skin, the cellular tissue, or the glands. For it must be remembered ti)at (as stated above) the relation between erysipelas and absorbent inflammation is a very close one indeed, and it seems a matter of perfect indifference whether the disease commences by one form of inflammation or the other, and whether it starts from the axilla or the forearm. The chronic cases are those which are also happily b}' far the most common, being limited merely to inflammation with or without abscess of the glands, or slight absorbent inflammation with slight and transient disturbance of the general health. Treatment. — In this, as in all other cases, prevention is better than cure. All students know the importance of having the hands well greased or oiled wlien performing a post-mortem examination in a case of acute internal inflammation ; and if they are unlucky enough to prick or cut tliemselves, the first thing is to tie a ligature tightly around above, and then the wound should be at once squeezed, so as to encouiage a copious flow of blood from it, and it should then be sucked for a long time, so that all morbid matter may be sucked out of it. It may then be right to cauterize it tlioroughly, and undoubtedly this plan gives more security against absorption of virus, but of course at the expense of some inevi- table local inflammation. On the first ai)pearance of any unpleasant symptom, rest, country air, purgation, and generous living are essential. Most surgeons agree in thinking that the reason why dissection-wounds are so much less fatal now ihan heretofore is because the so-called " an- tiphlogistic " has been superseded by the stimulant plan of treatment. When the characteristic symptoms are developed the treatment must be conducted on the same principles as in other cases of blood poisoning. ^ Sir J. Paget says : " This seem* tc be a point of distinction between these dissec- tion-poisons and pyjemia: their etfects are at first, however severe, comparatively Hniited to the part poisoned, and to tiie lymiihatic vessels and glands, or to the cellu- lar tissue nearly in relation with it. They may lead to pyaemiii, but they do this only by secondary changes or as it were by some accident "—Op. cit., p. 331. 96 ANIMAL POISONS. Eost of body and quiet of mind (if possible) are of great importance, but the latter is not eas_y to obtain. 1 have usually found that surgeons, when overtaken themselves by any grave surgical malady, are peculiarly nervous and ap|)rehensive, as, indeed, is natural. Yet such apprehensions are more common in the subacute than in the acuter and more deadly form of the complaint, in which the mind is too much oppressed to have much room for fear, and therefore the inevitable anxiety may generally be relieved by the assurance that such cases almost always iend well. The patient's strength must be su[)ported by such food and drink as he can easily and comtbrtably digest ; and Sir J. Paget testifies to the relief aiforded by free and early incisions into the abscesses, and I would add, into an}' iuHamed part where tension is manifest, though no pus may be formed. And, as the same great authority intimates, it is probable that diligent and judicious nursing has quite as much to do with the patient's recover^' as medical or even surgical treatment. II. Wound.-i of Venomous Animals. — Wounds inoculated with matters which act as general poisons are chicHy those inflicted by the bites of venomous seri)ents or the stings of venomous insects, though, as to the latter, it seems that practically it is only the scorpion, and that only in very hot climates, whose sting produces any serious general symptoms. The insects of this climate, hornets, wasps, bees, etc., produce only local inflammation by their stings, and this so trivial as seldom to require any skilled assistance. Some form of ammonia (sal volatile or eau de luce), indigo, in the form of the domestic *■' blueball," whitening, flour, ink, are some of the common remedies enumerated in the order of their apparent efliciency. It is said that bees' and wasps' stings inside the throat some- times produce a degree of swelling which requires scarificaLion. So also, in this climate, the bite of a snake usually produces local con- sequences only. The common snakes are, of course, perfectly harmless — in fact, are common and favorite playthings of schoolboy's — but the adder, or viper, is undoubtedly venomous. I never saw a case in which the venom produced any worse consequences than a sharp attack of phlegmonous erysipelas, thougli this may, of course, prove fatal. But the tropical snakes infuse into their bites a venom which acts as a spe- cific poison, and in the most venomous species this poison is as rapidly and as surely fatal as any substance known to pharmacologists. In the severest cases the effects are developed so rapidly as, according to Mr. Busk, to resemble those of prussic acid more tlian anything else, l)ut usually an interval elapses. The sym|)toms may be divided into general and local. 'IMie first symptom, in nearly all cases, appears to be a general shock to the nervous system, attended with faintness, tremor, and great depression, sometimes with stupor, loss of siglil, vcMuiting, trismus, and general insensibility. At the same time great and sometimes intense local pain is set up. The limb, if the wound is in one of the exti'cmities, rapidly swells; at first pale, the surface of the swelling soon becomes red, and afterwards livid, and covered with phlyctennht filled with sani- ons fluid. In some cases the swelling continues to spread through the whole limb up to the trurdc or even through the entire body, whose sur- face assumes a jaundiced hue. The [local] symptoms, in fact, very closely resemble those of ordinary phlegmonous erysipelas. The consti- tutional sym[)toms, independently of the first siiock, are what might be expected to accompany such a local affection, and in intensity are in proportion to its violence.' Mr. Husk points out the analogy between ' Busk, in Sy>t(!m (if Suii^^cry, vol. v, p. 941 ; 2d ed. SNAKE- BITE. 97 this dreadful poison and the ferments which act in the blood to develop the most formidable kinds of fever, as small-pox, and to the dissection- poisons of which we have just spoken. Bnt he also dwells on the fact that, unlike those poisons, which produce (as far as is known) the same intensity of symptoms, whether they are introduced in small quantity or large, the serpent-poison depends for its intensity directly on its quantity in relation to tlie mass of the blood into which it is introduced ; so that two l)ites will kill the same animal more quickly and surel}' than one, and a similar bite from the same serpent will act more intensely on a small animal than a large one. The situation of the bite also influences the rapidity and certainty of the action, a bite on the face or trunk being far more dangerous than one on the extremities. The knowledge of these deadly animals is essential to those who have to practice in tropical climates, but the present work is hardly the place for any description of them. I must refer the reader, for a condensed account, to the essay of Mr. Busk above quoted, and for more complete anatomical and zoological details to the special works on the subject, and particularly, on the sub- ject of the Indian snakes, to Professor Fayrer's great work, The Thana- tophidia of India. The treatment of these injuries must be divided into the prophylactic and the curative. As in all other poisoned wounds, the most effectual treatment is at once to tie a ligature tightly round the limb above the wound, to excise the part freely with a sharp knife, and then to suck the blood out repeatedly,' and cauterize the surface deeply before removing the ligature ; or if the finger is the seat of tlie bite, to cut it off at once. But it is obvious that op[)ortuuities for adopting such precautions can very rarely be afforded. Then arises the question, is any other treatment of any avail ? Now, it must be premised that the venomous sei'pents differ greatly in the activity of their venom ; that the probability of in- oculation and the intensity of the poisoning will differ according as the poison-gland is full or empty; and that a person may be bitten without any penetration of the skin having been effected, or any of the virus being brought into contact with the absorbent vessels. Thus it is never quite certain, when a person recovers after the bite of a deadly serpent under a certain mode of treatment, whether he has recovered in consequence of the specific effects of the treatment, or in consequence of the insutticiency of the dose of the poison ; and this ob- jection has been made to tlie only method of specific treatment which it is in the least worth while to discuss, viz., the intravenous injection of ammonia, and made on the great authority of Professor Fayrer. He attempts to show that in wounds produced by the deadly serpents of India, when those wounds fairly penetrate the skin, the injection of am- monia into the veins rather hastens death than otherwise, and he regards the plan as positively hurtful. The recoveries which have ensued in Australia he explains as due to the less poisonous nature of the serpents of that country', or to the insufficient injection of the poison. Yet it must be admitted that in mau}'^ cases of serpent-bite in Australia the poison seems to have been potent enough to produce death when no treatment has been adopted ; that the symptoms described in many of the Australian cases have been very alarming, and that the treatment seems to have approved itself to persons of experience, so as to have come widely into use in the country in which it was devised. And as to ' There is no danger in sucking the poison out of any wound, except the danger of there being a crack or wound in the mouth by which the poison may be absorbed. 7 98 ANIMAL POISONS. the increased danger wliicli the injection itself may cause, it is surely a matter of very slight importance. In a case which is certain otherwise to prove fatal in a very short time it matters little whetlier the treatment employed exposes tlie patient to the danger of dying a few minutes sooner, provided only that it otters an}- reasonable cliance of safety. And I must say that to my mind it is quite clear that Professor Halford's treatment, whetlier it is sufiiciently energetic or not to combat the effects of the virus of the most deadly serpents, has acted beneficially^ and, as far as we can judge from published accounts, has saved life in many of the bites from the Australian serpents, and deserves to be fully tested in those of other countries. Professor Halford directs that the liquor ammoniae fortior is to be diluted with two or three times its bulk of water, and of this mix- ture from twenty to thirty drops are to be injected into one of the large veins as near the bite as possible. If the symptoms are relieved, but the patient seems still in danger, the injection may be repeated as soon as the operator thinks it prudent. If this treatment is delusive, no other is at present known ; the various specifics so-called, such as theTanjore pill,thedecoction of snakeroot.etc, are, I believe, admitted to be inert, and the only thing that can Jie done is to keep the patient alive by copious stimulation or artificial respiration.^ III. The next class of poisoned wounds is that in which specific dis- eases are excited. These are wounds poisoned by tlie secretions from diseased animals, viz., Glanders and Hydrophobia.^ Glanders in the horse, and in man also, appears in two forms, one of which is acute,, and ver}' deadly' — acute glanders, ov glanders proper ; the other is chronic, and often followed by recovery — farcy, or chronic glanders. Glanders consists essentially in the eruption under the mucous membrane of the respiratory passages in the face of a number of inflam- matory deposits, or buds, somewhat resembling the gummata found in sj'philis, only much more rapidly formed. Accompan^'ing this eruption is a general inflammation of the whole submucous tissue, and usually also (though not always) a vesicular or pusttilar eruption on the free surface of the mucous membrane. Pi'evious to the eruptive stage there is a pre- monitory feverish stage, characterized b_y general in(lisi)Osition, with peculiar wandering pains, loUowed by feverish excitement and shivering, and succeeded by pains which simulate rheumatism, and which appear to be often due to an eruption nnder the skin similar to the glanders erup- tion under the mucous membrane. The longer the premonitory stage is dela3'ed after inoculation, and the longer the eruption is delayed after the premonitor}' stage, the more ho[)eful is the case. The glanders eruption attacks the internal organs, especially the lungs and pleural, and less commonlj' the testicle, kidney, pancreas, and the synovial membranes. JJesides the eruption in or under the skin and mucous membrane there is a peculiar alfection of the lymphatic vessels and glands, to which the name " farcy " is more particularly ai)pr()priated, and vvjiich consists in the development in the course of the lymphatic vessels of tubercles — " f;ircy-buds" as they are called — which appear to be exactly similar to tlie tubercles constituting the glanders eruption. And coincident with this are the usual symptoms of diffused intlamma- ' All intercf-tinu summary of. some experiments on intravenous injeetion and artifi- cial respiration in snake-bile will be found in Brit. Med. Journ., June 19, 1875. 2 Possibly the maligiumt pustule or " charbon " might bo added to tlicse, l.ut I have thought it better tt> place this in the same chapter with Carbuncle, under the affections of tlie Skin. GLANDERS. 99 tion and obstruction of the lymphatics, pain, cedema, suppuration, and ultimately permanent laming of the affected limb. It seems almost a pity to describe the disease under two different names, since glanders and farcy, as above described, do not differ from each other in an}' essential particulars, and the inoculation from a farcy- bud will produce glanders and vice versa. Sometimes the term glanders is restricted to cases in which the nose is affected, and farcy to those in which it is not: a more intelligilile though an equall}' arbitrary division. Virchovv describes the tubercles of glanders (or farcy) under the skin thus: ''At (irst there appear some red spots, which are very small and I'esemble fleabites, and soon acquire a papular elevation, subsequently rising above the level of the surface like small shot, assuming a yellow color. These shotlike knots are either flat or round, and do not lie in a bladder-like elevation of the epidermis, but in a kind of hole in the corium, as if the latter had been punched out. They are not always solitary, but often disposed in groups. There is some surrounding injection, and under the epidermis there is found a puriform and ^yellow fluid, seemingly consistent, and which is chiefly formed from softening of the knot. They are composed of a homogeneous yellowish substance, which is pretty firm and somewhat brittle, and has a great resemblance to tubercle. Micro- scopically examined, they present an amorphous granular appearance, mixed with cell-elements and cell-growths, and numerous fat-globules." ' The eruption is formed by vesication over these tubercles, tlie vesicles soon becoming filled with pus, in which stage the eruption is likened to varicella. The action on the mucous meml>rane of the nose must be similar, but it is less eas}' to verify it. It is accompanied with discharge from the nose, which soon becomes purulent, oedema, and inflammation of the face, sometimes passing on to gangrene, swelling and abscess of the salivary glands and of the tonsils. In its acute form the disease is very fatal, and sometimes very rapidly so. It proves fatal either by mere exhaustion or by a form of pya^njiain which the secondary deposits are found chiefly in the muscles and subcu- taneous tissue," or from the effects of the glanders eruption in the viscera, and particularly the lungs. But glanders or farcy in the chronic form may not prove fatal, though it is a very formidable disease, and usuall}- leaves the limb crippled by long-continued suppuration and sloughing. In some cases acute glanders follows on chronic farcy, doubtless from auto-inoculation. In some cases, dcnonnuatei] flying farcy^ the farcy-buds subside with- out suppurating in one part while the disease shows itself in another. The disease can only be communicated to man by inoculation from an animal similarly diseased — and the disease is only known in horses and asses ; but there is no doubt that when generated it is highly contagious from man to man, so that all possible precautions should be adopted; and it has been proved by experiment to be inoculable from man to the horse or ass. Mr. Poland, who has seen several cases (which I fortunately have not, only one case having, as far as I know, been admitted into St. George's Hospital during maiiy years, and that in my absence''), says that "in the premonitory stage it can hardly be diagnosed from other forms of blood- poisoning, and that in the early eruptive stage it is very much like the 1 Poland, from Handb. der Path, u Ther. Bd. ii, Abth. 1. ^ See the second illusti'ation on p. 70S of Mr. Poland'.* e>.s;iy, 3 It is described by Dr. Dickinson, Lancet, Marcli, 18G9. 100 ANIMAL POISONS. small-pox, and ma}' have its sliottv feel; but when once the eruptive stage is developed all doubt is at an end ; the presence of a peculiar exanthem, the local nasal discharge, if present ; the erj'sipelatous blush in the face and c\ves ; the tumors and knots in the cellular tissue and muscles ; and the local suppuration sufRcientl}' attest its character." The disease, both in horses and men, is now, we may hope, becoming rarer in consequence of its being better known, and in consequence of the greater attention which is paid to the cleanliness and ventilation of stables. It ought never to be generated in the horse, and if it is the ani- mal should be killed at once. If a groom or any one handling a horse supposed to be glandered is so unfortunate as to get any of the matter into a crack on his hand, or on to the naked hand (whence it is probably transferred to the nose in most instances), or if any is l)lown directly' into the nose the same prompt and decisive measures sliould be adopted as are recommended in serpent-bites or the l)ites of rabid animals: that is to say, the poison should be destroj-ed as promptly and as speedily as pos- sible by caustic, and if possible a ligature should meanwhile be tied above the part inoculated. The treatment of glanders and farcy offers nothing that is peculiar. Its principles are, first, to disinfect and deodorize the discliarge ; and, sec- ondly, to support the jDatient through tlie fever. For the former purpose the nose should be freely washed out either with creasote lotion, as recom- mended by Dr. Elliotson in his original paper (Med.-Ghir. Trans., vol. xvi), in which the disease was for the first time accurately described, or with Condy's fluid or carbolic acid. Mr. Poland speaks with approbation of turpentine embrocations and fumigation with volatile stimulating anti- septics, couve3'ed through the medium of warm vapor. The second indi- cation is to be carried out (as in dissection-poisons) by free and early incisions and the judicious use of stimulants and tonics. Equinia Mitis. — Glanders, when fully developed, is hardh^ to be con- founded with any other disease. Those who handle horses' feet when affected with a disease known to farriers as " the grease," are liable to a slight pustular eruption in the hands and wrists, to which the name of "equinia mitis " is given, in order to mark its origin and to distinguish it from tlie virulent constitutional poison of glanders. It is a merely local and a perfectly harmless affection. The eruption consists only of the common phlyzacious pustules, instead of the hard shottj- tubercles of glanders — there is no general disease — and tlie whole thing subsides in a few days with cleanliness and soothing applications. Such, at least, has been tlie course of those cases which I have seen, in all of which the hand has alone been affected ; but one is recorded by Mr. Cock^ in which the accidental inoculation on the nostril of the matter from a '• greasy " horse produced symptoms much resembling those of glanders. Ili/drojjJiobia. — Perhaps the most awful of all diseases is that which is derived from the bite of an animal suffering under dog madness, or rallies, and unluckily the ajipreliension often produces mental torture hardly less terrible tlian the disease itself It is consolatory, therefore, to be assured that the disease in animals is very far rarer than might be inferred from the constant cry of "mad dog" which is raised whenever a poor cur, being worried into a bad temper, bites and foams at the mouth. Dog- bites are extremel}'^ common — hydrophobia one of the rarest of maladies. Tlie disease derives its name from tlie dread of water which its develop- ment causes in the human subject, but rabies in the dog causes no such ' Lancet, 1851, vol. ii, p. 129. HYDROPHOBIA, 101 dread; in fact, the dog generally seeks the water greedily, though possibly spasm may prevent him from swallowing it. The disease in the dog ought to be known, in order that proper precautions may be taken ;^ but this is 1 The subject is so important in respect of precaution tliat I tliink it necessary to give the symptoms of doij madness as described by Trousseau (Clin. Medicine, vol. i, p. 693, New Syd Soc.'s Trans.), on the authority of Monsieur Bouley, clinical pro- fessor to the school at Alfort, "based on what he had seen himself, and on quotations from Youatt's work :" "There are three well-marked stages of the complaint in the dog. The first is characterized by melancholy, depression, sullenness, iind fidgeti- ness ; the second by excitement, by rabid fury ; and the third and hist by general muscular debility and actua- juiralysis. " Whether the f^lisease originated de novo or was communicated, the dog looks ill and sullen after a period of incubation of very variable length ; he is constantly agi- tated, turning round and round inside his kennel, or roaming about if he is at large. His eyes, when turned on his master or friends of the house, liave a strange look in them, expressive of sadness as well as of distrust. His attitude is suspicious, and indi- cates that he is not well. By wandering about the house and yard he seems lo be seeking for a remedy to his compb\int. He is not to be trusted even then, because, though he may still obey you, yet he does it somewhat slowly ; and if j'ou chastise him he may, in sjiite of himself, inflict a fatal bite. In most cases, however, a mad dog respects and spares the person to whom he is attached. But his agitation in- creases ; if he is in a room at the time he runs about, looking under the furniture, tearing the curtains and carpets, sometimes flying at the walls, as if he wished to seize a prey. At other times he jum])s up with open jaws, as if trying to catch flies on the winsT ; the next moment he stops, stretches his neck, and seems to listen to a distant noise. He probably has then hallucinations of sight and hearing, seeing ob- jects that do not exist, and hearing sounds that are not emitted. This delirium may still be suddenly dispelled by his mastei''s voice, and according to Youatt, ' dispersed by the magical influence of his master's voice, all these dreadful objects vanish, and the creature creeps to his master with the expression of attachment peculiar to him. There follows then an interval of calm ; he shortly closes his eyes, hangs down his head, his forelegs seem to give way beneath him, and he looks on the point of drop- ping. Suddenly, however, he gets up again, fresh phantoms rise before him ; ho looks around him with a saviige expression, and rushes as far as his chain allows him against an enemy who exists only in his imagination.' By this time already the animal's bark is hoarse and mufHed. Loud at first, it gradually fails in force and in- tensity, and becomes weaker and weaker, apparently indicating incomplete paralysis of the muscles of the jaws, just as the dropping down pointed to paralysis of the mus- cles of the forelegs. In some cases the power of barking is completely lost, the dog is dumb, and his tongue bangs out through his half-opened jaws, from which dribbles a frothy saliva. Sometimes his mouth is perfectly dry, and lie cannot swallow, al- though in the majority of cases he can still eat and drink. When he has vainly at- tempted toswallow lie pi'obablj' believes it is because some foreign body sticks in his throat, for he puts his muzzle between his paws and works with them as if he wanted to get rid of this. Although he can no longer drink people are misled into the be- lief that he does so from his lapping fluids with great rapidity. On close examination, however, the fluid is found to keep the same level in the vase which contains it, and one can see that the dog does not in reality swallow, that he does not drink, but merely bites the water. Although he cannot swallow fluids he can still in some cases swallow solids, and he may thus swallow anything within his reach, bits of wood, pieces of earth, the straw in his kennel, etc This circumstance is one of very great importance to bear in mind, because when the body of a mad dog is dissected a good many substances which have not been digested may be found in its stomach, and do thus furnish a ])roof of his complaint. " One period of the disease does not pass suddenly into another, but by an easy transition. Even in the first stage, that of depression and melancholy, the animal is from time to time very agitated, and shifts his posture. This agitation increases to a considerable degree, and in the second stage constitutes the rabid fury which charac- terizes this period, together with hallucinations of sight and hearing. During this second period the animal drops down in a state of exhaustion after paroxysms of rage ; he seems completely prostrate, his head hangs down, his limbs give way under him, and he can no longer swallow. These are signs of incipient paralysis. " Towards tiie close of the second stage the dog often breaks his chain, and runs far away from his master's house ; he wanders about in the fields, seized from time to 102 ANIMAL POISONS. not more the province of the surgeon than of any other person. A sur- geon has usually to form his own opinion as to the presence of hydro- phobia in the animal which inflicted the bite from the account given him b^' tlie patient or his friends when applying for advice on account of the injury, and I think I may say that the safest course — the one which is best for the patient, and that which is most likely to be correct in cir- cumstances where anything like certainty is impossible (for it is difficult for any one not very familiar with dogs to distinguish the early stage of rabies when he sees it, and still more so to judge on the subject from another person's description) — is to be very chary in admitting that the suspicion of the animal's madness had any foundation, and to give the most favorable prognosis, yet at the same time not to neglect any of the precautions against the imbibition of poison which are used in other cases of poisoned wounds, and which are descrilied on p. 95. When these pre- cautions have been taken, or if, unfortunatel_v, they have been overlooked, and an}' time over half an hour has elapsed, nothing further can be done ; though even at alater period it is quite justifiable to cauterize the wound, in order to relieve the patient's own ni)prehensions, even if it cannot really affect the progress of the case. What distinguishes hydrophobia from every other form of poisoned wound is the great uncertainty of its jDeriod of incubation, and the incredible length of time during which the poison may remain latent, and yet ultimately break out in all the viru- lence of the disease. Many cases are recorded in which more than a year has elapsed lietween the receipt of the injury and the outbreak of the disease — one in which as much as five j^ears and a half intervened — and though we might believe that in some of these cases a mistake had been made, and the disease had been due in reality to another injur^^ which had passed unnoticed, or that in others hysterical hydrophobia has been mis- taken for the real disease, 3'et we can hardl}^ resist the conclusion that (in some mysterious and hitherto perfectly' inexplicable manner) the poi- son contained in the saliva of the rabid animal may remain inactive in some part of the body for weeks or months, and then at length pass into the mass of the blood. Yet the neighborhood of the wound displays no visible peculiarity, nor the absorbent glands nor any other part. The wound has usually quite healed, and the patient has often altogether for- gotten the accident; so that the explanation which some have hazarded is quite insulTicient — that the disease is really no affection of the body at all, but a mental disorder due to constant apprehension — a form of in- sanity. The disease undoubtedly originates spontaneously in the dog, but in the human sul)ject it is only known as a consequence of inocula- tion. Like other poisons, except perhaps those which are most virulent, the poison of hydrophobia is very uncertain in its action. Thus, if several persons he lutten, only one may suffer, as was the case in the instance wbieh Dr. Marcct recorded in the first volume of the Medico- Chii'urgical tirno witli paroxysms (^f fury, and then lie stops from fiitij^ue, fis it wore, luid remains several hours in a somnolent stale. Ho has no Ioniser the strength to run after other creatures, although, if he be worried, he can still gather strength to tly at and bite an individual. If he bo not destroyed as \w. wanders about he generally dies in a ditch (jr in some retired corner. lie apparently perishes from hunger and thirst and in- tense fatigue; but veterinary surgeonsdo not say that bodies from asphy.\ia, brought on by spa.sm of the pectoral muscles or by convulsions " The dis(;ase is known in other animals — cats, wolves, horses, etc., and has been propagated by thcni to men — but its symptoms Imvo only been fully described in the dog. HYDROPHOBIA. 103 TranaacHoyis. Trousseau estimates that about half the persons bitten take the disease. Tlie disease begins not uncommonly with renewed irri- tation in the scar of tlie wound, or with irritation in the nerves leading from it, testifying to the fact that some morbid action is going on there. And there is often a period of sullen depression, a passion for solitude, and a change of temper and disposition exactly analogous to the first stage of rabies in the dog. There is also a general feeling of bodily malaise, differently described in different cases, but often referred to the nape of tiie neck, and sometimes mistaken for rheumatism or stiff'-neck, Feverishness tiien succeeds, more or less marked in different cases, and then, at a varialije period, the peculiar and cliai-acteristic feature of the disease manifests itself, viz., that any attempt to swallow fluids will pro- duce severe paroxysms of dyspnoea ; and in the worst cases these par- oxysms are produced not only by attempts at di'inking, but by swallow- ing anything, and even by the sight or the very idea of fluid, and in some cases tliey occur spontaneously. As the case proceeds, the mind, which was at first quite calm and reasonable, sinks under the agony produced by thirst and by constant restlessness, and the {)atient becomes more or less insane ; yet is usually quite under control, and easily made conscious of liis own delusions. The excitement increases, the eyes become wild and staring, the whole countenance expressive of rage mixed with terror; the patient is in a constant state of excitement, and gets hai-dly any sleep, and that little is nnrefreshing and im]ierfect. As is also noticed in the lower animals, the sexual feelings are often inordinately excited, producing satyriasis and involuntary emissions, or in the female, nymi)homania. After this stage of excitement and mania often follows one of exhaustion, in which the patient recovers his reason and his power of swallowing, but dies of asthenia; at other times he dies in the furious stage, either exhausted or suffocated.^ No instance of recovery has hitherto been re- corded. It must be added, also, that though i\\e disease is named from the dread of water, and though that symptom is a dreadful one, and the con- vulsions which drinking occasions may be terrible, yet patients who have sufficient resolution may overcome it, and may even take considerable quantities of fluid, and endure the contact of water in washing, as may be seen in the account of Dr. Marcet's patient above referred to. One other symptom deserves notice, since it has been regarded as the essence of the disease. I mean the development under the tongue of certain vesicles or pustules, which have been regarded as being the path through which the poison finds its way into the system, so that it is said that if these pustules be destroyed by caustic the development of the disease will be prevented. I fear the statement is delusive, though it should, of course, be kept in mind, and in so uniformly fatal a disease any slight hope of safety is not to be neglected. These vesicles (or Zi/.ss?', as the,y are called) are said to be always found in persons inocu- lated with the bite of a rabid animal, between the third and twentieth day after the bite. The}^ would not make their appearance, of course, if the virus had been thoroughly destroyed or eradicated at the time of its introduction. As they are very fugitive, soon bursting and disappearing, it is said that it is necessary to examine the patient twice a day in order to be sure of not overlooking them, and when detected they are to be at once laid open and cauterized ; and where this is done thoroughly it is ' Trousseau seems to regard asphyxia as the usual if not almost the universal way of death in these cases. 104 ANIMAL POISONS. said that hydrophobia has never appeared, Tliese statements rest chiefl}' on the authoritj^ of two physicians, Dr. Marochetti, of Rnssia, and Dr. Xanthos, of Siphnos. They embody the popular belief in those countries, and so far as the accounts which I have seen of them extend, I should not have thought them worthy of much credit, but they have been to some extent confirmed by a French physician. Dr. Magistel, who pro- fesses to have met with the eruption : and they are supported by the great authority of Trousseau, so far at least as that he believes the statements to be pi'obable, and the fact worthy of the attention of practitioners.^ It must be recollected that the whole subject refers to the prophylaxis of hydrophobia, not to its treatment when developed. Accepting the statement, the ditt'iculty would be to keep so constant a watch on the parts as would be necessary not to miss this verj^ fugacious S3Mnptom, without unnecessarily alarming the patient, for we know not what effect constant apprehension may have in a disease so manifestly connected with mental disturbance as hj'drophobia. The disease has never, as far as I know, been propagated from man either to other men or to the lower animals, though the saliva of hydro- phobic men has been inoculated for experiment into the dog. As to the real pathology of the disease nothing is known. That it consists in some disturbance propagated from the medulla down the eighth pair of nerves is clear enough, for though the leading phenomena of the disease have fixed attention chiefly on the mental disturbance produced bj^ the sight or touch or thought of water, and the spasms which follow on attempts at drinking, we must remember that the disturbance is corporeal as well as mental, and the eflfects are true reflex action proceeding from irritation of the hypersensitive afferent filaments. This is strikingly illustrated by a case which Trousseau relates (op. cit., p. 684) where an oesophagus tube was passed through the nares and seven ounces of broth poured into it. Half of the broth had been conveyed into the stomach, when the pharynx and oesophagus were thrown into such violent spasm as to compress the tube and prevent the further i)assage of the broth, and the spasm spread to the respiratory muscles with such force tliat the patient very nearly died. Tlie post-mortem appearances do not, however, throw any more light on the nature of this irritation of the medulla or eighth pair of nerves in hydrophobia than they do on that of the spinal cord in tetanus. Tlie fauces, pliar3'nx, and stomach are found congested, and congestion of the brain and other internal organs has been noted, but the minute examination of the nerves of the part and of the nervous centres has hitherto only led to disappointment. The diagnosis of this affection seems eas}'^ enough. It appears that it may be mixed with tetanus,'- but otherwise it can hardly be confounded with it, nor is there much difficulty in distinguishing the real from the hysterical (or, as Sir J. Paget would call it, the "neuromimetic") form of hydrophobia. The course of the two diseases is quite ditferent; the implication of the larynx in tiie spasms, so constant in hydrophobia, is absent in tlie simulated affection, and in the latter the patient is sure in the course of time to be able to swallow naturally. The treatment is unfortunately quite unsuccessful. Surgeons have thought that if the patient's strength could be keiJt up for a certain ' For a full acconnt of this pnrt of the subject sco the; interesting lectuie on hydro- phobia in Trousx'iiu's Clin Med., vol. i, p. 700. « See Ogle, in Brit, and For. Med.-Chir. Rev., 1868. HEMORRHAGE. 105 length of time the irritation would disappear, and perhaps it might, but the attempt has hitherto proved futile. Forcible feeding, as in Trous- seau's ease above referred to, has produced such tremendous s})asms as almost to kill the patient at once. Probably the administration of chloro- form or the attempt to perform tracheotomy would do the same ; yet it is a perfectly fair experiment to tr^- until the experience of a few cases shall have demonstrated, as I fear it would, its inefficiency. It is sug- gested by Trousseau's translator. Dr. Victor Bazire, on the theory that the essence of the disease is asphyxia, and that if death by asphyxia could be prevented the patient might be saved. A great deal might be said against this view, but I need not detain the reader with the discus- sion in this place. Some have suggested excision of the nerve supposed to be affected, or amputation of the limb. Either operation may be justifiable under given circumstances, but neither holds out much rational prospect of success. CHAPTER IV. HEMORRHAGE AND COLLAPSE. H/EMORRHAGE, its causes, sources, and treatment, forms a most impor- tant part of practical surgery, and in the judgment of many eminent sur- geons it is in the treatment of unexpected and profuse hiemorrhage that the resources and qualities of a great surgeon are displayed more than in any other emergency. The topic follows naturall}' after the consider- ation of wounds and their treatment, since haemorrhage is a symptom in every wound, and is the chief and most important symptom in many. Still a great number, perhaps the majority of the cases of haemorrhage which surgeons are called on to treat, are not traumatic ; and the reader will see in the sequel that thei'e are few surgical diseases in which the ques- tion of liiemorrhage does not at some time occur. It will hardly be pos- sible, therefore, to exhibit in this place an adequate view of all the causes of haemorrhage in surgical practice, nor, indeed, would it be desirable to repeat here matter which must form a great part of the sequel of the book. Hseraorrhage may be looked at from several different points of view. Of these, the most important, and those to which I shall here confine myself, are two — viz.: (1) as to whether the haemorrhage is spontaneous or traumatic, and (2) as to whether the bleeding is from one or more large vessels (arteries or veins), or from a great number of small ones. Spontaneous hsemorrhage is best illustrated hy that curious affection which is seen occasionally in this country, and more frequently, it is believed, in Germany, called the hsemorrhagic diathesis. In this diathesis there is a constitutional predisposition to bleed, sometimes with no pre- vious injur}-, but commonly after some slight wound, very frequently that of the removal of a tooth, or some other trifling laceration ; and 106 HAEMORRHAGE, the hoemorrliage will proceed, sometimes, unchecked by ireatinent, until the patient is exhaiisted, when it commonl3^ stops, though in rare cases it proves directly fatal. It is more common for death to follow some other disease, which the patient would if stronger have thrown off. The constitutional tendency is hereditary, and usually in the males of the family. Females suffer also from the disease, but more rarely — an exemption which has been attributed to the natural outlet provided by menstruation. And it is asserted that men who have hemorrhoidal dis- charges sometimes procure thereby the cessation of the luTemorrhagic diathesis. It seems, however, that though females suffer less frequently than males, the diathesis is commonly received through the mother. It is not, however, always inherited nor always congenital; and it is said that the diathesis may be excited b}' privation of exercise and confinement in a damp unhealthy place. In some cases the haemorrhage is periodic : and it is sometimes pre- ceded by a distinct warning — a period of excitement, in which the pulse beats excessively ; the patient is restless, and perceives an odor of blood in his nostrils. Some da^'s after this the bleeding will begin, or if an injury is received the wound will bleed forthwith. In the intervals be- tween the attacks of haemorrhage a peculiar affection of the joints may be noticed, varying from severe pain to synovial effusion, or the general inflammatory thickening of all parts of the joint, called " white swelling." So long as the joint disease is present the tendency to bleed seems to be suspended. The nature and situation of the haemorrhage vary: subcuta- neous haemorrhage (petechife), bleeding from the nose and mouth, hema- turia, and melena are the most common. The treatment is generally successful. If the patient is strong enough to bear it. free watery purging (as b}^ Glauber's salt, sodffi sulph., in ,^ss. doses) seems very beneficial, and the exhibition of some salt of iron (the carbonate is the favorate preparation) in the intervals between the haemor- rhages is often a great adjuvant. When internal hemorrhage occurs the ergot of rye is highly recommended, and may be given in 5-grain doses every half hour. External hemorrhage is best controlled by well-regulated pressure, aided by some astringent, of which the perchloride of iron is the best, or in some cases by the actual cautery. In some instances it has been noticed that the bleeding has ceased on converting a lacerated wound into a clean incised cut, and venesection has ever been practiced with advantage; but it seems unnecessarily dangerous to make fresh wounds in a case where any cut may bleed lfncontrollabl3^ The (jeneral symptoms of hsemovvhage are as follows: When profuse and rapid (as, for instance, when a large artery is laid open) the patient rapidly faints; or, if the hemorrhage is less excessive, the pulse and temperature fall, and he feels weak and faint; languor, yawning, noises in the head, throbbing of the temples, and flashes of light in the eyes l)recede the access of syncope. When syncope occurs, the bleeding as a rule stops; but if this is not the case, in consequence either of the size of the vessel or from some mechanical impediment to its closure,' the patient must die unless the bleeding is arrested by surgical treatment, (jlenerally, however, it does stop, but sometimes recurs with the same ' The main mechanical obstacles to the closure of the vessels are their dilatation by hfnt, as in the case of vessels wounded in the interior of the bod}', their being kept open V)y the walls of a bony or fibrous canal in which they lie, ilieir partial di- vi.-ion, and the presence of foreign bodies in their interior. INJURIES OF ARTERIES. 107 train of s^-mptoms, onl.y more rnpidly ending in syncope. On recovery from syncope vomiting often takes place, the pulse rises rapidly in rate, but not in volume, being wealc, small, and easily affected by any external agency. The recurrence of hiiemorrhage after syncope is prevented by the blood forming a clot in the bleeding vessel and in the tissues around it, which the returning circulation is too weak to displace ; and this process is greatly favored by the contraction and retraction of the arteries when completely divided, as will be explained further on. Repeated or hahilual hftmrji-rhnfie produces a general pallor, or rather a waxy appearance, of the whole body, fainting on slight exertion, rest- lessness, emaciation, sometimes partial or complete amaurosis, and fre- quently constant and extreme drowsiness. As it goes on the patient becomes more and more weak and exhausted, sometimes entirely uncon- scious, pulseless, and livid. Death takes place usually in a very sudden manner, or is caused by some slight exertion. It is hardly possible to estimate correctly the quantity of blood-loss which is necessary to occasion death. It varies much with age; infants succumbing rapidly — much with the patient's state of mind : a ha?morrhage which vvould not prove fatal if the j^atient were unconscious may easil}' cause death when his mind is agitated and his heart under the influence of terror — much with the temperature in which he is placed : bleeding which would not prove fatal if the patient were in a warm I'lace may prove fatal when the heart is embarrassed by the resistance offered by tissues congealed by cold — with the organ affected, and with the condition of health or disease in which he may ha|ipen to find himself. It has often been noticed that after repeated bleedings (either acci- dental or therapeutic) the blood becomes watery, more prone to escape from the vessels, even without injury, and less apt to coagulate. Injuries of Arteries. — The bleeding which occurs in most wounds pro- ceeds chiefly from the capillaries and from small vessels which cease to bleed spontaneously. But bleeding from the larger arteries must be at once stopped, or else it will prove fatal, or at any rate cause a most in- jurious loss of blood. The injuries of arteries may be thus classified : 1. Contusion. 2. Partial laceration. 3. Complete laceration. 4. Partial division. 5. Complete division. 1. About contusion of arteries little is really known. It seems unde- niable that contraction and even total closure of the artery may follow on mere contusion, and that this ma}' be a cause of gangrene. So Guthrie relates a case in which a bullet passed between the popliteal arter^^ and vein without opening either. Gangrene ensued, and the man died. " The coats of the arter^'^ were not destroyed in substance though bruised ; it was at this spot much contracted in size, and tilled above and below with coagula."^ But such injuries can hardly occur uncomplicated, nor can the exact condition of the artery be diagnosed. They must be treated b}' the ordinary rules for traumatic gangrene. 2. Partial laceration of the artery consists in the tearing of the in- ternal and middle coats while the external coat remains entire. I once had an opportunity of seeing the symptoms of this injury so clearly marked that it was easy to diagnose both the nature and the precise seat of the lesion. A man was brought into St. George's Hospital with a very * Guthrie, On Wounds and Injuries of the Arteries, p. 22, case 24. See also simi- lar cases in Moore's essay in Syst. of Surg., 2d ed., vol. i, p. 734. 108 HJEMORRHAGE. Fig. 13. severe injury to tbe head, caused by a fall from his horse, of which he died in 3^ hours. On examinino- one wrist there was no pulse; on the other side it was perfectly natural. The brachial vessels could be plainly felt in their usual situa- tion, but there was no pulse there. In the axilla the pulsation could be felt down to a certain point, and there it stopped at once. There was no bruise, nor any other injury in the armpit. It was eas3' to see that the axillary artery had been partly torn at this spot, and that the torn coats had been pushed into the tube of the vessel by the blood so as to close the tube ; and the condition of the artery was exactly verified by post-mortem examination, as is rei:)resented in the adjoining figure. The injury here is precisely the same as that which is inflicted bj^ the surgeon in the opera- tion of tying the artery, but without the abid- ing irritation of the ligature. The artery, there- fore, will not probably give way above the seat of the injury. It may expand into an aneurism of the kind sometimes caWed false — i. e., the sac formed only by the external coat (see the section on Aneurism) — but more probably this part will become lined and filled with coagulum, and be- 3'ond the obliteration of the artery nothing further will ensue. Gangrene is less likely to follow than after the ligature of the artery. 3. Complete subcutaneous laceration of an ar-. The axillary artery, showing tcry Is more commouly sccu in the popliteal than laceration of its two internal j^„y ^^1^^^. ^.ggg^j^ j,^ j^^^gt^ ^^ ^j^g j.gg^,n ^^ ^.^^^ costs wliicn hnvG l)GGn ciissGCtcd "^ by the force of the blood stream violcncc, and is therefore usually accompanied from the external coat for about b}' Other Icsions, such as laceratiou of the pos- haif an inch, and turned down terior ligament of the joint or rupture of the into the cavity of the vessel, so • ^ n i ii mi • i <-• as to block it up. a shows ihe ^^^lu, and usually both. The circulation ceases, coagulum lodged above the re- the pulsc disappears Irom the lower arteries, the versed portion of the inner coats; temperature of the limb rapidly falls, enormous 6, the sheath of the vessel, which extravasation of blood below the fascia distends ■was perfectlv natural. — From St. ^, ,. , . , . , , , George's Hospital Museum, Ser. the limb ; in somc cascs a bruit cau be heard, vi, No. 95. I have never seen an^^ case where pulsation was present in the extra vasated blood. Gangrene rapidly ensues if the limb is not amputated. Such cases are easy of diagnosis from the rapid fall of temperature, the great swelling, and the loss of pulsation in the arteries below the seat of injury. But I have seen cases where some amount of circulation went on, and where pulsation was at first perceptible, though feeble, in the tibial ar- teries, yet where gangrene set in, though not so rapidly;' and after am- putation the arteiy was found completely separated into two parts. Either the blood at first found its way from one end of the arteiy into the other, the rupture being complete, or, as is more probable, the laceration ' A case is relatfid by Mr. Pick, in Path. Trans., vol. .xvii, p. 74, in which the laceration wa.s at fir.^t incomplcto, and liifi j)atii'iit was al)l« to walk several miles after the accident. Gangrene came on very gradiuilly, and amputation was not performed till thirty-five days after the injury. Tiie two parts of the popliteal artery were still united by a fragment of the anterior wall of the ves.sel. WOUNDS OF ARTERIES. 109 Fio. 14. was at first incomplete, but the nntoni part of the vessel afterwards gave way. If the diagnosis can be made with certainty primary amputation is the safest course in the lower limb. In the arm the surgeon would tie the vessel if the swelling were increasing, or if not would trust to pressure on the artery above, vvith careful bandaging of the whole limb, and a com- press at the seat of injury. But in the upper extremity, as in the lower, when gangrene has commenced amputation should be no longer delayed. The total laceration of an artery in a wound, as when a limb is torn off by machinery, does not usually give rise to haemorrhage ; the artery is twisted by the force exactly in the same way as it is by the surgeon in an ampu- tation, and it can be seen pulsating down to the lacerated part. The process by which it is closed will be described under the head of Torsion, further on. 4. The incomplete is often a more seri- ous injury than the complete division of an artery, since the wounded artery is pre- vented from retracting. Thus, when arte- riotomy was a recognized operation, the anterior temporal artery was punctured, and would continue to bleed as long as the puncture in the vessel corresponded to that in the skin. When the surgeon wished to stanch the hremorrhage he cut the vessel across. The direction of the wound" is of some importance in reference to the proba- bility of future mischief. Tlius, if a longitudinal wound be inflicted on an artery in a living animal, and the wound be afterwards examined, it will be found to be a mere slit, while a transverse wound gapes open and becomes oval, or rather lozenge-shaped, in consequence of the state of longitudinal tension in which the vessel normally is placed, rather than from any retraction of the muscular fibres. Mr. Savory shows that a similar shape is assumed by transverse wounds made after death, and that on dissecting the artery away and removing it from the body the wound closes again.' An artery partially divided will go on bleeding until some efficient external ob- stacle is opposed to the exit of blood, a* ''»'■ »« ^^e nearest branch on eitherside, and this is often eflfected by the displace- tapering as it extends up the vessel, and „ , . , n • clot IS also poured out external to the ment Ot the various layers of tissue over- sheath. The cut in the sheath (?< 6) is here lying the vessel (so that the wound in the represented as a linear fissure. In practice artery no longer corresponds to that in the ^^^ ^'^''*''' ^""^"^ sape more widely as it is skin), and by the accumulation of blood- **" * ''^ "'''^'' clot in the interspaces. When the bleeding stops, the wound may close Diagrammatic representation of complete division of an artery. The ends of tlie vessel (a a) are seen to be retnicied, i. e., drawn up into the sheath ; and contracted, i. e., compressed into a conical shape by the contraction of the circular muscular fibres. The part of the sheath thus left vacant, and the ends of the vessel, are represented as tilled with clot. The clot often extends Savory, On the Shape of Transverse Wounds of the Blood ves.ting the passage ofllu! blood through tlieiu, without any assistance from art, or iVom the surrounding jj.n-ts in which they are situated." DIAGNOSIS OF ITS SOURCE. Ill apart from any danger of bleeding. Thus Mr. Syme' has shown that many of the deaths after ligature of the arteries may with great proba- bility be attriliuted to injury inHic-ted on the accompanying vein ; and since surgeons have been more alive to this consideration the mortality after ligature of arteries has, I believe, decreased considerably. Further observations on this topic will be found in the chai)ter on Diseases of the Veins. Entrance of Air. — Another very formidable consequence which some- times follows wound of a vein is the entrance of the air into it. When the air rushes into the vein in such large quantities as to fill the right auricle of the heart with air it usually produces instant death, for the air passes through the auriculo-ventricular valve and opens it; then, on the contraction of the ventricle, the air, being a much lighter fluid than blood, cannot shut the valve-flaps," and so the heart's action comes to a stop. When a smaller quantity passes in the patient faints, but recovery often ensues. The entrance of the air (which, in practice, always occurs in surgical operations) is denoted by a whistling sound, after which syncope at once occurs. As far as I know this has only hitherto occurred in oper- ations. on the neck or axilla, though it seems possible in other regions, also ;■' and it appears to have become much rarer, if not altogether un- known, since the operations have been more generally perfoi-med under the influence of full anaesthesia, the accident being no doubt often caused by the patient's struggles. The vein having been imperfectly divided, and being prevented from entirely collapsing by its adhering in part to the surrounding tissues, some sudden movement draws the incision open while the motion of the chest in inspiration is producing a tendency to vacuum in the venous system. The remedies are those for profound syncope, viz., the recumbent posi- tion, forcing the blood towards the heart by chafing the limbs, exciting the heart to action by galvanism, administering ammonia by the nostrils and brandy b}' the rectum, and possibly, if there be time for it, injecting warm water into the veins in quantities of about 2 ozs. at a time. Mr. Moore, who proposes this [)lan (which has not hitherto been tried), dii-ects that the head be raised and a vein in the neck be opened, in order that, if it be filled with air, the air may escape. The water is then to be injected vvith such force as would, in the operator's judgment, moderately distend the auricle. All the cases which have recovered have done so under the ordinary remedies for profound syncope long-continued, and sometimes after a long period of almost seeming death. The occasional occurrence of this terrible accident will of course teach the surgeon caution in dissecting operations about the neck and axilla. Dmyno^is of the Source. — W^hen a surgeon is called to a case of haemor- rhage his first care is to stop it for the moment, which is always readily done, if there is an open wound and the Meeding comes from a definite point, by moderate press.ure witli the finger on the bleeding spot. The ' Princii)les of Surijery, p. 97. '•* This is sometimes done experimontiiby in ivilling liorscs. A pipe is inserted into the jugular vein, and then, if sibout thriee as niuoh air is blown into the vein as a healthy man can emit at one full expiration, the horse will fall dead. See Moore's essay in Wyst. of Surg , vol. i, p. 757, 2d ed., to which I must also refer the reader for a full discussion of the various theories about the manner of death in these cases. I have only stated in the text the one which seems to me the most satisfactory. 3 Dr. Cordwent has related a case of parturition in which he believes that death occurred from entrance of air into the uterine veins (St. George's Hospital llcports, vol. vi). 112 HJEMORRHAGE. bleeding even from a very large arter}'-, if cleanl}' exposed (i.e., the femoral in an amputation at tlie hip), requires remarkably little i)rcssure to check it for the time. And if the bleeding point is not plainly visi- ble, well-directed pressure on a pad of some soft substance filling the whole wound will suspend the hiiemorrhage until time has been obtained for the definite treatment. Next, the question occurs — Is the haemorrhage arterial, venous, or capillar}^ ? Let us suppose a large arter}- wounded, and the wound in the artery corresponding directly to the skin-wound. The blood leaps out, of a bright-red color, in jets synchronous with the heart's beats, and often to a distance of some feet from the patient's body. In the wound of a large vein, on the other hand (phlebotomy is a faniiliar instance), the blood pours out in a dark purple (Modena-red) stream which is continuous, and, if jetting at all, the jets are not interrupted but onl^' augmentations of the force and extent of the stream, sj'nchronous not with the heart's action, but with expiration or with muscular efforts. So far there is no difficulty in the diagnosis. And in the case of smaller arteries there is also no difficulty so long as the How of blood is unobstructed by tlie superjaceut tissues. But in small wounds, even of considerable arteries, lying deeply and having a circuitous communica- tion with the exterior, the bleeding may be so gentle that there is little to distinguish it from venous oozing in its manner of coming out or in its color, for venous blood quickly turns red on exposure to the air. In this case the persistence of the hoemorrhage is a valuable sign that it is an arter}' which is wounded ; and the effect of pressure above is another. l*ressure applied to the nearest accessible trunk between the wound and the heart will suspend arterial hsemorrhage ; while, if it affects the venous bleeding at all, it will augment it. If a bruit can be heard it will of course be decisive. From Trunk Artery or Branch? — HaAing settled that the bleeding is arterial, the next question is whether it comes from a trunk artery or a branch. The bleeding caused by a wound of a branch close to its trunk (as of the supeificial pudic near the common femoral, the circum- flexa ilii near the external iliac, or the sural near the popliteal) has been constantly mistaken for a wouud of the trunk itself. The main diagnostic sign is that the pulse in the lower i)art of the aitery is very much more affected when the artery itself is wouuded than when one of its branches is cut across, and the persistence of the luemorrhage is a valuable sign of lesion of a main trunk. Treatment. — When the haemorrhage -has been diagnosed to be from a trunk artery no lime should be lost in securing it. If the position of the wound permits it a tourniquet, or finger pressure, should be placed on the artery at some distance above the wouud;' then the wound should be enlarged sufficiently to permit an easy dissection of the wounded vessel, and the artery should be tied al)0ve and below the hole in it. If the wound ill the artery is not at once visil)le, the relaxation of the tourni- (piet will show the surgeon where the bleeding comes from, and will lead him to it. A ligature altove the wound only will sometimes stop the bleeding, especially in arteries of the lower limb; but even here it is far more safe to tie both ends. If this is not done, the lower end will prob- ably begin to bleed as soon as the circulation is re-established; and it is ' I should myself prefer the use of Esmnrch's bandage, but have not hitherto had occasion to try it in a case of this kind. LIGATURE OF ARTERIES. 113 an old observation, on which Mr. Guthrie used to lay very much stress, that the bleeding from the lower end is of a venous character, both in color and flow.^ This is cei'tainlj- true of the arteries of the lower limb, but in the neck, and frequently in the upper extremity, both ends will bleed per solium. Having secured the artery, the surgeon must ex- amine the vein ; or if there is a wound of a large vein, the bleeding from which is increased by the application of tl)e tourniquet above, it may be held in check during the operation by another tourniquet below. When the wounded vein has been exposed the surgeon must choose for himself, according to tlie size of the wound and of the vein, whether he will trust to pressure, or tie the vein as well as the artery. The superficial femoral and its vein have often been tied together (by John Hunter, Roux, etc.), the popliteal artery and its vein for a wound (by Mr. Holthouse), and the common carotid and internal jugular in removing a tumor (by Laugen- beck), without bad consequences." If no tourniquet can be applied above the wound the operation becomes far more difficult and dangerous. The leading case here is one in which Mr. Syme tied the carotid artery when wounded at the root of the neck." Tiie left forefinger must be inserted into the wound, which is to be cau- tiousl}' enlarged for that purpose sufliiciently to admit tlie finger, so as to control all bleeding. Then, with the help of his assistant, the surgeon must bring the artery into view above his finger (i.e., between his finger and the heart), and when he has scratched it bare, and tied the ligature round it, he may remove his finger, clear all the clots away, and secure the distal part of the vessel. If the wound in the skin has been commanded by pressure and there is no bleeding, the surgeon may think it better to wait, in order, should a traumatic aneurism form, to treat it afterwards. But if the extrava- sation of blood be plainly increasing, the case should be treated just like a recent wound. When the bleeding has been arrested by pressure, it is, as a rule, un- advisable to disturb the dressings at all. Ligature of Artery above the Wound. — There are cases in which it is justifiable to tie the artery at some distance above the wound, as in aneu- rism. Thus, if the wounded vessel be inaccessible, as when the internal carotid has been wounded through the mouth, tlie common trunk has been tied with success ;* or when the patient has already lost a great deal of blood, and the surgeon thinks that a prolonged operation and deep incisions would prove fatal, the artery has been successfully tied above, where it was more superficial.^ But this must be allowed to be only apis ^ Guthrie, Wounds and Injuries of Arteries, p 248. ^ 8ee the account of Mr. Annandale (Lancet, April 24th, 1875), of a case in which he tied the popliteal artery and vein in a case of arterio-venous aneurism. ' Syme's UI)servations in Clinical Surgery, p. 154. ■• See Mr. H. C. Johnson's case, in Lancet, 1850, vol. ii, p. 118. This case is evi- dently alluded to in Mr. Guthrie's Commentaries, 6th ed., p. 256, where he proposes to secure the internal carotid artery when wounded from the mouth by an operation in which the ramus of the jaw is to be divided aU)ng with the internal pterygoid muscle, and turned up, the styloid process audits muscles with theglosso-pharyngeal nerve dissected, some of the styloid muscles divided, etc. But although a competent anatomist can execute this dissection on the dead subject, its practicability in the case of a wounded artery is a very different matter, and the relative safety of the other course seems to be conceded. If after ligature of the common trunk the internal carotid still bleeds, it might become tlje surgeon's duty to attempt to secure the bleed- ing artery in the manner Mr. Guthrie describes. * See Mr. Bujtccl's case, L-ancet, 1859, vol. ii, p. 236, where a man was found nearly dead from hsemorrhage after a wound of the femoral deep in the thigh, probably in 8 114 HEMORRHAGE. aUer, and if it fails to check the bleeding the patient will be in very se- rious danger. The only case in which the practice is recognized is that of a wound of the palmar arch. In some cases also in which the wound and the limb generally are much inflamed it may be more prudent to tie the artery higher up ; as recom- mended by Dr. Campbell, of New Orleans (in a paper referred to on page 119) ; and the success of this practice in such inflamed wounds has led to the proposal of ligature of the main arter^'' of the limb as a method of treating complicated wounds and diffuse inflammation of the limb generally. There are rare cases in which the surgeon departs from the usual rule, of not tying an artery unless it is bleeding. These are mainl}' cases in which he judges, by the severit}'- of the previous bleeding, that a large vessel has been wounded, and that the haemorrhage will probably recur, and when the patient must be left at a distance from competent aid. Otherwise it is better to put careful pressure over the wounded part, and leave a tourniquet loosely applied over the trunk above, with instructions to the nurse to screw it down if the bleeding recurs, and send at once for the surgeon. The ligature of arteriea was a method of suppressing haemorrhage so infinitel}^ superior in every wa}^ to the cauterj^, which was previously in vogue, in freedom from pain, in ease of application, in efficacy, in safety, and in immunity from future ill consequences, that it is hardly to be wondered at that Ambroise Pare, its inventor, declared that he consid- ered it almost a divine inspiration. Mau}^ attempts have been made to improve upon the original invention, so as to avoid the division of the vessel which is involved in the separation of the ligature. I shall pass over most of these in silence, but shall describe in detail the most recent, which we owe to Mr. Lister's genius, and which gives fair promise of com- plete success. First, however, I must describe the method which is still in common use. If a vessel is to be exposed in its continuity, the skin and all other tissues which cover its sheath must be divided according to rules based on the known anatomical relations of each arterv, and which will be found in the sequel. The sheath is recognized b}' the pul- sation of the vessel beneath it, and b}' the absence of the white color of the wall of the arter3\ It is i)inched up with a pair of fine forceps, and a small nick is made in it with the knife held horizontal, so as not to en- danger the artery. This little opening is enlarged with the point of the Fig. 15. Aneurism-neGdle. The point is roundotl or l)Iunt, and has an eye in it. director till the aneurism-needle can be easily passed round the naked vessel. The sheath is only to be disturbed so far as is absolutely neces- sary for this purpose. Of all ligatures which are intended to divide the Hunter's canal. The surgeon, thinking that a long and diflScult dissection must prove filial in the dospcriite state of tlie patient, tied the artery in Scarpa's triangle, and the patient recovered without further bleeding. LIGATURE OF ARTERIES. 115 vessel, the best, as Dr. Jones' has conclusive!}^ shown, is a stout round silk or hempen stinng, which, being tied firmly on the vessel, cuts the two inner coats evenly all round. These divided inner coats ma}' possibly re- tract a little from the external, which alone is left in the grasp of the ligature. The constriction of the vessel brings the cut edges of tlie inter- nal coats into apposition. The changes which now ensue are intended to effect (1) the separation of the ligature; (2) the closure of the divided ends of the artery, so as to obviate haemorrhage ; and (3) the restoration of the circulation. The ligature separates by a process of ulceration and sloughing, and when it comes away a small slough, consisting of the external coat, is generally em- braced in the knot. There is, therefore, after the fall of the ligature, a time at which the artery consists of two parts, though these soon unite again, and though they are, as a rule, glued to- gether by the inflammatory exudation which takes place in the tissues around the ligature. Tlie separation of a liga- ture from a large artery such as the femoral occurs usually in about a fort- night. The earliest recorded period in that artery seems to be eight days'^ in a case which recovered, but it often re- mains fixed for a much longer period. When it separates very early haemorrhage is much to be apprehended, the artery being probably diseased. The means by which haemorrhage is averted are chiefly threefold: (1) the blood coagulates in the interior of the artery, the coagulum extending in many cases to the nearest considerable branch on either side of the ligature, filling tlie whole tube, at least at the point where the artery is tied, and ultimately acquiring an organic connection to the wall of the artery; (2) the cut ends of the internal coats are united together by in- flammatory lymph, and are also united to the lymph wliich is effused into the interior of the artery around the ligature ; (3) the tissues around (sheath, cellular tissue, etc.) are occupied by inflammatory exudation, in which tlie tied part of the vessel is buried. Ultimately, after the fall of the ligature, the divided parts of the artery are united, and the whole of the portion of the vessel along which the coagulum has extended is con- verted into a solid cord. During this process the circulation has been re-established by the in- crease in size of the anastomosing vessels. That increase is in some cases very rapid, in others, as it seems, very slow. The rapidity with which it goes on in the lower animals is seen from an experiment of Broca, who amputated the leg of a dog at the knee, having previously placed a liga- ture under the artery in the groin. The distance to which the pulsating jet reached was noted ; then the ligature was tied ; the bleeding of course An artery tied with a stout ligature and then laid open, a a, show the internal and middle coats divided and turned down for a short distance below the ligature, in order to expose the undivided external coat. 1 Treatise on the process of nature in suppressing hsemorrhaije from divided arteries, and on the use of the ligature. 1805. ^ In a case of Eamsden's tabulated by Norris, No. 45. Contributions to Practical Surgery, p. 288, from Kamsden's Practical Observations. IIG HAEMORRHAGE. ceased, but it recommenced at the end of one minute, and in five minutes the jet (which, however, no longer pulsated) had attained a quarter of its former maximum distance, notwithstanding that the quantity of blood iii the body had of course been diminished by the lu\?morrhage.' And many recorded facts show that, in man also, the circulation is very rapidly re- established, particularly in the upper extremity. Wardrop says : " The enlargement of the anastomosing vessels to a certain extent takes place almost instantly al'ter the trunk has been tied. I observed this in a child in whom I had secured the carotid arterj'. I Fig. 17. could see the branches of the temporal and oc- cipital under the delicate integument enlarging immediately after the, operation."^ And in- stances are not wanting in which after the liga- ture of the main artery of a limb the pulse has been felt below the ligature in a day, or on the second day. But the anastomosing vessels con- tinue to enlarge for a considerable period, esti- mated by Porta as being usually under a year. All the time during which the collateral circu- lation is deficient, the limb remains cold, weak, and liable to suffer from any rapid change of temperature; and even after it has attained its highest grade the limb in which the main artery has been tied is weaker, smaller, and less vigor- ous than natural. Secondary Hsemon-hage. — When any of these three steps are incomplete, the operation usu- all}' fails, either b3' secondary haemorrhage or gangrene. If no clot forms in the artery — which from some unknown condition is not un- frequently the case — the force of the circulation in the upper end of the artery is resisted only b}' the uniting medium between the edges of the divided internal coats, assisted by the lymph which is deposited in and around the sheath. This, liowever, may be perfectly sufficient for the purpose, and accordingly we find cases in whicii the patient has recovered without any drawback, though only the very portion of Portion of a femoral artery tied artery embraced in the ligature has been oblit- some months before death. Avery erated (Fig. 17). Still the deprivation of its small part, 6, of the vessel (about 14 proper Support fVom the coagulum renders the in.) IS reduced to the size of a piece .S ^ • 1 1 , • of whipcord, being completely ob- "mtiDg material uiuch more prone,to give way, literated. Except a viry small pale and tliis is an indubitable cause of secondary haemorrhage. Another and probably a more frequent cause is the extension of the ulceration (whicli is necessary for the sei)aration of the artery, the chief brancli above the ligature) bcyoud itS proper bOUllds, SO that it lays open a portion of the vessel not comj)letely filled with clot. Periiai)s both causes of secon- dary hivmorrhage may act at either side of the ligature, but obviously that form of secondary haemorrhage which depends on yielding of the uniting medium, must be coagulum just below tliis narrowed part, the whole artery above and below this part is quite pervious and healthy, a shows the profunda ligature; and a large liranch wliicli comes off some distance lidow is also seen. — St. George's Hospital Museum, Ser. vi. No. 147. ' liroca, Sur los Ancvr., p. 507, note. Wardrop, On Anourisni, p. 12. LIGATURE OF ARTERIES. 117 more common at the upper end, where it has to bear the whole momentum of the direct circulation, than at the lower, where only the reflux circu- lation is actino-. But the form of secondary hremorrhage ^ich depends on ulceration is, there can be no doubt, nwfe con]^j^n ^wTe distal side of the ligature, though I am not aware tlraTt any Gxplan|PrrDn of this lact has been offered. ^« Treatment. — Secondary hpumorrhage comes on about the time that the ligature is falling, though sometimes several days afterwards, and it usu- ally commences gently, almost insidiously, so that the surgeon at first tries to persuade himself that it is merely a little oozing from the granu- lations of the wound, and this kind of secondary hiiemorrhage may often be successfully treated by well-applied pressure. Pressure is best applied by graduated compresses in the wound, or by filling the wound with small shot, which is to be firmly bandaged on, and an aneurism com- pressor adjusted over it; and it may be assisted by compression of the trunk above, which, if done at all, should be digital, much care being taken not to compress the vein. The limb should be carefully bandaged, and some authors recommend putting a compres'6 of lint on the artery below the wound. But if the bleeding begin furiously, as from the upper end, which has suddenly given way, or if pressure does not check it, three courses are open : to tie a higher part of the artery, to reopdi the wound and place another ligature on the bleeding vessel, or to amf)utate. The ligature of a higher part of the artery, which used to be the orthodox treatment, almost always fails, and I quite agree with Mr. Erichsen that it only adds to the danger of the patient. In a most interesting paper in the St. Bartholomexv''K Hoqntal Reports (vol. x) Mr. W. H. Cripps has shown that not only has it frequently caused death directly, but that it has usually failed to prevent the recurrence of bleeding, while 3^et in some of these cases a cure was obtained by the after-employment of compression. The attempt to retie the vessel at the seat of ligature is a dangerous and in some cases a very difficult operation ; the tissues are loaded with blood, the artery is very difficult to recognize unless the bleeding is allowed to go on ; and such renewed loss of l)lood raa}^ easiW prove fatal to one weakened by previous haemorrhage. Besides, the ar- tery may be too rotten to bear a ligature, or the vein may easily be in- cluded with it. Still the attempt has proved far more successful than the ligature above. Amputation is, I am persuaded, the best treatment in many cases of aneurism ; since it removes a formidable disease which is by no means cured at the time when secondary hemorrhage occurs ; but no one would willingly resort to it in a case of mere wound. The result of Mr. Cripps's inquiries is as follows. The paper includes all the cases which he could find of secondary haemorrhage after the liga- ture of the femoral in its continuity for all causes, fifty-three in number. There were fourteen cases in which the external iliac was tied ; twelve died, one recovered under pressure on the recurrence of haemorrhage,^ and one after amputation for gangrene; five others were amputated, two died, three recovered. In twelve cases the artery was retied : seven died, and five recovered. In fifteen cases pressure was used, and only three died. In seven cases, from various causes, no treatment was used, and three of these recovered.^ 1 In this case the surgeon in charge states his opinion that the ligature of the ex- ternal iliac was a useless operation. '■^ In cases of secondary haemorrhage from the stump of an amputation, the results of ligature of the artery higher up seem to have been less disastrous, but the number 118 HiEMOrvRTTAGE. It might be argued, in explanation of the far more favorable results of pressure, that that method had onh- been used in the mildest eases; but Mr. Cripps says that, on perusing the notes of the cases, he does not believe this lo kave been the fact. The perusal of the paper has certainly confirmed my previous impression, that most of the cases of secondary hiijmorrliage which can be saved will be saved Iw the persevering use of well-applied pressnre. But there are unquestionably in practice cases where secondary htemorrhage bursts out with such violence from tlie upper end of the artery that it is useless to spend time on the attempt at compression. Such cases must be treated, I think, like fresh wounds of the vessel, by retying it ; or, if the attempt to retie the vessel fails, by amputation. And there are other cases where the persevering use of pressure has failed. Here the surgeon must be left to choose between retying the vessel and amputation. Secondary haemorrhage occurs also from arteries that have been wounded and not tied, in consequence of the giving way of the clots, or of an}' uniting medium, which may have opposed the issue of blood. The practical considerations are the same as after ligature. I ought to mention that secondary hsemorrhage is often said to be due to unhealthy ulceration, caused by defective hygienic conditions in hospital — a state- ment of which I have found no definite proof, though it is probable enough. Certainly the most common cause of secondary haemorrhage is disease of the vessel. Recurrent Hsemorrhage. — There is another form of bleeding which is sometimes confounded with secondary haemorrhage, though it is of quite a different nature. I mean the recurrent haemorrhage, which sometimes comes on an hour or two after a wound, when the patient becomes warm in bed, and has recovered from the shock of the operation or accident. This depends merely on some vessel or vessels, which have not been se- cured, bleeding under the influence of warmth and renewed circulation. The bleeding vessels must be exposed and treated just as in primary haemorrhage. Gangrene after Ligature. — The other main cause of failure after liga- ture is gangrene, and it depends usually, as it seems, on the failure of development of the collateral circulation. This, however, is by no means the only cause of gangrene, for it may be occasioned also by coagulation in the vein, the result of bruising or laceration of that vessel in the injury or in the operation, and in cases of aneurism it depends sometimes on inflammation of the sac, by which the pressure on the vein or veins is increased and the veins themselves in some cases also affected by inflam- mation. Gangrene from the two former causes commences early, usually within four days after the ligature ; the latter cause may ])e several weeks in ])roducing its effect. The treatment to be pursued depends on the rapidity with which tlie gangrene spreads. If it comes on over a large surface, or in several places at once, and advances rapidly, no delay should be admitted, but the limb should be removed at once, the section of the artery being made as near as possible to the tied portion — not above it. If only a small part of the limb— say one or two toes — is affected, and the gangrene advances slowly, without constitutional symptoms, there is good reason to hope that tlie mortified parts will separate and a useful limb be preserved. Recurrence of Circulation. — This view of the causes of failure of the recorded here is very smiill. Three cases are referred to, in two of which the com- mon iliac was tied after the external. All recovered. THE ANTISEPTIC LIGATURE. 119 ligature would not be complete without the mention of what, however, belongs to the subject of aneurism, and not of haamorrhage, viz., that the collateral circulation sometimes errs from excess. When the main artery is tied in order to cure an aneurism, or when the operation is performed for general inflammation of the limb (as recommended by Dr. Campbell and Dr. Onderdonk, in America, and in this country by Mr Maunder'), the collaterals may enlarge so rapidly and to so great an extent as at once to reproduce the circulation below, which it was intended to suspend. The treatment of aneurisms when recurring from this cause will be spoken of in the section on that subject. Carbolized Catgut Ligatm-es. — Viewing the great danger of secondary haemorrhage and its comparative frequency (which, however, has been much diminished of late years, since arteries have been more gently dealt with in deligation, and the sheath disturbed to as small an extent as possible'-), surgeons have long been seeking for some means of tying an artery, so as permanentl}' to obliterate it, without dividing it. John Hunter attempted this in the very first operation which he performed, by gently constricting a large extent of the artery by means of four broad ligatures ; but he soon recognized the futility of that attempt. Again, the same end was sought by the use of temporary ligatures'^ tied over a roll of lint, or some such substance, laid on to the artery, so that the ligature could be cut and removed two, three, or more days after the operation ; or by nooses attached to an instrument left in the wound, whereby the surgeon could tighten or relax the ligature as he liked. And these attempts are not yet entirely given up, though, as far as I can dis- cover, only one preparation exists showing that the artery has really been closed in this wa}' in the human subject,' while the failures have been numerous and disastrous. Again, ligatures made of animal matter have been used in the hope that they would be absorbed (or perhaps, as some have thought, that they would unite with the tissues around) without causing any ulceration. The only one among the numerous experiments of this kind to which I need refer is the ligature of the femoral with cat- gut, which Sir Astley Cooper performed on an old man affected with popliteal aneurism,^ and which proved most successful. But he was dis- appointed in subsequent trials of the substance, and renounced its use. Recently Mr. Lister has revived the use of catgut, thoroughly soaked in carbolized oil, as a ligature, and with a success which is, I think, undeni- able." The success depends, as 1 have endeavored to show,'' not only on the material of which the ligature is composed being one which is capable of absorption, and which dissolves without exciting suppuration — though this is an essential condition — but also, and perhaps even more, on the rapid union by the first intention of all parts of the wound which are in contact with the tied vessel. We have already seen that the lymph eff"used in and around the sheath is a great support to the vessel and protection against secondary hoemorrhage when the artery is divided by 1 See Biennial Eetrospect of New Syd. Soc, 1867-8, p. 284. •■^ Lancet, 1874, vol. ii, p. 860. 3 First used apparently by Cline and Scarpa. See South's Cheliiis, vol. i, p. 304. ■• Tliis preparation is in the Museum of the Irish Collesfe of Surgeons. 5 The case is related in Cooper and Travers's Surgical Essays, vol. i, p. 12-5. * "During the last three years," says Mr. Bickersteth, "I have tied the femoral artery five times, the common carotid once, and the common iliac once, and in every case, with one solitary exception [one of the cases of ligature of the femoral], the wound has healed at once, and without suppuration." — On Recent Progress in Sur- gery, 1871, p. 20. 7'Lancet, 1872, vol. ii, p. 325. 120 HEMORRHAGE. the ligature. If this exudation forms rapidly, and without destructive inflammation, the tied vessel remains free from any tendency to soften or ulcerate, and the small knot of earbolized gut rapidly disappears, keeping the artery closed, however, quite long enough (as we know from the experience of acupressure) for permanent obliteration to occur. That this is, at any rate, possible is shown by a case in which I tied the sub- clavian and carotid artery in this Fi«- 18- manner, and where the patient died eight weeks afterwards from another cause. Neither wound had healed by first intention, but the suppuration seemed superficial. The external coat was perfect in both arteries, which were closed bj' a kind of diaphragm only at the point tied. This is, if I mistake not, the first definite anatomical proof that arteries can be obliter- ated at the seat of ligature without being divided. If this result could be attained in every case, second- ary haemorrhage would, of course, be unknown. But this is far from being the case, at least as yet. In some cases the catgut has softened prematurely, or perhaps has come untied, and the circulation has re- curred; but this is very rare, and might probably be avoided by care in the preparation and tying of the ligature. In other cases, wliere suppuration has taken place around the vessel, secondar3^ haemorrhage A, the subclavian, and b, the common carotid ar- tery, tied simultaneously with earbolized catgut on Nov. 16. Death took place on Jan. 9. The subcla- vian has been laid open above and below the seat of ligature, but not at the precise point. The ex- ternal coat is seen to be quite perfect, and the tube of the vessel is closed by a simple diaphragm. In the carotid this diaphragm has been cut through and the artery opened in its whole extent. Two small fissures or cracks are seen below the ligatured part, one of which (marked by a small bristle) leads into a minute cavity outside the artery, containing blood-clot. The case is reported in the St. George's Hospital Reports, vol. vi, and the preparation is in the Hospital Museum. has ensued ;^ but the constant use of this form of ligature in operations of all kinds for several years has convinced me that secondary hffimorrhage is far rarer than witli the silk ligature, even in wounds which suppurate freely, while the ligature itself does not seem to be felt as a foreign body at all, or to interfere in any- way with primary union. Great care should be taken in selecting the material for the ligature. The catgut should not be too thin, and it should be steeped in thecarl)ol- ized oil (1 part of the acid to 5 of oil) for many weeks before it is used. In fact, it seems that it continues to become tougher and more reliable for an indefinite length of time. A convenient ligature-case for private practice is made of a thiclc glass tube with a silver cover screwed on, in which a reel of the catgut ligature can l)e kept in oil in the pocket for an unlimited time. It is well gently to wipe ofiC the superfluous oil before use, as otherwise the ligatui-e is a little apt to slip ; and it is safer not to cut the ligature too near the knot, es|)ecially as the substance is very easily absorbed and creates no ap])arent irritation. Wounded ves.sela used in former days to bo secured by driving a sharp hook, called a ti^nneiilum, tlirough the blooding mouth of the vessel and the tissues immediately adjacent, and then tying a ligature under the 1 See a case by Mr. Holdcn. St. Bartholomew's Hospital Reports, vol. viii, p. 187. ACUPRESSURE. 121 convexity of the hook. The tenaculiitn being now withdrawn, the liga- ture of course compresses the vessel a little above its cut end. Tliis method, however, is somewhat rough, since a good deal more tissue is included in the ligature than is really necessary. It is, however, still often employed wlien tlie vessel lies in the midst of dense structures from Fig. 19. Liston's tenaculum (modified). which it cannot well be separated. Otherwise it is better to pick up the vessel, and separate it cleanly from the tissues around, drawing it slightly out of its sheath with one of the forms of forceps here figured. The name tenaculum which used to be appropriated to the sharp hook is now more commonly applied to the forceps used for tying arteries. Each form has its advantages. Liston's, when closed, catches with a spring which holds Flu. 20. Assalini'.s tenaculum. it on the artery, and enables the surgeon to tie the vessels more easily when he has no assistant. Assalini's may be ready armed witli the liga- ture, and I think enables the surgeon and his assistants to secure the vessels in a large wound more rapidly. But the use of one or other is more a question of fashion and habit than of any essential superiority. Acupressure. — I have spoken in the preceding sentences of "tying" arteries, since this is the general and for the moment, at any rate, the most certain method of securing thera. But there are two other plans 122 HiEMORRHAGE. Avhic'h have come much into vogue of late years, viz., Acupressure and Torsion. The chief object of these two methods is to avoid that which is the drawback of the sillc or hempen ligature, viz., the abiding irritation and ultimate ulceration by which the ligature is cast off. In acupres- sure the metallic foreign bodies by which the artery is tem25oraril3^ com- pressed are removed as early as is judged safe, and the wound is left free to unite. In torsion tliere is no foreign body at all. The different methods of applying acupressure are reduced by Pirrie, its most ardent and considerable advocate at the present day, to three, which he has denominated C'ircumclusion, Torsoclusion, and Retroclu- sion. In the tirst method (Fig. 21) ii pin is passed below the divided Fig. 21. Acupressure. First method, or Circum- clusion (after Pirrie). Acupressure. Second method, or Torsocltision (after Pirrie). arter}', and a loop of wire placed over the end of the pin compresses the tissues in which the artery is lying, and is twisted tightly enough round the stalk of the pin to stop all bleeding. Then the point of the pin is passed into the tissues, while the ends of the wire hang out at the other side of the wound with the head of the pin. When the pin is withdrawn tlie wire of course becomes loose, and is drawn out also. In the second Fig. 23. 1 2 Acuprcs-sure. Third mi'tliod, or ReJroclusion (altered from Pirrie). method (torsoclusion, or the Aberdeen twist), the pin is passed in par- allel to the vessel (Fig. 22 (1)), tiien twisted round a quarter of a circle and driven across the vessel into the tissues on its further side tightly enough to keep it in its new i)osition (Fig. 22 (2)). In the third method, retroclusion, the pin is passed first above the artery, under a few muscu- ACUPRESSURE. 123 lar fasciculi only (Fig. 23 (1)), then twisted round half a circle and driven below the artery into the tissues on the side where it first entered (Fig. 23 (2)). The pins are withdrawn as early as the surgeon thinks it safe. Dr. Pirrie gives eight hours for smaller arteries, such as the facial, temporal, radial, ulnar, mammary, and spermatic, and twenty-four hours for such as the humeral, axillary, and femoral, as periods at which the l)ins may be safely withdrawn ; and he intimates his belief that it will l)e found safe even to shorten this period. I have had sufficient experience of acupressure to testify that it is a perfectly efficient means of stopping hfemorrhage, and one which, with a little practice, is not difficult of application. Torsion is a very old method of stopping haemorrhage. It was exten- sively used in the last generation, and the readers of Porta's great work' will know that he emplo^'ed it successfully in many of the major opera- FiG. 24. Torsion forceps. Tlie artery to be twisted being caught between tlie blades of the forceps, they are closed as far as the thickness of the tissue embraced by them will allow, and the catch on the upper blade is then pushed down as far as it will go. The wedge-shaped projection from the lower blade enables the catch to hold the forceps firmly closed, whatever may be the distance between the blades. This is one of the most convenient and efficient of the many forms of catch forceps for torsion. Fig. 25. Torsion. Taken from a large artery which was i-emoved from the body before it was twisted. The internal and middle coats are seen to be separated from the external and pushed up the tube of the artery like a plug. tions ; but it passed out of practice, probabl}' in consequence of the loss of time which it sometimes occasions, and which was a very important consideration in operations performed without anaesthetics. It was re- vived by Mr. Syme, and is now used by many of the best surgeons. The action of torsion is very easy to understand. If the divided end of a 1 Sulle Alt. pat. delle Arterie, published in 1845. 124 H.T5MORRHAGE. large artery be taken hold of with a pair of forceps, all other tissues being carefully avoided, and twisted round four or five times till its coats are felt to give way, it will be found on laying it open that, its internal coat has been torn, and tlie middle coat has also been separated from the external, torn, and twisted up into the tube of the vessel, which is there- fore closed by a firm plug, while the external coat I'emains uninjui'ed, though more or less twisted. Even in the dead subject the vessel is so firmly closed that no fluid can be forced through it. In a large wound, such as that of an amputation, when all the divided arteries have been thus treated, the wound is left entirely without any foreign body. It is true that the twisted ends of the vessels may slough and come away, but it seems certain that this does not always even if it does often occur. Torsion is not easy to perform successfully, and this difficulty is felt even more with tlie smaller arteries than the larger ones. This depends on the difficulty of isolating the latter from the tissue around, especially while they are bleeding ; and it is on this proper isolation that the prompt success of torsion in stopping bleeding depends. A large artery can be easily drawn out of its sheath, and then two methods of twisting it are employed, called limited and free torsion. In the former the artery is drawn out of its sheath, seized with forceps about an inch above the divided end, and then twisted with a second pair of forceps so that only the part between the two pairs of forceps is twisted ; in the latter it is merely drawn out and twisted freely. Small vessels can, of course, hardly be twisted in an}' other than the latter way. If it is necessary for me to express an opinion on the value of these methods of arresting arterial hffitnorrhage, I must commence by saying that both acupressure and torsion are perfectly reliable methods of arrest- ing ha?morrhage. They have been used for many years together by emi- nent surgeons in large operative practice, without any accident or bad result. It is, therefore merely as a matter of private opinion that I say that neither acupressure nor torsion seems to me so convenient, so safe, or so likely to promote tlie rapid union of the wound as the carbolized ligature. The latter, as I have tried to show in the preceding descrip- tion, is perfectly easy to apply, takes up no appreciable space in the wound, liolds the arterj' closed as firmly as the silk ligature does, and for a longer time than it is found necessary to keep the largest artery com- pressed, excites no irritation or suppuration as it gradually melts away, and does not interfere in any degree with primary union. Both the other methods are more diflicult to practice. If a great number of vessels re- quire to be secured, the mass of pins and wire loops renders acupressure very inconvenient, distending the cavit}' of the wound, and effectually preventing all primary' union ; and when bleeding proceeds from a num- ber of small vessels, torsion is a very tedious business even in the hands of those most versed in it. Secondary hremorrliage is certainly rare after either method when practiced by experienced surgeons ; yet I should hardly think any one could leave a large artei y after either acupressure or torsion, in a i)atient not under his immediate eye, with the same com- fortal)lc security as lie would feel if the vessel were properly tied ; and I have certainly seen very acute and sudden hfcmorrhage a few days after torsion, in all prol)ability from detachment of the crushed end of the artery. In London we have taken up this question with no prejudice for or against either method, and the result has been that acupressure is as far as I know universally disused after a fair trial, and torsion is onl}' prac- ticed at a few of our hospitals. CAPILLARY HAEMORRHAGE. 125 Had I to choose, however, between the silk ligature and torsion, I do not think that I could speak with equal coniidence, for the ulceration and slonghing caused by the silk ligature must of necessity prevent complete union by the first intention ; while torsion, if dexterously and rapidly etTected, usually does not do so. Other Means for Arresting Hsemorrhacje. — There are cases in which a considerable artery is wounded, yet where it can neither be tied, com- pressed, nor twisted. In some such cases, as before stated, it is justi- fiable to tie the artery or arteries higher up, as is often done in wounds of the palm. Yet it must be allowed that the practice is an uncertain one, and has often led to loss of limb or life. No dmd)t in many such cases more accurate pressure would have been successful. Professor Vauzetti has lately proposed for such cases a plan which he calls "uncipression," and which I think is well worthy of a trial. A pair of sharp hooks, double or single, according to circumstances, are dug into the two sides of the wound, so as to make pressure on the bleeding point or points, and these hooks are fixed by an elastic band to a splint on which the limb rests, or to something at the side of the bed. The hooks may be mounted on handles or on a chain, like the ordinary dissecting-hooks. See Med. Record,, March 3, 1875, where another plan of applying compression may also be seen described by M. Yerneuil under the name of "forcipression," which consists simply in embracing the bleeding j^oint or points in the blades of a catch forceps or ordinary dressing forceps, tying the blades of the forceps together if necessary, and leaving them in the wound till they drop off", or till the surgeon thinks it safe to remove the instrument. And this, or something like this, is often done after amputation. Obstinate bleeding from a point which cannot be fairly brought into view, or where the tissues are too rotten to bear a ligature, may frequently be suppressed by taking up all the tissues around with a tenaculum or sharp hook, under which a common or an elastic ligature is passed, and which is left in the wound for a day or two, or allowed to fall off" l)y itself. Capillary Hsemorrhage. — Such are the surgical means for combating those formidable attacks of haemorrhage which result from injury to the larger vessels. But the common htemorrhage which proceeds from small arteries or capillaries and veins, when it does not cease of itself, as in the great majority of cases it does, is usually treated by one of three methods, — pressure, cold, or styptic applications — and sometimes by a combina- tion of them. Pressure is the most effectual haemostatic when it can be applied evenly over the whole wounded surface ; in fact, we have seen above how potent it is in repressing hsiemorrhage even from the femoral artery after ligature. In some cases pressure can only be applied with the finger. Thus, in a case under Sir B. Brodie's care, where the internal pudic artery had been wounded inside the ramus of the ischium, pressure was made by a rela3'^ of students for forty-eight hours successfully. But ordiiuirily i)ressure is made, as directed on p. 11 T, with graduated compresses, kept in position by strapping, and assisted if need be by a horseshoe tourniquet. The limb in all cases should first be evenly and firmly bandaged. Cold is usually applied by exposing the i)art to the air, as in opening bleeding abscesses (see p. 57), or in operations where a good deal of oozing is going on and cannot be repressed. In such cases the operator passes his sutures through the edges, but does not tie them, and leaves the part exposed to the air for a few hours, when any clot which has col- 126 JJJEU O R R IT A G E, lected may be gently removed and the stitches drawn togethei*. The ap- plication of ice in a bladder to the wound, and the irrigation of the wound with iced water, are also powerful hfemostatics. Of styptics the one in most use at present as a local application to ■wounds is the perchloride of iron. Lint steeped in the Tinct. Ferri Perchlor. is laid on the bleeding surface and gently pressed into it. An- other very useful styptic, especially when it is desired to produce a super- ficial slough as well as to stop bleeding, is blue lint, i.e., lint which has been steeped in a saturated solution of sulphate of copper, and is kept at hand dry for use. Matico leaves are often used with success to fill bleed- ing cavities, such as those of cancerous ulcers. Finally, the most powerful of all styptics is the actual cautery lightly used at a white heat. The shape and size of the cauteries should be adapted to the surface to which they are to be applied, so that a good many ought to be at hand at once. They should not be used too cool, otherwise the tissues are apt to stick to them, nor be pressed too hard or too long on the bleeding surface, for the same reason. If the charred tissue sticks to the cauter}- the parts will be torn in dragging it away, and the bleed- ing will most likely recur. Many surgeons think that this adherence of the tissues is less probal)le when the canter}' is heated only to a dull red; but whatever be the method of applying the canter}', the surgeon should not be contented till he has seen that every point from which free bleed- ing came has been perfectly and completel,y charred, and then the tissue may even be returned into the interior of the body (as in piles or ova- riotomy) with full security against recurrent haemorrhage. Nor is second- ary htiemorrhage at all common on the falling of the slough. The actual cautery is also used extensivel}'^ as a counterirritant, as will be pointed out in the chapter on Minor Surgery. Tronfifiision of Blood. — In some cases of the most extreme exhaustion from lijeniorrhage the patient has been rescued from death by injecting blood into the veins. This blood is taken instantly before injection from the arm of a healthy person.' There are two chief methods of transfu- sion, — the indirect, and the direct or immediate. In the latter the blood is passed directly from the arm of the person who furnishes the blood into that of the patient ; while in indirect transfusion the blood is received into a vessel, and may be defibrinated before it is injected into the patient's vein. The operation is not a difficult one, if the patient's veins are well- marked. A free incision is to be made over the largest of the veins at the bend of the elbow, so as to expose it ; it is then opened with a V- shaped cut of the scissors and the nozzle of the syringe inserted. This nozzle should be warmed to the temperature of the body and filled with warm water. Then the blood is procured as rapidly as possible from a healthy man, whose vein is opened in a similar w^y. If the immediate method is followed the nozzles of the two syringes are connected by a warmed tube, in the middle of which there is an elastic bulb, the capac- ity of whicii should be accurately known. IMie nozzles being inserted in the two veins, in the course of the circulation, the tube is fixed on to the ' In America lately lamb's blood seems to bavo been transfused in eiises of con- sumption. I Unow notliinn wliatevcr of tlie practice except from one casi-, in which it is spoken of with reprobation — Hostim Med. and Siirs:ij. Jour., Jan 14, 1875, p. 38. In the Med. Times, Sept. o, 1874, will be found a resume of some experiments on transfusion troni oncanitnal to anotiier, from tiie Centraiblatt f. Chir., of the same year. TRANSFUSION. 127 nozzle in the bloodgiver's arm, and the operation proceeds as described. The blood is injected by successive discharges of the bulb, until about ozs. has been passed in. It is not generally considered necessary or desirable to inject a larger quantity at once. For indirect, or mediate, transfusion numerous instruments are in use. The blood may l)e simply received in a warmed vessel, tlie fibrin rapidly whipped out of it, if the operator thinks this desirable, and the residue injected with a common anatomical injecting syringe, well warmed ; or Aveling's apparatus for immediate or direct transfusion. The more muscular arm on the right of the figure is the bloodgiver's ; the one on the left the patient's. The course of the veins is dotted down, as if the skin and the hands lying in front of them were transparent. B represents the hand of an assistant holding the eflerent tube and the lips of the small wound together, and a shows the atfc-rent tube secured in the same manner. The bevelled end of the afferent tube, which is made so in order that it may the more easily go into the collapsed vein of t)ie patient, is shown in Fig. 2. The noz- zles having been secured in the two veins, the india-rubber portion of the apparatus, filUd with water, and kept so by turning the cocks at each end of it, is now fitted into the tubes. Then the cocks are turned and the operation commenced by compressing the india-rubber tube on the efferent side, d, and squeezing the bulb c. This forces 5ij of water into the patient's vein. Next shift the hand d to d', and compress the tube on the afferent side. The bulb will expand slowly and draw blood in from the bloodgiver's vein, which is then to be passed into the patient's; and by repeating this manoeuvre as often as required any amount of blood may be injected, so long as the tube is not clogged by coagulum. See Obstetric Soc.'s Trans., vol. vi, May 4, 1874. some apparatus may be used, consisting of a bowl or cup to receive the blood, and, communicating with tliis, an appai'atus something like a stomach-pump. But the presence of valves is very undesirable in any instrument intended for the transfusion of blood not defibrinated, since tilery are liable to clog; and the defibrination of the blood does not seem at all to be recommended, for it necessitates much exposure of the blood without any proved advantage. The simpler the apparatus the better ; and if the simple instrument of Dr. Aveling, or something of the same kind, is not at hand, it would be better, I think, to use a common ana- tomical syringe, taking care, of course, that it is carefully warmed to a heat of 100° before commencing the operation. Various maladies, and especially intermittent fever, have been treated by transfusion in foreign countries (for which see the Medical Times, as above), but we have no experience of the practice here, and not much encouragement from the published reports to try it. Lately Mr. Wagstaffe has used milk, and milk mixed with an equal 128 COLLAPSE. quantity of dcfibrinated blood, for injection into tlie veins, using an ap- paratus originally proposed by Dr. Hamilton, of Ayr, in which the fluid is injected by means of a funnel with about two feet of tubing attached to it, so that tlie weight of the fluid forces it with an equable pressure into the vein.' But neither of Mr. Wagstaffe's cases were successful, so that the substitution of any other fluid for blood in these cases must at present be looked upon as at best a doubtful experiment. COLLAPSE. The condition called collapse is that of total suspension of some and extreme weakness of others of the functions of the nervous system, to- gether with great disturbance of the circulation, from the action of some sudden cause. This cause may be mental emotion, hjemorrhage, violent injury (and especially injury' of certain organs, such as the abdominal viscera, the large joints, the testicle, the mamma), severe pain, and cer- tain poisons. The shock may be so great as to prove fatal at once. Short of this the state is that of " extreme collapse," which is thus well described by Mr. Savory :'^ " The patient lies in a state of utter prostration. There is a striking pallor of the whole surface, most marked from its contrast to the natural color of the face ; the lips even are quite pale and bloodless. There is a cold, clammy moisture on the skin, and often distinct drops of sweat upon the brow and forehead. The countenance has a dull aspect, and appears shrunken and contracted. There is a remarkable languor in the whole expression, and especially in the eye, which has lost its natural lustre, and is partially concealed by the drooping of the upper lid. The nostrils are usually dilated. The temperature is considerably reduced, and if the person be a1)le he will complain of feeling cold, and perhaps shudder. Muscular debility is extreme — apparent at a glance in the condition of the lips and hands ; occasionally even to the relaxation of the sphincters. The pulse is generally frequent, sometimes irregular, always very feel^le, perha[)S quite imperceptible. In this latter case, although the ear may detect the fluttering action of the heart, the pulse does not reach the wrist. The respiratory movements are short and feeble, or panting and gasping, 'wanting the relief of sighs,' sometimes imperceptible; although in the majority of such cases some action of the diaphragm maj' be de- tected by careful observation. Vertigo, with dimness of vision, super- venes. As the rule, there is not complete insensibility, although there is much variability in this respect, depending no doubt on the nature of the injury ; but tlie person is drowsy and bewildered, yet conscious, and perliaps rational, when roused. Sometimes the intellect is singularly clear and the senses perfect ; the hearing occasionally even painfully acute. In the less extreme cases theie are often nausea and vomiting, with hiccough. The last is very variable in its occurrence. "The signs of syncope arc those of collapse. Travers says: 'The signs of syncope and the recovery from it present an epitome of tlie phe- nomena of shock.' So far as they extend, the symi)toms of an ordinary fainting fit are analogous to those of collapse. 'They differ in degree and duration more than in kind.' It is true that in syncope there is more uniformly a suspension of the mental faculties, as well as of the senses 1 London Med. Record, April 14, 1875 ^ Sygt. of Surg., vol. i, 765-6, 2d od. PROSTRATION WITH EXCITEMENT. 129 and voluntary powers; but this maj^ perhaps be explained by the fact that causes which produce syncope act more uniformly on the brain." From this extreme condition of collapse there are all possible grada- tions, down to a mere transient impression on the heart, pulse, and senso- rium, such as is familiar to everyone who has ever received a severe blow or felt any great emotion. lieaclion after Collcqii^e. — The immediate symptoms of collapse are followed by reaction, and in this stage the surgeon forms his prognosis mainly upon the rapidity of the recovery and on the character of the pnlse when reaction is established. Cases in which the patient hovers long between life and death, and in which the pulse when restored is weak, rapid, and excitable ("prostration with excitement," as Travers desig- nated it), are very unfavoi-able ; whilst those in which the patient, after transient collapse, recovers his senses rapidlj', and in which the pulse be- comes gradually more and more firm and regular, will probably terminate in recovery. The condition of prostration with excitement is one which we have only too frequent occasion to see after great railway injuries and otiier fright- ful lesions which do not prove fatal at once. I cannot do better than again quote Mr. Savory's description of its symptoms ■} " This state is marked at first by dry heat of the skin, a flushed face and anxious expression, a rapid and bounding pulse, which is sometimes even sharp but always easily compressed. The respiration is hurried and im- perfect, with partial and irregular sighs. The tongue is tremulous; there is often urgent thirst; vomiting is a frequent and sometimes most obsti- nate s3mptom ; there are occasionally rigors. The languor or stupor of collapse is succeeded b}* restlessness, jactitation, tremor, and twitchings of the muscles, prrecordial anxiety, often but not always delirium of various degrees, from occasional incoherence to wild and fierce excite- ment. This most frequently occurs, and is more marked during the night. There is either an entire absence of sleep or it is partial and interrupted, and it is succeeded by no relief. As the exhaustion increases the skin becomes covered with a cold and clammy sweat, which is very often pro- fuse. The face becomes pale and the expression haggard; the pulse innumerably rapid, irregular, fluttering; subsultus comes on ; slight con- vulsions; coma more or less profound; and death." Treatment. — The treatment of collapse is naturally divided into two parts, — the avoidance of immediate death in the first shock, and the treat- ment directed to carrying the patient through the subsequent reaction. The first care of the surgeon, when called to a case of collapse, is to save the patient from the danger of instant death. For this purpose warmth is one of the most essential requisites, and especially applied to the head; towels wrung out of hot water should be bound round the head, or hot aff'usion sedulously employed, together with heat to the epigastrium and the extremities, while the other means of supporting animation are in practice. Galvanism over the pr?ecordial region is a most efficacious measure. Small quantities of brandy are to be given by the mouth if the patient can swallow, and by the recium if he cannot, and ammonia is to be applied to the nostrils. If the heart is acting, but the patient seems otherwise dead, transfusion is clearly indicated. The efforts at revival should not be hastily given up ; recovery after long seeming death is not by any means rai'e. Operations in Collapse — Ansesthetics. — Many of the patients whom we 1 Syst. of Surg., vol. i, 2d ed., p. 768. 9 130 COLLAPSE. see in the hospital practice of large cities are collapsed from grievous inju- ries which must call ultimately for severe operations if the patient is to have any prospect of life. In such cases the question first occurs whether to operate at once^ or to postpone the operation till the patient has some- what rallied, and with this is connected the question whether antesthetics are desirable. 1 have seen operations performed in conditions of extreme collapse, without any manifestation of pain on the patient's part, or any apparent increase of the shock ; but wdien the operation is a severe one, such as a large amputation, it is better, I think, to give an anaesthetic; nor is anaesthesia under these circumstances attended with danger. 1 have often seen the pulse improve as the patient came under the influence of the anaesthetic. Ether is, 1 think, preferable to chloroform in these eases, and it is well, if the patient can swallow, to give him a little alcohol first.^ Such operations are rarely attended with any danger from haemor- rhage, and I think are best performed as soon as the surgeon believes that the patient can live through them. Treatment of Reaction. — When the danger of instant death is over the patient has still to be kept alive, a most difticult task in many of the more formidable cases. "Stimulants alone," as Mr. Savory says, "may be required in the first emergency, but they soon prove useless if unaccom- panied by nourishment," and in these cases the patient's power of taking and of assimilating food is too often suspended; and we often see in cases which survive that the first effect of recovery is that the stomach rejects the fluid which has been poured into it, and which it is unable to digest, showing that the supply has been excessive, and therefore, to some extent, injudicious ; yet the patient has been in so alarming a condition that the surgeon has believed that without stimulants and support he must die. On this subject Travers speaks as follows: "If we neglect to supply stimulus when called for the spark of life goes out. The signs of its indication must therefore be vigilantly observed. We are maintain- ing action upon inadequate power, in the hope that the natural resources may come to our relief, and that we may gradually diminish stimulus and increase nutriment, which is our only method of raising power to a balance with action. The respondence of the circulating forces to an increased supply of stimulus must serve as a caution against over-supply. Since power is deficient, we must carefully husband our only resource, and not waste it in inordinate action. When the signs of reaction are manifested, its excess is much to be apprehended if such reaction has been obtained by over-stimulation. Excessive reaction so induced is ' prostration with excitement' in its most perilous form. When such a state is the original form of the malady it is probabl}^ less dangerous, because in this case the inequality between power and action is less."" The practical rule to be deduced from these considerations is, that whilst death from collaijse is imminent, the circulation must be main- tained by artificial heat, galvanism, and by the administration of alcohol, but that the supply of the latter should be carefully graduated by the state of the i)ulse ; that it should be given in small quantities as frequently as seems necessary ; and that as soon as the itatient can bear it small and frequently repeated doses of concentrated fluid nutriment should be given by the mouth, being preceded by similar nourishment given per rectum ' Mr. R. Ellis devised an apparatus for administering the vapor of alcohol, ether, and chloroform successively, first pure and then mixed. I used this method in a case of double amputation at thl; shoulder and near thi; hip for severe railway injury, and the patient's pulse was certainly better aftc^r than before the operation. 2 Syst. of Surg., vol. i, p. 770, from Travers, On Constitutional Irritation. BURNS AND SCAT.DS. 131 in such quantity as will not provoke an action of the bowel, and that the supply of alcohol should be gradually withdrawn as early as is found to be possible. When the stage of reaction is established, if the patient passes into a condition of ordinary traumatic fever, all will probably go well. Hut when the stage of "prostration with excitement " is strikingly manifested — i. e., when the weakness of the pulse is as striking as its rapidity, when the temperature does not rise in correspondence to the rise in the i)iilse-rate, when the stomach rejects all or most that is put into it, and the patient is sleepless, restless, and more or less delirious — then, as Mr. Savory says, " the indications of treatment are clear and simple enough, but un- happily most difficult to fulfil ; to support and increase power, and to moderate and reduce action." The patient will not survive if worn out by restlessness, which must therefore be combated by morphia injected subcutaneously, or by chloral or opium in full doses, if the stomach will bear it. Mr. Savory speaks highly of the virtues of henbane in such cases in combination with opium, if the latter drug can be tolerated. The warmth of the body and extremities must of course be sedulously main- tained, and the most diligent nursing must be procured, so that the pa- tient may not be exhausted by any unfulfilled craving or by any unneces- sary exertion. The irritability of the stomach must be lessened by the application of mustard poultices, by sucking small morsels of ice con- stantly, and by the administration of dilute hydrocyanic acid, three or four minims in a small quantity of some vehicle, or creasote trijij in pil. every three hours. At the same time both food and stimulants must be supplied, and must be assimilated if the patient is to be kept alive; and there lies the difficulty, which must be met by giving the food in the most grateful and most nourishing form, in small quantities very often repeated, and the stimulant (which ought not to be more than is absolutel}^ neces- sary) in varied kinds, according to the patient's tastes and habits, and with similar precautions as to quantity and repetition. CHAPTER V. BURNS AND SCALDS. Burns and scalds are the most commonly fatal of all injuries, especially in cold climates, alad among the poor, whose children are frequently left for long periods in the neighborhood of fires and kettles with no proper attendance. Scalds are, as a rule, less fatal than burns, since the hot liquid is soon shaken off" the body, and itself soon cools ; but there are accidents somewhat resembling scalds, produced by the contact of molten metal, which are even more fatal than an ordinary burn, because the molten mass adheres to the charred parts and retains its heat for a long period. 132 BURNS AND SCALDS. Dupui/h'e)i-x Clafject of ulceration of the duodenum will be resumed with the third pe- riod, in which it is perhaps most common. The third period, that of suppuration and exhaustion, is held to com- mence about a fortnight after the accident, or else is said to begin after the slouglis have separated. The acute symptoms which may have fol- lowed the injury will have subsided, but chronic inflammation is not by any means uncommon, and is often the chief cause of death. The pa- tient becomes gradually weaker and weaker, and in this stage he often succumbs, perhaps, after exhausting diarrhoia, which is sometimes accom- panied by blood in the motions. Post-mortem examination may show no definite visceral lesion, or low inflammation of the lungs, pleura, perito- neum, or intestines may have been present. The duodenum may be found ulcerated ; and in this, as in every other injury, pyaemia or erysip- elas may be the direct cause of death; but neither is relatively common in burns. 1'etanus, again, sometimes follows the irritation of a burn. The ulceration of the duodenum is a singular and hitherto unexplained sequela of burns. ^ As stated above, the ulcerative action is not absolutely limited to the duodenum, but the instances of its occurrence in other parts of the intestine are purely exceptional. It is not necessarily fatal, for cicatrized ulcers have been found in the duodenum where death has occurred from other causes.'-' It occurs at different periods after the burn, the earliest hitherto recorded being four days ; but it is rarely so early, and is more common after than before the first fortnight. It occurs after burns of the extremities as well as those of the chest and abdomen. It is found in a tolerabl}'^ large proportion of fatal cases (in 125 post-mortem examinations 16 presented this lesion), and may very possibly be present 1 The explanation given that the destruction of the sweat-glands of the skin throws a strain on Briinner's ghinds, which are then charged with the office of separating watery elements from the blood, seems to me more ingenious than probable. The traces of irritation are not confined to Briinner's glands, for the solitary glands of the rest of the intestines are sometimes found enlarged ; and there is no proof that either Briinner's or the other glands are capable of any such vicarious office as is here assigned to them, nor is the transition from such unnatural activity to inflammation and {)erforating ulceration at all obvious. 2 Syst. of Burg., vol. ii, p. 23. 134 BURNS AND SCALDS. in many of those which recover. The lesion is not known to be accom- panied by any definite symptoms in its early stage. Pain on pressure near tlie pit of the stomach, and diarrhcea, with blood in the motions, naturally arouse a suspicion of this ulceration, and vomiting is not un- likely to be an accompaniment of it; but there are many other ways in which pain and tenderness of the stomach, vomiting and diarrhoea, may occur in burns, and even some blood may ^^•^'•27- be passed in the motions without any breach of surface ; obstinate diarrhoea, however, and copious loss of blood would point strongly to ulceration. When the lesion proves fatal it is either by h.nemor- rhage or by perforation through the coats of the bowel into the peritoneal cavity. The accompanying illustration shows a large artery, the pancreatico-duodenalis superior, laid open b}' an ulcer of this kind ; and our museums contain plenty of speci- mens of perforation. The ulcer is gener- ally single, cleanly punched out of the mucous membrane, and situated close to the pylorus. I have purposely abstained here from any reference to a very common cause of death in burns and scalds — viz., the injur^'^ Ulceration of the duodenum in a burn, which is SO oftCU douc tO the larynx by causing death by ha^morrh^^^^^^^ inhaling the flame or the hot fluid— think- large branch of the paucreatico-duode- c naiis artery, a. The pylorus. 6. The ui- ing it better to treat the subject aloug with cer on the duodenum, close below the the Other injuries of the air-passagcs (see pylorus. c,d. Bristles passed through the ^i^g chapter ou Iniurics of the " Neck) 1 artery and vein, which are seen to open ,,,, ,. .. i-i i in freely on the ulcer.-From Syst. of Surg., t>Ut the SUbjeCt IS OUC whlch should never vol. ii, p. 22, 2d ed. be absent from the surgeon's mind. The mouth and pharj^nx should be closely in- spected, if it can be done without difficult}^, in every case where the burn or scald is at all near the lips. If this cannot be managed without too much disturbance to the patient, a good idea of the immunity or other- wise of the interior of the mouth will be obtained by watching the patient swallowing and breathing, and every precaution should be taken to have help promptly at hand in an}^ case which may be likel}^ to require trache- otomJ^ If the mouth be much burnt it n:ay be right to feed the patient through tlie nose, and to eke out the support and stimulants which can be given through the pharynx by nutrient injection into the rectum. Local Treatment. — The treatment of burns is directed — 1. To the im- mediate lesion ; and, 2, to its after consequences. At tlie time of the accident the main indications are to exclude the air from the burnt sur- face, to allay pain by opiates, and to give stimulants in such ([uautities as ma}' be necessary. The applications which are in use for burns are too numerous to mention, and the choice of one or other of them will depend in a great measure on the depth of the burn. A mere superficial scorch is best treated by some warm lotion applied on a thick rag and kept constantly moist. Goulard water with a little laudanum is perhaps as grateful as anytliing. Painting the surface witli iidc soon relieves the pain of a small superficial burn, or covering it with whitewash or some other similar substance which will crust over it and completely' exclude the air from it. Common flour thickly dredged on the part is a very good TREATMENT OF BURNS. 135 and handy application. But such crusts should not be applied over iuirnt surfaces of the second desjree, since their removal would soon become necessai'v, and this would drag off the epidermis. The bullje should be pricked, the epidermis gently smoothed down, and some simple ointment put next the skin, or some oily substance whicli will not stick when it is necessary to change it. A very favorite ap[)lication to these burns and to others of greater depth is the Carron oil, made by mixing lime-water and linseed oil in equal parts, and deriving its name from its having come into extensive use at the great Carron Foundry in the numerous burns occurring there. Oil of turpentine is a very good application to those in which the surface of the skin is quite destroyed. But for the first days I doubt whether anytliing is better than simply swathing the part in thick layers of cotton-wool, vvhich is prevented from sticking to the burnt sur- face by some simple ointment (Cerat. Calaminse is generally used) spread on thin soft linen or Cambric, and covering the whole burnt surface. When after a few days the discharge becomes foul, this dressing should be changed for some deodorizing or antiseptic oily application, or the latter may be used from the first; but all the antiseptics I have yet seen used have been stimulating, and for the first few days it is desirable, I think, to avoid any local stimulation. The carbolized oil answers every indication better than any other substance which I know of, but it should not be used too strong; for it may both prove too stimulating, and thus increase the discharge, and it may be absorbed, producing a black con- dition of the urine^ and other symptoms of incipient poisoning. It is Avell, then, to begin with a very weak solution (about 1 to 12), and if this does not correct the fetor its strength may be gradually increased, or a stronger solution of carbolic acid may be placed over the dressings. If carbolic acid is not tolerated, some preparation of benzoin, or Condy's solution, or the Lot. Sodae Chlorinatfe may be applied either directly to the burnt surface or over the dressings. As the sloughs separate they should be removed at once, and any part of the slough which is hanging loose should be cut away, so that fetor may be diminished as soon and as much as possible. It is, in fact, to the foul air which fills the sick-room that many surgeons with much reason attribute a great share in produc- ing the mortality of the latter stage of burns. It keeps the patient in a low condition, destroys his appetite, and very probably keeps up or pro- duces diarrhoea. And in hospitals it often poisons the whole air, not only of the ward itself, but of all parts of the house which communicate with it. Hence the importance of remedying it in all possible ways. So long as there are offensive burns in a sick chamber or hospital ward the atmos- phere may be partially sweetened by carbolic acid, by burning cascarilla bark or by exposing chips of iodine, by diffusing Condy's solution or other deodorizing fluids in the pulverized condition about the room, but it cannot be doubted that some mephitic gases will still remain uncor- rected. After all sloughs have come away the patient has still to undergo all the troubles incident to a long cicatrization, and often the filling up of a deep cavity. The greatest care should now be bestowed to keep the parts in such a position as to obviate contraction if possible ; and the recent happy invention of skin-grafting has provided us with a means of hastening the process of healing when tardy, and of providing the ma- terials of a scar when the surface is too extensive to fill up naturally, which is of the greatest utility in burns (see the section on Skin-grafting). General Treatment. — At tlie time of the accident opium should be lib- 1 See St. George's Hospitiil Reports, vol. vi, p. 98. 136 LIGHTNING-STROKE. erally given to adults, and even in the case of children it is usually neces- sary, though more caution should be used ; or it may be thouglit desirable to administer chloroform for tlie removal of the clotlies and the first dress- ing, and to keep up partial insensibility by injecting morphia subcutane- ously before the patient has quite recovered from the auixjsthesia. Stim- ulants must also be given if there is mnch collapse, but they should not be poured down indiscriminately, for the administration of an excessive quantity of alcohol is always followed by reaction and renewed prostra- tion ; the pulse must be carefully watched, and only so much brandy or wine given as is required to keep it at a moderate rate and strength. If the patient can take food in good quantity this is a better source of warmth and power, and the power of assimilating food afibrds a good augury of recovery. If the patient be a child convulsions are to be dreaded, and are a frequent cause of death. They appear to depend on, or to be connected with, congestion of the brain, and are therefore better treated bj^ warmth to the surface than by an)' other plan. The warm bath being here inadmissible, warm affusion to the head, or cloths wrung out of hot water, should be tried. Diarrhoea must be treated by opium or by calomel and opium, or by starch and laudanum enema, the air being- changed as often as possible, if foul. Vomiting is to be controlled if pos- sible b}' prussic acid or by creasote. It is, however, of the last impor- tance in severe cases of burn not to exhaust the patient's strength need- lessl)' by too frequent changes of dressing, and this is still more impor- tant in childhood, when terror and screaming add to the exhaustion which is necessarily caused by the pain and the change of posture, besides prob- ably causing some bleeding from the granulations. So that burns ought never to be dressed too frequentl)'- ; and the surgeon has often great dif- ficulty in steering his way between these contrary indications, since if he puts off the renewal of the dressing too long the foulness of the atmos- phere becomes a source of danger. Amputation in Burns. — Finally, it may become a question in some cases whether amputation is ilesirable. This question occurs commonly only in the case of single fingers or toes, or of parts of the foot. It is but rarel}' that anything is gained by amputation, for the parts around the burn for some distance are sure to be more or less injured and prone to inflammation, so that the surgeon could not get materials for a healthy stump without going too high above the seat of injury; and burns so severe as to disintegrate a large portion of a limb are also attended with an amount of prostration whicli forbids amputation, at least at the time. After the patient has rallied the surgeon may think it better to relieve him of a member wliicli can only be a useless incumbrance, but such cases must be conducted on the same general principles as those which are ap- plicable to secondary amputation for other kinds of injury. Plastic Operations. — When recovery has been completed and the sur- face has cicatrized, great deformity is often left, requiring i^lastic opera- tion, or gradual extension, or some otiier proceeding by which the parts may be restored to tlieir normal appearance and function as far as may be possible. But 1 think it better to reserve tiiis topic for discussion, under the head of Plastic Surgery, in a future chapter. LIGHTNING-STROKE. A stroke of lightning produces injuries wliich are the combined effect of electric shock, mechanical concussion, and burn. The symptoms vary FRACTURES. 137 from instant death to a very trivial amount of shock. The effects are very various. The surface of the body may be burnt more or less severely ; it may, as is said, be marked by arborescent lines, which are believed to be in a sort of way photographed from neighboiing trees or other objects ; the hairs may be removed or may fall out soon afterwards ; the special senses, especially that of sight, may be more or less impaired or even totally destroyed; the other functions of the brain may be variously af- fected, sometimes to the extent of total paralysis; and other less definite and less certain effects have been described. In cases of sudden death from lightning it appears that the muscles are usually made rigid at once, though this rigor is sometimes so transient that some writers, notably John Hunter, teach that there is no rigor mor- tis in such cases; but the amount and duration of rigor vary. In some cases there is excessive and long-continued stiffness, the blood is often uncoagulated, and the heart flaccid and empty. The indications for surgical treatment in cases of apparent death from lightning are thus given by Brodie:' "Expose the body to a moderate warmth, so as to prevent the loss of animal heat, to which it is alvva3^s liable when the functions of the brain are suspended or impaired ; and inflate the lungs, so as to imitate the natural respiration as nearly as possible." The minor injuries must be treated on general principles. Galvanism appears the most appropriate remedy for any partial loss of cerebral power, and should be used in a mild form for a very long time, combined with small doses of strychnia and other tonics. It has often been noticed that success has attended this treatment, when long persevered in, even in cases where the special senses had at first been very seriously impaired. CHAPTER VI. GENERAL PATHOLOGY OF FRACTURES AND DISLOCATIONS, INCLUDING THE PROCESS OF UNION IN HARD PARTS. FRACTURES. A FRACTURE is defined as being a sudden and violent solution of con- tinuity in a bone. The force which produces it (its immediate cause) is generally external, though in some cases muscular action causes fracture. Occasionally disease of the bones acts as a predisposing cause of fracture, such diseases being rickets, senile atrophy, cancer, mollities ossium, necrosis, strumous or syphilitic inflammation. Classification. — Fractures are always divided by English authors into simple., which do not communicate with the external air; and compound, 1 Works, edited by Charles Hawkins, vol. i, p. 442. 138 FRACTUKES. which are exposed to the air through a wound in the soft parts ; and the distinction is an important one, since, as a rule, the two kinds of frac- tures involve a very different amount of danger, and unite in a very different manner. Fractures are also divided, according to the nature of the separation, into single, multiple, incomplete, and complicated, and these are again subdivided. Transverse, Oblique, and Dentated Fracture. — Thus single fractures may be tranaverse, oblique, or dentated. It may be true, as stated by Malgaigne, that the fractures of long bones are never truly transverse, 3-et the distinction is very important in practice between a fracture which runs in a tolerably transverse direction and one which is perceptibly oblique, since the latter is so much more liable to displacement than the former. The terms explain themselves, but good examples of each form of fracture will be found in some of the illustrations in the sequel. Trans- verse fracture is best illustrated by the common fracture of the patella (q. v.). A good specimen of oblique fracture is figured in the section on fractures of the lower end of the femur, and of dentated fracture on p. 147. To these classes of single fractures separations of the epiphj'ses should be added ; they will be further treated of below. Fig. 28. Incomplete or "green-stick " fracture of the clavicle, from a preparation (Ser. 1, No. 76) in the Museum of St. George's Hospital (Syst. of Surg., 2(i ed., vol. ii, p. 43). Splintered and Comminuted Fractures. — Multiple fractures are those in which the same bone is broken in two or more different parts of the limb, or in which there are fractures of two or more different bones ; or in which, along with a complete fracture, a splinter has been separated from the rest of the bone ("splintered fracture"), or in which there are several lines of fracture comminuting the bone, i. e., separating one or several large portions from it ("comminuted fracture"). Incomplete fractures are either simple fissures, very common in the flat bones, such as the skull, and seen, though rarely, in the bones of the limbs ; or bending of tlie bone, which is usually the result of green-stick fracture, i. e., of fracture of a portion of the fil)res of the bone, while the remainder are unljroken (Fig. 28), such as occurs when a soft bough is bent;' or perforations, though tliose are better described as wounds of bone, or splintering, when a small piece only is detached from the bone, its continuity as a whole being uninterrupted. The bone itself may be entirely fractured, but the periosteum may remain untorn, and this seems more common in fractures of tlie ribs than in any other bone. Complicated fractures are those in which a joint or some neighboring ' Bending is helioved .sometimes to occur in tho skulls of infants without the rup- ture of any of the bony fibres. FRACTURES. 139 cavity is injured (as the pleura in fractured ribs) or where there is lesion of some large vessel, or a wound not expos- ing the fracture. Sej^arations of the epiphyses are injuries which it is frequently dilticiilt, sometimes im- possible, to distinguish from fracture; in fact, pure separation of the epiphysis occurs ver}' rarely, for in the injuries which are so de- nominated the fracture usually involves the shaft to some extent, as well as the epiphysial cartilage.* In a pure separation of the epiphy- sis (t. «., where the line of the fracture runs through the cartilage only, and does not trench on the bony tissue either of the shaft or the epiphx'sis) it is presumable that there would not be the true bou}' crepitus, though there might be some analogous, but less dis- tinct, sensation. Where the line of junction is broad, as in the upper end of the humerus or lower end of the femur, there will be no shortening, but the lower fragment will most likely project.^ If the line of junction be within a joint, swelling of the joint will take place. The nature of the accident will then be marked by the loss of power following in- jury in a patient of appropriate age, the posi- tion of the displacement, the mobility of the epiphysial fragment (which, however, cannot be always ascertained), and possibly by the character of the crepitus, with the symptoms of injury to the joint. The treatment must be the same as for fracture. The chief im- portance of the subject is that such injuries are sometimes followed b\' suspended growth of the bone, producing deformity, apparently as the result of degeneration of the cartilage after the injury, whereby it loses its power of ossification. Further remarks on these in- juries will be found under the heads of frac- ture of the various bones. The symptoms of fracture are divided into the rational and the sensual. The former are inferential only, and are given either by the lesion which the fracture produces, such as the injury to neighboring viscera (of much im- portance in the chest, head, and pelvis), or by the loss of power caused by the fracture. The sensual symptoms are further divided into those which are equivocal, such as pain, swelling, and ecchymosis; and those which are uue(iuivocal, the latter being («) the crack heard or felt by the patient A preparation in St. George's Hospital Museum (Ser. i, No. 137), showing ttie lower epiphyses of the femur and tibia and both epiphyses of the fibula separated in the same injury. — From Holmes's Surg. Dis. of Childhood. 1 See Holmes's Dis. of Childhood, 2d ed., p. 238. 2 See a figure in the section on fractures of the upper end of the humerus. 140 FRACTURES. at the time of the accident, wliich, for obvious reasons, is not commonly observed; (6) the unnatural mobility of tlie fragments, which, however, is absent when the fragments are impacted., i. e., one fragment di'iven into the su])stance oftlie other, ^ and in all fractures of the skull, most of tliose of the ribs and pelvis, besides many others; (c) the deformity or displace- ment : which is decisive in all cases where it exists, but it is, of course, very often absent. The disi)lacement of fractures is divided for purposes of description, into (1 ) lateral or transverse, wdien the fragments lie more or less by the side of each other ; (2) shortening, or riding, or vertical displacement, when the lower fragment ascends above the lower end of the upper; (3) angular displacement, when one or both deviate from the axis of the limb ; (4) rotation, when one or both are twisted on tlieir own axis; and (5) absolute separation. It will be obvious that all the forms of displacement may be variously combined. Displacement is produced by the action of the original violence, aided in some cases by the weight of the bod}', or by subsequent violence or by muscular action, (d) The last and the most imi)ortant of the sensual symptoms of fracture is the crepitus, or the crackling sensation and sound pro- duced b}' rubbing the two fragments on each other. This crepitus is the sign commonly looked for, and when found is usually decisive of the nature of the injury ; but it is not always present, and in some excep- tional cases its presence is not decisive of the existence of fracture. It is a grating sensation which a little practice soon makes familiar and unmistakable to the surgeon ; but, as it is produced by rubbing the fractured ends on each other, it cannot be felt when these are immovable, as in all impacted and many dentated fractures, or when the fragments are not in apposition, as when they ride on each other (though in this case and in some cases of impaction they may be brought into apposition or made movable by extension), or are entirely separated, as in many cases of fractured patella; and in some cases where one of two bones of a limb is broken, and the sound bone prevents any movement being im- pressed on the broken fragments of the other. It seems- also that some fragment of muscles or blood-clot may get between the fragments and prevent crepitus. Taken altogether, however, it may be said that such cases are exceptional, and that in most of them the presence of frac- ture may be made out b}- the other signs. Crepitus may be present in cases where there is no fracture. Effusion into the sheaths of ten- dons or into the cavit}' of a joint will produce a sensation much resem- bling crepitus. Effusion round the dislocated head of a bone sometimes leads to a crepitus which very closely simulates that of fracture; and caries of the joint surfaces is accompanied by a crepitus under passive motion which is identical with that of broken bone. So that cases do occur in wliich dislocation with considerable swelling, or a contusion or sprain of a diseased joint is accompanied with crepitus, like tliat of frac- ture. ]5ut sucii cases can be distinguished b}' careful examination, espe- cially witli the aid of chloroform. It may be occasionally im})ossible to be quite certain of the absence of fracture in cases of severe contusion and in injuries of the chest, but in such instances it is more prudent to treat the cases as a fracture. In injuries oftlie head also it is impossible to aflirm the absence of a simple fracture without displacement. But the point is one of little moment. Tlius it ma}^ be confidently stated that fractures constituting substantial injuries are usually easy to diagnose. Treatme.nt. — The general indications of treatment are very simple, but * Characteristic illustrations of impacted fracture are furnished by the extra-cap- sular fracture of the cervix femoris. See the section on that subject. TREATMENT. 141 the method of carrying them out in practice can onl_y be understood 1)3^ studying each fracture separately. These general indications are: (l)to reduce or "set " the fracture, i. «., to place both fragments in tlie position which tiiey occupied before the accident; (2) to maintain the fractured ends in position for a period wliich experience shows to be sufficient to avoid further displacement, and which varies for different fractures and at dirterent ages; (3) to counteract unfavorable symptoms and com- plications. 1. Setting the Fracture. — A patient known or suspected to have re- ceived a fracture ought to be conveyed home with all possible care, having the limb defended by some temporary contrivance from all risk of further movement, whereby many simple fractures ave made com- pound. For this purpose pieces of tliin board or of sticks or of paste- board may be used, witli such impromptu bandages as can easily be made out of the clothes. He should he placed in bed (in cases at any rate of fracture of the lower limbs) before any serious examination is made, and the clothes carefully cut off the injured limb. Then, in order to reduce the displacement, its nature should first be carefully ascertained, and steady gradual fxtem^ion made in the appropriate direc- tion by the surgeon, or, if necessary, by an assistant. Another assistant \t\QkQ& cowiter-exteni^ion^ i.e., steadies and fixes the upper part of the limb and body so that the extending force acts on the lower fragment only. When by these means the proper length is restored, a little judi- cious manipulation will remedy any angular, lateral, or rotatory displace- ment. In impacted fracture more [)owerful extension may be required in order to disengage the fragments and restore the length of the limb, for whicii purpose chloroform is to be given. But the violence necessary to disengage an impacted fracture often produces disastrous consequences, and in most cases the patient will be well advised to submit to the de- formity wliich must ensue rather than run the risks incidental to violent extension. In setting a compound fracture there is often great difficulty from the protruding fragment being tightly girt by the skin and other parts, or from the irregular projection and interlocking of comminuted fragments. It must be remembered that there are two ways in which a fracture may be made compound, which are best illustrated by fractures of the leg. In one case a cart-wheel may have passed over the limb, crushing and tearing the soft parts off the bone at the same time that the latter is fractured. In this case tliere will most likely be a large wound, giving free access to the fragments, which are not likely to be embraced by tiie wound, though comminuted portions may require removal or replace- ment before they can be accurately adjusted. In another case a man re- ceives a simple fracture, and in his efforts to raise himself or in other muscular efforts he drives one fragment (generally the upper) through the skin. The fragment often protrudes to a great distance, and is tightly grasped by the skin; but the wound is much smaller and less contused, and tlie chance of its rapid union much greater. Whenever there is any difficulty in the reduction of a compound fracture chloroform should be administered, and the cause of the difficulty carefully ascertained. If it be the small size of the wound probably a free division of the skin will enable the surgeon to reduce the fragment, otherwise the latter must be sawn or clipped away. If comminuted portions interpose the}' may be occasionally pushed aside; but as they are generally much loosened from the soft pails it is better to take them away. If portions of muscles or fasciae are wedged in between the bones they can be drawn aside with a 142 FRACTURES. blunt hook or director. When the fracture is fairly set it must be put up so as to leave the wound exposed, in order that the dressings may be ap- plied without disturbing the fracture. Anipulntion is required in cases where the main arteries, nerves, or joints are also injured, or where the laceration of the soft parts is so great that gangrene is inevitable. But the indications for amputation vary much in the lower and upper limb. Thus, in compound fractures la^'ing open tlie knee-joint, amputation is usually (though by no means alwa3's) necessary in the adult ; while, in compound fracture of the elbow and shoulder, amputation is only performed in exceptional cases ; and similarly with injuries to the vessels or nerves, the surgeon is much more disposed to recommend amputation in the lower than in the upper limb; and in all cases injuries which in the adult are a decided motive for am- putation may be brought to a perfectly successful issue in a healthy child without any operative interference. 2. Reductiuii Splints. — When the fracture has been reduced the next care of the surgeon is to maintain reduction. The general nature of the apparatus used for this purpose need alone be treated of in this place, since the special contrivances applicable to each form of fracture will be described with each. Fractures communicating with the cavities of the head and trunk, as a rule, require no special apparatus. In fractured ribs, and sometimes in fractured pelvis, a bandage is applied to maintain the parts at rest; but even this is often found unnecessary. In the extremities, however, some firmer basis is usually required, in order to maintain the extension, and to prevent accidental displacement. This is provided by sjj/inte, i. e., pieces of wood or metal, or of some malleable compound, such as pasteboard, adapted to the size and shape of the limb, embracing it more or less completely, and fixed on by band- ages, webl)ing straps, or otherwise, so as to keep the fractured ends as accurately as possible in position, and immovable during the whole time of treatment. Many of these apparatus will be found figured or described in the sequel, under the head of the Special Fractures ; and I do not know that it is worth while to give any general description beyond what is to be found in the chapter on Minor Surgery as to the art of splint-making. Its main principles, however, can hardly be too often recapitulated. They are these: the splints should fit the limbs as evenly as possible, ex- tending as far on either side of the fractured part as is necessary to keep the fracture quiet, without limiting the movement of the neighboring joints, unless, indeed, it is necessary, with a view of obviating displace- ment of the fractured bones, to include the joint in immediate contiguit}' to the fracture, and this is ver}' often the case. The splints should not be so ai)[)lied as to impede the return of blood from the limb and produce oedema, still less so as to oppose the supply of blood, by which gangrene and the loss of the limb has sometimes been caused. The splints must not press anywhere on the soft parts so sharply as to cause ulceration. Another form of retentive apparatus is the junk. It is used only in fractures of the lower extremity. Its name is derived from juncus^ a reed ; and it used to be formed of a [)iece of thick cane or reed (for which a stick is now substituted) sewn into each side of a square piece of cloth. The leg is wrapped in a thin pillow (the "junk-pillow") after the fracture has been set, and the whole is steadied by being encircled in the junk, which prevents any lateral or vertical displacement. The angular dis- placement which might result from the toes dropping, and thus project- TREATMENT. 143 iiig the upper end of the lower fragment forwards, is obviated by ban- daging the foot at right angles. Hyponarthetic apparatus, or fracture-boxes, as they are more familiarly termed, are troughs in which the limb is fixed by various contrivances of straps, bandages, etc., screwed to the framework, so that the limb is main- tained in the precise position in which it has been placed after extension. The trough is often formed of two pieces jointed together, so as to keep up extension by means of a rack and pinion. Extension Apparatus. — The usual means of maintaining a permanent extending force, by which the lower fragment may be drawn away from the upper, is by means of a weight and pulley passing over the end of the bed, as is so commonly done now in disease of the hip, and which will be found delineated in the section on that subject. This plan is much in use in America, I believe, in fracture of the femur; but the numerous at- tempts which have been made to introduce it into English practice do not seem hitherto to have been very successful. Sivings. — One of the most painful and distressing features in the ordi- nary treatment of fracture of the lower extremity, when the limb is kept immovable on the bed, is that this immobilit}^ prevents the patient from making any but the most restricted movements of the rest of the body. Hence the invention of the sioing, of which the kind now in almost uni- versal use for the lower extremity, is that devised b}^ Mr. Salter, which will be found described in the section on Fracture of the Leg. Injuries of the arm and excisions of the elbow are often found treated with great comfort to the patient by swinging the forearm I)y means of a pulley from a pole projecting over the bed or from the bedstead (see Excision of the Elbow). 3. Treatment of Complications. — After the fracture has been set and put up, the only thing necessary is to keep watch for, and counteract, any complication whicli may ensue. In cases of simple fracture these are commonly few and trivial, so that these fractures are hardly ever danger- ous to life, and with moderate care are usually brought to unite without serious deformity. The chief points are : to see that the displacement is not reproduced, through slipping or imperfection of the apparatus, and to that end to I'enew the measurement, and, if possible, examine the seat of fracture from time to time — say every week; to combat the painful sj^asms which sometimes attack fractures, for which purpose even pressure, as by careful bandaging or strapping, is the most efficient treatment; to relieve the neuralgic pain which is occasionally very distressing, by blisters dusted with opium or morphia, b^' hypodermic injections, and by the usual remedies for neuralgia; to treat the very distressing itching which some- times attacks the skin by sedative ointments or lotions ; and to open ab- scesses, should any unfortunately form, as early as necessary. Compound fractures are much more difficult to treat with success, and far more exposed to complications of all kinds. They usually unite by suppuration and granulation, especially in the lower extremity ; the in- flamed bone often dies ; ihe matter frequently burrows about the limb, requiring incisions in various parts, which interfere with the application of the splints. The surgeon, therefore, has to be constantly on the watch to provide free exit for retained matter, to remove sequestra, to incise tense, inflamed parts, and to combat all other complications. I have elsewliere expressed m}' strong sense of the value of the so-called " antiseptic " method in cases of this nature (see page 49). Wounds of the hone are not exactly the same thing as fractures, yet it is 144 UNION OF FRACTURES. \ difticult to establish any essential difference. As seen in practice they are generally caused by gunshot, which sometimes perforates the bone, punching a hole more or less cleanl}^ through it, or else splinters and comminutes its substance, causing a compound fracture. In rarer cases the bones are cut into by a sharp-edged weapon, without an}' solution of continuity of the entire bone, though very probabl}' fissures may run down, radiating from the wound to some distance in its substance. Tliese wounds of bone are liable to many of the same dangers as com- pound fractures, and the}' unite by the same process. Closel}' connected also with the subject of fractures of the bones is that of injur}' of cartilages. In many cases of fracture — in all those which communicate with joints, and in many of those of the ribs — cartilages are also fractured ; and man}- wounds involve the cartilages to a greater or less extent. Some of these injuries are definite subjects of surgical treatment — as, for instance, fracture of the costal cartilages — which will be found treated of in the sequel; but as a general rule the injury is an unnoticed and a subordinate complication of a graver lesion. The pro- cess of union will be spoken of hereafter. UNION OF FRACTURES. The union of simple fractures is generally effected by a process of inflammatory exudation and organization analogous to that of union by first intention in soft parts ; while compound fractures usually unite by a process of suppuration and granulation (second intention); but excep- tions occur to both these rules, ?. e., we meet sometimes with simple frac- tures which heal by suppuration, and with compound fractures which unite by simple adhesion. Tlie process of union of a simple fracture may be thus described : The injury causes effusion of blood around the fractured ends, and between the bone and periosteum, as far as the latter is torn away from the bone. The muscles also are more or less lacerated. All this is re- paired in tlie usual way; the blood being gradual!}' absorbed, and the muscular fibres united Ijy fibrous tissue. This process is going on simul- taneously with that of the repair of the fracture itself. Supposing the fracture to be placed in good o.jipoaition, and kept quiet^ a fibrinous material is exuded between the fractured ends. The period at whicli this exudation commences varies with many circumstances, — the patient's age, the size of the bone, etc. For a large bone in an adult it may be given at about ten or twelve days. The exudation (teclinically termed "callus") is furnished by the vessels botli of the bone and of the periosteum. Fibrous tissue and eartliy material are developed in this exudation almost simultaneously in many cases; and sometimes, especially in cliildren, fibro-cartilage. True cartilage is met with in animals, but its occurrence in man is doubtful. The "callus," or uniting material, is then developed into bone, as in the intramembranous process of ossifi- cation. Tlie new bone is spongy and porous at first, but gradually hardens. If the fragments are not in good position this tissue may fill up the angle between them, or even extend into the medullary tube. It fills all the space internal to tlie periosteum {i.e., the whole medullary canal); and if the periosteum lias been torn, that membrane is at first lost in UNION OF FRACTURES. 145 Fio. 30. Fio. 31. a mass of newly formed callus. Gradually this mass is modelled down, the medullary tube restored, and the periosteum again becomes recoonizable. When the fragments overlap, the uniting medium is developed only between them — not, as a rule, over the exposed ends or in the medullary canal ; but as to the latter point there is con- siderable variety in different cases. The annexed figui'e shows a simple fracture, where the pa- tient died before the union was quite firm. The callus which was thrown out has become ossi- fied, though the ossification is not yet complete. The bony de- posit, however, is seen to extend over the end of the medullary canal of the upper fragment ; and this is the case in the lower fragment also. If the reader will compare some of the illus- trations to the chapter on In- juries of the Lower Extremity he will find that the condition of the medullary canal varies con- siderabl3\ The uniting material usually fills up only the angle between the fragments and the space which is left between the detached periosteum and the bone, and this is not often great. But there are cases where sucli periosteal deposits, uniting with separated splinters, form substantial bridges across the fracture, and afford a great deal of the solid uniting material (Fig- 31). Inammah and in man Xvhen f,«. 3o._a badly set fracture of the femur. Thetwo the fractured ends are not kept fragments are united by a bridge of soft bone, which at qriiei, this process is modified l)y thetimeof the patient's death (ten weeks after the ac- the formation around the frac- "dent) was so porous as to give way in part during . 1 IP • -t- A. e maceration. The ends of the medullary canal are tured ends of a ring or splint of ^^^^^^^ ^j^^ ^^^^^ fragment is lying on the inner " provisional callus." side of the lower; the lower fragment is directed from The process of formation of below outwards and backwards.— From St. George's provisional callus has been arti- Hospital Museum, Ser. i, No. 167 ^^^,^. . 1 T • 1 1 • n Fig. 31. — Union of fracture by the attachment to flCially divided into fivc^ stages : each fragment of a bridge formed by a separated splin- 1. The first is that of exudation ter.— From a preparation (No. 2938) in the Museum of of reparative material, external the Royal^College of Surgeons. (Syst. of Surg., 2d ed., and internal to the fragments, ^ ■^' ■ i.e., between the fragments and the periosteum, and between the medullary 10 146 FRACTURES. membrane and the bone. This occupies a period averaging from eight to ten days. 2. The provisional calhis then acquires tlie firmness and structure of fibro-cartilagc or cartilage in from ten to t\vent3'-tive days. 3. Both the external and internal callus then ossify into spongy bone in from twenty-five to sixty daj's. Fig. 32. Union by provisional callus in the human subject. The provisional callus has ossified, the fractured ends being still united by fibrous tissue only. A fractured rib three months after the accident. — St. George's Hospital Museum, Ser. i. No. 72. (System of Surgery, 2d ed., vol. ii, p. 73.) 4. The provisional bony callus is then modelled down and becomes compact bone, the ends of the fracture being still distinct from each other (Fig. 32). 5. Lastl}^ the permanent bond of bony union, or " permanent callus,'' forms between the broken ends, and the provisional callus is more or less completely reabsorbed ; so that the periosteal swelling disappears, and the medullary canal is restored. The period occupied b}^ these two latter stages of the process is too uncertain to be stated even approximatel}-. In some cases the provisional bony callus remains permanent, and the fractured ends lie within it, either ununited or only connected by ligament. As the formation of provisional callus is the result of the irritation pro- duced by motion of the fragments, it is exceptional in man, though b}- no means unknown ; while, on the other hand, its absence is rare, though also not unknown, in animals. In the human subject the ribs, which cannot be kept immovable, usually unite in this manner, and the clavicle for the same reason ver}' generally. Any fracture, however, which from accidental circumstances cannot be treated in the usual manner may undergo this process, of wliieh the humerus represented in the annexed figure (Fig. 33) is a good example. For obvious reasons it is more com- mon in childhood. The buttresses of bone which are sometimes found around fractures, particularly near the hip, are analogous to the pro- visional callus. The uuion of ill flamed i^imjjJe fracturea and of compound fractures is by granulation. The IVactured ends are inclosed in an imperfect capsule formed by the tiiickened and inflamed soft parts within which tiie injured ends of the bone suppurate, and often become necrosed in part; granu- lations spring up from them ; the medullary canal is more or less trenched upon, and perhaps filled u[) with ossifying material, in which bone is slowly and irregularly dei)osited. The medullary canal is often perma- nentl}' closed, especially when it has been freel}' exposed (as 113' the pro- jection of the fragment) ; but occasionally after a long period it ma}' be UNION OF FRACTURES. 147 Fig. 3;5. restored. This union l\y granulation is a far more tedious process than that by adhesion, generally occupying as many months as the other does weeks ; and it is liable to all kinds of irregularities from the separation of fragments which become necrosed in consequence of the sui)puration of the parts which surround and nourish them, from erysipelas or diffuse inflammation, from burrowing of matter in the limb — in fact, from all the complications incidental to severe injuries involving bone. And such suppurating compound fractures are one of the most fruitful sources of p^^jemia. It is therefore important to procure the imme- diate union of the wound — whenever that is possible — so as to convert the compound into a simple fracture ; and this is the more important the more vital is the organ which is in contact with the fractui'ed bone. Hence the care with which surgeons endeavor to procure the union of a scalp-wound which exposes a fracture of the skull, or a wound of the chest communicating with a fractured rib. Butit must be added that such attempts are of very doubtful utility in cases where, from extensive laceration and contusion, the wound must almost inevitably suppurate, and where the consequent suppuration will be prevented from finding an exit by the material used in sealing the wound. Much, however, may doubtless be done by care- fully sealing wounds with some antiseptic substance, and keeping all their parts in gentle apposition by appropriate bandag- ing ; but in so treating the wound of a com- pound fracture the surgeon should watch vigilantly for any indication of burrowing matter, and give it instant vent. Uniou of fracture by ensheatlnng or Irreqular C^riZOn.— Irregularities occur Provisional calU.s in the human subject ,, .y , % . , The patient was admitted into hospital in all these processes, whereby special pases ^uh fracture of the humerus, which are made to differ from that which is re- could never be kept quiet, in conse- garded as the typical course of each kind i"'^'^'^^ "^ !>>« suffering from repeated r. . mi ■ 1 • i> J? xi • 1 -i- attacks of delirium tremens, of which of union. 1 he chief of these irregularities ^^ ^^^^^ ^i,^^^ ^ .^^^t,, ^ft,r ^he acci- which needs notice here is the absor[)tion dent. which sometimes goes on in the neighbor- ^ dentated fracture was found just ing bone contemporaneously with the union of the line of fracture itself. This is often seen in thin papery bones like those of the orbit (see Injuries of the Head). And it is often noticed that fractures of the base of the skull, though they may unite, do so pointed end of the lower fragment, very imperfectly, and "that "parts of the which is seen to be quite ununited to „ "^ ' n^ . I , . , . . the upper fragment, and its surface is fissure are often wider when the repair is ^^^^ ^^^^ ^^p^^it ^^ ^ ^^^^ distance complete than they were at the time of the below the actual fracture. The frag- iniury. ments are freely movable on each rpi t- c i.\ c • L other to the extent permitted by the i he arrest of the process of union at any ,, , " - „ .„;.;„„, i ^.11,,. Ill p attachment of the provisional callus. — stage Will lead to the various forms of Un- gt. George's Hospital Museum, Ser. i, united fracture, as will be obvious from the No. 105. sequel. below ths insertion of the deltoid mus- cle, and the fractured ends were encased in a sheath or ferule of fibrous tissue about a quarter of an inch thick, and extending about an inch above and be- low the fracture. A hole has been cut in this sheath in order to show the 148 FRACTURES. Fig. 34. Delayed Union. — The usual period for the union of each fracture is specified in treating of each. But it must be understood that these periods are averages only. Various disturbances of health may cause delay in union — such are acute diseases, as fever, or chronic affections, as scurvy, possibly syphilis, and frequently disease of the kidneys leading to a phos- phatic state of the urine. ^ All such causes, however, allowing the reality of all of them (which is a matter of considerable doubt), are rare ; far more commonly the union of fracture is dela3'ed or prevented by inju- dicious treatment, as b_y tight bandaging, obstructing the blood-supply, or the other extreme of negligent apposition, allow- ing movement. But cases of dela_yed union are met with in which no such cause can be traced, where the patient seems to be in his usual health, and the fracture to have been properly treated. ■' In such instances of delayed union the indications for treatment are obviousl}', in the first place, to examine the patient's local and general condition, with a view to correct alkalescence of urine by the exhibition of mineral acids, to neutralize the syphil- itic condition by mercury or iodide of potassium, and to improve the general health by fresh air if possible. The local condition must be improved by correcting any obvious defect in the apparatus em- ployed, and by gently rubbing or shampooing the parts around the fracture. Some fractures of the lower limb, which have remained movable beyond the usual time, will unite if the patient is allowed to get up and move about a little with the limb in a case firm enough to prevent it from bending, yet not so tight as to make it swell. In other cases (whether in the upper or lower limb) union may be procured by fixing the two fragments in an apparatus made of two parts movable on each other, and provided with a screw and ratchet, by which the fragments can be pressed together. The aim of all these devices is to excite a little more action in the parts, and thus stimulate the fractured ends to throw out bone. Ununited fracture (soft union) of the ulna. — St. George's Hospital Museum, Ser. i, No. 202 a. Ununited Fracture. — By some such means as these union ma}- be pro- cured, even after considerable delay, when there is no definite obstacle to it. There will still remain a small proportion of cases in which the fragments continue permanently ununited — at least by bone — and there- fore are freely movable on ea(!h other. This takes place in one of three ways, i. e., the fragments are either united by a soft material (which is sometimes called ligamentous union) or by a false joint; or they are truly ununited, ?". e., are in no apposition whatever. 1 Pregnancy and lactation are said .sometimes to retard union, though they cer- tainly do not commonly di) so. The subject is discussed, tmd several interesting cases quoted, in Norris'.-* Contributions to Practical Surgery, pp. 25, 28. Tlic cutting oft' of the blood-suppl)' through the nutrient artery is also believed b^^ Mr. Curling to retard union (Med.-Chir. Trans , vol. xx). And Mr. Callcnder has pointed out the frequency of obstruction of the main vein from contusion in the injury, causing oedema, as a condition involving delay in the union of the fracture (Med.-Chir. Trans., vol.li, p. 152). '^ On the far greater frequency of the local causes of non-union, especially bad treat- ment, than the constitutional, see Callcnder, op. cit. UNUNITED FRACTURE. 149 Ligamentous Union. — The first form of ununited fracture is seen in Fig. 34, and a comparison of Fig, 33 (p. 147) will sliow its striking similarity to the condition of a provisional callus before ossification. Sometimes, indeed, in these cases of soft union there is a regular provisional callus, inclosing the broken ends in a splint or ferule, just as is seen in animals, and possibly containing fibro-cartilage. This soft or ligamentous union is the most common condition of ununited fracture. Fig. 36. Fig. 35. — An ununited fracture (false joint) of the tibia. The fracture had existed seventeen years, and the utility of the limb had been almost perfect, the patient having gained his livelihood by walk- ing as a messenger at one of the clubs ; he merely used a stick. The ends of the fracture, a, are rounded, the lower end being worn into a kind of cup to receive the upper end. They are lined by a fibro-car- tilaginous substance, and were inclosed in a firm fibrous capsule, which has been removed in order to display the false joint. There was even a membrane lining the ends and secreting a substance some- thing like synovia. A false joint also exists between the tibia and fibula, near the fracture. The fibula, 6, is much curved, and is very much thickened, so as to bear the weight of the body. The tibia, as shown at c, is considerably atrophied, so that a thin shell only remains to represent its compact ex- terior. — From a specimen in St. George's Hospital Museum, Ser. i. No. 202. Fig. 36.— Ununited fracture of both bones of the leg in a child set. 10, for which amputation was per- formed. The leg had been fractured eight years before, and had, it was said, been refractured on two subsequent occasions, a. The atrophied upper end of the lower fragment of the tibia. «'. The lower end of the upper fragment. This is not in any contact with the former, but is united to the back of the lower fragment below by a kind of capsular membrane. This is the case also with the fibula. The upper end of the lower fragment of the fibula is not plainly seen, being buried in the fibres of the ex- tensor long. dig. The tendons of the tib. auticus and extr. prop, pollicis are seen, pushed outwards by the fragment of the tibia, h. Shows the heel and the atrophied tendo Achillis.— From St. George's Hospital Museum, Ser. i. No. 203. Fahe Joint. — Another form of the lesion is that which is shown in Fig. 35, in which by the movement of the two parts of the fracture on each other 2i, false joint (" pseudarthrosis ") has been formed in the centre of 150 FRACTURES. the soft uniting medium, which tlien takes the form of a more or less regu- lar capsule.' True Non-Union. — Again, the broken ends may be in no apposition at all. A familiar example is that of a fracture of the patella, where the fragment is sometimes drawn far up tlie thigh, and is quite unconnected with the part which remains attached to the tibia. Fig. 36 shows another example of something of this kind. In tliat preparation, however, though the upper ends of the lower fragments are in no connection whatever with the lower ends of the upper fragments, yet these latter have an im- perfect fibrous connection to a lower part of each lower fragment, so that it ma}' be said that some attempt, though very imperfect and ineffectual, has been made to re-establish the solidity of the limb. It is not easy daring life to give a confident opinion as to the exact anatomical condition of a case of ununited fracture; but if the fractured ends are widel}' separated, and no motion of one is produced by moving the other, we may suspect entire non-union ; if they move freely on each other with grating, or pseudo-crepitus, like that felt in an old rheumatic joint, we conclude that the case is probably one of false joint; if they are more or less freel^^ movable on each other, but without grating, we may put it down as probably an instance of ligamentous union, remembering also that this is b}' far the most common condition, as it is also tlie most favorable for treatment. In cases of true non-union, and frequently in those of false joint, the fragments are greatly atrophied, as shown in the figures. Treatment. — The treatment of ununited fracture must be regulated in the first place by the utility of the limb, and in the next place by the age and health of the patient. The former varies very greatly. Thus Fig. 35 shows a case in which the fibula having remained unbroken (or having united), and having also become sufficiently hypertrophied to bear the weight of the bod_y, the leg was so useful that the patient could earn his living by walking. In such a case it is needless to say that there is no motive for surgical interference. Mr. Prescott Hewett told me a short time ago of a case wliich he had seen in private, where a lady had an ununited fracture of the femur. This was most freely movable when she laid down, and wlien she stood up the two fragments locked together in such a wa^'that she could walk fairly well, though with a limp. In such a case, and in fact generally when the patient's life is not made wretched by his infirmity, it is better to avoid any serious operation, for all such operations involve a good deal of danger. All operations on the upper limb are both more likely to succeed and much less dangerous than similar operations in the lower extremity. As there is no absolute separation between cases of delayed union and those of non-union, it is better to treat ever}' case when first seen, if at any reasonable period after tiie injur}', by the milder measures whicli have been recommended in cases of delayed unic^n. I have seen judicious apposition and mutual pressure of tlie fragments on each other l)y means of a rack and pinion apparatus successfully employed in many such cases. Shampooing the part, slight rubbing of the frag- ments on each other, occasional slight inflammation set up by blisters and other means, have been recommended. And of course careful attention to the general health, and especially the condition of the urine, is under- stood to be a necessary preliminary to all kinds of treatment. ' There is iin interestincj proparation in the Museum of the College of Surgeons, showing numerous loose boiii(!S (" loo.se curtilages "j in one of these false joints. See Syst. of Surg., 2cl ed., vol. ii, p. 80. UNUNITED FRACTURE. 151 If these means fail, and if the loss of power is not grave enough in the surgeon's judgment to justify his exposing the patient to any risk of his life, or if the patient is in such a condition of health that he can hardly be expected to survive the operation, the case must be abandoned, with such palliation as an apparatus can provide. In cases, hovvever, which are more hopeful as far as the patient is con- cerned, and where the infirmity is grave enough to justify the risk, the surgeon must very carefully examine the relations of the fragments to each other; their connection, as far as he can make it out, their size, and the possibility of bringing their ends into apposition by extension. He then has the choice of a great number of expedients. There are cases of false joint in which the cavity between the fragments maybe obliterated by scraping the ends with a tenotomy knife, keeping them afterwards at rest in the natural position ; and other cases where union seems to be prevented by some piece of muscle or fascia which has got between the fragments where a similar operation will succeed. There are cases (appar- ently both of false joint and of ligamentous union) where ossification has ensued on the passage of a seton between the ends, which should not be allowed to remain in much above a week. The measure appears to have had little success in England. Dr. Norris, however, says of it that "results in America have proved it one of the safest, least painful, and most etlicacious of the numerous operations that are performed for the cure of pseudarthrosis" (op. cit., p. 90). Sometimes the surgeon has cut down on the fractured ends in order to pass the seton ; but, as a general rule, when a seton cannot be passed without previous exposure of the bone, the probably more effectual and certainly less dangerous expedient is adopted of driving ivory pegs into the fragments, as recommended by Dietfenbach. The fragments are sufficiently exposed to drill holes into them, and then into these holes ivory pegs are driven, and the projecting ends cut off. The buried part excites an effusion of bone around, and by such effusion the fracture is united, much as it is by the periosteal bridge of bone figured on p. 145. The buried part of the peg sometime makes its wa}' out, sometimes perhaps is absorbed, and probably is sometimes encapsuled, and remains as lodged bullets do. The number of pegs to be driven into each fragment will depend on the size of the bone, and other circumstances. Mr. Erichsen speaks of having successfully used five pegs in a fracture of the humerus. Mr. Bickersteth has used copper nails in the same way,' or has driven a drill, the end of which is removable, from one fragment into but not through the other, and left the drill in the bone until it fell out. If one drill be not enough to support the frag- ments two or even more can be employed, a plan which has the advan- tage of requiring no external incision. The drills are simply driven in from the surface of the body. Another plan is to drive a metal suture from one end into the other by means of the drill, which is made to perforate both fragments obliquely;^ but this is commonly combined with the next plan, viz.: Resection of Ends. — To cut down on the fracture and to remove a slice from either fragment, after which the ends may be wired together, if the surgeon thinks right. Mr. Mason suggests that a needle may he driven through the ends, and the wire cast in a loop or figure of 8 round the needle, and this may be necessary when the sutures are very oblique, 1 Med. CUn. Trans , vol. xlvii, p. 115. 2 Mason, Med.-Chir. Trans., vol. liv, p. 313. 152 FRACTURES. otherwise the simple insertion of a peg or pin is sufficient to keep the fragments in apposition. Buhpe7-iOiifeal Besectioi}. — The late Mr. Jordan of Manchester suggested the subperiosteal resection of the fragments,* a tube of periosteum being dissected up first, and the portions of bone removed, as far as possible bare of periosteum ; and though this may not always be practicable, yet there is no doubt of the desirability of saving any periosteum which can be recognized and separated from the bone. Transplantation of Bone. — Lately an operation has been prescribed by Professor Xussbauni of Munich in a case of non-union of the ulnar, the result of loss of bone from gunshot fracture, which he denominates " transplantation of bone."" It consists essentially in cutting otf from the rest of the bone a portion of itb external shell covered by the perios- teum, and leaving this shell of bonf» attached to the remainder by means of the periosteum covering its terminal extremity, which is to be care- fully preserved from injur}', since it is the medium of the future repair. The semi-detached and now quite movable bone is next displaced into the gap in the same vfay as a flap of skin is twisted in a plastic operation and fixed in the indurated soft tissues of which the gap is formed. The uniting ligament and the atrophied ends of the fracture, together with the cartilaginous [fibrous ?] tissue which covered them are removed, as being in the way. This operation could only be attempted in cases where the separation between the fragments is unusually great ; and its utility must be tried by further experience. After all operations for ununited fracture it will be recollected that careful support in a firm splint or case of leather, plaster of Paris, or other material, is indispensable. Tiiere are many cases where subcutaneous section of the muscles which displace the fragments must be added to the other operative proceedings. Amputation. — Finally, there are cases so complicated, or of such long standing, or where previous operations have so far failed, that amputation ma}' be best. Vicious Union. — The fracture maj' have united by bone, but with con- siderable deformity and loss of the functions of the limb. Tlie kinds of vicious union spoken of are union of two contiguous bones, union with displacement, and projection of one of the fragments. The first and last may be summarily dismissed. Union of two contiguous bones is of no importance in the ribs, and of com[)arativel_y little in the leg. In the forearm it has, in one recorded case, been held to justify the resection of the bone.'' Projection of one of the fragments, or possibly of a com- minuted piece, is to be dealt with like an}' other exostosis, i. e.., when sufliciently inconvenient the projecting piece must be removed. But the cases we are f)rdinaril}' called upon to treat are those in which, IVom neg- lect, from unruliness on the part of tlie patient, or from yielding of the union after supposed cure, the deformity has citlier never been corrected or has recurred, and the limb is more or less entirely useless. Such cases are l)y no means hopeless. If only a short time has elapsed after the in- jury tlie deformity will often yield to extension by the pulleys, combined vvitii firm pressure on the part under chloroform ; or it may be reduced more gradually (as bent bones are in childhood) by pressure, with pads, ^ Traitement des Pseudarth roses par I'Autoplastie p Rindfleisch, PhUi. Hist , vol. ii, p. 822. New Syd. Soc.'s Trans. ^ Howott, in tlie Syst. of Siirj^., vol. ii, p. 202 3 " The symptoms of traumatic compression, when well marked and uncomplicated, arc those of apoplexy." Lo Gros Clark, Diagnosis of Visceral Lesions, p. 121. FRACTURES OF THE SKULL. 167 sibility, from apoplexy, as was supposed, under the care of one of the ph3'sicians. She was said to have had a fit two or three days before. She died on tiie following day. The head was carefully examined, and espe- cially with a A'iew to the detection of any mark of violence. No trace of injur}' was found, no bruise, no fracture, no laceration of any part of the brain. The whole of one hernisi)here was covered with an enormous quantity of blood, external to the brain, and chiefly in the meshes of the pia mater. Microscopical examination of the vessels did not enable me to detect any disease of their coats. The case was, in the absence of any further information, classed as one of meningeal apoplexy, and the woman had been buried, when the medical man who had attended her before her admission informed us that her death was attributed to violence on the part of her husband. It turned out that both of them were ver}' drunken people, and that finding her drunk on his return home he had beaten her, and then left her locked up in his room for the greater part of a da}'. The body was exhumed, and the man put on his trial for murder; but, though the circumstances were suspicious, it was found impossible to come to any certain conclusion, and he was acquitted. For, notwith- standing the apparently healthy condition of those vessels which were examined, it was impossible to affirm that constant intoxication might not have given rise to apoplexy in this case ; especially since cases of meningeal apoplexy have been put on record where no suspicion of vio- lence could be entertained, and where no disease of the vessels was detected. 4. So it is with extravasation of blood in the substance of the brain. It is, to sa}' the least, excessively difficult in many cases to say with any approach to certainty whether it depends on injury or on disease, or on a mixture of the two, i. e., on slight injury acting upon tissues degenerated b}' disease. lY. Fractures of the Skull. — We come now to fractures of the skull — divided into those of the vault and those of the base. The chief varieties of fracture of the vault are simple fissures, starred and comminuted frac- tures, fractures with depression of the entire thickness of the skull, frac- tures with depression of the outer or of the inner table only, and fractures with elevation of the fractured portion. In young subjects it is said that the skull may be indented or driven in (as any soft substance might) without any fracture, but this is doubtful.^ Any of these forms of fracture may be either simple or compound.' In the injuries which we usually meet with in civil practice fissured fractures frequently spread from the vertex far into tiie base of the skull, and some- times travel vertically round the whole cranium, so as to separate the an- terior completely from the posterior part. Compound fractures may be said as a rule to be more often of limited extent than simple. Fi'aetures with depression of one table only, and elevated fractures, are rare. The other varieties of fracture of the skull are of constant occur- 1 I mean that it is doubtful whether the indentations which are occasionally found in the skulls of children are not always accompanied by some amount of fracture. The occurrence of such indentations and their gradual disappearance is indubitable. See in Mr. Le Gros Clark's work, p. 94, a very characteristic case in a baby six months old, caused by fallinc: on a stone. " The indentation was oval, about three- quarters of an inch deep in the centre ; the end of the thumb might easily have been buried in it: it presented no sharp edge to the touch." There were no head symp- toms. Mr. Clark saw the child several years afterwards, and there remained no trace of the injury. 168 INJURIES OF THE HEAD. rence, FKactures N\-ith depression of the outer table only are best exem- plified b}' those which occur in the frontal sinus, where a great depression ma}' exist in the outer wall of the sinus without its inner wall having been in any respect interfered with. Such cases are easily known by the free Fl(}. 41. A fracture passin-g vertically round the skull, so as to divide it into two portions, anterior and pos- terior. The line of fracture can be traced from the vertex, where it follows pretty nearly the course of the coronal suture to the base, where it becomes comminuted, the chief branch passing through the body of the sphenoid bone and extending into the sphenoidal fissure on the left side, while another large branch traverses the basilar portion of the occipital bone, just in front of the foramen magnum. The petrous portion of the left temporal bone is quite isolated, a. The foramen magnum. 6. The basilar portion of the occipital Ixine. c. The foramen ovale, d. The sella turcica. — St. George's Hos- pital Museum, Ser. i. No. 6. escape of air out of the sinus, leading to considerable emphysema, and by the absence of brain symptoms, in spite of the extensive depression.' Fractures with depression of the internal table only are rare, and their diagnosis very obscure. The Museum of St. George's Hospital contains two-very well-marked specimens ;- and there is another specimen showing the skull-cup, from which a portion of the depressed inner table had been removed a year after the accident, but the patient died of arachnitis. This injury may be suspected, though it cannot be exactly diagnosed, from the continuance of constant pain in the part, accompanied with S3'mptoms of imperfect compres-sion of the brain, or followed by low in- flammation of the membranes ; and in such cases the trei)hine may be applied over the seat of injury, if the symptoms are grave enough in the jiulgment of the surgeon to warrant so serious a measure. The accidents which usually give rise to tiiis injury are blows or cuts with a moderately sharp substance, a sabre cut, a fall on a stone, the blow of a piece of slate, brick, shovel, etc. In almost all cases there is a fissure in the external ' A very woU-markod case of fracture of the out(;r lal)le only, from the blow of a bludgeon, in which the fractured portion ultimatelv separated, is related by Mr. Le Gros Clark, p. 91. ^ Series I, Nos. 7 and 8. One of these is figured in Mr. Hewett's article on In- juries of the Head, Syst. of Surg., vol) ii, p. 2GG. DEPRESSED FRACTURE. 169 table, but the internal table is said to have been fractured alone. Frac- tures with elevation of the fractured part can only be produced by direct wound, and are at once obvious.' The importance of the injury depends generally on the lesion of the brain or its membranes by the wound. The portion of bone turned up will be easily bent down again if it interferes with the union of the wound, or if it breaks in the attempt it may be removed. Fracture by '-'Contre-cnuj).'''' — We frequently hear of fracture of the skull by " contre-coup," but it seems undeniable that, as Mr. Le Gros Clark has pointed out [op. cit.^ p. 102), this expression is generally em- ployed in quite an erroneous sense. Strictl}', it ought to mean that, the skull being struck at a given point, fracture occurs at the point diametri- cally opposite, while no force is applied to the skull in the latter situation. This appears to be quite unproved. If the vertex be struck, fracture often takes place at the base, and not at the vertex ; or if one side of the head be struck fracture often takes place at the other; but in the former case the injury to the base is due to the skull having been made to impinge forcibly on the occipital condyles ; and in the latter, as far as I have been able to discover, it has always been the case that the opposite side of the skull has been driven against an obstacle ; so that both are instances really of direct force. Again, when a blow is struck on one side of the vertex of the skull, the opposite side of the base of the brain is often lacerated, but this is obviousl}^ caused by the brain having been driven down on to the rough base of the skull. The term is, therefore, speaking accurately, quite in- correct, but it may be retained as having now come into general use to express the fact that a blow at one part of the skull often produces its main result at the other end of the axis of the cranium, a fact which is of considerable practical importance. Diagnosis of Fracture. — The only diagnostic sign of a simple fracture of the skull is the depression by which it may be accompanied. If no such depression exists there is no means of knowing, in any case of con- cussion or other injury, whether the bone is or is not also broken. Nor does it much matter, for though, in popular language, a fracture of the skull is represented as a very grave injury — and rightly so, because frac- tures of the skull are usually accompanied by injury to the cranial con- tents — it should be remembered that it is this concomitant injury which alone gives them their gravit}', and that in themselves fractures of the skull are hardly more serious than fractures of any other bone. The skull is richly supplied with blood, and simple fractures of the vertex, unaccompanied by any other lesion, unite very kindly. In examining the skull for depression care must be taken not to con- found the depression so often found in the centre of a lump of extrava- sated blood with the depression of a fracture. There are also some rare cases in which an injury lias been received over a portion of the skull in which either the whole cranium or the external table only has been de- ficient from congenital malformation or from atrophy, and the edge of the deficient part has been mistaken for that of a fracture. The diag- nosis of compound fracture is generally obvious ; care must, however, be taken not to mistake a suture for a fissure ; this may easily be done when the sutures are irregular, as in the instance of numerous Wormian bones. Treatment. — The treatment of an undepressed fracture, whether simple or compound, consists merely in precautionary measures. In compound fracture everything should be done to promote the immediate union of 1 A good illustration of this rare form of fracture, also from St. George's Museum, will be found in Mr. Hewett's essay, p. 265. 170 INJURIES OF THE HEAD. tlic woiiiul, and very often the fracture will heal as uninterrupted!}' as a simple fissure. The rest of the treatment consists merely in watching for and treating any cerebral symptoms which may arise. Simple depressed fractures ought to be elevated by operation when ac- companied by symptoms of compression or of irritation of the brain, but not otiierwise, and in practice cases will often be met with where the surgeon will require all his acumen to determine whether the symptoms of cerebral irritation which exist do or do not depend on the depression of bone. When this depression, however, is considerable and there are cerebral symptoms, the operation is indicated. Fig. 42. An old depressed fracture of the skull souudly and perfectly cured without trephining. The frac- ture is seen to he chiefly of the frontal hone, extending slightly into the parietal. Its depth is equal to that of the whole thickness of the skull, and the length of the fissure is at least four inches. On the inside of the skull the angle of the depressed portion projects as a spike or thorn of bone which had penetrated the dura mater, and was lodged in a little pit or depression in the surface of the brain. Notliing is known about the original injury, except that the man was in the Middlesex Hospital in the year 18.53, fourteen years before his death, on account of some injury to his head; and that he had been subject ever since to violent paroxysmal attacks of pain in the head. The records of the ISIiddle- sex Hospital, however, contain no notice of the case. — Museum of St. George's Hospital, Ser. i, No. 244 a. In compound depressed fractures most surgeons are in favor of ex- tending the province of operation so far as to say that they ought always to be elevated, whether symptoms are present at the moment or not. But this is a rule which is by no means universally adopted. Cases of de- pressed fracture, both simple and compound, often unite, and the patient recovers without operation. This is illustrated by the accompanying figure (42) and by some striking preparations of sabre-wounds of the skull in the Museum of the College of Surgeons. For my own part, if the depth of the depression is slight, and especially if its extent is also considerable, I have no doubt that in the absence of symptoms it is best left alone, whilst under opposite circumstances (i. e., the deep depression of a small piece of bone) it might be better to elevate it ; but then such a depression will almost certainly produce cerebral symptoms. And depressed compound fractures with symptoms should no doubt always be elevated. On the whole, therefore, the treatment of compound and sim- ple fractures would not vary so much as used to be the rule. There is, no doubt, somewhat less hesitation in applying the trephine when the fracture is already exposed in a wound, but the depth and the extent of the depression are far more iini)ortant considerations. The more a frac- ture approaches the "punctured" form the more is trephining indicated. Fractures of the base of the skull are in the great majority of cases caused by indirect force, and are extensions downwards of fractures of the vault. Sometimes, however, they are caused by direct violence. This occurs most commonly in wounds of the orbit. Here it has fre- quently happened that a slight injury, such as the thrust of a foil or a FRACTURES OF RASE. 171 parasol or some weapon, has inflicted an apparent!}^ trivial injury on or below the eyelid (generally the upper), and that the accident has been taken little notice of, until some days afterwards symptoms of cerebral inflammation have appeared and have proved rapidly fatal. On post- A fracture of the skull in which some of the large branches of the middle meningeal artery were cut across, causing extravasation of blood between the bone and dura mater. A portion of the vault of the skull has been left on, in order to show that this fracture, contrary to what is usual in such cases, does not affect the vertex. It is of a trilateral shape, with a horizontal and two vertical branches, c, c, c. Some of the large grooves for the meningeal artery, d, are cut across, but not in the usual position. The main trunk of the middle meningeal artery was divided, and there was extensive extravasation of blood between the bone and dura mater, as well as laceration of the cerebral substance. Yet there was no paralysis as far as could be made out, though the patient was completely insensible and fre- quently convulsed, a, a refer to sections of the outer wall of the orbit, separated by the spheno-max- illary fissure ; 6, to the styloid process. — St. George's Hospital Museum, Ser. i, No. 260. mortem examination the weapon has been found to have passed through the papery inner wall of the orbit into the brain, and a fragment has not unfrequently been found lodged in the cerebral substance. In other cases, though the brain has not been wounded, the cavernous sinus has been laid open, giving rise to fatal haemorrhage, or to lesions of the orbital nerves, or to orbital aneurism.^ All such cases, therefore, should be very carefully examined at first, and sedulously watched afterwards. Other and rarer instances of direct fractures of the base of the skull are found, as, for example, in the preparation from St. George's Museum, figured in Mr. Hewett's essay, where the condyle of the lower jaw is driven through the base of the skull ; but the vast majority are indirect fractures, sometimes of the form of simple fissures, at other times branching in various directions. They are either confined to a single zone or fossa of the base, or the}^ implicate two or three fossoe at the same time.^ The great majority of these fractures pass through the mid- 1 See Lancet, 1873, vol. ii, p. 143, for a reference to some of these cases. ^ Mr. Hewett refers to the records of St. George's Hospital for ten years, compris- ing 64 cases of fracture of the base. Out of these there were 25 in which the line of 172 INJURIES OF THE HEAD. die fossa. As stated above the fracture iisuall}' extends into the vertex, being sometimes a branch of a fracture originating in tlie vault ; some- times but more rarely it originates in a shock transmitted through the Fig. 44. A, the external and b, internal, view of a preparation in which hernia cerebri took place into the external auditory meatus eight days after a gunshot wound. The case is related by Mr. Caesar Haw- kins, Contributions to Surgery and Pathology, vol. i, p. 318. — St. George's Hospital Museum, Ser. viii, No. 13. spine to the base of the skull, and spreading up into the vertex. In some cases, as in tliat which furnished Fig. 43, the fracture, though of con- siderable extent, nia^^ be confined to the base, but this is decidedly un- usual in indirect injuries. Si/mpfom.'i. — These fractures occurring as they do in severe injuries of the head, are therefore usuall}^ accompanied by the ordinaiy cerebral S3'mptoms. Irrespective of these the only symptoms of fracture of the base are the escape of the contents of the cranial cavity, or injury of the nerves which pass through the foramina at the base of the skull. Now, the contents of the cranial cavity are blood, subarachnoid fluid, and brain- fracture was confined to a single fossa; the anterior in 5 cases; the middle in 14; the posterior in G. There were 29 cases where 2 fossas were implicated, viz., the an- terior and middle in 14; the middle and posterior in 15. In the remaining 10 the fracture traversed all 3 fossaj. Thus the middle fossa was implicated alone or with the others in 53 out of the G4 cases. — Syst. of Surg., vol. ii, p. 281. FRACTURES OF BASE. 173 matter. The brain-matter very rarely, indeed, exudes from a fracture of the base. I have seen, however, a case in vvliich liernia cerebri took place into the meatus auditorius, and a preparation showing a hernia cerebri in the meatus is figured on the previous page. Wiien present this symp- tom is of course decisive of the existence of fracture. But tlie usual symptoms are either extravasation of l)lood or escape of watery fluid. In fractures of tlie anterior fossa the blood is extravasated at first in the deep cellular tissue of the orbit, and makes its way forward till it appears under the ocular conjunctiva and the lids. This extravasation is distinguished from that of ordinary black eye by its l>eing less in the lids, considerable in the ocular conjunctiva, and increasing as it passes backwards out of sight. The reverse is the case in a simple bruise. Blood may also pass through the body of the sphenoid bone into the nose, as it may also in fracture of the middle fossa. Persistent epistaxis, therefore, is sometimes met with in fractures of the base, or liiiemateraesis occurs from the blood having been swallowed and rejected by the stomach. Part of the base of the skull, showing a line of fracture which traverses the internal auditory meatus. The principal fracture formed the upper boundary of the piece of skull here depicted. At the point a a branch ran down through the internal auditory meatus into the jugular foramen. The patient had fallen down stairs, striking one side of his head. He was admitted in a state of partial insensibility, bleeding from the opposite ear and from the nose. Next day a copious watery discharge commenced from the ear and continued till his death, which took place three days after the accident from suppu- rative inflammation of the cerebral membranes. Small extravasations of blood were found in the anterior pillars of the fornix, and on the under surface of both middle lobes of the brain. — St. George's Hospital Museum, Ser. i, No. 243. The more common haemorrhage, however, in fractures of the middle fossa is from the ear, the membrana tympani being usually lacerated in such injuries, whereby a way is afforded for the blood to pass out from the lateral sinus, or any other large vessel in its neighborhood which may have been wounded in the fracture. Bleeding from the ears is accord- ingly a valuable sign of fracture of the middle fossa of the base of the skull, when copious and long continued ; though it cannot be said to be absolutely diagnostic of the injury, since considerable bleeding has been known to occur in injuries involving only the ear itself. Blood may also pass into the pharynx and nose, causing hrematemesis and epistaxis, which, however, may have so many other sources that they can only very rarely assist much in the diagnosis. In some rare cases extravasation of blood behind the wall of the pharynx is found. In fractures of the posterior fossa blood may be extravasated in the neighborhood of the mastoid process, in the occipital region, or at the 174 INJURIES OF THE HEAD. side of the neck, and such extravasation may become a valuable sign of fracture in cases where the soft parts are known not to have been bruised. Tenderness to pressure over the mastoid process is sometimes observed in such cases. Se7'ouf! DiftcJiarye. — But the most striking symptom of fracture of the base of the skull, and one which under certain circumstances is really decisive of the nature of the injury, is the discharge of serous fluid. This occurs, though very rarely, also in fractures of the vertex, and it has been Fig. 4G. Fig. 47. Fig. 46. — Fractuio of tlie anterior fossa of the .skull, united. The patient died of erysipelas two montlis after the injury. The fracture traversed the anterior and middle fossie of the skull. At a is seen the line of the fracture traver.sing the anterior fossa. The union uere is very perfect. In other parts a considerable deposit of vascular porous new hone is found around and between the edges of the fracture, b shows a mass of partly decolorized blood-clot, mixed with organized fibrin on the outer surface of the dura mater, corresponding to the fracture.— From the Museum of St. George's Hospital, Ser. i, No. .'}4. Fig. 47.— Union of an old fracture of the posterior fossa of the base of the skull. The accident had occurred three years before death. On post-mortem examination the line of fracture was found to commence at the upper part of the occipital bone, and its upper half has lieon completely united, and is seen on the outside of the skull as a mere groove in the solid bone. On the inner surface the bone was found thickened and vascular at this part, from deposit on its internal surface. The lower half of the line of fracture i.s not united, but a distinct fissure is left which (as seen in the engraving) is per- fectly open in the macerated bone, the margins being thinned and rounded oil' by absorption. In the recent state ibis fissure was coni])letely tilled by filjrous tissue. Ciiinplcd' bony anchylosis had taken place in the joint between the atlas and occiput, and the lateral sinus was obliterated at its termination (Path. Soc. Trans., vol. vii, p. 282).— St. George's Hospital Museum, Ser. i, No. 30. known to take place tiirough the nose, but in all ordinary cases the dis- charge is from the eai's. When, immediately alter the iiijiuy, a copious discharge of watery saline fluid — /. c, fluid containing only the faintest FRACTURES OF BASE. 175 Fig. 48. trace of albumen^ — is found issuing from tlie ear, there can be no ques- tion tliat there is a fracture of the base of the skull cutting the meatus auditorius internus across, and thus laying open that prolongation of the arachnoid membrane which accompanies the seventh pair of nerves down the meatus, where!)}' the subarachnoid space is laid open. For no other cavity exists in which there is any collection of such fluid. ^ But when after an injury to the head, followed b}' bleeding from the ear which has lasted more than a day, a watery (or rather colorless) discharge follows, which contains more or less of inflammatory products, the inference is not so clear, for such discharges ma}' be furnished by the lining mem- brane of the external meatus only, or by that of the tympanum, and have been known to occur in cases in which it has been proved by dissec- tion that there was no fracture of the skull whatever.'' Such discharges, however, are far less vvatery than those which consist of the cerebro- spinal fluid, and they can never occur immediately after the injury, though they may commence after a short interval. Lesions of the nerves which issue fi'om the base of the brain are tolerably often pres- ent in fractures of the base ; and the paralysis of the nerves, especiall}^ those of the seventh pair, is a symptom strongl}' confirmatory of the diagnosis, though, as will be seen in the sequel, paralysis of these nerves may also re- sult from ecchymosis into their substance, and prob- ably from inflammation fol- lowing an injury of any kind ; so that the symptom is liot in itself unequivocal. Union of Fractures of the Base. — Fracture of the base of the skull is by no means necessarily fatal. Excluding very many cases in which all the symptoms have ex- isted, but the patient has recovered, we have ample anatomical proof that such fractures do get well, and that they are not insuscepti- ble of union, though in the Fracture of the left temporal bone extpiiding into the base of the skull The patient died two months afterwards, from a different cause. The part of the bone here represented is the squamous portion. "The edges of the fissure have been so thinned away by absorption that an opening in the bone is formed 13*^ in. in length, tapering to its extremities, and }/g in. in breadth at its centre. At the points where the edges of the fissure are in contact (between a and 6) no bony union has taken place, as ascertained by Mr. Tomes on endeavoring to make a section for the microscope." See Mr. Gregory parts of the base where the Forbes in Lancet, vol. i, p. SSO, 18-19. ' "The absence, except in small quantity, of albumen, and the presence of an ex- cess of chloride of sodium in the cerebro-spinal fluid, has been repeatedly shown by analysis." — Le Gros Clark. '■^ There seems some possibility that the descending horn of the lateral ventricle may in some cases have been broken into; at least such is Dr. Moxon's idea; and cases which support this belief mav be found quoted in Mr. Hewett's essay, pp. 292, 293. 3 See in the Path. Soc. Trans., vol. vi, p. 22, a case reported by Mr. Gray, in which serous discharge followed upon injury to the tympanum, and inflammation of the 176 INJURIES OF THE HEAD. bone is very thin and the foramina large the union is apt to be irregular, and the edges may often be found somewhat absorbed, forming a chink or fissure. I apiiend illustrations of united fracture in each of the fossfe of the skull from the Museum of St. George's Hospital. No treatment is required for the fracture of the base beyond that which the concomitant injury of the brain demands. Y. Lesions of the Brain. — We must now pass on to those symptoms which accompany injuries of the brain itself. These are usuall}^ classed under two heads, — Concussion and Compres- sion of the brain. Such a classification, however, is far from complete; for many cases are met with in practice which it is very difficult to in- clude under the term Concussion, and 3'et which do not exhibit any de- cisive evidence of compression. The only way to include all cases under these two heads is to regard all those as instances of concussion in which there is insensibility after injury (to a greater or less extent), unaccom- panied by paralysis ; and all those in which there is paralysis, as cases of compression. But such a definition departs very far from the original meaning of the term Concussion. In fact, when this term was introduced it was believed that in cases where insensibility follows injury, without paralysis, the brain was often free fi'om an}' visible lesion — very much in the condition of a jelly when shaken up — and that, if examined, no lacer- ation of its substance or its vessels would be found. This opinion was supported b}' some histories of patients who had died immediately' after blows on the head, whose death was attributed to concussion, and in whom the brain was found free from any trace of injury, as in the case recorded by Littre' of a prisoner whose arms were bound behind him, and who rushed with his head against the wall of his cell, falling dead on the floor. The brain alone was examined, and no trace of injur}' found in it; and this case was put down as one of concussion without visible lesion of the brain. But in this, as in other cases of supposed death from concussion, the upper part of the spine was never examined, nor the viscera; and Mr. Hewett has pointed out that without such examination the fact that death was really caused by concussion is quite unproved; in fact, it is most probable that in the case mentioned above the man died from injury to the upper part of the spinal cord. Mr. Hewett gives a remarkable case where the death was attributed to concussion ; the head was alone ex- amined, and the case would have been recorded as one analogous to Littre's, had it not occurred afterwards to another surgeon to reopen the examination and investigate the condition of the medulla oblongata and spinal cord, when doatli was found to be due to injury of the upper part of the spine. In other cases death may have been caused by rupture of the heart or some of the great viscera. There is, therefore, at present no evidence that an}' case of concussion ever occurs without anatomical lesion of the brain or its vessels to some extent. We may nevertheless concede that, as Mr. Savory argues,'^ even if it be true that no case of concussion occurs without some lesion, yet this does not prove absolutely that such lesion is the cause of the insensibility, since that insensibility will pass away suddenly, while the lesion must, of course, still be present; lining membrane of the tympanum and mastoid cells, but without any fracture of the ti-mporiil bone. And in the same series (vol. xii, p 159) a case by myself, where serous discharge was produced by a fracture of the neck of the condyle of the lower jaw perforating the meatus, but without any injury to the sUull whatever. > Mem. de I'Acad. des Sc, 1705, p. 54. 2 St. Barth. Husp. Reports, vol. v, p. 72. CONCUSSION OF THE ERAIN. 177 and besifles, such lesions have been known to lie present without any symptoms of concussion. Therefore, though it is not proved that con- cussion occurs without anatomical lesion, it is certainly not disproved — nay, there is a pi'iori reason for thinking that it may do so. It would be far more satisfactory, and more in accordance with the practice of surgical literature in its other departments, if we could classify the injuries of the brain, not accordingto their symptoms, as Concussion, Compression, etc., but according to the anatomical lesion, as cases of ex- travasation in the membranes or in the substance of the brain, of contu- sion, and of laceration of the cerebral substance. But our knowledge of the symptoms which depend on each of these injuries is so very iuiperfect that this anatomical division is as yet impossible. No distinct symptoms exist from which it can be affirmed that in one case there is extravasation of blood in the cavity of the arachnoid ; in another, punctiform extrava- sation in the substance of the brain ; in another, laceration of the surface ; in another, of the central parts of the encephalon ; and still less can we localize the lesion which we may suspect. All that can be said as yet is, that in cases of slight concussion small extravasations probably exist either on the surface of the brain or scattered about in its substance, or the brain is bruised here and there, and that in all cases vvhere the symp- toms of head injury are very severe (as where there is severe spasm or profound coma, with general paralysis) the brain will be found lacerated. I exclude, of course, cases of external pressure in which the compressing agent and the part compresed can be diagnosed with more or less ap- proach to certainty. TJie symptoms of concusf^ion are as follows: The patient is stunned, and lies insensible, with pale face and cold skin ; the pulse is weak, pos- sibly imperceptible, and often very irregular ; the state of the pupils is variable, but usually they respond to light ; the breathing is feeble and Fig. 50. Fig. 49. — Depression of the brain, from a case in which the patient had suffered from severe concus- sion twenty years before his deatli. The case is related in Mr. Hewett's essay, Syst. of Surg., vol. ii, p. 321, from which the woodcut is taken. In this case the mechanical lesion which accompanied the symptoms of concussion must have been superficial laceration of the brain, followed by extravasation of blood into the lacerated part. In other cases punctiform extravasations have been found in various parts of the brain, and probably the ex- travasations of blood in the membranes of the brain uncomplicated with laceration or bruising of its substance, which are spoken of on p. 166, are sometimes accompanied by symptoms of concussion. Fig. 50. — Thermograph of concussion. shallow ; the urine and faeces ma}' be passed involuntarily, but there is no paralysis of the sphincters, nor any other s3mptom of paralysis. This is the first stage, that of insensibility or collapse. 178 INJURIES OF THE HEAD. Temperature. — I append a thermograph of an ordinary case of severe concussion, which passed over in about the average time, and have also noted the rate of the pulse and respiration. On the subject of temperature in head injuries I cannot do better than ao-ain quote from Mr. Le CJros Clark's valuable lectures: "Tlie tempera- ture in cases of severe liead injury seems to be no measure of the amount of lesion sustained by tlie brain. Thus, in two instances of simple con- cussion, in which the temperature was taken half an hour and an hour respectively after the accident, it was found to be 93.5° and 9(i.3° ; yet both these patients recovered without any reaction beyond tlie normal standard. In another case of haemorrhage into the brain, with total un- consciousness, the temperature was noted as being 95.2^ half an hour after the injury, and never sank below 94.9°. In another remaikable instance, however, of fractured base, with laceration of brain, tiie tem- . perature fell as low as 87.4° in an hour and a half after the accident. I am not aware of any lower recorded temperature. This patient survived about nine hours, but the temperature scarcely attained 90° just before death" (oj). cit., pp. 122, 123). The second stage is that of reaction. The patient can now be roused, though sometimes not without difficulty. He usually vomits. The pulse rises and becomes more regular, and the natural temperature returns ; headache generally is complained of for some time, and after this the pa- tient may entirely recover, or the third stage may ensue, which is that of traumatic inflammation of the brain or its membranes — to be afterwards described. Treatment. — No treatment is necessary in the early stage of concussion. If the collapse is very alarming it may be thought right to give some stimulant, but this is hardly ever necessary in cases of average severity. Warmth and sinapisms may be applied to the extremities and epigastrium. When reaction sets in it should be watched. If moderate, nothing will be rerpiired beyond quiet, cold to the head, and low diet, with occasional purgatives. If the pulse rises ver}^ rapidly in volume and rate it is right to take blood from the arm. But tiie question of venesection and of the administration of mercury' rather belongs to the treatment of traumatic inflammation, wliich will be considered further on. It must be remembered tliat the tendency to death in pure concussion is from syncope or shock — failure of the heart's action ; so that the only treatment which can be efficacious in the early stage is such an adminis- tration of stimulants as in the judgment of the surgeon will not involve the risk of provoking inflammation. I would repeat that in this, as in all other forms of injury to the head, perfect quiet, in a darkened chamber, seems of great importance as a precaution against too severe reaction. (Jomprci^niini of the tjrain is the term used to describe cases in which there is definite evidence of paralysis — a condition marked by stertorous, oppressed, and slow breathing; dilatation of the pupils, perlia|)s with insensibility to light; slow, labored pulse ; relaxation of the sphincters; coma; and paralysis of tiie liml)s on one or both sides. Compression seems to me to depend generally on the extravasation of blood into the interior of the bi'ain from laceration. It usuall,v proves rapidly fatal when that lacei'ation involves the central parts, giving rise to rapid extravasation into the ventricles, the pons Varolii, or the medulla oblongata ; and such cases are quite beyond the reach of surgical treat- COMPRESSION OF THE BRAIN. 179 Fio. 51. ment. It is onl}' when the paralysis affects one side (that opposite to the injury), and appears to be due to one of the well- known causes — viz., depres- sion of a fracture, lodgment of a foreign bod}' on the sur- face of the brain, extravasa- tion of blood between tlie bone and dura mater, or superficial effusion of pus — that the operation of tre- phining is justifiable. In such circumstances I think it is so, though in none of them is it often successful. The paralj'sis which accom- panies depressed fracture or the lodgment of a foreign body often depends reall}- on extravasation of blood with- in the brain from laceration. Extravasation of blood above the dura mater very rarel}^ is limited to the precise point which can be reached by the trephine, and it also is often accoraj)anied by central or by meningeal extravasation. And the numerous causes of failure in trephining for pus have already been fully de- tailed. Therefore, though in desperate cases any opera- tion is justifiable wliich holds out a reasonable hope of success, it is not to be wondered at that trephining is very rarely successful, or that some surgeons appear to have almost altogether renounced it. These views about the justifiability and tlie causes of failure of trephin- ing may be illustrated by the Figs. 51 and 52, taken from two cases of depressed fracture, in one of which trephining was performed, and in the other not. In Fig. 51, although the operation seems to have been per- formed most thoroughly' and most successfully, as far as the elevation of the depressed bone goes, it proved useless in consequence of the sulija- cent mischief. And I may take occasion to remark that in many instances ' the immediate object of the operation — viz., the replacement of the de- pressed bone — is not effected by any means so fully as in the case before us. The examination of a large number of Museum specimens has shown me that often, although the greater part of the bone has been lifted up, and the operation must have appeared to the surgeon to have been com- pleted (and no blame can attach to him for thinking so, and for abstain- ing on that account from any further interference), yet examination from the inside would show spicnla or depressed edges still irritating the membranes or the brain. In Fig. 52 is seen one of the ordinary injuries in which the practice of different surgeons varies. There was no positive compression ; the An extensive depressed fracture of the vertex of the skull which has been elevated by trephining. The mark of the trephine is seen at the corner of the .sound bone, and it has also just touched the end of the depressed bone; and the traces of Hey's saw, which has been used to take off the overhanging edges of the sound bone, are very distinctly marked. The depressed bone has all been very fairly ele- vated, and the operation did temporarily relieve the symp- toms of compression, as the patient became a little more sensible and was able to speak ; but lie only lived a few hours. Death was caused mainly, as it seems, by hsemor- rhage between the bone and dura mater, the source of which was not precisely ascertained. Tlie fracture passed across one of the main grooves for the middle meningeal artery, but the vessel itself appeared uninjured. The dura mater was not torn, but the lower part of the middle lobe of the brain was contused on each side. The depression seen at the back of this preparation appears to be due to some old injury; but nothing is known about it.— St. George's Hospital Museum, Ser. i. No. 16. 180 INJURIES OF. THE HEAD. bnvin was deeply injured, and the surgeon thought it useless to interfere. Yet it is perfeftly fair to argue that in a case where it would have been so easy to remove sharp edges of hone sticking into the wound of the membranes and irritating tlie lacerated surface of the brain, it ought to have been done, as affording a patient the last chance, however feeble it might be ; and such is unquestionably my own opinion. Fic. ")•?. A, OUTER VIEW. B, INNER VIEW. Compound depressed fracture of the parietal bone. The brain in this case was lacerated, and the escape of brain-matter from the wound relieved the symptoms of compression, so that the patient (a boy £et. 16) was sufficiently sensible to give an account of the accident. He had no head-symptoms for three days. Then pain in the head came on, with suppuration and increased discharge of brain-matter from the wound. A fortnight after the accident he became suddenly unconscious, with stertor and dilated pupils. Next day he died. At the post-mortem examination a large abscess was found, occu- pying all the outer part of the middle lobe on that side. The injury was caused by a fall through a skylight. The drawing shows the exact limitation of the fracture, and the ease with which the whole of the depressfd bone might have been removed. Fig. a presents the external aspect. At one angle is dotted the circle of an imaginary trephine hole. If this portion of bone had been removed, the whole fracture might have been elevated at once, for the large fragment at the opposite side of the fracture was per- fectly loose (and has fallen out in the preparation), and by lifting up the upper of the two other frag- ments which were interlocked they might both have been most easily removed. Thus all the rough, jagged edges, which are seen in Fig. b sticking into the brain, would have been taken away. — St. George's Hospital Museum, Ser. i, No. 248. Cases 7iof Claasifiahlc. — Besides the cases which correspond to the topical descriptions of concussion and compression cases are met with (and not rarely) in which tlie insensibility is by no means complete, and where it is dillicult to see whether tiiere is not some iini)erfecL paralysis, but where other sym})toms are far more prominent. In some of these cases there is delirium, sometimes (piicL, sometimes furious and maniacal, spasms or convulsions, constant screaming, excessive irregidarity of the jjulse, and in many cases great irritability when I'oused. Such symptoms may be connected witii laceration of various ])arts of the brain in which the haemorrhage lias iu)t l)ecn suflicient to produce complete compression ; but it must be admitted that we know little of the real anatomy of them beyond this, that in those cases which prove fatal (for many recover) some laceration of the l)rain, or extravasation into tiie meinbranes, ap- pears to have l)een always found. But as such laceration and extravasa- tion have existed in cases presenting no such symptoms, it is clear that TRAUMATIC INFLAMMATION. 181 the real cause of the difference in different cases between the sequelae of injuries which seem nearly identical in tlieir anatomy is still to seek. In all such cases it seems to he tlie chief object of treatment to avoid and soothe excitement, for wliich purpose strict quiet, in a darkened room, is most essential. Tlie head should be shaved, and cold lotion or an ice- bag applied, if the patient is not too restless ; otherwise it should be con- stantly wetted, so as to cool it by evaporation. Low diet should be in- sisted on, unless contraindicated by the state of the pulse; and the cau- tious but, if necessary, free use of morphia has in some striking cases appeared to me to be of the most signal service in calming tl»e spasms or fits, and so saving the patient from death by exhaustion. Traumatic Inflammation. — Compression tends to death by coma, i. e., by gradually increasing insensiliility and paralysis, which, when it ex- tends to the functions of deglutition and respiration, necessarily proves fatal. And such paralysis is due to one or both of two causes, viz., pres- sure by extravasated blood or pus or by foreign bodies, or softening from inflammation of the substance of the brain. Such inflammation is the most formidable accident in head injuries, and the chief object of our treatment is to obviate or to combat it. In old times bleeding was used unsparingly with this view — no doubt too indiscriminately; but I have met with no hospital surgeon who does not think that the reaction against this "antiphlogistic" treatment lias also been too indiscriminate, and who could not recall striking instances of the benefit of judicious vene- section in cases of apprehended or incipient inflammation after injury to the brain. The great point is to be aware of the symptoms which mark the onset of this inflammation, so as not, on the one hand, to depress the patient, and possibly favor the occurrence of diffuse suppuration by inju- dicious and unnecessary loss of blood, or, on the other, to allow the in- flammation to get ahead, when bleeding will probably prove useless. Traumatic inflammation affects either the membranes (meningitis) or the substance of tlie brain (enceplialitis). The membranes may be in- volved in injury of the bone, the inflammation spreading from the dura mater inwards, leading to effusion in the arachnoid cavity, where it is almost always diffused, and to inflammatory cellulitis of the pia mater; or the inflammation may spread outwards from the injured brain, and then it is often limited to the pia mater. Traumatic encephalitis may be caused by the spread of meningitis inwards, or it may be the result of lesion of the substance of the brain, and so follow on a case which has commenced as one of "simple concussion." Its common results are, softening, usually of the surf\ice, sometimes also of the central parts, of the brain, effusion into the ventricles, or abscess of the brain. The symptoms of meningitis and encephalitis have not been found as yet to admit of diagnosis from each other beyond such a conjectural opin- ion as is derived from the exciting cause. The early symptoms are, pain in the head, feverishness, hot skin, quick pulse, contraction of the pupils, intolerance of light and sound. Then sickness ensues, with restlessness. Convulsions succeed — at least this is the usual order of appearance of this symptom, though there are cases in which they come on very early, and are almost the first alarming symptom noticed. They are followed, or sometimes preceded, by delirium. Coma ensues, and then paralysis. The first onset of inflammation may be heralded by rigors ; but rigors occur usually in the later stage of inflammation, and may be taken as indicative of suppuration. Whenever traumatic meningitis or encephalitis is diagnosed, or even 182 INJURIES OF THE HEAD. DAY 1 ^ 3 OIID UNCONSCIOUS RESTLESS J DROWSY CONSCIOUS DELIRIOUS yenp !l04- 1 /■/ ,103 / lOZ /■' 101 '■■ 100 99 98 97 f- brain ; but inflainniation and suppura- tion of the injured anterior lobe rapidly supervened. Avlien there is reasonable cause for aiiprelieiidino; such an event, the first indication is certainly to shave the head, and !""■ •'■'' ^Wh' ^^^'^ to it, to purge the patient very freely by a large dose of calomel, followed by a saline purgative, and to keep him very quiet in a darkened room. If the pulse rises decidedl}' in rate, and if its volume and hardness also increase, 1 never saw a case in which any harm resulted from a mod- erate bleeding (say 10 to 12 ozs.), and many in which it did great good. At the same time mercur}^ should be given in powder, calomel being the salt usually selected, in doses of about 2 grs. four or six times a day. A (bcnuograph showing the rapid The powdcr cau be placed OH the back of rise oltemperature which sometimes is ^j^^ patient's tOUgue with a little SUgar, if noted in cases of head injurv as intlani- , . ' ,, mi- j_ h xtti niation comes on and passes into sup- he IS Unable Or UUVVllling tO SWalloW. When puration. The patient was admitted there is nuicli excitement, and especially if ^Tith compound fracture of the frontal eonvulsious are present and are severe, mor- sinus, involviuK also the internal table, i • • i /• • i -ii i • i -,.1 a porHon of wh.ch w«s driven into the P^ia IS Very beneficial, either combined with brain. The depressed bone was perfectly the Calomcl Or introduced UUdcr the skiu, loose, and was easily removed froin the or both. We have the high authority of Mr. Hewett for saying that ''opium, or better still, morphia is doubtless of great value in mau}^ cases presenting some of the most characteristic symptoms of inflammation." ^ The main questions in the subsequent treatment are whether to repeat the venesection, and whether the trephine is indicated. The first is a matter which will tax the sur- geon's judgment and tact. There can be no doubt that manj' cases have terminated unfavorably from overbleeding, of which Mr. Hewett records a remarkable example, where, however, the diagnosis was also at fault, for, after death, no anatomical proof of inflammation was found. But this ought not to discoui'age the surgeon when the indications are clear, 1 e., if the same symptoms which first led him to bleed still continue, or even increase. A very valuable contraindication to repeated venesection is pointed out by Mr. Hewett in the watery condition of the blood, which sometimes is noticed after one or two bleedings. In cases where the indications of cerebral congestion and excitement persist (heat of head, excessive pulsation of carotids and temporals, violent delirium), but the general circulation hardly warrants bleeding, leeches may be applied to the scalp and temples. As to the indications of the formation of pus beneath the cranium, and the symptoms which justify trephining, refer- ence must be made to p. 102. Hernia rerobri is a consequence of local or limited inflammation of a portion of the bi-ain, coexisting with wound or sloughing of exposed dura mater, whereby the inflamed brain is forced through the skull. It is not every wound of the. brain, even when it involves loss of substance, which necessarily produces hernia cerebri. I have seen a portion of the brain sliced off (in a case of encephalocele mistaken for encysted tumor), and no harm result. And there are plenty of instances on record in which large portions of the brain have been torn away in injuries of the head, and the wound has healed kindly. But very commonly after a compound Op. cit., p. 350. HERNIA CEREBRI. 183 fracture, in which the dnra mater has also been lacerated, in a few days an offensive ichorous discharge is noticed from tlie wound, and a fungous mass begins to sprout out of it. This sloughs and drops off in fragments, which, if examined in the microscope, are found to consist in great part of the products of inflammation. Sometimes, indeed, they consist en- tirely of such products, and to these protrusions the name of " false hernia cerebri" is sometimes given, reserving the name of "true" for those in which the characteristic structure of the cerebral substance can be found. Hernia cerebri is generally fatal, though by no means universally so. It commonly occurs in compound fracture of the vertex; but I have figured above an instance in which it took place in the middle fossa of the base of the skull ; and Mr. Holden has referred to a remarkable in- stance in the anterior fossa, where the patient, a boy, lost a large quan- tity of brain-matter through the nose, but ultimately recovered. 1 once watched a case in which the greater part of one anterior lobe of the cere- brum was discharged through a compound fracture of the orbit, in which the whole roof of the orbit had been removed. There were remarkably few symptoms, and the boj'^ seemed so have a fair chance of recovery, when symptoms of general pyaemia developed themselves, and he died eighteen days after the injury. It is often remarkable how little the functions of the brain suffer even when, as in this case, the actual loss of substance is great. Often, however, the real loss is but small, since a great proportion of the fungus consists of inflammatory products. No treatment is either necessary or indeed admissible in hernia cerebri, beyond such applications as may correct the fetor of the discharge as far as possible. AH attempts to repress the protrusion are dangerous, and probably inefficient, and the practice of shaving it off is quite exploded. I can say but little on the subject of direct lesion of the nerves at the base of the brain. Those of the seventh pair are the most common, and in fracture of the base loss of hearing and facial paralysis are not un- frequently noticed. Extravasation of blood in the sheath of the optic nerve has been found after death, and blindness may be so caused, and „ may pass away, though in other cases it has resulted from absolute laceration of the nerve, and is then probabl^^ permanent. But all the nerves of the base (with the excep- tion, I believe, of the little fourth nerve) have presented distinct evi- dence of traumatic lesion, as indi- cated by the loss of their function, and proved by post-mortem exami- Extravasation of blood in the sheath of the . sj . 1 optic nerve after injury to the head. Prom Mr. nation. JNo treatment can be Hewett-s essay, Syst. of Surg., 2d ed., vol. ii, p. adopted ; but the symptom is often 332. valuable in a diagnostic point of view. It is important to remember the fact on which Mr. Le Gros Clark has laid some stress, that the symptoms of paralysis, indicating lesion of the nerves at the base of the skull, often do not present themselves till three or four days after the receipt of the injury, showing that they are due to inflammatory reaction. This fact, however, by no means nega- tives the diagnosis of fracture, since a fracture is one of the most prob- able causes of such inflammation. 184 INJURIES OF THE HEAD. Trephining the Skull. — The operation of trephining the skull, although it is always called by that name, is not alwa^'s performed with the circn- lar saw called Trephine. The elevated edge of an injured bone is often more easily and expeditiously removed by the saw which bears Hey's name; tiiough, as Mr. Hey points out, it was originally figured in Scul- tetus's Armamenfarium Chirurgicum, and was either revived or rein- FlG. 55. ^♦'"♦vMv^*^ Hey's saw (from Hey's Stcrgei-y). vented by Dr. Corbell of Pontefract, who showed it to Mr. Hey. The straight edge enables the surgeon to remove any length of bone at one stroke. When a curvilinear direction has to be given to the section the round edge must be used. Trephining is an operation which is neither very easy in all cases nor destitute of dangers of its ovvn in any. The soft parts are first to be cleaned carefully from the part of the bone on which the trephine is to be applied, which in cases of fracture should be the sound bone on the edge of tl)e depressed portion, and, if there are two depressed and interlocking pieces, the trephine-hole should hit the edge between them (sec Fig. 52). The pin of the trephine being run out and firml}^ fixed, is Fig. 50. ^S^^^^¥%ti%if1^"^ 'rilfri'Tfi--''Mi The " elevator." Mem. In tripliitiiiiK it is well to liiive a few elevators of different shapes and curves at hand. The one here represented is, however, one of the most useful. a[)plied at such a point as will secure this object, and then by a screwing motion the section of the bone is commenced. Wlien the groove is deep enough to avoid all risk of tiie trephine slipping, its pin is withdrawn, and as soon as tlie surgeon believes that he has got through the external table he begins to proceed witii caution, and witli a very ligiit liand, often feeling the groove with a fine i)robe, or, as is more usual, a common quill toothpick. When tiie internal table is perforated at any part of the circle the elevator is introduced here, and the crown of l)one will generally come away. If it does not do so, the internal table must be sawn in some other part; but the trephine must not be pressed on the part TREPHINING. 185 already sawn through, for fear of womiding the dura mater. When the first crown of trepliine has been removed it may be necessary to take away a second or a third, or to saw off the projecting edges of the sound bone with Hey's saw (as in Fig. 51); or perhaps the whole operation Fig. 57. Fig. 57. — Trephine. The central pin is seen projecting slightly beyond the te«th of the saw. It can be withdrawn altogether within the crown of the instrument by the screw which is seen in the cleft of the stalk. Fig. 58. — The vertex of the skull, with a portion of bone removed in trephining for supposed de- pression of the inner table, ten months after the injury. The skull had been much thicktiied, espe- cially at its back part, by inflammation, so that the thickness of the bone removed is twice as great behind as in front. In consequence of this irregularity in thickness the dura mater was wounded in the operation —St. George's Hospital Museum, Ser. ii, Ko. 24. may be accomplished with the saw, in using which the same precautions are to be taken as in sawing with the trepliine ; but there is less risk of wounding the dura mater with Hey's saw, since it is only applied on the sound edge close to the fracture, and here the dura mater has of course been driven down by the depression. The greatest danger to the dura mater is in cases like the one from which Fig. 58 was taken, where the skull is of different thicknesses at diff'erent parts of the circle. CHAPTER VIII. INJURIES OF THE BACK. Sprains of the back are amongst the commonest of all accidents. They are the effects of wrenches or contusions, either of which produce violent flexion of the whole column, and which, therefore, sprain it at the part where such flexion is arrested, viz., near the sacrum. The injury consists in stretching, and in the severer cases probabl}^ more or less rupture, of the muscles, fascia, and ligaments on the pos- terior aspect of the spine, while the parts in front may be more or less crushed ; and, in particular, the kidney is sometimes contused or lacerated. 186 INJURIES OF THE BACK. The latter injury will, however, be treated of by itself in a subsequent section. When there are s>Mnptonis of injury to the spinal cord itself ('•concussion of the spine," as it is termed), those symptoms constitute the main feature of the casi;, and will be spoken of presently. In this place I shall t»peak merely of tlie uncomplicated sprains. Si/mplomK. — There is swelling at the injured part, with subsequent inflammation ; but oenei'ally no visible ecchymosis, since the blood which must have been poured out is beneath the deep aponeurosis. There is great pain in moving, and especially in extending the spine. The prog- nosis- is very favorable, though recovery is often slow. Treatment. — If, from the severity of tiie injury, the patient is at all collapsed, the first indication is to revive him from that condition. Then at first moderate general and local antiphlogistics will be indicated, with opiates, mercurial purges, Dover's powder at night, salines, spoon-diet, and leeches. Afterwards fomentation with poppy-heads, warm Goulard lotion, with laudanum, or compresses of tincture of arnica (.^j to Oj). When the patient is able to move in bed and sit up, friction and stimula- ting embrocations (liniment. lodi, Terebinthinse, Sinapis), or blistering or painting with iodine will probably relieve any remaining pain. In obstinate cases an occasional light touch with the actual cautery is very beneficial. Fractu7^e or dislocation of the sjnne is one of the most surely fatal of all accidents. Fracture sometimes affects onl}' some of the processes of the vertebrae — most commonly the spinous — and the mobility of the frac- tured process is the only symptom necessarily connected with the injury. No treatment is required be^'ond rest and a bandage. But when ''frac- ture of the spine" is spoken of, it is understood that the continuity of the whole vertebral column is severed. The gravity of the injury does not, howevei', depend on the fracture itself; for although no doubt the spinal column is the centre for almost all the movements of the body, and its integrity is, therefore, necessary for any active motion, yet this integ- rity would be restored after fracture, by bony union, as in any other bone, and the solidity of the column would probably not be materially' impaired. Fig. 59 is an example of the repair of a fracture of the spine by bony union in a patient who happened to survive long enough for the completion of the process. But tlie history of the same preparation also illustrates the reason why this injury is so fatal, for the cord in that case was crushed by the fracture as it almost always is ; so that, although the bones united, the spinal symptoms were unrelieved, and pursued their usual course to a fatal termination. In describing, therefore, the symptoms of fracture (or dislocation) of the spine, I must premise that most of these symptoms are what are called (on p. 1.S9) merely the rational symptoms of fracture, i. e., lesions for which we can find no other cause ; and that some cases occur in which similar symptoms (or symptoms very nearly similar) appear to be pro- duced by contusion of tiie cord without fracture; while on the other hand, there are cases on record in which fracture of the spine has l)een proved by post-mortem examination to have occurred, yet in which there have been no such symptoms, in consequence of the cord having escaped in- jury. The symptoms, then, of fracture of the spine are as follows: pain in the part, aggravated by passive motion, more or less incapability of moving the spine at that i)art and deformity of tlie spinal column. All tliese are no doubt direct symptoms of tlie injury ; but they are not decisive, with the exception of the last, which, if present in a marked FRACTURE OF THE SPINE. 187 Fio. 59. degree, leaves no doubt; but it is frequently absent. Tiiere is usually considerable collapse from the severity of the injury. The usual sequehie, and those by which we infer the existence of fracture, are complete par- alvsis of motion and sensation in all the j^arts supplied with nerves from below the seat of the lesion. Thus in fracture above the origins of the phrenic nerve (?'. ^., above the fourth cervi- cal vertebra), that nerve, as well as all the others which supply the respiratory muscles, will prob- ably be ])aralyzed, and death will be instantane- ous.' With fracture lower down in the neck, the patient will retain the power of diai)hragmatic breathing, but not the motion of the intercostals or of any other muscle of respiration, or of any of the muscles of the trunk or limbs. Sensation will also be completel}' absent in all parts below the neck (except that in some cases perception of impressions may still be noted in the parts supplied I)}' the superficial descending branches of the plexus) ; the sphincters are paralyzed, so tiiat the urine is at first entirely retained, and then dribbles over, and there is no power of re- taining the faeces ; the passage of the catheter, thougli nnfelt, usually excites priapism ; and tickling or pinching the limbs, though equally dorsal vertebra is crushed; some nnfelt, also very often i)roduces reflex motions. °'' i'« fragments are driven for- mi • . 11 , • n- \ ^ 1 ii J.- J. wards, forming an irregular ring The intellect is unaffected, and the patient usu- of bone which lies in front of the ally free from pain. The temperature of the bodyof the firstiumbar, to which paralyzed part varies. Sometimes it is higher it is soldered by bony union. An- 7i liij?i.i 1 1 \ ,. J.I • • 4.1 ii other large fragment is driven than that of the body; but this is not always the i.^.^wards into the canal. The case. solidity of the column is restored, In fractures so high up as this the patient b"t with slight angular eurva- usually dies in two or three days, and often much Z^:^;^^^^^^'-, sooner. Death is produced generally by the no. 49. accumulation of fluid in the lungs, which the patient is unable to cough up, and which chokes him. But when death follows more rapidly it is probal>ly from luiemorrhage into the substance of the cord or into its theca, which produces pressure on or disintegration of the spinal marrow above the seat of fracture. The lower down in the column the fracture is situated, the less is the extent of the paralysis. At the lowest part of the lumbar region, where there is no spinal cord, but only the leash of nerves of the cauda equina, Fracture of the spine united, the patient having survived five months. The body of the last 1 A very interesting case is related by Mr. Shaw, in the Syst. of Surg., vol. ii, p. 396, in which a fracture with disphicoment of the first and second vertebrae was ac- companied by no serious symptoms, the fragments being displaced forwards, towards the pharynx instead of backwards on to the cord. The patient died from dropsy a year afterwards, and the preparation is in the Museum of Middlesex Hospital. The same author (ibid. p. 393) relates a case in which the patient survived fifteen months after a fracture of the fourth or fifth cervical vertebra, though the cord was entirely disorganized at the seat of fracture, and there was therefore paralysis of all the parts below the head. 2 On the temperature after injuries to the cervical portion of the cord see Wunder- lich's Manual of Medical Thermometry, translated by Dr. Woodman for the New Syd Soc, p. 423. If we can trust the observations there recorded, the temperature has been fuund as high as 111° F. and as low as 86°. In Clin. Soc. Trans., vol. vi, p. 75, may be found acase of laceration of the cord opposite the first dorsal vertebra, where the temperature in the axilla is said to have fallen as low as 80.6° F. 188 INJURIES OF THE BACK. some of these nerves may escape injnry while the rest are torn, and so the resnltino; paralysis of the lower limbs may be imperfect. Usually, how- ever, in fractures of the liiml)ar spine the lower limbs and tlie sphincters are totally jiaralyzed. In the dorsal region there is also paralysis of the abdominal muscles and loss of sensation to an extent corresponding to the seat of the injury, while in the fracture of the upper part of the dorsal spine symptoms of ditficulty of breathing occur which api)roach more and more to those produced by fracture in the cervical region. The later symptoms of fracture of the spine are due to low inflamma- tion of the urinary mucous membrane, and to sloughing of the skin. The nrine which dribbles over, or which is withdrawn from the bladder, is at first natural; but it soon becomes very offensive, phosphatic and alkaline. For a while it may be secreted acid, and only becomes alkaline from de- composition in the bladder, but after a time it is secreted alkaline in the kidney, the inflammation having extended to that organ. This inflam- mation is partly due no doubt to the retention of the urine in the l>lad- der, but not entirely so ; nor can it 1)e entirely obviated by withdrawing the urine frequently and washing out the l)ladder with acidulated lotion, although these measures will diminish it. In fact, there is a tendency to low inflammation of all the mucous membranes as well as of the skin as a consequence of the deprivation of their nervous influence. This is shown sometimes in the intestines by the tarry condition of the fieces, and the congestion found after death; and probably the low bronchitis which is so constant in fractures high up is not caused by hypostatic congestion alone. So also the" gangrene of the skin, though greatly accelerated by pressure, is not due entirely to that cause, as will be stated below. Apart, then, from complications, the tendency to death in fractures high up is from the pulmonary congestion ; in those low down from urinary inflammation or from sloughing. Didocalion of the Spine. — The symptoms of dislocation are the same as those of fracture at the same level, and the cause of death is the same. Thus in the specimen from which Fig. fiO was taken, and which is one of pure dislocation at the level at which this injury is most common {i. e., at the root of the neck), the upper vertebra was brought forward and the lower backward, and the cord crushed between them. Death took place at the usual period, viz., two days after the accident. And some amount of dislocation is a usual concomitant of fracture, so that the two are always treated of as being jjractically the same injury.' There is, how- ever, one point of practical importance in connection with the subject, viz., the possil)ility of diagnosing and reducing dislocation, and the pros- pect of benefit from such reduction. Most dislocations occur at the lower part of the cervical region, though a few examples are recorded in the dorsal; and I have pul)lisl)ed an instance of one (of which the })repara- tion is in the Museum of St. George's Hospital) between the last dorsal and first lumbar vertebra, in which the dislocation was actually reduced.'"' But the reduction had no effect in relieving the symptoms of paralysis, and it is even possible that the force employed may have been the cause of suppuration which took place around the seat of injury, and which ' In Mr. Le Groa Clark's Lectures on the Principles of Surgical Dingnosis, p. 142, will bo found the account and drawing of a case in which, along with fracture of the spine, the tiftli kiiubHr vertebra was dislocated from all its connections, and thrown entirely hehind the spinal column ■' See Path. Soc. Trans., vol. x, p. 219. The patient was under Mr. Caosar Haw- kins's care. Sir Charles Bell seems to have possessed a somewhat similar preparation, but I do not know whether it is still in existence. FRACTURE OF THE SPINE. 189 proved the starting-point of general pyjBmia. Nor do I see by what signs it is possilile to recognize the existence of dislocation apart from fracture. Yet, though the diagnosis may be uncertain, and though it is certainly possible that harm may be done by the manipulation, I still tiiink that when the displaced parts can be returned with tolerable ease into their natural position, it is justifiable to try thus to liberate the cord from pres- sure, whether we believe the injury to be dislocation or fracture. And there are doubtless histories of cases in which the surgeon has found an amount of displacement of the spinous or transverse cervical processes which has been evidence to his mind of dislocation, or at any rate dis- placement of the bodies of the vertebrae, and which has been remedied by extension, the patient regaining perfect health. But it must be allowed Fig. 60. — Dislocation of the spine in the cervical region. The fifth and sixth cervical vertebrse are completely separated from each other, the ligamenta subflava are torn through, and the ariiciilating processes dislocated from each other. The intervertebral substance was lacerated, and the anterior and posterior common ligaments completely torn through.— St. George's Hospital Museum, Ser. i, No. 42. Fig. fil.— Fracture of the spine — to show the displacement which very coTnmonly takes pliice of a por- tion (or, as in this case, almost the whole) of the body of the vertebra into the spinal canal. T)ie frac- tured and displaced vertebra is the seventh cervical. The intervertebral substance between the sixth and seventh cervical vertebrae was ruptured, and their laminiie separated from each other by rupture of theligamenta subflava, i. e., the fracture was complicated with dislocation, as so commonly occurs. The cord in this case was entirely disintegrated from a point opposite the fifth cervical to the tliird dorsal vertebra. — St. George's Hospital Museum, Ser. i. No. 56. that these cases are in man}'^ respects of doubtful value, and we have yet to seek for one in which immediate paralysis after an injury accompanied with visible displacement of the spine has l)een remedied by reduction of the projecting portions. In any case in which the surgeon thinks it right to attempt reduction, all possible gentleness and caution sboidd be used, and if moderate force is unsuccessfid the attempt should be abandoned. Trejjhiniiig the Spine.- — This leads us to the consideration of the treat- ment of fractured spine. In the first place, if the displacement cannot be remedied by extension and counterextension, can it be b}' surgical opera- tion ? The proposal to "trephine the spine" — i.e. to attempt in one way or another to elevate the portions which have been depressed on to the spinal marrow — has been sustained by the supposed analogy of de- pressed fractures of the skull, and has received the support of many famous surgeons. It is not becoming, therefore, to speak of it with dis- 190 INJURIES OF THE BACK. respect. But the assumed analogy is obviously a very deceptive one, and I can lind no evidence that the operation has ever been really in any degree successful ; while, if unsuccessful in its object, it must tend to hasten death, for it is undeniably a very severe proceeding, requiring a long and deep incision through a large mass of muscle, and thus exhaust- ing the patient by hi^morrhage when the rational indication of treatment is to spare his strength in ever3' possible way. There is, in fact, little analogy between the indications which lead the surgeon to trephine the cranium and the conditions present in almost everj' case of fractured spine with displacement. The brain in cases suited for the operation, is compressed at a single definite accessible part (of no great extent com- pared to its volume) by a small portion of depressed bone or by a foreign body ; but its own proper tissue is believed to be only very slightl_y or not at all injured. In f*ractiires of the spine, on the other hand (as may be seen in Fig. Gl ), the displacement is generally due to projection of a por- tion or the whole of a bod}^ of a vertebra, and sometimes of more tlian one vertebra, into the spinal canal, at a part utterly inaccessible, crush- ing and disorganizing the whole spinal cord to an extent v.'hich cannot be remedied by the removal of the cause which produced it.^ Yer^^ often the cord is entirely' divided at the seat of fracture. No judicious sur- geon would think of trephining the skull if he believed that the brain was hopelessly lacerated — far less if it be thought that there was in all proba- bility a large mass of bone sticking into it at the base of the skull. Dr. Brown-Sequard tries to meet this action by urging that though the laminffi and spinous processes are the only parts which are accessible for removal, yet the removal of these from behind will liberate the cord from the pressure of the displaced bone in front. Even if this were so, how- ever, it would leave a rugged fragment irritating the cord, and the pros- pect of benefit would not justify the additional irritation produced by the operation. It is quite true that there are cases in which the displace- ment of bone is less than that shown in the figure, and that the cord is not always hopelessly disorganized; but it is also true that in such cases the patient has a good prospect of survival, and it seems that under such circumstances an operation is more likely to prove the starting-point of inflammator}' softening than to cure the patient. Dr. Gordon's case,^ though an interesting one, and though some improvement seems to have 1 The only part of the vertebral column which is completely accessible and which can be fairlj- removed, when depressed on to the cord, is the arch or lamina. Now, this is the part which is the most seldom affected. Mr. Le Gros Clark says : " Of the many cases of fractured spine which I have on record, and which I have examined post-mortem, I cannot recall an instance in which the depression of the arch alone sufficed to account for the symptoms. I am aware that such cases are recorded, but 1 speaU only of my own e.\p(!rience, and therefore I conclude that they are rare " He goes on to show that even when the injury is a direct blow on the back of the spine, the cord is in all jirt>babiiity disintegrated beyond recovery. The whole discussion of this topic in Mr. Lc; Gros Clark's Lectures on the Diaj^nosis of Visceral Lesions, pp. 187 and seq., is well worthy of perusal. The conclusion is as follows: "I fear we must abandon this operation. . . . To weaken still further the remaining connec- tions of a broken spint- ; to convert a simple into a compound fracture ; to expose the sheath of the cord, and possibly the cord itself; and to entail the risks attending the period of repair — cannot be regarded as circumstances of indifference. Accidentally, here and there, an instance may occur in which benefit does, or seems to, result from surgical interference; and the time may arrive when, perchance, the means of diag- nosis at our command may enable us to judge with more precision of the nature and extent of the injury inflicted ; but at prcssent I catniot regard trephining the spine ao brought within the pale of the justifiable operations of surgery." - Med.-Chir. Trans., vol. xlix, p. 21. FRACTURE OF THE SPINE. 191 followed the operation, cannot be quoted as successful, since the paralysis remained permanent ; and although the operation has been repeated man}' times since, in no case does it seem to have been of unmistakable service. Exceptional cases may occur in which, from the nature of the accident or the appearance of the part, the surgeon may think that only a small amount of bone is implicated in the injur}', and where he may determine to give the patient the poor prospect of relief which this opera- tion holds out ; but in general it will onl}^ hasten the end. Treatment. — The treatment of fractures of the spine must be directed to combat the two main dangers to life which can be met by surgical treat- ment, viz., the tendency to cystitis, and that to sloughing ; the other and still more formidable danger, from loading of the lungs, is unfortunately irremediable; but it only occurs in fractures high \\\^. The tendency to cystitis may be partly obviated by the careful and frequent use of the catheter, and by gently washing out the bladder with acidulated water ; but there is a strong disposition to low inflammation of all the mucous membranes, and especially' that of the urinary tract, in this accident, so that the relief afforded can only be partial.^ As the patient is not sensible to the pain of rough catheterization, injury may easily be done unless great care is taken. But if catheterization be neglected the inflammation may prove fatal by spreading up to the kidneys, or (as I saw in one case) by perforation of the bladder. Sloughing is a very frequent cause of death. Sloughs form on all parts exposed to pressure, but also on places (as the malleoli) where no pressure seems to have acted ; so that there can be no doubt that the privation of nervous influence acts as a cause of the gangrene, as well as pressure, though the latter is a very powerful agent in producing the sloughing ; and tlie tendency to this inflammation is much increased by neglect in nursing, whereby urine and fteces are left in the bed to irritate the skin. Scrupulous cleanliness, frequent slight changes of position, which can be effected by means of pillows in- serted here and there, and by gently rolling the patient to one side or another, and the use of the water-bed or water-pillow, seem to me all that can be done. Should the patient survive he may recover power to some extent, but I am not aware of an}^ case of complete recovery from paralysis which was proved to be due to fracture of the spine. Concui^mon of the spine is a term which is applied to cases in which after injury the functions of the spinal cord are more or less lost, but without any evidence of fracture. The injuries which produce concussion of the spine vary greatly in severity, and the symptoms vary also from slight numbness, pricking sensations, or difficulty of motion, to an amount of paralysis both of motion and of sensation as great as that of fracture, though commonly not so persistent. The anatomy' of concussion must vary also to a corresponding extent. Frequently, I have no doubt, the lesion consists in haemorrhage external to, or in the substance of the cord, sometimes most likely in laceration of the cord, and at others possibly in inflammatory effusion or inflammatory softening. That cases ever occur in which the tissues of the spinal marrow and its vessels are uninjured, as would be implied by tlie term " concussion," if rigidl}' interpreted, is as unproved in the case of the spine as of the cranium. The symptoms to which the term concussion of the spine is applied ^ Those who hold the germ-theory of disease dwell on the advantage of using ear- bolized oil for the catheter in such cases as these, and there can certainly be no harm in doing so. 192 INJURIES OF THE BACK. come on eithei- iinuiediately on the injury or after an interval of uncertain duration. I do not liuow that I can do better than quote two of the cases which Mr. Le Gros Clarli gives as instances of concussion of the spine following in one case immediately, and in the other subsequently to an in- jury. "A man 3G years of age, weighing IH stone, was tripped up in the road, and fell heavily on his left hip, and then turned over on his back.- On trying to rise he failed, not having any power of movement in either lower' extremity. He was brought at once to the hospital. On admit- tance he complained of pain in the lumbar region, and there was slight tenderness in pressing the spinous ridge of this part ; but careful exami- nation failed to detect any irregularity or other sign of mechanical injury of the vertebral column. There was entire loss of power in his lower limbs ; he could not even move a toe ; sensation was impaired ; he said his legs were numbed. There was slight priapism, and he was unable to micturate. His pulse was 60, but there were no signs of well-marked col- lapse. On the third day he was able to move his toes a little. On the ninth day sensation was perfect, but he had made very little progress in regain- ing muscular power. Nearly three weeks elapsed before he was able to dispense with the catheter; and at the expiration of five weeks he was still almost as helpless in moving any part of his lower extremities. He remained in the hospital for four months, his health being tolerably good throughout. He was tlien able to get about very fairly, but with a shuf- fling, unsteady gait." The diagnosis of a case of this sort from one of fracture will rest partly, as Mr. Clark observes, on the absence of the local signs of fracture, and on the fact that the accident is not one likely to have produced fracture, and partly on the partial extent of the paralysis. Yet, as he adds, "in some cases where the symptoms are persistent, doubt must remain as to the true nature of the lesion, and a cautious prognosis is therefore re- quired." The case in which symptoms of spinal concussion followed after an in- terval is as follows : " A man was injured in a collision in the tunnel four or five miles from Brighton. He walked this distance with some difficulty into the town, and within twenty hours became entirely paraplegic. He recovered slowly ; and after a lapse of two years was able to walk as well as before the accident. One spot in the back was always tender," and continued so at tlie time of the report, which was, I believe, about five years after the injury. These cases of spinal concussion have acquired great surgical and even public interest of late, from the frequency with whicii they really occur, and from the frequency also with which they are alleged more or less falsely to have occurred in cases of railway injury. No part of a surgeon's duties is more ditlicult than that of forming an opinion in these cases, in which the alleged symptoms are sometimes entirely fabricated ; at others mixed with more or less of unconscious exaggeration or delusion, the result of mental causes; at others really existing, but iii so latent a condition that it is hardly possible at first to l)elieve in their reality. It is, therefore, no wonder that the most eminent surgeons constantly dilfer in their estimate of such cases, and that they constantly make opposite errors, by denying the reality of symptoms which the after-progress of the case shows to have been perfectly genuine, or by accepting others which are fraudulent or imaginary. No doubt as this class of cases becomes more familiar such diff'erences of opinion will become rarer; and they would even now be far less common if the system of our courts of law would permit of a delib- erate examination and report by a medical commission authorized to avail RAILWAY INJURIES. 193 themselves of all necessary opportunities for pronouncing an unbiassed judgment. As it is, both sides in the trial have an interest in procuring medical testimony on hasty examinations from wiiich one aspect of the case has been concealed as far as possible. Railway injuries are not usually pure examples of concussion of the spine, but the spinal injury is mixed up with symptoms of general siiock, besides, as may easily be the case, detinite lesions of other parts of the body. I will again quote from Mr. Le Gros Clark, who speaks thus on the subject of railvva}' injuries affecting the spine: ''Spinal concussion may be immediate and well marked ; or the indications of spinal mischief may not supervene until after the lapse of some time. General shock is often, but not always, in excess of that which accompanies simple con- cussion ; in some instances the collapse is great, accompanied by insensi- bility, but without evidence of injury to the head. Reaction, under such circumstances, is tardy and irregular. Numbness and tingling, some- times local, sometimes universal, is complained of. Other symptoms are, rigor, continued sickness, intermittent fits of numbness, excito-motor spasm in the limbs, violent throbbing sensations, or sense of heat or cold in the head or other parts, want of sleep or continued drowsiness, confusion of intellect, enfeebled muscular power, deafness, defective sight, accompanied by ocular spectra ; hyperaesthesia in some parts, but espe- cially in the spine ; great emotional excitability. Besides these I could enumerate other more especial symptoms; but they have been peculiar to isolated cases. With rare exceptions, extreme sensitiveness of the spine is present in these cases, and more frequently located at some particular part than distributed over the whole column. Again, this pain on pres- sure is sometimes referred to the lumbar muscles, at others to the spinous ridge. In some of these cases the patients entirely recover after a longer or shorter interval ; in others the health is permanently enfeebled, and a life of protracted discomfort is entailed ; or the sufferer sinks, emaciated and exhausted, into a premature grave ; or becomes the victim of some acute disease, the destructive tendency of which his defective organism is incapai)le of resisting. "It will be perceived that many of the foregoing symptoms and signs may be referred to what we are accustomed to regard as concussion of the spine ; but many also are due to general rather than special nervous shock. In some instances there is probably meningeal mischief; but the indications in others clearly point to organic change in the cerebro-spinal centre. "I have already shown, in a preceding lecture, how powerful an influ- ence emotional shock or physical concussion may exercise on organic vitality ; and I think it not inconsistent with acknowledged facts to affirm that protracted functional disturbance, or even fatal disease, may be the consequence of a rude shock simultaneously to the nerve-centres of the emotions, of organic and of animal life. I am, therefore, disposed to regard these cases of so-called railway spinal concussion as, generally, instances of universal nervous shock, rather than of special injury to the spinal cord. At the same time I admit that in this class of cases we meet with instances of simple concussion, but I see no reason for taking them out of the category of concussion of the spine from other causes."^ Mr. Clark gives also an account of the post-mortem appearances of the spinal cord in two cases, one, under his own care, in a child who had sustained an injury to tlie spine without fracture, and not producing 1 Op. cit., p. f50. 13 194 INJURIES OF THE BACK. paralysis at first, though this soon afterwards supervened. The child died three niontlis afterwards with inflammation of the whole cord below the eighth dorsal vertebra. There was no trace of hi^^morrhage or of dis- ease of the membranes, but the spinal cord was replaced by a mere " string of soft atrophied nerve-matter." In the other case, which was under the observation of Dr. Lockhart Clarke, and is published by him in the Path. Soc. Tranx.. vol. xvii, the case was one of ordinar\^ railway injury, the patient having survived three and a half years. His gait had been "unsteady, somewhat like partial intoxication, but without jerking or twitching;" and latterly his speech had become thick and hesitating. The spinal cord was wasted and shrunken, and its white matter showed evident traces of inflammator}' degeneration.^ The brain was also pallid and soft, particularly on the under surface of both anterior lobes. Diagncsis of Spinal Goncuaaion. — It would be impossible in a work like this to go fully into the ver}'^ difficult problem of the diagnosis of cases of railway injury. The subject is treated of with conspicuous ability in Mr. Erichsen's well-known work on Eaihvay Injuries, to which I would refer the reader for a more adequate view of the symptoms, pathology, and treatment of these difficult cases than my limits allow. I w-ould only sa}' here, that when there is any doubt of the patient's veracity or of the reality of the symptoms in all cases of alleged inability to perform cer- tain movements, it is most satisfactory to have physical evidence of the wasting of the muscles concerned in those movements, or other tangible proof of the effect of the loss of function. The effects of the galvanic current applied to the muscles alleged to be affected must be carefully watched and compared with its effects when applied to those of the other side. When loss of sensation is alleged, it is desirable to examine the patient in many ways, and with his attention distracted from the part in which sensation is said to be deficient. Unsteadiness of gait may easily be simulated, and the fraud may be detected when the patient is cleverly thrown off" his guard. Alleged loss of power over the bladder ought to produce certain symptoms and appearances in the urine, and a urinous smell about the clothes and bed ; and finally, all the more serious cases of injury are accompanied with a disturbance of the general health which is often "conspicuous from its absence" in persons who prosecute claims against railway companies. But besides the grosser and more easily detected cases of fraud instances are met with often in practice in which the mental and bodily symptoms are so mingled together that it is hardly possible to say what is the real injury and what is the patient's prospect of recovery. Pi'ofjnosis. — The prognosis of these injuries is also a very difficult question. Those which come on at once, and with syn)ptoms of active liaMiiorrliage, seem to me on the whole more encouraging tlian those in which the mischief is consecutive on infiannnation, probably accompanied by textural changes (softening in most cases, in others imluration) ; and if, as is sometimes tiie case, the inflammation spreads upwards, and symp- toms of cerebral meningitis or softening begin to make their appearance, the prospect of recovery, or even of amelioration, becomes still worse. Much also will depend on the state of the general health. Those cases are the worst in which the patient's condition goes on deteriorating, and unluckily they are by no means tiie least common. Tre.aiment. — The treatment of these cases at their commencement must 1 A drawinpc from ii microscopical section of llio iifTocted cord will bo found in Mr. Le Gros ClarK's work. INJURIES OF THE FACE. 195 be by rigid rest and l>y antiphlogistics — much as in severe sprain ; and Mr. Ericlisen witli great probability suspects that many of the ill conse- quences which often follow on railwa3' injuries depend on the patient having neglected at first to observe that perfect quiet which should always be enforced after such an accident. When the first acute symptoms have subsided much benefit will probably be produced b}^ counterirritation and the actual cautery, and by the cautious administration of mercury in ver}' small quantities, the perchloride being the favorite preparation. When all inflammatory symptoms have subsided the use of strychnia is indicated ; and it is possible that then the patient may derive benefit from gentle exercise with all possible caution. The general health must, of course, be carefully attended to, and when he is able to move the patient may be advised to try the efl'ect of change of climate. CHAPTEK IX. INJURIES OF THE FACE. The free vascular supply which is enjoyed by all parts of the face renders the process of union rapid, and the prognosis of all injuries better, in this than in an}^ other part of the body. It is true that cutaneous erysipelas is common, but it seldonn produces alarming symptoms except in persons whose health is broken down by intemperance or visceral dis- ease. Bruises are often extensive, since the large vessels lie close under the skin, surrounded by a loose cellulo-adipose structure, in which ex- travasation can go on to an almost unlimited extent ; but it speedily subsides if the patient is in good health. All wounds ought to be imme- diately and accurately united, with sutures if the edges cannot be other- wise kept in exact apposition ; and the sutures must be supported with harelip-pins when the flaps are heavy, or in the lips, where powerful muscles are attached to the skin. Even if the wounds be considerably contused or lacerated they may nevertheless be united. Perhaps no sloughing will ensue, or if the edges slough still the resulting deformity will most likely be less than if the flap had not been replaced. But sutures will very likely leave a mark of their own, so that they should not be used unless absolutely necessary ; the}^ should be as delicate as is consistent with security, and they ought always to be withdrawn as early as possible. Even in adults and in the lips there is no reason for leaving the harelip-pins in longer than forty-eight hours. Saliva?^ Fistula. — One of the most disagreeable complications of wounds of the face is salivary fistula. This is caused usually by a wound, but sometimes by an abscess, which lays open Steno's duct. The saliva is constantly running out on the cheek, and the flow is increased when the patient eats or when his " mouth waters." If the division is complete the patient may be conscious of dryness of that side of the mouth. 196 INJURIES OF THE FACE. The disease is to he treated by restoring the passage for the saliva from the gland into the mouth. For this purpose the proximal part of the duct {i. e , the part of the duct whicli is still in connection with the o-land) should be found by examination of the wound; then the cheek should be everted, and along the natural opening of the duct, in the interior of the mouth (which is generally found without difficulty, oppo- site the second upper molar tooth), a probe or leaden string is to be passed across the wound and along the duct in the direction of the gland. The probe or string is fixed in its position by bending its extremit}^ round the commissure of the lips on to the cheek, where it can be secured. When the saliva is thus guided into the moutli the fistula will probably heal, either of itself or on its edges being refreshed and brought together. In some cases the opening of the duct in the mouth cannot be found, and when this is the case the distal opening of the duct as well as the proximal must be sought in the wound ; or if that part of the duct is obliterated, an artificial passage must be made and kept open ; but such cases are far less promising. And indeed many cases of salivary fistula present very considerable "difficulty, from the rottenness of the tissues surrounding the wounded duct, which renders them very unapt to unite when brought together, and favors the percolation of the saliva through the wound which it is intended to unite. Foreign Bodien in the Nose and Ear. — Children very frequently pass foreign bodies into the nose or ear, which they cannot withdraw again, and which afterwards may set up grave mischief. In the nostril they give rise to foul discharge from inflammation of the membrane, and may even produce disease of the bones. The case is constantly mistaken for one of " oziBua," or strumous disease — so constantly that it has become a familiar caution in surgery always to put dowai a case of foul discharge from one nostril in a child as being probably due to a foreign body, and to pronounce no opinion about it till after a thorough examination, for which purpose anaesthesia is generally necessary. The foreign substance is always quite easy to remove, either from the nostril or by pusliing it through into the throat, and then the discharge will at once subside. Foreign bodies in the meatus auditorius are more dangerous, for they may eas'ily cause perforation of the membrana tympani,or even cerebral mischief, by inflammation spreading through the base of the skull to the cranial sinuses. Sucli foreign bodies may be removed by constant syr- inging with warm water, or under chloroform with a pair of forceps, a bent probe, a loop of wire, or some special instrument of which several liave been devised for the purpose. But if these means fail, as they often do, nothing further should be done, beyond perseverance in syr- inging, since harm may easily be produced by the incautious use of in- struments, and in all probability suppuration will loosen the foreign sub- stance, and then it will come away. Fractures of Facial Bones. — The bones of the face can onl}- be frac- tured by direct force, and these fractures are not so frequent as might be expected. One observation which it is necessary to bear in mind in these injuries is that tlie distinction whicli in other regions is so impor- tant between simple and compound fractures lias really hardly any im- portance as applied t(j the bones of the face. Wounds of the face heal so rapidly, and the thin facial bones are so surrounded by structures rich in vessels, that compound fractures heal almost as readily as simple fractures do. FRACTURE OF LOWER JAW. 197 The ossa nasi when fractured are usually also depressed, causino; a flattening of the bridge of the nose and a very unpleasant deformity. The accident is a very easy one to recognize, but the treatment is not always satisfactory, for these delicate bones are often comminuted as well as fractured, and it is very difllcult to adjust the fragments properly. All possible care, however, should be bestowed on the restoration of all the fragments to their proper position, by means of a curved staff or a female catheter introduced up the nostril. If it is otherwise impos- sible to keep the fragments in their place the surgeon may try to support them by some substance introduced into the nostril; but Mr. Holmes Coote justly says that "plugging of the nostril should not be resorted to except in cases of severe displacement, for it causes the patient great discomfort, and not uncommonly fails to effect the purpose for which it is used." If it is found necessary to introduce a foreign body, it should be removed after a few days. The fracture unites very rapidly, in some cases the cartilages only are broken or bent. The treatment, however, of these cases must be conducted on the same principles. The septum is of course usually involved in the fracture and displacement, and great care must be bestowed in order, if possible, to keep it straight while the process of union is going on. Mr. W. Adams^ has lately described a screw steel apparatus for sui)porting the fragments in these cases, which is to be worn for two or three days, and then replaced by an ivory plug. And, no doubt, in some complicated cases the use of a metallic or glass support is necessary ; though in those where the fracture is only single, and the septum is not much deviated, it may be superfluous. Fractures of the upper jaw are accidents of little moment unless the displacement is such as to produce much change in the features. I re- member a case in which, a carriage-wheel having passed over the face, most of the bones seemed to be separated from the skull, and on recov- ery a peculiar and most disagreeable lengthening of the face was left. Such deformities are very difficult indeed to avoid, for there is little means of acting on the upper jaw from any side so as to replace its frag- ments when once driven in. Fractures of the malar hone are rare, and are usually caused by con- siderable violence. The only point of interest in their patholog}^ is one illustrated by a case which I published many years ago,'' where a gentle- man, who had fallen from his horse and had sustained fatal injury to the brain, presented an orbital ecchymosis exactly resembling that which at- tends on a fracture of the base of the skull. On post-mortem examina- tion the bleeding was found to depend on a fracture traversing the malar bone near its junction with the frontal. Fracture of the zygoma is exceedingly rare, and it is said that in some cases displacement is produced by the action of the fibres of the masseter muscle implanted into the fractured part, but I have no personal experi- ence of this injury. The displacement, when recognized, must be reme- died by careful manipulation under anaesthesia. Replacement by the insertion of a sharp metallic point into the displaced fragment and trac- tion upon it has been spoken of. Of the Loiver Jaiv. — By far the most common fracture in the face is that of the lower jaw. This is usually caused by a very heavy blow, such as the kick of a horse, though, as curiosities, cases are recorded in which muscular action is said to have caused it. It is frequently in some sense 1 Lancet, 1875, vol. i, p. 649. 2 Brit. Med. Journ., 1855, p. 907. 198 INJURIES OF THE FACE. compound, that is, the line of fracture communicates with the air in the cavity of tlie moutli, for the soft coverings of the jaw are very commonly torn. But the fracture almost always unites after the manner of a simple fracture. In some complicated injuries, however, the comminuted por- tions will exfoliate. Any part of the bone may be broken. There are cases in which only the alveolar edge is broken off, but the continuity of the bone is not interrupted, since its base is not broken. Such accidents are rare in the present day, but were said to be common when "the key" was in ordinary use in extracting teeth. Mastication will be painful or impossible at first, but as the parts consolidate the patient will completely recover, though perhaps with the loss of some of the teeth. Another rare fracture of the jaw is that of its neck.^ It is not difficult to diag- nose, by following the ascending ramus upwards with the finger intro- duced into the mouth. I once dissected a specimen of this injury in which the broken ramus had protruded through the meatus auditorius externus, and had so irritated its lining membrane as to give rise to a catarrhal discharge very much i-esembling that which is seen in some fractures of the base of the skull.'- Another fracture is that through the angle between the body and ascending ramus, and in this there is not much displacement, since the masseter and internal pterj'goid inserted on either side keep the parts in position. The fractures which occur be- tween the angle and S3'mphysis are generally much displaced, and especi- all}' when, as very commonly happens, there is fracture on both sides — the central piece being drawn down by the hyoid muscles in addition to the displacement caused by the force of the blow. Fracture often trav- erses the bone at or close to the symphysis, and this fracture will not be much displaced unless the force has been unusually severe, since the muscles of the two sides will balance each other. Fracture of the coronoid process is a rare accident, but one which is illustrated by a preparation in the Museum of King's College Hospital, of which Mr. Heath gives a representation, copied from Sir W. Fergusson's Practical Surgery. The former author thus speaks on the subject of this rare injury: "The fragment would, no doubt, be drawn upwards and backwards by the temporal muscle, and might be felt in its new situation, thougii this displacement would probably be limited liy the very tough and tendinous fibres which are so closely connected with the bone, form- ing the insertion of the temporal muscle, and reaching down to the last molar tootli. According to Sanson fractures of the coronoid process do not admit of union."* I venture to think that the latter statement is en- tirely unsupported, and that the idea that fractures of the coronoid pro- cess of the jaw do not unite by bone — though it has been copied from one author to another till it has become one of the loci communes of surgery — rests on no evidence. If the fragment were much drawn up the frac- ture would unite by ligament; but there is no proof that this displace- ment usuall}' occurs. Fractures of the lower jaw are often multiple or comminuted. This is the case, of course, in gunshot fractures almost always, but not infre- quentl^' in those caused by the passage of wheels over the face or by other unusual violence. And the nature of the displacement, as well as the ' Mr. Ilenlh says that, jvidging from the number of Museum specimens which exist of it, this injury is probably not so uncommon as it is represented. 1 can onlj- say that it seems rarely met with in extensive hospital practice, where other fractures of the jaw are common. 2 Path. Soc. Trans., vol. xii, p. 150. 3 Injuries and Diseases of the Jaws, 2d ed.,p. 14. FRACTURE OF LOWER JAW. 199 amount of deformity resultino-, is greatly influenced by tins circumstance. It is mainly in these more complicated fractures that non-union is to be apprehended. The state of the teeth should always be carefully considered in cases of fractured jaw, and an}^ which are so displaced as to interfere with union, or so injured as to be useless, had lietter be removed at once. Diagnoi^ia and Treatment. — The symptoms of fractured jaw are usually very plain, '^i'he patient will feel very great pain in trying to open his mouth, the saliva will very probably drivel, the line of the teeth will be broken, and one or more will very likely be loose or be knocked out ; there will be displacement as descrilied above, and crepitus will lie easily felt on manipulating the parts into position. If the fracture be com- minuted the diagnosis will be still more easy. The treatment consists in replacing the parts by proper manipulation, whicii is seldom ditticnlt in uncomplicated fracture, and then in the sim- pler injuries nothing further is necessary than to ])ut up the parts in a jaw- bandage, i. e., a four-tailed bandage, with a hole cut in the centre to receive the chin, the tails crossing each other, one pair tied behind the occiput (sometin)es for more security brought thence over the forehead), the other over the vertex. Inside this may be placed a gutta-i)ercha or pasteboard splint moulded so as to fit the chin.^ The teeth of the lower jaw are thus brought into close apposition with those of the upper, which serve in some measure as a splint for them, fixing in their natural posi- tion. For the efficiency of this treatment it is clear that the teeth must be kept together, i. e., that the patient must not be allowed to open his mouth. He must, therefore, be content with such fluid or semifluid nourishment as he can suck in through any gaps tliere may be in his teeth or can pass in through the hiatus tiehind the molars. After the first fortnight perhaps a little movement of the jaw may become tolerable. In a period of from three to four weeks from the accident the parts will be- come sufficiently united to dispense vvith the bandage, but the patient may prudently wear a handkerchief, in order to prevent his opening his mouth too far or using the teeth too violently. Complicated fractures of the javv are sometimes ver}' hard to deal with. If sound teeth remain on both sides of the line of fracture a piece of wire may be passed round them tight enough to draw the fragments together, and this is often a useful way of fixing a comminuted piece; but the wire should only be left for a few days, for it has a great tendency to cut into and injure the teeth. Mr. H. O. Thomas, of Liverpool, has dwelt strongly on the advantages, in cases of compound and much-displaced fractures, of wiring the fragments together, for which purpose he either drills a hole through the fragments and passes an annealed silver wire g^ of an inch in diameter through both of them, or passes the wire over or through any teeth which may be left firm enough to bear the strain. The wire is then so twisted at either end as to allow of its being tightened (which will be- come ne(;essary in a few days, from the subsidence of effusion between the fragments), and also of eas}' removal. The advantages claimed for this method are greater nicety of adaptation and more comfort to the pa- tient, who is able to masticate easily." In the case of non-union of frac- 1 An oval piece of pasteboard is taken of appropriate size, and a cut is made on either side in the long axis of the oval, leavins: a part in the centre undivided. The pasteboard is softened, and this central part is moulded on to the chin, while the di- vided ends overlap each other and hold the splint in place. 2 For further details I must refer to the original paper in the Lancet for 1867, or to a tract entitled Cases in Surgery illustrative of a new method of applying the wire ligature in compound fractures of the lower jaw. 2d ed. Liverpool, 1875. 200 IXJURIES OF THE FACE. tures I have already' spoken of the benefit which is often derived from pegging or drilling the fragments together (page 151). In eases where there is mncli comminution tliese simpler plans will not succeed, and there is much danger either that the fracture will not unite at all or that great deformity will result. In such cases a mouhl must be constructed in vulcanite, or better in thin metal, silver or gold. Such moulds are made on one of two principles, i. e., they either use the teeth of the upper jaw as a base on which the mould is fixed above, while its lower part carries cavities for the reception of the teeth of the lower jaw, and they are confined in those cavities by a splint and bandage exter- nally, the mould itself being attached to the splint by an arm at either corner of the mouth, or else the support of the upper jaw is dispensed with— a frame is moulded to the chin ; an arm projects from this frame on either side and carries a mould, in which the teeth are received. In the former plan (the interdental splint, as it is called) it may even be possible to dispense with any external support, and to confine the appa- ratus entirely within the mouth. The convenience of these apparatus which are moulded on to the teeth is, that the}' do not prevent the patient from opening his mouth, and therefore they cause no impediment to speaking or mastication, for the portions which fit on to the lower and upper teeth are hinged together inside the month. But the}' require more skill in modelling than a surgeon usually possesses, so that the services of a skilled dentist have to be called in, and great care must be taken to reduce the fracture completely under chloroform before the mould is taken. If the bone is much comminuted it may be necessar}- to wire, or peg, some of the fragments together inside the mould. The treatment of these complicated cases must extend over a much longer period than that of simple fracture, especially when some of the fragments become necrosed. In the celebrated case of Mr. Seward, the American states- man, who suffered from a fracture of the lower jaw complicated b}^ a sub- sequent gunshot wound of the same part, the interdental splint was worn for more than a year. The reader will find all the details, which space forbids me from inserting here, carefull}' and clearly described in a paper by Mr. Bei'keley Hill, in the B^nf. Med. Jonrn.^ for Februar}' and March, 1867, and in Mr. Heath's work already referred to. DiHlocalion of the Jaiv is an injury which is not very common, but which gives rise to striking symptoms, and which, when it has once occurred, is liable to recur from very slight causes. It is generally caused by a blow or fall on the chin with the mouth wide open, whereby the condyle of the jaw is driven forward; but when the jaw has once been dislocated the displacement is easily reproduced in extreme yawning, and the acci- dent also often occurs for the first time during yawning or in convulsions. The symptoms are very characteristic. If botli joints be dislocated, as is most usually the case,' the mouth is widely ojjcu, and cannot be closed ; the ciiin is advanced ; the saliva dribbles, partly as a consequence of in- creased secretion from ii-ritation of the ])arotid gland, partly from defi- cient power of deglutition ; the speech is almost unintelligible; there is a hollow just in front of the ear vvhere the joint should be, and a promi- nence near the malar protuberance caused l»y the displaced coronoid pro- cess, over which the fil^res of the temporal muscle are stretched. If the dislocation is unilateral the chin is generally much twisted to the oppo- 1 Mr. Bryant 6ay.s two out of every three cases lire bilateriil ; while Nolaton believes that the frequency of bilateral is only u little greater than tliat of unilateral disloca- tion. DISLOCATION OF THE JAW. 201 site side, as in the annexed drawing ; thongh this, as Mr. He_y states, is not always the case; but he points out as an infallible sign of the dislo- cation the hollow which is to be felt behind the dislocated condyle. Prof. Smith, in quoting these observations of Mr. Hey, says that he has seen, in a dislocation of the right condyle, the efforts at reduction applied to the left. I conclude, iiow- ever, that Mr. Hey's re- fig. 62. marks must apply to old dislocations; for if the dis- location lie left unreduced (which strangely enough is sometimes the case) the patient recovers the power of closing the mouth and retaining the saliva, and to a great extent tliat of pei'- fect articulation (see the figure in Smith, oj). cit.^ p. 289). Reduction is generally very easy, and has been efl[ected even as late as four months after the in- jury. The surgeon grasps the chin and jaw in l)oth hands, the thumbs resting inside the mouth on the angle between the body and ramus behind the last molar teeth, while the fin- gers embrace the chin. The thumbs are of course pro- tected with a cloth, or they would be severely bitten as the jaw returns to its place. The perpendic- ular ramus is thus forced down, whereby the condyle is disengaged from its unnatural position, while the chin is pushed back and raised; and when the condyle is thus disengaged the tense fibres of the temporal and masseter muscles will contract and replace the jaw with a snap. The process in unilateral dislocation is similar, the main point being to dis- engage the condyle, and then to assist the reduction by pressing the chin in the reverse direction to that in which it has been thrown b}' the violence. Some surgeons, not caring to trust their thumbs inside the mouth, de- press the angle of the jaw by pressing on the hinder part of its ramus with two pieces of stick, or some other kind of lever, held by an assistant, and having its fulcrum against the upper teeth, while the surgeon raises the chin with his hands. Sir A. Cooper directs that the posterior teeth should l)e separated from each other by corks, while the chin is raised by the hands. In a case of four months' standing Mr. Pollock effected reduction by separating the jaws with wedges inserted between the molar teeth, while he drew the chin upwards by means of the strap of a tourniquet applied round the head and beneath the jaw, so that the screw might exert its power upon the dislocated bone. Two views have prevailed as to the mechanism of this dislocation, and therefore as to the obstacles to its reduction ; and I have thought it better to preface what I have to say on this point by describing the Unilateral dislocation of the lower jaw. — From R. W. Smith. 202 INJUEIES OF THE FACE. method of reduction, since the latter has considerable bearing on the ques- tion of tlie pathology of the injury. Nelaton, who has given great atten- tion to this subject, and wliose description of tlie injury is well worthy of careful study,' remarks on the rarity of the dislocation, and on the fact that there is very little to separate the displacement of luxation from the ordinary and natural displacement of the condyle forwards which occurs in all cases of extreme separation of the jaws, and which requires no reduction, since the bone returns spontaneously into its place. He also shows that the ligaments are so lax (in order to allow of these nat- ural displacements) as to oppose no obstacle to reduction ; and the pro- jection of bone (eminentia articularis) in front of the glenoid cavity is also too slight to have much influence in that direction. But he says if the anterior part of the capsule be cut through on the dead subject, and the condyle of the jaw be forced through it far enough to bring the tip of the coronoid process in front of the malar prominence, then it will be found that if the coronoid process is long enough its summit will abut against the z3'goma, and this will prevent any reduction until it has been forced back again. This view is supported by the preparation here re- produced from Malgaigne, b}- looking at which the I'cader will see at once that the displaced coronoid process will effectually prevent reduc- tion ; but that by pi'essing on the angle of the jaw from within the mouth the surgeon might easily send it Yia. G3. back again, and so far disengage it that the fibres of the temporal muscle (which in the drawing are seen bent or twisted over the tip of the process) would become straight again, and with the masseter would easily restore the bone to its place as the chin was lifted. But, on the other hand, Mai- sonneuve and Otto Weber have experimented upon the dead body, and deny that any such locking of the coronoid process against the zygomatic arch ex- ists, at least in all cases. They would, therefore, attribute the mechanism of the dislocation to the tension of the muscles. In Nelaton's view, then, dislocation can only occur when the coro- noid process is so long as to catch against the zygomatic arch; and it is to the rarity of this peculiarity of the coronoid process that Ndlaton attributes the rarity of the injury; while in the other view the dislocation is caused by the muscles drawing the displaced condyle through the lacerated capsule, and fixing Dislocation of the lower jaw.— From MalgaiKHf. In this casn tlu' jaw had hccii often di.slocated. The liga- ments are entire. The condyles do not appear to have been thrown further forward than in ordinary gnaw- ing; but the coronoid processes, which are very much pushed upwards, and remarkably nearer the condyles than in the ordinary bone, ride up groaily over Ihc uiular bone, so as to lie external to the malar promi- nence. The patient was under Nfilaton's care. — Rev. Med.-Chir., vol. vi, p. 286. » Path. Chir., vol. ii, p. 306. INJURIES OF THE NECK. 203 it there by their contraction;' and in snpi)ort of tliis view the fact is mentioned that Roser was unable to reduce a dislocation of eight weeks' standing, even after cutting through both coronoid processes from within the mouth. I must refer tlie reader who wishes to follow the subject more minutely' to Mr. Heath's work. Subluxation. — In the ordinary dislocation the interarticular cartilage remains attached to the condyle ; but there is a condition descril)ed by Sir A. Cooper as subluxation, in which he says " the jaw appears to quit the interarticular cartilage, slipping before its edge, aud locking the jaw with the mouth slightly opened." He also points out that this usually subsides of itself, but says that he has seen it persist for a length of time, and the motion of the jaw and the power of closing the mouth have still returned. If necessary, it may generally be easily reduced by drawing the jaw directly downwards and then manipulating it into place. Somewhat allied to this is the siiapping which Sir A. Cooper describes as felt in the joint, accompanied with some amount of pain, in young women aud others of relaxed fibre, and which will subside spontaneously if the parts acquire more strength. '' Hamilton says that he frequently suffered from the atfection when a youth, but as he became older the an- noyance ceased without any special treatment." Sir Astley prescribes ammonia and steel, shower-baths, and a blister. CHAPTER X. INJURIES OF THE NECK. Sprains, contusions, and superficial wounds of the neck i)resent no features which render them worthy of special description ; but the wounds which lay open the deeper structures, such as the windpipe, the pharynx and oesophagus, or the great vessels, must be studied separately; and as these wounds are most commonly suicidal, it is better to descril)e the usual features and the proper treatment of cut throat. The same prin- ciples are easily ai^plied to the somewhat rare cases in which injuries occur accidentally. One point which may be noticed in stab-wounds of the upper part of the neck with arterial bleeding is the impossibility in many cases of distinguishing the exact source of hfBuiorrhage, so nu- merous are the great vessels in tliat neighborhood. In such cases it is justifiable to tie the common carotid, and the operation has often proved successful. The wound in cut throat is more commonly situated in the laryngeal than the tracheal region. This is accounted for partly by the greater prominence of that region, and partly by the easier accessibility of the 1 That is to say, the externul pterygoid muscles would draw the condyle directly forward, while the masseter, temporal, and internal pterygoid would fix the bone against the base of the skull. 204 TNJURIKS OF THE NECK. air-tiilie there; for suicides very often think tliat a wound of the windpipe is necessary fatal, and that therefore tliey can better accomplish their purpose by cutting through or near the thyroid cartilage. For the same reason the carotid artery usually escapes injury, since it becomes relatively deeper at that part; at least, though not really fiTrther from the surface, it is farther from the middle line as it ascends from the level of the cricoid cartilage; and as the cut is begun not very far on the left side of the middle line, it usually fails to hit the left carotid, while the force becomes exhausted and the cut ceases before the right carotid is reached. Still, I have seen a case in which both the common carotids and both jugular veins were divided. Wounds in which the carotid artery even of one side is at all freely opened generally i)rove fatal before medical aid is summoned. Otherwise, the first thing, of course, is to stop all arterial bleeding, and it is not often difficult to secure the wounded vessel, for the parts have jjrobably been freely divided and will gape widely. But the lingual artery is more commonly wounded than any other, or the superior thyroid may be divided; or the facial. Having secured the arteries, the surgeon must attend to the veins. They can generally be commanded by pressure with a graduated compress, but I see no danger in tying them ; and as this makes them almost absolutely secure from an}' irregular impulse on the patient's part, it seems far better to include any considerable vein which may be bleeding freely in a ligature of car- boiized catgut, or silk, with the ends cut short. The condition of the air-tube next demands attention. If it has entirely escaped, the injury (apart from the general condition of the patient) can hardly be regarded as serious; but generally it is perforated more or less extensively, as will be evident by the whistling of the air in the wound. If this perforation is simple, and especially if it involves only soft parts, the knife having passed between the cartilages, it will rapidly close. But often the weapon used has been blunt, the force considerable, and the attempt repeated more than once ; hence the cartilages are often hacked and fractured as well as cut. Loose portions hang down, partially obstructing respiration even at first, and any such obstruction will increase as the tissues around the loose pieces swell with oedema or inflammation. This displacement of portions is especially liable to take place when the wound has gone backwards far enough to injure the epiglottis, or when the arytenoid cartilages have been cut into. When the epiglottis is trenched upon, the wound often also lays open the mouth, and a piece of the tongue or of the floor of the mouth may fall back over the air-tube. Finally, the -wound may pass through the back of the air-tube into the pharynx, or, more commonly, into the cBsophagus ; and the latter may even be com- pleteh' severed without any large bloodvessel having been wounded. The treatment of the simpler wounds where the windpipe is not injured is merely that of similar wounds in any other part. They may be brought together with sutures or strapping, the patient's head being drawn down towards his chest and fixed tliere. For this purpose a bandage is passed round the head, and is attached, by means of two lateral strips, to another bandage going round the chest. In the first dressing of cases presenting unusual complications ana'sthesia may be useful. In cases where the windpipe is opened it is better to avoid sutures; at least, there is a traditional horror of them, and they are said to lead to erysipelas, and to produc^e a tendency to emphysema, and so to obstruc- tion of the discharges from the wound and even of the lireathing. How fiir all this is true I cannot say. Sutures are in ordinary cases unneces- sary, for the edges of the wound can be kept tolerably in apposition CUT THROAT. 205 without them ; and as primary union can liardly be anticipated, tliere is no motive for sewing tlie edges together. They are tlierelbre rarely used in sncli cases, and we have little experience of their alleged ill conse- quences. But in complicated cases, where fragments of cartilage or portions of the tongue or month cannot otherwise be kept out of the air- passages, sutures must be employed to support them, and I cannot sa}^ that they seem really to do much harm. There are cases in which the obstruction to respiration from such detached portions is so great that it is better to insert a canula into the lower portion of the windpipe through the wound, or to perform trache- otomy, after which the displaced portions can be lietter manipulated into position and kept in place. In wounds of the gullet the chief anxiety of the surgeon is to get the patient to take sufficient nourishment, and yet not to interfere with the closure of the opening. I must remind the reader that the mere fact of the escape of fluid nourishment by the wound does not at all prove that the gullet is opened. The opening may be in the mouth, or there may even be no wound at all except that in the larynx. We see the same thing constantly after laryngotomy. The folds which connect the larynx to the mouth get inflamed, the larynx is no longer I'aised under cover of the hj^oid bone, and drink runs into it and escapes by the wound. It is a distressing but not a very dangerous complication, and may be expected to disappear in a few days. Meanwhile, if the patient is thereby hindered from taking nourishment which is necessary for his life, he must be fed by the stomach-pump. If the oesophagus is wounded, and the wound is fairly within reach, it would be better, I think, to bring its edges into apposition with one or two carbolized gut sutures before dressing the rest of the wound, for the sutures require no removal, and will hold the parts together and allow of their speedy union ; but I have not had an opportunity of trying this since the introduction of this form of suture. Any other is inapplicable ; the silk from the ulceration which they cause, and the silver from their tendency to irritate the parts around by their ends. Then the patient must be treated as after oesopliagotomy, i. e., the wound must be disturbed as little as possible, yet the patient must be fed. It is even more necessarj' after suicidal than after operative wounds of the oesophagus that the patient should be well supported ; and hence it is usually more advisable even from the first to pass a small tube or catheter be^'ond the wound (taking great care to keep it against the spine, so as not to touch the wound if it can possibly be helped), and thus to fill the stomach moderatel}^ and slowly with concentrated nutri- ment twice a day. Great care must be taken not to pass the tube through the wound, and especially to avoid the air-passages.' In themselves all wounds of the throat which are not immediately fatal may be expected to do better, cseieris paribus^ than those in any other region of the body, except perhaps the face. It is true that dittuse infiam- mation when it attacks tlie cellular tissue of the neck is peculiarly fatal, but it is a rare complication of these wounds in healthy subjects. The experience of Larry, Langenbeck, Dietfenbach, and others in the extirpa- tion of large tumors from the neck, proves that if the immediate dan- gers of these formidable operations are avoided the cases do perhaps ' One of our museums contains, I believe, a preparation showing the bronchial tubes of the lungs filled with plaster of Paris injected through a stomach-pump tube, which it was intended to pass into the stomach in a case of poisoning. Such an accident might much more readily occur in cut throat. 206 INJURIES OF THE NECK. belter than any others in surgery.' IJiit the state of both mind and body of the unhappy victims of cut throat is far from healthy. Many have a desire for death, wiiich seems often to lead to its own fulfilment; others are broken down in constitution by years of intemperance; in others delirium tremens supervenes, or the wound has been inflicted during an access of delirium ; and some are obstinately bent on destroy- ing themselves, and unless closely watched will commit some renewed attemi)t on their lives or tear open the healing wound. Much care, there- fore, is required in these cases; careful nursing, the judicious use of opium or other sedatives, and a liberal suppl3'of nutriment in small quan- tities and at rejjcated intervals. After-com}jhcations. — If the patient has escaped the first dangers of the wound he may yet be troubled by its remoter consequences. Of these the commonest is fistula, either communicating with the o?sophagus or trachea, or sometimes leading from the one into the other. Tracheal fistula may often be closed by a plastic operation, but the fistula^ which communicate with the cesophagus are permanent, and if they are so free as to prevent the patient from taking food at all, the only thing that can be done is to feed him with the stomach-pump. He can generally learn to pass this for himself, and indeed often more dexterously than the sur- geon can pass it for him ; and I have seen life thus supported and the patient keep his strength and flesh apparently undiminished for nearly a year, after which he passed out of observation. In this case the oesopha- gus had been so freely opened that nothing could be swallowed. Another distressing complication is the loss of voice, and sometimes the growing d^^spncea which follows on the cicatrization of the wound in the air-passage. This arises from various causes: either from narrowing of the tube in consequence of the cicatrization which follows free (possi- bly complete) division of its walls, or from irregular union of wounds implicating the vocal cords, or from permanent displacement of detached portions, or from granulations springing into and obstructing the glottis. The occurrence of these irregularities in union furnishes a strong motive for uniting the wound in the larynx or trachea accurately with sutures at once, whenever this is practicable, and especially when the trachea is en- tirely divided. Tlie treatment of granulations obstructing the glottis will more fitly be considered in discussing the general subject of Tracheotomy. Of course when it is necessary to relieve dyspnoea in any of these condi- tions tile windi)ipe must be opened below, as a preliminary'^ step in the treatment of the cause of obstruction. Other conij^lications, such as abscess extending down the neck,' inflam- mation running along the trachea to the lungs, or inflammatory oedema making pressure on the neighboring parts, must be treated on general principles. Contusions of the larynx without fracture are generally produced in attempts at strangulation or throttling. They cause temporary pain and loss of voice, but rarely lead to any further ill consequences, and require only rest and soothing applications. iJislocalion of the hi/oid bone from tlie thyroid cartilage, or more prop- erly speaking, displacement of the former point of bone with respect to ' See Syst. of Surg., 2d ed., vol. v, p 984. '^ Such abi^cesses sometimes pass down to the pleura, and from the external surface of that membrane the inflammation is projtagated to its cavity. FRACTURE OF THE LARYNX. 207 the latter, is spoken of by Gibb, in Path. T7'ans., vol. x, p. 67. He de- scribes the displacement as being caused either by violence or disease, though tlie instances which he adduces appear to have been all sponta- neous, and due to relaxation of the ligament which naturally unites the parts, and which in the instance dissected and exhibited to the Society was replaced by a pouch or capsule of new formation. The symptoms are a "click" in the neck, the sensation of something sticking in the throat, and the appearances of displacement on examination, which, how- ever, are not clearly described. The displacement is to be reduced by throwing the head backwards and towards the side opposite to that dis- placed, thus relaxing the lower jaw, and if necessary manipulating the displaced bone into position. Fracture of the Hyoid Bone. — Tlie hyoid bone and the cartilages of the larynx are occasionally though rarely fractured b}^ direct violence, such as grasping the person by the throat, attempts at strangulation, blows and falls on projecting objects. The hyoid bone is said to be often fractured injudicial hanging. Fracture of this bone produces great dis- tress when the fragments are driven inwards, and especially if the mucous membrane is lacerated. All movements of the tongue, all attempts to swallow or speak, are attended with much pain and difficulty. The injury is easy to diagnose by the separation and mobilit}- of the fragments, and crepitus may be obtained when they have been restored to position, which is generally quite easy. If there should be any difficulty an anaesthetic should be administered, the mouth full}' opened and ke|)t so by means of a o^ao-, while the fragments are disengaged by one finger in the mouth and •another externally. After reduction the parts are to be kept perfectly quiet. The patient's instinct will prevent him from talking or other voluntary movements so long as they are i)ainful, and he must be fed with sops, conveyed well into the back of the mouth. In about a fort- night the parts will be so far consolidated that much of the inconvenience will have passed by, and the accident is not likely to lead to serious con- sequences. Fractureti of the laryngeal cartilages or of the trachea are of more se- rious import than those of the hyoid bone, and when the fragments are displaced so far as to penetrate the lining membrane of the air-passages active and immediate treatment is necessary. The injury most frequently affects the thyroid, and next the cricoid cartilage. Pain and dyspnoea follow the fracture; and if the mucous membrane is lacerated there is blood-spitting, constant cough, and frequently difficulty of breathing, which may rapidly increase and end in absolute suffocation. Of course the nearer the injury is to the vocal cords, so much the more acute will be the symptoms, and so much the more decisive must be the treatment. The diagnosis is generally obvious.' Whether absolute crepitus will be distinguished depends in a great measure on the patient's age and the consequent extent of calcification in the cartilage. The chief point in the treatment is, as to the necessity or advisability of tracheotomy. An interesting collection of these cases was made some time since by Dr. Hunt,'^ from which it results that when the fragments 1 Mr. Le Gros Clark gives a useful caution in the diagnosis of these injuries : tliat, "in moving the larynx from side to side on the cervical spine, or in deglutition, the manipulato'r may be deceived, especially when the larynx is largo, and, in elderly persons, by the peculiar feeling of roughness and inequality which is thus elicited." 2 Out of twenty-seven cases ten recovered, six with and four without operation. Only two patients died in whom tracheotomy was performed, while out of nineteen 208 INJURIES OF THE NECK. are displaced and the mucous membrane lacerated it is always desirable to perform tracheotomy at once, since in all cases it becomes ultimately necessary; and by having an opening made at once below the seat of in- jury the "patient is saved from the risk of sudden dyspnoea produced by Fjg. Hi. A, front, and b, back view of a preparation of extensive fracture of the thyroid and cricoid cartilages, taken from the body of a person who was murdered by her cook. Death resulted, in all probability, from the violence inflicted on the larynx. The hyoid bone was also fractured and comminuted, butis not shown here.— From a preparation in the Museum of St. George's Hospital. an accidental displacement. When there is no evidence of such perfora- tion the patient must be kept perfectly quiet, and the case must be watched with a view to tracheotomy if necessary. Complete Rupture of Trachea.— Sometimes the injury has been known to involve the complete subcutaneous rupture of the trachea,' so that there is a large depression in tlie neck where the trachea should be, and the patient breathes with great difficulty by the indirect passage of air from the upper part of the windpipe through the interval, which must be partly occupied with blood, and so into tlie retracted lower end of the trachea. Under such circumstances not a moment should be lost in attempting to find tlie lower end of the trachea and fixing it by introducing a tube. The parts are to be very freely divided in the median line, and the trachea drawn up to the surface. If it is very movable and retracts easily there is no ol)jection that I can see to fixing it temporarily with a suture. Foreifjn Bodies in the Air-Paamges. — The entrance of a foreign body into the air-passages is a formidable accident, and one which not unfre- quently proves fatal. It may occur at any period of life, but is more fre- quent in children, both from their natural want of caution and experience, and from their frequent habit of playing with things in their mouth. The accident is caused by a sudden inlialation while holding something in the mouth, as by laughing or gasping with fright while taking food, by catching a coin in the open mouth, etc. ; and in some rarer cases the foreign body has been driven in from the outside, as in the case of a who were not operated on fifteen died ; and in no case where emphysema and bloody expectoration testified to perforation of the mucou.s membrane by the fragments did recovery ensue without tracheotomy.— Am. Jour. Med Sci., April, 1866. « See Mr. Halford's case, in Syst. of Hurg., 2d ed., vol. ii, p. 464. FOREIGN BODY IN WINDPIPE. 209 child who was cracking a whip in the lash of which a large copper pin had been fixed. The pin got loose, and passed through the trachea. For- tunately the surgeon recognized the small i)uncture, and cut down on the foreign body.^ And I think there can be no doubt that, although in swallowing the larynx is usually so drawn up that no foreign substance can pass into it, yet occasionally a pointed body (such as a piece of bone) may hitch under the epiglottis and pass into the upper part of the larynx, in swallowing, without an inhalation.'^ Another comparatively frequent accident is the impaction of a large mass of food in the pliarynx, obstructing the upper opening of the larynx, and causing speedy death if not dislodged. The treatment is simple, if the nature of the case be recognized in time. The mass being pushed down or hooked up, the breathing may be at once restored ; if not, artifi- cial respiration is to be sedulously practiced. Foreign bodies which have passed fairly into the windpipe may be lodged in various situations. They may be detained above the rimaglot- tidis, and then may be thrust more or less completely into the ventricle of the larynx ; they may be caught between the vocal cords ; may stick in the cavity of the larynx; may lie either fixed or, more commonly, loose in the trachea; or may pass down beyond the bifurcation of the trachea into one of the bronchi, or even lower, into one of the bronchial tubes of the lung itself.^ The symptoms vary partly with the size and shape of the foreign body, partly with its position. The larger and rougher the foreign body is, the more acute will probably be the symptoms; the nearer it is lodged to the vocal cords the more spasm is it likely to cause; the more firmly it is impacted in one of the bronchi the more complete is the loss of breathing on one side. In their most marked form the symptoms of a foreign body in tlie air- passages are as follows : The patient being previously in his usual health, 1 De la Martiniere, Mem. de I'Acacl. de Cliir., v. 521. '■^ This was the case with a little child under mj- care a short time ago, in whom a large piece of the bone of a rabbit was lodged in the upper orifice of the larj'n.x, ex- citing great dyspnoea, and having set up extensive tracheitis and bronchitis extending through both lungs. It was extracted through the mouth about thirty-six hours after the accident. The bone was too large and too irregular to have been easily inhaled, and the mother said the child took the spoonful of food quite quietly and choked im- mediately afterwards. From the position and shape of the bone there could be no doubt that a large prong of it was sticking through the glottis and irritating the air- tube. 3 " Out of twenty-one cases analyzed by Professor Gross, in which death took place without operation, and witiiout expulsion of the foreign body, in four the foreign sub- stance was situated in the larynx ; in one, partly in the trachea, partly in the larynx ; in three, in the trachea ; in eleven, in the right bronchial tube ; in one, in the lung ; in one, in the right pleural cavity. " Out of forty-two cases subjected to operation or general treatment the extraneous substance was situated twice positively, and eleven times probably, in the right bron- chial tube ; four times certainly, and four tunes probably, in the left bronchial tube; seven times in the trachea, smd fourteen in the larynx. Out of fifteen cases under observation in Guy's Hospital during the last few years, in .seven the foreign body was in the larynx ; in five, in the trachea ; in two, in the right bronchus ; and in one, in the left bronchus. It would thus appear tiuit the larynx and the right bronchial tube are the most frequent situations in which foreign substances are arrested. This conclusion, however, does not precisely coincide with that derived by M. Bourdillat from the analysis of 15G cases. In eighty of these the foreign body was in the tra- chea; in thirty-five in the larynx; in twenty-six, in the right bronchus; and in fifteen, in the left bronchus." — Durham, in Syst. of Surg., vol. ii, p. 477. 14 210 INJURIES OF THE NECK. has been smlilenly incized witli (.'onvulsive cough and dyspiuva, aggravated into severe parox^'sms. At the same time it is possible that he, or if a child his parents, may know that he has swallowed something, or that something which was in his mouth has disai)peared. The speech will be more or less affected, and the breathing whistling or stridulous. There ma^' be some pain about the part where the body is lodged (probably about the thyroid cartilage), aggravated by pressure. The foreign body From a preparation (Ser. vii, No. 97 a, in St. George's Hospital Museum), showing a piece of tobacco- pipe impacted in the right bronchu.s ola child. The symptoms were very obscure, perhaps because the air passed throu;^!! the pipe into the lung. Ultimately tracheotomy was performed, but the foreign body could not be reached. Man. The lungs and bronchi have been somewhat displaced in making the preparation, so that the right bronchus looks much more perpendicular than it is. can in some cases be felt by exploration from the mouth,' and in others can l)e seen by the laryngoscope. More rarely it can be felt in the neck. Diagnosis. — The diagnosis, in cases where a foreign body is not per- ceptible and the history is not clear (which is very commonly the case in childhood) is by no means easy. It rests, mainly on the sudden accession of the symptoms during a condition of complete health, and is therefore easier the sooner after the supposed accident the patient is seen. In case the history should be doulttful the diagnosis between the irritation pro- duced by a foreign body and the dyspnoea of croup or laryngitis rests in a great measure upon the cumparative absence of fever in the former case, tlie patient being sometimes almost well during the intervals between the ' Such nn oxploration should never be ne<:!;l('cted. unless the .symptoms are so urgent lis to render the instantaneous opening of tlie windpipes a matter of nece.ssity. Under chloroform the finger can he pas.-icd into the upper part of llu; larynx easily in a child, and usually can be got beyond the epiglottis in an adult. FOREIGN BODY IN WINDPIPE. 211 spasms. In some cases, where the foreign body moves about in the traeliea, tlie patient is liimself quite cf)nscious of its movements, fio. or.. ^ When it lias dropped into one of tlie bronchi tlie entrance of air into that lung is prevented, either totally or in great part, and there- fore there is absence of the re- spiratory murmur and of the dila- tation of the lung, without dul- ness to percussion or any other sign of pleurisy or pneumonia. In some cases a whistling and cooing rhonchus has been heard at the point where the foreign body is lodged.^ The right bronchus is rather more commonly the seat of lodg- ment than the left, since the sep- tum is placed somewhat to the left, tliough the more horizontal direction of the right bronchus to some extent neutralizes this tendency. (See the footnote on Da<^'e 209.) Bifurcation of the trachea, seen from behind, show- ' fn cases where a nerfectlv con- ing tl^e septum to the leftof the median line, and show- in Ccibes niieie .l peiie<.ti_\ i^iJU ^^^^^^^^ tl^e ,uore vertical direction of the left bron- fident diagnosis cannot be made, chus.— FroniDurhara,Syst.ofSurg.,2ded.,vol. ii,p. 478. yet there seems good reason for thinking that there may be a foreign body in the windpipe, it is better to treat the patient as though this were the case, since an opening may relieve dyspnoea from other causes, and the operation does not add very much to the patient's danger.'' Treatment. — When the diagnosis of foreign body has been made, the surgeon should allow no delay in removing it at once. It is true, that substances have remained for years in the trachea innocuous ; but it is far more probable that a foreign body which may be setting up no very marked symptoms at the moment, will afterwards get displaced and cause urgent, perhaps fatal, dyspnoea when there is no help at hand. There are cases in which the foreign body can be seen with the laryngo- scope and extracted by means of forceps introduced by the mouth ; but these are rare. A case has lately been recorded^ in which a brass ring had been lodged near the upper opening of the larynx for four years. The patient was a child ('>l years old, and was then sutferiug from aphonia and laryngeal spasms. The position of the ring is thus described: "It encircled the left aryteno-epiglottidean fold and ventricular band ; but, except where it passed deeply into the tissues, it did not come into con- tact with the larynx." It should be remarked that the ring had a fissure at one part. Extraction by the help of the lai-yngoscope being found impossible, on account of the child's indocility, the foreign body was suc- cessfully removed by making a transverse incision through the thyro-hyoid ' Le Gros Clark, op. cit. , p. 237. 2 Mr. Barwell gives references to seven cases in which the foreign body was not found at the operation, yet the patients recovered; probably from the unnoticed escape of the substance. — Clin. Soc. Trans., vol. vi, p. 120. 3 London Med. Kecord, April 14, 1875. 212 INJURIES OF THE NECK. membrane, drawing the epiglottis, with the cushion of fat and cellular tissue at its base, downwards, and thus penetrating between the hyoid bone and epiglottis into the space above the glottis. To this operation the operator gives the name of "subhyoidean larvngotoray," and it is a proceeding wliich in rare cases may prove useful; but in general foreign bodies lodged in this situation can be extracted with forceps of appropri- ate sliape from the mouth when the patient is full^' narcotized. If the symptoms are not very urgent (in which case the windpipe must be opened without a moment's delay) chloroform should be given ; and unless the position of the foreign body is known the first step is to ex- amine the parts as far as the finger can reach. If it cannot be extracted from the mouth, but appears to be lodged near the glottis, the crico-thy- roid membrane, cricoid cartilage, and in children one or two rings of the trachea, should be divided, so as to have a very free opening. Possibly the bod}' may now be removed or ma}- shoot out of the wound ; otherwise the larynx must be examined with a large instrument, such as a female catheter,^ and the substance pushed up through the glottis or extracted with forceps. If this cannot he done, yet the substance can be felt lodged just above the glottis, a canula should be placed in the lower part of the wound, the two alae of the thyroid cartilage cautiously divided, and the foreign body picked out of the ventricle of the larynx. When the body is loose in tlie trachea, a free opening low down will generally procure its exit.-' When in one of the bronclii, all that can be done is to open the trachea as low down as is prudent, and by a ver}^ free incision. Tlien, if tlie situation of the foreign body can be ascertained b}' probing, it may be possible to extract it with forceps or to dislodge it with a hook ; or the patient's body being inverted and shaken, the foreign substance may be discharged either from the glottis or from the wound. Sir B. Brodie's celebrated case^ of Sir I. Brunei, in wliich a half- sovereign had dropped into the right bronchus, shows the advantage in these cases of making an opening in the trachea, even if the foreign body is not extracted from it. The inversion of the bod}', which before produced great dyspnwa from the coin striking on the glottis, became perfectly tolerable afterwards, and tlie coin dropped quietly into the mouth. The same case shows also the great difficulty which may be met with in ex- ploring the trachea with forceps or other instruments. The walls of the air-tube are so very irrital)le that any contact of the instrument is sure to provoke spasmodic cough, and the instrument is as likely to poke the foreign body further down as to bring it up, besides the risk of catching "the bifurcation of the trachea, or one of the subdivisions of the broncluis, instead of the foreign body." So that it is better, after liaving made a free opening in the trachea, to try and dislodge the foreign body by changes of position, by inversion of the l)ody, by shaking or slapping the chest, ratlier than to risk tlie evil consequences which ma}'^ follow tlie introduction of instruments ; and if such introduction becomes neces- sary, to try rather to dis[)lace the body by getting a hook, wire-snare, or bent prol)e below it than to catch it with the forceps. At the same time, as the forceps have no doubt been used successfully in such cases,^ the attempt ought to be made when the circumstances call for it. ' Mr. DurhaiTi rfcommends the ivory top of a gum ciith(^lxT. ''' Mr. llilton is in liivor <>(' making thi.soponiiii; transversely valvular. — Med. Times and Gaz., vol i, 18G7, p AOT. ' Mcd.-Cliir. Trans., vol. xxvi, p. 1^80. * Liston sueei'cded in (^xtracling a picee of bone from a point bi'low the right sterno-clavicular joint with forc(!ps ; and Diekin,of Middleton, near Manchester, ex.- FOREIGX BODY IN WINDPIPE. 213 Foreign bodies may also be successfully treated in some cases by in- version of the body and succussion without any previous operation. In many cases the substance has become loose and lias fallen through the glottis, and tlie plan is well wortii trying, particularly in cases where the body is smooth and heavy ; but as tiiere is a risk that the substance, if dislodged, may be caught by the spasmodic closure of the vocal cords, and instant suffocation be tluis i)roduccd, it is well before resorting to this plan to be prepared for laryngotomy in case of any such emergency. The afler-consequencea of the lodgment of a foreign l)ody, if it be not ex- tracted, are very vai'ious Tliey vary, as the immediate symptoms do, with the position, size, shape, and smoothness of the substance. Pointed rougli substances, wherever they may be impacted, produce a rapidly spreading inflammation of the internal membrane of tlie air-passages, spreading down the trachea into tlie smallest bronchial tubes. Thus, in the cases referred to on page 209, vote^ a pointed thorn of bone, sticking through the glottis into the larynx, produced in the course of a day bronchial effusion over both lungs. On the other hand, a smooth body (like Sir I. Brunei's half- sovereign) may remain impacted in the lower part of the trachea, in one of the bronchi, or even in a large bronchial tube of the lung itself, for a considerable period without exciting any such symptoms. Nor are cases wanting to prove the possibilitj^ of a smooth foreign substance be- coming encysted or encased by inspissated mucus and remaining perfectly innocuous.' But such cases are exceptional, and ought not to deter the surgeon from the necessary operation in any case in which he has certain evidence of the lodgment of a foreign body. The case far more com- monly proves fatal, and death is produced in various ways. The rougher substances cause acute inflammation, as above stated, paroxysms of cough proving fatal either b}' loading of the lungs or spasm of the glottis. In some cases a body which has long lain quiet changes its position, irri- tates the vocal cords, and so produces spasm of the glottis. In many cases in which a smooth body lias been lodged in the deeper parts of the tube it has ulcerated into the lungs and produced all the symptoms of phthisis;'^ so that Sir B. Brodie says: "The records of surgery furnish abundant evidence that, under such circumstances, disease of the lungs sooner or later is induced, and that the-death of the patient invariably ensues." And even when the body is lodged higher up, in the larynx or upper part of the trachea, there is good reason to apprehend that it will set up ulceration at the seat of its lodgment, and that disease of the lungs will follow. This is strikingly illustrated by a case reported liy South (op. cit., p. 396), in which a child died six weeks after the lodgment of a pebble in the larynx. The nature of the case was mistaken, and the severe paroxysms of cough attributed to pertussis. The cricoid cartilage in which the stone was lodged was laid bare by ulceration, and botli tnicted :i button which had lodged in and completely obstructed the right bronchus, producing the most characteristic signs of total suppression of breathing on the right side. The latter case is the more remarkable, since the opening was made between the cricoid and thyroid cartilages, and therefore tlie wound was further than neces- sary from the foreign body. (See South's Chelius, vol. ii, p. 402, or Liston's Practical Surgery, pp. 415-420.) 1 Sir T. Watson relates a case in which a piece of gold remained for years in one of the ventricles of the larynx without distressing consequences; and there are other cases recorded in which a foreign body has become glued to the wall of the trachea, or has ulcerated into its substance and tlius become encysted. 2 Characteristic cases, which want of space forbids me to introduce, wi in South's Chelius, vol. ii, p. 397. nil be found 214 INJURIES OF THE NECK. lungs were extensively hepatized, while one pleura was filled with turbid serum. Bi(7-)i and Scald of the Larynx. — The implication of the larynx in a burn or scald is a very grievous and dangerous complication of such an injury, and one which unluckily is by no means rare. The parts below the glottis are protected by the s[)asmodic closure of the vocal cords at the moment of the accident, but great oedema of the mucous lining of the fauces, epiglottis, and orifice of the larynx, comes on with fits of spasmodic dysi)na?a, which are always exceedingly alarming and not un- frequently fatal ; the voice is hoarse, the respiration croupy, and the mouth probably so much injured that the patient (especially if a child) can hardly be got to take food. The accident is more frequent in child- hood, and is often caused in very 3'oung children by sucking the spout of the kettle. The great danger is from the spasms, and the prognosis depends mainly on their severity and frequency ; but even after surviv- ing this danger the patient may still sink from bronchitis or broncho- pneumonia, the result of inflammation spreading downwards. In such cases the first point is that the patient must never be left until all immediate danger is over, since the spasms come on quite irregularly and with little warning.^ Leeches should be freely applied to the throat, and fi'equent small doses of calomel and antimony, or antimony and aconite, given. The dose must of course vary in proportion to the age. Mr. Durham prescribes one or two minims of vin. ant. with a quarter or half minim of tinct. aconit., at first ever}'^ quarter of an hour, then every half-hour, and then at longer intervals. Possil)ly the cautious adminis- tration of chloroform will relieve the spasms, and then the mouth can be fully opened and the cedematous parts around the fauces freely scarified. Finally, in the last resort, laryngotomy or tracheotomy must be per- formed ; but my experience of these cases has been that those which are so severe as to demand operation generally die, and that it is better if possible to refrain from opening the windpipe, remembering that even very alarming spasm seldom proves fatal.^ Some surgeons prefer the operation of tracheotomy to that of laryngotomy in these cases, in order to get further from the injured parts ; but as the oedema is always limited to the tissue above the vocal cords, the operation of laryngotomy is suf- ficient. Much benefit is obtained in the treatment of the broncho-pneu- monia which accom|)anies these and other injuries of the windpipe from the use of the "jacket-poultice." Cases occur in which the larynx is injured by corrosive fluids ; these must be treated on the same principles. "^{'he operative procedures for opening various parts of the air-passage, and the indications for each of them, will be found in a future chapter, under the head of Diseases of the Larynx. Foreign Bodies in the (Esophagus. — Nothing is more common than for 1 Mr. Bryant speaks of a case "in which the symptoms were so slic;ht that no anxifty was folt; but on« spasm took place two and a half hours after the accident, which put an end to life." (Practice of Surcjery, p. 139 ) A striking instanceof tlie necessity of constant watchfulness and preparation for constant operation in these as in all other cases in which spasm of the glottis appears imminent. 2 I would refer the reader to a striking case related by Mr. Le Gros Clark (op.cit , p. 280), in which the symptoms were so acute that, " though not entertaining a favor- able o|iinion of tracheotomy," he thoug])t it his duty to offer the alternative to the child's parents, who, however, declined the operation, and the patient ultimately struggled through. Mr. Le Gros Clark's remarks on the advisability of avoiding tracheotomy as much as possible quite coincide with the view stated in the text. FOREIGN BODY IN CESOPHAGUS. 215 a patient to imagine that he (or she) has got some foreign substance lodged in the pharynx or oesophagus, when no such thing is really the case. Something sharp has been swallowed with the food, such as a sharp edge of bone, and the sensation of the scratch remains after the substance itself has passed away, and, indeed, may remain for a consid- erable time, rendering deglutition painful and difficult. At the same time cases occur pretty frequently in which a pin or a small bone or bristle has been hidden behind the arches of the fauces and has escaped a hasty examination ; so that all such cases should be patiently and com- pletely investigated, and in doubtful cases the laryngoscope will be very useful, though the examination can of course only extend to the fauces and upper part of the pharynx. Large foreign bodies are generally ar- rested in the a\sophagus opposite the cricoid cartilage, but they may pass lower. I have spoken above of those cases in which a voluminous mass rests above the pliaryngeal opening of the larynx, and must be displaced or instant death results. But in cases of foreign bodies lodged in the oesophagus there is no such urgent danger. The impaction, however, of a solid body is inconsistent with prolonged life, since it prevents deglu- tition either by mechanically filling the gullet or by the pain which it produces when it sticks into the walls of the tube, as a pin or a sharp bone sometimes does. The nature, size, and shape of these foreign bodies are very various. A tooth-plate carrying one or two artificial teeth not unfrcquently dro[is into tlie month and is swallowed during sleep ; a coin swallowed intentionally ; a ragged piece of bone ; a pin or piece of wire, or a fishbone, are familiar instances. Some obstruct the gullet entirely, others partially ; some are organic and soluble, others metallic and insoluble ; some have smooth edges, others are jagged or sharp. The first point is to ascertain as nearly as may be what the size and shape of the substance is, and where it is lodged, in order to settle the important question whether it can be pushed down into the stomach or fished up from the mouth. A smooth metallic body deepl^y lodged is best dealt with by gently pushing it down into the stomach with a pro- bang having a sponge at the end ; and even somewhat rough bodies may be successfully treated this vvay, though the practice is not without its dangers.^ If more superficially lodged it may possibly he extracted with the long oesophagus forceps, which must, liowever, be very gently man- aged, in order to avoid injury to the coats of the oesophagus. Coins can often be dislodged and fished up by a blunt hook at the end of a probang. The situation of the coin having been ascertained, by means of a long probe or a urethra sound, the hook is pushed beyond it, turned round to- wards the coin, and withdrawn. Pins, small bones, etc, may be caught in the horsehair probang, shown in Fig. GT, p. 216. Pieces of meat and bone have been known to be so far disoi'ganized and softened by the constant use of dilute mineral acid as to be at length swallowed. Vomiting has sometimes been successful in dislodg- ing foreign substances. It is dangerous to the integrity of the oesopha- 1 Mr. Pollock, in the Lancet, 1869, vol. i, pp. 456-490, records two cases in which a toothplate slipped into the oesophagus. In one, where the plate was small, carry- ing only two teeth, but with very sharp edges, the patient seemed to be in danger of sinking from want of food, the plate being lodged near the stomach, whence it was somewhat dislodged by means of an cesophagus-tube, and then it passed into the stomach, on the nineteenth day after the accident Here it remained for ninety- seven days, and was then ejected by vomiting. In the other case a much larger plate, but with much smoother edges, passed through the whole alimentary canal, and was expelled in defecation in three days. 216 INJURIES OF THE NECK. gns ; but \\hen a large and tolerabl^y smooth foreign body is lying in the stomach and cannot pass the pylorus, it is probably best, as Mr. Pollock directs, to attempt its removal by inducing vomiting after a full meal, so that the foreign substance may be rejected along with the mass of food. The horsehair probang for extracting foreign bodies from the oesophagus, such as coins, bones, etc., which are lodged, but do not entirely obstruct the tube. The instrument contains a skein of horsehair inserted near its extremity, which is dilated by pulling its handle out. It is introduced, as seen in Fig. A, with the skein closed, past the foreign substance. Then the liandle is pulled out (Fig. b) and the instrument withdrawn with the skein opened, in order that the horsehair may catch and bring away, or at least dislodge, the foreign body. (Eiiopliagotomy. — Finally, there remain a few cases where the surgeon thinks it his duty to cut down on the foreign body and remove it at once. This operation is most easily performed on the left side, in conse- quence of the inclination of the oesophagus to that side, but the shape of the body raa}^ render it necessary to seek it from the right. In consists essentiall}' in making an incision between tlie carotid sheath and the lar\-nx or trachea, drawing the latter tube inwards, while the vessels are displaced outwards, and seeking for the foreign substance through the wall of the oesophagus, which is now exposed. The incision and the early steps of the operation are much the same as for the ligature of the carotid. The centre of tlie incision should be about opposite the cricoid cartilage. If it be too high the superior laryngeal nerve will be endan- gered ; if too low, the inferior th^'roid artery. When the foreign body is too small to be perceptible externally its situation and the position of the (jesophagus are to be fixed by passing a staff or catheter down the tube. When tlie surgeon lias felt the foreign body he divides the oesoph- agus longitudinall}', just enough to enable him to catch it and draw it into the wound; it must tl'.en be freed from the fibres of the (jesophagus as gently and with as small an opening as possible. No sutures have hitherto been used to close the wound in the oesophagus, but it seems probable that one or two fine catgut sutures might hasten its closure, and melt without producing any ulceration. Some sui'geons feed the patient by the rectum for a few days after the operation, but Mr. Cock tliinks it better to pass a small tube or elastic catheter l)eyond the wound, and let the patient have food in the stomach from a very early period after tlie opening. Foreign bodies have been extracted from a part of the aesophagus mucii lower tlian can be readied by the incision. Thus Mr. Syme re- moved a foreign l)ody lodged just op[)osite the top of the sternum, and Dr. Cheever one which was fixed below the sternum.' 1 Cheever, On two cases of cesophagotoiny. Boston, U. S., 1868. INJURIES OF THE CHEST. 217 The operation has hitherto proved very successful. Twenty-one cases are tabulated in Mr. Duriiam's essay on injuries of the neck in the second edition of the Siji^lem of Surgery, of which only four proved fatal ; and it seems undeniable that in some at any rate of these a more speedy per- formance of the operation would have given the patient a better chance ; for in one case (Arnott's), where the operation was not allowed till five weeks after the accident, the patient died of pneumonia, which had been developed previously, and in another (Martini's), where sixty attempts had been made to dislodge the foreign body (which was, in fact, swal- lowed during the operation), the pharynx was found to be gangreuous. Hence the propriety of the rule laid down by Mr, Arnott' is now generally recognized : that, "■ when a solid substance, though only of moderate size and irregular shape, has become fixed at the commencement of the oisoph- agus or low down in the pharynx, and has resisted a fair trial for its extraction or displacement, that its removal should at once be effected by incision, although no urgent symptoms may be present." In several cases where the foreign body has not produced complete in- ability to swallow it has nevertheless occasioned death by ulceration into the aorta or into the spinal column, pleura, or other parts. In one case even the heart was perforated.'' Injuries to the esophagus by the passage of foreign bodies, or by swal- lowing corrosive liquids, will sometimes produce a severe form of cica- tricial stricture ; but on this subject, and on the subject of gastrotoray, or opening the stomach in order to remove a foreign body, or to obviate starvation in stricture of the oesophagus, I must refer the reader to a future chapter in which the latter subject is treated. CHAPTER XL INJURIES OF THE CHEST. In describing the injuries of the chest, the pleura is always taken as the boundary between its parietes and its contents, so that wounds are classified as penetrating or non-penetrating, according as they do, or do not, open the pleural cavity. At the same time it must be recollected that the pleura, or any of the thoracic viscera or vessels, or even the viscera of the abdomen, may be injured in contusions and in non-pene- trating wounds by fragments of fractured ribs, and also that (though in very rare cases) the lungs or heart may be lacerated in contusions not involving any fracture of the ribs. Contusions and Flesh-ivounds. — There is little that is peculiar to the region of the body in contusions or flesh-wounds of the chest. It may, 1 His interesting paper in tiio eighteenth volume of the Med.-Chir. Trans, relating to the iirst case of oesophagotomy performed in this country is well worthy of study. ^ See Durham, in Syst. of Surg., vol. ii, p. 521. 218 INJURIES OF THE CHEST. however, be worth mention that the pectoral muscle is sometimes ruptured in severe sprains or other injuries in which the patient's arm is violently jerked while his body is in rapid motion in the other direction (as when in a fall a man grasps at a bar). The injury ma}' be known at once, by the great gap which is found in the front walls of the axilla, and the loss of the functions of the muscles. Sometimes also large extravasations or blood-tumors form under the pectoral muscle, which can only be distin- guished from subpectoral abscess by their rapid formation, and the absence of any inflammatory symptoms or appeai'ances. The treatment, liowever, of these complications differs in no respect from that of ruptured muscle, or of htematoma, in other parts of the bod_y. Subpeclo7-aI Abscess. — Abscess beneath the pectoral muscle is met with as the result of injury, and also forms spontaneously. The main point is to diagnose it from deepseated hematoma and from rapidly forming can- cer. The oedematous infiltration and inflammation of tlie surrounding cellular tissue, and the clearness of the fluctuation, are the main features which distinguish it from both, and in case of need the grooved needle will settle the question. A free and deep incision is necessary, and this is best made under anpesthesia, especially as large vessels may be divided. It is usuall}^ recommended to make the incision across the fibres of the muscle, a recommendation from which I venture to dissent. Quite as satisfactory exit for the matter may be procured l)y an incision running between the fibres, provided it be free enough, for which purpose, wlien the matter is reached, the incision maybe dilated with the finger ; and a large tent of lint should be kept in for the first three or four days. Fro.cture of the rihs is a very common accident, and occurs either as the result of direct violence, in which case usually onl}'^ one or two ribs are broken, or of indirect force from compression of the thorax by a crush either from the back or front, when a good many ribs give way at or near their angles and sometimes on both sides of the chest. A rib may also be fractured by muscular action in coughing, an occurrence which is some- what ominous of the presence of disease in the fractured rib, but has been known to occur without any evidence of such disease. Tiie broken ends of the ribs may be driven into the pleura, the lung, the diaphragm, and even througli the diaphragm into the liver or spleen, but the last-named lesions are very rare, and are usually only found in extensive and neces- sarily fatal injuries. It will be sufficient for practical purposes to discuss merely fractures of the rib: (1) uncomplicated, and (2) complicated with injury to the lung. Simp^le uncomplicated fracture of one or tvvo ribs is a very trivial acci- dent, hardly ever followed by any grave consequences if properly treated. But the danger increases considerably when many ribs are broken, and particularly on both sides. I have seen, however, a young woman recover from an accident in which, as far as could be ascertained, every rib in the body was broken and extensive injury inflicted on tlie bracliial plexus of one side. The first and (tliougii to a less extent) the second ribs are not 80 liable to fracture as tliose below tliem, the projection of the clavicle and the mass of the pectoral muscle shielding them to a certain extent; and the floating ribs by their extreme mol)ility also more commonly escape fracture. Fracture of the ujiper ribs is looked upon as a more serious in- jury than of the lower, since the lung is more often wounded. The pos- terior part of the ribs is less exposed to fracture than the middle, being under the protection of the tliick muscles of the spine. The ribs do, how- ever, give way sometimes near their tubercles, and the injury is diflicult FRACTURED RIBS. 219 of diagnosis ; sometimes discovered after deatli in eases where it has not been possible to form a distinct diagnosis during life. The signs of frac- ture of the ribs are pain at the part, aggravated l»y deep breathing or coughing, and crepitus. '^Plie breathing is often very shallow, and there is short hacking cough.' Emphysema of the cellular tissue can only occur if the fragment has penetrated the lung, and is decisive of the nature of the injury without further examination. It is not l)y any means always easy to detect the crepitus of a fractured rib. The periosteum is often untorn,- and then it is difficult to produce sufficient movement of the frag- ments on each other, or they may perhaps be interlocked, though we can hardly conceive them to be absolutely impacted. At any rate, it is cer- tain that in many cases where we have every reason to believe fracture to have occurred it is not possible to elicit crepitus. The best plan is to lay the hand flat on the suspected part and get the patient to breathe deeply or cough, if it does not give too much pain. If this does not succeed each rib may be traced, and manipulated at either side of the supposed fracture like any other bone, care being taken not to handle portions of two different ribs, as unskilful or careless persons sometimes do. Aus- cultation is recommended, but I cannot sa}' that it seems to me of any use. I have heard the crepitus of an undoubted fracture through the stethoscope, but never succeeded in thus hearing a crepitus that I could not feel. Tlie union of fractures of the ribs takes place, it is said, in about thirty to thirty-five days, but I believe that this is very variable, and that the time required for union is often much longer. I have felt crepitus a fort- night after the injury as fresh and distinct as at the time of its infliction. And the impossibility of keeping the fragments at rest causes fractures of the rib to unite by provisional callus more frequently than those of any other bone in the human subject. In fact, excluding some very excep- tional cases (like that represented in Fig. 33), all the instances of regular ensheathing callus in the human subject are taken from fractures of the ribs (see Fig. 32, p. 14()). The treatment consists in avoiding the movements of respiration as much as is compatible with the patient's comfort. Confinement to bed is necessary only in the severer cases, but all active exertion should be forbidden. A bandage to the chest usually aflTords great relief. It should be aiiplied around the whole thorax, as low as the end of the sternum, and should be commenced when the patient has emptied the chest as much as possible; the roller should be six inches broad, and should be adapted to the varying size of the chest b}^ reverses where necessary. When the bandage is finished a piece long enough to go across the chest should be left hanging, being secured by a pin or tacking ; this should be split half way down and the two ends brought over the shoulders and fastened on the other side like a pair of braces, in order to keep the bandage from slipping down ; or a piece of this kind should be sewn on. Another plan is to fix the injured side only of the chest by broad pieces of strapping applied from the spine to the sternum. This is thought to embarrass the breathing less, but it does not seem to me to give such 1 Mr. Le Gros Clark conjectures that these symptoms are sometimes the result of injury to or pressure on the intercostal nerve by the broken bone. '^ M. Coulon cites in his Traite des Fractures chez les Enfants, p. 90, a case pub- lished in the Bull, de la Soc. de Chir., 2nde ser , torn, i, p. 675, of a child who died of rupture of the lung, and in whom incomplete fractures of two or three ribs were found on both sidesT This author believes incomplete fracture of the ribs to be very common in childhood. 220 INJURIES OF THE CHEST. efficient relief. Sometimes a mere belt is applied round the injured part, fixed Avitli buckles. The bandage is to be worn till the patient can dispense with it with comfort, say for a month. When any noticeable displacement is felt, in consequence of one end lyin^ below the other, an attempt may be made to repress it by i)lacino- a pad on the projecting part of the rib which is driven in, so as to prize outwards its buried end. Fracture with Wound of Lung. — When the lung is injured the compli- cation is at once marked b}' the resulting em])hysema. The fractuied end of the rib or ribs must be driven through the pleural cavity into the lung, an occurrence much more likely to take place in fracture from direct violence, when the bone is driven directly downwards, than in that from indirect force, wlien (the curve of the bones being increased) tlie tendency is for the ends to spring outwards ; the air-cells of the lungs being thus opened, the elevation of the ribs in inspiration draws the air into the pleural cavity, from which it is forced into the wound which the broken rib has caused in the parietal i)leura, and thence into the subcutaneous tissue by the descent of the ribs in expiration. The sensation of emph}^- sema is so peculiar that when once recognized it can never afterwards be mistaken. It is a dry crackling sensation, perceptible on the very slightest touch, quite unlike any other phenomenon presented either in health or disease; and in cases of injury to the chest there is hardly any other source from which it can come except a wound of the lung.^ At the same time it should be remembered that a small quantity of air may be forced into an}- punctured or lacerated wound. I have seen it in a wound of the leg, and once I saw a case in which emphysema existed to a slight extent over the back of the chest, and it had been hastily con- cluded that the ribs had been fractured, the only injury being a spike- wouud at the back of the scapula. Such mistakes, however, must, be very uncommon, and very little care is necessary to avoid them. When fracture of the ribs is complicated with a wound of the lung the injury is, of course, much more serious than when no such complication exists. At the same time the lung is so prone to rapid union that if the injury be only slight the prognosis is not unfavorable. The first question is, whether or not to bandage the chest. Great surgical authority may be qnoted on both sides. The fragments have certainly been displaced inwards, and if this displacement be reproduced by bandaging, it may perpetuate an irritation which it is very important to stop at once. On the other hand, the movements of tlie chest may also produce irritation around the fractured ends, and so in the wounded portion of the lung. The patient's feelings are the best guide. If the steady pressure of the hand on the seat of fracture is gratelul to liim, it is well to try the effect of a bandage, which, however, must be removed at once if it increases the dyspnea or causes pain. Bandaging is certainly contraindicated wlien there is much comminution or tearing of the parietes of the cliest, as happens sometimes in such accidents as a blow from a carriage-pole, where a large rent may l)e seen in the chest-walls, into whicli the air bulges in the form of a large bladder under the skin with each expiration. The rest of the treatment of fractured ribs with wound of the lung con- ' In an open wound of the plfurn without wound of the lung emphysema may- occur, though it rarely does (see Gunshot Wounds), and (unphysema may also occur in stabs, implicating one of the large bronchi, and in rupture of the lung without fracture or wound. Spontaneous emphysema from rupture of a vomica, or even from rupture of the healthy lung in viohmt ctforts, such as those of parturition, is a rare and curious affection. EMPHYSEMA — HEMOTHORAX. 221 sists in perfect repose, with low diet (unless the patient be very weak at the time), until all fear of inflammation has passed over. The occurrence of inflammation will be noted more by the general symptoms of feverish- ness and dyspna^a, with rusty-colored sputa and hacking cough, than by any physical signs, since the condition of the part often forliids percus- sion or auscultation. When this is not the case the use of the stetho- scope is imperative. When inflammation is clearly marked nothing afljords so much relief as bleeding, especially if done early. Venesection is of course inadmissible if the pulse is very weak, but when there is much dyspna?a and a strong, hard pulse, the relief given by the abstraction of a moderate quantity (as 10 or 12 ozs.) of blood on the first accession of the symptoms is often decisive. Antimony in moderate doses fsa}' jo^'^ to |th of a grain every four hours) may also be given to robust patients; and if the symptoms call for it the bleeding may be repeated. In the weakly or in conditions of much depression a jacket-poultice should be applied, small doses of morphia combined with squills or some demulcent mixture ordered, and it may even be necessary to administer a little wine cautiously. Emphysema. — The emphysema in itself is usually of no consequence whatever. Cases are on record in which the cellular tissue has been said to be so blown up with air as to produce a real embarrassment to the patient's breathing, and to require evacuation by scarifications, but I have never met with anything of the sort. If necessary, however, any quantity of air might easil}^ be let out through an exploring trocar intro- duced in a few convenient places. The air generally disappears of itself, being probabl}^ taken up by the fluids of the part.^ The other complications of fractured ribs are very numerous. Air, blood, serum, or pus, or a mixture of several of these fluids, may be efl['used in the pleura; and in most cases of emphysema some air will probably remain in the pleural cavity, though if its exit into the cellular tissue be unimpeded the quantity Avill not usually' be sufiicient to cause any symptoms. Pneumothorax may, however, be present to an extent sufficient to cause embarrassment to the breathing, particularly if the wound in the parietal pleura has become closed and thus requires treat- ment. Besides dyspnoea, there will be unnatural resonance to percussion in parts away from the injury, flattening or convexity replacing the natural concavity of the intercostal spaces, increase in the circumference of that side of the chest, and loss of respiratory murmur. If the quantit}'^ eff'used be so great as to impede respiration the air must be drawn off" by a trocar or exhausting syringe, and this must be repeated as often as necessary; but, as Mr. Le Gros Clark has pointed out, it hardly ever is necessary, since when the air is in quantity suflScient to press on the lung that very pressure opposes further extravasation of air. Hspviothorax, again, may occur from wound of an intercostal arter^'^ or of some large vessel or vessels in the lung. Along with the dyspnoea there is in well-marked cases much depression or complete syncope, with other symptoms of internal ha?morrhage. The physical symptoms are those of fluid in the pleura (dulness on percussion, bulging of the inter- costal spaces, loss of respiratory murmur), and often metallic tinkling or splashing from the admixture of air with the fluid, and combined with these often a dark color under the skin of the loins, as if from sugillation of the blood through the pleura into the intermuscular spaces. If the 1 An interesting; discussion on the mode of removal of the extravasated air will be found in Mr. Le Gros Clark's work, p. 204. 222 INJURIES OF THE CHEST. patient seems to be really likely to die from the mere pressure of the blood, it is doubtless necessary to draw off the fluid part with the aspi- rator; or if this does not give the required relief, to make an incision and evacuate the semi-coagulated mass ; but such measures are hardly ever required, and are deprecated by many good surgeons as interfering with the closure of tiie wound in the artery, which is favored by the pressure of the clot. The occurrence of hydrothorax or empyema as the result of pleurisy after an injury is marked by the same symptoms, and requires the same treatment as when such conditions occur under other circumstances, for which I must refer to works on medicine. The other complications are much more rare, viz., lesion of the pericar- dium and heart, injury to the intercostal arteries, wounds of the diaphragm, causing laceration of the alxlominal viscera. As all these injuries are much more common from other causes than from fracture of the ribs the3^ are best treated of separately'. Fractures of the ribs are not unfrequently compound, i. e., the ribs are often fractured in gunshot and other wounds of the chest, but the frac- ture of the rib is in these cases only a subordinate part of a much graver injury, which usually involves the lungs, heart, or great vessels. The general features of such injuries will best be understood from the remarks on Gunshot Wounds in a subsequent chapter, and from those which fol- low presently, on Penetrating Wounds of the Chest. Fracture of Costal Cartilage!<. — The costal cartilages may be fractured, although I am not aware that the injury can be accurately diagnosed un- less one fragment overlaps the other, which does occasionally happen. Delpech is quoted by Mr. Poland as saying: "If the fracture takes place near the sternum the internal fragment passes in front and crosses the external; the contrary when the fracture is nearest the rib.'" In such cases it seems difficult to get the fragments into tiieir proper position ; and as no serious inconvenience results from the displacement it is un- wise to use any severe measures for that purpose. If the fragments can be manipulated into position a bandage should be applied to keep them so. If not, I should be disposed to leave them to unite as they are. Mal- gaigne speaks favorably of the use of a kind of truss. The injury is usually repaired by bone, sometimes by a mixture of bone and cartilage. (See page 155.) Fracture of the alernum rarely occurs as a separate injury, but it is not very uncommon as a complication of fracture of the spine, and it sometimes though rarely accompanies fracture of t lie ribs. The rarity of fracture in a bone so exposed to violence as the sternum testifies to the etliciency of the protection afforded to it by the costal cartilages, which supi^ort it exactly like so many elastic springs. The sternum, however, is sometimes fractured l)y direct violence, by indirect force (as in frac- ture of the spine), and even by muscular action.'-' Some surgeons seem to l)elieve that a frequent cause of fracture of the sternum is the forcible impact of the chin against the top of the bone in a violent bend of the neck. The fracture occurs generally tiuough or near the junction of the 1 Syst. of Surg , vol. ii, p. 561. 2 "'Chaussier rolatos two examples of the kind. Both patients were females, of the ages of twenty-four and twenty-five, and the fracture occurred during the efforts of labor with a fir.-it child."— Poland, in Syst. of Surg., vol. ii, p. 503. DISLOCATION OF THE RIBS. 223 first and second pieces of the bone, and what is called a (ractuve is often, as Mr. Rivinoton^ has shown, a true dislocation, there being a regular diarthrodial joint in this situation. The symptoms somewhat resemble those of fracture of a rib, and there is not generally much difficulty in detecting it by manipulation even when tiiere is no displacement, but very commonly the upper fragment is found behind the lower, leaving no doubt of the nature of the case. In fracture involving only the sternum there are rarely any visceral complications. The treatment is much the same as for fracture of the ribs ; the dis- placement often remains permanent, but no evil consequences need be feared from it, nor is the accident in itself a formidable one. Longitudi- nal fissures in the sternum have been dissected in the dead body, and more rarely recognized in the living by the displacement of the fracture. Dislocation of the Bibs. — Dislocation of the head of the rib from the spinal column, or of its extremity from the sternum, or from the carti- lage, can hardly be spoken of as a separate surgical injur}-, since it is usually only a subordinate part of the case, and in any event its treat- ment would be exactly the same as that of fractured rib. In Mr. Poland's article in the System of Surgery, the reader will find references to the recorded cases of this rare injury. Penetrating wounds are such as either open the pleural cavity only or pass more deeply, wounding the lungs, heart, or great vessels. There are no absolute signs by which a wound of the pleura only can be dis- tinguislied from one of the lung, since the passage of air out of the wound (traumatopnea) is noticed in wounds which terminate in tiie pleural cavity. As the parietes of the chest rise up in inspiration the air finds its way through the wound into the pleura, from whence it is expelled into the cellular tissue (emphysema), or through the wound (traumatop- ncEa) in expiration.^ However, when the lung is also wounded the ex- pelled air is usually churned up with the blood in the lung into a fine bloody froth, the absence of which sign in a penetrating wound encourages the hope that the pleura only is wounded. E^xploration with the finger or probe is only permissible when there is good reason for suspecting that a foreign body is lodged in the wound. Haemoptysis may be present to a certain extent when the lung is not wounded, and on the other hand it may be (though it rarely is) absent when the weapon has passed into the lung. These remarks apply, however, of course rather to small punctures than to free wounds of the lung, the nature of wliich is usually' obvious enough. In the graver cases of wound of the lung much air and blood will be effused into the pleura, and blood will also be extravasated into the tissue of the lung itself, so that the patient is menaced with death ^ Med.-Cliir. Trans, vol. Ivii, p. 101. ^ JSelaton eivos four conditions under which emphysema may occur : 1. In a wound of the hmg with external wound. The air passes during inspiration into tiie pleural cavity fmni the open air-cells and from the outer air through the wound, and in ex- piration is pressed out through the wound or into the cellular tissue. '2. In a wound penetrating the parietal [ileura but not the visceral, if there is any impediment to the free passage of the air out again through the wound. 3. In wound of the lung without external wound, as in fracture of the ribs. 4. In rupture of the lung with- out injury to the visceral pleura the air may be extravasated between the lobules of the lung, causing emphysema at the root of the lung, which extends to the lower part of the neck. [I cannot remember ever seeing this accident.] In rupture of the lung without injury to the parietal pleura, pneumotliorax'will occur, but no emphysema. (Nelaton, Path. Chir., vol. lii, p. 447.) 224 INJURIES OF THE CHEST. both from apiio?a, the result of pressure on the luug, and syncope, caused by loss of blood and shock. The chief danger in wound of the lung, ac- cording to Mr. Le Gros Clark, is in the early loss of blood; "if this peril be survived the risk of fatal inttanimation would appear to be less, under favoring conditions, than might be anticipated " (op. cit., p. 217). All penetrating incised wounds of the chest not involving fracture should be closed at once after the removal of any foreign substance, and it is a good practice in the severer cases, and those in which tlie lung is believed to be wounded, to strap the chest and apply ice externally. The collapse should not be interfered with at first, unless it be so severe tliat it threatens to prove fatal. The patient should be kept perfectly quiet and \evy cool. In fact, the object of the surgeon should be to avert biemorrhage. In reaction as the pulse rises bleeding may be indicated, and afterwards, when inflammation threatens or has commenced, the treatment already described must be pursued (p. 220). Wounds of the lung, under favorable circumstances and in healthy persons, unite rapidly, and the prognosis is by no means desperate. It need hardly be said that, if dyspna^a seems to be excited or kept up by the collection of air or blood in the pleura, the surgeon may find it neces- sary to reopen the wound in order to give it exit. Pneumocde., or the protrusion of a portion of the lung through the wound, takes place either immediately on the accident (primary), or after an interval (consecutive). Primary hernia of the lung, when the protruding lung is exposed by a wound, forms a globular mass, varying in size from a marble to a cricket- ball, the dark color, shining surface, and crepitating feel of which suffi- ciently indicate its nature. If recent, and if it can be reduced without violence, this should be done, the tissues of the wound which constrict the neck of the protrusion being, if necessary, divided, in order to allow of the easy return of the lung into the thoracic cavit}', when the wound is to be united. But if some time have elapsed, and the lung be altered in structure, no attempt at reduction should be made, nor is any other mechanical interference permissible — the herniated lung must be allowed to slough off. Some surgeons think it better to tie a ligature round the herniated portion, which may afterwards be removed if it be thought ad- visable, when the protruded part has contracted adhesions to the parietes.^ Primary hernia of the lung takes place also beneath the skin in cases of extensive fracture of the parietes of the chest accompanied by free laceration of the soft parts. In such cases it is useful to repress the protrusion b}' a carefully applied pad. Consecutive hernia takes place after the wound has cicatrized, so that the lung is covered by skin or cicatrix. It forms a globular, elastic tumor, which falls in during inspiration,^ disappears in holding the 1 Sec a case very clearly and succinctly described in Mcd.-Ciiir. Trans., vol. xx, p. 378, by Mr. Forde. '■^ This'is the usual account in the present day of the changes in volume in herni- ated lung during the movements of respiration. See Nelaton, Path. Chir., vol. iii, p. 408 ; Poland, Syst. of Surg., 2d ed., vol. ii, p. 583. But Mr. Le Gros Clark (op. cit., p. 20G), in relating a case of primary hernia of the lung with fracture of the ribs, distinitly observed that "at each inspiration a large tumor, of the size of the doubled fist, presented itself below the clavicle ; and tliis disappeared at each expira- tion, leaving a deep depression." Nelaton gives a mechanical explanation of the falling in of the herniated lung during inspiration, which does not appear to mo quite clear, lie says: " During the dilatation of the chest the portion of lung situ- ated outside is not able to participate in the distension of the viscus contained in the WOUND OF THE HEART. 225 breath, and swells in expiration, and particularly in coughing. On ma- nipulation it crepitates, and auscultation detects a harsh-toned vesicular murmur. Nothing can be done beyond protecting it, if it seems necessary, from any accidental injury by adjusting a concave shield over it. This will also obviate an}' chance of tlie increase of the protrusion. Foreign Bodien in the Thorax. — Foreign bodies whi(di are lodged in a wound of the chest must be extracted at once, and many histories testify to the possiliility of recovery even after complete perforation of the tho- rax by a very voluminous foreign body, as in the celebrated preparation in the College of Surgeons Museum, from a man who lived ten years after having a gig-shaft run through his chest from one side to the other. And life is not incompatible even with the permanent lodgment of a for- eign body, as in Velpeau's case of a man who lived fifteen years with part of a fencing-foil in his chest, which had entirely traversed the thorax, the point being implanted in the spine, the broken end fixed in one of the ribs, and the weapon itself buried in the lung, where it was surrounded b}' calcareous deposit.^ But such exceptional cases as this do not invali- date the general rule that foreign bodies should be removed at once, whenever it can be done without too great risk. Sometimes the foreign body (usually a bullet) drops into the pleura, and thus may entirely es- cape detection, though in some such cases the substance has been found by a probe, and has been extracted either by a pair of forceps or by di- rect incision. If the foreign body be left in the pleura it will probably produce death by pleurisy and empyema, though it is certainly not im- possible that it might become encysted. Wounda of the Mediaatimim^ Pericardium^ and Heart. — In some cases weapons liave penetrated the mediastinum without wounding any im- portant parts, and in still rarer cases the pericardium has been wounded, and yet the heart has escaped injury;'^ but no diagnosis can, I think, be made between tlie latter injury and that in which the heart is also wounded. Tlie symptoms of wound of the heart are chiefly those of acute internal haemorrhage, whicli usually proves rapidly fatal. There is a peculiar tremor about the heart, with intermittent small pulse ; and there is also a peculiar undulous crepitation and bruit accompanying the heart's ac- tion, and due to the blood effused around it into tlie sac of the peri- cardium. The position of the wound, and the severe symptoms which accompany it, are the only tests of the reaJitj' of the injury to the heart itself. Death is the ordinary but not, as it seems, the inevitable consequence of wound of the heart. The wound usually proves fatal by haemorrhage into the pericardium, the blood collecting about the heart and impeding its motion ; or in case of a free opening into one of the cavities the mechan- ism of the heart may be destroyed, the blood passing so freely out of the cavity " [but query why ?] " and as there is a tendency to a vacuum in the intratho- racic part of the organ, if the hernia is reducible it enters the chest ; if not it empties itself completely. These results," he adds, "are confirmed by accurate observation, but are contrary to what is found in authors." We must conclude that both condi- tions are found. I saw a case, many years ago, in which, if I can trust my memory (for I cannot now find the notes), the movements were as described in the text. 1 Syst. of Surg., vol. ii, p. 593. 2 On this subject consult Fischer, Ueber die Wunden des Herzens und des Herz- beutels. Langenbeck's Archiv, 1868. 15 226 INJURIES OF THE CHEST. heart tluat its pumping action is suspeiuled,^ A wound of the heart may also |)rove fatal at once by the " shock " to the heart or subsequenti}' by pericarditis, or from some of the many complications of penetrating wounds of the thorax. But there seems no question that in man and other warm-blooded animals wounds of the heart do not always prove fatal. Animals have been dissected in whom foreign bodies have been found which had been lodged for years in the substance of the heart, and others bearing the plainest marks of old scars. Nor are similar cases by an}' means so uncommon as is sometimes supposed in the human subject. Fischer has recorded 452 cases in whicli wound of the heart or pericar- dium was diagnosed, and out of these 72 recovered, and the diagnosis was in 36 cases verified to the satisfaction of the surgeon by post-mortem examination. In a case the preparation of which is in the Museum of St. George's Hospital the symptoms were at the time ill-marked, though the heart was perforated : the bayonet having passed through the wall of the left ven- tricle and opened its cavity. The patient was a young man, a volunteer, who accidentally fell on his bayonet. He withdrew the weapon, ran a short distance, and then fainted. When seen at the Nottingham Hospital, an hour afterwards, he bore traces of great loss of blood internally, but this seemed chiefl,y in the left pleura, from which a pint and a half of blood was drawn off next day. On the day after the accident pericardial fric- tion was detected. He lived four da3's.^ '• Treatment," says Mr. Poland, " will be mainly directed to prevent and arrest internal haemorrhage, by absolute repose, local and general em- ployment of cold, and early venesection to relieve the heart ;" and he also recommends the internal use of belladonna and digitalis. FaracenteMa Pericardii. — Paracentesis of the pericardium has been contemplated in wounds of the heart in order to disembarrass the heart of the etlused blood, but has never been performed for that cause. It has, however, been occasionally resorted to when effusion into the peri- cardium, the result of disease, could be distinguished to such an extent as seemed likely to prove fatal. The operation is best performed in the fourth or fifth intercostal space, just to the left of the sternum, in exactly the same manner as paracentesis of the pleura,^ or the parts may be dis- sected until the distended pericardium is exposed. In a case recently published/ the operation is thus described : "A fold of skin having been raised over the (if'th intercostal space, an incision a little more than an inch long was made jjarallel to the ribs, in the centre of the space, com- mencing about two-fifths of an inch to the lel'tof tlic sternum. The layers of muscle were then carefully divided, and an elastic dilatation was felt, which resisted a little under pressure, while the impulse of the apex of the heart could be indistinctly perceived. A puncture having been made in this, the point of a small trocar was introduced, and about 10 ozs. of fluid were removed, with immediate relief." ' Mr. Le Gros Chirk describes and figures a most interesting case of bullet-wound of the* heart, in which tl)e niiin survivod fourteen diiys, though there was a transverse laceration an inch in Icnj^lii in tl)(' right ventricle near its root, and the tricuspid valve was also lacerated (op. cil., ]>. 2GU). * Med. Times and traz., 18G3, vol. ii, p. 487. St. George's Hospital Museum, ser. vi, No. 224. * On paracentesis of the pericardium see AUbutt, in Lancet, June 12, 1869. * Lond. Med. Record, May 5, 1875, p. 275. WOUNDS OF MAMMARY AND INTERCOSTAL VESSELS. 227 Wounds of the Internal Mammary and Intercostal Vessels. — Many great vessels may be wounded in the cavit}'^ of the chest, but the only cases which need engage our attention, since they are the only ones susceptible of definite diagnosis and treatment, are tiie wounds of the internal mam- mary and of the intercostal arteries, and these are very rare, at any late as substantive injuries. It is possible that an intercostal artery may be occasionally injured in fracture of the ribs, but I am not aware that this has l)een proved by dissection. The internal mammary artery may be wounded in any of the first three spaces by a stab-wound on either side of the sternum without any division of the costal cartilages. Below the fourth costal cartilage it is said that it can only be divided by section of the cartilage, and in more than half the cases that have been noted the costal cartilage has also been cut.^ An artery laid open through a wound of so dense a structure as the costal cartilage can hardly be brought into view. When the artery is wounded in any of the upper three intercostal spaces it maj^, according to M. Tourdes, be tied by direct incision. The intercostal artery may be wounded in paracentesis or in a punc- tured wound or gunshot injury, and it may be perfectly impossible to secure it, from its remote position as vvell as the retraction of its divided ends. It is not eas}' in either case to distinguish the source of tlie bleeding, though there would be less hesitation in the case of the internal mammar}'^ artery than in that of the intercostal. The symptoms of bleeding from the latter differ but little from those of haemorrhage from a wound of a vessel in the lung, for in accidental injuries at least the lung is also in all probability wounded. The main diagnostic sign is the effect of pressure with the finger introduced into the wound, which may be enlarged for the purpose. It has also been proposed to introduce a strip of card or a thin spatula into the wound, and judge of the source of the haemorrhage by seeing on which side of the card the blood runs down. If the card is in- troduced into the pleura beneath the intercostal arter^^ it is clear that if that artery be the source of the bleetling the blood will run along the outside of the card, and if the bleeding be from the lung, along its inside. The treatment of wounds of either of these vessels has generally been unsatisfactory. There are, indeed, some cases in which the surgeon can tie the wounded artery, but the}' are exceptional. In other cases it may be possible to keep up pressure by the fingers of a relay of skilled assist- ants long enough to avert death by lu^morrhage ; or possibly the plan of uncipression recommended b}' Signor Vauzelti might find its use here (see page 125); or an oval sponge on a ligature might be introduced into the wound so shaped that when it swells up it will not come out of the opening when the ligature is drawn outwards, but will make pressure outwards on the bleeding vessel. Many good surgeons, however (as Larrey,^ in the case of the internal mammarj^, and Assalini in that of an intercostal artery), think that the patient has on the whole a better chance of recovery if the wound is simply' closed, and coagulation is ^ See Tourdes, Annales d'Hygiene Publique, vol. xlii, p. 165, wliere summary notes are given of eleven cases; in live of wliieli, however, the diagnosis was not verified by iiost-niorteni examination. This author insi?ts strongly on the necessity of liga- ture of this vessel when wounded, but I am not aware that the operation has ever really been iiracticed. 2. Larrey speaks thus : " It is much better to leave htemorrhage from the intercos- tal or internal mammary artery to nature. The wound being closed, the blood ac- cumulates in the thorax, and the lung, no longer compressed by the air, dilates again and fills up the cavity." — Clin. Chir., vol. ii, p. 18L 228 INJURIES OF THE CHEST. trusted to to repress the hfemorrhage, paracentesis being performed if the blood accumulates in the pleura' to such an extent as to threaten life. Bupture of Viscera xvithout Wound 07- Fracture. — The heart is some- times ruptured even in cases where there is no direct injur}^ to the chest. Thus, in the case of a mason's bo}^ who fell from the roof of St. George's Hospital and was killed on the spot, among other fatal lesions the sep- tum ventriculorum of the heart was found ruptured without any other in- jury of the chest. But such lesions hardly come within the range of practical surgery. In severe contusions of the chest (and usually from the passage of a carriage-wheel over it) the lung is sometimes lacerated without the chest- walls "sustaining any visible injury. Doubtless at the time of the acci- dent the glottis is spasmodically closed, and then the lung is torn be- tween the force impressed on it through the chest-walls and the resistance of the air confined in the bronchi. The injury may be diagnosed when the visceral pleura is also ruptured ; but, I should think, not otherwise." The symptoms in that case will be hydropneumothorax (dulness at the lower part of the chest, sonorous resonance at the upper, and metallic tinkling, possibly with splashing on succussion), and at the same time dyspnoea, haemoptysis, and sometim.es subcutaneous emphysema, without any fracture of the ribs. The accident is much more likel^^ to occur in childhood, from the elasticity of the chest-walls. The treatment is directed to avoid and combat the resulting inflammation, as in any other severe injury of the chest, and there can be no doubt that some cases end in recovery.' Pflracentesis Thoracis. — The present seems the best place to introduce a description of the operation of paracentesis thoracis, or thoracentesis. Tapping the chest is a very simple operation, and one which has now become so familiar that it is often performed by students or junior prac- titioners. In fact, with some simple precautions, it involves little risk of its own. At the same time, when performed on account of disease, or when the contents of the chest are, from previous disease, in unnatural relations to each other, it is not either so simple or so harmless. The objects of the operation are to evacuate fluid from the pleural cavity without injuring the intercostal vessels, the lung, or the diaphragm ; to avoid the entrance of air in place of the fluid removed ; and to do this without any lesion of the lung due to the change in the conditions of atniosplieric pressure which may be caused by emptying the fluid out of the pleura. In order to fulfil these several indications the first thing is to make sure that there is really fluid in the pleura at the point selected for tapping; by percussion, giving dulness; by auscultation, showing the absence of respiratory murmur; and by the change in the shape of the intercostal spaces, bulging outwards from the pressure of the contained fluid, instead of being concave, as in the natural condition ; by the increased measure- ment of the afliected side of the thorax, together with the displacement ^ In wounds of the internal mammary, low down, even the pericardium may be opened and may be filled with blood. '^ See, however, above (p. 222, footnote), N6hiton's observations on the occurrence of cmiihysemfi at the root of the neck in cases of laceration of the tissue of the lung without rupture of the visceral {)leura. 3 The chief authority on this subject is M. Gosselin's elaborate article in the first volume of the Mem. de la Soc. de Ohir. de Paris. PARACENTESIS THORACIS. 229 of viscera. The next thing is to make the opening near the upper border of the lower rib, since the main intercostal vessels run near the lower border of the upper rib. The best plan, I think (unless the parietes of the chest are unusually thin), is to make a lancet puncture on the lower rib, put a finger nail into the puncture, and enter the trocar above the finger- nail. The shape of the trocar seems of little moment. The lung can Fig. 68. The aspirator, a. The perforated needle or sharp-pointed canula, which is introduced into the col- lection of tluid. It communicates with the bottle, rf, by means of an india-rubber tube, which is inter- rupted at 6 by a portion of glass tubing, so that the nature of the fluid evacuated can be judged of at once, and the canula either plunged deeper or withdrawn. When the handle, c, is in the position shown the communication between the canula and the bottle is closed. The bottle is then exhausted of air by means of the pump,/. When c is moved to c', the canula-tube is opened, e is the waste-tube of the bottle, and is closed by a button at e. In using this aspirator the vacuum is formed, and the handle, c, is kept in the position shown till the canula has been introduced into the fluid, then it is turned to c', and the fluid fills the bottle. If tViere is still more fluid, the handle is turned back to c, the waste-pipe opened, and the fluid emptied out of the bottle, which is then again exhausted, and the handle turned back to c'. This is one of the simplest of the many forms of the aspirator. hardly be injured if there is plenty of fluid below the trocar. The dia- phragm is avoided by not going too low. A favorite seat for paracente- sis is in the fifth or sixth intercostal space, and just in front of the angle of the scapula, where the intercostal spaces are at their broadest. The entrance of air may be best prevented by using an exhausting syringe. One fashioned like a stomach pump was in use many j'ears ago, and acted very well. At present Dieulafoy's aspirator is more commonly employed, and certainly answers its purpose admirably. But in tapping the chest it must be recollected that if fluid is to be removed and no air is to replace it, this is only mechanicall}^ possible on the condition that the lung shall rise up to take the place of the fluid ; for the only other wa_y in which the vacuum could be filled would be by the bulging in- wards of the chest-walls. But in ordinary circumstances the parietes cannot yield to any appreciable extent. Now, if the lungs are bound down by adhesion, and attempts to exhaust the fluid are made with con- siderable force, the atmospheric pressure, acting through the air-passages on the tissue of the lungs, is no longer balanced by the pressure of the parietes, and the tissue of the lungs is forcibl}^ thrust towards the pleura by the air inside them, to their great detriment. Instances are not want- ing in which the lungs have thus been torn. Therefore the attempt to withdraw the fluid without the admission of air should not be persevered in if there is much resistance. And I cannot say that I am myself con- 230 INJURIES OF THE ABDOMEN. viiiced of the great danger of the admission of air in thoracentesis. Much difference of opinion exists on the subject.^ The patient should sit across tlie bed, supported by an assistant, and as the fluid escapes he shouUl be lowered nearer the horizontal position, the assistant keeping his hands on the two sides of the chest. As soon as the fluid begins to stop it is better to withdraw the trocar, closing the opening at once with the finger, and then witli strapping, and restoring the patient to the horizontal position. When the fluid is purulent, especially if mixed with flakes of solid sub- stance, it seems better to make a small incision along the upper border of the rib. This is conveniently done by puncturing the pleura with a grooved needle, along the groove of which, when the pus has been found, a small knife can be passed. CHAPTER XII. INJURIES OF THE ABDOMEN. Blows on the abdomen are always to be regarded with some apprehen- sion. They often produce a good deal of immediate shock, even when no permanent ill effects follow. That a severe blow on the epigastrium may destroy life by mere shock, without any visible lesion, is an old doctrine which cannot be said to be exploded, although Mr. Pollock has shown that much of the evidence on which it rests is highly unsatisfactory." If the fact is true its explanation is probably to he sought for in some direct effect on the great sympathetic system around the semilunar ganglia, analogous to "concussion" of the other great nervous centres. But the event is unquestionably a very rare one, and its treatment would resolve itself into that of collapse (see p. 129). The more formidable immediate dangers in contusions of the abdomen are rupture of one of the al)dominal viscera, or laceration of the peritoneum, followed by acute peritonitis, or by chronic peritonitis, or supjjuration in or beneath the abdominal walls.'' Cases where there is no symptom of visceral lesion, but where the blow has been severe, and the |)ain is great or extravasation extensive, should be watched with much care. 'I he bowels should be kept inactive for several days by doses of opium proportioned to the amount of pain, warm fomentations sprinkled with laudanum or turpentine should be applied • Soe a controvorsy in the Brit. Mod. .Journal (1871, vol. i) between Dr. Fuller, Dr. Pliiyfair, Dr. Doui^las Powcli, and others, as to the possibility of preventing the entrance of air into th(! pleura in paracentesis, and as to the importance of doing so, if pos.sible. 2 See Syst. of Surg., vol. ii, p. 020. Mr. Le Gros Clark, whilst admitting the pos- sibility of fatal shock witlKJUt visible b-sion, says that be has never met with such a case. (Op. cit., p. 267.) 3 In some ca.ses of severe contusion of the abdomen the muscles may be more or less lacerated. It is the rectus which is usually the seat of this injury. RUPTURE OF INTESTINE. 231 over the bell_y, or leeches to the painful part; and all distension of the intestines should be sedulously avoided, the patient being kept on meagre diet, given in very small quantity, at short intervals. If peritonitis comes on it must be treated according to the general symptoms and the patient's state of healtii. In all cases opium is to be given by the mouth, or morphia injected subcutaneously ; in cases of sthenic inflammation I entertain no doubt of the good effects of mercury; and in such cases free bloodletting is very advantageous — twenty or thirty leeches to the abdo- men, repeated if necessary — or even venesection. In cases of low diffuse suppuration (whether internal or external to the peritoneal cavity), vt'ith quick weak pulse, vomiting, tympanitis, and dry tongue, stimulants even in large quantity may be required. Suppuration near the seat of injury should be carefully watched for, and an early and free exit given to the matter. Rupture of the Stomach. — The stomach is very seldom ruptured with- out direct wound, and when this does take place the collapse is sudden and complete, and death occurs in a few hours. In a well-marked case pulilished by the late Mr. Moore, ^ one of the main symptoms was the excruciating pain which was caused by the administration of small quan- tities of brandy. There will probably be urgent thirst, but there will be no vomiting, unless the rupture be very small or incomplete. No accu- rate diagnosis is possible, and no treatment can be of any avail. Mr. Pol- lock conjectures that in some cases of small laceration, occurring possi- bly between the attachments of the layers of omentum, the patient ma}'^ temporarily recover, with a gastric fistula, and quotes a case which may be so interpreted. The diaphragm may also be ruptured by a severe contusion. The only known consequence is a phrenic hernia. The subject is discussed in the chapter on Hernia. Bupture of the Boicel. — Rupture of some part of the intestine is a tol- erably frequent and a very fatal injury. It occurs in any part of the bowel, " from the commencement of the duodenum to the termination of the sigmoid flexure of the colon " (Pollock). The laceration varies in extent, being sometimes little more than a pinhole, at others involving the whole or almost the whole circumference of the bovvel. The injury is cansed by severe contusion, such as the kick of a horse or the passage of a wheel over the abdomen when the intestine is full ; for there is no evidence as far as I know, that the intestine can be rup- tured when collapsed ; and this is a very important distinction between rupture from contusion and perforation by direct wound. Many instances of sword and bullet wounds of the intestines have been recorded in which recovery has ensued, though the occurrence of fa,'cal fistula has proved the reality of the lesion of the bovvel.'^ And such cases are easily intel- ligible if vve suppose that the bowel was empty at the time of the wound, so that no foecal fluid or gas escaped into the peritoneal cavity at the mo- ment of the perforation. For the mucous membrane of the bowel pro- 1 See Syst. of Surg, vol. ii, p. 641, 2d ed. 2 Amongst many other equally convincing cases I would refer the reader to one illustrated by a very striking photograph in the Circular No. 6 of the American Sur- geon-General, Nov. 1, 1865, p. 26." In this case the ball had passed clean through the abdomen and emerged near the spine. There had been ftecal discharge from both wounds, and a mass of sphacelated omentum was discharged from one of them. Still the patient recovered, and was in perfect health at the date of the report. 232 INJURIES OF THE ABDOMEN. trudes at once through the lips of the wound in tlie muscular and serous coats, and assisted by the contraction of the muscular fibres, so effectually closes the aperture that no extravasation takes place at the moment of tlie wound ; nor would any extravasation occur at all, if renewed disten- sion could be prevented. By the time that the injured bowel becomes distended with f.eces its wounded part has contracted adhesions to the neighboring coils and to the parietes,so that the faeces find their way out of the external wound, not into the peritoneal cavity. This protrusion of the mucous coat occurs also in the case of internal rupture.' But here, since the bowel is distended when ruptured, and as there is no other exit for the contents except through the wound, there must occur instantane- ously on the rupture a free escape of faecal gas at an3'rate, and in all prob- ability an effusion also of faecal fluid into the peritoneal cavity, though the latter may sometimes be in such small amount as not to be discover- able after death. Thus the germs of fatal inflammation are in all proba- bility implanted on the serous membrane; and there is not, as far as I can discover, any perfectly satisfactory proof that complete rupture through all the coats of the bowel without external wound has ever been followed by recovery. At the same time there have unquestionably been cases in which the symptoms have been held to justify the diagnosis of ruptured bowel w^hich have ended in recovery ; and the theoretical pos- sibility of recovery, even in cases of complete rupture, has not been dis- proved ; for we are not entitled to assert that the effusion of fiecal gas must inevitably prove fatal ; and there is again the remote possibility that although the bowel may be ruptured, 3'et the rupture may not impli- cate the peritoneum. Consequently the injury must be treated with a view to recovery. Rupture of the intestine can generally be diagnosed. After a severe blow on the abdomen acute pain comes on shortly, before the pain of the injury has subsided, often accompanied with much collapse (though not always so''), with urgent vomiting, intense thirst, great tenderness of the abdomen, involuntary contraction of the abdominal muscles, usually rapid sinking, with coldness of the surface, lividity, and loss of pulse some time before death. As the case goes on the vomit, which at first consists merely of food, becomes bilious, and then more and more resembles the contents of the small intestines ; but I have never seen absolute faecal vomiting. Tympanitis usually succeeds, probably from paralysis — the result of an impression on the sympathetic system of nerves. The col- lapse which depends on general shock may, as Mr. Le Gros Clark points out, be distinguished from tliat caused by haemorrhage, since in the latter case "the patient usually refers his suffering to some isolated spot, where fulness or dulness on percussion, or l)otli, may be detected." Treatment must of course be directed to prevent any reopening of the laceration — i. e., to keep the lacerated bowel perfectly quiet until union has occurred ; and this is the more important wlien we recollect that even if we believe all complete lacerations of the bowel to be fatal, yet we often see the distended intestine partiall_y lacerated on its external surface in cases of hernia by injudicious violence, and that if the same thing took 1 See a case by Mr. Partridge, Path. Trans , vol. xii, p. 109, where death occurred eifjht days after laceration of almost the whole circumference of the jejunum. The mucous membrane had so completely plu^'ged the opening that there was no trace of extravasation of the contents of the bowel into the i)eritoncal cavity. ^ See in Syst. of Surg., 2d cd., vol. ii, p. 043, a striking instance of the complete ab- sence of collapse an hour after the receipt of an injury in which the bowel was rup- tured. IIUPTURE OF THE LIVER. 233 place in contusion it might produce s3'mptoms very similar to those above described. Now, such an incomplete laceration would doubtless heal under favoral)le circumstances, if the i)art is kept at perfect repose, whilst distension and movement might easily render it complete, or set up fatal inflammation. Ab.^olute vest must be enforced — i. e., the patient must be not only con- fined to bed, but prevented from making the sliglitest movement which can disturb the abdomen ; opium must be administered in small doses often enough to relieve the pain, if possible, and to keep the bowels quite quiet, while any renewed distension of the intestine must be avoided by a rigid abstinence from food. Just so much fluid nutriment must be given in very small quantities as will support life, and thirst must be alle- viated by sucking small pieces of ice. If the patient survives for some days, and peritonitis then comes on, it must be treated according to the usual indications. Rupture of the liver is a tolerably common injury, and one which is not necessarily fatal, though it usually is so.' Cases have occurred in which a rupture of the interior of the liver has been found, the peritoneal coat being untorn, and such injuries are evidently susceptible of repair, if they do not involve too large vessels. But it seems certain also that small lacerations of the surface of the liver ma}' heal. I once saw a case^ in which all the symptoms of laceration of the liver were certainly present. The man recovered, and, about a year afterwards, died from another cause. On dissection traces of some injury were found on the surface of the liver, though it was impossible to say exactly what the extent of the lesion had been.'^ Rupture of the liver is also sometimes produced by fragments of the ribs perforating the diaphragm. Such injuries are almost of necessity fatal. Uncomplicated rupture of the liver causes death primarily, either by haemorrhage or by extravasation of bile into the peritoneal cavity, and secondarily by peritonitis. When, therefore, the laceration extends into one of the large bile-ducts or the gall-bladder^ the injury must prove fatal; and when the substance of the organ is so deeply broken up that several large vessels are laid open the bleeding can liardly be expected to stop. It is only the more superficial injuries in which recovery can be antici- pated. The diagnosis of rupture of the liver must commonly be only conjec- tural, resting on the nature of the accident, the pain over the region of the liver (which is by no means always observed), the collapse, the symp- toms of hseraorrhage, and occasionally the accumulation of fluid in the peritoneum. The treatment must be, as in all other similar injuries, absolute rest, small and rei)eated doses of opium, the application of ice to the part, and possibly the administration of styptics. If peritonitis comes on afterwards the usual treatment must be adopted, though antiphlogistic measures must only be employed with the greatest caution. ' Mr. Le Gros Clark takes a still more favorable view of these injuries. He says : "If the first efl^"ects of shock and haemorrhage are survived, recovery from lesion of the liver or kidney is probablj' not infrequent." (Op. cit., p. 292.) * Path. Soc Trans., vol. xi, p. 140. 3 Mr. Pollock quotes from the records of St. George's Hospital a still more conclu- sive case. A man died from the effects of fracture of the spine three weeks after the accident. An extensive but not deep laceration of the liver was found, which had almost entirely healed. Syst. of Surg., vol. ii, p. 648, 2d ed. '' For a case of rupture of the gall-bladder see Fergus, Med. Chir. Trans., vol. xxxi. 234 INJURIES OF THE ABDOMEN, Bupiurc of ihc SpJpen. — The s^Mnptoms of rupture of the spleen are practically indistinguishable from those of rupture of the liver. The situation of tlie contusion, if known, will justify a conjecture that it is the spleen rather than tlie liver which is rui)tured, but no exact diagnosis can be made. The treatment, however, being identical, no importance attaches to the differential diagnosis. The spleen being a still more vascular organ than the liver, its laceration usually produces even more acute haemorrhage. Rupture of the lidney is more common than that of either the liver or spleen, and it is a far less formidable injury, since it seldom involves the peritoneum. In fact, it seems probable that the real nature of the injury in many of the cases classified as "ruptures" might be more correctly described as " bruise," there being probably no visible laceration. There is no doubt, however, that extensive lacerations may heal, and a prepara- tion in the Museum of St. George's HospitaP shows a rupture which has divided the kidney into two parts and obliterated the ureter, but from which the patient entirely recovered, d3'ing a year afterwards in conse- quence of granular degeneration of the other uninjured kidney. The symptoms of uncomplicated rupture of the kidney are merely those of a bruise on the back, with haemorrhage into the bladder, occurring immediatel}' on the injur3\ In the case above referred to this hsematuria was very transient, lasting only a single day, for the ureter had evidently been obstructed by coagula, and thus all further haemorrhage was sup- pressed. This, however, involved the entire loss of the kidney' as a secreting organ. Generall_y the bleeding ceases gradually, and the viscus is probably not seriously altered in structure. In some cases, if the lacer- ation has extended through the capsule, blood and urinous fluid get infiltrated around the kidney, and an abscess results which usually pre- sents in the loins, and to which an early opening should be given. Similar effects are attributed to laceration of the upper part of the ureter or of the pelvis of the kidne}'.'- Many such cases have been brought to a favorable issue. When rupture of the kidney is complicated with lacer- ation of the peritoneum in front of it, the blood and urinous fluid will pass into the peritoneal cavity, and the case will probably prove rapidly fatal. Such injuries are indistinguishable from laceration of the liver and spleen, with which they are frequently combined. Death in uncomi)licated rupture of the kidney is caused either primarily by haemorrhage or secondarily by abscess, and this abscess may either present Ijchind in the loin, when speedy exit is to be given to the matter, or may make its way in front, and cause peritonitis even in cases where the peritoneum itself is quite uninjured.'' The treatment must therefore be directed at first to the suppression of haemorrhage by complete rest, opium, leeches to the loins, and perhaps st3q:)tics (acetate of lead gr. iii, every three hours, or gallic acid in 10-gr. doses every two hours), the bowels being kept freely open. If blood collects in the bladder the urine must be drawn off, and the clots washed away bj' a stream of water injected through a double-eyed catheter. On the first indication of abscess an exploratory puncture must be ' Ser. xi, No. 4. The ciise is roported in Path. Trans., vol. xi. p. 140. ^ See Stanley, Med. Chir. Trans., vol. xxvii, for two cases, one of which proved fatal The pelvis of thij kidney was found ruptured. 3 See Pollock, op. eit.. p. (>'^S. May not tliis be the explanation of a case reported by Mr. Lo Gros Clark (Lectures on the Principles of Surgical Diagnosis, p. 333), in which rupture of the bladder was suspected ? PENETRATING WOUNDS. 235 made, and the abscess either opened by the knife ov evacuated with the aspirator. Woirnds of the abdomen are divided into (1 ) superficial wounds — those which implicate the parietes only ; and (2) penetraiivg — those in which the peritoneal cavity is opened. Penetratin<)^ wounds may be (a) simple, i. f., there may be no indication of any injury to the viscera, or (b) the viscera may be wounded but not protruding, or (c) the viscera may pro- trude, but uninjured, or (f?) the protruding viscera ma}' also be wounded. 1. Superficial wounds are to be treated on the same principles as wounds in any other part of the body, but with this caution : that as the subperitoneal si)ace may very probably be laid open, in which haemor- rhage may go on to any extent, or in whicii suppuration may extend, producing irritation and inflammation on either or both sides of the peritoneum,' the surgeon should always be ready to enlarge the wound, with the view of securing an}^ vessel wiiich may bleed deeply, or giving exit to inflammatory products. Sir B. Brodie's case of ligature of the external iliac artery'' is a well-known example of the beneficial effects of laying open a non-penetrating wound of the abdomen when suppuration is going on in the subperitoneal tissue. Foreign Bodies lodged in Wounds. — In all cases of wound of the abdom- inal parietes the surgeon must also be most actively on the watch for the possibility of lodgment of foreign bodies. Many histories testify to the enormous size of foreign bodies which may be buried in the abdomen and may entirely escape observation for the time, though afterwards they must produce most serious mischief. It is quite true that exploration without urgent motive is a proof of very bad judgment, but when there is any reason to suspect the lodgment of a foreign body it should be very gently yet thoroughly carried out, and the foreign substance at once re- moved. When any foreign body present has been removed and all bleeding vessels carefully secured, the wound is to be sewn up, and the patient kept in such a position as will keep the walls of the belly relaxed. Even if the wound is somewhat lacerated, it seems better to bring its edges into apposition. In cases of extreme laceration the surgeon must use his own judgment, inclining towards such an amount at any rate of apposi- tion as v/ill secure the patient against the protrusion of the intestines through the wound. Ventral hernia is a common consequence of abdom- inal wounds, which is spoken of in the chapter on Hernia. 2. (a) Pevetraling ivouvds, in which there is no indication of injnry to the viscera, or in which the viscera, being exposed, are known to be uninjured, are to be treated in the manner so familiar to surgeons in operations for hernia and ovariotomy, ?'. p., they should be brought to- gether deeply enough to insure the union of the wounded surfaces of the peritoneum, and the patient should, if it seems necessary, be kept mode- rately under the influence of opium. Whether the sutures are passed actually througli the peritoneal edges or not seems of little importance, provided they are placed so close to the peritoneum as to keep the wounded portions of the peritoneum in contact, but it appears to me safer to take up the peritoneum as well as the abdominal wall in the 1 I cannot say that I recognize the distinction which some authors endeavor to draw between diffuse peritonitis and ditluse subperitoneal inflammation. As far as I have seen they produce the same symptoms and often coexist. 2 See Pollock, op. cit., p. 657. 236 INJURIES OF THE ABDOMEN. suture. The suture will really, in a very short space of time, be outside the peritoneal cavity, beino; buried in ettased lymph, while, if the stitches are passed outside the peritoneum, and the edges of the wound in the peritoneum should not be in contact, a ready way is left open for the per- colation of inflammatory material into the cavity of the peritoneum. With reference to the administration of opium, it is well, I think, to be governed more by symptoms than by routine. I would refer the reader on this head to remarks, in the chapter on Hernia, on the management of cases after operation. (b) Wounds of Viscera ivhich do not protrude. — Wounds in which the viscera are wounded but do not protrude, are amongst the most serious injuries met with in the abdomen, and the smaller the wound is the greater may be the danger. Gunshot wounds are spoken of in another cliapter; the injuries commonly met with in civil practice are either stabs or incised wounds. In these the surgeon can often only suspect the visceral injury from the pain and collapse which are present, at other times the escape of the contents, urine, fiBces, bile, or gas through the wound affords a certain proof of the nature of the lesion. Unfortu- nately nothing can be done. It would be useless to cut down on the wounded viscus with the hope of preventing the escape of secretion into the peritoneum, for if the peritoneum has been opened this effusion has already taken place. An enterprising surgeon might think it worth while to la}" the peritoneal cavity freely open, stitch up the wounded viscus, and wash the membrane out with an antiseptic lotion, afterwards uniting the wound ; and I should myself regard the operation as fully justifiable, but I am not aware that it has been tried. In all other respects the injury must be treated like any other grave wound of the abdomen. (c) Wounds with Protrusion of Uninjured Viscera. — When any of the abdominal viscera protrude uninjured through a wound, the first care of the surgeon should be to free their adhesive peritoneal surface from any small foreign bodies which may, and very often do, stick to them ; then return them into the belly with as little violence as possible, and treat the case exactly as after strangulated hernia. The bowel or omentum pro- trudes much more often than any of the solid viscera or than the bladder. The intestine, if unwounded, should in all cases be returned, even though somewhat contused or abraded, and for that purpose, if the accumulation of air in the bowel, or the thickening of its coats from obstruction, has rendered it impossible to pass it back otlierwise, the wound is to be gently enlarged l\y a very slight nick in one or two places, just as in hernia. A precaution is to be observed which is hardly required in hernia, viz., to be very careful not to push the bowel into an interstice between the muscles or into the subperitoneal tissues. The finger should be passed fairly through the wound, to make sure that the reduction has been complete. The omentum, though not absolutely wounded, is often so altered in texture from exposure or obstruction, or so beset with foreign l)odies, that the snrgeon may fairl}' prefer to remove it after pass- ing a ligature through its base, of course making sure first tliat no bowel is implicated in its folds. When any part of the solid viscera jirotrudes (which, however, rarely happens, except in shell or other gunshot wounds), the surgeon will be guided l)y the condition of the protruding part and the ease of reduction, in his ciioice between returning it, encircling it with a ligature, or leav- ing it in situ ; nor are such cases frequent enough (at least in civil prac- tice) to enable me to lay down an}^ definite rule, but in ni}' opinion the last course would usually be the best. FOREIGN BODIES IN STOMACH. 237 When any of the bladder protrudes uninjured a catheter must be passed, and after the bladder has been emptied reduction can hardly present any diflicnltv. (d) Wounds with Protrusion of Wounded Viscera.— If the omentum protrudes and is injured, it should be removed. The solid viscera when protruding ma}' be more or less lacerated, but the treatment of the case is not very much affected thereby. The best plan would be to put on a ligature or clamp tightly enough to restrain hoemorrhage, and leave things to themselves, treating the symptoms as they arise. But the more common case is where the intestine protrudes and is opened. The prognosis depends mainly on whetlier any of the contents have escaped into the peritoneal cavity, whether the bowel is lacerated as well as incised, and whether it is or is not entirel}' divided. In the first case the result must necessarily be fatal, nor do the others leave much hope of survival. If the bowel is lacerated as well as incised its ends must be attached to the wound, and an artificial anus formed,^ and prob- ably this is also the best course in total division of tlie gut, though it is certainly justifiable to sew the two portions together with a continuous suture. But in wounds which affect only a part of the circumference of the bowel, the wound must be united with the continuous suture^ (just as in a post-mortem examination), the thread divided as near the knot as is judged to be safe, and the suture left to ulcerate through into the cavity of Fk;. go. the bowel. While the suture is thus producing the slough of the small por- tion of the coats of the bowel embraced within it, its material is buried in lymph, which unites the gut either to neighboring viscera or to the parietes, so that on the fall of the suture no ex- travasation occurs into the cavit}' of the peritoneum. The suture inclosing the small slough falls into the intestine and is passed with the faeces. But this reparative action may fail, and on the to the parietes of the abdomen, e, or to neigh separation of the suture the contents boring coils of intestine, d, d, or probably in of the bowel may be extravasated into nio^t cases to both, when the suture separates •^ . .... it falls into B, the cavity of the bowel, while the the peritoneal cavity, or the irritation, eftuslon a, prevents the escape ofthe contents of instead of producing mere limited peri- the bowel into the peritoneal cavity. tonitis, which will bury the suture in a circumscribed mass of lymph, may set up diffused inflammation of the whole membrane, and this may prove fatal. Foreign Bodies in the Viscera. — Foreign bodies which lodge within the stomach or intestines from having been swallowed are either ultimately voided per anum, or else they make their way by ulceration through the coats of the viscera, and then usually cause death by effusion, or they may lodge in the tube and produce obstruction, or finally they may set up inflammation of the viscus and of the peritoneum without having caused perforation. Mr. Pollock divides these substances into : 1. Round and flat bodies, such as money, fruit-stones, bullets, pebbles, calculi. These Diagram ofthe repairof a wound in the bowel when united by a suture, a, a, a represent the lymph which is effused around the wound, and which glues the wounded part of the bowel, B, ' The subject of artificisil anus is treated of in tlie chapter on Hernia. ^ See tlie diagrams of sutures in the chapter on Minor Surgery. 238 INJURIES OF THE ABDOMEN. are gonorally the least dangerous in their ellects ; 2. Materials wliieh by aecuniulation form large masses, such as hair, string, the husk of the oat ; sncli substances constitute the largest foreign masses met with in the food-tube ; and 3. Sharp-pointed or cutting bodies, such as pins, fish or otlier bones, knives. These are generally attended by fatal consequences. The treatment in ordinar3' cases consists in avoiding purgatives, giving the i)atient opium, if necessary, to quiet the bowels and alleviate jmin, and encouraging him to take a large quantity of l)ulky, constipating food, hard-boiled eggs, cheese, etc. This is well illustrated by Mr. Pollock from the [)lan pursued by coiners when detected in their attempts to pass false coin, 'fhey are usually able to swallow and get rid of even so large a piece as a half-crown, though the attempt is not without its dangers.^ Finally, in some few cases, the operation of cutting into the stomach and removing the foreign body may be justifiable, and seven cases at any rate are recorded in which that operation has been successfully^ undertaken.'^ When the body has passed through the stomach and is lodging in the intestine its removal by operation is a matter of much more doubtful prudence, since even large substances will often ultimatel}' come down to the anus. Yet in the case of a long pointed body, which can hardly be expected to get through the ileo-ca?cal valve, the surgeon may feel justified in cutting down on it, where it can be distinctly felt. The bowel must then be drawn to the surface of the wound, opened by as small an incision as possible, the body removed, the wound sewn up, the gut returned into the belly, and the case treated as a wound of the intestine. There are other, very rare, cases in which a foreign body becomes lodged in the intestine, which has been passed up the rectum, and has from some unknown cause worked its way upwards. 1 once saw a hoy who presented in the right iliac and lumbar regions of tlie abdomen a long, hard substance which seemed to be a foreign bod}^ and seemed to be lodged in the caicum and ascending colon. It occasioned little inconve- nience. The boy could or would give no history throwing any light on the matter, and the diagnosis could be only conjectural. Ultimately a long piece of wood (I believe the greater part of a cedar pencil) passed from the bowel, which must have been pushed up the anus (though the bo}' would not admit the fact), since it neither could have been swallowed nor have passed through the abdominal wall. It is also possible that a foreign substance ma}' have passed into the intestine in a gunshot or other wound which has not proved fatal, but such substances will only iu the rarest instancs lodge in the intestine. The lodgment of foreign substances in the rectum, vagina, and bladder is common enough. The sul)ject will be discussed in the next chapter. Gaiilrolomy. — It I'emains to say a few words about the operation by which the stomach may be opened, and the indications for it. The opera- tion is i)roperl3- called (ja^tnAo^ny ; but unluckily, in consetpience of the identity of the Greek term for the stomach and the abdomen, the same name is also applied to operations in which the abdomen is laid open, for the purpose either of relieving obstiuction or of removing tumors. ' See Syst. of Surg., vol ii, p. 701, where a fatal case is reported in wliicli a half- crown h)dged in tlie oesuphagus prodiirecl ulcoralion and fatal hieinurrhage from the aorta. Mr. Qiiain relates one in which a pin which had heen swallowed passed through the vermiform ajjpendix into iht; common iliac artery and caused death. — Diseases of the Kcctum, p. .S'JO * Syst. of Surg., vol. ii, p. bA^. GASTROTOMY AND GASTROSTOMY. 239 Again, the operation of opening the stomach is performed on two dif- ferent indications: (1) when a foreign body is to be removed, and wlien the surgeon hopes to restore the patient to complete health; and (2) when through injury to, disease of, or pressure on the oesophagus the patient cannot take food, and the intention of the surgeon is to rescue him from starvation and secure a permanent opening — a sort of preter- natural mouth — in the walls of the stomach, through which food is to be introduced so long as the patient lives. The latter kind of ojieration is now often called Gastrostomy. Such operations are so rare that I must com])ress what I have to say about them into a very short space, referring my readers who wish to learn the details of the recorded cases to Mr. Durham's essay in S;jf) Turning to tlie back of tlie joint, two prominences are seen, one external, the other internal, in all three forms of fracture, as well as in dislocation. In all tliese injuries the two prominences are on dirterent vertical levels, the internal (which in all of them is formed by the displaced olecranon) being the higher. The external prominence in dislocation is formed by the head of the radius, and is therefore far more remote from the internal than it is in any of the fractures^ in which it is formed by the part of the humerus carried backwards with the radius, viz., the capitellum only in the infra-condyloid fracture, the capi- tellum and external condyle in the disjunction of the entire epiphysis, and probably some part of the external condyloid ridge of tlie humerus, in addition to the condyle in the common supra-cond3'loid fracture. In all four forms of injury the forearm is generall}^ flexed, and the hand midway between pronation and supination. The other fractures which communicate with tiie elbow are often com- minuted. Some ai'e of a T-shape, consisting of a transverse branch above the condyles and a vertical one between them, the condyles being mova- ble on each other with crepitus, and the end of the bone increased in width. Others are mere linear fractures running from the outer or inner side of the bone into the joint, so as to separate tlie external or internal condyle. It seems that the prominent extremity of the latter portion of the bone may be separated from the shaft without implicating the joint. The treatment of all tiiese injuries is the same. The elbow must be bent to something above a right angle, so that if anchylosis should unfor- tunatel}' occur the hand may be in good position. This position ma}' be maintained by an angular splint in the bend of the elbow ; or if there is any strong tendency to displacement of the lower fragment backwards the angular splint may be applied behind, while a straight splint is put in front of the arm to push back the upper fragment. After the end of three weeks passi\e motion must l)e sedulously made, the splints being removed and reai)plied daily. Dr. Hamilton'^ even recommends the total disuse of splints after the first seven days in fractures of the elbow, and the persevering use of passive motion dull}', remarking that, "though at this time no bony union has taken place, yet the elfusions have somewhat steadied the fragments, and the danger of displacement is lessened, while the prevention of anchylosis demands very earl}'^ and continued motion." This, however, does not of course apply to IVactures which are entirely above the cond3les, but only to those in wiiich the elbow-joint is clearly implicated. We must now speak of fractures of the forearm. Fracture of the Olecranon. — The olecranon process is usually fractured ' I'roCfKsor Smith says that in dislocation the vertical distance between the two tumors averafj;f,'S one and a half inch, while in infra-condyloid fracture it seldom ex- ceeds three-quarters of an inch. * On Frnclurcs and Di.'ilocations, p. 262. FRACTURES OF THE OLECRANON. 265 by a fall on the elbow, and sometimes by muscnlar action. The fragment is generally drawn npwards by the triceps muscle, thougii if the periosteum and the fibrous expansion around the bone is not broken tliere may be no separation. Bending the forearm will make tlie interval more distinct, if there is any difficulty in detecting it, which, however, is rarely the case. The loss of the power of extending the forearm is sometimes complete — more commonly the patient can perform this action, though witli pain and difficulty. Effusion into the elbow-joint generally occurs quickly, for the fracture almost always implicates the joint. It is said, however, that in rare cases only the tip of the process is broken off and the synovial membrane left intact. This fracture often unites by ligament only — but also by bone — and then frequently with obvious evidence of inflammation (Fig. 83). The joint is often left with hardly a trace of injury to its functions. Tliis will neces- sarily depend in a great measure on the closeness of apposition of the fragments, but also on the avoidance of subsequent inflammation, and it is to these two indi- cations that the treatment should be ad- dressed. The first thing is to relax the triceps muscle completely by putting the arm in complete extension on a long splint reaching from near the shoulder to the palm, leaving the fracture uncovered. One of the plans used in fracture of the patella may be employed here also to draw the movable fragment downwards. Inflamma- tion must be combated by cold, evaporating lotions, and leeches. If, however, acute inflammation nevertlieless sets in and per- sists, the surgeon must not allow anchylosis to occur in the extended position, but should examine the joint under chloroform, and if he finds that adhesions are forming he should i)lace it at an appropriate angle and allow it to anchylose in the bent posi- tion. In ordinary cases the splint should be siderabie interval, a large mass of new- removed after a "month, and passive motion ^y ^o^^d bone, 6, extends over the back , 1 1 •! '^i i i c i. of the olecranon, and forms a sort of be made daily, with great care at first, so as not to rupture the newly formed union. Compound Fracture of the Olecranon. — When the fracture is compound it is per- haps better, if the wound is small and uncomplicated, to treat it at first with a pltal, of which there is no history view to immediate union of the wound, so as to convert it into a simple fracture and preserve the motion of the joint; but if there is considerable laceration and the joint is very freely opened, the choice lies between excision and anchylosis in the flexed position. The former would be indicated if there is reason to suspect the presence of splinters or foreign bodies in the joint, or if tlie soft parts are much torn, but in most cases it is, I think, better to be content with anchylosis. Should much suppuration follow and the bones become ex- tensively exposed secondary excision can at any time be practiced, for Fracture of the olecranon united by bone. The edges of the fracture, a, a, are united by bone at tlie inner side, but at the outer they are separated by a con- splint behind the fracture. It is per- forated by numerous large holes, and separated in many places by a distinct interval from the back of the olecranon process. — From a specimen (Ser. i. No. 102) in the Museum of St. George's Hos- 266 INJURIES OF THE UPPER EXTREMITY. excision of the elbow, unlike excision of the knee, may be performed with success in the acute stages of inflammation, Frach(7'e of the coi'onoid proce.i^s occurs as a complication of dislocation of the elbow, and is treated of under that head (see Fig. 98, p. 282). It is also spoken of as a separate injury, but I am not aware that its exist- ence as such has ever been proved by dissection. It is said to unite usually by ligament, in consequence of the displacement of the fragment by tlie brachialis anticus. The treatment would, therefore, consist in keeping the forearm fixed in the bent position for about three weeks, should this injur}' be diagnosed. Fracture of the upper part (head or neck) of the radius is another of the proved complications of dislocation (q. v.), and is believed liy some authors to occur independentl}', but without anatomical proof. The most common fracture of the central part of the forearm is that in which both bones are broken, which usually occurs about the middle, though, as the fracture is generally caused by direct violence, any i)art may be broken, and I have seen cases wliere from the passage of a wheel over the bod}^ the bones have been splintered into a great number of frag- ments. In children the fracture is often incomplete, being marked by a bending of the bones, with no crepitus, the upper part sharing in au}^ movement impressed on the lower (see Green-stick Fracture, p. 138). The displacement in fracture of both bones of the forearm is often very considerable when the fracture is very oblique or much comminuted, but there is not in general any serious difflcult}'^ in getting the bones back into position. IS or is the treatment generally unsatisfactory' even in some- what complicated cases. There are, however, a certain number in which the power of rotation of the hand is more or less lost, a result wliich is ascribed by Mr. Flower^ (following Lonsdale in this particular) to the fact that the two portions of the radius have been put up in ditferent po- sitions as regards supination. There are also more numerous instances in which some amount of deformity is left after union but without au}' loss of motion. The indications are to keep the fragments from falling together, ?'. e., to ol)viate an}' tendency of the fragment of the radius to point towards the ulna, or vice verad^ and to see that the natural line of the superficial portions of both bones is completely restored. For the former purpose it is desirable in complicated cases to place a graduated compress in the intei'osseous space. With regard to the latter, the defect alluded to by Lonsdale and Flower of putting up the two parts of the radius in different positions of supination is most surely avoided by the completel}' supine position of the whole forearm. This, however, is more , irksome to the patient tlian the half-supine position. The latter is gener- ally adopted, and answers well for all ordinary cases. The splints in general use are two straiglit well-padded wooden ones, at least as broad as the limb, and extending from tlie elbow to tlie wrist, on tlie back and front ; or a pasteboard, leather, or starched case may be applied at once. The bones should be kept in apposition for a month, care being taken to give passive motion to tlie fingers if they seem inclined to stitfen. Fraclure of Ulna or liadius onbj. — The ulna or radius alone may be broken in its centre. The ulna can only be thus fractured by direct vio- lence, and this is also the cause of fracture of the shall of the radius in almost all cases, since the result of a fall on the hand if the radius gives wa}' is almost always Colles's fracture. Here also the great point is to see that the fragments do not fall towards the other bone, and for this » Syst. of Surg., vol. ii, p. 792. COLLES S FRACTURE. 267 purpose to thrust tliein out if uecessary In- a pad in tlie interosseous space. Tiie sound bone, acting as a splint, will in all probability prevent any displacement, and no lasting effects need be apprehended. Colles^s fracture,^ or fracture of the radius close to its lower end, is a very frequent consequence of falls on the palm of the hand, especially in old persons. It is one of the few fractures which are believed to be more common among women than men. and it is very liable to be followed by a considerable amount of stiffness of the wrist and fingers, due in part, A'ery likely, to a tendency to rheumatism in the patient. The radius is broken generally about an inch or a little more above its lower end. The displacement which usually accompanies this injury, and which is so char- acteristic of it that it enables a surgeon to recognize it at a glance, is well shown in the accompanying illustration, taken from Prof. Smith's work. Fig. 84. CoUes's fracture, showing the most common deformity. — From Professor R. W. Smith, On F"ractures, p. VST. The lower end of the radius carrying the hand is driven backwards and outwards, causing a deviation of the hand from the axis of the limb, a prominence of the styloid process of the ulna, a projection on the back of the forearm just above the wrist, and a corresponding projection on the front at a somewhat higher level caused by the flexor tendons being put on the stretch in passing over the upper fragment. The power of pronation and supination is lost. If the hand can be restored to its nat- ural position crepitus will be felt on rotation. The line of fracture is usually nearly transverse, rarely so oblique as to allow of verj' great dis- placement, which, indeed, is iinpossible so long as the ulna and the inter- nal lateral ligament of the wrist-joint remain entire. Much difference of opinion prevails as to whether this fracture is frequently impacted or not. It is believed to be so by most English and French authors,'^ and the ap- pearances of fractures which have been long united with some amount of displacement certainly resemble exactly those of impacted fracture. But the Irish surgeons, and notably Prof. R. W. Smith and Dr. Gordon, deny that impaction is common ; and they attribute the appearances referred to not to penetration of the lower fragment by the upper at the moment of the accident, but to subsequent inflammation which has produced an irregular callus encircling both fragments. There is no doubt, however, that in many cases there is an almost insuperable difficulty in disengaging the fragments, v^hich can hardly be accounted for except on the theory of impaction, and for myself I certainly hold the general view. ' Mr. CoUes's description of this fracture will be found in the Ed. Med. und Surg. Jour., April, 1814. 2 The testimony of eminent pathologists leaves no doubt, to say the least, of the occasio?tr/^ occurrence of impaction of the upper fragment into the lower. See Cal- lender, St. Bartholomew's Hospital Reports, vol. i, p. 283, where three cases are re- lated in which, the patient dying on the spot from other injuries, this impaction was found. 268 INJURIES OF THE UPPER EXTREMITY. The treatment is very often not entirel^y successful either in restoring the shape of the parts or the movements of the wrist and fingers, though the latter may be trusted to improve graduall3^ It is well to warn the patient of this. Several plans are in common use. Some surgeons use two straight splints, anterior and posterior, not reaching much beyond the wrist, and when these splints are used the surgeon generally draws the hand towards the ulnar side by means of the bandage which fixes the splint or by a webbing strap. The pistol-shaped splint is a very common apparatus, applied either to the front, or, as is perhaps better, to the back of the forearm and hand, with a short splint on the palmar aspect of the forearm. Dr. Gordon' teaches that in this fracture both the fractured ends are displaced forwards, and he follows Prof. Smith in denying the existence of impaction as a common condition. The means by which he proposes to remed}^ the displacement, or to restore the natural concavity of the radius anteriorly, consist in first reducing the fracture by traction on the hand and pressure on the fragments, placing the hand in the prone posi- tion, then appl3'ing to the anterior surface of the forearm a splint (Fig. 85 a) to which a wooden conical or triangular piece is so attached that the external border of the splint projects beyond it ; and on the back of the forearm a straight splint (Fig. 85 b) more thickly padded over the wrist than over the forearm. The splints are to be fixed by two webbing straps, not bj^ bandage. The triangular bevelled end of the anterior radial splint lifts up the lower end of the upper fragment of the radius, the pressure made by the straps (which is thrown entirely on the ulnar side of the limb in conse- Fi"- ^^- quence of the projecting border of the radial splint) remedies the pro- jection of the ulna in- wards, and the depres- sion of the hand elevates the lower or carpal frag- ment and raises it to the level of the upper frag- ment. Those who have tried this plan adequate- ly report in high terms of its results,^ and a somewhat similar plan is said'^ to have been employed by Sir P. Crampton. I have used all three plans ; Dr. Gordon's, in- deed, only in one or two instances, but in one of these with great success. M}^ own impression is that all methods give a good result in non-impacted fractures -which can be and are accurately set at the time of the injury, and where the patient is healthy and tracta- * On the Treatment of Fractures of the Lower Extremity of the Radius, Belfast, 1862. * See Porter, DubHn Quar. Jour., May, 18G5. » Ibid., Feb. 1862. Gordon's splint for fracture of the lower end of the radius. The si)lints apiilicd. COMPOUND FRACTURES. 269 ble ; and even when some deformity remains the movements of the wrist and fingers ai"e preserved if timely passive and active movements are in- sisted on. Dr. Gordon seems to me to have somewhat exaggerated the frequency of the ill-success, which, however, does undoubtedly sometimes attend the common methods of treatment. Whatever treatment is adopted, the part should not be kept too long stiff; but after about three weeks it should be taken out of the splints, and careful passive motion given to each tinger-joint and to the wrist, the limb being first well steamed. The lower end of the radius is also in rare cases comminuted or frac- tured in such a direction that its lower fragment is displaced forward, and sometimes the lower ends of both bones are crushed. Such accidents should be treated on simple straight splints, after careful reduction. When comminuted fracture aflfects both bones they are very liable to be soldered together in the process of union, causing entire loss of the rota- tory movements of the hand, and the surgeon must combat this tendency as well as he can by timely passive motion. Fractures of the carpal bones are rare, at least they are rarel}'^ diag- nosed — being possibly in many cases masked by the injury to the soft parts, which is usually severe. The accident in itself is not a very for- midable one, for two or more of the carpal bones may be anchylosed together without any loss of the functions of the hand. I had a case nnder treatment a short time since in which, after a severe crush of the wrist accompanied by fracture, the greater part of the semilunar bone became loose and was removed, but the patient recovered with a very useful hand. Rest on a splint and cold lotion till the movements of the hand are no longer painful, followed by careful passive motion if neces- sary, comprise all that is required in the way of treatment. Fractures of the inetacarpal bones and phalanges are generally the result of direct violence, though any of these bones (at least any above the terminal phalanges) may be fractured by a blow or a pull upon the finger. When a metacarpal bone is broken, the nature of the injury is at once declared by the dropping of the knuckle, and the break in the line of the dorsal surface of the bone. The treatment consists in band- aging the fist round a padded stick or a ball, or in putting the hand on a palmar splint which carries a pad of cork or other material, supporting the dropped knuckle at a proper level. Fracture of a phalanx requires only a splint reaching into the palm of the hand, and keeping the finger perfectly quiet and straight. Treatment may be given up in about three weeks in both cases. Gomj)ound fractures in all parts of the upper extremity are very com- mon, and are of far less gravity than the corresponding injuries in the lower limb. Gangrene also, if it occurs after the injury, is of less con- sequence to life, and secondary' amputation much more likely to succeed. Mucli, therefore, is justifiable in the vvay of removing fragments, endeav- oring to promote the union of wounds, and so saving the limb, which would not be allowable in compound fractures of the thigh, leg, and foot. Indeed, in the hand it is often better to allow the parts to slough away and afterwards trim up the stump if necessary, rather than by primary amputation to sacrifice fingers, or parts of fingers, which may ultimately recover and prove very useful. Primary resections also, which are so disastrous in the hip and knee, may be practiced with good hope of suc- cess in the shoulder and elbow, and are perhaps preferable to the mere removal of splinters — operations which will most likely be followed by 270 INJURIES OF THE UPPER EXTREMITY. anchylosis, and involve probably the same risk to life as the more formal excision. This, however, does not apply, I think, to the wrist and car- pns, where the removal of fragments is less likely to impair the move- ments of the fingers, than excision of the whole articnlating surfaces. In injuries of the hand the thumb, or any part of tlie thumb, should be preserved in an}^ condition, stiff or otlierwise. Any portion also of the metacarpus is useful if in connection with a thumb or movable fingers, since a very efficient apparatus can be fitted on to it. But if the flexor or extensor tendons of a finger are torn to pieces, or its joints destroyed, so tliat it must be stiff afterwards, it would onlj' be in the way ultimately, and should be at once amputated. Dislocation of the Clavicle. — The clavicle may be dislocated at either its sternal or acromial end, if we use the old nomenclature. It has now become more common to speak of the latter accident as a dislocation of the acromial extremity of the scapula. The sternal end of the clavicle may be dislocated forwards, back- wards, or upwards. Dislocation downwards is impossible, on account of the first rib. Dislocation forwards is the most common, though even this is a rare injur}^, for the sterno-clavicular, like some of the other joints which, in the skeleton, appear very weak (for instance, the knee), is provided witli so many and such powerful ligaments, and is so protected by the mech- anism of the parts, that it is little subject to displacement. The force which would otherwise act on this joint is usually neutralized and re- solved in the numerous and very powerful articulations through which it is transmitted, and wlien this is not the case it is generally expended in breaking tlie clavicle. When dislocation forward occurs the head of the bone rests on the front surface of the sternum. The only ambiguity which can exist is between this injury and a fracture of the clavicle close to its head ; but the shape of the displaced head is generally quite char- acteristic ; or in case of doubt measurement before reduction and exam- ination afterwards will show in the case of fracture that the injured bone has not tlie length of the sound clavicle and that crepitus is present. Eeduction is usually easy, by drawing the shoulders backwards, but it is difficult to keep the parts in position. The arm must be put up, as in fractured clavicle, with the elbow carried further forward than in the common fracture; or the hand may be bandaged on to the opposite shoulder. Nelaton prescribes that a truss shall be applied to press upon the displaced head. In the only case I have seen the displacement was not corrected, but the arm remained quite useful, and this is the ordi- nar}' event. In the dislocation backwards the head of the bones is thrown between the sternum and the traehea, and sometimes produces the most alarming dyspnoea, or even death. It is usually caused by direct force. The dysp- na-a, the consequent bending forward of the head (in order to make room for the displaced bone), and the changed shape of the parts, leave no doubt as to the nature of the injurj'. Reduction is generally easy by dravving the shoulders backwards, and this })osition should be maintained by "a splint passed behind the shoulders, with a pad between it and the spine, the shoulders being drawn to the splint by a bandage.'" After 1 See the account of a characteristic case by Mr. Hulke, in the System of Surgery, 'M edition, vol. ii, p. 805. DISLOCATION OF THE SHOULDER. 271 about a fortniglit the s{)rnit may be withdrawn and the patient kci)t quiet in bed till all tenderness and pain has subsided. Dislocation upwards (sui)rasternal) is a rare injury, of which only about eight cases are on record. Its anatomy is now fully known, from a case which was carefully dissected and published by Professor R. W. Smith,' the man having died of other iujnries. Dr. Smith's account con- tains two excellent drawings of the appearance of the part during life and of the dissected specimen. The head of the bone, carrying the in- terarticular cartilage with it, had been thrust between the two heads of the sternomastoid muscle, and lay in contact with the opposite clavicle. The sternohyoid muscle was behind it; the sternal tendon of the sterno- mastoid, tightly stretched over it, formed a considerable prominence during life. The rhomboid ligament was ruptured as well as the capsule of the joint. Treatment has hitherto been found unsuccessful in curing the displacement, but a good use of the arm may be anticipated. Dislocation of the acromial end of the clavicle takes place usually in the upward direction,?!, e., the clavicle lies npon the acromion process. If we follow the nomenclature of Messrs. Flower and Hulke we should call this a dislocation of the acromion process of the scapula downwards. It is believed to be caused in almost all cases by violence applied directly to the scapula, which is relatively by far the more movable bone. The accident is unmistakable. The shoulder is depressed, the arm apparently lengthened ; there is pain in raising the arm, voluntary motion is very limited, and the prominence of the acromial end of the clavicle is easily felt. The deltoid is considerably flattened, in consequence of the arm falling or being pressed downwards, by which the fibres of the muscle are pulled down. Reduction is not difficult. It is accomplished by drawing the siionlder back, while the dislocated end of the clavicle is pushed downwards ; but the bones easily slip away again. The shoulder must lie well raised, with a pad in the axilla, and a compress or truss placed on the outer end of the clavicle. Some little displacement will not seriously incommode the patient afterwards. The opposite disloca- tion, viz., that in which the acromion lies above the clavicle, is very rare. It must be treated on the same general principles. As surgical curiosities cases are spoken of in which the outer end of the clavicle has been thrown beneath the coracoid process as well as the acromion,- and cases in which the clavicle has been dislocated simultane- ousl}' from both its articulations.^ Didocation of the Shoulder. — Dislocation of the head of the humerus takes place usually in one of three directions — downwards, inwards, or backwards. A few cases of dislocation upwards have been described, and one of them was dissected by myself, but the injury is a very rare one. The common dislocation is downwards, or into the axilla ; but the posi- tion of tiie bone is not usually directly below the glenoid cavity, as would be inferred from Sir A. Cooper's language, and as he no doubt believed, but rather internal to it, though still in the axilla, and somewhat lielow its natural level. Hence the dislocations into the axilla are divided into two varieties, — the subglenoid, or that directly downwards, and the sub- coracoid, or that downwards, forwards, and inwards. The latter is the common dislocation of the shoulder,* the subglenoid ' Dublin Journal of Med. Science, DubUn, 1872. 2 System of Surgery, vol. ii, p. 807. ' Gaz. des Hop., 1859, No. 33. * According to Messrs. Flower and Hulke thirty-one out of forty-one preparations of dislocation of the shoulder preserved in museums, and forty-four out of fifty re- cent cases, were found to be of this form. 272 INJURIES OF THE UPPER EXTREMITY. Fig. 86. Dislocation of the shoulder. An imaginary sketch, shovrlng the usual appearance in the axillary dislocation. In the dislo- cation inwards, or beneath the pectoral muscle, the prominence of the shoulder will be more marked ; and the head of the hu- merus will form a considerable prominence in the situation of the furrow between the deltoid and pectoralis major. — See A. Cooper, 2d cd., pi. xxviii, Fig. 42. Fig. 87. Subcoracoid dislocation (after Flower). being decidedly more rare. Tlie dislocation inwards, " below the pectoral mus- cle," of Sir A. Cooper, or '' subclavicular," as it is now usually termed, after Malgaigne, and that back- wards "on the dorsum scap- ulte," or " subsiDinous," are very rarel}^ met with, Thei'e are certain symp- toms common to all disloca- tions of the humerus, viz., a loss of the natural rounded shape of the shoulder, a change in the direction of the axis of the humerus, an increase amounting to be- tween one and two inches in the vertical measurement of the shoulder and axilla, loss of the power of voluntary motion, and resistance to passive movements except in certain directions. 1 . Dinlocation downvjards. — In the dislocations into the axilla the acromion is prominent and the deltoid flattened. The subcoracoid form of this dislocation is shown in Fig. 87. The head of the bone usually lies im- mediately below the coracoid process, in front, internal to, and rather lower than its natural situation. In other cases the head of the bone is thrown further inwards, so as to rest more on the venter of the scapula than on the upper part of its neck, as it does in the usual subcoracoid dislocation, Fig. 88. This is described b}' Malgaigne as a separate form, under the name of "intracoracoid" dislocation ; but I do not see any object in separating it from the other, and I much doubt whether the cases could be diagnosed from each other during life. Mr. Flower points out that in old un- DISLOCATION OF SHOULDER. 273 Intra-coraeoid dislocation (after Flower). reduced dislocations of the purely snbcoracoid form the newly formed cavity for the head of the bone will trench on the old glenoid fossa, and will also be formed partly by the coracoid process, and that such specimens have often been described as partial dislocations. In the intra-coracoid form the new cavity is independent of the fig. ss. glenoid fossa, and the cora- coid process is not usually affected. In the subglenoid dislocation (Fig. 80) there is a more considerable interval between the coracoid process and the head of tiie bone, which latter is also more prominently felt when the fingers are thrust into the axilla. In both forms the arm is directed away from the side, but more so in the subglenoid ; it usually ap- pears lengthened, and some- times is really so, especially in subglenoid dislocations. In the subcoracoid this elon- gation is usually proved by measurement to be only ap- parent, being due to the drop- ping of the affected shoulder ; sometimes the arm is even shortened ; there is often considerable pain from pressure by the dislocated bone on the nerves of the brachial plexus, especially the circumflex, which in some cases is so much injured that the deltoid muscle does not recover its functions after the reduction of the dislocation ; and in rare cases there is congestion or even oedema from pressure on the vein. The arm can be moved backwards and forwards, but cannot be lifted or brought to the side. The great tuber- osity of the humerus is said to be often torn off, and some- times drawn into the glenoid cavity. The two forms of disloca- tion ma}' be regarded as va- rieties of the same injury, in which the head of the humerus has been driven through the lower part of the capsule, and in the subglenoid form has been arrested by the inferior costa of the scapula ; while in the subcoracoid it has been drawn up by the muscles under the coracoid process. 18 Fig. Subglenoid dislocation (after Flower). 274 INJURIES OF THE UPPER EXTREMITY. The usual causes of dislocation into tlie axilla are either direct blows or falls on the shoulder, or a fall on the elbow or hand when extended, b^' whic'li the lower end of the bone is violently raised and its liead thrust against the lower part of the capsule. Muscular actions of the same kind (as in raising the arm to strilce a blow) have been known to produce it, especially' when the shoulder has been dislocated before. I have seen it produced (and for tlie first time) wliile the patient was lying in bed in the hospital. 2. Dislocation imvards. — In the dislocation inwards (subclavicular), (Fig. 90) the head of the bone usually makes a considerable projection on the front of the chest, below the middle of the clavicle, aud usually can easily be felt, though it is said that sometimes it lies deeply in the subscapular fossa. The head of tlie humerus cannot be felt from the axilla, though some part of the shaft may ; the arm is less separated from the side than in the axillary dislocations. The causes of this dislocation are the same; in fact, it is regarded as a variety of the common disloca- tion, in which from some unknown reason the liead of the bone has been drawn further inwards than in the ordinary subcoracoid dislocation. There can be no doubt, however, of the accuracy of Mr. Flower's opin- ion, that most of the cases described as " dislocations beneath the pec- toral muscle" would now be classed as " subcoracoid." The true subclav- icular dislocation, in which the whole head of the bone lies internal to the coracoid process, is very rare. 3. Didocalion &ac^'ioart?.s' (subspinous) is a well-marked injury, in which the head of the bone forms a considerable prominence on the dorsum of Fm. 90. Fig. 91. .Subclavicular ilisloeatioii faftiT Fluwer). Subspinous dislocation (after Flower). the scapula, and a considerable depression is left beneath the coracoid process. The arm is usually rotated inwards, pressed closely to the side, and the elbow thrown forwards. It is caused by direct violence, or by DISLOCATIOxV OF SHOULDER. 275 falls on the elbow when advanced, or by violent twisting of the arm inwards. 4. Dislocation upivards (supra-coracoid) can only occur after fracture of the coracoid or acromion process (usually the former) ; it is caused, I believe, always by direct violence, applied in the upward direction — the head of the bone lies in front of the clavicle, immediately under the skin.^ Diagnosis. — The rarer forms of dislocation of the shoulder present usually no difficulties of diagnosis ; what follows, therefore, relates mainly to dislocations into the axilla, though here, again, the errors which are unfortunately common are more often the result of haste than of any real difficulty in the diagnosis. The flattened shape of the shoulder and prominence of the acromion process are usually ver}' characteristic of the injury, and so is the in- crease in the vertical measurement around the armpit. Dr. F. Hamilton '^ has lately pointed out two diagnostic signs between dislocation and all the other injuries of the shoulder which will be found useful in all cases where the swelling is not very great. 1. If in the healthy state, or when- ever the head of the bone is in the glenoid cavity, a rule be laid on the outer side of the arm, touching the elbow and shoulder, it will be distant from the acromion process at least half an inch, generally an inch or more. In any form of dislocation, on the contrary, the rule will touch the acromion. 2. If the surgeon stands behind the patient and places the forefinger and thumb on each side of the acromion process just external to the joint with the clavicle, the forefinger in front and the thumb be- hind, and then carries them vertically downwards, the tip of the finger will rest on the centre of the front of the rounded head of the humerus, while the thumb will also feel its posterior part, indistinctly at first; but if the elbow is thrown forwards and the arm rotated, the head of the bone will strike the thumb more plainly. This is the case when the head of the bone is in the socket ; but if dislocation exists the head of the humerus cannot be felt by the thumb thus placed. Cases occur in which, from paralysis of the deltoid muscle, the shoulder has the same shape as in dislocation ; but when this is the result of in- fantile paralysis the history is different, and even when the paralysis fol- lows on a dislocation (from lesion of the circumflex nerve) the surgeon may easily satisfy himself that the dislocation has been reduced, by the absence of any prominence in the axilla, by the freedom of passive mo- tion, and bj' the vertical measurement round tlie shoulder — which in un- reduced dislocation is greater than on the sound side — while in paralysis it is equal or less ; and the same remarks apply to wasting of the deltoid after lesion of the circumflex nerve from other causes. From fracture of the surgical neck of the humerus dislocation may be distinguished by the more pronounced flattening, by the difference in shape of the bone which is felt projecting in the axilla, and by the crepitus which is felt when the arm is reduced to its natural position, such reduc- tion being usually very much easier in the fracture than in the disloca- tion, while the displacement is also easily reproduced. The higher up the fracture is, the more it is impacted, and the longer the time which has elapsed since the accident, the more difficult does the diagnosis be- come ; nor is it always by any means easy to satisfy one's self whether there is some fracture of the glenoid cavity or neighboring part of the scapula in cases which at first sight seem pure dislocations. The difficult}^ is iu- ' See my paper in the Med.-Chir. Trans., vol. xli, p. 447. ^ See London Med. Record, April 21, 1875. 276 INJURIES OF THE UPPER EXTREMITY. creased by the effusion of fibrin into the sheaths of the tendons and cavity of the joint which usually follows on unreduced dislocation, and which gives rise to a sensation of crepitus very hard to distinguish from that of fracture. Tliere are few practical surgeons who have not had to confess the gieat ditliculty of pronouncing a definite opinion in such cases. The diagnosis may, again, be complicated by fracture either of the scapula or of the humerus. In a former section (page 25fi) I have dis- cussed the question, raised by Sir A. Cooper, as to the probable frequency of fracture running through the neck of the scapula and leading to such displacement of the glenoid process along with the humerus as ma}' simu- late dislocation. But exclusive of such injuries, in which there is no dis- location, there can be no question that in some cases where dislocation does exist there exists also fracture of a portion of the glenoid cavity, or of the coracoid process, or of the great tuberosity, or possibly some other part of the upper end of the humerus. Dislocation, complicated with fractui'e of the glenoid cavity, will produce, as Malgaigne has shown, many of the s,ymptoms which Sir A. Cooper attributed to fracture of the neck of the scapula ; and it is, as far as I can see, indistinguishable from the fracture of the anatomical neck of the bone, described b}^ Lotz- beck ; but it does not separate the coracoid process from the rest of the scapula, and therefore may be distinguished (though not without diffi- culty) from the fracture of the surgical neck of the scapula which Sir Ast ley so clearly describes. Fractures of the coracoid process or of the great tuberosity produce crepitus, but do not cause that insecurity of re- duction which is so marked a feature in fracture of the neck of the scapula, and in dislocation complicated with fracture of the glenoid process. The fracture in tliese latter cases is an unimportant complication, only neces- sitating longer confinement of the arm. When dislocation is complicated with fracture of the shaft of the bone the injury is a much more serious one, since reduction is often impossible ; and the nearer to the joint the fracture is, the greater is the difficult}'. Nor is it always easy to recog- nize the real nature of the injury at the time. Much care, therefore, ought to be bestowed on the examination of every case of fracture high up, in order to ascertain b}' careful exploration of the axilla that the head of the humerus is in its place. Should dislocation be detected the patient must be brought into a condition of complete anaesthesia, and all avail- able means used to manipulate the dislocation into position. If this at- tempt fails then the fracture must be set in such a position as will best restore the shape of the humerus ; and in a month or six weeks, when consolidation seems to have far enough advanced, reduction must be at- tempted, much caution being, of course, observed not to refracture the bone. Reduction. — There are numerous methods of reducing these disloca- tions, and those methods seem at first sight so different from eacli other as to lead the student to suppose that the force is applied in one in just the opposite direction to the other. For instance, in the common method, witli the heel in the axilla, the arm is pulled directly downwards, towards the patient's feet, while in another method it is pulled directly upwards, above his head. But Mr. Skey' has shown that the mobility of the scapula to a great extent, at any rate, neutralizes these differences, and that in all the plans of reduction the arm is pulled in a direction more or less perpendicular to the plane of the glenoid cavit}'. The best plan, and the nriost usual one, is to place the patient in tiie 1 Operative Surgery, 2d ed., p. 105. DISLOCATION OF SHOULDER. 277 horizontal position. The surgeon, sitting down on the edge of tlie bed or sofa on which the patient lies, puts his heel (unhooted, of course, ) into the axilla and presses the head of the bone upwards and outwards with it, while he pulls on tiie hand and wrist, slightly rotating the arm if neces- sary'.^ The dislocated bone generally goes in with a snap, and the natural appearance and mobility of the joint are at once restored. Recent dis- locations are generally reduced easily enough, especially if the involun- tary resistance of the muscles is obviated by calling off tiie patient's at- tention, or b}' making- him believe that the proceeding is one of explora- tion only, when by a sudden movement the bone uiay generally be slipped back; but if the patient is unusually timid (and especially if it be a female), or a very muscular person, or if there is much pain in the part, or unsuccessful attempts have been already made, it is better to induce anaesthesia, which very much facilitates tiie proceeding. Another and a ver}' good method is to lay the patient flat on the floor, or with his head to the foot of the bed or sofa, stand behind his head, steady the scapula with the left hand, and pull the dislocated arm in a line with the patient's body ; i. e., in a direction which, if he were stand- ing, would be vertically upwards ; or to place the patient, sitting on the ground, in front of a chair or sofa, on which the surgeon stands and steadies tiie scapula vvith his foot, while pulling the arm vertically up- wards.'^ Sir A. Cooper used sometimes to employ downward traction on the arm, the patient being seated in a chair, and the surgeon putting his knee in the axilla ; but this method is much inferior to the two pre- ceding. Reduction by Manipulation. — Sometimes a sort of combination of these two methods succeeds at once, and with little or no pain or force. The surgeon steadies the shoulder with his left hand and supports the arm with his knee, while he raises, rolls inwards, and slightly pulls on the dis- located arm, pressing the head of the bone at the same time outwards and upwards with his left hand. The head of the humerus, thus disengaged from the scapula, will slip into its socket by the action of the muscles. Some authors speak of the efficacy of circumduction, '' the arm being made to describe a half circle over the face and head ;" and other sur- geons describe the manipulation method somewhat differently.^ I have no experience of it, having never met with a case in which the disloca- tion, if recent, was not at once and easily reduced by the heel in the axilla; and it is only in recent cases, if I understand aright, that manipu- lation is recommended. Another and a very powerful method is thus described bj^Mr. Flower: " The patient is seated on a high chair, which is placed about two feet from an open doorwa}-. The surgeon iiaving his back against the door- post, places one foot upon the side of the chair, and with his knee pressed into the axilla, and both hands upon the shoulder, steadies the patient's body. A jack-towel is then fixed by a clove-hitch knot to the patient's arm, just above the elbow; and by its means two or more assistants, placed on the other side of the doorway, make steady extension vertically outwards." ^ If necessary, in old dislocatinns a jack-tovvol can be fixed on the arm, by a clove- hitch, above the condyles of the luunerus, on which the surgeon and his assistants can pull. This is not required, however, except in old dislocations. 2 See Lowe, St. Bartholomew's Hospital Reports, vol. vi, p. 4. 2 Bryant, op. cit., p. 792. Pirrie, Principles and Practice of Surgery, 2d ed., p. 319. 278 INJURIES OF THE UPPER EXTREMITY. Reduction by PuJIei/s. — As a general rule it is only in neglected dislo- cations that pullej'S are needed.' The patient is brought fully under ana?sthesia. and placed either in the sitting or reclining posture, the bod}' fixed to a firm staple on the side opposite to the dislocation by means of a leather bandage, which encircles the shoulder and fixes tlie scapula, its two ends being secured by a cord to the staple. The arm should be bandaged from the hand, and the pulleys attached to a leather collar fitted to the arm above the condyles of the humerus. Traction is made in the horizontal direction, with gradually increasing force, and wlien the surgeon finds that the liead of the bone is moving he tries to manipulate it into the glenoid cavity. In cases of long standing it is well to begin by breaking down all adhesions, as far as possible; and if any tendons can be found on the stretch which seem to oppose reduction, they may be subcutaneously divided a few days before the attempt is to l)e made. Since the introduction of chloroform the limit assigned by Sir A. Cooper to the time at wliich attempts at reduction may be made has been much exceeded. That limit was fixed b}' him at three months ; but cases have now been recorded in which reduction has been eflTected even as much as two years after the accident.^ The propriety of such attempts must, how- ever, depend in a great measure on the amount of inconvenience which the patient complains of. There can be no question that the necessary force cannot be applied without danger. The artery has occasionally been torn in reducing a dislocation, though, as Mr. Callender has sliown,^ the cases of which we have a complete record are verj' few, and in a large proportion excessive violence was used by unskilful persons.* The vein has also been ruptured — though this is even more rare — or the humerus fractured. It is true that these grave injuries are not common, especiall}^ vvlien the patient is not advanced in age and the arteries are healthy, yet no one can have used or seen used the force which even prudent surgeons are obliged to employ in such cases without feeling that it must involve some risk of immediate damage or subsequent inflammation; and the consideration which Sir A. Cooper puts forward is a very grave one — whether the arm is reall}' likely to be useful after reduction. It must be remembered tliat Sir Astley did not deny the possibility of reduction later than three months; he even says he had seen examples as late as six mouths; but he says "the injury done in extension was greater than the advantage received from reduction." And 1 would remark, tliat in the published accounts of cases of late reduction we are, as a rule, left quite in the dark on this head. It is, therefore, onh' in cases where the unreduced dislocation is a source of much misery to the patient that I should be disposed to make the attempt. After unreduced dislocation, as a general rule the limb acquires ver}' considerable usefulness — the patient regaining the power of raising the arm nearly to the horizontal line ; the parts accommodate themselves to their new position, and there is neither pain nor (edema. After reduction the arm should be bandaged to the chest, the hand and * It may be well to remind the reader that in the system of pulleys in common use, where parallel strings pass round a number of pulleys, the force applied is multiplied by the number of strings on the block, or twice th<.' nuinl)er of the pulleys. ' See on this subject an interesting paper by Mr. Brodhurst in St. George's Hos- pital Reports, vol. iii, p. G7. ■'' St. Bar. Hosp. Reports, vol. ii, p. 9(i. * There sfcms no doubt of the truth of an account of a case which occurred in France a few years ago, in which an old woman's forearm was pulled offm an attempt to reduce a dislocation. DISLOCATION OF SHOULDER. 279 forearm beino; kept inside the clothes, so tliat no moveinent is permitted; and it is well to place a pad in the axilla. After a week of this rigid confinement the patient may be instructed to carry the arm in a sling for anotlier ten days or a fortnight, and may then be allowed to make some use of it; but he should be careful to avoid violent or sudden exertion for a considerable time, at least a quarter of a year. Renewed disloca- tion is very common, and each time the joint is dislocated it becomes less secure. Compound dislocation of the shoulder is a rare injury, and a very seri- ous one. "It still remains to be determined by experience," says Mr. Hulke, "whether under such circumstances reduction, or resection of the head of the bone, is the safer method of treatment." My own feeling would be decidedly in favor of reduction in healthy persons, and in the absence of complications ; but where the patient was weak or old, or the exposed bone injured, or the parts much lacerated, it would probably be better to saw off the exposed head of the bone. Partial Dislocations. — We do not know very much about partial dislo- cations of the shoulder. The case so frequently (quoted, described by Mr. Soden of Bath, ^ as partial dislocation upwards, with rupture of the tendon of the biceps, was, there is every reason to believe, an instance of chronic osteoarthritis, supervening on a sprain. Such displacement and disappearance of the tendon is constant in that disease.- Mr. Flower " is disposed to agree with Dr. R. Adams in denying that the case of partial luxation of the head of the humerus, as the result of accident, has ever been satisfactorily proved, either in tlie living or the dead subject." Very lately, however, Mr. Le Gros Clark has published a case of partial dislo- cation of the head of the bone backwards, which, I think, must be allowed to be conclusive. The patient, a spare, elderly man, had slipped in get- ting over a hurdle, about two hours previously. There was no effusion into the joint; the movements of the joints were almost lost; the head of the humerus was "in its natural position as regards height, but its pro- jection in front of the acromion was absent, and there was an abnormal prominence at the back of the joint, behind and below the acromion. On gently raising the elbow from the side, and rotating the humerus, its head slipped into the glenoid cavity with an audible click, and the joint at once resumed its normal form and appearance — the patient exclaiming that he lost his pain as soon as he felt and heard the bone go back."^ The thin- ness of the patient and the absence of any effusion left no doubt of the position of the bone ; and since a week's rest in a great measure restored the use of the joint, Mr. Clark concludes that there could have been no laceration of the capsule or tendons. The case, also, which is described by Mr. South* shows very plainly indeed the possibility of partial disloca- tion of the head of the humerus forwards, at least when, as in that case, the coracoid process is fractured — a condition which Mr. South regarded as essential to the occurrence of partial dislocation in this direction. In that case a depression existed behind and below the acromion, which led to the supposition that some displacement of the head of the humerus or fracture of the neck of the scapula existed, but still the roundness of the shoulder was not lost. On making certain manipulations the head of the 1 Med.-Chir Trans , vol. xxiv, p. 212. 2 See the criticism of Mr. Soden's case, by Dr. R. Adams, on Rheumatic Gout, 2d ed., 1878, pp. 140 et seq. 3 St. Thomas's Hospital Reports, New Series, vol. v, 1874, p. 145. * Med.-Chir. Trans., vol. xxii, p. 100. 280 INJURIES OF THE UPPER EXTREMITY. humerus was felt to move backwards, and then the appearance of a pit ceased. The patient having died two da3S afterwards from the effects of other injuries, the liead of the bone was found in its proper position ; tliere was a rent or slit about an inch long in the capsular ligament, through which the cartilage covering the humerus was exposed. On lift- ing up the shaft and pressing the liead of the humerus forwards it was seen to be " partially thrown forwards and over the front edge of the glenoid cavity, so that it became fixed, and behind it the dej^ression below the acromion appeared, in consequence of the sinking of tlie tendons of the inlVa-spinatus and teres minor muscles into the glenoid cavity, from the altered position of the head of the bone, which, however did not pro- trude through the slit in the capsule, although it was there more distinctly visible." From these cases the conclusion would be that partial dislocation of the shoulder is, in itself, a trifling accident, easily remedied, and not liable to produce any permanent mischief; and that it is a very rare injury, though its occasional occurrence is undeniable ; and very possibly it may be overlooked, from the head of the bone having slipped back before the patient is seen. Didocation of the elbow is a tolerably common accident, taking place usually in youth, as the result of a fall or wrench, or sometimes of a blow. If diagnosed at once and properly treated, the injury is one in which a good result may be confidently expected. But it is singular how very often cases are met with in which the accident has been overlooked, and then the dislocation becomes rapidly irreducible. I cannot remember to have seen such a dislocation reduced after six weeks, and I have known cases in which mischief has been done from the attempt. It is charitable to suppose that in some such instances of mistaken diagnosis the nature of the injury has been masked by an unusual amount of contusion and inflam- mation ; but I cannot help saying that no such explanation could be given of otliers, and that the patient appeared to have lost the use of his joint from the negligence of the surgeon. The practical inference is that in all injuries affecting the elbow, the surgeon should study minutely the relations Ijetween the various prominences of the bones — viz., the internal condyle, olecranon, external condyle, and head of the radius — and should not affect to give a diagnosis until he has observed at any rate the fol- lowing points: 1. Is there any transverse fracture of the humerus? t. e., on grasping the condyles in one hand and the lower part of the shaft in the other, can they be made to move or crepitate on each other ? 2. Is there any longitudinal or partial fracture of thelower end of the humerus? i.e., are the condyles unnaturally separated from each other, can they be made to crepitate when grasped by the finger and thumb of opposite hands and moved on each other, or is there a movable fragment of either (prol)ably the internal) condyle without an}' fracture into the joint? 3. What is the distance between the olecranon and the internal condyle on the injured as compared with the sound side? 4. Is the olec- ranon itself fractured? 5. Does the liead of the radius move with its shaft on passive rotation, and is it in the normal relation to the external condyle? 6. Do the axes of the two bones of the forearm correspond in direction ? I allow that in some cases some of these questions may not admit of an immediate answer, from the amount of swelling present, but usually they do, or at any rate the most important of them. If they do not, the diagnosis of the case siiould be deferred, and the surgeon should not be DISLOCATION OF THE ELBOW. 281 ashamed to say that he cannot at present say what the natnre of the injuiy is. Unfortunately, we constantly meet with cases in which con- fident opinions are given on insufficient data, to the great injury of the surgeon's reputation; and what is worse, to the permanent detriment of his patient, who remains satisfied perhaps that his arm is only "sprained" till it is too late for the overlooked dislocation to be reduced, or the frac- ture to be set and the motions of the joint restored. Dislocation of both Bones backivards. — The commonest dislocation of the elbow is that of both bones of tlie forearm backwards. The radius and ulna maintain their normal relation, the orbicular ligament remaining attached to the sides of the small sigmoid notch. The olecranon projects considerably ; the arm is semiflexed (see Fig. 81, p. 2G2) ; the head of the radius may perhaps be felt at the usual distance from the olecranon : but the distance between the tip of the olecranon and the internal condyle very greatly' exceeds that on the other side. There is a great rounded prominence in the bend of the elbow, or rather, perhaps, pushing the fold of the elbow downwards, so that the forearm seems shortened. There is commonly no crepitus ; though, perhaps, in some cases the pro- jection of the internal condyle may have been chipped off'. Most of these distinctive characters of the backward dislocation of the elbow can be clearly traced on Fig. 92, taken from an injury of this kind which I accidentally found in the body of a seaman who died from a different cause. By these signs the dislocation can be readilj* distinguished from the injury which most resembles it; i.e., a fracture of the lower end of the humerus just above the condyles, in which there is often displacement of the forearm backwards, with semiflexion, projection of the olecranon and tendon of the triceps, and a prominence near the bend of the elbow. But in the fracture, though the olecranon projects, measurement will show that it is at the same distance from the internal condyle as on the sound side — the prominence which is formed by the other fragment of the humerus is not in or below the bend of the elbow, but above it ; and has not the rounded outline of the head of the bone. And the diagnostic sign on which Sir A. Cooper laid so much stress is of great value, that reduction, though easy, is very insecure, the displacement being imme- diately reproduced. Also when the parts are reduced crepitus may be felt. There is not, therefore, ordinarily any real difficulty in diagnosing the two injuries. (See page 262 for a fuller account of the fractures near the elbow.) Such are the sj'mptoms and the pathological anatomy of the complete dislocation backwards. But from the less amount of flexion, and from the great ease with which reduction is effected, it is believed that in manj'^ dislocations the displacement is not complete — i. e., the coronoid process is not carried fairly into the olecranon fossa, but rests on the trochlear surface, from which, of course, any slight traction will replace it into its natural position. Dislocation, ivith Fracture of the Coronoid Process. — Again, it is believed by many surgeons that this displacement of both bones back- wards is often, accompanied by fracture of the coronoid process of the ulna, as was the case in the remarkable pair of specimens one of which is represented in Fig. 93. I am not prepared to speak confidently on this point. I have met with one case in which during life all the symptoms of the injury were very plain, — dislocation of the bones backwards, very easil}' reducible, some crepitus after reduction, and constant reproduc- tion of the displacement. But in ordinarx' cases the reduction when once 282 INJURIES OF THE UPPER EXTREMITY. effected is so secure, and passive movement of the ulna round the trochlear surface of the humerus after reduction is so smooth and uninterrupted, that it is ditlicult to believe in the existence of any such fracture. Nor is there any anatouiical confirmation of the doctrine which affirms the frequency of fracture of the coronoid process, as far as I know. Fin. 92. Fig. 92. — Old dislocation of both bones of the forearm backwards. From the body of a man who died from other injuries. Nothing is known about the accident, a shows the olecranon process projecting, with, e, the triceps muscle attached to it. 6, the radius, the head of which has formed a new articular cavity for itself on the back of the external condyle and enjoyed some little mobility. The coronoid process of the ulna was lodged in the olecranon fossa, and was almost immovable, so thai there seems to have been no power of flexion and extension, d points to the biceps muscle, which remained attached to the radius, c, to the brachialis anticus, which had been torn away from the coronoid process. The principal part, here shown, was fixed to the humerus, so that its action had been abolished. Some fibres, however, were also attached to the ulna below its natural insertion. — From a specimen in the Museum of St. George's Hosiiital, Ser. i, No. 108. Fig. 93. — Dislocation of both bones of the elbow backwards, with fracture of the coronoid process of the ulna, o shows the fragment of the coronoid process, which remains connected to the humerus. 6, the surface of the ulna, from which it lias been separated, c, the upper end of the radius displaced backwards, as was also the ulna. A vertical fracture traversed the head of the radius. The specimen in the Museum of St. George's Hospital (Ser. i. No. Ill) was taken from the body of a man who, while at work on some repairs in the Hospital, fell from a great height into the courtyard, and was taken up dead. Tliere was exactly the same injury of the elbow on both sides, even to the longitudinal splitting of the head of the radius, sliowiiig that he must have come down with both hands on the ground in precisely the sunic position. Reduction. — If dislocation backwards remains unreduced it leads to very lamentable U>ss of the motion of the arm. In the preparation, Fig. 92, there remains no movement of flexion and extension whatever, the coronoid process being wedged into tlie olecranon fossa and tightly bound down there by inflammatory adhesions, the brachialis anticus torn away, and the ])icei)s having lu) means of acting on the radius, which is itself firmly attached to the idna. All that the patient seems to have pre- served is a little rotation of the rtidius in the new cavity which it had formed on the outer condyle. But when treated early reduction is gen- erally very easy. Many tli.slocations of the eli)0\v slip in on the least traction being made on the hand, probabl}-, as hinted above, because the coronoid process is not fairly lodged in the olecranon fossa. If the coro- noid process be fractured no obstacle to reduction can possibly exist. DISLOCATION OF RADIUS. 283 And even in the complete dislocation steady traction on the hand, com- bined, if necessary, with slight rotatory movements, will almost certainly disengage the coronoid process, which can then easily be slipped roniid the trochlea by bending the arm. Chloroform is generally nnnecessary, bnt may be administered if the patient is unusually timid, or if attempts without it have failed. If the surgeon have no assistance he generally places his knee on the projecting humerus, to make counter-extension, steadies the arm with his left liand, grasps the forearm with his right, and pulls it downwards, and then, when he feels the displaced bones move, he bends the forearm sharpl}', and they slip into place. In old dislocations either the pul- leys must be put on in order to bring the bones of the forearm downwards, and when they are thought to be dis- engaged reduction is attempted by acute flexion ; or, after all adhesions have been broken down by A'arious movements, the case is treated as a recent dislocation. Care must be used in such cases not to fracture the bones. Dislocation of ihe Head of the Radius. — The form of dislocation Dislocation of the head of the radius backwards. The head of tlie radius is niucli altered in form. The orbicular ligament had been carried away along with the head of the radius, and had taken an attachment to the humerus on either side of the dislocated head, so that the motions of prona- tion and supination were abolished. The outer which is most frequent next to that condyleof the humerus is much changed in shape of both bones backwards is that of from deposit of new bone. The ulna is perfectly natural. Flexion and extension could be per- formed, through about a quarter of their natural extent. The preparation in St. George's Hospital Museum (Ser. i, No. 109) was taken from the body of a young man who had received a blow on the elbow about two years previously, and noticed the change in the shape and motion of the joint next day. the iiead of the radius only, the ulna remaining in its place. This occurs either on the back (Fig. 94) or the front (Fig. 95) of the external condyle. Careful examination can hardly fail to detect in the disloca- tion backwards the projection of the displaced head, and the change in the axis of the bone, which are so well shown in the figure; in the dislocation forward the loss of the head of the radius from the part where it should be felt; and in both the total loss of the power of voluntary pronation and supination, and the almost total loss of passive motion. If the injury be overlooked the patient will lose more or less completely the power of turning the hand except b}' the comparatively awkward device of rotating the humerus. The dislocation of the head of the radius is remarkable as being one of the few which are not uncommon in earl}' life, as Fig. 95 shows. It has been known to be produced by traction made by the accoucheur on the child's hand in delivery. The backward dislocation is the most common. In its reduction the forearm should be flexed so that tlie biceps may be relaxed, and tlien, while an assistant manipulates the hand as directed, so as to approximate the head of the radius towards the ulna, the sur- geon tries to press it directly into the lesser sigmoid cavity by the ^Dres- sure of his thumbs, supported by the counter-pressure of the fingers on the other side of the limb. The other dislocations are much rarer. Both bones have been found dislocated laterally, the outward dislocation being the more common. A 284 INJURIES OF THE UPPER EXTREMITY. few instances liave even been recorcled of dislocation forwards, the olec- ranon process being thrown more or less completely down to the end of the trochlear snrface of the humerus, and the arm elongated ; or the ulna alone may be dislocated from both the humerus and radius. It would Fig. 95 Dislocation of the head of the .radius forwards, at the age of two years, witli fracture running through the cartilaginous olecranon. The dislocation was compound, and the child died of pyaemia. — From the Museum of St. George's Hospital, Ser. i. No. 110. serve no useful purpose to describe minutely the characters of these rare injuries, or to dwell further on the symptoms of the fractures of the va- rious processes which are constant accompaniments of dislocations of the elbow. Great care is necessary in the examination of every case. After reduction the arm sliould be kept quiet on a splint for a fortnight at least, and should then be used very cautiously. Comjjound Dislocations. — When the dislocation is compound the sur- geon is guided in his treatment chiefly by the amount of the concomitant lesions. If these are trifling it is better, especially in elderly persons, to reduce the bones, close the wound, and trust to earl^^ passive motion to restore some movement to the joint. If the bones are considerablj^ injured it may be better to perform excision of the whole joint; and if the great A^essels or nerves be also injured, amputation may even be uec- essaiy, though this is quite exceptional. Dislocation of Lower End of Radius. — The lower radio-ulnar joint may be dislocated ; and as in tliis joint the radius is the movable bone, it is usual at the present da}', following the analogy of the nomenclature of other dislocations, to call this a dislocation of the radius from the ulna, instead of the ulna from the radius, as Sir A. Cooper called it. The radius seems displaced forwards rather more commonly than back- wards ; the hand is of course displaced forwards, and the styloid process of the ulna projects backwards, sometimes comes through the skin. The opposite dislocation causes similar symptoms reversed. Tiiese injuries are caused b}' violent twisting of the liand. They are to be reduced by extending the hand and manipulating the radius into position. If there be a wound it must be carefully closed, and in any case the hand should be kept in splints for aljout a fortnight. Dislocation of the icrisl occurs almost always backwards; the bones of the carpus project on the dorsal surface of tlie forearm, the articular sur- faces and styloid processes of the radius and ulna being felt below them. The dorsal projection gives this ijijury some resemblance to Colles's frac- ture, especially when the hand is somewiiat twisted, so that the styloid process of the ulna projects ; and the two injuries were generally con- founded together before Colles's time; but there is no real difficulty in the diagnosis, for the position of the styloid processes in relation to each I DISLOCATION OF THUMB. 285 other and to the hand, is an unfailing test. In the dislocation the st_y- loid processes are on the same level, and lie much nearer to the fingers as well as much lower than natural. In the fracture the styloid process of the radius is displaced along with the hand, while that of the ulna, though prominent, is at nearly the same distance from the little finger as on the sound sid*^. Reduction is usually easy. It is better, I think, to keep the part quiet on a splint for a few days at first, and then to wear the hand in a sling for about a fortnight. The dislocation in the other direction (?. 6., with tlie hand in front of the forearm) hardly ever occurs as a traumatic lesion. Its symptoms would be the same as the above reversed. Dislocations of the Carpus. — Though the bones of the carpus are so small, and so securely locked together, yet dislocations do occur. Such as I liave seen have been compound. The Museum of St. George's Hos- pital contains a pair of semilunar bones which were exposed in a com- pound dislocation of both wrists, and were removed before the wounds were dressed. The patient died from other injuries, but the parts were unfortunately not preserved. Another preparation shows dislocation of the rest of the carpal bones from the semilunar, which alone remains at- tached to the bones of the forearm. The scaphoid was fractured, and the fractured portion extracted through the torn dorsal ligaments. I saw, a short time since, a case in which the greater part of the semilunar bone came away, but the patient recovered a very useful hand. In other cases the head of the os magnum has been the protruding part. I do not think any special directions need be given for the diagnosis and treatment of such injuries. The protruding parts are generally easily replaced, and the patient usually recovers the utility of the hand ; the great point is to see that the motions of the fingers are early restored. Dislocation of the Thumb. — The first phalanx of the thumb is com- paratively often found dislocated on to the metacarpal bone. The articu- lating surface of the phalanx usually lies on the dorsal surface of the metacarpal l)one, though a few cases of the opposite dislocation hav^e been met with. Either may be recognized at once b^- the shortening of the thumb, and by the projection on the dorsal aspect of the hand, formed, in the one case, by the displaced end of the first phalanx, in the other by the prominent head of the metacarpal bone. The dislocation backwards is often very hard to reduce. When the first phalanx is carried backwards it takes wath it the two lieads of the flexor brevis pollicis and tlie sesamoid bones developed in them ; the anterior and lateral ligaments of the joint are torn off the head of the metacarpal bone, which tears a way for itself through the fibrous tissue uniting the two heads of the flexor brevis, between which it projects as a button does out of a buttonhole. (See Fig. 96.) In these two conditions consists the diflficulty of reducing the dislocation, viz., in the tension of the short flexor, and the diflficulty of slipping the tissues forming the buttonhole over the mushroom-shaped head of the metacarpal bone. The first principle, therefore, in reducing any dislocation of the thumb which presents diflHculty is to relax the short flexor, and this is done by forcibly adducting the thumb; i. e., pressing it as far as possible over to the middle line of the hand. This being done by an assistant, the surgeon takes the displaced first phalanx and places it in extreme extension, in order to relax the tissues of the buttonhole, and to push 286 INJURIES OF THE UPPER EXTREMITY. up those which form its distal part over the projecting head of the meta- carpal bone. This is done by drag-ging the hyperextended thumb down- FlG. 96. Fig. 97. Fig. 96. — Dislocation of the thumb backwards, showing how the displaced jihalanx carries backwards with it the heads of the flexor brevis pollicis, and how the head of the metacarpal bone is consequently forced forward through a buttonhole opening in the tissue which unites those heads in front. The margin of this buttonhole is seen constricting the neck of the bone just above the letter a in the figure. — From the dissection of a dislocation artificially produced in the dead subject. After Fabbri. Fig. 97.— Reduction of dislocation of the thumb (after Fabbri). The metacarpal bone is flexed as far as possible by squeezing it towards the centre of the hand. This carries the displaced phalanx with it, and so approximates the insertion and origin of the flexor brevis pollicis, relaxing the tissue forming the edge of the buttonhole, a. The dislocated thumb is then hyperextended in order to slip the upper edge of this buttonhole round the prominent head of the metacarpal bone. When this is even partially effected the muscles will draw the phalanx into position. The tension of the fibres of the flexor brevis pollicis in the former figure may be contrasted with their relaxation in this. wards, i. e., away from the wrists, and then acute flexion will restore it to its place.* Such, I have no doubt, are the main obstacles to the reduction of this dislocation, and the appropriate method of obviating them. But there are probably in some cases other causes concurring, such as the interpo- sition of some of the torn fibi'es of the ligaments, or of the fascia form- ing the distal portion of the buttonhole between the ends of the bones, and possibl3^ the interlocking of the bon^^ projections themselves. These minor obstacles can usually be overcome by slight rotatory movements of the phalanx during extension. As there is often need for the application of considerable force, it is important to apply some apparatus which will keep (irmly in place and at the same time not cut tlie skin. The Indian puzzle-toy, which holds the more firmly the more it is pulled upon, may be found useful; and there is a pair of forceps (called the "American forceps"), manufactured for the purpose, with handles like those of the lithotomy forceps, and two ' The difficulticb attonrling the rodiiotion of thi.s di.''location, and the method of uniting them, an; admirably described in u memoir by Prof. Fabbri, in vol. x of the Meraorie dell' Accad. delle IScienze dell' Istituto di Bologna. DISLOCATION OF THE FINGERS. 287 sheets of leather attached to the blades, which cross each other. These hold very firmly, and can hardly damage the soft parts. But when such contrivances are not at hand a clove hitch must be made of any appro- priate material (the broader, softer, and stronger the better) and applied around the first phalanx, hitching against the projection of the joint. Manual extension is generally suflticient; but I had once occasion to use the pulleys successfully. When reduction has been eflb'^ted some sur- geons recommend that the joint be flexed and extended once or twice to disengage any of the tissues which may have slipped between the bones. If all attempts at reduction by mere manipulation have failed, the case should be left for a time, cold being applied to combat inflammation; and if renewed careful attempts have no better result, the course generally followed is to make a subcutaneous section of the parts between the skin and the displaced phalanx on one or even both sides. This is usually spoken of as " division of the lateral ligaments ;" but it really, I presume, involves a more or less complete division of the head of the flexor brevis, and is successful when "the buttonhole" is laid open, and the metacarpal bone thus liberated. Another plan, recommended by Dr. Humphry,' is to introduce a blunt hook, through a small incision, beneath one of the sesamoid bones, and draw it forwards with the phalanx. I have seen both plans successfully adopted; but I believe neither will often be required if Prof. Fabbri's directions are carefully followed in the manipu- lation. Finally, if all fails the case must be abandoned, passive motion being early and sedulously practiced. Cases are on record in which the thumb, though dislocated, has been very freely movable. When the dislocation is compound, the projecting bone, which may be either the phalanx or the metacarpal bone, should be removed, and passive motion early practiced. Dislocation forivards. — Of the dislocation of the phalanx forwards, four examples are related by Nelaton.^ One of these, though seen early and treated by some of the best surgeons in Paris, remained irreducible. Dislocations of the Fingers. — The phalanges of the fingers are rarely dislocated, but occasionally, in a fall, this injury may take place at any of the joints, the distal bone being generally thrown behind the proxi- mal.^ Reduction is usually quite easy. I saw one case of old dislocation in which I found it impossible ; but the patient was not in a condition to explain the circumstances to me, and I believed that it had been neglected. After the reduction the finger should be bound up for a few days, to pre- vent any use of it until the torn ligaments have consolidated, and then careful passive motion should be given. 1 Humphry on the Skeleton, p. 434. 2 Path. Chip., vol. ii, p. 423. ^ While this sheet was passing through the press I saw a case in which the distal phalanx of the thumb was dislocated and forced through a wound in the palmar sur- face. The injury occurred in a scuffle. 288 INJUKIES OF THE LOWER EXTREMITY. CHAPTER XV. INJURIES OF THE LOWER EXTREMITY. Sprains of the joints of the lower extremity are amongst the com- monest injuries in surgery, especially of the ankle and knee, and in the ankle it is often difficult to decide whether there is fracture or not. The injury is often a severe one, causing great pain at the time, being accom- panied probabh- with much laceration of the ligaments and other struc- tures near the joint, and leading frequently to prolonged lameness. Severe sprains are followed generally by a good deal of effusion into the synovial cavity, which is sometimes slow to disappear ; and they often lay tlie foundation of permanent disease of the articulation. Hence we can hardi}' be too careful in our treatment of them. At first, while the active state of effusion is present, antiphlogistic measures are necessary. When it is grateful to the patient the sedulous application of cold by means of icebags is, I think, the best; but if this is not tolerated leeches, followed by warm fomentations, or evaporating lotions, or irrigation with spirit and water, will t)est check the tendency to effusion. As soon as the patient can bear it equable pressure by strapping and bandage or b}' splints, with pei'fect rest, should be adopted, and is one of the most potent means of cure in such injuries. But it is important, as soon as the patient has lost all pain, or if he has not quite lost pain, yet as soon as he can bear passive motion without renewed swelling and inflammation, to commence bringing the joint into use, b}' cautious motion and shampooing at first, and then by more free motion of it day by day, combined with steaming and free rubbing in of oil, and to encourage the patient to exercise it as much as he can witliout harm. Sir J. Paget has called attention to the coldness which aflects joints which have been kept too long at rest, and he cau- tions his readers in the following emphatic terms against tlie bad effects of too protracted inaction : "Too long rest is, I believe, by far the most frequent cause of delayed recovery after injuries of joints in nearly all pei'sons who are not of scrofulous constitution. In the healthy, the chronic rheumatic, and the gouty, it is alike mischievous; and not only to injured joints, but to those that are kept at rest because parts near them have been injured. Mere long rest stiffens them and makes them over-sensitive ; cold douches and elastic restraints and pressures make them worse, and nothing remedies them but movement, whether forced or voluntary.'" And he points out that such cases are the most frequent examples of the class which are cured by the rough manipulation of the bone-setter, who gets a joint which has been sprained and kept too long at rest, then pretending or l)elieving that it has been dislocated, wrenches it, and tells the patient that it has been put in, and that now he may use it. The patient, finding himself al)le to do so, naturally believes what the quack tells iiim, and thinks that his surgeon has overlooked a dislo- cation. The real fact is, that rest of the sprained joint has been carried on too long. But this fact — though there can be no doubt of it, and ' Clinical Lectures, p. 96. FKACTURE OF CERVIX FEMORIS. 289 everyone must have had frequent opportunities of verifying it — must not lead us into the opposite error of decrying the use of complete rest in sprains, especially in the lower limb ; nor into that of insisting on too early passive or active motion, which would reproduce the inflammation and much prolong the mischief. Passive motion, shampooing, etc., should be begun as early as seems prudent, but always gradually and with caution, and at first with prolonged intervals of rest. Wounds of the lower extremity need not detain us in this place. The injuries of large arteries (as the femoral) have been spoken of above. The wounds of joints, and especially of the knee-joint, are the most striking feature in the regional surgery of such injuries. When the knee- joint is opened by a clean cut, the nature of the injury is known by the escape of synovial fluid and by the effusion into the cavity. Unless a foreign body is known to be lodged, no probing or other examination is admissible. Otherwise the cut is to be carefully united, and the joint equably and firmly strapped, the limb being bandaged from the toes up- wards on a well-fitting splint, just as after the operation for removing a loose cartilage. If swelling, pain, and fever should testify to the access of acute inflammation, then the joint must be exposed, leeches very freely applied, and afterwards ice kept on the part constantly. If the case does badly, its furtlier progress resolves itself into the diagnosis and treat- ment of acute abscess in the joint (for which see the chapter on Diseases of the Joints); but if it does well, the symptoms gradually subside, and the patient recovers, usually with more or less of anchylosis, though pos- sibly in some cases completely. Foreign bodies may lodge in wounds, especially of the buttock, and are frequent in the foot; but I can add nothing on this head to what has been said above (page 251). Fracture of the neck of the femui — a common accident in old persons of both sexes — takes place either entirely within the capsular ligament of the hip joint, or else partly or wholly external to that cavity. The former fractures are called intra-capsular^ the latter exlra-co.psular. The annexed figures (p. 290) will show the usual forms of fracture of the neck of the femur. The division into extra- and intra-capsular — which was made by Sir A. Cooper, and which is ordinarily followed in our schools — appears to me one of considerable importance; but another of equal, and according to the judgment of some writers of great authority, of even greater practical value, is into the impacted and the non-impacted frac- tures. The series is not, of course, intended to exhibit all the varieties which are met with, but it does sliow those which are most clearly dis- tinguishable from each other, and the characters of which it is important to bear in mind. Fig. 98 is the truly intra-capsular fracture which generally occurs in old age, and often from slight causes ; it is usually free from impaction, and rarely found united by bone. This fracture, however, may be impacted, and in such cases, at any rate, bony union does occur. This is shown by Fig. 104. Fig. 99 shows the ordinary impacted extra-capsular fracture which occurs both in old age and at earlier periods, in which the upper frag- ment (comprising the head and the whole of the neck) is driven into the cancellous tissue of the base of the trochanter, and firmly wedged there; so that in the case from which the preparation was taken, and where the same fracture had occurred on both sides, at four years' interval, in the 19 290 INJURIES OF THE LOWER EXTREMITY. recent fracture the upper fragment was so firmly wedged into the lower that it was only separated by maceration. This fracture unites always by bone. Fig. 98. Fig. 99. Fig. 98. — The common, uon-impacted,intra-capsular fracture of the neck of the thigh-bone. — From a preparation in St. George's Hospital Museum, Ser. 1, No. 180. Fig. 99. — The common, impacted, extra-capsular fracture of the cervix femoris. From a woman aged seventy-four at the time of her death, who had had fracture on one side four years, on the other five weeks, before her death, both injuries being almost exactly similar. The old injury was com- pletely united by bone ; the recent one was firmly impacted, but the fragments separated in macera- tion. — St. George's Hospital Museum, Ser. i, No. 207. Fig. 100, on the other hand, represents the common form of commi- nuted fracture of the neck and trochanters, also produced at any age by Fig. 100. Fig. 101. Fig. 100.— The comnu)ii, comminuted, non-impacted fracture of the neck and trochanters.— From a specimen (Ser. i, No. 142b) in the Museum of St. George's Hospital. Fio. 101.— A gunshot wound, causing intra-capsular fracture of the neck of the femur, in a young man (aged 2.'5). A charge of small Hhot passed through the hip-joint, from a very short distance, at the back of the limb (" balled," according to the common expression), cleanly dividing the femur. It will be noticed that the back part of the bone is notched by the shot in two or three places.— From a speci- men in St. George's Hospital Museum, Ser. i, No. 136. FRACTURE OF CERVIX FEMORIS. 291 Fiy of the lower frasori)tion of the bone from senile atrophy, producing fatty degeneration of its tissues, shortening, and loss of the natural obliquity of the neck of the femur, must render it prone to give way from very slight causes ; and thus, in extreme old age, the neck of the thigh-bone is sometimes broken from the most trifling injuries, even from catching the toe in the carpet or bedclothes. Such fractures are in all probabilit}' intra-capsular. It is, however, a mistake ^ I have myself sc'Pn this shortonin;; from intorstitial absorption come on gradually in a case which was carofiilly fxaniiiicfl soon after the injury by myself and other surgeons, who wt-re all satisfied that no fracture existed. '•' Inversion in impacted fracture depends on the usual kind of impaction beini^ re- versed. Instead of the neck bein<; driven into the tissue.it the base of the trochanter major, driving the trochanter baekwiirds, tlie two trochanters are widely separated from each otluT, and the neck, wedged in between them, has so pushed forward the trochanter and lower fragment as to turn the wh()]e femur inwards on its own axis. In Bigelow's work and in sf)mo papers recenll}' published by liim in th(i Boston Medif'al and Surgical .Journal, January, 1875, lh(i reader will find some interesting speculations on the strurture of the neck of the femur and the effect of such structure on the impaction of fracture ^ See Med.-Chir. Trans., vol. xxxiv, p. 107. There is a specimen in the Museum of .St. Georg(^'s Hospital, Ser. i, No. 12.3, showing this injury, which was mistaken for fracture of the neck of the thigh-boni', as mentioned in the text. FRACTURE OF THE CERVIX FEMORIS. 293 (though one often committed) to believe that this change in the neck of the thigh-bone is one whicli is universal or nearly so in old age, and that therefore most fractures of the cervix in old people are intracapsular. On the contrary, the change in question only occurs in some proportion (hitherto, I believe, undetermined) of the aged ; and the extra-capsular is certainly more common in old age than the intra-capsular fracture. This latter form, however, is almost exclusively found in the aged. When, tlierefore, the fracture has occurred from a very slight cause in an old person we conclude that it is probably intra-capsular. 2. If the fracture be not impacted the amount of shortening which immediately follows the injury is usually less after the intra- than the Fig. 103. Fig. 104. Fig. 103.— Section of the femur to show the atrophy of its head and neck, and the alteration in the direction of the latter from senile changes. The head is on a lower level than the great trochanter, and the neck has a horizontal instead of an oblique direction. — St. George's Hospital Museum, Ser. ii. No. 7. Fig. 104. — Bony union of intra-capsular fracture. — From St. George's Hospital Museum, Ser. i. No. 142a. extra-capsular fracture, and there is less crepitus, if the surgeon thinks it desirable to make the manipulation necessary in order to elicit the crejiitus. But this, in my opinion, should rarely if ever be done. It puts the patient often to much pain, and may have an injurious effect on the progress of the case, which the object sought to be obtained does not justify. 3. The surest test between an intra- and extra-capsular fracture when it is available (which, however, in the majority of cases it is not) is to note whether the trochanter moves with the lower fragment. If the movement of the lower fragment is not communicated to the trochanter the fracture cannot, of course, be above the inter-trochanteric line ; but the movement of the trochanter along with the lower fragment does not prove the contraiy (^. e,, that the fracture is intra-capsular), since the fragments may be more or less closely interlocked. 294 INJURIES OF THE LOAVER EXTREMITY. Such are the characters which seem to me worthy of stud_v when we wish to distinguish those two forms of fracture from each other. I may add that they become less trustworthy the more completely the fragments are impacted. This impaction happens much more frequently in the extra-capsular form, so frequently, indeed, that one great authority — Dr. R. W. Smith — believes that all extra-capsular fractures are impacted at the moment of injury, though doubtless the fragments are often detached from each other afterwards. When the impaction is complete the fragments cannot be moved on each other by any force which the surgeon would employ. Hence the shortening cannot be made to disappear, nor can crepitus be elicited. But in less firm imjiaction (or perhaps simple interlocking of the frag- ments) passive motion detaches them, crepitus is produced, and when extension is removed the shortening is found to have become much greater than before. The treatment of fracture of the neck of the thigh-bone will depend mainl}' on the age and constitutional condition of tlie patient. Sir Astley Cooper proved that fracture of the neck of the thigh-bone within the cap- sule does not usually unite l\y bone. In some rare cases it will do so, as shown in the annexed figure ; and it is probable that when it does do so the cause is gericrally impaction of the fractured head in the tissue of the cervix, as was the case in that instance.^ More commonly the union is ligamentous or there is no union at all. and in the latter case the fractured surfaces are often polished oflT. and a kind of false joint is found in the interior of the true one. The causes of this defect of union are variously stated. There can be no doubt that the main reason is the impossibility of keeping the ends in contact, and perhaps the frequent slight displace- ments to which, under the action of the muscles inserted into the tro- chanter, the lower fragment is constantly liable. But many other causes have been assigned, viz., the age of the patient, the atrophy of tiie bone, the percolation of synovial fluid between the fragments, and the small supply of blood to the upper fragment — only from the small branch wliich runs in the ligamentum teres. The first is a cause about which there can be no doubt ; and in the only other very common injury where non-union is the rule, viz., the transverse fracture of the patella, the conditions are similar in respect to the impossibility of proper coaptation of the frag- ments, though in every other particular they are usually quite different. This, therefore, may safely be regarded as the main reason, though some others may conspire in preventing l)ony union. This want of liony union exists, however, only in tiie intra-capsular fracture. Extra-capsular frac- tures unite as soundly as any other fracture. The treatment which Sir Astley Cooper recommended consisted merely in supporting the knee on a pillow, keeping the patient in bed until movement was no longer very painful to him — say from a fortnight to three weeks — and then allowing him to get up and move al)Out as mucli as he could with ease. The result of this would, of course, be the non-union of the fracture; but this was a matter of minor importance in Sir A. Cooper's view, since he laid so much stress on the fact that intra- capsular fractures do not as a rule unite by bone. And there can be no doubt that if attempts are too much persisted in to procure consolidation of the fracture by rigid confinement during many weeks, the patient 1 Two similar instances of bony union of intra-capsular fracture with impaction are rocordpd and ficurcd by Bigelow, On Dislocation and Fracture of the Hip, pp. 131-135. The figures are strikingly like that in the text. FRACTURE OF THE TROCHANTER MAJOR. 296 (being an old person) is almost sure to suffer from sloughing produced by the splints, or from bedsores, and will very likely die. And in such patients the treatment above described, or something like it, is the best. But this does not apply to fractures of the neck of the thigh-bone in 3'ounger and more vigorous people. In them the fracture is either im- pacted or non-impacted. If the former, no attempt should be made to disengage the fragments, since it cannot be done without an amount of violence which would be highl\- dangerous, and which is quite unjustifi- able. Such impacted fractures require only rest for their consolidation. The limb is steadied by the application of a weight to the foot, along with a case of splints lightly applied to the thigh, or by the long splint, for about six weeks, when it can be put up in a starched pasteboard, or a Hides's felt splint. Comminuted and other non-impacted fractures in patients tolerably vigorous and not too old are to be treated with the long splint, just like any other fracture of the thigh. Some surgeons prefer Fig. 105. Earle's bed, or the double inclined plane for the treatment of fracture of the upper part of the femur. Extension is made by fixing the foot, or feet, to the movable foot-pieces at the bottom of tbe bed. Counter-extension is made by the weight of the body gravitating down to the bottom of the bed in which there is an opening for the passage of the dejecta. Earle's bed in these cases, and it is certainly less exposed to the risk of producing ulceration or sloughing of the skin, although it makes far less efficient extension than the long splint. Some alleged cases of disjunction of the upper epiphysis of the femur are recorded : ^ but they do not seem to me conclusive as to the real existence of this lesion as a substantive injury. Fracture of the trochanter major, without any solution of continuity of the shaft or neck, has been known to occur both before and after the junction of its epiphysis. One in an old man is recorded and figured by Sir A. Cooper,^ and in a girl of sixteen b}- the same author, on the authority of Mr. Aston Key. It is caused h}- direct violence. The S3'mp- toms given are i^ain at the part, and particularly on passive motion, ever- sion of the foot, deformity of the trochanter, and crepitus, without short- ening of the limb. The injury- is to be treated in the same way as frac- 1 Syst. of Surg., 2d ed., vol. ii, p. 859. ' On Fractures and Dislocations, 2d ed., pp. 158, 171. 296 INJURIES OF THE LOWER EXTREMITY. ture of the cervix. The fracture unites well, and the limb will very proba- bly be perfectly useful. Fracture of the body of the femur is a very common accident, and it generally occurs in the middle of the bone, at a variable level. The cause is usually indirect violence, i. e., a fall or strain, by which the bone is bent and snaps, in rarer cases it breaks in consequence of a direct blow upon the tliigli. There is rarel}^ any difficulty in recognizing the nature of the injury, as the lower part of the limb is freely movable. Exceptional cases, in which impaction causes some amount of difficulty, will be recog- nized by the alteration in the length and in the axis of the limb. Three forms of fracture of the femur are described, viz., fracture of the upper third, of the body, and of the lower end. Fracture of the upper third of the femur is a formidable injury. In the words of Sir A. Cooper,^ "it is a difficult accident to manage, and miser- able distortion is the consequence if it be ill-treated." The distortion to which Sir Astley refers is that shown in the annexed cop}'^ from his figure. Fig. 106. Fracture of the upper third of the femur with great displacement. From Sir A. Cooper's work on Fractures and Dislocations (pi. xii, Fi;,'. G), thus described by him: "The tliigh-bone fractured below the trochanter minor, and drawn into a most deformed union by the action of the psoas and iliacus interuus muscles." showing the upper fragment tilted forwards and outwards, and the lower fragment lying under it, irregularly united to it by a I)ridge of bone, the axes of the two fragments forming a great angle. But tins distortion is not the one which is always found in these cases. Fig. 107, from tiie Museum of St. George's Hospital, shows an equally " miserable distor- tion," but in the opposite direction, since here the upper fragment re- mains in its natural position, wiiile the lower fragment is driven across the front instead of the back part of tiie lower, and points upwards anct outwards. In both cases the foot must have been far from tlie ground, and the patient could onl}' have walked witli great slowness and difficulty. * See the section On Fractures below the Trochanter, in Sir A. Cooper's work On Dislocations and on Fractures of the Joints. FRACTURE OF FEMUR. 297 Sir A. Cooper refers the distortion to tlie action of tlie psoas and iliacus, and to tliat only ; but the explanation is evidently imperfect. Allowing that these muscles may exercise traction on the upper fragment, it is evi- dent that they cannot abduct it as well as flex it (as is seen in Fig. 108), and tliis part of the displacement in this and cases similar to this is now generally ascribed to the pressure of the lower fragment, which often drives the bone upwards, though other surgeons believe that the action of Fiu. 107. Fig. 108. Fig. 107.— Oblique fracture of the femur, just below the trochanter minor, most irregularly consoli- dated. The upper fragment appears to have retained its normal position, but the lower one crosses the front of the upper fragment obliquely from within outwards, and is firmly united to it by a bridge of new bone passing from the fractured end of the upper fragment to the surface of the lower fragment below the fracture. The medullary canal of the upper fragment was filled up by bone at the seat of injury, but in the lower fragment it is pervious. The head of the femur presents several irregular projections of bone, one of which, close to the attachment of the ligamentum teres, is of a curious hooklike form,, and fitted into a similar depression in the acetabulum. The cartilages of the hip-joint were almost de- stroyed, but there was no pus in the joint nor any adhesions. The preparation was found in exam- ining the body of a man aged seventy-six, who died of disease of the kidneys and bladder. Fig. 108. — Fracture of the femur immediately below the trochanters, seen on the anterior aspect. The lower fragment has passed immediately behind the upper, and the latter is driven into a position of extreme abduction, so that the head is inclined considerably inwards and forwards. An enormous callus enveloped the two fragments behind, and in this anterior view a broad and long osseous stalac- tite is seen leaning against the lower part of the head of the femur, as if giving it support. It is re- markable that the upper fragment, though in front of the lower, is not flexed in the slightest degree. On the contrary, one might say that it had been directed a little backwards, as if to meet the lower fragment. The shortening, due to the riding of the fracture, seems to have measured about an inch. — From Malgaigne's Atlas, pi. xiii. Fig. 1. the abductor muscles is also called into play. The shortening is often caused really more by the abduction and consequent angular deformity than by the riding or anterior displacement (Fig. 109). Evidently the position of the lower fragment is the point to which the greatest atten- tion should be directed, both in the reduction and in the after-treatment. The great point, as it seems to me, is to disengage this fragment, in what- ever position it may be lying, to draw it down, and to place it in the axis of the limb, for which purpose it is desirable to put the patient under chloroform ; and it may l)e justifiable in extreme cases even to apply the pulleys. When the fracture has thus been completely reduced I have never seen au}^ evil consequence, nor any difficulty in treating it by 298 INJURIES OF THE LOWER EXTREMITY, means of the long splint, which is far more trustworthy than any other apparatus in this fracture. 1 have never seen cases successfully treated by the double inclined i)lane (Earle's bed), recommended by Sir A. Cooper; in fact, it appears to me to exercise no influence whatever on the progress of the case, and to be very insufficient as a safeguard against the repro- duction of the displacement, which is the real danger. If, however, the surgeon is so under the influence of a venerable authority as to fear the action of the psoas in displacing the upper fragment, he can adopt Mr, Busk's thigh-splint, in which there is a joint at the hip, so that the body can be flexed while the long splint steadies the lower fragment. Fracture in the Middle of the Bone. — In fractures of the body of the bone the lower fragment generally lies behind and above the upper, either to its inner or outer side. Fig. 110, and Fig. 30, p. 145, illustrate Fig. 109. Fig. 110. Fig. 100. — Fracturo about two inches below the .small trochanter. The upper fragment is directed considerably outwards; it.s anterior projection docs not mea.sure more than one-third of an inch, and thi8 is all the shortening that is due to the riding of one fragment on the other, wliile the .shortening due to the angular di'forinify is more tlian an inch. — From Malj-'aigne, pi. xiii, Fig. 2. Fio. 110. — An old. badly set fracture of the femur, united by a largo bridge of bone, which covers over the medullary canal of both fragments. The upper fragment projects on the outer .side of the lower, and is directed from aljove outwards and forwards, while the lower is dis])laci'd considerably upwards, and points from below alsf), backwards and outwards. Compare this with Fig. .'SO, p. 14."). varieties in the displacement of this fracture, but it is certainly almost constant for the upper fragment to be in front of the lower; tiie foot also is always everttid or rotated outwards, unless in some rare cases the fragments should be so interlocked that it is driven inwards. The main cause of botli displacements seems to be the weight of tlie lower part of the limb. It is not impossible tliat the psoas and iliacus may raise the FRACTURE OF FEMUR. 299 lower end of the upper fragment, and that the hamstring muscles may draw the lower backwards, and this explanation is accepted by man}' authors; but it seems to me that when the support of the skeleton is withdrawn by snapping the femur the leg naturally falls backwards and the foot outwards. At any rate, if muscular action has anything to do with the displacement it does not usually affect the treatment to any recognizable extent. This treatment consists first in the careful setting of the fracture, and in doing this the surgeon should not grudge the time necessary to verify its accuracy. He should ascertain by the most exact measurement that the length of the fractured thigh is tiie same as the other, and by careful comparison of the various points of the two limbs that there is no angular or rotatory displacement. The treatment which is usually adopted at St. George's, and I believe at all the other London Fig. 111. Fig. 112. A fracture of the thigh put up with Desault's long splint and short thigh-splints. Fig. Ill ghoWS the general features of the apparatus. The long splint extends from the foot to the axilla. Desault's splint is provided with a footpiece, as shown in Fig. 112. Liston's splint, which is in more common use, though I think inferior to Desault's, ends in a notched extremity, extending several inches below the foot. The object is to correct the tendency to eversion of the foot by the traction exercised on it by the bandage passing through the notch. The objection to it is that, in the words of a late house sur- geon at one of the hospitals where it is in use, "it is apt to strain the ankle-joint, and .sores are liable to form about the malleoli, and overth? tendo Achillis" (Lancet, Oct. 10, 1874, p. .'512). The short splints are strung on the perineal band, as shown in Fii;. 112. They are secured by a couple of webbing straps, and the long splint is kept in position by a bellyband. The perineal band is passed through the notch, then around the splint from below upwards, and finally out of the notch again, being buckled outside the splint. This buckle has been accidentally omitted in Fig. 111. hospitals, is that by the long splint, whether Desault's or Liston's makes little matter, assisted by short splints, encasing the thigh, and prevent- ing any minor displacements of the fragments on each other (Figs. Ill, 112). Tliese latter, perhaps, are not absolutely necessary, and some sur- / 300 INJURIES OF THE LOWER EXTREMITY, geons only use the short splints to correct any deformity which is obvi- ous. If short splints are not used, it is an old and, I believe, good practice to bandage the limb evenly and carefully up to the seat of frac- ture, and some surgeons carry the bandage up the whole limb. There are many other methods of treatment, of which I cannot profess much personal experience ; for though I have occasionally tried some of them I have not found any reason for thinking that they are superior to the above in the ordinary fractures of adults, while they unquestionably involve some risk, and are not so eas}' of application. Thus, the Ameri- can surgeons are fond of applying the constant extending force of a weight passing over a pulley at the bottom of the bed, counter-extension being applied by fixing a perineal band to the head of the bed, so that the pa- tient cannot get down below a certain level in it. The weight is in some cases supplemented by short splints applied between the knee and the groin. The amount of weight must be regulated by the size of the limb. For an adult probably ten or twelve pounds would be about the average (Fig. 113.) Other plans contemplate a combination of the steadiness of the long splint with the i)ermanent extension produced by the weight, substituting for the latter a spring or india-rubber band or accumulator inserted into a jointed splint. Such is the splint invented by Mr. Cripps, in which the Fk:. II?. Extension apparatus for fracture of the thigh. Modified from Gurdon Buck. New Yorlt Medical Record. foot is drawn down and kei)t down by a constant elastic force, and of which Mr. IJryant speaks in high terms; and other similar apparatus have been invented by Mr. De Morgan and other surgeons; but I have not sufficient experience of them to have formed any opinion of tiieir real practical value as compared with the usual plan of treatment.' Many surgeons adopt the jjlan of putting up the fractured thigh at once, or very soon after the accident, in an immovable apparatus, such as a starched bandage, a plaster of Paris splint, or a leather collar. In America the limb is sometimes slung by means of a bent rod adapted by the front of the foot, leg, and thigh, the knee-joint being slightly bent. 1 The latest of these plans of making constant extension will be found described by Mr. G. B. Browne, from Mr. Erich.son',? hospital practice, in the Lancet, October 10, 1874, FRACTURE OF FEMUR, 301 Hooks are inserted into the back of the rod, so as to sling it from a pulley over the bed. The fracture is carefully set, and the rod then securely bandaiied on to the limb. The constant traction of the weight of the leg and foot is supposed to counteract any tendenc}' to shoi'tening. But the plan should on!}' be employed (if at all) when a wound on the front or side of the limb prevents the use of the ordinary splints. Even in such cases it woidd be better, in my opinion, to put up the limb in plaster of Paris, cutting a hole for the wound. Now, if we wish to form an estimate of the relative value of these new plans, we have, in the first place, to inquire what has been the result of the old treatment — tliat by the long splint. I think we may take it as estal)lished by consent of all the best writers that in ordinary'' cases of fractured femur in the adult with displacement, the- result of treatment by the long splint is, as a rule, to leave a certain amount of shortening. Malgaigne, in fact, goes so far as to say: " When the fragments remain in contact, or when we can replace them, and keep them so by means of their serrations, it is easy to cure a fracture of the femur without shorten- ing; in the absence of these two conditions the thing is simply impossi- ble" (Packard's Malgaigne^ p. 581). Without going quite so far as this, I think we may say tliat everyone who has examined liml>s treated witli the utmost care by our best surgeons witli the long splint agrees that if they are measured with perfect accurac}- a shortening of at least half an inch is ordinarily found in the adult, but that in children recovery without shortening very often takes place, and is probably' tiie rule. In children, however, the first of Malgaigne's conditions is generally present, i. e., the fragments have never quitted each other, but remain in contact, so that as soon as the limb is straightened it is found to be the same length as the other. By those who advocate the use of permanent exten- sion, either by the weight or elastic springs, this defect is attributed to the indisputai)le fact that the long splint can make no active extension, and that the liandages by which it is fixed must relax to such an extent as to prevent the extension made at the moment of" setting" from being accurately maintained. But it must be admitted that up to the present time we have obtained no reliable evidence that the treatment by perma- nent extension gives any better results, and it may also be said that in fact the results of tlie long splint, though not mathematically i)erfect, are usually good enough for all practical purposes ; for though a slight amount of shortening may in all cases be detected by measurement, its amount in careful hands is not generally so great as to be perce])tible to the patient, since it is corrected by a slight involuntary inclination of the pelvis, and he walks without limping. It is in the more formidable cases, in which the fractured ends have been greatly displaced, or where the- fracture is double or comminuted, that the shortening becomes really a deformity, and it is yet to be proved that in such cases permanent exten- sion could be so applied as to remedy this displacement, or that if applied it could be tolerated by the patient; for it must be remembered that per- manent extension is much more likely to produce ulceration of the skin than the ordinary method, and affords, as it seems to me, much less se- curity against angular deformity. The method of putting up fractures of the thigh at once is very appli- cable in the case of infants and young children. In them the long splint is not well l)orne, and the bandages are constantly soiled with urine and ffeces, and require renewal. A starch or gum bandage, or better still, the leather collar, shown in Fig. 114, will keep the limb straight, which generally 502 INJURIES OF THE LOWER EXTREMITY. f!^., Leather collar for the treatment of fracture of tlie (right) femur in a chilJ. The upper part of the collar is covered with oiled silk, to prevent its becoming soiled with urine or fieces. is all that is wanted, and the chihl may be nursed if in arms. IMie collar is better than tlie immovable apparatus, since it can be changed if necessary. Some surgeons are in favor of treating frac- tured thigli in young children without any apparatus at all,^ merely laying the limb in the abducted position flat on the bed. I have treated some cases successfully in this way, but it seems to be exposed to the risk of angu- lar deformity, as evidenced by the preparation represented in Fig. 115; and as all such risks are obviated by the simple plan above described, I cannot see what motive there is for running any such risk, or for the vertical extension of the limb, which Mr. Biyant recommends.^ If the surgeon wishes it, a weight can be hung to the child's foot at the same time as the collar is applied, but I see no necessity for it. In the adult a fracture of the femur appears to be sufficiently consolidated to bear the weight of the bod}'^ without danger in nine or ten weeks. The usual period for which treat- ment is continued is twelve weeks. Six weeks or more are to be passed in bed, after which, if on examination the union seems firm enough, the immovable apparatus is to be applied, and the patient allowed to move about on crutches for the remainder of the period. When the immovable apparatus is used from the first the patient is spared this confinement to bed : so that Mr. Erichsen, who is the main advocate for its use, says that he scarcely ever finds it necessary to keep patients with simple fracture of the thigh in bed for more than six or seven days. Most surgeons, however, think that the tedium of the confinement to bed is overbalanced by greater safety, and therefore employ some apparatus by which the seat of fracture is exposed, which involves the necessity of keeping the patient in bed. In the child, under twelve, the period of union and of treatment may be reckoned as about half that of the adult. Double fractures and comminuted fractures are more diflicnlt to deal with, and require more care in their reduction and treatment, than simple single fractures. In such cases it seems to me undeniable that the treat- ment by the long splint is much superior to that by permanent extension. Compound fi-acture of the femur is a very grave accident — tiie danger inci'easing with age. It is the result usually of gunshot, or of very severe falls, in which the end of the bone is thrust through the muscles and the skin. The first question is, wluither to save the limb or ampu- tate. This being settled, on the indications described at p. 142, the limb must be i)ut up in the same way as in simple fracture, onl}' that, if a long splint be used, it must be liracketed, if necessary, at the situation of the wound, wiiich is hardly ever at the posterior aspect of the limb. The surgeon should be vigilant to detect and give exit to matter as soon as it has formed. Fractures of the loioer end of the femur are very common. Long ' See a paper by Mr. Bloxnrn, " Rcispectini^ tlio Troatmcnt of Fractures of the Lower Extremities in the Wards under the care of Mr. Paget," St. Bartholomew's Hopp. Reports, vol ii. 2 Lib. cit., p. 954. FRACTURE OF FEMUR. 303 fissures run down into the knee-joint from a considerable distance ; but the communication witli the joint is often a matter only of conjecture, and they heal frequently, as l' believe, without any loss of motion in the joint. More frequently the lower end of the femur is separated from the shaft, by a fracture running transversely above the condyles, and often passing vertically down between them into the joint ; and in youth (i. e., below the age of nineteen or twenty) the fracture often passes more or less entirely through the line of junction of the epiphysis, constituting Fracture of the femur in au infant fourteen months old, which had been treated without splints. The child died of measles thirty-two days after the accident. The bone is seen to be much bent at the seat of fracture. This malposition was observed and could easily have been remedied before death, had the child's condition admitted of any interference. In another case similarly treated the bone also bent, but was easily straightened, and the cure completed by means of a leather collar. In two other cases the fracture healed well, and without observed shortening.— From Holmes's Surg. Dis. of Childhood. what is called a separation of the epiphysis. 1 have shown elsewhere that these separations of the epiphyses are usually complicated with more or less of fracture of the shaft or of the bony epiphysis itself (see page 139), and this is illustrated by the two figures annexed, in one of which the line of fracture runs up into the shaft, and in the other also separates the two condyles from each other. Still there are a few preparations in 304 INJURIES OF THE LOWER EXTREMITY. our museums in which the separation is confined to tiie epiphysial line. The differential diagnosis of separation of the epiphysis from fracture must be generally conjectural only, resting on the patient's age. It is conceivable that in a pure disjunction of tiie epipiiysis the surgeon might succeed in absolutely diagnosing the injury, by the absence of bony crepitus, together with the mobility of the fragment ; but I am not aware Fiu. 117. Fig. 116. — Partial separation of the lower epiphysis of the femur. The part of the epiphysis which forms the inner condyle is detached from the shaft by a fracture traversing the epiphysial line. The fracture then bifurcates — one line running down into the lower surface (inter-condyloid notch of the femur), the other somewhat upward, detaching the outer condyle and adjacent portion of the shaft from the rest of the bone. — From the Museum of St. George's Hospital. Fig. 117. — Another case of separation of the lower epiphysis of the femur complicated with fracture. The line of fracture, after running for about half the thickness of the bone in the line of junction of the epiphysis, then turns upwards into the shaft, leaving a large portion of the latter adhering to the outer condyle.— From the Museum of St. George's Hospital. — See Holmes's Surg. Dis. of Childhood. that any such case has occurred. The only importance of tlie diagnosis would be that, if the surgeon could satisfy himself that tiie epiphysial cartilage had been injured, he might warn the patient or his friends of the possibility of subsequent susjKMision of growth. Fracture of the lower end of the femur is in general perfectly easy to diagnose. When the fracture runs transversely across the bone the lower Iragment usually falls backwards by the weight of the limb, assisted per- haps by the hamstrings, and the mobility and displacement make the nature of the case obvious. If the separation be as low as the epiphysial line it involves the knee-joint, vvhicli will be more or less swollen ; and this swelling may mask the other symptoms. Here also, the fracture being within the knee-joint, tlie attachments of its capsule hold the bones together, and prevent displacement from occurring, at any late, to an}'' great extent. But in sucli cases tlie loss of power will indicate the proba- ble nature of tlie injury, and attentive examination under cliloroform can hardly fail to elicit definite proofs of it. FRACTURES OF FEMUR. 305 Wlien the fracture runs down between tl»e condyles it will often be found that the breadth of the lower end of the femur is perceptibly increased. The condyles may be movable on each other; and an impor- FiG. 118. Fk;. 119 Fl(i. 118.— Fracture of the femur above the condyles. The seat of fracture is more than 3 inches above the lower end of the bone. The lower fragment is drawn behind the upper and displaced upwards as much as 13^^ inch, the antero-po.sterior diameter of the femur at this part being more than doubled. The callus is formed by two large bridges of bone, between which there is a large tunnel, closed below. The medullary canal of the lower fragment is seen to be patent, and in the specimen the same is found to be the case in the upper fragment also. — From Malgaigne's Atlas, pi. xv. No. 1. Fio. 119. — Fracture ol the femur just above the condyles. The fracture runs obliquely downwards, outwards, and a little forwards. The upper Iragment displaced in this direction, has pushed the patella downwards on to the tibia, so that the patella is really diflocated downwards from the femur. The lower fragment remains parallel to the uppi'r. — From Malgaigne's Atlas, pi. xlv. Fig. 1. tant symptom of fracture running down into the joint is the sensation elicited by rubbing the patella over the condyloid notch. If there be any fracture its unevenness is very plainly felt, in contrast to the smooth motion of the kneecap in the uninjured limb. It may be added that in some cases the capsule of the knee-joint, or even the patella itself, has been wounded by the upper fragment. The treatment of such fractures is usually very successful. The bent position of the limb is best, both for the purpose of relaxing tlie ham- string muscles and of pushing the lower fragment into position by the projecting angle of the s{)lint. The surfaces are so broad in fractures near the knee-joint that there is probably no shortening, and even when the fracture runs into the joint it often heals without producing any anchylosis. If anchylosis is apprehended it is desirable, after six weeks of rigid rest, to adapt some apparatus which can be removed daily or every other day, for the purpose of giving passive motion to a gradually in- creased degree, in order to obviate such a result. Should anchylosis have 20 306 INJURIES OF THE LOWER EXTREMITY. t:iken place it must be treated on ordinary principles, and will often yield to the treatment. Compound fracture into the knee-joint is an accident which, as a general rule, demands amputation ; but to this general rule exceptions may be made in cliildren and in unusually healthy young adults, if the surgeon thinks it justifiable. Mr. Canton has reitorded two cases in which he excised the knee-joint for the secondary results of abscess in the joint, after an attempt to preserve the limh, in cases of simple fracture, or par- tial separation of the lower epiphysis of the femur ; but amputation became necessary in both.' How far the same operation would be applicable in compound fractures into the joint is doubtful. In cases of gunshot frac- ture excision has hitherto proved very unsuccessful. Fracture of the patella is a ver}' common injury, and occurs in two main forms. The ordinary form of fracture is transverse, and is very commonly caused entirely b}' the action of tlie great extensor muscle, Fig. 120. Fig. 121. Fig. 120. — Union of a fracture running down into the knee-joint. The patient, a middle-aged man, recovered with a very useful limb, and died a year aftnrwards from adifTcrent cause. The greater part of the fracture is united by masses of new bone, but tliere is no new bone in the interval between the fragments of the condyles, and the fragments of the cartilage are united l)y fibrous tissue. — St. George's Hospital Museum, Ser. i, No. 195. Fio. 121.— A transverse fracture of the patella, without laceration of the fibroustissue in front of the bone, produced by violence acting from within, in a compound fracture of the femur, one of tlie frag- ments having, as it seems, been driven against the deep surface of the patella. The cartilage covering the patella is diseased. — From St. George's Hospital Museum, Ser. 1, No. 205. the bone being snapped by the muscle before the patient falls to the ground. But there are a certaiu proportion of cases (ecpial, according to some authors, to those caused by muscular action) in which the same transverse fracture is produced by direct violence.'^ In some cases ' Path Trans., vol. x, p. 232; vol. xi, p. 195. * Mr. Hutchinson remarks very truly, "In thi> numorous cases in which direct violence i.s applied to tlie bone at the moment of fracture, there i.s almost always mus- cular contraction i-imultaneoMsly present, and it is impo.ssiblc to say which takes the chief share in the re.«ult." Med. -Chir. Trans., vol Hi, p. 328. FRACTURES OF PATELLA. 307 disease of the knee has preceded and raa}' have been a predisposing cause. ^ The fracture, though called transverse, is often more or less oblique. It is accompanied by a laceration of the fibrous tissue covering the bone; and in proportion as this laceration extends completely through the apo- neurosis of the extensor muscle the upper fragment is liable to be torn away from the lower by tlie action of the quadriceps extensor at the mo- ment of the accident, or to be pushed up by the accumulation of blood and synovial effusion in the cavity of the joint. In some cases the fibrous investment remains entirely untorn, especially when the fracture is the result of direct violence. This is illustrated by Fig. 121, whicli also shows a peculiar cause for the fracture, viz., the direct impact of a frag- ment of the femur. Fig. 122 also shows the ligamentum i)atell8e untorn on one side. The symptoms are usually ver3' plain. Tlie patient may have snapped the bone before falling, or even with no fall at all (as in Boyer's case, where a coachman snapped his i)atella in making an eff'ort to hold hitnself on to the coachbox). He will be almost or entirely unable to extend the limb ; there will be swelling and effusion into the knee, and a depression will be felt between the two fragments, the upper one of which will be Fig. 122. A specimen of fracture of both patelte, occurring in a severe injury, from the other eft'octs of which the patient died fifty days after the accident. On one side (a) the fragments were widely separated, and there was no attempt at any union ; on the other side (b) the ligamentum patelliSB had not been completely ruptured; the fractured ends were in close apposition, and there was some amount of fibrous union. In both the cartilage bears very evident traces of intlammation. No record exists of the treat- ment beyond the fact that both knees had been put up in pasteboard splints before the final accession of the fatal symptoms, which were due to traumatic encephalitis after fracture of the base of the skull. movable at a height above that of the upper border of tlie bone on the other side. Sometimes the bulging of the synovial effusion into the depression can be made out. Treatment. — The foot and leg are to be placed on a straight splint properly padded. It used to be considered essential to raise the foot in order to relax the extensor muscle. But this is now regarded as a matter of little moment, for it has been noticed that after the direct results of the injury have subsided the quadriceps muscle is not contracted, but, 1 See Fig. 121 in text ; also Packard's Malgaigne, p. 602. 308 INJURIES OF THE LOWER EXTREMITY. on the contrary, quite flaccid and inactive;^ and it has been found on trial tliat the results of treatment in the horizontal position of the limb are not inferior to those obtained in the raised position.- Still, I am not aware tiiat there is any valid objection to the raised position of the foot on a comfortal)le a()pai'atus. I have often questioned patients so treated, who have complained of no inconvenience; but if they do find the posi- tion disafi^reeable I see no use in insisting upon it. The main point is to keep the limb extended and fixed in that position. The next point is to endeavor to bringdown the upper fragment and keep it as near the lower as possil)le. This is often very f"'«- 1-'''- difficult, from the persistence of effusion in the joint, and from the slight hold whicli can be got on the fragment. I liave often emploj'ed Malgaigne's hooks, and have not experienced any bad effects from them. At the same time cases have been recorded in which sup- puration has followed, and even Malgaigne's hooks for fractured patella. The onC, I belicVC, in wllich it extended hooks are fixed either into the skin and fibrous jnto the joint, necessitating ampu- tissue above and below the fragments, or into ^^^^^^^ gut SUch ill COnsequeuCCS plaster firmly applied in these situations, and the • i. upper pair are then gradually approximated to the are SO rare aS nOt tO Constitute, tO lower by means of the key and screw. niy mind, aU}' Valid objection tO the careful use of the hooks. I have found, however, that the,y have a uniform tendency to displace the lower edge of the upper fragment upwards, so as to render the space between the two fragments V-shaped, the angle backwards. Very close and useful union may, however, often be obtained l\y their means. It is desirable not to apply them till all active efiusion has subsided, but it is not necessary to wait for the entire removal of passive effusion. An- other plan — suggested, I believe, by Mr. Callender — which I have found useful, is to hitch under the upper edge of the upper fragment a bandage or strapping, to which a weight is attached, over a pulley at the end of the bed, so as to draw the upper fragment continuously and gentl}' down- wards. Numerous other plans have been introduceil, but they nia}' all, I think, be comprised under one or other of these heads, viz.: (1) to trust to nature, assisted or not by the raised position of the limb, to hring the fragments as near as is possible on the subsidence of the effusion ; (2) to drag the upper fragment downwards by hooks fixed in the fil»rous tissue above it; and ('.i) to draw it downwards by tlie traction of bandages or strapping applied to the skin over its upper end. Union. — The unif)n of the ordinary transverse fracture of tiie patella, in wllich the fragments have been separated at the time of the accident by a considerable interval, is always (as far as has been proved hitherto) by ligament, when it unites at all. It is true, that many preparations of bony union exist and others are found, as shown irj Fig. 124, where the union appears bony externally, but a section is found to be partly or entirely fibrous. But there is no proof that in such cases the fragments have ever been separated ; and, in fact, from the traces of inflammation always found in such fractures (as evidenced by the great thickening of the bone), it seeras more probable a priori that they have been injuries due ' Hutchinson, op. cit., p .380. ' Bloxam, inSt. Barth. Hosp Hop., vol. iii, p. 38(j. FRACTURES OF PATELLA. 309 Union of fracture of the patella with hardly to direct violence, as in Fig. 121, above. No history has yet been put on record proving that the displacement in transverse fracture of the patella has ever been so effectually corrected as to admit of bon}' union. The cause of this want of bony union is evi- dently the separation of the frag- ments, and when that separation has been very extensive, it is common enough for the fragments to be en- tirely ununited. The length of treatment must be regulated by the consideration of the state of parts. We must not on the one hand keep the knee stiff for so long a time as to risk permanent an- chylosis, nor on the other allow move- ment so early as to endanger the yielding of the ligamentous union. When the uniting ligament is short and strong, the knee is very useful indeed ; and it is doubtful, whether bony union, accompanied as it gene- rally is by much inflammation, is any separation of the fragments The latter really better for the l)atient than a are enormously enlarged in all their dimen- firm fibrous union sions, and their tissue much denser than nat- . Ill • i 1 ural. The interspace between them is filled Asa general rule, the patient ought ^nh dense fibrous tissue, and is not more than to be kept in bed for six weeks, and one-third of an inch in extent. During life for at least six weeks more he should ^'>« ""'^'^ ^""^"^ ''^''^ ^'^^'"'^'^ hony.-Krom a , ii 1- 1 • !• ^ I • I -11 preparation in the Museum of St. George's keep the limb in a splint which will '^^^pj^^i ^^^ i ^^_ ,9e j^^,,,;,,^ j^ ^^J^^^ not allow of an}' bending, after which about the case beyond the fact that the man he may use the leg cautiously with a ^as in St. George's Hospital with fractured pa- laced bandage having an aperture in teiia many years before his death. front to receive the patella. The fracture is often reproduced by accidental rupture of the uniting ligament, and persons wlio have fractured one patella are liable to frac- ture the other. I have even seen two or three cases where the patella has been broken a second time in a diflierent place, the uniting medium of the old fracture remaining firm. Direct Vertical or Y-ahaped Fractures. — The fracture wiiich is purely the result of direct violence is sometimes star-shaped (or Y-shaped) or comminuted, at other times a mere longitudinal crack running more or less vertically. Tne ligamentum patellae is generally untorn, and in fact the fracture often does not correspond on the two faces of the bone, so that no separation of the fragments is i)ossible. There can, therefore, be no doubt that such fractures are susceptible of bony union, and prepara- tions of such bon\' union exist in the College of Surgeons' and other museums. At the same time the inflammation caused by the injury is doubtless more deleterious to the motion of the joint than the ligamentous nature of tiie union in transverse fracture, allowing that in the latter case the bond of union is short. Compound fracture of the patella is a rare and a very grave accident^ usually accompanied by other injuries to the articulation, wiiich necessi- tate amputation, but occasionally occurring alone, and then allowing the chance of saving the limb. The principles on which the surgeon must 310 INJURIES OF THE LOWER EXTREMITY. be ofiiided in his choice, whether to save the limb entirely oi* to excise the joint, or to amputate, are the same in this as in other injuries of the knee. If the limb is to be savetl all foreign bodies or fragments of bone should be removed, the wound carefully closed and treated in the manner which Flo. 126. f^ Fig. 125.— a patella, showing a vertical fracture running from the base to the apex of the bone, so as to divide it into nearly equal halves. The fracture is joined above by a small oblique fissure (" Y- shaped fracture"), which, however, is not visible on the cartilage. On looking at the cartilaginous surface the principal fracture is seen to extend through the cartilage into the joint at the lower part only, and when traced upwards on this aspect is found to break up into two principal and numerous smaller fissure.-«, which have uo correspondence with the fracture of the bone. The patient, a young woman, had thrown herself out of a third-floor window, in a fit of insanity, and died on the following day.— St. George's Hospital Museum, Ser. i, No. 187. Fig. 126.— Internal view of an oblique fracture of the patella, extending downwards from near the base to the apex of the bone. The articular cartilage is also cracked transversely.- St. George's Hos- pital Museum, Ser. i. No. 186. is believed most likely to guard against subsequent inflammation ; in fact, treated like a simple wound of the joint (see page 289).^ Fracture of the leg is perhaps the most common accident which is met with in our hospitals, since most of the other common fractures are treated at the patient's own house. It occurs mostly in adult life, chil- dren being comparatively rarely the subjects of this injur}' ; and as a general rule, when the fracture is simple, the patient recovers with no permanent disablement, though to this rule there are unfortunately nu- merous exceptions. The fracture usually occurs at the junction of the middle and lower thirds of the leg, and botii bones are usually broken, the fibula often at a higher level than the til)ia; the lower fragment is generally displaced backwards, as tiiough drawn by the gastrocnemius, so that its upper end projects under the skin, and sometimes punctures or perforates it. The displacement varies chiefiy with the direction of the fracture through the tibia ; when this is nearly or truly transverse there is often little or no displacement ; when the fracture runs from the front of the bone oblicpiely downwards, the upper end of the lower fragment may be displaced he- hind the l(;wer end of the upper ; but generally the obliquity is in the reverse direction, or the fracture is comminuted, and then the displace- ment is as described above, combined very probably with some rotation of the lower fragment outwards. " Out of nineteen specimens of united ' See Poland, in Med.-Chir. Trans., vol. liii, p. 49. FRACTURES OF THE FIBULA. 311 fracture of the leg," examined by Mr. 81iaw, " sixteen had the lower frag- ment rotated outwardly, and situated somewhat to the outer side and he- hind the upper." ' There is hardly ever any difficulty in the diagnosis. The cause should engage some attention. Generally the fracture is the result of indirect violence, as in falls on the feet. But it may be caused by a blow or kick on the part itself, which is of course accompanied by more bruising of the soft parts. The treatment is very simple in ordinary cases. The bones being sedulously brought into exact apposition, are to be kept so for about eight weeks, when the i)atient may be allowed to use the leg, with merely the support of a bandage. The apparatus for maintaining the bones in apposition are very numerous. It is usual in hospital prac- tice to apply side-splints, i. f?., two thin pieces of board, properly padded, cut somewhat to the shape of tiie side of the leg, and provided with a footpiece. These are kept on with straps and bandages, care being taken to see that the heel is well padded, so that the skin is not cut by the bandage, and to see that the foot is at riglit angles, otherwise the upper end of the lower fragment might be again displaced forward. The pa- tient is then kept in bed for four weeks, after which the limb is encircled in pasteboard or leather splints for the other four weeks, and he is allowed to move about on crutches with the foot slung from the neck. But it is very common, particular!}' in the case of persons whose business renders it important for them not to be confined to bed, to put up the fracture in a pasteboard, plaster of Paris, or other case at once, if there is no bruising, or else as soon as the bruising has subsided ; and the practice is a safe one, if care is taken in applying the bandage at first, and reasonable pre- cautions observed afterwards to guard against subsequent swelling. I have never myself seen any ill consequences. Yet, as the practice cer- tainly involves some risk, in consequence of the withdrawal of the seat of fracture from the surgeon's observation, it ma}' be well to explain this to the patient, and obtain his consent.^ In fractures with much bruising, or comminution, or displacement, one of the plans recommended below for the treatment of compound fractures may be employed. Fractures of the tibia alone are much less common, since the force required to break this bone generally fractures the fibula also, and they are usually the result of direct force. There is little, often no displace- ment, since the fibula acts as a kind of splint and prevents the separation of the ends. They must be treated in the same way as fractures of both bones, and are peculiarly appropriate for putting up in a case directly after the accident, provided the state of the soft parts permits it. Fractures of the fibula alone are very common, the usual cause being indirect violence, as a false step, or slipping off the pavement, or falling with the foot jammed. The bone is generally fractured near the junction of the lower and middle third, though, especially when the cause is a direct blow, any part may be broken. The diagnosis is not alvvay easy, for there is often no displacement, and the patient can in rare cases even 1 Path. Soc. Trans., vol. ii, p. 125. ^ A case was reported some years ago in which a surgeon put up a fracture of the leg (in a j'oung child) in a plaster case imiiu'diately after the accident, and allowed the parents to take the child home. The parts swelled, and the little patient became uneasy. The parents brought the child back to the surgeon. Ho was in too great a hurry at the time to make the proper examination by removing the apparatus. The whole skin sloughed, amputation had to be performed, and the surgeon was justly cast in damasres. 312 INJURIES OF THE LOWER EXTREMITY. walk.' Whenever a patient is totally or almost entirely unable to walk, and complains of fixed pain referred to a certain spot in the libula on active or i)assive motion, fracture may be suspected. The best plan to detect it is to rotate the foot, keeping the fingers of one iiand on the suspected i)art; or to press alternatel}^ on both sides of the supposed fracture. The existence of the fracture will be proved .either by crepitus or by the fact that tlie upper part of the bone does not share the motion impressed on the lower fragment. If the surgeon remains in doubt whether the injury is a fracture or a severe sprain, he should treat it as fracture. When deformity exists there is no diflficnlty of diagnosis. The deformity consists in eversion or abduction of the foot, winch is ascribed by Malgaigne and others to efforts made l\v llie patient to walk, in which the foot, having lost the guard afforded by the external malleolus, is necessarily turned outwards. It is to remedy this displacement that the various formal plans of treatment are designed. Usually nothing is re- quired beyond side-splints, or a case of pasteboard or plaster, since the displacement is easily remedied and there is nothing to reproduce it. The fracture should be kept in apposition for six weeks. The plans wliich are intended to act decidedly on the displacement are: 1. Pott's method — the patient being placed on the injured side, with the knee bent to relax the gastrocnemius muscle, the foot inverted, a splint applied to the inside of the leg, not reaching the foot, and a side-splint with a foot- piece to the other side of the leg and foot, the footpiece being more thickly padded than the leg, so as to turn the foot inwards. 2. Dupuy- tren's method, in which a straight splint is applied to the inside of the leg, reaching several inches below the foot ; a wide shaped pad is applied, with its broad end downwards, corresponding to the internal malleolus. The foot and leg arc bandaged to the splint, and by making the pad of sufficient thickness any amount of inversion of the foot which is judged necessary to disengage the lower fragment (which is supposed to be locked in or turned towards the tibia) can be secured. Pott's fracture, or fracture of the fibula complicated with dislocation of the ankle, will be found treated of under the latter heading. Compound Fractures. — When fractures of the leg are compound the injury becomes much graver, and the treatment a matter of more anxiety. Many such fractures prove fatal in the practice of civil life from pyaemia or diffuse inflammation, and in military surgery they are still more fatal. The cause of the accident has much infiuence on the progress of the case. When, as often happens, the fracture was originally simple, but the patient in trying to move has pushed one fragment (generally tlie upper) through tiie skin, there is little or no laceration of the soft parts beyond the mere skin-wound, and there is generally no difficulty in getting the bones back into position witli, or even without, a slight division of the skin, which sometimes tightly gras|)s tlie protruding fragment. But when the bones have been crushed by a heavy body passing over or striking the limb, and this force has at the same time carried the lower end of the leg backwary sloughing; but this is not always the case, and Dr. Simon, of Rostock, has recorded some instances of primary union after such injuries;' and this possibility of primary union has been probably increased by the introduction of the modern " arms of precision," which project their bullets at a greatly in- creased speed, so as to cut tlirough the tissues more like a knife (a result to which the conical shape of the bullets also contributes), instead of tearing and contusing them, as the old bullets alwaj's did, since these latter rapidly lost their velocity as they traversed the tissues. But as respects the fatality of gunshot injuries any slight diminution in the ten- dency to sloughing in tlie track of the wound which may be occasioned by the use of rifled arms is far more than counterbalanced by the great increase offeree acquired by the projectiles used in modern warfare. It is not only that their great speed enal>les them to pass through the body of one man after another when standing in a mass — a result to which their lower trajectory also much contributes, and therefore that they cause many more wounds in proportion to the number of bullets discharged — but also the wounds inflicted on each individual are more grave. For the old round bullets used to be constantly deflected by the edge of a bone, a tense fascia, a muscle suddenly starling into action, and thus the sub- jacent viscera often escaped, so that a ball might enter at the front of the chest and pass out at the back, and yet the track might be entirely out- side of tiie ril)s. No such ol)stacles avail to check or turn aside the course of tiie newly invented rif]e-l)alls ; the bones are shattered, and their fragments are the source of complicated misciiief ; the viscera far more rarely escape, and the l)ullet often i)asses thrcnigli a limb thrown in front of the body into the trunk, or vice, versa. The old distinction also which ' NewSyd. Soc. Bienniul Kotrospeet, 1807-8, p. ;!25. Deutsclic Klinik, 1867, p. 261. SYMPTOMS OF GUNSHOT WOUNDS. 335 used to be made between Llie wounds of entrance and exit is inapplica- ble in those made by such projectiles at their full speed. Bullets which are moving at moderate speed are so checked and slackened as they pass through the tissues that when tliey emerge they tear and turn outwards the parts through which they pass. The entrance-wound is comparatively small, and either flat or inverted ; the exit-wound is much larger, more lacerated, and its lips everted. Wind Contusions. — There are gunshot injuries which are unaccom- panied b}' any skin wound. These used to be called " wind contusions," and were supposed to depend on the mere windage of tlie ball, but now they are referred to oblique impact, since it has been al>undantly shown that balls may pass so close to the body as to cut the clothes without producing any injury, provided tiiey do not touch. These gunshot con- tusions are often very grave injuries, for though the skin is not broken the muscles and other deep parts may be so disintegrated that traumatic gangrene speedily follows. Gunshot wounds are often complicated b}' the lodgment of the bullet, or of a fragment of it, or of pieces of the clothes or articles which the patient has had about him, or foreign substances from without, or even of portions of a comrade's body. Lodged bullets may travel to a considerable distance without any obvious 83'mptoms, or the}' may remain quietly imbedded, or encysted, though in the latter case if in tlie neighborhood of important and sensitive organs (such as a nerve), any slight movement or attack of inflammation may renew the painful symptoms first produced bj' the injury. Wounds from cannon-balls and from fragments of shells often produce the most extensive and ghastly mutilations. Examination of the Wound. — A common gunshot wound is divided into the wound of entrance, the track, and the wound of exit. Sometimes the bullet splits, and there is more than one wound of exit, or a portion may lodge whilst the rest passes out. From this circumstance, and from the much more common lodgment of foreign bodies, it is always necessary to examine the wound, whether there be an orifice of exit or not. This is best done with the finger, if the size of the wound permits its introduc- tion ; otherwise a probe must be used proportioned to the length of the wound. Balls and foreign l)odies are as a rule to be removed at once, unless in the judgment of the surgeon the operation for their extraction would cause greater mischief than the symptoms they might occasion if left behind could do. The symptoms of gunshot wounds are of course as various as their situa- tion and extent, but some general remarks may be made on the shock, the pain, and tlie hsemorrliage whicli are immediatel}' caused by them. The shock depends a good deal on the state of the patient's mind, and on his nervous constitution as well as on the part injured. Thus, though sliock is usually and doubtless correctly enumerated among the symp- toms of a gunshot wound of tlie lung, yet cases occur where the lung has been perforated without any marked collapse, and again others in which the most severe shock has accompanied a small flesh wound. The pain, again, is very variable, and often in the heat of a battle is perfectly unnoticed ; so that a patient is brought in as suftering from a single wound, in whom, on examination, a second wound is found of which he has been quite unconscious. The pain is often referred to the extremity of a nerve which has been injured at some remote part of its course. Thus, Professor Longmore relates the case of an officer who supposed the upper part of his arm had been smashed, and ran to shelter supporting the limb, which he believed 336 GUNSHOT WOUNDS, was broken. On examination the wound was found to be confined to the neck, and the sensations were due to injury of the brachial plexus.' Hiemorrhage is not a prominent feature of gunshot wounds. The main ves- sels very often escape injury altogether, even in wounds directly leading down to their course, and when they are hit they are usually so contused and lacerated that they do not bleed. But to this there are of course many exceptions, and there is an impression (which has never been brought to proof) that death on the field of battle very frequently occurs from wounds of the large vessels of the thorax. When a limb is torn off", whether by cannon-shot or otherwise, the main artery is generally seen pulsating up to the point at which it has been torn, and often hanging beyond the surface of the wound, exactly in the same way as when it is drawn out of a stump and twisted. Treatment. — In the treatment of gunshot wounds the first thing is to get the patient as soon as possible into a place of security. If he is in a state of syncope it may be proper to give a little stimulant at once. Some extemporized support should be arranged for a fractured limb; wounded arteries should be compressed or tied, if they are exposed, or possibly a tourjiiquet may be adjusted. When all this is arranged he is to be removed to the place where the definite treatment is to be under- taken, and then a thorough examination is made, the object of that ex- amination being '^ (1) a correct knowledge of the nature and extent of the wound, (2) removal of any foreign bodies which may have lodged, (3; adjustment of lacerated structures, and (4) application of the pri- mary dressings" (Longmore). The examination is most easily made immediately after the injury, since then sensibility is numbed, and there is less swelling. The patient should if possible be put in the attitude in which he was when he received the wound, as this will often give valua- ble hints as to the possible course and place of lodgment of the ball; his clothes should be carefully inspected, in order to see whether any pieces have been carried in with the l)ullet, and the track should be attentively examined for fragments of the clothes, the bullet, splinters from it or from the bones, and any other foreign substances. No search, however, should be made in wounds penetrating the great cavities of the body. The skin is only to l)e divided when such division is necessary in order to extract bullets or fragments of siiell (of which very large pieces some- times pass in through a comparatively small wound), or to tie vessels or replace herniated viscera. The old plan of enlarging the orifices of gun- shot wounds to obviate retention of matter is (juite given up. The detection of a l)ullet or lodged foreign body is by no means eas}'. P^ragments of clothes can hardly be detected by any other means than tlie linger; but very important questions sometimes occur (as in the cele- Fic. 147. Nfclaton's probe. The bulb iit the eiidix of white china. bratcd case of Garibaldi) witii reference to the detection of bullets. It is for such cases as these that tiie various instruments enumerated by Mr. Longmore* have been invented : Neiaton's test-probe, in wiiich a small knob of biscuit-china is |)repare(l for taking an impression of lead or 1 Syat. of Surg., '^d cd , vol. ii, p. 136. » lb., p. 146. TREATMENT OF GUNSHOT WOUNDS. 337 rust, on being rubbed against a leaden or iron projectile ; Lecompte's " stilet-pince," in which an arrangement exists for nipping oft" and bring- ing away a minute fragment of the foreign body; and the electric indica- tors of Rhumkorf and De Wilde, in which contact with metal at the bottom of a wound is indicated by the ringing of a bell. I believe I should be right in saying that none of these contrivances have been proved to be of undoubted utility.' For the extraction of lodged bullets numerous contrivances have been invented. That which seems most in favor with military surgeons is Coxeter's extractor. Forceps are also contrived the blades of which can Fig. 148. Coxeter's extractor. be introduced separate and then connected together, as midwifery forceps are, while in the wound. Parts torn by gunshot wounds are only to be replaced as far as may be necessary to prevent subsequent deformity in cicatrization ; for since pri- mary union is not to be expected, it is useless to be very exact in their adjustment; and the dressings should be as light and cool as possible, so as to moderate and allow for the swelling which will ensue. As suppu- ration comes on the openings must be kept free. Gentle syringing with tepid water or weak astringent lotions is well spoken of by Mr. Longmore, as keeping the discharge free and removing any torn fibres of cloth which may have stuck inside the wound. Free incisions must be practiced when the swollen condition of the parts or the bagging of matter requires it, and the strictest attention must be given to keep the wounds clean, and in hot weather or tropical climates to keep them free from flies, which are not only in such circumstances dreadfully annoying, but also appear often to act as carriers of contagion. The constitutional treatment should be simple and supporting. Iron, both internally and as a lotion, often seems very us'eful. The wound heals gradually after the separation of the sloughs from its track ; and during this separation secondary hemorrhage may occur, and is the more to be apprehended the nearer the ball has gone to the known course of a large vessel. It may sometimes be advisable under such circumstances to leave a tourniquet, loosely applied, in charge of the attendant, with instructions to screw it down if the vessel should begin to bleed. If 1 With regard to the use of N^laton's probe, since much stress is sometimes laid on using it — and in a late trial at Dublin the surgeon was severely censured for not hav- ing done so— it mny he right for me to record an error into which I was led by trust- ing to it. A man was admitted into St. George's Hospital under my care in whom the bullet of a small j.istol had passed into the foot from above. A small \youndover one of the mi'tatarsal bimes exposed some smooth, hard body. The question in this, as in Garibaldi's case, was whether this was the edge of the bone or the bullet. To settle this we employed Nelaton's probe. This probe was used in my ab.sence by two gentlemen on whose accuracy I relied, and who assured me that the metallic film which it brought away was quite distinct, and this I believe to have been the case. On repeating the experiment we could not find any such film. I then cut down and exan)ined the parts, when it turned out that there was no bullet there. It had passed down into the soft tissues of the sole. I have no doubt that in this case the bullet had If-ft a streak of lead on the bone, which stained the probe and thus led to the error. 22 338 GUNSHOT WOUNDS haemorrhage occurs, no time should be lost in cutting down on the artery and tying it above and below, if the state of the parts admits. Should it be impossible to lind the artery, or should it be so disorganized as not to bear a ligature, tlie choice lies between compression in the wound, tN'ing the trunk artery above, or amputation. The surgeon would incline to tlie first alternative in all ordinary circumstances ; but if local pressure carefully made has fiiiled, and if tlie haemorrhage is urgent, the second alternative, that of tj'ing the main arterj- at a higher point, may be adopted in the upper extremity in almost all circumstances, and in the lower where gangrene does not seem imminent. In other cases it would be better to remove the limb. A few points must be noticed in the surgery of gunshot wounds in each region of the body in which their prognosis, diagnosis, or treatment dirters in some respects from that of the ordinary injuries of civil life. GunsJiot icoundi^ of the head are always to be looked on with grave ap- prehension. Even simple contusions may be accompanied by fatal injur}' to the brain, and many histories are on record showing the rapidly fatal result of drinking or excitement after injuries which had not been known to involve any deeper mischief than a mere bruise or a small contused wound on the head. Such is the case quoted by Longmore, from the surgical history of the Crimean campaign, of a man who was sent home from the Crimea after a superficial wound of the head, and in whom, after a drinking bout, coma supervened, and he died shortly afterwards. "Post- mortem examination showed traces of inflammatory action in the dura mater, and just anterior and superior to the corpora quadrigemina was a tumor the size of a walnut composed of organized fibrin and some clotted blood." In this case the existence of some mischief w^as sus- pected in consequence of persistent headache, on account of wliich the man was invalided ; but a similar result has been known to take place without any symptom having been observed. The same liabilitj^ to re- mote and unapparent injur}' of the brain and other parts renders all gun- shot wounds of the skull more serious than similar injuries are in civil life. Thus fracture or fissure may extend far be3'ond the part struck, or the internal table maybe fissured and driven in with little or no apparent injury to the external, or the meningeal vessels or the brain itself may be lacerated. Fractures with depression are usually fatal unless the de- pression is very slight, since the braiu is generally injured. And pene- trating wounds of the brain are still more certainly fatal. Out of eigiity- six cases recorded in the history of the Crimean war none survived. Never- theless tliere are instances of recovery in which either the ball has passed out again or has become encysted in the brain, though in the latter instance it may set up secondary inflammation at any subsequent period. The treatment is to be conducted on the same general rules as in other injuries of the head. In men previously in strong health both the general and local treatment should be strictly antiphlogistic. Venesection is of the greatest service in such cases, and the constant application of cold to the iiead, strict rest in a darkened room, and low diet, are also undeni- ably requisite. Trephining should, as a general rule, be avoided; at least this seems the opinion of the most experienced militar}' surgeons. Professor Longmore speaks as follows on this head: "Two or three instances are known in wiiieli the course of a ball has been traced from the site of entrance across tlie brain, and trei)hining resorted to for its extraction with success ; but there are also many others in which the mere oj)erati(ui of the extraction of a foreign body has apparently led to the immediate occurrence of fatal results. Moreover, splinters of bone OF THE SPINE. 339 are not un frequently carried into the brain by balls, and these may elude observation ; or the ball itself may be divided and enter tlie brain in different directions, as was observed in the Crimea, when the operation of trephining can only be an additional complication to the original injury, without any probable advantage. Where irregular edges, points, or pieces of bone are forced down and penetrate — not merely press upon — the cerebral substance, or where abscess manifestly exists in any known site, or a foreign substance has lodged near the surface, and relief cannot be afforded b}' the wound, trephining may be resorted to for the purpose; but the application of the operation, even in these cases, will be very much limited if certainty of diagnosis be insisted upon. In all otlier cases it seems now generally admitted that much harm will be avoided, and benefit more probably effected, by employing long-continued constitutional treatment, viz., all the means necessary for controlling and preventing the diffusion of inflammation over the surface of the brain and its membranes — the most careful regimen, ver_v spare diet, strict rest, calomel and antimonials, occasional purgatives, cold application locally, so applied as to exclude the air from the wound, and free deple- tion by venesection, in case of inflammatory symptoms arising. Similar remarks will apply in case of lodgment of a projectile within the brain. If the site of its lodgment is obvious, it should be removed with as little disturbance as possible, but trephining for its extraction on simple infer- ence is unwarrantable." Gunshot icounds of the spine are usually complicated with injury ol other parts, and the mischief to the column and cord is extensive and probal)ly fatal. Little can, therefore, be done in most cases. There are, however, instances of the impaction of a bullet in or near the larainre in which much good has been done by cutting down and extracting it, so that in any case where there is reasonable ground for suspecting that the bullet has lodged in an accessible situation, it is justifiable to cut down and ascertain whether this is the case; and if the bullet can be felt im- pacted near the spinous process or laminae, its extraction should un- doubtedly be attempted. A case occurred some years ago in London in which Mr. Canton suc- ceeded in removing a bullet which was lodged in the upper part of the spinal column, and the patient recovered.^ The case which recently occurred in Dublin is also well known, in which Mr. W. Stokes made an attempt to extract a bullet which was lodged in tiie atlas. '^ The man died, and the treatment was blamed, but most unjustly, as there is no doubt that such an attempt should be made whenever there aie no special counter-indications. Gunshot wounds of the face are more distressing and horrible than dangerous, that is, if they are limited to the face. Large parts of the features may be shot away and yet the patient survive. But they are 1 The Lancet, July, 1861. In this case (the details of which are of a most interest- ing nature) the bullet had been fired from a very short distance, and struck against the spinous process, or some part of the arch, of one of the highest cervical verlel)rae. The wounded man felt a momentary shock, and thought himself y)aralyzed ; but on being again shot by his assailant in the face, and lo.^ing. a good deal of blood, his powers of motion returned, and that to so vigorous a degree that he was able to carry out successfully a dreadful and protracted struggle for his life, which ended in the death of his assailant, from repeated blows on the head. A portion of bone ex- foliated from the injured vertebrae; but the man recovered completely. 2 Brit. Med. Jour., 1871, vol. ii, p. 716. 340 GUNSHOT WOUNDS liable to be complicated with injury to the skull, pharynx, lar3mx, or large vessels, which may easily cause death ; and there are often very distressing though not fatal consequences from lesions of the eyes or of nerves, ducts, etc. These wounds are also peculiarly liable to secondary haemorrhage. It is to be noted, however, that much may be done in the way of saving deformity by replacing parts, even if the whole of the part replaced may not preserve its vitality, so that chloroform should be administered, the torn parts replaced, trimmed up if tliey are lacerated beyond all hope of union, and sewn together as neatly as is possible. In gunshot wounds of the neck the large vessels often escape injury, otherwise the case terminates fatally at once. When the cesophagus is injured nothing can be done beyond supporting the patient with nutrient enemata, and when this is no longer possible endeavoring to convey food into the stomach through the wound till the latter has contracted suf- ficiently to allow a tube to be passed from the mouth. In wounds of the trachea the opportunity of performing tracheotomy below the wound is sometimes, though rarely, obtained. li\ however, the trachea is wounded, but there are no indications of portions of cartilage or foreign bodies being in the trachea, and the patient breathes easily, it is better to let him alone. The great nerves at the root of the neck may be wounded or contused — and I have already alluded to a case of wound of the brachial plexus — but little can be done in the way of treatment. The reader is referred to the section on Injuries of Nerves. Gunshot wounds of the chest are divided into penetrating and non-pene- trating, the latter being those in which the serous membranes (pleurre or pericardium) are not opened, and the former where the}' are. Again, in penetrating wounds, tlie contained viscera may be injured or may not. Non-penetrating wounds present few peculiarities. It may be noted that, when the ribs are fractured, such fractures are more comminuted than in the injuries of civil life, and that the fragments may wound vessels or be driven into the lung even when the bullet itself has not penetrated. And it should also be remembered that without penetration, and even without any fracture of the ribs, the lung may be more or less bruised or lacerated. JHagnosis of Wound of the Lung. — In penetrating wounds the chief point is to decide whether or not the lung \\r>, been injured. The symp- toms of injury of the lung are shock, haemorrhage from the wound, hfemo- thorax, h8emopt3'sis, dyspnoja, traumatopnoea, and emphysema. These symptoms are of different value in proving the point, and any of them may be present in cases where the lung is not wounded, and absent in. cases where it is, so that it may be said that there is no one symptom which is absolutely pathognomonic. Yet the presence of all of them, or of the great majority, or of the leading symptoms in a very high degree, renders it extremely probable that the lung is wounded, and justifies the surgeon in that diagnosis. Shock is a very variable symptom. Jt is frequently present to a great extent in cases where no serious mischief has been done, and it has been often found aljsent where the lungs have been perforated. Its presence could, thei'efore, only strengthen a diagnosis which has been formed upon more relialile symptoms. External haemorrhage from the wound, if abundant, and if there is no large vessel near in the parietes (and there is rarely any such vessel), must come either from tlie lung or from an intercostal or internal mam- OF THE CHEST. 341 raary artery within tlie chest. The direction of the wound, and the result of introducing a small spatula or piece of card (if it can be done without risk) into the inside of tlie parietes, will enable the surgeon to form an opinion as to which of these two is the source of the bleeding. Still, by itself, external haemorrhage is only one of the minor diagnostic symptoms of wounded lung. Hivmothorax^ if considerable, usually comes either from the substance or the root of the lung; in the latter case it is almost certainly fatal, and in the former very often is so. Still a good deal of blood may pass into the pleura from a wound of the intercostal arteries without wound of the lung, so that hpemothorax also is not an infallible symptom. Hfemopfi/His may occur from mere bruising of the lung without any absolute penetration, and therefore does not by itself prove even that the wound has opened the chest. But if haemoptysis is very copious it renders it very probable that the lung has been wounded ; and this is converted almost into a certaint}' if the blood is churned up together with air into an abundant pink froth, and especially if a similar pink froth escapes from the wound. Dyspnoea is a very variable sign, and depends in a great measure on the patient's previous condition and other circumstances which it is hardly possible to enumerate ; and it is often present in mere wounds of the parietes. Traumatopnoea^ or the passage of air out of the wound, is possible with- out an}' wound of the lung; for the pleura having been laid open, the air may pass in through the wound as the parietes recede from the lung in inspiration, and then be forced out again as they descend in expiration. It is, however, a sj'mptom which must always excite the surgeon's suspi- cion; and it proves, at any rate, that the wound is a penetrating one. Emphyiagate and extend its use. * It is a.s.sumed that the u.sual rules of practice have been carried out and foreign bodies if possible removed. OF THE EXTREMITIES. 345 be removed by excision ; and the extension of fissures into tlie shaft of the humerus, or into the bones of the forearm, does not greatly prejudice tlie chances of the patient's recovery, though in tlie case of the shoulder the frequent injuries to the scapula or axillary vessels and nerves is certainly a formidable complication. When, however, along with grave Fig. 150. A and B show the head of a humerus which has been strurtk by a round ball in nearly the identical spot at which the specimen represented in Fig. 149 had been struck. The round ball, like the conoidal, has also entered to a distance corresponding with its own depth, its surface being on a level with that of the surrounding bone. Although the head of the bone has been greatly shattered, as shown in A, the rending asunder, or splintering, is very limited ; and the saw, in resecting the injured head, has passed through the shaft (see c) without crossing a single fissure, and this notwithstanding the opera- tion has been performed somewhat nearer to the neck of the bone than in the preceding instance. The figures represent two preparations, Nos. 2926 b and 2926 D, in the Museum of the Royal College of Surgeons, and are taken from Syst. of Surg., 2d edit., vol. ii, pp. 123, 124. injuries to the soft parts, or with comminuted fracture, the main vessels or nerves or both are wounded, it is usually more prudent to amputate. Yet even in some cases of wound of the main artery in the upper ex- tremity complicated with fracture, if free from other complications, and in a young and healthy subject, the attempt to save the limb may be made. II. In the lower extremity gunshot fractures involving the hip-joint or the upper third of the femur are usually fatal, however treated. Primary amputation is so fatal in these cases that it is almost abandoned. Several cases have recovered under strictly conservative treatment ; a few cases of successful excision are on record ; and secondary amputation has been decidedly more successful than primary.* The surgeon must use his own discretion in each case, but all surgeons nowadays have a well-founded 1 M. Jules Koux, of the S. Mandrier Hospital, at Toulon, has given a list of no less than twenty-one cases of recovery without amputation after gunshot injuries of the upper third of the femur among the soldiers whom he examined on their return from the Italian war of 1859. Longmore, op cit., p. '22Q. For a comparison between primary and secondary amputation at the hip-joint in military surgery see pp. 228-9 of the same essay. .346 GUNSHOT WOUNDS OF THE EXTREMITIES. horror of primary ami)utation at the hip, believing that the operation is almost necessarily fatal, wliile the injury is not so. In gunshot fracture of the lower part of the femur amputation is the rule. Cases have also been treated, when free from other complications, on the conservative method, all comminuted portions being removed, and the parts put up in the best apparatus which circumstances permitted the surgeon to make ; but it seems the opinion of the most experienced mili- tary surgeons that in the general run of cases amputation is the best course, though in special instances the attempt to save the limb may justifialily be made. When a bullet lodges in the knee-joint, or passes through the joint, splintering the bones yet not producing any further discoverable lesion, excision may be resorted to. But hitherto it must be admitted that the attempt has led to disappointment, or in plainer terms to loss of life,^ and that amputation is a far safer practice. In the rare cases of such accidents occurring in civil life at an early age, and with all the necessary appliances for undisturbed treatment, it may be justifiable (though it is certainly rather doubtful practice) to risk excision; but in common mili- tary practice no doubt can be entertained that until we possess some more successful method of practicing excision the surgeon's duty is to amputate. There are, however, cases in which the surgeon may very reasonably attempt the entire preservation of the limb, giving exit to matter and loose fragments as they present. Langenbeck believes, and I have no doubt with good reason, that the success of such attempts would be much favored by putting up the limb at once in a well-fitting case of plaster of Paris. In gunshot injuries of the leg the limb may often be saved, and in many of these cases the resection of the comminuted bones, and possibly of the portion of the shaft around them, may be advisable. The same observations apply to those injuries in which the ankle has been laid open. In such cases the removal of comminuted portions of bone is often spoken of as an " excision of the ankle," and if the term be admitted the operation may be said to be a successful one. Langenbeck is the chief authority in recommending excision of the ankle in military surgery, having operated five times in the Schleswig-Holstein war of 1864, and eleven times in the Austro-Prussian war of ISBB, with thirteen successes and three deaths. In all the cases the periosteum was preserved as far as possil)le, and the limb put up in a plaster of Paris splint at once. But the operation differs from the ordinary excision of the ankle for disease in this vei'y important particular, that the bones of the foot are not dis- eased and are usually untouched, and that the patient, instead of being a sufferer from chronic disease, is usually healthy. The success of the excision of bones of the leg (called excision of the ankle) for gunshot injury, even if we allow that it has been real — i. e., that the same success could not have been attained witiiout operation — does not bear on the question of excisions of tlie ankle for disease. For wounds of the nerves of tiie limbs I must refer the reader to a sub- sequent chapter, in which the affections of nerves are treated. ' In the American Burgeon-General's report it is stated that out of eleven resec- tions of the knee all but two terminated fatally, aad a doubt is expressed of the reality of recovery in one of the remaining two. TUMORS CLASSIFICATION. 34- CHAPTER XVII. TUMORS. Fio. 151. There are few parts of surgical pathology in which such constant alterations have been made ;is in the diagnosis and nomenclature of tumors — alterations which are very puzzling to the student, and the advantages of whicii have not as yet become at all evident to the prac- tical surgeon. I will endeavor to treat the subject as practically and as shortly as pos- sible, without ignoring the theoretical re- finements which modern pathologists have introduced, yet only giving them such prominence as their bearings on practical surger}' seem to demand. A tumor is defined as "a new formation — an addition to some part of the body of a substance organized or partly organized, and not the result of inflammation only" (Caesar Hawkins), and this is probably the best definition whicli can be given, although we must allow that some genuine examples of tumor owe their origin to inflammatory processes — as, for example, the bursal tu- mors, of which an example is figured here. Other tumors occur congenitally, either as the result of foetal inclusion, from an abnormal and excessive formation of epi- dermal tissues, or from unknown causes. And it may be stated generally that tlie cause of formation of any tumor is as a rule entirely obscure. Pathologists and statisticians have labored in A'ain to dis- cover any reason, either in the local or Two bursal tumors, L e., enlarged general condition of the body, why the in- bur-sse pateiis, which had become con- 5- • 1 11 111 a- ^ ^ -li ii i.1 verted into cystic tumors by the de- dividual should be affected with the growth ^^^^^^.^^^ J an imperfect fibrous of a tumor. Hereditary tendency is often material in their walls, leaving only traceable, especially in malignant tumor; acavity in their centre, with smaller but this affords no explanation, since we know no reason for the original occurrence of the tumor in the first member of the family ; nor, beyond the vague fact that children usually resemble their parents in constitution and predisposition to disease, cessfully. (St. George's Hospital Mu as they do in physical appearance and dis- seum, ser. iv, No. u &.) position, do we know any reason why the disease after it has once originated should be transmitted to succeeding generations. The fact, however, that cancer is often transmitted from parent to child is one of impoi'tance in diagnosis. alveolar interspaces in the fibrous tissue composing their walls. The cavities were filled with partially de- colorized blood. The enlargement had existed for about two years. The tumors were removed at the same operation from a woman aged 34, sue- 348 TUMORS. Innocent and Malignant Tumors. — The most superficial acquaintance witli tumors will show that there are two well-marked classes of them, separated by broad distinctions, both anatomically and clinically. There is one class in which the substance of the tumor has an exact anatomical resemblance to some tissue of the body (homologoua tumors), and in whicii the tumor gradually increases in size, displacing the structures in which it grows, but not invading them, and producing no other symptoms than those caused by its increasing bulk. Such tumors are clinically termed innocent^ though, of course, the increase in their bulk may cause death, if they are situated in a vital part. There is another class of tumors which do not present any reseml)lance to the normal tissues, and which are therefore descrilied as heterologous. Clinically these tumors show a strong local disposition to ulceration ; they also invade all the textures of the part in which they grow, and they influence the general health, passing into the 13'mphatic system, appearing in remote parts of the body, reappearing after complete removal, and affecting the mass of the blood, so as to cause profound cachexia and ultimate death. Tumors of this kind. are therefore called malignant. Semi-malignant Tumors. — But though there is no difBculty in placing the well-marked examples of either class under their proper category, either anatomicall}'^ or clinically, it has long been seen that in both the anatomical and the clinical division a third class must be made, the classification of which is by no means so easy. There are some, such as the adenoid tumors of the mammary and prostate gland, which very nearly reproduce the structure of the part in which they grow ; others, such as the " fibro-plastic " tumors of Lebert, which are formed in a great measure of tissue resembling the embryonic state of some natural organ of the bod3' ; and others, such as the myxoma and glioma of Vir- chow, in which a similar, though still more rudimentary, resemblance to the normal tissues can be traced. Modern pathologists, especially the Germans, have revived for such tumors the old designation, Sarcoma, which had originallj^ no certain meaning, but is now defined as a tumor whose structure presents some resemblance to the rudimentary forms of some natural tissue of the body. The term Carcinoma is then defined anatomically as a tumor consisting of a congeries of cells resembling those of epithelium, and in some cases nearly identical with them, lying in the interstices of a connective tissue, in which aaain other cellular elements are to be found. But the cells of carcinoma have no structural connection with the connective tissue, nor do they appear to undergo any transformation into higher stages of development. Looking, again, at these so-called ''sarcomatous" tumors clinically, we find that among them are well-marked examples of a third class, be- sides the innocent and the malignant, above spoken of. There are tumors which will recur after their complete removal ; others which gradually spread to all the tissues in their neighborhood, and others which ultimately destroy life by their iilceration, although they have not the other features of malignnncy; that is, they do not affect the lym- phatic system, nor make their appearance in remote parts of the body. To such tumors the terms semi-malignant, locally vialignant., and cancroid have been applied. The class of sarcomata is largely formed of tumors of this kind ; but what renders the subject so complicated and difficult, and prevents us from accepting the lal)ors of modern pathologists in this direc- tion as holding out any hope of finality, is that this same class contains some tumors wliich are perfectly innocent, and many others which are more truly malignant than tliose classed anatomically among the carcinomata. CYSTS. 349 Amidst all this confusion there is one important point to which Mr. Savory has recently called attention in a very suggestive paper in the Brit. Med. Jour.., Dec. 19tli, 1874, viz., that, speaking generally, "the less the structures of which a tumor is composed tend to ciiange from their primary or embryonic form tlie more abundantly will they multiply; so that lliose tumors whose structures retain most nearly their primary . form are the most malignant. And as the structures of a tumor are capable of transformation so tliey lose their power of repetition ; so that those tumors wliicli consist most completely of fully formed tissue are the most innocent." Thus the most lowl}' formed tumors are the carci- nomatous, the cells of which show no tendency to grow into any higher forms, and wliich consist in great measure of juice, which is partly, in- deed, the product of the disintegration of the cells, but parti}' is a new morbid formation ; and these tumors show all the characters of malig- nancy most plainly'. Next in order are the sarcomatous, in which an attempt has been made at the formation of tissue, although imperfet^t and embryonic, and these tumors, though unstable in their composition, prone to ulceration, prone to recur after removal, and occasionally making their appearance in dis- tant parts of the body, have all these characters in a far less degree than the carcinomatous tumors have; wliile the best examples of the purely innocent tumors are sucli as consist throughout of a highlj' developed tissue, such as l»one. Many of the latter kind of tumors are as stable and as little prejudicial to the health of the individual as if they had been original portions of his organism. Jt remains to describe, as well as our present knowledge permits, the kinds into which the purely innocent, the sarcomatous, and the carci- nomatous tumors are now usually divided. Innocent tumors are subdivided into cystic and solid. The cystic tumors are again subdivided into simple, or purely cystic tumors, and proliferous cysts, in which a growth springs from the cyst-wall and fills tile cavity more or less completely. The simple cysts, which consist merely of a fibrous envelope filled with fluid, are classified according to the nature of the fluid they contain. They are serous, synovial, raucous, sanguineous, and seminal. Milk- cysts, oily and colloid C3'sts, may be added, but the milk-cysts will come under notice with tlie diseases of the breast, and the others are merely pathological curiosities, for which the reader must consult some of the manuals of Pathology. Nor will anytliing further be said here about the synovial cysts or enlarged bursje, nor the seminal cysts or encysted hydroceles of the epididjmis. These will be found described in tlieir proper places. BerouH cijsta occur very commonly in the neck, constituting what is called hydrocele of the neck., and this is the best example of their inde- pendent formation. The hydrocele of the neck forms a large encysted tumor (occupying sometimes the whole side of the neck, and falling like a dewlap over tlie' cliest), containing clear or sliglith' tinged serum, grow- ing slowly, and producing no definite symptoms. I have seen such a cyst completely transparent like a common hydrocele. These cysts are generally supposed to be formed by accuuiulation of fluid in the cellular spaces, which then produces by its pressure the stratification of the areolar membrane, and thus becomes encapsuled. Most of the other serous cysts, such as those whicli occur in the thyroid body, in the tunica vaginalis (common hydrocele), in the testicle (the uou-malignant form of 350 TUMORS. Fig. 152. cystic (iisejise of the testis), in tlie breast, or in tlie kidne}', are formed by effusion of serum into spaces naturally existing in the organ, and their contents have some resemblance to that of the part in which they are formed. Thus, the serum filling these cysts is of the most various color and composition, in some cases almost watery, at others nearly the consistence of honey, and of ever}' color — sometimes black or nearly black,' at others perfectly colorless. More or less fat, cholesterin, or • some of the elements of the blood, may frequently be found in it. Mucous cysts are such as, being formed in or in tlie neighborhood of a mucous surface, contain a fluid similar to that secretion, but usually more concentrated. Their cause appears to be the obstruction of a mucous fol- licle. They are found most commonly in the antrum, in the mouth (ranula), in the glands of Naboth and Cowper, and in the muciparous glands of the vulva and vagina. Sanguineous cysts occur either as a consequence of haemorrhage into a serous cyst, which seems common in the neck (htematocele of the neck), or possibly in connection with a vein, the orifice of communication having afterwards become obliterated, or from effusion of blood into a tumor, the substance of which, expanded over the collection of blood, appears like a <;yst. This was the case in the in- stance from which the annexed illus- trations were taken. The patient, a man tet. 30, was under my care at St. George's Hospital, in consequence of repeated hcemorrhages from the large tumor which is shown growing from the outer side of the leg, and which is seen to be ulcerated in several places. The whole mass was excised, and was at first thought to be a simple cyst filled with l)lood; but minute cxami- A blood-cyst .situated on the leg. The pa- nation by Mr. Beck and Mr. Arnott tient was a healthy man aged 30. The tumor showcd a thill layer of Sarcomatous had hei'n noticed about two years, and had been ,. .. ,i „ I'l „^ i.i,„4. +1,,, , „„„ the .seat of repeated and severe luemorrhage ^ISSUC Ul the wall, SO that the CaSC during the last three months. The drawing was really onc of an cuormous efl[u- shows thcMli'ip fissures in the tumor from which sion of blood intO the SUl)Stance of a this ha.-morrl.age proceeded. It shows also the g^j^jj t^„^jor. TllC man did Well, and shape of the tumor, springing from a broad base, , 1.1 . .1 pendulous, and overhangingthe healthy skin for "O recurrence has hithcrto taken some distance. It wa.s removed, together with plaCC. Again, blood-CystS are Very the skin around - ■• March, the cicatrization of the wound being assisted by ceed in size the solid growth in wiiich they form, so tliat surgeons are alwa3's lalher appreliensive of more serious mischief when dealing with these cysts. sme aistaiice. it wa.s removes, logeiner wiin piacc. 71 gam, uiouu-cysis art; vtiiy le skin around its Ijase for some distance, in fVcqucntlv formed Hu "malignant tU- [arch, 187:i. The patient made a good recovery, "1,1 .• 1 le cicatrization of the wound being assisted i,; mors, and they sometimcs mucli ex- skin-grafting. lie was seen in good health two years afterwards. On examination of th(! tumor its walls wiTe found to be composid of a tliiri layer of sarcomatous tissue, the cells from which are represenled in Fig. 153. • A.S in soini' fluid from a mammary cyst preserved by Sir B. Brodie in the Museum of St. Gi'orgc's Hospital. SEBACEOUS TUMORS. 351 Fui. 15;{. The diagnot;is of f^imple ci/sts rests on several considerations. The synovial, seminal, and mucous cysts, forming as they do definite diseases of the parts in which they occur, are recognized mainly by tlieir position. Cysts in general are distinguished from solid tumors (a distinction not easy to make when the cyst is very tense and deeply seated) by tlieir elasticity and perfectly rounded outline — from chronic abscess by the absence of all pain and inflamma- tory infiltration of the tissues around ; and when any doubt is felt an exploratory puncture can never do any harm, gives hardly any pain, and will at once settle the question. Treatment. — Serous cysts may often be treated successfully by iodine injection, exactly as in hydrocele, or they may be oblit- erated by a seton, tliough this sometimes sets up dangerous in- flammation, especially in the neck. I once saw death occur in a week through the insertion of a seton into a CVSt of the thy- Cells from the sarcomatous envelope of the hlood- roid body. Any form of simple ^^^^ ^''°^» '» ^'-- ^^-- ^he large oval cells shown , ' , , ,".' , , , . below formed the bulk of the tumor. Smaller spindle- cyst may be obliterated by being ^^^^^^^ ^ells are shown at a. The sarcoma tissue freely incised and the incision formed a thin layer, not perceptible to the naked eye, kept open until the cavity has in some parts arranged in slight bands shooting up arinnlated un • but tllis ^,.p„^. into the papill* of the skin or spreading beneath gianuiaiea up, out iriis neat- ^j^g,^^. i^ ,j(,^g^gp^„j.^,gg^j,y ,^^5^^^^ ^,p ^;^,^ ji^gj^j^^^, ment is hardl}' applicable to clot which filled tlie cyst. From Path. Soc. Trans., blood-cysts, on account of the "s'oi. xxiv, pp. 208, 211. danger of renewed haemorrhage or of violent inflammation of their walls. They are better removed en- tire, in which case, if truly simple, they will not recur; but if their wall is formed bj' sarcomatous tissue such recurrence is probable, and if by cancer material is nearly certain. Compound cy.s^.s are (1) such as contain the elements of the skin — cu- taneous cysts and dermal cysts ; and (2) such as have growing from their lining membrane secondary cysts, or masses of solid substance, which nltimatel}' either partly or entirely fills the original cavitj' — proliferous cysts. Sebaceoum Tumors. — Of the former kind the commonest are the seba- ceous, whicli are found mainly on the head and face, though most other parts of the surface may be affected, the axilla being remarkably exempt. Sir J. Paget describes them under two classes — one marked by a dark point on the summit, indicating the opening of a hair-follicle, and show- ing that the tumor was formed by the obstruction of such follicle ; the other presenting no sucli opening, and probably formed in tlie same man- ner as any simple cyst. They contain usually inspissated sebaceous matter of a peculiarly offensive odor, more rarely fluid of various colors, mixed with epidermal scales and cholesterin. The3' grow often to a very large size, and appear in very large numbers in tiie scalp, and then the operation for their removal becomes a serious one, on account of the great liability to erysipelas in such cases ; but there is some risk of this complication even after the removal of the smallest tumor, and pyoemia 352 TUMORS. may also follow. I well remember the death of an apparently healthy young- man from pyremia very shortly after the removal of a little seba- ceous tumor, the operation being a most trifling one, over in a minute, and of which neither the surgeon nor the patient thought much. Hence it is always desirable before performing any such operation to take all adequate precautions to see that the patient is in good health, and after- wards to take care that he does not expose himself injudiciously to any risk of cold or indulge in excess of any sort. The oi)eratiou is usually a very simple one. The whole cyst being freely cut across and its con- tents allowed to escape, it may be seized with a pair of forceps and dragged out, while the skin is held with the fingei'-nail or another pair of forceps ; or, in the case of smaller tumors, the skin only may be divided, separated from the surface of the tumor with a few touches of the knife, and the bag turned out with the spoon-end of a director or the handle of the knife. When the skin is firmly united to the surface of the tumor, as haijpens in many regions from pressure, the surgeon will be unable to pull out the cyst, and more or less dissection is necessary.' Great care should always be taken to remove such cysts entire. If a portion be left it may reproduce the secretion, prevent the healing of the wound, and set up a chronic form of ulceration with foul discharge much resembling that which accompanies epithelial cancer. If there is any especial reason to dread erysipelas the caustic treatment is believed to be safer, i. e., to destroy the skin over the tumor to a suffi- cient extent with some caustic, so as to make a free opening into the cyst, and then either to leave it to discharge itself, draw it out, or procure its elimination by renewed applications of the caustic to its interior. Congenital cutaneous cysts are not of very rare occurrence. A very common situation for congenital cysts is at the outer upper angle of the orbit, forming a little round tumor, slowly increasing in tliat situation. Its early removal is necessary, or at least expedient, since tlie deformity it causes will ultimately render the operation inevitable, when it would require a larger wound and be more difficult ; but the operation is never so eas}' as it would at first sight ai)pear, since the cyst-wall is very thin, and it may extend very deeply into the orbit, lying constantly in close proximity to the periosteum, and even (as in a case which I once saw) perforating the bone and lying in contact with the dura mater. Tlie dis- section, therefore, sliould be conducted very carefully, all possible care being taken not to open the cyst — an accident which will much embarrass the dissection. If this has occurred it is perhaps best to lay the whole cyst freely open, and after evacuating its contents, dissect it all carefully from the i)arls lying below it. Any little fragment of the cyst wiiich has been left l)eliind may prove a source of very serious trouble. Tliese cysts usually contain thin fluid and liairs. Cutatuous cijsfs in the scalp are often congenital, and tliey may then perforate one or both tables of the skull. But cysts have also been found in the interior of the skull, having l)een included within it in the process of its ossification. Such congenital sebaceous tumors are matters of sin- gular interest, on account of the mistakes in diagnosis to which they may give rise. Many cases of meningocele or encephalocele have been mis- taken for such sebaceous tumors and operated on, usually with a fatal result, though sometimes the patient has been lucky enougii to escape ' It will oftf-n bc! founil ciisicr to disspct out one of these cysts after it has been laid open, if the dissection be beijiin from below, whei'e Ihi^ cyst lies lot>sely in the ccillular tissue, rather than abuve, where the skin is firmly united to it. CYSTIGEROUS CYST. 353 with life. The greatest care, therefore, should be taken in examining a case of supposed sebaceous tumor lying in one of the usual situations of encephalocele to ascertain, in the first place, whether it is congenital, and secondly, whether pressure on it reduces it either wholW or partly, or causes any cerebral symptoms. If the tumor be reducible it can hardly be sebaceous, and there can be no doubt that it should be left alone. If pressure cause cerebral sjanptoms it may doubtless nevertheless be a sebaceous tumor lying on the dura mater ; yet even so the risks of its I'emoval would be too great to render the operation under ordinary cir- cumstances justifiable. If, however, an operation be undertaken, the tumor must on no account be opened. It must be exposed by very free incisions and careful dissection, and its base must then be separated with all imaginable care from the subjacent membrane. The other dermal cysts are most familiar to us in the ovary, and next to that in the scrotum. They contain masses of hair, portions of skin with cutis and cuticle, and frequently one or more teeth, mixed often with a large quantity of fat ; and sometimes, besides these truly dermal struc- tures, irregular pieces of well-formed bone are present in them. They seem to be often if not always congenital, though, like other congenital tumors, they may have remained for a very long time without growing. They used to be regarded as instances of foetal inclusion, i. e., the elements of which they are composed were regarded as fragments of a blighted twin foetus which had been included in the body of the one which grew to maturity. But there is no reason whatever for such a supposition, in the case of the ordinary dermal cysts of the ovary or scrotum. The}' seem to be merely tumors growing in the foetus, just as any other cutaneous tumor may in the adult. There are, of course, cases of well-marked foetal inclusion, in which a portion of the body of one foetus is buried in the other, while the lower limbs protrude, but these rare cases will form the subject of a future section. The dermoid cysts are now universally allowed to be, if not always, yet at least as a rule, quite independent of twin impregnation. Their diagnosis can only be conjectural before removal, resting on the long existence of the tumor, its irregularity and heterogeneous consistence. After removal no recurrence need be antici- pated. In the scrotum the}' have been known to be spontaneously ex- truded by suppuration. Proliferous cysts are those in which some solid substance springs from the interior of the cyst-wall, which may entirely fill it up. They occur frequently in the ovary, and still more often in the female breast. The proliferating solid portion of the tumor is a vascular tissue which springs from the wall of the cyst, generally at one definite part, but not uncom- monly from a great part of the lining membrane, filling it up more or less completely, and ultimately making its way through the cyst, and then through the skin out of which it fungates. Such are the sero-cystic. tubero- cystic, or cystic-sarcomatous tumors. The,y are almost confined to the neighborhood of glands, and are far more common in the female breast than in any other gland. I think, therefore, it will save space and time if I refer the reader to what is said in the chapter on Diseases of the Breast as to the diagnosis, pathology, and treatment of these tumors. Cystigerous Cyst. — Another kind of compound or proliferous c^-st is the cystigerous., in which the lining membrane of the parent cyst becomes the seat of the formation of a number of secondary cysts. In the ovary such compound cystic tumors are very common ; and in tumors which before removal appear to be simple cysts secondary cysts will sometimes be discovered. But I do not know that there is much importance in the 23 354 TUMORS. diagnosis of this from the other form of compound cystic tumor or from the simple cysts. The fat ti/ are amongst the most common examples of purely innocent tumors. They spring in almost all cases from the natural fat of the sub- cutaneous membrane, or Fi«- 154. i,^ connection with deeper- seated fat. In some rare instances fatty tumors have been found in parts naturally destitute of any growth of fat, and fatty tumors have sometimes been found in patients who had died of exhausting diseases, and who had lost the natural fat from all parts of the bod}'. They may grow to any size ; and if developed in ver}^ early life (which, however, is not common), they sometimes attain enormous propor- tions, as was the case in a child, then aged seven years, from whom Mr. Pol- lock removed a fatty tu- mor which had been mis- taken for a spina bifida, being situated in the mid- dle line of the luml)ar re- gion, and had therefore been allowed to grow. When removed it weighed 12| Ibs.^ I saw her many years after, in perfect health. Fatty tumor does not often appear at so early an age as in this instance. In other respects the case illustrates the common history of fatt}' tumors : their gradual growth to a large size, without any tendency to suppuration or to degeneration of an}' kind, or to ulceration of the skin, their size being the only inconvenience, and the complete restoration of health on their removal. The illustrations (Figs. 154, 155) show the characteristic forms of fatty tumor, the former a collection of deeply lobulated masses, the latter a lai-ge globular mass of fat, both of them inclosed in a capsule formed by the condensed areolar tissue, and therefore easily separated from the parts around. The skin is generally attached to the surface of a fatty tumor by numerous strings of areolar tissue; and when the skin is moved on the tumor dimples are ))roduced in it by the tension of these attachments, a point somewhat characteristic of fatty tumor. The lobulated surface, soft, solid feeling, and slow growth are tlie other characters of this form of tumor, and are usually sutlicient for its diag- nosis. Occasionally this, like other forms of tumor, is the seat of neu- ralgic pain, and this is especially the case in young women, who often have fatty tumors in the shoulder or in the neighborhood of the breast. In rare cases cysts are formed in fatty tumors, and in still rarer instances abscesses may form in them. A large mass of fat under the skin of the scrotum, collected into lobules, and continuous with the fat of the abdomen. The patient died of phthisis, and the rest of his body was much ema- ciated. The case is described at length by Mr. H. Gray, in the Path. Trans., vol. vi, p. 230. — (St. George's Hospital Museum, Ser. xiii. No. 14.) ' Path. Soc. TraiLS., vol. viii, p. 360. FIBROUS TUMORS. 355 Fatty tumors generally form after the period of maturit}', but in some rare cases they occur congenitally, as was probably the case in a remark- able instance of fatty tumor, growing in the interior of the spinal canal, which I assisted Mr. Athol Johnstone to remove, and the history of which will be found in the Path. Soc. Trans., vol. viii, pp. 16, 28. Besides the definite and encapsuled collections of fat which deserve the name of tumors there are often met with, especially in very fat elderly people, enor- mous ill-definedoutgrovvths of fat and cellular tissue — such as used to be called "lipoma." These have no capsule, but graduall_y pass into the fat of the part. It may become necessary to remove them on account of the inconvenience they cause ; but the operation should not be lightly un- dertaken. In order to be efficient for its purpose it must involve a verv large . , , .. . . ,„ ^ „ • .. ^i - . ■ . S A very large fatty tumor, moasuring 12 by 8 niches, removed incision, and the patient is f^^^^ ^,,g j,^^^ of the thigh, it extended from the trochanter to generally not a very good the middle of the back of the leg, and was freely movable. It Subiect for operation. was invested by thick areolar tissue. The darker parts consist 1^ X. . ^ ^4- „ of tissue in which blood seems to have been accidentally extrava- ratty tumors are not 1111- . ^ j u- », • i v. i /■ •^ , . , sated, and which is more or less broken down. commonly multiple. The removal of a fatty or any other perfectly innocent tumor is merely a question of convenience. The tumor must be expected to increase slowly; but if the patient is out of health, or there is any other special reason for dreading an operation, it may be better to advise him to bear what is after all only a deformity and an inconvenience, rather than incur any real danger. But in most cases the operation involves such trifling risk that it should be at once performed. If the tumor has not been irritated, its attachments will be so loose that if it is lifted in one hand from the subjacent fascia, while with the other hand the surgeon makes a free incision across the whole of the mass, he can turn it out of its capsule with his fingers in a moment, without any dissection. If, on the other hand, the tumor has been irritated or compressed — as, for instance, is often the case in the common tumor on the shoulder by the pressure of braces or shoulder-straps — the skin will adhere to it, and it will require formal dissection. Fibrous Tumors The purely fibrous tumors are also typical examples of the innocent class. Their external characters are not always easy to distinguish from those of fatty tumors, when they grow in the subcuta- neous tissue ; and, indeed, in this situation the two textures are frequently 356 TUMORS. Fig. 156. intermingled, so as to form a fihro-fatty tumor ; but the true fibrous tumors are harder, rounder, and less adherent to the skin than the fatt_y. Fibrous tumors occur in connection with the uterus, with the nerves, the bones, especially the lower jaw and the base of the skull, where they form the "naso-pharyngeal polypus," the testicle, the lobe of the ear, and in many other parts. The fibrous is often mixed with other texture, as in the uterus, where an admixture of the unstriped muscular tissue is constant (fibro-muscular). In the nerves the disease forms a special aflfection, which will be described in a future chapter under the name of "Neuroma." The progress of a true fibrous tumor is usually slow; those of the uterus are prone to a retrogressive change, in which they calcif}'^ more or less completel}^ ; ^ the others usually advance slowl}' till they protrude through the skin or mucous membrane and ulcerate. Sometimes cysts form in their substance — " fibro-cys- tic tumors" — as is not un- common in the bones (see Diseases of Bones). The true fibrous tumors are usu- ally inclosed in a capsule, rendering their removal both easy and safe ; and after re- moval, if the tumor be found to be composed of perfect and well-formed fibrous tis- sue, no recurrence need be apprehended. There have, it is true, been a few in- stances in which tumors supposed to be purely fibrous (and that by competent ob- servers) have afterwards run the course of cancer ; but remained free from any recurrence at least for eighteen months, during wliich time she was repeatedly seen. The tumor was removed from the subperitoneal tissue of the iliac fossa. The patient was a woman, aged 41, who had borne children. The case is reported in Path. Trans., vol. xv, p. 211. Neiaton has also called attention to the occasional growth of fibroid tumors in the iliac fossa in child-bearing women. — St. George's Hospital Museum, Ser. xvii. No. 42. A specimen of fibro-cellular tumor, showing its perfect identity in external appearance with the common fibrous tumor. On microscopical examination, however, oat-shaped tllCSC exceptional instances nuclei and fibre-cells were readily detected. The patient ^^ ^^^^^ perhaps WaS after all only an accidental error of observation need not inter- fere with the general state- ment that a slowly growing tumor definitely separated from the surrounding parts, and composed of well-formed fibrous tissue onl}^ will not recur after complete removal. The more rapid the growth is, the more embryonic or ill-formed the fibres, and the more they are mixed with cells, and especially cells of variable sliape and size, the more is recurrence to be dreaded. And this leads us to speak of i\\Q fibro-cellular tumors. Fihro-cellular Tamom. — These contain, along with the fibrous element, a more or less large proportion of cells. They grow more rapidly than the purely fibrou^ tumor, tliey occupy more variable positions, and are often more deeply' situated, and they are less definitely marked off from neighboring parts and less frequently encapsuled ; they often contain ^ See the chapter on Diseases of the female Generative Organs. CARTILAGINOUS TUMORS. 357 glandular elements, when they grow in or in the neighborhood of glands. Each of these circumstances has its value in the prognosis fig. 157. of the disease ; but in the present state of our knowl- edge it is very difficult to estimate that value, or to give a consistent and intel- ligible account of the tu- mors grouped under the term "fibro-cellular." Some of them are, as far as can be judged, as purely innocent as the typical examples of fib- rous tumor,^ others are of a very malignant nature. The latter are such as will be found described below un- der the names of round- celled and spindle-celled sar- coma, myxoma and glioma. The innocent fibro-cellular growths are those in which both the fibres are well- formed and have attained their perfect development, and the cells are homoge- neous, generally round or oval, and display little ten- dency either to growth into fibres, to proliferation, or to decay. Such are tlie cells frequently found in the fib- rous epulis on the jaw, and in the firm fibro-cellular growths of the skin. The cells usually bear only a small proportion to the bulk of the fibrous tissue. The diagnosis between the firmer fibro-cellular and the true fibrous tumors is only possible after removal, and the looser kinds are again ver}^ difficult to distinguish in many situations from cancerous tumors. Their removal is urgently indicated, and in the less well-defined speci- mens the surgeon will do well to cut as wide of the disease as prudence permits. Ca7-tilagi7ious himors (enchondromata) are far more common as out- growths from bone than in any other part, and they will accordingly be described furtlier among the Diseases of Bones, where also will be found some illustrations of their most characteristic forms. But they do occur also in the soft parts, frequently in the parotid gland, occasionally in the testicle, and very rarely in the subcutaneous tissue, in the thyroid body, ^ Paget, in speaking of flbro-cellular tumors, says : " What has been said of the excision of fatty tumors might be repeated hero, and so might the statements as to the very favorable prognosis after removal ; but with this reserve, that if a fibro- cellular tumor be incompletely developed, soft, looking like little more than size or other soft gelatin, or presenting a great preponderance of its elemental structures in an embryonic state, it is likely to prove recurrent." — Syst. of Surg., vol. i, p. 525, 2ded. A mass of fibro-cellular tumors, removed from the labium pudendi, weighing 1}4 ft>s. avoirdupois. They were removed by operation, and only one vessel required the ligature. They had given the patient (a widow, aged 40) very little inconvenience during the three years they had been grow- ing, until one burst and discharged a thin sanious fluid. a refers to the skin and fat of the labium ; b to the pendulous fibro-cellular outgrowths. — Museum of St. George's Hospital, Ser. xvii. No. 47. 358 TUMORS. and in other parts. The}' are distinguished from the harder fibrous tumors, which they much resemble, mainly by their firmer consistence and deei)er lobulation. Tliey are as a general rule purel}' innocent, and if once removed entire will never recur. Sir J. Paget has, however, re- corded' a single instance in which a cartilaginous growth originating in the testicle, and presenting ever}^ character of an ordinary enchon- droma, i)assed up the lympliatic vessels, pressed upon and perforated the vena cava inferior, and was thus conveyed into the lungs, where it at- tained so large a size as to prove fatal. The case is a very striking and instructive one ; it does not, however, show — nor does Sir J. Paget record it as showing — that enchondroraa is ever, when occurring un- mixed, a malignant disease, but as proving that the elements of any growing tissue if they pass into the blood ma}- become multiplied there to an indefinite extent. Besides the purely cartilaginous tumors — ^. e., those which consist of cartilage and nothing else — there are a great number of tumors, some innocent and others malignant, which consist partly of cartilage; but as the cartilage in these tumors forms only a part, and that a subordinate part of the growth, and does not give its character to the disease, it seems to me erroneous to classify such tumors as enchondromata. Thus cartilage is often found in osteoid cancer, and the recurrent growths in tlie lung often consist in great measure of cartilage. This illustrates the presence of cartilage in cancer, while the common fibrous tumor of the parotid or the ordinary fibrous epulis will often be found to contain more or less cartilage ; and these may be used to illustrate its formation in in- nocent tumors. But such tumors should be classified under the name of their principal constituent, and the name enchondroma siiould be reserved for those growths which consist entirely or almost entirely of cartilage. / Cartilaginous tumors degenerate in various ways. Some break down in the centre, so as to form large cysts (cystic enchondroma), others soften througliout, others become converted into a calcareous mass, in which it is difficult to discover any definite organization. Many ossify, but this is far more common in those which are attached to bone than in those formed in the soft parts, and it will be spoken of along with Diseases of the Bones in connection with the subject of exostosis. The free removal of an enchondroma is all that is necessar}' for tlie patient's future safety. Amputation may be indicated if the size and connections of the tumor demand it, and in cases of multiple enchon- dromata on the fingers or toes it may be the only resource available; but such cases will be discussed hereafter. Bony lumom are not absolutely unknown in the soft parts. There are some rare cases in which the muscles ossify, as in a skeleton preserved in the Museum of the Royal College of Surgeons, in which many of the bones are connected immovabl}' by masses of bone which have replaced some of tlie largest muscles in the body; and otlier singular cases occur like that recorded liy Mr. Caesar Hawkins,'-' in which masses of bone were formed loose in the cellular tissue of the muscles. But such cases are so very uncommon and have so little bearing on practice that exostosis may ' Mod.-Chir. Trans., vol. xxxviii, p. 247. 2 C(jiitril)Ution.s to Palliolouy unci SurtijtTy, vol. ii, p. 193. Mr. Hawkins describes the forniation.s of bone in the case which he relates as the result of ossification of tho muscular fibres in consequence of inflammation, and refers to some similar instances ; though, as he observes, " we cannot say why the muscles inflame, nor why the com- mon results of inflammation are modified .«o that bone is formed in the cellular tissue of the muscles." VASCULAR TUMORS. 359 be regarded as a disease of the bones, and will accordingly be treated of in that chapter. Vascular Tumors. — The only other form of innocent tumor is the vas- cular, in which the bulk of the disease is composed of eidarged vessels, these vessels being either arterial, capillary, or venous. The tumors which are formed chiefly of enlarged arteries are called aneurisms by anastomosis. They are large, irregular lobulated pulsating masses, in which a considerable bruit can often be heard, and numerous large ves- sels can be traced into them on all sides. The capillaries share in the enlargement, and the veins thus receive the pulsation. As the arteries enlarge their coats become thinned, so that the distinction between the arteries and veins around the tumor becomes impossible. The growth of the tumor sometimes causes ulceration of the skin, and severe or even fatal haemorrhage ; but ai)art from this there is not much danger, and I have seen cases which have gone on for an unlimited time without material change. Sometimes, however, when the disease occurs, as it usually does, on the head, the constant noise is so distressing, and the increase of the tumor so threatening, that the surgeon is compelled to interfere. The diagnosis is usually obvious. At the same time I have seen a pul- sating cancer of the skull mistaken for aneurism by anastomosis and Fig. 158. Aneurism by anastomosis of the upper lip. From a drawing presented by Sir B. Brodie to the Museum of St. George's Hospital. operated on, the patient being with difficulty saved from death on the table. A more accurate examination would have shown in this case that the skull was perforated, for pressure on the tumor produced vertigo, loss of consciousness, and partial hemiplegia. The favorite seats of this disease are the scalp and the lip. In the scalp they are commonly close to the ear, and the disease often extends into and implicates the vessels of the ear. They have been treated by all kinds of operations. When small they might possibly be cured by setons or by ligature applied as to an ordi- nary nsevus. The larger tumors are best treated by the galvanic cautery.. 360 TUMORS. The wire being passed througli the mass at its base is tlieii attached to the battery, so as to bring it to a wliite heat, and is drawn slowly out to the surface, cutting the tumor into two parts and searing the divided sur- face as it cuts, so that no hjemorrhage occurs. This may be repeated la several places, and so the tumor will be divided b}^ several cicatrices, by which the vascular tissue will be obliterated. As fresh parts threaten to grow tliey must be treated in the same way. Bleeding may occur during the sei)aration of the sloughs, and must be combated either by the lio;a- ture or actual cautery. The total removal of the tumor is a still more certain method of treat- ment, but the operation is highly dangerous when the growth is large. An incision is made around a part of the base of the tumor, cutting across several large vessels, which are then tied. If the patient has not lost too much blood the cut is then extended around another part or the whole of the circumference, and again the divided vessels are tied. When the whole circumference has thus been dealt with the mass is rapidly removed and all vessels at its base secured. In large tumors it is often necessary to divide this operation into several, allowing an interval between each for the recovery of the patient from the results of haemor- rhage. The ligature of the main trunk artery (the common or external carotid j has often been practiced in aneurism b}' anastomosis; even the common carotids on both sides have been tied, with a due interval. But I cannot discover that the practice has been so successful as to justify the operation. Mr. Southam has published a successful case,^ but here the seton was also employed. On the other hand, I remember a remark- able case in which the patient had been in great danger from repeated haemorrhage. This had been suppressed and the patient restored to heallli and comfort by the persevering use of the galvanic cauter}-. Three years afterwards the bleeding recurred, and a surgeon was sent for, who, unluckily for the patient, tied the common carotid. The man bled to death fifteen days afterwards, while the ligature was still firm on the ves- sel.^ At the same time cures are claimed after this operation the reality of which I am not concerned to dispute. All that I would say is that I believe local cauterj' to be safer and more efficient. NxvuH. — Capillary and venous tumors are called naevi,'' and n?evi are also divided into cutaneous and subcutaneous, the purely venous nnevi being usually subcutaneous, those entirely confined to the skin being always capillary only ; while those in vvhicli the skin and cellular tissue are affected simultaneously are usually of the mixed kind ; and in all such cases large veins will l)e seen running away from the tumor. Tiie nature of the common ntevus, or mother-mark, is obvious at first sigiit, and in some more serious cases the whole or great part of the side of the face is iini)licated in a similar dilatation of tlie capillaries, called •'^ port wine stain," or along with the enlarged vessels there is a pigment- ary foi-mation, and often an overgrowth of hair. But I do not know that anytliing has yet been successfully attempted for the relief of this deformity. The ordinary capillary n.nevus is very common indeed; and as a great many i\ tiiink the majority) of such n.'cvi remain without an}' growth indefinitely, tiicy should Ite left alone, unless from their situation they occasion any unpleasant dcfornuty, or from their growtii it becomes necessary to treat tiiein, in wiiich case, if they are in a position where a scar is of no consequence, they siiould be removed either by ligature or I M(!fl..Chir. Trans., vol. xlviii, p. (55. * Lancet, 1858, vol. ii, pp. 75, 339. ' Some authors also speak of nn(!uri.sm by anastomosis under the name of " arterial nffivus." N^vus. 361 with the knife. The latter is safe enough if the tumor be avoided, but as the former is quite free from all risk of haemorrhage it is more com- monly used, especially in private practice. Two stout harelip needles being passed beneath the nievus at right angles a strong ligature is tied beneath them as tightly as i)ossil)le. If the mass is large it is well to cut a groove in the skin from each needle to the one next it for the liga- ture to lie in. The great point is to tie the ligature tight enough, in which case there is no pain afterwards. The surgeon may be certain that the tumor is completely strangulated if he pricks it with a needle here and there while the ligature is drawn tight and sees that at last onl}^ a little serous fluid oozes from the punctures. The points of the needles should be cut off with pliers made for the purpose, and a strip of lint wound under them and round their ends. When the mass has turned black the needles may be removed and a poultice applied till the slough drops oft". The subcutaneous nrevi may be removed like any other sub- cutaneous tumor, by dissecting the skin from above them and removing them without opening the capsule in which they are contained ;' or if at any stage of the operation the surgeon should meet with alarming iijemor- rhage the ligature ma}' be substituted. And in naevi which are only partly subcutaneous a similar operation may be performed, i. e., the skin may be dissected from the mass below, generally without much hfemorrhage, and the latter be thus removed. But I cannot say that in the few trials I have made of this method I have seen much use in the skin so preserved. It is, in fact, so thin and ill-nourished that it generally sloughs or withers away. The caustic treatment of small njevi is very satisfactory. The caustic generally used is nitric acid, or the acid nitrate of mercury, which will remove a small mother-mark in two or three applications, leaving, how- ever, a small depressed cicatrix very like that of vaccination. The actual cautery by means of a white-hot needle, or a point of white-hot metal with a bulb above, by which the heat is prevented from too suddenly being quenched, is also often used, and successfully. But many of these small naevi may be removed with less deformity by the application of tiie elec- trolytic current ; i. e., a current of electricity of very low power continued for some time, so as to disintegrate the tissues without cauterizing them. Another plan which should be mentioned is vaccination. If the child has not been previously vaccinated he may be vaccinated on the nrevus, the vaccine being introduced in a great many places very close together. The object is to obliterate the va,scular tissue by the inflammation pro- duced around the vaccine pustules. But the plan is not one which deserves recommendation. It is very uncertain, since the vaccine may be washed away b}' the blood, and it has usually, if not always, failed in the cases which I have seen ; and when vaccine pustules are produced, it by no means follows that the nsevus is cured, or that the child has obtained the proper immunity from small-pox. Coagulaling Injection. — Again, subcutaneous nrevus, especially those large ntevi which sometimes occur in the parotid region, may be treated by the injection of perchloride of iron. The method, however, is a dan- gerous one, one case, at least, being on record in which instant death was caused, probably by coagula carried into the heart.^ If it is employed the solution should be used in small quantity, three or four drops being injected through the hypodermic syringe first in one place and then in 1 See Teale, in Med.-Chir. Trans., vol. 1, p. 57. The existence of a complete capsule subdividiniz; the growth into lobules is very distinctly described in the account which Mr. Birkett has given of the structure of a nsvus in the Med.-Chir. Trans., vol. xxx, I). 193. 2 Teale, Med.-Chir. Trans., vol. 1, p. 62. 362 TUMORS. another. Fig. 159. Some surgeons first break down the tissue of the nrevus with a broad cutting needle, and then introduce the coagulating injec- tion into the cavity so produced. Subcutaneous Ligature. — The larger nsevi require complicated forms of ligature for their strangu- lation. Those that are entirely subcutaneous are generally treat- ed by the subcutaneous ligature. The needle (which should be a large curved one) is armed with a strong piece of whipcord. This is entered at one point of the cir- cumference and carried round the base as far as possible, when it emerges through the skin. The lig- ature having been drawn through as far as necessary is re-entered at the same puncture and carried round another portion of the circle, and so on, till at length it reaches the original point of entrj'^, through which its two ends now protrude, and must be tied as tightly as pos- Subcutaneous ligature of nreviis. The upper figure shows a single ligature carried round the tumor. The lower (iu which no tumor is depicted) shows a double string carried below the centre of the base, then divided into two, a a' and b b', and each of the two carried subcutaneously round half of the naeviis, and then tied. Fig. 160. 1. The threaded needle passed under the centre of the base of the tumor; one thread divided near the needle. 2. The other end of the divided thread passed 3. The needle withdrawn and the nsDvus stran- into the needle's eye. Both threads carried gulated iu quarters, round a quarter of thecircumfereuce and passed under the base alright angles to their former direction. Fio. 160.— "Fergusson's knot," for the strangulation of large ntcvi, or other tumors. In order to keep the diagrams of a convenient size the tumor has been represented relatively much smaller than it is in practice; and in Fig. 3 the incisions, which are usually made through the skin from each puncture to the next, have been omitted, to avoid complication. They are not absolutely necessary, if the mass is not very large, but they reduce the quantity of ti.ssue which is to be cut through by the ligature, and promote the success of the operation, besides very probably saving the patient some pain while the ligature is separating. NJiiVUS. 363 Fig. IGl. sible. Or if the mass is too large to be dealt with in this way the ligature may first be carried under the middle of the tumor, and may then be di- vided into two, which is applied as before subcutaneously to eacli half. Another excellent knot for a large n?evus is that which goes by Sir W. Fergusson's name, and which is represented in Fig. 160. In otlier cases, where the tumor is of an elongated form, the form of ligature represented in Fig. 161 is more appropriate. The tumor is strangulated in pieces by passing a double ligature under its base from side to side, as there shown. The ends of the ligature are colored differ- ently — sa}' one white and the other black. Eacii loop is left long, so that the whole ligature must be of great length. Then the white loops are divided on one side and the black on the other, and the pairs of white and black strings are tied tightl}'. The whole tumor will thus be found to be strangulated. The two latter methods necessarily involve the death of the skin, and even although the purely subcutane- ous ligature does not, perhaps, in- volve the death of the skin by abso- lute necessity, since enough nutrition ma}'^ be provided by the vessels which pass into tiie skin between the punc- tures to avert gangrene, j^et sucli a fortunate result is often obtained. More commonly the subcutaneous ligature sets up extensive inflamma- tion, in which the whole tissue per- ishes, including the skin. Mr. Barwell has lately described a process for the " scarless eradication" of nsevus* by means of an instrument whereby a wire conveyed subcutane- ously around the base of the tumor is gradually tightened bj' means of an appropriate mechanism until it comes away, and so divides all the vessels which nourish the subcutane- ous part of the nsevus. After this the subcutaneous ntevus can be treated with nitric acid if necessary, but often withers away and disappears spon- taneously. ♦ Another plan which will often check the growth of large naevi, and which is eminently useful in situations where their complete removal is impossible or very dangerous, is to cut them into pieces by ligatures con- veyed under their base and tied tightl}'^ round tlie entire tissue. If the growth be so large that the first ligature will not ulcerate through it, a second can be introduced into the groove which the ulceration of the first has caused, and thus when the Matures have come away the tumor will be divkled into portions by wounds, in which l)ands of cicatrix will form, and so its growth will be arrested. A case of venous nsevus in the scro- tum treated successfully in this w^ay will be found described and figured in the Path. Soc. Trans., vol. xv, p. 95. There are other methods of treatino- naivi too numerous to mention. Ligature for strangulating a large naevus. The white loops are divided on one side, and the black on the other, and the corresponding ends (as a a', b b') tied together. The termi- nal strings c c may be either tied or withdrawn, as the surgeon thinks best. 1 Lancet, May 8, 1875. 364 TUMORS. I need only add that ver}' large njevi are often cured by the introdnction of setons. Some surgeons steep the seton-threads in perchloride of iron. Degeneration. — Na?vi which do not grow may remain stationary, or ma}' disappear, or may degenerate. In some cases, usually after an attack of some gi'ave illness, such as scarlet fever or hooping-cough, even large noevi have been known to disappear altogether. Thus in the discussion on Ml'. Teale's proposal for enucleating the large ntevi which sometimes form in the parotid region, Mr. Prescott Hewett related an instance in his own family where a nrevus of this kind had entirely disappeared soon after one of the common affections of childhood. In other cases the tumor after ceasing to grow degenerates into a c^'stic mass, and this is a well-known cause of congenital cystic tumor. The contents of the tumor nia}^ vary very much from the composition of the blood, though they generally show some trace of their origin. Sarcovm. — Sarcomatous tumors are defined to be such as in their for- mation and growth present some resemblance, though an imperfect one, to the formation and growth of the normal tissues. The class of semi- malignant or locally malignant tumors belong to the sarcomata, but many sarcomata are innocent, and others, on the contrary, are extremely malig- nant. The classification, therefore, does not seem to me, I own, a good one, or likel}'' to be permanent ; but as it has lately come much into vogue it seems better for the present to adhere to it. The general characters of sarcomata are, that they consist of fibrous tissue more or less perfectly formed, and of cells which display some resemblance to the normal cells of either embryonic or adult fibres, Fi"- 1*52. membrane, muscle, bone, cartilage, or nerve, the cells and fibrous tis- sue having an organic connection, and the former showing a tendency to higher development. The class of sarcomata, there- fore, embraces a considerable num- ber of those tumors which have been described above as " fibro-cel- lular,^' and it very nearly coincides with the tumors described formerly as " fibro-plastic," the only differ- ence being that under the term sarcoma man}'' tumors have been included by the German patholo- gists which are of a truly malig- nant clinical nature, and which used to be described as cancer. Taking this definition, the follow- ing are the tumors which are ar- ftingcd by Billroth under the head of sarcoma : • a. Round felled or granulation sarcoma, in which the chief constitu- ents are small round cells like lymph-cells, such as are found in granula- tions, the intercellular substance being either distinctly fibrous or libril- lated or perfectly homogeneous, as in the neuroglia or transparent sheaths of the nerve-tubes (glioma). h. Spindle-celled sarcoma, which is composed of small elongated cells (oat- or awn-shaped), sometimes without any intercellular substance, at Round or oval-celled sarcoma. From a tumor of the female breast, de.scribcd in I'ath. Tran.s., vol. xix, pp. 394-^97, and figured in the. same vol- ume as pi. xii, Fig. 6. SARCOMA, 365 other times united by a homogeneous, fibrillar, or fibrous tissue. The cells are variously regarded as embryonic connective tissue (Lebert), or embryonic nervous or muscular tissue (Billroth). t,^)^ *" o -6 »^ -OO- ^ Section from a spindle-celled sarcoma of the femur, taken from the exterior of the tumor, a shows the "indifferent granulation material" or " adenoid tissue" stretching out from the tumor structure (6) into the adipose tissue (c) separating its cells. The tumor was of a malignant character, and con- tained in other parts of its substance cartilaginous and osteoid material. Path.Soc. Trans., vol. xxi, p. 341, and pi. viii, Fig. 1. c. Giant-celled sarcoma, or myeloid tumor, in which the cells distinc- tive of the form of tumor are very large, contain numerous nuclei (some- FlG. 164. ' Giant-celled sarcoma," or myeloid tumor. — After Billroth, a points to a part where cysts were being formed by the softening of the tissue of the tumor; 6, to a focus of ossification. 366 TUMORS. times as many as twenty or thirty), and are often provided with numerous offshoots. These cells are likened to those which occur in the marrow of fa?tal bones. Such cells are found mixed up with the tissue of any of the other forms of sarcoma, but they are most common in tumors which spring from bone, and they will be further spoken of in the chapter on Diseases of Bone. d. Mucvus or net-celled sarcoma (myxoma. Yirchow), characterized by the development of caudate branching cells, communicating with each Fig. 165. Fig. 166. U ni 4 IS Fig. 165. — Section of myxoma, a. Angular or stellate bodies, the prolongations of which anastomose so as to form a network traversing the whole section, h. Small round cells, having no apparent con- nection with the angular corpuscles, c. Corpuscles having much resemblance to mucous corpuscles, but smaller, contained in the prolongations of the branching or angular bodies. These prolongations had double outlines, and appeared to form canals, in which the mucous corpuscles were contained. Some fatty tissue was mingled with the structure of this tumor. (From Path. Trans., vol. xx, p. 344.) Fio. 166.— "Alveolar sarcoma."— After Billroth. other, and lioaring a resemblance to the structure of the gelatinous tissue of tlie umbilical cord or that of the vitreous body. Mixed with tliis is commonly a variable quantity of soft mucous substance (colloid) or soft tissue, more or less resembling cartilage ; and bone may also be found in these mucous sarcomata. e. Billrotli's next class of sarcomata is the alveolar, in which he allows the great difficulty of distinguishing the structure from carcinoma, and in wiiich his description hardly shows any difference. The cells are round, larger than the lymph-cells, with one or more large nuclei, con- taining glistening nucleoli, and about the size of cartilage-cells, or mod- erately large flat epithelium. The}' lie in the interstices of a beautifull}' alveolar cellular tissue. f. Finally, we have the pigmenfarij or melanotic sarcoma, in which one or other of tlie above forms of sarcoma is colored black or dark-brown by the deposit of granular pigment, which almost always occurs in the SARCOMA. 367 cells, and more rarely in the intercellular substance also (Fig. HI, p. 373). I have thus given the anatomical division of this class of tumors from one of the most recent and most authentic of the German pathologists, in order to place before the reader, as intelligibl_y as I can, the views which have recently prevailed. Not that sui-geons or pathologists are by any means agreed upon those views. For instance, Billroth's alveolar sarcoma is not recognized by otlier authors,' and seems to me, according to his own description, to belong ratlier to carcinoma; and mt'Ia» otic tumors are certainly in the human subject often regarded as carcinoma- tous ; but the other members of Billroth's series are usually admitted as distinct anatomical forms of tumors, and classified as sarcoma. Their clinical characters are unfortunately very varial)le. We only know of glioma as occurring in the interior of the eye and in the brain. In the latter position its separate clinical history cannot be traced, since it causes death by its situation. For its description as it occurs in the eye I must refer to the chapter on Diseases of the Eye.^ Some of the other sarcomatous tumors ai"e among the " recurrent," or " locally malignant " type, and many others are decidedly cancerous in their clinical history. The spindle-celled sarcoma is in some of its forms identical with the recurrent fibroid of Paget, or the fibro-plastic tumor of Lebert. Such tumors will when removed, however completely, occasion- ally but not always recur in the cicatrix of the operation, and their con- stant recurrence will cause death. Thus, the Museum of St. George's Hospital contains specimens from a case of this kind, in which a fibro- plastic tumor, or fibre-celled sarcoma, originally developed in the female breast, was removed ten times, until at length the extent of tissue impli- cated bv it became too great for adequate removal, and the patient died exhausted bj' its ulceration, eighteen years after its first appearance.* Further, there are cases, though not so numerous, in which tumors of this sort recur, not in the cicatrix, or not there only, but in the internal viscera, usually the lungs or the liver, very much after the manner of cancer. For example, Mr. Mitchell Henry* man}' years ago related a case in which a myeloid tumor amputated at the shoulder-joint recurred both in the stump and in the lungs; and I have myself recorded a case in which a fibro-plastic tumor of the thigh, recurring after imperfect re- moval, was amputated at the hip-joint, and the patient died some months afterwards, with a similar growth in the pelvi^s, in the lungs, the brain, and in other still more remote parts of the body — viz., the spine and the thorax — the stump of the amputation being all the time quite sound and healthy. The structure of the tumor in this case was minutelj' examined both before and after recurrence by several experienced microscopists, so that its nature cannot be doubted.^ In another case, where the breast had been removed for a large fibro-plastic tumor, the growth recurred in the cicatrix, and afterwards in the opposite breast, which I also removed; but the recurrence was not checked, and it ultimately proved fatal. There is no question that when these sarcomatous (myeloid and fibro- ' See the very useful and practical account of the anatomy of tumors by Dr. Moxon in Bryant's Practice of Surgery, chap. Ixv. 2 Since glioma is only connected with the neuroglia, it is often described as a dif- ferent form of tumor from the ordinary sarcoma, which springs from connective tissue, and this is the view tal^en in the chapter on Diseases of the Eye. * St. George's Hospital Museum, Ser. xvii, Nos. 58 to 60. * Path. Soc. Trans., vol. ix, p 367 6 Path. Soc. Trans., vol. xvii, pp. 217, '2dO. See also the woodcuts and report on p. 292. 368 TUMOES. plastic) tumors are thus diffused into remote parts of the body the ele- ments of their diffusion are sometimes carried by the veins ; and Billroth claims to have been one of the first to show that sarcoma (contrar^^ to what is very common in carcinoma) never attacks l^'mphatic glands, and he therefore believes that it is through the venous system tliat such in- fection proceeds in sarcoma. This is probable, but it is a matter of sec- ondary importance. Wliat is more important to tlie surgeon is to know whether sarcoma can be diagnosed from other less dangerous forms of tumor, and whether after removal any prognosis can be arrived at — ?'. p., whether the surgeon can saj^ with any approach to accuracy whether the tumor will recur or not. With regard to the diagnosis between sarcoma and carcinoma at an earl}' stage — i. e., before any glandular affection has been developed and before the skin has given wa}'^ — it can hardly, I think, be established definitely. The diagnostic signs which Billroth points out are as follows : " Sarcomata develop with peculiar frequenc}' after previous local irrita- tions, especially after injuries; cicatrices also are not unfrequently the seat of these tumors ; black sarcomata (melanosis) may come from irri- tated moles. Skin, muscles, nerves, bone, periosteum, and, more rarely, glands (among these the mamma most frequently) are the seats of these tumors. Sarcomata are rarest in children, rare between ten and twenty 3'ears, most frequent in middle life, and rarer again in old age. . . . The growth is sometimes rapid, sometimes slow ; the consistence varies, so that it can rarely be used as a point in diagnosis" {lib. cit.^ p. 618). To these diagnostic signs Billroth adds that sarcomata are usually encap- suled, and carcinomata are not ; but as it is certain that the more rapidlj'^ growing sarcomata are not encapsuled, this can hardly be regarded as diagnostic. And I need scarcel}^ say that the above diagnostic signs are far indeed from estahlisliing any reliable distinction b}^ which sarcoma and carcinoma can in all cases be distinguished ; in fact, this is often hardh' possible, even after removal and careful examination. Tlie rapidity of their growth is that w^iich more than anything else distinguishes the sarcomatous from the purely innocent tumors; and the only indication, as far as we know as yet of the probability of recurrence, is drawn from this rapidity and from the succulence of the growth. Rapidly growing soft tumors are regarded with much more apprehension than those of firmer consistence and slower increase. In any case the l^rognosis is better if th^ tumors have been very early and ver}^ freely removed. Even after one or more recurrences the case is not absolutely hopeless. Cases are on record where, after the second or third removal, no further development of the disease has taken place, and such cases render it the plain duty of the surgeon to interfere, and at the earliest possil)le moment, when recurrence is ascertained ; though, as a rule, a tumor which has once recurred will go on doing so ; and the more rapidl}'' it recurs the more rapidly it will in all probabilit}^ ulcerate ; and, as a general rule, the oftener it has been removed the shorter will be the pa- tient's next respite. Sarcomatous or fibro-i)lastic tumors when ulcerated much resemljle cancer; but as there is certainly more hope of successful removal in the former than the latter, it is important to draw the distinc- tion ; and tliis is made chiefly by the amount of infiltration of the sur- rounding skin. A tumor which fungates out of a cleanly cut hole in the skin is probably sarcomatous ; one in which the tissue of the skin around tlie hole is redematous, hardened, and studded with nodular masses, is in all likelihood cancerous; and the diagnosis of cancer becomes estab- lislied if tlie glands are implicated. CARCINOMA. 369 Carcinoma. — The words " cancer " and "carcinoma" are sometimes used as synonymous and equivalent to the term " malignant tumor;" by other authors this use is made of the word "cancer" only, by which is then meant a tumor presenting the clinical characters of malignancy, while the term " carcinoma " is made to be strictly anatomical. In the latter terminology, which is perhaps now the more common, all carcinom- atous tumors are also cancerous or malignant, but the term cancer ap- plies also to many of the sarcomatous tumors, as will have been seen from the above description of the latter. Carcinoma is defined anatomically as a tumor which is composed of an areolar framework of fil)rous tissue, within which areohie are contained collections of cells bearing a consider- able resemblance to those of the epithelium, and believed by most modern pathologists to be developed from that structure, so that they deny the possibility o^ carcinoma taking its origin anywhere except upon the sur- face of the body, whether external or internal, including, of course, in the surface the deeper layers of the epithelium and all the involutions formed by ducts, follicles, etc.; though no one denies tiiat cancer or malignant disease originates in situations such as the interior of bones, in the sub- stance of the brain, and innumerable other localities far away from any pre-existing epithelium. Taking this definition of carcinoma, it would be defined as consisting of a network of fibres in which may be found the nuclei peculiar to con- nective tissue, and contained in these areolae a mass of cells varying in shape, size, and special characters in different examples and even some- times in the same example of the disease, but all of them bearing some resemblance, more or less distinct, to the normal epithelium. The cells show no tendenc}^ to pass into a higher stage of development, as those of sarcoma do, nor have they any organic connection with the fii)rous stroma. On the contrary, they are marked by a tendency to fatty degeneration and often contain oil-globules, and the whole tumor tends more or less rapidly to degeneration and ulceration. Carcinoma is prone to aflTect the hmphatics leading from the part in which it was originally developed; so that the glands next in order are very commonly found to be the seat of a similar tumor, and this glandu- lar formation, when confined to the glands immediately connected with the primary tumor, is by many surgeons considered rather in the light of a portion of that tumor than as an extension of the disease. And cer- tainly the disease often stops for a time at these first glands. But from this first range of glands it will pass either to more remote glands or will infect the mass of the blood and reappear in the remotest parts of the body. Meanwhile the primary tumor has been locallj' infecting the tissues in its neighborhood, and thus making its way to the surface either of the skin or of a neighboring serous or mucous cavity. In its course it breaks down, as above stated, so that its structure presents traces of fatty de- generation in the form of small dots of a yellow chees^^ consistence, visi- ble to the naked eye, and in the presence of a creamy juice (so-called " cancer-juice ") which can be scraped or squeezed from its section. The cancer-juice, however, is not entirely formed b}' the breaking down of the tumor. In some cases it certainly must be so, in great part — as shown by the quantity of oil and debris which it contains — but in other cases it shows only well-formed and perfect cancer-cells, and is regarded with great probability by many pathologists as the medium in which the cells grow, and by which they are propagated to the parts around.' When ' See Savory, Brit. Med. Journal, Dec. 19, 1874. 24 370 TUMORS. the disease has made its wa}- to the surface an indolent ulcer is formed, with hard, elevated edges, the cancerous material being infiltrated into the integument for a variable distance, tlie surface of the ulcer varying in character according to the form of the disease. These cancerous ulcers are ver}- prone to hii^morrhage, and the patient's life, if not cut short otherwise, is gradually worn out by the bleeding and the exhaustion of the discharge. Carcinoma kills, however, in many other ways. The growth of the primary tumor interferes witli the functions of vital organs ; or the disease is propagated into one of the great viscera ; or it infects the mass of the blood, causing a peculiar cachexia, which sometimes proves fatal without any obvious mechanical cause. The forms into which carcinoma is divided are as follows : 1. Hard cancer or scirrhus — carcinoma fibrosum — very common in the female breast. This is distinguished by its stony hardness (hence popu- larly called stone-cancer) ; it feels \\ke a lump of some hard foreign sub- stance let into the part; in its growth its structure often shrivels, so as to draw the neighboring tissues to it, producing an apparent loss of size, gluing the integument to its surface, and causing the dimple of the skin so often seen in this form of cancer, and the retraction of the nipple which so commonly occurs when it is situated in the breast. Stretching out from the main tumor may often be found indurated strings, being the cellular tissue infiltrated and drawn in towards the tumor. It was these projections which, being fancifully likened to a crab's claws, gave its name to the disease. When cut into, scirrhus presents a characteristic hardness, feeling like a raw potato does when cut ; its section is whitish or grayish, dotted with minute yellow points, and its surface often presents a concavity caused by the shrinking of the tumor. The tissue of its exterior passes into that of the healthy structures by no exact or defined margin. Examined microscopically it shows a stroma which is often extremely definite — the cells are ''of an epithelial type, of varying size and shape, but with tolerably uniform (and usuall^^ single) large nuclei, closely packed in the meshes of a stout fibrillated stroma, without au}^ visible intercellular elements." ^ The stroma, which man}' pathologists regard as merely the compressed connective tissue of the part, is believed by Mr. Arnott to be, often, at any rate, a new formation. Tills form of scirrhus, collected into a se})arate nodule, is called the tuberous form ; the other is the infiltrating, in which the cancer appears more as a general induration of all the tissues in the neighborhood, the skin Ijcing tliickened, tense, and livid, and adhering closely to the parts below ("liidebound cancer"); the disease spreads slowly and superfici- ally, ulcerating in one part, and possibly afterwards healing there while spreading in other parts. The ulceration of a scirrhus tumor leaves a sluggish sore, with sharp edges, bounded to a variable distance by cancer-tissue, sometimes with a nearly flat surface, at others with prominent granulations, and with a peculiar fetid discharge, the smell of which much distresses the patient, and which is mixed with more or less blood from time to time. Such ulcers may heal for a time, leaving a thin livid scar very prone to break down again. Scirrhous cancer may be operated upon, whenever tlie skin is unaffected and the glands are not implicated, with a tolcrabl}' certain prospect of benefit from the cessation or prevention of the stabbing pain which often H. Arnott, in Syst. of Surgery, 2tl cd., vol. i, p. G14. CARCINOMA. 371 accompanies the growth of the tumor, and from the removal of what is a source of constant annoyance and apprehension to the patient. Cases are also unquestionably on record in which the tumor has never recurred, but these are so rare, especially if we insist on anatomical evidence of the correctness of the diagnosis, that they need hardly be taken into account, and as a general rule the return of the disease must be anticipated. Xor is there, as far as I know, any conclusive evidence that the operation pro- longs life, for it must be remembered that the course of scirrhus is some- times very slow, and against the few cases in which no return has takeu Fig. 167. Fig. 168. //■f' Fig. 167. — Microscopical appearances of scirrhus of breast (after H. Arnott). " The typical form of hard cancer. To one side of the section are drawn a few detached and larger cells from another speci- men of undoubted scirrhus of the breast, showing more clearly the varying size and shape of these cells and their occasional multiple nuclei." (Syst. of Surg., vol. i, Fig. 13, opposite p. 614, 2d ed.) Fig. 168. — Cancer stroma (after H. Arnott). "A very thin section was made, through a tolerably firm pink-white cancerous nodule, in the liver of a patient dying with hard cancer of the breast, and the cells brushed away with a camel's hair pencil under water. There is thus left the typical stroma dimly fibrillated and granular, inclosing meshes which have been closely tilled with cells." (Syst. of Surg., ibid., Fig. 18.) place for many yeai's after the operation may be set, perhaps, as many in which the tumor, having never been interfered with, has remained indo- lent and innocuous for a very long time, until, perhaps, the patient h.as died of old age or of some other affection, or, after this long interval, cancer has shown itself in other parts of the body.' But there is certainly no reason to say that operations shorten life ; and as they give a period of immunity, and usually with ver}' little danger, they should be per- formed in all appropriate cases. Even when ulceration has occurred to a considerable extent I have known the operation successful in procuring a considerable period of health, and avoiding impending death from haemorrhage. The question of operating when the glands are affected is a doubtful one. If all the affected glands can be removed, there seems no reason why the operation should not be as successful as in any other case, since the glands, as was said above, are rather a part of the primary disease than a propagation of it ; but it must be allowed that in the axilla espe- cially it is extremely difficult to remove them all, without a most formid- able and frequently fatal operation ; those that are obvious being only a superficial part of a chain of glands which often stretch deep into the axilla, and where a second chain (as, for example, the cervical glands in cancer of the breast) has become involved it is unjustifiable to operate. 1 In the Path. Trans., vol. xi, p. 220, is the account of a case in which the scir- rhous tumor had existed for more than thirty years, and then deposits of cancer took place in various parts of the skeleton. 372 TUMORS. "When there is a second tumor perceptible in a remote part of the body, or any symptoms of the formation of such a tumor, the operation is inad- Tnissii)le, as also when the presence of general cachexia testifies to the infection of the mass of the blood. 2. ^leduJJary Cancer. — The next variety of carcinoma is the encepha- loid, medullary, or soft cancer, in which the cells are more plump, rounded, and usuall^^ more uniform in size and shape, and the alveolar stroma less distinct. This form of cancer is often secondary to scirrhus, so that a primary scirrhous tumor in the breast will be accompanied by the growth of medullary carcinoma in the glands or viscera. It grows much more rapidly than scirrhus, is often exceedingl}- vascular, so that large blood-cysts are formed in the interior of the tumor, and its surface is very commonly permeated by large veins. To the most vascular exam- ples of this form of cancer Mr. Hey's name, " Fungus hfematodes," is still occasionally applied. This form of cancer differs from scirrhus in the greater softness of the whole mass (whence the name), in tlie relatively smaller proportion of the intercellular substance, in the greater juiciness of the tumor, and the more rounded shape, larger size, and more varying form of the cells. The favorite seats of encephaloid cancer are the bones, the female breast, the eye, the testicle, and less frequently the uterus, bladder, and other viscera ; but any tissue of the body may be affected by it. It occurs Fig. 169. Fig. 169. — Medullary cancer. "From a lymphatic gland — secondary to hard cancer of the hreast. This form of cancer differs from the scirrhus only in the proportion of the cell element to the fibrous stroma — the cells heinj,' here seen to be still of the cpitlielial type, and lying close together withoutany visible intercellular substance." — From Arnott, ibid., Fig. LO. Fig. 170. — Melanosis, springing from the mucous lining of the urethra, a, the urethra laid open. 6, the prepuce, c, the section of the corpora cavernosa. The disease was removed by amputation. — St. George's Hospital Mus(!um,Ser. xiii, No. 10 a. very commonly in young people in blooming health, and its nature is often overlooked at first, it being mistaken for innocent tumor, or for abscess, from its extreme softness when not covered by any hard tissue, or for clironic inflammation in the testicle when bound down by the firm tunica albuginea. It rapidly affects the glands, and when removed it gen- MELANOSIS — OSTEOID. 373 erally rapidly recurs, so that the prognosis is even more unfavorable than in scirrhus. Nevertheless operations are eminently justifiable in this form of cancer. They certainly tend to prolong life, and usually they restore the patient for a time to complete health. When left to itself tiie tumor speedily makes its way through the skin, ulcerates, and bleeds copiously. If death is not caused in this way it is occasioned by the rapid growth of the tumor. Some peculiarities in encephaloid cancer as it exists in bones deserve especial notice, viz., its tendenc}^ to ossify and its occasional pulsation. The reader is referred to the section on cancer in bones later on. MeIa7}osi,<. — As subvarieties of encephaloid I would name melanosis and osteoid cancer. Melanosis, or black cancer, is usually developed from parts, such as the eye or the skin, where pigment is always or com- monly found in the natural state. When occurring in the skin it seems often to originate in a mole. The liver, again, is a tolerably common seat of melanosis, and it is found comparatively often as a secondary forma- tion in many other parts of the body, such as the brain or the i)ones. It also sometimes originates in parts where no pigment naturall}' exists (Fig. 170). The pigment is deposited chiefly in the cells and also to a cer- tain extent in the intercellular substance. That melanosis is clinically a malignant disease in man is a fact to which I have not as yet met with any well-marked exception.^ But that the disease is always of the character which would be technically called carcinoma by all pathologists is a very dilferent matter. The anatomical characters of the tumor may either be those of soft cancer, as shown in Fig. 17 of Mr. Arnott's plates,- or of spindle-celled sarcoma, as in a re- markable instance under my own care of melanosis of the urethra, here figured. Odtoid cancel' is a xary rare form of the disease. Its primary seat is almost always in the bones ; but it presents the remarkable pe- culiarity of forming secondary de- posits of bou}' cancer in the glands and in the viscera, and of recurring as a bony mass in remote parts of the body. In all cases that I have seen the lungs have been the seat of the secondary growth. The primary tumor is usually, as Mr, Moore describes it, " a mass of the hardest enamel or ivory-like bone," mixed with which are the materials of ordinary encephaloid cancer, and often a considerable pro- portion of cartilage. And sometimes the primary tumor has been judged to be of the common encephaloid nature, while the recurrent growth in the lunffs has been osteoid.^ Fig. 171. The cells which were found in the microscopic exainiiiiition of the tumor shown in tlie previous figure, a. Section from the peripheral part of the growth, showing "indifferent" or "granulation tissue," with isolated j)igment-cells among it. At one point a l)loodvessel is seen. 6. A portion of the growth more highly magnified, showing large spindle-shaped branching cells, many of them quite filled with pigment— From a drawing l>y Dr. T. H. (heen in the Path. Soc. Trans., vol. xxiii, p. 17G. ^ In exceptional cases, however, recurrence after operation may be long delayed. Mr. Pollock removed a melanotic tumor from the thij^h, and afterwards one which showed itself in an inguinal gland '''' ^~^ *"''"" "'"'^" fl(-t„„., „^o,.o afterwards ^ Even in this plate it is doubtful, as Mr. Arnott say characters are not rather those of round-celled sarcoma. ^ Syst. of Surg., 2d ed., vol. i, p. 574. No recurrence had taken place fifteen years whether the anatomical 374 TUMORS. Fig. 172 The diagnosis of osteoid cancer is sometimes rendered self-evident by the presence of bony masses in the glands, otherwise it can only be formed by anatomical examination or by the nature of the recurring tumor. I would refer the reader to the chapter on Disease of the Bones for further particulars with regard to this form of cancer. EpithcJioma. — The other indubitable form of cancer is the epitiielial, or epithelioma. This form of cancer takes its origin from the epithelium of the part in which it grows, and is therefore always de- veloped from the surface, or from the parts in contact with the surface of the skin, or mu- cous membrane. A favorite seat of epithelioma is the orifice of some cavity (mouth, anus, vagina, urethra), where the skin and mucous mem- brane become continuous. It usually appears as a hard flat- tened lump, the surface of which easily breaks down and ulcerates, and which readily affects the nearest glands. Its connection with simi)le in- flammation is very close ; the continuous irritation of some foreign substance is an un- doubted cause of the disease, as, for example, that of a clay pipe in causing epithelioma of the lip or tongue, of soot in the rugse of tiie scrotum in causing chimney-sweep's cancer, of retained secretion under a phimosed prepuce in causing epitlielioma of tlie penis. And the enlargement of the glands is often due merel}' to ordinary inflammation, and will subside completely after the removal of the tumor.' On microscopic examination tlie epithelial ele- ments are very distinct, in the form of large nucleated cells, often bearing a very close resemblance to those of the ei)idermis, frequently arranged in concentric lamiii.'c like the layers of a bird's nest, while in other cases the cells liave no definite arrangement, but lie heaped confusedly together among the fibres of tlie stroma. Epithelioma is esi)ecially prone to break down and ulcerate, and is the fortn of cancer which usually gives rise to the cancerous ulcer (lescrii)ed in a subse(pient chapter. Epithelioma, although it appears to me to realize moi'e exactl}' than any of the other forms of cancer the anatomical descriptions of carcinoma Epithelioma. "A section through a chimney-Sweep's cancer of tlie scrotum, representing two nests ('laminated capsules' 'globes epidermiques'), the larger one display- ing the structure of these bodies — plump epithelial cells in the midst, surrounded by drier and flattened scales; whilst the smaller shows a more common appearance, tlie cells being so flattened and alterc d as to resemble a ball of hair ; both nests were imbedded with numerous others in the subcutaneous tissue." — I'rom Arnott, ibid., Fig. 21. ' Mr. Arnott puy.'' : " Theso bodies are commonly mot with, in greater or less number, in all epithelial eancer.«i, thoii.^ vol. xxxix), who speaks of it as never infecting the glands, as not prone to affect the liver and lungs, as true cancer peculiarly is, and as not prone to recur after complete removal. The anatomical characters of colloid, however, certainly seem to agree in essentials with those of carcinoma, and, as far as can be judged by the rather rare cases which become the subjects of surgical operation, it is quite as prone to recur as epithelioma is, and cases in which the glands have been affected are not wanting. It appears probable, as Mr. Croft has said,' that "some tumors are colloid in character from the outset, others appear to undergo a colloid change," and it may be possil)le that the nature of the developed tumor may depend on that of the one which it has replaced. Villous tumors, or papillomata, are now almost universally allowed to be in general not cancerous. They spring from mucous surfaces, and the situations in which thej' are most commonly found are in the bladder and rectum. Very striicing instances have been put on record of the differ- ence which generally marks their course from that of cancer.'^ Nor is the anatomy of the disease that of cancer. The tumor consists usually of a loose floating mass of processes with a dendritic arrangement, springing from a base, in which no cancerous elements can be detected. The vil- lous processes are composed " of a fine membranous envelope like the finger of a glove, inclosing a quantity of granular matter in which nu- merous cells are imbedded, which are chiefly spheroidal in form, and can- not be distinguished from those of the membrane adjacent to the villous growth." These villi bear the most exact resemblance to the villi of the chorion.' It appears, however, undeniable that cancers may be covered b}' a similar villous growth. The anatomical diflerence, therefore, between a sim[)le and a cancerous villous growth would rest on the presence or absence of cancer underlying the villous surface. Clinicallj' the rapidit}"^ of growth and acuteness of symptoms would enable the surgeon to form a diagnosis, which, however, in many cases would be only conjectural. These are all tlie new growths which appear to me to require separate description as coming within our definition of tumors. For the other forms of growth which are described in some systematic treatises under the head of tumors, I would refer to other parts of this work. Thus the reader will fiml Lymphoma or Lymphadenonia spoken of under the Dis- easesofthe Absoi-bent System; Neuroma under those of nerves; Adenoma under tliose of the breast, prostate and other organs where polypi of that kind are met with. 1 In the account of the case from which Fig. 173 is taken, Path. Soc. Trans., vol. xxiii, p. 2fi8. * Hini below, in the chapter on diseases of the bhiddcr, jui ilhistration taken from a typical case of villous tumor in that oru;;in ; and see Patii. Trans., vol. xii, p. 120, for a striking example of villous tumor of the rectum. In both these cases the tumor was clearly of an innocent nature. » See a "jia|)er by Mr. Sibley in Path. Trans., vol. vii, p. '212, where the villi from tumors of the intestine and bladder are figured side by .side with those of the chorion. SCROFULA. 377 CHAPTEE XVIII. SCROFULA. The terms "struma" and "scrofula" are usually regarded and em- ployed as synonymous ; but some writers make a diiierence, and a very important one, between the two. In the most intelligible sense of the words, and in the class of cases which are most easy to diagnose, scrof- ula or struma is the constitutional diathesis which leads to (or which tends to lead to) the deposit of a substance called " tubercle" in various organs of the body. Tubercle is described as being of two kinds, the gray or miliary, and the yellow or crude. The latter is now regarded by most authors, following the authority of Virchow, as a secondary stage of the former. Gray or miliary tubercle is " a grayish-white, translucent nonvascular body of firm consistence and well-defined spherical outline, usually about the size of a mil- let-seed. Although in its earlier fig. 174. stage it is uniformly translucent, its central portions quickly be- come opaque and yellowish, ow- ing to the retrograde metamor- phosis of its component ele- ments. In structure tubercle, like the other ' l3Miiphomata,' consists of lymphatic cells con- tained in the meshes of a very delicate reticulum. The cells are mostly round, or roundly oval, colorless, transparent, and slightly granular bodies, much resembling lymph - corpuscles ; and, like these, varying consid- erabl}' in size ; many of them contain a small distinct nucleus. In addition to these there are a few larger cells, containing two or even three nuclei."^ These minute gray granulations are often aggre- gated together into larger masses, and then, though the granulations themselves are essentially nonvascular, vessels may be found in the inter- stices of the aggregate mass belonging to tissues interposed between the component parts of the mass. The deposit of miliary tubercle is pe- culiarly apt to follow the course of the small arteries and capillaries, and seems first to occur in the " adventitia," or fibrous envelope of the ves- sels." This aggregation of tubercle softens into a yellow caseous sub- Elements shown by teasing out a miliary tubercle, after Rindfleisch. 1. The large tubercle-cells. 2. The small tubercle-cells. 3. Endogenous cell development. 4. Delicate recticulum from the interior of a miliary tubercle, the cells partly removed by pencilling. ^ Green's Pathology, pp. 146-7. ^ See Rindfleisch, op. cit., p. 137, and Wilson Fox, On the Artificial Production of Tubercle, where beautiful representations of its microscopic structure will bo found. 378 SCROFULA. stance, and in that condition forrns the yelloiv or crude tnbercle.^ Be- sides the cells floured above as typical of tubercle, all sorts of debris are met with in microscopical examination — "ill-formed epithelial cells, masses of pigment, crystals, and plates of cholesterin, remnants of in- closed and distintegrating tissue" (Savory). As the yellow tubercle de- generates it undergoes one of two forms of metamorphosis. In most cases it softens and breaks down, and in this degeneration the tissues around are involved. They become disintegrated by low inflammation, and thus a strumous abscess, vomica, or strumous ulcer is formed. It seems that this softening may either commence in the centre of the tuber- cle, and thence gradually spread to the tissues, or else the inflammation of the latter may involve the destruction of the tubercle. In other cases the tubercles harden as they degenerate, the fluid parts are absorbed, leaving a hard, chalky mass, the cretaceous tubercle, and this change may affect the gray granulation as well as the crude tubercle.'^ In this condition the withered, dried-up mass generally remains innocu- ous, though sometimes, as Sir J. Paget points out, renewed suppuration is set up around it (" residual abscess"), and thus it is cast out. It is indisputable, however, that cases described as scrofula are often nnasso- ciated with any visible deposit of tubercle, and this leads to two ques- tions: 1. Is there anything essentially peculiar in tubercle, or is it merely a form of chronic inflammatory deposit? and, 2. Is the presence of tu- bercle, or a tendenc}' to its development, a necessary characteristic of scrofula, or is there a distinct class of scrofulous affections in which there is no such tendency? To the first question there is much reason for giving a negative answer. The researches of Drs. A. Clark, Burdon Sanderson, and Wilson Fox have shown that by the inoculation of non- tubercular products, or by artificial irritation of the tissues in the lower animals, products indistinguishable from tubercle may be generated ; and this doctrine lends strong support to the belief which experience justifies, and which has been expressed by myself and others,'^ that tuber- culosis in the human subject is often the result and not the cause of some exhaustive suppurative lesion which, being described as "scrofulous," is often regarded as being dependent on the diathesis, of which, on the contrary', it is itself the cause. If we assume that these experiments made on the lower animals are exactly applicable to man Ave shall conclude that the deposit of tubercle is only a more definite form of chronic inflam- matory lymph; or, in Dr. C. J. B. AVilliams's words, that tubercle is " a degraded condition of the nutritive material from which old textures are removed and new ones formed, and that in its origin it differs from the normal jjlasma or coagulable lymi)h, not in kind but in degree of vitality and ca[)acity of organization." If we regard tubercle in this light, the difficulty which has always been felt in distinguishing between a crude tul)ercle and a mass of old 13'niplio-pus is easily accounted for, and the occurrence of cases in wliicli there is a constitutional predisposition to low inflammation, though no characteristic masses of tubei'clc are de- tected anywhere in the body, is )iatnral enough. Two forms of struma are spoken of both liy Mr. Savory* and by Sir 1 Chfiraotoristio illustrations of tho nikod-cye appearance of crude tuburclfi will be found in tlio ctiajjtc^r oti Discuses of IJono. 2 lioUitansky, who 7-ci,Mrd('d tlic two kinds of tubercle as independent, speaks of this as the only metannorphosis which the gray granulation undergoes. 8 See Wilson Fox, op. cit., pp. 27, 28. * Syst. of Surg., vol. i. FORMS OF SCROFULA. 379 W. Jenner/ The former speaks thus of the two forms : " In the first, distinguished as the sanguine or serous, there is a general want of mus- cular development; for, although the figui'e maybe sometimes plump and full, the limbs are soft and flabl\y ; tlie skin is fair and thiti, showing the blue veins beneath it; the features are very delicate; often a brilliant transparent rosy color of the cheeks contrasts strongly and strikingly with the surrounding pallor: the eyes, gray or blue, are large and humid, with sluggish pupils, sheltered by long silken lashes; hair fine, blonde, auburn, or red ; teeth white and often brittle ; there is frequently a ful- ness of the upi)er lip and ala? nasi ; the ends of the fingers are commonly broad, with convex nails bent over their extremities. Such persons usu- ally possess much energy and sensibility, with elasticity and buoyancy of spirits; they often possess, too, considerable beauty. In this variety, with the same delicac3', the skin and eyes are sometimes dark. " In the second, distinguished as the phlegmatic or melancholic, the skin, pale or dark, is thick, muddy, and often harsh, the general aspect dull and heavy ; hair dark and coarse ; the mind is often, but not always, slow and sluggish. "Children especially, in whom the diathesis is strongly marked, are often distinguisiied by the narrow and prominent chest, the tumid and prominent abdomen, and the pastelike complexion ; the limbs are vvasted ; the circulation languid ; chilblains are common on the extremities ; the mucous membranes particularly, and above all of them the digestive, are liable to morbid action ; tlie breath is often sour and fetid ; the tongue is furred, and the papillae towards the apex red and prominent; the bowels act irregularly, and the evacuations are unusually offensive; the diges- tion weak, the appetite variable and capricious. In Dr. Todd's opinion, ' the strumous dyspepsia presents a more characteristic feature of this habit of body than any physiognomical portrait which has yet been drawn of it.' The relation of disorder of the digestive organs — the subject upon which Abernethy was so wont to insist — to scrofula was, many years ago, particularly dwelt upon by Lloyd. There is often a singular assumption of age both in character and appearance — in mind and manners they are prematurely old. " Moreover, persons, and especially children, possessing this diathesis are ver^' subject to certain atfections which are regarded by many as mani- festations of scrofula ; such, for instance, as various erui)tions, frequently seen behind the ears; chronic inflammation of the eyelids and conjunc- tivae ; a certain form of ophthalmia, described as strumous ; chronic ulcers of the cornea, etc." {Op. cit., p. 363.) Sir W. Jenner also divides the strumous diathesis into two forms: 1. Tuberculosis, the leading pathological changes of which are " fattj' de- generation of the liver and kidneys, deposits or formations of tubercle and their consequences, inflammation of the serous membranes;" and (2) scrofulosis, the leading pathological tendencies of which are "inflamma- tion of the mucous membrane, of a peculiar kind ; so-called strumous ophthalmia, inflammation of the tarsi, catarrhal inflammation of the mu- cous membrane of the nose, pharynx, bronchi, stomach, and intestines ; inflammation and suppuration of tlie lymphatic glands on trifling irrita- tion, obstinate diseases of the skin, caries of bone." I would prefer to substitute for "caries of bone " "low inflammation of bones and joints." Sir W. Jenner attributes to his " tuberculous " class the same general characters which Mr. Savory specifies as characteristic of the "sanguine 1 Lectures on Rickets, Med. Times and Gaz., 1860, vol. i, p. 259. 380 SCROFULA. or serous " type of serofula. and to the " scrofulous " those which charac- terize the "i)hle<>ii)atic or nielaucholic " type. No doubt the distinction pointed out by Sir W. Jenner in the tendencies of these two forms or types of scrofula is very generally true, and is important to bear in mind; but I do not tliink that the two types are so far distinct from each other as to justify us in regarding them as different diathetic conditions. If we do so regard them we should use the word "struma" as the general term for both the diatheses — the one in which tubercle is met with being called tuberculosis, and the one in which only low inflammations are developed scrofulosis. From what has gone before it will result clearly that the diagnosis of scrofula cannot be a very decided one. If we agree that tubercle itself, which is the most recognizable anatomical peculiarity of the diathesis, may after all be onl^' a modification of ordinary inflammatory lymph, it cannot surprise us that many cases which one practitioner will denomi- nate as "strumous " another will regard as examples of chronic inflam- mation. My own impression, derived from a tolerably extensive experi- ence of cases of so-called " strumous " disease of joints, is that the great majority of them are usually the results of slight injury, and have no connection of anj^ sort with any constitutional peculiarity ; and I am glad to see this view of the case gaining ground and obtaining the support of eminent practical surgeons. The question, indeed, of the causation and of the prognosis of struma is of the most essential importance when we come to give advice about the treatment of any case diagnosed as " stru- mous." If struma were, as we conceive cancer to be, a general blood disease, or a tendency in the constitution which has indeed local mani- festations, but these only subordinate, and, as it were, accidental, the inference is irresistible: that the way to cure the complaint must be by modifying the general disorder, so as to restore the blood or the S3^s- tem to a health}^ condition, and that the local conditions are of subordi- nate importance: and this is the view which has prevailed hitherto, and wliich is still most extensively entertained. If, on the contrar}'^, we be- lieve that these strumous diseases are often only instances of common inflammation, and that their relation to the general disease is often that of cause, not that of effect, the motive for curing the disease b}' surgical interference at the earliest possible moment becomes even stronger than in other cases. Causes. — The causes of scrofula are not very easy to ascertain. It is undouI)t{'dly true tliat hereditary- predisposition plays a very great part in tlie prcjduction of the disease ; and it is also, I think, indubitable that it may be caused l)y any permanent source of malnutrition, such as bad air, insufficient clothing, bad or scanty food, and I would add, the de- pressing influence of prolonged suppuration and confinement. Trealmcnl. — The treatment of scrofula must be regulated according to our views of its causes. We cannot act upon the liereditar^^ predisposi- tion further than by enforcing increased caution in tlie management of such children and young persons as are clearly under its influence, so as to witlidraw tiiem as far as may be possil)le from all the agencies by which the diathesis may be subsequently acquired. When tlie disease is once develoi)ed every condition which can improve the patient's general health must, as far as possible, be secured. Fresh air, moderate exercise, the free action of tiie skin and bowels, an c(iuable and temperate climate, residence by the seaside, a bght, nutritious, iinstimulating diet, are, as a general rule, of more importance than medicines, and routine practice is as bad in strumous as in other cases. But there can be no question of the TREATMKNT. 381 great advantages which are obtained by the judicious administration of cod-liver oil in cases accompanied by emaciation witlioiit much dyspepsia, of iron in those where anjemia is a prominent feature, of the syru|) of the iodide of iron where the patient is weak, fat, pale, and flabby ; of bark and mineral acids in cases where hectic is present; of alkalies in combi- nation with sarsaparilla or milk, along with the moderate use of i)urga- tives, where the secretions are disordered and the digestion fault3\ Of these, by far the most important agent in the treatment of scrofula is the cod-liver oil ; and, although there is no space in tliis work for details which more fitly belong to a treatise on therapeutics, yet I must state the most necessary precautions in the use of this drug. The chief objection to its use is the nausea whicii it produces, especially at first. This is much diminished by commencing with small doses, and by giving the oil on a full stomach — about a quarter of an hour after meals. The full dose for a child would be about two teaspoonfuls and a tablespoonful for an adult. The taste may be very successful!}' disguised by floating the oil on orange wine or tincture of orange, or steel wine ; or by mixing it with five or six drops of Liq. Strychnitie, or a little mineral acid. Often, if the patient can be induced to persevere, his repugnance to the oil will wear off; and as the oil will have to be taken for many months, if it agrees, it is well worth some trouble to establish this tolerance. After a time pa- tients, and particularly children, can take it as an ordinary article of diet, not only without disgust but with pleasure. I should be sorry if anything which I have said above as to the neces- sity for eradicating strumous diseases, or diseases reputed strumous, before they permanently impair the health, should mislead the reader into the idea that I advocate hasty operative interference in such cases. They are essentially chronic maladies, whether we regard them as local or constitutional in their origin, and the great majority of them can usually be brought to a successful issue by the mildest treatment, i. e., by laying open any suj)purating cavities, dressing exposed surfaces with mildly stimulating lotions or ointments, and keeping the parts at rest. It is only when prolonged suppuration, or this conjoined with enforced deprivation of air and exercise, is breaking down the health, or when extensive disease of the bony or other structure of the part holds out no hope of natural cure in any reasonable time, that I advocate the removal of the affected organ by excision or amputation; and I tliinkthat I have had abundant experience even in my own practice to show that such operations are usually followed by complete and permanent recovery in cases which would by every one be classed as strumous.^ Scrofula is generally a disease of youth ; but similar symptoms appear sometimes after middle age, and have lately been more especially described by Sir J. Paget {Clinical Lectures^ 1875) as "Senile scrofula." The dis- ease at this age holds out little prospect of cure, but the general indica- tions of treatment are the same. 1 See a paper in the Lancet, Feb. 24th, 1866, on The Sequel in some Cases of Excision and Amputation. 382 HYSTERIA. CHAPTEK XIX. HYSTERIA AND NERVOUS DISORDERS. Hysteria is a disease which it is very difficult to speak of intelligibly and adequately within the compass of a work like this. Yet, as there is no disease which it does not sometimes simulate, and as the diagnosis between real or, to speak more correctly, organic disease and hysterical or nervous affection is of daily importance and of the greatest difficulty in some of the most common surgical complaints, notably those of the spine and joints, it is a condition which cannot be passed over unnoticed in any systematic treatise on surgery. Besides the general remarks in tliis chapter the reader will find observations on the various special affec- tions in other parts of the book — especially in the chapters on diseases of the Joints, the Spine, and the Breast. I have just said that it is more accurate to speak of hysterical disease of a part as contrasted with " organic " than with " real " disease ; and this is very important. Hysteria is sometimes spoken of as if it were unreal — a mere fancy — perhaps a mere simulation. Such a view is most erroneous, and practice founded on it cannot be successful. The struc- ture of the part is not as a rule in any visible or tangible way affected (though to this rule some exceptions will be pointed out), and there is no danger to life or limb ; yet it is impossible to doubt that in many, and I would say most cases the sensations are as real as those of any other disease, and the patient as anxious to be rid of it as of any other disease. Tlie cause of the disease may be imperceptible to our senses ; but it is none the less really present, and its effect is as real as any tumor or other visible product. Perhaps the best definition of hysteria would be tiiat it is a morbid state in which various symptoms are produced depending, not on disease of the part affected, but on some condition of thti central nervous organs. That condition was supposed to be excited in the cerebro-spinal centre by uterine disturbances when the disease was named, and doubtless such disturbances are a frequent exciting cause ; but the disease may exist in women whose uterine functions are perfectly normal, and even (though not so often) in men. In these latter cases the origin of the hysterical disturbance is obscure ; and in tlie case of disordered uterine functions, tliough the cause may be plain enough, its mode of action is utterly unknown. Hysteria differs from mere delusion, hypochondriasis, or fictitious dis- ease in the fact that the morbid sensations or other symptoms are due to a really existing physical cause — though it is remote from the part affected, and though its detection may be difficult; but it must be allowed that much of delusion and hypochondriacal exaggeration is mixed up with almost all cases of hysteria, and that in many of them the patient wilfully exaggerates many of tlie symptoms, and very likely feigns others. So that there is a mixture of mental and jjhysical causes in the disease, and its cure must be attempted by treatment addressed to the mind as well as to the body. SYMPTOMS AND DIAGNOSIS. 383 ^''Nervous Mimicry.'" — Sir James Paget, in a strikinor series of lec- tures on this subject, recently publisherl,' wishes to abolish the old term "hysteria" altogether, at least to restrict it to the mere hysterical convulsive affection. The great class of diseases usually spoken of as hysterical he would call "neuro-inimetic," or "nervous mimicries" of the diseases of the various organs. As a general rule he denies tliat such diseases have any more connection with the sexual than with any otlier system of organs in the body. "In the defective ovarian or uterine func- tions of certain patients," he says, "some see the centre and chief sub- stance of the whole disease: a very mischievous fallacy. Of course, the sexual organs appear generally in fault to those who are rarelly consulted for the diseases of any other part; but in general practice they are, in a large majority of cases, as healthy as any other parts are, or not more disturbed. The close and multiform relations of the sexual organs with the mind, and with all parts of the nervous sj'stem, are enough to make the disorders of these organs dominant in a disorderly nervous consti- tution ; but their relation to 'hysteria' or to 'neuromimesis,' though more intense, is only the same in kind as that of an injured joint or an irritable stomach. All, in their degrees, may be disturbers of a too per- turbable nervous system, and equally on every one of them the turbu- lence of a nervous centre may be directed with undivided force." (Op. ciL, p. 191.) In fact, nervous or hysterical disease may be excited by anything which makes a strong impression on the nervous system : whether it be sexual disturbance, imagination, bodily injury, mental affection, intense emotion, or any form of disease. Symptoms and Diagnosis. — The usual manifestations of hysteria are the hysterical fit, the globus hystericus, the clavus hystericus, and the diseases resembling those of various organs. The hysterical fit may be taken as a simulation of epilepsy, though it is usually distinguished from it by characters too obvious to allow of any mistake. It begins generally with rising in the throat, a sense of chok- ing, followed b}' wild, convulsive movements, or rather semivoluntary movements resembling convulsions, with partial or sometimes complete loss of consciousness, flushed face, eye usually sensitive to light, the fit ending generally in crying, screaming, and laughing. This is followed by a copious flow of pale urine, very often by tympanitis, and generally by profound sleep. Sometimes one fit, or a succession of fits, may last for several hours. The diagnosis and treatment of hysterical fits is more within the prov- ince of the physician than the surgeon. The imperfect insensibility, the absence of any obstruction to respiration, the age and sex of the patient (for true fits hardly ever occur in male hysteria), are the main distinctive marks. No treatment should, as a general rule, be adopted beyond see- ing that the patient does lierself no harm by her movements, and limiting the officiousness of bystanders. The rough awakening of a cold douche or some other similar shock is often effective enough in dispelling tlie fit, and it may occasionally be advisable to use such measures, but ordinarily they do more harm than good. The globus hystericus is tlie sensation of some weiglit or substance which rises from the abdomen into the throat, and this sensation is often followed by the choking and otlier phenomena of a fit o*f hysterics. The "clavus," or hysterical headache, is a feeling as if a nail were driven into 1 Clinical Lectures, p. 172 et seq. 384 HYSTERIA. the head. It is a common and troublesome but subordinate feature in the general disease. The main point, however, in practical surger}^ is to distinguish those surgical diseases which are hysterical or nervous from the organic affec- tions of the same organs. Tlie joints, the spine, and the breast are the most frequent seat of h^'sterical pain and loss of function ;^ but hysteria may simulate almost any surgical as well as medical disease, and the diagnosis is often rendered the more perplexing by the fact tliat hysteria very frequently aggravates, and sometimes masks, diseases which really exist ; so that in the former case the surgeon, seeing that there is distinct proof of organic disease, is apt to attribute grave im- portance to what is really only a trifling complaint aggravated by hys- terical symptoms; while in the latter case the symptoms of hysteria are so prominent that he overlooks some disease which is really present. The diagnosis between hysterical and organic affections rests mainly on the following considerations : 1. The podn in hysteria is usually inter- mitting, irregular, and often much in excess of anything that the visible condition of the parts can account for; it bears no relation to the dura- tion of the disease, and is often obviously affected by emotional causes, and often b}- the state of the uterine or digestive functions. It differs from true neuralgia in not being general periodic and in not following the distribution of any nerve, though in many cases hysterical pain is called neuralgia. 2. The tenderness which is almost always complained of is diffused, and is, as it were, inconsistent. Thus, for instance, in hysterical disease of the spine the patient will often complain of quite as much pain from a light touch to the skin as from pressure made on the vertebral spines themselves, and it is greatly aggravated by tlie patient's own attention being directed to it : a patient who, while her attention was fixed on the surgeon's examination, could not bear the lightest touch on the back without complaining of acute pain, will often be hardly sensible of firm pressure, if made at a moment when she is eagerly talk- ing of something else. 3. The course of the disease is, however, one of the main elements in the diagnosis, and perhaps of all others the most satisfactory in cases wliich are otherwise somewhat obscure. We have only too often opportunities of seeing poor women who from unfortunate errors in the diagnosis have been condemned to years of total inactivity for supposed spinal or articular disease ; yet no abscess, no deformity, no material alteration in the shape of the parts has resulted,'^ still less any of the formidable consequences which inflammation would have pro- duced on the parts in the neighborhood. It is, however, noticed, and not in<^leed very rarely, that there is some tumefaction round the seat of the disease, often the result, as Sir B. Brodie tells us, of local applica- tions,' but also present, I think, in some cases where no friction or blistering has been employed, and then probably the result of conges- tion. The cause which produces such congestion is no doubt the pain, for the pain in h^'sterical disease is often (as I have said above) as real as any other pain, and pain easily affects the suppl}'^ of blood to the part, just as in periodical neuralgia the pulsation of small and previously * Sir B. Brodie says that " among tho hiijher classes of society at least four-flfths of th(! fomale patients who are comniDnly supposod to labor under disease of the joints liihor under hysteria and nothing else." Sir B. Brodie's collected works, vol. iii, p. 157. ^ Sir J. Paget gives some striking instances of tho perfectly heulthy condition of joints aft/'r prolonged disuse (op. cit.. p. 20G). 3 Op. cit., p. 159. TREATMENT. 385 invisible arteries becomes plainly perceptible before and during the paroxysm. Sir B. Brodie has noticed that in some hysterical affections of the joints there is a periodical change of temperature, not only of tlie part but of the whole limb, and he dwells on the value of quinine in such cases (Works, vol. ii, pp. 308, 309). These cases mark still more })lainly the affinity between hysteria and neuralgia. Temperatui'e in Hi/sleria. — Sir J. Paget has also pointed out the 'extra- ordinary' variations in temperature which sometimes occur in "nervous" maladies. As a general rule the temperature is an important fact in the diagnosis of hysterical affections, since it is far nearer the normal than it would be if the disease were organic; or, if it varies, the variations are limited and probably periodic. But these excitable and nervous patients are liable to great disturbances of temperature from slight causes, so that Sir J. Paget says of the temperature, that though "prudently estimated, it is of the highest value, even in nervous patients ; overesti- mated, it is more fallacious in them than in any others." General Character of Hi/sterical Fatienta. — These are the chief features in the diagnosis of hysterical affections from their local symptoms. Next the surgeon has to weigh carefully the general symptoms which the patient presents. The complexion of the patient's mind must be studied. The extensive experience of Sir J. Paget has taught him that " nothing can be more mischievous than a belief that mimicry of organic disease is to be found only or chiefly in the sill}', selfish girls among whom it is com- monly supposed that hysteria is rife, or almost a natural state." He believes it to be more true to say that these nervous diseases are seldom found in "patients who have ordinary' minds — such minds as we may think average, level, and evenly balanced"— but that in the majority of patients of this class " there is something notable, bad or good, higher or lower, than the average." Any observations, however, which may thus be made on the patient's mental constitution can amount to nothing more than a probability, and that not of a very high class. More tangible evidence may be obtained from the patient's family history; many of the worst instances of hysteria occur in girls brought up by mothers them- selves hysterical; from the circumstances of the case, many nervous dis- eases springing from the contemplation of cases occurring in the family or in public ; and from the strange possession which such diseases take of the patient's mind and will. "Few patients," as Sir J. Paget says, " with real hip disease or real spinal disease think half so much about their ailments as the}' do whose nervous systems imitate those diseases;" and he also gives some striking illustrations of the possession which such affections obtain over the will even of those who in other matters possess some firmness of mind ; so that " a man who has intellect and will to manage a great business .... cannot will to endure sitting u})rlght for ten minutes, or cannot distract his attention enongli to be indifferent to an unmeaning ache in his back." With the best attention the surgeon can give to the case it must be allowed that the diagnosis is often a ver}' doubtful one; and in order to justify a confident opinion in any but the plainest cases repeated exami- nation and observation are essential. Treatment. — Nothing can be more difficult than the treatment or man- agement of some of these hysterical affections. Too much attention on the part of the surgeon fixes the patient's mind on her ailment, increases its apparent importance in her eyes, and in many cases certainly tends to protract it ; on the other hand, roughness or neglect loses her confi- dence, without which all treatment is nugatory. The moral treatment 25 38G HYSTERIA. of hysterical affections is of as much impoitance as the medical, or more. The lifst point is to convince the patient that the disease is understood, and its real importance admitted, though not exaggerated. For we must allow that liysteria, though not dangerous to life, and seldom threatening the reason, is a very grave disease, and often entails lifelong misery on its victim. When, however, tlie patient is relieved from the worst anxie- ties, such as the fear of permanent paralysis, lameness, or other organic disease, the medical or surgical treatment of the case becomes easier. I can hardly do better than transcribe Sir B. Brodie's excellent remarks on the treatment of hysterical joint affections: '' The recovery of patients laboring under these hysterical affections is often tedious. But much depends on the treatment, moral as well as physical. The sulphate of quinine, preparations of iron, the citrate of quinine and iron, may generally be exhibited with advantage; and these may, according to circumstances, be combined with ammonia or the ammoniated tincture of valerian. In most instances the bowels are in a very torpid state, and active purgatives are from time to time required. The air of the country, and especially that of the seacoast, is more favor- able to the patient than that of a large town ; and while at the seaside she may use cold sea-bathing with advantage during the summer and earl}- part of the autumn. However, as to constitutional treatment, the best rule that can be laid down is, that the medical attendant should inquire into the state of the general health, and prescribe for tlie patient according to the circumstances of each individual case. If the menstrua- tion be irregular, deficient, or excessive, he should make it an especial ol>ject to restore this function to a healthy condition To a consid- erable extent these cases admit of being benefited by medical and surgical treatment ; but what I have termed the moral treatment of them is of still greater importance. If a young lady who is thus afflicted be con- fined to her sofa, her attention being constantly directed to her complaint by the anxious inquiries of her friends, the daily visits of her medicial attendant, and the exhibition of a variety of drugs, the symptoms may continue unaltered for many months, and even (and that is by no means an unusual occurrence) for several years. The very opposite course to this should be pursued. Her attention should be as much as possil)le directed to other objects. She should enter into the society and join the pursuits of persons of her own age. She should be encouraged to use the limb, even though the attempt to do so gives her pain in the first instance, and she should pass a portion of each day in the open air. Under this mode of treatment I have known many cures to i)e obtained without any medical or surgical treatment whatever."* Sir Benjamin also gives some direc- tions for the local treatment, as applicable to hysterical affections of joints. Such treatment must, of course, vary for different organs. Its general [)rinciple is to do as little as possible to fix the patient's attention on the part. Any plaster, bandage, or other application which keei)s the i)art' comlbrtably warm, and [jrevents the patient from handling or looking at it, may do good. Sometimes pain suddenly inflicted, as by the tnoxa or a galvanic shock, effects a wonderful cure, similar to Sir I>. Brodie's case, in which a young lady was cured of an hysterical i)ain in the hip by a fall from a donkey. An(l there are cases (as he also mentions) in which a sudden mental impression, such as a sudden call to " rise up and walk," has produced the desired result. But, as a general rule, little is required in the way of local applications beyond what is necessary to maintain the ' Sir IJ. Brodie's Work^, vol. ii, p. 309. COMPLICATIONS OF GONORRHCEA. 387 natural warmth of the part. Warm bathing is often of much service; and so is galvanism, if properly applied. Cold, Sir J. Paget says, almost always does harm. Narcotics and opiates are to be avoided by all means if possible. They are generally unnecessary and often most injurious, and should only be used when it is impossible to avoid it; and this impossibility should not be hastily admitted. I have often known patients habituated to the use of o[)ium for nervous pain who could l)y no means sleep without pills, but who slept quite as well when they were made of bread as of opium. At the same time the patient must have quiet sleep; and althougli exercise is to be enforced, yet long periods of rest afterwards arc needed. CHAPTER XX. GONORRHCEA AND SYPHILIS. The diseases which owe their origin to sexual intercourse are gonor- rhcEa and syphilis, the former almost exclusively a local disease, yet which has, as we shall see, its constitutional manifestations also ; the latter usually also entirely local, yet in its constitutional form one of the most insidious and abiding infections to which the human body is liable. Gonorrhoea differs widely in the two sexes. It is so much slighter a disease in women that the descriptions of it are always taken from the male sex. Four stages of the complaint are described, — the premonitory, the inflammatorj', the stage of decline, and that of gleet. The Fremonitory Stage. — The tirst lasts often only a few hours, some- times as much as two da3's, and commences generally from two to five days after intercourse — rarely later. It is marked by a slight itching and a little tumefaction of the lips of the meatus, and possibly some slight discharge, just enough to make the lips stick together. The Inflammatory Stage. — This is succeeded by the second stage, in which there is high inflammation of the lips of the urethra, and sometimes also of the prepuce, causing phimosis, with cream\^, greenish, purulent dis- charge, tenderness to pressure along the urethra, scalding in making water, which is sometimes so painful as to occasion much spasm and diffi- culty in doing so, even temporary retention ; a sensation of vveight in the perineum, and painful erections, especially at night. Sometimes char-dee is present, i. e., an ett'usion of lymph into the corpus spongiosum, which prevents distension of its cells in erection, causing the distended corpora cavernosa to bend over it, and thus giving the organ a curved shape, as if bound down by a cord. This, however, is rare by comparison with the occurrence of mere painful erections, and still rarer are the cases in which the ett'usion takes place into the corpus cavernosum, causing the penis to curve to one side in erection. The inflammatory stage lasts from one to three weeks. Its symptoms are due to acute inflammation and sometimes ulceration of the mucous 388 GOXORRIICEA. membvaiie lining the urethra, usually situated around the fossa navicu- laris and in or almut the bulb,' though it seems that any part or the whole of the canal may be aflected. The Sloge of Decline. — The third stage (which is, in fact, a part of the second) is marked by the recession of all the s3^mptoras, the scalding sub- siding, the discharge becoming more and more mucous, and the disease tlien either disappearing altogether or passing into the fourth stage, that of gleet, which is a mere thin water}'' discharge, unaccompanied by any symptoms except, perhaps, a little tenderness to pressure over the affected part of the urethra, the discliarge proceeding from localized in- flammation, or, as some think, probably ulceration of the mucous lining of the fossa navicularis or bulb. The common complications of gonorrhoea are as follows: Abs^cess may form in the areolar tissue of the penis or scrotum ; or, as is mucli more common, in one of the lacunfe of the urethra. Such ''lacu- nar abscess" also occurs from other causes, as from riding on a wet sad- dle or inflammation behind a stricture. It forms a small, hard, painful swelling in the course of the urethra, which often occasions considerable difficulty in micturition, amounting even to complete retention. For its treatment it is usually sufficient to apply a poultice and pass a catheter when necessary to relieve retention, in inquire into the I'atliiiiogy and Treatment of the Venereal Disease, published in 1807. INFECTING SYPHILIS. 399 of mercnry do not intend to assert that syphilis is any exception to the common rnles which are observed in all otiier diseases, viz.: (1) that dis- eases when left to themselves do not always run through all their phases, but that they may' be spontaneously cured and disappear at any period of their course; so that constitutional syphilis, though it naturally tends to produce secondary symptoms, does not always do so, but may disap- pear spontaneously and no secondary or tertiary symptcMiis ever Ibllow ; and (2) that remedies, however eliicient, are not always and uniformly successful; and therefore that mercury, though when thoroughly given it usually eradicates the disease, and especially if given as soon us the disease shows itself, yet does not always do so, and, therefore, that secondary symptoms are sometimes seen even after a perfectly satisfactory course of mercury. But many of the cases which are cited by the indis- criminate opponents of the nse of mercury (who, I may perhaps be ex- cused for saying, are not always very correct diagnosticians) in order to prove that constitutional syphilis can be treated with success by other means than mercury, so that no secondary symptoms will follow, were no doubt instances of mere local syi)hilis ; and in man}^ of the cases in which mercury is said to have lailed to eradicate the disease, so that secondary symptoms followed on its use, the course of mercury has been insuMicient, or it has been begun after the secondary sj'mptoms had really been developed. The best form in which to administer mercury has long been a subject of dispute. The common plan of giving it by the mouth has the advan- tage of requiring no confinement to the house, and being easily carried on without attracting observation — an important and in some cases almost indispensable condition in the treatment of these maladies ; but it has the disadvantage of seriously disturbing the digestion and general health of many ijatients. The mildest form, and the one least likely to disturb the bowels and derange the digestion, is the blue pill, which may be given in doses of 3 or 5 grains twice a day, with a small quantity (gr. ^-h) of powdered opium, this quantit}^ of opium being the smallest which is found necessary to obviate irritation of the bowels. This is to be continued for about six weeks, until all traces of the sore and all subcutaneous hardening around it and around the bubo has disappeared. During the course of mercury the state of the breath and of the gums should be cau- tiously watched. There is a peculiar fetor in the mouth, easily recognized by the initiated, and usually accompanied by a coppery taste, perceived by the patient, which generally precedes the spongy and congested state of the gums. When the latter sets in, and tlie blue line is seen round the roots of the teeth, it becomes a little unpleasant to the patient to chew a crust. If the mercury be pushed, in nndiminished quantity, salivation commences, and then the gums recede from the teetii ; the latter may drop out, and even the jawbones may become necrosed. At the same time a peculiar state of constitutional cachexia sets in, well knovvn in old days under the name of "mercurial erethism," of which, happily-, we see but little now, since the indiscriminate use (or rather abuse) of mercury has been given up. It is described by Pearson as being characterized by "great depression of strength, a sense of anxiety alxnit the praecordia, irregular action of the heart, frecpient sighing, trembling, partial or uni- versal, a small, quick, and sometimes an intermitting pulse, occasional vomiting, a pale, contracted countenance, a sense of coldness." He adds that in this condition any sudden exertion will sometimes prove fatal, and tiiat in his day almost every year one or two deaths took place in the Lock Hospital of men who had nearly, and sometimes entirely, 400 SYPHILIS. completed their mercurial course, for which he could find no other explanation.' Another mild and unirritating preparation of mercury, much in use when the drug is to be given for long periods, is the* " gray powder'' — Hydr. cum creta — in 5-grain doses, either in the form of powder or pill. The late Mr. H. C. Johnson used to use the Ung. hydrarg. made into the form of a pill, as bringing the patient rapidly under the influence of mer- cur}-, and generally agreeing well with the bowels.^ Calomel is more irri- tating, but also more powerful. It generally purges if given alone, but may be administered in 2 or 3 grain doses, with half a grain of opium, twice a day. The endermic method of giving mercury is much more easily tolerated, produces far less depression, and is quite as efficient; but it is not so easily carried out, especially in private practice. In hospitals it is exten- sively used, either by inunction or fumigation. The former consists in making the patient rub 3^^.-5] of the Ung. hydrarg. into the inner sur- face of the thigh (where the skin is thin) until the ointment has entirely disappeared. In the latter the patient sits naked on a cane-bottomed chair, witli a mackintosh sheet or a cloak or a common blanket wrapped round his neck and reaching to the ground all round the chair. Under the chair is placed a spirit-lamp, over which is a saucer containing a little boiling water, and projecting out of the saucer a shelf^ on which is laid powdered calomel, gr. x-xx. As the water evaporates its vapor mixes witli the sublimed calomel, and the fine powder is deposited on the moistened and relaxed skin, Avhich is thus prepared to absorb it. The quantity of calomel, of water, and spirit is so adjusted in the regular lamp that when the flame goes out the saucer is dry and all the calomel sublimed. The patient should sit quiet for a few minutes, then put on his nightgown, and without wiping the skin at all get into bed. In hos- pitals, when the patient is confined to bed, the bath may be given at any time ; in private practice it should always be at bedtime, since any check to the perspiration spoils the action of the remedy. It will usually be found that after about twelve baths, given every other da}', the patient begins to get slightly affected. Then the action should be kept up by decreasing the quantity of calomel, so tliat the patient should just be conscious of the mercurial taste. The action of mercury is made much more safe, speedy, and certain b}' confining the patient to bed, though, of course, this is seldom possible in ordinary cases of syphilis; and, as my late friend and teacher Mr. Cutler used to point out, it is a very useful jjrecaution to weigh the patient every thice or four da3s. A rapid loss of weight will often show that the remedy is disagreeing, and will s[)arc the patient some more disagreeable proof of the fact. When the patient cannot tolerate mercury the iodide of potassium may be administered, but it does not appear to exercise any radically curative effect on the syphilitic cachexia, though it rapidly removes some of its remote effects. The other alleged remedies for syphilis are now generally thought to be quite inert. 1 Sec South's Chelius, vol. i, p. 677. * Thf ff>rnuila for "Sedillot's pill" is strong nifrcurial ointment, soap, powdered mnr.slimaliow, Ih gr. of oafii. 3 Tills little apparjitus cjiri now bo hiid at any instrument maker's. If a proper apparatus is not at hand an extemporf! contrivance may Ix; made out of a common saucer with u piece of hot brick laid in the water, on which the calomel is to bo strewn. SECONDARY SYMPTOMS. 401 There are surgeons who, while they admit the power which mercury exerts over the constitutional manifestations of syphilis in its secondary form deny its power of preventing secondary symptoms, and therefore repudiate its use in primary syphilis. These are reduced either to an expectant treatment or to the extirpation of the sore by means of caustic. But there seems little proof of the advantage of such extirpation even when practiced during the period of incubation,' and no proof at all that when the sore has become developed any advantage could be derivecv from its removal. Secondary Syphilis. — The secondary symptoms of constitutional syph- ilis appear at a variable period after the original inoculation, usually not till after the primary sore has healed, which it will commonly do, if left to itself, in about six weeks, though harden^ing ma}' persist and the cica- trization may not be quite sound. The period, however, is quite uncer- tain at which secondary syphilis shows itself. In the great majority of cases it is under half a year, but there seems no time of life at which a person can be pronounced absolutely safe, though doubtless most of the liistories which we have of persons who have suffered from secondary symptoms a very long period after the primary sore are mistakes or wilful inaccuracies, the patient having really contracted the disease afresh in the interval. Sometimes, it is said, the advent of secondary syphilis is ushered in by what is termed " the syphilitic fever ;" " the patient feels feverish and uncomfortable, the skin becomes dry, and the tongue perhaps coated," and rheumatic pains are complained of, especially in the head and at night.- It is certain, however, that secondary syphilis is very often developed with no such premonitory symptoms. The first symptoms are generally either in the throat or the skin, the early skin eruptions being usually either roseola (very common in young girls) or lichen, and the sore throat being referred with great probability to the formation of similar spots on the mucous nien)brane of the mouth or fauces. The syphilitic eruptions which are peculiar to the secondary or earlier stage of the constitutional disease are all considered to resemble each other, and to resemble the primary sore in the fact that they depend on, or tend ^ In Lancereaux's Treatise on Syphilis, translated for the Now Syd. Soc, vol. ii, p. 304, will be found an account of some experiments by Sigmund in fifty-seven cases of probable syphilitic contagion, in the persons of physicians, accoucheurs, nurses, etc., who had been induced to place excoriated surfaces on their own bodies in con- tact with syjihilitic matter. Of twenty-two left to themselves eleven, exactly one- balf, became syphilitic. Of the other thirty-five, in whom the excoriated part was removed by caustic at various times from the first to the tenth day, ten became syphilitic. But twenty-four out of these thirty-five were Ciuiterized before the end of the third day, and of these only three became syphilitic. These facts, allowing their reality, would seem to sht)W, as far as such very small numbers can, that there would be some chance of removing the virus before it had entered the system, if we could know the spot on which it has acted, and destroy that part thoroughly by an active caustic ; but the opportunity for doing this in practice must be infinitely rare. It would tinly occur where a person knowing him or herself to have a crack oi' sore on the genital organs has been exposed to a suspicious connection, and then consults the surgeon at once; and in such a case it would certainly be justifiable to cauterize the sore freely with one of the active caustics. Lanceneaux himself, though he rejects the mercurial treatment in ordinary cases of primary's.ypi)ilis, even when the hard- ness of the Hunterian chancre is well marked, because he says it does not prevent the occurrence of secondary symptoms, yet admits its necessity when the hardening is long in disappearing. ^ In Lancereaux's work, vol. i, p. 125 et seq., will be found a very complete account of these premonitory symptoms of secondary syphilis. 2(5 402 SYPHILIS. to, the effusion of adhesive or fibrinous material in the neighborhood of the inflamed part, and tlie same is tlie case with the lesions of other parts of the body, as the eye, the bones, etc. As the disease progresses into its later secondary and into the tertiary stages the tendency to ulceration and suppuration becomes more marked.^ The earlier eruptions are either exanthematous (roseola), papular (lichen), tubercular (syphilitic acne on the skin,'^ mucous tubercle on the mucous surfaces or on their orifices), or squamous (pityriasis, psoriasis, and lepra). They are distinguished from the similar eruptions which are not specific partly by conforming less completely to the regular form, parti}' by their color, which in English works is generally described as copper}', and in the French more accurately as the color of lean ham, and partly by their circular or horseshoe form, and the tendency they have to disappear in the centre while creeping or spreading at their edge, from which the old term "serpigo" was derived. As the disease progresses vesicular and pustular eruptions are seen, the latter especially on the hairy scalp.'* JMany other tissues of the body are, however, affected in secondary s^'philis, though tiie deeper the parts affected are the later probabl}^ is the stage of the disease, and the more it approaches to the tertiary pe- riod. Thus the eye and tlie larynx are affected in the later secondary stage — both parts of the general surface of the body, but lying deeper than the common integument, and liable also to be involved in tlie ter- tiary symptoms. The superficial affections also of the bones (periostitis or nodes) are seen at the later periods of secondary as well as in the ter- tiary stage, but the deeper alTections of the bones (caries and necrosis) are as a rule tertiary symptoms. The ulcerations of the skin which are due to syphilis may he the result of the giving way of skin affected by secondary eruptions, but are far more common after the suppurating eruptions (pempliigus, ecthyma, and rupia) which are characteristic of the tertiary stage. The affections of the viscera, such as the tubercles in the liver and the ''cirrhosis" of the lung which are due to syphilis seem to be amongst its later manifestations, though in some cases they have lieen noted as secondar3^ MucouH Tubercle. — Other secondary symptoms must be briefly, but very briefly, mentioned. One of the most important is the development of "mucous tubercles," flat, raised, oval patches, generally situated at or near the junction of the skin and mucous membrane, covered with a whitish velvet}' epidermal tissue, and yielding a secretion which is easily inoculable, and which is probably a fertile source of syphilitic inocula- tion. Their usual seat is near the anus or vulva, and the mouth is a common situation, liut any part of the body may be affected, especially where the skin is in fohls, and where it is irritated by heat, dirt, and retained discharges. The local action of mercury is very beneficial in these cases. The tubercle generally disapi)ears rapidly under the use of powdered calomel, kept upon it by means of some simple ointment, strict cleaidiiiess being, of course, enforced. Syphilitic vegetations and con- dylomata are very nearly allied to mucous tubei'cle, and like it seem ' Lancereaux divides a complete attack of constitutional syphilis into four periods : 1. That of incubation. 2. Tliat of local eruption or primary lesion. 8. Tliat of general erupli'iti or .secondary atfeclion. And 4. That of gum m}' [gummatous] prod- ucts or terliary and quatcrnar}' alVections. 2 Acne is g(;herally, lit>w(!ver, a late secondarj- symptom, and is often regarded as one of ihe tertiary forms. 3 See, on Skin Diseases, the chapter on that subject in the sequel. SECONDARY SYMPTOMS. 403 decidedly contagious. Tliey will be best described in the chai)ter on Skin Diseases. One of the commonest of all secondary affections is sypliilitic baldness, or "alopecia." The hair of the head becomes thin, comes away plentifully in combing, and at length the patient may become almost or entirely bald. There are cases much less common in whicli the baldness attacks other parts, usually the chin and eyebrows. The remedy lies in shaving the head, applying some gently stimulating lotion,' or in more serious cases painting the part occasionally with blistering fluid. But far more important than the local treatment is the correction of the syphilitic diathesis by a proper mercurial course. Alopecia, like many other of the symptoms which usually are secondary, appears also in the tertiary stage of the disease. Alopecia is often accompanied by des- quamation of the epidermis — pityriasis, an affection which is essentially almost identical with the shedding of tlie hair. Onychia, again, is an affection, very nearly allied to the affections of the skin and liair, and is often described as a psoriasis of the nails. I must refer the reader on this point also to the chapter on affections of the skin. Syphilitw sore throat is an almost universal symptom in the secondary stage, and generall}' the earliest of its phenomena. But affections of the throat are also to be met with in the later secondar}^ and in the tertiary stages. The main forms of syphilitic sore throat are three :'" 1. The ulcer of the tonsils, a deep ulceration commencing on the surface of the central part of one or both tonsils, and accompanied by swelling and induration of the gland around it. This is said by Mr. Babington to be often ac- companied by a tubercular eruption. 2. The phagedenic or sloughing sore throat, commencing with ulceration on either the tonsils, the velum palati, or the pharynx, and often leading to extensive destruction of those parts. This is usually accompanied by rupia, and is therefore a later phenomenon. 3. The sore throat which is due apparently to tlie development of psoriasis on the mucous membrane of the fauces or mouth. This is distinguished by the opaque white color of the surface. "•This appearance sometimes supervenes at the edge of an ulcer on the tonsil. More frequently there is no ulceration, but simply this change of the surface, accompanied by more or less of redness, and as it were of excoriation of the neigliborhood, more or less swelling of the membrane, much soreness, but ver}' little pain. This superficial affection may attack any part of the tonsils, arches of the palate, velum pendulum and uvula, and even the tongue or the inside of the cheeks. It is very frequently to be seen at the angles of the mouth. It often occupies the soft palate, spreading upwards in a semicircular form towards the roof of the mouth. The white appearance may be removed by slightly touching it with caustic, and tlien the surface beneath looks as if excoriated." There are other forms also of syphilitic sore throat, but the above are those which are commonly met with. Affeclions of Glands — Next in importance to the affections of the skin and its appendages are those of the glands. It is an old and a very ob- vious observation in syphilis that the absorbent glands become less prone to sliare in the affections of the surface tlie later the stage of the disease IS. Thus in primary syphilis bubo is constant in the glands which derive their absorbents from tlie seat of the chancre ; in secondary affections of the skin the absorbent glands are not nearly so often affected, and in tertiary disease they are hardly ever enlarged. But the glands thcm- ' Mr. Nayler prescribes the following: Liq. Ammon. Acet. ^ss. ; Sp. Ammon. Co., ^ss. ; Glycerinas, §ss. ; Aq. Kosa; ad ^viij. 2 See Hunter's works, vol. ii, p. 415, note by Mr. Babington. 404 SYPHILIS. selves are very liable to secondary and tertiary' syphilitic enlargement apart from all atlection of the parts from which they derive their lym- pliatics. In those allections which are excited by the presence of eruption the gland is more disposed to inflammation than in tliose which are due to the eHect of tlie general syphilitic poison. The posterior cervical glands, those lying in the posterior triangle of the neck, are the most commonly atlected independently' of other organs in constitutional syphilis, forming a chain of hard, knotty tumors under the edge of the trapezius muscle, or the inguinal glands below Poupart's ligament. These glandular affections are more marked either at a late stage of the secondary or in the tertiary stage. The other common secondar}- affec- tions are those of tlie periosteum, of the testicle, of the larynx, and of the eye, for which I must refer the reader to the chapters on diseases of those organs. Inoculability. — That secondary syphilis is inoculable on a healthy per- son has been abundantly proved,' and practitioners of experience seem now to be of the opinion that syphilis is very often propagated in this manner. Mr. H. Lee has lately' called particular attention to the contro- A'crsy which has been going on ever since the days of Hunter on this subject. Hunter taught that the contagion of all venereal diseases — gonorrhoea, local syphilis, and constitutional syphilis — was the same, though he appears to have been perfectlj' acquainted with the fact that some kinds of syphilis are local only ; and he taught also that secondary syphilis was not inoculable on the patient's own body, while he doubted (though, as Mr. Lee shows, he did not deny, as he is usuall}' represented as doing) that it can be inoculated on a healthy person. The experi- ment on which Hunter mainly relied for showing the identity of the gonorrhoeal and syphilitic poisons was one vvhicli he made on himself, by inoculating on his own person matter taken from a patient suffering, as he thought, only from gonorrhoea, and this inoculation produced pri- mary and secondary syphilis. But Mr. Lee has called attention to the Cfjmparative frequency of discharges fi-om the male uretiira in secondary' syphilis which proceed from some inflammation of the urethra, the pre- cise nature and seat of which has not yet been ascertained, but which seems to affect any part of the tube from the prostate forwards.* This affection is analogous to those somewhat rare cases in whicli the l)ron- ciiial or the gastro-intestinal mucous membrane is aflfected in secondary syphilis, probably with some of the forms of eruption which are seen on tile skin. The matter with which Hunter inoculated himself was, there- fore, probably syphilitic. Treatment. — That secondary syphilis requires the mercurial treatment for its cure is admitted by many even of those who do not use mercury in tlie treatment of the primary disease. But the course of mercury must be more prolonged, and therefore milder, since the patient's general health is to be maintained during tlie whole period. The symptoms will, indeed, rapidly subside in many cases under the use of iodide of potas- sium, especially such as are accompanied by pcrcejjtible fll)rinous exuda- tion ; but it is, however, I think, more and more admitted that such cures are usually only temporary, and that for the complete eradication of the diathesis a full and prolonged mercurial course is necessary. No hesita- tion need be experienced in prescribing raercur3' in cases where there ' Sec Lancereaux, vol. i, p. 69. 2 Sec Mr. Lee's Lettsomian Lectures, publi.slicd in the Glh vol. of the St. George's Hospital Reports ; also bis Lectures at the Royal College of Surgeons in 1876. TERTIARY SYPHILIS. 405 is no ulceration or suppuration ; but when this is the case mercur}^ is generally held to be contraindicated. I think, however, that any one who will make trial of the fumigation of syphilitic ulcers or syphilitic eruptions of the pustular form, with very small doses of calomel (say 5 grains every night), will be convinced of the great benefit of this form of treatment. In many cases also of ulcerated sore throat fumigation or a mercurial gargle (as Liq. hyd. perchlor., with equal parts of water), acts most favorably. In conditions of extreme cachexia, indeed, every form of mercur}' may be inadmissible ; but in sucli conditions iodine is generally inadmissible also, and the patient's health must be renewed by careful feeding, stimulants in moderation, rest, and, if possible, in bed, tonics, and opium, before any definite treatment is commenced. I know of no tonic which seems so generally beneficial as the compound decoc- tion of sarsaparilla, a pint daily, with steel wine and laudanum if neces- sary. The administration of iodine and mercury together is a very successful plan of treating secondary syphilis. Thus the iodide of po- tassium may be given in doses of 5 to 10 grains, while the patient is undergoing a course of mild mercurial fumigation ; or the red or green iodide of mercury may be prescril)ed either in pill or draught. The red or biniodide is the salt generally used, and may be given in doses of Jg to 1^ of a grain in pill three times a day, or in a draught by combining the iodide of potassium, gr. v-x, with the liq. hyd. perchlor., 5ss.-j in some bitter infusion. Tertiary SijphiHs. — The tertiary stage of syphilis is distinguished from the secouflary in the same way as the latter is from the primary, namely, by the occurrence of an interval of health. The secondary symptoms have disappeared, with or without treatment, for I repeat that secondary syph- ilis does sometimes disappear spontaneously, and then, after a very varia- ble interval, commences tlie stage usually called tertiary, or, as Lance- reaux puts it, the stage of the gummatous products. The period which separates the latest from the secondary stage of syphilis is very uncer- tain, and often it is not separated at all, the secondary or exudative stage passing on into the tertiary or gummatous condition with no definite limit ; whilst at other times there is an interval of months or even years. The main distinction between the secondary and tertiary stages of syphilis is that the new growths in the former resemble more the products of inflammation regarded as a reproductive process, they resemble more the filirous tissue, while in the latter the}' resemble more the products of inflammation regarded as an ulcerative process. In fact, a gumma bears a very great resemblance to a granulation, and it is prone to soften, break down, and leave an ulcerating surface.^ It is not, however, in every part tliat such gummatous tumors can be observed preceding the ulceration of tertiary syphilis ; nor, again, do these gummata always ulcerate. In many cases the ulceration occurs without an}' recognizable deposit, being, however, probably preceded by a similar aplastic deposit diflfused in the cellular tissue of the part. And 1 Dr. Green thus describes the structure of gummata : " The gummata consist of atrophied and degenerated elements imbedded in a scanty and obscurely fibrillated stroma. The central portions of the growth are composed almost entirely of closely packed granular debris, fat-granules, and cholesterin, amongst which there may be an exceedingly scanty fibrillated tissue. Surrounding this, and directly continuous with it, is a more "completely fibrillated structure; while the peripheral jtortions of the growth, which are continuous with the surrounding tissue, consist entirely of small round cells, resembling granulation-cells and lymph-corpuscles. The bloodvessels, which only exist in the external portions of the growth, are very few in number." — Pathology, p. 120. 406 • SYPHILIS. in the interior of the body, as well as near the surface, tertiary syphilitic deposits may long remain inert, and then wither away into a kind of cicatrix or he reabsorbed. The affections characteristic of tertiary syphilis appear in every part of the body, and I cannot affect to give a complete account of the matter here. I will endeavor to direct the reader's attention to the points most commonly met with in practice. For the rarer and more dubious lesions which are connected with syphilis, such as the affections of the viscera and nervous system, special works on the subject must be consulted. The affections of the skin which are seen in tertiary syphilis are of the suppurative and ulcerative type — rupia and ecthyma are the commonest eruptions ; and the softening of the subcutaneous gummata frequentl}^ leads to ulceration. The various forms of syphilitic ulcer are described in the following chapter. Even more important than the external affec- tions are the diseases of the bones which so constantly occur in tertiary sypliilis, and which now no longer affect only the periosteum and exter- nal table of the bone in the form of nodes which show little tendency to suppuration ; but, on the contrary, the tissue over the bone rapidly softens and exposes a carious or necrosed condition of the bone itself, which is regarded as being the result of a similar aplastic deposit in the substance of the bone to that which we have just spoken of as met with in the cel- lular tissue of soft parts. These syphilitic affections of bone will be afterwards more fully treated of in speaking of the Diseases of the Bones. The glands are deep!}' affedted in tertiary syphilis, not exclusively or even mainly the absorbent glands (though the induration of the posterior cer- vical and inguinal glands is constant in tertiary syphilis), but also the great secreting and blood glands, the liver, spleen, thyroid, testicle, etc., and it seems probable that though generally the syphilitic deposit occurs in the form of definite masses (gummata or syphilitic tubercles), yet that the diffused waxy or lardaceous disease of these organs may also be sometimes of syphilitic origin. The nervous system is also profoundly affected, not merely by inflammation propagated to the brain, spinal mar- row, and nerves from their bony cavities, but b}^ tertiary deposit in the structure of the nervous masses or their membranes, leading to irritation or paralysis. Thus it seems that there is no part of the body which may not be and is not constantly affected in constitutional syphilis. The treatment of the tertiary must be the same in principle as that of the secondary stage of syphilis. But here again, as the cachexia is more profound, so must the treatment be milder, more supporting and stimu- lating, and longer continued. The iodine or mercury which may be nec- essary for tiie treatment must be introduced gradually in very small doses combined with tonics and opium. Wine and good food are essential. Change of air, a warm climate, and the use of appropriate mineral waters are most useful adjuncts to a treatment which must be carried on through so long a period of time. The length of time during which a course of mercury should be con- tinued is stated by Ricord' at about twelve months, and Lancereaux es- timates it at about half a year. In such prolonged courses the mildest prei)arations of mercury must be selected, the dose must be a very mod- erate one, intermissions must be allowed from time to time, and the prep- aration and vehicle must be varied. ' See Carter On the Principles of Oplitlmlmic Tlicrapoulics, St. George's Hospital Reports, vol. vii, p. 111. INFANTILE SYPHILIS. 407 Infavtile or Congenital Syphilis. — Two special forms of sypliilis remain to be described — infantile or congenital sy|)hilis and vaccino-syphilis. Congenital syphilis is a form of secondary or constitutional disease, transmitted to the foetus in utero eitlier through the blood of the mother or the semen of the father, or both. The old idea, that infants are inocu- lated with syphilis at the time of birth from syphilitic sores in the mother's vulva is given up. Without denying the possibility of such an occurrence, the disease which we usually see is strictly analogous to secondary syph- ilis, and is, in fact, a form of it, differing only in this, that the ])rimary sore has occurred on the body of the parent instead of the infant itself. The popular name of infantile syphilis is "the snuffles," and this ex- presses one of its chief features — a persistent coryza, or snuffling in the nose, along with which is a reddish or coppery eruption, usually either roseola or lichen, on various parts of the body, and especially on the genitals and on the palms and soles. In these latter situations, however, it is sometimes more of a scaly nature ; there are also very commonly crescentic patches of mucous tubercle on the interior of the mouth, on the lips, anus, etc. Combined with these symptoms there is a peculiar cachexia, a wasted look like that of age, and a good deal of emaciation, with a yellow complexion. These symptoms begin at a variable period. If they commence in utero they usually lead to the death of the foetus, and often to abortion. But very commonly they do not commence till some weeks after birth ; and it is believed that the affection in the parent becomes milder as the stage of the disease is later, so that the later children are less profoundly poisoned than the earlier. Thus there are families in which, after several abortions, a child has been born alive, but with advanced congenital syph- ilis, and soon died ; the next has perhaps survived, and the later children have shown no marks of the disease for the first few months of life, or even perhaps at all. The diagnosis of this complaint is a matter of much importance. My late friend Dr. Ballard published a paper which he read at the Medical Society of London, the effect of which would have been almost to shake our belief in the reality of congenital syphilis altogether. This conclu- sion I cannot accept, but I think Dr. Ballard succeeded in showing (what, indeed, I have always believed) that many of the cases which are diag- nosed as syphilis infantum are really only eruptions due to dirt and neg- lect. Children's skins are tender and irritable, and if they are allowed to remain wrapped up in hot dirty flannel in which urine and faeces are putref^'ing they will be affected with some of those eruptions which ai'e included by nurses under the vague name of " red-gum " — however healthy and sound may be their constitution — and such neglected chil- dren are also very likely to suffer from chronic cold ; but in the genuine instances of infantile syphilis the eruption is quite different from the effects of common irritation, and it is present on the soles of the feet, the palms of the hands, and in the mouth and cheeks, where no such cause is possible. Besides, the family history is a very powerful aid to the diagnosis, and in doubtful cases there is no objection to defer the spe- cific treatment until the effects of cleanliness and attention have been ascertained. When, however, the diagnosis is clear the mercurial treatment is ur- gentl}^ indicated. Infantile syphilis has its tertiary stage, though the phenomena are not very well understood. I have seen two or three cases in which the bones, especially of the palate, have been destroyed, and there seems no doubt that some of the gummatous tumors found in the 408 SYPHILIS. Sypliilitic teeth. — From a paper by Mr. Jona- than Hutchinson, Path. Soc. Trans., vol.x, p. 296. lungs, liver, spleen, and other viscera in childhood have been syphilitic. The affection of tlie cornea described b}^ Mr. J. Hutchinson as interstitial keratitis is admitted to be syphilitic, and so is the condition of the per- manent teeth which he has also described. The syphilitic keratitis will be found treated of in the cliapter on Diseases of the Eye, but a few words must be added here about the condition of the teeth. It is only seen in the permanent teeth, at least it is only in them that it can be recognized, since the milk-teeth are subject to so many irregularities that if any of these are due to syphilitic Fi«. i"G. causes it has not been found possi- ble to identify them. The affections of the teeth are believed by Mr. Hutchinson to be the effects of stomatitis merely;^ so that if a syphilitic infant escape stomatitis his teeth will not be irregular, and, therefore, the non-occurrence of this dental irregularity is no proof of the absence of s^'philis, though its presence is a strong confirmation of the diagnosis. The syphilitic characters are onl}' marked in the incisors and canines, which will be found to be small, of a bad color (dirty gray instead of pearl}' white), and notched, so as to display a deep groove on their edge, or sometimes several (serrated teeth), or two with a central projection (pegtop teeth). They are also soft, from deficienc}' of enamel, and therefore wear down easii.v, so that these characters can hardly be recognized after many years of wear. It is, therefore, only from the age of eight to twenty-five or thirty that any confident opinion can be formed on the subject. The occurrence, then, of tertiary symptoms after infantile syphilis forms a powerful argument for eradicating tlie disease by mercury, and the effect of the disease on the general health is a still stronger one. When mercur}'^ is administered in an appropriate case the general health, the complexion, and the digestion immediately improve, while under ordi- nary remedies (cldorate of potasli, etc.) the child may have been pre- viously deteriorating from day to day. I have frequently tested this experimentally. There is no necessity for giving large doses of mercury — in fact, they are not well borne b}' the bowels — nor, indeed, is there any need to ad- minister mercury by the mouth at all. If the mother or nurse be also syphilitic the calomel vapor-bath can ])e administered to both at o)ice with advantage ; otherwise the old plan recommended b}' Brodie answers admi- rably, viz., to make tiie child wear around its arm a piece of flannel about two inches wide, smeared with ung. hydr. The objection to this plan is that ignorant people tliink "nothing is l)eing done'' for the chiUl, and consequently are very liable to neglect the use of the ointment. In such cases 1.",- or 2 grs. of gray powder, witli 3 grs. of compound chalk-powder, ma}' be given twice a day. The treatment should last about six weeks, or al>out a fortnight after all traces of eruption, snuflles, and cachexia have vanished. No other treatment is needed, except cleanliness, and, if the obstruction of the nose is so extreme as to constitute an impedi- ment to sucking, constant cleansing of the nostrils by gentle syringing with an alkaline lotion. > Path. Trans., vol. ix, p. 449. INFANTILE SYPHILIS. 409 Under this treatment the disease is seldom dangerous, nor, indeed, is congenital syphilis, as far as I have seen, often fatal directl}' ; but many S3'philitie infants die, in consequence of the cachexia, being too weak to resist any intercurrent disorder. We ought not to quit the subject of congenital syphilis without noting the important observation of Mr. Hutchinson, which seems to be sup- ported by other experience, that healthy women may be infected with secondary syphilis by carrying syphilitic children. In such cases there is, no doubt, some difficulty in determining.whether the woman has been infected directlv from her husband or indirectly from her child. The test is, of course, the occurrence or non-occurrence of primary syphilis; but this may easily have been overlooked. A"on-co)}genifal Syphilift iu InfontK. — There is no doubt that syphilis is inoculable in the secondary as well as in the primary stage — in fact, one of the forms of secondary syphilis (the mucous tubercle) yields a secre- tion which is often very contagious — but other secondary sores may be communicated, though their contagion is less active than that of the pri- mary sore, so that it requires a longer contact in order to act, and takes a longer time to develop its effects. But it must be recollected that the effect of the inoculation of syphilis anywhere, whether primar}' or secon- dary, is to produce a chancre on the part inoculated. This appears to be the usual cause of the non-congenital form of syph- ilis in infants. In countries where wet-nursing is common it appears to be not very unusual for an infant when nursed by a syphilitic woman to contract the disease, either from secondary ulcers on the nurse's nipples, or from contact between some accidental abrasion on any part of its body and some sore on the person of the nurse. In the former case tlie chan- cre will be on the lip, and the bubo which almost always accompanies it will l)e in the glands under the jaw ; in the latter case the glands next in sequence to the inoculated crack will be affected. Vaccino-si/philis. — Tliis accidental syphilis of infants is exactly the same disease essentially as vaccino-syphilis, in which the S3'philitic poison is inoculated by mistake in conjunction with the vaccine matter. Such cases are rare, but it is impossible to den}' that they do occur, although it would appear that a very moderate amount of caution would prevent them.^ In vaccino-syphilis the vesicle soon suppurates, and the edges of the resulting sore become hard and chancrous,- the axillary glands- soon en- large and run the ordinary course of the indolent non suppurating bubo; the hair then begins to drop off, and eruptions show themselves on vari- ous parts ; in fact, the usual train of secondary- and tertiary symptoms ensue. Other ir?'egular foinns of Syphilis. — The treatment of these unusual instances of syphilis is exactly the same as that of the common disease; but their exceptional character renders the diagnosis somewhat difficult, ' The cautions requisite are well known. They are four in number, viz. : 1. Use a perfectly eleiin lancet. 2 Take the lymph not later than the eighth day after vaccination, so as to avoid any mixture of pus. 3. Take only lymph — no blood or any other secretion. 4 Examine carefully the child from whom the lymph is taken, so'astobe sure that it is not syphilitic It seems probable that the blood or any other secretion of a syphilitic person may convey the disease, and Mr. Leo believes that the mixture of blood with the syphilitic virus under any circumstances much increases the virulence of its contagion. Hence the desirability of taking lymph only; but there can be no doubt that most of the instances of vaccino-syphilis were produced by a neglect of the ordinary precautions — 1 and 4 above, "^ See pi. vii, Fig. 15, in Mr. Lee's essay. 410 SYPHILIS. as it is also in the irregular chancres that occur in adults. Such chancres are most common either on the lip or on the finger. A chancre on the lip does not present exactly tlie same appearance as it does on the geni- tals. It is generally much larger and flatter, and there is less induration around it ; but its indolent appearance, flat surface, and accompanying bubo in the glands beneath the jaw will generally indicate its nature to a practiced eye; and if there be much doubt a few weeks' delay will usually prove the existence of syphilis by the appearance of a secondary eruption. Chancres on the fijigers are still harder to diagnose. In fact, the natural action is interfered with in these exposed parts by the con- stant irritation to which the sores are subjected. But in doiilitful cases the effect of mercury generally settles the question, by producing the rapid subsidence of the sore and disappearance of the bubo, I have seen man}' instances of this in supposed epithelioma of the lip. Syphilitic Inoculation and Syphilization. — It remains to say a very few words about syphilitic inoculation. The purposed inoculation of syphi- litic matter into the body of a healthy person is an experiment which I cannot speak of as otherwise than unjustifiable, even if the subject be the experimenter himself, though we liaA^e the example of Hunter; and if done on another person, however well-instructed that person ma}^ be on the sul)ject, it seems to me little less than criminal. But to inoculate innocent and ignorant patients in a hospital, as has been done before now, is an action which should at once be made the subject of judicial punishment.' So far, I presume (at any rate in the last particular) most people would agree. Yet syphilitic inoculations have been most exten- sively practiced of late years in hospitals, on patients who could only very imperfectly apprehend the enormous risk which they were running for the purpose of testing a theory which teaches that, as the constitution may be made proof against a renewed attack of small-pox or scarlatina or any similar constitutional malady by saturating the body with the virus, so a person might procure an immunit^^ from constitutional syphilis if his or her system were once properly "syphilized," or saturated with the dis- ease.^ The analogy no doubt is good, if constitutional syphilis be inocu- lable on the patient alread}' affected (for not even the most ardent advo- cate of the method has proposed to give a healthy person syphilis in order to protect him from it) ; and that this was so was taught unhesitatingly by Kicord, who laid it down as a test of the infecting or constitutional disease that tlie matter from the chancre would reprocluce a similar chan- cre, if inoculated on a different part of the patient's own body; from the second chancre a third coulcl be produced, and so on, until after a variable number of successive crops of chancres had been produced (sometimes as many as fifty or more) the system would get charged with the virus and no further action could be elicited. And tliis was the treat- ment whicli was absolutely followed out for a long time in some Conti- nental hospitals, and wliich received a full trial at our own female Lock llosjjital in Ijondon. Mr. IT. Lee, however, teaches the very reverse of Ilicord's doctrine. He says that the chancres which are autoinoculable are the soft chancres, that the matter from a Hunterian chancre is only ' Can any ono road without indiijnation and di.«£jiipt the record of experiments such as tho.«e of Waller of Prat^ue, (quoted by ^Fr. Lee in St. George's Ho.^pital Reports, vol. vi, p. 0, where heiiUhv eliiidren wlio were elio.^en tor tlieir proved iniinunily from svfibilitic cachexia were inoculiitcd with tlie secretions of diseased prostitutes? No scientific end can for a moment justify the use of meun.s so barbarous and so criminal. '' Med.-Chir. Trans., vol. i, p. 281. ULCERS. 411 inoculable in its initial stage, before the characteristic induration has manifested itself, or at a later stage, whenever the sore has been artifici- ally irritated and made to sni^pnrate; and that even then the inocnlation will not last any long time, but that on the second or third trial it will fail ; while, on the other hand, the soft sore can be inoculated for an unlim- ited number of times ; and this doctrine seems to be a jyriori the more probable, and is now extensively accepted. If this be so, syphilization' would be doubl}^ unjustifiable, since at the end of the process the patient would only have procured immunity from a local action which was never formidable, and would have ceased much earlier if left alone, and an im- munity which is only temporary, as Mr. Lee demonstrated clearly by reinoculating a patient who had previously been tlioroughly syphilized not very long before, and was thought to have obtained complete protec- tion from all future infection. As a method of treatment, therefore, syphilization is now given up, at least in this country ; but it is still practiced as a means of diagnosis. If a sore be repeatedly inoculable it may safely be pronounced syphilitic. Secondary sores can be inoculated a few times, but not nearly so often as suppurating primary chancres. Those who hold unreservedly to Mr. Lee's doctrine w^ould believe that the repeated inoculability of a sore was a contraindication to the use of mercury. A very interesting question is, what degree of immunity does a patient obtain by a previous attack of constitutional syphilis against a renewed infection ? To this question we are not in a position at present to give an altogether confident answer. That there is considerable immunity from the risk of another constitutional infection cannot be doubted, but several cases, recorded b}' careful observers, seem to show that this im- munity is by no means so complete as in the case of the eruptive fevers, though in them it is not perfect.^ CHAPTER XXL ULCERS— CICATRICES, AND THEIR DISEASES. The process of ulceration has been described in a previous chapter (see p. 43). When this process has gone on for some time around a wound, so that it has spread to a large size, or when, as is more com- monly the case, a slough has formed and come away, the granulating surface which is left is called an ulcer, and it maintains this name till ' By syphilization is meant the process of inoculating the patient from the original sore (say on the genitals) in three or four places in a different {)art of the body, usu- ally the thigh, from these on another part, and so on, until sometimes the whole body is covered with the marks of more than 100 chancres. (See the cases recorded in the 50th volume of the Med.-Chir. Trans.) 2 See a series of cases of reinfection reported by Mr. G. Gascoyen, in the forth- coming (58th) volume of the Med.-Chir. Trans. 412 ULCERS. the healing process has been completed and the whole is filled up and converted into a .s-ca?-. The matter which is furnished during- the ulcerating process varies in character according to the nature of the ulcer, being sanious or foul, ichorous, contagious,' etc., approaching more and more nearly to health_y pus as the healing process advances. The distinctive characters of ulcers depend on differences observed in the base, the granulations and the pus which they secrete, the edge, and the parts surrounding the ulcer. Ulcers are divided into classes (I), according to the constitutional causes on which they depend, and (11), according to the local characters which tiiey present. 1. With reference to the constitutional causes which modify the char- acter of the ulcer, the following varieties are described : 1. Tlie simple or healthy ulcer, such as that which follows accidental injur}- in a healthy person. Its base is level and slightly depressed. The granulations are florid, uniform, small, soft, elastic to the touch, vascular, hut not usually bleeding spontaneously, and not highl}' sensi- tive ; the edges shelve gentl}-, are not peculiarly hard, and are of an opaque white at the circumference, where the epithelium is condensed and heaped up, getting redder towards the ulcer ; the pus is healthy or " laudable." This form of ulcer will heal under the simplest treatment, or, in fact, under no treatment at all, if defended from all irritation or congestion. If the patient is obliged to go about the ulcer should be protected from congestion by strap[)ing and bandage. This is most thoroughly done by the plan called Ba^nton's. The limb is encircled with strips of strap- I^ing, each lying half over the one below it, and all crossing in front, from an inch below to as much above the ulcer, and is evenly bandaged from the foot to some distance above the sore. 2. Injlammator-y Ulcer. — The nearest to healthy ulcers are the inflam- matory. Tlie}' are usually single and small; the skin around is hot and red, often edematous, with burning pain in the part. The base is level and little depressed, but ragged and flocculent ; the granulations are generally absent, so that the base looks raw ; it is rudd_y in color, or ash- gray, or yellowish, with thin adherent sloughs. The edges are abrupt, irregular, or shreddy. The pus is ichorous, thin, water}', excoriating the edges, and frequently blood-stained. In the treatment of such ulcers the main point is to subdue the inflam- mation by rest in the raised position of the limb, with warm soothing applications, such as warm Goulard-water, Oss. ; tinct. opii, .^j ; on a tiiick, soft rag or compress of lint covered with oiled silk. In some cases benefit seems to accrue from applying leeches at a distance. The patient is often weak, and requires tonics and support. 3. Eczemalous Ulcer. — The eczematoun resemble tlie inflammator}' ' Tlu! f-pecific characters of pus have not boun much studied, but we sometimes see the inr)oulability of matter tested in tlie case of ulcers or sores prcsiitned to be syphilitic, and in ca-cs of jjjonorrhojiil ophthalmia. Sy|)hilitic pus will excite a specific action, reprodiicini; a similar action for a grctat minihcr of times in cases of soft sore, and Pomcthin<^ similar takes place in hard sores which have been inflamed. The inocu- lation of ordinary pus, on the contrary, only causes a little pimple, which soon dis- appears. So with gonorrhfi'al nuilter. I'us taken from a case of acute gonorrhoea and placed in the conjunctival sinus will excite the most acute infliimmation, often rapidly destroying the eye, while pus from an ordinary abscess will only cause a slight and transient inflainrnalion, and often none at all. STRUMOUS ULCERS. 413 ulcers, but are complicated with eczema of the surrounding skin. The constitutional condition which is the remote cause of the eczema must be discovered and treated — whether it be gout, struma, or other cachexia — and the eczematous skin must be treated as well as the ulcer. AVet strapping to the limb is often useful, i.e.^ the application of strips of wet linen exactly in the same way as the strips of diachylon or other plaster would be used for strapping it, the application being kept moist by wet- ting it as often as necessary; or blotting-paper may be applied, or the skin dusted with starch or washed over with nitrate of silver lotion. Na3der recommends an ointment of red precipitate of mercury, 5 to 10 grains to the ounce, covered with a compress of linen wrung out of hot water.^ Occasional Harvi froyn Healing an Ulcer. — Paget^ sa3's : " It is prob- ably these more than any otlier ulcers that have given rise to the question whether ulcers should always be cured if possible. There is sufficient reason to believe that the cessation or cure of an established eczema has been attended with serious disease of the brain or other internal organ ; the same may happen with an ulcer of this or probabl}' some other kinds. The event is certainly very rare, but it may often be right to guard against it by making an issue in some place more convenient than the ulcer, or by renewing the cutaneous disease by counter-irritants." Ulcers similar to the eczematous form in other constitutional eruptions. 4. Cold ulcera resemble small inflammatory ulcers, occurring spontane- ously, especially at the ends of the fingers and toes, preceded by severe pain and small inflammatory spots. Thej^ occur in persons of feeble cir- culation, whose feet and hands are always cold, and the parts around them are livid and cold to the thermometer. The treatment is by dry applications or stimulating lotions, tonics, especially iron, with purgatives, warm clothing, warm bathing, and ex- ercise. 5. Senile ulcers somewhat resemble the inflammatory, but with more tendency to sloughing. The base of the ulcer is generally dr}', the gran- ulations rusty in color, and surrounded with a dusky pinkish area. The skin is sometimes sloughing in one part while the ulcer is healing in an- other. Such ulcers are found in the dry, withered limbs of those "who are growing old witli either a timely or premature degeneracy." For their treatment, besides generous diet, wine, tonics, opium, warmth, and all the comforts which old age sliould have, stimulating and balsamic applications are required. Paget recommends strapping them with equal parts of Xing. Resinaj and Balsam of Peru spread on lint. 6. Strumous ulcers are such as occur in strumous subjects, usually in combination with other local symptoms. Thej' often follow on suppurat- ing glands or softening of subcutaneous masses of tubercle, as evidenced by the presence of small nodular masses, which soften, with a low inflam- mation of the skin over them. They are often multiple, the individual ulcers being originally small and oval, but afterwards coalescing into irregular shapes. The}' are found more frequently in the situation of the lymphatic glands, i. e., in the neck and groin, and are frequent on the face and head ; but they do also occur on the limbs. The base is soft, unequal in level, the granulations are large, pale, soft, cedematous, often exuberant, and bleed easily ; the pus is thin, greenish-\-ellow, and pos- sibl}'^ curdy ; the edges are undermined, pale pink or purplish, with over- ' See the chapter on Eczema in Navler's Diseases of the Skin, 2d ed. * Syst. of Surg., vol. 1, p. 184, 2d ed. 414 ULCERS. hanging, thin, or irregularly hardened skin, and there is often a warty growth of the papilhu around (particularly in tlie hands and feet), which, coml)ine(l with tlie otlier character of the edges, gives some resemblance to epithelioma, but strumous ulcers want the hard base, sinuous raised border, and rapid progress of cancerous ulcers. There is seldom much pain, tliough wliere they have existed long the parts around become (Edematous. Tlie edges often require to be destroyed with caustic potash before the sore will heal. The general treatment of struma must be pursued, and the ulcers locally stimulated with iodine in the form of ointment, or of lotion applied on linen strapping, or with nitrate of silver lotion. Their scars are often causes of deformity, either by contraction or by overgrowth, which is more frequent, and which must be combated by repeated slight blistering. Very deep, obstinate, and'extensive ulcers may justify amputation, par- ticularly when situated near the ankle, and when au}^ neighboring joint or bone is simultaneousl}^ affected. 7. Sco7-butic ulcers are those which accompau}' scurvy, and derive their peculiarities from the effusion on their surface of the same semi- organized plastic material which occasions the swelling of the gums, the intermuscular swellings, and the vibices and petechia of scurvy. The ulcers are livid, with irregular, swollen borders, their surface covered with a dark, spongy, fetid crust, which adheres so strongly that its removal causes free bleeding, and which is rapidly reproduced. The treatment must be directed to the constitutional disorder. When this is removed the ulcer becomes of a simple nature. 8. Gouiy Ulcers. — Gouty persons often suffer from inflammatory or eczematous ulcers, but the proper gouti/ nicer is that which is found "over gouty deposits or in parts distinctly gouty, and it usually involves only part of the thickness of the skin. The base is florid, the granulations absent, or grayish or yellow, the edges low and shelving, the pus thin and ichorous, frequently leaving a white, chalky deposit. The ulcers^are very indolent, " exceedingly- slow in getting either better or worse." The treatment here again is directed to the disorder of the constitution. The local treatment is limited to water-dressing, simple cerate, or weak solutions of nitrate of silver. 9. Syphilitic ulcers are those which form on the skin in secondary or tertiary syphilis. They are situated usually on remote parts, but the genital organs may also be affected with secondary sores, and it seems certain that the matter from such sores is contagious. r Secondary ulcers are much more rare than tertiary. They generally proceed from the sloughing of parts affected with pustular eruptions in cachectic persons. Tertiary syphilitic ulcers " usually appear among the latest signs of syphilis, and are most severe in those who are most reduced, whether b^'' the syphilitic i)oison abiding in them or b}- mercury, or both, or by poverty, intemperance, or naturally unsound constitution. Tliere is probaldy no form of ulcer in which the influence of all these evils is more intensely felt." Tertiary ulcers are divided into two forms, not, however, generally dis- tinguishable at a late stage : (a) the superficial., which follows on rupia or some oilier ulcerative eruption, sometimes, though not usually, com- mingled with such eruption. These are best known by their annular or horseshoe form, spreading from the exterior while healing from the inside (serpigo), and are often multiple, arranged in some circular or curved LUPOUS ULCERS. 415 figure. Their local characters are not otherwise very decisive, and the diagnosis is made from the history or concomitant symptoms. Some- times the discharge is heaped up into scabs resembling tliose of rupia. These ulcers have usually no induration, and often do not penetrate the whole cutis, (6) The deep tertiary ulcer usually commences in the softening of a subcutaneous gummatous swelling, over which the skin gives way, leaving a circular sore, which looks as if the skin had been punched out. The base of the sore is often found sloughing. The sore is at first surrounded by a ring of induration, which is gradually destroyed and falls into the ulcer. There is often an area of dusky redness round the ulcer, which forms a contrast to the pink halo already described as surrounding the strumous ulcer. Tertiary ulcers may extend to any depth, tlirough the fascia to the muscles, periosteum, or bone. They occur in late stages of syphilis, often with no other syphilitic svmptoms, though in other cases ostitis or periostitis may be present elsewhere. Frequently the diagnosis can only be made by the eftccts of specific treatment. In ulcers situated on the leg it is useful to remember that the simple and the varicose ulcers generally occur on the inner aspect of the limb, a little above the malleo- lus, and are usually single; while the syphilitic ulcers occur more often on the outer side, and are commonly multiple, ver}' often appearing simuUaneousl}' on both legs, and sometimes nearly or quite symmetrical on botli. Specific treatment is usually of no use so long as the ulcer is inflamed ; but when by rest and soothing applications all inflammatory complica- tions have been subdued it generally succeeds rapidly. The iodide of potassium, in full doses of gr. v-viij or x three times a da}^ usually pro- cures the speedy healing of the ulcer, which, however, in many cases soon breaks out again. For permanent cure a course of mercury is generally necessary, and it is best administered in the form of the calomel vapor- bath, either applied to the whole bod_y, with some mercurial ointment or lotion to the part, or in the form of local fumigation ; and in that case smaller doses of the salt suffice: about 5 grains, in a small lamp sur- mounted by a tube, with a mouthpiece fitting the sore, will usually be enough, if applied every night so long as the sore is open, and followed by a somewhat larger dose up to the end of six- weeks, the quantity being regulated by the state of the gums. 10. LujwuH ulcers are characterized by the precedence of the tubercles of lupus, which, however, perish in the ulceration. Tliey are more com- mon on the face than on any other part, and particularly the ahie of the nose, where the skin joins the mucous membrane, and are frequently accompanied l)y perforating ulcers of the septum nasi or in the plu\r3'nx. They generally occur in persons of strumous constitution. The base is pale and in sou)e cases level, but in others covered with coarse, dusky, prominent granulations, raised highest at the centre of the sore. The borders are abrupt, irregular, eroded, and sometimes slightl}' raised and thickened ; the pus often scabs on the surface. The ulceration slowly extends at the margins and beneath the scabs till it perforates tlie parts below, as the cartilages and bones of the nose, the mucous membrane, etc., thx)ugli still vvitliout pain. Tiiese ulcers are allied to struma, of which other symptoms may be present, and the general treatment is the same, but thej' are seldom got to heal without destroying the surface of the ulcer. This is best done b}^ one of the powerful caustics, as potassa fusa or acid nitrate of mercury. Other forms of lupus are, however, frequently met with — the chronic, or 416 ULCERS. lupus non-excdens, the syi^hilitic, the erythematous, etc., for the full de- scription of which I must refer to works on diseases. of the skin/ The contraction of lupous ulcers, especially around the mouth or the orihce of the nose or near the eyelid, gives rise to deformity, which is best treated when it assumes the form of an annular constriction by gradual dilatation with sea-tangle tents or ivory wedges, and in case of ectropion by a plastic operation, which will be found described in the chapter on Affections of the Eye. 1 1. Rodent ulcer is very like lupous ulcer, but it occurs later in life ; the latter, like other strumous affections, is more common in early years. Ro- dent ulcers occur most commonly on the face and head, though tliey are found also on the female organs of geneiation and breast, as well as in other parts. The}' spread gradually, with little acute pain, but sometimes with constant aching, destroying all the parts with which they come in contact, so as sometimes to remove every feature of the face.'' The}' are, therefore, sometimes classed with the cancers ; •' but the}' lack the solid deposit and characteristic cells of epithelioma, and the}' are not attended with glandular disease or with deposit in remote parts. Their edges are usually smooth, hard and rounded, sometimes slightly tubercular. The base is tough and hard, smooth, yellowish-red, halt-dry and glossy ; but when any granulations are present they are sometimes exuberant. In rare cases there is a warty, lobed mass like epithelioma, and such cases can only be distinguished from epitlielial cancers by the microscope. The ulcer is indistinguishable by the naked eye from epi- theliomatous ulceration, and cases are given by Moore and others in which " epithelial cells, and brood cells, like the section of an onion," were found, as in epithelioma, but such cases would by most surgeons be called ei)ithelial cancer. The cases which are most satisfactorily distin- guished from epithelioma are those in which "the disease is made up of such innocent microscopic corpuscles that it has been likened tp a chronic ulcer of the leg and to a perforating ulcer of the stomach." (Moore, p. 13.) The most perfect general health is quite compatible with the most ex- tensive destruction of the tissues by rodent ulcer. In tlie case above referred to the patient lived for years in good health with almost the whole face destroyed, and then died of old age. Further, it lias been abun- dantly i)roved that if the parts concerned in the rodent ulcer be entirely removed, so that nothing but healthy parts are left, the patient may live for an unlimited period without the return of tlie disease. In other cases, however, it has returned, probalily on account of incomi)lcte removal. '^i'he indication, therefore, is to remove the disease thoroughly and com- pletely, and tills is best done by a combination of the knife and caustics. All the visiljle ulcer having been cut out freely, the part sliouhl be lelt for a day or two, till tlie bleeding lias quite ceased, and then an active caus- tic, such as the chloride of zinc, spread on lint, is to be freely applied to the exposed soft parts. If the bones are implicated they must be soaked 1 Sec cppecinlly Nayler in Diseases of tlie Skin, 2d ed., for a very careful descrip- tion of th(! various foi nis of lupus. * See a preparation at St (icort^e's Hospital Museum (Ser. xvi, No. 57), in which the patient lived for a long time with every feature of his face renioV(?d, exi;ept one eye ; the eye and the tongue being in the same common cavity. ' An interesting little work was put)lished in 18(j7, on Rodent Cancer, by the late Mr. C. H. Moore, which is well worth reading. Mr. Moore, however, clearly dis- tinguishes between the local malignity of rodimt ulcer and the constitutional infec- tion of cancer; in fact, thi; main obj(?ctof his book is to show tlx; possibility of eradi- cating rodent ulcer iicrmariently b\' adeijuale surgical operation. VARICOSE ULCERS. 417 in strong sulphuric acid until they come away. I well remember seeing at the Middlesex Hospital a case which had been thus treated with suc- cess, in which a great part of the side of tlie face and one eye had been removed, and the neighboring part of the base of the skull, so that in looking into the gap the pulsation of the brain was perceptible over a large surface. The hiatus in the face had been cleverly filled up by a mask of A'ulcanite painted to resemble the natural features. 12. Cancerous alcen^ occur either from the adherence of the skin to a cancerous mass or from the deposit and softening of cancer in tlie skin itself. Those which commence in the skin are generally of the epithelial variet3^ The edges of cancerous ulcers are raised and everted, hard, nodular, and wart3^ Their granulations are coarse, uneven, deepest in the centre of the sore, and they bleed spontaneously ; the base is hard, nodular, and surrounded by the cancerous deposit ; the pus is foul and ichorous. There are often enlarged glands or other cancerous deposits in the neigh- borhood. It is sometimes of importance, and especially in tumors of the breast, to distinguish the ulceration produced by a cancerous tumor from that which may be caused by any other formation. The main sign is that cancerous tumors cause ulceration b}' infiltrating the skin with cancer, which then breaks down, while innocent tumors cause ulceration by pressure only. Therefore, in the latter case, besides the absence of all other signs of cancer, it will be noticed that the skin is merely thinned, and retains its perfect softness and flexibility even up to the edge of the opening. The treatment of cancerous ulcers consists in removing the whole part on which they are situated whenever that is possible. In parts which do not admit of amputation the skin around the ulcers may be freely cut away, and in some instances a healthy cicatrix will be obtained, and the disease at any rate temporarily checked. If this also is impossible only palliative treatment can be adopted in most cases — i. e., some application which will keep the wound clean, and a sufficiency of opium or other nar- cotic to allay the pain — thougli there is no objection, if the disease has not gone too far, to the removal of the ulcerated surface with some pow- erful caustic, of which the sulphuric acid made into a paste with asbestos seems the least painful. This treatment, indeed, can only be regarded as palliative, for the disease is almost sure to return soon, even if the caustic should succeed in removing it for a time. II. The following varieties of ulcer depend on local conditions: 13. Varicose ulcers are such as are occasioned by the pressure of the blood in varicose veins above, rendering the skin congested and prone to low inflammation. These ulcers are of the ordinary chronic, inflam- matory, eczematous kind, and are situated usually above the inner ankle. Well-regulated pressure, and the maintenance of the elevated position of the limb, are necessary adjuncts to the ordinary treatment above de- scribed; or the veins maybe obliterated by operation (see the chapter on Diseases of Veins). Tonic medicines are indicated, and opium is useful where there is pain or inflammation. 14. (Edematous or iveak ulcers are such as occur on edematous limbs, and the granulations of wliich are oedematous from partaking of the general redema, or from being constricted by a neighboring scar or by tense skin. The remedies are to reduce the oedema, to apply astringents to the granulations, to strap and bandage the ulcer and tlie whole limb below it; or, in some cases, to divide the constricting medium. 27 418 ULCERS. 15. Exuberant ulcers are those in which the granulations project con- siderabl}'^ beyond the surface, but are free from any cancerous deposit. In sucli cases the general health must first he carefully attended to, free purgation being usually necessary ; the granulations are to be repressed by pressure and by the light application of stick caustic. 1(5. Heeinorrhaglc ulcers are such as bleed from a great variety of causes; l)ursting of varicose veins and venous congestion are the com- mon causes. Phagedenic and cancerous ulcers not unusually bleed spontaneously. Vicarious menstruation and ulceration into a blood- vessel are other but much rarer causes of bleeding. The appropriate treatment is involved in the discovery of the cause. 17. Neuralgic Ulcers. — In neuralgic ulcers the pain generally depends on some unhealthy condition of the ulcer or on some local cause — true neuralgia attacking an ulcer is much rarer. The remedy is to cure the ulcer, for which purpose its division is often indicated. The painful ulcer of the anus is an example ; but painful ulcers of the legs are also often brought to heal by complete division, under anaesthesia, the knife being carried through their whole extent in various directions. is" Inflamed ulcers are distinguished from the "inflammatory" de- scriljed above, in that the inflammation in these depends on a local irri- tation, while in those it is part of a constitutional condition. In inflamed ulcers there is an increase of pain with redness and oedema around them — the discharge is copious and bloody ; the granula- tions become swollen and congested, and then slough ; the edges are often abrupt or jagged. Sucli inflammation occurring in a callous ulcer is often curative, as in the treatment by blistering, or the inflammation excited by erysipelas. The indications of treatment in an inflamed ulcer are to remove any source of irritation, to apply soothing warm lotions, and to enforce rest. 19. Callous Ulcers. — The callous, chronic, or indolent ulcer is usually situated on the leg, with its long axis parallel to that of the limb. Some- times it encircles the leg. Its base is deej), flat, pale, or tawny, and ad- herent to the deei)est parts; the granulations are very small; the edges raised and callous, with heaped-up white ei)idermis; the pus is thin and often offensive. The kinds of ulcer thus modified are usually the syphi- litic, inflammatory, and eczematous; but any kind of ulcer may become chronic, and when a specific ulcer does so the specific treatment ceases to lie efficient. The most effective plan of treatment is by blistering — a common blister applied over the whole sore and its edges often sets up an inflam- matory action, which leads to cicatrization, and removes the heaped-up epidermis, which seems to interfere with the healing of the edges. It is not very jjainful, and the ei)idermal tissues, or their scarlike islands, which the blister may remove from tlie surface of the ulcer, are of no real value in closing tlie sore. Slighter cases may be brought to heal by strapping and bandage, with some exercise of the limb ; and opium in- ternally seems often of service. In tlie more advanced cases incisions may lie made through the ulcer and through its base well into healthy parts on all sides. And there are callous ulcers which cannot be brought to heal, and in which amputation may be justifiable. But the healing of all obstinate forms of ulcer has lately been rendered much more feasible by the introduction of the method of skin-grafting — a method which is often used to expedite the process of iiealiiig in a large lUcer or to sup- ply material in one wliich (like the surface of a burn) is so large that no iieallhy scar can be formed on it. 20. Phagedenic ulcers have been already treated of (page 83). t TUMORS OF SCARS. 419 CicafTtces and their Diseases. — The healing of an ulcer produces a scar or cicatrix. The process has been described above (page 44) ; and when the scar tissue remains permanent, altliough the scar is ugly and of a lower organization than the natural parts, yet it causes no important inconvenience. But the imperfect vascularity of scars, their low and abnormal growth, and tlie absence from tliem of the sebaceous and sweat-glands which lubricate the natural skin, render them peculiarly liable to yarious disease and degenerations, which it will be convenient to describe briefly in this place. Ulceration of Scars. — The most common surgical complication of a large scar is its breaking down and ulcerating, a very common event in deep and extensive scars. ^ Such ulcers are slow to h^eal, and are very prone to recur, so that often when the scar is seated on a limb amputa- tion becomes necessary. The scars of large burns are peculiarly liable to this degeneration, which is best combated by attempting to implant fresh tissue in the sore by means of skin-grafting. Grafting, however, will not, in all probabilit}^, prove successful until some healthy action has been set up in the part, which may be effected by some active stimulant, as iodine, in increasingly strong solution, or perhaps brushed over the part pure, or blistering fluid ; though before making trial of such powerful irritants, it is well to try the gentler stimulus of mercurial lotions or some of the balsams. As proph^dactic measures against this tendency to ulceration everything which tends to promote ra|)id union of the wound may be reckoned, and all possible means should be used to protect large scars from cold and from any accidental friction or violence. Neuralgia of Scars. — Another common and very distressing aflTection of scars is neuralgia, or constantly recurring pain. This proceeds some- times from unknown or constitutional causes, in which case it must be treated like any other neuralgia, in others from local peculiarity, as from adhesion of the scar to a subjacent bone, or from implication of the enlarged ends of nerves in the cicatrix, and such conditions ma^^ in some cases be relieved bj' subcutaneous separation of the scar from the underl3'ing tissues, or by removal of the affected nerve or nerves. Excessive Formation of Scar. — A defect which is very frequent in slowly forming scars (and especially those that follow strumous ulcers) is their excessive formation. Their superficial part is heaped up, cord- like, and ver}^ hard, and they adhere in an unnatural manner to the deeper tissues.'* This, like every other defect of scars, is best obviated by getting the wound to heal rapidly if that be possible. Otherwise it becomes very difficult to correct it, the only available means being to reduce it by constant blistering or painting with iodine. Keloid of Scars. — Closely allied to this is the limited excess by which one or more and often very numerous flat, rounded tumors are formed on the cicatrix. When such keloid growth is solitary it is difficult to see any diflerence between it and an excess of scar formation. But when a number of small scattered tumors occur upon a large scar the distinction 1 " Of all ?cars," shjs Sir J. Pa^et, " none are so ready to ulcerate as those that adhere to bones ; and the ulceration may happen twenty or more years after their formation." ^ Sir J. Paget points out that even after the deepest wounds which can never heal by first intention — sucli as that of lithotnmy — though the scar at first implicates all the tissues for a great depth, yet that ultimately only a ihin cicatrix should be left, wiiich, when examined, will be found to be perfectly sujierlicial, and to move as the skin moves over the deep fascia. 420 ULCEES. becomes apparent. The structure of these tumors is identical with that of the scar, viz., a lowly organizecl fibrous tissue, only mingled in keloid with ''cell structures in progress of development, or arrested and de- generate in their incomplete forms," to an extent which is not seen in merely thick scars. The admixture in these keloid growths of cells in process of development corresponds to the tendency of such growths to increase, and to the irritation which they sometimes cause, and their property of returning after removal, which is sometimes very trouble- some. The same remedies as for excessive growth may be tried, but are usually of little avail; and the excision of the growth is often followed b^' its return of a larger size, so that it is very doubtful policy to operate, except in cases wliere the whole part can be removed, and healthy sur- faces brought together for immediate union. This can usually be done in the growth which follows occasionally in the lobule of the ear after piercing for earrings, though no such operation should be recommended unless the growth is really of a size to cause considerable deformity, and is on the increase. Tlie keloid of scars difters from the "true keloid " of Addison in certain particulars, which will be pointed out in the chapter on diseases of the Skin. Other forms of tumor are' occasionally met with in scars, but the epi- thelial cancers are the onl}^ tumors of much practical importance. They were first minutely and accurately described by Mr. Csesar Hawkins as "wart}^ tumors of cicatrices."' The great majority of such tumors are epithelial cancers, and all ought to be regarded and treated as being of this nature, though in some rarer cases it seems that their course is that of an innocent tumor; in fact, a mere collection of large warts growing on tlie surface of the scar. Such tumors form most commonly on scars of slow formation, as those of burns, and especiall}^ oir those which used to follow the comi)licated superficial injuries inflicted in a military flog- ging. As in other cases of epithelioma, the complete removal of the part affected holds out a tolerably good prospect of complete recover})-, or at least of a considerable period of immunity from return. The glands, as Mr. Hawkins points out, are rarely affected in this form of tumor. Contracted Cicatrix. — The most troublesome of all the consequences of scarring is the contraction which slowly forming deep cicatrices are so liable to undergo — a contraction so powerful that it will bind the arms to the trunk, distort the most powerful joints, and even alter the shape of tlie bones. The worst cases of this deformity occur in the neck, by which the chin is drawn down and fixed upon the chest, all the features of the face are distorted, the shape of the jaw so changed that its body is more horizontal than vertical, and the patient's appearance rendered in tlie iiighest degree repulsive. The best jjlan in these as in all other progressive disorders is to en- deavor to hinder their commencement, or, when thTs is impossible, to treat them before they l)ecome inveterate. In all deep burns, and in all other injuries which destroy the whole skin to any great extent, the greatest care ought to be taken to keep the parts on the stretch during the whole period of union whenever that is possible. If a scar which has fully formed shows a tendency to contract, that tendency is to be coun- teracted either b}' gentle and constant manual extension, the scar being well oiled, and gently but very frequently stretched (which seems to me the best plan when the services of an intelligent nurse or mother can be 1 Mcd.-Chir. Tran.s., vol. xix. Conlribution? to I'allioloicy and Surgery, vol. i, ])p. 14y-lG9. SKIN-GRAFTING. 421 secured), or by the action of a constant extending force, as a rack and pinion apparatus, or a weiglit. But when contraction is inveterate and very tirm, or when mechanical extension is impi-acticable, some of the autoplastic operations described in the section on Plastic Surgery may become necessary, for which I must refer the reader to that place. Skin-grafting. — What has been said about scars and their diseases illus- trates in every topic of which I have treated the absolute necessity of rapid union. This is one of the many reasons which induce English sur- geons utterly to repudiate the foreign practice of stuffing wounds with charpie, and, on the contrary, to seek to remove every obstacle to their immediate union. But in cases where large granulating surfaces must be left exposed for an indefinite period (as after a large burn) we have only recently obtained any means of artificially hastening their cicatri- zation. This is now most happily effected, at least in many cases, by the method of skin-grafting, invented by M. Reverdin, of Geneva, and intro- duced into this country by Mr. Pollock.^ For the success of this process it is essential that the granulations should be perfectly healthy, and that all irritation in the sore should have ceased — ^.e., that the ulcer should be prepared to cicatrize — and it is at any rate desirable that the patient's general health should be good. Then, if a small piece of the surface of the skin, consisting of little more than its epithelial layer, be laid on the granulations and left undisturbed for a few days, it will often form a nucleus, from which cicatrization will extend rapidly in all directions, as it sometimes does from the islands of skin which maybe left undestroyed in the centre of an ulcer. The pieces grow best when planted not far from the edge of the sore (say about half an inch), so that the sore can first be diminished by a zone of skin-grafts planted all round its margin, and then the operation be repeated, and so on, until it is all covered. The growth of the graft seems to depend on the cells of the rete Malpigliii. These are newly formed and growing, and possess the power of prolifera- tion. Attempts have been made to produce the same effect by grafting merely the cells scraped from the surface or loosened by a blister, but such cells are as a rule effete and will not grow.'* Nor is there any proof that the tissues of the cutis itself, and still less the subcutaneous cellular tissue, take any part in the new formation. The red budlike appearance which the graft presents for the first few days after its insertion is doubt- less due, as Dr. Page points out, to the desquamation of the effete super- ficial layers of the transplanted epidermis, and to the transparency of the cells of the rete mucosum, allowing the color of the subjacent parts to show through them. It is best, I think, to take up a small portion of the true skin as well as the epidermis, in order to make sure of removing tlie rete mucosum, but on no account should the whole thickness of the skin be cut through. An ingenious combination of fine forceps with scissors enables the surgeon to remove a small piece with hardly any pain at all : but when this is not at hand a pair of fine forceps and sharp curved scissors answer the pur- pose.^ The grafts should be very small, hardly larger than a pin's head. ^ M. Reverdin's original psitient was presented to the Soc. de Chirurgie de Paris on Dec. 8, 1869 (Ball, de la Soc. de Chir., Nov. 27, 1871). Mr. Pollock's first case was published in the year 1870. '■^ See an interesting paper on this subject by Dr. Page, of Edinburgh, Brit. Med. Jour., March 27,1871. 3 The pieces are generally taken from some other part of the patient's own body ; but the process of cutting them is so little painful, that often a bystander oflers his 422 DISEASES OF THE BONES. They should be laid firml}' on the granulations, about an inch apart; and if the patient can be trusted not to disturb them in any vvay, I think they are be.-t left exposed for a Fig- i'^^- few hours. After this, or at once, if there is any danger of their being dis- turbed, they should be cov- ered with oiled silk, mois- tened with oil, to prevent its sticking when removed, and the whole fixed with strapping and covered with cotton-wool. The,y siiould then be left undisturbed for three or four days and redressed as before. At first they change into little round vascular-looking buds, which some- times become almost imperceptible at first in the neighboring granula- tions, but afterwards the new cuticle is seen extending in all directions from the bud. That this new cuticle is formed by growth from the old is proved b}^ the fact that when black skin is engrafted on an ulcer in a white man, as recorded by Mr. Bryant, or when the reverse experiment is made, as in a case in my own practice, the newly formed skin is of the color of the graft to the extent due to the action of the latter. M}' own experience as far as it has gone leads me to believe that the cicatrix formed by skin-grafting is more highly organized and less liable to all forms of degeneration than that which is produced by the slower natural processes. Skin-grafting scissors. Tlie piece of skin which is shown in the grasp of tlie forceps is larger than -would be taken in prac- tice. CHAPTEK XXII. DISEASES OF THE BONES. Inflammation in bone is strictly analogous to the same process in soft parts ; in fact it occurs in the soft parts of the bone. Its first effect is to increase the size of the vascular channels of the bone, which also become more irregular in shape and outline ; the union which previousl}' existed between the earthy salts and the vascular network in which they are con- tained is loosened and the salts partially removed, while their place is occupied by inflammatory products (leucocytes, serous effusion, pus- globules, newly formed fibrous tissue), and thus the compact is converted into a kind of cancellous tissue, while the cells of the cancellous tissue are much enlarged and the bone becomes soft, light, fragile, and much moister than in its Jiatural state.' arm for the purpose. They should be taken from a part where the skin is quite healthy, thin, and .supple. • For more detailed accounts of the early phenomena of inflammation in bone I PERIOSTITIS. 423 To this early softenins; stage of ostitis succeed other stages equally analogous witli the results of the inflammation in soft parts, but modi- fied by the peculiar condition of the parts. Thus the inflammatory prod- ucts ma}' pass through the stage of fibrous organizatiou into that of ossi- fication, and so new bone l)e produced, just as it is in the union of frac- tures. In fact, the ordinary process of repair of fractures is that of " first intention" in union of wounds of bone, while the repair of compound fractures exhibits the process of union by granulation. Just so after common inflammation. The leucocytes which have been effused into the intervascular spaces of the bone itself, into the cells of the cancellous tissue, medullary canal, or still more frequently the interval between the periosteum and the surface of the bone, become developed first into fibrous tissue, and next (in some cases, as it seems almost simultane- ously) the earthy constituents of the bone are deposited in this tissue, in a manner similar to that of the iutra-membranous ossification. Pe7-iosfitis. — We know how slight a stimulus will produce ossification on the deep surface of the periosteum, which, in fact, is the source of the greater part of the growth of the bone ; so that, as M. Oilier has shown, the periosteum in animals, even when transplanted into other parts of the body or into the bodies of other animals, will produce bone from its deeper surface. This form of inflammation is called Periostitis. It is almost alvvays associated with more or less inflammation of the substance of the bone itself, and ought perhaps only to be regarded as one of the forms of ostitis ; yet, as it is always spoken of as a sei>arate disease, it may be better for practical purposes so to regard it. Periostitis occurs in two very distinct manners, viz., the common or chronic, and the acute or diffuse periostitis. Nodes. — The former is a very common affection ; it occurs very often as a consequence of syphilis, and when limited to a small extent of sur- face constitutes the affection called Node, from the lump or " knot " (nodus) which it produces on the surface of the bone. Nodes are most common on the most superficial bones, as the cranium, tibia, clavicle, etc. They are formed of thickened and inflamed periosteum, raised up and separated from the surface of the bone by more or less fibrinous eff'usiou. The surface of the bono is also probabl}^ inflamed. Their usual causes are syphilis, rheumatism, and struma. The symptoms are pain in the part, increasing — as all other " rheu- matic " pains are apt to do — when the patient begins to get warm in bed, swelling and apparent softening of the affected bone, which is really due to fluid effused over it. The swelling is usually round and small, like a half-marble. If left alone such nodes pursue one of three courses, — many are absorbed, i. e., the fluid is absorbed as the inflammation sulisides and the swelling disappears; or the inflamniatoiy effusion ossifies, and a periosteal thick- ening of the bone remains permanently ; or finally suppuration follows, and an ulcerating carious surface is exposed. Syphilitic nodes occur either in the secondary or tertiary stage, and, as may be inferred from what has been said on p. 405, those which are secondary are more prone to resolution or ossification, while the tertiary nodes, like other gummata, are more prone to suppuration and caries. must refer the reader to Von Bihra, On the Decomposition of the Bone by Caries, in Lieliig Q Wohler'a Annalcn, vol. Ivii ; Barvveli, in Brit, and For. Med.-Chir. Rev., April, 1860; Black, On the Pathology of Tuberculous Bone, Edin., 1859; and my own essay, in vol. iii of the Syst. of 8urg. 424 DISEASES OF THE BONES. The treatment consists in the proper remedies for the general constitu- tional state, combined with connter-irritation. Iodide of potassium in moderately large doses, combined with opium, certainly seems to relieve the pain both of syphilitic and rheumatic nodes. Five grains of the iodide three times a day may be combined with 10 or 20 drops of lauda- FlG. 178. A internal and b external view of a preparation illustrating the ordinary anatomy of periostitis, from a well-marked example of that disease, in the Museum of St. George's Hospital. — System of Surgery, 2d edition, vol. iii, p. 739. num, according to the severity of the pain, and the dose may be raised to 10 or 15 grains of the salt if it is judged necessary. There are cases where the formation of a node, especially if the inflammation is severe and suppuration is threatening, is accompanied with so great pain that the division of the periosteum by an incision reaching fcom one side of the tumor to the other is called for, and this measure often gives instant and permanent relief. The ordinary cases of "chronic periostitis," so called, are really cases of inflammation of the whole bone, in wliich there is more or less deposit on its surface, which may be perceptible to the hand during life, but in wliich there is also induration and thickening ('• .s-c/ero«i.s ") of the whole bone. The s^'inptoms are wearing ])ain, heaviness of the limb, prol)ably some increase of the temperature, little if anj' redness, and irregular deposit on the surface of the bone. The only treatment which is available is the same as was recommended for nodes, but it seems uncertain whether such treatment has really much PERIOSTITIS. 425 specific effect on the disease, though rest and shelter and good medical supervision no doubt do much for its cure. Difl^'um or suppurative periostitis, leading to the condition known as acute periosteal abscess, is one of the gravest affections of bone, fre- quently producing a general pyjeraic condition, and, indeed, sometimes itself only a manifesta- tion of general pyremia. Very often, however, it occurs simply as a result of local injury, and is perfectly curable. It is an affection of early life, much more com- mon about puberty than at any other, age; not very rare at earlier periods of life, l)ut hardly seen after middle age. It affects more often the long bones, and especially the tibia and femur, but any bone may be the subject of the disease. It follows usually on slight injuries, sometimes from no known cause, and in these latter cases the constitutional affection is often severe, and general pypemia may he suspected. The disease commences by the effusion of lymph between the periosteum and the bone, which is not at first purulent, but in the actiter cases soon be- comes so.^ This is accompanied by a good deal of pain, heat, and swelling, often mistaken for acute rheumatism. If the disease is acute the inflammatory effusion soon softens and forms a large abscess surrounding the bone, sometimes over its whole surface, necessarily depriving it of its nutrition, so that it dies, and often tiie whole shaft thus perishes in a very short time. The articular ends are usually unaffected.^ The treatment of this formidable affection in its acutest forms must be very energetic and decided. A free incision should be made down to the bone as soon as suppuration is detected ; and if the pain and tension are severe, it is well to do this even though the presence of fluid is not established. The patient must be supported through the ensuing fever and exhaustion, a sharj) watch must be kept for any secondary abscesses, and they must also be opened as soon as they occur. If the bone become dead it is K ''>^ Fig. 179. — The entire diaphysis of the tibia, necrosed, in a case of acute periostitis. The wliole bone was removed by subperiosteal resection a month after the commencement of tlie disease. (See Lancet, 1866, vol. i, p. 340.) The line (a) indicates where the bone was sawn across in order to remove it. The patient, a hoy aged 10, recovered, with perfect use of the limb, which, however, was some- what shortened, and the knee anchylosed. — From Holmes's Surg. Dis. of Childhood, 2d edition, p. 392. ^ See a case in my essay, op. cit., p. 741, footnote. 2 The joint, however, does not always e.^^cape. A girl aged fifteen was admitted into hospital four days after an injury with groat swelling of the forearm, evidently depending on the formation of matter. A grating sensation, perceived on rotating 426 DISEASES OF THE BONES. desirable to remove it as soon as practicable. It is neither necessary nor advisable to wrJt in such cases for the formation of the periosteal sheath. I have removed the whole diaphysis of the tibia, and in anotlier case several inches of the shaft of the femur, in this condition, and satisfactory reo-eneration has taken place. It is to be recollected that young persons will recover in conditions which in after-life would be hopeless. I have even known recover}- take place after the occurrence of pya^mic pericar- ditis ; so that any measure which can give an additional chance should be adopted even in very desperate cases. At the same time no such active treatment is required in the snliacute cases where there is no great pain or tension and no constitutional sympathy. Here local depletion and iodide of potassium will usually lead to a cure without suppuration. Before quitting the subject I would notice that I have seen tolerably often the diffused swelling of subacute periostitis, particularly' of the femur, mistaken for a malignant tumor.^ Oateo-myelitis. — When the inflammation affects chiefly or entirely the medullary cavitj' and the lining membrane of the cancelli the disease is called osteo-myelitis. It is an affection well known by its post-mortem appearances, which show in the first stage of the disease the whole medullary membrane, including in some cases that lining the cancelli, injected, thickened, sprinkled here and there with ecchyraoses, and very soon permeated with purulent extravasa'tion. In acute osteo-myelitis the disease generally proves fatal at this point. But if it does not do so, or if the action is more chronic, the matter must make its way to the ex- terior through some sinus, the interior of the bone will die and form a slough or sequestrum, the com[)act tissue being thickened and pei'iosteal de|)Osit formed on the surface, or the whole thickness of the bone may die (Figs. 182, 183).^ All this forcibly reminds the surgeon of diffuse inflammation in the soft parts ; in fact, the two diseases are analogous in all essential characters. The symptoms during life are not equally familiar; in fact, it is not often distinctly diagnosed, except in the case of amputations, where the cut end of the medullary cavity is exposed to view. In such cases, if the medullary tissue becomes inflamed, there will be seen sprouting from the cut end of the bone a large fungous granulation, in which specks of bone can be recognized; but in other instances, where the medullary cavity cannot be examined, we must endeavor to recognize the disease b}- its general symptoms. These are best studied in such a case as an excision of the hip-joint or of the knee, where the cancellous interior' of the bone has been laid open, but the wound is buried in the soft i)arts. In such cases, in the acute form of the disease, the symptoms vvill much resemble those of pyaemia, viz., rigors and acute traumatic fever, but with the addition of more or less pain in the part and swelling of the whole limb, not due to superficial a-dcma. Sometimes, as in the case shown in Figs. 180, 181, phlel)itis is developed at the same time. If the liml) be examined by a free incision down to the bone, under chloroform, which the hand, to<:ji'thor with the hi.story of the acoident, led to the belief that fracture had occurred She died of pyemia; then it was discovered that a periosteal abscess, ex- tending from the shaft of tlie radius into th(^ wrist-joint, had so (eroded the articular cartilages as to occasion the stir.sation of crei>itus. 1 Holmes's Surt; , Treatment of Children's I)is., '2d ed., p 832. 2 Sec my work On the Surgical Treatment of Children's Diseases, 2d ed., p. 401, for a colored illustration of the I'emur after chronic osteo-myelitis. ■"* It is not absolutely nec(!ssary that iIh; medullary canal itself should have been wounded. No doubt wounds of that onal are more dans^erous than those in which only the cancelli arc involved, but the latter may also be followed by osteo-myelitis. OSTEO-MYELITIS. 427 under such circumstances is usually justifiable, it will be found that the periosteum has receded or is receding from the bone ; and if the niedid- lary tissue can be exposed it will be found to be suppurating. Now, in the acuter cases of this formidable disease there can be no question of the advisability, in fact, the absolute necessity, of instant amputation of Fig. ISO. 'm Fig. 181. Fig. 180. — Osteo-myelitis of the femur. — From a drawing in the Museum of St. George's Hospital. Fig. 181. — Inflammation of the femoral vein from the same case. Fig. 182. — Upper portion of humerus amputated for necrosis after osteo-myelitis. The necrosis does not extend into the tuberosities, neck, or head of the bone, which, however, are expanded by inflam- mation (osteo-porosis). — After Longmore, in Med.-Chir. Trans , vol. xlviii. the limb above the inflamed bone, if the patient is to have any chance of life, for tlie disease has a great affinity with pyaamia, which rapidly fol- lows in the great majority of cases, if the}' survive long enough for the symptoms to develop themselves complete!}'. Unfortunately it is ex- tremely difficult to distinguish the symptoms at the outset, and in many cases whicli are taken for mere osteo-myelitis pyaemia has really com- menced.^ ^ The reader who wislies to follow up this question of reamputation in cases of acute osteo-myelitis following on operations on bone is referred to Profe.'sor Fayrer's Clinical and Pathological Observations, pp. 48-94; and to some ob.«ervations of mine in Surg. Dis. of Childhood, 2d ed , p. 53G, and !St. George's Hospital Keports, vol. i, p. 152. 428 DISEASES OF THE EONES. Chronic osteo-myelitis is more common than the acute form, or, per- haps, is only more commonly recognized, the osteo-myelitis being passed over in acute cases as only one (and that possibly an unrecognized) phe- nomenon of pyaemia. It causes total disorganization of the internal part of the bone, frequently extending througli its entire thickness, and ultimately leading to death of the whole shaft for a variable length. Thus are produced those long tubular sequestra which separate from the femur or other bones after amputation (Fig. 182). This disease I'equires no such active or immediate treatment as acute osteo-myelitis. All that is necessary is to provide for the free exit of discharges and wait until the dead bone is felt to be loose, or until the lapse of time renders it probable that it will be found so. Then the soft parts are to be freely Fig. 183. Fig. 184 V^ .9/ J K^-. Fig. isrj. — a !• imn showing the wliole shaft in a state of necrosis after osteo-myolitis from injury- X, Y sliow the limits of tlie necrosi.s. The sequestra (which do not extend into the epiphyses) are vis- ible through the cloaca;. — After Longniore, ibid. Fifi. 184. — Chronic al).scpss in the lower end of the tibia. From the original case, in which Sir B. Brodie first described this affection. (.Sec his works, vol. iii, p. 404.) — St. George's Hospital Museum, ' Ser. ii. No. 'iO. dissected off the end of the bone, and the sequestrum twisted out with a pair of strong bone forceps.' Chronic Abscess. — One of the most curious local results of ostitis is ' On thn snbjpct of osteo-inyolitis a paper by Mr Longmoro, in tho 48th vol. of the jNIed.-Chir. Tran.s., will wi-il rcfiiiy ponisal, Ijoth u.s a clear staleiiifiit of tlie .symptoms of the.«o two forms of osteo-myelitis or diffu.sc inflammation of bone occurring after gunshot wounds, and us a pri)of of the success of the expectant treatment in tho milder form. CHRONIC ABSCESS OF BONE. 429 the formation of a chronic abscess in the cancellous tissue. Tliis occurs most often in the head of the tibia — not unfrequently in its lower end, the part in which it was first discovered by Sir B. IJrodie — or in the lower end of the femur. It has, however, also been noticed in many other parts of the skeleton, and occasionally occupies a circumscribed part of the medullary cavity. The symptoms are obscure, and the diagnosis is formed more by their persistence and by their resisting the treatment which usually relieves rheumatic pain in the bone than by an}' striking pathognomonic sign. There is constant wearing pain referred to the part, with little or no ex- ternal inflammation, perhaps a little enlargement, and usually some local tenderness. When the abscess lies very near the cavity of a joint the inflammation may be propagated to the joint, giving rise to occasional attacks of synovitis, and in such cases there is considerable risk that the abscess may burst into the joint, and so lead, in all probability, to the loss of the limb or joint (Fig. 185). The abscess is almost always seated superficiall}', covered by little more than the cortical part of the bone (which perhaps may be somewhat thickened by inflammation, as in Fig. 186), and it seems to be due in Fig. 185. Fig. 185. — Drawing of the lower end of the femur from a case of excision of the knee. An abscess which lias formed above the position of the epiphysial line has made its way into the joint. The car- tilages are seen ulcerated. A probe passed through the track of the abscess shows its opening into the articular cavity. — From a drawing in the Museum of St. George's Hospital, Ser. xxi, No. 55 b. Fig. 186. — Unsuccessful trephining in abscess of bone. a. The point where the trephine was applied, about half an inch from the abscess. 6. The wall of the bone, thickened by inflammation, c. The cavity of the abscess, d. The pyogenic membrane. — St. George's Hospital Museum, Ser. ii. No. 31. From Syst. of Surg., 2d ed., vol. iii, p. 751. most cases at any rate to contusion of the surftice. In a striking case which occurred to me some years ago the disease dated from a contusion by spent shot received at the battle of the Alma, more than fifteen years previously. In some of these cases the abscess contains a nodule of dead bone, and it seems very probable that in such cases a portion of the interior of the bone has been so far detached from the neighboring parts as to have perished. There are, however, many cases in which there has been no injury whatever, and where the affection niust be at- 430 DISEASES OF THE BONES. tributed to iiiflanimation of a rheumatic nature, the result of cold.^ The pus ma}' remain encysted in the cavity for a very long period, possibly for the whole of life, since one of the earliest effects of the inflammation is to produce hardening (" sclerosis ") of the bony walls of the cavity. But in other cases it does slowly make its way either to the cutaneous or the articular surface (Fig. 185), and I have known a case in which, on turning down the periosteum, a small opening was perceived leading into the abscess. It is of great importance to diagnose this affection with at any rate such an api)roach towards certaint}' as will justify the surgeon in apply- ing the trephine. When once the abscess has been opened the pain will cease, the cavit}' slowly fill up, and the patient be restored to perfect health. Mr. Carr Jackson (op. cit.) justly relies principally on the se- verity, the continuance, and the paroxysmal character of the pain, and on the localized tenderness, sometimes referred to a single definite spot, pressure on which gives rise to the most agonizing sensation. It must be admitted, however, that the diagnosis is not easy. Sir B. Brodie re- lates a case in which he applied the trephine and found no pus ; and Mr. C. Jackson has recorded a similar instance. In both these cases it is true that the operation did good, and it may be conjectured either, as Mr. Jackson seems to think, that there was a minute quantity of pus, which was not seen at the operation,,but the evacuation of which re- lieved the pain, or that the relief was due to the incision of the tense and indurated periosteum and shell of the bone. In such cases, however, there has been, at any rate, ostitis, and the treatment by incision is a rational one, whether necessary or not. But there can be no doubt that in many instances the mistake has been made of taking what is merely a neuralgic or hysterical affection for abscess of bone. Therefore the greatest care should be taken by the surgeon to assure himself of the reality of organic lesion, or at least to have the strongest evidence of it before undertaking an operation which is certainly serious, though not often fatal. The operation is a simple one. The surgeon, as Mr. Jack- son recommends, would do well to mark out on the skin previously the precise spot to which the pain or tenderness is referred. The patient being fully narcotized, a crucial incision should be made down to the bone, the periosteum turned down by a similar crucial incision, and the trephine applied at the spot marked. If no pus be found it is well to perforate the walls of the trephine-hole in various directions with a brad- awl or small chisel, in order to see whether the matter ma}'^ be situated in the immediate neigl)l)orii()od. This was the case in the patient from whom the above drawing (Fig. 180) was taken. The trephine has been ap[)li('d close to tlie collection of matter, but the latter was not opened, and the i)atient remained unrelieved till his death.^ The figure illustrates almost every point in the sui'gery of the disease — ^ Sep the tliii'd ca.«e in Jlr. (Jarr Jackson's pamphlet, On Circumscribed Abscess of Bono, L-indon, 1807. 2 Or pMS-ihly till the limb wiis amputated. In the hospital catalogue it is said that " the p!iti''iU died .';omo short time afterwards, and the ab.'^cess was then discovered." Yet Sir J3 Brodie alludes as follows to an exactly similar case, and Mr. Carr -Jackson says that tlii.s jireparation is taken from that case: " A very experienced hospital suryeon ajiplied the trephine for a sufjposed abscess in the head of tlie tibia. No ab.sces.s, however, was di>covered, and in consequence the limb was amputated. On the parts bi-inij examined afterwards the abscess was discovered at a small distance from the pi'i-foralion made in tiie operation, and it was ]ilain that the removal of a amnll purtioii more of the bone would have preserved the patient's limb." CARIES. 431 Fig. 187. the small cavity in the head of the bone, lined (as these abscesses almost always are) by a very definite pyogenic membrane, the slight tumefac- tion of the bone caused by the thickening of its periosteum, the indura- tion oftlie bone around, and the tendency which the matter has to make its way, however slowly, to the surface, for all the bone which covered the matter has been removed at one point; and the wall is formed by the thickened periosteum only. Carien.- — The term " caries " is used in the context as being synonymous with " ulceration of bone," just as necrosis is used as synonymous with gangrene of bone. Some pathologists make a ditterence between caiious ulceration and healthy ulceration of hone, and in the wi'itings of these authors the term is used in the same sense as w^e use " strumous caries." Caries is the stage which succeeds to the softening stage of ostitis, when the intlammatory process pursues its course towards disintegi'ation in- stead of being arrested and repaired, in which case it is followed by con- densation, or sclerosis. The inflammatory exudation breaks down into pus, the connection between the solid particles of the bone and their fibrous stroma is dissolved, and the bon^^ particles are removed in imperceptible portions in the discharge. When the disease oc- curs on the surface of the bone the periosteum will be found to be thick, and loosened from the bone ; in the more advanced stage of tlie disease it is converted into a villous mass of a pink color, resembling a mass of granulations. When this is raised from tlie bone the latter will be found ex- cavated into pits, into whicli this granulation-tis- sue dips, and around these i)its the bone is softened and rarefied by inflammation. Other neighboring parts of the bone may, on the contrary, be en- larged and hardened, the inflammation there hav- ing shown itself in the reproductive form. Most of these points are illustrated by the accompanying engraving, which shows the deep pits worn into the tissue of the bone, the change of sliape of the head, the attenuation of the shaft, so that it has given way at one part, and the attempt at repro- duction or consolidatinginflammation in the neigh- borhood of this injury. Strumous caries differs from ordinary caries less The iiead and upper part of in essentials than in degree ; there is more soften- '^;;^ uLorat,S"The he^ ing, less attempt at repair, more extensive disin- is iu great part destroyed, a tegration of the neighboring l)one. In some cases transverse fracture of the shaft there is a distinct deposit of tubercle in the can- "^ ti'e bone has taken phice ,, . 1 • T 1 • 1 • immediately below tlie head. CellOUS tissue, but this, 1 think, is not common; Below the part wlierr the shaft tile clieesy masses which are seen sometimes in of the bone has been broken a the head of the til)ia, the bones of the tarsus, the considerable amount of new ^ , T ,1 1 1 bone is thrown out in the veitebrai. and other large porous bones, are re- neighborhood of the frag- garded with more probability, I think, by some of ments, which are only siighiiy the best pathologists as collections of lymph or displaced. The medullary ca- ; • t 1 nal is open throughout. — St. inspissated pus. q^^^^^,^' H^^pi^^i" j^j^^^^,^^ The symptoms of caries are merely those ot in- ser. ii, No. 46. flammation of bone with an abscess or sinus leading down to exposed, softened, rough bone, which bleeds readily under the 432 DISEASES OF THE BONES. touch of the probe. The discharge h.is sometimes the fetid, offensive smell of putrefying bone, but by no means always. The chemical cliar- acter of the discharge is said in some cases to assist in the diagnosis by showing a larger quantity of phosphate of lime than is contained in matter derived from soft parts ;^ but if these observations be allowed to be correct, the fact is hardly clear enough to afford a basis for satisfac- tory diagnosis. Indeed, in deepseated caries the diagnosis is often only inferential ; i. e., no other cause can be assigned for the persistence of discharge, with perhaps some pain or symptoms of inflammation around the bone. Often, also, the prominence of the granulations around the opening of a sinus gives indication of the presence of an abiding source of irritation below, which, if not a foreign bod}'', can hardly be anything excei)t a piece of dead or diseased bone. The repair of health}^ ulceration of bone is constant, and even in stru- mous ulceration it may occur when the disease is not too extensive. The ulceration gives place to condensing inflammation ; the bones, if more than one is affected (as in the spine and tarsus), grovv together by bony anchy- losis ; new bone is thrown out to defend and support weak parts, and there results a hard, irregular mass of bone, often much more solid than the parts which it has replaced. \ This is well illustrated in the repair of caries of the spine, leading to angular curvature. The treatment of cairies must often be expectant merely, as in the in- stance just gi\en of carious spine, where no application to the ulcerated surface is possible, and many good surgeons are inclined to believe that the expectant treatment is in most cases the best. However, it is unde- niably tedious, and either the urgency of the patient or the impatience of the surgeon often leads him to endeavor to accelerate matters ; and this is i\\d more reasonable in cases where neighboring parts may be involved in the progress of the disease, as in the case of diseased bone in the tarsus, where the disease, if not early treated, may very probably extend from one bone to another till the whole foot is incurably diseased. The methods of local treatment are various. The most common one is to expose the diseased bone and to remove as much as is found to be dis- eased with the chisel, gouge, or some other cutting instrument, until a surface of bone is exposed suflficiently healthy to take on reparative ac- tion ; and this plan is often successful, particularly when the ulceration is of a health}' nature, as in that which follows on accidental injuries. But it is liable to the danger of extending the disease instead of stopping- it, by the inevitable contusion and crushing of the portion of bone left behind. M. Sedillot^ has proposed a method, to which he gives the name of "evidement des os," by which the whole inflamed and softened bone is to be gouged out from the jjeriosteal case, leaving nothing but the soft parts from which the bone is to be rei>roduced. I have no experience of this method, believing the total extirpation of bones which are so com- pletely disintegrated as to require such a plan of treatment to be prefer- able. Most of the excisions of joints and resections of bones which are performed are necessitated by caries of the bones which has entirely de- stroyed the utility of the part ; but before so grave a step is taken it is desiral)le to try all appropriate means of local treatment. In aid of the treatment b}' rest (or the expectant treatment) various local applications 1 Bransby Cooper's Lectures on Surgery; Barwell, Dis. of Joints, p. L'38. 2 Gaz. des Hop., Jan. 19, 1875. NECROSIS. 433 are in use for removing the ulcerated bone and exposing sound tissue by a process less dangerous than gouging to the integrity of the bone left behind. The most successful of these is, I think, the application of sul- pluiric acid after the manner described by Mr. Pollock, in the Lancet^ May 28, 1870. The carious bone being thoroughly exposed l)y incision or removal of the soft parts which cover it, a solution of equal parts of sul- phuric acid and water is applied to it with a glass brush, or a lotion of five or six parts of water to one of the strong acid is kept in constant contact with the bone by impregnating a piece of lint with it and pushing it down to the diseased part. The former plan is the more efficient when the carious surface is actually superficial. The strength of the acid is gradually raised till at lengtli it is applied pure. As the diseased bone is dissolved out healthy granulations spring up here and there till the whole surface seems healthy, when it mav be left to heal. Dr. Kirkpatrick^ eflects the same object by the caustic action of Vienna paste (potassa cum calce). He destroys the soft parts with this paste till a large funnel-shaped opening is left, leading down to the bone, which is then to be perforated with astrong knife, chisel, or trephine, and into these perforations the caustic is to be introduced. As the bone which is thus destroyed and cauterized comes away the parts around are consoli- dated by healthy inflammation. This plan is more easily applied to deep- seated caries than the sulphuric acid treatment, but is otherwise, as far as I have seen, less successful. Other local applications are the actual cautery, which, however, can only be used in rare cases in which the whole carious surface is exposed, and seems to me less energetic and penetrating than the acid ; the injec- tion of iodine, much recommended at one time but now fallen into de- served disrepute, and injections of dilute mineral acid, which, however, are superseded b}^ the more methodical use of the strong acid. Phagedenic Ulceration. — I need only refer here in the most cursory manner to cases in which the inflamed bone is removed with great rapidit}'. Mr. Stanley ^ describes this under the name of " phagedenic ulceration of bone," likening it to phagedena of the soft parts; but Mr. Stanley's cases appear to have been instances of epithelioma or rodent ulcer. Mr. Cffisar Hawkins^ has recorded two striking cases of extensive destruc- tion of the bones of the head, accompanied, in one instance, by suppura- tion, in the other not, which shows how rapid sometimes is the absorption of inflamed bone. But the cases of this disease are so rare that I must content myself with this brief mention of it. JVecro.s■^■^^, or the total death of a considerable portion of bone, is dis- tinguished from caries, or the ulceration of bone and its disintegration in invisible molecules, just as the gangrene or death of a visible portion of the soft tissues is distinguished from ulceration, or " molecular gangrene." The phenomena of necrosis, also, are strictly analogous to those of gan- grene. It may be produced, as gangrene is, either by inflammation or by loss of blood-supply or by chemical disintegration of the tissues ; but in the bones inflammation is a far more common precursor of necrosis 1 Dub. Quart. Journal. New Syd. Soc. Bien. Rep , 1807-8, p. 259. 2 Diseases of the Bones, p. 65. 3 Med.-Chir. Trans., vol. xxxix. Contributions to Pathology and Surgery, vol. i, p. 349. 28 434 DISEASES OF THE BONES. than it is in soft parts: Fig. 1S8. in fact, the cases where necrosis does not depend on inflammation are only exceptional, while in the soft parts, thou<2;h inflammation usnall}'' bears its part in indncing gangrene, yet other causes almost always co-operate. The reason of this is obvious : the soft parts easily accommodate themselves to the en- largement of the vessels and to the inter- vascular effusions which are necessary ac- companiments of inflammation, whilst in the bones the vessels are confined in rigid canals; and any such attempt at expansion being checked at once, the circulation comes to a standstill. The dead bone then turns white (unless it is exposed to the air and bathed in the products of putrefaction, when it may be perfectly black) ; if cut into it will not bleed ; the periosteum and soft parts recede from it, leaving its surface smooth, hard, and ringing when struck; the living bone in the neighborhood becomes inflamed, leading to condensation of its tissue for some distance, and to periosteal deposit, both on the surface of the living bone and especially over the dead bone, so that the dead bone is roofed in or invaglnated (as the technical term is) b^^ a cover or sheath of living peri- osteal bone. While this is going on the irri- tation of the dead bone sets up inflammation in all the parts with which it is in contact, viz., the living bone and the deep surface of the periosteum. The pus so furnished finds its way to the surface through the sheath of new bone, which thus is interrupted by holes or sinuses, through which the pus burrows to the surface of the bod}-. These Necrosis of the lower part of the sliaft and cfiiphysial extremity of the lihia. The larger fipture shows the .sequestrimi surrounded by its sheath of new hone, the latter gradually merging above into the healthy .surface of the bone. A seelion ha.s been made through the se(|uestrum and its eavity near the articular surface. The smaller figure t.hows the articular end of the bone, where the e.xtremity of the sequestrum is seen, surrounded by an ulcerated surface of bone, from which the articular cartilages were completely removed. The sequestrum was here perfectly accessible, and could have been removed by a free incision into the joint. — From a drawing in the Museum of St. George's Hospital, presented by Sir B. Hrodie. sinuses are technically called doacfje, and the piece of invaginated dead bone thus sequestrated from the soft parts is called a sequestrum. NECROSIS. 435 When the periosteum is destroyed there is iisualh' no sheath, though it is j)ossil)le that new bone may be pro- duced by tlie soft parts. Tliis, however, is a far slower and more imperfect process. Wlien there is no sheath and the dead bone is exposed on the surface the process of separation and tlie piece of dead bone which separates are botli described by tlie name of exfoliation. As the inflamma- tion proceeds it digs a trench around the dead bone by a line of demarcation, as in the soft parts, and thus the sequestrum becomes loose in its cavity, and if the cloaca^ are large enough it may escape through one of them. But this rarely happens, and for the most part it is nec- essary to enlarge the opening of the cloacjie before the sequestrum can be re- moved. This descrii)tion applies to necrosis of the superficial part of the bone, and this is by far the most common situation. Central necrosis, however, is occasionally though not very frequently met with, as the result of inflammation of tlie medul- lary tissue, and possibly sometimes of contusion of the substance of the bone. The s^'mptoms are very obscure, and are, in fact, usually merged in those of chronic abscess ; since the resulting inflammation, supposing the affection to be seated in a part such as the head of the tibia (where there is abundance of cancellous tissue), will set up suppuration around the dead bone. In the sliaftS of the long bones with a deposit of new porous bone. The the same thing may occur. The pus will large irregular cavity which is seen in the , ,.^. 1 ■ .1 1 i>i\ tibia lias lesulteJ from the necrosis and re- become diffused among the meshes of the ,„ovai of the whole thickness of the shaftof medullary tissue, and the disease has been the bone, with the exception of two small known to be many years in progress be- bridges or pillars, which extend from the fore tlie dead bone has become loose.^ ''?^.'\ 'V'"," '"T/ "f, V'VT' J""^ . tibia IS tirmly soldered to the tibula, above, 1 he bones most subject to necrosis are below, and opposite to the cavity.-From a those which are most exposed to the preparation in St. George's Hospital Mu- various causes of inflammation, of which seum, Ser. li, No. si. syphilis, struma, and local violence are the commonest. Hence the superficial bones are found affected more commonly than those which are further removed from participation in the various afl'eetions of the surface. The cranium, the tibia, the clavicle, the bones of the forearm and hand are most commonly the subjects of the affection; but it is by no means uncommon in the femur or humerus. The denudation of the bone by destruction of its periosteum is very fre- Extensive ulceration of the tibia and fib- ula, with necrosis. Botli bones are much thickened by inflammation, and covered ^ In the Museum of St. Bartholomew's Hospital, Ser. i, No. 176, is a specimen of a femur removed l>y amputation, in which there was a small necrosed portion of the inner layers of the medullary cavity. The bone had not separated, though the dis- ease had been in progress for thirty-iive years. 436 DISEASES OF THE BONES. quently ft)lloNved by necrosis, but not always, since the exposed bone may derive suflicient nutriment from the neigliboring soft parts of tlie bone, and to some extent from the neighboring soft i)arts, to preserve its vitality. Thus, after a severe scalp-wound large portions of exposed bone may be seen to become gradually vascular, small granulations springing from the surface here and there, and ultimately forming a cicatrix by which the whole is covered without au}^ visible exfoliation. And in the bones of the face large denudations of the periosteum are perfectly compatible with the regular nutrition of the bone. Thus, in the operation for cleft of the liard palate the surgeon denudes the bones of their periosteum, without any apprehension whatever of necrosis. But in bones which are less vascular than those of the head and face, or in bad conditions of health, or where the denudation is very extensive, the outer table of the bone will usuall^y exfoliate, though not to so great an extent as would at first appear probable. The soft parts almost always adhere around the edges of the wound to some extent, and preserve the life of the circum- ferential portions. Acute Neci^osis. — Necrosis sometimes occurs with almost as much rapidity as gangrene of the soft parts, and then the constitutional dis- turbance may be great, and pysemia is yery likel^y to ensue. I have spoken of this in connection with diffuse or acute periostitis, which is the common cause of acute necrosis. The next most common cause is de- struction of the periosteum and injur}' to the surface of the bone, either by contusions, chemical injuries, or fire. But there are rare cases in which acute necrosis ensues from obscure causes, and without any visible affection of the periosteum or medullary membrane, of which I have related a striking instance in the essay already referred to in the System of Surgery (p. 11 C^). Such cases must be treated in the same way as those of acute periostitis. Treatment. — The treatment of necrosis is, as a general rule, to wait until the bone is loose and then to remove it. In the case of an exfolia- tion nothing more is necessary than to lift out the loose portion b}' put- ting an elevator beneath its edge and extract it with a pair of forceps. Very often when the soft parts lock in the exfoliation it l)ecomes neces- sar}- to cut the loose part across in order to remove it piecemeal, and this is effected by a pair of cutting forceps or bone scissors. But under certain circumstances this usually simple operation becomes a very com- plicated, rlifiicult, and dangerous proceeding. The most familiar instance is in that necrosis of the popliteal space of the femur which occurs so often, and in which for some reason not very obvious there is rarel}', if ever, any periosteal sheath, so that the exfoliated bone lies close under the popliteal artery, and may easily wound it, as happened to a young man the subject of this affection, who in dancing ran the loose splinter of bone into the poi)liteal artery and bled to death.' The same accident may occur in removing the bone, or the knee joint may be opened, or the arter}- may lie wounded by the knife, trephine, or cutting pliers. It is necessary, therefore, to proceed with great care, making the incision on the outer side and somewliat to tlie back, so as to avoid the synovial membrane, yet not to wound the external popliteal nerve ; then to dissect witli great care along the l)ack of the femur and use the bone scissors, if necessary, with great caution. In withdrawing the bone all rough manip- ulation should be avoided, and the parts scratched and pushed off it with ' Byron in Med.-Chir. Kev., vol. xxiv, p. 259. Jacob, Diss. Med -Chir., de Arieur., Edin., 1814. NECROSIS. 437 the finger-nail and handle of tlie scalpel in preference to any cutting instrument. When the dead bone is invaginated it is necessary, in the first i)!ace, to endeavor to ascertain whether it is loose, but this is by no means easy. The length of time during which it has been exposed will of course justify a guess — but only a guess — for the period at which the dead bone sepa- rates depends on many causes of which the surgeon can hardly have any knowledge, and in great part on the acute or chronic nature of the origi- nal action. Still, if the disease has been long in progress, and there is not much risk in cutting down on the bone, it should certainly be done, if only to get a perfect knowledge of its condition. The sequestrum may be (piite detached from the bone around it, yet so locked in that no move- ment can be impressed on it by the probe. Sometimes the groove of de- marcation between the living and dead bone can be felt, and if so it is a valuable sign the sequestrum is loose. The operation consists in freel}' exposing tlie invaginating bone with its cloacoe and enlarging one or more of the latter by cutting the new bone away, either with the trephine applied round one of the openings or by cutting through the bridge between two neighboring cloac.ne with chisel or forceps, and so obtaining free access to the sequestrum, which is then to be taken out with the for- ceps, or, if too large, to be cut through with the cutting pliers, trephine, or an}- handy instrument, and so removed. The surgeon must be careful to leave none of the dead bone behind in the cavity. The wound need not be closed, since it can only fill up by granulations. The discharge is often most putrid, and the pit in the bone requires for some time to be very freely washed out with some disinfecting solution. It used to be recommended in surgical lectures to defer this operation till the periosteal sheath might be presumed to have acquired strength enough to preserve the continuity of the limb, but this is not now con- sidered advisable. In the leg and forearm, where there is a second bone, the peri(>steal inflammation will be sure to unite the affected to the sound bone, if the necrosed portion be at all large (see Fig. Is9) ; and even if this does not occur, or if there is only one bone, it seems better to remove the sequestrum at once, since it is a permanent source of irritation, and to trust to careful splinting and bandaging to maintain the parts in posi- tion and prevent any fracture. However, it cannot be denied that the danger of fracture from necrosis is a real one, and particularly if the neighboring bone has been cut away to some extent; and when this acci- dent has happened in the case of the femur amputation will usually be- come necessary (Fig. 190). In the arm careful treatment will probably preserve the limb. Some other plans of dealing with necrosed bone are occasionally useful. They consist chiefly in applying chemical solvents, by which the dead bone may be dissolved out and thus its removal lie effected more quickly than by waiting for its separation. Of these the sulphuric acid is the best (see page 433), and by its means I luive seen large portions of the skull removed, and certainly with the effect of much diminishing the fetor of the discharge. The difl^iculty is when tlie limits between the dead and the living bone are reached, since any substance strong enough to dis- solve the tissue of the bone may easily kill the living but inflamed bone in the neighborhood of the exfoliating portion. The complications of necrosis are very numerous; but as the majority of them are merely the results of inflammation propagated from the in- flamed bone to the soft parts in its neighborhood, and are marked by the symptoms peculiar to such inflammations, it would be impossible to 438 DISEASES OF THE BONES. speak of all of them here, nor would it be necessar}'. It ma}' perhaps, however, be proper to take notice of the fact that necrosis is not an Fig. 190. ^Ik1i|\^|; ''H ih'f \\ Fu;. 190.— Fracture In consequence of necrosis, necessitating amputation, from which the patient (a boy aged 15) recovercfl. a refers to the necrosed bone; \> to tlie new bone, wliicli (along wltli the remains of tlic old sluift) has given way. The patient had liad diseased l)one for more than four years, and had been frequently operated upon. At length he again came into the hospital in 1861. The femur was trephined and some more dead bone removed. He went on well, and the wound was nearly closed, when, six weeks after the operation, he fell in running across the ward and fractured the thigh. It was put up in the usual way, l)Ut no union could be procured. The wound discharged a large' quantity of thin unhiallhy pus, and it l)ecame necessary to amputate. The fracture has passed tlirough the trephlne-hole, a part of the outline of which is seen on the necrosed bone. The artery lay to the inner side of the broken end.s — it was uninjured. The intersi)ace between the fragments was filled witli white fibrous tissue, In which many ossifying specks were visible under the microscope. — St. George's Hospital Museum, Ser. ii. No. 100. FifJ. 101. — Necrosis of the whole shaft of the til)ia, from a patient aged 18. The upper eijiphysis is unafTectcd, but the disease extends into the ankle-joint, an, and a swelling of the UOt lift them, and in which the feet end of the radius, due probably to the same cause. were simultaneously affected, but this is unusual. No treatment can be proposed in such cases except amputation, which is necessary when, the hand or foot has become entirely useless. The tarsus would be left in the case of the foot, or a portion of it, if the extent of the disease pre- vented the formation of a flap entirely in front of the tarsus. Cysts ai'e also often found iu enchondromatous tumors which show no trace of degeneration.^ The structure of enchondroma is usually that of pure hyaline cartilage, indistinguishable from the normal tissue. The diagnosis of enchondromata depends on their hard, lobulated sur- face (sometimes, however, with a certain amount of elasticity, if the car- tilaginous tissue is soft, or if there is a cyst in the interior of tlie tumor), their slow growth, and the absence of all other s3Mnptoms. When they grow (as they often do) from the interior of a bone, the shell of the bone may be expanded over the surface, and may be felt to yield with a crepi- tating sensation. Generally there is little difficulty about the diagnosis, for the symptoms are usually quite different from those of cancer; there is not the hardness of exostosis, and the otlier innocent tumors of bone are very rare. The treatment must be by amputation or enucleation. The former is required in cases of multiple enchondromata, when any treatment is indi- cated, in very large tumors, and generally when the operation for removal of the tumor would leave the member useless. Sir J. Paget' has shown how much better the prospects of recovery by enucleation are than used to be believed ; and since the publication of his paper amputation will be less frequently resorted to, at any rate without preliminary incision, in order to ascertain the nature of the tumor. It is in sucli exploratory operations tliat the ''bloodless method" recommended by Professor Esmarch (see the chapter on Operative Surgery) finds one of its most * Path. Trans , vol. xxii. j). 252. 2 Soe a bountiful ])r('paration in the Museum of the Royal College of Surgeons, No. 20;^ A, which is, I believe, Mr. Frogley's preparation, described and lij;ured in the Mcd.-Chir. Trans., vol. xxvi ; and in Syst. of Surgery, vol. iii, p. 816. ' Med.-Chir. Trans., vol. liv, cases 1 to 3, pp. 254-5. EXOSTOSIS. 447 striking uses. Under the elastic bandage, properly applied, the tissue and the relations of the tu- mor can be studied on the ^^*^' ^^^• living subject almost as easily as on the dead, and any vessels, nerves, or other important structures, as easily dissected oft' the tu- mor. Such operations, how- ever, will occasionally ter- minate in amputation, a contingency which must be provided for before com- mencing. I would refer to Fig. 198, whicli shows a very large en chondroma springing from the humerus outside the shoulder-joint. At the period of the opera- tion the large size of the growth left the operator no choice ; but at an earlier stage of the disease it would have been a perfectly justi- fiable proceeding to have attempted the removal of the tumor alone, preserving the arm. Yet the operator might easily have been baf- fled in the attempt by find- ing the great vessels and nerves so buried in the mass A cartilaginous tumor of the humerus, of two years' growth, springing from the compact tissue, and encroaching on the cancellous structure. It was removed by amputation at the shoulder-joint, and the patient was seen quite well, two years afterwards. On microscopic examination the tu- mor was found to consist of large oval cells, with one or two nuclei, the wall of many being indistinct. These were closely placed in a finely granular matrix, which in some parts was dimly fibrillated. — St. George's Hospital Museum, Ser. ii, No. 176 a. that he coidd not hope for any usefulness in the member after the operation, and would find himself compelled to resort to amputation. Exostoi^is^ or bony tumor springing from a bone, is a comparatively common aflTection in some parts of the body, and occurs under three chief forms. The first is the ivory or hard exostosis, which is composed of })one resembling the compact shell of the long bones or the external table of the skull, from which it often springs, but even more compact, so that it exactl}' resembles ivory, no pores or bone-fibres being visible in its section. On microscopic examination these ivory exostoses show the lacunae and the vascular canals of true bone, but the lacunse are more irregularly distributed, and the vascular canals are more numerous and smaller than the Haversian canals.^ This form of exostosis is met with only in connection with the bones of the skull and face, and especially on the vertex of the skull and on the lower jaw (Fig. 199). It never attains a larger size except when it grows into one of the cavities, — the orbit or the antrum. Its growth is very slow, and as a oreneral rule such tumors are best left alone. Their removal is 1 See Path. Trans., vol. xvii, plate 13, for drawings and description of the micro- scopic examination of Dr. Duka's case of ivory exostosis, figured below, p. 448. 448 DISEASES OF THE BONES. often extremely difficult, in consequence of their great hardness; and the violence which is neces- sary for this purpose in- volves very great danger; while the tumor can lead to no ill consequences, apart from the trifling deformity which it causes. But to this rule an exception must certainly be made in the case of ivory exostosis of the orbit. The gradual growth of such a tumor displaces the e3'e, causing blindness by the stretching of the optic nerve, and a very hideous squint. The base (which is usually at- tached to the inner or outer angle of the root of the or- bit) is often of no large size, and when full}^ exposed can be partially cut tlirough with a fine saw, and then broken with a few blows of a chisel and hammer. If the operation have not been too long delayed the eye will return into position and sight will be restored. It is well not to go too near to the skull in making the section, though this must, of course, depend on the shape of the tumor's neck. Again, an exception may be made in ivory exostosis of the antrum. These exostoses often have very small bases, and are found to have undergone fracture at their neck and to be lying loose in the antrum. Such was the case in the instance which furnished the preparation here figured, and which occurred in a native of India, a patient of Dr. Duka.^ On removing the front wall of the lower jaw the large mass of ivory-like bone here figured was found lying quite Ivory exostosis of the lower jaw. There is no history, but the preparation has evidently been taken from the body of a Tery old person. — St. George's Hospital Museum, Ser. ii, No. A shows the general appearance and n the appearance on section of the bony tumor removed from the antrum by Dr. Duka, the account of which is to be found in the Path. Trans., vol. xvii, p. 256. The position of the tumor during life was the reverse of that here shown —St. George's Hospital Museum, Ser. ii. No. 191 a. loose, its attachments having been separated either by the weight of the mass or by some accidental violence. It may l)e mentioned, as some encouragement to the attempt to remove such tumors when it is otherwise indicated, that the neck of the tumor is ^ Path. Soc. Tran.s., vol. xvii. EXOSTOSIS. 449 Fig. 201. sometimes much smaller than its size would lead one to expect, and also that the interior may be cancellous, while the exterior appears perfectly ivory-like. Such was the case in a remarkal)le tumor of the skull de- scribed and figured by Mr. Ilott.' The patient had consulted many emi- nent surgeons^ but all had shrunk from the apparent danger of removing it, believing that the neck was of great breadth, and of ivory-like consist- ence. On the contrary, when the patient died it was found that the tumor was of a mushroom-shape, the neck comparatively small, and the interior of the tumor wholly cancellous. The tumor might, therefore, probably have been removed with safety. On the other hand, many his- tories show the risks that may be encountered in such attempts. There are in St. George's Hospital Museum two preparations, one showing a small bony tumor with the marks of a trephine with which and other instruments Mr. Keate strove in vain for more than an hour to take away the little lump, but was obliged to desist. The patient obstinately refused to submit to the slight deform- it}^, and was ultimately re- warded for his perseverance by its removal. Repeated applica- tions of strong nitric acid and potassa fusa at intervals during ivory exostosis, winch was trephined, unsuccessfully, several VearS produced its ex- on account of its great hardness. Exfoliation was after- foliation, but at an expense of '''''^y^'^t^f ""^ ''" -T^TfZtt.T^^^^^^^^^ ' . ' ,. caustics, chiefly nitrio acid. — St. Georges Hospital Mu- pain and danger quite dispro- seum, Ser. li, No. ISO. From Syst. of Surg., 2d edition portionate to the result. In vol. iii, p. 822. the other case Sir A. Cooper had tried to saw off a small ivory exostosis from the margin of the orbit, but in vain. This also exfoliated after repeated applications of caustic, and the marks of the saw are still to be seen upon the little tumor. The soft or cancellous exostosis is a much more manageable disease, and operations for its removal are at any rate under certain circumstances justifiable. It grows either as an outgrowth, consist- fig. 202. ing primarily of bone, or as the result of the ossifi- cation of a cartilaginous tumor. In the latter case the internal tumor, com- posed of cancellous bone, is surrounded and encased by a layer of cartilage. The favorite seats of ex- ostosis are in the neigh- borhood of the epiphyses, ,• 1 .1 , fl f tVi A small exostosis of the femur, situated just above the internal particularly tnose 01 tne condyle. The neck- of the tumor, shown at the upper part of the femur and humerus, and woodcut, is composed of firm cancellated bone; the part marked on the extremity of the <» of opaque white cartilage, composed of large cells, of an oval last phalanx of the great or circular form closely approximated^ The surface of the t^mor * p IS covered by a thin incrustation of fibro-cartilage. — St. Greorge's toe ; but they occur in all Hospital Museum, Ser. ii. No. 178. 1 Path. Soc. Trans., vol. iii, p. 149. 29 450 DISEASES OF THE BONES. parts of the body. They should only be removed in consequence of some symptom caused b}' their presence greater than the risk of removing tliem would be, for there is no doubt that, as a rule, if not always, their tendency is to stop growing. Hence on the great toe, where the little tumor causes serious inconvenience in walking, and it can be removed with hardly any danger, this should always be done; but when the exostosis is deeply seated (as in the very common instance of that which grows just above the internal condyle of the femur) and is near important structures,' it is ver}"" doubtful whether the patient is well advised in incurring any great risk in order to avoid inconveniences which after all are often tritiing, and which may be trusted not to increase. If the surgeon have made up his mind to operate he may be certain that the removal of the surface and the greater part of the neck of the tumor will perfectly suffice to stop the disease; 110 renewed growth need be apprehended. In the cartilaginous exostosis all the ossifying material is removed in such an operation, and in the bony outgrowth the remains of ^i^'- -^'^- the neck never, as far as 1 know, are the origin of any renewed growth. It has often been noticed that exostoses sometimes suffer fracture, and a remarkable case has lately been pul)lished- in which an exostosis of the femur, having been thus broken off from the bone, became entirely absorbed, so that a tumor which ^ seemed at first to be of the size and sliape of a walnut left no trace whatever of its existence; Exostosis of the finger, springins from the base of the and Mr. Maundcr'' haS related first phahinx, in a man aged 58. The bone is seen to be . i • i i i 4. ^ healthy. The whole tumor is co.npletely ossified into ^ ^ase HI whlch he treated an spongy bone, with the exception of a very thin layer of exOStOSis in this rcgiou by fraC- cartilage which covers its surface (on the unshaded per- turing its neck, with what rcSult ier.nJo'isT^"""^'^'' '^'°''^''' ""'"'" ''"''"'"' is not yet known. The treat- ment, however, is eminentl}'' worthy of trial. If the exostosis is not absorbed after the fracture of its neck, and its presence gives the patient inconvenience, it might be re- moved when loose with far less danger than is involved in cutting through its base. Fig. 203 will illustrate the feasibility of tliis method of treat- ment. A tumor so large as this relatively to its neck could easily be divided from its attachments, either by fracture or by subcutaneous section with a chisel or fine saw, and passive motion would prevent any tendency to reunite. The diffused bony tumor is illustrated b}^ the accompanying figure (■204), showing a large lol)ulated mass of bone envelo|)ing the jaw for a con- siderable distance, and only removable by extirpation of the whole of the Ijonefrom which it grows. Another and a very singular case is illustrated by a series of three preparations in the Museum of the College of Sur- geons, in which after amputation on account of such a tumor, situated ' The knee-joint hasoftcn lieen opened in removing this exostosLs, for in such case.s previou.* attacks of inflammation may have enlarged the synovial membrane beyond its natural limits. '•^ Dr. Chicnc, Ed. Med. Juur., July, 1874. 3 Ibid , Aug., 1874. TUMORS OF BONE. 451 near the knee, the tumor recurred in the stump five years afterwards ; reamputation was performed, and then the disease again recurred in the pelvis. The tumor couhl not have been malignant, for the duration of the affection was no less than twenty-five years, and the patient died only A cliffused bony tumor of the lower jaw (diffused exostosis), removed with success at St. George's Hospital, by Mr. Tatum. a shows the articular surface of the jaw ; 6, the symphysis. The operation consisted in the removal of the whole of that side of the bone.— Path. Soc. Trans., vol. ii, p. 59. St. George's Hospital Museum, Ser. ii. No. 185. of the local consequences of the pressure of the tumor.^ Other similar cases have been noticed, and they bear a remarkable analogy to those of the recurrent fibroid tumor of soft parts. Innocent Soft Solid Tumors. — The other innocent solid tumors are rare, if we except epulis and fibrous or naso-pharyngeal polypus, which are treated of in other chapters. They generally grow from the perios- teum, and are of the fibrous, " fibro-cellular," or fibro-cystic variety. Very commonly they are mistaken for enchondroma before operation ; and as tiie treatment and the prognosis are the same, the mistake is of no impor- tance, nor can I lay down any trustwortiiy rules for the diagnosis. The majority of such tumors seem to be connected with the femur.- Cystic tumors of bone are serous and sanguineous. The former, if they are not confined to the jaws (as Mr. Stanley believed them to be), are at any rate only known in that situation, and these are in all probability always caused by some irritation around the teeth-cavities. They form sometimes enormous tumors in the jawbones (usually the lower), with the wall formed in some parts by thin crepitating bone, in others by fibrous tissue, and containing clear fluid. The diagnosis is easily made by puncture. In other bones the presence of hydatids has given rise to the formation of cavities containing a thin fluid, but whether independently of hydatids serous cysts form in other bones seems doubtful. Both forms require similar treatment, viz., to be laid open pretty freely, 1 See Syst. of Sure; , vol. iii, p. 825, 2d ed. 2 See Adams and Hewett, in Path. Trans., vol. 254. 452 DISEASES OF THE BONES. when if hydatids are found they are to be evacuated, otherwise the open- ing- is to be kept free and the cyst left to fill up gradually. In a case which furnished a preparation to the Museum of St. George's Hospital, Sir B. Brodie removed the whole side of the lower jaw, on account of an unusually large cyst of this nature, but the operation proved fatal from erysipelas. I never saw one of so large size, but have seen a few smaller ones which have done well under the simpler treatment. The blood-cysts in bone are still rarer, and many of the cases were clearly only instances of malignant or myeloid (sarcomatous) tumors, witli blood-cysts of very large proportionate size formed in them. I must refer the reader to the authorities named below' for illustrative cases. The treatment would generally consist in laying open and stuffing the C3'st if no tumor formation could be detected in the walls, otherwise in excision oi' amputation. Pulf some other affection, and in the generality of cases to disea.se in the articular extremities of the bone." — Bryant's Practice of Surgery, p. 823. ULCERATION OF CARTILAGE. 4Cu ay 1 TJ) -•'0) ^ to Acute inflammation of cartilage. — After Redfern. The appearances of inflamed cartilage to the naked e3'e consist in the formation on its surface of ulcera- ted si)ots, where the cartilage is ^'°- -*^'''- removed in a part or the whole of its thickness, and in a degeneration of its substance, which becomes fibrous (so as to be compared to the hairs of a small brush or to the pile of velvet), and in some cases thickened and softened in texture. The union also between the carti- lage and the bone becomes much loosened, so that the cartilages are in some places quite detached, though still lying over the bone ; or pieces of the cartilage may be detached and free in the joint. Examined by the microscope two kinds of changes are seen in such cases. In one, which is more dis- tinctly inflammatory, the nuclei of the cartilage-cells increase in size and divide, so as to increase in number; the contents of the cell become granular ; the cells enlarge at the expense of the hyaline substance, which is ultimately absorbed, and then the cells burst, setting free their contained nuclei, which have be- come transformed into bodies resembling pus-corpuscles. In the other change, which partakes more of the nature of degenera- tion, the ilitercellular substance is not destroyed, but is rend'^red granu- lar, and the cartilage-cells are separated from each other by a fibrillated material, which is probably developed from tlie nuclei of the cartilage- cells by a process of pro- liferation. Rindfleischi fig. 206. has depicted in these more chronic instances of inflammation canals ex- tending through the car- tilage from the granula- tions on the articular lamella to those on the synovial membrane, into which vessels shoot which bring these two layers of granulation into contact. These more chronic changes depend, as it seems, partly on loss of nutrition from the loosen- ing of the connection be- tween the cartilage and the bone. This sliaht sketch of -^r^ 1(1 _Jl.. -»(«(.*- Vertical section of inflamed cartilage showing the splitting into fibres of its surface.— From Redfern. 1 Pathological Histology, New Syd. Soc. Trans., vol. ii, p. 260. 468 DISEASES OF THE JOINTS. the morbid anatomy of inflamed cartilage, which ought to be supplemented by a study of the works named in the footnote,' will, it is hoped, enable the student to understand what has been said about the symptoms and the re- sults of the disease called '' idceration of the cartilages." The mere erosion of the cartilages themselves does not produce any special symptoms — at least that is the opinion of almost all surgeons of the present day'^ — and the grievous starting pains which characterize the disease are produced by pressure on the inflamed bony surfaces which are exposed by their removal. Sir 13. Brodie himself came to this conclusion, and has expressed in the latest edition of his work the opinion "that the increased sensibility in these cases is in the bony plate beneath the cartilage rather than in the car- tilage itself; and that the presence of severe pains with involuntary start- ings of the limb is always to be regarded as a sign of the bone partaking of the disease."^ If any further proof of this be wanted it may be found in the fact that similar pains and startings often take place after excis- ions of the knee and elbow, when every portion of the cartilage has been removed, though they are not so severe as in joint diseases, partly, perhaps, because in excision the sensitiveness of the bone where it has been divided is less than that of the articular lamella, and partly because the muscular action is interfered with by the wound. For there can be no doubt that the spasms which produce such agony in ulceration of the cartilages are due to reflex irritation of the muscles, bringing the inflamed end of the bone into contact either with cartilage opposed to it, or, what must be far more painful, with another inflamed portion of bone. 1. The various events which we have just noted are easily understood from a consideration of the anatomy of the disease. AVhen the disease subsides after the cartilages have been ulcerated and the bone only somewhat inflamed, no pus, or no considerable amount of pus, having been eff"used into the articulation,* the ulcerated spot may fill up l)y means of fibrous tissue, and possibly no anchylosis whatever may take place ; or if a slight fibrous band or bands should form between the ulcerated spot and the opposite surface of the joint it may give way. The formation of these fibrous bands is easily understood from the ten- dency to fibrillation observed in the articular cartilage in inflammation and the rapid development of vascular channels in it. 2. When the suppuration has been more considerable but chronic it will make its way to the surface, leaving, in all probability, some part of the bone exposed, and as the suppuration progresses the ligaments are ' Redfcrn, Anormal Nutrition of Cartilage. Barwell, Diseases of the Joints. Weber, Ueber die Veranderunccen der Knorpel, etc. Virchow's Archiv, Jan. 1858. Kindttf'isch, Path. Anat., vol. ii, pp. 260, 260. A. Johnstone, in Syst of Surg., 2d ed., vol. iv. 2 Rcdfern says: " Most extensive disease may be going on in many joints at the same time, and may proceed to destroy the whole thicUness of the cartilage in y)ar- ticular parts, without the patient's knowledge, and while he is engaged in an active occupation." I once saw a striking ocular demonstration of the utter painlessness of ulceration of the cartilage. I had amputated at the knee-joint in a case of injury, leaving the whole of the cartilage cov(^ring the femur intact. Unluckily my ante- rior flap (which had been injured in the accident) sloughed, and the end of the femur covered by its cartilage lay exposed. We watched the cartilagi! melt away by ulcer- ation during many days till the whole bone was denuded. The patient remained quite insensible to the process. 3 Works, l)y Charles Hawkins, vol. ii, p. 244. * Sr^veral interesting cases will be found recorded by Rrodie, in which anchylosis apparently complete has ensued on ulceration of the cartilages, without any formation of pus See especially the case numbered xliv, on p. 242 of the second volume of his collected works, edited by Mr. Charles Hawkins. LOOSE "cartilages." 469 inflamed and softened, so that the interarticular ligaments are apt to give way and tlie capsule to yield to the pressure of the bone now displaced by the muscular action, and so dislocation will ensue if great care is not taken. Finally, the occurrence of acute suppuration in the joint needs no explanation, since pus is furnished not merely by the cartilage but in far greater quantit}' by the granulations on the inflamed synovial membrane and bone. The treatment of this acute inflammator\' disease is at the present time less active than it used to be; but still, though we have, perhaps, been wise in giving up the excessive local bleeding and counter-irritation and the free administration of mercur3' which was in vogue some years ago, we have abundant opportunities of testing the value of more i^ioderate antipidogistics and counter-irritants in the form of the free application of leeches, blistering, or issues. The strictest local rest siiould lie at the same time enforced. If the joint is too irritable to bear a splint it should be supported on all sides by some soft substance, such as a junk well padded with tow or cotton-wool sufficiently to prevent any serious dis- placement ; or if such displacement has taken place before the case is seen the limb should be at once put into as good a position as possible nnder chloroform. The free administration of opium to such an extent as will relieve the pain is necessary. In robust persons with high inflam- mation I have often seen great improvement from a course of mercur}^ rapidly administered; and although conscious of the evils which follow the indiscriminate use of mercury, in such cases I venture to recom- mend it. The necessity for amputation arises when the symptoms of abscess in the joint are plain, and wlien in the surgeon's judgment the patient has not strength to survive the opening of the abscess — as to which enough has been said above (p. 4(52). Excision is not successful, and should not be practiced in these acute conditions of inflammation in the lower limb ; but in the upper limb there is no such ol>jection, and I have more than once excised the elbow with success in the acute stage of the disease. There are other degenerations of the articular cartilages, as hypertroph}', atrophy, fibrous, fatt}^, and calcareous degeneration, but they produce no known symptoms during life, and I must, therefore, refer the reader to works on pathological anatomy for their elucidation. The extensive changes thus found in the cartilages, with no symptoms during life, strengthens the opinion that in the destructive disease called "ulceration of the cartilages" the condition of the latter is really a subordinate feature. Loose '■'•cartilages^'''' or, as some prefer to call them "loose bodies" in the joints, are sometimes numerous. They are seen almost but not quite exclusively in the knee-joint. Rare cases are recorded and preserved in the elbow and other joints, but they are rather surgical curiosities than matters of practical interest. The following will, therefore, apply to the disease as found in the knee. They are not usually cartilaginous, at least, if there is any true car- tilage in them it is often in such small quantity as to escape even a careful examination. The bulk of the body consists usually of fibrous tissue, in which perhaps a small cartilaginous nodule may be found, and the car- tilage is sometimes extensively or almost entirely calcified. In other cases, however, they have been found cartilaginous throughout, and in 470 DISEASES OF THE JOINTS. some true bone forms a part or tlic whole of them, and I have seen a case in which the supposed loose cartilage turned out to be a piece of semi- solid lyini)h. Tlic causes whicli produce these loose bodies will throw some light on their anatomy. Hunter believed' that tliey often arise from contusions in wliifh lilood is ett'used into the joint ; and this blood becoming organized and then being separated from the inner surface of the synovial mem- brane, gives rise to the loose body. And although modern pathologists may hold difl'erent views from Hunter about the frequency of the process of organization of blood-clots, it cannot be doubted that accident is a fi'equent cause of loose cartilage. This accident may possibly produce extravasation into some of the fringed processes of synovial membrane in which it is well known that minute portions of cartilage may often be found. If such extravasated fringes become subsequently thickened by inflammation their attachment to the main portion of the synovial mem- bi'ane may l)ecome gradually looser, until at length they drop completely into the cavity, and then would be found to present exactly the structure generall}' seen in a loose cartilage. And this explanation of their origin is also consistent with the fact that they are frequentl}' found not per- fectly loose, but pedunculated. In other cases, however, there is no doubt that they originate spontaneously from the detachment of similar fringed processes, which in some persons are found unusually large and numerous,- or they ma}^ and often do originate from disintegration of the cartilages in chronic rheumatic arthritis, and possibly in other affections of the joints, though in these cases they are seldom made the subject of any special treatment, the existence of the loose body being only a sub- ordinate feature of the case. Finally, there are cases (though probably not very many) in which a piece of the articular cartilage or even of the articular end of the bone may be knocked off, and fall as a loose body into the joint.'* The symptoms which they produce are acute pain when the foreign bod}' gets between the ends of the bones in the movements of the joint, often followed by more or less synovitis, so that the limits of the joint are somewhat extended. The loose body is often plainly to be felt in the sac of synovial membrane which extends in front of the femur, and then may fall into the back of the joint again and perfectly disappear. The patient usually is quite conscious of its presence, and can often bring it into reach when the surgeon cannot. In the treatment of this affection it is necessary, I think, to bear in mind that the knee-joint cannot be opened without grave danger. There- fore in persons whose occupations are not active, and who do not suffer much from the presence of the foreign body, it may be more prudent to temporize with the disease by fixing the loose cartilage if possible in the upper sac of the synovial cavity, where its presence is comparatively harn)less. 'IMiis may sometimes be accomplished by circular strips of strapping fixed above and below it, or by a bandage with a hole to re- ceive it, and it is even possible that the loose body may at length adhere in that position. It will be, of course, understood that the movements of the joints are restrained meanwhile by a firm bandage or knee-cap. 1 Hunter's Works, vol. i, p. 520, and vol. ill, p. G25. * See tlie fij^ure on p. 4, vol. iv, Syst. of Surg. " See the cases of detftchment of a piece of cartilage, related by Mr. Teale, Med.- Chir. Trans., vol. xxxix, p. 31 ; by Mr. Brodhur.^t, St. George'.s Hospital Keports, vol. ii. p. 141 ; and of detaclinnMit of a portion of the bone along with the cartihige over it, by Mr. Simon, Path. Trans., vol. xv, p. 20G. CHRONIC 08TE0-ARTHRITIS. 471 Attempts have been made to fix the loose body by driving a silvei- suture through it, but not, I believe, witli encouraging results. But in most cases where the joint is otherwise healthy and the patient is ol)liged to use it, the removal of the loose cartilage becomes necessary, and this is effected in one of two ways. In both the body must be securely held by the surgeon's left forefinger and thumb placed under it. Then in the direct method of extraction tlie surgeon cuts down on the loose sub- stance and gently squeezes it out of the wound, following it with his finger and thumb, so as if possible to prevent the escape of synovia from the joint. And in order that the wound into the joint may be less direct it is well to have previously drawn the skin to one side over the loose cartilage, so that when the parts return to their proper position the skin- wound no longer corresponds to tlie opening in the joint. In the subcu- taneous method (which is believed to be more safe, though the evidence on that point is not conclusive) a tendon-knife is passed down to the surface of the loose body and a bed or cavity formed for it in the track of the knife; an opening is then made into the capsule of the joint, tlirough which the cartilage can be squeezed into the subcutaneous tissue. There it is left, either for life or, if it causes any inconvenience, until the opening in the joint has long healed, when it is cut down upon and extracted. In tiiese operations it is essential to disturb the parts as little as possible, to unite the skin-wound or puncture immediately and very carefully with strapping, to bandage the limb evenly from the toes, and to fix it securely on a well-fitting splint. The tendency to inflammation will thus be best obviated ; but if the knee does inflame cold should be at once applied; and if the inflammation increases and becomes violent suppuration is imminent, and the case must be treated accordingly. Chronic rheumatic arthritis, rheumatoid arthritis, osteo-arthritis, rheu- matic gout, or nodosity of the joints, is a disease which has only lately been accurately described, mainly by Irish surgeons — Dr. Haygarth, Dr. Robert Adams, and Prof. R. W. Smith. The tissue originally affected (if, indeed, the disease begins in any single tissue) is difficult to deter- mine, since we hardly ever see the disease dissected except in an ad- vanced stage, but it is commonly believed to commence with injection of the synovial membrane, which becomes distended with fluid, its vascular fringelike processes overdeveloped, the joint somewhat filled with fluid, the ligaments distended and inflamed ; the bursas near the joint often share in the distension ; bony deposits form in the ligamentous capsule giving rise to the formation of tlie '' additamentary bones" so character- istic of this alfection; the cartilages become degenerated and gradually disappear, sometimes portions of them drop into the joint, forming one kind of loose cartilage. As the cartilage disappears the articular surface of the bone becomes polished and eburnated, the shape also of the bony surface becomes greatly changed, the cavities being much enlarged, and the articulating ends flattened out as if they had been partly melted and then squeezed out into a kind of mushroom sha|)e. There is little or no tendency to suppuration, nor does anchylosis ensue, thougli the limb may be stiffened from the unnatural shape of the bones. In the more favorable cases, however, just the opposite issue follows ; for as the joint surfaces become polished on each other the movement be- comes again free and painless. Tlie chief symptoms of chronic rheumatic arthritis are wearing pain in the part, alteration of its shape, and crackling on motion. This crack- ling is sometimes so loud as to be distinctly heard all over the room. It 472 DISEASES OF THE JOINTS. is due partly to tlie rubbing of the joint-surfaces on each other and partly to that of the additanientary bones. The treatment of this complaint when it is fully established — i.e.^ when the shape of the joint surfaces is much altered and they are ex- posed and crackle on each other — is never very satisfactory'. All that can then be done is to palliate the pain by opium if necessar}-, hot douches, regulated pressure, and support to the joint. But in the early stage the general treatment of rheumatism carefully carried out, and particularly'^ residence in genial climates, and the persevering use of hot springs, may do much to avert the occurrence of the more profound and incurable changes in the bones and ligaments. In a very few cases excision of the affected joint has been practiced. Thus Dr. Humphry excised the condyle of the jaw,^ and the head of the femur has been excised on account of chronic rheumatic arthritis at an unusually advanced age, and with alleged success. Such operations, however, can be seldom advisable, since the disease is a constitutional one, and therefore liable to present itself anew in another joint ; nor is the suflering which it occasions sufficient, as a rule, to justify so dangerous an operation. It is now universally admitted that most of the cases which have been published as "partial dislocations," especially of the shoulder, and as "fractures with ligamentous union," of processes in the neighborhood of joints, such as the acromion, were really instances of chronic rheumatic arthritis accompanied by changes in the shape and position of the joint surfaces, by erosion and unnatural adhesion of the tendons near the heads of the bones, and by the formation of the additamentary bones, which are characteristic of this affection. (See Dr. R. Adams's work on Rheumatic Gout, 2d ed., pp. 118 and seq. ; and his plate iii. Figs. 1, 2.) Anchylosis, or stiffening of joints, is of three kinds. In the first, which is denominated the exb'a-articular, it depends on fibrous adhesions in the soft parts external to the bones, such as take place in limbs which have been long kept in constrained positions, as in the treatment of frac- ture. In the second, or fibi^ous (false) anchylosis, the joint surfaces are united by bands which pass from one articular cartilage to the other, such as have been above described as forming after ulceration of the cartilages or after synovitis. In the third, or hony (true) anchylosis the articular cartilages having been removed, the bones, exposed and ulcer- ated, unite, as in compound fracture, by granulations, in which ossifica- tion occurs, until at length the whole becomes one solid mass of bone. The diagnosis between bony and fibrous anchylosis can usually be made under chloroform, for in the fibrous anchylosis some amount of passive motion is alwa3's possil)le, while in the bony there is none. And again, in bony anchylosis the muscles around the joint waste to an extent which is never seen in the fibrous. The diagnosis between the fil)rous and the extra-articnlar anchylosis can be made in part by the history and in part b}' the result of examination under chloroform. In fibrous anchylosis movement is fettered by a definite band or bands. It is, therefore, per- fectly unopposed until those bands are put on the stretch, when it is ab- ruptly checked. In the extra-articular it is a generally stiffened condi- tion of all the parts around which opposes motion. The treatment must be determined parti}' by the nature of the anchy- losis, and partly by the amount of inconvenience which it causes. Extra- 1 On the Human Skeleton, p 306. ANCHYLOSIS. 473 articular adliesions can usuall}' be got rid of by constant passive motion, oiling the part, gradually or abruptly stretching it, or applying various extending apparatus. Many sudden cures are effected in this and in fibrous anch^'losis b}' sudden wrenches, which break down the bands and restore motion at once. Such cures are often worked haphazard (and sometimes, also, it must be owned, with a definite purpose and knowledge) by quacks in cases neglected or given up by regular practitioners, much to the shame of the latter. Remembering the frequency of these cases, we should be cautious of insisting too long on confined positions of joints in the treatment of accident or disease ; and when stiffening has taken place, and all inflammatory symptoms have subsided, a cai'eful ex- amination under chloroform will often detect one or more definite bands, which can be ruptured and the part at once restored to its function, gradually increasing passive and active motion being afterwards care- fully insisted on. In more extensive fibrous anchylosis there will be much more difficulty in restoring moliility. Long patience is required on the surgeon's part, and unusual conttdence on that of the patient, before the desired end can be reached, and often the adhesions will reform time after time. Still even if ultimately a stiff joint is left, at least its position may be im- proved and the limb be left useful instead of useless. Some caution is necessary in making forcible extension in sucii cases to avoid doing in- jury to neighboring parts, or fracturing the bones in childhood, or in adults when the bone is weakened by atrophy. A useful precaution is to hold the bones as near the joint as may be, and to rupture the adhe- sions by short movements in the way of flexion before attempting to put the limb straight by extension movements. Again, the tendons, in case of old dislocation or anchylosis in false positions, are often so contracted as to require division before the case can be successfulh' treated, and this must always be done some days before the attempt at extension. Bony anchylosis is one of tlie methods of cure in joint disease, and it should not, therefore, be interfered with, unless the position in which it has occurred renders the limb useless. In such cases the simplest plan (and it is also the least dangerous) is to fracture the bone below the joint and put the limb straight; but this is seldom possible or safe except in childhood. When there is little change in tlie shape of the bones, and the uniting medium is not very extensive, the operation introduced in the case of the knee-joint by Langenbeck and Gross, ^ and since practiced more frequently b}'^ Mr. W. Adams'- in the hip-joint, of dividing the unit- ing medium, or the bone in its neighborhood, b}' means of a fine saw introduced as much as possible subcutaneously, like a tenotome, is easy and successful. But in cases whi(;h really require any such opei'ation — i. (\, where the change in the relative position of the bones is considerable — there is often a very large deposit of bone around the old joint, and the shape and size of the anchylosed articular ends has been much altered. It m;iy, therefore, be impossible in such cases to execute any section really deserving of the title subcutaneous, and the operation approaches in gravity and in extent to that of excision, and is liable, like excision, 1 Langenbeck 's and Gross's operations on the knee are referred to in the New Syd. Soc.'s Biennial Retrospect, 1867-8, p. 256; and in the Syst. of Surg , 2d ed., vol. iii, p. 722. ^ Laiigcnbeck's, Gu^rin's, and other surgeons' labors in this operation will be found summarized in Mr. Adams's pamphlet on Subcutaneous Division of the Neck of the Thigh-bone, 1871. 474 DISEASES OF THE JOINTS. to be followed by renewed disease in the divided surfaces, 1)3' exhausting supi)urjvtion, or by pyn?mia. Neuralgia and hysterical affections of joints, though they are not iden- tical, yet are hard to separate from each other in practice. They are both characterized by pain which is out of all proportion to the evidence of actual change of structure, though there is in some cases some amount of swelling or puffiness around the joint, testifying to the presence of a certain degree of increased vascular action, which, however, is rather the consequence than the cause of the pain. In many cases this neuralgic affection is only one of the symptoms of general hysteria, as testified by the other ordinary phenomena of that state, but in other cases there is no such general affection. True neuralgia is periodic, and is usually con- nected with some disturbance of general health or digestion. It must be treated, as in other parts, by anti-periodics, as quinine, arsenic, or hydrochlorate of ammonia in full doses, and especially by attention to the general health and the condition of the bowels, and by free exercise of the part. The distinction between hysterical aff"ection of a joint and organic dis- ease is made chiefly by noticing the disproportion between the pain and the evidence of local lesions,* l)y the varying and inconsistent nature of the symptoms, and by examination under chloroform, which is often per- fectly decisive, as it is also in voluntar3^ imposition. It is strange in these cases to see how motion, which has seemed almost impossible while the patient was conscious, becomes at once completelj' natural when annesthesia is obtained, and the perfectly smooth and natural condition of the articular surfaces testifies to the absence of all serious disease. The diagnosis is, however, most difficult in practice, though its prin- ciples when stated in the above summary manner appear to be easy. A careful perusal of Sir J. Paget's lectures on this topic will show that there is no symptom of organic disease of a joint which may not be imitated by "nervous mimicry," as he calls it — the lameness, the permanent loss of use, complete stiffness, wearing pain, even wasting of the muscles around the joint; and the matter becomes still further complicated when we reflect that on tlie one hand a patient most obviousl3' hyster- ical may, nevertheless, have articular disease, and that on the other a patient may be suffering from nervous disease who displays no trace whatever of hysteria, llencc Sir J. Paget dwells forcibly on the neces- sit3- of commencing the investigation of the case with the local symptoms and appearances, and giving to the latter far greater weight in diagnosis than to the general aspect and history of the patient. But it is wise not to be in a iuirry, and only to form and announce a positive opinion, after careful an.ynoviti>, the heat of the joint is perceptibly increased, as felt by the hand laid over it, and this i.s not the case in nervous disorders. This test, however, is only apj)licable to the superficial joints. — Paget's Clinical Lectures, p. 215. MORBUS COXARIUS. 475 Disease of the Hij). — The disease of the hip {Morbus Coxarius) which is so common in the poor weakly children of our large cities, and which is seen occasionally also in children who are more fortunatel}- circum- stanced, is often denominated slrumoiis disease. But 1 should like (in accordance with the observations made above, page 4G4), to commence its description by protesting against the use of a term which includes a theory that is not only unproved, but, as I contend, disproved by the result of numerous cases. It would indeed be absurd to den}' that strumous children often suffer by hip disease, that hip disease is often associated with pulmonary consumption in the family or in the person affected, or that it is sometimes, though more rarely, accompanied by other strumous or scrofulous aff^ections. But I think it would be an equally gross error to deny that it often occurs, just as disease of any other joint does, from local injury or exposure to cold ; that it is suscep- tible of complete cure, without any constitutional aff"ection left behind it, or any tendency to disease in any other part of the body ; and that at even the most advanced stage it may in appropriate cases be extirpated by surgical operation with just the same prospect of definite cure as after excision of any other joint. In fact, each case must be judged on its own merits — there are strumous cases of morbus coxarius and cases not strumous, and their successful treatment depends in a great measure on their diagnosis. The symptoms of disease of the hip are generally divided into three stages: 1. Stage of Inflammation. — The first, or inflammatory stage, is charac- terized by starting pain at night, by pain in the knee, limping, and wasting of the muscles. Sometimes one of these symptoms, sometimes another, is the first which is noticed. Perhaps of all other symptoms the loss of motion of the joint is that which is most convincing. On laying the child down and rotating or flexing first the sound and then the af- fected limb, the contrast between the easy and even movement of the former and the stiff", painful, imperfect motion of the latter is very striking. There is occasionally, but not often, some fulness of the hip as if from effusion into the capsule of the joint, and some heat of the parts. The limb very commonly appears to be lengthened, but this is found on measurement to be only apparent, and dependent on the posi- tion of the pelvis, which is adducted — that is, drawn down on the affected side — so that the spine of the ilium is lower on that than on the sound side. The opposite side of the pelvis, however, is often dropped and the affected limb is apparently shortened, though no real change in its length has taken place.^ ^ What the cause of the various phenomena of hip disease may be is not easy to determine. The wasting of the muscles is a most striking phenomenon, and is present often to a considerable extent before the diagnosis of hip disease has been formed ; though not, therefore, before the disease has commenced (see Nunn, in Path. Trans., vol. xviii, p. 217) ; and it aflf'ects, as Mr. Nunn has pointed out, notthe muscles of the hip only — though chiefly these — but also the whole limb. Sir J. Paget (Clin. Lec- tures, p. 208) has called attention to the great extent of wasting which goes on in these and other acute diseases of the joints, and has shown that it is too rapid to be accounted for entirely by disuse; though disuse, of course, pla3's a part in it. The causes also of the apparent lengthening and shortening of the limb are the subjects of much difl'erence of opinion. It is clear that the lengthening depends on position only. The two main theories which are now adduced as reasons for this position are that of MM. Martin and CoUineau, which refers it to the disposition of the Kbres of the capsule, and that of Mr. Barwell, which attributes it solely to a contracted con- dition of the abductor muscles of the thigh. In the view of the French authors there are different kinds of hip disease, and that kind which commences in inflam- mation of the articular capsule (" capsular coxalgia," as they style it) is accompanied 476 DISEASES OF THE JOINTS. The pathological anatomy of the earl}' stage of hip disease is not easy to determine, and it appears to me probable that the disease commences at one time in the ends of the bones, at anotlier in the synovial mem- brane or in the ligaments. On this head I would refer to the observa- tions which I have made in a work on tlie Surgical Treatment of Children's Diseases. 2d edition, pp.435 et seq., in which I endeavor to prove that in most cases the visible results of inflammation are first seen in or about the ligamentous capsule and the ligamentum teres, though some cases prob- abh' commence as common synovitis, and others with low inflammation of the bones. 2. Stage of Abscess. — The second stage is that of abscess., which is not, however, necessarily connected with disease of the bones, nor always situated in the cavity of the joint. Very frequently it is external to the articulation and the bones are unaffected. Examination under chloro- form will settle this point by revealing true crepitus when the bones are diseased, or the grating sensation of roughened cartilage when the mis- chief is less deepseated. 3. Stage of Beat Shortening. — The third stage is that of real shortening. This shortening is produced by caries and absorption of the head and neck of the femur and of the acetabulum. The upper end of the femur is in some cases so disintegrated that only a small irregular projection may remain above the trochanter, and in most cases the head is found to be diminished in size, and nearer the trochanter than natural. The acetabulum is often greatly enlarged, and not unfrequently perforated by ulceration. There is abscess, which has generall}' burst externall}', either in the thigh, the pelvis, or both. In consequence of this change of sliape of the bones there is a displacement, commonly called dislocation, but which differs from dislocation in the very important particular that the at first by a relaxed condition of the capsular ligament, which produces abduction and rotiition outwards, or rather necessarily involves that poi*ition, in consequence of the anatomical disposition of the fibres of the capsule, and the muscles accordingly place the limb in abduction. This position of the femur induces, secondarily, an adducted position, or dropping, of the pelvis, in order to maintain equilibrium in the erect jiosition. After a lime tlie inflammatory elongation of the capsule is succeeded by induration and contraction, involving a change from the elongated to tlie appar- ently shortened condition of the limb. Thus are explained the many cases in which elongation is the primary, and shortening the secondary symptcjm. Shortening, adduction, and rotation inwards of the femur are also produced, according to these authors, by an inflamed condition of the acetabulum and liead of the femur, and by the mu.-rcular contractions provoked by sucii inflammation. This species of hip dis- ease ("coxalgic osteitis ") may occur either primarily (and thus are explained those cases in which shortening occurs without previous elongation), or it may follow on the "capsular coxalgia," which produces elongation. Th(! real shortening everybody allows to be produced by changes in the size and relation of the acetabulum and up- per end of the femur. Mr. Barwcli attributes the lengthening to a spasmodic condi- tion of the abductor muscles, which he says always accompanies the distension of the capsule; and he ap])ears to believe that such distension is always relieved by the bursting of tiie ca])sule before the second stage — that of adduction or shortening — comes on. If I have rightly understood Mr. Harwell's theory, it hardly explains those cases in which shortening is not preceded by elongation, nor those more numerous cases in which there is dccitledly no trace of any such perforation of the capsule as Mr. Barwell speaks of. But bulb theories agree in this, that they refer both jiosilions to the preponderating and spasmodic action of cci'lain sets of muscles; and without professing myself satisfied as to the correctness of the details of either theory, I fully agree in tin; main practical inference to which they point, viz., that the early symptoms of hip disease aris in a great measure muscular, and can only be treated successfully by measures directed to the rcilief of muscular contraction, i. c, by mechanical extension. — Holmes's Surgical Treatment of Children's Diseases, p. 443. MORBUS COXARIUS. 477 Dislocation of the hip from disease. A preparation, Ser. iii, No. 86, in the Museum of St. George's Hospital. — System of Surg., 2d edition, vol. iv, p. 83. ulcerated articular surfaces are not separated from each other, but re- main in mutual contact, and therefore irritate each ^^'^- 2*'^- other. To this rule there are, of course, exceptions, in which the head of the femur has entirely quitted the acetabulum ; but, as far as I have seen, they are very rare. In some still rarer cases the capsule is so stretched and the liga- ments have so far yielded that the head of the bone will quit the acetabulum and return again into it on manipulation with per- fect ease. I have referred to such a case in the work above quoted (p. 438), in which the patient had not suffered from any congeni- tal affection, where there had been no formation of matter, and there was no grating of the bones on each other. But by very slight manipulation the head of the femur could be dislocated on to the dorsum ilii, as proved by the sensation of the head slipping out of the socket, which could be plainl}' perceived ; and the characteristic shorten- ing of the limb was then immediately produced, and the bone could be felt on the dorsum ilii. It was equally easy to reduce the bone into its natural position. Dislocation from disease can always be diagnosed by measuring tlie length of the limb and observing the position of the trochanter, which is elevated above the natural level. The readiest way of ascertaining this is by what is called " Neiaton's test." If a string is stretched from the anterior superior spinous process to the tuberosity of the ischium on the sound side it will be seen that the trochanter is entirely below it, or possibly the upper border of the trochanter just touches the string. On the affected side the trochanter rises above this line to an ex- tent proportioned to the destruction of the neck of the femur. Or, if the surgeon prefers it, he may use Mr. Bryant's method of measuring by the vertical distance of the top of the trochanter from a horizontal line car- ried through the anterior superior spine (see page 291). Diagnosis. — The diagnosis of hip-joint disease is not always easy, at least many mistakes are committed. Excluding hysterical or neuralgic affection, the diagnosis of which from organic disease must rest on the same principles in this as in other joints, congenital dislocation, disease of the knee, psoas abscess, caries of the pelvis, disease of the bursa beneath the psoas muscle, and infantile paralysis affecting the muscles of the but- tock, are the aflections usually confounded with morbus coxarius. The best test is the loss of motion in the affected limb. For in every one of the affections above enumerated the suspected limb can be moved easily and painlessly. This is the case even in those which are accompanied by inflammation, if care be taken to relax and steady the parts which ai'e in- 478 DISEASES OF THE JOINTS. flamed. But some special diagnostic s.ymptoms must be added. In con- genital dislocation there is limjnno;, possibly wasting of the muscles, and when the child stands on the limb there is shortening. But he moves quite readily and actively, Fio. 208. though with an awkward waddle; the length of the limb can generally be re- stored by traction, and there is no pain on pas- sive motion. In disease of the knee there is pain in the knee, as there is also in disease of the hip ; but careful examina- tion will show the thick- ening and increased heat of the parts forming the knee-joint, the stiffness on attempts at passive mo- tion, and the other symp- toms of disease of the knee. I may just remark in passing that disease of the knee and hip may co- exist, so that the proof of disease of the knee is no actual disproof of hip dis- ease. In psoas abscess, or in abscess in tiie iliac fossa or buttock from dis- ease of the pelvis, there are the characteristic symp- toms of disease of the spine or pelvis superadd- ed to the freedom of mo- tion of the hip. Disease of the bursa of the psoas is a rare affection. It may be known l)y the pain which is produced in the tumor on extending the muscle, and the relief of symptoms and freedom of movement on its relaxa- tion, and by the presence of a resisting and elastic, if not lluctuating, tumor, of perfectly defined shape and size, in the immediate neighborhood of the hip. Passive motion of the joint is free and painless, except when it causes pressure on this tumor. Infantile paralysis, wlicn confined to the muscles around tlie hip (which is rare), sometimes gives rise to mistake on a careless examination, but the painful symptoms of hip disease are absent, and there is no obstacle to passive motion, while active motion, if any power is left, though limited, is painless. Congenital dislocation of the hip. From a typifal case iu which both hips were dislocated, .showing the symptoms char- acteristic of this allection, viz., obliquity of the pelvis, causing lordosis, disproportionate length of the lower limbs, the shoulders thrown back, the legs weak and flaccid, the feet flat. The trochanters are promint'nt and nearer the spine of the ilium than natural, and the head of the thigh-bone, if of the natural size and shape, can be felt on the dorsum ilii.— From Syst. of Surg., 2d edition, vol. v, p. 831. MORBUS COXARIUS. 479 Treatment. — The treatment in the earlier stages of hip disease consists mainly in rest and attention to the general health. If the limb has been drawn into an nnnatnral i)osition it must be put straight under chloro- form, which is always perfectly easy in the early stages, and extension must be applied eitlier by a long splint or b}^ a weight suspended from a pulley at the foot of the bed,' which is far better in children, since the long splint irritates them and is constantly displaced. The weight must be proportioned to the age of the child — 3-4 lbs. for a young child and 7-10 lbs. for one approaching puberty may be taken as a rough average, but this must be ascertained by experiment.^ Its traction seems to prevent the mutual contact of the inflamed surfaces, and the consequent muscular spasms which are so painful a feature of the disease. In cases where the inflammatory symptoms are unusuall}' severe leeches may be applied in the groin, and where there is much pain blisters or the light application of the actual cautery in the neighborhood of the joint are often of service. But prolonged rest in bed is the main agent in the cure of the disease, and this confinement to bed, far from being deleterious, is generally attended with considerable improvement in the general health. In sum- mer weather, if the {patient's circumstances admit of it, his bed should be placed on a wheeled couch without disturbing him, and he should enjoy the fresh air; but so long as there is any tenderness of the parts on mo- tion no disturbance of tiie hip should be permitted. How long that may be it is very hard to say. I have known cases treated earl}' recover after less than half a year's rest, while more obstinate cases will require several years; but when taken in the earliest stage of the complaint hip disease is often curable most completely, with no loss of motion, no change of shape of the parts, and no defect of health ; and this forms a powerful motive for recognizing the earliest symptoms of the affection. Those symptoms are often verj' insidious; there is little or no tangible pain, the child is often believed to suffer only from "growing pains," and the limp- ing may not be constantly noticed ; but the stiff"ness of the joints on pas- sive motion, and the pain which is produced by attempts to move the thigh, especially in the sense of abduction,^ are symptoms which careful examination can hardlj^ fail to verify at any period at which the disease can be diagnosed. It is not advisable, I think, to open abscesses connected with diseased hip unless there is some special reason fordoing so. I have seen unmis- takal)le abscesses disappear; and even if they are to burst it is better to allow the deep parts as long a time as possible to consolidate before the opening forms. If the abscess seems to be increasing, its evacuation by means of the aspirator is very desirable. In the third stage, when the bones are obviously diseased, the question of excision becomes a practical one. The answer to this question will depend mainly on the prospect that we believe the patient to have of spontaneous cure ; and this again depends on the means he has for pro- curing long-continued rest, with careful nursing. If this can be had, more patients I believe will get well than after excision, and with better 1 A diagram of extension by means of the weight will be found on page 300 * I do not see any object in using more force than is necessary to prevent pain and insure the complete repose of tlie parts. American surgeons use very much greater extension than tliat suggested in the text. In a case recently published by Dr. Tay- lor, of New York, in a child aged thirteen, besides an extending apparatus calculated to exercise a traction equal to 100 lbs., a weight of 50 lbs. was applied to the foot. — See London Med. Record, July, 1875. 3 Holmes's Surg. Dis. of Childhood, 2d ed., p. 441. 480 DISEASES OF THE JOINTS. limbs ; but in the poor children whom we are often called upon to treat, it ma}' be more judicious to remove the parts, and if this is to be done with an}' prospect of success it should not be delayed too long. The operation is not a ver}' severe one, and it leaves a very useful limb ; though I think generally the shortening is greater and the union not so firm and strong as after natural anchylosis. For the details of the opera- tion I must refer the reader to the chapter on Operative Surgery. Other Affections. — The hip is also the seat of many other diseases. The ordinary so-called " strumous " disease is one of the common affections of childhood, yet an identical affection is not by any means unknown in later life ; and it is curious, but I believe true, that the disease in the adult is less severe and dangerous to life than in the child. I have often noticed this with surprise, and recently saw the observation confirmed in a paper by Dr. Taylor, of New York. Then we meet comparatively often with affections of the great trochanter or its neighborhood, sometimes with, sometimes without, suppuration, which it is difficult to separate from hip disease, and which may, in fact, spread to the hip. These are usually the consequences of falls or blows, and they demand careful but decisive treatment, in order, if possible, to avert the implication of the joint. Rest and counter-irritation before suppuration sets in, and free incision, exposure of the carious or necrosed bone, the removal of seques- tra and the application of sulphuric acid to the softened bone are the chief indications. Chronic rheumatic arthritis has its favorite seat in the hip, so much so that the disease was for a long time only known in that joint, and called malum coxoe senile. The change of shape in the parts, producing short- ening of the limb, the wearing pain, the slow course of the disease, the crackling on passive motion, plainly mark the nature of the affection. The treatment is usually unsatisfactory (see p. 473). Sacro-iliac Disease. — Closely connected with disease of the hip is dis- ease of the pelvis. In fact, we have seen that some amount of disease of the pelvis almost always accompanies the last stages of hip disease. But the most characteristic affection of the pelvis is that which occurs at or near its junction with the spinal column. In many cases which are diag- nosed as sacro-iliac disease it is probable that the disease aflfects the bones of the pelvis or spine as much or more than the sacro-iliac joint itself; but when the disease is localized in the articulation its character- istic sign will be pain in sitting, standing, or walking ; in fact, in any action which brings the weight of the body to bear on the pelvis. On examination it will be found that there is no pain when the hip is moved, or when the spine is flexed or extended, provided the pelvis is kept steady, but there is pain when the pelvis is moved on the spine. There is also swelling or some pnffiness about the part, with increased heat to the hand or to the thermometer, pain rnnning along the course of the lumbar nerves, and sometimes, flexion of the hip from irritation of the psoas muscle. These latter symptoms may cause a suspicion of disease of the hip or spine, but carelnl examination will show that the movements of these parts are free and their temperature is not elevated, while the heat and pain about the sacro-iliac joint will point to the real seat of the mis- chief. The prognosis depends on the age of the patient, and on the stage which the disease has attained when the treatment has commenced. When the patient is an adult, and the disease has proceeded to suppuration, the prognosis is generally unfavorable, though instances of recovery are not DISEASE OF THE TARSUS. 481 wanting. It mnst be treated, like disease of the spine, by complete rest, with proper attention to diet and regimen, so that the patient may be supported through the stage of exhaustion or hectic which may possibly supervene until anchylosis is obtained. As in disease of the spine and hip, it seems better to allow abscesses to open spontaneously, unless they are causing irritation. The diseases of the knee having been taken as typical of those of the joints generall^^, no further remarks need be made on them here, AnJde and Tarsus The ankle is, perhaps, next to the knee and hip, the most frequent seat of disease, and it is also very commonly impli- cated in inflammation of the tarsus. It is, therefore, very impoitant to stud^' carefully the diagnostic signs between disease limited to the ankle- joint, disease limited to the astragalus, the os calcis, or the joints between these two bones, general disease of the tarsus, and disease implicating the ankle and tarsus simultaneously. Disease when limited to the ankle- joint is marked by effusion into that cavity, which raises up the extensor tendons and produces fluctuation on either side of them, and as it in- creases presents at one or other or both borders of the tendo Achillis. The movements of the foot on the leg are painful, and if the disease has proceeded to denudation of the bones crepitus may be felt under chloro- form, or there may be sinuses from which the probe can feel bare bone in the joint. At the same time there is no increase of heat, no swelling or tenderness over any part of the os calcis, except possibly just the upper part where it is overlapped by the articular effusion ; nor over the front of the astragalus. Disease which is limited to the astragalus produces swelling, heat, and tenderness corresponding to the position of the inflamed bone, and, therefore, very close to the ankfe-joint, but unaccompanied by the effusion beneath the extensor tendons, or the pain on passive motion. Still it must be allowed that the diagnosis is a difficult one, and that the cases in which the disease commencing in the astragalus does not impli- cate the ankle are exceptional. Such cases are, however, met with, and it has occurred to me several times to remove the whole astragalus for extensive disease of the bone, leaving a healthy ankle-joint, and with com- plete success. Disease of the tarsus has very commonly its starting-point in the joints between the astragalus and os calcis, as Sir B. Brodie long ago pointed out, though it ordinarily begins in the structure of the bone. When the astragalo-calcanean joint is the seat of the affection there will be pain, tenderness, swelling, and heat about the upper part of the os calcis, and the movement of the calcaneum on the astragalus will be pain- ful, though that of the foot on the leg is not. Careful manipulation is, however, necessary to discriminate this. Rest and counter-irritation before the formation of matter, and early incision with continued rest afterwards, are the essentials of treatment. The patient need not, how- ever, be confined to bed after the abscess is opened. The foot should i)e put up in a plaster of Paris splint, with a hole cut for the opening, and he should go about, resting the knee on a wooden leg. In inveterate cases, where the bone is exposed, and the disease threatens to spread, the foot may often be preserved by excising the os calcis and removing any part of the astragalus which is diseased. Disease of the calcaneum is easily known by the presence of swelling limited to the bcme, or of sinuses, all of which lead towards or to it, and by the al)sence of all the special symptoms above enumerated as chai-acteristic of disease of the ankle, astragalus, and astragalo-calcanean joints. The presence of general disease of the tarsus is usually indicated by 31 482 DISEASES OF THE JOINTS. extensive swelling of the whole of the foot and by pain in all its move- ments ; indeed, all use of the foot is soon lost. And in all cases of dis- ease of these parts the foot should be carefully examined under anaisthesia before any serious operation is contemplated, in order to ascertain whether or not these various affections are combined, as thej' so commonly are. It would, of course, be a serious error to excise the ankle-joint or resect the OS calcis if the tarsal bones left behind be in a state of chronic soften- ing in the one case, or the ankle joint diseased in the other. This is an error which is, perhaps, not often committed, but it is, on the other hand, exceedingly common to see a foot amputated for supposed "strumous disease of the tarsus,'' when on examination the affection turns out to be limited to one of the tarsal bones, and the patient might have been cured b3' a less extensive mutilation. Diseases of the joints of the upper extremity are as a general rule more curable than those of the lower. Besides the generally less serious char- acter of all affections of tlie upper limb as compared with those of the lower there is the powerful consideration that the joints of the upper limb have not to bear the weight of the body, and can be easily kept at rest while the patient is moving about and getting air and exercise. Diseases of the sternoclavicular joint are rare, and as far I have seen occur generally in persons of bad constitution, and are to that extent to be looked on with suspicion, though recovery- not unfrequently takes place, even after extensive abscess and destruction of the joint. Rest, tlie prompt removal of sequestra, and the sulphuric acid treatment to any exposed bony surfaces are the general indications. Tlie shoulder is far less frequentl_Y diseased than any of the other large joints, iiotwitlistanding its constant movement, and its exposure to all sorts of injury; and when inflammatory disease does occur the prospect of recovery with a useful liml) is tolerably good, provided treatment be early, patient, and judicious. Osteo-arthritis, however, is rather common in later life, and will in all probability impair the use of the joint, and prove a source of pain and trouble during the jDatient's life. I have ali'eady pointed out (p. 279) how the change in shape of the head of the bone, the new cavity which is often worn in the capsule, the erosion of the biceps tendon, and the loss of the mobility of the joint, occui'ring in this disease, liave been confounded after death with the effects of partial dislocation. The disease is easily recognized during life b^^ the crackling in the joint and the change in shape of the parts, togetlier with the wear- ing pain. Tlie treatment is, unfortunately, a less eas}' problem (see p. 473). Inflammation of the shoulder-joint may long exist without suppuration, and its diagnosis from nervous aftection demands much care, patience, and attentive examination, u}Hler chloroform if necessary. Kest and counter-irritation shouhl be persevci'ed in so long as much pain is pro- duced by motion, but no longer. Too long confinement is apt to produce rigidity of the lower part of tlie capsule, depriving the patient of tlie power of raising the arm. Suppuration, when it occurs, is often directed by one of the tendons around the joint to a considerable distance, so that the real origin of tlie discharge is occasionally overlooked for a time. Another source of ambiguity is the occasional occurrence of disease in tile l)ursa which lies between the deltoid muscle and the head of the bone, and which does not communicate with the joint.' I once treated a case ' The synoviiil fold which (.'xi.sts boiu-iUh the; subscnuiilaris, and is spoken of as its bursa, is really a part of the synovial iiienihrano; and when the infraspinatus has a bursa below its tendon this also forms a part of the joint. DISEASE OF THE WRIST. 483 in which the swelling beneath the deltoid, the pain on motion, and the crepitation which was perceived on rotating the head of the bone, led to the diagnosis of disease of the joint. On cutting down through the fibres of the deltoid the bursa was laid open, filled with a mass of lymi)h and pus; the joint was found healthy, and all tiie symptoms subsided. The excision of this joint is so successful, that, if the symptoms demand it, no hesitation need be experienced in recommending it. At the same time the surgeon must remember that the natural cure, by anchylosis, if it can be obtained, usually leaves at least as useful a limb as that after excision, and he should therefore only recommend operation when he thinks the patient is losing ground, or when it seems necessary to hasten: the cure. The elbow is a very frequent seat of carious disease, and in some rarer cases of necrosis. Dislocation very rarely occurs, except of the head of the radius, which is comparatively often found on the back of the outer condyle, a displacement attributed to the hand having been kept in the pronated position. This position should therefore be avoided in disease of this joint, the forearm being placed at an acute (not a right) angle with the arm, and in the position midway between pronation and supina- tion. When aljscess has formed and the bone is exposed I am in the habit of recommending excision, provided the patient is in good health. It is true that the disease is limited in many of these cases ; in some after the removal of a sequestrum, or after cutting off a portion of the articu- lating surface a cure has been obtained with a moderately useful limb, and in many a natural cure by anchylosis would ultimately result ; but on the whole it seems that the free excision of the joint is both more certain in its prospects of prompt recovery, and more promising as far as the utility of the liml) goes, than either of these other operations. Chronic rheumatic arthritis of the elbow is generally accompanied with a similar affection of other joints, otliervvise it would be a question whether excision might not be recommended in some of these cases. It is probably this affection which generally is the cause of the occurrence of loose car- tilage in this joint. Next to the knee loose cartilage is perhajjs more common in the elbow than elsewhere ; but I never saw a case operated on. The writit and carpus are often diseased, and that to a very great extent, and especially at late periods of life, in the class of patients who are met with at hos|)itals, though far more rarely in persons who are exempt from manual labor. Chronic rheumatic arthritis also attacks this joint, and sometimes produces a pseudo-dislocation, or so changes the relations of the parts that dislocation occurs on some slight injury. The effects of disease of the wrist on the tendons whose action is neces- sary to the use of the hand are perhaps as formidable as the direct injury to the joints, and when the disease has proceeded far the results of all methods of treatment are imperfect. The early treatment, therefore, of such cases is very important; but from the circumstances of the patients it is but seldom that an opportunity is obtained for it. When suppura- tion has occurred the abscesses should be earl^'^ and freely opened, the parts should be kept at rest on a splint, and passive motion carefully given to every joint which admits of it, the patient being also encouraged to use as much voluntary motion as he can without much pain. It is only in the last resort, and as a substitute for amputation, that excision ought to be proposed. 484 DISEASES OF THE SPINE. CHAPTER XXIV. DISEASES OF THE SPINE. Fig. 209. Caries of the spine, or, as it is sometimes called simply, " disease " of the spine, is very frequent among strumous and other weakly children and young persons, often fol- lowing on slight accidents, but as often occurring spon- taneously — insidious, and marked by few or no symp- toms in its commencement, but leading to the greatest lesions in its progress, and very frequently fatal. It affects any part of the spine, from the highest cer- vical to the lowest lumbar vertebrte, and cseteris pari- bui< is more dangerous the higher in the column the affected part is. It has its origin always in the spinal column itself, i. e., in the body of the vertebra, or the intervertebral substance, ' rapidly spreading from one to the other. In the can- cellous tissue of the verte- bra it seems to originate either in a deposit of tuber- cle, which softens, or in low inflammation, leading to sup- puration, which spreads through the bone. In the intervertebral substance its pathology is the same as ... ■ m f ■ ■ cA that of other ulcerations of Angular curvature of the spine. The preparation is viewed from the right side. Therein no difference whatever between Cartilage (seC DlSCaSCS Ot the size of the two pleural cavities. The smooth surface a, Joints). The inflamed 1)0116 is a buttress of new hone, the result of inflammation, which fm'nislies PUS wllicll is at has replaced or has soldered together the remains of the /. . i- •, i, '.i , . bodiesof seven dorsal vertebrae At the side of this is seen first limited by the Structures a mass of rough, irregular bone by which the heads of the arouild the Sl)ine, COndcilSCd corresponding ribs arc anchylosed together. The projecting j,^^q ^^ kind of SaC for it (Fig. spinous processt-sareal-so firmly united by bone -l^om a .^IQ) j,nd the absCCSS ma'y preparation 111 the Museum of !5t. George's Hospital, ber. V, ^'. . . •' ^,^27 remain quiescent in this state for an unlimited time, then dry up and be absorbed, leaving little trace of its former presence; ' Thiidual abscesses, spoken of on p. 57, have one of their most common seats. Spwal abscess is generally psoas or lumbar. Little more need be said about lumbar abscess. It presents at the outer edge of the erector spina; muscle, between the ilium and ribs, and the only questions which occur in its diagnosis are usually whether it is a simple abscess or one caused by diseased l)one, and in the latter case whether the disease is in the spine or pelvis. These questions will be settled by the symptoms and by exam- ination of the parts. When the pelvis is diseased it can often be felt with the probe ; but the spinal disease, being situated on the front of the col- umn, is out of reach. Psoas abscess, however, constitutes a distinct surgical disease, the diag- nosis of which, as well as its treatment, requires special rules. The dis- ease in the spinal column which gives rise to it is often seated above the origin of the psoas muscle, the pus travelling down the front of tlie col- umn in the posterior mediastinum till it makes its way beneath the liga- mentum arcuatum internum, and so gains the sheath of the psoas — some- times on both sides. It then travels down the loins, forming a fulness which can often be distinctly recognized at the side of the lumbar spine, and sometimes irrritating the muscle so as to produce flexion of the thigh and pain on attempts to extend it.' It then fills the iliac fossa, passes be- neath Poupart's ligament on the outer side of the vessels, crosses beneath the femoral sheath to the inside of the thigh, where it usually stops, pre- senting and burstingjust below the groin ; but in rarer cases it may travel a long distance down the thigh before it bursts. The diseases with which psoas abscess is likely to be confounded are femoral hernia, simple ab- scess, cystic tumor, cancer, and aneurism. Like femoral hernia, it often has a distinct impulse. Its orifice of communication with the iliac fossa and the portion of the abscess external to the vessels is often so small as not to be readily discovered. But tlie fulness in the iliac fossa is usually quite sufficient to distinguish it from hernia, even if the pain in the spine and deformity be absent. And although a psoas abscess may be to a certain extent reducible on pressure in the recumbent position, this is merely a diminution of size, quite different from the sudden and complete disappearance of hernia. From simple abscess and from cystic or bursal tumor the spinal .symptoms and the fulness in the iliac fossa are sufficient marks of distinction. Cancer may simulate abscess in this as in other regions, but the diagnostic marks are numerous. Singularly enough the disease which most closely resembles psoas ai)scess is that which would at first sight appear to be farthest removed from it, viz., aneurism, at least that form of disease of arteries to which the somewhat unmeaning name of diffused aneurism is given, i. e., a collection of V)lood communi- cating with a diseased artery, and which is often caused by the rupture of a small pre-existing aneurism ; at other times by the giving way of a diseased portion of the artery. The growth of an abdominal aneurism 1 Similar flexion and pain may, liowever, exist in sacro-iliac disease (see p. 480) and in disease of the pelvis. 488 DISEASES OF THE SPINE. against the spine often gives rise to weaving pain in tlie back from ab- sorption of the vertebrffi; tlie tumor in some cases does not pulsate, and it grows down the loins just as a psoas abscess would do. So close is the resemblance that the mistake has been committed by some of the best surgeons.' Doubtless, in most of these cases auscultation would reveal a bruit ; and this, though it might not be decisive of the nature of the disease, would at least induce caution in opening the tumor, and a preliminary exi)loration with the grooved needle, if the surgeon should still desire to make the opening. When the diagnosis of psoas abscess has been established the question of treatment occurs. The patient must be confined to bed and kept in the strictest repose for a very long period. It is better not even to allow him to rise from his back, but merel3^ to turn from side to side, but it is not always easy to enforce such complete repose. At the same time his strength must be supported by nourishing diet, without stimulants, and cod-liver oil or iodide of iron may be administered internally if they agree with the digestion. In fact, the general treatment must be regu- lated by the constitutional condition. But the main question is whether to open the abscess or not. As a general rule it is better to allow it to burst; but if there is much pain or inflammation, or if it is increas- ing to a very large size, it will be proper to open it. I have no doubt that this is best done in the manner described by Mr. Lister, i.e., by allowing the pus to ooze gradually through a veil made of lint or muslin saturated with carbolic acid lotion, which is to be replaced by the usual carbolized dressings after the oozing has almost ceased (see p. 5fi). If inflammation nevertheless occurs (which, however, has not taken place in several cases I have treated in this way) the sac should be well washed out by injection of carbolic lotion (I to 40) and a drainage tube intro- duced. Other plans are to tap the abscess with the aspirator (p. 229) or with an exhausting syringe attached to a trocar, or to tap it with a trocar the tube of which passes into a basin of w^ater, so as to avoid the entrance of air. After a considerable quantity of pus has been evacuated the punc- ture is closed, and after a few days the operation is repeated; or a small valvular puncture may be made, and a poultice applied. The risk in open- ing these abscesses is the probability of inflammation supervening, marked by shivering, fever, swelling, redness, and oedema around the puncture, and foulness of the discharge. This is a dangerous occurrence, likely to lead to death directly from fever or septi- caemia, or indirectly from exacerba- tion of the disease in the bones. Free incision, washing out the cavity with antiseptics, vigorous stimulation, and support are the measures which should be adopted. When the abscess has healed, or remains in the state of a mere inactive sinus, the treatment resolves itself into that of the spinal disease only. And the treatment of spinal disease really resolves itself Fig. 212. Apparatu.s for supporting tlio spini' and re- ceiving the projecting vertebra;, in a case of angu- lar curvature. ' See a paper On the Diagnosis of Aneurism. — St. George's Hosp. Keports, vol. vii, p. 192. CARIES OF CERVICAL VERTEBRA. 489 into mere rest, that is to say, the bones themselves should be kept at rest, and all the muscles which act upon them as far as is possible. So long as the patient can be kept in bed, without detriment to his health, he is better there than moving about; or the bed can be placed on a carriage, and he can be wheeled into another room or into the fresh air. When it seems expedient, on account of his suffering from confinement, and the bones appearing to be sulficiently soldered, an apparatus may be con- structed by which the weight of the upper part of the body is taken off the spine and transmitted through crutches supported on rigid rods to a girdle I'esting on the pelvis. This should be worn even for a considera- ble time after it is believed that the bones have become anchylosed. The symptoms of such ar.chylosis are the disaj)pearance of pain on motion, the wasting of the muscles in the intervertebral gutters, and the fact that the vertebrae move altogether when the back is bent. It need hardly be added that no attempt should be made to rectify the curvature, which, in fact, is a necessary part of the cure, and which often becomes more marked as consolidation becomes perfect, and the soft parts waste around the anchylosed bones. Disease of Cervical Vertebrae. — Disease of the cervical portion of the spine deserves special notice. It is much more fatal than the similar affection of the lumbar or dorsal regions, and it has both special charac- FiG. 213. Fig. 214. Fig. 213. — Caries of the cervical vertebrie and ulceration of the intervertebral disks, communicating with the pharynx by an ulcerated opening. The membranes of the cord were found united to each other and to the posterior surfaces of the vertebrae, and the upper part of the cord was softened, a, section of the basilar process ; 6, the opening in the pharynx communicating with the diseased spine ; c, the epiglottis, with a portion of the tongue below it. The symptoms were so slight that the ulcer in the pharynx was not known to have any connection with diseased spine till the post-mortem examination. The patient died suddenly, after being in the hospital for a few days. Fig. 214. — The back view of the same preparation, showing: n, the base of the skull; 6, the opening of the pharyngeal abscess; c, the posterior common ligament and theca vertebral is, thickened and turned down, in order to show the diseased bone and the opening of the abscess; d, carious and ex- posed surface of some of the lower vertebrae. — From a preparation in the Museum of St. George's Hos- pital, Ser. V, No. 13. ters and special dangers of its own. The disease is, I think, even more common in childhood, relatively to adult life, than that of the other re- gions of the spine, and it usually at first simulates mere " stiff neck," the 490 DISEASES OF THE SPIXE. })ain on motion causing the child to hold its neck stiff. When the dis- ease atttvcks quite the upi^er end of the column, so that the movements of the head produce an immediate effect on the carious bones, the child gets a hahit of keeping the head instinctively but very carefully fixed in a certain i)Osition which is very characteristic, and in turning often turns the whole body, and steadies the head with both hands. Often a slight tap on the top of the head will produce pain. There is usually thickening around the affected vertebrae, very rarely any curvature, the small size and deep position of the spines preventing it; often sinuses ai>out the neck, and frequently postpharyngeal abscess, which causes a swelling or opening at the back of the pharynx (Figs. 213, 214). The chief danger in this disease is that of softening of the upper part of the cord, leading to dysp- na?a and speedy death. But another and still more sudden mode of death is that which results from displacement of the odontoid process in disease of the two upper vertebrae, and which is illustrated by the two annexed figures. The former (Fig. 215) shows all the ligamentous appa- FlG. 215. Fig. 216. Fig. 21.'5.— Dispase of the skull and upper part of tlie spine, in which the transverse lijj;ament has been almost entirely destroyed. There is a large opening through the base of the skull (occipital and sphenoid bones) communicating with the pharynx, through which a rod is passed. Below this the odontoid process is seen exposed by the ulceration of the transverse ligament and its vertical append- age. Only a thin string remains, under which two black bristles are passed. The odontoid process, however, is still retained in position by some remains of tlie cheek ligaments. The connections be- tween the second and third vertebra; are almost destroyed. The flap turned up at the top of the prep- aration consisted of the dura mater, covered externally by a quantity of tliick scrofulous matter, which had produced pressure on the spinal marrow.— From the Museum of St. George's Hospital, Ser. V, No. 14. Fk;. 210. — A preparation showing displacement of the odontoid process backwards from ulceration of the transverse and cheek ligaments in disease of the upper part of the spinal column. Death was instantaneous.— St. George's Hospital Museum, iSer. v, No. 15. ratuK connected with the odontoid process destroyed, with the single ex- ception of a small string of the transverse ligament which has escaped destruction, the patient having died from the extensive affection of other LATERAL CURVATURE. 491 parts of the vertebral column. Had this not been the case the slight re- mains of the transverse and cheek ligaments would liave given way, and the same result would have followed as that which is shown by the other fignre (Fig. 216). This was taken from the body of a girl aged nine, who had been for some time in St. George's Hospital, with disease of the upper i)art of the spinal column. One day tlie nurse was raising her head to wash her, when she fell back dead. The figure shows that the whole ligamentous apparatus which confines the odontoid process has been destroyed ; and that process being suddenly displaced backwards and upwards has impinged on the medulla and produced instant death. The same accident has happened in cases where (as in that which fur- nished Figs. 213, 214) there had been no previous suspicion of disease of the spine. Thus, a lady was sitting in her chair, and turning her head to greet a person entering the room fell dead. Another was playing with her child, who pulled her head back, and she died on the spot. In both cases this displacement of the odontoid process was found. In order, then, to guard against the risk, not merely of this fatal dis- placement of the odontoid process, but also of the irritation of the spinal cord and of the extension of the disease of the bones by movements of the affected vertebrre, the most rigid rest must be insisted on. It is not enough merely to put the patient to bed. The head and neck ought to be confined in a case of gutta-percha, in the moulding and applying of which all imaginable gentleness should be used;^ and the patient must never be allowed to rise from the horizontal posture, the sheets being so arranged that they can be changed without raising him. This rigid rest must be continued until the pain on motion of the head has ceased for some time. In other respects the treatment is the same as in disease of other portions of the spine. Lateral Curvature. — Next in frequency to angular curvature, if not even more common, is what is usually called lateral curvature of the spine, though, as the curvature is not in ordinaiy cases merely to one side, but each vertebra is also somewhat rotated on the next to it, the distortion is sometimes called " rotation curvature." The annexed illus- tration (Fig. 217) shows the spine in a very extreme example of this deformity, so extreme that the atlas in the erect position is only a few inches above the sacro-vertebral prominence ; and it will l)e observed that the spine is so rotated that there are vertebrae wliich look towards each side and some which are directed almost backwards. This rotation of the vertebra; is obviously caused by some active force which can only be exercised by the muscles inserted into them. The original cause of the distortion, however, appears to be merely passive. The deformity com- mences in almost all cases about the period of puberty, and in girls far oftener than in boys, the patient being weakly and sickly from confine- ment, and possibly over-study, or from menstrual irregularity. In such persons anything which produces habitual inclination of the spine to one side, as the habit of standing on one leg, acting on the lumbar spine, or the habit of carrying a burden (such as a nurse-child) on one arm, acting on the dorsal region, may prove the starting-point of more extensive de- formity. The muscles are now thrown into irregular action ; and as the attachments of the muscles on the convex side of the curve are approxi- 1 This is better on the whole than putting the head and neck into a kind of sand- bath, as is sometimes recommended, or fixing anything on the coueh to contain the head, since these will not move along with the patient when it becomes necessary to move him ; but, of course, the making of the splint involves some risk. 492 DISEASES OF THE SPINE. mated their fibres become indurated and thrown into chronic action, while the stretched muscles on the other side are proportionally weak- ened and inactive. The displaced vertebne are also changed in shape by pressure, so that when tlie deformity has lasted long the body of the vertebra? is much thicker on the convex than on the concave side of the curve, and the transverse processes almost locked together, and the de- formity is, at that stage at least, incurable. When the spine in either the lumbar or dorsal region is thus primarily curved a somewhat similar secondary incurvation commences in the dorsal or lumbar region, pro- duced by the elforts necessary to maintain the balance of the bod\'. This secondary curve is, however, always less marked than the primary one. A third compensatory curve in the cervical region may sometimes be traced in cases of extreme lateral curvature, as in Fig. 217. Lateral A preparation of extreme lateral curvature (or " rotation curvature ") of the spine. — From the Museum of St. George's Hospital. curvature in the dorsal region produces, in the first place, a displacement of the ribs and scapula upwards on the convex side of the curve, so that that shoulder is raised higher than the other. This is commonly on the right side, and the first thing which attracts attention is the "growing out" of that .shoulder, as it is termed. When the deformity is extensive and confirmed the thorax will be greatl3^ altered in shape, so that the ribs are flattened down, the intercostal spaces nearly obliterated, and the cavity for the lung greatly narrowed, while on the other side it is the reverse. In the lumbar curve the distance between the last rib and the ilium (i.e., the flank) is much increased on the convex side of the curve, while on the concavity it is so much diminished that the patient is some- times annoyed by the rib impinging on the ilium ; this produces consid- erable falling in of that flank. The hip also is raised and prominent on the convex side of the curve. The diagnosis is generally simple. The patient being stripped, the line of the spinous process should be dotted with ink as she stands with both feet flat on the ground and planted together. She should then i)e made to stoop; the position of the shoulders should be compared, the distance between the ilium and last rib on either side ascertained, and the extent of the thoracic and lumbar curvatures compared. The only affections of the spine which it is possible to confound with lateral curvature are : a, curvature from caries; 6, curvature from rickets ; and, c, curvature from SPINAL CURVATURES. 493 empyema. In some very rare cases of caries of the spine the sides of the bodies are either entirely or chiefly affected and tlie spine falls to one side instead of directly backwards ; but on attentively investigating the history of such a case there is never any ditticulty in discovering its na- ture ; the curve is always limited to a few only of the vertebne instead of being diffused over the whole regiou, and is always accompanied by more or less of angular deformity. The curvature from rickets is usually also of an irregular kind, the softened vertebrae projecting backwards as well as to one side. It commences at quite a different period of life frou) the ordinary lateral curvature, and is generally, if not always, accompanied by deformity of other bones, as the legs or forearms. The curvature which follows on empyema is a truly lateral curvature, accompanied by no rotation, and is always easily distinguished from lateral curvature by the history and by the sinuses.^ Having fixed the diagnosis, the next thing which is to be done is to ascertain the cause and how the disease has commenced. If it has com- menced in the lumbar region as a consequence of inclination of the pelvis depending on unequal length of the limbs (as in diseased hip), the first step in the treatment is obviously to restore the length of the limb by a proper boot, and thus to act on the pelvis. If it seems to depend on a habit of standing on one leg or of dropping one shoulder, that habit must be corrected and the patient carefully drilled. Any habitual exertion that tends to distort the spine (as carry- ing a weight, working at a one-armed fig_ 218. trade, etc.) must be given up. Gym- nastic exercises wdiich call the muscles of the two sides of the body into equa- ble action are extremely useful, under careful supervision, in the early stage of the disease. A long rest in the re- cumbent position, and with the body in a perfect state of extension, in the middle of the day, after dinner, is also very desirable, as avoiding over-fa- tigue. The general health must be cared for, and steel is generally indi- cated. An apparatus may also be ap- plied to press gently on the convex side of the curve in the back and to separate the ribs from the ilium on the concavity of the loins. When the curve is pronounced and the disease invet- erate nothing can be done to correct the existing deformity, though the ap- plication of an instrument may be still advisable, in order to prevent it from increasing. Other Spinal Curvatures. — The other curvatures of the spinal column are kyi)hosis, or the general antero-posterior curve which is common in weakly children and in old men ; and lordosis, or the incurvation of the bodies of the lumbar vertebrte forwards. The term kyphosis is sometimes applied to all antero-posterior displacement, including angular curvature ; but it seems to me better to speak of the latter by itself. Kyphosis oc- 1 Un the diflerence between the ordinary lateral curvature and that from empyema, see a treatise by Dr. Little, On Spinal Weakness and Spinal Curvatures, 1868, p. 73. Apparatus for supporting the spine and press- ing the projecting part of tlie thorax and spine towards the middle line in a ease of lateral cur- vature. 494 DISEASES OF THE SPINE. curs in early infnnc_y from mere relaxation. In fact, the spine has no pronounced curves in early life, and when the baby is made to sit up for a time the back will always be found to be bowed ; but this bend is only temporary, and is effaced by suspending the body from the shoulders. Weakly children suffer in the same way from what is called in schools '•cat's-back " — the chin poking forward and the spine projecting often to such an extent that the case is mistaken for one of incipient angular cur- vature. But attentive examination shows that the curve is uniformly distributed, unaccompanied by pain or inflammation, and capable to a great extent, if not entirely, of obliteration by gentle extension or sus- pension. It will disappear with rest, strengthening, and correction of any lazy habit of stooping; and if extreme some bandage to the back may be necessary. The kyphosis of old age can hardly be mistaken. It is not susceptible of more than partial relief from rest and snpport. Lordosis, or saddleback, is caused chiefly by disease or congenital dis- location of the liip (Fig- 208, p. 478). It is, therefore, a secondary change, the treatment of which must consist mainly in the correction of the pri- mary disi)laceraent. The forward inclination of the pelvis which produces the lordosis is necessitated by the backward displacement of the centre of gravity of the body, caused by tlie dislocation of the hip, hence the first step is, if possible, to remedy this displacement. This may be sometimes effected, in congenital dislocation, l)y fixing the head of the bone, if mova- ble, in or near its natural position, or in anchylosis b}' dividing the neck of the bone and putting the limb straiglit. When this has been done extension by an appro|)riate instrument will diminish the lumbar cnrve, though it is not probable tliat it will succeed in wholly rectifying it. Anchylosis of the spine is another condition not very uncommon in old age, and is one of the causes of the rigidity of the spine in advanced life, though by no means the only or, perhaps, the most common. It is proba- bly' allied to, or associated with, chronic rheumatic artiiritis. The anterior common ligament is often in these cases found converted into a mass of bone, and tlie ossification seems to have invaded also the intervertebral disks. It is, of course, incurable. Cancer of Ihe Spine. — Tumors of all kinds may be found in the spinal canal, but I cannot spare the space necessary for their detailed descrip- tion, nor do I consider it necessary. The symptoms are those of irrita- tion or of pressure on the cord, together with absence of prool" of any disease in the bones; but the diagnosis is seldom made quite confidently till a post-mortem examination sliovvs the nature of tlie tumor. The only other affection I sliall speak of is tlie carcinomatous deposit which is found in the bones of the spinal column, sometimes as a primary disease, sometimes as secondary to cancer in other parts, and especially to scirrhus of the breast.' The disease is seen at all periods of life (Mr. Hawkins relates the case of a child five years of age), but is more common after middle a'ge. The form of cancer is usually encephaloid, though scirrhus is not unknown. The symptoms are often very severe — great pain, severe muscular spasms from irritation of the nerves emerging from the affected portion of the siiine, i)aral3sis more or less extended, rapid emaciation, and death. When the disease occurs primarily the diagnosis can only be confidently made when the tumor can be felt, though the severe localized pain and the rapid wasting may cause a susiiicioii of the nature of the malady. In cases where cancer in other parts has preceded, or is ' See Ca;.«ar Hawkins's Contributions to I'atli. iind Surijj., vol. i, p. 380; Med.-Chir. Trans., vol. xxiv, p. 45. SPINA BIFIDA. 495 Fl(i. 219. still present, less hesitsition will he felt,' All that can be done is to soothe the patient's sutierings by the free use of narcotics, and to insist on total rest. Spina bifida is a tnmor formed by a congenital hernia of the spinal membranes (dura mater and arachnoid j, through a cleft left in the arches of the vertebrjB by incomplete coalescence of their laminie. The disease is more common in the lumbar than in any other region (though it may occur in either the cervical or the dorsal), and this is consistent with the fact that the closure of the arches takes place gradually from above down- wards. As in the analogous tumors in the brain (meningocele), there is not only want of closure of the bones but also dropsical effusion in the sac of the membranes. The sac of the tumor is formed by the skin and the dura mater and arachnoid, and it always contains the cerebro-spinal fluid. Sometimes also the i)ia mater and the cord, or in the lumbar region the nerves of the cauda equina, are carried into the sac, and united to it in the middle line (Fig. 219). In some cases the skin is more or less delicient over the tumor, exposing the membranes through which the fluid shines as through a thin bladder. On the other hand the skin has been found much thicker than natural. There are often other deformi- ties, such as clubfoot, harelip, hydro- cephalus, or meningocele ; and if the child survives, permanent paralysis of the sphincters or paraplegia may result. But as a general rule such children do not long survive. The tumor often bursts, and fatal convul- sions come on, or the child is too weakly to resist some of the ordinary ailments of infancy. Still there are cases on record in which a person with spina bifida has been known to survive to and beyond middle life''' without any apparent drawback from the disease; and at least one remarkable instance is recorded in which a tumor which was believeil to have been a spina bifida (though it was more prol)al)ly a meningocele) gradually lost its com- munication with the cerebro spinal canal, and was removed from the back of the neck as a simple cyst;' and other instances of spontaneous cure are recorded. Viewing, then, the great danger of any effectual sur- gical treatment, it seems better to the sac, whilst others intersect lis cavity.-St. watch the case CarefuU}', and not to George's Hospital Museum, Ser. v, No. 54. interfere unless the tumor is growing. In that case the tumor should be tapped with a fine trocar on one side, Spina bifida, taken from a child who died a fortnight after birth, the immediate cause of death being sloughing of the parietes of the sac. The arches of the three lower vertebrie and part of the sacrum are deficient. The cauda equina passes into the tumor, and some of the nerves are spread out upon the inner wall of 1 I saw a singular case of cancer the other day, in which, after severe pain in the spine, but without paraplegia, one of the verte'brie was found to crepitate distinctly on the other. After a few days this symptom disappeared, the soft mass having grown in between the two vertebrae 2 In u published case the patient survived to the age of fifty, and I have heard of older cases in private. See Jaohnes's Surg. Dis. of Childhood, p. 83. 3 Solly, Med.-Chir. Trans., vol. xl, p. 19. 496 DISEASES OF MUSCLES AND BURSiE. since when the nerves are in the sac they always adhere in the middle line, and as much of the fluid should be drawn off as will decidedly relieve the tension. A shield or compress of gutta-percha, well padded, should then be a|iplied. Under this treatment, b}' repeated tappings, some cures have been effected.' In other cases tiiere seems no doubt that a radical cure lias been produced by the injection of tincture of iodine. Perhaps the best plan is to draw off a good part of the Huid through a fine trocar, and then inject a drop or two drops of the pure tincture of iodine into the remaining lluid.- Attempts liave been made in tumors wliicli are pedunculated — and which, tiierefore, are less likely to contain the cord or nerves — to obliterate the neck by the gradual pressure of a clamp, and such tumors have even been successfully removed.^ It must be left to the surgeon's own judgment wlietlier he thinks it justifiable to risk this last resource. The pedunculated condition of the tumor and its high position are doubtless favorable circumstances for the success of the attempt. Yet it might be argued that such tumors would very probably remain inactive. 1 have never but once performed the operation myself, and tlien on a tumor in tiie loins, in the case of a girl eet. 8, whose life was rendered intolerable from permanent paralysis of the sphincters, but spinal meningitis soon set in, and proved fatal by opisthotonos. I ought to add that there are tumors which may be mistaken for spina bifida. I have seen a fatty tumor allowed to grow to an enormous size, under the idea tliat, being situated in the middle line of the spine, it was a spina bifida ; but this was onl}^ for want of careful examination. But congenital subcutaneous tumors, when situated exactly in the middle line, ma}' lead to greater difficulties.* In almost all spina bifida tumors, how- ever, the sac swells up when tlie child cries, and the edges of its aperture can be felt when it is flaccid. Some malformations are classed with spina bifida in wiiich tlie whole spinal laminse are deficient, and others in which the ventricles and tlie central spinal canal are distended, and the sub- stance of the cord spread over the sac, but they are of little practical interest, being incomjjatible with life. CHAPTER XXV. DISEASES OF MUSCLES AND BURSiE. Muscles are liable to rupture from injury such as occurs not unfre- quently in the pectoral muscle when a man in falling grasps at a bar and suddenly brings the whole momentum of his body to bear on the flaps of ' Sir A Cooper, Mod.-Chir. Trans., vol. ii. ^ TJriiinard injects t^ss. of a solution of 5 j^rs. of iodinn and 15 of iod. of pot. to the r>7.. <<{' WiitfT, washini; tlu; sae out afterwards witli wati'r, and rciinjecting some of the orif^inal ccrcjhro-spinal fluid. Vclpeau injects a .spina bifida, lille to kneel upon. Be- sides, the treatment is painful and not free from danger. Incision is necessary when suppuration is cleai'ly present, and is quite justifiable when it is onl}' suspected. If no pus is found the sac is evacuated, and will probably fill up by granulation. Incision and pressure is a vei'y valuable plan of treatment in many cases, much less dangerous and painful than the seton, and often likely to obviate the necessity' of re- moval when the walls are even of considerable solidity. It is warmly advocated b}^ Mr. Savorj-,' who, indeed, says, "it may be adopted in almost ever}' case." It consists merely in puncturing the enlarged bursa with a lancet or small knife at its most prominent part, evacuating its contents, and liringing the walls together as accurately as possible with strapping. The [)atient need not be confined to bed, though this is in my opinion desirable. Sometimes the cyst does not refill. If it docs, it must he again punctured, and will then usually suppurate, when a poul- tice is advisable. The thickened walls melt down in the suppuration, and when the wound closes only an ill-defined hardness is left. The pressure of the strapping should be kept up in cases which do not suppurate for a week or fortnight after the cure appears complete. But when the walls are much thickened the total removal of the tumor is the most advisable course. It can hardly be denied that the operation involves some risk, but this cannot be great, for I have removed many such tumors, and seen many others removed, and never heard of any bad consequences.'^ The surgeon will remember that the lower [tart of the tumor is in contact with the capsule of the joint. A free incision is to be made from top to bottom over the middle line of the tumor and the skin fully dissected back on both sides. Then the upper portion of the tumor is separated ' St. Bartholomew's Hospital Reports, vol ii, p. 79. ^ Mr Erichsen speaks ot the occasional occuri'cnce of abscess spreatling into the ham, whicli he attributes to the layer of deep fascia having been divided, which, after surrounding the knee, is fixed to the borders of the patella. Science and Art of Surg., 5th edition, vol. ii, p. '250. I have never seen this complication, but it furnishes an- other motive for carefully keeping the edge of the knife on the tumor during the dissection. 500 DISEASES OF MUSCULAK SYSTEM. from the periosteum of the patella, and in removino; the lower part from the contiguity of the joint care is taken to put the cellular adhesions which fix it on the stretch and divide them with the edge of the knife turned towards the tumor. In this way it is impossible to wound the joiut. The wound is to be strapped up carefully, and the limb put on a splint and carefull}' bandaged from the foot upwards. Affections of Various Bursse Numerous other bursoe exist in the normal condition or are developed from constant friction between the skin and an underlying bone. There is one on the anterior aspect of the upper end of the tibia, between the tubercle of the tibia and the liga- mentum patelhie, which is occasionally though rarely found enlarged ; one over the olecranon, which is peculiarly apt to enlarge in miners, from the attitude in which they constantly work, and is then denominated "miner's elbow ;" and several in the popliteal space, ^ one of which, that beneath the tendon of the semi-membranosus muscle, is comparatively often enlarged, and when it shares the pulsation of the popliteal artery lias been mistaken for aneurism, though such a mistake can onl}' be accounted for by care- lessness. The bursa under the tendon of the psoas is anotlier instance in which a natural bursa is occasionally enlarged. The subject has been treated of in reference to the diagnosis of hip-disease on p. 477. None of these bursal enlargements (if we except the last) are difficult of diag- nosis to one who remembers their position and the fact of their occasional diseased condition. But if any hesitation is felt as to the nature of the tumor the grooved needle will solve the difficulty at once. They must be treated in the same way as housemaid's knee, by blisters, iodine injection, or incision. And if tliey suppurate, as some are very prone to do, es- l)ecially that over the olecranon, they should be laid prett}' freely open. Su[)puration in this bursa often produces a diffused inflammation extend- ing down the forearm, which is sometimes mistaken for phlegmonous erysipelas, but which really requires no treatment beyond the free evacua- tion of the bursal abscess. In treating the bursas which are comparatively often found in the pop- liteal space the surgeon must remember that those at the outer side of the ham almost always communicate with the joint, and that beneath the tendon of the semi-membranosus not unfrequently does so. Great care, therefore, is necessary to examine the limb in various positions, in order to ascertain whether this is tiie case before any active treatment is under- taken. The communication, if it exists, can generally be opened by flex- ing the knee, and then some or all of the fluid in the bursa can be pressed baik into tlie joint. When this is the case no o[)eration is admissible. Wlien the bursa does not appear to communicate with the joint, if the patient suffers mucii inconvenience from the jiresence of the tumor, and external appUcations with rest have failed to ciire it, it will be justifiable to inject it with iodine, or to put a line seton through it. But such bursse often exist and attain a large size withovit giving tlie patient any trouble. I saw a man the other day who had been for more than ten years an al)le seaman in her Majesty's navy, and who had never suffered in the least from the presence of the bursa, though it was unusually large. Bursas of new formation are found over the displaced bones in clubfoot, over the end of the lii)ula in tailors, and in many parts of the body subject to pressure ; and accidental or irregular bursa; are met with in various ' For an account of tlic noiinul anatomy of tiiosu bun'^a; see Gray's Anatomy, 7th ed., p. 415. GANGLION. 501 parts — e. f/., over the 113'oicl bone or larynx — but they seldom grow to a size requiring any serious treatment. Bunion. — A bunion is a bursa formed over the half-dislocated phalanx of the great toe from the i)ressure of the boot. It is often followed by destructive disease of the joint. But it does not always (at least at first) communicate with it. Wlien the atfection is confined to mere inflamma- tion of the bursa rest and sootliing api)lications will probably subdue it, and its recurrence must be obviated by some change in the shape of the boot. If it suppurates it is better to allow it to burst without interference ; but if the matter will not come to the surface it must be incised, and then if it does not seem to communicate with the joint its interior may be rubbed with lunar caustic or the strong nitric acid, in order to procure its ol)literation. If the joint is involved the shortest and, on the whole, the best course for the patient is to amputate the toe, though if the patient wishes it there is no objection to the resection of the diseased joint. It is doubtful, however, whether this operation, even if successful, will leave the foot more useful than after amputation of the toe. Ganglion is the name given to an enlarged bursa which is developed in connection with one of the tendons. Such bursae are most common on the back of the wrist, on or near the extensor secundi internodii pollicis, though thej'^ are not rarely developed in other tendons. The exact connection of the sac with the tendon does not seem to be quite clearl}' ascertained. It forms a small, hard, round swelling at the back of the joint, and the main symptom which it causes is weakness of the wrist and hand, sometimes to an extent which is hard to reconcile with the apparent triviality of the affection. It has been clearly- proved that, in some cases, at any rate, a ganglion owes its origin to a protrusion of the synovial membrane of the wrist or carpal joints,^ and this is proljably often, if not always, tlie nature of those ganglia which present deep in the wrist under or close to the radial artery ; but that the more superficial and movable ones are formed in the same way is at any rate unproved. Nor is it proved or probable that as a rule they have any open com- munication with the sheaths of the tendons, though they are believed to be often developed by an outgrowth from them originally, the communica- tion between which and the sheath of the tendons has become obliterated. A ganglion almost always contains a clear gelatinous fluid exactly re- sembling thin jelly. The treatment consists in freel}^ dividing the ganglion subcutaneously, squeezing out the contents, and applying pressure. The old rough method of bursting tlie sac by a blow of a book or by forcible pressure was essen- tially the same, but it is far less certain, more painful, and is besides excessively rough and unsurgical. It is far better to pass in a tendon- knife at a little distance from the small round lump, apply its edge fairly to the side of the tumor, and cut the sac across as freely as possible. Then all the contents of tlie sac are to be squeezed out — whether through the puncture or into the cellular tissue does not matter — and pressure is to be applied bj' means of a piece of sheet lead or other firm substance carefully strapped on to the remains of the sac. This method succeeds in the great majority of cases, but in some the tumor refills even after it has been subcutaneously divided with all possible care many times. Such cases may usually be cured by a seton of two or three threads run through the sac, and kept in till suppuration is set up, when it can be withdrawn. 1 There is a preparation in the Museum of St. George's Hospital showing such a communication in a case of ganglion. See also Nelaton, Path. Chir., vol. v, p. 905. 502 DISEASES OF MUSCULAR SYSTEM. If tin? tilso fails the choice is between laying tlie ganglion open and dress- ing in the cavity till it fills up, or dissecting it out. The com poll ml palmar ganglion, is a tumor or cyst developed in the sheath of the common flexor tendons passing under the annular ligament of the wrist. It forms a tumor which presents in the forearm and in the palm, extending on both sides of the annular ligament which binds down its central part; and often, on making the patient move his fingers, a creaking sensation is perceived, caused by the "millet-seed" bodies whi(;h are found in it. These are small masses of lymph, often very nu- merous, wiiich are almost always contained in these compound ganglions. The wrist is very much limited in its movements in these cases, and some of the fingers also are sometimes entirely deprived of motion, flexed into the palm, and utterly useless. The main obstacle to the cure of the dis- ease is the presence of the millet-seed bodies ; when these are evacuated the case generall}^ does well. I have never hitherto seen a case of this disease in which any progress to cure was made until these bodies had been evacuated, and I have now given up as useless any attempts to cure it by blisters or injections. The best plan is to make a limited incision into one part of the tumor (that in the forearm is usually selected) and press out all the millet-seed bodies, emptying the sac as completely as possible. Strapping should be applied methodically from below upwards, so as to keep the parietes of the sac as closely as possible in contact, in the hope that they will close, and that no further inflammation will occur. In all the cases, however, that I have seen suppuration has taken place; but this has not interfered with the success of the treatment. Unless the suppuration is unusually violent or some complication should occur, the prognosis is good, and the patient generally recovers the entire use of the hand and fingers. Simple and Progressive Atrophy. — Muscles are subject to various de- generations, some of which constitute definite and important surgical affections; others are rather the consequences or accompaniments of dis- ease, or are mere pathological curiosities. The atrophy which follows on disuse requires no further notice — the muscle is merely smaller, but with- out any change in the anatomical structure of its fibres. Clearly con- trasted with this is the "progressive muscular atrophy " of Cruveilhier, in which, from some general cause which is not at present completely understood, the muscular tissue in one or more regions becomes, without any known injury or other reason, wasted — the wasting extends during an indefinite period, involves fresh groups of muscles, and may go on till the patient's death. The disease is often hereditary, and it affects usually the male members of the family. In other cases it has been thought to be excited by cold and damp, or by syphilis. Cruveilhier believed that the disease depended on degeneration of the anterior or. motor roots of the spinal nerves ; but this seems contradicted by the result of post-mortem examination in many cases where no such lesion existed. Dr. Lockhart Clarke believes tiiat the essence of the disease consists in "lesions of the gra^' substance of tiie cord, consisting chiefly of areas of what he calls granular and fluid disintegration," and other pathologists have supported this statement, wiiich is rendered still more probable by the fact that symptoms identical with the hereditary aifection have been noted in cases of ol)vious disease of the spinal cord. It is probable, therefore, that the disease should be classed with those of the nervous centres ; yet, as this is not yet al)Solutely proved, it is generally still assigned to those of the muscles. It commences most commonly in the u[)per extremity, and INFANTILE PARALYSIS. 503 usually with wasting of the muscles of the palm, spreading upwards to those of the arm, chest, al)domen, and lastly to those of respiration and deglutition. More rarely it begins in the thorax, and still more rarely in the lower limbs. The weakness is accompanied by a loss of co-ordi- nation, producing uncertainty in the movements, vvith (U'amps and twitches in the i)art. Sensation is usually unaftected. Occasionally there is some numbness, and pain is complained of in the affected muscles in about half the cases. The wasting does not involve the vvhole muscle. On micro- scopic examination side by side with the wasted fibres are seen others which are perfectly natural, and the same is the case to the naked eye. The atrophy is accompanied by granular or fatty degeneration of the muscular tissue, the sarcous elements being replaced by granules or fat- cells, while the strife have become more or less indistinct. In other cases a rarer degeneration is found — the waxy or vitreous — in which the fibres are changed into a transparent homogeneous substance, in which no strife can be seen, and the muscle resembles a piece of tendon or apo- neurosis. The treatment of this disease is rarely satisfactory. Strict attention to the general health, the treatment of any syphilitic taint which may be present or lie suspected, the prolonged use of galvanism in its various forms, and the use of the warm sulphurous water of Aix-la-Chapelle, ap- pear to be of admitted value. Medical treatment may succeed in some cases, and if so the drugs which are most likely to be of value are arsenic, phosphorus, and the mineral tonics, as zinc or iron. But to be erticacious these remedies must be long-continued, in small doses. Dr. Lockhart Clarke suggests the trial of counter-irritation to the spine. Besides these two well-marked forms of atrophy there are others in which the atrophy of disuse is variously combined with fatty or granular degeneration, '' in acute diseases, alcoholism, lead-poisoning, rheuma- tism," etc.; but as this is merely a subordinate feature of the general disease, nothing further need be said about it.' Two forms of degeneration of muscles in childhood claim notice here. 1. Infantile paralysis, or "essential" paralysis, so called, because it is not supposed to be connected with any morbid state of the nervous cen- tres. We may fairly reserve our opinion on the latter point. No proof has, it is true, been obtained hitherto that the spinal cord is alfected in infantile paralysis ; yet the symptoms point strongly to disease either of the cord or nerves as the cause of the paralysis which so speedily occurs in a muscle or group of muscles. The disease begins usually after a feverish attack, or sometimes during teething, after convulsions, in some cases without any noticeable derangement of the general health. The muscular affection, whether preceded by general ill-health or not, is in itself sudden. It usually affects the lower extremities, and either the whole limb or groups of its muscles, or a solitary muscle may be affected. Less commonly it is noticed in the upper extremity. The muscle which is most commonly affected alone is, I think, the deltoid. The sternomas- toid is also sometimes alone affected. When special groups of muscles of the leg are paralyzed the corresponding form of clubfoot follows from the unbalanced action of their antagonists. Paralysis affecting the muscles or one buttock sometimes leads to a suspicion of hip disease, but is easily distinguished from it on attentive examination b}^ the perfect freedom and painlessness of passive motion. 1 I do not speak hereof "locomotor ataxy," regarding it as lying more in the province of a treatise on medicine ; and I apply the same observations to trichiniasis. 4 504 ORTHOPAEDIC SURGERY. When the disease is inveterate nothing can be done except to restore the limbs by tenotoni_y and mechanical appliances to such a position as may be most useful to the patient, if he has the power of using them in any degree. But in early cases a cure may fairly be hoped for from the persistent use of galvanism, from exciting the muscles to voluntary action as far as is possible,^ from tonics, such as strychnia, and from shampoo- ing or rubbing the limbs. 2. The other form of paralysis in childhood is that curious disease called " pseudo-hypertrophic paralysis," or " Dnchenne's disease." The subjects are more or less idiotic. After a stage of partial paralysis, or weakness of the lower limbs, which may last several months, the patient being quite unable to stand or walk, the stage of hypertrophy commences, in which the gastrocnemii, the gluteal muscles, and those of the loins become very much swollen. Tiie swelling, however, or apparent hyper- trophy, is found to be due not to any real hypertrophy of the muscle, but to an abundant formation of connective tissue or fat, or both, amongst its fibres, which are themselves at least at first health}^ and present the normal response to galvanism. In the third stage (which may be de- ferred for 3^ears after the commencement of the second) the limbs begin to waste, complete paralysis ensues, and the patient dies sooner or later, unless some accidental malady carries him off. "During its first stage the disease is sometimes curable. Duchenne has recorded two such cases. ^ But in the second stage scarcely any hope of recover}' can be entertained. The treatment consists chiefly of local faradization and shampooing." — Lockhart Clarke. Tumors of Muscle. — Muscles are subject to all the forms of tumor de- scribed in chap, xvii, but I do not know that their occurrence in muscles is a fact of any special significance. I have spoken on p. .358 of the sin- gular cases in which muscles ossify, or where loose bony tumors are found to be developed in them. The gummatous tumors due to syphilis some- times attain an enormous size, and in one well-known case'* the scapula was removed for such a growth. The}' are, however, almost always amenable to internal remedies. CHAPTER XXVI. CLUBFOOT AND OTHER DEFORMITIES.— ORTHOPAEDIC SURGERY. The various deformities which are treated of in this chapter, and of which clubfoot may be taken as the type, as it is also by far the most fre- quent example, are due to permanent contraction of the muscles, the re- 1 Much good often results from putting the child in a "go-cart," where, in order to move about, the affected musch;s must be called u])on to act. ^ De la Paralysie musculaire p.seudo-hyperiroplnque. Paris, 1868. 3 South, in Path. Trans., vol. vii, p. 346. TENOTOMY. 505 suit either of the relaxation of their antagonists from paralysis, of a tonic spasm in their own substance, or of some change in the structure of tiie muscular filires leading to their permanent contraction.^ It is very diffi- cult, indeed, to determine the share which paralysis or spasm respectively may have in producing the congenital forms of the malady, but in many of the non-congenital cases the deformity clearly depends on infantile paralysis. Congenital cases, on the other hand, seem more of a spas- modic nature, though the spasm relaxes to a great extent in sleep or in A'awning.'and they are accordingly generally believed to depend on some abnormal state of the nervous centres, though what that state is remains unknown. The cases in which deformity is produced by disease of the muscles themselves irrespective of spasmodic or paralytic deformity are purel}' exceptional. The main point to determine in the treatment of deformities is their curability by or without surgical operation. The milder cases of deformity, whether spastic or paralytic, may be remedied by gradual extension by means of appropriate apparatus, and some even by the manipulations of the nurse or mother; Init for cases of ordinary severity tenotomy is required before the application of the instrument intended to place the parts in the natural position. Tenotomy, or the subcutaneous division of tendons, is an operation now very extensively practiced, but for which the surgical profession is indebted to the genius of a surgeon still living — the illustrious Stromeyer.^ It consists in passing a small thin knife through a minute puncture close to the contracted tendon, dividing it, if possible, without injuring any part in its vicinity; then withdrawing the knife, closing the wound care- fully and allowing it to heal, which in almost all cases it does by the pro- cess of first intention. The upper end of the divided tendon retracts in its sheath, and the latter becomes filled with lymph, in which fibrous tissue is developed, very much as a simple fracture is united. This fibrous tissue is at first soft, and easily yields to an extending force (Fig. 220) ; and the subsequent treatment consists in gently drawing it out to the required length. When tiiis process is completed the uniting mate- rial is thinner than the natural tendon, and the muscle comparatively weak ; but it gradually acquires strength and breadth, and when exam- ined some time afterwards so closely resembles the original tendon,* that the difference is only visible on a fresh section, and after very close ex- amination. Sometimes after division one or both ends of the divided ' This change is called by American surgeons " contracture," and is chiefly ex- emplitied by the state of the muscles on the flexed side of a permanently contracted joint, as the hi[) or knee. ^ See Dr. Little's observations on this head in Syst of Surg., vol. iii, p. 660 et seq. 3 Mr. Adams says: -'On February 28th, 1831, Stromeyer first divided the tendo Achillis by subcutaneous puncture in a case of non-congenital equino-varus in a boy aged nineteen. No inflammation followed. By gradual extension the deformity was cured in two months, and the boy allowed to walk with a steel support to the boot." — Rust's Magazine, 1833, vol. xxxix, p. 195. But though Stromeyer's priority in the practical use of tenotomy is undisputed, the priority in the suggestion is due to Delpech, as Stromeyer has expressly pointed out. John Hunter, after he had suffered in his own person from rupture of the tendo Achillis (see p. 497), investi- gated the process of union after subcutaneous division of the tendo Achillis in dogs, and his preparations are still in the Museum of the College of Surgeons. He came to the perfectly correct conclusion that the process " was similar to that of fractured bones where the skin is not wounded." In fact. Hunter may, as Mr. Adams has said, be regarded as the originator of subcutaneous surgery. * The process of union in divided tendons has been most minutely described by Mr. W. Adams, On the Reparative Process in Human Tendons after Division. I would refer the reader to the fourth chapter of that work for many details for which space fails me here. 506 ORTHOPAEDIC SURGERY. tendon may adhere to a neighboring bono, and the function of the di- vided musi'le may thus be lost, at any rate for the time. Still it seems that these adhesions often give way ultimately, and the muscle resumes its functions; and even if not the limb will in'obably be very useful. The tendo A chillis, which is the most important of the tendons usually di- vided, lies too far away from the tibia to be subject to this accident. In other cases the tendon, if divided near its insertion, may form for itself an entirely new attachment, as was the case in the instance from which Fig. 221 was taken. But in such a case the operation will proba- bly lie as successful as if the two ends of the tendon had been united in the ordinary way. I mention these irregularities in the method of union, inasmuch as they have been made the ground for decrying the operation of tenotomy alto- FlG. 221. Fig. 220.— a specimen .sliowing the condition of the tendo Achillis in an adult 22 days after its divi- sion. The operation had Vjeen performed in order to assist in the reduction of a compound fracture of the leg. Amputation became necessary at the above period. — From St. George's Hospital Museum, Ser. iv, No. 20. Fio. 221. — An eye, showing the union of the tendon of the external rectus uuiscle, after its division in a case of squint. The patient died of phtliisis a month after the operation. The muscle (wliich isseen at the upper part of the figure) is now conuecttd to the sclerotic by a lonL'thin Innidle of fibrous tissue. The insertion of the original tendon into the tunica albuginea is perfectly distinct, and appears quite separate from the new unitins material. The latter was so firm that itallowid of forcible traction without giving way. The deformity appeared to be cured. — St. George's Hospital Museum, Ser. iv, No. 7. gether, except as applied to the tendo Achillis, and for substituting exten- sion for it as the general method for treating clidjfoot.' Mr. Barwell is impressed with tlie belief that after the division of the tibialis posticus and othei- deeply seated tendons the tendon often does not unite in its natural relations, and that a lameness is lei't — " less apparent perhaps, but 1 Barwell, On certain grave Evils attending Tenotomy, and on a New Method of Curing Dofonnilics of llic Foot. ]\Icd.-CIiir. Trans., vol. .\Iv, p. 25. TALIPES EQUINUS. 507 certainly more incurable than the orit^inal disease." I can only say that after the appearance of Mr. Barwell's paper I have carefnlly examined man}' cases under my own and other surgeons' care in which these ten- dons have been divided, and have failed to verify Mr. Barwell's statement. The foot, in favorable cases, is very nearly natural. Beyond some flat- tening of the arch and widening of the sole, there is little change in its external appearance, and the patients vvalk nimbly and with no percepti- ble limp. Nor is Mr. Barwell's method of extension, by means of india- rubber cords, hooked on to splints which are kept in place by plaster, at all easy to apply successfully in cases where the deformity is serious, since the traction necessary to correct the deformity will either |)ull the splints off, or, if they are more securely fastened by the strapping, the latter will cut into tlie skin. My own trials of this method have conse- quentl\' been disappointing; yet its principle, that of substituting gradu- ally increasing elastic tension for the muscles which are paralyzed, is so obviously sound for the treatment of paralytic deformity, that I thought it right to direct the reader's attention to it. I consider it a valuable method of treatment in the slighter cases of paralytic deformit_y, though Mr. Barwell's statement of the evils attending tenotomy seems overdrawn, and tenotomy is still in general use in all ordinary cases. Tenotomy is generally employed in the case of clubfoot ; sometimes as the case from which Fig. 220 was drawn, to facilitate the reduction of a fractured bone, sometimes of a dislocation ; also for squint and wryneck, and in various deformities, as those produced by diseased hip, knee, etc. Muscles also are occasionally divided, either subcutaueously or otherwise, in plastic operations, as the levator palati mollis, in staphyloraphy. In all these cases the object of the surgeon is to divide the tendon or muscle as cleanly and with as small a wound as possible ; and, if the operation be subcutaneous, to keep the parts quiet until primary union is insured. The attempt to put the parts at once into the desired position after sub- cutaneous tenotomy may, indeed, be successful, but it is somewhat risk}'^, for suppuration may easily follow, and then time vvill be lost instead of gained; or the divided tendon may be matted to the parts around, and the attempt to cure the deformity prove an entire failure ; whilst the slight delay in waiting for primary union does not increase the difficulty of treating the case at all, since the union is perfectly soft and extensible then and for a long time afterwards. I now turn to the various kinds of clubfoot. Talipes equmus is the deformity produced by a contracted state of the gastrocnemius muscle drawing the os calcis directly upwards, and causing the patient to walk on the metatarso-phalangeal joints and the toes, the foot bearing a strong resemblance to that of a horse, whence the name. The two annexed representations (Figs. 222, 223, p. 508) of a prepara- tion, taken from an old neglected case of this deformity, will give a better idea of its anatomy than words can do. It will be seen that the heel-bone is drawn into a tolerably vertical position, the tarsus is much curved for- wards, and the muscles of the sole of the foot, with the plantar fascia, are very much contracted, the long muscles in front proportionall}'- stretched, those on the inner and outer aspects of the foot not materially affected. The cure of the deformity is to be sought in the elongation of the con- tracted gastrocnemius muscle. In very slight incipient cases this might perhaps be done by repeated manipulations and by the gradual traction of a splint of ductile metal applied in front, the angle being carefully increased till the foot is drawn up to and beyond a right angle. 508 ORTHOPAEDIC SURGERY. Tenotomy offers a ready means of restorino- the position of the foot, and experience proves that the muscle after its elongation may recover its functions sufficiently for all the purposes of ordinary life. So that if the Fig. 222. Fig. 222. — A preparation of talipes equinus seen from the inner side, a, tibialis anticus; h, extensor propriiis pollieis; c, extensor longus digitonim; rf, skin, with contracted plantar fascia ; e, tibialis pos- ticus;/, tendo Achillis; h, tendon of flexor longus pollicis; k, flexor longus digitoruni. Fig. 22:J.— Tlie same preparation seen from the outer side, a, tibialis anticus; 6, extensor proprius pollicis; c, extensor longus digitorum ; (f, flexor brevis digitorura ; c, plantar fascia;/, tendo Achillis; 5^, A, peronieus brevis and longus; i, peronteus tertius. — From a preparation in St. George's Hospital Mu.seum, Ser. iv, No. 22. deformitj' is at all sti'ongly prononnced — that is, if the foot cannot be brought to a right angle, or on being released flies strongly back — it seems of little use to waste time on less ett'ectual treatment. The tendo Achillis should be divided by turning the child on its belly and introducing the tenotome on the inner side below and as close to the tendon as possible, a short distance above the point of its attachment, where it seems thinnest, the foot being still extended. When the knife is fairly under the tendon the foot is to be strongly flexed by the assistant, while the surgeon, with a slight sawing motion, presses the knife's edge against the tightened tendon. As soon as it has been sufficiently divided the extending force will rupture it with an audible snap, when the knife should be instantly turned flat, so that the skin may not be cut, and should be withdrawn. If the operation has been dexterously performed hardly a drop of blood will escape. The wound should be stra[)ped, and the foot placed on a splint in the extended position in which it was found before the operation. No attempt should be made to bring it to the natural angle till the wound is soundly healed, which will probably lie the case in about five days. In complicated cases the division of the plantar fascia, and possibly of some of the muscles of the sole, is necessary in order to unfold the tarsus, as will be sufficiently seen from Figs. 222, 223. TAIilPES VARUS. 509 Scarpa's shoe is to be R[)plie(l when the wouikI is lienled, in order to stretch the uniting material and elongate the muscle to the extent neces- sary to bring the sole of the foot flat to the ground. When this is done (which in a favorable case may be in about two months) a boot with irons is to be applied, to prevent recontraction, and if the child is old enough he may be allowed to walk. Talipes Varus. — The severer forms of talipes equinns, such as that rep- FlG. 22-1. Fig. 225. Fig. 224. — Shoe for the treatment of simple talipes equinus in infancy. — From Holmes's Surg. Treat, of Children's Diseases. Fig. 225.— Severe adult congenital varus, viewed from the front and inside, a, the tibia cut down, in order to show the relatively posterior situation of the fibula; b, the external malleolus; c, the fibula; d, the posterior extremity of the os calcis drawn abnormally inwards; e, the astragalus unduly promi- nent on the dorsum of the foot; /, the navicular bone in contact with the internal malk'olus; g, the cuboid, its posterior surface applied to the ground. — From Little, in Syst. of Surg., vol. iii, p. 6G5, 2d ed. resented above, are commonly congenital; and, as Dr. Little has ob- served, such cases of congenital equinus usually remain throughout life purely equinus — i.e.^ the foot is perfectly straight, without any deviation to the inside or the outside. But the common form of congenital club- foot is talipes varus, or equinovarus. In the pure T. varus the os calcis would be on the same horizontal level as the metatarsus; but if this is ever the case it must be very rare. In practice the os calcis is always found more or less elevated — i. e., the case partakes more or less of the essential characters of T. equinus. The term T. varus is usually applied to those in which the heel is not very much elevated; when it is so the deformity is named T. equinovarus; but in ordinary nomenclature they may be regarded as synonymous. The deformity consists in a simultaneous contraction of the tendo Achillis and the tendon of the tibialis posticus, that of the tibialis anticus being also almost always contracted, and veiy often the flexor longus digitorura as well. The internal portion of the plantar fascia is also con- stantly found contracted ; and this, if the deformity is inveterate, involves also the contraction of one or more, or all, of the short muscles of the sole. The deformity of course increases the longer it is neglected. When the child begins to walk he rests on the outer side and partly on the dor- sum of the foot, on which part large bursie usually form. If the skeleton of the foot be examined (Fig. 225) in a case of old deformity, the ankle- 510 ORTHOP.llDIC SURGERY. joint will be found distorted, the fibula being drawn behind the tibia, the internal malleolus almost or quite in contact with the scaphoid bone, the astragalus jnished out towards the outer side of the dorsum, tlie cuboid bone turned downwards, so that its dorsal face su[)i)orts the arch of the tarsus; the metatarsus, which is curved towards the calcaneum, is more or less vertical instead of horizontal. In old cases all the bones are changed in shape, and the ligaments, muscles, and fasciae have also undergone corresponding changes. Such cases are, of course, incurable; or, if the position of the foot is to be remedied at all, it can only be so by excising some of the deformed bones. But in earlj' life, while the structures are yielding, and the parts have not undergone any irremediable change, a ver}- useful foot indeed may be obtained. In all the cases of cure which I have seen, a certain degree of flattening of the sole re- mained, and the patient, if severely tested, would not have been able to run. iiop, or leap from a height with the same force or security as one who had the natural arch and spring of the foot, but for ordinary loco- motion there is often little to be desired. The treatment by manual extension or by india-rubber bands or other mechanism may succeed in the slighter cases, but for cases of ordinary'- severity the section of the tendo Achillis and that of the two tibial ten- dons is commonly necessary. Very often also the plantar fascia and the muscles in the sole of the foot will require division.^ Many surgeons prefer to divide the tibial tendons first, and to convert the deformity into one of simple eqninus before dividing the tendo Achillis, and this is no doubt the better plan in the graver cases of the deformity, since the heel forms a firmer point d'apjjui for the instrument than if the great tendon has been divided. The operation of dividing the tendon of the tibialis posticus in a fat bab}^ is not always an eas}' one, and several cases have occurred in which the child, having accidentally died soon after the sup- posed tenotomy, it has been proved by dissection that the tendon has been missed. The small size of the tendon and the depth at which it lies buried account for these mistakes. Another danger is that of wound- ing the posterior tibial artery, which lies close to the tendon in the leg. For this reason apparently some surgeons have practiced the division of tiie tendon in the tarsus, but in the infant it is very dithcult indeed to find it there. The sharp tenotomy knife is to be introduced close to the posterior edge of the tibia,''^ about an inch above the ankle ; and the fascia liaving been freely opened (including the sheath of the muscles), a blunt- pointed tenotome is sul)stituted for it, and its edge turned towards the tendon. An assistant holds the foot inverted during this stage of the operation. Then he forciiily eveits the foot, and as the o[)erator raises his knife tiie tendon is felt to yield. If the operator believes that he has missed the tendon he must reintroduce his knife close to the bone, pass it somewhat more deei)ly, and repeat the i)revious mananivres. It is very dillicult in relapsed cases, where the tendon has been previously divided, to l)e sure whetlier it has been severed or not. The assistant often feels the snap of the divided tendon more plainly than the surgeon. If pro- fuse bleeding and blanching of the foot testify to a wound of the poste- ' Dr. Geurgi! Bufhaiiim, of Ghisf^ow, lias roceiilly called attention to the necessity in many cases of clubfoot for deep incision in the sole of the foot for the unfniding of the contracted tarsus and metatarsus (see his address in Clinical Surgery, 1874, p. 24). A glance at Fig. 222 will show how the plantar muscles are contracted in these cases. '' If the edge of the tibia cannot be felt the knife is to be inserted about midway between the anterior and posterior borders of the leg, and the bone is to be felt with the i)oint of the knife. TALIPES VARUS. 511 rior tibial artorv, careful grarliiatecl pressure should be made on the wound, and the linil) be neatly and firmly bandaeen tlie starting-point of nervous disorders which have been held to justify amputation, leaving the patient still uncured; and other similar instances might be quoted. As in other nervous dis- orders, the less active the surgeon is the better. It may sometimes be advisable to put the parts in a natural position under anaesthesia and fix them so, and thus give the patient an irrefragable proof that the deformity is not incura!)le. But the chief reliance must be placed in medical and general treatment, with manipulation and calisthenic exercises when they are indicated. ^ Med.-Chir. Trans., vol. Ivii. INJURIES OF NERVES. 517 CHAPTEE XXVII. AFFECTIONS OF NERVES. Wounds of nerves occur, of course, from injuries of all kinds, but are peculiarly common in gunshot wounds. They never occur uncompli- cated, but in some cases the wound of the nerve is the chief feature in the injury. The symptoms of wound of a nerve vary according as the nerve is sensory, muscular, or mixed, and as the wound is partial or complete. Complete division of a large mixed nerve (of which the most familiar example is the ulnar or median, at the wrist) produces total loss of the function of the muscles supplied from below the point of division, and loss of sensation in the part corresponding to its distribution, to- gether with a sensible loss of temperature in the limb below, and loss of nutrition, sometimes leading to low eruptions on the skin.' Division of a purely muscular nerve, such as the portio dura, is usually accompanied only by muscular parahsis ; at least as far as is known, for thermometric observations in such cases are difficult and uncertain. Division of sym- pathetic trunks is known to be accompanied by dilatation of the capillaries and increased heat of the parts, from experiments on animals ; but in man such lesions could only form subordinate features in complicated injuries. The anatomical phenomena of wounds of nerves and of their repair is thus described by Dr. Lockhart Clarke : " Both portions of the divided nerve retract a little, and their extremities, especially the upper one, enlarge and become more vascular, while coagulable lymph exudes around and between them. In a short time this exudation becomes gradually firmer, and is found to contain cells and nuclei, and then fine nerve-fibres, which proceed from the extremity of the central portion of the nerve to that of the peripheral portion, which, on being separated from its nervous centre, undergoes a gradual atrophy or degeneration. These newly formed fibres are finer and grayer than those of the central portion of the divided nerve, and it is not till after a period of some months that they become fully developed. In the meantime a regenera- tion of fine fibres is going on in the peripheral or atrophied portion of the nerve ; but it is a long time before these fibres acquire the normal size and appearance. The same kind of reparative [)rocess takes place when a portion of a nerve has been excised, only it occupies a longer period."- The remote consequences of wounds of nerves are very various. I have seen a case in which the total division of the musculo- spiral nerve— evidenced by complete loss of sensation in the parts sup- l>lied by the radial and by loss of power in all the extensor muscles of the limb — was followed after the lapse of some months by gradual, but ultimately complete, recovery of all the functions of the nerve. Mr. Syme has put on record a case in which the ulnar nerve was divided in an excision of the elbow, and in which the functions of the nerve were also regained ; and here, on dissecting the parts some years afterwards, the ends of the divided nerve were found united by a kind of splint or 1 See a paper by Mr. Jonathan Hutchinson on Injuries of Nerve-trunks. (Lon- don Hosp. Reports, vol. iii, p. 321.) 2 Syst. of Surg., vol. iv, p. 103, 2d ed. 518 AFFECTIONS OF NERVES. ferrule of fibrous tissue (exactly as fracture is united by provisional callus)/ inside which the ends themselves seemed to be ununited, though in con- tact. But in other cases there seems no doubt that a permanent irrita- tion is generated in the substance of the wounded nerve, which is re- flected down other nerves, originating from the same part of the cerebro- spinal centre, and that thus the whole limb may ultimately become more or less paralyzed.* There are numerous other reflex symptoms produced by injuries to the nerves, but they are too miscellaneous and too rare to make it worth while to summarize them here, and in most of the recorded cases the real s3-mptoms have doubtless been mixed with many which were of an hysterical character. I would refer the reader to an interest- ing article by Dr. Brown-Sequard and Dr. Lockhart Clarke, in the fourth volume of the System of Siir-gery, 2d edition. Partial division of nerves, or their permanent irritation by the lodgment of a foreign body, or a ligature, is liable to produce symptoms even more formidable than those caused by their complete division, though essentially of the same char- acter. Tlie abiding irritation which sometimes ensues on the implication of a divided nerve in a cicatrix is of the same nature. A common ex- ample of it is the irritation and jerking which occasionally attacks the stump of an amputation. Sometimes the nerve is compressed by the formation of callus around a fracture. The symptoms caused by injury to a nerve must be treated according to their gravity. Since there can be no doubt that many of the worst symptoms depend on some constant irritation, the result of partial divi- sion, the lodgment of a foreign substance, or the implication of one or more nerves in the cicatrix, it is right in such cases to cut down on the nerves which seem implicated, and either divide them completely or remove a portion of tliem. In cases depending on lesion of one of the digital nerves it may often be better to sacrifice the finger, and in painful stumps to reamputate, taking care to cut all the large nerve-trunks so short that they cannot be implicated in the scar. But in slighter cases the symptoms will probably subside by galvanism of the aff'ected nerve, sedulously employed, blisters, the application of belladonna in ointment, and the hypodermic injection of morphia, if there is much pain, with careful attention to the general health. In all recent wounds, in which large nerves are divided, great care should be taken to put their extremities into accurate apposition, and it may be right to pass a silver or gut suture through the soft parts around or tlie sheath of the nerve, so as to keep them in accurate contact. Besides the direct and remote consequences of wounds, there are a few other affections of nerves which are occasionally met with, though as a rule the symptoms which are caused by lesions of nerves are only some- what subordinate features of surgical diseases and injuries. Neuralgia, in its strict sense — i.e., pain referred to the course and dis- tribution of some one or more of the sensory nerves — is a disease which is almost always periodic in its attacks, and bears a strong resemblance to ague in its course, causation, and cure, and falls more especially under the care of the physician. Still surgeons are so often consulted about it, and an accurate diagnosis of many surgical affections depends so much on a knowledge of the i)henomena of true neuralgia, that I must say a few words about it. The word neuralgia is used loosel}' to describe any 1 See a case related by Mr. Cullender, in Path. Trans., vol. xv, p. 180, in which the ulnar nerve seems to have been divided in excision of the elbow, and where the whole limb became paralyzed. NEUROTOMY. 519 gainful affection for which no anatomical or organic cause is known, and there is no objection to this use of the word if some otlier term were nsed to distinguish the cases wliich are of hysterical, dyspeptic, mental, or obscure origin from the truly neuralgic— ?'.e., those in which tliere is dis- tinct evidence of an affection limited to a precise nerve, and dependent, we cannot doubt, on some anatomical disturbance of its tissue, though this may be transient and imperceptible to our senses. The phenomena of true neuralgia are best studied in the familiar affec- tion known as tic, or brow ague, which follows the course of the supra- orbital branch of the fifth nerve. This commences very commonly b}' an increased afflux of blood, the pulsation in the little artery which accom- panies the nerve becoming plainly perceptible to the sight and touch as the pain is coming on. Then tlie neighborhood of the nerve becomes very tender to the touch, and this is followed by pain, often agonizing, extending along tlie ramifications of the nerve. In other cases all the branches of this or one of the other divisions of the fifth, or even all the branches of the trifacial nerve are similarly affected, producing in the latter case what is called hemicrania. It would be beside my purpose to speculate on the cause of this affection, or to spend any time on discuss- ing its treatment. I merely wish here to direct the reader's attention to it as illustrating an affection of tlie nerves quite unconnected with in- flammation, for the symptoms, intolerably severe at one minute, may have entirely disappeared at another, and also, for the same reason, not due to any abiding irritation in the course of the nerve. I may, however, add that the cure of this disorder must be sought in the discovery and removal of its cause, in the amendment of any disorder of the general health, and in cases where no cause can be ascertained, in the adminis- tration of antiperiodic remedies, as quinine and arsenic, with free purga- tion, and the local application of aconite, or the subcutaneous injection of morphia, or morphia and atropine, before the paroxysm. It is curious, and is valuable as a diagnostic sign, that though the parts near the affected nerve may be excessively tender to the touch, yet firm pressure will generally relieve the pain, and patients with lirow ague often learn to give themselves some relief by pressing the finger firmly into the supra- orbital notch. Many, however, of the cases classed as true neuralgia are really not periodic, but permanent affections, due to the implication of the nerve in inflammation of the bone in or near which it lies, or to its inflammation from some other cause, or to its being involved in cancerous or other ulceration, or compressed by a tumor. But in all these cases the symp- toms are persistent and continuous, though not therefore necessarily equal in severity at all times. In other cases, from some irritation applied to the motor nerves, or to the part of the nervous centre with which they are connected, strange convulsive movements are produced. Spasmodic wryneck is the best known of these affections, and it manifests itself as an affection of the trapezius or sternoinastoid and trapezius, which is often propagated to the other muscles of the neck and head, jerking the head about in various directions. From this origin the affection may be re- flected to the nerves of the cervical or also of the brachial plexus, causing neuralgic pains in the course of their sensitive branches, with possibly some affection also of the motor nerves. Neurotomy. — In all cases of obstinate neuralgia, or of obstinate spasm, the question will ultimately occur whether any relief can be given by surgical operation, and if so, whether the s3MBptoms are severe enough to warrant the attempt. I say this question occurs ultimately^ for it is 520 AFFECTIONS OF XERVES. Fig. 229. not until all known medical treatment has failed that the division of the aflected nerve ought ever to be tried, except in cases where the pain obviously depends on some irritation which cannot be removed applied to a definite part of the trunk. In such a case it ma}^ fairly be expected that the division of the trunk above this part will relieve the symptoms. When the cause of neuralgia is central or is unknown the operation is far less promising, though under proper circumstances it is quite right to give it a trial. There are two methods of dividing a nerve ; — one — which is the less formidable as an operation — is to make a sub- cutaneous puncture, or a small incision down to the bone in the known course of the nerve, by which the trunk is divided along with the parts in relation with it. But this is much less satisfactory than the other, both because the operator maj' after all miss the nerve, and because the latter may soon reunite and the symptoms recur. The more effectual method is to expose the nerve by a regu- lar disection, and remove a piece about half an inch long.^ Neuroma. — Tumors are some- times painful from their pressure on nerves, and in some of the "painful subcutaneous tumors," as the}^ are called, a definite nerve has been found implicated in the tumor. At other times, however, there has been no such explana- tion of the pain, which is tiien to be regarded as " hysterical." Like other forms of hysteria, this pain in simple, fibrous, or fatt}^ tumors generally occurs in women. But tliere are tumors formed in the substance of nerves, and called on that account neuromata, of which a remarkable example is depicted here (Fig. 229). They are of a fibrous or fibro-cellular Neuroma. A large oval tumor, six inches long by four wide, implicating the sciatic nerve and its pos- terior tibial branch. The surface of the tumor is nodu- lated. It is liollow, presenting a large central cavity, with soft shreildy walls. The trunk of the nerve, a, is seen passing into tlie tumor above and emerging be- low at a point below the popliteal space. Various fila- ments are represented spread out on the walls of the tumor, 6 b, and many other nerves can be detected by examination in the central cavity. For about one and a half inches above the tumor the nerve is much thickened and indurated. All that is known of the history i.s that the limb was amputated. The chief StrUC!,Ure, grOW generally slowlj^, massof the tumor was found ou microscopical exami- aj,(| ^re ofteu the SCat of Vei*y nation to consist of fibrous tissue, of various consis- tence, granular aiuorplious material, round and oval cells of the si/e of pus-gloliules for the most part, elongating fibre-cells, and remnants of nerve-tubes. — From a specimen, Ser. viii. No. 172, in St. George's Hospital Museum, described in vol. iv of Beale's Archives. acute pain. The fibres of the nerve will be found spread out over them and imbedded in their substance. They are incurable except by removal ; and when ' Some int'ire.stintj and typical ca.sos of noiu-otomy in puinful affections of the limbs will b(' found rolatisd by .Mr. Rfidfern Davies, in the Dublin C^uiirtorly Journal of Medical Science, November, 1800. DISEASES OF THE ARTERIES. 521 such removal would involve the destruction of the main nerve of the limb and its consequent paralysis, amputation becomes necessar}-. CHAPTER XXVIII. DISEASES OF THE ARTERIES. Atheroma and Calcification. — The degenerative changes which are found in the arteries appear under two chief forms, viz., atheroma, a softening, pulpy change, akin to fatty degeneration ; and calcification, or so-called ossification, in which the arterial tube becomes rigid and brittle. The latter, however, is a late stage or consequence of the former. In atheroma the internal and middle coats of the artery are found thick- ened by a material which is variously regarded by different authors as the result of chronic inflammation affecting the middle coat, and so push- ing the internal coat inwards and afterwards invading it ; or as deposited on the internal surface of the artery' from the circulating blood, and then giving rise to fatty degeneration. The former view of the inflammatory nature of atheroma is maintained with great ability by Dr. Moxon,' and is the one which certainly appears to me the more probable and the more consistent with the phenomena of the disease. The latter, however, rests on the great authority of Gulliver,^ and is the view usually adopted. However originating, the disease soon causes visible opaque patches of a yellow color, and thicker on section than the neighboring portions of the internal coats. In these patches there are found on microscopic examination oil-globules, cholesterin, and the degenerated tissue of the internal coat of the vessel, besides cell formations which are described by Rindfleisch, Moxon, and others as inflammatory. The progress of atheroma is in one of three directions: 1. The ather- omatous patch may soften into matter somewhat resembling pus, which passes into the tube of the artery, leaving a small cavit}' — the atheroma- tous ulcer — in the internal coat and inner part of the middle coat. The vessel at such a spot is much weakened, and may give way either totally and at once or partially and gradually, so as to form an aneurism. This softening is regarded as the acutest form of the inflammation which has produced the disease. 2. The athei'omatous matter may become organized into a low form of fibrous tissue, with wliicli fatty matter is mingled, until the coats of the vessel become "opaque, dull, and condensed into a material similar to hardened albumen and eventually to ligament" (Moore). In this change also, I believe, aneurism often finds its com- mencement, the difference in elasticity at the points where the healthy and diseased parts of the vessel join predisposing it to give way at that part. 3. The salts of lime are deposited in the atheromatous matter by a still more chronic process ; and then sometimes the whole vessel is graduallj' involved in this calcareous degeneration, so that it becomes a 1 On the Nature of Atheroma in the Arteries, from Guy's Hospital Reports. 2 Med.-Chir. Trans., vol. xxvi. 522 DISEASES OF THE ARTERIES. perfectly brittle and rigid tube, incapable of either contraction or dilata- tion, or of any change in length. Such arteries may, of course, be rup- tured by any slight force, and they are quite incapable of [)erforming one of the chief functions of arteries, — that of regulating tlie blood-supply according to the demand. Hence the frequent occurrence of gangrene in such cases. This process of calcification is popularly denominated ossification of arteries ; but there is no proof that true bone is ever found in such a patcii, though a certain resemblance to bone-cells has been thought to be discovered in the calcareous deposit. Sometimes in extensive calcification of the aorta the blood makes a way between the internal rigid and the external elastic portion of the artery, i. e., either between the external and middle coats or (as Dr. Peacock has shown to be almost always the case) between the layers of the middle coat, and distends the outer part of the artery into what is known as a "dissecting aneurism " (Fig. 234, p. 525). Both atheroma and calcification are frequent causes of secondary haemorrhage after surgical operation, the latter more especiall}^ ; in fact, the arteries are sometimes found so "ossified" in amputations performed on aged people that they break off when an attempt is made to tie them. In such extreme cases of calcification the ligature must be used very gently, and onl^^ tied just tight enough to command the bleeding ; or what is, I think, safer, acupressure may be employed. But secondary hfemorrhage is almost sure to ensue. Atheromatous arteries also are very liable to secondary hoemorrhage, being already badly nourished, and more prone to degeneration than to repair. I have shown from the records of St. George's Hospital that, judging from the result of fata-1 cases only, it would seem that secondary htiemorrhage is almost always due to disease of the arteries. (St. George''s Hoi< hetween the Sac and Artery. — The relations of the aneurismal sac to the artery are a matter of some importance. Very often a single part only of the artery has given way, although a considerable part of the vessel is, as it were, buried in the sac (Fig. 237) ; at other times, even Fig. 237. Fig. 238. Fig. 237. — Showing iin aneurismal sac, in wliieli tlie artery has given way at a single point, and where tlie artery is imbedded for some distance in the tissue of the sac. This is regarded by many surgeons a.s the usual condition in aneurisms of the limbs. Fig. 238. — Showing an aneurism in wliich the whrile circumference of the artery has given way for some distance, so that tlicre are two communications between the artery and the sac, one at the upper end of the tumor, tlie other near the middle, from which the lower part of the artery springa. This is a very common form of aneurism, especially in the interior of the body, and represents a stage intermediate between the former figure and the true fusiform aneurism, sliown in Fig. 235. in a sacculated aneurism, tlie whole circumference of the arteiy has given way, and there are two op(Miings, tnie of entrance and one of exit, sepa- rated by a considerable interval (Fig. 238). This is, of course, always * Sfe a paper On the Diagno.sis of Aneurism, in St. Georgo's Hospital Keports, vol. vii. PROGRESS OF ANEURISM. 531 the case in a fusiform aneurism. Tiie walls of the artery are by no means always diseased in the neighborhood of the mouth of the aneurism. Still, it remains trne that this jiart of the artery is, in a spontaneous aneurism, more likely to be found diseased than any other, and that operations on that part ought therefore to be avoided if possible. Pror/ress of Aiieurinm. — The usual progress of aneurism is to the rup- ture of the sac. The tumor increases gradually; it comes into contact with neighboring structures, which it compresses and absorbs, and which in their turn also compress and cause the absorption of the tissue which forms the sac. Thus, in thoracic and abdominal aneurisms, the spinal column is al)sorbed b}' pressure till the theca is often exposed ; in l)op- liteal aneurism the femur and the posterior ligament of the joint are worn away, etc. And as this goes on the sac softens and its tissue is replaced by tlie fasciae, muscles, or bones which the sac has met with in its prog- ress, until it gives way and the lilood exudes. This sometimes occurs by a sudden rent, the symptoms of which, if it takes place into the cellular spaces of a limb or into a joint, are sufficiently well marked. The tumor suddenly loses its pulsation and its shape, becoming flattened ; a sharp sensation of a crack, or of something giving way, often accompanies this; the limb becomes swollen and cold; possibly ecchymosis may be perceptible beneath the surface. If nothing is done gangrene will prob- ably ensue. When the rupture occurs through a serous surface it is often by a sudden crack, accompanied by rapidly fatal hremorrhage. On mu- cous surfaces the bleeding is usually gradual.^ Aneurisms do not often burst through the skin ; when they do the bleeding is generally, but not always, fatal at once. Spontaneous; cure, however, may take place, and this in several ways. First, tlie aneurism may simply lose its pulsation gradually as its sac be- comes more and more occupied l)y coagula, fresh laminae forming con- centrically till the whole sac is filled and obliterated. Secondly, the distal opening of the aneurism, or tlie distal portion of the artery, may become closed by an embolic clot, and this clot may gradually grow into the sac by fresh accretion till it is filled up. Thirdly, the whole sac may sup- purate, the resulting inflammation may seal both portions of the artery, and the tumor may thus be extirpated, a mass of blood-clot, mixed with pus, l)eing evacuated on the opening of the abscess. Fourthly, it is re- garded as possible by many eminent surgical pathologists that the tumor may itself compress the trunk of the artery above it, and so produce a hindrance to the circulation through the sac sufficient to permit of the entire consolidation of the blood in it. Finally, it may be said that some aneurisms, or perhaps aneurismal dilatations, make no progress whatever for an indefinite time. It is com- mon to find a dilatation of the root of the right carotid artery, which seems to remain in a stationary condition for inany years, without pro- ducing any appreciable inconvenience to the patient, except a loss of the power of active exertion. Ti'eatmeyU. — The treatment of aneurism is either internal (medical) or external (surgical). The internal treatment aims at producing a cure as in the first process of spontaneous cure above described. Its main object is to reduce the circulation by rest and low diet, and to keep the heart's action at a uniform level.'' The rest should be iperfect^ the patient being never allowed to leave his bed nor to assume the erect or even the sitting posture, and everything about the bed and chamber should be carefully 1 See Gairdner, in Med.-Chir. Trans., vol. xbi. 2 See Tufnell, On the Successful Treatment of Internal Aneurism, 1864. 532 DISEASES OF THE ARTERIES. arranged so as to make this as little irksome as possible. The diet should be spare in quantity but nourisiiino- in quality (say 6 to 8 ozs. of solid food, of which meat forms a good part), with as little fluid as he can be persuaded to take. A little wine is usually desirable. The object is not, as in tlie treatment of Valsalva, l)y repeated bleedings, to reduce the l)atient's strengtli or exhaust his supply of blood, but to keep the heart's action perfectly equal)le and somewhat below the standard of healtii, the pulse being between GO and 70, and never varying, as far as tluit is possible. The bowels must be carefully regulated if necessary by the gentlest possible laxatives, no purging or constipation being permitted, since both involve disturbance. If it be necessary, chloral may be given to procure sleep, or small doses of morphia injected. Under this plan pursued for several months much benefit may be obtained in the majority of cases of internal aneurism, and a few complete cures may be hoped for. As to medicines, none have as yet been proved to have any effect on the disease. Much benefit has, no doubt, in many cases followed the administration of iodide of potassium, and if it does not disagree witli the general healtli a trial may be given to it. At the same time I have often administered it with no efl[ect whatever, and in cases where it has done good, as perfect rest has also been employed, it is impossible to say how much of the benefit was due to this. The iodide may be given in five-grain doses three times a day, gradually increasing ; and if the heart's action is excited a small quantity (irijv-viij) of the tincture of digitalis or Fleming's tincture of aconite ("K''j-^') "^^.V be conbined with it. The acetate of lead has not seemed to me to act in any wa}' beneficially. The Old Operation. — The surgical or operative methods of treating aneurism are very various. The old operation (that of Antyllus) is an imi- tation of the cure by suppuration. It consists in cutting into the sac, turning out the clots, tying the artery above and below the tumor, and allowing the cavity to fill up by granulation. The operation is usually difficult, always dangerous, and sometimes impossible; but it has the merit that if successful it is certain to cure the disease, whicii is not the case with any of the otliers. Mr. Syme has lately done much to reintro- duce this operation into practice; not in popliteal aneurism, in which there can be no doulit tliat other methods are preferable, but in some of the other forms — axillary, gluteal, iliac, and carotid.' When it is possi- ble a tourniquet should he applied, and then, the circulation being com- pletely commanded, the sac may be freely split open (by a crucial incision, if need be), so that its interior can be inspected throughout and the opening of the vessel clearly seen. But in some cases (as in carotid aneurism) this cannot be done. It is then necessary, in order to avoid fatal hfemorrhage, to make an opening into the tumor just large enough to admit the finger, and enlarge it if necessary till two fingers can be in- troduced, tlic opening being all the wliile plugged by the finger. Then the surgeon feels around the interior of the sac till he gets his finger on tiie point from wlience tiie blood is issuing. Keeping this steadily com- manded, he next splits u|) the sac freely, turns out all the clots, and by the help of his assistant lays bare the artery above the opening of the aneurism, and ties its cardiac part. This being done, he withdraws his finger, to make sure that the direct circulation is controlled ; then dis- sects out the distal part of the artery and ties this also, in order to bar the reflux stream. The Hunlerian operation for aneurism consists in tying the trunk of ' See Syme, Med.-Chir. Trsms., vol. xliii, p. 1:57, and vol. xlv, p. 381. HUNTERS OPERATION. 533 the artery at a variable distance above the aneurismal sac. French writers nsnally speak of this as the method of Anel; but the difference is, tliat in Anel's method the artery is tied close to the sac, no branch intervening, while in Hunter's it is tied at a distance, and often a great distance (as when the external iliac is tied for an aneurism of the super- ficial femoral), so that in the former no branch intervenes between the ligature and the sac, while in the latter often many considei'alile branches arise in the interval. Anel's method selects for ligatun; that part of the artery which is most likely to be diseased, and in that respect has no superiority over the old operation. In many cases it would be hardly possible to carry it out without wounding the sac (see Fig. 237). In fact, it is only a part of the old operation, and the latter is in most cir- FiG. 230. Fig. 240. Flu. 241. Fig. 239. — Anel's operation. Fig. 240. — Hunter's operation. Fig. 241. — A preparation showing the definitive cure of aneurism. The aneurism affected the pos- terior tit)ial artery, and the femoral had been tied some months before death. & shows the posterior tibial nerve spread out over the tumor c; a, the artery, wliich appeared to be closed up at the seat of aneurism.— St. George's Hospital Museum, Ser. vi. No. 129. cumstances equally feasible, more certain to cure the disease, and there- fore preferable. Hunter's method is an imitation of the first mode of natural cure. It does not (as might at first sight be thought) altogether suspend the circulation through the tumor, except for a very short time, but greatly diminishes it. The collateral circulation brings back the blood into the tumor certainly after the first few hours, at which time there is often enough movement of fluid in the sac to be perceptible to the hand, and very likely even sooner. In animals it has been proved by experiment' that the collateral circulation is restored in a very few min- utes, and the same is most likely the case in the human suliject. But this sligiit stream of blood, instead of retarding coagulation in the sac, is thought by many surgeons to promote it. Thus Broca draws a dis- tinction between the clots which are formed by the coagulation of the blood en masne^ such as are produced after death, containing all the solid elements of the blood, and a good deal of serum also, and which he calls passive clots, and the layers of coagulated fibrin mingled only with more 1 See Syst. of Surg., 2d ed., vol. iii, p. 470. 534 DISEASES OF THE ARTERIES. or less of blood-corpuscles and comparatively destitute of fluid, which he calls aclire c/o/.s, believing that tlie former are rather injurious than use- ful in the coagulation of an aneurism, as irritating to the sac and liable to suppurate ; while to the latter he attributes the active process of filling up the cavity. For the coagulation of the blood en masse no circulation is necessary, but for the production of laminated fibrin he believes that some amount of circulation is at least very advantageous, if not neces- sary. This theory, however, is refuted by the fact that when the circu- lation is completel}' commanded for a few hours by pressure on the artery under chloroform, the sac often becomes filled with coagula (which must necessarily be of the kind which Broca denominates passive), and that tiiese ver}' often become gradually more and more solid and a definite cure results; proving that circulation is not essential for the production of laminated fibrin, and that soft clots are not a hindrance to the con- solidation of the tumor. The stress of the circulation being removed from the aneurism by the ligature of the vessel, the sac and the parts around contract upon the blood ; the latter becomes gradually more and more solid, and generally no more pulsation is perceptible in the tumor. By the time the ligature has come away (see p. 115) the tumor is much reduced in size; this shrinking goes on for some time, and the tumor becomes harder as it becomes smaller, till at last only a hard kernel is left, and sometimes no perceptible enlargement remains. On dissection the sac is found filled with laminsB of fibrin much resembling the coats of an onion, entirely discolored, if old; if tolerably recent the outer layers are perfectly butt-colored, while the inner retain more or less of coloring matter. The arter^^ also is usually obstructed at this part. If no con- siderable branch comes oft' between the ligature and the sac (^. f., if the case resembles Anel's operation to this extent) the whole artery from the ligature to the tumor is obliterated, and a single arch of anastomosis carries the blood into the artery below the aneurism ; otherwise there are two arches of anastomosis, one to convey the blood round the portion obliterated by the ligature, and the other to convey the blood round the obliterated aneurismal sac, above which there is a pervious tract of artery (Fig. 242). The main dangers which attend on this operation are those which have V)een spoken of as incidental to tlie ligature of an artery, viz., gangrene and secondary haemorrhage (see pages 116-1 18) ; but we ought not to omit to mention that the operation may also fail in one of two ways. The more usual is the suppuration of the sac. The coagulation remains somewhat imperfect, and after a longer or shorter time — for this is very variable — the part becomes swollen, red, and painful, and an exploratory puncture will discovcfi" i)us. It is vvell to wait till the matter has come near the sur- face and then to open the sac pretty freely. Usually the artery will be found to be closed; and if the patient can support the suppuration the cavit^"^ will fill up, and a cure will result ; but if on opening the tumor haemorrhage ensues, or if there be bleeding afterwards, ami)utation is indicated. In rarer cases the ligature does not suppress the pulsation, or after it has been temporarily suppressed it recurs. It is not very uncommon for a little pulsation to be percei)tible tor a short time, whicli ultimately dis- appears ; but in the cases here spoken of, as a result of too free anasto- mosis the tumor returns to exactly its former condition and resumes its growth. It now becomes necessary to undertake its treatment. The first indication is to employ genuflexion or pressure both directly to the tumor and to the artery above. This failing, the surgeon must choose between the ligature of the arter\- lower down and the old operation. Both plans TREATMENT BY PRESSURE. 535 have been successfully adopted, and the choice would depend more on the individual features of the case than 1 • • 1 HM F"i- 242. on any general principles. I here might, of course, be circumstances which would render amputation more advisable. Distal Ligature. — The distal liga- ture after the methods of Brasdor and Wardrop is a method of treatment which is now restricted to aneurism at the root of the neck, and which will be discussed on a subsequent page in treating that form of aneurism. Compression Treatment. — Pressure on the artery above has now become a recognized method of treating aneur- ism, and on the whole has been very successful. There are many ways of doing this, amongst which I have no hesitation in sa_ying" that compression with the finger is far the best, when it can be carried out. But it must be recollected that pressure cannot be ex- pected to succeed unless it is regular, efficient, and equable. Irregular pres- sure, which allows the sac to lelill fre- quently, cannot but aggravate the dis- ease by perpetual disturbances both of the sac and its contents, as well as distress and pain to the patient. What- ever form of pressure, therefore, is selected, care should be taken to as- certain by constant supervision that during the whole of its application no circulation is perceptible through the tumor.' And it is well not to com- a preparation showing the collateral circula- mence the treatment until, by a few tlon after the cure of aneurism by the ligature, days of complete rest and low diet, The external iliac artery has been tied for the ■' . 1 . I cure of aneurism of the superfacial femoral. the circulation lias been brought down The whole length of the external iliac is ob- tO the level of health or below it, and Uterated, and the femoral is obliterated at the until, as Dr. Carte suggests, a weight seat of aneurism, a points to the internal iliac, „ , , o 11 1-1 li .^ • Ti the branches from which and from the aorta of about 8 lbs. laid on the artery in the have anastomosed with b b, the two branches of groin (taking the case of l)Opliteal the external iUac, as well as with those of the aneurism) will stop the circulation in pr<>funda,c, and thus have brought the blood into . 1 . rill -c T -i 1 the common femoral, which is enormously en- the tumor. 1 hen, if digital pressure ,^,^3^ ,, ,, t„ ,^,^1 i„ ^^.^ .^e common iliac is to be used, a staff of assistants must artery. Again, the branches from the profunda be Organize(i, who are to take charge havecommunicated with the superficial femoral, c ,1 . • • 111- .1 which is pervious from a point immediately be- of the artery 111 pairs, one 10 dma: the , ., ' . «. ,. , u ^ ,Ar J I ^ a " ^ low the aneurism. St.(jceorge'sHo.spital Museum, arteiy while the other keeps his hand ser. vi. No. 120.— From the Syst. of Surg. • When compression was first introduced into general use surgeons were a good deal under the influence of the theory which Broca has so strongly advociited, and only Slimed at reducing not stof)|)ing tlie circulation. I believe 1 am correct in say- ing that this plan is given up even in France since the great success which has been proved to attend on digital pressure in the practice of Vanzetti and others. For digital pressure is always applied so as to stop the circulation altogether. 636 DISEASES OF THE ARTERIES. on the tumor, to see that the pressure is effectual. Without assistauce a man can hardly command the femoral artery completely for more than ten minutes, but the compresser's fingers can ])e much assisted b}' a weight or bag of shot made to fall upon the end of the finger.' In this way it is said that the same person can maintain compression for an hour. In changing the coin|)resser care should be taken that the artery does not escape even for an instant. The process is by no means painful, and a very rapid cure is in some instances obtained." In other cases the pressure must be intermitted, in order to give the patient needful repose during the night, and resumed uext morning. So long as the case goes on well — i. f\, if the pulsation and size of the tumor are obviously diminishing — the treatment should be continued ; but if no impression whatever is made on the disease I do not think it is wise to persevere be3'ond the first few days, at least in those forms of aneurism where (as in the popliteal) the operation of ligature is easy and involves comparativel}^ little danger. In cases where the artery lies too deep for digital compression it may be compressed manually by means of a pad mounted on a handle. A very useful instrument for this purpose has been devised by my friend, Mr. Coles, which has been successfully employed in the compression of the carotid arter\'.' A small pad, about the size of the end of the finger, is mounted on a rod fixed in a tubular stem, with a spring so that the pad does not exercise completely dead pressure. Instrumental compression is most easily made by means of a weight suspended from a frame, svhich can be improvised out of any materials that happen to be at hand, or which may be held by the patient or an attendant. The end of the weight ought not to be much larger than the finger, in order to avoid as far as may be the simultaneous compression of the vein or any of the neighboring parts. But in this, as in all other forms of compression, the most careful and continuous supervision is necessary. It is obvious that any sudden movement of the patient's body u)ay entirely displace the whole a[)paratus, and a few moments' negligence may undo the effect of hours of compression. Still, niany cases, especially of femoral and popliteal aneurism, have been success- fully treated in this way. The femoral artery in the groin is peculiarly well situated for this form of treatment. Numerous more elal)orate instruments have been devised ; modifica- tions of the Italian or horseshoe tourniquet (Signorini's), which com- presses the artery by means of an arm carrying a pad, and supported on a plate moulded to the opposite side of the limb. The i)ad is movable, either by a joint, or by a screw. The best form, I think, is Carte's compressor, in which the arm which carries the pad is mounted on a universal joint, and is supported i)y stout india-rubber springs, so as to l»e somewhat elastic without siiifting. IJut the great success of digital pressure has much restricted the ai)plication of these instruments, and I think it unnecessary to describe or figure their various forms. The reader will find them figured in Broca's work on Aneurism, or in the illustrated catalogues of the instrument makers. ^ Si'e Holdfiri, in 8t BartliolDiTunv'.* H()s|iital Reports, vol. viii, p. 140. A similar plan lia.s Ik-imi fjroposcd b}' a l"'ri'nch .siiri^con. In a oa.m are cured by digital pressure in three daj's, and by instrumental in fourteen. — Lancet, May 8. 1875. ^ Lancet, June 14, 21, 1873. TREATMENT BY PRESSURE. 537 The advantasies of the digital over the instrumental form of pressure are that it involves less risk of compressing the vein along with the artery, a drawback which is inseparable from instrumental compression ; that it is less likely to ulcerate the skin ; that tiie minimum of pressure nec- essary for the purpose is more easily ascertained ; and that it is more easy to shift the point of its application to one at a short distance, so as to give relief to the skin at the point (irst compressed, yet not change to a different part of the artery.^ The advantage of instrumental over digital pressure consists in its requiring no numerous staff" of trained assistants; but it does require the constant supervision of at least one well-trained and competent attend- ant, and is much more likely to succeed when that attendant is the surgeon himself. It very often fails from being left to students, nurses, etc., who direct the pressure wrongly or use it too severely. The cure of an aneurism liy pressure is generally preceded by enlarge- ment of the neighboring collaterals, arteries being felt pulsating in situ- ations where normally no artery is perceptible, and it is often accom- panied by very severe pain in the part,^ which sometimes is so agonizing that the patient declares he can bear the pressure no longer, and desires that an operation may be at once performed. " Bapid " PreaHure. — Another method of attempting the cure of aneur- ism by pressure is by what is called "rapid" pressure, ?'. e., the endeavor to keep the circulation entirely stopped for as long a time as may be neces- sary to fill the sac with clot, in the hope that definitive coagulation will follow on this. Generall}' speaking, the proceeding is too painful to be endured without antesthesia, and for this puri)ose a patient has been kept under the influence of chloroform sufficiently to bear the pressure for as many as fifty-two hours,'^ being allowed to recover consciousness at inter- vals just enough to allow him to swallow. The plan has hitherto been carried out chiefly in aneurisms of the abdomen and thigh, by compres- sion of the aorta or one of the iliac arteries. Where the vessels are more accessible to pressure, orwiiere their ligature does not involve very great danger, it seems very doubtful wliether it is justifiable to resort to it. The pressure has in all known cases been applied by some form of tourniquet. Further particulars will be found under the head of Abdom- inal Aneurism. Flexion of the limb has often proved successful in the treatment of poi)liteal aneurism. It has been used also with success, I believe, in the treatment of aneurism at the bend of the elbow, and has been tried in femoral aneurism, but, as far as I can ascertain, with no definite results.* 1 Mr. Walker, of Liverpool, insists, and I think with some reason, on what he calls " the one artery system " of pressure. That is to say, for instance, in popliteal aneurism the pressure is always to be applied either to the coniinim or to tlie super- ficial femoral. In changing from the one to the other the system of collateral vessels is also changed, and the course of the cure interrupted. In tlie instrumental form of pressure it is almost always necessary to shift the pad a considerable distance ; not so in the digital. — tSee Walker, in Liverpool Med. and Surg. Reports, vol. v, and Lancet, May 8, 1875. p. (i39. 2 See Mr. Cam[)bell DeMorgan's case, related in theSyst. of Surg., 2d ed., vol. iii, p. 445. 3 Mr. Holt's case, in Clin. Soc. Trans , vol. vii, p. 56. ■* A case of Dr. Gordon Buck is always quoted in the books as a successful adapta- tion of fli'xion to femoial aneui'ism. A reference to the original (Amer. .Jour. Med. Sc, 1870, p. 69) will show that the case was merely one of temporary return of pulsa- tion after cure by compression, and that the effect of the flexion was to exercise direct pressure on the sac. It bore very little resemblance to a recent case of aneurism. 538 DISEASES OF THE ARTERIES. Genuflexion acts by retarding the circulation much as compression of the arterj' does, and also, as I believe, by displacement of clot and by direct pressure on the parts, including, perhaps, the artery above the tumor, as in our fourth mode of spontaneous cure (p. 531). It need not be enforced to an extent which is either painful to the patient or likely to injure the tumor, and if not speedily successful should not be long per- sisted in. The simplest cases are the best for it. More will be said on this subject under the head of Popliteal Aneurism. 3IanipuIafio)} of the tumor was introduced into practice by Sir W. Fergusson. in order to imitate the second mode of spontaneous cure above described. The object of the manipulation is to press the two walls of the aneurism together, and so far to displace some of the coagula which are contained in it that they ma}' either be carried into the distal mouth of the aneurism or at least project into the blood-stream and form the starting-point of renewed coagulation. It has been employed with success in popliteal, femoral, carotid, and subclavian aneurisms, and is an undoubt- edly justifiable measure in tumors which cannot be operated on without ver}' great danger, which are not near to bursting, and in which there is evidence of the formation of blood-clot. Coagiilatmg Injections. — The injection of coagulating fluids (generally the perchloride of iron, about 25 per cent, of the salt) has been occasion- ally used with success ; but it can only be rarelj'^ useful in arterial aneurism, since in order to be employed with safety it requires that the circulation should be commanded above the tumor, i. e., that the case should be amenable to ligature or pressure, which therefore are generally indicated, as the injection is neither free from danger nor by any means certain to cure the disease. Galvano-puncture. — Electricit}' may also be employed to coagulate the blood in the sac. A weak stream of galvanic electricity passed through the blood will be found to decompose it, hydrogen being disengaged at the negative and oxygen at the positive pole, and in this way coagulation may be commenced, which under favorable circumstances will go on till the sac is completely filled ; but the method is a very uncertain one, and is liable to failure from the melting down of the soft clot which may have been formed, or it may prove fatal by setting up inflammation of the sac, or bj' causing sloughing around the needle punctures, followed by haemor- rhage. Introduction of Foreign Bodies. — Finally, it has been proposed and attempted to produce coagulation in the sac by the introduction of foreign bodies into the blood which is circulating through it — much in the same wa}' as the fibrin is whipped out of blood in a basin by a bunch of twigs. Mr. Moore' originated this method of treatment, by introducing a large quantity of iron wire into the sac of an aortic aneurism. Considerable coagulation was produced, but the wire caused fatal inflammation of the sac-wall. Di'. Muriay of Newcastle tried carbolized catgut, but without result. Ilecently horsehair has been used, by Dr. I^evis of Philadelphia, in a case of sul)claviaM aneurism, and by Mr. I>ryant iu one of popliteal aneurism, and also with the elfect of producing a good deal of coagula- tion.'^ Both cases, which were of a ver}- unfavorable nature, ended fatally; iMit it does not appear that the foreign body caused any injury to the sac or other parts in either, and the expeiinient may be worth repeat- ing iu a case uliich is not auienal)le to more hopeful measures. But treat- ment which acts only on the blood in tiic sac holds out comparatively ' Mod.-Chir. Trjins., vol. xlvii, p. 129. ' The preparation from Mr. Bryant's case is in the Museum of Guy's Hospital. INNOMINATE ANEURISM. 539 little hope of success. The really successful methods of treatment — rest, ligature, and pressure — are assisted in their operation by the reaction of the tissues around and of the sac itself. The weak point in the treatment by manipulation, coagulatiuii; injections, galvano-puncture, and the intro- duction of foreign bodies is, that these metliods either tend to injure or to produce inflammation of tlie sac-wall. A short exposition of the chief kinds of surgical aneurism is necessary here, to which I shall append a description of the operation of tying each artery. Thoracic Aneurit^m. — Aneurism of the arch of the aorta can only very rarely be made the subject of surgical treatment, but the surgeon should be acquainted with its main features, in order to diagnose it from other diseases, as well as to distinguish those rare cases in whicli operative treatment may be justifiable. Bruit is very frequently' absent in thoracic aneurisms, which are often of the tubular variety, or open into the artery b}' a wide, unobstructed orifice.^ The pulsation also is often imperceptible, so long as the thoracic i)arietes remain intact, and it may be simuhited by pulsation communicated by the heart to a cancerous or otlier tumor.^ Consequently the diagnosis often rests more on the indirect than the direct symptoms. These are usuallj" pain between the shoulders from pressure on the spine, ringing cough from pressure on the trachea, spas- modic d3'spna?a, either from pressure on tlie recurrent nerve or on the windpipe itself, dyspnoea, haemoptysis, and inequality of the pulse in the wrists and sometimes also in the carotids. Very commonly one of the large branches given off' by the arcli is so obstructed that no i)ulse can be felt in its branches. Thoracic aneurism is, as a rule, best treated b}' the internal or medical treatment descril)ed on p. 531. Under this plan of treatment almost every case of thoracic aneurism, and many cases of aneurisms of the limbs, will rapidly improve ; and in some rare cases even of aortic aneurism a com- plete cure may possibly be obtained. Tlie only surgical measures which are admissible in aortic aneurism are either galvano-puncture or the liga- ture of the carotid on Brasdor's method. The former is, as far as our present knowledge extends, an uncertain and a dangerous measure, which, however, has yielded some good results in the skilful hands of Signor Ciniselli and others. The latter seems to me to be useful or justifiable only in aneurisms believed to implicate the transverse position of the arch and to be extending along the course of the carotid into the neck, in which case the corresponding artery (generall}' the left carotid) may be tied, and this has been done by Mr. C. Heath in one well-known case with very considerable benefit. The patient, an agricultural laborer, under Dr. Cockle's care, is now alive, and remained in good health for about four years after the operation, earning his bread by fieldwork. Latterly the tumor has begun to grow again.' Innominate Aneurism. — Aneurism of the innominate artery is difficult to diagnose from aortic aneurism, and many cases, under the care of the best surgeons, are on record, in which supposed innominate aneurisms have on dissection turned out to have been purely aortic. It forms a pul- i On the other htrnd, I have known the bruit so loud as to bo heard, all over the room. '■* See a case reported by me in the Path. Tran.s., vol. ix, p. 29*. 3 On thesubject of thoracic aneurism 1 would refer the reader for details and dis- cussions, for wiiich I can tind no space here, to a series- of liectures- pubiish«d. in the Lancet for June and July, 1872. 640 DISEASES OF THE ARTERIES. satiiio- tumor near the right sternoclavicular articulation, pushing the upper part of the sternum forwards, often dislocating the end of the clavi- cle or eroding it, and usually first presenting in tlie interval between the tendinous and muscular origins of the sternomastoid. More or less dysp- noea may be present from pressure on the trachea, and the pulse in the riglit wrist is generally mucli feebler than in the left. The other symp- toms will vary with tlie size of the tumor. In innominate as in aortic aneurism it is desirable to avoid sui'gical measures if possible, since no operation can be practiced without very great danger, and the i)rospect of success or even of benefit is very slight. But if tlie tumor be extending, in spite of the treatment by rest, and es- pecially if it be extending along the trachea, as evidenced by its growth and by the increase of dyspnoea, it is, in my opinion, quite justifiable either to try galvano-puncture, or to tie the right carotid on Brasdor's method, or even, perhaps, to tie the subclavian artery as well.^ Cay^otid Aneurism. — Aneurism of the cai'otid artery is generally situ- ated at the bifurcation of the common carotid. It ma}', however, affect the common trunk lower down, or one of the secondary carotids, gener- ally' the internal. The diagnosis is usually easy, but the lower down the tumor extends the greater is the difhculty in distinguishing it from aortic aneurism ;- and cases have been recorded here, as in other regions of the body, where eitlier an abscess pressing on the artery, and receiving pul- sation from it, has been mistaken for an aneurism, or, vice verm, an an- eurism has been mistaken for an abscess ; but I do not know that the danger of mistakes is greater here than elsewhere.'' Brasdor^s and Wardroj)^s Operations. — An aneurism of the common carotid low down in the neck, or an aneurism of the intrathoracic part of the left carotid (if the latter affection ever occurs, of wiiich, as far as I know, no instance exists at present), ma}^ be treated with good pros- pect of success by Brasdor's operation ; and it is to these aneurisms, as Hodgson and Wardrop have clearly shown, that Brasdor's operation is in strictness applicable; and a good augur}' of its probable success in sucli cases is given by the fact — which Wardrop noticed vvitli surprise in a case in which he had tied the arter}^ beyond the aneurism — that the ^ As I have myself tied the subclaviiin (third part) and the carotid simultaneously in a case of innominatt; aneurism, I need hardly say that I think the distal operation justifiable in appropriate cases of this atiection. But I must say that the study of ray own case and of the published records of the others has led me to the decided conviction that the benelii which has been obtsiined in some of them has been due usually to the licjature of tlic carotid b}- which the carotid or tracheal portion of the sac has been obliterated ; and I should be disposed in any future cases to commence with the less severe; measure of tying the rigiit carotid. It must be remcunbered that the lari^e branches from the; first part of the subclavian must carry on the collateral circulation after the third part of that artcM-y has been tied ; and for this purpose the circulation must go on through the sac into the first part of tlu; subclavian artery, and probably with increased force, after the operation, so that the entire obliteration of the sac by ihi- disial ligature seems impossible! unless the first part of the subcla- vian could be secured inside its large branches, which ufi to the present timci has b(;en found incompatible with the patient's recovery, even without the complication of ligature (if tlie right carotid. Still Mr. Kearn's I'asc, where; a prae-tical cure c(;rtainly resulted (a channel about the; .-ize of the originsii artery being maintained through the clot which filled the aneurism), is an encouragement for tying the two arteries either simultaneously or, perhaps better, with an interval, as in that case. 2 fSee the well-known case under Sir A. ('ooper's care in Allan Hums, On the Sur- gical Anatomy of the; Head and Neck, p. 00 et seq. 3 Traumatic aneurism of the vertebral artery has also been mistaken for carotid aneurism. On this subject see a lecture published in the Lancet, July 26th, 1873. LIGATURE OF CAROTID. 541 tumor collapses immediately the artery is tied, instead of increasing in tension and pulsation, as it would do if the stream of blood pumped in from tlie heart were not derived down the collaterals, which at once begin Fig. 243. Fig. 244. Fin. 24.3 shows Wardrop's operation, /. e., the ligature of the carotid artery for aneurism of the innominate. Wardrop's idea seems to have been that as the quantity of lilood conveyed by the carotid, that by the branches of the first part of the subclavian, and that by tlie third part of that artery, may be taken to be about equal, he could deprive the sac of one-third of its blood by tying the carotid, and of two-thirds l:)y tying the third part of the subclavian also. He had not allowed for the increase of the collateral circulation. Fig. 244 shows Brasdor's operation as applied to an aneurism limited to the trunk of the carotid, the only situation in which this operation can in strictness be applied. I have shown reasons for believing that when these operations succeed they do so, not so much by retarding the blood-flow through the tumor as by the extension of coagulation from the tied artery into the aneurismal sac. to enlavge. It is possible that some aneurisms seated low down on the carotid might even be cured by distal compression, but no case is at present recorded. Aneurisms seated near the bifurcation or in one of the secondary caro- tids or their branches may be treated either by the old operation, by the Hunterian ligature, or by compression. The first method has been de- scribed above. Compression of the common carotid is not an easy thing either to perform or to endure; nevertheless at least five successful cases have been published.^ It may be effected either by the finger, by an ap- paratus with a movable arm carrying a small pad, or by Coles's com- pressor. The point against which it is most easily compressed is the anterior tubercle of the transverse process of the fifth cervical vertebra, which lies about two inches al)0ve the clavicle, and is called sometimes " Chassaignac's tubercle," since that surgeon first drew attention to the comparative ease with which the carotid could be compressed there. Ligatiu-e of the Common Carotid. — The common carotid maj' he tied in any part from the root of the neck to the bifurcation, and either of the secondary carotids are accessible as high as the parotid gland. The "lieu d'election " for the ligature of the common trunk is just above where it is crossed by the omohyoid muscle, i. e., at tlie level of the cri- coid cartilage. An incision is made with its centre at this level, '^ and in 1 See Lancet, June 21, 1873. 2 In the chapter on Operative Surgery diagrams will be found showing the external incisions in all the ordinary operations on the arteries. 542 DISEASES OF THE ARTERIES. the course of the vessel (?". f., in a line from the sternoclavicnlar articu- lation to the point midwa}' between the angle of the jaw and mastoid process), its length being proportioned to the size of the neck. After the skin, platysma, and deep fascia have been divided the edge of the sternomastoid is seen, and the upper belly of the omohyoid may be noticed passing upwards and inwards. Then the operator searches for the sheath of the vessels, lying close on the trachea, and often having the deseendens noni nerve Fig. 245. in front of it. Having opened the sheath, the pul- sation and the color of the arter}^ will be recognized. Then it is to be cautiously separated with the director and the point of the knife from the sheath and the vein, for a ver}^ short dis- tance, so as to allow the needle to be got round it. Compression of the bare artery between the finger and the needle will stop the pulsation in the tumor, or, if the operation be on the distal side of the aneurism, will stop the pulse in the temporal artery ; and this experiment should never be neglected, for very good sur- geons have been so deceived LigErtureof the common carotid artery. The edge of the ^.V pi'lsation COmmunicated Bternomastoid muscle is seen with a double hlunt hook passed tO a piece of faScia as tO tie under it. b shows the carotid artery, with a ligature passed it instead of the VeSSCl. round it. The sheath is shown opened, and on the sheath Thp lowpr mrf of thp Cir- may be seen the deseendens noni nerve. Crossing the sheath . , . ' *, , ' , is the omohyoid muscle, a. The opening in the sheath is ^tld IS morC deeply Seated, represented larger than it would be made in practice, in and in tying it it is better order to show the jugular vein external to the artery, and ^q divide tllC stcrnomas- ihe pneumogastric nerve between the two vessels and poste- , ._, f i p,ir>no-h fr> a^r rior to them. In practice, however, the nerve ought never ^^'^ neciy eiiuiij^ii lu ex- to be exposed ; and the jugular vein, unless it is distended, is pOSC fairly the Sternohyoid ■ueuaiiy not brought into view. and Sternothyroid muscles. These muscles should tlien be carefully divided on a director, when the sheath will be exposed. In tying the carotid the jugular vein and pneumogastric nerve are not usu- ally seen, l)ut eitlier of them may be, especially the vein, which is some- times swollen and laps over the artery, so as to give some trouble. At the root of the neck, on the riglit side, the vein is separated from the artery by an interval, while on the left side it somewhat overlaps the artery. The slieath of the vessels near the root of the neck is usually covered \ry several veins descending from the thyroid body, whicii in- creases the difficulty of the operation. The ligature should alwa3's be passed from without inwards. Ligature of the common carotid has hitherto proved fatal in about 40 per cent, of the cases operated on. Dr. Pilz has tabulated (iOO miscel- laneous cases in the 9th vol. of Langenbeck's Jrchives, with 259 deaths. But the danger seems to depend more on the patient's general condition LIGATURE OF LINGUAL AND THYROID. 543 than on the intrinsic, severity of the operation, the great mortality being in cases where the artery has been tied for hjiemorrhage. In ordinary cases the death rate is estimated at abont one-tliird.' Ligature of the External Carotid. — Ligature of the internal carotid is not an operation witli which I have any acquaintance, except as a dis- secting-room exercise; but the external carotid has often been tied,Mn the following manner : Make an incision downwards, from a little external to the angle of the jaw to near the anterior edge of the sternomastoid, from one-third to half an inch below the upper border of tiie thyroid car- tilage, dissect away some cervical glands and the venous branches con- nected chiefly vvith the facial and lingual veins, which lie over the artery. The glands should not be torn away or lifted, for fear of tearing tiie veins, to which the}' adhere closely, but freely incised, and the veins tied and divided if necessary. Then look for the hypoglossal nerve, which crosses the artery perpendicularly, and will serve as a guide to the vessel lying immediatel}' beneath. There is usually about half an inch of the trunk available for the purpose of placing the ligature, between the origin of the superior thyroid, which is generally close to the bifurcation, and that of the lingual, facial, and occipital above. The identity of the vessel may be known by its relation to tlie iiypoglossal nerve, the presence of a collateral (the superior thyroid), when it happens to come into view, and the fact that pressure on the exposed vessel commands the pulse in the temporal,^ Ligature of the Lingual and Thyroid Arteries. — Some of the branches of the external carotid have been tied. The lingual is the one most fre- quently operated upon, and mainly on account of hemorrhage from cancer of the tongue. An incision is made having its centre opposite the great cornu of the liyoid bone, and either horizontal or downwards and for- wards, at an angle of 45^. The superficial parts and the deep fascia having been divided, the operator seeks for the ninth nerve, which runs superficial to the hj'oglossas muscle, while the artery crosses beneath it to pass under that muscle. One plan is to draw the nerve aside and tie the vessel as it plunges under the muscle ; the other is to divide the fibres of the hyoglossus from the bone and look for the artery, lying parallel to the upper border of the hyoid bone. It must be remembered that the artery varies in its origin, and in its course external to the cornu of tiie hj^oid bone, so that it is sometimes very difficult to find it in the first portion of its course. As to tiie other arteries in the neck I may quote the following direc- tions : " For the superior thyroid an incision is to be made, two inches long, parallel to the inner margin of the sternomastoid, its centre correspond- ing to the great cornu of the thyroid cartilage. This brings into view the omohyoid muscle and the sheath inclosing the jugular vein and common carotid; the fibrous lamellae which cover the artery having been torn away with a director, the superior thyroid may be found running down- wards between the vessels and the tliyroid gland ; or, if tlie facial is the arteiy sought for, it can be found by the same incision, the search being conducted upwards towards tlie jaw, where the arteiy is found between the great vessels and the submaxillary gland. " The inferior thyroid is to be sought by an incision similar to that for 1 Syst. of Surg., vol. iii, p. 589. '^ M. Guyon quotes twenty-four cases in the 6th vol. of the Mem de la Soc. de Chir. de Paris. 3 Syst. of Surg., vol. iii, p. 592, 2d ed. 544 DISEASES OF THE ARTERIES. the carotid in the lower part of the neck. It is usually concealed by the upper part of the omohyoid muscle. This muscle must therefore l)e de- pressed or divided, and tlie artery sought for between the trachea or a^sophagus and the trunk of the carotid. The recurrent nerve and the descendens noni will be endangered in this operation.'" Orbital aneui-ism is a rare disease, i. ^., pulsating tumor in the orbit is rare, and true aneurism is still rarer. The case which first attracted the notice of the profession was published by Mr. Travel's' as one of aneurism by anastomosis, but it is now conceded on all hands that most of the cases of pulsating tumor in the orbit are certainly not of this nature, altiiough we may still admit the occasional occurrence of aneurism by anastomosis here, distinguished by its appropriate symptoms.^ But the objections to regarding the ordinary cases of pulsating tumor in the orbit as aneurisms by anastomosis are irresistible. Mr. Nunneley, in two most interesting papers on pulsating tumors in the orbit,* succeeds, I think, in proving this point, since " aneurism by anastomosis involves all the neighboring vessels, arteries, and veins in active disease; aneurism of the orbit is generally limited to a single part, or if the neighl)oring vessels are dilated they seem only enlarged from obstruction — ligature of the trunk of a vessel leading to an undoubted aneurism by anasto- mosis is an extremely unsuccessful operation ; in aneurism of the orbit, a very successful one — finally, the cases dissected have turned out to be common aneurism." But that some of these tumors are not arterial aneurisms seems clear enough, from a tract published by M. Delens^ recounting two cases under tiie care of Nelaton, in both of which the disease' was found to consist in a communication between the internal carotid arter^^ and the venous channel in the cavernous sinus ; and again, Mr. Bowman's case (published in Streatfield's Ophthalmic Beports^ April, 1859) shows that all the ordinary symptoms of what is called "orbital aneurism " may be caused by coagulation of blood in the venous sinus pressing on the carotid arter}' and occasioning protrusion of the eyeball. The s3'mptoms of "orbital aneurism " (so-called) are protrusion of the eyeball, eversion of tlie lids, loss of vision, and pulsation ; sometimes in the form of definite rounded tumor above the eyeball, sometimes as a general pulsation perceptible throughout the orbit. In cases which have been followed to their conclusion uninfluenced by treatment, it has been found that the tumor will sometimes subside en- tirely without any permanent mischief,'' or in some cases with loss of vision in consequence of the long exposure of the protruded eyeball;' and this is in itself a strong presumption against the presence in such instances of arterial aneurism, and a strong argument against the too early resort to any serious surgical operation. Tlie aj^jiearances on dissection have also been very various. In some cases it is said that an ordinary encysted aneurism of the ophthalmic artery has been found," whether in tlie orbit or in the sella turcica." In other 1 Syst. of Sure;., vol. iii, p. 594, 2d ed. 2 Mcd.-Chir. Trans., vol. ii. See also anolhor case, by Mr. Dalrymple, in vol. vi. 3 S<^e Hayncs Walton, Suru'. Di.«. of the Eyo, 2d cd., 1861, p 230. ■* Med.-Cliir. Trans., vols, xlii and xlvlii. * De la Communication di- la Carotido internn etdu Sinus Cavornoux, Paris, 1870. 8 Erichsen, Scinnce and Art of Sur<;jcry, vol. ii, p. 28. Holmes, Amer. Jour, of Mod Science, .July, 1804, p. 44. ' Franco, Guy's IIosp. Reports, Ser. iii, vol. 1, p. 58, 1855. * Guthrie's case, quoted by Nunneh^y. s Nunneley, Med.-Chir. Trans., vol. xlviii, p. 29. SUBCLAVIAN ANEURISM. 545 cases, as in tliose reported by Pr. Delens from Nelaton's practice {op. nupr. cit.) there has been a communication between the internal carotid and the venous channel of the cavernous sinus (arterio-venous aneurism), and in tliese the pulsating tumor over the eyeball has been proved to have been formed b}^ a dilating and pulsating vein ; in others, again, nothing bevond a collection of blood-clot (thrombosis) in the sinus press- ing on the artery (as in Bowman's case). For these reasons surgeons are now less quick than they used to be to resort to the ligature of the carotid artery in such cases. It is better at first to watch the case ; and if no great inconvenience is caused by the disease it is very doubttul whether any treatment is necessary ; other- wise digital pressure on the carotid artery as long and as frequently as the patient can tolerate it is advisable. If, in si)ite of this, the symp- toms are advancing, the choice lies between the injection of perchloride of iron and the ligature of the carotid.' Subclavian aneurism is a very formidable and fatal disease ; like all other aneurisms near the heart, it is usually fatal if left to itself, while surgical treatment generally only hastens death. The only really suc- cessful methods of treatment in aneurism are those in which the surgeon deals, not with the blood or the contents of the sac only, but also with the sac and the tissues which surround it ; by taking away the eccentric pressure of the blood on the walls of the sac, the latter are allowed to react on the contained blood, and this is a powerful aid in the cure of the disease. On the other hand, a softened, inflamed, or ruptured sac is usually the precursor of death when the tumor is near the heart. Now, in aneurism of the first or second part of the subclavian artery the liga- ture can onl}' be applied to the innominate arter^', and in aneurism of the third part of the right subclavian to the first part of the same vessel; and both operations have proved uniformly fatal, except in one case, in which the innominate and subsequentl}^ the vertebral artery were tied by Dr. Sm3"th, of New Orleans, and the patient survived after several sex ere attacks of secondary haemorrhage. Galvano-puncture may be tried, but its eflfect is so commonly to set up inflammation of the sac that it must always be doubtful whether it is not more dangerous than abandoning the case to nature. The " manipulation " of the tumor remains as the only active surgical measure ; and this, though perfectly justifiable, and indeed indicated, when the sac contains a good deal of clot in one part, but is growing in another, must be allowed to be a desperate measure. In cases which are not growing perhaps gentle direct pressure may grad- ually eflTect a cure.'"' In some cases, where aneurism afl'ects the end of the subclavian, and the artery rises high in the neck, it may be possible to make compression, either digital or instrumental, on the artery above, as in Mr. Poland's case.^ If there is gangrene or a threatening of gangrene ami)utation at the shoulder-joint is indicated. The great branches of the subclavian having been removed, the aneurism may cease to grow. In Mr. Poland's paper a case of this nature under Mr. Spence's care is related. Ligature of (he Innominate. — When the surgeon has made up his mind to risk the ligature of the innominate arter^', or of the first part of the right 1 The whole question of the pathology and treatment of pulsating tumors in the orbit has been elaborately discussed by Mr. Eivington in a paper which will be found in Med -Chir. Trans., vol Iviii. ■^ A case under Mr. Corner's care is related by Mr. Poland (op. infr. cit ) as one of cure by direct pressure ; where, however, it seems to me that the recovery was spon- taneous. 3 Med. -Chir. Trans., vol. Hi, p. 277. 35 546 DISEASES OF THE ARTERIES. subclavian,' his best plan is to obtain free space externally y^y a Y-shaped incision made along the inner margin of the sternomastoid and the upper border of the clavicle. The sternomastoid having been cut awa}^ freely from the clavicle, is turned aside, and the sternoh^'oid and sternothyroid divided. Now the carotid sheath is fairly exposed. If the innominate is to be secured, the surgeon follows the carotid down to its bifurcation and passes his finger into the thorax along the artery, which is now the innominate. This manoeuvre may be somewhat facilitated by drawing the head strongly backwards. The needle must then be passed around the vessel from without inwards, as low down — ^. e., as near the aorta — as can be reached, great care being exercised to avoid puncturing or contusing the right innominate vein. A needle with a sharper curve than ordinary may be employed, or some special contrivance, provided with a catch for drawing up the ligature. If the surgeon intends to tie the first part of the right subclavian, this can only be done just external to the point where the pneumogastric nerve crosses it. On the right side a triangular interspace is left between the carotid artery and the jugular vein, and here the nerve is seen cross- ing the artery. As the recurrent laryngeal runs inwards round the ves- sel, and as the phrenic nerve crosses the artery close to its termination, either of these important nerves will probablj' be injured; but sympa- thetic filaments must almost necessarily be interfered with, while the proximity of the large branches of the artery almost necessitates sec- ondary haemorrhage (of which the great majority of those operated on have died); and the risk of wounding the large veins of the pleura has also to be considered. This operation has never, as yet, been successful. Axillary aneurisvi is a more common aflTection than subclavian, the free movement of the joint, near which the artery passes, rendering it liable to slight injuries, like the popliteal, though in a lesser degree ; so that these aneurisms are frequently found to follow upon sprains or con- tusions. Total rupture of the axillarj' artery has been known to be pro- duced by the efforts to reduce a dislocation of the shoulder-joint.'' There is usually little or no difficulty in the diagnosis, but the treat- ment is only too frequently unsuccessful. Three principal measures have to be considered: 1. The ligature of the subclavian artery was long the only resource in this form of aneurism, and it still remains the most easy of application ; but it is doubtful whether it is tlie safest, since the mor- tality has been very great. 2. Mr. Syme'* speaks strongl}' in favor of the old operation; and in cases of rupture of the axillary artery, where no sac has formed, this is no doubt the best course to pursue. The sub- clavian artery must be commanded by the fingers of an assistant, for which purpose an incision may be made in the usual situation for the ligature of that vessel, and the artery be held firmly against the rib. Then the blood-tumor is to be opened in its whole extent, the clots re- moved, and ])oth ends of the lacerated vessel tied. The same course may very projjerly be followed in a traumatic aneurism, particularly if the tumor has so far elevated the clavicle as to make the operation of tying 1 The left suDclavian has been tied in its first part behind the apex of the left lung by Dr. J. K. llodejers, of New York, but the oporation is so difficult that most surgi- cal writers liave sfKikon of it as inipriictifiiblf^ ; and it is known that Sir A. Coopur, having attempted it, was obliged to desist, b(^lieving tliat lio had injurcid the thoracic duct. It is hardly worth while to spend time in describing an operation which will probably not be repeated. 2 See Callender, in St. Bartholomew's Ho.sjiital Reports, vol. ii, p. 9G. 3 Med.-Cliir. Trans , vol. xliii, p. 137. LIGATURE OF SUBCLAVIAN ARTERY. 547 Fig. 246. the subclavian difficult and dangerous ; but, as I have shown in another place, the relations of the sac to the artery and to the nerves of the plexus are ver}' variable, and the surgeon may easily meet with very great diffi- culties. 3. Compression has been successfully applied to the third part of the subclavian artery;' and though the difficulty of doing this is in some cases so great as to make it well-nigh impossible for the surgeon to do it, or for the patient to endure it, yet in others it will be found quite easy. These differences depend, of course, on the varying height to which the artery rises in the neck, the varying level at wliich the clavicle is found,-' and the varying thickness of the neck. In any case in which it seems at all feasible to make compression, and where the rapid growth of the tumor does not contrain- dicate the attempt, I think the surgeon is bound to try this method of treatment before re- sorting to the ligature. Cole's compressor, an apparatus con- structed for the purpose, or the finger, may be used, ac- cording to the depth of the vessel. Ligature of the Subclavian Artery. — The subclavian artery may be tied in the third part of its course under ordinary cir- cumstances with no great diffi- culty, though in complicated cases few operations are more embarrassing. The patient's head is to be turned to the op- posite side — the affected shoul- der is drawn downwards by an assistant as far as possible. The operator draws the skin of the neck down over the chest with the fingers of his left hand, and makes an incision on to the clavicle for about its mid- dle third. The skin is then I'e- leased, and the incision lies about a finger's breadth above the bone. In this way the sur- geon avoids all risk of wound- ing the external jugular vein as it dips under the clavicle. This vessel is next defined and drawn aside ; or, if there is any difficult}' in getting it out of the way, it is divided between two ligatures. The deep fascia is Ligature of the subclavian artery. At the inner an- gle of the external incision the root of the external jugular vein is seen, and its course above is indicated through the skin. Some fibres of the sternomastoid muscle would also probably be seen in this situation. Deeper down is seen the scalenus anticus muscle going into the first rib, and the artery emerging from behind it, with the nerves of the brachial plexus above and behind the vessel. Above these is seen the posterior belly of the omohyoid. The outer angle of the incision reaches to the trapezius muscle. 1 Lancet, Sept. 27, 1873, p. 445. 2 It may be worth while to notice that some surgeons believe with jV[r. Spence that the clavicle is not merely pushed up passively by the size of the tumor in the axilla, but that its elevation is also, and perhaps chiefly, an active one, due to irritation of the nerves, causing the muscles to contract and draw the scapula and clavicle upwards. 548 DISEASES OF THE ARTERIES. now opened to the extent of the skin-wound, and the celhilar tissue of the subclavian triangle scratched through with the point of the director till the margin of the scalenus anticus muscle is plainly seen. In doing this the omohyoid muscle may be exposed, and possibly the transver- salis colli artery may be met with. The surgeon now traces the scalenus anticus muscle down to its insertion into the first rib, and he will then find the arter}' lyiiig" close beneath his finger, emerging from behind the muscle, immediately behind the scalene tubercle. The nervous cord formed Iw the eighth cervical and first dorsal nerves lies close above and behind the artery, and great care must be taken not to mistake it for the vessel, which may easily be done, if from an}'^ cause the pulsation is not plainly perceptible in the arter}^, or the parts cannot be brought into view. The needle is passed around the vessel either from above or below, as is most convenient, and when this has been done it should be carefully as- certained, first, that only one structure is embraced b}^ the needle, and second, that pressure on that structure commands the pulsation. Sometimes when the aneurism extends too far up the vessel to allow of the third part of the artery being safely tied, the second part has been secured. The operation is essentially the same, only a freer incision is desirable, which is obtained by notching the inner end of the skin-cut upwards, and by dividing the fibres of the sternomastoid as far as may be necessar}^ to bring tlie scalenus anticus into view. When this has been done the fibres of that muscle are to be divided transversely on a direc- tor, with all possible care, to avoid injuring the phrenic nerve, and thus the artery is exposed. The surgeon must remember that on the right side the superior intercostal usually comes off from this part of the artery, so that it is very undesirable to tie the second part of the right artery ; but if circumstances have rendered it inevitable he should try and include the branch also in the ligature. The greatest care should be taken not to wound the pleura, which lies close below. Ligature of the sul)clavian artery is a very formidable operation, about 45 per cent, of the cases operated on having proved fatal.^ Aneurism below the Axilla.-— Spontaneous aneurisms below the axilla are extremely rare, though they are not unknown even in arteries so small as those of the hand ; but I do not think it would answer any good purpose to speak in detail here of such rare cases. The main point to remember is, that spontaneous aneurism of these small vessels is verj- commonly associated with disease of the heart or general arterial degen- eration, and ought not to be too actively treated. Tiic arteries of the up|)er extremity are, however, usually tied for wound, either at the part wounded, or, in the case of wounds of the palm, at a higher spot. Lie Norri.s's Contributions to Sursrery. 2 B_v similar cmscs 1 mean cases in which the femoral artery was tied, as in those tabulated \>y Norris, without the previous use of compression. ' See two ca>es r( hUed by Tufnellon Aneurism, pp. 120-130; and see also a lecture in the Lancet, Dec. 12, 1874. 658 DISEASES OF THE ARTERIES. all the severer cases, and in those where the tnmor has already burst, hut where the surgeon does not think it necessary to amputate at once, the ligature is probably the safest course.' Genufie.rion. — Flexion is indicated in small aneurisms, situated on the posterior or lateral aspect of the artery, in which the pulsation and bruit are susj)ended by bending the knee. It need not be extreme nor painful, nor need tiie limb be bandaged or confined in any way, at least in many cases. Voluntary flexion, in which the patient is allowed to change the position of the limb slightly, will succeed in many cases, and will be tol- erated where forced flexion would produce pain and would be given up. Besides, forced flexion has been known to produce rupture of the sac, which voluntary flexion hardly could do. Flexion seems to act partly bj' retarding the blood-stream, partly by direct pressure and probable dis- placement of clot. It may easily be combined with digital or instrumental pressure. When pressure or flexion, either alone or in combination, are to suc- ceed, a perceptible amelioration of the symptoms is generally noticed at once, i. e., in the course of the first two or three days. If this is not the case it becomes a very important question how long the attempt should' be continued. Relying on the doctrine that if pressure failed to cure the aneurism it would produce, at any rate, some benefit by causing dilatation of the anastomosing vessels, and thus diminishing the risk of gangrene, and influenced also by the published statistics of ligature of the femoral artery — which, I think, I have shown to be more unfavorable than the re- sults of modern practice justify — many surgeons were in favor of persever- ing with pressure for a very considerable length of time, and it is not to be denied that in many cases a cure has been so obtained,'^ but at the expense of an amount of suffering to which few persons would willingly submit unless in order to avoid some very great danger. And, as it seems, it is very problematical whether the danger is not the other way. Certainly the mortality after ligature of tlie femoral artery appears not to be di- minislied, but, on the contrary, increased, by the previous unsuccessful trial of compression f and, on the whole, I have been led to the conclu- sion that if no considerable improvement has been effected by the blood- less methods in the first week, it is better to give up the attempt, allow the patient a few days to recover from the distress which the compression has general!}' caused, and then tie the artery. In making compression I have myself no doubt whatever of the supe- riority of the digital over all other forms of pressure, if carefully employed ; and I think the observation of Mr, Walker an important one, that the pressure should not be varied from the common to the superficial femoral and vice vernd^ but should be applied to the same vessel througliout ("the one-artery system," as he calls it), so that the same collaterals should al- ways be called upon. Ligature of Tibial Arteries. — Aneurism occurs below the popliteal space, but aluiost always from traumatic causes, or in cases of extensive disease of the heart and arteries. Traumatic aneurisms of small arteries 1 Cases of successful h'gature after the rupture of the tineurism may be found re- corded in the IJrit. Med. .Jour , 1809, p. 47!) (where tlie tmcurism had burst into the knee-joint) ; and one in the Lancet, 1851, vol. ii, p. 30, wlierc the aneurism (femoral) bad burst throui;li the skin. 2 See a remarUuble instance of resolute persistence on the ])art of the surgeon and of the i)atient for a space of half a year, after which a cure was at length obtained, recorded by Mr. Walker of I^iverpool. — Liverpool Hospital Reports, vol. v. 3 Lancet, May 1, 1875. LIGATURE OF TIBIAL ARTERIES. 559 are best treated as recent wounds ; and in the present day the nse of Esmarch's bandage enables the surgeon to exclude the blood completely from the tumor, while he dissects out the vessels and ties them as easily as on the dead subject. Aneurisms the result of cardiac or general arterial disease are best let alone or treated by the mildest forms of com- pression. They are usually not in themselves very dangerous, and the patient's life cannot in any case be a long one. For these reasons opera- tions on the tibial arteries, other than their direct ligature for wound, are amongst the rarest operations in surgery. In some very rare cases, how- ever, one of the tibial arteries has been wounded from the other side of the leg by a stab through the interosseous membrane, and then it has been necessary to cut down formally on the arterj' according to the rules of the dissecting-room. The posterior tibial can be secured near the ankle with facility, as it lies between the tendons of the tibialis posticus and flexor longus digitorum in its inner, and that of the flexor longus poUicis at its outer side. All that is necessary is to make an incision half-way between the internal malleolus and the heel and dissect the pai'ts. To secure the vessel higher up two different plans are adopted. Mr. Guthrie's has the advantage of enabling the surgeon to secure the peroneal artery, if his diagnosis should prove at fault and the wound or other lesion should implicate that vessel and not the tibial. A vertical incision is made in the centre of the calf about six inches long, through the gastrocnemius Fig. 251. Fig. 252. Fig. 251.— Ligature of posterior tibial artery. The posterior liook draws aside tlie deep mass of mus- cles and the intermuscular fascia. The vessels and posterior tibial nerve are seen lying on the tibialis posticus. Fig. 252.~Ligature of anterior tibial artery. The vessels are seen with the nerve lying in front and to the outer side. and soleus muscles, the deep or intermuscular fascia freely divided, and the vessel sought immediately beneath this fascia, superficial to the tibialis posticus muscle. The old method of tying the posterior tibial is to make an incision parallel to the posterior border of the tibia, and about a finger's breadth 560 DISEASES OF VEINS. behind it tlirongh the skin, superficial and deep fascia, exposing the tibial origin of the soleus muscle. This is then cut from the bone, the intermuscular fascia opened, the arter>' found, with a vein on either side of it, and the nerve probably superficial to it, separated from these struc- tures, and tied. Tlie anterior tibial artery will be found in any part of its course by an incision in a line drawn from the head of the fibula to the central point between the two malleoli. At the upper part of the leg it lies very deeply, at the outer edge of the tibialis anticus muscle, in a septum of the fascia, which shows as a white line, separating that muscle from the extensor long. dig. above and the ext. prop, pollicis in the middle of the leg. Success in this operation depends on hitting the edge of the tibialis anticus, for which pui'pose the surest way is to get the patient to put it into action before he is put under anaesthesia and mark it out, and to make the incision very freely, and carefully search for the white line before open- ing the fascia. The artery has venai comites on either side, and the nerve superficial to it. CHAPTER XXIX. DISEASES OF THE VEINS AND ABSOKBENTS. Phlebitis and Thrombosis. — The leading symptoms of phlebitis, or in- flammation of veins, is the occurrence of coagulation in them, as evidenced by hardness along the course of the vein. In true infiammation this is accompanied by pain and ledness, and some amount of general fever. The mere coagulation of the blood in the veins by no means implies any inflammation, or any general aflection of the system, or even any altera- tion in the tissues of tiie vein itself. Such passive coagulation of the blood in tlie veins used to lie denominated "adhesive phlebitis," on the theory that the cause of the coagulation was tlfusiou of lymph from the lining n)embrane of the vein ; but it has been satisfactorily shown, both by clinical and anatomical observation, that in many of these cases there is no evidence of any inflammation whatever; and the direct experiments of Guthrie, Travers, H. Lee, and Calleiider, in our own country, besides foreign observers, have shown that the lining memlirane of the veins does not secrete lymph. Consefpiently the condition known to the older pa- thologists as "adhesive phleltitis" is now usually designated more cor- rectly as "thrombosis." It proceeds from a variety of causes, — from pressure or obstruction to the return of blood, from diminished power of the circulation, from varicosity of the veins, from the extension into them of chits forming nearer the heart, and from conditions of the blood itself wliicii are not as yet perfectly understood. Thus, in the thrombo- sis wiiich occurs in the veins of the lower extremity alter parturition, and to which the name of " phlegmasia dolens" is applied, the coagula- tion which has necessarily taken place in the uterine sinuses extends down the iliac, femoral, and other veins. In fractures where a vein has PHLEBITIS. 561 been contused or torn the coagulation so produced often extends into the lower veins and impedes the union of the fracture/ And sometimes we see cases in which, with no definite local exciting cause (though commonly in some condition of general disease), the veins become blocked, often to a very great extent. The same passive coagulation or thrombosis occa- sionally, though rarely, happens in the pulmonar}' arteries, and is a rec- ognized cause of sudden death, ^ and there can be no doubt that similar passive coagulation of blood in the cavities of the heart occasionally pro- duces death. The first symptoms of thrombosis are a sense of uneasi- ness and an aching pain in the part affected, followed by some difficulty in moving the limb. On examination a hard cord is felt in the place of the vein aflTected, which is somewhat tender on being handled, and there is general swelling and oedema of the limb. The affected vein is some- times though not always surrounded by inflamed cellular tissue. If there is an opportunity of examining the vein it will be found filled with coagula, which are more or less adherent to its inner surface. The coagula are of a variable or mottled color, almost black in some places, in others nearly decolorized, and generally the decolorized parts are firmly connected to the lining membrane, while the central portion of the clot is, on the contrary, often broken down into a creamy fluid, looking like a mixture of blood and pus. In some cases, even when the obstruc- tion of veins is great, no constitutional disturbance can be traced. There is no feverish excitement, no change in the normal temperature or pulse, and the affection subsides spontaneously as it arose — the vessels regain- ing their natural appearance, and the functions of the limb being com- pletely restored. But this is not always the case. Whether along with or, as seems more probable, in consequence of the coagulation,^ the walls of the vein and the cellular tissue which support it become inflamed, and this inflammation is often accompanied with severe pain and with much constitutional disturbance, and the serious symptoms may ensue which are described as acute or suppurative phlebitis, and which are often de- veloped by severe injuries, such as amputation or excision, when the cav- ities of large veins have been laid open, and especially those veins which, being contained in bony canals, are incapable of closure, and thus of im- mediate union. The anatomical characters of phlebitis are perceived partly on the cel- lular tissue which supports the vein, partly in the coats of the vessel itself, and partly in its contents. The disease consists — in some measure at least — of diffuse inflammation spreading along the cellular membrane in which the vein lies. Hence the redness, hardness, and oedema which are seen during life in the course of the affected vessel. Although this inflammation most commonly extends in the course of the circulation, cases are not wanting in which it spreads towards the distal veins. In this inflammation the outer or cellular coat of the vein participates. Co- incidently with this the tissues of the vessel itself become altered. " The circular fibrous coat becomes injected and thickened by deposit ; the inner coat loses its natural transparencj-, and becomes wrinkled and even 1 See Callander, Med.-Chir. Trans., vol. li. 2 The reader will find a very interesting account of these cases of thrombosis in the superficial veins, the cerebral sinuses, the cavities of the heart, and the pulmo- nary arteries, in a paper On the Coagulation of the Blood in the Venous System during Life, by Dr. Humphry, republished in 1859 from the British Medical Journal. 3 " Coagulation of the blood in a vein," says Mr. Lee, " may be either a primary or secondary aifection : it may be either the cause or efi"ect of the inflammation of the coats of the vein." — Practical Pathology, 3d ed., vol. i, p. 24. 30 562 DISEASES OF VEINS. fissured. It is of a dull, opaque, dirty-white color, staiued more or less bj' the contents of the vein ; exudation often occurs between the inner and outer coats, and the different layers of the former then become dis- integrated, or the lining membrane may be cast oft" in large portions into the interior of the vessel. All the coats of the vein may, under these cir- cumstances, be easil}' detached from each other, or may be separated by serous, fibrinous, or puriform exudation. When these form under the lining membrane they may be seen as patches of various sizes and shapes through the transparent structure, so long as this retains its in- tegrity. Afterwards the}' may be poured, together with the fragments of the disintegrated membrane, into the cavity of the vessel. The in- flammatory exudation between the diff'erent coats of the A'ein destroys its natural pliabilit}', so that when divided it will remain open like an artery." (Lee, op. cit., p. 25.) So much for the anatomical changes in the vein itself. Along with this there are changes in the blood contained in it. We have seen that the blood may clot in the veins without any previous inflammatory symptoms or appearances, and sometimes without any sub- sequent bad consequences (thrombosis), but we have also seen that this obstruction of the vein may, on the other hand, prove the starting-point of inflammation of its tissue. Coagulation may also follow on injury to the vein, or on the passage into its cavity of any irritating or decompos- ing matter. In such cases the coagulation is to be regarded as salutary — a barrier thrown up against the passage of the products of inflammation or decomposition into the mass of the circulating blood. Should this barrier hold, the inflammation will be limited to the part first affected, the general symptoms which may have been excited will subside, and the patient recover. But the coagulum often breaks down and softens into a creamy puriform fluid, resembling sanious pus to the naked eye, but only showing under the microscope granular matter and disintegrated blood cells ; and when this matter passes into the general current of the blood it will spread the inflammation of the vein to an indefinite extent, and will produce the general symptoms and signs of septicfemia or pytemia. And, lastly, as clotting in a vein and the decomposition. of the clots some- times excites the general symptoms of pyaemia, so conversely the passage of putrid matter into the blood — septicaemia — often is the cause of clot- ting and of decomposition of clot in the remote veins. As Mr. Lee phrases it, "the decomposition, originating in a local action, may infect the general mass of the blood and rapidly kill the patient, without the occurrence of any blood-clotting; or coagula may form in the vessels, disintegrate and decompose, and become conveyed to other parts. In the last instance the phoiomena of thrombosis and afterwards of embo- lism become superadded to the original septicaemia" (op. cit., p. 58). Various Kinda of Phlebilis. — The kinds of thrombosis and phlebitis, ranked according to their causes, are enumerated by Paget as: (1) The traumatic, including those due to distension ; (2) those occurring in ex- haustion, during or after either acute or chronic diseases; (3) those due to extension of inflannnation, or of blood-clotting from nlcers, morbid growths, or gangrenous or acutely inflauied parts ; ' (4) those of the so- called idiopathic or rheumatic form ; (5) the pyiemial ; (6) the puerperal (among which it is probable that examples of all kinds, only modified by the puerperal state, are grouped) ; and (7) the gouty .'^ 1 Sec Fig. 181, p. 427. 2 Clin. Lect., p. 293. Sir J. Paget'.s cssny gives an interesting sketch of gouty phlebitis, distiiigiiiirnal carotid itself, in otliers from the enlarged arteries of the gland In such cases it has .sometimes been thought necessary to tie the com- mon carotid lint usually the bleeding may bi; stopped by firmly pressing a com- press of lint steeped in the jierchlrjride of iron on tiie bleeding spot for some time. If the ])atient is too nervous or distressed to tolerate this without auiesthesia, ether or chloroform may be administered ; and then the mouth being held open with a gag in ft good light, the bleeding spot will be well under command. RELAXED UVULA. 585 daiio-erons. But tlie enlarsfed tonsils are liable to constant attacks of sore throat and ulceration ; the.y spoil the Aoice ; sometimes they (or rather the inflamed and thickened condition of the mucous meml)rane around them) impede the hearing; they prevent sleep except with the mouth open ; and when extremely large in early life they may so obstruct the respiration as to produce a partial vacuum within the chest, and thus the pressure on the soft parietcs of the thorax may much alter the shape of the chest. Slighter cases may be left with confidence to constitutional treatment; as the health improves the enlargement will subside. But when the swell- ing is great the removal of the projecting part of the tonsil is urgently indicated, and affords the patient instant relief at the expense of only momentary inconvenience. When the enlarged tonsil projects fairly from this surface this little operation is most quickly performed with the French (or Charriere's) guillotine. This instrument terminates behind in a ring, into which the surgeon's thumb is inserted ; at either side is another ring for his fore and middle fingers. The instrument consists of three parts, — a base, or lowest stem, which ends in front in a ring, which is to be slipped over the tonsil; above this and travelling in it in a groove is another stem which ends in a ring, and the edge of this ring is sharp, so that as it is pushed forward it cuts ofif the part of the tonsil over which the instrument has been slipped ; and above this again, also travelling in a groove on the base of the instrument, is a stalk, ending in the thumb- ring behind and in a double hook in front, and so jointed on to the base that as it is pushed forwards it rises away from the stem. In using this guillotine the surgeon sees first that it travels freely ; then he draws all its parts well home, passes it into the mouth, where it serves as a spatula, gets the ring fairly round the tonsil, then by pushing his thumb forwards digs the double hook into the tonsil, and as he pushes his thumb on as far as it will go the double hook rising away from the stem draws the tonsil still further into the grasp of the ring, and the knife-blade shaves it off. The whole affair is momentary, and the pain very slight. But when the tonsil is flatter and more irregular in shape it is better to seize it with a vulsellum, and cut it off with a curved blunt-pointed bistoury', its blade guarded with lint to within half an inch of its end, directed from above, upwards and inwards. Children, and other nervous persons, who cannot be persuaded to open the mouth, may be narcotized, the mouth being kept open by Smith's gag (page 575). There is not much bleeding after the removal of the tonsil, unless the surgeon has been more anxious to remove the whole mass than is at all necessary. All that is really required is to cut the surface off freely. The swelling is produced by obstruction of the orifices of the gland-ducts, lead- ing to a retention of epithelial secretion within them, which dilates the follicles and gives rise to inflammatory exudation into the cellular tissue. When the follicles have been freely cut across all this will subside. Relaxed Uvula. — Relaxation of the uvula is an affection very trifling in itself, but it produces distressing symptoms, such as constant cough and frequent vomiting, which when the cause is overlooked often causes needless alarm for the patient. In many cases the relaxation is habitual, recurring on au}^ trifling cold or disturbance of health. Painting with an astringent lotion (as glycerate of tannin or nitrate of silver), with purges and tonics, is sufficient in such cases. When the elongation is consider- able and inveterate, the uvula should be taken hold of with clawed for- ceps and snipped oflf. 586 DISEASES OF THE MOUTH. " Alveolar ah^ce! Lancet, Nov, 26, Dec. 3, 1804. 2 Special apparatus are i^old lor the purpo.'^c, l)ut wlicn these are not at hand a per- fectly .serviceable one can be extemjK)rizc(l witli a common ewer and a siphon pro- vided with a tube. The addition ot' a stopcock near the nozzle is convenient ; but if there is none the patient can easily stop the stream when necessary by pressure with his thumb and finger. POLYPUS. 599 the crusts, and it can easily be increased or diminished in force by raising or lowering the receptacle, or by suddenly stopping and opening the tube. The detachment of the crusts is also much hicilitated by reversing the stream, the nozzle being changed from one nostril to the other. The lotions recommended liy Dr. Thudichum are — for mere ablution warm salt and water, which iritates the nose less than plain water ; for deodor- izing purposes Condy's solution diluted or carbolic acid lotion, 1 to 40; solutions of the alkaline phosphates (phosphate of soda, or phosphate of ammonia and soda) for dissolving the crusts and promoting their removal ; as astringents, alum, sulphate of copper or of zinc; and as alteratives and specifics nitrate of silver, bichloride of mercury, or a solution of chloride of calcium, with suboxide or oxide of mercury suspended in it, made by mixing the ordinary black or yellow wash with common salt. In obstinate cases these applications must be often varied. Blood Tumors. — Deviations of the septum have been spoken of above. The septum is also liable to the formation of blood tumors from injury, which affect both sides of the septum, and sometimes proceed to such an extent as to obstruct respiration and render an incision necessary. But this is rare. The affection is, it seems, usually accompanied by fracture of the septum. In most cases it will subside under the local application of cold. Abticess of the septum is sometimes the result of injury, but it occurs also spontaneously, and sometimes in a chronic form, going on to per- foration, which may produce a disagreeable whistling in speaking or deep breathing. The diagnosis of the complaint is sometimes a little ditHcult at first, the swelling being confounded either with polypus or chronic thickening of the Schneiderian membrane; but an attentive examination will show the difference in the seat of the swelling, and an exploratory puncture will clear up the case. Free and early incision is always desira- ble, and Mr. Durham sa^s that benefit may be derived by injection of a weak solution of nitrate of silver or of some detergent lotion into the nostril. If the septum is perforated by a small opening and the unpleas- ant whistling sound distresses the patient his conditiom may sometimes be relieved by making the opening larger. Enchoiidroma. — The septum is not unfrequently the seat of cartilag- inous tumors, which sometimes also spread to the other cartilages. Those I have seen have been of small size, and have grown into both nostrils, and it has been sufficient to remove such portions as could be got at from the nostril without any external incision. But larger tumors might require the free division of the nostril in order to allow of their complete extirpation. Nasal polypus is a very frequent, and in some of its forms (though these are fortunately the less common ones) a very formidable disease. The division generally made of nasal polypi, and that which best corre- sponds to what is seen in practice, is into three chief forms, — gelatinous or mucous, fibrous, and malignant. The first are by far the most common. They originate generally from the mucous membrane which covers one or other of the turbinated bones, more commonly, as I believe, from the middle, though opinions differ as to what is commonly their precise attachment; but all authorities agree that they rarely if ever spring from the septum or from the roof of the nose. They are often multiple. Their structure consists of a fine fibrous tissue covered externally by the mucous membrane with its ciliated epi- thelium, whilst at other times adenoid structure is found in them as 600 DISEASES OF THE NOSE. The common polypus of the nose. After Listen. tbougli from a hypertrophy of the glands of the part. The microscopic structure is generally of the myxomatous character (see p. 366). Other polypi ap- proach more to the character of fibrous or fibro-cellular tumors, and in some cysts are found developed. They produce well-de- fined symptoms by which the nature of the disease may often be suspected before phys- ical examination converts the suspicion into certainty. These symptoms are a mixture of catarrh and obstruction. Tlie patient seems to be constantly catching cold and sneezing, but besides this he notices that his breathing is obstructed, he cannot sleep but with his mouth open, his voice is aff'ected and acquires a nasal tone, he observes that he cannot breathe, or can hardl}' breathe thi'ough the nostril ; but the nose is scarcely ever deformed. The obstruction as well as the catarrh are noticed to in- crease in damp weather, when the tumor increases in bulk. The proper course to pursue is to remove the polypus, but it frequently presents again, either in consequence of renewed growth from the base or from there having been really several polypi, of which one or more have been left behind unperceived. The best security against this recur- rence is when the portion of bone from the covering of which the polypi grow has been designedly or accidentally removed along with them. Polypi ma}' be removed either with the snare or forceps. The snare is a loop of wire, the ends of which are passed into the tube of a double canula, either before or after the loop has been conveyed around the poly- pus and pushed up as near its base as possible. The canula has a handle at- tached to it, by means of which the wire is drawn through the base of the polypus gradually or rap- idly, as the surgeon thinks best. Some operators even use the galvanic ecraseur for this purpose, but, as far as I can see, without any sufficient cause. The main point is to get up to the root of the polypus, and I confess that it appears to rae that this end is better attained by means of the common force])S. If the nostril is wide the tumor may be gently diawn down with one pair of forceps, while another is pushed firmly up to its attachment and the mass twisted off. Then, after bleeding has somewhat ceased, or next da}', the nostril is to be carefully examined to see wiiether there are any others. The chief error made in tiie diagnosis of polypus is to confound the chronic thickening of the mucous mem- brane, which often occurs in strumous young persons, with polypus. Fig. 270. Hilton's na.sal polypus snare, a, ring for the surgeon's thumb ; h h, movable crosspiice, pushed backwards and forwards by the fore and middle lingers, .so as to advance and retire tlie loop ff, wliieli in practice is far larger than is here shown. The stem c is hollow for the ends of the wire to run in. They are wound round the crosspiece. e is a hinge-joint, by means of which the stalk (I which is in the nose can be placed at the requisite angle ■with the stem c. Its bulbous end,/, is perforated by two holes to convey the wire. The end of tlie wire is pushed round the polypus either with the fingers or a kind of fork. FIBROUS POLYPI. 601 When the end of the inferior turbinated bone is covered with this thick pulp.y mass it looks at first sight exactly like a polypus ; but careful ex- amination can hardly fail to detect the nature of the case, if the surgeon is alive to the possibility of the error, since there is in this case no stalked pendulous soft tumor, as in the other, and the neighboring mucous mem- brane will be found similarly', though perlmps less distinctly, affected. The success of astringents as applied for the cure of so-called polypus is, I suspect, more real in cases of this sort than in true polypoid growths. At the same time Mr. Bryant has spoken highly^ of the success some- times obtained by the insufflation of the powder of tannin (about ten grains blown into the nose with a tube) in some cases even of large polypi, though he owns that it is a very uncertain remedy. Cases have been known in which the deviation of the septum has been mistaken for polypus, but this is mere carelessness. Tumors of the sep- tum are distinguished from ordinary polypus by their position. Fibrous polypi are far more formidable tumors than the gelatinous. They spring generally from the roof of the nasal fossfe or from the base of the skull behind the posterior nares,-' and they grow into the nasal cavity, displacing the bones of the nose (causing the peculiar appearance called " frog's face ") or into the nose and pharynx at the same time (naso-pharyngeal polypus). These polypi are usually accompanied by considerable bleeding, and I have known this bleeding allowed to go on so long (in consequence of its cause having been overlooked) that it threatened at last to prove fatal. Yet the tumors are not themselves so vascular as to occasion any formidable luvmorrhage on removal, though they get congested and their depending surface bleeds freely on being- touched. Their continued growth causes various symi)toms due to pres- sure on the neighboring organs (deafness, epiphora, etc.), and they may even absorb the base of the skull and cause pressure on the brain. The extirpation, therefore, of the tumor is urgently indicated, and there are many ways in which this may be done. In some cases it may be possible to reach the base of the tumor either from the nostril (if this is much dilated) or under chloroform from the pharynx, the mouth being kept wide open by means of Smith's gag, and thus a wire can be convej^ed round the base of the tumor, which can be connected either with the gal- vanic or common ecraseur, or with the ordinary snare, and then the mass may be removed. In some cases it is perfectly easy to twist ofl' the tumor from the mouth with a pair of curved forceps. But such cases are the minority'. In most instances of fibrous polypus a way must be made by surgical operation through the tissues of the face to the base of the tumor, and this by one of three operations: (1), from below, through the hard and soil palate ; (2), from above, through the nose ; (3), from the front, through the upper jaw. The first method is known as Nelaton's. It is little practiced in this country and seems much inferior to the third in cases where the nostrils are not much dilated, and to the second in those where they are. The soft and hard palates having been divided with the knife, and as much of the palate processes of bone as may be necessary having been removed with the bone forceps, the tumor is to be exposed and removed, and the palate then sewn up. 1 Lancet, Feb. 1867. 2 1 ought to mention that these tumors, besides their primary attachment, are some- times implanted, as it were, into other parts of the nasal mucous membrane, where probably ulceration has occurred both on the surface of the polypus and of the Schnei- derian membrane, and the ulcerated surfaces have coalesced. 602 DISEASES OP THE NOSE. 2. When the nose is much dilated ample room may be obtained l\y an incision on one side of the middle line from the roof of the nose to the nostril. The nasal bone is to be divided in the course of the incision, the soft parts turned aside, and the tumor exposed. Then the wonnd is accnratoly adjusted by sutures, and unless any accidental complication interferes with union only a trifling mark will be left. 3. An incision is to be made along the lower margin of the orbit along the side of the nose, curving round the nostril to the middle line of the lip. and so to its free edge, and the cheek turned outwards. Then the hard i)alate is to l)e sawn through, and next the zygoma, and then the saw or bone nippers must be carried through the nasal process below the orbit, and in this way the whole of the alveolar portion and body of the jaw are removed, when the operator will have free access to the base of the skull. After the tumor has been taken awa}' the bone from which it grows is to be freel}' rasped, and the actual or potential cauter}^ applied to the place of implantation. Again, the whole upper jaw may be removed, or Langenbeck's method adopted, by which tlie soft parts are incised down to the bone externally and internally, as in the old method of removing the jaw ; then the attachments of the bone are sawn through in the same lines, the palatal Fig. 271. A fibrous nasn-pharyngeal polypus, whicli had long caused epistaxis, so that the patient .was ex- hausted by daily loss of blood. It was removed from the base of the skull by partial resection of the upper jaw. The portion of lione removed is figured with the tumor, and is seen to comprise the whole of the u])per jaw, with the exception of its orbital jjortion. The tumor consists of two parts— rt, that which projoelcd into the nostril, and, c, that which hung down into the pharynx. Between these is a constricted pari, 6, where the mass was implanted into the base of the skull just behind the posterior nares. On microscopical examination it consisted almost entirely of fibrous tissue with some cellular elements. The patient remained well for some years, but gradually the bleeding recurred, and tlie tumor was found to be growing again. It was again removed eight years after the original operation, and was found to have the same structure. The patient again rapidly recovered his health. — See Clin. Soc. Trans., vol. vii. attachments divided, and tiie jaw with its coverings turned up over the eye, and after the removal of tiie tumor brought down again and fixed in its place by deep sutures ; the soft palate is left undivided. DISEASES OF THE TONGUE. 603 Malignant Polypus. — Sometimes cancer grows in the form of a poly- pus from tlie mucous membrane of tlie nose.^ Sucli tumors are usually of very rapid growth ; tliey speedily dilate the side of the nose, and cause much haemorrhage. They rapidly fuugate out of the nostril, and are very apt to infiltrate the skin of the face. The patient is usually somewhat advanced in years, and the general health is much impaired. The diagnosis is not difficult, from the rapid growtli of the tumor, the change of shape in the features, and the great cachexia which is com- monly found. The removal of the tumor is urgently indicated, for which purpose any of the plans previously proposed in the case of naso-pharyngeal polypus may be selected, according to the presumed attachments of the tumor, which, however, it is by no means easy to ascertain. Careful examination should be made both anteriorly and from the posterior nares with the finger, and if possible by rhinoscopy, before such an oper- ation is attempted ; and the surgeon ought to have the actual cautery and all other necessary haemostatics ready, in case he finds the tumor implanted by a broad base of vascular tissue. After all, a speedy recur- rence is to be feared. CHAPTEE XXXI. SUEGICAL DI8EASES OF THE DIGESTIVE TRACT. DISEASES OF THE TONGUE. Tongue-tie is a tolerably common deformity, which, in its higher de- gree, will prevent the cliild from sucking, and may hereafter interfere to some extent with articulation ; though this is more spoken of than really proved. However, if the deformity be at all pronounced, it is well to perform the little operation which will release the tongue and restore its motion. If performed carefully this slight incision is free from danger of any kind. All that is necessary is to avoid dividing the ranine artery as it passes along the fri^num linguae. The tongue is pushed up and the artery siiielded from harm either by the surgeon's fingers or by a slit in the flat end of the director, which used always to be made in this shape for the purpose. The incision or little nick need only extend through the semi-transparent edge of the constricting tissue, and then the tongue can be forcibly pressed upwards to the roof of the mouth, by which ma- noeuvre the rest of it will be torn. I have performed this little operation a very great number of times — chiefly for the satisfaction of the parent — ' I hMd lately under treatment a case in which the tumor was of the mehinotic variety (spindlu-celled sarcoma, with black pigment in the cells). It grew from the outer side of the nasal cavity, and was easily removed by laying open the nostril. The patient, a man of advanced age, recovered from the operation, but died from some aftection of old age not long afterwards. Similar melanotic deposits were found on the lining membrane of the antrum. 604 DISEASES OF THE TONGUE. thoiigb in onl}' a small proportion of thera could I persuade myself that it was really indispensable. I have, however, seen cases in which the child undoubtedly could not take the breast till the tongue was released. Ulceration. — The forms of ulceration to which the tongue is liable are the irritable, the dyspeptic, the syphilitic, and the cancerous. The fol- lowing are the rules for their diagnosis and treatment, abbreviated from one of the excellent clinical lectures of Mr. Cresar Hawkins:' 1. Irrita- ble ulcers are excited by the irritation of rough teeth ; they also affect the lips; they are very painful, and afford considerable impediment to eating; are apt to become phagedenic, and are accompanied often by a gooddeal of indigestion. The haggard aspect of the patient produced by pain and loss of food may cause them to be mistaken for cancer; but they are generally multiple, while cancer is single, and they lack any evidence of solid deposit around the ulcers. The treatment consists in extracting or filing down the offending teeth, correcting the state of the digestive organs (by a mei'curial pill, followed by a brisk purge, alkaline tonics and laudanum, etc.), and attending to the local condition of the ulcers by cleaning their surface with a poultice, and when clean touching them with nitrate of silver, either solid or in solution, which often relieves the pain considerably. 2. Closely allied to these, but still more nearly resembling cancer, is the dyiipeptic ulcer of the tongue, which arises without any local irrita- tion, often as the result of psoriasis. This ulcer is usually situated at the middle of the tongue, which is an unusual situation for cancer ; it is often accompanied by similar cracks and fissures in other parts, which have not gone so far as to form a definite ulcer; there is no hard deposit beneath the base of the ulcer, and there are signs of disturbance of the digestive organs. The diagnosis from syphilitic ulcer must be made chiefly by the absence of the history and signs of syphilis. The treatment is very much the same as in the irritable form, and of the tonics which become necessary in the treatment after the unhealthy state of the mucous membrane is corrected Mr. Hawkins especially praises arsenic. 3. The si/jihilitic ulcer when in its worst state forms a large excavation, with foul raised edges and sloughy surface on the back or sides of the tongue, which greatly resembles cancer. The diagnosis, indeed, cannot in all cases be confidently made without testing the efficacy of treatment, in persons who have had primary and secondary syphilis. At the same time there is in syphilis an absence of the characteristic induration of the cancerous ulcer, and a presence in most cases of other syphilitic symp- toms, which enables the surgeon to come to a correct opinion. The glands may be enlarged in either, but are more frequently so in the can- cerous ulcer, since the syphilitic is usually a tertiary symptom, and in S} philitic ulcers if any glands are enlarged in the neck they are not usually the sui)maxillar3', which are in direct connection with the ulcer, but tlie posterior chain of cervical glands beneath the trapezius. In doubtful cases the effect of a mercurial course will in all probability settle the matter. Mercury, however, siiould not in these late cases of syphilis be given eitiier rapidly or in large (luautities. The calomel fumigation is, I doubt not, by far the best form, and is very easily managed by adapting a mouthpiece to the vaporizing machine and inhaling the vapor. Five grains of calomel every night is the quantity usually prescribed, or ^ Contributions to riitli. aiul Surg., vol. i, p. '214. OPERATIONS ON THE TONGUE. 605 the ulcer may be dusted with gray powder (gr. v) daily. In some cases sarsaparilla and iodide of potassium may be given when the surgeon dares not risk the debilitating effect of mercury, which, however, is very trifling in the method of fumigation. 4. The cancerous ulcer appears on the side of the tongue, generally at first as a small common ulcer, which is attributed to the irritation of a bad tooth ; but the removal of this does not stop the disease (though I think there can be no doubt that if the irritation of a bad tooth had not originated the cancer it is at any rate powerful in determining its out- break at that precise spot), and soon a deposit of hard tissue is apparent at the base of the ulcer, which spreads an indefinite distance into the sub- stance of the tongue, with much pain, salivation, difficulty in articulation, loss of appetite from the foulness of the discharge, and consequent ca- chexia. The glands below the jaw are apt to be affected early, and the sore will spread to the floor of the mouth or arches of the palate. The diagnosis will follow from what has been said above on the other forms of ulcer. Though it may be often difficult or impossible at first, it becomes only too easy as the disease progresses. Trfa(me7it.. — In doubtful cases the treatment consists in removing all irritating teeth (which, indeed, ought to be done in all ulcerations, whether cancerous or not), and treating the disease as either dyspeptic or s^'philitic, as the case ma_Y be. If the cancerous nature of the affection admits of no doubt, the only question is whether a surgical operation is to be recommended, and if so, of what nature. If the glands or the floor of the moutli or the palate be implicated, surgical operations should be declined.^ But if the whole disease can be clearly removed the patient will Fig. 272. Mr. Henry Lee's clamp. The curved shape of the blades causes this clamp to make uniform pressure on all the tissue which it embraces. no doubt derive much temporary benefit from the operation, though the disease will in all probability return in no long time. When on\y a small portion of the tongue requires removal this is best effected by means of the knife or scissors. A clamp with curved blades being fixed around the part to be removed so as to control the vessels, 1 Perhaps, if the pain and distress is great, and the affection seems merely epithe- lial, a surgeon may be justified in risking an operation, even though there be a small hard gland under the jaw ; but the general rule is as above. 606 DISEASES OF THE TONGUE. tlie portion affected with cancer is to lie completely cut awa3^ The blood- less condition of the parts cut through enables the surgeon to judge much more certainl}' whether those parts are healthy or not. When he is satis- fied that all is as it should be the arteries are to be tied and the clamp cautiously relaxed. Some surgeons either instead of, or in addition to, the use of the ligature to the large vessels, use the actual cautery to the cut surface ; but tliis is oiijectionable if it can be avoided, on account of the sloughing and fetor which ensues. Bemoval of Pai't of the, Tongue. — When larger portions of the tongue are to be removed, either the ordinary ecraseur or the galvanic ecraseur^ Fig. 273. Ecraseur. are preferable, as affording more security against secondary haemorrhage, provided the chain is drawn through the tissues very slowly. Haemor- rhage during or after the use of the ecraseur depends generally on hurry on the surgeon's part. In all operations on the tongue the surgeon should alwa3's have a com- mand on the part left behind by means of a stout ligature passed through it, tied loosely, and held by an assistant, so that on the occurrence of acute htemorrhage the tongue can be at once pulled out and the bleeding part exposed ; and the mouth must, of course, be kept open b}^ a gag, the smaller and stronger the better. Hutchinson's gag, here figured, is rec- ommended by Mr. Heath, and is a very convenient one as taking up no room in the mouth. Removal of the Whole Tongue. — When the whole or the greater part of the tongue is to be removed it becomes necessary by some preliminary operation to obtain access to the root of the organ, and this is done in one of three ways: 1. A small incision may be made close inside the lower jaw from the mouth to the skin, through which the chain of the Ecraseur can be passed ; and the tongue being then pulled forcibly out of the mouth, the chain is passed around the base of the organ as near the epi- glottis as practicable, and so the whole organ is removed except a stump, which is left at- tached to the hyoid bone. 2. Sir J. Paget recommends that, in order to render it easier to drag the tongue out, all the muscles which Hutchinson's gag. pass from the jaw to the hyoid bone should be Fig. 274. ' Tlio giilviinic ecraseur i.s a stout wire chain attacliod to the polos of a galvanic hattery. The tissues to be removed are taken uji ))y means of curved needles; the wire is then conv(!yed around th(im beneath the needles, drawn tight, and connected with the battery, when it turns white hot. As it burns its way into the ti.ssues it is slowly wound u[) h)y a contrivance insid<' tiie machine, and so gradually cuts its way out. In practice it is well to have the battery managed by an electrical mechanician. OPERATIONS ON THE TONGUE. 607 divided on botli sides as near tlie jaw as possible by an incision inside tlie month. When this has been done tlie tongue can l)e drawn almost entirely out of the month and removed either with the knife or ecraseur. 3. But the method which oives the freest access to the root of the tongue is, doubtless, the division of the symphysis of the lower jaw. An incision is made in the middle line through the whole lower lip and drawn nearly down to the hyoid bone. Then the jaw is sawn through and the lingual muscles cut away from it close to the bone on either side. The halves of the jaw being held asunder, the tongue is forcibly pulled forward and to one side by means of a vulsellum, and its attachments to the hyoid bone severed on the opposite side, in doing which the lingual artery is cut across, and must be tied at once. The same manoeuvre is repeated on the opposite side, in doing which it is desirable to get an assistant to hold the parts around the hyoid bone with a pair of strong claw forceps, in order to prevent the tissues which contain the severed end of the lingual artery from retracting down the neck. Then the second lingual artery and any other bleeding vessels having been tied, the glosso-epiglottic ligaments and the remaining attachments of the tongue are to be severed, and all bleeding vessels commanded. Then the severed halves of the jawbone must be united by means of a silver wire passed through them with a drill, the wound of the lip accurately closed with the harelip suture, and the patient kept under the influence of morphia for some time, and fed if necessary by the rectum. The operation is a severe and a very dan- gerous one, followed by great distress of mind and body, and often fatal by its ulterior consequences, even apart from its operative risks, which are nevertheless considerable. There can be no doubt, however, that it has often prolonged life, and rendered its remaining time more bearable to the patient, and therefore, under appropriate circnmstances and at the request of the patient, this chance of relief ought not to be refused to him. At the same time I think it is one of the most unpromising of all the operations of surgery, and one which no surgeon undertakes without repugnance. It is curious that even after the removal of the whole tongue, as close as possible to its root, the patient is not quite deprived of the power of speech, though the voice is reduced to a hoarse whisper. In some cases, in which the pain is great or in which the growth of the cancer is rapid, or where it bleeds profusely, the gustatory nerve has been divided, to relieve the pain ; or the lingual artery has been tied, to check growth or to stop hiemorrhage. The division of the nerve i$ a very simple operation, which can do no harm, and the effect of which ought to be tried in any case in which pain is a prominent feature, or the patient suffers much from profuse salivation. " The guide to the nerve," says Mr. Moore,' " is the last molar tooth. A line drawn inside the mouth from the crown of the last molar tooth to the angle of the jaw would cross it at right angles about half an inch from the tooth. An incision, there- fore, in the direction of such a line three-quarters of an inch in length, and carried through the mucous membrane to the inner surface of the bone, must divide the nerve.'' The nerve, as Mr. Moore mentions, is shielded by the alveolar ridge, so that it is necessary to take care that all the soft parts are absolutely severed down to the bone. The opera- tion can be easil^^ and safely performed on both sides, and may afford a good deal of relief for the time. The ligature of the lingual artery is a much more difficult operation, 1 Mcd.-Chir. Trans., vol. xlv. 608 DISEASES OF THE TONGUE. and one liable to be followed by various grave consequences. It will be found described on page 543. I have only had occasion to perform it once — the only time I ever saw it tried — on a patient rapidly sinking under ha^moi'rhage, and then it quite failed in checking the bleeding. Syphilitic Affections. — Syphilitic ulceration has been spoken of above in connection with the other forms of ulceration which are met with in the tongue. But there are various other sj'philitic affections of tliis organ. Mr. Fairlie Clark^ divides the syphilitic affections of the tongue into four classes. 1. Mucous tubercles or vegetations. 2. Superficial ulcera- tion. 3. Gnmmatous tumors and deep ulcerations. 4. Morbid condi- tions of the mucous membrane. 1. Mucous Tubercle. — The first, the raucous tubercle, is an early secondary symptom which affects both tlie papilhie and epithelium, tiie tubercles in which the epithelium is chiefly implicated being broad, flat, and whitisli ; the others small prominent, and florid. Tliey have much resemblance to the mucous tubercles so often seen on other parts, and are distinguished from the papillary elevations of cancer by the absence of any hardening at the base. 2. Secondary Ulcers. — The superficial ulceration is also usually a secondary affection. It spreads from similar ulcerations on the sides of the mouth and cheeks, forming superficial and very painful fissures, which in their healing leave milk-white scars; and if these are very numerous and the epithelium gets overgrown around tliem the condition named ichthyosis is present. In other cases the superficial cracks spread out in large circular or oval sores. 3. Gummafa. — The gummatous tumors which form in the tongue are seen either at the edge, or more frequently close to the septum of the tongue ; and when they soften they leave the deep tertiar}' ulcer, or some- times deep fissures which may implicate and distort the whole organ. In other cases they become absorbed, and then may be followed by some distortion of tlie organ from loss of substance. 4. Syphilitic Glossitis. — The syphilitic affections of the mucous mem- brane generally resemble psoriasis, consisting of a heaping up of epithelium of a dead-white color over a limited area; in other cases the whole of the dorsum may l)e attacked witli superficial inflammation (syphilitic glossitis), but tliis is often the result, not of syphilis only, but also partly of the abuse of mercury, and according to Mr. Clarke iodide of potassium, when it does not agree with the 2)atient, may produce a similar affection. It is rare for any of these syphilitic ulcerations to be accompanied by an}' glandular affection, belonging as they do to tiie later stages of secondary or to the tertiary period. Cases of indurated chancre of the tongue witli enlarged glands are said to be met with, but I have not seen any such case. The treatment of these affections has been alread}' suflficiently indicated. Glossitis. — Acute inflammatory swelling of the tongue (acute glossitis) is l)y no means a common affection. It occurs from wounds, from mer- curial or iodine poisoning, and from unknown causes. Tlie swelling is sometimes so great as to threaten suflocation from backward pressure on the larynx, and in such cases the tongue should be freely and deeply'' scarified, in doing which it is useful to remember Mr. Holmes Coote's ' DU. of llie Tongue, ch. viii. DISEASES OF THE PHARYNX. 609 caution, viz., that tlie swelling is sometimes i-eallv more in the lower than the upper portion of the tongue, and that the lingual arteries have there- by been pushed up so that they may even appear on the dorsal surface of the organ. A little preliminar}^ examination before the incisions are made will point out where they can be placed with safety. At the same time astringent gargles (alum, tannin, or iron) and warm fomentations should be assiduously used, and the patient's strength supported as may be necessary. Most cases, however, which we see are not so severe as this, and require no incisions. In other respects the)^ are to be treated in the same way. Abscess. — Inflammation of the tongue may end in deepseated abscess, an affection which has before now been mistaken for cancer and the tongue removed. Abscess forms a deepseated, round, elastic tumor, situated in the thickness of the tongue. The shape a-nd feeling of the tumor, the history of the case, and the resemblance to those chronic ab- scesses with which the surgeon is familiar in the female breast, ought at any rate to awaken suspicion, when an exploratory puncture will clear up the diagnosis, and a small incision will form all the treatment required. Macroglossia. — A few other and much rarer diseases of the tongue re- quire little beyond mention. There are: 1. The congenital hypertrophy to which the name " macroglossia " is sometimes applied, in which the tongue becomes so large that the child cannot close his jaws or talk in- telligibly, and which requires the removal of the central part of the tongue by amputation and the formation of side-flaps which are to be brought together to form a more convenient organ, an operation usually attended with great success.^ Congenital Tumor. — Another congenital afiection of the tongue is a fibroid tumor which sometimes grows from the tongue, and which may be quiescent at first and then increase at a later period of life and require removal.^ Nsevi also are found, but very rarelj', on the tongue. They ma}^ be treated by electrolysis, the actual cautery, or some of the potential cau- teries, or even by excision, or the ligature, should that be necessary, which, however, is seldom the case, since these ntevi more commonly prove quite innocuous. Ichthyosis of the epidermis on the dorsum linguae is spoken of by Mr. Fairlie Clarke," and a model of this affection exists in the Museum of the Royal College of Surgeons. Finally, there are sometimes found imbedded in the substance of the tongue fibrous or other innocent tumors, which may in some cases require removal. DISEASES OF THE PHARYNX AND OESOPHAGUS. The aff"ections of the pharynx need not detain us long. Acute inflam- mation is constant in sore throat of all kinds, in inflammation propagated from the spine, and in erysipelatous affections spreading inwards. But in all these cases the condition of the pharynx itself is of minor impor- tance. The two former classes of cases have been spoken of along with the affections of the mouth and of the spine. The main importance of > The leading cases of this disease will be found reported by Dr. Humphry, Mr. Hodgson, and Mr. Teale, in the 36th vol of the Med.-Chir. Trans. 2 See Mason, Path. Soc. Trans., vol. xv, p. 216. •'' Diseases of the Tongue, p. 97. 39 610 DISEASES OF THE (ESOPHAGUS. the erysipelatous aftections, besides the ordinary dangers of erysipelas, consists in the risk of spasm of the glottis, which is peculiarly liable to complicate these cases, and which will be treated of in the chapter on Diseases of the Larynx. Tumor!< sometimes arise in the pharynx, as in the remarkable instance which Mr. Holt has recorded,^ in a man eighty years of age. Here a large pendulous fatt}^ tumor springing from the wall of the pharynx extended nine inches down the oesophagus. It had been growing certainly more than twelve years, and occasionally caused s^'mptoms of suffocation. At last, under some circumstances not fully explained, it suddenly obstructed the upper opening of the larynx and at once caused death. In cases such as this, where a tumor of the pharj'ux is pedunculated, there is no doubt that it should be removed. The patient should be brought fully under antesthesia, the mouth widely opened by a gag, the tumor drawn fairly into reach by a vulsellum ; then, if the neck is at all broad, or if there is any reason to apprehend haemorrhage from its division, it should be per- forated b}" a stout double ligature and firmly tied. Or else the tumor should be simply removed, tlie actual or potential cautery being at hand for use if necessary', and the surgeon should be prepared for the necessity of laryngotomy. 3Ia {formations of the pharynx and oesophagus are not common. There are cases in which the pharynx is congenitally obstructed, and in which it opens into the larynx ; but they are only of scientific interest, as the infant is not viable. More interesting in the surgical point of view is the pouched condition of the phar3'nx or oesophagus '^ which is sometimes found, probabl}' either as a congenital defect or as the result of some atrophy and yielding of its muscular walls. A large pouch extends some distance down the tube, and the continuation of the oesophagus appears as an opening some distance above the bottom of the pouch. The result is that the food collects in the pouch, and is often rejected afterwards, producing a suspicion of stricture. On passing a bougie it is liable to be arrested in the pouch instead of finding its way down the oesophagus. The case from which Mr. Pollock's drawing is taken was believed during life to be one of stricture, nor is the diagnosis, easy ; but the patient will probably be able sometimes to swallow, the surgeon may happen some- times to hit the natural opening, and the symptoms will probably not be so urgent as in stricture, so that a conjecture as to the nature of the case may perhaps be formed. No treatment is applicable — the course of the disease will to an attefitive surgeon contraindicate the use of bougies, which, indeed, after the first exploration can only do harm. Stricture of the oesophagus is one of the most terrible diseases which afflict humanity. It occurs " as the result of several distinct conditions : folds of the mucous membrane; cicatrices after injury; pressure occa- sioned b}' neighboring tumors ; thickening and contraction of its walls; or lastly, and most frequently, cancerous affections of the tube " (Pollock). Little can be hoped from surgical treatment in these cases. It is, there- fore, of very great importance to distinguish between organic stricture or obstruction from tlie causes above enumerated and the somewhat common affection called hysterical strictui'e of the oesophagus, or nervous dyspha- gia, which simulates the graver malad}'. ' Path. Soc. Trans , vol. v, p. 123. ' A beautiful illu-tration of this pouchod condition will be found in Mr. Pollock's essay in Syst. of Surg., 2d. ed., vol. iv, p. 487. NERVOUS DYSPHAGIA. 611 NervoKs dj/spharpa is more common in women than in men ; it often is conjoined with symptoms clearly h^^sterical ; the patient, in spite of alleged long-continned inability to swallow, is in good health and general condition ; the dysphagia is not constant ; frequently he feels less diffi- culty in taking solids than fluids, and sometimes the jjatient can be proved to be able to swallow quite well when no one is looking.' Such cases, like cases of nervous disease in other organs, require judicious manage- ment more than medical or surgical treatment. The symptoms produced by stricture of the oesophagus may be summed np in two words, — dysphagia and emaciation. The patient is at first able to take small quantities of solid food when well chewed and lubricated, then he is gradually conscious of increasing difficulty, and sometimes the oesophagus rejects the food which it cannot drive down ; then he is re- stricted to fluids, and soon he sinks from exhaustion, if not cut off by some of the local consequences of ulceration about the stricture. It is by no means easy to distinguish the various forms of stricture from each other. Those which proceed from cicatrization will be known by their history, if the accident which caused them is remembered, but this may not be the case. The malignant will differ from the innocent stricture by occurring generally later in life, by the implication of the glands of the neck, b}^ the more rapid cachexia, and by the tendency to implication of the larj'nx and neighboring organs. Obstruction from a tumor is generally caused by aneurism of the aorta (at least when caused by a tumor of any other nature the cause is usually obvious), and it there- fore occurs always at the part where the aorta is in contact with the oesophagus, so that the difficulty is referred to the upper part of the chest. In such cases very careful examination is necessary before the diagnosis is made, and above all before a bougie is passed. Cases are known in which the instrument has perforated the aneurism and produced instan- taneous death. Careful auscultation and percussion of the chest, and the examination of the pulse in both wrists by the sphygmograph, if availa- ble, are indispensable ; and it should be ascertained whether any of the other symptoms of aneurism are present — the ringing cough, the pain in the back, the so-called rheumatic pains about the neck, etc. The innocent forms of stricture are fatal only by starvation; but malignant disease very commonly produces death by spreading into the larynx^ or into one of the great vessels. It is justifiable and indeed necessary in the first instance to pass a bougie, except in advanced stages of cancer, in winch case no mechanical interference is justifiable, since the bougie has often passed through the softened tissue of the cancer into the pleura, pericardium, or great vessels. When the seat of the obstruction has been ascertained the next question is, whether the stricture can be treated. If it is clearly cicatricial, the cica- trix might be divided by either external or internal incision, certainly not without very great danger ; but, under circumstances such as these, danger would justifiably be incurred. The objection would be the great difficulty of maintaining the opening. I do not know that the attempt 1 Sir J. Paget in his interesting little essay on Stammering with other Organs than those of Speech (Clin. Lectures, p. 82), has pointed out that the difficulty of swallow- ing may in many of these cases be analogous t<> that in stammering, viz., an inability from mental causes to co-ordinate the various muscular actions which are necessary to deglutition. If the patient knows he is being watched, or directs his mind too anxiously to what he has to do, he cannot swallow, whilst if he is easy and uncon- cerned he feels no difficulty. In some cases the patient also stammers in speaking. * Or it may be itself an extension from the larynx, though this seems less common. 612 DISEASES OF THE INTESTINES. has ever been made. Billroth has attempted the extirpation of a can- cerous deposit in the oesophagus, but the operation is not usuall}^ re- garded as justifiable. I have alluded to the possibility, in cases of stricture not obviously malignant, of preserving life by gastrotomy (page 239) ; and though the attempt has hitherto failed, it is worth making. Failing these means, the only thing that can be done is to keep the passage open by means of bougies ; and in spite of the known and ad- mitted dangers of the treatment, I cannot but think that it is the best course for the patient, unless the cancerous symptoms are so urgent as to deter the surgeon from fear of rupturing the oesophagus. If the bougie can be passed the patient will be able to swallow, and so will be kept free from the tei-rible pangs of starvation for a time. If nothing else can be done, the prospects connected with the operation of opening the stomach should be explained to him, and at his request the operation should be undertaken. Fi6. 275. AFFECTIONS OF THE INTESTINAL TUBE. Internal Strangulation. — The strangulation of a portion of the intestines inside the abdomen is an even graver evil than its strangulation in a hernial sac, since though it is not so rapidly fatal (perhaps because usu- ally' not so acute), it is much less susceptible of relief. The causes are vQvy numerous, and by no means easy to diagnose. A common one is the formation of adhesions from previous peritonitis. Such adhesions sometimes unite with an appendix epiploica or the edge of the mesentery to form a ring passing round one of the coils of bowel, and the contrac- tion of the material which forms this ring, or the accidental enlargement of the contents of the bowel, seems to cause the constriction. At other times the constricting agent is formed by a mere band passing from one coil of intestine to another, and pressing the bowel against the wall of the bell}' behind ; or the bowel may be bent or twisted on itself (volvulus), and thus the passage of fueces through it may be stopped ; or the pres- sure of tumors in its neighbor- hood, or stricture of its walls may produce the same result ; or, fin- ally, a portion of bowel may slip into the tube below, just as the finger of a glove maj^' be shortened by slipping one part of it over the other — intussusception — a con- dition which sometimes producses strangulation, but not always. In- tussusception must be spoken of by itself. The other conditions are indistinguishable from each other unless the cause which pro- duces them is within the reach of the hand. The great point is to distinguish, if possible, the part of the bowel affected, in order to determine whether a surgical oper- ation for its relief is feasible. Tiie main diagnostic symptoms are these : Strangulation produces at first constipation, then vomit- Internal strangulation of a eoil of intcstin(> l)y a band of peritoneal adhesion, which passes on to the surface and mesentery of a neighlioriiif; coil of gut. The band has been displaced from the groove which it has worked upon the strangulated bowel, in order to show the extent to whicii the latter is constricted. — St. George's Hospital Museum, Ser. i.\, No. 15.3. IMPACTION OF F^CES. 613 ing, which afterwards becomes fecal. The liigher the obstruction is situ- ated in the intestine the sooner will the vomiting commence; but if the obstruction is high up it will not rapidly become ftecal. The amount of nourishment which the patient has taken will, however, influence this to some degree. Usually he is both unwilling and unable to take any- thing ; but if the diet has not been restricted so that the stomach and upper part of the bowel are filled, vomiting will probably (;omraence earlier than would have been the case under more judicious treatment. All the symptoms are more acute when the obstruction is high up. When, on the contrary, it is seated in the large intestine or close to the end of the small, the belly will sometimes continue to swell gradually' without any vomiting for several weeks, and the i)atient sutlers little except the loss of appetite consequent on repletion and constipation. Another most important diagnostic sign is the quantity of water which can be injected into the bowel. If the obstacle is situated at the sigmoid flexure of the colon it is rarely possible even with the utmost gentleness to inject more than about a pint and a half before it is expelled, and usually with some force. The higher up the obstacle is situated the larger is the quantity which will pass in ; and if the small intestine is the part affected, a very large quantity of fluid may be passed up, especially if the patient is under chloroform, and will at first run out quite gently until the bowel is roused to expulsive action. Palpation of the abdomen is of course useful, and it is said that auscultation while the fluid is being injected ma}^ sometimes give valuable information of the position of the obstacle, but I have never been able to realize this. Imjjaction of Faeces. — During the constipation much may be done to alleviate the patient's sufferings. The first question is, whether the con- stipation depends on a real organic obstacle or merely on impaction of faeces, which will produce the same symptoms if long neglected. Such masses of impacted faeces are comparatively often mistaken for tumors. The distinction is made b}' observing that though there may be a good deal of swelling around the bowel, the substance is to some extent soft and will take the impression of the fingers; that its size has been known to vary with the state of the bowels ; and that there is the history of neglected constipation. If the mass is situated within reach of the anus it should be broken down with a scoop, otherwise free purgation and injections should be employed. Treatment of Obstruction. — But when an invincible obstacle has been pi'oved to exist, the first rule of practice is to abstain from irritating the bowels with purgatives, to give nourishment in the fluid form only, and in the smallest possible quantities at a time, and to soothe the patient's sufferings with opium, subduing thirst with small pieces of ice kept in the mouth. As to surgical operations they are directed either to relieve the strangulation or to give an artificial exit to the faeces above it. The former can only be used in cases of strangulation by adhesions. It was successfully' carried out by Mr. Br^'ant,^ in a case in which thei'e was a hernial sac, but no strangulation, and where the band was reached by carrying the incision which had been made into the sac a little upwards. Mr. Bryant thinks that such bands are more common when there has been hernia, so that the existence of a hernia may encourage the surgeon to attempi the operation. In the only case where I have mj-self operated I found a band crossing the lower part of the ileum (a very common situation), and divided it, but the operation had been put ott' too long, 1 See Bryant, Med. -Chir. Trans., 1867. 614 DISEASES OF THE INTESTINES. and the bowel gave wa}' on the division of tlie band, having been pre- A'iously ahnost perforated by the constriction. Goiotomy may be practiced on either side when the seat of obstruction is dearly localized in the large intestine. Jt is more commonl}- practiced on the left side (descending colon) in obstruction and other affections of the rectum, and is more promising than on the other side, partly because the descending colon is less often provided with a mesentery than the ascending, but chiefly because affections of the rectum exhaust the patient less, and are. more easily diagnosed, and therefore more promptly treated, than those situated higher up. When the obstruction is complete, and the flank is distended by the swollen intestine, the operation is an easy one ; but when performed for the relief of cancer or other aflfections which do not produce coniplete obstruction, and the gut happens to be collapsed, it is sometimes very difficult. A free transverse incision is to be made midwa}' between tlie .ilium and, last rib, and the edge of the erector spinse is to be sought. The fascia which bounds this muscle (fascia himborum) is then to be fully opened, and the fascia covering the intestine to be sought through the fat which surrounds it. The peritoneum may be distinguishable from this fascia, but it generally is not so. If, however, the bowel is much distended there is little risk of opening the peritoneum. When much difficulty exists in finding the intestine the lower end of the kidney forms the surest guide. The bowel is sure to be found just below and in front of the kidney, on careful search. It is then to be drawn up to the surface, stitched to the two edges of the wound, and opened be- tween the stitches to an extent sufficient to admit the end of the finger, after which the mucous membrane of the bowel is to be carefull}'^ attached to the skin around the whole circumference of the opening. It is well not to make the opening too large, as the posterior wall of the intestine is sure to protrude from it afterwards. The intestine will become adherent to the wound before the sutures have come out, and after all has been consolidated and the patient has got up, a plug of ivory or glass can be fitted on to the opening and fixed by an elastic bandage. The bowels will very often regulate themselves, so that the action will occur usually at stated periods and the patient be quite clean and comfortable. The operation on the riglit side is performed in exactly the same way. The horizontal incision (Amussat's) is certainl}- preferable to Callisen's plan of making a vertical incision at the outer border of the erector spinte. Mr. Bryant has proposed cutting obliquely, at an angle of 45*^, as less likel}^ to injure the vessels and nerves of the part. Gatiirolomy. — When the surgeon has made up his mind to look for the seat of strangulation inside the peritoneum (an operation often descrilied by the name Gastrotomy, see page 238) he usually makes an incision through the linea alba below the umbilicus, as in ovariotomy, long enough to get the fingers in, feels for the seat of stricture b,y tracing down the distended l)owel, passes a director under the adhesion when found, and divides it with a liernia knife. LHlre\s Operntioii. — Another plan which is sometimes justifiable is to make an incision on the distended intestine wherever it happens to be perceptible and attach it to the skin (Littre's operation), so as to make an artificial anus in the small intestine. This is best done in the groin, when possilile. /»/«.s>-i'/.'y passing the finger through into the peritoneal cavity, and then the wound is to be sewn up and a pad and bandage applied. Every step in the operation thus summarily described has its own diffl- 632 HERNIA. culties and clangers, and presents many points for observation. I will try briefly to indicate those which are most important. In tlie first place, with reference to cutting down upon the sac. It is a matter of great consequence for the rapid and satisfactory performance of the operation to be able clearly to recognize the sac from the mem- branes which surround it, nor is this at all easy. The subperitoneal fat often so closely resembles the omentum that the operator is tempted to think that he has opened the sac without knowing it. But on trying to pass his finger round the supposed omentum and up into the peritoneal ring, he will find that he cannot do so, and the error will be manifest. Much time is sometimes lost in carefully dealing with membranes taken for the sac which are merely the investing fascifE or the membraniform layers of the common cellular tissue. But the sac is usually recognized by its more distinctly fibrous appearance, and bj^ the color of the fluid which is seen through it. Comparison of the Extra- and Intra peritoneal Ojjerations. — The parts constricting the hernia external to the sac are usuall}^ very perceptible when the operation without incision of the sac is indicated, and in ordi- nary cases of strangulation I can see no motive for exposing the perito- neal cavit3\ It is true that the statistics of the two operations do not show any such striking differences in rate of mortality as to be decisive of the question, for allowing, as Mr. Bryant's ^ figures show, that the death- rate is lower after the operation performed external to the sac, yet it seems probable if not certain that the cases were more favorable. But common sense (which I hold to be a better guide than statistics) appears to me to be in favor of leaving the sac untouched if possible. A surgeon attempts to reduce a hernia by taxis ; failing in this, he thinks it neces- sary to operate. If he could reduce the hernia without cutting the skin he would be well pleased, for experience will have taught him that death is excessively rare after successful taxis. Surely, then, we may argue, if it could be conceived that the mere division of the skin could make the hernia reducible he would not incise the deeper parts ; if the mere division of superficial bands of fascia would make it reducible he would not expose the sac. Similarly, if the division of the constriction above the sac cnal)les him to reduce the hernia, why should he open the peri- toneum ? The only conceivable motive is in order to obtain a view of the hernial contents, in case it should prove unadvisable to attempt their re- duction, and therefore it ma}^ be admitted that in cases where the taxis is contraindicated (see p. 621) the sac should alvva3S be opened at once. And, of course, if no constriction can be found external to the sac, and the surgeon is clear that the neck of the sac forms the stricture, no good can be done (and some harm perhaps ma}') by trying in vain to reduce the gut after having divided some structures which are not really on the stretch. But when any definite stricture external to the sac can be made out it should be incised. I have often reduced herniaj by this operation,'^ and have never had to regret it. Seat of Stricture. — The seat of stricture varies much for diflferent kinds 1 Practice of Surgorj', p. 348. 2 I may perhaps ineiUinn Unit an erroneous idea prevails that tlie operation exter- nal to the sac is not practiced at St. George's Hospital. Po.ssibiy we may not form so high an opinion of its advantages as some do, and may not therefore attempt it so frequently, but it is certainly u--ed in all the cases wiiich seem to the operator appro- Sriate. The reader may refer to Sir J. Paget's Clin. Lect , p. 127, and Mr. Howard [arsh's note on that passage; also to u paper by myself in the 3d vol. of the St. George's Hospital Reports, p. 322. HERNIOTOMY. 633 Fig. 290. of hernia. In those forms, as the femoral, which are surrounded by very tight fibrous structures, these are very liable to be the agents, or at least the chief agents, of constriction, while in other cases the sac itself is alone con- cerned iu producing the strangulation, which will last even when the sac and its contents have been liberated from all the surrounding parts, as in reduction en masne. This is partly illustrated by the accompanying case and drawing. In such cases it is evident that the con- striction cannot be relieved without opening the sac, and in many cases where the main agent of strangulation is anatomicall}^ external to the sac, such as the deep crural arch or Gimber- nat's ligament in femoral hernia, yet it has become so buried in and incorpo- rated with the neck of the sac that prac- tically it is impossible to divide it ex- ternal to the tumor. Inspection of Contents of Sac. — When the sac is opened the nature of the fluid which it contains should be noticed, in respect of prognosis. If it be merely thin serum it is so far favorable. Flakes of lymph speak of commencing inflam- mation of the bowel; ^ blood, of bruis- ing by taxis or unusual congestion from tight stricture; a dark, sanious, fetid condition, of commencing gangrene; and bubliles of gas, of perforation of the bowel, which, if not gangrenous, is rup- tured or ulcerated, and should be care- fully examined in order to detect the spot. Now, the stricture being divided, the condition of the sac and of the hernia absorbs the most careful attention of the operator. If there is both omentum and gut in the sac the first point will be so to disengage them from each other that the latter can be sei)arately returned. In some cases the whole sac is closely lined with omentum, and when this is the case there is the strongest reason for apprehending that it is a case of what Mr. Hewett has so well described as "an omental sac," in which the bowel descends into the centre of a mass of omentum, and is con- stricted within the sac so formed, by the thickening of the tissue at its neck. This may happen in any form of hernia, though it is most com- mon, I think, in the umbilical. In such cases the omentum must be care- fully torn or scratched through until the bowel is found inside, when the finger must be passed along the bowel, the director inserted below the ring of the omentum, and the constriction incised just sufficiently to ad- Strangulation of a hernial tumor by the neck of the sac, at the internal abdominal ring. This preparation was taken from the l)ody of a patient who was admitted with a strangulated hernia, the size of a man's fist. Attempts at reduction were made in vain; then the patient was put into a warm bath, and Iresh attempts were no doubt made, as the tumor suddenly disappeared, although at the time the hernia was said to have disappeared without being touched. The man died six and a half hours afterwards, unoperated on. The hernial tumor was found to be entirely within the inguinal canal, the external ring being quite free. ^ As a surgical curiosity I may mention the presence of a loose body in the hernial sac, an example of which is related in Path. Trans., vol. xv, p. 96. These loose bodies bear considerable resemblance to the loose cartilages. They are formed by aggrega- tions of lymph and fibroid tissue, often, as it seems, in appendices epiploicse, which then become detached ; sometimes, perhaps, as the result of contusion. 634 HERNIA. mit of the return of the bowel. Of course, in so dealing with a vascular structure like the omentum h.neraorrhage may be caused, but unless the omentum be divided the relief of the strangulation is impossible. Treatment of the Sli-angu- lated Bowel. — The omentum being unravelled,or if neces- sary divided, the bowel is exposed ; or if there be no omentum in the sac the gut comes into view at once, and the surgeon has to decide what to do with it. In all ordinary cases the decision is instantaneous and the gut is reduced at once, for it is important not to expose it to the air a moment longer than is necessary. But it is by no means easy to re- duce a large tense mass of bowel even when one has it in one's hands, and much patience and care is neces- sary to avoid bursting it. In dealing with a large mass of bowel the operator should try to pass one end back at a time (and if the upper end can be distinguished from tlie lower he -had better be- An "omental sac," from a case in which the stricture was gi'^ ^ji^h that) by gently relieved hy operation, the omentum being divided in order lo pressing the COllteutS of the reach the howel. a points to a dense fibrous membrane, ap- \)owel into the abdominal parently a condensation of the different fascise and neigh- (.jj^y||;,y ^(.W^ DUSllino" tlie o-nt boring areolar tissue, b to tlie peritoneal sac ; c, the external ^^ '' . ^ _ K\ " ^? surface of the omentum, which is spread out over the interior after it with a kneading of the whole of the hernial sac; d, the wound made in the motion of the twO liauds. operation ; e, the testicle. ^Yn assistant steadies the This preparation is from one of tlie cases referred to by Mr- ^ r.,, i i i <• n Ilew.tt in Med.-Chir.Trans.,vol xxvii, and is in the Museum IGSt of the bowel and follows oi St. George's Hospital. the movements of the sur- geon. When once a part of the gut is redu(;ed the rest soon follows. 0|ierators have even found it necessary in cases of extreme distension of the bowels to prick them in one or two places with a needle and evacuate tlie air from them. As the,y collapse and the three coats slide on each other the punctures in thein no longer correspond, so that no extravasation of fseces follows. But this cannot be necessary except in very rare cases. If the bowel is found ruptured by previous taxis, or if it gives way during the efforts at reduction, yet is tolerably healthy, the rent should be sewn up with the continuous suture, and the bowel returned,' and the 1 For a case in which this was done with perfect succos.s, see a paper entitled Re- marks on two Cases of Strangulated Uerniu, in the St. George's Hospital Keports, vol. iii. TREATMENT OF STRANGULATED OMENTUM. 635 same course should be followed in case of an accidental wound or punc- ture with the knife. Ulceration. — The bowel may be ulcerated at the seat of stricture, though healthy in other parts. This ulceration begins on the mucous surface, and is always seen to be more extensive on the inner than the outer face of the bowel, even when it has penetrated all the coats of the gut. It may, therefore, be going on without i)eing at all perceptible ex- ternally ; and for this reason, and also because traction on the weakened bowel ma}' break it down, while it otherwise might recover, I think the advice generally given to draw the herniated bowel down so as to exam- ine the part constricted and ascertain the absence of such ulceration, is mistaken, and 1 would only do so if the escape of air shows that perfora- tion has occurred somewhere. The reduction of a bowel in which such ulceration is impending is by no means necessarily fatal. I have seen many cases in which after a few days faecal fistula has followed in all probability from this cause, yet the patient has completely recovered. The ulcerated part has been shut off from the general peritoneal cavity bj' inflammatory effusion before perforation has occurred. Tliese tistuloe sometimes remain permanent, but more frequently contract and ultimately heal. Reduction of Inflamed Bowel. — In all states of inflammatory degenera- tion short of gangrene I think the counsel given by Aston Key to reduce the bowel into the peritoneal cavity is judicious. It is more likel}' to recover itself there than if left protruding, and if it does not do so fjecal extravasation into the peritoneal cavity is by no means common. On this subject, however, every operator must follow his own judgment. There is no question that a gangrenous bowel, including one in which gangrene though possibly not present is absolutel}^ commencing, should be left in the sac, the stricture having been freely divided. And it is better, I think, to lay the gut open and attach it round the wound, not because there is any chance of its receding into the belly — for it is glued to the neck of the sac by inflammatory adhesions — but in order that the rest of the wound may be united and a free exit left for fieces at the artificial anus. Gangrene of the gut, if complete, is unmistakable : its earlier stages are marked by mottled greenish discoloration of the bowel, loss of lustre, and formation of blebs under its serous coat, as well as by the before-mentioned characters of the serum in the sac. Treatment of Strangulated Omentum. — The practice of different sur- geons differs in dealing with the omentum, when in a morbid state, eitlier from bruising or inflammation. At St. George's Hospital our practice is to surround it at its neck with a stout double ligature and cut it off, leaving the ends of the ligature projecting out of the wound, and this seems as successful as an}' other plan. Others prefer simply to leave it in the wound, a plan which has the assumed advantage that the omentum becomes consolidated to the ring and may act as a plug, preventing the return of the hernia; but it has the drawback of prolonged suppuration in the unhealthy mass, and possible imperfect closure of the ring, so that instead of being obstructed it may be, on the contrary, kept permanently open. Others again having cut off' the omentum tie each vessel which they find bleeding in it. If this plan is adopted it is best to secure the neck with a clamp before cutting the mass away. The objection to it is that vessels which do not show while exposed may bleed on being re- turned into the abdomen. On the whole, I liave seen no reason to try any other than the first method. When the omentum adheres to the sac it should be removed. 636 HERNIA. If the gut be adherent to the sac it is probable that the adhesions will be too extensive to be separated ; at least it has been so in the instances which I have seen, and it is necessary to leave the bowel where it is, after dividing the stricture freely.' But it is a very unfavorable element in the prognosis. Operation in CaKS of Reduction en masse. — In cases of suspected re- duction en masse the opei'ation is of much more complicated and difficult character. The external opening must be made ver}' free, and the ring must be clearh^ exposed. In cases of inguinal hernia an incision is made on a director up the spermatic canal, and the surgeon feels with his finger for the sac or the bowel as the case may be. When this has been found it is, if possible, to be exposed by incision ; in any case it must be drawn gently down till the parts are fairly in sight. Then the sac, if un- opened, is to be freely incised, and the dissection conducted along the bowel till the seat of stricture is reached and the constricting tissue so fully divided that the finger can be passed along the bowel without re- sistance into the peritoneal cavity ; and not till he is perfectly satisfied that no further constriction exists should the surgeon try to reduce the intestine. In cases of femoral hernia the position of the sac is prol)ably less deep, but care must be taken to avoid injuring the femoral vein. When the operation is completed the wound is to be carefully adjusted and dressed, and then it is usual to put on pressure with pad and band- age. This is perhaps a!)Solutely necessary only when the patient is troubled with cough, in which case the gut might certainly reprotrude ; and I liave seen it do so even under the pad, requiring the wound to be laid open and the gut reduced afresh. Under ordinary circumstances the bowel would probably remain in place without any special dressing; but the pad does no harm, and gives some support to the wound. It need not be used after the first dressing. The spica bandage is put over the pad, as figured in the chapter on Minor Surgery. After treatment. — The after-treatment of cases of hernia which go on favorably is generally very simple. No length of constipation is now held to necessitate a resort to purgatives, so long as there are no symptoms calling for their administration. Cases do perfectly well in which the bowels do not act for a fortnight, and even a longer period. And it seems most rational to avoid any disturbance of an intestine which has just undergone so serious an ordeal as exposure and operative reduction involves. Yet the indiscriminate resort to opium and the extreme horror of purgatives which some operators display appear to me unnecessary. Unless there is some special indication from pain or restlessness, or some threatening of peritonitis, I see no reason for administering opium, unless perhaps a single dose or a single subcutaneous injection to pi-ocure tran- quil sleep after the operation. And wiien the abdomen is l)ecoming dis- tended from constipation much relief will be found from evacuation of the bowels by an enema ; or if there is also a foul state of the tongue, by a gentle purgative. Seqnehi- of Strangulation. — A few other points deserve notice in speak- 1 English surgeons are, I think, Onanimous in reconnmending the reduction of the gut, uniifT filmost all circumstiinees. Yet some French surgeons advocate, on the contrary, " kelotoniy without reduction " as theuniversal practice. This proceeding is, I think, only justifiable when the surgeon cannot reduce the herniated gut with- out dangerous violence. It loses the gn-at advantage r)!' the immediate closure of the parts about the nock of the sac after operation, whereby the peritoneal cavity is at once isolated, instead of being kept in open communication with a suppurating sac. SEQUELS OF STRANGULATION. 637 ing of the phenomena of strangulation, and of the operation for its relief. In the first place, I would observe that although the taxis if successful in fig. 292. wholly reducing the bowel is hardly ever followed by any symptoms what- ever (so that the patient is at once re- stored to his usual health), yet this is not always the case. I have seen two or three cases, in the course of an ex- perience of about a quarter of a cen- tury, in which peritonitis has persisted after the reduction of the bowel, and has proved fatal.' And a case lately occurred under my care in which after the reduction of the herniated intestine it sloughed, and the patient died about ten days after the reduction with very obscure symptoms, which afterwards were found to depend on gangrene of the bowel formerly contained in the sac, without any general peritonitis. The bowel after strangulation, though neither ulcerated nor gangrenous, is ■often so inflamed as to be unable to resume its functions at once. Thus, even after the complete reduction of the bowel, constipation and vomiting not unfrequently continue ; in fact, Contraction of the bowel after strangulation. The portion wliich has been in the hernial sac is so contracted that, at the time of exami- nation, water would hardly flow through it. The bowel above is much dilated, that below is of the natural calibre. The contraction is due to induration and thiekeningof all the coats of the bowel. The patient, a woman, had been operated on for femoral hernia. At the operar tion the bowel was found considerably inflamed. She went on pretty well for a time, complain- ,. ,. .,, , .,. , . ing, however, occasionally of griping and con- constipation without vomiting almost stipation. The wound healed, and a truss was invariably follows strangulation, and is fitted about a month after the operation, but no doubt salutary, as providing rest the griping and constipation became worse, and fo.l . . 1 • ._ i- -r> J. about eight weeks after the operation she died _r the injured intestine. But some- quUe suddenly, as if from perforation of the times it appears as if the bowel were bowel. On post-mortem examination, how- more permanently injured, as it was in ever, no perforation was found, nor anyperi- 4-i,„ , „ ^ 1 • I 4.1 „>„. .,„;.,™ tonitis, but the bowel was much ulcerated on the case from which the accompanying it, „,„;ous surface.-St. George's Hospital Mu- figure was taken, in wiiich the bowel seum, Ser. ix, No. 84 c. which has been strangulated is seen much thickened, narrowed, and obviously incapable of the natural action, and the distension of the bowel above the seat of stricture is considera- ble. The history shows this to have been the result of the inflammation caused by the stricture. Peritonitis after the operation for hernia is a very common cause of death, being sometimes connected with inflammation of the bowel ; at others with inflammation spreading from the wound. It must be treated by free leeching, if the symptoms are those of the acute form of the dis- ease, fever, rapid and hard pulse, great pain in the belly, with frequent vomiting and tympanitis. After the leeches bleeding should be en- couraged by warm fomentations, and the addition of mercury to the opium, which is indicated in all forms of traumatic peritonitis, ma}' be useful. The low form of peritonitis is even more fatal, in which there is little pain, and a low irritable pulse, with dry brown tongue, the nature of the affec- tion being marked rather by vomiting and tympanitis than by any other more definite symptoms. In such cases the peritoneal cavity will be found 1 One of these cases is reported in the St. George's Hospital Reports, vol. iii, p. 326. 638 HERNIA. filled with puiiilont serum, and there will most likely be pus diffused amono- the meshes of the subperitoneal tissue. Here reliance must be placed mainly on opium, stimulants, and fomentations, all depressing measures be avoidcil ; but the treatment is rarely successful. ArtifivioJ AnuK. — Two different conditions lead to the discharge of fa?ces from the wound after operation, which ought to be distinguished from each other by aiipropriate names. They are, however, usually con- founded under the common designation of " artificial anus," which is only appropriate to one of tliem. The one, which should be Qii\\Q(\ fsecal fis- tula^ depends on the ulceration of the bowel in the course of the stricture al)()ve described. A portion of the f^ces passes from the wound, but another portion usually, if not always, is voided by the natural passage. In this case, as the ulceration has made its way from the interior or mu- cous surface, it has caused a limited inflammation of the serous coat by which the ulcerated portion of the bowel has been glued to the parietal peritoneum coating the wound, the discharge from the bowel is directed externall}-, and thus extravasation of fteces into the peritoneal cavity is, under ordinary circumstances, prevented. If this should not be the case profound collapse occurs, speedily followed by death. More commonl}", however, there is no very great inconvenience connected with this acci- dent beyond the appearance of faeces in the discharge, an event which Fig. 293. A, the internal, and B, Uie external, views of a preparation showing the state of parts in artificial anus after an operation for femoral hernia. In the first figure may be seen the largersize of the coil of intestine (a), which Is nearer the stomach and has transmitted the ficces, in comparison with that of the lower coil (6), the very acute angle at which they join, and the small extent of the union of their internal or peritoneal surfaces. In b may be seen the aspect of the opening on the skin, and the projecting septum (eperon of Dupuytren), which divides it into two parts, and which must be destroyed, in order that ficeal matter can pass from the upper to the lower iiart of the l)owel. The projection of this septum would doubtless have increased had the patient lived longer. She was pregnant, and died after miscarriage about three weeks from the date of the operation. — St. George's Hospital Museum, Ser. ix. No. 102. may be apprehended when the gut has been seen at the time of operation to be much inflamed, and when (with or witliout i)reliminary pain in the wound) the discharge has been noticed to be foul and offensive. I have seen many such cases terminate in complete recovery, the fiieces passing by the anus in gradually increasing quantity until the fistula has been soundly healed. J3eyond rest in bed and the avoidance of constipation I ARTIFICIAL ANUS. 639 do not know any treatment which can be adopted, nor in cases where the fistula lias remained permanent have I ever heard any surgical measures proposed. But the condition to which the name of artificial anus is appropriate, and to which it should be restricted, is that which is shown by the annexed illus- trations (Fig. 293). It is caused by gangrene of a considerable portion of the wall of the gut, leading to a state of parts which can only be reme- died by a surgical operation. Whilst the gangrenous part of the bowel has been separating, the living portions have been contracting adhesions to the parietal peritoneum, and the bowel, l)ent at an angle, is found (as in Fig. a) adherent to the wall of the belly all round. Tlie superficial gan- grenous portion of the knuckle of intestine having come away, a large orifice is left (as shown in Fig. b), in which the upper and lower coil are seen to open, much like the muzzle of a double-barrelled gun, except that one is larger than the other, especially after a time. For the lower coil of intestine (6), as it no longer transmits any faeces, shrinks up and be- comes smaller than the upper, sometimes obliterated and cord-like. The septum betvveen the two orifices, called by Dupuytren the eperon, or spur, on account of its prominence, is formed by the posterior wall of the intes- tine at the junction of the two coils, and it is projected forward by the bowels which lie in the receding angle be- tween the two. Tiie angle of junction is ^"^■- -^*- generally very acute, and this spur is some- times of considerable length. It is this pro- jection which diverts the faeces from the upper bowel through the skin wound and prevents them from passing into the lower part of the bowel. Tiierefore, so long as this spur remains the condition is incurable, and the first step in the surgical treatment of artificial anus is so far to destroy the Eperon as to permit the passage of fteces directly from the upper Into the lower bowel. This is efiTected by the gradual pressure of Du- puytren's enterotome. One blade being passed up each of the coils of bowel as high as is deemed necessary, they are connected together and are brought into close contact b}' means of the screw. This is twisted tighter and tighter as ma}' be necessary until the instrument ulcerates through the walls of both intestines and drops oflT. While this ulceration is in progress, the peritoneal sur- faces of the two coils of intestine pour out lymph and adhere together all round the portion included in the blades of the enterotome. This prevents any efiTusion of fteces into the peritoneal cavity. The contents of the upper bowel (a) now pass freely into the lower bowel (6) within the peritoneal cavity, the eperon withers avvay, and the wound contracts. It may possibly heal of itself. If not its edges must be cautiously refreshed and a piece of skin be transplanted into the opening, if the orifice is too large to admit of the edges being brought into direct contact. The dangers connected with this operation are mainly two. One is that a coil of bowel may lie in the receding angle betvveen the two coils a and 6, Fig. A, and this may be caught or bruised by the enterotome. To avoid Dupuytreu's enterotome. 040 HERNIA. this all imaginable care sbonld be taken to examine well with the two forefingers in order to make sure that there is nothing except the walls of the bowel between the blades of the instrument. The other danger is that the adhesions may not form sutRciently, and that the faeces may escape into the peritoneal cavity. I ought not to quit the subject without adding that there are cases in which the sloughing of a considerable portion of bowel may take place, and yet no permanent artificial anus may result. Thus Mr. Hey relates an instance from Sir A. Cooper's practice in which the bowel, in an opera- tion for femoral hernia, was found extensively mortified; an incision an inch and a half long was made in it, and its contents evacuated. The mortified portion of intestine separated by sloughing, and from the length of the incision it seems certain that it must liave comprised the whole cir- cumference of the bowel ; yet soon afterwards the faeces passed naturally and the wound ultimately healed, the patient, a woman, passing through the efforts of parturition afterwards without ill effects. In such cases some accidental adhesion probably has prevented the two coils of bowel from becoming bent at an angle with each other, and has thus hindered the formation of the projection of the posterior wall of the bowel which directs the faeces out of tlie wound. We must now speak of the various anatomical forms of hernia, and of the treatment appropriate to each, and first of inguinal hernia. Inguinol hernia is divided into two varieties, according to the position of the neck of the sac with regard to the epigastric artery. If the neck of the sac be internal to the artery it is called a direct or an internal hernia; if external, an oblique or external hernia. The latter is much the more common. The oblique variety passes out through the internal or deep abdominal ring, traverses the spermatic canal, appears below the skin through the external or superficial ring, and then drops into the scrotum. Its coverings, therefore, will be the skin, subcutaneous tissue and super- ficial fascia, the intercoluranar fascia, the cremaster muscle, the infundi- buliform fascia, the subperitoneal cellular tissue, and the peritoneal sac. Different Forms. — There are numerous forms of oblique inguinal hernia. The first is the congenital^ in which the internal abdominal ring and the infundil)uliform process of the peritoneum liave never been obliterated, but the general peritoneal cavity communicates freely with the cavity of the tunica vaginalis. When this communication is of very small size no symptoms need be caused by it. It is recorded that in the post-mortem examination of Sir A. Cooper's body a minute canal was discovered lead- ing from the internal ring to the tunica vaginalis on both sides; yet lie never suffered, as far as is known, from either hydrocele or hernia. When too small to allow the passage of the bowel or omentum it may give rise to hydrocele. Larger communications will give rise to hernia. An exam- ple is figured below (Fig. 295), in which this communication existed on both sides, and will serve to illustrate the state of parts which predis- poses to congenital hernia. Such a state of parts may, however, long con- tinue before the hernia actually makes its appearance. I have known the hernia to show itself for the first time after tlie age of forty, and even later periods have been recorded. By congenital hernia, tlierefore, is meant in surgical language not precisely a hernia originating at or before birth, but a hernia which takes place through a congenital ojjening. The pecu- liarity of congenital inguinal hernia is that the gut and testicle are in con- tact. When fully formed and large the testicle is buried in the bowels HERNIA AND RETAINED TESTIS. 641 instead of being below or behind the tumor, as in ordinary inguinal hernia; but it is impossible without operation to do more tlian surmise the precise nature of the hernia apart from a trustworthy history. At the operation the presence of the testicle in the sac is conclusive. Congenital hernia may be known in the infant from congenital hydrocele by its want of transparency, the hydrocele being always quite transparent, and also by the feeling of gurgling in the bowel, which is rarely absent. Retaiyied Testis. — There are other congenital conditions which may in- volve the existence of inguinal hernia. Of these the most frequent is the retention of the testis in the inguinal canal. This keeps the internal ring patulous, and a hernia may easily come down which usually adheres to the testicle, but which may pass beyond it even into the scrotum. The annexed engraving (Fig. 296) illustrates this. It shows the testicle, Fig. 295. Fio. 296. Fig. 295.— Non-clos\ire of the pouch of the tunica vaginalis, from a case in which this state of things existed on both sides. On this, the right side, there was no hernia, the ring not being sufficiently dis- tended. But on the opposite side a hernia existed which was strangulated and was operated on with a fatal result. The patient was five mouths old.— St. George's Hospital Museum, Ser. ix. No. 82. Fig. 296.— Retained testicle and sac of congenital hernia, seen from the abdomen. The testis is the globular body with a narrow neck seen on the left side of the drawing, the more cylindrical tumor to the right, and behind it is the hernial sac. The scrotal cord is attached to the testicle and descends beyond it through the inguinal canal, and the gubernaculum is plainly shown in the preparation attached to the testis. The retained testis is healthy and natural in character, as determined by the microscope ; the spermatic cord and the testicle are adherent to the abdominal aspect of the internal inguinal ring.— St. George's Hospital Museum, Ser. ix. No. 91. which is adherent to the internal inguinal ring, along with the spermatic cord, and has evidently been occasionally in the canal and at other times in the abdomen. Connected to the testicle is a hernial sac, which can travel independently of the testicle, outside the inguinal ring. In all cases of hernia it is most necessary to examine the scrotum care- fully, and if it is found that the testicle has not descended on that side, then a very careful examination of the inguinal canal should be instituted, in order to see whether the testicle is detained there, and if any bowel can be felt to adhere to it, or to move independently of it. The mere retention of the testis in the canal, together with some accidental lesion, will produce pain and vomiting ; and if constipation be also accidentally present, I have more than once seen it mistaken for strangulated hernia. 41 642 HERNIA. When the nature of the case is plain, if sj-mptoms of strangulation be present, the operation should be at once performed ; and it is better, I Fig. 299. Fig. 297. — Diagram of congenital inguinal hernia. The process of peritoneum which passes down ■with the cord (funicular process) remains freely open ; the general cavity of the peritoneum is, there- fore, identical with that of the tunica vaginalis testis forming the hernial sac, the bowel contained in which is in direct contact with the testicle. Fici. 298. — Diagram of the (assumed) condition of the parts in an infantile hernia. The tunica vagi- nalis (1) is closed above, at or near the external inguinal ring, but its funicular portion is open. The bowel in the hernial sac lies behind this funicular portion, and is represented in the diagram as having made its way between the funicular process and the cord. The relation of the sac to the cord seems, however, to be variable. The bowel is covered in cutting down from the skin by three layers of peri- toneum, viz., 1 and 2, the opposite surfaces of the funicular process, and 3 the anterior layer of the peritoneal hernial sac. Fig. 299. — Another variety of infantile hernia (the encysted form). The bowel instead of passing behind the closed funicular process has distended the membrane which closes its upper end, and has pushed itself into the funicular process, the upper or back wall of which envelops it. In this case, therefore, the hernial sac is furnished by the funicular process itself, and only two layers of peritoneum cover the intestine. think, to remove the misplaced testicle. Such testicles are constant sources of trouble, and it seems very dubious whether they are of any real use. Fig. 300. Fig. 301. Fh.. :iiii). — Diagram of the common scrotal hernia. The tunica vaginalis is seen behind and below^ and is represented as distended with a certain amount of hydrocele fluid, but quite distinct from the hernial sac. Fig. 301. — Diagram of partial obliteration of the funicular process, to illustrate the formation of the hernia "en bissac " and of cysts in the cord (encysted hydrocele of the cord). The cavity of the tunica vaginalis testis is closed at c ; the funicular process is also separated from the peritoneal cavity at a, the situation of the aMominal ring. Tliere is also another septum at h. When one or more of these septa are absent or imperfect various conditions occur, as explained in the text. Fig. 302. — Diagram of the (ormation of the "hernia into tlic funicular process of the peritoneum" of Hirkett and i)f tlie "hernie en bissac" of French authors. Keferring to the diagram. Fig. 301, the septum or obliteration at c is supposed to be absent, so that the tunica vaginalis is open as high as the septum, b, whicli is in)perfect, or has given way from some accidental cause. In the diagram the septum at the external abdominal ring, a, is drawn as being widely open, but strangulation may occur either in this septum or at b, somewhat lower down, or at both. BUBONOCELE. 643 If the hernia be not strangulated the question of wearing a truss oc- curs. Whenever a truss can be tolerated it should be worn, irrespective of the probabilit}^ of atrophy of the testis from its pressure. For the disuse of the truss certainly entails risk of increase of the hernia and of strangulation ; while, if the testis is incapable of secreting (as most of these retained testes seem to be) its atrophy is a matter of no conse- quence. Generally, however, the organ is too sensitive to bear the pres- sure, and then a suspensory bandage, or a concave pad, must be fitted. If the testicle is liable to frequent attacks of inflammation it may be worth the patient's wliile to submit to its removal, in which case care must be taken not to wound the hernial sac. The next form of oblique hernia is that described b}^ Mr. Hey under the name of hernia infantilis, and which is also called encysted hernia. In this form the communication between the peritoneal cavity and the infundibuliform process leading into the tunica vaginalis is obstructed at or about the external (or superficial) ring, but the process itself is not obliterated, so that the cavity of the tunica vaginalis extends up to the external ring. Then a hernia comes down and generally slips behind this upper prolongation of the tunica vaginalis (Fig. 298) ; but the her- niated bowel ma}' bury itself in the upper end of the infundibuliform process and thus be encysted by it (Fig. 299). This may occur in con- sequence of adhesions having obstructed the neck of the infundibuliform process and formed a membrane. This membrane, being distended by the protruding bowel, forms a hernial sac for it. It seems certain also that there ma}- be two other forms of congenital inguinal hernia, viz., one where the funicular process is obliterated at its lower part, so that it is not in communication with the tunica vaginalis, but the upper end and body of this process is not obliterated, so that the peritoneal cavity extends down to the testicle. This remains usually without any hernia till the commencement of adult life, when in some violent effort a hernia suddenly comes down and is often acutely strangu- lated. Or the state of parts maj' have been that which has just been described as the initial stage in the formation of infantile or encysted hernia, i. e., the upper end of the funicular process may have been ob- structed, and this obstructing medium may have given way, causing a hernia, which now is reall}' one of the congenital form, and which also will probably be acutely strangulated. It is in this way that Mr. Birkett explains the indubitable fact of the frequent occurrence of acutely stran- gulated inguinal hernite, in some of which the testicle is found in the sac, and not in others. Hey, in describing his infantile hernia, has pointed out that the membrane which shuts off the cavity of the peritoneum from the expanded or infantile tunica vaginalis (Fig. 298) may give way again and admit a hernia into the cavity containing the testicle, the hernia being therefore of the congenital form, though it does not occur congeni- tally nor from congenital patency of the funicular process ; and he cites a passage in which William Hunter had pointed out the possibility of this event, though he had never seen a case (Hey's Pract. Obs. in Sur- gery, p. 229). The other forms of inguinal hernia are acquired, i.e., they form slowly, the inguinal canal being in the condition natural to the adult (Fig. 300). Bubonocele. — The peritoneum, containing omentum, gut, or both, is slowly projected at the internal ring down the scrotal canal. If the hernial tumor has not reached the external ring the disease is termed bubonocele. It presents a small rounded swelling, traceable to the inter- 64-4 HERNIA. iial ring, where it becomes lost without an^' neck, very little movable, with an impulse on coughing, and reducible under ordinary circumstances. Its diagnosis is sometimes difficult, the affections with which it is most liable to be confounded being enlarged inguinal glands and encysted hydrocele of the cord. Neither mistake is possible, however, when the bubonocele is completely reducible, and presents a distinct impulse. If the symptoms of strangulation should be present they are always a suffi- cient reason for treating the disease as a hernia and cutting down on the tumor, though there is no doubt that a cyst lying high up in the cord ma}' so for simulate a bubonocele as to deceive the best surgeons, the symptoms having depended on the strangulation of some small deep- seated hernia (such as obturator hernia) or on strangulation of the bowel inside the peritoneal cavity (see Figs. 275, p. 612, and 308, p. 651). Usu- all}^ however, a cyst in the cord or an enlarged gland can be pulled down sufficiently to convince the surgeon that it is separate from the internal ring. Besides which the cyst, if it is at all large, will show its character- istic transparency on very careful examination, and the position of the inguinal glands is not exactlj' that of inguinal hernia. However, when any doubt exists and the symptoms of strangulation are present, it is far more prudent to ascertain the nature of the case by an exploratory operation. The common external or oblique hernia forms a large tumor which lies generally above or in front of the testicle, with a long neck reaching up Fig. 303. An oblique inguinal hernia. The sac contains a large amount of omentum. The testicle is seen at its lower part. Running round the neck of the sac and close to the inner border of the ring may be seen the epigastric artery (a), the position of which and of the internal ring, concealed here by the omentum in the sac, arc indicated by dotted lines. to the position of the internal ring, the cord being generally behind it, though instances are not wanting in which the cord is spread over the front of the tumor, or in which the elements of the cord are separated OBLIQUE INGUINAL HERNIA. 645 and lie on either side of the neck of the sac. The abdominal muscles are tightly spread over the upper part of the neck of the sac in the canal ; and I have met with several cases iu which strangulation has been produced by tight bands running across it, probably portions of the ten- don of the external oblique, on the division of which the hernia was at once reduced. The neck of the sac is often most tightly constricted at the internal ring (see Fig. 290, p. 633), and this lies at a very great depth when there is a large hernial tumor, besides which there are often one or more minor constrictions in the course of the canal which must be di- vided before the operator arrives at the ring. So that the operation is often both severe and troublesome.^ The epigastric artery lies close to the inner margin of the ring (Fig. 303) and at its lower border. The The same hernia seen from the outside. — St. George's Hospital Museum, Ser. ix, No. 72. incision into the neck of the sac should therefore be directed upwards. When the hernia is of gradual formation and old standing the neck be- comes much more oblique and relatively shorter, so that its month is more easily reached. Such herniae, also, are far more likely to be stran- gulated external to the sac, and to be susceptible of relief by the extra- peritoneal operation. The operation for bubonocele is of the same nature as that for scrotal hernia. In both an incision is to be made along the long axis of the tumor, which is most conveuiently done by pinching up a fold of skin transversely' and transfixing it, the incision being made of sufficient length to give easy access to the neck of the sac at tlie internal ring. The various layers of fascia having been divided successively^ (on a director, if they are tense), the surgeon may examine for anj'^ bands which he can feel constricting the tumor external to the sac and divide ^ Such constrictions sometimes form real double sacs, as would be the case in Fig. 301, if the septa a and c were imperfect, and the hernia after passing through them had become enlarged or the septa had contracted so that the gut were strangulated at both points. 646 HERNIA. tliem by passing a probe-pointed bistoury beneath them. If the hernia is still irreducible the sac must be opened and the neck of the tumor traced up into the peritoneal cavity, in doing which the seat of strangu- lation will be met with. In a voluunnous tumor, with a tight, deep- seated stricture, much care is needed (especiall}' with an inexperienced assistant) to keep the bowel out of harm's way while incising the stric- ture. It is of no use to commence the reduction of the bowel until the stricture has been so thoroughly divided that the finger passes easil}'' into the cavity of the peritoneum and it is of course necessary to have the bowel and omentum freed from an}- entanglement with each other, and to ascertain the absence of adhesions. Direct inguinal hernia is far less common than oblique. It does not occur congenitally in the male sex at least. The bowel protrudes in the space denominated the triangle of Hesselbach, which is bounded exter- nally by the epigastric artery and internally by the sheath of the rectus muscle, Poupart's ligament forming its base. Two varieties of this hernia are described in the anatomical theatre as occurring in cases where the obliterated h^ypogastric artery divides Hesselbach's triangle into two parts. In the ordinary state of parts it seems more common for the course of this obliterated vessel to correspond pretty nearl}' with that of the epigastric. Its projection inwards throws the peritoneum into two fosstB, the bottom of the internal fossa being at the external or super- ficial ring, while the bottom of the external fossa will lie at the internal or deep ring when the course of the hypogastric and epigastric vessels corresponds, but will be internal to the deep ring when the obliterated arter}- runs across the triangle ; and in the latter case the hernia will push before it the wall of the spermatic canal, and pass down a portion of that canal before reaching the superficial ring. This causes a slight diflerence in the coverings of these two forms of hernia. The common form of direct hernia is covered by the skin, subcutaneous tissue or superficial fascia, intercolumnar fascia, conjoined tendon, transversalis fascia, and subperitoneal tissue, while the less usual form has the cre- master muscle or fascia in place of the conjoined tendon. This is not a matter of any consequence ; in fact, it could only be demonstrated by very careful dissection ; what is of more sui-gical importance is to re- raemljer that the neck of the sac may be very close to the epigastric artery. In the ordinary' form the epigastric artery is at such a distance as to be quite out of the way in an operation. In all cases, therefore, it is belter to incise the neck of the sac directly upwards. Direct inguinal hernia passes at once into the scrotum, and its diagnosis is not usually a matter of any ditticulty. The neck of the sac is more superficial than in oblique hernia, and the operation is therefore simpler, but is the same in principle and in most of its details. Inguinal hernia occurs also in females, and a certain amount of pro- trusion at the external ring and into the top of the labium is very com- mon in female infants — congenital hernia — which as a rule graduall}"^ disai)i)ears without any treatment, but if unusually large requii'es the constant a[)pli('ation of a truss just as congenital hernia does in the male. A congenital hydrocele (hydrocele of the round ligament) also occurs in females, and may be mistaken for iiernia, though the disease is a rare one. In infancy I am not aware that the difliculty occurs, but, in the adult, cases have been recorded in which an operation has been necessary in order to settle the diagnosis. The tense nature of the tumor, the want of impulse on coughing, and in some cases its translucency, are the chief FEMORAL HERNIA. 647 diagnostic marks ; but in tliis, as in all other embarrassments of diag- nosis, when the symptoms are sufficiently urgent to justify it, an explora- tory' operation should be early performed. The inguinal hernia of later life in females is of the acquired form and usually direct. No special directions are necessary for the operation in cither form. Femoral l^ernia occurs more commonly in the female than in the male sex, although it is by no means rare in men. The hernia is never of the congenital form, and therefore occurs very rarely in childhood. There seems no doubt that pregnancy and parturition predispose to it. The neck of the sac is at the crural ring, which is tightly constricted at its inner and upper part by tlie deep crural arch, the upper cornu of the falci- form opening and Gimbernat's ligament. The pressure of these dense unyielding structures often causes very acute strangulation, in which cir- cumstances the symptoms are urgent and taxis unsuccessful. The neck Fig. 305. Femoral hernia. External view. Tlie internal view of this preparation is .shown as Fig. 306. a shows the sac ; b the omentum contained in it. The femoral vessels are seen on the interior of the sac displaced outwards, so as to be tlirown into a curve. The mouth of the circumflex iliac artery is shown passing outwards, and that of a large vein is seen close to the outer border of the hernial sac. — St. George's Hospital Museum, Ser. ix, No. 84 a. of the sac can be traced below Poupart's ligament, though its fundus, or the bod}' of the tumor, in many cases rises up into the abdomen, lying upon that ligament. The coverings of a femoral hernia are the skin, the subcutaneous tissue and superficial fascia, the cribriform fascia, the sheath of the vessels, the crural septum, and the subperitoneal tissue. The crural ring, or the mouth of the sac, has on its outer side the femoral vein, and the epigastric vessels lie a little above it ; but it has usually no important vessels at its inner and upper angle, where the incision is made to relieve strangulation. The anastomosing artery between the epigastric and obturator passes around the ring, and its size varies con- siderably, so that sometimes free bleeding occurs in this incision, and in fact I have known such hgemorrhage prove fatal in a case where, the vessels being uninjected, no conspicuous artery could be detected at the 648 HERNIA. post-mortem examination. But in cases of anomalous origin of the obturator artery tlie trunk of this A'essel may entirely encircle the ring, so as to be in danger of being divided at the operation. This is not ordinaril}' the ease even when the obturator comes off from the epigastric, for the anomalous artery usually takes its course towards the obturator foramen on the outer side of the sac, as shown in Fig. 306, and is quite Fig. 30G. Irregular distribution of tlie obturator vessels iu a case of femoral hernia. The obturator artery arises from the external iliac close to the origin of the epigastric ; the vein opens into the epigastric vein. As, however, they lie on the outside of the hernial sac, the}' could he in no danger in an opera- tion ; a, the hernial sac, on the inner side of which the Incision would be made in case of strangula- tion ;. 6, its contents; c. the obturator vessels; d, the epigastric vessels. This is the internal view of the preparation in Fig. 305. out of harm's way. But when, as in Fig. 307, the obturator vessels pass around the neck of the sac the}'' are liable to be wounded in dividing the Fig. 807. A specimen of femoral hernia in which the obturator vessels given off from the epigastric encircle the neck of the sac. a shows the artery curving over the inner side of the sac, and just above the letter a dark space is seen, which is an extension from the wound of the operation. The vein (cut sli(irt) in marked by the letter fc.— St. George's Hospital Museum, Ser. ix, No. 84. FEMORAL HERNIA. 649 stricture, although they may accidentally escape. In the instance from which that figure was drawn it seemed probable that the vein was wounded at time of the operation, but the artery escaped, though it gave way afterwards. There was considerable venous haemorrhage at the time of the operation ; but this was supi)ressed by pressure. A good deal of omentum which was in the sac was left in the wound. Sloughing at- tacked the wound, and then arterial hsemorrhage took place, the source of which could not be discovered. It recurred two or three times, and proved fatal. The vein and artery were both found open, the opening in the artery being a minute puncture, into which a bristle could just be passed. As it is impossible to ascertain the existence of this anomaly, the only security against injuring the vessels is to make the incision as is consistent with the easy reduction of the hernia.' If the artery has been wounded the surgeon may possibly succeed in securing it, either by seizing its mouth and tying it, as some operators have claimed to have done, or by thrusting a curved needle under the tissues in which the bleeding vessel lies and passing a ligature around them, needle and all, as in one of the forms of acupressure, or possibly by the method of "uncipression" recommended by Vanzetti (see page 125). Diagnosis. — Femoral hernia is not always easy of diagnosis. Enlarged glands sometimes lie in the crural canal and exactly simulate a small hernial tumor, the impulse in which is absent or obscure. In fact, so close is the resemblance that exploratory operations are frequently per- formed. And a small hernial sac may be found lying behind an enlarged gland. The diagnosis is best made b}' the greater mobility of the gland, its being isolable from the underlying parts, its having no impulse when separated from the abdominal muscles, and its owning some cause, such as a sore in the lower limb, buttock, anus, or parts of generation. Varix of the saphena vein has been mistaken for hernia, but is distin- guishable 1)3' the fact that after reduction of the tumor — which may be accomplished easil}^ in the recumbent posture — pressure on the ring, which would keep the hernia back, will cause the varix to reappear. Psoas abscess has been mistaken for hernia, and has often a ver^' per- ceptible impulse. But the fulness in the iliac fossa which always can be detected by careful examination in psoas abscess would alone be sufficient for diagnosis ; besides, a strict examination will show that the region of the crural ring is natural, the swelling being at a point below this on the inside of the thigh, and being also perceptible on its outer side. Some verj' rare cases of hernia, however, have been recorded in which a hernia has descended on the outside of the femoral artery. A cyst has sometimes been found to lie in the crural ring, which must be distinguished from a hernia by the same signs as an enlarged gland. The tumor in femoral hernia is usuall}' small, though cases are met with of very large hernise of this kind ; it generally turns upwards after reaching the saphenous opening, and requires to be drawn somewhat downwards before the true position of its neck is seen. Immediate at- tention should be given to it, and it should be kept rigidl}' reduced, since its strangulation is very often irremediable except by operation. The operation is exactly' the same in principle as that for inguinal hernia, only that here the crural ring and the edge of Gimbernat's liga- ment are the points towards which the surgeon aims. An incision is ' It is desirable on every ground to make the incision into the neck of the sac as small as possible, for, if the neck of the sac be too much enlarged, it is verj' difficult to apply a truss satisfactorily. 650 HERNIA. made over the long axis of the tumor, somewhat internal to its middle, and the parts are divided until the sac is exposed. Then a director may be passed under Gimbernat's ligament (or an}^ other constricting tissue that can be felt), as recommended b}' Mr. Gay,' and the extraperitoneal operation attempted. If this does not succeed the sac is to be opened. rmbilical Hernia^ — The only other form of hernia which is of very common occurrence is the umbilical. Tliis occurs constantly as a con- genital affection, the bowel protruding througli tlie unclosed navel. And there can be no doubt, from the rarity of the affection in the adult as compared with its extreme frequency in the infant, that this congenital umbilical hernia tends to spontaneous cure. Nevertheless, it should not be neglected, especially when large. The bowel should be kept reduced by means of a well-fitting pad which covers the whole ring, and which is kept accurately applied to the belly by being let into a laced belt with india-rubber sides. If this apparatus is too costl3' some extempore sub- stitute can be easily devised. Careful attention for a few months is almost sure to be followed by the disappearance of the swelling. The acquired form of umbilical hernia is generalh' caused by the dis- tension of the abdominal parietes. as a consequence of obesity, repeated pregnancy, or both. The subjects of strangulation in this form of hernia are often fat elderly women, who have had the disease for a long time and neglected it. The ring is often of very large size, the sac almost al- ways contains omentum, and frequeutl}' large intestine as well as small. The hernia is covered only by the skin and expanded linea alba, and its orifice is often not the navel itself, but some weakened part of the neigh- boring linea alba. Often in this hernia the symptoms which are described as strangulation are rather those of obstruction ; and constipation with vomiting ma}' continue for several days, and 3'et be susceptible of ultimate relief from rest, enemata, and the administration of calomel and opium. Tlie hernia is ver}^ probably irreducible, the sac being coated internally with omentum (for in this hernia the "omental sac " is very common), and the symptoms are rather due to the entanglement of distended bowel in the folds of this omenium than to strangulation by an}- definite band. The obstruction may subside on the subsidence of distension ; and the results of operations on these irreducible hernioe containing large quanti- ties of omentum are so unfavorable that it is prudent to avoid them if possible. ''J'he amount of pain and fever (in other words, the acuteness of the symptoms) is the test of the necessity for an operation. If the tumor is very tense, the pulse quick and irrital>le, the tongue dry, and the patient complaining greatly of pain in the tumor and the bellj', the operation should not be delayed, especially if the vomit be inclining to the faecal character. The tumor is to be freely laid open in the vertical direction, the con- tained bowel and omentum unravelled, and the finger passed beneath the ring to feel for the point of stricture. This being divided, tlie bowel should be first reduced, and ihe omentum then dealt with as seems advisable. I have seen a case in which the symptoms wliii-h were referred to an umbilical hernia turned out after death to have been due to strangulation of the bowel internal to the peritoneum, and fairly within reach of the operator. Kemeral)eiing this case, and that under Mr. IJryant's care, cited on p. 618, it would be advisable if no strangulation is found in the ' See Mr. Gay's work on Femoral Hernia. OBTURATOR HERNIA. 651 hernial sac to pass the finger into the peritoneal cavity, in order to ascertain vvhetlier there is an}' internal constriction. Ohluralor Hernia. — Of the rarer forms of hernia the obturator, though not the most frequent, is that which presents most of surgical interest, since it has in late years been made the subject of successful diagnosis and treatment.' The accompanying illustration, from a case which occurred at St. George's Hospital before the snccessful treatment of ^^^- ^'^^■ this disease was known, will well illustrate its main features. The small sac of the obturator hernia is seen lying at the upper and outer part of the thy- roid foramen, almost ver- tically below the femoral ring, and there is a small empty hernial sac also in the external inguinal ring. Mr. Birkett has col- lected twenty-five cases of strangulated obturator hernia,^ from which it ap- pears that this variet}' of hernia when strangulated may be distinguished from inguinal hernia by find- Obturator hernia in a female, tet. sixty-seven, who died in St. George's Hospital, in the year 1846, from the strangulation of ing the inguinal rings and this hernia. She had also a small inguinal liernia, but the sac canals empty, and from femoral by tlie empty con- dition of the femoral ring, by the fulness of the " fe- moral fossa" (b}' which term is intended the flat appeared to be empty. An exploratory operation was performed, and proved that this was the case. In the preparation the small sac is seen opened outside the external abdominal ring, and with a bristle placed in it. Below the femoral vessels and horizontal ramus of the piibes the sac of the obturator hernia is seen unopened, projecting from the outer margin of the thyroid foramen, and having the nerve and vessels on its outer sido. It contained a small knuckle of surface of the thigh, just intestine, comprising only part of the calibre of the bowel, tightly below Poupart's ligament, strangulated. .in r \ • \ • e J The case occurred before the operation for this form of hernia the floor Ot which is formed ^^^ ^^^^^ Jntroduced.-St. George's Hospital Museum, Ser. ix, by the pectineus muscle), no. oo. by the fact tiiat the fe- moral vessels lie in front of the tumor instead of outside it, by the position of the neck of the sac, if perceptible, below the ramus of the pubes, and by pain which is often present in the course of the obturator nerve. 13ut the diagnosis is often very difficult, and in many of the re- corded cases (as in that figured above) other forms of hernia have been present and have complicated the case. In some it is said that no tumor has been present, and such cases could not be distinguished from in- stances of internal strangulation. But whenever the symptoms of strangu- lation are present with no tumor in the situation of the umbilical, inguinal, or femoral hernife (or if such herniae though present are completely re- ducible), the femoral fossa on the two sides should be carefully examined 1 This very satisfactory advance in operative surgery was due, not to a hospital surgeon, but to the late Mr. Obre of Paddington. — Med.-Chir. Trans., vol. xxxiv. 2 Syst. of Surg., 2d ed., vol. iv, p. 781. 652 HERNIA. both by palpation and sight, and if any fulness on one side be found as compared with the other, it will be justifiable to perform an exploratory operation, for which there is still more encouragement, if the characteristic pain in tlie course of the nerve is present. The incision should be made as for femoral liernia, but should be extended further downwards, so as to have a very free oi)ening, lying to the inside of and well away from the femoral vessels. The pectineus muscle being exposed is to be freely divided in the course of the skin-wound and the sac searched for and opened. It may be even necessary to separate or to divide some of the fibres of the obturator externus muscle before the sac is reached, but the suroeon should not desist from his search until the obturator foramen is clearly exposed. The position of the vessels and nerve with regard to the sac being variable, this search must be conducted carefully. If the hernia be recognized while reducible (and Mr. Kingdon has made the diao-nosis no less than five times) tlie surgeon must explain the nature of the case to the trussmaker, and must see that the pressure acts in the right spot, and is directed backwards and somewhat upwards below the ramus of the pubes. Ventral Hernia. — Hernia occurs also at any part of the belly which has been weakened by a cut, or by accidental rupture of a part of the mus- cular fibres, or an abscess, or possibly by overdistension. To such hernioe the name of " ventral'" is given. The protrusions which follow on ovar- iotomy' or ligature of the iliac arteries are familiar examples. Such hernial sacs have no neck, and are not liable to strangulation. When the patient stands up or coughs they form large bulging tumors, in which the bowels can be plainly felt. Reduction is perfectly easy, and the wearing of an appropriate bandage, so as to keep the hernia completely reduced, is all that is necessary as far as I have seen. Phrenic or diaphragmatic hernia occurs as a congenital defect, a por- tion of the diaphragm, usually the left leaflet, being deficient, whereby the pleural and peritoneal cavities communicate quite freely, and the stomach, the transverse colon with its omentum, or other viscera, are allowed to pass freely into the thorax. It is surprising that this exten- sive malformation should produce no definite symptoms. I have more than once found it in the bodies of adult persons who died from other causes and had never been known to make any complaint connected with the hernia. But in other cases the diaphragm has been ruptured in consequence of severe contusion, or has been lacerated l)y direct wound. When phrenic hernia occurs after injury it is generally a consequence of the free rup- ture of the muscle from contusion, which, like tlie congenital defect, takes place usually on the left side. The stomach and transverse colon are, therefore, the viscera which usually protrude in this form also, and the accident may possibly be diagnosed by the greater fulness and unnatural resonance of that side of the chest, the sickness, and the symptoms of obstruction which follow it. As the accident is almost inevital)ly fiital, either from pleurisy or from strangulation, the question of cutting freely into the abdomen and endeavoring to reduce the viscera from below has been mooted ; but no case has as yet occurred in which the diagnosis has been made clearly enough to justify the surgeon in this hazardous attempt, 1 Some of these hernise when lying between the curtihiges of the false ribs and the navel are called " epigastric." VAGINAL HERNIA. 653 and the record which we now possess of cases in wliich the patient has snrvived for a considerable length of time would still further indispose any prudent person from making such an attempt. Mr. Le Gros Clark has related and figured a most interesting case, in which the patient lived more than two years after an accident in which there seemed good reason to believe that the diaphragm had been lacerated, and in whom after death the usual conditions of phrenic hernia no doubt existed. The only am- biguity about this case is the remote possibility that the deficiency of the diaphragm might have been congenital.' Vaginal Hernia. — The other rarer forms of hernia occur chiefly in the vagina or female perineum. Vaginal hernia is not, I think, on the whole as rare as is supposed. It occurs as a congenital defect or as a conse- quence of stretching of the vaginal walls in parturition. The diagnosis is generally very easy. In a congenital case I ventured upon an opera- tion to close the ring, which appeared successful.^ In the adult I have never seen any inconvenience, but it has been observed that in some cases tiie urinary bladder protrudes — an affection, however, which should be distinguished from hernia, under the name of vaginal ctjdocele. The intestinal hernia only requires support by an appropriate form of pessary. The vaginal cystocele may I'eqnire to be operated on by removing a limited portion of the vaginal wall and sewing up the edges after having reduced the prolapsed bladder. In perineal hernia the recto-vaginal pouch of peritoneum is thrust out between the vagina and rectum, forming a hernial sac with small intestine in it, and I have seen the same thing occur into the rectum itself. Cases rarely occur in which the male perineum is similarly pushed out. These hernioe merely require reduction and proper support. Of a similar nature are the pudendal hernia?, in which the neck of the sac lies between the ascending ramus of the ischium and the vagina, and the sac itself protrudes into the posterior part of the labium ; the ischiatic hernia, where the gut protrudes beneath theglutjeus maximus muscle and the neck of the sac lies either above or below the pyriformis ; and the lumbar hernia, in which the bowel makes its way between the quadratus lumborum and external oblique muscle. In all these forms of hernia the main point is their diagnosis, and in all such swellings around the female parts of generation this is a matter to which much care should be given ; but space fails me to point out the exact points of distinction between such hernias and the abscesses, cysts, or other formations which may be met with in each region, nor is it per- haps necessary. A surgeon who is well acquainted with the principles of diagnosis and pays proper attention to his patient will be in little danger of mistaking a lumbar hernia for an abscess or a vaginal hernia for a cyst. As to treatment I am not aware that any of these forms of hernia have required kelotomy ; but if they do they would present no special diflfi- culties, except, perhaps, the sciatic, in which a large incision would have to be made, and care taken to ascertain if possible the position of the gluteal or sciatic vessels in relation to the neck of the sac. Sir A. Cooper directs that in such a contingency the incision into the neck of the sac be made directly upwards. 1 Lectures on the Principles of Surgical Diagnosis, p. 258. 2 Holmes's Surg. Dis. of Children, 2ded., p. 560. 654 DISEASES OF THE RECTUM. CHAPTEE XXXIII. DISEASES OF THE RECTUM. HAEMORRHOIDS, or piles, are divided into external and internal, and the division is a useful and natural one, though there are many examples of piles in which both the mucous membrane of the bowel and the skin ex- ternal to the anus form a part of the covering of the tumor, and which, therefore, are partly external and partly internal. Both kinds of piles are formed of enlarged vessels surrounded by infiltrated cellular tissue. External piles consist internally of an enlarged vein or veins, partl}^ oc- cupied by clot, and externally of skin and connective tissue more or less thickened and inflamed. They owe their origin to any cause which deter- mines the blood to the part or prevents its return. Pregnancy, obstruc- tion to the portal circulation, too luxurious habits, and sedentary employ- ments are well-known causes of external piles, and they are very com- monly increased by any accidental attack of constipation. These external piles are liable to inflammation, when they become distended, livid, and intensely painful. In cases of external piles there are generally also folds of loose integu- ment about the anus in which no enlarged vessels can be detected, nor does the skin or cellular tissue appear indurated. The treatment of external piles consists in the removal or palliation of their cause and the application of sedative and astringent lotions or oint- ments, and this is quite sufficient in the great majority of cases. Where habitual constipation exists it must be relieved, and the bowels kept rather loose, by some mild laxative, for purging is by no means desirable. The confections have obtained an extensive reputation for this purpose, especially the Conf Sennse cum Sulphure and the Conf. Piperis Nigri. All improper habits, whether of diet, exercise, or anything else that can pro- mote irritation about the pelvic organs, should be given up, and the pa- tient should be encouraged to take gentle but regular exercise. When the piles are inflamed, if the inflammation is mild, leeching is often serviceable; if severe, the tumor should be cut across with a lancet, and the blood squeezed out of the mouth of the vein, for an imperfect clot might keep the mouth of the vessel open and encourage bleeding. Also when old i)iles have become much indurated and are liable to con- stant attacks of irritation, it is better to snip them off, and along with them to remove any loose folds of skin. But in doing this care should be taken not to cut into the anus, so as to implicate the mucous membrane in the incision. Negligence in this respect has been followed by very troublesome contraction of the orifice of the anus. Internal haemorrhoids are produced by causes similar to those of the external variety, but they constitute a far more formidable malady. They produce bleeding, which in tlie worst cases is constant, though greater during defecation, and which so exhausts the patient as to drain him of all strength and color and leave him waxy in complexion, exhausted, languid, and unable to make any continuous clfort. The piles may also OPERATIONS FOR PILES. 655 cause pain and straining in defecation ; and if the tumors are large they may protrude even when the bowels are not acting, and sometimes drag the whole end of the gut out of the anus — prolapsus. The}' are gener- ally situated close to the anus, and often are parti}' external as well, i. e.^ part of them is covered by skin, but sometimes they are seated at a little distance up the bowel, and hence the necessity of having the bowel well protruded in examinations for piles. This is accomplished either by the patient's voluntary efforts, which are quite sufficient, in cases where there is an}' tendency to prolapsus, with, perhaps, a little assistance by gentle traction on some of the more prominent tumors, or by filling the bowel with a large quantity of warm water, so as to make it act forcibly, when the whole will be protruded, or by sitting over warm water. The struc- ture of internal piles is less uniform than that of the external variety. Some consist chiefly of varicose veins, with more or less condensed cel- lular tissue; in some the mucous membrane is also hypertrophied ; while in others the hypertroi)hy of the mucous membrane and its capillaries seems to constitute the bulk if not the whole of the tumor ; in others, again, there are large arteries intermingled with the enlarged veins or capillaries and with the hypertrophied mucous membrane. The form also of these tumoi'S varies equally. Some of them are sessile and bright- red like a strawberry, while others are pendulous and livid, the arterial vessels or enlarged capillaries predominating in the former, the venous in the latter; while in piles which have long been irritated and inflamed the bulk of the tumor will l)e formed of condensed cellular tissue, there will be little trace of vascularity in its appearance, and its consistence will be harder. The treatment of internal piles must vary according to their extent, appearance, and form. When only recent, and of no great size, they may usually be relieved, as external piles may, by removing or palliating their causes, and by similar treatment — i. e., gentle purgatives or laxa- tives, unloading the liver, and astringent applications, as the Ung. Gallfe Co., to the tumors when protruded, or astringent injections in small quan- tity after the bowels have acted. The patient ought to be instructed always to return the piles when protruded, by gentle pressure. The con- striction of the sphincter on the protruded piles pi'oduces much pain and congestion in the tumors. Sometimes, it is true, this proves curative, the whole tumor sloughing as if the sphincter acted as a sort of natural lig- ature, but this is too rare and too uncertain to be counted on. Far more commonly the congestion increases the bleeding and causes painful inflam- mation. In cases where the bleeding is considerable or the other symptoms are urgent some steps must be taken to remove the piles. The least painful and dangerous is the application of strong nitric acid to the whole of the surface, under which it will shrivel up, possibly the superficial part of the mucous membrane will exfoliate, and thus a cure be procured, and no doubt for those piles which are of the sessile and capillary variety such treatment is often very efficacious, at least for the time. It not unfre- quently happens that the symptoms recur, but in that case the treatment can be repeated. It causes usually but little pain, and is attended with no danger, at least I have never seen or heard of any harm from it. But it is not likely to succeed in tumors of large size, and in those which are pendulous or hardened from inflammation it is useless. As these three classes form the majority of piles wliich require operation, it follows that the treatment by nitric acid is not very frequently serviceable. There are two chief plans of operating for piles, viz., with the ligature 656 DISEASES OF THE RECTUM. niul with the clamp and cautery. In the former each pile is drawn out in succession with the forceps, any skin which is covering it is turned off the hiumorrhoidal tumor with a knife or scissors, its base transfixed with a stout double silk ligature if large, or encircled in a ligature if smaller, and the ligature tied as tightly as possible and cut short. Some surgeons puncture the pile, or cut away its superficial part, but this is unnecessary. Wiien all the piles have thus been tied the mass is returned into the bowel. In operating with the cautery each pile is, as before, successively drawn out, and then a clamp is applied to its base. The clamp should have its lower surface coated with ivory, so that the heat applied to its upper part may not burn the skin. If the pile is only small its whole tissue may Fig. 309. Mr. H. Smith's clamp for piles. be seared down nearly to the level of the clamp b}' the cautery, or this may be done without any clamp ; but it is generally necessary to cut off the pile a short distance above the clamp, and then sear the base of it till a thick eschar is formed. Mr. Bryant saj^s that for this purpose tlie gal- vanic is better tlian the actual cautery, as forming a thicker eschar. It has the advantage that the supplj^ of heat is continuous, and the disad- vantage that the surface of the cautery is not so large. A heat a little below white heat is safest, because it chars the tissues more slowly; if burnt too rapidly the eschar ma}' stick to the cautery and be pulled away, causing bleeding. When the surgeon thinks the parts sufficiently seared he cautiously relaxes the screw of the clamp, and if any point still bleeds repeats the cauterization. When all is safe and every pile has been treated in this manner the whole is returned into the bowel with all possible gentleness. Chloroform may be given in anj^ operation for piles, but it makes the proceeding a little more difficult, as the piles are rather liable to slip up wliile the patient is becoming unconscious. However, filling the bowel with water or gentle traction will bring them down, and few patients have the resolution to submit to the actual cautery without it, though in reality the operation does not seem very painful. The operation by the cautery is the more recent of these two plans, and is the one now in greater use, and it has some incontestable advan- tages over the ligature, — the recovery is more rapid, there is less need of confinement to bed, and it is less painful than the ligature. Against these advantages is to be set the risk of secondary haemorrhage, which, however, is not very great, and the somewhat terrifying nature of the proceeding, if from any cause chloroform is not used. As to danger, though very confident opinions were expressed of the great safety of the canter}', further experience lias shown their incorrectness. Pyaemia fol- FISTULA. 657 lows operations for piles, in consequence of inflammation of the divided veins. This is very rare in any form of operation, but seems to occur quite as often after the cautery as the ligature. Tetanus has been known to occur after ligature, but it is a very rare event indeed. ProIapsKf^ Ani. — By prolapsus ani is meant tlie inversion of tlie lower part of the bowel, and its protrusion in tlie form of a ring of red tumid membrane. lu slighter eases this ring consists of the mucous membrane only, but in the more formidable examples the whole bowel protrudes, and sometimes for several inches. Its causes are constitutional and local. Thus, in cachectic children with relaxed fibre any intestinal irritation, such as worms, will produce prolapsus, and in the healthiest persons, whether children or adults, prolapsus may be caused by any cause of straining, as stone, stricture, or enlarged prostate, Mr. H. Smith also says, with indisjjutable truth, that " the pernicious plan of frequently using copious enemata is ver}- constantly productive of the disordei*." The first thing, then, is to ascertain the cause, and if this can be removed the prolapsus, if moderate, will soon disappear with a little attention. When the gen- eral health is at fault the appropriate treatment must be employed. In childhood ferruginous tonics are commonly needed, and if the complaint depends on the irritation of worms this must be remedied. In this way most cases of prolapsus will be cured if the protruded bowel be always at once carefull}' reduced (which is generally easily done by pressing it gently up with the flat of the hand) and supported by a T-bandage. If very large the protruded mucous membrane is to be pencilled over with nitrate of silver in stick or smeared with nitric acid. P^or the cases which resist such measures (which will be very few, and chiefly inveterate cases in the adult) an operation similar to that for piles must be performed, portions of the inverted gut being tied at opposite parts of the circum- ference of the bowel, so that the resulting cicatrization may keep the gut in ; or if the anus be very much stretched lunated pieces of the skin and bowel may be removed with the scissors, and the edges of the wound stitched together; or similar portions of the skin and bowel maybe clamped, cut off, and seared, just as in the operation for piles. Fistula ill Alio. — A fistula in ano is a channel or sinus leading by the side of the rectum, and having usually two openings (complete fistula), the upper one in the bowel, and the lower on the skin. The upper open- ing is generally very near the anus, and the lower is also generally not far from the margin of the orifice, so that the fistula is usually of no great length. But many exceptions occur in both respects. The sinus may open a long way up the gut, and the external orifice may be a very long way from the anus; and again, there are fistulre which pursue a curved course, coasting round the bowel as they pass upwards, so that theopening in the gut is on the opposite side from that on the skin (" horse- slioe fistulte "), or a single opening in the bowel ma}' communicate with two or more orifices on the skin ('"Y-shaped fistulre"). Inattention to these peculiarities may cause a surgeon to overlook the internal orifice in cases of complete fistula. But there is no doubt that incomplete fistuhie also exist, and that of two kinds, — blind external fistula (Fig. 310), in which there is a sinus leading up along the bowel, but no internal open- ing ; and blind internal fistula, where there is an opening in the bowel, leading down into the cellular tissue, but no orifice in the skin. Fistula originates in two ways, viz., either as an ulcerated opening in 42 658 DISEASES OF THE RECTUM. the wall of the bowel, the matter from which makes its way down along the gut to open externally, or as i''*^'- •"'^- an abscess in the cellular tissue which bursts at one end into the bowel and at the other through the skin. It is obvious that either of these actions may be so modified as to give rise to incomplete fistula. Thus, if the matter from the ulcer- ated opening in the bowel does not make its way through the skin, but after gravitating or " pocket- ing" down towards the anus con- tinues to discharge into the bowel, we have the incomplete internal fis- tula. If the abscess outside the bowel makes its way through the skin, but does not burst into the gut, or if in a complete fistula the internal opening should close (as in Fig. 310), we have the blind external fistula. The causes of the ulceration of the bowel which leads to fistula are not always easy to trace. It is al- ways customary to speak of foreign bodies, such as a fishbone, passing through the whole intestinal tract, and then irritating or lacerating the rectum, being detained there by the sphincter, and certainly I once saw a case in which a fishbone was found in a fistula, but such cases are mere curiosities. It is quite possil)le, however, that either foreign bodies or hardened freces may irritate this or an}' other part of the mucous membrane and cause ulceration, and of course this part would be far more exposed to such irritation than any other. In many cases the ulcer- ation seems to be due to the strumous cachexia, and fistula is a well- known complication of phthisis. lachio-re.ctal Abacesa. — The frequent connection between abscess near the anus and fistula renders the surgeon always anxious to open such ab- scesses early and very freely, in order to avoid any denudation of the wall of the gut and consequent perforation. The abscess is to be punc- tured, a director passed into the puncture, and the whole cavity laid open as far as its extremity on either side. If this is early done fistula hardly ever follows. In examining a case of fistula the first care of the surgeon is to ascer- tain the condition of the patient's health, and more especially whether or not there are any clear symptoms of phthisis. If the patient be undoubt- edly phthisical it is often better not to operate, for the operation is fre- quently unsuccessful, the wound continuing unhealed up to the time of the patient's death ; and tlu; divisinn of the fistula sometimes appears to aggravate the internal mischief, possil»ly by the irritation and discharge which it causes. But these objections apply chiefly to advanced stages of phthisis. If the disease in tlie lungs is in an early stage, and the patient is much annoyed by tlie consequences of the fistula, it is better to operate. Fistula? in ano, witliout any internal opening. There are two fistulous openings, into which bou- gies have been inserted, and which run for some distance in the cellular tissue, terminating beneath the wall of the bowel. At a is an elliptical depres- sion which has every appearance of being the orig- inal oritice of one (perhaps of both) of the fistulie, but is now soundly healed. — Museum of St. George's Hospital, Ser. i.x. No. 45. FISTULA. 659 Diagnosis. — It must not be forgotten that every fistulous opening near the anus is not necessarily a fistula in ano, i. e.. a sinus originating in or leading to the rectum. I have seen a lal)ial abscess from gonorrhoea, contracted to a sinus, mistaken for a fistula in ano, and fistulous chan- nels iu connection with disease of the pelvis not very uncommonly open near the anus. Another very imi^ortant caution as to the diagnosis of fistula is not to confound with simple listuhie those fistulous openings which form in connection with stricture of the bowel. Such cases are not rare, and they are overlooked sometimes by people who ought to know better. When the stricture is simple nothing is required for the cure of the fistula but the dilatation of the stricture, just as in perineal fistula. When the stricture is cancerous no local treatment can do any good. In either case the incision of the fistula is a great mistake. Care- ful examination of the higher part of the bowel is, therefore, necessarj'in any case of fistula whose course is obscure, and particularly in those which are multiple and surrounded by a good deal of indurated tissue, as the fistulas in connection with stricture usually are. Treatment. — The operation for fistula is one of the simplest possible. It consists merely in passing a director through the (istula and laying its whole track open. But it is often very difficult to find the internal open- ing, from the sinuous direction of the fistula, or from the small size of the opening into the bowel comjiared with the extent of the abscess, for the abscess often stretches to a great distance up the gut, while the internal orifice is close above the sphincter. Often the surgeon may feel the orifice as a small pimple on the wall of the bowel, and if this be on the opposite side of the gut from the external opening, he will discover it by laying open the superficial part of the sinus under chloroform and tracing it carefully step by step around the bowel. But no doubt in some cases (Fig. 310) there is no internal opening, and then the surgeon must make one by pushing the director through the wall of the bowel where it feels most thinned and exposed. Such oi)erations, however, are unsatisfac- tory. If the internal opening has been overlooked the fistula vvill surely reproduce itself. If there be no external opening the internal orifice can usually be seen or felt, and a bent probe can be hooked in it, so that its point projects under the skin. This is then cut down upon, and so the fistula is rendered complete and at once laid open. There is no necessity for any elaborate dressing after the operation. It is well, I think, to put a piece of oiled lint into the wound, and keep it there twenty-four or forty-eight hours, so as to avoid the agglutination of the superficial part of the wound ; and afterwards to pass a probe or director down to the bottom of it, to insure its filling up regularly; and it is a comfort for the patient if he can be spared any action of the bowels for a lew days. The other methods which have been used for the cure of fistula are the elastic ligature, the electric cautery, and the ecraseur. Tliey are much inferioi' to the cutting operation, but one or other may be used on jjatieuts who will not submit to the latter, and I should think the best would be the elastic ligature, but I have no experience of it.^ ' I would refer tins reader to a disoussi(/n at the Clinical Society, reported in the Lancet, June 5, 1875, on an interesting case under Mr. Maunder's care of double fistula in the same patient. One was trf^ated by incision, the other with the elastic ligature. The result showed the great superiority of the cutting operation, for the wound made with the knife united kindly and with little pain, while that jiroduccd by the elastic ligature was left with callous in-ominent edges, and did not unite till five weeks after the other was healed. Ail the surgeons who took j)artin the debate 660 DISEASES OF THE RECTUM. Fig. 311. The cause of the persistence of fistula, is doubtless the action of the sphincter ani, which constantl}' presses upon the walls of the abscess and disturbs any attempt at union. Yet spontaneous cure, in long periods of time, is not unknown. Mr. Prescott Hewett mentioned a short time ago at St. George's Hospital two as occurring under his own obser- vation ; but the event is too rare and the length of time re- quired too long to afford anj'- valid argument against the ad- visability of operating whenever the general health will bear it. Fistula in ano. The puckered part represents the -tlSSlire, Or, aS it IS perhaps amis. A bougie has been passed through the fistula, better Called, ulcer of the anuS, and the mucous membrane has been removed, in order Jg a VCrV paiuful and distressino" to show the fibres of the external sphincter, outside „^,„„i„:,,i ,„k;^U l>^.„„,r^.. i^ „,.,., , I <• »i c . 1 / J T, , „ complaint, wiiicn, liowever, is wliicli the channel of the fistula extends. Below the '- ' ' ^ v. v^i, i^ letter a is seen an external pile, which has been cut USUally relieved immediately by across. The preparation well illustrates both the cause very simple treatment. It foriUS of the persistence of fistula and the manner in which ^ ^^^^-^^ ^j.^^^]. ^^^ ^j^^ g^|„^ ^f ^j^g the operation removes that cause. The director being , i i ^i • i- • passed in the track of the bougie above figured, the "OWei, hardly implicating the sphincter is cut completely across, and is then pre- wholc tllickueSS of the skiu, CX- ventcd from reuniting till the track of the sinus below tending, perhaps, a Certain dis- has been obliterated by cicatrization. — St. George's Hos- . ii ^ i lo pitai Museum, ser. ix. No. 42. t^nce up the gut— Say half an inch — and situated in the great majority of instances towards the coccyx. It is the seat of great pain, especially when the bowels act, and this pain frequently lasts for a long while after defecation, and is often so severe that the dread of it causes the patient to avoid emptying the gut as long as possible, so that some- times a very deleterious habit of enforced constipation is set up, which greatly impairs the digestive functions. The obstacle to the healing of this ulcer lies obviously in the connection of the ulcerated skin with the sphincter ani. Its cause is not always apparent. It is more common in women than men, and may be produced by the irritation of discharges. Cracks form on the anus from gonorrlujeal and syphilitic discharges, but are generally more superficial and more easily cured than the proper "fissure of the anus." Some of the milder cases of fissure are amenable to treatment by clean- liness, attention to the state of the bowels, so that the fasces are never hard nor the action costive, and some stimulating application, of which the stick-caustic is the best. But the operation which cures the disease is so sim))le and alfords so much immediate relief that it is seldom w^orth while to spend time on any other local treatment. It consists simply in exposing the whole extent of the nicer with a speculum, and then making an incision tlii-ougli its whole length and depth with a stout straight probe- pointed })istoury. This incision should be made carefuU}', so as to reach the healthy tissue throughout its whole extent. This is usually' quite appoarod to be unanimou.'i in cimclcmniiiij; flu; trcatmont by the elastic ligature as a method for general use, while admitting that it might be indicated under exceptional circumstiinccs, chiefly when the ()j)ening is very high and the surgeon has rea.^on to fear the effect which the necessary division of somewhat large vessels may have on hi.> patient. POLYPUS OF THE RECTUM. 661 sufficient. If it fails, the division of the entire sphincter (including, of course, the ulcer in the cut) may be necessary. Pruritus ani is often a troublesome aftection, and in some cases is so distressing and uncontrollable that, as is the case with pruritus vuIvjb, it almost ol)liges the sufferer to renounce society. Usually, however, it is symptomatic of some disorder of the digestive organs, and if taken in time is perfectly manageable. Careful attention to the state of the bowels, the expulsion of worms, and the careful regulation of the diet, are the first requisites. It seems to me often to depend on the too free use of stimulants. The local treatment consists of astringent and sedative lotions, with scrupulous cleanliness, and perhaps a narcotic, at bedtime, when tlie itching is apt to be severe. Careful examination, however, is necessary to ascertain the absence of fissure of the anus or condylomata, of which pruritus is sometimes only a symptom. The disease is often attended with small excoriations, hardly deserving the name of fissures, around the anus, and the itching will disappear when these are brought to heal, which is usually effected by touching them with nitrate of silver and applying nitrate of silver in solution. Mr. H. Smith recommends in these cases glycerin ointment — a drachm of glycerin to an ounce of lard — or an ointment composed of calomel of the same strength (3j : Sj). The black or yellow wash is also sometimes useful, and the daily passage of a bougie will sometimes render the anus less irritable. Polypus of the rectum is a disease which, though not confined to child- hood, is most common at that period of life. Two forms of it are de- scribed — the vascular and the fibrous — but the difference is one rather of degree of vascularity than of kind, both being formed of fibrous tissue with vessels intermixed.' The earlier the age is the more vascular as a rule will be the polypus. These polypi are often attached by long stalks to the bowel, so that when they float up into the gut they are impercep- tible and cause no symptoms, but when they are carried down they are grasped by the sphincter, and this causes pain and bleeding. If a child suffers from occasional bleeding from the bowel it is usually from this cause. Piles are very rare in childhood. The polypus, however, may easily escape detection, especially if the bowels have not acted recently. The surest way to detect it is to make the bowels act by an enema, when it will probably present as a small red projection at the anus, or can be felt and drawn down by sweeping the finger round the bowel. Sometimes the surgeon, in so doing, breaks it off and cures the disease, otherwise it is necessary to remove it. There is little or no danger in the less vascu- lar specimens in twisting it off with a pair of forceps ; but it is, of course, safer to tie the base and cut it off close to the ligature ; and as this gives little if any pain, it is the course generally adopted. Villous disease of the rectum is a rare form of tumor, of which, how- ever, I once saw a very striking instance,'' in wliich the tumor used to grow to such an extent as to produce some obstruction, from which the patient was relieved by tearing away portions of the mass. This was 1 In some of these polypi adenoid tissue may be detected; others consist entirely of epithelium — are, in fact, gic;antic warts. A case of this sort is figured in Mr. H. Smith's essay, Syst. of Surg., 2d ed., vol. iv, p 8(50. 2 Path. Trans , vol. xii, p. 120. The jireparation is preserved in St. George's Hos- pital Museum, and is figured in Mr. H. Smith's essay. 662 DISEASES OF THE RECTUM. Fig. 312. done thirty-three times, and always with temporary relief. The patient survived tive years, and died at the age of seventy. The whole course of the disease in tliis case, as well as tlie microscopic examination, showed that the tumor was of a non-malignant nature, though probably in the rectum, as in the bladder, cancerous tumors may be covered with a layer of villous i)rocesses. The diagnosis of such tumors when within the reach of the finger or hand will rest on their comparatively slow growth, the villous character of their surface, the absence of hardness at their base, and of an}' symptoms not explicable by their mechanical pressure. Mucous Tubercles and Condylomata. — I ought to mention here, though chietly for the sake of diagnosis, the syphilitic atfections so frequently found ne?a" the anus, vnz., mucous tubercles and condylomata. Mucous tubercles are often confounded, even at the present day, with external jjiles. Yet the diagnosis is as easy as possible. Piles are rounded, somewhat pendulous tumors, covered with healthy skin, and only occasionall}' con- nected with any symptoms of syphilis, which on careful examination will be found to have nothing but an accidental refer- ence to the disease. Mucous tubercles, on the contrary, form small, perfectly flat, sessile elevations covered with a velvet}' or warty and moist epidermis, and are always developed in the course of a reg- ular outbreak of secondary or (what is the same thing) congenital syphilis. I have spoken above (page 402 ) of the proliably contagious nature of their moist secretion and the great etRcacy of the local and general administration of mer- cury in their treatment. Condylomata are generally syphilitic, though they may proceed from the irrita- tion of gonorrhoeal and possibly other dis- charges. They form large pedunculated masses, in which all the textures of the skin can be detected, covered with a foul warty surface and exhaling a fetid mois- ture, frequently very vascular, and bleed- ing to an alarming extent sometimes when removed. The elastic ligature, thougli infe- rior in most situations to the knife for tlie removal of tumors, seems to me very appro- l)riate for the treatment of condylomata. Sii i| 1 ^ti 1 till I I tui 1 Tt a iKiinl about .111 inch irom the iiiuv The sur- Stvicture of the rectum is either simple lace of the mucous membrane is much ^.. „ „„.,„.,„ "n^i-K ,.,:n ^e «^.,..^^ \^^ «« , , , , ,, „ ,r,u. 1,,., 1 ;., or cancerous. J3oth will, ot course, be ac- ulcerateu, and tlio walls of the bowel lu " " this situation (wiiich was continuous to compauicd by tlic Same symptoms of me- Ihe uterus) are much thickened and indu- cliauical obstrUCtioU in proportion tO their rated. On microscopical examination g^tent, i. fi., COnstil)ation, foUowcd by diar- tlii.s tbickeninL' was found to be due en- , ;,.',. t , • i.,i i n tirely to thedevelopmentofafirm fibrous ^'l^^^, UUllgestlOn, dlStCnSlOU of tllC bclly, material in the submucous areohir tissue, losS of appetite, health, and COmplcxioU. and in the cellular tissue outside the ThcSC symptouiS are UOt, llOWCVCr, whollj bowel. N^u.ecuiiare,.ii..oniiati.,nscouid n.ecliau ical, though they pcrhaps are be detected in this material. — Museum of , ,, i i i i . i i ^ St. George's Hospital, ser.ix, No. a?. whoUy caused by the mechanical obstruc- STRICTURE. 663 tion. There can be no clonbt that the diarrhoea and the acrid discharge present cA'en in non-cancerous stricture are caused in part at least by re- tention of the faeces setting up inflammation of the mucous lining of the bowel and catarrhal discharge. In some cases (rarer, however, than might perhaps be inferred from their constant mention in surgical books) foreign bodies become impacted in the strictured intestine and thus com- plete the obstruction w])ich otherwise would be imperfect. Simple stricture depends on tlie deposit of fibroid material in the wall of the bowel or external to it, probably from chronic inflammation, or on the healing of ulcers, and these are either strumous, syphilitic, dysen- teric, or accidental. Strumous ulcers are believed to be very common. When they perforate the bowel they lead to fistula, and are then usuall3' of small size. Larger strumous ulcers may produce firm bands of cica- trix considerably narrowing the calibre of the intestine. So also with venereal disease. Sir J. Paget has shown how common it is in women who sufl^er from constitutional sy|)hilis to find the rectum occupied by ulcerations of a horseshoe shape, which in their healing pro- duce cicatricial bands stretching across the cavit}^ The main feature in the diagnosis between these simple forms of stric- ture and the obstruction of cancer lies in the fact that in cancer the mor- bid deposit is infiltrated for a considerable distance into the walls of the bowel and the neighboring tissues, producing a hard irregular nodular mass which extends for some distance from the seat of obstruction (Fig. 313), while in simple stricture there is often merely a constriction as if a string had been tied round the bowel, the coats of which feel quite healthy up to the stricture; and if the finger can be passed through it, the mucous membrane on the other side feels healthy, and there is no deposit around the bowel. It must be admitted, however, that the diagnosis is often by no means easy in cases such as that shown in Fig. 314, where the ulcerated and contracted surface is very extensive, and the patient exhausted by suf- fering. After either kind of stricture fistulous passages will form, precisely as after stricture of the urethra, the wall of the bowel giving way from ulceration above or in the tissue of the stricture, a little of the contents being infiltrated into the textures around, and suppuration extending gradually from this point to the skin. Such fistulous passages, however, form much more readily in cancerous strictures, for obvious reasons, since the substance of these cancerous deposits very readily breaks down and ulcerates ; and for this reason also, as well as from their greater ex- tent, the passage of fffices through the stricture is much more painful in cancerous than in simple stricture, and is often the chief source of the patient's misery. The treatment of stricture of the rectum is in some cases decisive and very successful. When the obstruction is formed merely by an ulcer which has cicatrized, and the constitutional condition on which it may have depended has passed away, the health may be as completely and rapidly restored by dilating the stricture as in the parallel case of stric- ture of the urethra ; and, as in the urethra, this dilatation may be ac- complished either gradually by means of bougies or rapidly by incision. The latter method is by no means free from danger. I have seen peri- tonitis and death follow Ihe incision of a stricture of the rectum even when the incision was quite away from the peritoneal cavit}' and strictly limited to the posterior wall of the bowel. It should be reserved for dense cicatricial strictures in wdiich the method of gradual dilatation fails 664 DISEASES OF THE RECTUM. or is too painful. It is accomplished by passing a director through the stricture (which is suppose to be too tight to admit the finger) and guid- ing a hernia knife upon it, with which the tissue of the stricture is to be slightly notched backwards or towards the sacrum in one or two places to an extent suflicient to admit the passage of the little finger, and there- fore of a small bougie. Perhaps the bistouri-cache is a safer instrument. Fig. 313. Fig. 314. Fig. 313.— Scirrhous deposit and ulceration of tte rectum.— Museum of St. George's Hospital, Ser. i.v, No. 64. Fig. 314.— E.xtensive ulceration and contraction of the bowel, with distension above the contracted part, due probably to strumous ulceration. — St. George's Hospital Museum, Ser. ix. No. 149 a. This operation, however, is only intended as a preliminary to the use of the bougie. Although, as I have said before, it is not free from grave risk, in appropriate cases (r. e., cases of tough cicatrix) its beneficial effects are almost magical. For slighter cases of non-cancerous stricture the rectum bougie is all that is required. It should be passed at first l)y the surgeon or by a skilled attendant until the stricture will freely admit an instrument the MALFORMATIONS. 665 Fig. 315. size of the middle finger, and all trouble from obstruction is over, when the patient may be instructed to pass it, and should at first be watched to see that he really does pass it through the stricture. As in the urethra it will be necessary to keep the stricture dilated for a time, which is practically unlimited. Malignant stricture, on the contrary, can only be aggravated by any form of mechan- ical treatment. Gentle laxatives, to keep the motions soft and avoid the irritation produced in the upper bowel by the deten- tion of hardened faeces ; opium or morphia, to relieve pain and procure sleep; and nour- ishing food in small bulk, constitute all that can be done in an early stage. Later on the question of affording relief, though only for a time, by opening the bo\vel above the seat of stricture becomes an urgent one. Gololomy. — The operation of colotomy is one which has become a very common one of late, and about which, therefore, much more is known than was the case formerly. We know that after successful colotomy, or indeed after the formation of an artificial anus in any part of the intestine, the pa- tient's life is not by any means so miserable as was thought formerly to be the case ; and we also know that the cancer which affects the lower bowel is frequently of the less malignant and rapidly growing forms,' and consequently that if the effects of mechan- ical obstruction and consequent irritation can be obviated the patient may survive a long time. Then, again, the sufferings which cancer occasions when the surface over which the fseces pass is extensively ulcerated are often very acute, and it is worth his while to submit to the risk of the operation even for that cause onl}', irrespective of any obstruction. The operation, however, is much more urgently indicated and much more certain to afford immediate relief when it is performed with a view of relieving the symptoms of total obstruction, besides being more easy of execution. For a description of the operation see the section on Internal Stra'ngu- lation (page 614). Bistouri-cache. The instrument is passed through the orifice to be in- cised, with the knife concealed in the stem. By pressure on the handle the blade is projected to an extent which is regulated by the screw. Malformations of the lower bowel are usually described as either (1) imperforate anus, or (2) imperforate rectum. 1. In the former case there is no anal opening ; in the latter there is, but it does not lead into the bowel. When a child is born with no anal aperture the circumstance may escape notice for a time, and then the symptoms are usually com- plicated by the useless administration of purgatives. Yery commonly, ^ Cancer of the rectum is either of the epithelial or scirrhous form. It often re- mains for a long time without spreading to the neighboring viscera, and without much growth or ulceration, if not irritated by the constant passage of fjBces. 666 DISEASES OF THE RECTUM. bowever, the malformation is detected soon after birth. If relief is not afforded the usual symptoms of obstruction set in ; after a day or two of constipation the belly becomes distended, vomiting commences (the period being dependent in a great measure on the amount of fluid put into the stomach), the food only being rejected at first, and then the meconium, and the child dies in a few days, either from exhaustion or peritonitis. Many of these cases are, however, perfectly curable, and b}' so simple a proceeding that it should hardly be dignified with the name of an operation. The bowel comes close to the skin, and if the surgeon will make a moderately free incision in the position of the anus, draw the bowel down to the level of the skin, and attach the mucous mem- brane to the skin around the whole of the circumference, nothing more need be done. The patient's life Avill be preserved for the moment, and it ma}' be confidenth' anticipated that the power of retaining the faeces will ])e perfect.^ These are the simplest cases, and they maybe recognized conjecturally b}' the perfect development of the pelvic bones, so that the coccyx is at the normal distance from the scrotum or vagina, and by the bulging in the perineum when the child cries. A surgeon who would not operate in a case of this kind would, I think, neglect one of the plainest duties of his profession. Yet man}' such cases are sacrificed to the prejudice that children with imperforate anus had better be left to die. With Faecal Fialula. — There are other cases in which imperforate a'nus is complicated with fistuloe opening into the vagina, into the bladder or the male urethra, or into the scrotum. When the rectum communicates with the vagina, there are cases in which the deformity has produced so little inconvenience that the patient Imperforate rf!ctuin with scrotal fistula. An incision has been made into the rectum from the natural situation of the anus, and a probe passed through this incision from the scrotal fistula. has reached maturity, and even had children, without being sensible of it.'' In such cases some sphincter action must be exercised by the fibres ^ The .sphincter exists in some of these cases, tlioucjii the anus is imperforate. See a dissection by Mr. Partridge, described in the Path. Trans., vol. v, p. 176. But oven if there were no external spliincter, tiie circuhir fibres of the internal sphincter would prevent any incontinence oC fieces. ^ A striking case recorded by Mr. Loon Lcfort, will be found in my work on the Treatment of Children's Diseases. IMPERFORATE ANUS. 667 of the vagina as the gut passes obliquely through them. But generally the patient suffers the most terrible misery from tlie deformity, and then an attempt must be made to draw the bowel down, as is done in simple imperforation, and at tiie same time to detach it from the vagina, and this is sometimes successful.^ When the opening is into the male bladder or urethra the only thing that can be done to preserve life — which will otherwise be gradually but surely destroyed b}' the accumulation of semi-solid fneces in the urinary passages, causing symptoms analogous to stone, or absolutely forming the nucleus for a stone — is to open the bowel higher up, either in the loin or groin. In cases where external fistula exists the bowel is, I think, never or very rarely far from the integument, and the free re-establishment of the natural passage will cure the unnatural one. WifJi Deficiency of the Bowel. — But there are more formidable cases of imperforate anus, in which the bowel is entirely deficient, and may terminate at an}^ level, though usually it ends at the sigmoid flexure of the colon, which then sometimes bends over to the right side instead of ending on the left. These eases of deficient rectum may be suspected b}' the ill-developed condition of the pelvic bones, the tuberosities of the ischia being close together, and the coccyx near to the parts of genera- tion, and by the absence of all bulging in the perineum when fig. 317. the child cries. The surgeon is, however, justified in making an exploratory incision — keep- ing very close to the coccyx as he gets deeper — and if he does not find any bowel it is a mat- ter for his own judgment whe- ther to open a higher part of the gut, and if so which part. I cannot doubt that in healthy infants such an attempt to pre- serve life should be made, and that the groin is the best place to make the opening. Persons in whom this operation (Lit- tre's) has been performed in infancy have been known to live till middle life or be3'ond it in perfect health and com- fort, marrying and taking their part in all the business and pleasures of their station;'^ and though such cases are un- doubtedly very exceptional,'' still I think we are bound to give the patient the chance. M. Hug-uier has recommend- Dissection of the parts from the above case. Tlie bowel is seen with the Madder lying in front of it. The bowel terminates in a eul-de-sac, close to the skin, from which a small canal runs forward. This opens on the skin at B, and from thence an almost imperceptlTjle tube can be traced forwards as far as c, where it opens into the urethra, a marks the situation of the anus, while the incision is shown in the previous figure. — From Larcher. Translation of Holmes's Surg. Dis. of Childhood. 1 Sigr. Rizzoli has lately published several cases in which this deformity has been treated with much success. 2 See Rochard, Mem. de I'Acad. Imp. de Mi«d., 1859. 3 Holmes, Surg. Dis. of Children, 2d ed., p. 173. 668 DISEASES OF THE RECTUM. Fig. 318. ed that in these cases the opening should be made in the right groin instead of in tlie left, as would seem more natural. His reason is the occasional deviation of tlie sigmoid flex- ure to the right side in cases of deficiency of the rectum. But tliis deviation is after all only occasional. I think it better to make the opening in the left groin ; and if the end of the bowel is not found there a slight extension of the wound upwards will probably enable the surgeon to open it as it bends over to the right side. Imperforate Rectum. — In imperforate rectum (in the proper sense) the anus and the portion of bowel contigu- ous to it, which are developed, as the skin is, from the ex- ternal embryonic layer, are natural, and this almost al- ways causes the deformity to be overlooked at first. But as the child can pass no mo- tions the same symptoms come on as in imperforate anus, and then on examination with the finger the anus is found to lead into a depression, or cul-de-sac, like a thimble. The bowel ter- minates at a variable height above. Usually, as in the figure, the lower end of the gut is at no great distance; but the condition of parts may be just the same as in imperforate anus, i.e., the gut may end at the sigmoid flexure or at any higlier level. The first thing to be done is to make a free incision, through the skin and soft parts, including the cul-de-sac, from the coccyx as far forwards as the parts of generation permit, having a staff in the urethra or vagina, according to the sex, so that the bladder, uterus, and peritoneal reflexions may be avoided. The incision should be extended as deep as possible by very gradual dissection, the surgeon feeling constantly for the bulging- bowel, and when tliis is reached he endeavors to draw it down and at- tach it to the external wound before opening it. When tliis cannot be done it must be opened in situ, and the patency of the opening main- tained either by tents or, what I tliink is better, by passing the little finger gently through into the gut twice a day. But as these fistulous channels are very liable to close, it is far better, if possible, to draw the gut down. The old plan used to be to explore the parts with a trocar, but it is an undeniably l)ad one. The gut may be missed altogether, and the pe- ritoneum or some otlier part opened (as shown in Fig. 319); or if the upper cul-de-sac is readied and punctured, the escajje of air from it renders it more difficult to dissect down on it afterwards, and no punc- Iiuperforate rectum. The bowel terminates at the mid- dle of the sacrum. There is an anal cul-de-sac, separated by a small cellulo-fibrous interspace from the bowel. — After Giraldfes. DISEASES OF THE LARYNX. 669 tare with a trocar, however enlarged by subsequent passage of instru- ments, gives that free exit for the motions fig. 319. which is necessary in after life. In many cases the obstruction of the bowel is forined by a mere membrane, and all that is necessary is to make a free crucial opening and keep it distended by the daily passage of the finger for a month, with oc- casional exploration Parts removed from a case where Littre's operation was performed from time to time after- ^y ^^^- -^^ Johnstone, in a ease of imperforate rectum, after an unsuc- _ 1 cessful exploratory puncture, which passed into the recto-uterine WaiClS. ^ pouch of peritoneum, a, the uterus ; 6, a bristle passed in the course The cases of imper- of the trocar tlirough the anaJ. cul-de-sac into the peritoneal cavity, c, forate rectum in which the termination of the rectal cul-de-sac partly invested with perito- r. t oon ho fnnurl neum, and lying close to the track of the trocar ; d, the artificial anus no gUl can Oe lOUna j^ ti,e left groin— From a preparation in the Museum of the Hospital on exploration must for sick children.— Holmes's Surg. Treatment of Children's Diseases, be treated on similar p. 172. principles to those of imperforate anus with the same malformation. In fact, the presence or absence of a small anal cul-de-sac is quite immaterial. CHAPTER XXXIV, DISEASES OF THE LAKYNX. Lori/ngoscopy. — The diseases of the larynx have been brought within the fieid of actual observation, and their treatment has been rendered certain and successful, by the happy invention of the laryngoscope, an instrument which is usually regarded as the invention of Signor Garcia, an eminent musician, though tlie late Dr. Babington, of Gruy's Hospital, is believed to have a prior claim to the distinction. The late Dr. Czer- mak was perhaps the one who did more than any other laryngoscopist to perfect the details of the method and to extend and popularize its use. Laryngoscopy has now become so universal that a certain amount of familiarity with it may fairly be expected of every practitioner. The details of instruments \ary considerably, and it would be impossi- ble here to speak of their various advantages. All I shall attempt is to descrilie the essentials of the method. The laryngoscope consists, then, essentially of two mirrors, one the reflector, which is usually fixed to the forehead of the surgeon, who sits in front of the patient; and the other. 670 DISEASES OF THE LARYNX. the laryngeal mivrov or speculnm, mounted on a stem, small enough to vest between the tonsils on the lower surface of the uvula and soft palate, and inclined at an angle of 45° to the stem. A po\verful lamp is })laced behind the patient, unless the direct rays of the sun are available (which is but rarely the case). The speculum is warmed by holding its reflecting or glass surface over the lamp flame till its back is just warm enough to be comfortably borne on the cheek. If it is hotter the patient's palate will not bear it, if colder his breath will dim it. He is then directed to open his mouth widely, holding the tongue down, if he can, and breath- ing easily. A person who can show the fauces well, and who is not pecu- liarly sensitive, requires no preparation ; and if the surgeon is dexterous at the examination he can lay the speculum on the uvula and direct the light on to it so as to show the image of the larynx on it at once. This imase will be reversed, so that the epiglottis and the convergence of the vocal cords appear to be behind and their divergent extremities with the arytttnoid cartilages in front, and the right vocal cord is on the left side ofthe image. Most patients wdio are examined for the lirst time require a little preliminary exercise, especially if in the hands of an inexperienced examiner, for practice gives a precision and a gentleness in manipulating tiie mirror which are invaluable as aids to successful laryngoscopy. And there are many patients whose fauces are so narrow or so irritable that they can hardly tolerate the lightest touch of even the smallest mirror. Still, with patience on the part of the surgeon and perseverance on that ofthe patient, almost all adults can ultimately be successfully examined. In children it is sometimes actually impossible to obtain a satisfactory view of the parts. The management of the tongue is often very trouble- some. After a little practice most patients can keep it out of the way. If not, the patient may hold the tip of it out of the mouth with his hand- kerchief or a cloth, or the surgeon may depress it with a spatula. The shape of the mirror seems to me of little importance, though I prefer a round one; but it is of unquestionable advantage to use as large a one as the fauces can tolerate. With the laryngoscope all the back of the mouth and the fauces can be thoroughly examined, and in the mirror the epiglottis, arytoeno-epi- glottidean" folds, the apices of the arytenoid cartilages surmounted by the cornicula, the openings of the ventricles, the true vocal cords, and a part of the wall of the trachea (while the glottis is open) can be fully seen. In some cases where the cords are widely apart an experienced ex- aminer can direct the light so as to catch the bifurcation of the trachea.' When the parts are fully in view the patient is directed to pronounce the vowel '■'Ah " in tones varying from the lowest to the higiiest pitch of his voice, so as to throw the vocal cords into free vibration, and show whether they are as mova])le and as elastic as they should be ; their outline is carefully examined for the marks of ulceration or other injury; vegeta- tions on the cords or tumors of any other kind in any part ofthe larynx, or foreign Ijodies^can hardly escape observation; and any deviation from the natural color of the various parts will be readily appreciated by one who has accustomed liimself to the examination of the paits in health. This is, indeed, indisjicnsable. No description or Ijook of plates will en- able a surgeon to recognize morltid ai)pearances, unless he has habituated himself to the aspect of the parts in health, which is perhaps best done by auto-laryngoscopy at first, though it is also very necessary to examine 1 I think Prof. Czermiik was tho first to show this on his own person, but many dt-monstrators of iuilo-laryngoscopy have been able to follow his example. RHINOSCOPY LARYNGITIS. 671 a variety of individuals, in order to learn the wa.y of overcoming the difficulties caused by varying idios^'ncrasies, which can only be done by various little changes in manipulation. Success in l^l•^•ngoscopy can only be obtained by constant practice, and this is still more necessary in order to succeed in the delicate manipulations by which some afl'ections of the larynx must be treated. Rhinosco])}/. — The posterior nares and npi)er part of the pharynx can also be illuminated more or less completely b}- means of the laryngeal speculum, but the view obtained is far less satisfactorj- ; still, enough can in many cases be seen to enable the surgeon to diagnose with confi- dence aftections which would otherwise be only matters of inference. The instruments are the same, with the addition of a long, narrow spatula turned up at the end, or a blunt flat hook, by whicli the uvula and soft palate are to be gently raised and drawn forwards with the left hand while the mirror, which is somewhat smaller and longer in the stalk than the common laryngoscopic speculum, and has the stem a little bent downvvards near its junction with the handle, is passed to the back part of the pharynx. By slight variations of its position and of that of the reflector the surgeon tries to bring successively into view the various parts of the naso-pharyngeal region. Mr. Durham sa3's : "Under the most favorable circumstances the two superior meatuses may be inspected more or less completely, and considerable portions of the mucous mem- brane covering all three turbinated bones may be seen ; the septum may be examined throughout a great part of its extent, but the view obtained is necessarily very oblique. Some portions of the posterior surface of the velum palati may also be seen. Lastly, if the mirror is turned to- wards one side, the lateral wall of the nasopharyngeal cavity and the orifice of the Eustachian tube may be brought into view. But the dififi- culties of posterior rhinoscopy are great, and it is rarely that the cavities ma}^ be inspected to the extent indicated, although this is theoretically possilile in most eases, and has been actually accomplished in man3^"^ When the laryngoscopical appearances in health and those in disease to a certain extent have become familiar, the surgeon proceeds to learn the use of the laryngeal brush and the stem by which solutions or solid substances are conveyed to any accessible point of the larynx which may be desired ; and that of the forceps, laryngeal scissors, or guillotine, by which new growths may be removed. Laryngitis occurs either in the acute or chronic form. In the former it is a most formidable aflTection, very dangerous to life, and often prov- ing fatal in spite of the most vigorous and judicious treatment. Its causes are exposure to cold (acute catarrhal laryngitis), the poison of the contagious fevers, small-pox and scarlet fever especially, doubtless from the extension to the mucous membrane of the characteristic affec- tion of the skin (exanthematous laryngitis), the extension inwards of cutaneous or phlegmonous erysipelas (erysipelatous and diffuse cellular laryngitis), and injury (traumatic laryngitis). Chronic laryngitis may also be catarrhal, or phthisical (strumous), or syphilitic, or it may result from overuse of the voice (clergymen's sore throat, chronic glandular or follicular disease of the larynx). Besides these affections, which are found at any time of life and local- ized in the lar3'nx, there must be added to the list of acute affections the peculiar spasmodic inflammatory affection in children called croup, and Syst. of Surg., 2d ed., vol. iv, p. 259. 672 DISEASES OF THE LARYNX. the diphtheritic affections of the throat which spread downward into the air-passages. It would be out of place here to attempt a complete view of the affec- tions of the larynx. I must content myself with a general summary of the more important practical points connected with its acute and chronic diseases, referring the reader for more extensive details to Mr. Durham's excellent essay in the System of Surgery, or to some of the special treat- ises on the subject. Acute laryyigitis is characterized by the sudden accession of formidable obstruction, very liable to be complicated by attacks of spasmodic d3'sp- ncea (spasm of the glottis), in which life may easily terminate. The ra- pidity with which the disease proves fatal in some cases is well known. I have known a man, tolerably well in the early afternoon, who died four hours afterwards ; nor are such cases very rare. The complaint begins with ordinary sore throat (and probably' the catarrhal form usually com- mences in the pharynx), then feverishness and distress supervene, inspi- ration becomes difficult and painful, with some cough ; dysphagia in- creases, the patient begins to hawk up small hard masses, which are supposed to come from the ventricles of the larynx ; then the d3'spnoea rapidly increases, expiration as well as inspiration is obstructed, the face becomes livid, the features bathed in sweat, the pulse small and inter- mittent, and death follows either from spasm of the glottis, from sudden suffocation without spasm, or from more gradual obstruction preceded by unconsciousness. The treatment of this formidable disease must necessarily be vigorous and decisive if the patient is to have any chance. In the first stage, when dysphagia and dyspnoea, for which there is no other cause present, point to the spread of pharyngitis over the epiglottis to the larynx, a careful inspection of the fauces (with the larjnigoscope, if the patient can tolerate it, if not with as good a light and as free an opening of the mouth as can be procured) is essential; and if, as will probably be the case, the parts about the arytffino-epiglottidean fold are found congested and thickened they should be very freely scarified. At the same time antimony and aconite should be given in small but frequent doses. ^ If the inflammatory appearances are less decided, the patient should be in- closed in a warm, moist atmosphere, and the throat should be constantly steamed with simple steam, or the same mixed with henbane or hops; or the inflamed membrane may be carefully pencilled with a very strong solution of nitrate of silver (3j to ^j). But if, as too often happens, the symptoms advance, tracheotomy, or laryngotomy, must not be long delayed. Unfortunately it seldom saves the patient's life, but it is his on!}' chance, and the earlier it is performed the better for him. There is no necessity for opening any part of the tube lower than the cricothyroid interval in these cases. Mr. llewett has shown that the (cdema never extends below the A'ocal cords, so that the ordinary operation of laryngotomy will give the patient the means of breathing, but in most of the cases I have seen he has sunk nevertheless. In many of these instances, especially when occurring in later life, the kidneys will be found diseased ; otherwise I do not know how to account for the fatality of the affection. After the opening is established I do not tliink any further employment of depressing remedies is indicated. ' Mr. Durham prescribos two or throe minims of the Vin. Ant. with one or two drops of Tinct. Aconit. (B. P.) imd half a druclnn of Liq. Amnion. Acet. in some vehicle every quarter or half hour till some obvious effect has been produced on the pulse, and then the same less frequently. ACUTE LARYNGITIS CROUP. 673 The pulse and temperature should be watched, and the patient supplied with stimulants and nourishment in accordance with his condition. The above refers to the catarrhal form of acute laryngitis. In the exanthematous forms no scarification and no depression should be thought of. The onl}' question is, whetlier tracheotomy will give the patient any further chance of survival. When erysipelas in either form extends inwards to the larj'nx the complaint is usually fatal. Still, instances of successful tracheotomy are not wanting, and the operation should not be long delayed. In traumatic cases, as I have stated above (page 208), the operation should always be performed early, when tiiere are loose portions of car- tilage lianging into the lar3'nx, or the mucous membrane has been pene- trated by the edge of a fracture. For the treatment of the laryngitis which follows burn or scald I would refer to page 214. Croup. — The acute laryngitis of croup is not preceded by pharyngitis, as the common catarrhal laryngitis is, nor is there any diphtheritic or croupous memljrane in the phar3nx or mouth, as there is in diphtlieria. Still, the resemblance or relationship between croup and ordinary laryn- gitis on the one hand and diphtheria on the other is very close, so that many authorities regard croup and diphtheria as essentially^ the same disease, an opinion which is strengthened by observing that in epidemics of croup there are cases in which the false membrane does extend into the fauces, and which are called "diphtheritic croup." Croup sets in with feverish symptoms and a hard, dry, ringing cough, without dys- phagia, but soon running on to considerable dyspna?a, aggravated into formidable paroxysms, and accompanied by cough and expectoration, in which very commonly shreds of false membrane may be observed. In- flammation rapidly' extends down tlie trachea to the bronchi, the breath- ing becomes more oppressed, so that the sides of the neck are seen to be drawn in during inspiration, the face becomes livid, consciousness oppressed, and the child dies asphyxiated. In this formidable disease there are two stages to be considered in the treatment — the first, that which occurs before the dyspnoea has become very dangerous, when there is suHicient evidence of acute laryngeal inflammation spreading down the trachea, but the breath still comes pretty freelj'. In such cases anatomical examination would show the larynx inflamed and more or less coated with a fibrinous or leathery exu- dation, whicli extends some distance down the trachea, but does not line the whole of it nor reach the lungs. During this stage emetics, leeches to the chest, and the free use of antimony are the measures indicated. Some practitioners rely much on mercury, on account of its solvent action on fibrinous exudations ; but, as Dr. Barclay has pointed out, that action is too slow to lie available in croup. At the same time mercury may be combined with the antimony, on which latter drug, no doubt, the chief reliance is to be placed. Warm fomentation, with opiate liniment to the throat, and the creation of a warm, moist atmosphere round the bed, are decidedly useful. Most cases of croup are thus brought to a favorable issue. But in the second stage, when the respira- tion is very labored, and the subclavicular spaces are seen to be de- pressed in every eft'ort at breathing, when the child is becoming livid and oppressed, yet the lungs are not much loaded, tracheotomy becomes urgently necessary. At this period it will be found that the glottis is extensively trenched upon by the exudation which now nearly fills the larynx, and which is beginning to extend beyond the bifurcation of the 4S 674 DISEASES OF THE LARYNX. traclica. If the operation is delayed till the lungs also become much loaded it is useless to perform it. Opinions differ as to the place which should be selected for the opera- tion. My own is in favor of operating above the th^yroid isthmus; for though, if we could make sure of getting below the lower end of the in- flammatory membrane, it would no doubt be worth some risk and trouble to attain tliis object, yet the extra half or three-quarters of an inch which is the distance between the incisions in the two operations is quite use- less for this purpose, while the operation below the thyroid isthmus is in a fat child a very dangerous one. The more the disease approaches to pure diphtheria the less is the prospect of relief from tracheotom}-, though the chance of relief should not be refused, as numerous examples of recovery have been recorded, even when the patient's condition had been regarded as desperate. Larynginmuii Stn'duIuH. — Clearly distinguished from croup or diph- theria is laryngismus stridulus, or "■ child-crowing," a spasmodic affection allied to convulsions, often very alarming, but accompanied by no general fever and by no exudation, therefore having .intervals of perfect remis- sion, and to be treated, not by the administration of depressing rem- edies, still less by tracheotomy, but by bringing the child slightly under the influence of chloroform when the spasm comes on ; or, if the spasm is not very powerlul, by the use of the warm bath. The success of traclieotomy in croup will depend a good deal on the period at which it is employed. If the surgeon resorts to the operation early, and is dexterous in its performance, a large proportion of his pa- tients will recover ; but then a good man}' of these would certainly have recovered without. Nothing seems to me to show the fallacy of statis- tical reasoning in matters of practice more than the conclusions hastily drawn from the great apparent success which attends the operation of tracheotomy for croup in the hands of the surgeons who perform that operation very frequently. Without denying that an early resort to tracheotomy may be better practice than waiting till the child is nearly in extremis, I would point out that this conclusion rests on observation, and cannot be proved by quoting numbers. Chronic Laryngitis — Phthisical. — The constitutional forms of chronic laryngitis are all marked by the prominent symptom of aphonia rather than by any danger to life, though any of them may become dangerous to life when complicated with ulceration, since that ulceration may irri- tate the vocal cords and produce spasm of the glottis, or may extend to the cartilages, and portions of the necrosed cartilage may become dis- placed or entirely loose and act as a foreign body.^ In "phthisis laryn- gea" the disease consists, as it seems, in tlie development of tubercle beneatli the mucous membrane of the epiglottis and larynx, which runs on witi) more or less rai)idity to ulceration, leading to loss of voice, destruction of tlie epiglottis, dysphagia, cougii, expectoration, necrosis of the cartilages, and death. Asa general rule the disease in the larynx is only a part of tlie general affection, and tlie patient's death is due to the disease in the lungs; but in othei- cases the complaint commences in the larynx, and may, iiideed, be confined to it. The treatment of the disease must, of course, be regulated by the general condition. When the lungs ' There is even a case on record in whieli a diseased gland made its way by uleera- tion into the trachea, and a |iortioii of it dropped into tlie tube, producing the usual syni[)tonib of foreign body. FOLLICULAR LARYNGITIS. 675 are profoundly affected notliing can be done beyond soothing the patient's sufferings by steaming the lar^'nx from time to time with hot water mixed with henbane or sti'amonium, touching any ulcers which may he visible on laryngoscopic examination with a wire coated witli nitrate of silver or with a solution of nitrate of silver on the laryngeal brush, and enjoining rest to the laryngeal organs as much as possible. Even in these hopeless cases, however, Mr. Durham urges the occasional justifiability of trache- otomy as a palliative, if the patient is greatly troubled l)y pain or diffi- culty of breathing ; while there are doubtless cases in which the laryngeal disease is the essence if not the whole of the complaint, and in which tracheotomy is urgently indicated. S[/pJiilitic larijngitix is either secondary or tertiary, and the affections of the larynx apjiear to bear a general resemblance to tlie secondary and tertiary |)lienomena of syphilis in other parts of the body. Thus the seconciary laryngitis seems to depend usually on the spread of roseola or psoriasis from the throat, or to the development of similar affections, or of mucous tubercles on the laryngeal mucous membrane. Secondary ulceration may also spread from the fauces down to the larynx, and may either destroy the vocal cords partially or completelj', or maj' so displace and bind them down as to prevent their proper action, and so lead to per- manent aphonia. Secondary laryngitis as a rule involves no worse consequence than loss of voice, which is usually only partial and temi)orary, though when ulcer- ation or inflammation occurs in the neigliborhood of the cords the patient is, of course, never free from the danger of spasm. The tertiary affections of the larynx are more deep and more dangerous. Some of them seem to consist in warty growths in tlie larynx, not unlike the syphilitic vegetations or condylomata found elsewhere ; but the chief tertiary affection of the larynx is ulceration, which rapidly extends to the cartilages and vocal cords, destroying the larynx as an instrument of voice and producing the most serious danger to life. Syphilitic affections of the larynx can usually be diagnosed from other diseases by the concomitant symptoms; but in any case of doubt the effect of anti-syphilitic remedies will assist the diagnosis. The exhibition of mercury in the form of calomel vapor, inhaled through a moutlipiece attached to the common mercurial lamp, or the repeated application of the Liq. Hyd. Perchlor., pure or diluted with an equal bulk of water, are the most useful applications in sypliilitic sore throat. In secondary affections the i)atient should undoubtedly be brought fully, though grad- ually, under the intiuence of mercury. In the tertiary stage of the disease iodide of potassium with tonics may be given internally while the local mercurial treatment is being carried on. In these, as in all other ulcera- tive diseases of the larynx, the surgeon must be prepared for the necessity of tracheotomj', and must not let his patient die or run an}' serious danger of dying for want of an opening tlirough the cricothyroid membrane. Follicular Laryngitiii. — The follicular disease, or dysphonia clericorum, has its seat in the glandules or follicles of the mucous membrane, and is often accompanied by a similar affection of the mucous membrane around. "The membrane covering the aryta?noid cartilages and immediately adjoining parts is more rich in glandular structures than any other por- tion of the laryngeal mucous membrane. Now, this part is constantly subject to a very great extent of motion, and also perhajis to considera- ble strain, during forced vocalization." — (Durham). Thus is explained the prevalence of this complaint in those whose occupation leads to con- stant exertion of the voice, though it occurs in others also ; in photogra- phers, according to Gibb, who are exposed to acrid chemical fumes ; and 676 DISEASES OF THE LARYNX. in persons laboring under the herpetic diathesis, according to Trousseau and others. '' The symptoms are : alteration of the voice and sense of effort in sus- taining it — these are by far the most prominent and constant symptoms ; more or less discomfort about the larynx, never amounting to pain, but occasionally troublesome ; dryness and sometimes a sense of heat about the throat; and constant desire to clear the throat by 'hemming' and ' liawking.' There is little or no regular cough ; and the expectoration which sometimes occurs is slight, scanty, and mixed with saliva. There is neither difficulty in swallowing nor tenderness upon pi-essure over the larynx. There are no definite constitutional symptoms, but the general health and spirits of the'patient are otlcn observed to be more or less depressed." ' The voice is much affected in these cases, and especially in distinct or loud speaking or reading. The mucous membrane of the fauces and throat as well as that of the larynx is seen in the early stage of the com- plaint studded vvith enlarged glands, surrounded by an area of redness, and at a later period these may have formed small points of ulceration ; but it does not seem that the deeper structures are liable to disease or that the larynx is ever incurably disorganized. The local treatment consists in the persevering application of astrin- gents, nitrate of silver, tincture of iodine, sulphate of zinc or copper, in such strength as is found to be suitable, toucliing the ulcerated parts with the solid nitrate of silver, and the inhalation of pulverized solutions of "common salt, chloride of ammonium, iodide of potassium, and in some cases alum or weak solution of perchloride of iron." Mr. Durham says also that benefit may be derived from sucking medicated lozenges (ciiloride of ammonium, with or without cayenne and the "red gum lozenges ") and from wearing the beard. The general health must be care- fully attended to, and the patient may be comforted with the assurance that though the treatment may be tedious tliere is every reason to hope for complete success.. Tumors of the Larynx. — The diagnosis of tumors of the larynx is due exclusively to the laryngoscope. Formerly, though tiie existence of such a tumor miglit be guessed at, it could never be affirmed. Now they can be seen, and^ what is of far more importance, tliey can often be removed without any incision or any inconvenience whatever, and the patient in some instances restored to tlie full use of the voice, and in all rescued from the imminent danger of suffocation which is incident to the presence and growth of a tumor in the neighborhood of tlie glottis. Most of the tumors which affect the larynx are common warts or papil- lomatous growtlis,'^ which spring up from any part of the mucous mem- brane, sometimes in considerable number, and often grow to a very large size. They are sometimes congenital. They are said to spring more commonly from the front of the larynx, near the convergence of the vocal cords, tliough they may grow in any part of the cavity. Fibrous and fibrocellular tumors are next in number, some of which are sarcomatous and grow rai)idly ; otiiers are pedunculated, like the l)olypi of otlier parts. Adenoid growtlis are rare, and grow from the base of tlie epiglottis, the arytaeno-epiglottidean folds, or the membrane covering the epiglottis. 1 Syst. of Siirg., 2d ed., vol. iv, p. 548. 2 Out of 244 case.* of hiryngoiil tumor collected by Mr. Duriinni 110 were of tliis nature — 19 only were cancerous. TUMORS OF THE LARYNX. 677 A few instances of cystic, cartilaginous, and osseous tumors are also recorded. These are tlie innocent forms of tumor — the cancerous growths are mostly epitheliomatous, though instances of soft cancer are not want- ing. Epithelioma is generally an extension from the pliar>'nx ; but it sometimes begins, as Mr. Durham describes it, on the mucous membrane lining the back of the cricoid cartilage, and doulttless in other parts of the larynx also, in the form of small irregular nodules, which gradually in- crease in size and soon ulcerate. In any case the tumor will soon present an ulcerated surface, and can then be recognized from the other forms of ulceration by its elevated edge, by its dirty gray color, by the amount of new deposit, causing irregular thickening in the parts around, and in some cases by the presence of enlarged glands. The symptoms caused by a tumor of the larynx are the same as those accompanying an}' other chronic affection, viz., aphonia, more or less com- plete ; hoarseness, cough, occasional dyspnoea, sometimes aggravated into fits of si)asm, and in some cases (chiefl_v those of cancer), more or less dN'sphagia. The more movable and pedunculated the growths are, the more liable are tliey to cause spasm of the glottis, while the degree of permanent obstruction of course will depend mainly on the size of the growth. The diagnosis can only be arrived at by laryngoscopy, unless in the rare instances (chiefly in childhood) in which the growths can be felt by passing the finger round the epiglottis. The treatment of a tumor of the lar^'nx is directed to fulfil two different indications, viz., either to remove the growth altogether or to protect the patient from the danger of suffocation liy tracheotomy. Of the perform- ance of laryngotomy or tracheotomy, in order to avert suffocation by a tumor, I need say nothing further; the indications are the same as in spasm of the glottis, or alarming dyspnoea from any other cause. There are various ways of removing laryngeal tumors. There may be small warty elevations hardly deserving the name of tumors, yet quite suffi- cient, if seated on the cords, to produce aphonia, and which ma}' be repressed by touching them with the nitrate of silver, fused and ai)plied to the end of a bent wire, or by means of a wire carefully conveyed down to them and connected with a galvanic battery ; but this last manoeuvre is a very delicate one, and the surgeon must first well exercise himself and his patient to see that he can always bring the wire into unfailing contact with the little growth. Removal from the Moulh. — More commonly, however, the growths which are large enough to produce symptoms, are also large enough to be seized and removed by delicate forceps of appropriate shape and con- struction, or by a snare or ecraseur, constructed on the same principles as Hilton's snare for nasal polypi, figured on p. 600, with the necessary modifications in size and shape ; or by a knife, scissors, or guillotine, i. e., an instrument which is slipped over the tumor, and pressure on a handle then projects a blade which cuts it off. Laryngeal grovvths have also been removed b}^ the galvanic cautery, though the method seems unnec- essarily dangerous, and those which are cystic have disappeared after simple puncture. In all cases where it is possible the method of removal from the mouth ouglit to be adopted. But sometimes, from the age of the patient, from his intolerance of the necessary manipulation, or from the size and attach- ments of the tumor, it may become necessary to remove it by external incision. Thyr-otomy, as the operation is called, is an extension of laryngotom}' , 678 DISEASES OF THE LARYNX. the incision into the larynx being continued upwards between the alae of the th3^roid cartilage. It is best done, I think, at two different sittings. The usual oi^ening having been made through the cricothyroid membrane, the patient is relieved from all danger of suffocation, and the common tube is introduced. Then, at a subsequent da}', a tube can be substituted which has a notch in its upper or convex wall. Into this notch the knife is inserted (the patient being, of course, fully narcotized, which is readily effected by administering the ansestbetic through the tube), and the in- cision is slowly and cautiously carried along the middle line of the pomum Adarai, so as to wound neither vocal coi'd, till the thyrohyoid membrane is reached. A couple of blunt hooks will now drag the two halves of the larynx apart. If there is much bleeding (as there often is) a piece of sponge must be firmly pressed into the larynx till it has subsided. The patient is all this time breathing quietly through the original tube. On the subsidence of the bleeding the whole interior of the larynx, with the mouths of its ventricles, will be exposed, and the tumors can be cut away, their bases cauterized, and any other manipulation carried out most satisfactorily. The same proceeding is sometimes required for the removal of foreign bodies impacted in the ventricle (see p. 211). E-xtirpation of the Larynx. — Latterl}^ in Germany, still more extensive operations have been practiced for malignant disease of the larynx, all the parts affected having been removed, so as to extirpate the whole larynx and lay the pliarynx freely open. I have no experience of this formidable operation, and should be disposed to believe that it will not ultimatel}' Itecome received into general surgery; but I think it right to direct the reader's attention to the possibility of its performance, and will quote the following account of a case recently operated on by Pro- fessor von Langenbeck. The patient had had tracheotomy performed previously^ chloroform being administered through the tube: " A transverse incision was made above the hyoid bone, and a perpen- dicular one carried down from it; and the two flaps of skin having been turned aside, the diseased parts were removed. The specimen was shown b}' Dr. von Langenbeck, at a meeting of the Berlin Medical Society. The anterior wall of the oesophagus and pharynx was divided, the larj'nx cut away, and the hyoid bone sawn through in the middle. The disease, which was cancerous, had involved the upper part of the larynx, the epiglottis, and the hyoid bone to such an extent that it was difficult to distinguish the several parts. The inner surface of the cricoid and thy- roid cartilages as far as the laryngeal pouches and the inferior vocal cords were free. The disease commenced close above the ventricles of the larynx, in the form of nodular masses which completely filled the upper part of the organ. The arytenoid cartilages and the arj'tfeno-epiglottic ligaments, the hyoid bone, and the base of the tongue, were all involved in the disease, and were removed. A week after the operation the patient was free from fever, and his general condition was satisfactory."^ Aphonia^ Nervous and Hii^terical. — Aphonia, besides being a symptom of all chronic laryngeal diseases, occurs also from causes unconnected with any disease in the larynx. The nervous or hysterical aphonia, which is often seen in young women — though sometimes in men — is an affection not very well understood, and sometimes devoid of any other symptom of iiysteria or nervous disease, tliough agreeing with such disorders in the fact that there is no visible degeneration of tissue in the parts af- ' Brit. Med. Jour., Aug. 21, 1875. SPASM OF THE GLOTTIS. 679 fected, and that the function may often be completely and immediately restored without any visible cause for the change. In a case of this kind laryngoscopic examination will show all the parts of their natural appearance, but the motion of the cords is variously af- fected. The voice sometimes appears and disappears quite suddenly, and in all cases there is the same want of proportion between any recog- nizable cause and the presumed effect which is noticeable in other "■ ner- vous mimicries." There may have been some little cold or some extra exertion of the voice alleged as the cause, but this is wholly insufficient to account for a total inability to speak. These cases often get well of themselves, or any method of treatment may cure them — the mere introduction of the laryngoscope has produced a return of the voice.' The approved methods of treatment seem to act by giving the patient a shock — a "shake-up," as Mr. Durham terms it. Such are the pinching or squeezing of the larynx, the application of gal- vanism either to the cords themselves or to the parts near them, the ap- plication of strong or irritating lotions to the interior of the cavity, such as solutions of nitrate of silver or sulphate of copper, and the applica- tion of irritating fumes, as those of solutions of ammonia or chlorine. Aphonia is said also to result from idiopathic atrophy of the muscles of the larynx, but on this head little,, I believe, is known. Aphoina from Paralysis. — Usually, when a patient has lost his voice and ori lar3aigoscopic examination one of the vocal cords is seen to be motionless, the cause is to be sought in pressure on the recurrent nerve, and the commonest cause of that pressure is either an aneurismal tumor, especially aneurism of the aorta pressing on the left recurrent, or an en- larged gland, or a malignant tumor in the thorax or neck. It is not very uncommon for a person to be unaware of the existence of aortic aneurism until the attention of his physician is called to the part by either paraly- sis or spasm of the glottis. And there seems good reason to believe that the pressure of a tumor on any part of the windpipe may set up irrita- tion in its substance which may lie so reflected down the nerves of the part as to produce either paralysis or spasm of the cords without any direct interference with the nerve-trunks. Spasm of the glottis is one of the most painful and most fatal of all surgical accidents. It comes on from the most various causes, and may terminate life in a few minutes, if prompt help be not given. That help lies in the immediate opening of the windpipe below the glottis; and when, as sometimes happens, a patient is found in obvious and imminent danger of death from spasmodic dyspnoea, of the cause of which the by- standers can give no account, the surgeon's duty is to make an opening at once through the cricothyroid membrane, and if necessary perform artificial respiration through the opening. But what has been said above is sufficient to show that in many cases of spasm of the glottis the im- mediate opening of the windpipe is unnecessary, and fortunately it is only in rare emergencies that we have not the opportunity for more de- liberation in the treatment. The chief causes of spasm of the glottis have been pointed out in the foregoing pages. They are : Foi'eign bodies fixed in the larynx or loose in the lower part of the windpipe when they impinge on the cords, burns and scalds of the larynx, inflammation and ulceration (whether acute or chronic) trenching on the neighborhood of the cords, tumors when they 1 See Durham, in Syst. of Surg., 2d ed., vol. iv, p. 592. 680 DISEASES OF THE LARYNX. move so as to get between the cords, aneurisms, tumors, and enlarged glands irritating the recurrent nerves or pressing on the windpipe, and central irritation, such as is often seen in tetanus and less frequently in cerebral affections. The treatment of all these conditions has been dis- cussed, as far as the}' fall within the surgeon's province, and the neces- sity of tracheotomy under certain circumstances pointed out. I would merel}' add that the patient's safety is best consulted in circumstances of doubt b\' resort to operation, rather than by hesitation, which may at any time involve fatal consequences. Bronchotomy. — The windpipe may be opened in three different posi- tions, viz., between the cricoid and thA'roid cartilages, above the thyroid isthmus and below it. All three operations are often comprised under the comnion name Tracheotomy, which is thus used as synonymous with Bronchotomy, meaning any operation by which an artificial opening for respiration is made: otherwise the word Bronchotomy is used for all the operations on the air-passages, while the term Tracheotomj' is restricted to the operation below the thyroid isthmus, that above it being called Laryngo-tracheotomy, and the operation through the cricoth3'roid inter- val Laryngotomy. Laryngotomy is the easiest of the three. Nothing is necessary except to keep in the middle line, to divide the skin pretty freely from the th3'- roid to the cricoid cartilage, and to cut through the cricothyroid mem- brane entirely from the lower border of the thyroid to the top of the cricoid cartilage, and then insert the tube. In urgent cases there is no need to make any preliminary incision. The knife can be plunged direct into the windpipe, and the tube may follow it at once. No vessel of im- portance can be injured. The little anastomotic arch formed by the cricothyroid arteries never, as far as I know, furnishes more than slight haemorrhage, whicli is stopped at once by the pressure of the tube. Laryngotomy is often required under circumstances of urgency when no tube is at hand. A pair of forceps, or in the last resort the blades of a pair of scissors, or a couple of hairpins or pieces of bent wire, will suf- fice to keep the wound open, and if necessary the operation can be done with a common penknife. This operation is suflficient in all cases which involve only the vocal cords or the tissues above them. It is, therefore, practiced in spasm of the glottis from all causes, including burn and scald, in erysipelatous affections spreading down the throat, and in cases of foreign body lodged in or above the glottis. Opinions differ as to the operation which is to be employed in cases of laryngitis and croup, as to which I have already expressed my own. Lary I) go-tracheotomy consists in making a freer incision than in laryn- gotom3' from the lower border of the pomum Adami to about three- quarters of an inch below the cricoid cartilage, dissecting the parts till the trachea and the isthmus of the thyroid body are plainly seen, and plunging the knife into the windpipe with its back to the thyroid isthmus and cutting upwards through the two upper rings of the trachea and the cricoid cartilage. This operation is chiefly used in childhood, when the small size of the larynx seems to forbid lai-yngotomy and the depth and shortness of the neck renders tracheotom3' dangerous. Tracheotomy Proper. — Tracheotomy below the thyroid isthmus re- quires a freer opening and a deeper dissection. The extent of the in- cision will, of course, be proportioned to the thickness of the neck. In a TRACHEOTOMY. 681 short, deep neck there is no objection to extending the incision from tlie cricoid cartilage to the episternal notch, bnt this is rarely requisite. An average incision would be from an inch and a half to two inches down- wards from the cricoid cartilage. Having divided the skin and deep fascia, the sternothyroid muscles may be seen touching each othei- in the middle line, and these parts should be drawn asunder with hooks. Any vessels (arteries or veins) which bleed freely had better be tied ; the lower border of the thyroid isthmus will be recognized, and may be drawn lip vvith a hook if it is unusually broad. The trachea should be dissected clean till three rings are seen fairly exposed, and should then be opened in the whole extent whicli is denuded, with the edge of the knife turned upwards. Then the tube is to be inserted. If the thyroid isthmus comes down unusually far it is safer to divide it in the middle line than to risk a deep dissection close to or under the sternum. In following the other course I once lost a patient from wound of a branch close to the innomi- nate vein. There are a few precautions which are essential to success in all these operations. The first is to keep in the middle line, and this is not always easy in cases which are operated on late at night under urgent circum- stances. The head ought to be extended, as much as is possible without increasing the dyspnoea, by putting a pillow under the neck and shoulders ; and the surgeon, if he has no trained assistant, must see that the head is held firmly and the body kept straight. Next it is desirable to stop bleeding before the trachea is opened ; but if the bleeding is merely venous or capillary, and from a number of imperceptible vessels, the best plan is to make the opening at once. If a gush of blood passes into the windpipe the patient must be instantly turned on his face, and it will run out again. The free admission of air into the lungs will relieve the venous congestion and the haemorrhage will cease. It is most important to make a free opening at first, so that the tube has ample space. I have seen the patient die while the operator was vainly endeavoring to force a tube through an opening too small for it, and thereby of course increasing the dyspna^a. There is no objection in most cases to the administration of chloroform, nor is there usually an}' reason for hurry in the dissection. A quiet and methodical dissection may take a minute or two longer than one where haste is the only thing thought of; but it really often saves time, as it fig 320. enables the operator to insert the tube at once, instead of boggling about it. As to the insertion of the tube there is not generally any difficulty if the windpipe has been opened with the requisite free- dom. The old solid canula is now rarely UJ used. Fuller's bivalve canula is the one most commonly met with ; but Durham's Fuller's bivalve tracheotomy canula. lobster-tail director finds its way in ver}' The canula is introduced with its blades easily, and enables the surgeon to glide in «'°^«','^- Then, by depressing the handles , /^ \ ... Txri 5 /.to the position marked by the dotted the tube very readdy. Whatever form of ,i„es_ the blades are opened, and a tubular tulje is used it must be double, for it will canula is introduced between them. soon become obstructed with mucus, and the inner tube must often be withdrawn for the purpose of cleansing it. For the same reason the inner tube must project beyond the outer one, otherwise the withdrawal of the inner tube might leave the outer one obstructed. When the double canula is securely lodged in the trachea it must be 682 DISEASES OF THE LARYNX. tied in with a piece of tape round the neck ; and if there is any super- tlnons incision it may be united with one or two stitches. Several dan- gerous complications may occur after the operation. The secretion (especially in the diphtheritic affections) will collect in the tube and must Fig. 321. Durham's canula, with " lobster-tail" director. be assiduously removed by passing the feather of a pen down the inner tube, and when this no longer serves, by removing the inner tube and clearing it. It may even become necessar}' to remove the outer tube also and draw up the croupous membrane out of the trachea. I haA^e seen a complete cast of the trachea and bronchi thus removed with immense re- lief to the dyspno?a. Again, the pressure of the end of the tube against the windpipe some- times produces ulceration of the trachea, which has even been known to extend into the innominate artery, and still more frequently induces tracheitis and bronchitis. To obviate this Mr. Bryant has devised a canula in which the shield lying on the skin is jointed to the stem which rests in tlie trachea, in order that the tube may follow the motions of the windpipe. But the presence of the foreign bod}^ must always cause some irritation, and this seems often to be the starting-point of general tra- cheitis and bronchitis. Another frequent complication is that the fluids run down from the mouth into the larynx, and so are expelled from the wound. I have Fig. 322. Bryant's cauula. The shield is movable on the neck-plate by means of a joint, and can be shortened if required. already spoken of tlie same distressing complication after cut throat. After tracheotomy it seems to depend on the obstacle which the presence of the foreign body causes to the elevation of the larynx under cover of the epiglottis, and possibly to effusion into the arytoeno-epiglottidcan folds from inflammation. It is very desirable to restore the natural respiration as early as possi- ble after traciieotomy, and dispense with the canula. Not only is the foreign Ijody a constant source ol" irritation, but the vocal cords ma_y get more or less consolidated together, and even in some cases the upper DISEASES OF THE EYE. G83 part of the larynx nearly obliterated. A canula should be inserted having an opening in its eonvexity looking towards the glottis, through whicli the air can pass in expiration, and a valve ap[)lied to its moutli, so that the air can be drawn inwards in insi)iration, l)ut the valve then shuts. If it is found that this cannot be borne and tliat the glottis seems ob- structed, the patient should be narcotized and a bougie passed tlirongh the glottis, to break down the adhesions. CHAPTER XXXV. DISEASES AND INJURIES OF THE EYE. By R. B. Carter, Ophthalmic Surgeon to St. George's Hospital. The great importance of the eyes as the instruments of the visual function, their accessibility to many kinds of examination, and tlie trans- parency of many of the structures of which tliey are composed, have combined to invest their diseases with much attractiveness, and to render them objects of speciall3^ careful and painstaking research. Tiie benefits hence arising are attended by the disadvantage that it is scarcely possi- ble, in the space which can be devoted to tlie subject in this work, to pre- sent anything more than a sketcli in the liarest outline of the present state of Ophtlialmic Surgery ; and by tlie still greater disadvantage tliat surgical students are apt to look upon tlie subject as one which is especially re- condite or difficult, and hence, doubting whether they will have time to master it, to turn from it without even tliat moderate degree of attention which is necessary in order to enable -them to deal skilfully with the com- mon forms of eye disease which constantly present themselves in practice. Than this there can be no greater error, for these common forms are as a rule extremely easy of recognition, and are highly amenable to well- directed treatment. AccesKibility of the Organ. — Perhaps the first consideration which should be impressed upon the mind of the student is the importance of utilizing to the utmost extent the accessibility and the transparency of the eye, in such a manner that he may become acquainted with all the facts of every case which is brought under his notice. Errors of diag- nosis in the ordinary forms of eye disease are scarcely possible to any one who habitually practices careful scrutiny of the affected tissues ; and in this, even more than in any other branch of surgery, haste and careless- ness are the most frequent sources of mistake. A general observance of the cardinal rule never to prescribe for an inflamed eye without making sure that no foreign body is either imbedded in the cornea or lodged beneath the lids, without looking to see whether either the cornea or the iris is implicated in the inflammation, and without determining the pres- ence or absence of heightened tension of the globe, would do much to withdraw ophthalmic diseases from the domain of specialists, and to re- store ophthalmic surgery to the general body of the art. Sujyerfieial Examination. — Tlie first glance at a patient will often suf- fice to show to an ordinarily careful observer in what direction disease of the eves is to be looked for. Sometimes there will be manifest coarse 684 DISEASES OF THE EYE. external changes, such as swelling and redness of the lids, with or witli- ont exudation at their margins; sometimes there will be manifest con- gestion of the ocular surfiice, witli or without discharge, and with or without loss of tlie natural polish and brightness of the cornea; some- times thei'e will be evidence of failing vision in the gait, the aspect, and the manner of approacli ; sometimes, in the absence of all the foregoing conditions, there will lie complaint of speedy fatigue or dimness of sight wiien the eyes are employed upon near objects. Any clue which may be thus afforded must, of course, be taken as a guide to further inquiry, but must not be accepted, without complete examination, as containing or expressing the whole truth of the case. For instance, it is not very uncommon in hospital practice to see patients who have been energeti- call_y treated for an inflamed eye by leeches and local applications, but in whom the presence of a foreign body under the lid, or even imbedded in the cornea, has been overlooked by some one who was more ready to prescribe than to practice careful scrutiny. The EijeliiU. — It is most convenient to consider the diseases of the eye in an anatomical order; and the eyelids first present tliemselves for examination. Being covered externally b}' the common integument, the}^ are exposed to all the morbid changes to wliich it is prone, and may be the seats of inflammation, of ulcer, of eruptions, of ntevi and other growths, all of which conditions pass into the domain of general surgery. Regarded only as appendages of the eye, they are liable to tumors caused by obstruction of the ducts of the Meibomian glands, to distortions of shape caused by the shrinking of inflammatory effusions, to alterations of position caused by excessive or perverted muscular action, and to chronic inflammation of the follicles of the hairs which fringe their mar- gins. They are also liable to marginal boils, which do not differ in any essential resi)ect from boils elsevvhei'e, but whicli are called "styes," and require especial consideration, on account of their tendency to destroy the eyelashes. Tamal Tumoi's. — When the duct of a Meibomian gland is obstructed at its orifice tlie duct itself becomes visible through the inner portion of the tarsal cartilage as a white line, which is sometimes sutiiciently promi- nent to produce mechanical irritation of the eye. This condition is most common in gouty people, in whom the retained secretion is often rendered still more irritating l)y becoming the seat of chalky deposit. In such cases the margins of the lids may be soaked with a warm alkaline lotion, con- taining perhaps ten grains of bicarbonate of soda to an ounce of water, in the hope of dissolving the accumulated secretion at the orifice, so that tiie rest may I)e forced out by pressure along the inner surface of the lid. If this method does not succeed, tiie white line may be split with the point of a sharp lancet, and the little cylinder of fatty or clialky matter turned out of its bed and removed. Wlien the obstruction is in tlie channel of a duct, above its orifice, the ordinary' result is the formation of a small hemispherical tumor, fixed in the tarsal cartilage, and projecting exter- nally. The skin is freely movable over such a tumor, and is unchanged in appearance; but when the lid is everted the base of the tumor appears as a thinned and discolored spot on the cartilage. If left alone the tumor will eventually suppurate, and will in most cases discharge itself through the cartilage and conjunctiva rather than through tiie skin, in the former case leaving a l)utton of granulation projecting from the orifice by which tiie pus lias escajjcd. This button may for a time be a source of irrita- tion, but it will eventually disappear. The tumors are harmless, but in- BLEPHARITIS. 685 convenient and nnsiglitly, and they ma}' be got rid of hv a simple incision through the tliinned cartilage. If this gives exit to pus nothing more need be done; but if suppuration has not taken i)lace the tumor will con- tain semi-transparent gelatinous matter, and is then lined by a secreting membrane. In such case the contents must be emptied out by a scoop or by pressure, and the lining membrane must be lacerated in all direc- tions by the point of a knife or cataract needle, in order to excite sufficient inflammation to destroy its secreting pro|)erty. When this is done the cavity will fill with blood, and then, in the course of a few weeks, the swelling will dwindle and disappear. Should it fail to do so it may be punctured again, and its lining membrane scarified moi'e effectually than before. A patient who has once had such a tumor will l)e liable to others, because, as in the case of sebaceous cysts, there seems to be a special proclivity on the part of some persons to obstruction of the ducts or orifices of glands. Blepharitis. — The inflammation of the hair-bearing margins of the e3elids, which has been called ophthalmia tarsi, tinea tarsi, l)lei)liaritis, and l)y other names, is almost confined to the children of the poor, and seems to be due either to the direct influence of dirt and atmosi)heric irritants, or to contagion. The seat of the disease is in the follicles of the eyelashes, and it is essentially an ulcerative inflammation, atfecting the lining of these follicles. It usually commences in the upper lid, near its middle portion, and first shows itself by the formation of a scab or crust, which cements together the bases of three or four of the cilia. The maroin of the lid, at the point corresponding to the scab, is somewhat swollen, and the swelling extends a line or a line and a half upwards. The skin cover- ing the swelling is seldom reddened, but is usually smooth and glossy from tension. The size of the swelling is about equal to that of the scab, and the whole matter looks very unimportant. If the scab is softened and removed, it may be seen with a magnifying glass that the orifices of the hair-follicles are patulous, and that they yield a small quantity of thin discharge. This, mingling with the secretions of the adjacent Meibomian and sebaceous glands, dries into the crust which is characteristic of the malad}-. The inflammation appears to commence near the orfice of each follicle, and gradually to spread to its deeper parts, killing and loosening the eyelashes as it proceeds. The secretion is either contagious or is at least actively irritating, so that the disease spreads along the margin of the lid from its original centre, and appears liefore long in the lower lid also. After a time the swelling of the lid-margin removes the lower lachrymal punctuni from contact with the eyeball, so that the tears are no longer carried into the nose, but lodge and overflow and become additional sources of irritation, often giving rise to inflammation of the conjunctiva, and to the development of bloodvessels beneath the corneal epithelium. The effusion which forms the marginal swelling of the lids undergoes gradual contraction, which curves and everts the tarsal cartilages, while the persistent follicular inflammation destroys the eyelashes, or leaves them weak, scanty, distorted, and useless. The edges of the lids become bare, red, everted, and unsightly, the tears overflow the cheeks, the con- junctiva is highly vascular, and the cornea is clouded by active inflam- mation or residual opacity. Such are the results of neglected blepharitis. Treatment. — In its early stages the malady yields readily to treatment. It is then onl}' necessary to remove the crusts by soaking them with a warm alkaline lotion, and to apply an astringent to the inflamed surface beneath. A good lotion is made by dissolving five grains of bicarbonate of soda in an ounce of hot water; and the best astringent for home use 686 DISEASES OF THE EYE. is an ointment of tlie precipitated yellow oxide of mercniy, which may be. thrown down by any alkali from a solution of the perchloride. This ointment is commonly known as Pagenstecher's, and has many uses in oplithalmic surgery. For blepharitis it should contain about twenty grains of the oxide to an ounce of simple ointment. It is necessary to remove the crusts and apply the ointment once a day, and to persevere with this plan for some little time after recovery is apparently complete. If the application is too soon abandoned the disease will again creep out of t he follicles, and speedy relapse will occur. In cases which resist treat- ment the surgeon should himself remove the crusts, and should pencil the exposed surface with a fine point of nitrate of silver, diluted b}' having been fused with an equal weight of nitrate of potash, and then run into a mould for use. In the chronic cases, in which structural mischief has already taken place, in which the eyelashes are destroyed and the lids everted, little more can be done than to slit up the lower lachrymal cana- liculus as far as the caruncle, so as to permit the escape of tears, and thus to diminish the discomfort of the patient. Sii/es. — The little marginal boils whicli are called styes do not differ in any essential resjiect from boils in other parts of the bod3% and, like tliem, tliey generally indicate some derangement of health, to which at- tention should be paid. They run an ordinar}' course in a brief period of time, and woulcl be of little importance were it not for their tendency to destroy the hair-follicles, and thus to occasion unsightly gaps in the row of eyelashes. On this account, while an endeavor is made to prevent their recurrence b^' constitutional treatment, it is desirable to check the development of each individual boil, which may be done, if it is seen sufficiently early, by pulling out an eyelash from the centre of the little pimple, and then touching it with a fine point of nitrate of silver. If supi)uration cannot be pre\'ented a poultice and an earl}^ incision will be desirable ; and, if there is no special indication for constitutional treat- ment, the administration of the tincture of perchloride of iron will often prove advantageous. Malposition of Eyelashes. — Perverted growth or direction of the eye- lashes, by which the}- are brought into contact with the eyeball, and l)e- come sources of irritation and even of ulceration, is met with under three different conditions: first, as a result of hypertrophy or redundancy of growth ; secondly, as a result of incurvation of the tarsal cartilage by tiie contraction of inflammatory products in the conjunctiva; thirdly, as a result of disi)lacement of tlie cartilage by muscular spasm. Tlie first variety is most commonly a remote consequence of a slight degree of Idepharitis; the second is a remote consequence of the more severe forms of conjunctivitis; the third occurs chiefly in elderly persons, is confined to the lower lid. and occasionally follows operations upon tlie eye. Redirndancij of Eyi'lashes. — Redundancy of growth of cilia is usually met with only on some small portion of the margin of the upper lid, and generally near the outer cantluis. The superfluous hairs may be i)lucked out from time to time with forceps ; and if this is done frequently, the follicles from which they spring will sometimes undergo atrophy. In other cases epilation will rather tend to the production of a more active growth; and then the portion of cartilage containing the follicles may be excised without sacrifice of skin, or the follicles may be destroyed bj' in- cluding tlicm in a thread of silk, inserted after the manner of a seton, and left until it produces suppuration. When the cartilage is incurved the beist method of treatment is U) split it into an anterior and a posterior layer, b}' the careful use of a thin and keen scalpel. The middle portion AFFECTIONS OF THE LIDS. 687 of the anterior la^yer may then be excised in a horizontal direction, in- cluding skin and orbicularis muscle, and the lower strip, carrying the eyelashes, may be transplanted upwards and secured by sutures, leaving the lower margin of the posterior layer exposed. No dressing but the dried blood is required, and the disfigurement of the lid which is at first produced will be recovered from in the course of a few weeks, leaving the lashes permanently removed from the eye. The inversion of the lower lid by muscular action may sometimes be overcome by the applica- tion of sticking-plaster or of contractile collodion, but will more fre(piently require the excision of a strip of skin and muscle, which should l)e \evy narrow, and should be taken from immediately below the tarsal margin. When inversion follows an operation upon the eye, excision of skin should, in most cases, be performed without delay, as otherwise the me- chanical irritation of the displaced lashes may produce disastrous conse- quences. The good result of the operation depends chiefly on the re- moval of the marginal portion of the orbicularis; and, if too much skin is taken, absolute eversion of the lid may be the result. Ectropium. — Eversion of the lid (commonly called ectropium) may be produced in the way already mentioned, by^ the contraction of inflamma- tory exudations external to the cartilage, by the contraction of cica- trices on the face, l)y redundancy or hypertrophy of the conjunctiva, by the mere weight of the lid in cases of paralysis of the portio dura, and also, sometimes, in aged people in whom there is no paralysis, but in whom the orbicularis is very feeble and tlie skin loose and relaxed. In the treatment of wounds about the face the probable action of cicatrices on the lids must be considered, and contractions must as far as possible be prevented by skin-grafting, and by carefid attention during the heal- ing process. When tlie cicatrix has assumed its permanent condition any ectropium which has l)een produced may often be remedied by a well-planned plastic operation. The treatment of paral\tic ectropium resolves itself into that of the paralysis, which ma,y sometimes be amena- ble to the judicious application of a continuous or an induced galvanic current; and the form which is due to conjunctival hypertrophy, or to mere senile relaxation of parts, may often be cured by the contracjtion of a conjunctival eschar, made by the free application of solid nitrate of silver. Ectropium should always be remedied if possible, for it is not only a conspicuous and unsightly deformity, which entails much incon- venience by interfering with the natural course of the tears, but it also exposes the eye to injury from tlie altsence of its natural protectors. Wounch of Eyelidfi.— W oundn or injuries of the eyelids, of whatever nature, should be treated on the principle of jireserving every fragment of skin, and of endeavoring to avoid distortion of shape. Cuts or lacer- ations should be carefully cleansed from dirt and coagula, their edges accurately united by a sufficient number of fine sutures, and tlien covered by a crust of styptic colloid, or of dried blood and tincture of benzoin, beneath which primary union will often take place under the most un- promising circumstances, thanks to the vitality and vascularity of the parts concei'ned. The best material for eyelid sutures, especially for complicated or irregularly lacerated wounds, for which many are required, is the finest platinum wire, as fine as human hair; and it may be con- veniently inserted b}' the needles which are made for threading the smallest beads. When wire is not at liand human hair makes a good substitute, except that its elasticity exposes it to slip when it is being tied. Fto.sis. — The condition known as ptosis, in which the upper lid is par- 688 DISEASES OF THE EYE. tially or entirely closed, may be a result of injury, or of paralysis of the levator palpebral muscle. I have seen one instance in which complete ptosis was [)roduced by accident. Tlie i)atieiit, a lad of ten years old, fell down in sucli a manner that a small batswing gas-burner caught be- neath his ui)per lid, and the weiglit of his l)ody tore the tarsal cartilage from its attachment to the tendon. Some months after the injury I made an incision along the upper lid, sought for and recovered the muscle, and reunited it to the cartilage by three catgut sutures. The result was en- tirely successful, only very slight drooping of the lid remaining. When ptosis is caused liy paralysis it is often recovered from under the influ- ence of treatment addressed to the nervous affection on which the paraly- sis depends ; but, failing this, an operation may be required in order to reopen the eye, and to enable it to take part in vision. The most suc- cessful plan is to make a single horizontal incision along the middle of the fallen lid, to detach the skin upwards and downwards, to excise a broad strip of the orbicularis muscle, and to unite the edges of the muscu- lar gap by catgut sutures without any sacrifice of skin. In this wa3' the lid may be effectually lifted, without producing the appearance of dragging or straining which follows the removal of skin, and also, if the operation is nicely m^anaged, without tilting forward the lower margin of the cartilage. Diseases of the Conjunctiva. — Next in order to the diseases of the eye- lids come those of the conjunctiva, which, after lining the lids, is reflected to cover the surface of the eyeball, and is continued over the cornea by its epithelial layer, although its other elements are firmly united to the sclerotic at the corneal margin. The conjunctiva, as a mucous mem- brane, is liable to inflammation attended by increased secretion, which may assume a purulent character, and may become actively contagious. It is also, as the external covering of the eye, exposed to irritation by atmospheric dirt or noxious vapors, or by the lodgment of foreign bodies upon its surface. In fammatio7i of the covjnndiva is commonly divided into the simple or catarrhal and the purulent ; and, although these two forms pass into one another by imperceptiV)le gradations, the distinction is not without practical convenience. In simple conjunctivitis the membrane is con- gested and somewhat tumid, and its secretion, which is of a mucous character, readily dries into crusts upon the eyelashes and the margins of the lids. The caruncle and plica semilunaris are somewhat swollen, there is a certain amount of itching or smarting, and the lids become adherent during sleep from the drying of the viscid secretion. There is also some increase in the flow of tears, but there is no tensive or deep- seated pain, no impairment of vision, no turbidity of the cornea or dimin- ution of the lustre of the iris, no irregularity or sluggishness of the pupil, and the congestion is limited to the conjunctiva, and neither extends to the cornea nor to the fine zone of sclerotic vessels which surrounds the corneal margin. The latter point may readily be determined by finger- pressure, through the medium of the lower lid, which should be first pushed up so as partially to cover the cornea, and then made to glide downwards over the ocular surface. The pressure w^ill empty the con- junctival vessels for a moment, and will leave a pure white track right up to the corneal margin. This track will be instantly effaced by the return- ing blood ; but its perfect whiteness in tiie neighborhood of the cornea is the point to i)e observed, and shows the absence of any tendency to iritis. In order tf> see that there is no encroachment of vessels upon the cornea, it isVjest to examine the margin with a magnil'ying lens. INFANTILE PURULENT OPHTHALMIA. 689 Simple conjunctivitis, such as lias been described, is a trivial affection, which can be cured in a short time by the local employment of any metallic astringent, and which yields most readily to the frecinent use of a comparatively mild application. A solution of nitrate of silver, of about two grains to the ounce of distilled water, is perhaps the most effi- cacious ; but its tendency to stain handlvcrchiefs is an objection to its use, and a solution of sulphate or chloride of zinc, or of sulphate of cop- per, will usually fulfil every indication, Tlie lower lid should be drawn down, and a little of the lotion should be applied to its inner surface, by means of a goosequill scoop. A solution of acetate of lead would be equally beneficial, but the application of a salt of lead to the eye is attended by the objection that, if there should be any loss of corneal epithelium, an opaque white deposit of carbonate of lead may be left upon the abraded surface. The lotion wliich has been beneficial in one case is sometimes preserved by a patient, to be used again under very different circumstances ; and hence an application containing lead should only be ordered with great circumspection. When conjunctivitis passes beyond this simple form, and produces purulent discharge and swelling of the conjunctiva and eyelids, it often becomes a very formidable afl!"ection, which not unfrequently leads to blindness by interfering with the nutrition of the cornea and producing sloughing or necrosis of that membrane. The chief forms of purulent conjunctivitis are three in number, the infantile, the gonorrlioeal, and the epidemic. Infantile Purulent Ophthalmia. — The first of these, infantile purulent ophthalmia, commences about the third day after birth, and is, in most cases, clearly due to inoculation with the vaginal secretions of the mother. The inflammation rapidly gains in intensity, the conjunctiva lining the eyelids becomes greatly swollen, the lids are puffy and red externally, and a profuse discharge of thick pus is poured out. The conjunctiva covering the globe is always much congested ; and in the worst cases it is elevated by swelling, and overlaps the corneal margin, producing the condition called chemosis. When this occurs the cornea, which derives much of its nourishment from the conjunctival vessels, is placed in great danger. It soon becomes turbid, and the turbidity may soon pass into necrosis. In neglected cases the pus dries upon tlie palpebral margins and cements them together, so as to retain the fresli secretion in the conjunctival sac, where it distends the lids and presses injuriously upon the eye. The severity of the affection varies much in different cases, and may be measured by the swelling of the lids, and by the viscidity of the discharge. It probably depends in some measure upon the character of the vaginal secretion, and also upon the strength and vital resistance of the infant; and on both grounds the worst cases are met with in the subjects of inherited syphilis. When the inflammation is violent, or the infant diseased or weakly, sloughing of the cornea may take place very rapidly ; but when the inflammation is moderate, the infant vigorous, and the discharge thin and as if muco-purulent, the disease may even wear itself out harmlessly. Under almost all circumstances, if the cornea is bright and clear when first seen by the surgeon, a favorable prognosis may be confidently given. If the cornea is turbid the prognosis must be very guarded ; and, if it is concealed by the swelling of the lids, no opin- ion must be hazarded until it can be seen. Treatment. — As long as the cornea retains its integrity the treatment required is cleanliness, and the regular application of an astringent ; and if properly carried out it is not too much to say that this treatment will 44 690 DISEASES OF THE EYE. be invariably successful. The lids being separated by the fingers, a small stream of warm water may be allovved to trickle gently between them from a sponge, being received at tlie side of the face in a basin, until all diseiiarge is washed awa3\ The lids must be gently pressed with a soft absorbent handkerchief, to remove water from the conjunctival sac, and then a few drops of a solution of nitrate of silver, of the strength of two grains to the ounce of distilled water, must be suffered to fall between them. Ijastl_v, the margin of the lids must be effectually anointed wath spermaceti ointment or with almond oil, to prevent their adhesion from the drying of the discharge; and the whole proceeding must be repeated every four hours. In a very short time manifest improvement will take place ; and the applications may be made less frequently, but they must not be entirely discontinued until the cure is complete. Merrurial Inunction. — If the infant is the subject of inherited syphilis mercurial inunction should lie practiced. For this the best method is to spread half a drachm of blue ointment on a strip of flannel, and to but- ton it round the abdomen, renewing the ointment, on the same piece of flannel, every day. If the infant is feeble it may take half a drachm of cod-liver oil, with a drop of liquor cinchouiTe, twice a da,y ; and if the mother's milk is deficient in quantity or quality, a wet-nurse should be procured, or careful hand-feeding should be had recourse to. It is sel- dom enough for the surgeon to be content with verbal instructions, but he must show the nurse how the nitrate of silver lotion'is to be applied, and must carefully supervise the arrangements for the feeding. Implication of Cornea. — When the cornea is already turbid the same kind of treatment must be pursued, and if sloughing does not occur the turbidity will in most cases clear away in the course of time, if not en- tirely, yet sutficientl}' to leave useful vision. If only a small portion of the cornea should perish, recovery may still take place, leaving the curvature of the membrane altered and flattened, the iris adherent to the cicatrix, and the pupil more or less closed or displaced. When the corneal slough is extensive the result is the condition called complete staph3'loma, in which the iris becomes blended with the cicatrix, and projects as a bluish- wdiite prominence in the situation of the cornea. In such cases percep- tion of light is often preserved, but never vision of objects ; and the subjects of this misfortune form a very large proportion of the inmates of our blind asylums and similar institutions. It should never be for- gotten, esi)ecially by those who are engaged in obstetric practice, that no case of corneal staphyloma would ever occur, as a result of infantile purulent ophthalmia, if that malady were alwaA s promptly and properly treated. Tiie medical attendant of a lying-in woman should alwa3's leave orders that he must be summoned without delay, if any inflammation of the child's eyes should be perceived. GonorrhfroJ ophfhahnia.i in its s^ymptoms, course, and termination, greatly resembles the infantile variety. As its name implies, it occurs only in adults, or at least only in those who have been in contact vvith the secretion of gonorrhoea. It is generally believed to be the result of direct inoculation with the urethral discharge, and is doubtless often produced in this way. It is thought by some to be occasionally part of the original disease independently of inoculation, and I have seen a few cases which rather tend to this conclusion, although inoculation would be very difficult to disprove. In the treatment of gonorrluea, more especially of a first attack, it is always desirable to caution the patient about his eyes, so that he may neither rub them vvith fingers soiled with urethral discharge nor thi'ow a drop of discharge directly into one of them (a thing which I have known happen) by shaking the penis. It GONORRHCEAL. OPHTHALMIA. 691 is an- important difference between infantile and gonorrhneal ophthalmia that the latter, either from the essential natnre of the affection, or from the different character of the mncons membrane in the adult, is mnch less amenable to treatment than the former, so that a very guarded prognosis should be given in every case. In old times the treatment of gonorrhoeal ophthalmia was of the most heroic description, including bleeding from the arm, the application of many leeches to the temples, the administration of purgatives and mercury, and the enforcement of an antiphlogistic regimen. Under this method the cornea usually sloughed; and the credit of introduciug a more rational system is due to Mr. Dixon, who perceived that slonghing was the danger chiefly to be guarded against, and that the best way of guarding against it was by stimulants and a generous diet. Von Graefe carefully studied the ques- tion of local medication, and laid down rnles for the application of nitrate of silver, which, if they are carefully observed, will conduct most cases to a successful termination. The first principle of treatment, when only one eye is affected, is to protect the other from accidental inoculation. For this purpose the sound eye should be covered with a piece of water- proof tissue, gummed down to the skin by collodion, and over this a compress and bandage should be applied. A still better protection has lately been introduced at the Moorfields Eye Hospital, and consists of a watch-glass inserted into a piece of waterproof tissue, which is spread with adhesive plaster. The sound eye being covered, the surgeon takes a solution of nitrate of silver, of about a scruple to the ounce, or, still lietter, a solid stick of a compound made by fusing together one part of nitrate of silver and three parts of nitrate of potash. The eyelids being everted and cleansed from discharge, their inner surfaces are carefully painted over with the solution, or touched in every part with the stick; and then, after a few moments, befoi'e they are released, the superfluous nitrate of silver is decomposed by a brushiul of a solution of common salt, which, in its turn, is washed away with water. The nitrate of silver should be so applied as to produce only a superficial eschar, extending no deeper than the epithelium, and sparing the basement membrane, and it should not be suffered to come into contact with the cornea. The application should be renewed as often as the superficial eschar is cast off, which will gener- ally be about every eight hours. It will occasion acute pain, and hence, more especially in bad cases, in which the lids are brawny, much swollen, difficult to evert, and slippery from discharge when they are everted, it is often desirable to administer an an;iesthetic, and to hold the margin of the upper lid with toothed forceps. In the intervals between successive cauterizations, unless the patient is sleeping, the conjunctival sac should be frequently and gently syringed out — perhaps every hour — with a weak solution of chloride of zinc, of one or two grains to the ounce; and, as the local symptoms abate, the nitrate of silver may be laid aside and the strength of the zinc lotion increased. General Treatment. — While such is the local treatment as far as the eye is concerned, the constitutional state and the urethritis should also receive attention. For the latter it is the best to use very weak astringent injections, and to abandon any internal remedies, such as copaiba, which might interfere with appetite "or digestion. The diet should be nourish- ing but nnstimulating, and means should be taken to allay pain and to procure sleep. As already stated, the chief risk attendant upon the ophthalmia is that of sloughing of the cornea, which is produced partly by the mechanical arrest of its'blood-supply, and partly also, in all prob- aisility, by the depressed state of the general bodily nutrition, or even. 692 DISEASES OF THE EYE. Fig. 323. in some cases, by the septic influence of the gonorrhooa itself. In order to obviate the etfects of these conditions, the administration of quinine, in doses of two or three grains tliree times a day, will generally be de- sirable. Scarijication. — When tlie swelling of the ocular part of the conjunc- tiva is very thick and firm, tlie cornea will be exposed to additional danger, and in sucli cases it is desirable to divide the swollen tissues freel,v, by three or four incisions radiating from the corneal margin, and carried well down to tlie sclerotic. Such incisions may be conveniently made witli scissors, which do not expose the sclerotic itself to an}' danger of being divided. Sloughing of Cornea. — When sloughing of the cornea takes place it will sometimes be universal, destroying the whole of the membrane, and leading to collapse and wasting of the globe, or to the forma- tion of a complete staphyloma, in either case with total loss of sight. More frequently it is only partial as regards its superficial extent, but it usually goes on to perforation, after which improvement commences, and the resulting ulcer heals, leaving an opaque cicatrix, to which some portion of the iris, and more or less of the pupillary margin, are firmly and in- separably adherent. When this happens vision will be more or less impaired, according to the position of the cicatrix, to the degree of flattening of the cornea which has been pro- duced by its contraction, and to the extent of the incarcera- tion of the pupil ; and the flattening of the cornea often seriously limits the improvement of sight which may be gained by placing an artificial pupil behind some still trans- parent part. It is, therefore, highly important to prevent perforation of the cornea, and this may often be done by paracentesis of the anterior chamber at the corneal margin, the artificial evacuation of the aqueous humor having a ten- dency to prevent the extension of the sloughing process, and arresting it, as spontaneous perforation arrests it, prob- ably by diminishing the pressure from within. Paracentesis of the anterior chamber should be performed at the corneal margin on the outer side, by a puncture from any sharp in- strument, and by the subsequent insertion of a blunt probe, so as to press back the posterior lip of the little wound, to allow the aqueous humor to escape. It is most safely per- formed b}' the aid of the special needle made for the purpose, and shown in Fig. 323. This neetUe has a stop or shoulder to arrest its penetration, so that it can wound neither the iris nor the lens ; and a probe for opening the puncture is mounted on the same handle. It is best to have the patient recumbent, and the operator, standing behind his head, should raise the upper lid and lock it under the orbital margin with two fingers, which should also rest against the inner side of the eyeball to check rotation inwards. The point of the needle should then be thrust through into the anterior chamber at the spot indicated ; and, in most cases, the puncture should be reopened, either with the needle or with the probe, twice daily, until healing of the ulcer has commenced. FlalUuring of Cornea. — Whenever there is considerable loss of corneal substance, even although there may be no EPIDEMIC OPHTHALIyri A. 693 perforation, a certain amonnt of flattening of the cornea must be ex- pected ; and whenever perforation lias taken place tlie cicatrix will be likely to become inoniiuent under the influence of the pressure from within whicli is produced l\y the action of the recti muscles. In order to obviate this tendency the eye should be supported, during the whole period of healing of an ulcer which has perforated, by the careful applica- tion of a pad of carded cotton-wool, retained by a compressive bandage. Epidemic Ophthalmia. — The purulent ophthalmia of infancy, and the purulent ophthalmia of gonorrhoea, are alike highly contagious, and would be likely to be communicated in their most virulent forms by any con- veyance of their discharges to the conjunctiva of a healthy eye. I3ut as a matter of fact, on account of the precautions taken with regard to them, they are seldom propagated in this way; and the term contagions oph- thalmia is used almost exclusively to denote an epidemic form of con- junctivitis which is said to have })revailed in Egypt from time immemo- rial, and to have been introduced into Europe by the Fi-ench armj' in the beginning of this century. Epidemic conjunctivitis may assume every degree of severity, from the most trivial catarrhal form, which is curable by an astringent lotion in a few hours, to the most severe and destructive suppurative inflammation. In hospital practice it is very common to see conjunctivitis of no great severity run through a family, or even to see it prevail in a particular street or group of buildings ; and the tendency to pus-formation will usually be much more marked in some patients than in others. When the maladj^ api)ears in large communities who are living under insanitary conditions it usually spreads with great rapidity, and assumes a highly dangerous character. The most remarkable examples of tliis tendency have been furnished by regiments and by large schools, more especially schools for pauper children. Both in regiments and in schools it has been found that circumstances generally prejudicial to health, such as overcrowding, imperfect ventilation, want of cleanliness, and im- proper feeding, have a tendency to produce the development in the con- junctiva of bodies which are known as ''sago-grain," or follicular granu- lations ; and tliat the presence of these granulations involves a peculiar vulnerability to the causes by which contagious ophthalmia is produced. The granulations themselves are chiefl}' found about the reflection of the conjunctiva from the outer part of the lower lid to the surface of the eye- ball; and they appear as small rounded, pellucid prominences. In their essential nature they are strictly analogous to enlarged glands, and they consist of aggregations of lymph-cells, the connective tissue between which has undergone absorption or displacement. Sporadic cases of follic- ular granulations are frequently met with even among people of good sur- roundings, and the granulations may shrink and disappear without pro- ducing ophthalmia. But the_y are, nevertlieless, a delicate test of the sanitary state of a community ; and, when contagious ophthalmia appears in a school or regiment, all eyes should be examined for granulations, and all in which tliey are present should at once l)e taken under treat- ment. For the granulations themselves it is only necessary to touch the conjunctiva at intervals with some stimulating application; and there is probably none better than the so-called lapis divinus^ a mixture of equal parts of sulphate of copper, nitrate of potash, and alum, fused together and run into a mould. The resulting stick may be heated at one end over a gas-flame, and its fused external parts wiped away, until it is shaped to a smooth and tapering point, which can be applied conveni- ently to all the wrinkles of tlie conjunctival membrane. The lapis occa- sions some smarting, especially at the first few applications ; but this may 694 DISEASES OF THE EYE. be diniiiiished by holding down the lid until tlie effect has exhausted itself upon the i)alpebral conjunctiva, and also b}'' bathing" with cold water im- mediately afterwards. It is sutticient to make the application once daily; and, as the granulations diminish in size, the intervals maybe increased. In the coarse of two or three weeks, in favorable cases, the enlargements will be absorbed and will disappear. Treatment. — In the treatment of the conjunctivitis itself, whether or not it has been preceded by tlie presence of granulations, the practitioner must be mainly guided by the severity of the affection, by the amount and apparent density of the swelling of the ocular conjunctiva, and by the presence or absence of turbidity or irregularity of the corneal epi- thelium, or of a tendency to the passage of vessels from the conjunctiva to the cornea. It is first of all necessary to ascertain, in every case, that the disease is not due to tlie presence of a foreign bod}-, and the next point is to observe whether the inflammation shows an3' tendency either to spread to the cornea or to interfere with its nutrition. In very acute forms, with much swelling and profuse discharge, the ocular conjunctiva soon overlaps the cornea, as in gonorrhceal ophthalmia; and in propor- tion to the bulk of tlie resulting chemosis, and to the firmness of the effused material, it threatens the life of the corneal tissue, and sometimes produces rapid necrosis, without antecedent inflammation. In other cases, less severe in degree, there is an early tendenc}' to the develop- ment of a vascular keratitis, and fine twigs and loops of newly formed vessels may be seen encroaching upon the cornea, especiall^^ at its upper and lower portions. In others, again, there is a tendency to corneal ulceration of an inflammatory characier, the first evidence of which is furnished by irregularity, roughness, and dulness of the epithelium at the margin. When these conditions are absent, when the swelling of the lids is not excessive, and when the corneal epithelium is bright and undis- turbed, the treatment resolves itself into the employment of metallic astringents. Among these a solution of acetate of lead is perhaps the best; but, on account of the already mentioned danger of applying it to any case in which the corneal epithelium is abraded, and in which it would lead to the formation of an opaque deposit of carbonate, it is generally safer to use tiie sulphate of copper, or the sulphate or chloride of zinc, or the nitrate of silver; or the sulphate of copper ma^' be applied in the form of lapis divinus. In some instances it will be found desirable to vary the astringent from time to time, care being ulwa^'s taken not to select one of too active a character, and to limit its operation as far as possil)le to the eyelids and the palpebral folds. In the more severe forms, with i)rofuse purulent discharge and early and considerable swelling, it is Ibund that the stronger astringents are not well borne at the commencement of the disease, and that sedatives are first required. In such cases Yon (jJraefe strongly recommended the application of liquor chlori, as a step towards astringents of a more active character; and this remedy apjx-ars to have the incidental advan- tage of dcstro3'ing the infective (piality of the secretion. It should he dropped into the eyes twice daily, and the results of its employment should be watched with the greatest care. If the conjunctival swelling shows a tendency to become more dense, or if there are symptoms threat- ening the spreading of inflammation to the cornea, then the liquor chlori must be laid aside in favor of atropine and soothing fomentations. If, on the contraiy, the conjunctival swelling becomes more lax and vohuni- nous, and the secretion more abuntlant, then the liquor chlori should be superseded by the diluted solid niliale of silver, ai)plicd as directed for PAPILLARY GRANULATIONS. 695 the gonorrhoea! form of the affection ; and this in its turn, as the condi- tion of the patient improves, shouhl be superseded by soUitions of the salts of copi)er or zinc. Bearing in mind, then, that it is impossil)le to draw any line of demar- cation between the mildest form of conjunctivitis and the most severe purulent ophthalmia, and that the successful treatment of each case will depend upon a correct appreciation of its stage and its tendencies, and upon accurate observation of the effects of the first remedies selected, it may be laid down as a general principle that all mild forms will bear metallic astringents from the beginning, and will often be readil}' cured by them. The more severe forms display an early period of acute irrita- tion, in which any stimulation would be mischievous, and would increase the severity of the attack. This period must be tided over by the local use of atroi)ine and hot fomentations, aided by such regimen and general treatment as the state of the health may require. It may lead either to a brawny swelling of the conjunctiva, witli thin discharge and a tendency to c(n'nenl death or inflammation, or to a voluminous and lax swelling, with discharge of a purulent character. The former condition, when of a pronounced kind, forbids the use of local stimulation ; the latter requires tiie repeated destruction of the epithelium by caustic. Trealment of Corneal Comijlicationx. — When the cornea becomes ulcer- ated, if the ulcers threaten to perforate, the treatment by paracentesis must be had recourse to. Ulcers which do not threaten to perforate require at first no modification of the plans already mentioned ; but as soon as a process of repair commences it may be promoted b3^ various local applications, which need not interfere with those required by the conjunctiva. Among these the first place ma}' be given to Pagenstecher's yellow oxide of mercurj' ointment, or to dry calomel sprinkled over the cornea in small quantity; or Dr. Williams's citrine ointment may be tried (in which olive oil is replaced by cod-liver oil), or one containing a little red oxide of mercury or a little sulphuret of arsenic. Papillary Granulations. — Whatever may be the fate of the cornea, the subsidence of the acute stage of the disease may lead either to perfect recovery or to a state of chronic inflammation of the conjunctiva, in which thqre is great liability to frequent relapses, and a tendency to hyperplasia, which shows itself in an exuberant crop of secondary granulations in the palpebral folds and on the lining of the lids. These granulations differ from the follicular or sago-grain granulations both in appearance and in nature ; and they are a result of hypertroph}' of the conjunctival papill;>3, which are strictly analogous to those of the dermis. Tlie eyelids become villous over their whole internal aspect, and the palpebral folds may be almost shaggy with enlarged and vascular papilla?. In process of time the tendency to relapse dies out, but the papilla? remain, and maj' assume a warty appearance, while the subconjunctival tissue becomes tliickened and indurated. Such a state is apt to occasion the development of ves- sels beneath the corneal epithelium, and these vessels are sometimes so numerous and so closely set that they produce opacity and loss of sight. In order to prevent such an occurrence the stage of improvement from the acute attack requires to be carefully watched, and the application of nitrate of silver should be regularly made for some time after the violence of the disease is exhausted. When the nitrate is at last laid aside it must be replaced by the long-continued use of some milder application, as by a lotion containing some salt of zinc or lead or copper. The most disas- trous results are often produced in cases in which granulations in the palpebral folds are neglected or suffered to escape notice, because they G96 DISEASES OF THE EYE. undergo in course of lime a gradual degeneration and contraction, by wliich tlie cartilages of tlie upper lids become incurved, and tlie cilia are bronglit into contact witli the eye. Tlie cases of chronic trichiasis which frequent our liospitals liave nearl}- always this liistor\\ The tarsal car- tilages are shortened, thiclvcned, and unduly convex ; and on everting the lids the conjunctiva is seen to be crossed by hard dense lines resem- bling cicatrices. Tfeatment m Public Instifutions. — When contagious ophthalmia makes its appearance in any public institution, or in any body of people living under similar conditions, the surgeonshould at once recognize the gravity of the evil, and should enforce the most stringent precautions to prevent the spreading of the malady. In the first place, the patients should be entirely separated from the unaffected persons ; and tlie latter should be examined for follicular granulations, which should be subjected to local treatment whenever they are found. The general conditions of living should be considered, with especial reference to the quantity' and quality of food, the ventilation of dwelling-rooms and dormitories, and the cubic space allotted to each person. The ordinary means of communication of ophthalmia, especially by a community of washing arrangements, should be remembered and guarded against ; and the treatment of the inflamed eyes should not only be conducted vvith the greatest care, to discriminate the special requirements of each, but should be continued until no trace of mischief is left lurking in the palpebral folds. Diphtheritic Conjunctivitis. — In every epidemic of conjunctivitis we meet with a few cases in which the discharge, instead of resembling ordinary pus, is coherent or fibrinous, so that it can be peeled off in strips from the conjunctiva, leaving a bright-red surface, which is usually dotted over with bleeding points. These cases require no modification of treatment, but they are worthy of notice, because they have often, and erroneously, been termed '^ diphtheritic." True diphtheritic conjuncti- vitis does not appear to be known in England, but it is not uncommon in Berlin and other parts of Germany, and has been described by many German writers. The diphtheritic fibrinous effusion does not occur on the conjunctival surfaces, but in the interstices of the subconjunctival tissue. The prominent symptoms are great pain, heat, and swelling of the eyelids, with distension of the subconjunctival tissue by a pale, firm, brawn}' effusion, which arrests the local circulation and threatens the cornea with speedy destruction by necrosis. The prognosis is exces- sively unfavorable, and the treatment must be conducted on the general principles already laid down, with the addition of compresses wrung out of iced water in the early stages, to relieve the heat and pain. At a later period hot fomentations will promote vascularization and repair of tissue, and the internal use of mercury is said often to have been beneficial. Phli/clcnular Conjunctivitis. — A familiar form of inflammation of the conjunctiva is that which is associated with the course of the little pimples known as ^' phlycteiiuliE." Phlyctcnuhxi a[)pear to resemble follic- ular granulations, in that they are essentially abnormal aggregations of lympli-cells, but they are seated on the ocular instead of the pali)ebral conjunctiva, and they undergo inflammation and ulceration. Each phlyc- tenula runs its course in al)out eight days. The elevation throws out fluid at its summit and becomes a vesicle, which bursts and forms a small ulcer, the centre of which is covered by a tenacious film of buff-colored material. This undergoes disintegration and is cast off', and then the ulcer heals. The phlyctenuUe may he either single or multiple, and they often appear in successive crops. The Ibrniation of each vesicle is attended EPISCLERITIS. 697 by some burning or stinging pain, which subsides when rupture has taken place, and is succeeded only by such sensations of itching or discomfort as ma}' be due to the amount of attendant conjunctivitis. Phlyctenulae may occur in the cornea, but their most common seat is in the ocular conjunctiva, just beyond the corneal margin. A single one hardly re- quires any other treatment than rest of the affected eye and the api)lica- tion of a weak astringent lotion ; but recurrent phlyctenuUe point to disorder of the general nutrition, and either to something faulty in the habits of life or to some unfairness in the conditions under which the e3'^es are exerted. Covjunctival Groivths. — The conjunctiva may be the seat of morbid growths of various kinds, among which may be mentioned dermoid and sarcomatous tumors, the former sometimes bearing hairs. Such growths, if they are increasing, or unsightly or inconvenient, may be pinched up and removed by scissors, the resulting conjunctival wound being closed by a point of fine suture. If the wound is large the conjunctiva should be dissected from the sclerotic on either side, so that the edges may come together more readily'. It is not uncommon to see subconjunctival col- lections of fat or of yellow fibrous tissue, and these, which are mostly situated on either side of the cornea, are apt to be nipped and moulded by the closure of the lids, so as to form little tumors, sometimes almost pedunculated, on the horizontal meridian. Such growths are harmless but unsiglitl_y, and they also may be excised with good effect. Another form of conjunctival growth is pterygium, which consists of a hypertrophy of tissue, sometimes very trifling in amount, sometimes ver^' considerable, having a generally triangular outline, with its apex trespassing more or less upon the cornea. Pterygium is usually a final result of long-con- tinued inflammation, and is scarcely at all amenable to treatment. The hypertrophied material may be removed by excision or ligature, but the same kind of action is often renewed in the cicatrix, and the patient seldom derives lasting benefit from any operation. A pterygium does no harm unless it extends so far over the cornea as to obsti'uct vision, and then the best course is to enlarge the pupil b}' iridectomy. Epinclerilis. — An affection which is apparently conjunctival, but which is really seated in the tissue intervening between the conjunctiva and the sclerotic, is that which has received the name of Episcleritis. It appears as a patch of congestion, gradually fading into the natura,l appearance, and seated on the ocular surface near the corneal margin, most frequently on the temporal side and below the horizontal meridian. On close ex- amination the congestion, with the exception perhaps of one or two dilated vessels, is seen to be subconjunctival, and to be attendant upon a circumscribed but not sharply defined swelling or thickening, which is adherent to the sclerotic, and which presents, in the interstices between bloodvessels, an appearance as if it consisted of some new deposit ex- ternal to that membrane. The swelling is indolent, chronic, and gener- ally painless, although it sometimes produces neuralgia. The subjects are most frequently women, and generally those who are anaemic or otherwise out of condition. P]i)iscleritis may last for months with little change, and it seems to be harmless as regards the other structures of the eye. I have found it resist all treatment except the internal admin- istration of mercury, and to this it will often yield in the course of a few weeks. I give the perchloride in solution, in the dose of a sixteenth of a grain three times a day, usually combined with five or ten minims of the tincture of i)erchloride of iron. With this treatment I am accustomed to combine a daily sprinkling of dry calomel over the swelling ; but the internal medication is that which is most to be relied upon. 698 DISEASES OF THE EYE. The diseases of the cornea, in some instances, as already stated, are resnlts of conjnnctival aflections ; and the sloughing ulcers produced by purulent ophthalmia have already been mentioned. When the period of convalescence from purulent ophtlialmia has been neglected, and when papillary granulations have been suft'ered to lurk in the palpebral folds, and ultimatel_v to undergo shrinkage and degeneration, these conditions act as mechanical irritants to the corneal surface, and produce a develop- ment of vessels under the epithelium of a kind whicli, when it reaches a certain degree, is called'" Pannus." The vascularization of pannus dif- fers from other forms of vascularity in that tlie vessels proceed to the cornea from the conjunctiva as twigs or branches of some magnitude, and ramify upon the cornea in an irregular, arborescent fashion, with considerable intervals between them. In these intervals, when they are tolerabl}^ large, the cornea may remain transparent ; but, as the growth of vessels increases, the inter- vals diminish in size, and the epithelium covering them becomes cloudy and disturbed. When a vascular development of this kind is seen in the upper part of the cornea the upper lid should always be everted for ex- amination, and in most instances its inner surface will be found rough- ened or granular. Where the upper lid only is at fault only the upper half of the cornea will suffer ; but, if there are granulations also in the lower palpebral folds, the subepithelial vessels may extend over the wiiole cornea, and may reduce vision to a mere perception of light. The aggravated forms of pannus are chiefly seen among discharged soldiers, or among the sufferers from a great wave of epidemic ophthalmia which swept over Ireland a few years ago, or among persons who have had se- vere conjunctivitis in some dust}' locality, away from medical aid. Cases come to the London hospitals from certain parts of Australia; and there can be little doubt that the contagious ophthalmia of the Hanwell Schools in 1862-65, and of the schools at Anerley more recently, will yield a crop of cases b}' and b}'. In order to be successful the treatment of pannus must be continued over many months, and it consists in the application, daily or at short intervals, of astringents to the lining membrane of the lids. The cornea must be left alone, for, if the condition of the lids can be greatly improved, the corneal vessels will gradually dwindle and dis- appear, and the transparency of the membrane will be restored. I have not seen benefit arise from very strong applications, nor from the long- continued use of any single one, and am accustomed to ring the changes between lapis divinus, gl3^cerole of tannin, and solutions of hj^drochlorate of quinine, nitrate of silver, sulphate of copper, sulphate and chloride of zinc, and acetate of lead; the quantity of any salt not exceeding five grains to the ounce of distilled water. In order to make the application both lids should be everted, and their exposed inner surfaces either touched or j^ainted with the selected medicament. If no benefit is ob- tained, and if the cornea is so generally vascular as to appear tolerably safe against sloughing, excellent results may sometimes be produced .I)}' inoculation with the pus of infantile o]jhtlialmia. A little of this pus should l)e taken up by a probe or seoop, and i)laccd in the conjunctival sac of tiie patient. The resulting purulent ophlhaluiia will recpiire no treatment beyond frequent bathing and great cleanliness; and, after it lias worn itself out, the cornea will usually clear in a very remarkable manner. It must be remembered that tliis treatment is not wholly free from risk; and that, notwithstanding the vascularity, it may produce sloughing of tiie cornea and total loss of sight. Inoculation is sometimes preceded liy peritom}-, or the excision of the annulus of conjunctiva and DISEASES OF THE CORNEA. 699 subconjunctival tissue which immediately surrounds the cornea, and which is dissected off the sclerotic as completely as possible with forceps and scissors. In this proceeding I have but little confidence, and do not recommend it for adoption. Co7'7ieal Phlyctenulse. — The phlyctenulte, which have already been de- scribed as occurring upon the conjunctiva, occur also upon the cornea, where the morbid formation in which they originate is seated imme- diately under the epithelium. In this position, partly perhaps on ac- count of the comparatively unyielding character of the tissnes concerned, the little elevations occasion much more distress than wlien they are lim- ited to the conjunctiva. Even during their period of formation, it is con- jectured that the}' press upon or otherwise irritate the sensory nerve- filaments of the cornea; and, as soon as the elevations ulcerate, it is ob- vious that nerve filaments ma}' be exposed in the resulting solutions of continuity. The sensor}' filaments of the cornea, when irritated, produce photopliobia, or intolerance of ligiit ; eitiier because these filaments re- spond to the stimulus of light by common sensation, or else because they convey irritation to the ciliary region, and cause the reflex movements produced by light — the contraction of the pupil, and so forth — to be acutely painful. Wliatever may be the explanation, the presence of even a single suiall phlyctenula on the cornea may occasion intense photopho- bia, and this, in its turn, may greatly aggravate the condition in which it has its origin. Sometimes before the elevation ulcerates, and always afterwards, a little leash of new vessels creeps from the conjunctiva to the affected spot, and these vessels only dwindle after the healing of the ulcer is complete. Each ulcer leaves behind at least a faint nebula, sometimes a more conspicuous and even a flattened cicatrix ; and tlie cicatrices are united to the corneal margin by linear nebulae marking the track of the vessels. Phlyctenular may occur in successive crops, ex- tending over a long period of time, and tliey may then constitute an aflfec- tion which is now commonly described as " recurrent vascular ulcer" of the cornea, and which is apt to be exceedingly troublesome and obstinate. Recurrent vascular ulcer is prominent among the group of diseases which were once described as "strumous ophthalmia," and the subjects are more frequently strumous children. There is, indeed, a great analogy between the history of follicular granulations or phlyctenulse and that of tubercle. Photophobia. — In some cases of recurrent vascular ulcer the photopho- bia is excessive. The child hides its head in the darkest corners or in its mother's dress, contracts its orbicular muscles with an energy by which the whole face is spasmodically contorted, and screams and strug- gles at every attempt to expose it to the light. If it is securely held, and its eyelids are forcibly separated, a gush of confined tears escapes, but the cornea is rolled upwards by the superior rectus, and often remains hidden from view. Under such circumstances the proper course is to relax muscular spasm by an anaesthetic, and then to make a careful and complete examination of the eye. If the case is already of some dura- tion, and especially if the photophobia is of some duration, the cure of the muscular spasm is the first requirement, because this, by re- taining tears and by exercising hurtful pressure upon the eye, is itself a serious obstacle to improvement. As a test of the severity of photo- phobia, and to distinguish it from voluntary contraction of the orbicu- laris, I am accustomed to place reliance on the presence of a little red chink, extending horizontally outwards from the external canthus. This chink shows that the muscular spasm has been suflScient not only to close 700 DISEASES OF THE EYE. the palpebral fissure, but also to hold two surfaces of skin in contact, and to convert them into something resembling mucous membrane. When- ever I see this chink I divide all the tissues, with one stroke of knife or scissors, from the external canthus right up to the margin of the orbit, on a horizontal line, cutting through conjunctiva, orbicularis muscle, and skin. There is alwa_ys free bleeding from veins which had been previously' congested by the muscular action, and the orbicularis loses its power to contract. The bleeding, which is probably highly salutary, stops of itself in a few minutes ; and the only treatment required is to apply compresses wetted with cold or iced water, and to put the patient to bed in a dark or dimly lighted room. At the end of twenty-four hours it will almost invariably be found that the photophobia has disappeared, and that the e^'es are accessible to inspection. Tlie incisions heal with- out leaving any visible scars, and the power of the orbicularis is soon and completely restored. Local Treatment. — When the photophobia is not sufficient to require this treatment, but yet interferes with the comfort of the patient, he may be confined to diml}" lighted rooms when at home, and suftered to wear a thick veil or dark blue spectacles when abroad. A drop of a solution of neutral sulphate of atropia, of the strength of two grains to the ounce of distilled water, should be applied to the inside of the lower lid twice daily, by means of a goosequill cut to a blunt scoop ; and a good deal of time, perhaps two or three hours a day, should be devoted to bathing the eyes with cold or iced water. When the stage of irritation connected with the development of an ulcer has terminated, and the period of heal- ing is commencing, a little dr_y calomel may be sprinkled over the cornea once a day, or a morsel of Pagenstecher's ointment may be placed in the lower conjunctival sac. General Treatment. — The subjects of this disorder are nearly always feeble children of strumous tendencies, and they are often rendered even artificially unhealthy by the state of their eyes. Compelled to shun light, they have been deprived of its beneficial influence as a stimulus to vital action, and they have acquired a habit of stooping which gives them contracted chests and congested heads. Deprived of mental occui)ation, they have become dull and listless, and want of outdoor exercise has re- duced their physical powers and their muscular tone. Very frequently their tempers have been spoilt by foolish indulgence, and their digestions impaired by overfeeding. Under such circumstances it is often neces- sar}' for the surgeon, for a time, to make the necessary local applications himself, lest they should go anywhere but into the eyes; and it is always necessar}^ to lay down minute rules for diet, habits, and exercise. Cod- liver oil, with or without steel or quinine, ma,y generally be administered with advantage; and I have been accustomed to recommend skipping with a rope as a means of bringing the limbs into activit}'. It requires no vision, may be practiced in any darkened but well-ventilated room, and it employs many muscles at once. Care must he taken, however, not to occasion overfatigue at the beginning of the treatment. Setons. — In some children, notwithstanding all that can be done, the disease is very obstinately recurrent. In such cases Mr. Ci'itchett strongly recommends the use of setons in the hairy scalp, just above the ears. He inserts a single thread of rather thick silk through a needle-track about an in(th in length, and knots the ends loosely together. By inserting the seton in the iiairy scalp not only is the looj) itself rendered inconspicuous, and the resulting scar invisil)le, l)nt the operator is able to lift up the skin IVom the deep fascia by tlie haii- before passing the needle, and thus VASCUI^AR KERATITIS. 701 to avoid all risk of wounding the temporal vessels. Some persons insert the setons below the hairy scalp, in front of the ear, but this practice is much to be condemned, especially for girls, on account of the cicatrices which are produced. Mr. Critchett l)elieves that the setons establish an artificial weak place in the neighborhood of the eye, and that they thus break the habit of morbid action. He leaves them in the temples for six months or longer, and reinserts them if they cut their way out prema- turely. In a small number of cases these setons are extremely useful, but they are employed in many instances which would yield perfectly well to the judicious use of milder remedies. Iridectomii. — In young adults, especially in young women, recurrent vascular ulcer sometimes continues even for years, and in these cases the ulcers are often sufficiently deep to leave permanent and flattened cica- trices, so that tiie corneoe become dotted over with opacities and distorted in outline. Under such circumstances the chain of morbid action will usuall}^ be broken by an iridectomy, and for this purpose it is sufficient to excise a very narrow strip of iris, which should generally be taken from behind a clear part of the cornea. When this has been done not only will the recurrence of ulceration cease, but the cornea, in the course of a few months, will often clear in a surprising degree. We meet with a few instances, chiefly in strumous children, in which conditions analogous to recurrent vascular ulcer produce an extension of vessels upon the cornea, but no ulceration. In such cases we find here and there a faint corneal nebula, in which a lens will still discover fine vessels, and in another place there is an arborescent encroachment of vessels from the margin towards the centre, attended with some intoler- ance of light. A careful scrutiny will generally discover, at some point of the corneal margin, a narrow zone of thickened and pellucid tissue, formed by something resembling little beads or dots, and clearly of the same character as the ordinary phlyctenulte, but not tending to ulcera- tion. In all such cases the local and general treatment required for mild cases of vascular ulcer may be applied with advantage. Keratitis. — The cornea is liable to several forms of inflammation, which are grouped together under thegeneral term keratitis, and are conveniently divided into the vascular, the interstitial, and the suppurative. All these forms of inflammation are attended, at their onset and throughout their course, by hyperaemia of the conjunctiva, but this hypersemia is never limited to the conjunctiva. The vessels either extend over the corneal margin, or else there is congestion of a fine vascular zone in the sclerotic, which immediatel}' surrounds the cornea, so that, if the blood is pressed out of the conjunctival vessels by a finger, in the manner alread}' de- scribed, the finger-track is not white but pink. It is very important to observe and to attend to this distinction ; for, while astringents are use- ful in all the mild forms of conjunctivitis, they are always hurtful, and often very hurtful, in all forms of keratitis. Vascular keratitis commences by the development of two fine crescents of vessels, one at the superior and the other at the inferior margin of the cornea. These crescents appear, in the first instance, as fine red lines, and graduall^^ increase in size, invading more and more of the corneal tissue. Examined by a lens they are seen to consist of a congeries of minute bloodvessels, situated immediately beneath the epithelium, and so closely packed together that the interstices which separate them are scarcely discernible by the naked eye, which perceives only a general effect of redness. The crescents are a little elevated above the natural surface of the cornea, and each one pushes before it, so to speak, a belt 702 DISEASES OF THE EYE. of precursoiy epithelial turbidity. Unless this pvecnrsorv turbidity reaches the central portion of the cornea, so as to cover tlie pupil, sight is scarcely at all affected; and, as a rule, there is little or no pain, and little or no intolerance of light. In cases of a severe character, or which have been aggravated by improper applications, the vascular crescents ma}' ultimately coalesce and cover the whole of the cornea, whicli then becomes uniforral}' red and opaque, so that vision is almost entire abol- ished. After a longer or shorter time the vessels begin to dwindle, and they ultimatel}'' disappear, leaving behind theui a dense opacity of a very enduring nature. When the whole of the cornea has been invaded the oiDacity is usually most dense over the central parts ; and, in consequence of the greater distance of the centre from the sources of blood-supply, absorption progresses more slowly there than elsewhere ; so that a bad case, even under the most favorable circumstances, must involve loss of sight for a very considerable period of time. Vascular keratitis some- times attacks both eyes at once, and sometimes one onl}' ; but in cases of the latter class I have frequentl}^ seen the second eye become affected in the course of time, even after an interval of three or four years. Treatment. — The great object of treatment, in vascular keratitis, is to arrest the pi'Ogress of the disease before it has reached the central region of the cornea, and for this purpose the first essential is a negative one, namely, the avoidance of all irritants. If the case, in its earl}'- stages, is mistaken for simple conjunctivitis on account of tlie conjunctival hy- peremia which attends it, and if this error leads to the application of nitrate of silver or of sulphate of zinc lotion, or of any of the other stimu- lants or astringents which conjunctivitis would require, the keratitis will always be much aggravated, and will often be rendered uncontrollable. In ever}' case of apparent conjunctivitis it is necessary to scrutinize care- fully the upper and lower margins of the cornea; and whenever a fine net- work of vessels can be seen creeping over either of these margins all astrin- gents must be witiiheld. The only local application which should be used in such cases is atropine, and it should be applied in the form of a two- grain solution, two or three times a day. It is not only valuable as a local sedative, but it paralyzes for a time the muscle of accommodation and the sphincter of the pupil, and thus procures functional rest for the eye. Gompresaion Bandage. — In addition to functional rest, the movements of the eyelids over the affected surface should be restrained by the careful application of a compress of carded cotton-wool, retained by a bandage. The closed lids should first be covered by a small piece of fine soft linen rag, in order to prevent mechanical irritation of the eye by fibres of avooI, and over this rag tlic wool should be so adjusted as to fill the orbital hollows, and to form a covering through which a bandage will exert uniform compression. Tiie bandage should be nearly two yards long, about an inch and a half wide, and made of some loose elastic texture, what is called "water-dressing bandage " being the best for the purpose. The end of the roller is placed on the forehead, imme- diately above the affected eye, and is secured by one horizontal turn, which passes across the forehead and round the head. When the roller readies the forehead, over the sound eye, for the second time, it is in- clined downwards under the lobe of the ear on the same side, round the occii)ut, under tlie loVie of the ear on the affected side, and over the wool-pad to the horizontal turn, to whicli, when tlie degree of pres- sure is properly regulated, it is secured by a pin. Another horizontal turn is then made over all, and the bandage is complete. If proiierly applied, it is scarcely at all liai)l(' to slii), but when it is required at night TREATMENT. 703 it is the safest plan to stitcli the fokls together at intervals. This ap|)lies chiefly to operation cases ; and in inflammation of the cornea the bandage may generally be laid aside during sleep, when the lids will be quiescent without its aid. Cold Applicalion. — An important influence upon the development of vessels in the cornea ma}' often be exerted by temperature, cold applica- tions being highly valual)le to diminish vascularity-, and hot applications to increase it. In the early stages of vascular keratitis it will often be useful to bathe the closed lids with cold or iced water, or even to apply to them small linen compresses wetted with iced water, and fi'e(iuently renewed. For these puri)oses the compressive bandage may be laid aside for half an hour or an hour, two or three times a day, the use of cold for longer periods being seldom desirable. Counter-irritation. — In many cases I have seen great benefit arise from counter-irritation ; and the agent which I commonly employ for this purpose is an iodine liniment, of a strength adapted to the degree of irri- tabilit}' of the skin, and in which a little morphia, perhaps a grain to the ounce, is dissolved. I usually begin with the tincture of iodine, painted over the brow and temple of the afl'ected side every night, and strengthened if it fails to irritate after one or two applications. General Health to be considered. — In nearly every case of vascular keratitis the general health of the patient will require careful considera- tion and treatment; and in a considerable proportion there will be evi- dence of a syphilitic taint, either inherited or acquired. In such instances the administration of mercury or of iodide of potassium, according to the circumstances of the case, will be imperative!}- called for ; while in others iron, or quinine, or bromide of potassium, or cod-liver oil, may be the more appropriate remedies. It may be laid down as a general principle that, Avhen the disease is spreading over the cornea notwith- standing the administration of any of the latter, they should be experi- mentall}' laid aside in favor of an anti-syphilitic medication ; and also that the surgeon should not persevere too long in any plan which does not appear to be beneficial, but should reconsider the whole case with a view to more effectual action. Iridectomy. — When the inflammation extends in spite of all treatment, and covers the central portions of the cornea with vessels, or even with the turbidit}- precursory to the advancing vascular crescents, iridectomy should be performed in a direction inwards and a little downwards. The operation appears to exercise a distinctly controlling eff'ect over the course of the malady, and it leaves a lateral pupil through which, as the opacity of the cornea diminishes, vision will be obtained long before the central parts are clear. Treatment of the residual Corneal Opacity. — When the progress of the disease is arrested, the disappearance of the new vessels leaves the parts which they occupied in a state of peculiarly dense opacity. As soon as the stage of progressive increase is over, and that of decline has commenced, the atropine and the closure of the eyelids ma}" be discon- tinued, and the cold compresses may be replaced by hot fomentations, which will tend to diminish the density of the opacity by promoting absorption and tissue-change. During the period of recovery and of convalescence tlie general treatment must be continued, and the health of the patient promoted by suitable air, exercise, and habits of life. When, all inflammatory action has ceased the absorption of residual opacity may often be greatly promoted by injecting under the conjunctiva a few minims of a solution containina: ten o-rains of common salt to an 704 DISEASES OF THE EYE. ounce of water. The injection may be made with an ordinary h3'po- derraic S3'ringe (a fold of conjunctiva being pinched up with forceps to allow the neinlle-point to pass freely between that membrane and the sclerotic), and it may be repeated ever}- fortnight or three weeks. If iridectomy has not been performed during the acute stage it will often be required afterwards, on account of the more rapid clearing of the marginal parts of the cornea, for the restoration of vision at an earlier period than by natural processes, or even on account of the central parts of the cornea being altered in curvature b}' the disease. Such alteration may be of two kinds, flattening from the shrinkage of the effused mate- rial, or increased convexity from the general yielding of the softened membrane to the intraocular tension. From its long duration, and from the character and permanence of the changes which it ma}' produce, severe vascular keratitis is a most formidable affection, and one which can hardly be too carefull^y treated in its incipient stages, so that, if possible, it may be arrested before the i^art of the cornea directly con- cerned in vision is involved. Interstitial keratitis is the form of inflammation of the cornea which occurs in children and 3-oung persons who are the subjects of inherited s^'philis. It was first accuratel}- studied, and its specific character made known, by Mr. Jonathan Hutchinson, who has described it in the follow- ing words : " Chronic interstitial keratitis usually commences as a diffuse haziness near the centre of the cornea of one eye. There is at this stage no ulceration, and exceedingl}- slight evidence of the congestion of any tunic. The patient, however, almost always complains of some irrita- bility of the e^'e, as well as of dim sight. If looked at carefull}^ the dots of haze are seen to he in the structure of the cornea itself, and not on either surface ; the}^ are also separate from each other, like so many mi- croscopic masses of fog. In the course of a few weeks, or it may be more rapidly, the whole cornea, excepting a band near its margin, has become densely opaque by the spreading and confluence of these inter- stitial opacities. Still, however, the greater density of certain parts — centres, as it were, of the disease — is clearl}' perceptible. Early in this stage the comparison to ground-glass is appropriate. There is now almost always a zone of sclerotic congestion, and more or less intoler- ance of light, with pain around the orbit. After from one to two months the other cornea is attacked and goes through the same stages, but rather faster than the first. A period in which the patient is so far blind that there is but bare perception of light now often follows, after which the eye first affected begins to clear. In the course of a year or eighteen months a very surprising degree of improvement has probabl}' taken place. In milder cases, and under suitable treatment, the duration may be very much less than this, and the restoration to transi^arenc}' com- plete, but in man}' instances patches of haze remain for years, if not for life. In the worst stage the corneal surface looks slightly granular, and from the very beginning it has lost its polish, and does not reflect images with definite outlines. In certain cases, after the ground-glass stage is passed, a yet more severe one ensues, in which the wliole structure of the cornea becomes pink or salmon-colored from vascularity, and in these crescentic fringes of vessels are often noticed at its circumference. In the best recoveries tiie eye usually remains somewhat damaged as to vision, and often a degree of abnormal expansion of the cornea, is ap- parent. Only in one or two cases have I ever observed ulcers of distin- SUPPURATIVE KERATITIS. 705 guisliable size on the surface of the cornea, and T have scarcely ever seen pustules on any part of it." Gharactem of Inherited Sy])hili^. — Mr. Hutchinson has also described the facial and other characteristics by which the subjects of inherited syphilis may be known, and the most imiiortant of these characteristics is a peculiar malformation of tlie teeth, and especially of the two central permanent incisors of the upper jaw, which are bounded laterally by curved outlines with their convexMties outward, and present crescentic notches on their lower borders. The lateral incisors of the upper jaw are often similarly deformed, and the incisors of the lower jaw misshapen, dwarfesorbed more will come forward in a similar manner, and as long as this process con- tinues, and there is no iritis, there is no cause for furthei- interference. But in most cases the first wound in the cai)sule will close, or at all events the progressive absorption of the lens will lie arrested, and then it will be necessary to use the needle again, somewhat more freely than on the first occasion. A third or even a fourth operation may be required; but eventually the lens will undergo com[)lete absorption ; and, if the punc- tures have been made in the centre of the capsule, this structure will un- dergo retraction, and will leave a central clear space behind the pnpil, through which good vision may be obtained. Iritis during Solution. — The eyes of infants are extremely tolerant of this procedure, provided that it is executed with due care ; but if too much of the lens is broken up on any one occasion, or if dilatation of the pupil is neglected, so that its margin comes into contact with the lens-matter, iritis is apt to be excited, in which case the whole of the lens should be evacuated as speedily as possible, by suction, in the man- ner presently to be mentioned. In order to avoid such a necessity the 718 DISEASES OP THE EYE. surgeon should always be sure, before treatment is commenced, that the mother or nurse understands the use of the atropine solution, and can be trusted to apply it effectually. Pyramidal. — A form of cataract which is not congenital, and which consists essentially of a deposit of lymph on the anterior capsule, is sometimes called "pyramidal" or "punctated," according to its appear- ance. It is produced 1)\- the purulent ophthalmia of infanc}^, during which, if the cornea is perforated, the lens falls forward into contact with Des- cemet's membrane, and is pushed back again, carrying with it a dot of lymph, as the aqueous chamber is restored. If the lymph deposit is very small it remains flat ; but if it is abundant it is apt to be stretched out before the cornea and lens separate, and to remain attached to the latter as a little pyramid, the apex of which projects through the pupil. Upon the lym})h thus deposited some saline matter from the aqueous humor is thrown down, giving a chalky whiteness to the ultimate formation ; and then, as the cornea recovers its transparency, either a minute white dot or a small white pyramid will be seen in the centre of the pupillary space. Such cataracts are so small that the patient would usually be able to see round them without dilatation of the pupil ; and any impairment of sight with which they may be associated is usually due rather to haziness of the cornea than to opacity in the lens. In consequence of the former, such cataracts are often complicated with nystagmus. In any case in which such a proceeding seemed advisable, the lenses could be removed by suction or solution ; but improvement of sight would rarely follow. Laminar. — In "laminar" cataract, the opacity, although sufficiently dense to interfere with even the beginning of lessons, is seldom dense enough to be conspicuous through undilated pupils, or to cause anything approaching to actual blindness ; and hence, although probably a con- genital affection, it is seldom discovered until early childhood is passed, and frequently not until the patient has been unjustly punished for sup- posed obstinacy or stupidity, which in reality would be nothing but want of sight. Whenever a child's first teachers complain of it in this manner the surgeon should dilate the pupils and carefully examine the eyes. The color of laminar cataract is rather gray or nebulous than white, and the turbidit}' is limited to a stratum of lens-matter which surrounds a trans- parent nucleus, and is itself surrounded by transparent cortical substance, so that it occupies tlie position of the dark line A in the annexed diagram. The size and thickness of the cloudy stratum ^'"^'' ^-^- are variable, so that some laminar cataracts are muchlessthan others in superficial extent. They differ also in this, that in some the transparent l)eriplieral portion of the lens is absolutely transparent, while in others it is broken by opaque dots or striae. In the former cases the periphery may be expected to retain its trans- parency, in the latter it will in time become tur- V)id throughout. On these physical differences depend great difterences in the treatment that Diagram to illustrate the position slioiild lie pursued ; for, if the periphery around of laminar cataract. tlie opaquc lamina is broad and transparent, it is obvious that good vision through this por- tion of the lens may be f)btained by dilatation of the pupil, or by making an artificial pupil in front of the transparent portion; while, if the trans- parent annulus is very narrow, or if it is itself threatened with opacity, the vision obtained by the above methods will either be imperfect in its degree or only temporary in its duration, and removal of the lens, which CATARACT. 719 Fig. 32G. will eventually be necessary, may properly be undertaken in the first instance. For the determination of these questions the suroeon should examine the lenses with the ophthalmoscopic mirror and witli focal illu- mination in a way which will be described when the diagnosis of senile cataract is being considered. Removal hij Hurfion. — The removal of laminar cataract may often be successfully accomplished by solution ; but, as the patients are mostly children, whom it is more or less ditlicult to restrain, the risks of inflammation or of injury during the often- times lengthy process are much greater in them than in infants, and a less protracted treatment is exceedingly desirable. This is aflbrded by the old Persian method of suc- tion, which, with improved appliances, has been introduced into modern practice by Mr. Pridgin Teale, of Leeds. The principle of suction is that the whole of the lens should be thoroughly broken up and cut to pieces with needles at a single sitting; and that after the lapse of a few days, when the dis- organized mass has been rendered pulpy by the aqueous humor, and before its presence has excited irritation, it should be sucked out of the eye through an appropiiate tube introduced through a small corneal opening. When this is successfully accomplished a cataract which would have required months for complete absorption may be entirely re- moved in the course of a single week. For the successful performance of suction it is necessary that the original cutting up, or " discission " of the lens, should be com- plete, and it is highly desirable that the vit- reous body should not be penetrated in the process. The plan which I pursue is to ob- tain the widest possible dilatation of the pupil, and then to introduce two needles at once, one on the nasal, the other on the tem- poral side of the cornea; each needle being used for the half of the lens which is farthest from its wound of entrance. Each needle is made to cut through its portion of lens by a succession of regular, closely set, parallel strokes, reaching from margin to margin, and carried to a depth corresponding with the thickness of the lens-tissue in each place. Nothing but practice can enable the operator to accomplish this as completely as he would desire. Dilatation of the pupil must be main- tained, and in the course of a day or two the broken lens-matter will fill the anterior cham- ber, in a condition much resembling a white flocculent precipitate. It may then be evac- uated by suction, an operation which is per- il Curette and mouthpiece for the re- moval of cataract by suction. 720 DISEASES OF THE EYE. formed by means of a small slightly curved tubidar curette, semicircular in section, smooth and rounded at its free extremity, and provided with a small round or oval opening, near this extremity, in its flat or concave surface. The curette has been attached to more tlian one form of ex- hausting syringe, but its action is most eflectual and most delicate when it is fixed to a glass tube which serves as a handle, and which is connected h^-an india-rubber tube with a glass monthjjiece, thus forming the instru- ment of which the extremities, the intervening piece of tube being omitted, are shown in the preceding figure. The curette itself may be of various sizes, and its opening may be large enough to admit quite large fragments, and should be notched transversely, as shown in the small figure, to pre- vent it from being closed by contact with the cornea. It should be intro- duced into the eye through a small incision in the cornea, near its margin, with its flat or perforated side towards the inner suiface of the cornea; and it should be made to dip down into the lenticular space. When thus placed, gentle mouth-suction will draw all the lens-matter through the aperture and into the glass tube; and any stray fragment may be followed until the aperture is beneath it, when it must needs fall into the stream. If the tube appears to be obstructed it may be withdrawn from the eye, blown clear and reintroduced ; and throughout the operation the course of the fragments should be carefully watched, and the suction regulated with a nicety which no mechanical substitute for the mouth can imitate. When all turbid matter is removed the eye should be closed by a com- pressive bandage, and atropine should be applied daily until recovery is complete. Complicationi<. — If the preliminary discission of the lens has been in any wa}^ faultily performed, the course of events will be less smooth. If the posterior portion of the lens has been left untouched by the needles it may remain transparent, and hence invisible, until after the anterior or broken portion has been removed. In such a case the suction may ap- pear to be complete, and the pupil may look clear and black at the time of operation ; but yet, a day or two later, fresh portions of turbid lens- matter may present themselves, and may not only interfere with vision, but may even produce irritation. If the quantity thus left in the eye is insignificant, and if no inflammatory symptoms appear, it will be suflH- cient to keep the pupil dilated and to wait for absorption ; but if the quantity is large, or if there should be any evidence of threatening or commencing iritis, suction should be repeated without delay. If the needles have passed through the lens, so as to pierce the hyaloid mem- brane and to permit vitreous humor to mingle with the fragments, the latter will be less readily softened than by the aqueous alone, and some amount of vitreous will be removed by the suction curette, and may after- wards escape through the corneal wound. In early operations it is better to do too little than too much, and a second recourse to suction is prefer- able to an admixture of vitreous with the lens fragments. JilsLs. — Under ordinary circumstances the removal of laminar cataract by suction is a very safe operation ; but in a few instances it is followed by severe plastic iritis, and it may even lead to suppuration of the eye- ball. The dangers attending it may be looked upon as arising from the circumstance tliat eyes which are the subjects of laminar cataract are often in other respects feeble and im[)erfectly developed organs, prone to destructive changes under slight provocation ; and the operation must be very cautiously undertaken where other evidences of imperfection are manifest. If there is congenital displacement of the lenses, or nystag- mus, or strabismus, or if the eyeballs are small and generally malformed, CATARACT. 721 the treatment of Laminar cataract must be undertaken with some hesita- tion, and must be made the subject of a very guarded prognosis. After discission or suction has been practiced, if any symptoms of acute in- flammation should show themselves, an iridectomy sliould be performed without delay ; all remaining lens-matter and all inflammatory products should, as far as possible, be evacuated ; a leech or two should be applied near the margin of the orbit, and cold comi)resses over the lids ; rest in bed should be enforced, and pain should be subdued by anodynes. Under such treatment it will often happen that a favorable or partially favor- able issue may be obtained ; but, if suppuration of the eyeball should be plainly impending, it is generally advisable to save pain by the early performance of enucleation. It is obvious, supposing laminar cataract to affect both eyes, tliat the}^ should never be operated upon together. Senile Cataract. — By senile cataract is meant an impairment of the transparency of the crystalline lens, which commences in persons past the middle period of life (or, in rare instances, in those who are com- paratively young), and which appears to depend upon a local failure of nutrition. The central parts of the healthy lens are of somewhat firmer texture than the superficial; and the gradual hardening of the whole structure which occurs as life advances is more marked in the former than in the latter. In the lens of any aged person, whether it is trans- parent or opaque, a variable depth of the outer laminie will be soft, and readily removed by the fingers ; while a variable bulk of the central laminae will retain a marked degree of firmness and coherence. The former portion is termed the cortex, or tiie cortical substance, the latter the nucleus ; and they are readily to be distinguished from each other, although no exact line of demarcation can be drawn between them. Senile cataract appears in two principal forms, the nuclear or hard cataract, in which the natural hardening or drying process is exaggerated, and in which there is a large, hard, or almost horny nucleus, surrounded by a thin la3'er of transparent cortex ; and the cortical or soft cataract, in which the nucleus may remain transparent long after the cortex is in- vaded by opaque strise, which appear to be lines of fatty degeneration, and which, as they increase and coalesce, tend to envelop the hard nu- cleus in a layer of softened and degenerated cortical substance, which may even break down into complete liquefaction, and may become the seat of calcareous deposits. But both the forms of senile cataract diff'er from those which are congenital, or which occur in early life, in this, that both, whatever may be the state of their outer layers, contain a hard nucleus which does not undergo softening, which cannot be broken up with needles, and which cannot be absorbed within the eye ; so that, for tlie restoration of vision, the nucleus must be removed, or "extracted" entire, through an opening sutticiently large to aflTord it a free passage. Diagnosis. — In childhood and early life, when the pupil is naturally of a clear, bright black, any milkiness or turbidity of the crystalline lens can be ascertained by simple inspection, and cataract can hardly be* over- looked if there is any complaint of defective vision. There is only one condition at all liable to be mistaken for it, and that is the growth of a malignant tumor in the vitreous chamber, when, although the pupil may be of a whitish or yellowish color, the diagnosis would generally be rendered eas}' by the hardness of the eyeball produced by the increase in the quantity of its contents, and by the presence of a greater degree of blind- ness than cataract would explain. But in elderly people, in whom there is alwa^^s a certain degree of yellow coloration of the lens, and in whom, from various conditions, more light is often reflected from tlie fundus 46 722 DISEASES OF THE EYE. than in 3'Oiing people, the pupils are seldom or never of a bright black, and they often present a most deceptive resemblance to the color of com- mencing cataract. At the same time, persons in the decline of life are subject to other affections, such as nerve atrophy and chronic glaucoma, whicli may in some degree imitate cataractous blindness ; and hence the diagnosis, while it is of the highest importance, is not altogetlier free from difhcult}'. In former times, indeed, it was ver}' difficult, and there can be little doubt that even highly skilled persons were often led to erroneous conclusions with regard to it. Of late years the difficulties have been in great measure removed by the employment of the ophthal- moscope. By the Ophthalmoscope. — For this purpose it is not necessary to use the instrument in such a manner as to obtain a view of the details of the background of the eye, but onl^' so as to illuminate the area of the pupil. The observer takes the mirror alone, places its edge in contact with the margin of his orbit, so that he can look through the sight-hole, and then directs the light from a suitably placed lamp fully into the eye of the patient, which, if the pupil is not artificially dilated, should be directed somewhat inwards towards the nose. Under such circumstances, if the media of the patient's eye are transparent, the circular area of tlie pupil will appear as a field of uniform and unbroken illumination, the brighter the larger it is, and more or less whitish, reddish, or yellowish in color, according to the part of the fundus which is opposite to the observer, and to the degree of pigmentation of the fundus. If, on the contrary, the media are anywhere opaque, the opacities will intercept the return of the light, and will appear as black lines or patches in the illuminated field. They may be situated in the cornea, in the crystalline lens, or in the vitreous body, but* in the cornea they will be readily discoverable by superficial examination, and in the vitreous they will in almost ever}^ instance be movable, whisking about in response to quick movements of the eye itself, and slowly sinking by gravitation when it is at rest. In the lens they are of two chief classes, which may be found either singly or in combination, namel}^, the wedge-shaped stride of cortical cataract, which have their bases towards the periphery and their points directed towards the centre of the pupil ; and the central irregular cloud of nuclear cataract. By Focal Illumination. — When opacities in the lens are discovered by the ophthalmoscopic mirror they should next be studied by focal illumi- nation, that is to sa}', by concentrating the light of a lamp upon the pupil with a lens, while the illuminated surface is magnified for examinatic^n by another. The annexed figure shows the relations of the lamp and lenses to the eya. of the patient; and by focal illumination the ojiacities will no longer appear as dark objects, but will be shown in their proper colors. The opacity of nuclear cataract will generally be of a dark yellowish- brown or London fog color; and the stride of cortical cataract will be lines 'of yellowish-white. At the same time the depth of the opacities ma}' be discovered, so that it becomes easy to say about what thickness of transparent cortex covers a cloudy nucleus, and whether cortical striae are chiefly in tlie anterior or in the posterior portion of the lens. Extraction of senile cataract, which is practically the only i-emedy for the blindness which it produces, must be deferred, whenever possible, until the cataract is mature; that is to say, until the degeneration has so far involved the cortical layers that they have lost their natural adlicsion to the capsule of the lens, and will slip out easily wlien that structure is divided. If extraction is prematurely practiced the nucleus may leave CATARACT. 723 behind a qnantit}' of cortical substance, invisible by reason of its trans- parency at tlie actual time of operation, but whicli on tlie following day will be seen lying in the pupil as an opaque and swollen mass, which not seldom excites dangerous or destructive inflammation. A mature cortical cataract is either uniformly whitish or has a striated appearance, like that Fig. 327. Pocal illumination for detection of cataract. of spermaceti ; and a mature nuclear cataract may retain its pea-soup tint ; but the best test of maturity is that the iris, under lateral illumination, casts no crescentic shadow, or only a very narrow one, upon the opaque surface on the side fi'om which the light comes. The presence of the shadow evidently implies the existence of a space filled with transparent matter between the margin of the pupil and the opaque surface behind it. If the opacity appears to touch the pupillary margin, so that there is no room for a shadow between them, then maturity is complete, and nothing can be gained by delaying the operation. Under some circumstances, and especially when the fear of blindness or the actual impairment of vision is either a source of great mental depression or a cause of physical privation by producing iucapacit}' to labor, it may be advisable to operate before cataract is mature, even although the risk of failure is thereby somewhat increased. Operation. — The operation of extraction is one of great delicacy, which, after having been performed in the same way, almost without variation, for about a century, has of late years been " modified" in so many ways, and by so many different o|)erators, that it would be impossible, within the limits here available, even to enumerate the changes which have been suggested. In the old method, which is now usually called ''flap extrac- tion," the surgeon cut through about half the circumference of tiie cornea, immediately in front of its attachment to the sclerotic, thus forming a semicircular "flap." Through the wound thus made, and through the pupil, the anterior capsule of the lens was freely lacerated by an appro- priate needle, the lens itself was expelled by well-directed pressure, and the lids were closed and secured. This method, when it was successful, left nothing to be desired; but it was followed, in about 20 per cent, of 724 DISEASES OF THE EYE. Fig. 328. the eyes operated upon, by destructive changes, which commenced, in about equal proportions, in iritis due to the stretching of the pupil, and in slougliing of the cornea due to its extensive severance from the sources of its nutrition. Yon Graefe was the first to suggest that the excision of a segment of the iris would prevent the stretching of the pupil by the lens, and would diminish the tendency to iritis, and when this suggestion was carried into effect it was found that the iridectomy rendered it pos- sible to extract through a smaller external wound than had formerly been required, and thus to dimin- ish the risks of corneal sloughing. Von Graefe worked very sedulously during several years at the endeavor to exclude, one by one, the chief sources of danger by which extraction was beset ; and he arrived at last at the point of losing only four eyes out of a hundred operations. Since his death a few improvements of detail have been introduced, but as far as principles and broad outlines are concerned he had covered the ground ; and the operations of a few surgeons who have since departed from his methods, either returning to a modification of flap extraction or making some form of transverse sec- tion of the cornea, do not appear likely to find favor with an3^ but those who have introduced them. Modified Linear Extraction. — The general idea of modified linear extraction is that the preliminary incision should be no longer than is required for the exit of the lens, that it should lie entirely in a por- tion of a larger circle than that of the cornea, that it should be in a tissue which will heal readily, and that the escape of the lens should be facilitated l)y the excision of a portion of the iris. At the same time the surgeon must be careful to avoid the ciliary region, a wound of which would be likel}'^ to produce sympathetic ophthalmia. For the fulfilment of these indications the extremi- ties of the section should be just behind the true corneal tissue, in a line parallel to, and two millime- tres below, a horizontal line touching the upper margin of the cornea. The patient being recuml)ent, and fully etherized, the surgeon separates the lids by a spring speculum. A linear knife (Fig. 328), whicli should have a blade thirt}' millimetres long, two broad, and as thin as is compatible with the necessary' rigidity, is lield in the right hand for the right eye, and in the left hand for the left, the ope- rator standing behind the head of the patient. Tlie eyeball is secured by fixation forceps, and the point of the knife is then entered, its cutting edge up- wards, just behind the margin of the cornea, as at A, in the diagram (Fig. 329). The direction of the tlirust is towards the centre of the eyeball, until the anterior chaniber is penetrated, when the point is turned so as to descend, in a direction parallel with the plane of the iris, to about the position n. Wlu!n this is reached the handle is depressed, turning on the back of the blade in the incision, Linear knife for extraction of cataract. EXTRACTION OF CATARACT. 725 Fig. 329. until the point is brought to c on the same horizontal line as the puncture. When this is reached the liandle must be inclined somewhat backwards, and the point pushed on with a quick movement, so that it may transfix both sclerotic and con- junctiva at its place of first impact. The flat surfaces of the blade should now be parallel with the plane of the iris. The fixation instrument should bo laid aside, the edo;e of the knife turned very slightly forwards, and the incision completed by a succession of gentle drawing cuts, which should bring its centre to coincide with the junc- tion of the cornea and sclerotic, and the last of which should be made with especial care. The Iridectomy. — The next step is the iridectomy, which has not for its object the formation of a large coloboma, but only to destroy the resistance of the sphincter of the pupil to the passage of the lens. A pair of delicate forceps, shown open in Fig. 331, and with their minute teeth, both open and closed, at a, b, and c, are introduced closed through the incision, and suffered to expand a little when they approach the pupillary margin of the iris, which will then rise be- tween them, and may be seized, gently drawn out, and cut oft close to the forceps blades by one stroke of a pair of scissors. If this is properly done the angles formed between the terminations of the incision and the margin of the pupil should be visible within the anterior chamber, as at a and b, in the annexed diagram ; but if the iris is dragged out and cut close to the angles of the external wound, the appearance shown in the next figure will be presented, and por- tions of iris will often be left incarcerated at the Diagram showing the incision for linear extraction. Fig. 331. Diagram of tlie correct and faulty sections of the iris. angles, where they may excite great subsequent irri- tation. The iridectomy completed, the operator lace- rates or freely divides the capsule of the lens, using for this purpose a needle slightly curved at its ex- tremity, or the " fleam-shaped " cystitome of Von Graefe, or the forceps cystitome of De Wecker, by which a piece of capsule may be brought out of the iridectomy forceps. eye. In lacerating the capsule it is essential to divide it very freely, and to use tlie selected instrument very gently, as other- wise the lens itself might be dislocated into the vitreous. The last pro- ceeding is to expel the lens from the eye by gentle and well-directed pressure. For this purpose the conjunctiva may be seized with forceps, and the back of a small vulcanite spoon applied just below the cornea, where its pressure should first be directed backwards, so as to turn the upper border of the lens forwards towards the incision, then upwards, so 726 DISEASES OF THE EYE. as gradnall_y to force it out through the opening. As soon as the nucleus has escaped the speculum may be removed, and gentle friction exercised througli the closed lid, by wliich any remaining cortical fragments will be gathered together in the pupillary space, from whence they may be extruded by carefully regulated pressure. As soon as everything is re- moved the eye may be finally closed and bandaged. Loss of Vitreous. — If vitreous hnmor should escape before the lens the latter must be at once removed from the eye by a scoop or hook ; and if vitreous should follow the lens the eye must be closed as quickly as pos- sible, even though a certain amount of cortex may be left behind. Yery rarely, the exit of the lens is followed by intraocular luiemorrliage, due to the rupture of a choroidal vessel suddenly deprived of support. When this happens there is no hope of preserving sight, and the distended eyeball usually becomes the seat of painful and tedious suppuration. It is better to prevent this, whenever blood or coagulum is seen issuing from the wound, b}' performing enucleation while the patient is still under the influence of an angesthetic. Of course the trivial bleeding which ma}^ arise from the cut iris must not be confounded with that from a deeper source. Natural Healing. — If the whole of the cataract has been removed without mishap, and if the reparative powers of the patient are even mod- erately good, the external wound will heal quickly. The patient may usually rise from bed on the second or third day, and may lay aside the bandage in the daytime after the fourth or fifth day, wearing-a shade, and replacing the bandage before assuming a recumbent posture. As irritation subsides the light may be gradually admitted; but the eye should not be brought into use for a few weeks, so that the cicatrix may become firmly consolidated before it is exposed to the traction of the recti muscles. Suppurative Inflammation. — In cases which proceed less favorably there are two chief dangers to be dreaded. In some patients the injury is followed by acute iritis, with a tendency to suppuration, or by slough- ing of the cornea, and either of these conditions commonly leads to com- plete suppuration of the eyeball. They are ushered in, usually on the second da}^, by redness and swelling of the upper lid, with swelling of the conjunctiva and slight puriform discharge ; and these conditions call for the administration of quinine, ammonia, and alcohol, for the applica- tion of firm pressure, alternated with hot fomentations, and for the use of a lotion containing five grains of hydrochlorate of quinine to the ounce of distilled water, to be applied to the conjunctiva of the lower lid by a quill. By such treatment it is sometimes possible to save an only partially damaged eye; but if the suppuration and swelling increase, and the whole cornea becomes opaque, all hope must be given up, and free incisions should be made tlirough the sclerotic between the recti muscles, to diminisli pain and tension, and to permit tlie escape of pus and sloughs. Such instances are fortunatel}'^ much less common tlian they were when flap extraction was practiced ; but a moderatel}' large proportion of pa- tients still suffer from a chronic iritis of plastic character, which is often excited by the remains of cortical substance left witliin the eye, and which in severe cases may produce a good deal of very obstinate neural- gia, terminating in wasting of tlie globe and loss of sight. In mild cases it may do no further mischief than to leave the i)u[jillary space obstructed liy bands or menibranes of blended capsule and lymph, wliich may re- quire to be torn b\'- cataract-needles, or even cut out and removed by scissors and forceps, in order to afford useful vision. The treatment of CATARACT-GLASSES. 727 this chronic iritis must be hy atropine, an occasional leech at the margin of the temple, the seclusion of the eye from all irritants, the control of pain by morphia or other anodynes, and the use of such constitutional remedies as circumstances may require. Gataracl-Olaases. — An eye from which a cataract has been extracted, unless it was originally very highl^^ myopic, will have no defined vision until the optical power of the natural lens is supplied by an artificial one. Moreover, as it is the elasticity of the natural lens which allows the eye to be adjusted for different distances, and as this quality is wanting in the artificial one, it must lie supplied by the use of diflferent powers. As a general rule, an eye whicli has been operated upon for cataract will re- quire a convex lens of about 2 or 2^ inches focal length for reading, and of about 3 or '6\ inches focal length for distance. Excepting large hoemorrhages into tlie vitreous body, and the growth of intraocular tumors, both of which may produce a deepseated change of color discernible by focal illumination, the diseases of the parts of the eye behind the crystalline lens were formerly concealed from observation ; and, until many of them were revealed by the invention of the ophthal- moscope, they were all included, when they produced impairment of sight, under the general term " amblyopia ; " and when they produced blindness under the general terra " amaurosis." The impossibility of seeing into the deeper chambers of the eye without optical assistance depends upon the fact that the rays of light can only return from an eye by the same track along which they enter it ; and hence the eye of an observer cannot be so placed as to receive tlie returning rays without his head at the same time intercepting the entering rays, and throwing what he wishes to see into darkness. The ophtlialmoscope is a mirror with a central perfora- tion, and it acts by reflecting the light of a lamp, which is placed at the side of and a little behind the head of the patient, into the eye under ex- amination. The returning light then comes back to the mirror, and some of it passes through the central perforation into tlie eye of the observer, which is so placed as to receive it. There are two methods of using the ophthalmoscope — the direct and the indirect. The latter affords the best general view of the interior of the eye; the former is more especially adapted for the minute examination of details. Direct Method.— In the direct method the eye of the observer is brought close to that of the patient, the mirror only intervening, and the ob- server looks into the eye, and sees the structures within in their natural positions, as real objects, magnified by their own crystalline lens. The position is shown in Fig. 332, which is a dia- grammatic section of the two heads and the mirror. The heads are inclined a little ob- liquely, and the left eye should be used for the examination of the left, and nice versd^ to avoid contact between the faces or annoyance from the breathing. In the diagram the observer, A, receives the light from the flame upon his mirror, directs it into the left eye of the patient B, and sees the fundus of b's left eye through the perforation in the mirror. The statement that only the mirror is interposed is only true wlien both eyes are normal-sighted. If either of them is shortsio-hted the defect must be „. f,- f wi i „ •„ » Diagram of direct ophthalmoscopic corrected by a concave lens of proper strength, examination. 728 DISEASES OF THE EYE. Fig. 333. and if either of them is flat or hypermetropic the defect must be corrected by a convex lens of proper strength before a perfect picture will be ob- tained. In either case the correcting lens is most conveniently placed in a clip behind the mirror, or in a revolving disk carr3'ing several lenses, so that different ones maj^ be brought over the sight-hole by simple rota- tion. Indirect Method. — In the indirect method the observer remains at some distance from the patient, and holds up near the C3'e of the latter, and in the track of the light, a strong convex lens, which produces, between itself and tlie observer, an inverted, aerial, brightly illuminated image of the fundus of the eye looked at. This image, and not the fundus itself, be- comes the object of vision. By placing another convex lens behind the mirror the image may he. magnified and rendered more distinct ; but it can only be seen so long as the observer handles the mirror properly, so as to maintain the illumination, and so long as he keeps in a straight line with the eye examined, so as to be in the track of the returning rays. The diagram shows the position of things. A is the head of the observer, B of the patient, whose left eye is under examination. The rays of light from the flame, received on the mirror and directed into the eye of b, are united on their return by the convex lens into the image i, and this image is seen by a, through the mirror per- foration, as soon as he is at the proper visual distance from it, and as long as he keeps strictly on the line l b, along which he must move to and fro until the proper distance is obtained. If he moves laterally to a' or a" he loses the image entirel}^ The whole art of using the ophthalmoscope is comprised in keeping the eye of the ob- server in a line with that of tlie patient, in maintaining a steady illumination, and in finding the correct distance. The instrument is extremely simple both in construction and application, and any intelligent person may acquire the knack of seeing with it in half an hour, although the art of interpreting the appearances exhibited can only be gained b}^ practice and reflection. The opportunities for learning to han- dle the ophthalmoscope are now so abundant that it is nnnecessar}'^ to devote space, in a manual of this kind, to any more detailed description of the way in which it should be managed. Glaucoma. — Among tlie diseases wliich involve the deeper parts of the eye the most important is glaucoma, and it owes its importance mainly to these circumstances — first, that its nature is often overlooked until irreparable mi.schief has been done ; secondly, tliat if it is recognized in time it may in most cases be arrested or cured by the operation of iri- dectomy. Tlie word glaucoma was originally ai)plied, in a very vague manner, to nearly all cases in which the blackness of the pupil liad changed to a greenish hue ; but of late years it has come to have a per- & Diagram of indirect oplitlialiuoscopic exami- nation. GLAUCOMA. 729 fectly definite meaning wliich stands in no sort of relation to its etymol- ogy. It used to denote all the morbid conditions which arise from in- creased hardness or heightened tension within the eyeball ; and it is coupled with adjectives which denote different periods of duration — such as "•chronic," ^'subacute," "acute," and "•fulminating." Its Nature and Degrees. — Concerning the essential nature of the pro- cesses by which the fulness or tension of the eyeball may be increased there is nothing certainly known ; but they are conjectured to be in- creased secretion, as an effect of some perversion of nervous action, and diminished exhalation or transudation, as an effect of some change — ■ probabl}' senile hardening — of the tissues of the eye; these conditions l)ossibly existing either singly or in combination. When a state of over- fulness of the eyeball is once produced it tends to maintain and to in- crease itself, chiefly because the vente vorticosae, which convey blood from the choroid, pierce the sclerotic so obliquely that their channels are compressed and partially closed by any increment of fluid within the globe. Hence a certain degree of venous congestion or blood-stasis is produced, and may lead to transudation of liquor sanguinis and conse- quent redema. Notwithstanding the retarded outflow of blood the arterial inflow continues, even if in diminished quantity, and in this way a steadily increasing degree of pressure may be brought about. The natural or physiological tension of the eye varies, in different people, within rather wide limits, and the instruments which have been devised for measuring it with exactness are of no great practical value. The best estimate of tension for clinical purposes ma>' be made by careful palpation, but care- less palpation may lead to very erroneous conclusions. The patient should be directed to look downwards, closing the lids gently, and the surgeon should i)lace the tips of the two forefingers on the upper part of the eye- ball, close under the orbital margin, as far back as the closed lid will allow. One forefinger should be used to steady and support the eye, the other to feel its degree of hardness by gentle and intermittent pressure. A healthy eye will dimple somewhat under the finger, with a peculiar slight elastic resistance ; and a diseased one may be either too hard or too soft. Mr. Bowman proposes to recognize nine degrees of tension — the normal, four of increase, and four of diminution. He distinguishes the normal tension as T. n., and the four varieties by a T with a /^/ws ( 4- ), or minus ( — ) sign, and with either a note of interrogation or a numeral. T 4- ? is doubtful increase; T -f 1, distinct increase; T -f 2, considerable increase ; T -f- 3, great increase ; while the minus sign indi- cates diminution of tension in the same manner. Tiiis method of stating tension is now in general use, although it has the obvious defect of affording no standard for anj' of the degrees which it records. Its Effects. — The manifest effects of heightened tension are produced, first, upon the circulation of the eye ; next, upon its nerves ; lastly, upon its tunics; and they diflfer in their more marked characters in accordance with the rate at which tension increases. If the increase is very slow the tunics accommodate themselves to it, and, for a time at least, yield painlessly, while the sensibility of the retina is slowly destroyed by com- pression and by arrested circulation. If the increase is rapid the sti'etch- ing of the tunics is acutely painful, and, together with the sudden dis- turbance of the circulation, produces inflammatory reaction. Hence chronic glaucoma is liable to be mistaken for atrophy of the optic nerve, and acute glaucoma is liable to be mistaken for inflammation. In con- sequence of the attendant pain it has often been mistaken for gouty or 730 DISEASES OP THE EYE. rheumatic inflammation, and lias been suffered to go on to blindness before its true nature was discovered. On the Circulation. — As soon as the free exit of blood through the venae voi'ticos;i3 is impeded, q,n endeavor is made to obtain the necessary outlet through other channels, and chiefly through a series of veins which pass out from the eyeball through the sclerotic not far from the corneal margin, and course backwards under the conjunctiva. In health these veins are scarcely visible, but lieightened tension renders them distended and toi'- tuous, carrying dark-colored blood. They are very visible under the con- junctiva, and can hardly be mistaken for the A'eins proper to that mem- brane. At the same time a remarkable phenomenon is produced in the vessels of the retina, which constitute a closed circuit of their own, almost independent of that of the rest of the eye. Of course, when there is increased tension, the entrance of blood through the central artery of the retina and its exit through the central vein are both impeded, and the result is the production of a visible pulse in the larger portions of these vessels where they lie upon the surface of the optic disk, first in the veins, secondly in the arteries. The observer, looking at the optic disk with the ophthalmoscope, sees it alternately more and less pallid, the variations occurring synchronously with the radial pulse. What first happens is that the blood in the veins is driven a little back towards the capillaries, so as to make I'oom for the entering arterial wave, the walls of the veins collapsing, and the disk losing color, until as the pulse-wave flags the blood in the veins flows back again, and is thus constantly driven to and fro. The venous pulse, therefore, consists of an emptying of the veins from the centre of the nerve-disk to its margin, alternately with a reflux of blood from the margin of the disk to the centre. A venous pulse may be readily produced in most eyes by pressure upon the globe with the tip of a finger, and it is an early symptom in glaucoma, occurring either spontaneously or under very light pressure indeed. As tension increases tlie arterial blood can no longer enter in a continuous flow, but only during the acme of the pulse-wave, so that the arteries collapse during the cardiac diastole, producing a visible arterial pulse, the reverse of that in the veins, the arteries emptying themselves from the margin of the disk to the centre, and refilling from the centre, to the margin. It must be observed that these pulses, arterial and venous, are neither peculiar to glaucoma nor pathognomonic of it. They indicate increased resistance to the entrance of blood, or diminished propelling force; and they only point to glaucoma when there is a distinct increase of tension. In some eyes a venous pulse is a physiological phenomenon, and it can be pro- duced in all by pressure. An arterial pulse may be due to defective power of the heart, or to aortic regurgitation, or to heightened tension and increased resistance of the bloodvessels. On the Nerves. — The effect of heightened tension upon the nerves of the eye is to impairtlieir function, and sometimes to alter their physical struc- ture by direct compression. The motor, vaso-motor, and common sensory nerves are the long and short ciliary, which receive twigs from the third and liftli cranial nerves and from tlie sympathetic. The}^ course between the choroid and the sclerotic, and during the progress of glaucoma they are squeezed against the latter tunic. If the compression to which they are subjected is slight it produces numbness or imperfect function ; if greater, it may excite the sensory nerves to pain. On the retina, the effect is to render it torpid to the impressions produced l)y light, and ultimately insensible to them; and the optic nerve, the surface of wliicli is mechanically the least resist- GLAUCOMA. 731 ing part of the eyeball, is often forced back in such a manner that it be- comes an excavation or pit, instead of being slightly prominent as in the natural state. The nerve-fibres, bending round the edge of this pit almost at a right angle, are squeezed against the margin of the sclerotic opening and undergo wasting, by which this margin itself is rendered conspicuous ; while the bloodvessels, following the same course, may be seen to bend in a similar manner, and the portions on the floor of the cup may even appear to be disconnected from their continuations on the retina. Couri;S OF THE EYE. Fig. 337 Diagram to illustrate the operation for strabismus. e3"e onl3^ If the degree of deviation is not large, such an operation may produee parallelism when the eyes are at rest, and may correct a conspic- uous deformity, but it can only do so at the cost of producing a perma- nent ditlerence of convergence power between the two, so that a common motor impulse would aifect them dif- ferently, and the eye operated upon would lag behind the other during every eflbrt to direct both to some near point. Fig. 337 represents a pair of eyes, A, b, in the ordinary po- sition of fixed squint. At rest, that is, during sleep, the}^ would be equall}' convergent, but the working eye, A, is habitually directed forward, for visual purposes, along the line A a', and the whole convergence is manifested by the squinting e3'e b, which is habitu- ally directed inwards along the line B b', these two lines forming always an angle of the same magnitude. The internal recti muscles of the two eyes are inserted into the sclerotic at the points c c'. Let it be supposed that an operation upon the eye B, which put back its internal rectus to a new attachment at D, would overcome the habitual convergence, and would allow the line of direction b b' to become parallel to the line of direction a a'. When the eyes were di- rected forwards the squint would be cured, but the internal rectus of the eye a would be left in a position of advantage, with its strength undi- minished, while the internal rectus of the eye B would be weakened by being placed in a position of great disadvantage. When any attempt was made to fix both eyes on a near object the same central motor im- pulse would produce different results upon the two, and the eye b would either lag behind its fellow and appear to squint divergently in relation to it, or its muscle would become tired and strained by being called upon for a greater exertion than its fellow. The proper operation is to divide the correction equall}' between the two eyes by putting back the two nuiscles to the points of attachment E e'. By this we not only obtain parallelism when the eyes are at rest, but leave them with equal and suffi- cient convergence power, and replace them in that natural condition from which they had been caused to deviate by the acquired hypertrophy of their internal recti muscles. Mcnpritnde of a Hquint. — The magnitude of a stpiint is commonly expressed by the distance between two vertical lines, one of which bisects the palpebral oi)ening of the scpiinting eye, while the other bisects the pupil of the same eye when the working eye is directed forwards, as shown at A and b, Fig. 338. It is obvious, as tenot- omy of the internal rectus cannot be made to of csUmating the degree of producc less than a certain minimum of effect, squint. that a scjuint may be so small as only to admit of a single operation, which should then be per- formed upon the squinting eye; and it is also obvious that a squint may DiaKrarn to sliow the inctlio[r. Dalhy teljs me that three weeks is the siiortest and five years the longest period that he has known tliis disease to be in progress before the hearing was entirely lost. Meniere's disease. 765 of disease of the ear is its liability to extend to the brain. Inflammation of the meatus or mastoid cells tends to spread towards the lateral sinus or the cerebellum, inflammation of the tympanum towards the middle lobe of the brain, and that of the labyrinth along the auditory nerve towards the medulla. The result is meningitis, abscess in the substance of the brain, or phlebitis of the lateral sinus, possibly followed by pyaemia. The symptoms commence with pain in the head and neck, and rigors; then delirium ensues, followed by paralysis, coma, and death. In cases of general pytemic infection from phlebitis of the lateral sinus, the char- acteristic symptoms of pyemia will be superadded. The affection fol- lows on all kinds of disease of the ear, but mainly, I believe, on the acute inflammation of the tympanum, which is one of the sequelae of scarlet fever, and which rapidl}' spreads to the bone ; in fact, the more the bone is inflamed and the acuter that inflammation is, the more danger there is of cerebral complication. This is strictly analogous to what we have noted above with regard to acute inflammation of bone in other parts. But these complications also follow in chronic diseases of the ear, though in such cases the discharge has generall}' ceased on a sudden, and in all probability such obstruction marks the supervention of some acute dis- ease of the bone, which rapidly S2)reads along the veins to the interior of the skull. Treatment can be of any avail only in the first stage of the disease, when pain in the head and the cessation of some habitual discharge gives warning to the surgeon of the possibility of the inflammation spreading inwards. Free leeching behind the ear, incision dovvn to the mastoid process, if there is any pufliness or tenderness there ; blistering behind the ears or setons in the nape of the neck, purgatives, and the encouragement of the discharge by assiduous warm syringing and fomen- tation, are the measures which seem most worth}' of trial. Possibly if the menibrana tympani be entire it may be well to incise it, and wash out the tympanic cavity. 31eniere''s Disease. — In connection with nervous deafness and affections of the internal ear I ought to mention the obscure and singular aff'ection called after its describer "Meniere's disease," in which a person previ- ously in good health sutlers from a severe attack of vertigo, sometimes so that he falls down and cannot stand for a long time, and this is ac- companied by some tinnitus. On recovering from this condition one ear is found to be quite deaf. No disease can be detected in the tymi)anum, nor is tlie general health afterwards affected. "The nervous lesion," as Mr. Dalby says, "must be situated in the brain or the labyrinth — most likely the latter," — but the pathology of the affection is at present un- known. It is, however, important to be aware of it, and to distinguish such symptoms, caused b}' local disease in the ear, from the more alarm- ing disease of the brain. 766 DISEASES OF THE URINAEY ORGANS. CHAPTER XXXVII. DISEASES OF THE URINARY ORGANS. SURGICAL AFFECTIONS OF THE KIDNEY. Nephritis. — Acute inflammation of the kidney is a very common affec- tion in surgical cases, and occurs usually as' an extension of the inflam- mation of the bladder, which will presently be described as the result of stricture, stone, diseased prostate, and other common surgical affections. It may also follow on injuries, or arise from exposure to cold, or from poisoning by cantharides, or alcohol. It is marked l\y rigors, vomiting, pain in the back, frequent scanty micturition, bloody or albuminous urine, frequently purulent, and often containing casts of the renal tubes, with a good deal of general fever. In spontaneous cases anasarca may occur and total suppression of urine. Suppuration in the substance of the kidney may ensue, marked by increase of pain and retraction of the testicle, and is rapidly followed by the unconsciousness and sinking which attend urfemic poisoning. Galculvus Nephralgia. — The passage of a calculus down the ureter — " calculous nephralgia " — is attended with some of the above sjmiptoms. " Indeed, excepting the severe febrile symptoms, all those of nephritis are present," the leading symptoms being acute pain shooting down the loins, retraction of the testicle, and vomiting. The urine is scanty and often mixed with blood. The suddenness of the invasion of the disease, the coniparativel^' healthy condition of the urine, and especially the in- stantaneous subsidence of the symptoms as the stone passes into the bladder, are the diagnostic signs from nephritis. The treatment consists in the very free use of the hot bath, cupping and fomentations to the loins, the free administration of opium and other narcotics, and, if the pains are severe, the occasional adrainisti'ation of chloroform — not to total anaesthesia. Calculous Pi/elitis. — Acute calculous pyelitis is distinguished, accord- ing to Sir II. Thompson, from nephritis by the greater severity' of the l)ain in the back, and the retraction of the testicle, and b}- the less rapid course of the disease. Blood and pus will be found in intimate admixture with the urine. Nephritis ma_y also be confounded with abscess from diseased spine, witli lumbago or rheumatic affection of the muscles, and with hysterical or neuralgic pain ; but the special symptoms of all these conditions are almost in tliemselves sufficient to mark the difference, and the state of the urine is a conclusive proof of the absence of nephritis. Finally, inflammation of the bladder from stone or other causes may to a great extent simulate renal inflammation, and, of course, tlie two are very often combined in various jjroportions. lint the localized pain in the region of the bladder, the absence of any tenderness in the lumbar region, and the discovery- of the cause of the cystitis, will distinguish it from nephritis. HEMATURIA. 767 Treatment of Nephritis. — Tlie treatment of acute nephritis is directed chiefly to relieving tlie congested kidney by free diaphoresis from the skin, by free purging, and by leeches and counter-irritation to the loins, ^ with perfect rest and low diet. The vomiting must be combated by iiydro- cyanic acid or creasote, and b}^ mustard-poultice to the pit of the stomach. At tlie same time any known cause of inflammation or obstruction must if possible be removed, and as little mechanical interference with the urinary organs practiced as the exigencies of the case permit. Nephrotomy. — The diagnosis and treatment of calculus in the kidney come rather within the province of works on medicine. The sui'geon is sometimes consulted as to the possibility of removing a stone from the kidney (or perhaps, more accurately speaking, from its pelvis), and the attempt may be justifiable under certain circumstances, thougli hitherto it has ended in disappointment. In a case lately under Mr. Callender's care the stone was, I believe, found ; but the patient died — in other cases the diagnosis has been at fault or the stone has not been in an accessible position. Often, however, the stone is ratlier situated in a cavity near the kidney than in the organ itself, and under these circumstances is much more favorably situated for extraction. Chronic nephritis, as a sequel of the acute and the other conditions which lead to albuminuria, or Bright's disease, would form a subject too extensive and too purely medical for the present place. I will content m3'self with saying that in all surgical cases the state of the urine should be carefully examined, and the surgeon should be familiar with tlie signs of chronic degeneration of the kidney, since the}' powerfully influence prognosis, and will often contraindicate operations and other active treatment in diseases where otherwise they would be pressed upon the patient. Hsematuria. — The passage of blood in the urine is a frequent sj'mptom both in medical and surgical practice; and although the treatment of many of the conditions which give rise to it lies within the province of the physician, yet it is necessary to review all of them for the purpose of diagnosis. The blood may come (1) from the kidney, including the ureter ; (2) from the bladder, including the prostate gland ; (3) from the urethra. 1. The sources of renal hamiorrhage are — rupture or laceration of the kidney by blow or fall, cancer of the kidney, and possibly other tumors ; congestion from nephritis or from the use of certain drugs ; the irritation of a calculus, eitlier in the kidney or ureter, to which may be added that in some general diseases, such as purpura, the hjtmorrhagic diathesis, scurv}', the "endemic hematuria," lately spoken of in Africa, blood passes from the kidneys. The diagnostic symptoms of such of these affections as lie within the province of surgery will be found under their ap})ropriate headings, to which I will only add that the blood from the kidney is always intimately mixed with the urine (giving it a dark porter-color), and that " as a general rule, such urine, passed without pain or any other local symptom whatever, is more likely to derive its blood from the kidney than else- where " (Sir H, Thompson). The urine should be carefully examined microscopically, in order to determine the presence or absence of casts of the kidney-tubes. ' The onmnion blister phould not be used in tbe>e cases, for fear of the absorption of the eantharides. A bli.-ter can be raised at once by the strong liquor ammonise or by chloroform, covered with a watch-glass or oiled silk. 768 DISEASES OF THE UEINART ORGANS. 2. The sources of vesical hiPiiiaturia are — wound of the bladder or prostate; tumor, cancerous or villous ; calculus in tlie bladder; conges- tion of the prostate gland ; ulceration of the coats of the bladder or acute congestion in cystitis. IMood from the bladder is generally less intimately mixed with the urine than that from the kidney ; it very commonlv clots in the bladder and remains behind after the urine has been passed; the urine first passed is often comparatively clear, while at the end of micturition the blood is passed almost or quite pure. But tliese signs are not alwa3's to be im- plicitly relied on, and the surgeon must examine the patient carefully for the diagnostic symptoms of the afl'ections above enumerated, 3. Urethral haimorrliage is caused by blows or wounds (including laceration by the catheter), impacted calculus, rupture of the corpus spongiosum in sexual intercourse or chordee ; tumors in the urethra; ulceration, chiefly in syphilis ; congestion in gonorrha3a or stricture. The most reliable test of this source of htBinorrhage is wlien it can be detected as occui-ring independent of micturition, which can almost always be done if the patient be carefully watched, or when the blood collects in the urethra and forms a cast of it. The source of the hiemorrhage being determined and its supposed cause, the treatment of the latter is of course the main indication, but the haemorrhage itself sometimes requires treatment. The bladder may be so abundantly occupied by clot as to require its disintegration and re- moval piecemeal, by means of the injecting catheter ; the amount of blood from the kidney ma}'^ be so alarming as to demand the administration of internal styptics ; urethral haemorrhage may sometimes be controlled by pressure, a metal catheter having first been passed ; and perfect rest should in all cases be enforced, whenever the bleeding is considerable. Sn2^p7'essio7i of urine is an event which is almost certainly fatal, and which must be carefully distinguished from retention. Obvious as this distinction is, it is strange how often the mistake is still made. The causes of suppression are general, while those of retention are local; the bladder is found perfectly empty on passing a catheter, or almost so ; the patient experiences no ditlicult}' in passing water, but has none to pass, or only a very small quantity. He is troubled with vomiting and gener- ally pain in tlie back, and is feverish; becomes stupid, perhaps delirious, and then comatose, and almost always dies. Sir H. Thompson mentions a case in which the patient recovered after fort^'-eight hours of complete suppression, as I have known another similar one. The chief points in the treatment are free action on the skin by the hot bath and vapor bath, fomentations and leeches to the back, and free purgation. DISEASES OF THE BLADDER. Malformation. — The bladder has been absent, the ureters opening into the urethia, rectum, or vagina, but the malformation is a very rare one. Congenital Cyd. — Less uncommon is the presence of a "double blad- der," or large congenital cyst, of whicli a remarkable instance is sliown in Fig. 844, which occurred in my own practice. Such cases cannot be diagnosed or treated during life. Their main interest consists in know- ing that sucli diverticula may occur, and may very easily become the seats of a calculus, wiiich then would present great ditliculties in its operative treatnienl. Exiromraion. — The ordinary malformation of the bladder, however, is extroversion. Tliis condition depends on a malformation of the ab- MALFORMATIONS OF THE BLADDER. 769 Fig. 344. dominal parietes. In most cases the whole of the hypogastric region is deficient, from the navel to the pubes. There is no um- bilicns ; the anterior wall of the bladder is also deficient; its posterior wall is attached to the skin and projects from the belly in the form of a red prominence, bleeding- read- ily, and showing tlie slit- like mouths of the ureters, from which the urine can be seen distilling. The pa- rietes extend, however, in some cases lower than the umbilicus, which is then natural. Bounding the ex- troverted bladder is a double ridge, like a V inverted, which marks the coalescence of the skin and bladder. The penis is rudimentar}', and is marked by a groove on its dorsal aspect, into the back of which as it joins the vesical membrane the semen is discharged in adult life. The prostate is hardly to be discerned. The testicles are generally natural. There is often hernia on one or both sides. The pubic symphysis is often deficient. The same malformation occurs in the female sex Malformation of the bladder, showlug a large cyst, or false also but much more rarely, ^'^'^'^ler, wluch commuDlcated with the true bladder. The It is not necessaril}' compli cated with any malforma- tion of the internal sexual organs, and women so af- flicted have borne children. The malformation is per- position of j)arts has been reversed in the preparation, the kidneys being seen below. The parts were taken from a male infant, wlio was born with retained testicles, a peculiar shape of the abdomen, the parietes of which were deficient below, so that the viscera protruded beneath the skin. There was a nsevus of the skin of the pubes. The child throve for a few days, then began to refuse the breast, passed blood in the water, and died on the eighth day. a, the large cyst lying above in fectly consistent with health, the preparation. This was the true bladder; its walls were and I have often seen vigor- ous adults affected by it. Its inconveniences are the con- stant dribbling of urine and the tendency of the exposed membrane to bleed. The much hypertrophied, and its interior covered with nsevus tissue, from which doubtless the bleeding had come. The openings of the ureters and urethra were quite natural ; 6, the secondary cyst, the walls of which were very thin and destitute of muscle. It showed no trace of any vascular tissue on its interior. It lay in the right side of the pelvis and right iliac fossa. Death had evidently been caused by its pressure on the ureters. The kidneys, c, d, are seen to be much dilated and latter infirmity mav be cor- absorbed by pressure, especially the left, and the ureters were rected by a plastic operation, coated and tortuous. The testicles lay close below tire kid- r. /. n neys. — Path. Soc. Trans., vol. xvi, p. lO'J ; St. George s Hospital which was first successfully Museum, Ser. xii, No. 115. performed in this country by me in the year 1863,' and a similar proceeding has been successfully 1 Lancet, 1863, vol. i, p. 714. 49 770 DISEASES OF THE URINARY ORGANS. repeated by Mr. J. Wood and other surgeons. It consists in bringing two skin-flaps over the bltidder, one turned with its cutaneous surface downwards, so as to be in contact with the extroverted mucous mem- brane ; the other with its raw surface downwards and in contact with the raw surface of tlie former. These being united to each otlier form a thick bridge over the cleft, which ma}' be afterwards implanted into the skin of the abdomen till only a narrow oriOcc is left below, to which a bottle can easily be applied. But the patient or his friends must be instructed to wash out the cavity frequently with acidulated water, to prevent the for- mation of phosphatic concretions. Attempts have been made to divert the course of the ureters into the rectum, so as to form a cloaca there, and obviate an}' incontinence of urine, but these have hitherto failed. Tnver,^ion of the Bladder. — In connection with malformations I may mention the inversion of the female bladder which is sometimes met with in childhood, and which though not due to malformation might easily be mistaken for it. It seems to occur from constant straining in making water, and the bladder projects through the urethra, as a pyriform red A\T,scular tumor in which tlie orifices of the ureters can be seen. On a careless examination this might be mistaken for extroversion, or still more fatally for a polypus, and it has nearly been tied on that supposi- tion. Treatment by careful reduction, maintained by a catheter with a bulbous end, and frequent cauterization of the expanded urethra with the actual cautery, has been successful in restoring the power of retaining the urine.^ Hernia of the Bladder. — The bladder may protrude as a hernia into the scrotum or vagina, or may form part of the contents of an inguinal her- nia in the male, or a femoral in the female. The occurrence is a rare one, the diagnosis difficult, and in one case recorded by Pott the herni- ated bladder was opened by mistake. When by careful examination, the surgeon has reason to apprehend that the bladder is herniated — i. e., when pressure on the hernia always causes the immediate exit of urine, and when a catlieter passes into or towards the hernial orifice — double care should be exercised to reduce it and keep it reduced. In the female when it protrudes into the vagina it forms one of the forms of vaginal C3'sto- cele, which will be found treated of in a subsequent chapter. Tumors of the Bladder. — Many kinds of tumors have been found springing from the walls of the bladder. The innocent tumors are warty growths, polypi, and fibrous tumors. These, however, are rarely found, and can hardly be diagnosed, at least in the male. They cause merely symptoms of obstruction to the flow of urine, the cause of which it is impossible exactly to discover. In the female, where the finger can be passed into the l)ladder under chloroform, the diagnosis might be made and the tumor removed by ligature. These tumors are too rare to require more than a passing mention. But the tumors which are commonl}^ met with in practice, and which give rise to definite symptoms of their own, besides those which are due to the mere obstruction due to their position, are the villous tumor and cancer. Villous tumor of the bladder is usually innocent, both structurall}^ and surgically (see p. 870), though a cancerous tumor may also sometimes be covered by villous processes of mucous membrane, as seen in Fig. 845. Tlie true villous growths, however, consist merely of numerous processes exactl}' resembling the villi of the chorion in structure, very vascular, 1 Low<', in Lancet, 1862, vol. i, p. 2-50. CANCER OF THE BLADDER. 771 and often developed at different parts of the bladder, so as to form mul- tiple growths, many of which are only perceptible on anatomical exami- nation, and probably give rise to no symptoms. When the growth has attained a size large enougli to form a tumor (as in Fig. 346) it usually gives rise to fits of hfiematuria, which, however, as in that case, may be extremely irregular, separated by long intermissions of perfect health. Tlie pain caused by this tumor depends apparently on its situation in the Fig. 345. — A mass of malignant disease, growing out of a cyst on one side of the bladder, and pro- jecting to a certain extent into its cavity. Its outward appearance is exactly that of villous tumor, and it is only on microscopic examination that the difference is perceived. The disease had existed for many years, and at times occasioned hoemorrhage, the source of which could not be detected. — From the Museum of St. George's Hospital, Ser. xii. No. 24. Fig. 346. — Villous tumor of the bladder, from a patient *t. eighty-one, who had suffered from attacks of hematuria occasionally for twenty years. The mass of the growth is seen to be connected with the neck of the bladder. A portion consolidated by coagulum, so as to resemble a soft calculus, was found loose in the bladder, and is represented in the corner of the figure. The patient had exhibited no dan- gerous symptoms till shortly before his death, as the htematuria had yielded to astringents. But a week before his death complete retention of urine came on, requiring the use of the catheter, and a small portion of the growth came away in the eye of the instrument, which on microscopical examination revealed the nature of the disease. — From a preparation in the Museum of St. George's Hospital, Ser. xii, No. 113. bladder. When a small tumor (whether villous or malignant) is growing near the neck of the bladder and is tightly grasped by its muscular fibres during each action of the bladder tlie pain is often very considerable, indeed, I have known it to be agonizing, whilst a similar tumor might exist in the fundus or upper part of the bladder with comparatively few symptoms. The same applies to retention of urine as well as pain. Cancer of the bladder is generally of the encephaloid variety. I have not as yet met with any other form of cancer as a primary growth, though authors admit the existence of scirrhus, and Sir H. Thompson has re- corded one of epithelioma.' Other forms of cancer affect tlie bladder by continuity, as in scirrhus of the rectum, epithelial cancer of the vagina, etc. The symptoms of cancer of the bladder are usually persistent hoema- turia, "generally," sa^^s Sir H. Thompson, "occurring suddenly, and in 1 Path. Soc. Trans., vol. xviii, p. 162. There was a similar growth in the kidney. 772 DISEASES OF THE URINARY ORGANS. large quantities, rather than by frequent or continuous oozings from capillarj' vessels, which latter mode is more characteristic of villous growths." There is usually much distress from obstruction to micturi- tion and from chronic cystitis, great pain in the bladder or perineum, and shooting down the thighs or into the loins. The general health usually soon suffers, and the glands in the iliac fossa or in the loins be- come enlarged. Death generally occurs early. As to the diagnosis of tumor of the bladder. This rests (a) on exclu- sion of the other sources of hgematuria, (b) on direct examination, (c) on detection of portions of the growth in the urine. Reference may be made to the section on Htematui'ia (p. 767) for the symptoms attending the A'arious forms of bleeding from the urethra. The patient must be carefully sounded, when not only will there be no sensation or sound of stone, but the tumor ma}?^ sometimes be easil}'' felt. Prostatic haemorrhage sometimes gives rise to a suspicion of tumor, but the transient character of this affection will distinguish it, at any rate from the hasmaturia due to malignant disease. The tumor, when malignant, sometimes grows so rapidl}^ as to fill the bladder almost entirely, or projects as a large hard mass, easily felt with Fig. 347. Malignant disease, nearly filling the cavity of the bladder ; a points to the ureter, which is somewhat dilated; b shows the urethra and prostate quite unaffected; the disease being limited to the cavity of the bladder. — St. George's Hospital Museum, Ser. xii. No. 26. the sound. But this is by no means common, and the absence of any sensation of tumor does not go for much in the diagnosis. At other times the surface of the tumor breaks down rapidly, and shreds of it come away in the urine, the structure of which can easily be recognized by microscopic examination, and it is said that separate cancer-cells may be recognized in the urine ; but mistakes are often made about this from taking the cells of epithelium variously modified for cancer-cells, and in cases of cancer it is so common for no such cells to be found, that I think little importance is to be attributed to microscopic examination. In cases of rapidly growing cancer, apart from all direct examination, when once the diagnosis of stone and of prostatic haemorrhage is ex- cluded, the course of the symptoms usually sufficiently indicates the na- ture of the case. CYSTITIS. 773 Diagnosis. — To diagnose a villous growth is often a very difficult mat- ter; in fact, the diagnosis is often made only conjecturally, bj' excluding other sources of haeraaturia. In a case, such as that from which the illustration (Fig. 346, p. 771) was taken, where the symptoms extend over many years, and cannot be referred to prostatic causes, the diag- nosis is extremel}' probable, and sometimes, as in that instance, is ren- dered certain by the accidental escape or detachment of a portion of the tumor. The treatment of either of these forms of tumor can be only palliative, i. e., directed to subdue pain Ijy opiates and to check haemorrhage from the bladder by astringents. In cancer the disease will probably prove fatal within a few months. Cases of villous tumor run too irregular a course to justify any confident prognosis. Sometimes, as in the case re- ferred to above, the patient lives many years in moderate comfort. At others the growth rapidly implicates the neck of the bladder, and the ex- haustion caused by haimaturia and cystitis soon overcomes the patient's powers. Cystitis. — Inflammation of the bladder is divided into three degrees, acute, subacute, and chronic. Most of the cases which are seen in sur- gical practice belong to the subacute or the chronic variety. The causes are usually those which produce obstruction to the flow of water or direct irritation of the mucous membrane. Thus cystitis is a frequent, or even constant, complication of stricture and enlarged prostate ; it is one of the symptoms of stone or other foreign body in the bladder, and is very liable to be caused by the retention of a catheter in the bladder. Frac- tured spine usually produces cystitis, and cystitis is often produced by the irritation from decomposing urine in other forms of paralysis where the patient is unable to pass water. Some materials which are elimi- nated b}^ the urine out of the blood having been taken as food or ab- sorbed from the skin may cause cystitis. The familiar example of this is the inflammation of the bladder sometimes produced by cantharides taken into the stomach or applied as a blister. The bladder may also be inflamed by the spread of inflammation from a neighboring organ, as in gonorrhoea or in inflammation of the prostate. Finally, direct mechani- cal violence, as in surgical operations, is a frequent cause of cystitis, and it may originate spontaneously either after exposure to cold, or from tubercular irritation, or the softening of tubercular deposit, or from no known cause whatever. * Anatomy of Cystitis. — Inflammation of the bladder commences always on its mucous surface, the membrane becoming so loaded with blood as to assume a dark-purple color, thickened and velvety, in some cases coated with adherent Ij-mph and phosphatic deposit from the urine, in others ulcerated here and there. The irritation which accompanies it produces frequent and spasmodic muscular action. Often the cause of the aff'ection involves obstruction, and consequently much straining to make water, and from these circumstances muscular hypertroph3' is a constant phenomenon in cystitis, so that the muscular fibres stand out under the mucous surface somewhat like the columnae carneae of the heart, and they cross each other in ever}^ direction, leaving small spaces or alveoli between them. To this condition the terms " columnar and fasciculated bladder" are applied. The mucous coat of the bladder is often protruded through the openings of these fasciculi, causing pouches, which sometimes do not reach through the whole thickness of the walls of the bladder (Fig. 374), while at other times they form distinct 774 DISEASES OF THE URINARY ORGANS. and definite projections (Fig. 375), often of very large size. Similar and sometimes much larger pouches or cysts are found as congenital mal- formations (Fig. 344). The symptoms of cystitis in -the acute form are general fever, great pain in making water, frequency in micturition, blood\' urine, soon tnrn- ing pui'ulent, pain and tenderness to pressure in the region of tlie blad- der, and pain extending down the thigh and perineum; often also the straining produces prolapsus or piles. Formation of Ropy Mucus. — We commonly see, however, the less se- vere form, which is variously described as subacute or chronic, in which the mucous membrane of the bladder secretes an abundant deposit of alkaline mucus or muco-pus, and in which the urine is turbid' and con- tains a variable quantity of a mortary deposit usually called '•'rop^'' mucus." This deposit is formed of phosphate of lime mixed with pus and mucus, and is ver}"^ viscid, clinging to tlie vessel when inverted and slowly falling out in a mass. The supernatant urine, when examined by the microscope, usually is found to contain a good deal of pus, and the triple phosphate of ammonia and magnesia. This phosphate is also sometimes found mixed with the phosphate of lime in the sediment. The urine decomposes, becoming intensely alkaline and ammoniacal, whereas, when the mucus is onlj' in small quantity, though the deposit is itself alkaline, the urine may be acid,^ It appears, then, that the essential cause of the decomposition of the urine is the mixture vvith it of the alka- line mucus or muco-pus secreted by the walls of the bladder; and this decomposition is connected, at any rate by some pathologists, with the chemical composition of urea. Thus the formula for urea being C2HJN2O2, its elements are exactly the same as those of carbonate of ammonia, minus 2 atoms of water. Thus 2 atoms of carbonic acid C20^-|-2 atoms of ammonia N.^Ag = C.^O^N^Hg — deduct O^H,^ (2 atoms of water), and the result is as above, CjH^N^Oj, or one atom of urea. This decom- position readil}' ensues out of the body on heating urea with an alkali, and the decomposition of the urine is regarded (and certainly with the highest probabilit}^) as an analogous if not identical chemical change. The carbonic acid partly goes to the base of the phosphate of lime, form- ing carbonate of lime, which is found to constitute a part of the mortary mass, and the ammonia is parti}' set free, partly unites in forming the ammonio-magnesian phosphate. This ammoniacal urine again acts as an irritant on the bladder and propagates the inflammatory condition by which it was caused ; the inflammation may even spread up the ureters to the pelvis of the kidney, exciting inflammation of its lining membrane, in whicli case the urine will be secreted alkaline, and earthy phosphates may be found on the renal cal3^ces ; sometimes the inflammation causes the formation of small abscesses beneath the lining membrane of the kidney, a condition to which the term pyelitis is applied. Otlier changes occur also in the bladder besides the ordinary morbid phenomena above described. Generally speaking the inflammation pro- duces only muscular hypertrophy accompanied b}' no permanent change of the mucous meml)rane ; but in some cases organized inflammatory or fibroid deposit may be found in the submucous coat. At other times de- posits of pus (abscess of the bladder) occur in the thickness of its walls ; and there are cases (thougii chiefly in stone or foreign bod}') where the mucous coat is ulcerated, or even where ulceration extends througli the whole bladder and produces perforation. This ulceration is usually • Sir B. Brodie's works, vol. ii, p. 466. CYSTITIS. 775 rnarked by acute localized agoi\y in the part affected, much aggravated by the contact of instruments. I remember meeting witli it once in a case of stone, where it persisted long after the removal of the calculus (which was a very small one) by a single sitting of lithotrity, and ulti- mately proved fatal by pyaemia. Contraction and Dilatation of the Bladder. — In these cases of cystitis with hypertrophy the cavity of the bladder is usually contracted, and often very much so. But there are maii}^ cases of passive obstruction in which, on the contrary, the bladder is simply distended and much thinned. "This condition occurs not in stricture, but in those cases of enlarged prostate where, by reason of the size of the prostatic mass implicating the muscular apparatus at the neck of the bladder, the viscus is incapaci- tated from contracting and suffers passive distension." — Thompson. Treatment. — The treatment of cystitis, like that of all surgical affec- tions, to be rational and successful, must be guided by a knowledge of its cause. In the rare cases where no cause can be ascertained the treat- ment must be directed to soothing irritation and removing pain. For these purposes rest in the horizontal posture, warm fomentations, warm hip-baths, and opiates by the mouth or as suppositories are very useful. In acute or subacute cases the application of leeches or cupping the peri- neum is extremely beneficial. The bowels are to be kept open without purging. Hyoscyamus in large doses is often of great service. The other medical means must be regulated by the acuteness of the attack and the condition of the urine. If the latter be acid and the attack moderately acute, no good can be done by local interference, nor by the administration of the mineral acids; in fact, alkaline carbonates may sometimes be given with advantage. But in ordinary cases the attack is not acute, nor is there any doubt about its cause. The presence of a stricture, an enlarged prostate, a stone, a gonorrhoea, or an injury of the spine at once points out that the cystitis is but a symptom, and that its cure must depend on the surgeon's success in removing the cause on which it depends. Still even when this is impossible, much, as Sir B. Brodie remarks, may be done towards re- lieving the affection of the bladder. In cases which are purelj' chronic, accompanied by copious secretion of mucus, but with little irritation, and in which after death the bladder will be found rather dilated than contracted, and thin rather than h3'pertrophied, a condition to which the term catarrh of the bladder is properly ap[)lied, much good is done b}' washing the bladder out and by injections acidulated with nitric or sul- phuric acid. The exhibition of diluent or demulcent draughts in toler- ably large quantities, or in some cases the balsams or turpentines, is followed by improvement. In catarrh of the bladder the favorite rem- edies are the decoction of uva ursi, or pareira brava, or a combination of the two ; in cases where there is somewhat more inflammation large doses of the decoction of triticum repens, or a smaller quantity of bucliu may be given ; alkalies and opiates being combined with these as circumstances demand. Sir H. Thompson quotes with approbation a prescription of Dr. Gross : one ounce and a half of the leaves of the uva ursi and half an ounce of hops are infused for two hours in two pints of boiling water in a covered vessel, a wineglassful to be taken several times a da}'. The mere demulcents are used chiefly as vehicles for other medicines and as diluting the urine ; such are barley-water, gum-water, decoction of mal- lovvs or of Irish moss, linseed-tea, etc. Caution is to be observed in estimating the reaction of the urine. It does not follow because the urine when passed is alkaline that the secretion is alkaline. Acid urine 776 DISEASES OF THE URINARY ORGANS. coming into an inflamed and irritable bladder will cause it to secrete alkaline mucus, the decomposition of which soon turns the secretion alkaline. In such cases there is generally obstruction, and the secretion may be best made healthy by removing the obstruction, washing out the bladder, and administering a soluble alkali, such as the citrate of potash. Vesico-intestinal Fistula. — This may be the place to mention the occa- sional (though fortunately rare) occurrence of a fistulous communication between the bladder and some part of the intestinal tube. This painful symptom is found usuall}' in cancer, but there are instances (of which I have recorded a very remarkable one') in which the formation of the opening seems due to common ulceration of the bowel. It occurs usu- ally in the male sex, but sometimes also in the female. The communi- cation is either with the large or small intestine. The appearance and odor of the urine, and probably the pain in the part, first attract the pa- tient's attention, and then the faecal matter can be detected either with the eye or the microscope. As the opening enlarges, and especially when the large bowel is the seat of the fistula, masses of solid fseces pass into the bladder, causing obstruction of the urethra, and probably' form- ing the nucleus of a phosphatic stone. In such cases the lumps must be broken up with a lithotrite ; and if on careful examination the surgeon is satisfied tiiat the communication is with the sigmoid flexure, the de- scending colon should be opened. This operation was performed in the case under m}' care, and with temporary success. The patient was much relieved and was about to resume his ordinar}' avocations, when a relapse took place in an even severer form, and he died fourteen months after the operation. The cause of death was found to be the formation of a similar communication with the caecum, the original opening between the bladder and sigmoid flexure having closed. DISEASES or THE PROSTATE. Acute inflammation of the prostate is genei'ally a consequence of gon- orrhoea, but may be caused also by injuries (one of the most frequent being rough catiieterization), by inflammation of the bladder, by stricture setting up inflammation of the urethra behind the obstruction, by the application of caustic, and bj'^ the lodgment of a calculus. The symptoms of acute prostatitis are rigors, feverishness, pain, and irritation in making water, with frequent calls to do so, pain in defaeca- tion, and pain radiating from the loins down the back, thighs, and peri- neum. If there is any tendency to piles they will probabl}^ show them- selves, on examination l»y the rectum, and this examination is found to be very painful ; the prostate is swollen, hard, hot, and very tender; and if a catheter is passed, there is acute tenderness of the prostatic part of the urethra. There will [jrobabl}' be some pus in the urine from inflam- mation of the prostatic urethra, even irrespective of abscess, which, however, is very lial)le to form. Tiiis is marked l)y the continuance of the feverish condition for several days, witii rigors, tension, and pulsation in the region of tlie perineum and bladder. The ditticulty of passing water will also probably increase. Examination with the finger will now prove that the hard prostatic tumor has given place to a soft swelling, in which perhaps the surgeon may detect fluctuation, though from the awk- 1 Med.-Chir. Trans., vols, xlix and 1. See also Mr. Pennell's and Mr. Charles Hawkins's cases there referred to. CHRONIC PROSTATITIS. 777 ward position in which it lies for palpation this is not always possible. These abscesses are not, however, always situated inside the capsule of the gland, for very similar symptoms are caused by suppuration around it — periprostatic abscess. The diagnosis of acute prostatitis is not usually ditiicult if attention is paid to the course of the symptoms, and the disease usually has a favor- able issue. It generally subsides of itself, on the withdrawal of irrita- tion, or under treatment, or else runs on to abscess, which bursts, witli free discharge into the urethra and a sudden relief to the symptoms. But things may not go on so happily. Sometimes acute inflammation leaves behind it the troublesome symptoms of chronic prostatitis, and I have seen one striking case in which an abscess neglected and overlooked proved fatal. The patient, a young man, was admitted into hospital in a feverish and semi-unconscious condition, and was placed under the care of the physician, as suffering from fever. A gonorrhoeal discharge being detected the surgeon was called in ; but he, not suspecting any connec- tion between the gonorrhoea and the fever, made no accurate examination. The patient soon died, and upon post-mortem examination no disease whatever was found except an unusually large prostatic abscess, and the inference was irresistible that if this had been detected and freely opened his life might have been preserved. The treatment of acute prostatitis, before abscess has formed, consists in the very free application of leeclies around the anus (or even, if it can be tolerated, inside the bowel) with frequent hip-baths and constant warm fomentations to the perineum, combined with the moderate use of anti- mony if the patient is ^oung and strong, and free purging. If retention of urine takes place a catheter must be passed; otherwise it is very un- desirable to irritate the parts in any way. But on tlie first indication of suppuration an incision must be made into the softened part. This is best done from the rectum. It is devoid of danger, and even if the pus is not found the opening will probably relieve the congestion and the pus will very likely make its way soon into the bowel. The opening is best made by putting the patient under an anaesthetic, passing the duckbill speculum into the rectum in the lithotomy position, and fuily exposing its anterior wall, though if he is not nervous no anaesthetic is absolutely required. Some abscesses (chiefl}' I believe the periprostatic) are not perceptible from the rectum, but fuhiess and tenderness may be made out by palpation in the perineum. In these cases a deep exploratory puncture should be made, with the left forefinger in the rectum, and if pus is found the puncture should be extended into a moderately free in- cision. In most cases no further ill consequences take place ; Imt in ex- ceptional instances the abscess bursts into the urethra also, and a recto- urethral fistula follows, the consequences of which are most distressing, and its cure very difficult. The treatment would be the same as in the cases where a similar distressing event follows after lithotomy ; but I must allow that in the few cases of that complication which I have treated, and seen under the treatment of others, the result has been dis- appointing. I must refer to the section on Lithotoni}'. Chi'onic Proatalitiii. — The acute disease may leave the prostate hard- ened, somewhat enlarged and tender, with irritable bladder, frequent desire to pass water, with some pus in the urine — probably frequent seminal emissions — weight and pain in the rectum ; some tenderness in def'gecation, pain in sexual intercourse, and loss of power in propelling urine. This, like most chronic inflammations, is best treated by contin- uous counter-irritation. Sir H. Thompson recommends the continuous 778 DISEASES OF THE URINARY ORGANS. counter-irritation of the perineum with nitrate of silver or acetum lyttoe, and the application to the prostatic portion of the urethra of a solution of nitrate of silver ten to thirt}' grains to the ounce,' and the adminis- tration of the bromide and iodide of potassium, with tonics, change of air, and sea-bathing. But it must be recollected that very similar symptoms may follow on prostatic irritation and discharge, the result of gleet or of syphilis. The subject of prostatic discharges and their treatment is not as 3'et com- pletely understood. Mr. Lee has lately published some interesting lec- tures on this topic to which I would refer the reader. {Lancet, 1875. " Lectures delivered at the Royal College of Surgeons.") Enlarged Prostate. — Enlargement of the prostate gland is an affection of old age ; not that all, or the majority of old people, suffer from this affection ; but that it only occurs after the middle of life." It consists either of a hypertrophy of the prostate itself (Fig. 349) or of a tumor developed in the neighborhood of the gland, but separated from it by a capsule of fibrous tissue (Fig. 348), or of a combination of the two. The enlargement very often affects FiO' 348. t,he whole of the gland, sometimes only one side ; sometimes it consists chiefly of an abnormal development of the central portion — the uvula vesica?., or third lobe as it is called. The separate tumors consist of tissue bearing great resemblance to that of the prostate itself, but not perfectly developed, just as in the adenoid tumors which have a similar relation to the female breast. Sometimes, as in Fig. 350, the enlarged prostate is also ulcerated on its surface, and often in old age, either with or with- out such ulceration, the veins around the prostate gland (prostatic plexus) become engorged and bleed into the bladder. I have seen the urine al- most black with blood for many days together from this cause. Haemor- rhage from the prostate is easilj' known by the absence of stone, by the absence of all previous history and sj^mptoms of cystitis, by the sud- denness and copiousness of the bleeding (reminding one in this respect of epistaxis), and by the enlargement of the organ. It rarely requires an}' treatment. If it does, washing out the bladder with acidulated lo- tions, and the administration of internal styptics, as acetate of lead or gallic acid, would be indicated. ' A CiitliL'ttT-syringo is manufactured with a piston in tin; stem and an oj-e at the side This i.s lilli'd like an ordinary syrint:;(', tlie distance to whicli the piston is with- drawn only pcrniitliiig it to take u|) a small quantity of tlie solution. Then, wiien it has arrived at the desired spot (which is easily known by the patient's sensations), the piston is slowly depressed while the eye is made to rotate round the circumference of the urethra. '^ The res(!arches of Sir H. Thompson (S^'st. of Surs^., vol iv, p. 917) and of Dr. Messcr render it jirohablc that enlargement appreciable on dissection exists in about OJie-third, and enlargement causing symptoms in ab.)Ut one-tenth, of males over sixty. A section of a prostate gland, in connection with which is a small tumor, separated from the rest of the gland by a definite capsule and occu- pying the situation of the " third lobe." This tumor consisted of csecal pouches filled with epi- thelium, and connected togetlier by fine fibroid tissue. There were the usual symptoms of en- larged prostate. The bladder is seen to be much hypertrophied, and at the post-mortem examina- tion was fouud full of purulent urine. The ure- ters, pelvis, and infundibula of the kidneys were dilated, and the kidneys themselves contained numerous small abscesses. — From the Museum of St. George's Hospital, Ser. xii, No. 112. ENLARGED PROSTATE. 779 Symptoms of Enlarged Prostate. — The first effect produced by enlarged prostate is a certain degree of difficult^' and straining in making water, which is most perceptible at tlie end of the evacuation. This is succeeded, if treatment be neglected, by chronic cystitis. For in all obstructions to the flow of urine, a certain amount being constantly left in the bladder, the walls of the bladder are continually irritated; the urine as previously explained becomes turbid and alkaline; the bladder is never fairly emp- tied, and some of the residue of the urine must always be left, by which the irritation is kept up and propagated. • Then, if the obstruction con- tinues unrelieved, all the usual sequehe may ensue, dilatation of the uri- nary passages, and urremia, inflammation of the ureters and kidneys, and pyelitis, and in either case speedy death. Diagnosis. — The diagnosis is generally very easy. The patient at first believes himself to have stricture, and, of course, he may have both. But a case of uncomplicated enlargement of the prostate is very easil}^ distinguished from one of stricture. The patient's age and tiie absence of previous history of stricture make the diagnosis of enlarged prostate most probable, and this is easily confirmed by examination from the rec- tum, when the enlarged prostate will be felt as a hard tumor pressing down into the bowel ; or by passing an instrument after the patient has made water, when it will be found tliat there is no obstacle till the point of the catheter passes under the pubes, when by depressing the handle between the patient's thighs the catheter can usually be easily made to ride over it, and all the more so if a full-sized instrument be used, which is, of course, the direct reverse of what is found in stricture. Treatment. — Unless it has been long neglected, there is not usually much difficulty in dealing with prostatic enlargement. A catheter should be passed daily with all possible gentleness; if there is much muco-pus in the urine the bladder should be washed out; if the enlargement of the gland is considerable, as indicated by the large amount of residual urine in the bladder after the patient has emptied it as much as he can, the catheter should be passed more frequently, two or three times a day, or even whenever the patient wishes to make water. The catheter should not be tied in unless there is unusual trouble in passing it. This treat- ment is palliative only, but I am under the impression that it does tend to prevent the further growth of the disease, which seems to be quickened by irritation. And it certainly saves the patient's life by obviating the various complications which otherwise ensue. But it is be3'ond the power of medicine to reduce the enlargement which has once formed. Tlie Prostatic Catheter. — There are some cases (by no means so many as has been taught) in which the passage of an ordinary full-sized cathe- ter is difficult. Sometimes this depends on lateral enlargement, which may be detected by exploration per rectum and an appropriate direction given to the instrument. At other times it depends on the urethra being really lengthened and pushed up into a vertical direction somewhat by the tumor. When this is the case a "prostatic catheter" must be passed in order to reach the bladder. This is longer, and has a larger curve, than the ordinary instrument. These means will succeed in the great majority of cases. But there are some in which no dexterity will succeed in reaching the bladder, either from the extent of enlargement, or from the existence of false passages. 1 Surgical writers sonietime.s Ui=e bingiiage which conveys to j^tudents the idea that the same urine is constantlj' retained in the bladder. This, of course, can hardly be intended, but the bladder is excited to inflammation by its never being evacuated. '80 DISEASES OF THE URINARY ORGANS. In such cases it has been recommended (and the recommendation is in- dorsed by Sir B. Brodie, Works, ii, 527) to thrust the catheter through the substance of the prostate, as was done in the case from which Fig. 350 was taken. But this proceeding is now, I thinlc, given up, at least I have not of late years heard of its being done. When the enlargement is not too considerable and the bladder can be felt behind the prostate, most surgeons prefer to puncture from the rectum. 1 cannot say that Fig. 349. Fig. 350. Fig. 349. — Bladder, symphysis pubis, and enormously enlarged prostate. A portion is removed from the left wall of the bladder, to show the vertical ascent of the urethra as it enters the bladder. After Sir H. Thompson. Fig. 350. — Great enlargement and ulceration of the prostate gland. Retention of urine having taken place it was relieved by forciiily thrusting a catheter through the substance of the prostate. A bougie is inserted in the artificial paassage. A section has been made through one side of the enlarged pros- tate to show the extent of the hypertrophy.— From a preparation presented by Sir B. Brodie to the Mu- seum of St. George's Hospital, Ser. xii. No. 109. this appears best to myself, since the puncture will only give temporary relief and the sj'mptoms may recur. It is quite true that the irritation may subside or the false passage may heal, and then the surgeon may suc- ceed again in passing the catheter. But the same advantages also attend what I conceive to be the better plan in these cases, viz., to puncture above the pubes. Fmidure of the Bladder above tlie Puhea. — This is an operation of no difficulty, an(l I believe of little danger, when the bladder is fully dis- tended. A puncture, or small incision, is made in the middle line im- mediately above the pubes ; and the fat, if there is much, may be broken down with the director or handle of the knife. Then the finger will feel the fluctuating bladder and a c(>mmon trocar and canula, or a curved one, if at hand, is passed in, and a piece of gum catheter passed through to steady it and prevent its slii)ping out. After about a week or ten days, when the track of the wound is consolidated, the instrument may be removed, cleaned, and changed. Tiie advantage of this puncture is that the canula can be worn permanently with little or no inconvenience, if it is necessary. A canula provided with a shield and stopcock is MALFORMATIONS. 781 adapted, and the patient removes the ping wlien he wants to relieve his bladder. lie is thus spared all the annoyance of instrumentation. The bladder, however, must be kept carefully washed out. The onl}^ time I have as 3'et had occasion to perform this operation, the patient (who was in a ver}^ bad state at the time) survived, and I heard of him a year afterwards in good health and still wearing the can u la. Cancer of the Proi^tate. — Cancer only rarely originates in the prostate gland, though its primary occurrence there is indisputable, and in some cases it remains confined to the organ. It gives rise to acute pain, ha?morrhage, and frequent micturition, in fact to many of the symptoms of stone, and in a well-marked instance which occurred in my own prac- tice, it was not till after repeated examination, and under antiesthesia, that I fully satisfied myself of the absence of stone; but the distress is usuall^^ even more acute than in stone, and the wasting and loss of health are striking phenomena. There is more pain also in neiglibor- ing parts than is usually felt in stone in the bladder. When the tumor has grown considerably it ma}^ be possible to assure one's self of its nature by examination from the rectum ; but at first it will simulate the ordinary enlargement of advanced life, and these cases almost always occur after middle age.' The cancer is of the encephaloid variety and ma_v spread to the neighboring organs, or may affect the inguinal glands, or fragments of it may be found in the water — in any of which cases the diagnosis will be clear enough. Nothing can be done except to palliate the patient's sufferings as best may be. Tubercle is found in the prostate in cases where the whole urinaiy tract is affected, and cysts of the prostate are spoken of, but only as cavities formed by prostatic calculi, which will be described later on. Hydatids have been found lodged in the neighborhood of the gland, and have produced retention of urine by pressing on the bladder; but the condition hardly allows of diagnosis before operation. The indication will be to open the bladder in the most accessible situation on failing to pass the catheter. Then the nature of the case will probably be recog- nized, when the hydatids must be freely evacuated by incision, and all remains of them frequentl}'^ washed out. DISEASES OF THE URETHRA. Malformations. — There are cases of congenital obliteration of the urethra, but I am not aware that the deformity has been recognized during life. In fact the infant generally dies very soon after birth, other- wise there could be no difficulty in cutting down to the seat of obstruc- tion, and opening the posterior part of the urethra, which seems gen- erally natural. Hypospadias and Epispadias. — But the malformations about which the surgeon is usually consulted are hypo- and epispadias. The former is, in its minor degrees, a very common malformation, and one of no con- sequence whatever. The urethra opens oji the lower surface of the penis at some distance behind the natural joosition of the meatus. When, as is most usual, this opening is only a little behind the glans the patient can pass water naturally, and the semen will be lodged fairly within the vagina, so that there is no motive for surgical interference. The pre- 1 Sir H. Thompson says that it has also been noted in early childhood, but that no cases are on record between the ages of eight and forty-one. 782 DISEASES OF THE URINARY ORGANS. puce also is in these eases usually somewhat misshaped, forming merely a large flap on the dorsal surface of the glaus, which falls in to the skin of the penis on either side, but does not form a complete circle. Hypo- spadias, however, in its higher grades is a very serious infirmity. The urethra opens at the root of the penis, the urine runs down over the tliiglis, so that the patient is obliged to make water sitting, and the semen would be discharged externall_y, if the patient were capable of sexual intercourse ; but this is seldom the case, for the penis is bound down to the scrotum by a firm band, which becomes very perceptible in erection, and the organ curves downwards, somewhat as in chordee. This band is i)robably the remnant of the undeveloped corpus spongiosum. Elaborate attempts have been made to remedy this deformity by plastic operations, but, as far as I can learn, hitherto without success. Three several indications have to be fulfilled : (1) To liberate the penis, so that it may assume its natural direction wlien erect ; (2) to form a new urethra, so that the urine and semen may find a channel to the glans; and (3) to close the original opening. The penis is accordingly dissected free of the scrotum, and raised up to the abdomen. The neigh- boring skin is transplanted from the penis and scrotum in two layers laid on each other by their bleeding surfaces, and with the cutaneous surface of the inner flap turned towards the penis to form the new urethra, and after these flaps have adhered and are healed, the fistulous orifice is re- freshed and united to the new urethra, a catheter being kept in the bladder. The attempt is worth making in healthy boys or 3'oung men, and it is said to have been followed by partial success, so that a patient previously unable to effect an entrance was rendered capable of sexual intercourse, but the fistulous orifice remained. I have tried the operation in early childhood, but should not feel disposed to repeat it at that age. A A'ery guarded opinion must be given as to the possibility of an infant afflicted with this malformation ever being able to beget children. The opposite malformation — epispadias — in which the urethra opens on the dorsal aspect of the penis, is very much rarer, and is generally accom- panied with great general malformation of the rest of the external genitals. In its extreme degree it constitutes the extroversion of the bladder before spoken of. Attempts have been made here also to put the parts in a more natural condition by plastic operations. In fact the operation which I performed for extroversion of the bladder was adapted from one which had been practiced in epispadias. But it is very doubtful whether any good can be done in such cases. Stricture of the urethra is a disease which is very frequent in every rank of life, but of which the worst and most complicated examples are found amongst the poor, who do not understand the gravity of a com- plaint which is so insidious at first, and who very often have not the time or the means required for its successful treatment. I mention this, inas- much as, like hernia, and like many other surgical affections, stricture would not, generally speaking, prove formidable, certainl}' would very seldom lead to death, if it were made the subject of early and intelligent treatment. 6'avy.«f.s' of Stricture. — The cause of stricture is in general either a low inflammation of the submucous tissue of the urethra, or cicatrization, the result of an injury. A very common cause of stricture seems to be the persistence of a neglected gonorrlucal discharge, and some surgeons l)elieve (and certainl}^ with much probal>ility) that ulceration of the uiethra in gonorrhoea, such as is known to occur sometimes, maj' often CAUSES OF STRICTURE. 783 prove the starting-point of cicatrization, and so of stricture. However, speaking general!}', it is impossible to prove anything of the kind ; the urethra at the seat of stricture displays more or less of induration and thickening beneath its mucous surface, causing contraction of its canal, but no such definite band as we should expect to be the result of the cicatrization of an ulcer. And though there can be no question that gonorrha'a is a frequent cause of stricture, yet in many cases of stricture it is impossible to trace any connection witli gonorrhoea, or indeed any cause whatever. Another cause of stricture may be syphilis. Fig. 352 is taken from a case in which the healing of a syphilitic sore led to stricture at tlie meatus, and I have introduced it also to show how great destruction is sometimes allowed to take place from a disease in itself very readily curable. The Fig. 351. Fin. 352. Fig. 351. — Stricture of the urethra about three inches from the meatus urinarius, formed by a bridle which is seen crossing the canal. A bristle is passed in above and below this bridle; the dilatation of the canal behind the stricture will be noticed. — From a preparation presented by Sir B. Brodie to the Museum of St. George's Hospital, Ser. xii, No. 49. Fig. 352. — Stricture at the orifice of the urethra, producing dilatation of the whole urethra, and extensive ulceration with abscesses in the tissues of the penis, communicating with the ulcer- ated urethra. There were also several perinseal abscesses. The bladder is enormously hypertrophied and the kidneys were much absorbed. The urine was of course alkaline and loaded with mucus and pus. The patient died soon after his admission into hospital. The stricture of the meatus is believed to have been caused by a syphilitic sore contracted two and a half years previously. — St. George's Hospital Museum, Ser. xii, No. 60. simplest means would, no doubt, have sufficed at first to cure this stric- ture, which was, nevertheless, permitted to lead, through A-ears of agony, to the patient's death. The most formidable form of stricture is that which follows traumatic rupture of the wall of the urethra, after a fall or blow. This kind of stric- ture is generally in the part which passes below the arch of the pubes, although occasionally, from blows or wounds, it may occur elsewhere. The resulting cicatrix is usually very dense, hard, and contractile, so that even after complete dilatation it will recur again and again. It constantly leads to fistula in perinseo, and occasions death or serious complications, in spite of the most judicious treatment. 784 DISEASES OP THE URINARY ORGANS. Seat of Stricture. — The most common seat of stricture is said by Sir B. Brodie to be the membranous portion of the urethra. The researches of Sir II. Thompson have, however, proved that in tlie majority of the specimens contained in museums the constriction is rather in the bulbous than in the membranous part, but it would be hardly possible to detect the dirt'erence during life. Any anterior part of the canal may be the seat of stricture, tliose at tlie meatus (Fig. 352) being generally the result of accidental circumstances. Fig. 351 shows a stricture in the spongy portion of tlie urethra, and when this is the case it is very common to find another farther back. Stricture again is said to be met with at the prostatic portion or neck of the bladder, but its existence is denied by the best authors. Sir H. Thompson has never met with a case. Stric- tures are occasionally multiple. John Hunter speaks of having met with a case in which there were six, but it is rare to find more than two or three. Forms of Stricture. — The anatomical forms of stricture are various. Fig. 351 shows an example of what is sometimes called the "bridle stricture," in which the obstacle is caused by a bridle or band stretched across the canal, wliich may with great probability be referred to past ulceration, as may also be those (of which, however, no example has fallen under my own notice) in which a lunated Fig- 353. ^ fold occupies a part of the circumference" of the urethra, such as is often seen in the rectum after the healing of an ulcer. More commonly the obstruction is a mere narrowing of the canal at the part affected, as if by a diaphragm placed in it, the "annular" stricture. (Fig. 353.) When tliis diaphragm extends for some distance under the mucous membrane on either side of the point of greatest obstruction, it is stricture of the urethra. About called the " indurated annular stricture," and two-thirds of the tube is closed by a i • i i i i. ^ i.i i • diaphragm of no great thickness, in ^hcn a Considerable part of the canal is con- which a small circular hole is seen, strictcd it is denominated a " tortuous " or a with a bristle passed through it.— "cartilaginous " Stricture. From a preparation in the Museum rpj^ practical importance of theSC distinC- of St. George's Hospital, Ser. xii, . . ' i No.sga. tions IS not very great, except in regard to the obstacles which may be experienced in the forcible dilatation of the stricture. But it must be allowed that so much is stricture (meaning thereby real organic material obstruction) complicated by spasmodic action of the muscles around the urethra, and of the muscular fibres which form part of it, that it is often very difficult to determine during life how far the obstruction occupies the walls of the tube, so that a stricture which during life had been supposed to extend over along distance has been found after death to have been, mechanically speaking, insignificant. The si/mptoms of stricture are at first simply mechanical difficulty in making water, and consequent prolongation of the length of time re- quired to satisf^^the calls of nature, with (as the disease advances) some straining, leading very likely to involuntary discharge of some of the contents of the bowel, and prolapsus. Still, there is no evidence of any alteration in tlie parts not immediately implicated in the stricture, or any change in the functions : and the disease is, no doubt, easily under the control of treatment. But if it is neglected, other graver symptoms super- vene, which are partly mechanical and partly vital. The difficulty in micturition may pass into total retention, and. with or without retention, URINARY ABSCESS. 785 very grave ulterior consequences may ensue. Any obstruction to the flow of urine will lead, as it would if tlie urinary tract were a piece of lifeless elastic tubing, to gradual loss of tone and distension of the part behind the obstruction. Thus, in every such obstruction, whether from impacted calculus (Fig. 377), stricture (Fig. 352), enlarged prostate (Fig. 848), tumor of the bladder (Fig. 347), or any other cause apart from the results of vital irritability, the consequences would be dilata- tion of the part of the uretlira behind the obstruction, of tlie bladder, of the ureters, and finally of the pelves of the kidnej's, leading to absorp- tion of their cortical structure, suspension of the secretion, and death from uraemic poisoning. But this supposes the absence of vital irrita- bility, which is of course never entirely the case. Sometimes even in so muscular an organ as the bladder the eflCects of pressure overcome those of irritability, and it becomes distended and thinned. Even then, how- ever, its walls are inflamed as well as thinned ; but it is much more com- mon in the bladder for the effects of irritation to overcome those of pressure, so that the walls of the bladder are thickened and fasciculated, and its cavity perhaps diminished, or certainly not increased. In the urethra, on the contrary, which though muscular is much less so than the bladder, and which is exposed more directly to the action of pressure, there is almost always dilatation behind the stricture (unless relieved by ulceration behind the obstruction, leading to urinary fistula), which in stricture of the meatus may involve the whole of the urethra (Fig. 352). But along with this, there is also inflammation of its walls, leading to ulceration and abscess round the urethra. In the ureters we commonly see only the eff"ects of distension, the signs of inflammation being con- fined to some vascularity of the mucous membrane not usually percepti- ble after death. The kidneys are as often atfected by inflammation as b}' distension, and this shows itself generally in the form of small abscesses scattered about the secreting structure of the organ (pyelitis), sometimes associated with vascularity of the lining membrane of the pelvis and "calyces of the kidne}^, and depending on inflammation spreading up the mucous tract. Complicatio7is. — Besides these fatal sequelae of stricture there are va- rious complications which must be noticed. Fistula in Perinseo. — The most frequent is fistula in peri^^seo, when the mucous surface of the urethra gives way behind the stricture and allows the urine to make its way towards the surface graduall}' (the in- flammatory condensation of the tissues around preventing extravasation of any large quantity of urine) until it burrows through the skin and the water passes through the unnatural channel, sometimes whoU}^ but more frequently in part, some of it escaping also from the meatus. There are often moi*e than one and sometimes many such fistuhie, and they open not only in the perineum but in the penis, scrotum, buttock, or groin also. Urinary Abscess. — When the ulceration which leads to the escape of a small quantity of urinous fluid from the urethra does not proceed to the surface, but remains limited by inflammatory exudation (as in the cavi- ties seen in Fig. 352), a small, hard, exquisitely painful swelling results, which is generally situated in the perineum, and hence called "abscess in perinaeo ;" but, as it may be (as in the figure) in the penis or even in the groin, the more general name "urinary abscess," now in common use, is better. Extravasation of Urine. — Or again, instead of merely giving way by a comparatively slow limited process of ulceration, the urethra may yield 50 786 DISEASES OF THE URINARY ORGANS. suddenl^y and entirely to the pressure/ when the urine is poured violentl^y out into the tissue of the perineum, scrotum, penis, etc. This is called exl7'avai>atw7i of u7Hne. If the stricture be in the spongy body (as in Fig. 351) the urine may be efiused only into the penis, the perineum being unatlected, but this is rare. Generally speaking, the stricture is at or about the ])ulb of the urethra, and the urine is etiused between the triangular ligament (Camper's ligament or the superficial layer of the deep perineal fascia) behind, and the deep layer of superficial fascia in front. As the latter membrane is attached on either side to the rami of the ischium and pubes, the effused fluid cannot pass on to the inner side of the thighs. The attachment of the same meuibrane to the deep fascia around the low^er border of the transversus perinaei muscle prevents the urine from passing backwards to the anus and buttock. But there is no obstacle to its passing forwards to the scrotum, penis, and abdomen, and this is, accordingly, the path it takes. As the inflamed and putrid urine comes into contact with the cellular tissue it sets up acute phlegmonous inflammation, rapidly running on to gangrene with its usual concomitant of low typhoid surgical fever. At, or just below, Poupart's ligament, the superficial fascia of the abdomen adheres to the deep fascia,?', e., there is no subcutaneous cellular tissue, or very little, and there the inflammation ceases at least for a time. Ultimately, it is said, the adhesions which connect the deep and superficial fascia may be stretched, and the. in- flammation creep down the thigh ; but this must be very rare, as the patient usually dies if the inflammation does not stop before this takes place. Hitpture of the BIadde7\ — Finally, a still more terrible catastrophe may occur, the rupture of the bladder, followed by extravasation of urine, probably into the peritoneal cavit\', which is necessaril3' fatal — or into the pelvic cellular tissue, which in all probability will be so. This is a very rare effect of stricture, but undoubted examples of it are recorded. It must not, however, be taken into account in the prognosis or treat- ment of a case, being altogether exceptional. TreMmeni of Stricture. — Although many of the above-described symp- toms are vital, the origin and source of the disease is purely mechanical, and so must its treatment be at first. As a general rule, if an instrument can once be introduced through the stricture or strictures into the blad- der, the case becomes at once amenable to treatment. Nor is there any difficulty in doing this in an uncomplicated ease of recent spontaneous stricture. But in old neglected cases and in the worse forms of traumatic stricture it is exceedingly ditlicult, and in some cases impossible. To these cases the term " impassable strictures " is applied. In endeavoring to pass an instrument for the first time in any case of stricture its features should first be carefully studied. We should in the first place endeavor to exclude the idea of mere spasm, or what is called spasmodic stricture (p. 798), or of mere prostatic enlargement (p. 779), and satisfy ourselves that the case is one really of organic stricture. A reference to the above pages will indicate the diagnostic symptoms. The urine should be examined (if the patient can pass any) to show^ the state of the l)ladder; and the condition of that organ as to distension should be carefully ascertained. When the bladder is considerably distended it rises up from the pelvis into the abdomen, forming a definite rounded tumor, perfectly dull to percussion, and sometimes rather sensitive to 1 This is often accompanied by a feeling of sudden relief to the painful sensation of straining under which the patient has been suflfering, and a deceptive lull occurs. CATHETERIZATION. 787 pressure, which ma}' reach up as far as the umbilicus, and which can be felt ill the rectum (unless the prostate is very much enlarged), and fluc- tuation can be communicated to the finger in the rectum by tapping on the abdominal tumor. When, on the contrary, the abdominal muscles are merely rigid from spasm (a condition not unfrequently mistaken for distension of the bladder) all these symptoms are absent except the sensation of resistance above the pubes. There is no definite rounded tumor, no dulness on percussion, no projection in the rectum, and, of course, no fluctuation there. Besides the above points, it is desirable (if the patient is a person whose answers can be trusted) to know what has been about the usual size of the stream latterly and what it is now, since, if there is a great difference within a very short time it may fairl}' be conjectured that a good deal of the dysuria depends on si)asm. It is also important to ascertain what if any attempts have been made already to pass an instrument, and whether they have been accompanied by much pain and bleeding, in which case the existence of a false passage may be suspected if the instrument failed to draw off the water. Catheterization. — When the surgeon has reason to diagnose the exist- ence of organic or permanent stricture, an instrument should be passed at the earliest convenient moment. This need not necessaril}- be imme- diately after the case is seen, for if there is no retention of urine an in- terval of rest in bed, with a warm bath every night, and abstinence from any recent cause of excitement, may form a good preparative, and facili- tate the introduction of the catheter or bougie. Surgeons vary as to the kind of instrument which the}' habitually em- ploy at the commencement of a case of stricture. Some prefer the com- mon metal catheter, others the gum catheter with or without stilet, others a probe-pointed or simple flexilile bougie, others a solid metal bougie. The matter is more one of individual preference and of habit than of rule, and is hardly fit for discussion in an elementary work. But what- ever instrument is used, dexterity in its management and the utmost gentleness in its introduction are essential both to the comfort of the patient and to the success of the treatment. Dexterity can only be ac- quired by practice, and therefore it is of the utmost importance for stu- dents to embrace every opportunity of practicing the passing of catheters on the dead subject and on those who require the passage of a catheter without any obstruction, before undertaking the treatment of a really difficult case. In the natural condition of things there are only two ma- terial obstacles to the introduction of an instrument, viz., hitching the point in one of the lacun^B of the urethra, and pressing it against the triangular ligament as the point dips under the pubes. The former . hitch occurs at any part of the spongy portion, very commonly near the meatus. Both can easily be overcome by withdrawing the instrument a little and allowing it to find its own way without the use of any force. In dexterous hands a solid instrument, or even a metal catheter, ai)[)ears rather to drop into the bladder by its own weight than to be pushed into it; and this dexterity is very well acquired b^' practicing on tiie dead subject until the art of passing the catheter easily with one hand is per- fectly familiar. Though the difficulty from spasm and pain does not exist in the dead suliject, yet the laxity of the tissues causes a difficulty of its own, and if a man can pass instruments with perfect ease on the dead he has gained a most important advantage for commencing his practice on the living. Besides these merel}' mechanical obstacles, however, there is tlie ditfi- 788 DISEASES OF THE URINARY ORGANS. culty resulting, particularly in nervous i^ersons, from real or apprehended pain, throwing the muscles around the membranous part of the urethra into spasmodic action. This sometimes produces contraction of other parts of the canal ; but as a rule the spasmodic resistance is not met with till the point of the catheter passes under the pubes. If the instrument be gently held (rather than pressed) against the contracted part of the tube the spasm will probabty soon relax and the instrument jump into the bladder. Catheters are passed either in the erect or recumbent posi- tion. This depends in a great measure on the circumstances of the case and the habitual practice of the surgeon. Most surgeons prefer to pass instruments with the patient standing against the wall, perfectly erect, with his feet resting against the wall, and the surgeon seated in front of liim ; but if the patient is nervous or unaccustomed to instruments he may easily faint, and the surgeon must he prepared for that event. False Passage. — When after experiencing some resistance the instru- ment is pressed forward, makes a sudden jump and remains fixed, while the patient complains of pain and loses some blood, the surgeon may con- clude that a "false passage" has been made. No further attempt to passan instrument should be made for a few days under these circum- stances. It is rare for any formidable symptoms to ensue, for the false passage, being valvular towards the bladder, the urine does not find its way into it, and there is seldom any serious bleeding. My own practice in commencing the treatment of a case of stricture is first to use a very small gum catheter without a stilet. If this passes easily I take a larger size until the measure of the stricture is taken. If it passes, but with much difficulty, it is best, if circumstances permit, to tie it in for a couple of da3"s or so. If this is tolerated the case will be found much more tractable. Gradual and Bapid Dilatation of Stricture. — The two most common plans of treatment are by gradual and by rapid dilatation. In the former, after an instrument has been passed once or twice on successive or alter- nate days, the next larger size is taken, and so on until in a few weeks the stricture is dilated so as to admit a catheter the natural size of the tube. This size of course varies in different persons. In practice the No. 10 of our ordinary English scale may be taken as an average.^ The pa- tient is then taught to pass a similar catheter for himself, and the sur- geon gives him such directions as to the frequency of passing it as he thinks fit, once or twice a week, according to the apparent tendency of the stricture to contract; and he is to be told that although after a few years it may no longer be necessary to do this so often, yet that it is dangerous to neglect the occasional passage of an instrument in order to ascertain whether there is any tendency to reneAved contraction, on the first suspicion of which he should immediatelj' consult a surgeon. Rapid Dilatation. — The other method, by rai)id dilatation, is one which has been long a favorite plan of treating stricture at St. George's Hos- pital, and which Mr. Savory has recently strongly recommended from his experience at St. Bartholomew's.^ It is a very convenient and very ^ Th(! normal calibre of the male urethra is generally believed to be represented by a tuhe about one inch in circumference. Dr. Fessenden N. Otis, of New York, believes that this is too low. He says that he has met with two cases in which calculi measuring IJ in. in their largest and 1^ to 1| in. in their smallest circumference pa.ssed without any incision, and that he has measured urethrte even larger than this. He also figures an instrument for measuring the size of the uretiira behind the meatus. — Lancet, July 11, 1874. But in practice the patient may be well satisfied when even No. 8 can be easily introduced. * See St. Barth. Hosp. Reports, vol. ix. TREATMENT OF STRICTURE. 789 rapid method of treating cases in which confinement to bed is not ob- jected to ; and is therefore peculiarly appropriate to hospital })ractice. As much progress may often be made in the dilatation of a stricture in ten days by this method as would have been in a month by that of grad- ual dilatation. I cannot better describe the plan than in Mr. Savory's words : "After an instrument has been introduced and secured the patient should, of course, lie quiet — in the great majority of cases he will rest most comfortably on his back. It is well to move it slightl}' and very gently in the urethra from time to time. This gives the surgeon addi- tional assurance that all is right, and tells him at once the degree of progress that has been made by the loosening of the stricture. The instrument may be either withdrawn at the end of twenty-four hours, and one a size larger introduced, or it may be left for two or three days, when it may be replaced by a much larger one. As a rule I change the first instrument, if it be a small one (No. 1, 2, or 3), at the end of twenty- four or forty-eight hours, when I can usually pass No. 4 or 5, leaving that in for two or three days, when No. 1, 8, or 9 can be easil}^ substituted. As to cliange of instrument, I am chiefly guided by the size of the cathe- ter and the amount of suffering experienced by the patient. A large instrument maj' be retained longer than a small one, and the withdrawal of the original instrument and the substitution of another often gives relief when the patient is restless. Of course, patients vary much in their abilit}' to bear a catheter in the urethra. To some it seems to give little or no trouble; they make no complaint, feed and sleep well, and, in short, give no signs of disturbance of any kind ; while others complain very loudly, declare their utter inability to bear the instrument any longer, and urgently demand its withdrawal, sometimes withdrawing it them- selves. In my experience these latter cases form the exception to the rule, and even in these I think the difficulty ma}^ usually be overcome. In the worst cases of stricture, where only the smallest instruments can be passed, the chief difficulty in treatment is overcome if an instrument can be retained for twenty-four or forty-eight hours. " In my opinion the mode of action of this plan of treatment contrasts favorably with that of any other. The stricture is overcome, the abnor- mal tissue is removed, by constant pressure. The great influence of pres- sure in producing absorption is a well-recognized fact. We are familiar not only with many physiological, but also with raau}^ pathological illus- trations of its potency. And it comes in very happil}' for the remedy of stricture. When an instrument is then introduced it is tightly grasped by the contracted portion of the canal, but is loose and free elsewhere, so that pressure is brought to bear at the very spot where it is required, and there only ; and in proportion to the amount of good effected is the degree of its action reduced. It acts not b}^ mechanical force, but by a physiological process. Of all methods of treatment this undoes the mis- chief in the most natural manner ; and herein, I submit, is its claim to be considered the best." Tiie drawbacks to the plan, besides the confinement which it entails, are that in some patients the retention of the instrument causes pain and inflammation, and that frequentl}', if after-treatment be neglected, the recontraction is even more rapid than the dilatation has been. But the former danger can easily be guarded against by carefully watching the case and withdrawing tlie catheter if it really seems to be setting up miscliief, of which the condition of the urine will be even a more trust- worthy guide than the complaints of the patient. And the tendency to 790 DISEASES OF THE URINARY ORGANS. recoutraetion after cure can easily be obviated by a somewhat more fre- quent passage of the catheter than is needed after gradual dilatation. Method of Ti/ing a Catheter in the Bladder. — A few directions are needed as to the mode of tying in a catheter. This can be done in va- rious ways. Tlie easiest, though not the most secure, is to tie a tape round the end of the catheter with a clove hitch, or to pass tapes tlirough the rings made on the ends of catheters which are intended to be retained, and then to secure the ends of the tapes under one or two pieces of strap- ping rolled circularly round the penis. The insecurity of this plan de- pends on the loosening of the strapping by the various conditions of erec- tion and flaccidity of the penis.' A more secure plan is to pass the tapes which hold the catheter through the substance of a T-bandage, or of a broader piece of tape arranged after the manner of a T-bandage. The tape attached to the catheter ought to be loose enough to allow the instru- ment a little movement in the bladder but tight enough not to permit it to slip out. The T-bandage should be as tight as is comfortable to the patient. Mr. Savory believes that a silver instrument can be as conveniently retained as a gum catheter. My own inclines to the general opinion that a soft catheter is less irritating than a metallic one; but the difference is certainly not very great. The same instrument should not be left in the bladder too long. I once saw a case in which the prolonged retention of a metal catlieter in the bladder caused ulceration of its coats and perforation leading into the peritoneal cavity. This is of course very rare, but it is very common to see a catheter become coated with phosphatic deposits, and this in- creases the irritation of the bladder. So much for the treatment of strictures in which the catheter can be passed. Treatment of Impassiahle Stricture. — Should the surgeon be unable to pass any instrument, the treatment of the case will vary according as there is or is not retention. When there is not, the attempt will be put off till another day, the patient being prepared for the renewed attempt as above prescribed (p. Y86). But if he is suffering from retention of urine, unless the bladder be distended to an alarming extent, a full dose of laudanum (say 30 or 40 drops) should be given in a little hot water, and he should be put into a hot bath until he begins to feel faint. Then if the retention has been relieved in the bath (which is often the case) he should be put to bed and left quiet till another day, otherwise the surgeon should try to introduce the catheter while the patient is still in the bath. If this attempt also fails, careful examination is to be made to ascertain how far the distension of the bladder has gone and whether there is an}'' sign of fulness or great pain in the perineum. If not, the same meas- ures may be repeated, and I have seen cases treated with success after nu- merous repetitions of sucih attempts ; but they are of course not free from the risk of extravasation of urine occurring unexpectedly, on which ac- count Mr. Cock'' recommends the puncture of the bladder per rectum in preference to perseverance in the attempt to pass the catheter when a patient and sufllcient trial has proved fruitless. At an}' rate, at some period or other, surgical relief must be given. Three courses are open, — to puncture the distended bladder from the rectum or above the pubes, ' For private patients who have to wear a catheter, a little apparatus is sold to buckle round the penis, with rings to wliich the catheter is attached. * Med.-Chir. Trans., vol. xxxv, )>. 153. PUNCTURE OF BLADDER PER RECTUM. 791 or to force a way into it with the catlieter. The latter (" forced catheter- ization") is no longer employed, except possibly by some surgeons in cases of great enlargement of the prostate, under which heading it has been discussed. Puncture of the, bladder f 7' ovi the rectum is a simple operation, and in the cases which I have seen it has proved quite as successful as the con- dition of the patients permitted. It is to be employed in impassable strictures at such a time as in the judgment of the surgeon is desirable. It must lie remembered that, even allowing that ultimately the retention of urine may be relieved, whether instrumentally or otherwise, before ex- travasation occurs, this argument is not of itself conclusive, in order to show that the operation of puncture is not desirable, since every liour which elapses increases the patient's sufferings and the inflammation of the urinary organs, while the repose that follows the puncture is of course complete ; and after the canula has lieen retained some time in the bladder, the stricture being no longer irritated by constant straining and the con- tact of inflamed urine, will probably become much more tractable. The matter must be left to the surgeon's judgment, weighing the circum- stances of each case. The fact that no case of stricture has been admitted into St. George's Hospital which was held to require puncture by the rectum from the time of Sir E. Home down to the year 1852, when Mr. Cock's paper was read at the Medico-Chirurgical Society, certainly shows that the operation is not often rigidly necessary ; while the fact that it has been very frequently performed there in the comparatively few years which have elapsed since that date proves that Mr. Cock succeeded in showing that in many cases, even if not rigidly necessary, its more early performance is advisable. The operation itself is done thus. The patient is put up in the lithotomy position and had better be narcotized. The surgeon, being provided with a long curved trocar and canula made for the purpose, examines the bladder with great care with his left forefinger in the rectum in order to define the posterior border of the prostate gland, and to make himself sure that the fluctuation of the urine in the bladder can be felt with that finger when percussion is made on the bladder above the pubes. Having ascertained this beyond doubt, he passes the canula, without the trocar, up the rectum and fixes it with his left forefinger just behind the prostate on the place where the fluctuation of the bladder is felt. His assistant holds the shield of the canula in this exact position while he takes the trocar, passes it through the canula, and then drives it into the bladder with a decisive plunge, as though he vvished to bring it out through the abdominal wall above the pubes. There can be no risk in plunging it in boldly, if the bladder is well distended, while if it be more gently introduced it may either not perforate the bladder at all, or to so short a distance as to slip away again readily. It is well to pass a long piece of gum catheter through the canula in order to fix it more securely in the bladder, and it is to be tied in in much the same way as a catheter (see p. 790). The canula is not to be stopped, but the urine can be conducted into a vessel below the bed by fixing an india-rubber tube to it ; otherwise it must soak into oakum or tow, which is to be frequently changed. After seven to ten days a cautions attempt should be again made to pass the catheter, and if this is successful the canula is to be withdrawn ; otherwise it may be left even for as long as a month. In a case under my own care, however, it became necessary to withdraw it after about three weeks, in consequence of the diarrhoea caused by the dribbling of water into the rectum, although no instrument could be in- 792 DISEASES OF THE URINARY ORGANS. troduced. Tlie patient, however, was relieved of his retention and was satisfied with this relief, and so I lost sight of him. Puncture of the bladder above tiie pubes is not usually necessary in cases of stricture unless when they are complicated with extreme enlarge- ment of the prostate gland. Moderate enlargement of the prostate does not preclude the possibility of puncture per rectum as shovvn by a prep- aration in the Museum of St. George's Hospital from a patient of Mr. Tatum, in wliom the canula slipped out accidentally and the puncture was repeated. No diHicult_y was experienced either time, though there was considerable enlargement of the prostate gland. The operation of punc- ture above the pubes has been described in speaking of enlarged prostate. The aspirator has of late been often used for the relief of stricture, by evacuating the bladder above the pubes. I hope it is not merely from ignorance that I am somewhat skeptical as to the real value of this method of puncturing the bladder. No doubt it will afford relief for the time, and without any serious danger if the bladder is much distended, but the puncture will heal immediately and the relief will be transient. In severe strictures, when any operation for puncture of the bladder is re- quired, my own impression is that the operation through the rectum will ultimately be found to be the most serviceable. At the same time, the use of the aspirator is perfectly rational, and further experience will teach us its real value. Treatment where there is no Retention. — Such is the treatment of im- passable stricture when complicated with retention of urine. There are, however, strictures which the surgeon finds impassable, and yet there is no retention. In such cases much time and patience should be employed. Rest in bed, free purgation, and the constant use of the warm bath, will get the organs into a quiet state, and some day the surgeon will succeed in reaching the bladder, an attempt which is greatly facilitate'd b}'^ anaes- thesia. But if he does not, what must be done? The patient is, perhaps, free from retention while quiet, but is liable to it at any time after exer- cise, exposure to weather, drinking, or sexual intercourse, and his life is made a torment to him by constant ineffectual instrumentation. For such cases there is no resource except the old operation for stricture called "la boutonniere," or perineal section, which must be carefully distinguished from Syme's operation, or external urethrotom}^ on a grooved staff, an operation which can only be performed when the stric- ture is not impassalile.^ Perineal Section. — The operation of perineal section is thus performed. The patient is to be secured in the lithotomy position, the perineum having been shaved. A large grooved staff is to be passed down to the anterior face of the stricture and carefully maintained in position by an assistant. If a false passage is known or suspected to exist, the surgeon must take the greatest care to ascertain that the staff has not passed down it, but is in the middle line, i. e., in the urethra. If there is a fistula in perinajo thi'ough which a director or female catheter can be passed into the bladder, as is often the case, it facilitates the operation ver}' materially. An incision should now be made in the raphe of the perineum in nearly its whole extent. As the incision must deepen at its lower part, it saves tinae and lessens the risk of losing the middle line to make this incision ' Mr. Syme ii.sed to dwoU with chanictftristic force on the fact, in whicli all .surgeon.s of much experience in urinarj* diseases concur, that there are really very few stric- tures which are impa.ssablo, ifonly the surgeon is dexterous and fiatient. The necessity for perineal section ougiit, to say the least, to occur very rarely. ABSCESS IN PERIN^O. 793 boldly by placing the left forefinger in the rectum as a guide ; then plunging the knife with its edge upwards deep into the perineum above the finger, so as just to avoid the rectum, and cutting outwards. The staff is then to be exposed b}' reversing the knife and dissecting carefully until its point is reached. Now commences the difficult part of the operation, — the attempt to find the posterior part of the urethra by a dissection con- ducted along the course of the canal. If there is an instrument passed through a fistulous passage into the bladder, the posterior part of the urethra cannot of course be missed, but it does not follow that the dis- section will be conducted along the urethra, still less when there is no such guide. Indeed, I have seen, after death from this operation, anatomical evidence that the surgeon had made a kind of artificial urethra, i.e.^ had dissected along the side of the urethra, leaving the stricture on one side only very imperfectly, if at all, divided. The parts should of course be held asunder, and the urethra looked for as carefully as possible. But it is seldom possible to see any distinction between the structures, and the only precaution which' can be taken is to keep steadily in the middle line until, possibly, a gusii of urine takes place and the director can be passed into the bladder. In any case even when the surgeon cannot assure him- self of the position of the urethra, it is always easy to reach the neck of the bladder by putting the left forefinger on the edge of the subpubic ligament — always easily felt when the tissues of the perineum have been divided deeply enough, and then entering the knife below it. And I have known a successful issue in such a case, though the surgeon has not been conscious of exposing the vesical portion of the urethra. When the director has been passed into the bladder, a catheter should if possible be conducted along it from the wound, and tied in. If, however, it is not possible to get the catheter into the bladder at once, the operation may nevertheless be quite successful if onl}' the stricture has been freely divided. The patient should be left alone for a few days, and when the parts have consolidated somewhat, but not so much as to oppose the obstacle of cicatrization, an instrument will probably be easily passed under chloro- form. I have followed this course with complete success. The instru- ment must be changed as often as is necessary, at first, perhaps, every three days, and afterwards every five or seven (an anaesthetic being given, if it is absolutely required) until the parts have completely cicatrized. And after this, as after every other method of dilating stricture, the dilatation must be maintained by the constant passage of instruments. Treatme)it. — The complications of abscess and fistula in perina^o are unfortunately very common. The former, however, rarely leads in itself to any graver consequence than considerable pain to the patient and con- finement to bed for a time. The abscess in perinteo is rarely of large size. It commonly forms a small hard very painful lump in the central line, much too small and deep to permit any fluctuation to be felt, but known to be an abscess by the presence of stricture, by the pain, and usually also by rigors and other feverish symptoms. No time should be lost in lajnng it open ; it would be very reprehensible to wait until the matter has come forward, and till the surgeon can feel fluctuation. The patient should be brought to the edge of the bed, placed in the lithotoni}' posi- tion, and a deep puncture should be made with a lancet or (better) with a scalpel, great care being taken to keep in the middle line, when matter mixed with urine, and usuall}' very foul, will be evacuated, to the great relief of the patient. It is undesirable to tease him at first with instru- ments. The urine very seldom comes through the wound, for though the abscess is formed by ulceration of the urethra its small orifice is 794 DISEASES OF THE URINARY ORGANS. generally closed by inflammation, otherwise the pus would flow out by the urethra and there would be little pain and no pressure on the tube, or increase of dysuria. Even if urine do escape, the cure of the stric- ture will soon cure the fistula. Treatment of Fistula in Perinseo. — Fistula in perinreo is generally the result of a much more chronic action than abscess. Their origin is in some sense the same, only that of abscess is accompanied by more irrita- tion, probably from the greater putridity of the urine; while the fistula results from the gradual extension of ulceration from the urethra to the surface with no increase of the obstruction, and few if any symptoms. These fistula? accompany all kinds of tight strictures, but are particularly prone to accompany the traumatic, which are the tightest of all. They have been known in such cases to form the onl}'' channel for the urine, the urethra being absolutely obliterated. Such unnatural channels, how- ever, can never properly replace the natural urethra ; they are very liable to partial obstruction from sabulous deposit, causing low inflam- mation of the urethra and bladder behind them, and they are a source of great discomfort to the patient, by incapacitating him from passing water in the usual manner. Their cure is to be sought in the restoration of the proper channel for the urine, by passing catheters increasing gradually in size, or by otherwise dilating tlie urethra to its normal extent. When this is done, the fistula will generally close of itself. If it does not, the reason usually is that a drop of water passes into the urethral end of the fistula every now and then and keeps it irritated. The best way to pre- vent this is bj" instructing the patient in the use of the catheter till he can easil}' pass a full-sized instrument for himself. This he must do every time he wants to make water, and must stop the end of it with his finger as he withdraws it, so that no drop of urine can get into the mouth of the fistula. This plan, if sedulously persevered in for a week or two, can hardly fail to cure the fistula, unless its persistence dei^ends on the chronic thickening and low inflammation of its walls, in which case the tissue should be destroyed by passing a red-hot wire down the fistula, or by passing a wire down the fistula to meet a catheter passed into the urethra and then connecting the wire with the galvanic battery, or sometimes these fistulae heal on the stimulation of their walls with the tinct. lyttae, or by means of a probe coated with the nitrate of silver. In some very rare cases, a plastic operation may be justifiable. The tissue through which the fistula runs is laid open freely and deeply until the urethra is reached, a grooved staff having been previously passed. All the diseased tissue which can be recognized is pared awa^^ and the parts sewn together, a catheter being kept in the bladder. Such an operation, however, is very rarely indeed called for. Urinary fistulae may also be produced by otlier causes, such as the im- paction of a foreign body, a wound, as in lithot'^m}^, and in rare cases by the bursting of an abscess into the urethra. I once saw a very healthy- looking man with a large fistula of which he could give no account, except that it appeared to him to form after prolonged sitting on the driving- box, and who certainly had no stricture. In some wounds or injuries of the urethra the tube becomes completely obliterated, and this gives rise to the most obstinate form of fistula. Anie-Hcrotal Fistula. — The most difficult form of urinary fistula to treat is that which opens in front of the scrotum, called on that account "ante- scrotal fistula." It is caused usually by syphilitic sores on the skin, which, having ]>ecome phagedenic, have opened into the urethra, or by sloughing, tlie result of accident. The main obstacle to their closure is EXTERNAL URETHROTOMY. 795 the constant clisturbance of their edges by the varying size of the penis in erection, and this is especially the case after plastic operations, for the sutures which haA^e been put in seem to act as irritants, and the patient is very liable to frequent erections. Patience, however, on the part of the surgeon and the patient will usually procure their healing after re- peated operations. I once saw a case of ante-scrotal fistula from injury, in which thirteen operations were practiced, and ultimately the fistula was perfectly cured. In these cases it is well to dissect up the skin freely around the fistula and to make free lateral incisions, so that the edges of the incision may meet over the fistula without any tension whatever. It may even be necessary to transplant flaps from the neighboring i)art of the penis, and to divide the prepuce freely from the glans, in order that the erection of the peuis shall produce as little effect on the wounds as possible. The wound is to be united either longitudually or transversely, as may seem to produce least tension on the sutures. The evacuation of the urine is verj^ troublesome after such operations. It is best, on the whole, I think, for the surgeon himself to i)ass a metal instrument three times a day with all imaginable care not to disturb the sutures, and to stop the catheter while he withdraws it. If a catheter is tied in it irri- tates the wound, and the urine is apt to dribble away beside it. Recurrent Strictures. — There are cases of urinary fistula with stricture in which the stricture can be passed, but cannot be dilated. The patient suffers constantly from rigors' after the passage of the instrument, and any progress tiiat may be made at one time is soon lost again. In such cases the stricture must be divided either by internal or external urethro- tomy. Syme^s operation — that of external urethrotomy on a grooved staff — is thus performed. The patient being in the lithotomy position, a "shoul- dered" staff is passed into the bladder, viz., a staff which is narrower at the end than it is in the stem. We may suppose that the end which passes through the stricture into the bladder is the size of No. I or No. 2 catheter, while the stem is the size of No. 8 or No. 10. At the junction of the two parts there will be a projecting "shoulder," and this shoulder will necessarily be arrested by the mouth of the stricture. A groove commences on the shoulder, i.e.., on the thicker part of the staff, and runs along the convexity of the staff, though not quite to the end. The surgeon passes his left forefinger into the rectum, and passes the point of the knife, with its edge looking upwards, into the raphe of the perineum a little above his finger, so as not to wound the rectum, but to open the perineum deei)ly and almost expose the stafi" in the urethra at a single Incision, which is to be drawn upwards nearly to the scrotum. The shouldered part of the staff with its groove will now be very perceptible in the wound, and should be further exposed if necessary by a few touches of the knife. Then the point of the knife is to be inserted in the com- mencement of the groove, where it is, of course, in front of the stricture, and the knife is to be steadily pushed along in the middle line, so long as any resistance is experienced. The staff is then to be pushed on until its thick portion will pass freely into the bladder. Great care must be given to tiiis part of the operation, to see that the stricture has really 1 These rigors are in some cases most distressing. They are apt to recur whenever an instrument is passed, accompanied by a definite and often considerable rise of temperature, and great malaise, a condition sometimes spoken of as " urethral fever." They are best avoided by giving the patient a glass of hot brandy and water with a full dose of laudanum in it and wrapping him up warm in bed immediately after the passage of the instrument. 796 DISEASES OF THE URINARY ORGANS. heen divided quite freely enough, for if this has not l)een effectually done, recurrence is almost certain. Then the staff is to be withdrawn and a full-sized gum catheter passed from the penis and tied in. There is some- times a difiicult)' in introducing the catlieter after the withdrawal of the staff. This may be obviated by passing a director from the wound into the bladder before the staff is withdrawn, or by the use of a staff' in which the shouldered part screws on to the thin portion, and when the stric- ture has been divided is unscrevved, leaving the central part to serve as a conducting rod, over which a large catheter open at the end is passed down and the rod withdrawn. But after all it is not a point of very much importance whether a catheter be passed into the bladder immediately'' after the division of stricture or not. In a few days, when the wounded parts have a little consolidated, there will be no difficulty in passing the instrument (under chloroform if necessary) if only the stricture has been freely divided. Syme's operation is now used chiefly, if not entirely, in cases of very hard traumatic strictures complicated with fistulae in perinseo. Such strictures are very difiicalt to treat by gradual dilatation, or by rupture, and are hardly amenable to internal division, though there is no harm in trying this if the surgeon thinks fit. But the free division of all the morbid tissue, and the constant retention of a large-sized instrument afterwards, certainly afford the best prospect of a cure, after which con- stant catheterization must not, for many years at least, be neglected. Rupture^ or Forcible Dilatalion^ of Strictm-e. — Another successful method of treating rebellious strictures which admit tlie introduction of a small instrument is by what is generally called in England "rupture" of the stricture, and in France "forced dilatation." This, however, like every other violent method of treating stricture, should be reserved only for cases of exceptional occurrence, viz., those in which there is unusual sulfering from catheterization, or in which no progress can be made in dilating the stricture, or the patient suffers constantly afterwards from fever and rigors, or after dilatation the stricture immediately recontracts. Numerous plans have been devised for this end. At first, the simple plan was followed of passing a central rod and sliding over it tubes in- creasing in size till the desired dilatation was reached. This, however, is a very imperfect device, since the tube is liable to catch and tear the mucous membrane at tiie site of resistance. Two methods are now em- ployed, in each of which a dilatable instrument is first passed, consisting of two blades, attached to each other at the point, but separable in tlie rest of their urethral portion and fastened on to a central rod. The dila- tation is effected in the one case (Sir II. Tiiompson's plan) by turning a screw in the handle, which causes a small lever to project from the central stem and so drive the blades asunder. In the other, wliich is the one in common use, a tube is forced down over the central stem, and thus separates the blades to the required extent. This instrument was invented by a French surgeon, M. Perreve, and lias been somewhat modified and introduced into English practice by Mr. Holt, whose name it generally bears in this country. Mr. Richardson, of Dublin, and otliers have also modified Perreve's instrument. The great risk in the use of any of these instruments is that of passing it down a false passage. In these cases of obstinate stricture there are generally false passages, and some- times the instrument slips into them so easily and they run so much in the direction of the l)ladder tliiit it is very difficult to know whether the point is in the bladder or not unless the urine can be seen to escape. Accord- ingly- Mr. Holt has had the stem of Perreve's instrument perforated, con- INTERNAL URETHKOTOMY. 797 verting it into a minute tube, through which a drop of urine will escape, unless (as frequently hai)pcns) the little hole is obstructed b}' clot; in that case the surgeon should not proceed farther, if there is any question about false passage, until by examination by the rectum and palpation of the abdomen he has coniijletely satisfied himself that he is reall}' in the bladder. The tube is to be aj^ijlied to the central rod (the handle being opened for the purpose V»y removing all the screws), and driven smartly home, in doing which the stricture will be felt to give way. The instrument is then withdrawn with the tube still in it, and the urine is drawn off with a fuU-siz^d catheter. Two tubes are supplied with the instrument: if the larger one has been used. No. 10 will pass; if the smaller. No. 8. As a general rule the catheter sliould not be left in, but it is well to draw the water off, both as a proof that the stricture is prop- erly dilated, and in order to spare the patient the pain of passing water soon after the operation. Chloroform may be given or not according to the wishes of the patient and the surgeon. In very tight and hard stric- tures it is perhaps necessary, and in all cases where the operation is really required it must be j)ainful, though soon over. The patient should keep liis bed for a couple of days, and then the catheter should be re- introduced and the case treated as an ordinary one of stricture which has been dilated up to that size. It is not always possible, or at least easy, to pass the same catheter as at the time of operation, but in all cases which I have seen (except one of traumatic stricture) tiie case was very easily managed afterwards. In this proceeding it seems doubtful wdiat is the real action generally on the stricture. We speak of it farailiarl}' as "rupture," but there seems good reason to think that it is often little more than a forcible dilatation, or if there is any rupture it is confined to the submucous tissue, and there is no breach of surface in the urethra. If this is so, it evidently dimin- ishes the risk of inflammation from foul urine being extravasated or passing over a raw surface. I have seen death after this operation, but it was in the person of a man whose urinary organs were in so advanced a condition of disease that he could not in any case have lived long. Internal Urethrotomy. — Another method of treating rebellious or con- tractile strictures is b}- internal division, and this is indubitably superior to rupture in stricture situated far forwards, and possibly in traumatic stricture ; though it ma}' be questionable whether in traumatic stricture not in the spongy body, the freer division produced b}' Syme's operation is not preferable. The general use of Syme's operation and of the method by forcible rupture renders the use of internal urethrotomy rare in this countr}'. It is performed in two ways, ?'. e., by incising the stricture from behind forwards, or from before backwards. The former is the safer course, and the one usually followed. Many instruments have been invented for this purpose, but the one most in use is Civiale's, which may be taken as the type of them all. The principle of all is that of the bis- touri cache, i. e., a stem containing a knife which is projected b}' pressing on a handle. In Civiale's urethrotome the head of the instrument is bul- bous, and in this bulb a small knife-blade is concealed. The position of the stricture is clearl}' ascertained, and it is felt by the bulb in passing tiirough it. Then as the Inilb is witiidrawn the knife-i)lade is projected from it, and the whole tissue of the stricture is freely incised, the inci- sion being directed by preference to the floor of the urethra, and care must be taken that the incision extends completely through tlie obstruc- tion. After the division a full-sized catheter ought to pass easily, and it 798 DISEASES OF THE UKINARY ORGANS. is well to retain it for the first twent^'-four hours, and to pass instruments frequently afterwards. Incisions from before backwards require a guide to be passed through the stricture. Maisonneuve's guide is a flexible filiform bougie, on the end of which a grooved rod is screwed. This bougie being passed through the stricture, the grooved rod is screwed on to it, and is passed on. The filiform bougie coils up in the bladder, and guides the rod down the urethra, through the mouth of the stricture. Then a semi-sharp lancet-shaped knife is passed down the groove, which incises or tears the stricture, l)ut is not sharp enough to wound the normal urethra. Sir H. Thompson has devised a grooved catheter for the same purpose, along which a sheathed knife-blade is passed. When this comes to the point of resistance the knife is unsheathed and the stricture divided. A large gum catheter is then passed over the grooved conductor, and the latter withdrawn. The advantages claimed for internal incision over rupture are that its results are said to be more permanent. I have not sufficient experience of the matter to enable me to pronounce an opinion of my own. Sir H. Thompson, whose experience of internal urethrotomy extends to above 100 cases, recommends it " for all non-dilatable strictures situated from two to four inches from the external meatus," and for these somewhat rare cases I doubt not that it is both safe and easy; but for strictures situated behind the scrotum I should long hesitate before resorting to it. In any case it appears that tlie extent of the incision through the stric- ture is not in itself a matter of any great importance ; but it is highly important to make sure that no part of the stricture is left undivided. Spasmodic Retention — The retention which proceeds from organic stricture is to be carefully' distinguished from that which is due to spasm only. To the latter the somewhat incorrect term " spasmodic stricture " is usually applied. " Spasmodic retention," or "spasm of the urethra," better expresses the nature of the case, since there is really no stricture in the proper sense of the term. I have already stated that much spasm almost always attends organic stricture, and therefore the retention of urine, as well as the difficult}^ in i)assing instruments, in cases of stric- ture, depends usually to a great extent on spasm induced by irritation of the stricture. But the cases here spoken of are unaccompanied as far as is known by any anatomical change in the tissue of the urethra. Spas- modic retention occurs in gonorrhoea, from excesses in drinking, from prolonged voluntar\' retention, from the use of cantharides or turpentine, after surgical operations about the pelvis, from morbid conditions of tlie urine, and from unknown causes. It ma}' be known from the retention which accompanies stricture or enlarged prostate by its sudden occurrence, micturition having been quite natural up to the time when retention took place; and from that caused by impaction of stone b}^ direct examination. In some cases, as when retention complicates surgical operations, the history points out the nature of the case. There is seldom any difficulty in passing a catheter, and as this settles the case at once, and spares tlie [)atient a good deal of time and some distress, it is better in ordinary cases to take a medium-sized gum cath- eter, and pass it rapidly. The muscles may, as it were, be taken by surprise, and the catheter reach the bladder at once. If not, the ob- struction will be found to be at the point where the membranous part of RETENTION AND INCONTINENCE OF URINE. 799 the urethra is surrounded by its muscles, and gentle steady pressure for a few seconds will often carry the instrument in. If this attempt does not succeed, the patient should be put into a liot bath till he is nearly faint, having previously had a full dose of laudanum,' and then in almost all cases the spasm will yiekl. In some rare instances it may be desirable to administer an anaesthetic. Retention of urine is, as will have been seen from the foregoing pages, and from the chapter on Stone, a common symptom of a variety of morbid states. In children it proceeds most commonly from impaction of a stone in the urethra, or from a ligature round tlie penis, and in very rare cases from tumor of the bladder or urethra, or from abscess pressing on the urethra. In men stricture is by far the most common cause, though it ma}^ proceed from spasm, or from lacunar or other abscess pressing on the urethra, from prostatitis, from stone, or from various general diseases. In old age retention is commonly associated with enlargement of the prostate. Stricture of the Female Urethra. — In the female sex retention is gen- erally due to nervous causes (hysterical retention) or to pressure (as in parturition). It may be caused by stone, and in some very rare cases has been known to be due to stricture. Stricture of the female urethra is an exceedingly rare affection, but does undoubtedly occur. Its usual cause is, I believe, injury in parturition or otherwise. Careful examina- tion is necessary to distinguish it from hysterical retention. It is best treated by rupture or internal incision. Retention from obstruction of any kind (spasmodic or otherwise) must be carefully distinguished in the first place from suppression (p. 168), and in the next place from the kind of retention which is caused by paralysis, and from the atony which follows overdistension. Both of these are suc- ceeded b,y overflow of urine, a condition sometimes incorrectly spoken of as incontinence. There is no difficulty in distinguishing between retention from obstruction and that from paraljsis. In the former, after the obstruction has been overcome, the bladder will discharge its contents with natural force. In the latter (which is very rare, and which is ac- companied b}' other paralytic symptoms) the urine merely runs out under external pressure when the catheter is passed, but there is no muscular action in the bladder itself, and there is no obstacle whatever to account for the retention. Atony from overdistension occurs in numerous classes of obstruction, enlarged prostate, stricture, tumor, etc. After a certain amount of retention the urine begins to dribble awa}' from dilatation of the neck of the bladder. The treatment consists in relieving the ob- struction and keeping the bladder constantly empty. Incontinence of urine is in the great majority of cases the result of overflow from distension, and ought not to be spoken of as a substantive disease at all, being merely a sym[)tom of obstruction. At other times it means the overflow of paralysis, or of the irritability of the bladder so often connected with paralysis. Hence the lirst thing in the treatment of incontinence of urine in the adult is to ascertain whether there is not one of those two conditions present, which in the very great majority of 1 Sir H. Thompson says that the Tinct. Ferri Perchloridi, in doses of 15 to 20 minims, administered four or six times at intervals of a quarter of an hour, will re- lieve the sjijism. 800 DISEASES OF THE URINARY ORGANS. cases there is.^ A veiy few cases will I'einain in which the urine, though health}', cannot be retained for any length of time in the bladder. This happens sometimes in persons broken down b}'^ sexual excesses, and in other morbid conditions of the nervous system. The treatment must be regulated by the apparent cause. In some very rare cases of prostatic enlargement incontinence is caused by the projection of the " third lobe " into the neck of the bladder, keeping it constantly patulous, a condition for which there is no remedy. E)U(i-esis in Childhood. — Bat the condition of pure incontinence which is commonly met with is the juvenile incontinence, or " enuresis " of childhood, much more commonly seen in boys than girls, in which the child becomes a nuisance to himself and ever}' one else by constantly wetting the bed, and in some severer cases cannot hold his urine in the daytime. In some very rare instances there is also a similar incontinence of feces. Yet there is no evidence of spinal disease, the urine is natural, and the child in other respects health}', though many of these children are dull and stupid. In many cases, no doubt, the habit is to be referred to mere wilfulness, and may be corrected by appropriate punishment, or by moral means. It is well known that it is very liable to spread in a school into which a case has once been admitted. But there are many cases in which the child is as desirous to get rid of the infirmity as any one else can be, and I have seen more than one instance in which a ligature has been tied so tight round the penis as to cut into the urethra by a boy who was determined to rid himself of the habit. In these cases the first thing is to make sure of the absence of worms, then to see that the child is awoke every three hours and made to pass urine, to act freely on the skin, to give tonics, especially steel and strychnine, and to administer cold douches to the spine. 13elladonna is the drug which in my experience has acted most favorably in these cases, beginning with |-th of a grain of the extract three times a day, and raising the dose till the characteristic symptoms of poisoning (of which paralysis of the bladder is one) begin to show themselves. Other practitioners speak highly of chloral. Sir H. Thomp- son says that in obstinate cases the application of a solution of the nitrate of silver, 10 grains to the ounce, to the neck of the bladder may be beneficial. The complaint almost always subsides before the patient grows up. I will merely add that I once saw a case in which the dilatation of the neck of the bladder by a stone projecting into the urethra was mistaken for juvenile incontinence. Of course such an error could only arise from want of examination. 1 " There is no principle more important to rememher in the treatment of diseases of the urinary organs than this, — that an involuntary flow of urine in the adult indi- cates a distended, not an empty, bladder." — Thomp.son. CALCULUS. 801 CHAPTER XXXVIII. CALCULUS. Stone, whether in the kidney or bladder, is produced by the aggrega- tion of some of the ordinary urinary deposits, which we may divide with Mr. Poland into two classes, — those allied to the urates and derived from the organic constituents of the urine, and those derived from the inor- ganic salts of the urine, — the phosphates and carbonates. A familiarity with the external appearance of these deposits in the urine and with their microscopical characters is necessary for any successful treatment of urinary diseases. Lithates. — Of these deposits the urates or lithates of ammonia and of soda are the most common. They form a variously colored cloud in the urine, sometimes pure white, at others almost purple, most commonly yellowish-red, which generally clears entirely on being heated. Such de- posits occur constantly as an occasional phenomenon in conditions of perfect health, especially in cold weather, and no importance is to be at- tributed to the circumstance. But their constant or habitual presence shows that either the digestive or cutaneous functions are disordered, and should induce a strict examination and proper eliminative measures. The microscopical appearances of the lithates are that they eitlier form a completely amorphous deposit, or that, as shown in the annexed dia- gram, tliere are minute spheres, having protruding from them acicular spicuUie, which are regarded as being those of uric acid. Uinc acid is also a very common deposit. It occurs in the form of acicular prisms or of rhombic plates, such as are shown in Fig. .355, and Fig. 354. Fig. 355. Lithate of ammonia. Uric acid deposits. these often attain a very large size, so as to be perfectly visible to the eye as "red sand," or even to form a minute calculus. Dr. Golding Bird attributes the formation of uric acid deposits to the following causes : " (1) the waste of tissues being more rapid than the supply, as in fever, 51 802 CALCULUS. Fig. 356. rheumatism, etc.; (2) the supply of nitrogen in the food being greater than is required for the reparation of the tissues, as in over-indulgence, especially in the use of animal food ; (3) the process of digestion being insufficient to assimilate an ordinary and normal supply of food, as in dysjiepsia; (4) obstruction to the cutaneous outlet for nitrogenized secretions, as met wfth in diseases of the skin, variability of climate, etc. ; (5) congestion of the kidneys from injury or disease." Imperfect respira- tion is also said to be a cause of excess of uric acid in the urine. The treatment will be regulated by a knowledge of the causes. O.ralafc of lime is another common deposit in the urine, and often forms a calculus in the kidney or bladder. The microscopic appearances are twofold — the octahedral cr3'stals (shown on the left of the diagram) and the dumb-bell shaped cr^'stals (on the right). The oxalic diathesis is variously regarded either as being allied to the lithic or the saccharine diathesis — to gout or diabetes. Its causes are either indigestion, exhaustion, or the abuse of saccharine food or fermented liquors. Attention to the cutaneous and diges- tive functions, the regulation of the diet, and the use of the mineral acids are the main indications of treatment. Tlie rarer deposits in our first class are the uric or xantliic oxide, which closely resembles uric acid, and the cystic oxide or cystine, which in external appearance resembles the pale lithates, and under the microscope appears as six-sided prisms superimposed on each other into a mass. This seems to indicate a more profound dis- turbance of health than the other deposits, and to require more support- ing and tonic treatment. The inorganic deposits are the phosphates and carbonates. The phos- phates of soda or of soda and ammonia (alkaline phosphates) which exist in the urine are perfectly soluble and do not give rise to deposits or con- cretions ; but the earthy phosphates — those of lime and of ammonia and magnesia — are insoluble in water, and when set free from their solution in the urine are easily thrown down. This precipitation is readily effected by ammonia; and we have seen above (page 7'14)that in inflammation of the bladder urea is converted into carbonate of ammonia by the agency of the mucus secreted by the bladder. Thus a deposit of phosphates is constant in inflammation of the bladder, and any of the numerous causes which diminish or destroy the proper proportion of acid in the urine, as inflammation of the kidney, spinal injury or disease, the ingestion of large quantities of alkali, nervous exhaustion, and many other morbid states may produce phosphatic urine. Fho^'phate of Lime. — The deposit of phosphate of lime generally occurs as a white cloudy mass, often mistaken for mucus or muco-pus, and as it is precipitated by heat it is often hastily confounded with albumen ; but the precipitate is redissolved by acids. It is generally amorphous under the microscope, but it is also found (especiall}- after standing) in the form of splicrules, which may coalesce into a dumb-bell or rosette-like form, or of oblique hexagonal prisms. (Fig. 357.) The trijjle phosphate of ammonia and magnesia forms large and very Oxalate of lime deposits. KINDS OF CALCULI. 803 conspicuous crystals in the form of triangular prisras, with truncated ex- tremities, or of foliaceons or stellate prisms. The urine is often very fetid, frequently acid or neutral. (Fig. 358.) Fig. 358. Phosphate of lime. Triple phosphate. Both kinds of phosphatic deposit may be mixed in the urine, as they so commonly are in the formation of the stone. Garhonate of Lime. — The carbonate of lime is a rare deposit, which still more rarely collects into a calculus. Under the microscope the de- posits may sometimes be seen as minute spherules, which adhere together something like a drumstick. These are the ordinaiy prismatic deposits, but the student must learn also to recognize the various other deposits found in the urine, such as the epithelium of the kidney or bladder, blood-cells, pus-globules, casts of the renal tubes, spermatozoa, and the various substances which are found in decomposing urine. It is most important to detect the pres- ence of blood-globules, and still more so that of renal casts, as proof of disease of the kidneys. The kinds of calculi correspond in a great measure to those of the deposits. They are commonly formed in the kidney, and come down into the bladder, where they grow, and sometimes to an enormous size. Fig. 359. Fig. .360. Fig. 359. — Urate of ammonia calculus from a child, aged five. It contains a little uric acid, and traces of earthy phosphates disposed in layers. — From one of Mr. Poland's plates. Fig. 360. — Uric acid calculus. The external part shows the laminated, the internal the foliaceous ap- pearance. In the latter situation some oxalate of lime is mixed with the uric acid. — From a plate in Mr. Poland's essay, after a calculus in the Museum of the College of Surgeons. 804 CALCULUS. Sometimes the}^ form in tlie bladder spontaneously, and at other times are deposited round a foreign body. Lithate or ui-ate of ammonia seldom forms an entire calculus except in children, though it is often found as a deposit in the alternating cal- culi. Urate of ammonia calculi are of a whitish color, and usually are of an amorphous non-laminated appearance. Lilhic Acid. — The lithic or uric acid is the commonest of all forms of pure calculi. It is of a very hard consistence, and usually of a dark-red or brownish color, though often the nucleus is pure white. The surftice is tolerabl}' smooth in most cases. On section it is laminated or radiat- ing (foliaceous). The laminated stones when broken are apt to separate into hard sharp fragments very liable to wound or irritate the bladder and urethra. Oxalate of Lime. — The oxalate of lime calculus is believed to be the next in frequency after the uric acid. Its peculiar form has given it the Fig. 361. Fig. 362. Fig. 361. — External view of a mulberry calculus. Fig. 362. — Oxalate of lime, or n ulberry, cajculus, showingits internal arrangement " in an imperfect laminated manner, like fortification agate," and the deposit of a white material, doubtless phosphates in portions of its interior. — From one of Mr. Poland's plates. name of the mulberry calculus, from the number of small knobs or pro- jections which are found on its exterior, and which certainly present a remarkable resemblance to a mulberry, and this is increased by its color, which usually " varies from a gray to a rich brown or almost black. " This calculus forms, of course, in acid urine, but it often sets up a good deal of irritation, and then the urine becomes alkaline, and phosphates are deposited on the exterior of the stone. As rarer varieties of oxalate of lime calculi are mentioned " hempseed " calculi, small smooth bodies found in considerable numbers in the kidney, and the crystalline calculi of oxalate of lime, which are more or less white. Xanthic and Cystic Oxide. — The xanthic oxide and the cystic oxide calculi are extremely rare ; of the former, indeed, only four specimens were known to Mr. Poland. The cystic oxide calculus is not quite so rare. It is found in the kidney, is often multiple, and there seems some hereditary predisposition to its formation. It is distinguished by its waxlike lustre on fracture, by its containing a good deal of sulphur, and by its changing color with age from a pale yellow to brown, gray, or green. Phosphate of lime calculi are chiefly found deposited around a nucleus of some other substance, which may be a lithic acid or oxalate of lime calculus, or may be a foreign liody. It is usually of vesical origin, and forms a confused mass, not laminated, but "resembling mortar, or a TESTS FOR CALCULI. 805 granular semi-crystalline powder, enveloped in a tenacious mucus." There are the "bone-earth" calculi; but there are others of renal origin, consisting of neutral phosphate of lime, which are " pale brown, with a smooth polished surface regularly laminated." Triple Phosphate. — The triple phosphate does not very commonly form a calculus by itself. There are only three specimens in the Museum of the Royal College of Surgeons, and one or two at Guy's Hospital, one of which is figured by Mr. Poland, a remarkable specimen, in which the triple phosphate has been deposited round a piece of tobacco-pipe. Fumble Calculus. — But the majority of phosphatic calculi are of the mixed kind, and these mixed phosphatic calculi have the remarkable property of melting in the blowpipe flame, from which circumstance the concretion has received the name of the " fusible calculus." Alternating Calculi. — Many calculi are of the "alternating" variety, in fact, few are absolutely pure; but in those properly called alternating. Fig. 363. — Phosphate of lime calculus, formed round a nucleus of lithic acid, showing the laminated variety of the phosphatic calculus.— After one of Mr. Poland's plates. Fig. 364.— Alternating calculus. The nucleus is urate of ammonia, mixed with oxalate of lime; this is followed, tirstly, by oxalate of lime, secondly by uric acid, and lastly by alternate layers of urate of ammonia and earthy phosphates. — After Poland. the condition of the urine has varied during the period of growth of the stone, so that the calculus is composed of definite concentric layers of different deposits alternating with each other. In a very great majority of cases the external layers are formed of the phosphates ; and phosphatic calculi are very seldom succeeded by any other form. Carbonate of lime calculus is exceedingly rare in the bladder, but the small concretions which are often found in the ducts of the prostate some- times consist almost entirely of this substance, and are usually exceed- ingly numerous. Pseudo-calculi. — There are various forms of pseudo-calculus, or con- cretions of organic matter. These are the fibrinous, consisting of con- densed fibrin or albumen ; the urostealith, consisting of small collections of some resinous or fatty matter ; and " blood calculi," composed of the remains of blood-clot, with some phosphate of lime. But their occurrence is so very exceptional that they are of little practical importance. Tests for Calculi. — The following table was drawn up by Dr. Bence Jones as containing the easiest and most practical directions for the chemical examination of urinary calculi : 806 CALCULUS. A. Destroj'ed by heat ; combustible; leaving only a small residue. \. Become red on the addition ofnitric acid, and form a murexide. a. Soluble in carbonate of potash, evolvinf)- no ammonia; soluble in caustic ammonia or potash ; on the addition of an excess of acid crystallizes in angular crystals, not soluble in water. ~b. yoluble in carbonate of potash, evolving ammonia; soluble in water when boiled ; solution in water with a few drops of am- monia, when evaporated, crystallizes in needles. 2. Do not become red on the addition of nitric acid. a. Soluble in ammonia, not crystallizing when evaporated ; in- soluble in carbonate of potash; dissolves without effervescing in nitric acid, leaving a lemon-colored residue; soluble in strong sulphuric acid, not precipitated by dilution. I). Soluble in ammonia, crystallizing in six-sided plates when evaporated; soluble in strong caustic potash; the solution when boiled for a few moments, on the addition of a drop of dilute ace- tate of lead, gives sulphuret of lead. c. "With difficulty soluble in ammonia, not crystallizing ; with nitric acid becomes bright yellow; solution in caustic potash pre- cipitable by acetic acid in an amorphous form ; emits an odor of burnt feathers on ignition. B. Not destroyed by heat ; non-combustible ; leaving a considera- ble residue. 1. Soluble with hydrochloric acid; effervesces before heating ; soluble in mineral acids with effervescence; solution in acid when neutralized gives a precipitate with carbonated alkalies and oxalate of ammonia ; soluble in dilute acetic acid with effervescence. 2. Soluble with hydrochloric acid; effervesces after heating; soluble in mineral acids without effervescence; solution in acid when neutralized gives a white precipitate with carbonated alkalies and oxalate of ammonia; insoluble in acetic acid ; decomposed by strong sulphuric acid, yielding carbonic acid and carbonic oxide; and when boiled with carbonate of soda, oxalate of soda is found in the solution and precipitated by chloride of calcium. 3. Soluble with hydrochloric acid ; do not effervesce either before or after heating. a. Solution in acid with excess of ammonia gives a white crys- talline precipitate; with half its bulk of phosphate of lime (bone- earth) is very fusible before the blowpipe, and gives off an ammo- niacal odor ; dissolves in acetic acid without effervescence. h. Solution in acid with excess of ammonia gives an amorphous precipitate; with twice its bulk of phosphate of ammonia and magnesia is very fusible before the blowpipe. c. Solution in acid with excess of ammonia gives a white, partly crystalline, partly amorphous precipitate; without addition easily fusible before the blowpipe. 4. Not acted upon by acids or alkalies; fused with twice its bulk of carbonate of soda forms glass. Uric acid. Urate of Ammonia. I Uric or I Xanthic oxide. J (Cystic oxide or Cystine. Fibrinous. Carbonate of Lime. I Oxalate of ! Lime. Phosphate of I Ammonia and Magnesia. Phosphate ot Lime. Mixed Phosphates. Silica. Calculus in the bladder is a complaint which affects all ages and both sexes, but by no means equally. Males are far more liable to be affected than females at all periods of life. This seems due chiefly to the differ- ences in the urethra of the two sexes : for although at a late period of life we could suppose that differences in habits might account for it, yet no such cause can be imagined in infancy, where, however, the exemption of females is quite as striking. And renal calculus, which is the first stage of most cases of vesical calculus, is common enough in the female. The cause of stone is at present unknown. It is far more common in some parts of England than in others, and far more common in some foreign countries than in any part of England ;^ but the reason for the ' So frequent is it in the Northwestern Provinces of India, that I have been assured by a surgeon stationed there that he has operated eight times in the same day. SOUNDING FOR STONE. 807 difference is not apparent. If there is any determining; cause in either tlie air, water, diet, or habits of the natives of the affected districts it has not as yet been satisfactorily pointed out. Sedentary habits, indulgence in acid intoxicating drinks, and all other causes which favor the deposit of uric acid or oxalate of lime in the urine may, of course, lead to their deposit in such quantity as to form a stone. Phosphatic stones also form in the kidney under any conditions which increase the elimination of phosphates, and in the bladder from any inflammatory condition, espe- cially when a nucleus is present on which the phosphates may be deposited ; but why stone should form in little children who seem to have no reason for any such formation, why it should be so comparatively common in the children of the poor and almost unknown in those who are better fed and tended, and why it should prevail among children in one district while it is hardly ever seen amongst those similarly circumstanced and fed in another part of the country, are questions to which no answer has as yet been given which has commanded universal assent, or which has assumed any practical imi)ortanoe. Syv^ptoms. — The symptoms of stone in the bladder are very much the same whatever the composition of the stone may be, though the rougher and more angular the stone, the more pronounced will be the symptoms. They are pain in making water, referred especially to the end of the penis, and causing children to be always pulling the prepuce, so as to produce considerable elongation of it. There is usually pain on making any active exertion, such as running or jumping, or jolting in a carriage, though this is not always the case ; and pain is often absent in cases of ver}^ large stones. Blood in the water is, I believe, a symptom always present at some period or other of every case of stone, though it may, of course, be absent at the time when the case is under examination. There is often a good deal of straining at stool, leading to prolapsus of the rectum in children. Many of these symptoms, however, may be produced by mere irritation of the bladder, and the evidence of the sound is necessary be- fore we can pronounce definitely on the presence of stone. And even this is not always conclusive. There may be a stone, but from some accidental implication in the walls of the bladder, or from its being con- tained in a cyst (as in Fig. 375), the sound may fail to strike it. The latter is a very rare complication, but the former is common enough. We constantly see patients who Imve been sounded, and the surgeon has felt the stone ; but on proceeding to operate he cannot feel it. Believing that either the stone has been passed by the urethra, or that he has made a mistake, he puts off the operation, and the next time, or even after several such trials (I have known as man3' as five), the stone has been felt and removed. When therefore the symptoms are well marked, the surgeon should not too confidently pronounce that there is no stone, merely because he cannot feel it. Again, there have been cases (and I confess it has occurred to myself, even when assisted by veiy able colleagues) in which the sensation communicated to the sound by some- thing lying outside of the bladder has so exactly resembled that of a stone that the bladder has been cut into and no stone found. This mortifying error is caused by the sound striking some point of bone, I believe generally the spine of the ischium, others say the sacrovertebral angle. Bearing this in mind, it is unsafe, I think, to operate for stone unless as well as the sensation the ring of the stone has been heard, or the stone has been felt (as it sometimes may) with the finger in the rectum. The ring or sound communicated to the instrument by striking a stone is of course decisive. It varies in loudness. When a large hard stone (as 808 CALCULUS. of uric acid) is fairly struck with tlie point of tiie sound it rings so loudly as to be audible at a good distance ; wlien the calculus is soft and phos- phatic, or the sound cannot be moved freely in the bladder, the ring will not be so distinct. A few words may be useful about sounds. The in- strument in common use is a solid polished steel bougie, the shape of a common catheter, made in one piece with a smooth flat handle. It has the disadvantage that in consequence of its comparativel}' large curve, the point is directed so far upwards that it may ride over the stone and fail to strike it ; especially if there be any enlargement of the prostate, behind which the stone lies in a kind of pouch. Then again it is often desirable, if the stone has not been hit at once, to vary its position by emptying the bladder, or on the other hand to distend the bladder with water and so disengage its walls from the stone. All these desiderata are accomplished by the beaked catheter-sound. This is a catheter with a small bore, and an enlarged or " lobbed " extremity. It has the length and the curve of a lithotrite, i. e., it is straight till within about 1^ inches of its end, where it is turned up, so to form a "beak." There is a stop- cock near its handle, and the handle itself is a sort of flat shield on which the flnger and thumb can easil_y rest, and can accurately appreciate sensa- tions from any object which the beak may touch. The smallness of its shaft as compared with its end render it much more movable in the urethra and neck of the bladder than the common sound is. If introduced with the stopcock closed it acts as a common sound, but its small end can be more easily' applied to ever}' part of the bladder, or can be reversed so as to feel behind the prostate. By opening the stopcock it is converted into a catheter, and as the bladder is emptied the stone often drops down and the sound touclies it, and then if the surgeon thinks right an inject- ing syringe can be applied and tlie bladder filled to distension and care- fully investigated. Calculi are often numerous, and it is very desirable to ascertain if possible with some approach to precision what the size of the stone is, and whether there is only one or several in the bladder. An experienced surgeon will usually form a tolerably correct idea of the size of a stone from striking it, and examination with the sound will sometimes enable him also to guess at the presence of more than one stone, but the only sure way to ascertain either of these particulars is to sound with the lithotrite. By catching the stone in one or two positions an accurate idea of its size is obtained, and often the surgeon having one stone in the grasp of the forceps can distinctly ascertain the presence of another. The endoscope, a tube illuminated by a lamp at its extremit}' and closed by a piece of glass, was introduced some 3"ears since as a means of look- ing down the urethra, and seeing the face of a stricture or the wall of the bladder, and some surgeons have professed to be al)le thus to determine the presence, nature, size, and number of foreign substances in the blad- der ; but the dilliculty of the investigation is so great, and the portion of tissue seen at one time is so minute, that I believe I am not wrong in saying that the endoscope is now generally disused. Terminalions of Stone. — If the symptoms of stone be allowed to per- sist unrelieved the patient usually dies from general disorganization of the urinary organs, the result of obstruction and inflammation ; sometimes from pyajmia brought on by phlebitis of the veins around the prostate; sometimes by ulceration and perforation of the bladder.^ In any case, ' Stones have been known to travc:l by ulceration tli rough the bladder into the scrotum or perineum, from which they have been extracted by an incision. LATERAL LITHOTOMY. 809 the mode of death is a very painful one, and it is desirable to attempt the removal of the stone even in cases where the surgeon feels that there is but little chance of success. Operations for Stone. — Two methods only are at present known for I'eraoving calculi. Chemical solvents have been sought for ceuturies ; sometimes it has been believed tliat the discovery has at last been made; the electric current also, it has been imagined, might be used for their disintegration ; but hitherto all such plans have failed, and though it seems most probable that ultimately stones will be dissolved iu the bladder, we have at present to deal with lithotomy and lithotrity. Comparison. — The preference of one method to the other is regulated on some such general rules as these : 1. In male children litliotomy is very successful ; lithotrity, on the con- trary, is not ver}' appropriate, in consequence of the small size of the urethra, and the irritability of the bladder. Hence most surgeons re- ject lithotrity absolutely in childhood, and if it is ever to be practiced it should be only when the stone is judged to be so small that it may easily be pulverized at one sitting. B3' childhood I mean any age up to fifteen. 2. Lithotrity is not to be recommended in cases of tight stricture. It is true that if the symptoms are not urgent the stricture may tirst be cured ; still, stricture is often associated with an irritable condition of the urethra and bladder, highly unfavorable for the success of the crush- ing process. In slighter cases of stricture there is not the same ob- jection. 3. Lilhotrit}- has no chance of success in patients suffering from ex- tensive renal disease. It is true that such patients usually die after litliotom}', but if it is judged necessary to perform any operation at all, lithotomy is on the whole the best. 4. In cases of very large or very numerous stones the lithotrite may perhaps not have room to work. Such cases must be dealt witli by lithotomy, and even when the stone does not fill the bladder, but still is so lai-ge that it would require numerous sittings, and the patient is at all irritable, it is doubtful which is best. The composition and hardness of the stone become now questions of much importance, since a large con- cretion can be rapidly' broken up if it consists chiefly of soft phosphates and the do'bris will pass with but little pain, whereas a uric acid or oxal- ate of lime stone is broken into sharp fragments, many of them of con- siderable size, very apt to lodge in the urethra or to inflame the coats of the bladder. 5. Iu the female, as a rule, lithotrity is easy if the stone be small, but in larger concretions, and in the case of children, lithotomy may become necessary. Lateral Lithotomy. — The operations of lithotomy are numerous. The one in almost universal use in England is the lateral operation, which accordingly I shall first describe. The pei'ineum is to be shaved if necessary. The staff is then to be passed, and the patient is to be drawn to the edge of the table with the buttocks slightly projecting over the edge, the feet aud hands secured together, the hand grasping the dorsum of the foot. Thej' are secured either with the garters or shackles.' The kuees are held apart, the pa- ^ The " liihotomy position " is used in many operations on the genital organs both of the male and female. Three methods are in use for maintaining the patient in this attitude, i. e., in the sitting posture with the feet grasped in the hands, and the knees widely separated. L The lithotomy garters, two bandages of some firm webbing 810 CALCULUS. tient's bod}' kept quite perpendicular to the table, the staff held vertical by a steady assistant, with its point well in the bladder, and if possible restino: on the stone. Then an incision is made from the left side Fig. 365. A dissection of the perineum, showing the position of the bulb of the urethra and the floor of the ischio-rectal fossa. (After Pirrie.) The incision in lateral lithotomy is commenced just over the bulb, but the operator makes that part of the incision superficial, so that the bulb and its artery- escape. He divides the floor of the ischio-rectal fossa (the anterior fibres of the levator ani), and reaches the membranous part of the urethra, as shown in the next figure. of the central point of the raphe to the point midway between the anus and the tuber ischii and drawn backwards into the ischio-rectal about eight yards long and terminating in a loop. The whole bandage is first passed through the loop, and into the loop so formed the forearm is passed, and it is drawn tight. Then the hand is made to grasp the foot and the bandage is wound around them in successive turns of figure of 8, and the end firmly pinned. 2. The " shackles " consist of a h'ather footpiece securely laced over the ankle, and a leather band around the wrist. To the footpiece is attached a ring and to the wristpicee a hook. The pieces are put on while the patient is taking the anicsthelic, and when he is insensi- ble he is put in proper position, and the hook passed into the ring. 3. Mr. Clover has lately invented a very handy crutch — a piece of iron about a foot long, ending at either side in a bend, to which a strap is attached. The thighs being Hexed on the abdomen and abducted, are supported by the bent ends, and prevented from moving by the straps, and thus are kept bent and open. Of the three plans the shackles are much superior to the lithotomy garters, bfing less troublesome to apply iind more secure from slipping. Mr. Clover's crutch is very easily and quickly ajjplic^d, and answers its purpose very well ; but does not, I think, keep the patient quite so steady. When none of these apparatus is at hand common bandages will do very well, ap- plied like the lithotomy garters. LATERAL LITHOTOMY. 811 region as far as is judged necessary. This incision should divide the skin and superficial parts. The surgeon then puts his left forefinger into the upper angle of the wound, deepens the incision till he can dis- tinctly feel the groove of the staff, puts the point of his knife into the groove, and then pushes the knife on till it reaches the bladder. Having reached the bladder he withdraws the knife, enlarging the wound a little as he does so, by lateralizing the edge of the knife and pressing it a little on the parts. Then he pushes his left forefinger along the concavity of the staff till it reaches the bladder, which it will do if he have made the wound free enough. Having placed his forefinger on the stone he with- draws the staff, and passes the forceps along the upper side of his finger. When the forceps have reached the bladder he opens them, and then a gush of urine occurs. The stone is often thus carried into the grasp of the forceps, otherwise it must be caught by them (taking care that the coats of the bladder are not caught also) and withdrawn in the axis of the pelvis. If the stone is not very large there is no difficulty about this ; but if it is, gradual dilatation of the wound with the stone and forceps by a sort of corkscrew motion is necessary. After the stone has been removed the bladder should always be carefully searched to see whether there is another. A few words about each step of this operation is necessary. In the first place it is essential that the stone should be felt with the staff itself upon which the surgeon is to make his incision. It is not Fig. 366. The second step of the operation for stone. The knife entering the groove of the stafF in the mem- branous portion of the urethra. — After Pirrie. enough that a calculus has been felt on a previous occasion, nor even with another instrument while the patient is on the table. In order to 812 CALCULUS. be certain that the stone is really present and the staff" properly lodged in the bladder, the stone shonld be struck with the staff itself. As to the shape of the staff there are different fashions. Most sur- geons use a staff" of the same shape as a catheter. At Guy's Hospital, the "straight" start'(which, however, is not accurately straight), is preferred, the supposed advantage being that there is less risk of the knife slipping out of the groove. But as tliis ought never to happen in careful hands, and the straight staff" is more diflicnlt to find in the perineum, I fail to see any advantage which it has ; nor can I see the necessit}'^ of making the groove on the side, instead of in the centre of the staff. The rectan- gular staff" was for some time in favor with some good surgeons, but, I believe, is now generally disused. It has the great drawback of being very awkward to pass and very liable therefore to make a false passage, a drawback very imperf"ectly counterbalanced by its one advantage, tiiat its angle is easily found in the perineum.^ As for the position of the staff" in the bladder, some surgeons direct that it should be inclined to the left side, in order to pi'esent its groove more readily to the operator. This seems to me a matter of indiff'erence ; the main point is that it shall be steady and not slip out of the bladder, and this, I think, is best se- cured if the assistant liolds it vertically, hooking it against the pubes. The main dangers in the operation are as follows : Danger)^ of the Operation.— There ma}^ be unavoidable haemorrhage from some unusual distribution of the arteries. This proceeds generally from the internal pudic furnishing an accessory internal pudic, instead of bifurcating in its usual position under cover of the ramus of the ischium, or from an abnormal course of the artery of the bulb. Again, ver}' free hfemorrhage may take place in old persons from the veins about the prostate and neck of the bladder. The only thing that can be done is to tie any divided artery if possible, or if the vessel cannot be secured to hasten to complete the operation, and then plug the wound with "the petticoat plug," i.e., a large catheter or tube passed through a piece of stout clotli into which a quantity of lint is pressed sufficient to fill and make considerable pressure on the sides of the wound. Avoidable luem- orrhage proceeds generally from the artery of the bulb if the wound be deepened too much at its front part, for it must be recollected that the incision commences over the position of the arterj^ But in children this artery is so small that its division is of no consequence, in fact, I believe, that it is almost always divided. It is said that the internal pudic may be cut if the incision is extended too far outwards ; but this seems im- possible if the artery occupies its natural situation, and probablj'^ in the cases in which this has liappened the artery has been abnormal. The great danger in lithotomy is, that the urethra should be broken across and puslicd before the finger into tlie pelvis ; or that the knife should leave the groove of the staff", and so the incision be m:ide not into the bladder, but between it and the rectum. In either case the surgeon does not reach the bladder, and I have seen cases in which an inexperienced lithotoniist under tlicse circumstances, believing that he had reached the bladder, witlidrew the staff", and in one case was obliged to give up the operation altogether; in another, completed it by the help of a senior colleague, but with great risk and difficulty. This is avoided by making the inci- • If the rectangular staff is ever to be used, the apparatus invented by Dr. Buchanan should be employed. In this aii})aratu.s aflcr the stafl" is lodged in the bladder a di- rector is fixed on to it which t(!rminatcs in a point. This point pierc(^s the perineum and is r(!ceived into a hole in the angle of the; staff. The surgeon has now nothing to do but follow the groove of the director straight into the bladder. LITHOTOMY. 813 sion into the staff free enough to admit the finger, and never letting the point of the knife quit the groove as it is being pushed into the bladder, nor taking the staff out till the finger is in actual contact with the stone. One of the great difficulties in lithotom}' in little children is to make the incision large enough to admit the finger without wounding the rectum or other parts around. Much has been said as to the danger of incising the whole of the prostate and thus laying open the cellular tissue l)eneath the rectovesical fascia, whereby it is supi)osed the urine from the bladder is admitted into the meshes of the cellular tissue, infiltrating it and pro- ducing diffuse cellulitis. This doctrine rests on high authority, yet it has been much questioned. In childi-en the whole prostate must neces- sarily be divided, for tho gland is too small to allow an entrance to the bladder otherwise ; yet children never suffer from the diffuse sui)puration which is supposed to be the result of such division. And as Sir H. Thomi)son has justly observed, the effect of the passage of an irritating fluid like urine over the fibres of the cellular memiirane would be to close the interstices between the fibres, not to open them.' It is, no doubt, prudent not to carry the deep incision farther than is absolutel}' neces- sary ; yet it appears to me safer in the case of large stones to make a sufficient incision than to lacerate the prostate and the neighboring tis- sues, as is often done in such cases. For small stones, a very moderate incision, dilated by the forefinger, suffices; for larger calculi, a freer cut is required, or if the stone sticks in the incision a blunt-pointed straight bistoury may be passed along it, and the constricting parts nicked here and there. When the finger is placed on the stone, the latter may be so small and smooth as not readily to be grasped by the forceps. The scoop is then very useful. This is an instrument exactly resembling a small spoon with a very long handle. It is slipped under the stone, which is held in it by the forefinger. When the operation is over some surgeons always pass in a straight tube which is tied in ; but this is not necessary, except in order to repress lu^morrhage, as stated above. The rectum is to be unloaded before the operation, and will then almost certainly escape injury if the surgeon is moderately dexterous. A gentle purge should be given on the second night before operation, and the lower bowel should be complete!}' emptied by an injection exhibited about eight hours before the operation. This will both unload the bowel and prevent the patient being disturbed for a day or two afterwards.'' If it should happen that the rectum is injured the wound in it should be united if pos- sible, and may very probably heal, otherwise the resulting fistula is very intractable (see below). The after-treatment is very simple. The urine runs into some tow or carded oakum placed beneath the patient and frequently changed ; and if he is irritable, he is to be kept tolerably under the infiuence of opium. Causes of Death after Lithotoviy. — The main causes of death after lithotomy are pyaemia, hfemorrhage, peritonitis, diffuse inflammation, and 1 The student must recollect that the " cellular" tissue, though capable of being distended into cells or spaces, yet in the living body contains no such spaces — all its fibres are in close contact, and the old term "cellular membrane" is far more ex- pressive of its real condition. 2 In children the rectum often protrudes during the operation. This gets it more out of the way, and the advice usually given to repress the prolapsus is undoubtedly wrong. 814 CALCULUS. sinking from renal disease. The operation, particularly when protracted, as in the case of very large stone, may prove fatal by the immediate shock. The danger of the operation depends mainly on three things: the state of the general health, and especially of the urinary organs ; the age of the patient, and the size of the stone. In persons of almost any age, -who are of sound constitution, aud in whom the kidneys are healthy and the bladder not extremely degenerated, lithotomy is a very successful operation. In children death is very rare; the small proportion (about 5 per cent, on an average) wlio die being chiefly weakly infants exhausted by previous suftering or laboring under visceral disease. But when the stone is of large size, and there are evidences of very acute inflammation, that inflammation has usually extended to the ureters and kidneys, and any slight injury would probaV)ly prove fatal, still more, the formidable oper- ation by wliich alone a large stone can be removed. The inference is that no delay is admissible in cases of stone. When the symptoms become more accurately known to the public, and the necessity of seeking com- petent advice at an early period is generally recognized, stones will be disposed of when of small size by lithotrity, lithotomy in the adult will become an even rarer operation than at present, and stone will be only rarely a cause of death. Becto-vesical, or Recto urethral Fistula. — After the operation for stone, a fistulous communication may be left either with the bladder or urethra. The latter is far more common, for the wound in the neck of the blad- der generally heals, and the patient regains the power of retaining his urine ; but it passes into the rectum and becomes a source of constant annoj'ance and irritation. Recto-urethral fistula occurs also (as mentioned above) from prostatic abscess, though rarely ; and I have known it follow on too free incisions for anal fistula. The cure is by no means easy. If the catheter can be passed into the bladder without going into the rectum, the urine should be drawn off in this way every time the patient wants to make water ; and a few weeks' perseverance in this treatment may be successful — the edges of the fistula being stimulated with the tinct. lyttae or the galvanic cautery. But unluckily, it is only in rare cases that this can be done. A plastic operation is then necessary and, of all other plastic proceedings, seems to me one of the most disappointing. It may be performed in one of two ways. The patient (under chloroform or not) is placed in the prone position with his legs separated and hanging over the table. A duckbill speculum in the rectum exposes the fistula, which is to be pared and its edges united, and a catheter passed into the bladder and kept open, so that the urine shall flow out constantly. If this fails the surgeon may lay the parts freely open into the anus, endeavor to separate the urethra from the rectum, and unite the tissues over a cathe- ter passed into the bladder, so as to close the urethra and leave the rectal wound to granulate. I have, however, treated, and seen others treat, these fistuUe after lithotomy, and, I confess, with very little success. Mecliav Lithotomy. — The lateral operation appears to me to be the best suited for all ordinary cases. In some instances, however, where the stone seems impacted in the urethra or neck of the bladder (as seen in Fig. 377), the median operation, which often bears the name of Mr. AUar- ton in consequence of his having revived it, and recommended its general adoption, may be preferred, and it is also an easy and ready way of re- moving small stones in childhood. A grooved staff" is passed into the bladder ; the left forefinger in the LITHOTOMY. 815 Fig. 3G7. rectum feels the groove just as it disappears in the prostate gland. The surgeon plunges the point of his knife into the groove, at or near this point, holding the edge upwards and taking care not to perforate the rectum. He pushes the knife on a little way so as first to nick the prostate gland, and with- draws it, making at the same time a free division of the raphe of the perineum, leaving a conical wound at the bottom of which the groove of the staff is ex- posed. A director is then passed along the groove of the staft' into the bladder, and when the stone lias been felt with this director the staff may be withdrawn. A pair of dilating forceps are passed along the director, and the wound di- lated until the finger passes into the bladder, when the operation is completed in the usual way. Other Methods of Perineal Lithotomy. — The aim of the operation is to avoid the danger, or supposed danger, of in- cising the prostate. Its drawback is the difficulty of removing anything like a large stone through the wound without a most injudicious amount of violence. Other surgeons join with a lateral or median incision of the perineum inci- sions into the prostate gland, made by means of a lithotome, which is a bistOUri lithotomy was performed, the incision being cache with one or two blades, made to "^"^^ '" '''' "'^'^'^° ""^' '"■ '"^ P'^""''"™ project at different angles so as to incise both lobes of the prostate horizontally (Boyer); or with a curvilinear incision on each side (Dupuytren) ; or horizontally on one side and obliquely on the other (Senn) ; or obliquely upwards and down- wards on both sides (Vidal de Cassis). Such operations are known as bilateral lithotom}-. Others, again, make the incision in the middle line of the perineum while incising the prostate with the knife in various directions. But these operations are little if at all practiced in this country, experience having shown to the satisfaction of the great majority of surgeons that the lateral operation is. on the whole, the best ; as affording more room than any of the others if the stone be large, and being equally safe, if not more so, when it is small. It is true that it has its difficulties and dangers, but they seem, on the whole, less than those attending on the other methods. Rectal Lithotomy. — It remains to speak of two plans which are occa- sionally resorted to, viz., rectal lithotomy, and the hj'pogastric or high operation. The rectovesical operation is now only used in this country as a last resource, when the stone is too large to come through the ordi- nary incision, and the operator cannot break it,^ and consists merely in A bladder displaying several large sacculi, and a large wound, the result of the operation of lithotomy. One of the sacculi was about half as large as the bladder itself. The preparation was taken from a hospital patient, 43 years of age. He had for many years passed sand with the water. He had latterly been unable to retain his urine. A stone was detected, and the operation of A stone of great size was found fixed near the neck of the bladder. As it could not be got out entire, it was broken up in its posi- tion with strong forceps,and finally extracted. The fragments of stone weighed 31 drachms, 16 grains. He gradually sank, and died on the third day after the operation. — Museum of St. George's Hospital, Ser. xii, No. 40. ^ See a case by me in vol. xxv of the Path. Trans. 816 CALCULUS. extending the incision into the rectum as far as is judged necessary. Tliis may sometimes be tlie operator's duty ; but in a case which I once saw, and which, in other respects, was quite successful, a fistula was left between the urethra and rectum which could not be closed. The old rectovesical operation (which was, I believe, frequently adopted by Mr. Lloyd, of St. Bartholomew's Hospital) was commenced in the rectum. It resembled the median operation to some extent, but the surgeon, in- stead of plunging his knife into the urethra in front of the prostate, passed it with his left forefinger into the rectum, pierced the wall of the rectum and urethra or neck of the bladder, and then cut outwards in the middle line, through the external sphincter and perineum. The Hi/pogastric Operation. — The hypogastric or high operation is only used in this country when the stone is believed to be too large to be ex- tracted through the perineum, or when the pelvis is too rickety. The blodder should be filled with water in order to distend it and push away the peritoneum as mucii as possible. Then the linea alba is to be divided for an inch or more above the pubes, and the dissection carried cautiously down until the point of the staff is felt, when the bladder is to be care- fully drawn up into the wound and opened, the stone extracted, and the wound left to itself. The main danger is that of wounding the peri- toneum. In one case, at which I assisted, the peritoneum came down so low, and the bladder could be so little distended, that it was only possible to avoid that membrane by incising the parietes in a cruciform instead of mereh^ a vertical direction. The patient, a rickety infant much ex- hausted by his sufferings, ultimately sank from exhaustion. Perineal Lilhotrity. — In cases where the stone is too large to be ex- tracted, it must be broken down by a kind of lithotrite or forceps before its fragments can be brought out of the wound. Various contrivances have been invented for this purpose, and it is well to have an instrument of the kind at hand when the stone is suspected to be very large ; but operations on such complicated cases are rarely successful. Lately Pro- fessor Dolbeau, of Paris, has introduced, as a substitute for lithotom}^ in general, an operation which he calls " perineal lithotrity." As this operation has not yet obtained a recognized place in surgery, I cannot describe it minutely. It consists in making a small median opening into the membranous part of the urethra, dilating successively the external incision — the urethral opening — the deeper part of the urethra — and the neck of the bladder — seizing and breaking the stone — extracting the pieces and carefully washing out all ddbris. The operation requires pecu- liar instruments and various precautions, for which I must refer to Pro- fessor Dolbeau 's work. La Lilhotritie Perineale., or a short account b}^ Dr. Ewart in the Lancet for October 17, 1874. Lithotomy in the female is an operation of much less danger than in the male, the parts being so much more supeiUcial, but it is much more liable to be followed by incontinence of urine. It may be performed in many ways. A proceeding something like lateral lithotomy may be effected by passing a staff into the bladder and making an incision run- ning outwards through the upper wall of the vagina. Or the urethra may be incised directly upwards to an extent sufficient to allow of the passage of the finger and forceps into the bladder. It must be remembered that the female urethra is so distensible that in the adult, even without any in- cision, the finger can, under chloroform, be introduced, by dilatation and gradual pressure, into the bladder. In fact when it is difficult otherwise to detect a stone, a foreign body, or a tumor, this plan should be adopted. Vaginal lithotomy may also be practiced, the lower wall of the bladder LITHOTPwITES. 817 being laid open, and the incision sewn up at once, and the case treated as a vesico-vaginal fistula ; and this is on the whole the most appropriate operation in the adult, as involving less risk of incontinence than any other ; but most stones can be removed from the female bladder without any cutting operation. If they are too large to be extracted wliole, they can be broken with the litliotrite and removed in fragments, the uretlira having been dilated. Lithoirity is the operation by which the stone is broken to pieces in the bladder, and the pieces either extracted at the time through the urethra, or allowed to come away with the urine. I can only give a general sketch of the process, leaving all minute de- tails for special works on the subject. The lithotrite is a pair of forceps. Fig. 368. The common screw lithotrite. The male blade is opened and shut by the lunated catch seen on the handle, and when the stone is firmly caught the screw is driven home. The female blade is usually perforated by a large opening (" fenestrated") in order to avoid the jamming of fragments in the blades. When it is intended to use the lithotrite as a scoop and remove the fragments this blade is not fenestrated. the shape of a catheter, only with a much smaller curved end, and curving more abruptly, one blade of the foi-ceps (the male) being received into the lower or female blade, moving in a groove by means of a handle, and shutting down by a screw. The object of lithotrity is to catch the stone between the two blades of the lithotrite, without injuring the walls of the bladder, and then, by forcing the male blade througli it, to fracture or crush the stone, and by Civiale's lithotrite. By turning the two little buttons on the handle horizontal, the male blade is detached from the screw, and made movable. When the stone is caught, the buttons are turned vertical and then the screw will act on them. repeating this operation break it down into pieces small enough to pass througli the urethra. The urethra should be pi'eviously dilated, if necessary, until it will Fig. 370. V. Thompson's lithotrite. The fluted cylindrical handle affords an easy hold for the surgeon. Pressure on the l)utton in the handle disengages the screw. The object of these newer forms of lithotrite is to enable the surgeon to grasp the stone and set the screw in motion, with less manipulation, i. e., less change of position of the hands, than in the common screw lithotrite. 52 818 CALCULUS. easily admit a large instrument, and it is better to ascertain beforehand that the passage of instruments is well borne by the i)atient. Then, the general health being ascertained to be good, and all other indications being favorable (see p. 809), the process should be commenced. It was always usual to inject a certain quantit}' (say 6 oz.) of water into the bladder. This is now often omitted as superfluous ; but if it is not done the surgeon ought at any rate to ascertain that his patient's bladder is full, i. t"., that he has not passed water for three or four hours previously. Fig. 371. The English, or Brodie's, method of lithotrity. The lithotrite has been passed to the base of the bladder and the stone allowed to fall into its grasp.— After Sir H. Thompson. The lithotrite is to be passed fully into the bladder before it is opened. Then there are two ditierent methods of catching the stone. Both are in use b}' most eminent and successful operators, and it seems clear to me that they are about equal in value. The most important matter is to acquire dexterity l)y constant practice in the method selected. The one which is commonly called the Knglisli or Sir B. Brodie's method, consists in sinking the closed lithotrite to the base of the bladder, when if the instrument be opened to its full extent the stone will usually fall within its blades, especiall}' if the patient's i)elvis be moved or slightly sliaken. The other method — the French or Civiale's — consists in feeling the stone LITHOTRITES. 819 with the lithotrite, as with a sound, and then geutl}^ inclining the instru- ment a\va_y from the stone sufliciently to open the blades, which are then to be applied to the stone. This may be necessary when the stone lies partly or entirely behind the prostate. When the stone is grasped, and the male blade securely screwed down on it, the lithotrite shouhl be moved a little way so as to make sure that it is free of the wall of the Ijladder, and then the instrument is closed and the stone crushed. When this has Fig. 372. The French or Civiale's method of lithotrity. The lithotrite is reversed to seize a large stone. — After Sir H. Thompson. been once done, there is generall}^ no difficulty in picking up and crush- ing other fragments ; but it is not prudent at first to proceed too far. As a general rule about three actions of the lithotrite will be enougli at first. If the patient bears the operation well, more may be done at subsequent sittings. The administration of chloroform or ether is not, ordinarily, necessary, since the operation, if dexterously done, does not give much pain ; but if the patient be nervous there is no objection to it. Some surgeons, and especially Sir W. Fergusson, have recommended the with- dravval of such fragments as can be extracted by means of a scoop ; but the general opinion is that it is on the whole better to allow the fragments to pass of themselves, and to avoid all manipulation which is not abso- lutely necessary. If the bladder is paralyzed, or if the surgeon from any cause is anxious to hasten the process, the ingenious apparatus devised by Mr. Clover ma}' be employed to remove the fragments from the bladder. It is figured and its action explained on p. 820 (Fig. 373). The sittings 820 CALCULUS. may be repeated at intervals of five or six days if there liave been no bad symptoms. In cases which do well the patient passes the stone in small fragments with little or no inconvenience, nntil ultimately the nucleus comes away, and his symptoms are relieved; but there is often a good deal of trouble in deciding whether there is a small fragment left in the bladder or not, and it is obvious that there ma}' be cases in which the detection of a Fir.. 373. Clover's syringe. The india-rubber ball is filled with water. This is injected into the bladder with the instrument vertical. Then the ball is allowed to expand, drawing the water and fragments of stone up to the eye of the instrument. The fragments fall into the glass receptacle by their own weight, and the process can be repeated several times without any risk. If a fragment too large to pass should full into the eye of the catheter itmust be dislodged before withdrawing the instrument. This is accomplished by passing the stem figured below the catheter. single fragment may be well-nigh impossible. Thus the bladder may be fasciculated as in Fig. 374, and it will be easy for a fragment to slip into one of the pouches between its muscular fibres, where it will be very difficult to strike it. For the purpose of disengaging such fragments, the bladder is to be filled with a large quantit}' of water before searching in a doubtful case. Or it may even happen that there is a definite pouch in the bladder, as in Fig. 375, when the surgeon will naturally believe that he has removed Fig. 374. Fig. 375. '^&k^^'^'^ ' f Fig. 374.— a fasciculat(;d bladder, having in the interstices of the muscular coat a number of lithic acid calculi, some of which appear ti> be partly adherent to the coats of the bladder. From a prepara- tion pre-sented by Sir li. Brodie to the Museum of St. George's Hospital, Ser. xii, No. 30. Fig. 37.5.— Impaction of frai-'ments of calculus in a pouch of the bladder after lithotrity.— St. George's Hospital Museum, Ser. xii, No. 34. all the fragments, and the patient will suflTer from no symptoms except when the sloiie happens to (!scai)e from the pouch. Such cases are very difficult to treat, but they are rare ; and in ordinary instances there is no LITHOTRITY, 821 difficulty either in determining the presence of a fragment, or in detect- ing and crushing it. Sir PI. Tliompson says — " As long as an}- remain, there will almost in- varialily he pain in passing water, especially at the close of the act, wliile the urine ma}' be cloud}' and often tinged with blood, and quick movements of the body give pain. As long as these symptoms persist we may be assured some portions still remain behind, and these must be found." GompJications. — The bad s^ymptoms which sometimes follow lithotritj'- are as follows : 1. Inflammation of the bladder may be produced by unskilful manipula- tion, or even when all possible skill has been exercised, the cystitis previously existing may be ag- gravated either by the necessary operation, or by the sharp edges of fragments. This may run the usual course of CN'stitis and sub- side, leaving the patient in a con- dition to continue the treatment, or perhaps in the surgeon's judg- ment rendering a resort to lithot- omy prefei'able. 2. Enlargement of the prostate gland may cause much difficulty in passing the fragments, which will be detained in the bladder, irritating it and propagating in- flammation to the kidney's. In rarer cases the same effect is pro- duced by partial paralysis, or by atony of the bladder. 3. The plexus of veins which surround the neck of the bladder may be irritated and inflamed, and this may prove the starting- point of general pyaemia. I have seen pyaemia prove fatal in a chronic form, ca'cu in a case where the stone had been very small and had been entirely crushed and removed. A small ulcerated surface existed in the bladder, which had doubtless been produced by the stone it- self, as the patient had com- plained of acute pain for a long time before the operation, espe- cially after making water. But I have also seen pyoemia come on in the acutest form and prove fatal in a week. 4. The impaction of fragments kidneys were inflamed, large, and soft in texture, the is one of the most dreaded sequelae Pe'^is of the right being covered with lymph, and con- ^f li'f K/^f ..If XT ^^ ;^ 4-1,^ ^,,?,,;^., ^e taining a quantity of puriform fluid. On the external oi iitnotrity. it is tne opinion ot <• ^ ,, ■ , / ,, . ^ ■ ■ ■^ i surface of this kidney were some small cysts containing some 01 the best authors that this pus.-St. George's Hospital Museum, Ser. xii, No. 35. Hypertrophy of the prostate gland, the middle lobe of which projects into the cavity of the bladder. The bladder is thickened and fasciculated, and its mucous membrane was in astate of chronic inflammation. In the bladder was a stone, for which the patient, an elderly person, underwent the operation of lithotrity. The first operation passed off' well, but at the second, which was seven days after the first, he had a severe rigor, from which he never rallied, and died ten days afterwards. Some fragments of calculus, seen at the bottom of the figure, were found in the bladder, which had not been in the least injured by the operation ; the 822 CALCULUS. impaction hardly ever happens unless the urethra has been lacerated, i. c, that a fragment which is small enouo-li to pass into the urethra will be passed on by the walls of the canal if they remain perfect, however sharp its edges or angles may be. This does not of course apply to the meatus, which is much smaller than the rest of the urethra. It often happens that the nucleus or last fragment of the calculus lodges there, but this merely requires that the meatus should be incised and the frag- ment removed. The fact that impaction is far more frequent when the urethra has been lacerated constitutes a grave objection to the proposal to remove the debris in the lithotrite scoop immediately after crushing.^ When a fragment is impacted retention of urine and pain will be pro- duced. Retention, however, occurs, sometimes without any impaction. Sometimes the fragment comes so far forwards as to be felt from the sur- face, more commonly it is buried in the perineum. In the latter case, if the symptoms are not very urgent the warm bath and opium will some- times enable the patient to make water and bring the fragment forwards, when possibly it will pass without further trouble. If the fragment is lodged near the neck of the bladder, it may be gently pressed back with the lithotrite and crushed at once. If- further forward than the scrotum it may be extracted by means of the urethra forceps — an operation re- quiring great care, delicacy, and slowness of manipulation. In a very few cases it is necessary to cut down in the middle line of the perineum, when the surgeon will naturally consider whether he ought not to per- form lithotomy at once, and in still rarer cases he may have to cut into the urethra in the penis. 5. The other complications are of minor importance. Some amount of retention not unusuall}^ follows a first sitting; orchitis, or epidid^'m- itis, is not uncommon fi'om irritation of the ui'ethra after the passage of fragments. Rigors and "urethral fever" occur after this, as after all other operations on the urethra, but all these complications are to be treated on general principles. It will perhaps be best to close the section with the following " prac- tical hints" from Sir H. Thompson's work on Lithotrity. 1. It is occasionally desirable that the urethra be accustomed to in- struments before operating, so that the lithotrite, which it is necessary to employ, can be passed without causing much uneasiness, or any bleeding. 2. Always operate, whenever this is possible, without previously dis- turbing the bladder by injecting or sounding. 3. Having determined the position of the patient according to the ne- cessities of the case, slowly introduce the lithotrite, and take care that the blades reach or pass beyond the centre of the bladder before the male blade is withdrawn. 4. Execute every movement deliberately ; open and close, incline, or rotate, slowly, without any jerk whatever ; and all without bringing the blades into contact, as far as it is possible, with the walls of the bladder. ' Sir B. Brodie writes on this subject as follows : " 'Ihere are, however, some very grave objections to this mode of proceeding. The withdrawing of the forceps, if much loaded with calculous matter, stretches the urethra beyond its natural diameter, and, in so doing, not only gives the patient much pain at tiie time, but renders him liable to rigors afterwards; secondly, in four instances in which 1 had adopted this practice the urethra was torn, and an infiltration of urine into the surrounding tissues followed by urinary abscess, was the consequence Two of these patients in whom the mischief ])roduced was deep in the perineum, died, notwitlistanding the abscesses having been freely opcn(;d as soon as they were detected." — Med.-Chir. Trans , vol. xxxviii, p. 175. Sir H. Thompson speaks also to the same eflect. REMOVAL OF FOREIGN BODIES. 823 5. Maintain the long axis of the instrument in tlie median line of the body and the blades at or near the centre of the bladder, tliis being the area for operating mostly to be chosen. In screwing home the male blade to crush, it is especially necessary to keep the instrument stead}', to avoid much vibration of it or much lateral movement of the blades from its axis at each turn ; a small deviation at the handle produces a large one at the blades. 6. The position of a large stone is often very near the neck of the bladder. But the position of the stone varies much in different cases. When it is difficult to find or seize it, the reason usually is that the stone lies close to the neck of the bladder, so that the male blade, when drawn out, impinges upon the stone, instead of including it within the grasp of the instrument. It is necessary then to insinuate carefully, l)y a lateral movement, the male blade between the stone and the neck of the bladder. 7. When the stone is caught, especially if in the fenestrated lithotrite, rotate it a fourth of a turn on its axis before screwing up firmly or crush- ing, to make certain that nothing is included besides the stone. 8. Having broken a stone or a large fragment, the operator may pick up and crush piece after piece consecutively, without further searching, if he is only careful to work the lithotrite exactly at the same spot— the patient of course not shifting his position — since fragments fall imme- diately beneath the blades of the instrument, and rest there. 9. Never witlidraw a lithotrite loaded with calculous debris ; a moderate quantity will come away between the plain blades; but if an impediment is felt at the neck of the bladder on withdrawing, return to the centre of the cavity and unload them. This can always be done with a properly constructed lithotrite. 10. No sitting should exceed five minutes in duration, except under very peculiar circumstances. The large majority of sittings should oc- cupy onlj' three minutes, some less. The mere sojourn of a litliotrite, without any movement, for three minutes in the bladder, causes uneasi- ness, and often subsequent irritability, which may be considerable if the time is prolonged. 11. If the patient experiences an unusual amount of pain at the com- mencement of any sitting, it is wise to postpone it until another day, or make it very short. Such unlooked-for pain is a useful intimation that the urinary passages are not at this time in fit condition for our purpose, and by acting upon it, we may avoid serious mischief. 12. After the first sitting it is generally desirable that the patient should have hot fomentations to the hypogastrium and perineum, remain in the horizontal position, and pass liis water in that position if he can. He should remain tolerably quiet until the debris has passed, which usually happens within three days of the sitting. 13. The removal of debris by injecting and washing out the bladder is to be considered the exception to, and not the rule of, practice. Removal of Foreign Bodies. — The lithotrite, or lithotrite scoop, or some analogous instruments, may often be employed with signal success in the removal or foreign bodies from the bladder. The most common case is where the fragment of a bougie has been broken into the bladder. If the surgeon is called in at once, he may pick up the foreign substance, and generally with ease, and should the piece be small it may come away without any trouble. If large it may be cut into pieces, which will pass of themselves. If the case has been put off till a crust of phosphate has been deposited on the fragment, it must be treated like any other case of stone. 824 CALCULUS. More complicated foreign bodies generally require lithotom^r, for, even if they could be caught and crushed, the fragments would be very danger- ous to the urinary apparatus. Such cases are, as a general rule, very favorable for lithotomy, since there is no disease of the bladder or kid- neys (see page 249). Prostatic calculi have been spoken of incidentall}^ on previous pages. They form small and often Fig. 377. Very numerous concretions, con- taining a good deal of animal matter, but consisting generally of phosphate and carbonate of lime,^ sometimes almost entirely of the latter salt. These small concretions grow into the urethra, and often (I believe usually) do not cause any special symptoms, but they may occasion pain and irritation in making water, fre- quent erections and discharges of semen. In such cases tliey might be detected hy careful exploration wilh the sound and finger. Cal- culi also ma}' pass out of the A stone impacted in the neck of the bladder of a bladder and lodge in the prostatic child aged three. The stone seems to fill the prostat- nrethra, producing total Or partial ic urethra, but there is no history of complete reten- . ,• -, ,1 tion of urine, tbonsh there had'boen great difficulty I'eteutlOn, and a Calculus may in passing water for about eight weeks. The child grOW fl'Om the bladder iutO the was brought to the hospital to be operated on, when urethra (vesico-prostatic Calculus), thus dilatino: the neck of the blad- der and causing more or less in- continence. It often happens, however, that the urine can be re- tained, though not for any long symptoms of scarlet fever showed themselves and he died in a few days. The bladder is small and thick- ened, the ureters are dilated. There is some malfor- mation of tlie bladder, one side of it being much larger than the other, and from its apex projected a small elongated cyst (through which a bristle passes), which had every appearance of being a pervious por- tion of the urachus— From a specin)en in the Mu- period, although a CalculuS is pi'O- seum of St. George's Hospital, Ser. xii, No. 87. jecting OUt of the bladder. In the female, also, I have known a stone grow out of the bladder into the urethra, and produce incontinence of urine. Removal of calculi from the prostatic urethra by means of for- ceps is spoken of, and in the case of the small prostatic concretions it seems piiysically possible, and the attempt may be justifiable ; but in all cases in wiiicli the stone is known or believed to have a vesical origin it should, if possible, be pushed back into the bladder with a lithotrite, and crushed. If this is not possible, median lithotomy is indicated. Slonc in the urethra is a common cause of retention in boys. It is in all ordinary cases carried down from the bladder, though it is said that stone has formed in a pouch or diverticulum behind a stricture. The im- paction of a calculus does not necessarily cause retention, in fact, a smooth and small calculus may produce very few symptoms, its impaction being due merely to its being turned with its longest diameter across the urethra, and when it happens to turn the other way it will come out. But large and sharp stones or fragments of stone give rise to much suffering, and unless removed early much mischief will follow from abscess, extrav- asation of urine, urinary fistula, etc. In some cases the obstacle to 1 Their chomiciil composition, at'cnrdinif to Dr. WoUaston, is phosphato of lime 84.5, carbonsitc of iinio .5, iinimal iiuiIUt 15.0. EETAINED TESTIS. 826 the passage of the stone depends on spasm of the urethra, and relaxa- tion of this spasm by opium and the warm bath will prove successful. The patient should be directed to hold his urethra in front of the stone as long as possible while passing his water, in order to increase the force of the jet. If the stone be lodged far forwards patient and gentle attempts at extraction with the forceps will often succeed, especially if the stone can be manipulated so as to turn its long axis along the urethra. If they ilo not, and the stone is near the scrotum, it may be better to push it into the perineum and cut down on it there, though I must say that I have not seen the harm which some surgeons describe as resulting from cutting into the urethra in the penis. If a catheter is passed into the bladder, tied in and left open, the wound is pretty sure to heal. Stones impacted far back will not, probably, be extracted by the forceps. A free incision should be made on them, keeping the left thumb or forefinger pressed on the urethra behind, to prevent them from slipping into the bladder. CHAPTER XXXIX. DISEASES OF THE MALE ORGANS OF GENERATION. AFFECTIONS OF THE TESTICLE AND ITS APPENDAGES. Congenital Molformah'mis. — The congenital malformations of the tes- ticle with which we are concerned in practice relate chiefly to irregular- ities in the descent of the gland. The cases reported of multiple testi- cles seem to be apocryphal : cysts in contact with the testicle having been mistaken for additional testicles. There are cases in which the testicles are imperfectly developed or even entirely absent, though the patient retains sexual feeling and power. Such persons, however, are probably sterile. Their possession of sexual power is accounted for by the fact that the vesiculse seminales are present, being developed along with the vas deferens and epididymis from a different source. Retained Testis. — More common, however, and in a surgical point of view more important, is the retention of the testicle either in the abdo- men or in the inguinal ring. Such retained testicles do not, in the opin- ion of most pathologists of the present day, secrete seminal fluid, i. e.^ fluid containing spermatozoa, so that the patient is sterile, if both testes be retained, though there is no reason why he should be in any respect deficient in sexual power. When a testicle has only descended into the inguinal ring, or when it descends very late into the scrotum,' a portion of bowel very often ad- heres to it, and may easily become strangulated, especially, as in these cases, the internal ring is often very deep and narrow. And in other cases, though the testicle does not descend, the gut may come down into 1 Sir A, Cooper relates tliat he has seen the testicle descend as late as seventeen years of age, and Dr. Humphry speaks of a case as late as forty. 826 DISEASES OF MALE ORGANS. the scrotum, and, of course, may be strangulated there (see Fig. 296, p. 641). In all cases of hernia with retained testis, the first care of the sur- geon is to replace the hernia if possible. If the testicle adheres to the hernia and tlie latter is reducible, so that the replacement of the bowel involves the reduction of the testis also into the abdomen, or into the groin, this is a matter of but little importance, provided a truss can be worn and the risks of hernia obviated. Even if the pressure of the truss were to cause atrophy of the testis, this is not an objection to the prac- tice, since the testicle is probabl}^ useless from the beginning. But very often the hernia will be found irreducible, or the truss cannot be borne. In such cases a bag truss must be fitted. If an operation becomes necessary the surgeon will probably embrace the opportunity to remove the testicle, which is useless and in the way. Such retained testicles have not unfrequently been known to be the seat of cancer,^ and in other cases of hydrocele. Gonorrhoeal orchitis is pe- culiarly painful when the testicle is retained in the canal. There are also instances in which the testicle instead of descending into the scrotum has passed into the perineum, or even through the saphe- nous opening into the groin. The knowledge of these rare anomalies will be useful to the surgeon in examining cases of supposed hernia or peri- neal abs(;ess. In other cases the testicle is inverted in its descent, so that the cord lies in front of it, and the tunica vaginalis behind. This fact has its im- portance, as we shall see, in the practical surgery of hydrocele. The persistence of the funicular canal is a fact of as much importance in hydrocele as in hernia. The malformations of the penis derive their practical importance from the condition of the ui'ethra and bladder, and have been spoken of on pp. t68, 781. The diseases of the male organs may be divided into those of the tes- ticles, scrotum, and penis. Tlie vesiculae seminales might perhaps be added, but their affections are not well understood, and the diseases of the prostate are treated along with those of the urinary organs, with wliich they have a nearer connection than with those of the generative system. Hydrocele. — The diseases of the testicles will be first considered — of these perhaps the commonest is hydrocele, a collection of fluid in the tunica vaginalis, the result of over secretion or passive dropsy. No symptoms attend the formation of a hydrocele, so that any swell- ing in the testicle which forms painlessly and gives no inconvenience ex- cept that occasioned b}' its weight is suspected to be a hydrocele till proved otherwise. The forms of liydrocele are various, corresponding to the condition of the tunica vaginalis and its funicular process. In the ordinary condition the tunica vaginalis is entirely separated from the peritoneal cavity by the whole extent of the scrotum and ingui- nal canah It only covers the front and the sides of the testis, extending somewhat under the epididymis and around its head, but is reflected for- wards from tlie sides of that bod}^ so as to leave its posterior part free. Consequently, when this cavity is distended with fluid, which constitutes the common hydrocele, the swelling lies in front of the testicle and above it (Fig. 300, p. 643). The testicle may be sometimes felt at the back of 1 Dr. G. Johnson, Med.- Chir. Trans., vol. xlii. Mr. Hodgson, St. George's Hos- pital Keports, vol. ii. HYDROCELE. 827 the tumor; the scrotal cord is perfectly free. The collection of fluid is generally too tightly bound down to permit of the feeling of fluctuation ; it is commonly transparent, though often not so, in consequence of the thickness of the sac. It is pyriform, and if the patient is intelligent he will have noticed that it has begun from the bottom of the scrotum and extended upwards. When punctured a greenish or yellowish serum is drawn off, which is rich in albumen, so tliat it coagulates on the applica- tion of heat or nitric acid like the serum of the blood. The causes of hydrocele are not well understood. It is a common complication of chronic inflammation of the testicle (hydrosarcocele), and a certain amount of hydrocele also usually accompanies acute orchitis. Its inflam- matory origin is testified also by the fact that it is not infrequently re- ferred to an injury. Yet in most cases of pure hydrocele nothing of the kind can be traced. It is spoken of vaguely as a "• local drops}'," but cer- tainly has no connection or affinity with general dropsy. Diagnosis. — The diagnosis of this form of hydrocele from hernia is usually easy — in fact obvious — for, as the cord is free between the tumor and the external inguinal ring, no confusion between hernia and hydro- cele, or any other uncomplicated tumor of the testis or its coverings, is possible. But hydrocele, or any other scrotal tumor, ma}' be combined with hernia, as shown in the diagram above referred to ; and then in the part caused by the hj'drocele transparency will be found without impulse or reducibility, and in the hernia opacity with impulse and probably with reducibility. If tlie hernia is strangulated, the characteristic symptoms of that condition will demand the reduction of the bowel either by taxis or operation, and after this has been accomplished the nature of the tu- mor will become plain. But old hydroceles with a thick non-transparent sac are not so easily distinguished from solid tumors of the testicles ; in fact, are sometimes almost indistinguishable from them. I once assisted a surgeon of great experience in an operation on a case which I Fig. 373. had not seen before, where he proposed to remove the testicle on account of supposed malig- nant disease, which on incision turned out to be a simple hydro- cele; and I was once consulted in a similar case where, remem- bering this, I avoided the same error onl}^ by a puncture with a trocar after the patient had been prepared for the operation. So also with hfematocele, as to which tlie reader is referred to the section on that disease. The treatment of simple hy- drocele may be palliative or radi- cal. The latter cannot be de- void of pain, and involves some, though a very trifling risk. Con- sequentl}', man}' persons prefer to go on with the palliative treat- Tapping a hydrocele. After Listen. The probable ment, or, in plainer terms, to position of the testis is indicated by a dotted line. have the hydrocele tapped from time to time instead of attempting its cure. Tapping a hydrocele is a very 828 DISEASES OF MALE ORGANS. simple proceeding, though it is sometimes mismanaged. The back part of the scrotum is to be drawn backwards so as to make its front surface tense. A part of the skin is to be chosen free from large A'cins, and the trocar is to be plunged in boldl_y, inclining upwards, in order to avoid the testicle. This gives, it may be said, no pain, and after the swelling has been emptied the canula is withdrawn and a bit of strapping applied. When the fluid has re-collected to such an extent as to cause pain and dragging on the loins, this little operation may be repeated, or the radical cure may be undertaken. When the fluid has all been withdrawn, the condition of the testis must be carefully examined ; for before the empty- ing of the sac it is difficult, if not impossible, to be sure that the gland itself is healthy, and if it be not so it will be vain to try and cure the disease by any measures directed solely to the tunica vaginalis. In this, the common method of tapping a hydrocele, the testicle is supposed to be behind, as it is in ninety-nine cases out of a hundred. But there are rare instances in which the position is reversed, and the gland lies in front of the fluid. I once saw such a case in which a trocar had been twice thrust into the testicle in attempts to empt}" the hydro- cele. This reversal of the position depends on one of two causes : (1) The hydrocele may have been tapped, and in this operation the front surface of the testicle may have been punctured. In consequence of this the testicle contracts an adhesion to the front of the hydrocelic cavity, and when the fluid re-collects the testicle lies at the front of the tumor and the fluid laps round each side of it, so as to appear behind it, though this is hardly the case in strictness of speech ; or (2) the hydrocele may really lie entirely behind the testicle as a consequence of congenital peculiarity, for it seems that sometimes the testis gets twisted as it were in its descent into the scrotum, so that the epididymis and cord are in front of the gland and the tunica vaginalis behind it; and if in a case like this hydrocele should occur, it must, of course, be altogether behind the testicle. Such a position could not be detected if the tunica vagi- nalis were thick and opaque ; but in ordinary cases careful exploration by transmitted light will distinguish the position of the testicle, or the elasticit}^ of the part will convince the surgeon where fluid is to be found ; or palpation may elicit sensations in the patient which will enable him to point out the situation of the gland. Fortunately, if in an obscure case the testicle is punctured, no serious mischief usually follows ; the error, however, is a discreditable one when, as commonly happens, it is the result of pure negligence. Radical Cure. — The radical cure of hydrocele used to be effected by la3'ing the sac freely open, and this is sometimes still necessary in cases of obstinate recurrence. I have had occasion to perform the operation and to see it performed by others. It used to be prescribed to stuff the wound with lint in order to excite suppuration, but this is painful and superfluous. It is only necessary to keep the wound open by gently separating its lips when necessary and the cavit3^ will fill up. Injections, — Commonl}^, however, the injection of the sac suftices. The old plan was after withdrawing the fluid to fill the sac with port wine and water in equal parts (the French use alcohol and water in various propor- tions), and keep it in the sac till the patient felt a good deal of pain and began to feel sick and faint. Then the canula was opened and as much of the fluid as would run out was allowed to escape. The modern plan (introduced bj" the late Sir R.Martin) is less troublesome to the patient, and is usually effective, though, I think, less certain to cure the disease than the port-wine injection. Two drachms of an equal mixture of Tinct. HYDROCELE. 829 lodi and water are passed into tlie emptied sac and left there. Tlie effect of the injection of a liydrocele is always a smart attack of inflam- mation, the sac usually filling to the same size as before, and witli a good deal of redness of the skin and pain. But as this subsides the part re- sumes and retains its natural size, at least if tlie operation is successful. The tunica vaginalis is sometimes ol)literated by adhesions ; but this is not necessary for cure, and is believed not to be the usual result; though precise information on this head can hardly be obtained, since such operations never prove fatal and have been forgotten before the patient's death, even if his body is examined. Should the hydrocele recur after the iodine injection, as it sometimes does, the best plan is to inject it with port-wine or with sulphate of zinc lotion (gr. iv to 3J) used in the same way as the port-wine injection, and if it still recurs to lay it open; but in these cases very careful examination of the testicle should be made, to ascertain whether it really is a case of simple hydrocele. Seions are also used in the cure of liydrocele, but the silk seton seems to me a more severe measure than incision, and the silver seton is very uncertain in its action. I have seen it in some cases produce too little inflammation to cure the disease, and in others such violent symptoms as are out of proportion to the gravity of the disease, ending in fact in one unlucky case in death. The other forms of hydrocele depend on the condition of tlie tunica vaginalis and its funicular process in respect of their obliteration. Congenital Hydrocele. — When the whole funicular process remains open and the communication is not large enough to admit a piece of bowel, the serous secretion of the peritoneum ma}' distend the scrotal pouch and form a congenital hydrocele^ (Fig. 295, p. 641). Congenital is distinguished from common hydrocele by its shape and extent, and by the fact that the fluid can be returned, though often only slowly and with much difficulty, into the belly, and from hernia by its transparency^ (which, I believe, is almost, if not quite always present), and by the different sensation which the surgeon feels in reducing it. The treatment of congenital hydrocele consists in evacuating the fluid with a fine trocar and endeavoring to procure the obliteration of the patent canal by making continuous pressure on it near the external in- guinal ring by means of a truss, which should be worn night and day if possible; and as fast as the fluid reaccumulates the puncture should be repeated. Most cases, I believe, ultimately recover. If not, the commu- nication will probably enlarge and hernia will ensue. In France it seems common to treat congenital hydrocele by injection with alcohol, pressure being maintained on the ring while the sac is being injected ; but the gravity of the disease seems hardly sutticient to warrant a measure which cannot be free from considerable risk. Infantile hydrocele is vei\y common. The tunica vaginalis and its funicular prolongation are distended with clear serum, but they are separated from each other by a septum at the external ring (Fig. 298, p. 643), so that the fluid will not pass into the peritoneal cavity whatever ' It must be recollected that this is not a necessary consequence of the persistence of the communication if it be very small, as shown by the case of Sir A. Cooper, quoted on p. 640. ^ It must be remembered that a hernia cannot under ordinary circumstances be transparent, since botli the viscera and the omentum, which form its contents, are themselves perfectly opaque. In very rare cases the hernial sac is dropsical or dis- tended with clear serum — " liydrocele of the hernial ssic." Such cases could only be distinguished from hydrocele by the impulse of the bowel in the tumor. 830 DISEASES OF MALE ORGANS. force be used ami however the canal may be straightened out; but very careful examination in this respect is necessary before the hydrocele can be confidently said not to communicate with the peritoneum, so easy is it to close a small communication by any folding over of tiie parts ; and then what is really a congenital maN^ easih' be mistaken for an infantile hydrocele. Infantile hydrocele generally disappears spontaneously or after the application of a stimulating lotion of arnica or hydrochlorate of ammonia or tincture of iodine to the skin ; or it may be punctured sub- cutaneously or otherwise. There is no objection to injecting such a hydrocele, but it is rarely necessary. Hiidrocele of the cord proceeds from the effusion of serum into an un- obliterated portion of the funicular process (Fig. 301, p. 643), or perhaps from the growth of an independent cyst in the cellular tissue of the cord. It is commonly met with in children or boys about puberty, and causes a small, round, tense SMelling in the course of the cord, separate from the testicle, and therefore easy to distinguish from common hydrocele or any tumor of the testis, and if also distinctl3- separable from the external in- guinal ring, equally eas}- to distinguish from hernia, and therefore unmis- takable. But as the cyst may extend up to or beyond the ring there is in such a case a very great resemblance to hernia ; so that I have seen a case of the kind treated for hernia at one of our truss societies. Careful examination, however, will show that the supposed hernia cannot be made to return into the bell}', though there is no strangulation ; that the impulse it receives is much less than a hernia would have ; and that it forms a small rounded swelling instead of a long tubular one ; and if the child be taken into a dark room, and the candle be dexterously arranged, trans- parency can usually be detected in spite of the smallness of the cyst and fatness of the part. There is then no further doubt. But if with a cyst situated so high up there should be any symptoms of strangulation, it would be right to cut down on the tumor and open it ; and, in fact, whenever there is any considerable doubt the same course may be justifi- able, rather than expose the child to the annoyance of wearing a truss unnecessarily. These cysts are easily curable by injection with a small quantity of tincture of iodine, say 5J of a mixture of equal parts of the tincture and water, or 5ss. of the pure tincture. I have also cured them by a silver seton, but with more inflammation and distress, and once by cutting the cyst across and strapping it. Besides these encysted hydroceles of the cord, which are common enough, diffused hydrocele of the cord is spoken of, forming a long, sausage-shaped tumor around the whole cord ; but if it occurs it is ex- ceedingly rare. Dr. Humphry saj's that no such case is known to have presented itself in modern times, and refers to the works of Pott and Scarpa for all that is known about it. Enci/Hted hydrocele of the testicle consists in the formation of a cyst in contact with the testicle itself and not with the cord. The usual position of these cysts is in the head of the epididymis, and they generally con- tain spermatic fluid. But they are found in other situations, as between the tunica vaginalis and albuginea ; and they may contain, not the milky fluid which results from the admixture of semen, and which i)resents sper- matozoa under the microscope, but the same nearl}^ watery secretion as is contained in the cysts of the cord. Their diagnosis from common hydrocele is formed either from their position, for they do not envelop the testicle like common hydrocele, but lie behind or at the side of it, like a double testis ; or from the milky or watery nature of their contents, HEMATOCELE. 831 which contrasts forcibly with the albuminous serum of ordinary hydrocele. The way in which semen gets into these cysts is not, perhaps, fully under- stood ; but there is no question that in many cases a distinct communi- cation has been seen between the cyst and the tubes of the epididymis; and even if we allow that in the cases where no such opening has been found there was really no opening, still it might have been present at one time, and then have become obliterated. In the watery cysts, how- ever, no such communication can at any time have existed. It seems on the whole most probable that these cysts originate in different ways, either as outgrowths (or buds as it were) from the tubes of the epididy- mis, the opening of which may or may not become obliterated, or as in- dependent formations in the cellular tissue of the cord, which afterwards may or ma}' not form a communication with its seminiferous tul)es. It has also been suggested, but on pure hypothesis, that they ma}' be over- developed remains of the Wollffian body which have not become con- nected with the testicle. A much more probable hypothesis is that put forward in a very interesting paper by Mr. S. Osborn in the St. Thomases Hospital Reports for the present year. He traces the development of these cysts to the " hydatid of Morgagni," a small C3'stic body which is always found between the testis and the globus major, and is the remnant of the Miillerian duct. The paper and the preparations depicted in it are well worth studying. The treatment is the same as that of common hydrocele ; but as the tumor is usually smaller and fills more slowly than in hj'drocele of the tunica vaginalis, there is less motive for undertaking the radical cure. Loose Bodies in the Tunica Vaginalis. — The cavity of a hydrocele sometimes contains a loose body. These, as Mr. Osborn points out, may be formed by the hydatid of Morgagni becoming degenerated into a solid tumor, much as an enlarged bursa does, and then dropping off its pedun- cle ; and Dr. Humphry (op. cit.., p. 106) has pointed out a similar process for the development of these movable bodies, and has given an interest- ing example of the recognition and removal of one of them during life by incision. In a case by Sir B. Brodie a patient who had one of these loose bodies used to complain of intolerable pain after the operation for tapping; and they often set up a certain amount of irritation, and no doubt either produce or keep up the eftiision of fluid into the tunica vaginalis. They should, therefore, always be removed when they can be recognized. I have no doubt that they ma}' arise from various causes, just as loose car- tilages do ; and their structure bears much analogy to that of the loose bodies in the joints. In Dr. Humphry's case the loose body, which was the size of a bean, was composed of "compact fibrous layers encircling an earthy nucleus." Hsematocele. — Common hjematocele is a collection of blood in the cavity of the tunica vaginalis. It usually follows on some sprain or injury whereby a vessel is ruptured on the internal surface of the membrane, and this is often the case when hydrocele is already present. The same thing happens sometimes in hydrocele of the cord and in encysted hydro- cele, which by some blow or injury becomes filled with blood, or converted into hfcmatocele. In the cord, however, this is so uncommon that I think it not worth while to spend more space upon it. In the tunica vaginalis it appears common enough. Hsematocele may be produced by a blow or a strain in the previously sound condition of the organ, giving rise to haemorrhage into the cavity of the tunica vaginalis, or by similar injuries, or the puncture of the trocar, in cases of hydrocele, and perhaps by spon- 832 DISEASES OF MALE ORGANS. taneous rupture of, or exhalation from, some vessel in the lining of the sac. The tumor has generally a somewhat more rounded shape than a hydrocele, is heavier, less homogeneous, part of it being knobbv and semi-solid, is perfectly devoid of transparency, and often accompanied by a dark color of the scrotum, due to blood sugillating into the subcu- taneous tissue. Diag)wsi>^. — The diagnosis is an3'thing but easy. It is hardly too much to say (at least I may say it for myself) that the surgeon can never be sure of the diagnosis of a hi\?matocele till he has punctured it. It ma}' be a solid tumor of the testis (perhaps inflammatory, but more probabl}^ malignant), or a hydrocele with a thick sac. The diagnostic signs are as follows: Chronic orchitis is generally accompanied by a more definite history of its causation than hematocele, i.e., it follows directly on acute orchitis or as the result of a blow-, the tumor having been always solid, and increasing gradually ; or after syphilis, with some other distinct syphilitic symptoms. Cancer of the testicle advances more rapidly', has a greater tendency to spread up the cord, and is accompanied with more pain. [I do not speak of advanced cases of cancer complicated with en- larged lumbar glands, where there is no difficulty in diagnosis.] Hydro- cele is wanting usually in the history of injury and of sudden increase to a certain size, at which when a hsematocele has attained it usually stops. But the reader will see at once that all these signs are dubious ; and an experience of the complexities of practice and the uncertainties of pa- tients' histories will enable him easih' to judge how^ dubious the}^ are. It is, however, more especially the early stage of cancer which bears the strongest resemblance to hematocele. Notwithstanding, however, the difficulty experienced in diagnosing hematocele, there are many cases in which the S3'mptoms and history point strongly to the correct conclusion ; and in any case w^here there is a real necessity for operative interference a preliminary incision will settle the matter, and can do no harm. Sometimes hematocele, if neglected, grows to an enormous size, pro- ducing atroph}' of the testis ; at other times the blood degenerates into a turbid, grumous mass, very like the contents of the small intestine.^ Treatment. — In ver}' old cases of hematocele probabl}' the safest and best course is to remove the whole tumor with the testicle ; but as a gen- eral rule it will be sufficient to lay open the tumor by a free crucial inci- sion, turn out all the clots, tie an}' vessels in the thickened tunic which bleed freely enough to require it, and allow the cavity to granulate up. At the same time it should be remembered that the operation is a severe one, and in old or unhealthy persons it should not be lightly undertaken. I have seen death follow it. It is said that cases of recent hematocele occur in which the absorption of tlie blood can be procured b}' rest, evaporating lotions, ice, etc. I have not met with such cases, nor with any in which the blood is entirely fluid and can be evacuated through a trocar like hydrocele, and in which injection might be tried, but am quite willing to Ijelieve in their occasional occurrence. Acute Orc/iitis. — Orchitis, or inflammation of the testicle, is divided into acute and chronic. If the word orchitis were construed so literally as to restrict it to inflammation of the body of the gland, excluding the ^ I once saw a surj^con on ojx-niiig a hannatocelo of this kind start back, fancying for a moment that he had laid open a hernia. ORCHITIS. 833 epiclidymis, we might say that acute orchitis is ahnost always caused by a blow, or by metastasis in mumps, since the familiar acute intlau)mation of gonorrhoea is properly epididymitis, but this is in ordinary language included in the term orchitis. The inflammation also wliich follows from impaction of calculus, after lithotrity, catlieterization, etc., is originally, like gonorrheal orchitis, situated in the epididymis. Gonorrho'cil orchitii^ usually occurs somewhat late in the disease, and often after the discharge has more or less subsided; whether it occurs from inflammation spreading up the vas deferens to the epididymis or from some nervous " sjmpath}'," the nature of which is obscure, is as 3'et undecided. It commences when in its severest form with rigors, sickening pain in the back and loins as well as in the testicle, heat and redness of the scro- tum, swelling and tenderness of the epididymis, and distension of the tunica vaginalis with serum and lymph. The body of the testicle be- comes more or less affected as the disease progresses. The inflammation appears to be at first seated in the intertubular connective tissue, after- wards the tubuli themselves become loaded with lymph. On the subsidence of the disease it seems not very uncommon for the tubuli seminiferi, and probably also the large excretory tubes of the vas deferens, to be choked up by this lymph, so that the testicle is left useless, and if both testes have been affected the patient is sterile,' though the testicles may not be wasted, nor the patient deficient in sexual vigor. Treatment. — The treatment of gonorrhoeal orchitis is now far less severe than it used to be. Yevy many cases are found to get perfectly well with no more active treatment than rest in bed, with the testicle wrapped up in a warm poultice.^ When there is much pain opium should be freely given. Leeches sometimes also relieve pain if followed b}^ warm bathing. Free purging is very desirable, and if much inflammatory fever be present antimony in moderate doses is indicated. In the initial stages when con- fined to the epididymis the disease may sometimes be arrested by care- full}^ strapping the part, according to Dr. Humphry. When the pain is gone, but swelling lingers, strapping is most beneficial if the pressure be well and equably applied, but this is an art which all people do not possess.'^ The application, also, of mercurial ointment below the strapping, or rub- bing in a small quantity of mercury, often removes the swelling. I never saw any need for puncturing the testicle, nor have observed any relief from following the practice in the ver}- few cases in which I have seen it tried, nor- can I see why it should relieve the pain. The orchitis which follows on injuries, mumps, or other causes, must be treated on the same general principles, and Dr. Humphry gives a useful caution to examine the urethra in cases of recurrent orchitis, since the recurrence often depends on the presence of stricture, and can only be obviated by its cure. The acute orchitis of mumps is remarkable as being an affection of the body of the. gland, and as being liable, occasion- ^ See Humphry, op. cit., pp. 111-112. * Dr. Humphry says that without treatment or even rest, most cases would end in resolution. ^ To strap a testicle, separate it from its fellow and pull the skin tight, put the first strap round the scrotal cord, the next perpendicular to the iirst between the testicles, the third half overlapping the first, and the fourth the second, and so on till the whole gland is equably covered. The skin ought not to be pinched any- where between the straps, nor should the pressure be painful anywliere. The straps should be about half an inch wide. 53 834 DISEASES OF MALE ORGANS. ally, to be followed by total wasting of the organ ; but as far as recorded cases go this unfortunate event does not seem ever to occur on both sides. Acute (or subacute) orchitis also happens occasionally in gout and rheumatism. Chronic oi'chitis is frequently the remains of the acute disease, but its more usual cause is syphilis. It consists in a knotty enlargement of tlie various lobes of tlie gland, proceeding from infiltralion of lymph into tlieir connective tissue, aud this knotty infiltration has given rise to the name "tubercular testis," a somewliat unfortunate one, since it seems to be intended to apply to a disease wliich ought carefully to be distinguished from that whicli pro- ceeds from scrofula, to wliich the designation "tubercular" would be more ai)propriate. As the disease progresses it involves the whole organ in a common hard swelling, in which all distinction between testis and epididymis is lost, and tlie whole becomes uniformly hard and heav3\ There may also be more or less fluid in the tunica vaginalis, forming the " liydrosarcocele " of the older authors. The ultimate end of the disease is various. Not unfrequently, if suc- cessfully treated, it seems to be entii'cly cured with no resulting mischief to the gland whatever; at other times the affected portion of the gland shrinks, and becomes atrophied as the liver does in cirrhosis, or suppura- tion ensues, and then the abscess may either heal or hernia testis may follow. Diar/nosis. — Chronic orchitis is a disease of slow progress, and it seldom attains a large size. It is hard to distinguish it at first from scrofulous orchitis, except by the concomitant affections in the latter. And in some cases where chronic orchitis has attained a rather large size it is very diffi- cult to distinguish it from malignant disease in its earlier stage. In fact, the physical appearance is nearly identical, and I have seen the mistake made l)y the greatest masters of surgical diagnosis. The history and rate of progress of the diseases are dilferent, but histories are very often deceptive. The effect of a course of mercury, however, and the progress of the disease while that course is being administered will enable the surgeon to form the diagnosis, though, probably, if it do turn out to be cancer, the nature of the case may not be ascertained with certainty be- fore the patient's health is broken down by the combined effect of the disease and the mercuiy. The presence of other sj-philitic affections will be a material aid to the diagnosis. Treatment. — In chronic orchitis, whether syphrlitic or not, mercury is generally successful. The best plan seems to be to keep the patient in bed and l)riiig him under the influence of calomel and opium, slowly but fully, till the gums are slightly tender. After about three weeks of this general mercurial action it may l)e ke[)t up by inunction of mercurial oint- ment into the scrotum, and then iodide of potassium and sarsaparilla should be given. Fiiiall}', when the patient gets up the testicle should be strapped. ScrofulouH Orchitis. — Scrofulous disease of the testicle consists in the deposit of tubercle in and around the tulmlar structure, usually of the epididymis, with thickening and enlargement of the vas deferens, but it is soinetitnes confined to the body of the testis. The tubercle softens and makes its way to the skin, causing first adhesion of the layers of the tunica vaginalis, then redness and thinning of the coverings of the scrotum, and finally, bursting as a chronic abscess, through which often CYSTIC DISEASE OF TESTICLE. 835 the tissue of part of the testicle protrudes, and sometimes almost the whole gland. It is frequently associated with genei'al plitliisis or with some other tubercular aflection, and very often both testicles are diseased. Occasionally, instead of softening, the tubercles wither and calcify, leaving the organ little affected. It has been noticed that in some of these cases an examination by the rectum will disclose tubercular deposit in the vesiculjE seminales, and sometimes in the prostate. This is only another form of chronic orchitis, and accordingl}', it is not always easy to diagnose it from the common or the syphilitic orchitis; in fact, nothing prevents a strumous patient from having syphilis, so that the two diseases may well be mixed together. And as the diagnosis of chronic orchitis from cancer is sometimes difficult, so is also (but much more rarely) that of strumous orchitis. On this head, however, enough has been said above. In the treatment the general management of the constitutional condi- tion is far more important than any local treatment; in fact, the disease requires no local treatment unless abscess has formed. Such abscesses may sometimes be incised with advantage, and hernia testis, whether proceeding from strumous or from ordinary chronic orchitis, requires treatment, which will be described immediatel}'. Very rarely when the testicle seems hopelessly disorganized, and is a source of pain and ex- haustion to the patient, it may be removed, though, as a rule, this should be avoided. I removed a testicle under these circumstances a short time ago, for a poor fellow in an advanced stage of phthisis, though the other testicle seemed also slightl}' affected, and with very great benefit to the general health. Treatment. — Hernia testis requires, in the first place, careful attention to the general health ; in the next place, strict cleanliness and the removal of all sources of irritation ; and, finally, some gentle stimulant to the granulations. Povvdering them with the nitric oxide of mercur}', and slightly repressing them b}' strapping with an ointment of the same, is the favorite plan of treatment at St. George's, and is very successful when combined with good diet, rest in the hospital, and the usual remedies for struma when the disease is strumous, as is commonly the case. Under such treatment as this, the sore usually scars over, and no further inter- ference is necessary. Two kinds of plastic operation are, however, prac- ticed in hernia testis. Tlie only one which I have either performed or seen is that which consists in paring the edges of the scrotum, and bringing it over the exposed gland. In order that this may succeed the granulations must previously be brought into a healthy condition, and when this is the case I have obtained a speedy permanent cure in this way. Dr. Pagan, of Glasgow, has also described an operation in wliich the edges of the opening in the tunica albuginea, which he believes to constrict the herniated testis as tiie neck of the sac constricts a hernia, are notched with a bistoury and the protruding gland repressed before the skin is brought over it.^ P'inally, in some extreme cases it ma}' be better, on the whole, to re- move the exposed gland. Cystic Disease. — The common cj'stic disease of the testicle is usually in fact cancer, with one or more cysts in it. But besides this malignant cystic tumor, there are cases of innocent tumor formed of a number of 1 See Dr. Humphry's essay, p. 121. 836 DISEASES OF MALE ORGANS. Section of a specimen of nou-malignant cystic disease of the testicle. — From a preparation presented by Mr. Csesar Hawkins to the Museum of St. George's Hospital. cysts of variable size scattered over the whole substance of the organ. Car- tilao;e is often found mixed Fit; 379. '^ with these tumors, as it is with malignant tumors of the testicle. And I have seen a case in which a congenital tumor was developed in the testicle, which contained nu- merous cysts lined with cilia- ted epithelium, and in which portions of bone were found. The diagnosis between the innocent cystic tumors of tlie testicle and malignant disease is very difficult indeed, unless the history points clearly to a non-cancerous formation, and clear serum can be here and there evacuated by punc- ture. But on removal of the testicle,, an operation which must be performed if the size of the tumor requires it, the distinction will be made : and then the patient may safely be assured that the cure will be permanent. Endiondroma of the testicle is generally associated with cystic disease ; in fact, Mr. Curling teaches that the deposit occurs in the dilated tul)uli seminiferi, and that the cysts are the dilatations of the tubes. Thus tlie cartilage is found in its initial stage in the form of beads strung together upon the tubes. In other cases, however, the formation of the cartilage has seemed to be more in connection with the lymphatics of the testicle, as in the celebrated case recorded by Sir J. Paget in the .38th vol. of the Med.-Chir. Trans., and to which reference has been made above (page 358), where the growth spread up to the great veins and proved fatal. The purely cartilaginous tumors are of somewhat slow growth usually, and of great consistence and weight. They undergo calcification, and sometimes probably cystic transformation. Their removal is plainly indicated, and if they are not nuxed with cancer (which, however, they not uncommonly arej, the prognosis is good. Innocent tumors other than inflammatory, cartilaginous, or cystic, are decidedly rare in the scrotum, and as originating from tlie testicle still rarer. A few scattered instances of what have been described as fibrous or fibrocellular tumors of the testicle are recorded; but 1 think hardly with sufficient details to make us certain that those which grew from the testicle itself were not really malignant (see Humphry, ojj. cit., p. 138). I have recorded' an instance of a fibrous tumor of the scrotum enveloping the testicle, but clearly having no organic connection with it, which had grown gradually during thirty-thiee years. This might doubtless have been removed without injury to the testicle at an early period, but was so implicated with the cord and gland at the time 1 saw it, that they were necessarily removed together. As well as could be determined the 1 Path. Trans., vol. xx, p. 246. REMOVAL OF TPIE TESTICLE. 837 tumor seemed to have grown in the tunica vaginalis. Several such in- stances are recorded, and it may be said in general that the fibrous tumors of the scrotum are developed apart from the testicle, though their removal often involves that of the gland. Cancer of the testicle is generally of the encephaloid variety, and it usually begins in the body of the gland, expanding the substance of the testicle, which is then spread out as a thin layer over the tumor, easily known from the cancerous mass by the seminal tubes, which form the bulk of this expanded layer, as well as by its general appearance. There are often large cysts in these tumors, and masses of cartilage are often found here and there in them. The cancer usually obliterates in great part or entirely the cavity of the tunica vaginalis, but it rarely bursts through the skin of the scrotum. It tends more to spread up the cord and into the lumbar glands, i. e., the glands which lie around the aorta and common iliac arteries. The inguinal glands are also sometimes affected, and that not only when the skin of the scrotum is implicated. As the disease progresses (and its progress is usually rapid) the patient's health breaks down rapidly, and death ensues either from the pressure of the mass in the abdomen, or from its interference with digestion, or from fungation, whether of the secondary tumor or the primary. Diagnosis. — The diagnosis rests mainly' on the fact that cancer is a rapidly increasing solid enlargement of the testicle itself, unaccompanied by inflammation ; but the remarks made above in the sections on hjema- tocele, chronic and scrofulous orchitis, will show that this diagnosis is by no means easy in the early stage ; for at this period there is no can- cerous cachexia (on the contrary, cancer comparatively often occurs in florid healthy young menV nor any perceptible enlargement of the glands. There is no difficulty in forming a correct opinion in the latter stage of cancer, but then the time for surgical interference will probably have passed. However, with a rapidly increasing solid swelling an exploratory incision is justifiable, all the necessary arrangements for castration having been made. Castration. — The operation of removing the testicle is a very simple one, and free from danger, at least I cannot recollect a single case of death after the numerous operations of the kind which I have performed and witnessed, though these operations have been performed chiefly on patients exhausted by illness and dissipation, and in those metropolitan hospitals which are falsely said to be so unhealthy. A free incision is to be made from the situation of the external inguinal ring down to the bottom of the scrotum. The cord is then exposed and the skin peeled oflE" it with the fingers. If it should be diseased up to the external ring a director must be passed into the spermatic canal, the aponeurosis of the external oblique divided, and the cord followed higher up ; but this is very seldom required in any case which the surgeon has selected for operation. The healthy part of the cord is to be caught in a clamp, such as is figured on page 605, and when it has been entirely secured it is divided above the disease, and as far from the clamp as cir- cumstances permit. Then the tumor is rapidly shelled out of the scrotum, and if it adheres to the skin all the adherent portion of the latter is removed as well as a good part of the skin in the neighborhood. The 1 " Cancer of the testicle makes its appearance at all periods of life, from the earliest infancy to old age, but is most frequent from twenty to forty. It is rare after sixty." — Humphry. 838 DISEASES OF MALE ORGANS. cutaneous vessels which are large enough to give any trouble are tied, anil then the ends of the cut vessels in the cord are picked up and tied. If this is done with the carbolized gut, and the ends of the ligatures cut short, the wound will often heal almost or altogetiier by first intention. If a clamp is not at hand, the cord, if it be healthy for a considerable distance below the ring, may be held between the thumb and finger of an assistant with a piece of rag ; but this is a very inferior method of securing it. Or the old plan of passing a stout ligature through it to hold it by may be adopted, and, in fact, must be, if there is not room to hold it otherwise. I have often seen the cord on its division slip from between the assistant's fingers up into the spermatic canal, and then there is very profuse bleeding, and the surgeon has to slit up the canal and follow and bring down the bleeding stump of the cord with hooked for- ceps. This danger is avoided by the clamp, provided the division of the cord is not made too close to it, in which case the clamp also is very likely to slip off. I have frequently followed the old plan of tying the whole cord with a strong double ligature, and have not found any of the evils, such as pain, tetanus, etc., which are said sometimes to result from it; but it is a tedious method, as it delays the patient's convalescence, and condemns him to suppuration and confinement to bed during the long i)eriod of separation of the ligature. Before the operation the patient should be carefully examined as to the presence or absence of hernia. Unfortunately the immunity from disease which this operation procures in cases of cancer can only be expected to be short. The disease will recur in the stump of the cord, or in the lumbar glands, or in some cases in the opposite testicle, or in remote parts of the body. Still the respite is one usually of complete health, and it amply justifies the operation, even if we believe that life is not prolonged by it. No doubt also in some cases the recurrence is long delayed. Mr. Curling has given four cases in which the patients were well four, nine, ten, and twelve years after the operation. Dermal and other Fcetal Tumors — I have spoken above (page 353) of the occasional occurrence in the scrotum of congenital tumors containing bone, teeth, hair, and other structures. The}' are sometimes, as it seems, at first included in the testicle itself, out of which they grow; but at other times they have been proved to be separable from the gland. The diagnosis is usually obscure until suppuration sets in around the mass and exposes a part of it, or till the whole tumor has been removed. This should be done in all cases, for though they have been spontaneously extruded, yet operative removal is far less dangerous and distressing. In the operation, it is reasonable to make an attempt to preserve the testicle, thougli it will probably be found impossible to do so. Spermatorrluea. — The consequences of masturbation, the apprehen- sions of spermatorrluea and loss of sexual power, form a highly un- pleasant sul)ject, which has become still more disgusting as afibrding a field for the practices of some of those unscrupulous and degraded char- latans wiio infest the profession, or who falsely assume a connection with it. These men make money out of the fears of unfortunate youths, some of whom are merely nervous and are frightened at the natural emissions by which the testicles relieve themselves from distension in persons who are not in the habit of sexual intercourse. The majority, however, of the victims of such fears are conscious of having indulged either in solitary abuse or in immoderate sexual intercourse. A judicious and honorable V A R I C O O E L E. 839 surgeon cannot be better emi)loyed than in deliverina: such patients from the consequences of unfounded apprehensions, andincnlcatingthe strength of mind and manliness necessary to give up vicious liabits which liave been once contracted. In a work of this kind it is fortunately unnecessary to dwell on this unsavory subject. So long as the power of complete erec- tion continues and the patient does not lose semen involuntarily or un- consciously (which is very rare) the genital organs will recover them- selves under proper treatment. Very frequently what is mistaken for spermatorrhcra is some slight mucous discharge, the result of irritation of the urethra. Proper treatment, however, involves as its most essen- tial feature the renouncement of the habit of self-abuse, and either absti- nence or only moderate indulgence in sexual intercourse. If the patient cannot be persuaded to put this restraint on himself he deserves the ruin that will fall on him. With this, and with tonic regimen and active exer- cise of body and mind, recovery will be regular and permanent. Real impotence may, of course, occur; but it is very rare. The cauterization of the prostatic urethra, which is so highly recommended, seems to me often useful, less perhaps from its direct action tiian indirectly, by making masturbation or venereal excitement painful. On the whole of this subject, and especially on the morbid fears of impotence and other horrors which haunt the unfortunate victims of "sexual hypochondriasis," I cannot do better than refer the reader to Dr. Humpiu'y's remarks on Functional Disorders of the Testicle^ op. cit., p. 151 et 8(^9., and to Sir J. Paget's excellent essay on Sexual Hyjjochon- driasis, in his recently published Clinical Lectures. AFFECTIONS OF THE CORD. Varicocele is a very common affection, at least in its minor degrees. It consists, as its name implies, in a varicose condition of the pampini- form plexus of veins which return the blood from the testicle into the spermatic vein. The enlarged veins are easil}' felt in the cord, " feeling like a bag of worms," as it is always described, and the description is very accurate as applied to the extreme instances of the affection. When the varicose veins are at all large they can be seen and the disease at once recognized without even touching the skin. Varicocele may be compli- cated with any other affection of the testicle or with hernia; but it can hardly, as far as I can see, be confounded with any of them, at least by any one who has ever seen it before. The swelling, of course, subsides to some extent in the recumbent and increases in the erect posture ; but this is utterly unlike the disappearance and return of a hernia. The enlarged veins are often the seat of some amount of real pain on prolonged standing, and still more often of a considerable amount of nervous pain. The testicle on that side is often smaller than the other, and the patient is often worried (especially if he has fallen into dishonest hands) by apprehensions of impotence. As a general rule, however, nothing can be more unfounded.' Sir A. Cooper said with much truth : " Varicocele should scarcely receive the title of a disease, for it produces in the greater number of cases no pain, no inconvenience, and no dimin- ution of the virile powers." It follows incontestably, if we believe this — and there are few surgeons of experience who would question it — that the number of cases of varicocele which require serious treatment are 1 Sir J. Paget goes so far as to say of varicocele : " I do not believe that it ever produced wasting of a testicle, or impotence, or any such thing." — Clin. Lee. p. '274. 840 DISEASES OF MALE ORGANS. very few indeed, and that any snrgeon who operates ver\' frequently for varicocele must operate on many cases which he would have done better to let alone. I do not deny that such operations may sometimes be re- quired, under circumstances which 1 will immediately point out; but the great majority require nothing but a bag-truss. If the enlarged veins should intlame, rest in the recumbent posture, with the testicles raised by a small pillow, fomentation, and leeches are indicated. There are cases (probably those in wliich the upper part of the vein is varicose, and where the enlargement of tlie lower veins depends on the pressure of the column above) in which a light truss applied on the ring gives relief. Mr. Wor- raald's plan of drawing a part of the scrotum through a ring of soft metal coated with leather, the ring to be pinclied together when the skin has been drawn through it, ma}' be tried ; and some surgeons still have confidence in Sir A. Cooper's method of removing all redundant scrotum and sewing it up, so as to give support to the testicle, which, however, must still be also supported by a bag-truss. Nervous pain may be much relieved by convincing the patient of the trivial character of the disease. Operations for Varicocele. — There will remain cases in which the pa- tient will wish for an operation, and that mainly for three reasons — either that he wishes to get into some employment, as the array, from which the state of the veins excludes him (though I believe army sur- geons do not reject recruits for the slighter degrees of varicocele), or he suffers real and considerable pain, or the testicle is wasting. As to the latter point, however, I do not think that any slight diff"erence between the size of the testicles is necessaril}^ a motive for operation. Several years ago I was consulted by a young man with varicocele, who was very anxious to be operated on, the varicocele being rather large and the tes- ticle much smaller than the other. With difficulty I persuaded him to wait, and then, as the testicle did not continue to waste, I advised him to give up the idea, telling him that he might safely marry Tas he wished to do), and might rel_y on it that he had the same chance of off'spring as anyone else. He is now the fatherof a large family, and suff'ers nothing from his varicocele, which has remained stationary. And we must recol- lect that such operations are by no means free from danger to life, and that if they sometimes cure the atrophy of the testicle, on the other hand they sometimes produce it. The celebrated instance of Delpech is in point. He was assassinated by a man on whom he had operated for vari- cocele on both sides, and who had lost sexual power in consequence of the operation. The assassin was executed, and on examination of his body after death both testicles were found flaccid and wasted. This un- toward result arose doubtless from obliterating the greater part of the spermatic artery along with the veins. Usually the trunk of the spermatic artery adheres so closely to the vas deferens that as the latter is drawn out of the way of injury the artery follows it and escapes also ; but often in dividing tlie veins a large artery is severed, and the distribution of the spermatic artery is b}' no means uniform. Numerous cases of death after the operation are known to have occurred ; and in cases which ulti- mately recovered I have seen so much suppuration, sloughing, and other evil consequences, that I have thought the remedy has been much worse than the disease. I would therefore recommend the surgeon to let his patient urge the operation upon him, and even then only to consent when his judgment goes along with the request.' The only operation I have ever practiced for varicocele is that recom- ' See also on this subject Paget, op. cit., p. 68. ELEPHANTIASIS OF SCROTUM. 841 mended by Mr. TI. Lee, and which is the same as that which he employs in varicose veins of the leg. The vas deferens is to be carefully isolated and held aside, then two needles are to be driven in beneath the enlarged veins and above the vas deferens at a distance of about an inch from each other. The veins are to be compressed between these needles and the skin by a figure-of-8 ligature wound pretty tightly over the needles, or l)y an india-rul)ber band. In the latter case the needle is introduced with the hand strung on it, and the band tlien passed over its point. When the veins are tlius secured the.y are divided subcutaneously in the interval between the needles. In doing this a good deal of bleeding often takes place. This is judged to be arterial when it comes from the upper or cardiac end, and venous from the lower. If it is too great to be stopped by the circular band of strapping which is applied between the needles another needle must be driven in more deeply either above or below the former (as the hiiemorrhage is arterial or venous), so as to command tlie vessel which has escaped the needle previously put in. The needles are to be withdrawn in about four days. If matter forms in the scrotum it must have early exit. Tumors in the Spermatic Canal. — Fatty tumors are occasionally, though very rarely, found in the tissue of the spermatic cord, which very closely simulate omental hernia. The diagnosis can only be formed by very careful examination, showing that the tumor is movable by traction on the cord, and that the fingers can be made to meet round its base ; but I am not aware that these tumors have ever been made the subject of oper- ation. Dr. Humphry refers to a few cases from Mr. Curling's ex[)erience and his own, and to some preparations of fatty and flbrocellular tumors of the cord in the Museum of the College of Surgeons. AFFECTIONS OF THE SCROTUM. (Edema and Inflammation. — The scrotum is very liable to passive oedema both from general and local causes. The chief point in tlie man- agement of such affections is to see that gangrene is averted by timely punctures and fomentation. Inflammatory a?dema also tolerably often occurs from erysipelas, from the contact of urine, and from other causes ; and sometimes an abscess forms in the cellular tissue of the scrotum and produces swelling quite out of proportion to the amount of matter in it. An abscess containing only a few drops of pus will often form a large swelling which gives the patient very grave uneasiness, aud which I have even known mistaken by the inexperienced for a tumor. Nothing is re- quired but a poultice and a timely puncture, after which the swelling will rapidly subside. Ulephautiasis of the scrotum is a disease of tropical countries, which is only seen here, as far as I know, in those who have contracted it abroad. There it extends to an enormous size, making the patient's life intolerable, in consequence of its weight preventing him from any of the necessary exertions of dail}' life, and rendering any operation, however desperate, justifiable. Tlie opportunity of seeing these cases in their early stages, when the}' might be amenable to pressure or to astringent applications, is hardly ever granted. In the more moderate condition, the surgeon would prob- aV)ly think it better to dissect out all the hypertrophied skin and remove it from the penis and testicles, even if these organs were exposed. Gran- ulation would cover them, and the patient would in all probability be 842 DISEASES OF MALE ORGANS. restored to perfect health.^ But wlien the disease has attained an enor- mous size, and it is nevertheless thought right to remove it, no dissec- tion is possible, on account of the excessive hieinorriiage. Tiie mass must be embraced in a temporary ligature, or in a clamp, in order to re- strain the bleeding as far as possible, and the whole mass be removed as quickly as may be, without regard to tlie genital organs. Such operations, however, are very fatal. Cancer of (he sci'otinn, soot-cancer or chimney-sweep's cancer, is an epithelioma which arises from the irritating properties of coal-soot. Wood-soot is not so irritating, and therefore will not usually excite the disease. Hence it is nearly unknown in countries where fires are mostly made of wood ; and on the other hand it is not entirely confined to chimney-sweeps in this country, Init afiects also people who deal much in soot, as gardeners — witness the well-known instance recorded by Earle of the gardener who habitually carried a bag of soot over his arm to dress his beds with, and was affected with soot-cancer on that arm. No doubt the development of this epithelioma is due mainly to the continu- ance of the irritation, so that constant removal of the soot will hinder it. And therefore in the present day, when people know more of the value of cleanliness, and when even chimney-sweeps wash themselves, this disease has become rarer than it used to be. In fiict, it might proliably be banished by the sweep using always a clean or fi'eshl}' brushed suit, and thoroughly washing himself whenever he comes home. As usually seen it forms a foul epitheliomatous ulcer on one side or sometimes on both sides of the scrotum, with hard, prominent granula- tions and raised, irritable edge, very frequentl}^ complicated with enlarge- ment of the inguinal glands, and in some cases (but rarely) spreading inwards to aflect the coverings or even the bod_v of the testicle. The diseased tissues must be freely removed, and it is justifiable to do this at any period of the disease, provided the whole of the morbid tissue can be comprised in the incision, even though the testicles should be entirely denuded, or though it should be necessary to remove them as well as the diseased skin. The enlargement of the inguinal glands, if not excessive, constitutes no bar to the operation, nor does it even necessitate the re- moval of the glands themselves. Constant experience sliows that on the removal of the epitheliomatous ulcer the enlarged glands will subside. But if the glands are unusualh' large and hard it is better to excise them at the same time. If after tlie removal of the scrotum the flaps of skin can meet over the testicles without much traction, the wound should be united. But if not, granulations will cover the testicles, and the cicatrix will form an excel- lent substitute for the scrotum. AFFECTIONS OF THE PENIS. Cancer of the penis is also usually epithelial, and like cancer of the scrotum, is usually excited by some irritation, of which the secretion retained behind a congenitall}' phimosed prepuce is a well-known instance. This liability of persons with congenital phimosis to cancer of the penis ^ Two interestine; casps wern latoly reported by Dr. Lloyd, of the Indian Army, in which tumors 65 pounds and 61 ])ounds in wciiijht respectively were removed with success, and the penis and testes dissected out of the mass. In one of these cases the exposed testes hunp down nearly as low as the ankles afti-r the operation, yet on convalescence they had completely retracted to the normal level. — Lancet, Aug. 29, 1874. AFFECTIONS OF THE PENIP. 843 forms one motive for circumcision in such cases, tlioiioli ordinary consid- erations of cleanliness would be quite snflicient vvitliout any such motive.^ The only special point in the surgery of cancer of the penis is to dis- tinguish it from secondary or tertiary syphilitic ulceration of the glans penis. And there can be no doubt that in many cases the ))enis has t)een amputated for supposed cancer, which has been only this form of ulcera- tion, and that many of the cases of permanent recovery after am})utation for supi^osed epithelioma, have been of this nature. In some cases, again, a confusion may have been made with common warty growth, tliough this is less likely. The characteristic hardness around the sore and tiie hard surface, indurated edge, and prominent granulations of tlie epitheliom- atous ulcer will distinguish it from tlie syphilitic; or if any doubt re- mains, in consequence of the history or the coexistence of teitiary syph- ilis, a gentle and prolonged course of mercury will settle the question, and this is best administered in the form of vapor. Sometimes melan- otic deposit is mixed with the cancer of the penis, as in a remarkable case which I communicated to the Pathological Society a few years ago, and which is figured above on p. 372. When the diagnosis of cancer is clear, the removal of the whole penis at a level well behind that of the disease is imperative. Amjjutation of the Penis. — The old rough plan of simply rutting the organ off with the loss of a large quantity of blood from artci'ies which the surgeon proceeded afterwards to tie, leaving his patient exhausted l)y hjemorrhage, would now be unjustifiable. The penis is to be constricted by a clamp (see p. 605), by means of which it can be removed without the loss of a single drop of blood, and all the vessels whose mouths can be discerned are to be tied. Then the clamp should be slightly relaxed, and new vessels, will, perhaps, be found which require ligature. P'inally the affair is completed without any haemorrhage or witli very triflinii loss, and the patient generally recovers without any serious symptom. IJut unless some care is taken to prevent the cicatrization of the cut end of tlie ure- thra, a most painful stricture will result, and I have seen the oi'ifice of the urethra contracted to the size of a pinhole. This, however, is the result of unpardonable negligence. Always after the amputation of tlie penis, as soon as the bleeding is suppressed, a director should be i)assed down the urethra, and the tube should be slit down with scissors on its lower aspect for about half an inch. Then the flaps of mucous meml>rane should be picked up and attached to the skin, whereby a large valvular opening will be left that will show no tendency to contract. The old p\an of passing bougies constantly to keep the end of the urethra from con- tracting, is painful and far less eflicient. Congenital phimosis should always be treated by circumcision. It is a malformation which often leads to considerable irritation, causing many of the symptoms of stone in the bladder, and, as stated before, it un- doubtedly predisposes to epithelioma. Ci7-cumcision. — The operation of circumcision is a very easy one and requires no special apparatus. A director is passed up between the glans and prepuce on the dorsal aspect, and the knife thrust through the skin and made to cut out. The mucous, or internal, layer is never sufiiciently divided by this cut, but should be afterwards incised to the same extent as the outer skin. Any adhesions between the i)repuce and glans must 1 Sir J. Paget has, however, pointed out that in many cases the orifice of the pre- puce may be so stretched by constant gentle traction that the glans can ultimately be exposed, and the operation avoided. 844 SURGICAL DISEASES OF WOMEN. be divided. Then the two la^'ers should be removed with sharp scissors by a cut ruunino- parallel to the corona glaiulis evenly all round the organ, leaving just enough of the inner layer to hold the stitches. This is now to be united to the skin by a few points of fine suture. Sometimes the artery of the fn^num requires twisting or tying. The wound is to be covered with oiled lint and the penis raised by a pad between the thighs and a bandage. The sutures may be removed on the third day. When the opening is merely narrowed, but the prepuce is not inordi- nately long, it is surticient to slit up both its la3'ers thoroughly and unite the lips of the little wound with sutures. A few cases of persistent priapism have been recorded from obscure causes, wliich are best treated by low diet, tartar emetic, or bromide of potassium. In other cases priapism results from disease or injury of the nervous centres, from irritation of the urethra or prostate, or from injury during connection. The treatment, in these cases, must be directed to the cause. Gangrene has been known as one of the sequelae of typhus fever, or from paraplegia, and a remarkable case of spontaneous gangrene of the penis foUovved by recovery is recorded by Mr. Partridge in the twentieth volume of the Medical Times and Gazette. CHAPTER XL. SURGICAL DISEASES OF THE FEMALE ORGANS OF GENERATION. The diseases of the female organs of generation which come within the province of the surgeon are as follows: MalformaHonH. — 'I'lie commonest malformation (if it deserve so grave a name) is tiie closure or adhesion of ttie labia, which is often seen in in- fants and sometimes passes undetected so as to be presented to the notice of the surgeon in later childhood. Very rarely it is allowed to persist till puberty. It is not unfrequently confounded with imperforate hymen ; but the mistake ought not to be committed ; for the adhesion is between the laliia majora quite in front of the hymen, and it is not, at least in the early years of life, in any sense membranous. After years of neglect it may become tougher and require division with a knife and director; but usually all tliat is necessary is to pull the parts asunder forcibly, and pre- vent readhesion V)y keeping the labia sei^arated with a piece of oiled lint. Imperforate hymen, is a much graver malformation, especially if (as is almost always tiie case) it escapes detection in infancy, and the patient first applies for advice wiien the collection of the menstrual fluid has con- sideral)ly dilated the cavity of tlie uterus. Under these circumstances any slight operation, thougli it is indispensable, involves serious danger. Hence tiie advice usually given in such cases to wait for operation till after puberty, seems quite erroneous. If the condition of parts is dis- TUMOR OF THE URETHRA. 845 covered in childhood, it is easy and perfectly safe to remove a small por- tion of the hymen, so as to make an opening into the vagina. But when the nterine cavity becomes distended with menstrual fluid, or with the treacly inspissated remains of sucli fluid, it is often noticed that after an opening has been made in the hymen^ the uterus is thrown into spas- modic action, and the Fallopian tube, which is dilated as well as the uterus, often gives way under this action, causing extravasation of the fluid into the peritoneal cavity, and fatal peritonitis.' Im-perforak'. Vagina. — 'IMie point of chief importance in these cases is to decide whether the case is merely one of imperforate hymen, or whether the vagina is itself imperforate, and if so, whether the uterus is present or absent. Mr. Jonathan Hutchinson speaks on this head as follows: ''When there is evidence of the retention of menstrual fluid, and therefore of the presence of a uterus, and probably of a vaginal cavity above the occlusion, the case will come fairly under surgical treatment. In the first place, the character of the obstructing medium must be determined. If the obstruc- tion be found within an inch or two inches of the vulva, and if it be con- stituted by a membrane, stretched across an otherwise well-formed vagina, the case is probably one of imperforate hymen. In some of these during coughing, the propulsion of the fluid downwards may easily be felt, or the distended membrane may even be forced as low as the vulva itself." When the obstruction is of only slight thickness there is no diflficulty about the treatment. The patient being secured in the lithotomy posi- tion a puncture is made into the collection of fluid and this is enlarged with the fingers, director, and forceps. It seems that a free opening is safer than a small one, as rendering the forcing action of the uterus less likel}' to act on the Fallopian tubes. If the obstruction be of consider- able extent, a very careful dissection in the direction of the supposed upper part of the vagina must be undertaken, assisted by the finger in the rectum and by a staff in the bladder. If this has to be done deeply, the deeper incisions are more safely made horizontally- ; but in such cases the operation is doubtless both embarrassing and dangerous. 1 do not speak here of cases of doubtful sex, since it is only in the rarest possible circumstauces that any surgical treatment is required, and advice as to the sexual relations lies more in the province of the accoucheur. Vascular Tumor of Urethra. — A very troublesome affection, and one which is sometimes very difllcult to treat, is the small vascular tumor, or urethral hsemorrhoid, which is sometimes found surrounding the meatus of the female urethra. In structure it much resemljles a nrevus. It oc- casions a good deal of pain and irritation ; leads to troublesome fre- quency in micturition; renders sexual intercourse very paiiiful, some- times impossible, and often bleeds a good deal. Though the disease appears trifling, it is often very troublesome in its treatment, recurring again and again, even after apparently com|)lete removal. Three methods of treatment are in use, — caustics, the ligature, and excision. Tlie first are often successful if freely used and if suflKciently strong. The pure 1 Let nie in passing just call the reader's attention to this amongst other facts which prove that the assertion ordinarily made in anatomical works tluit tiie Fal- lopian tube opens into the peritoneal cavity cannot be true, at least in its literal sense. There is no membrane separating the two cavities, and the one can be made to open into the other by passing a probe; but that they do not communicate during life is proved by the fact that no interchange of fluid ever takes jilace, however much the peritoneum may be distended by dropsy or the Fallopian tube by retained menses. 846 SURGICAL DISEASES OF WOxMEN. nitric afid, repeatedly applied, will often ultimately eradicate the growth, with little pain and no risk or confinement to bed; but it often fails, The actual or t)alvanic cautery is perhaps more efficient, but requires aniesthesia for its a|)|)lication. If only a portion of the circumference of the meatus is involved in the growth, the latter may be encircled in a ligature passed deeply under its base, through healthy tissues, care being taken to keep the urethra open while passing the ligature, so that the opposite wall of the canal may not be included in it. But the most etticient plan is to dissect the growth out completed with the knife or scissors, taking care to carry the incisions through healthy tissues. No formidable bleeding need be apprehended ; but even after this operation, I have seen the growth return, and if it be necessary to cut deeply, there is often i)artial incontinence of urine, i.e., the patient is obliged to attend to the first desire to empt}' the bladder, otherwise the nrine will very soon pass in spite of her. Tumors of (he Labium. — Cj'stic and other innocent tumors are not uncommon in the tissue of the labium. The cysts are probably always, and certainly they usually are, formed by the obliteration of the duct of a mucous follicle, as is often seen in the mouth. This is sometimes the result of irritation, so that they are not unfrequently developed soon after marriage. They contain a glairy mucus, and they are only trouble- some if the patient is in the habit of sexual intercourse, or if they inflame and suppurate, which will occur occasionally. Thej^ may be dissected out entirely, or they may often be cured by laying thera freely open and stuffing the orifice with lint; or still more certainly by clearing away all the secretion and rubbing the interior with caustic. The recommenda- tion of the treatment by laying the cyst open is that it does not render the employment of chloroform necessar}', nor are any assistants re- quired, '['he removal of tlie entire cyst is, of course, more certainly successful. Fil>rous tumors also form in the labium, and are frequently allowed to attain an enormous size. They then become pendulous, and greatl}'' interfere with all movements, as well as with the functions of the parts. Their removal is sometimes attended with ranch hfemorrhage, and when this is apprehended, in consequence of the size of the mass, or its vascular appearance, it is prudent to control the bleeding by a temporary ligature or clamp passed round the base of the tumor beyond the part at which it is removed. With regard to condylomata, raucous tubercle, and other syphilitic affections of the labium, I do not know that I need add anything to what has been said in other parts of the work. Hi/pcr trophy of /he Labia and Clitoris. — The tissues of the labia and clitoris are sometimes so much hypertrophied liy the constant recurrence of inflammation (whether sy[)hilitic or not), or by elephantiasis, that it becomes iiecessaiy to remove the diseased part. In such a case the sur- geon should be prepared for free lucmorrhage, and as the base of the growth is usually too extensive to be included in a clamp, the best plan is to pass a numi)er of stout harelip pins through it, and having removed the diseased tissue pretty close to these pins, and tied any large vessels, to pass the twisted suture round the pins tightly enough to restrain any further oozing. Cancer of the external parts is almost always epithelial. It ma}- occur as a primary disease, and then usually in later life, or it may be devel- oped on a venereal ulcer. It rapidly affects the inguinal glands. Its RUrTURED PERINEUM. 847 diagnosis from tertiary syphilitic affection rests on the cliff'nsed hardness and irregular surface of the ulcer, and on the affection of the glands, as well as on the history. From rodent ulcer, which is sometimes, tiiough rare!}', found in the same situation, it is distinguished by the distinct deposit which is found in ei)ilhelioma ; but the diagnosis is not of very great importance, since both require the same treatment. Early and complete excision is urgently demanded ; although there is great prob- ability of return, much more so than in the analogous disease of the scrotum. The enlarged glands should be removed at the same time, if they are decidedly indurated. When the patient will not submit to the removal by the knife, the use of caustics must be substituted, but is de- cidedly inferior. Rupture of the perineum is an accident following on parturition, and in its highest grades constitutes a serious infirmity which imperatively calls for a surgical operation. The slighter ruptures can often be brought to heal at once, by bringing the parts together with a stitch and keeping the legs together for some time after parturition, the strictest cleanliness being enforced. But when the whole tissue of the perineum, including the si)liincter, has been lacerated, so that there is little or nothing to separate the vagina and rectum, this will probal)ly not succeed, though even in such cases the attempt should be made. When the rupture is extensive the patient has very imperfect control over the f?eces, and often can hardly walk about from a sense as if the uterus were coming down. Frequently there is a considerable amount of prolapsus. The operation for the restoration of the perineum relieves the prolapsus, at any rate for a time; and in some cases of the prolapsus where the vagina is very wide, an operation exactly similar may be performed with advantage, even if there has been no rupture of the perineum. The operation is thus performed. The patient is narcotized, and se- cured in the lithotomy position ; the hair is removed from the labia as far forward as is necessary ; the vagina is well opened by means of a duckbill speculum. The two flaps are marked out with the knife of a quadrangular form by two lines running parallel to each other along the labia about three-quarters of an inch from the orifice of the vulva. These are joined b\^ a transverse incision just in front of the anus. Another in- cision is drawn in the middle line from the centre of this last to about three-quarters of an inch inside the vagina, and from this the base of the flap extends in a slanting direction forwards and outwards to join the incision on the labium as far forwards as the surgeon thinks fit. The further forward the dissection is carried the more firm and resisting will the new perineum be ; !»ut it is, of course, undesirable to narrow the ori- fice too much. After marking out the flaps, the surgeon proceeds to care- fully dissect up the mucous membrane and skin from the whole of the part so marked out. On the rectovaginal septum this is facilitated by an assistant putting his forefinger in the bowel. Great care must be taken to remove every vestige of the mucous membrane. Mr. J. Hutch- inson inclines to the practice of preserving the fla[)s, leaving them at- tached by their base in the vagina, paring them down as much as is nec- essary^, and sewing them together in order to form a covering for the wound. I have not found much advantage from this proceeding in the cases in which I have tried it. When the denudation is complete, and the bleeding (which is often free) has been checked by torsion of the vessels and the free application of iced water, the parts are to be brought together with the quilled suture. For this purpose three or four loops of 848 SURGICAL DISEASES OF WOMEN. Strong" silk or whipcord (according to the depth of the new perineum) are i)assed througli the whole thickness of the tissues. This is most readily etiected by means of a long and very strong deeply curved needle on a handle — called Baker Brown's needle. The point of this is entered just inside the left tuber ischii and the ligature is cari'ied to the very bottom of the denuded part, and the point brought out near the right tuberosity. The posterior suture should not cross the cleft at all, but should be buried in the rectovaginal septum, when that septum exists. If such a needle is not at hand, the loops can easily be passed with a common ciirved needle, exactl}- as in fissure of the palate (p. 576), draw- ing the ligature across from one side to the other by passing one loop inside the other. There are now a series of loops on the right side of the perineum, and a series of double ends on the other. A piece of bou- gie is passed througli all the loops, another is laid between the double ends, the patient's thighs are brought together, and these deep sutures are tied very firmly. The pressure on the deep parts forces the cutaneous edges in the middle outwards. These must, therefore, be attached to- gether with silver sutures. Finally, if the vaginal flaps of mucous mem- brane have been preserved, the}^ must be attached to the front of the wound. In some cases where the rectum has been much lacerated, and there is tension on the parts, it is necessary to make free lateral incisions through the sphincter on either side, sloping towards the tuberosities of the ischium ; but this is not required in ordinary cases, and should always be avoided if possible. Ice may be applied in the vagina if oozing of blood occurs after the operation. Before the operation the patient should be freely purged, so that there ma}^ be no call to pass motions for some time, and artificial constipation is to be kept up for about a fort- night by the administration of about ten droi)s of laudanum twice a day. The water must be drawn off careful!}' b}' the surgeon or a dexterous attendant twice or three times a day, as may be necessary. On no ac- count should the patient be allowed to pass any urine for about ten dajs. Then she may pass it in the prone position. She should be fed as well as her appetite permits. It is scarcely necessary to say that the period immediately succeeding menstruation should be selected ; but in spite of this the operation may provoke premature recurrence of the flow, and this may prevent the healing of the wound. There is usuall.y a great deal of foul discharge, which should be carefully syringed away with Condy's fluid. The operation is a very successful one. In some cases fistulous oi)enings are left in the new perineum after union, but they can generally be easily united again. In one unfortunate case I have seen death from pliletiitis and pyjemia, but such a disaster is purely excep- tional. 'I'he worst which is to be apprehended is that union may not occur, and this will not generally preclude success in another attempt. Frola}).'wly. 852 SURGICAL DISEASES OF WOMEN. is to be tapped, if it has softened in an_y part, in order to facilitate its extraction, or if lobnlated, portions may be removed with the ecrasenr to diminish its bullv. Wlien the base is reached it may, in some cases, be secured with a strong clanij), in otliers divided by means of the ecrasenr. The operation is one wdiicli is not often practiced at present, and more definite information as to tlie indications before operation is required be- fore we can say how lar it lias been justifiable in those cases in which it has been performed. Ujccision of Os Uteri for Cancer. — Cancer of the uterus commences not uncommonly at the os, and in some cases it is detected at a period when it has not spread too far for removal. In such cases much benefit has, no doubt, sometimes been produced by the excision of the diseased structures. The operation is, however, a dangerous one, and in most cases the relief is only temporary. Still, if the surgeon can be sure of the diagnosis,' if the disease has not spread to the vagina, and if the general health is still good, it is his duty to make the attempt. The parts may be removed with the knife or the whipcord or galvanic ecrasenr, and the preference for one over the other method depends in a great measure on the shape of the mass. The uterus must be gently drawn down as far as possible. If the knife or scissors is to be used, the uterus must be commanded by a ligature of stout wire driven through both its lips, and the part in front of the wire cut away in a conical shape, the wound being bevelled towards the uterus. The actual cautery and perchloride of iron must be at hand to repress haemorrhage, and the wire can be made use of to tie a compress of lint steeped in the perchloride over the wound if necessary. The application of the ecrasenr is facilitated by passing needles through the uterus just behind the part to be removed and slipping the chain over these needles. Ovarian Tumors. — The ovary is liable to tumors of all kinds. The solid tumors are fibroid or malignant. The fibroid tumors are difficult of diagnosis from similar tumors of the uterus, which are sometimes pedun- culated, and attain a very large size. The fibroid tumors also are at first difficult to distinguish from the cancerous, but the different rate of growth will settle the question ultimately. No surgical interference is advisable in solid tumors of the ovary. Those which are innocent will probably cease to grow, and the patient will ultimately become accustomed to their presence, while in malignant disease an operation would do nothing but harm. Cy^ta of the Broad Ligament. — 13ut the ovarian tumors with which sur- geons are most concerned are cystic. These cysts are serous, colloid, or dermal. The serous cysts are unilocular or multilocular. The uniloc- ular cysts are occasionally situated, not in the ovary itself but in the broad ligament, and result, it is believed, from degeneration of the re- mains of tlie Wolffian body or of the duct of Miiller.^ They seldom attain ' Mr. Hutchinson says: "It is not by any means an easy matter in many cases to make a contidenl differential diagnosis between a simple or venereal ulceration of the OS uteri and one ot a malignantnatiire in an early slJige. The tendency of tiie latter to bleed, its warty and thickened edges and fetid disehargo, are the chief symptoms on which to rely. The surgeon must notice especially whc;ther there be any tendency to new growth, and if practicable a small portion of the e(lg(i sliould be removed for microscopic examination. Pain, if severe, is a very suspicious sign." ^ bee Osborn, in St. Thomas's Ilosjjiial Reports, 1875. OVARIAN TUMORS. 853 Fig. 380. a size large enough to call for surgical operation, though one containing eighteen pints was successfully' removed by Mr. Ctesar Hawkins, and is preserved in the nuiseum of St. George's Hospital. In the ovary cystic tumors attain an enormous size. Like c^ystic tu- mors in other organs tliey are either simple single cysts, or proliferous ; and the latter are eitlier merely cystigerous (mul- tilocular cysts) or with a solid intracystic growtli, whicli may be of a sarcomatous nature. Otlier compound cysts contain colloid matter, and are some- time spoken of as instances of " alveolar cancer." Mr. Hut- chinson, however, points out that tliere is no proof that any of the forms of ovarian tumor are really cancerous except the encephaloid, althougii the more compound the tumor is, and the more active the intracystic growth, the more does it ap- proacli in clinical characters to malignancy. Dermal cysts (p. 353) occur here more frequently than in any other situation, but are indistinguishable from the other forms before operation, a watery eystiu the broad ligament of the uterus, which unless tiiere is a history of con- '^ perfectly separate, both from that viscus and from the genital origin. * Tlie cliaracter of the fluid contained in ovarian cysts va- ries greatly. Tlie cysts in the broad ligament usually contain nearly watery fluid, as the en- cysted hydroceles of the testis sometimes do, but the true ovarian cysts contain a fluid rich in albumen, which is generally less serous than the fluid c)f peritoneal dropsy, and is very commonly thick and glutinous, like thick gum. It also often contains a good deal of cholesterin. Often it is very deep in color. Sometimes it is seropurulent, and occasionally is unmixed pus. Suppuration in an ovarian cyst is accompanied in some cases by definite symptoms, constant pain, acute tenderness, some fever, and daily rise of temperature, but it occurs also vvithout any such symp- toms. I have recorded one such case in tlie Medico- (Jhirnrgical Tra))s- actions, vol. Iv, and a very short time since I assisted at the removal of a dermal cyst of the ovary which contained pure pus, and in which there had been no suspicious symptoms whatever. ' Tlie gradual growth of an ovarian C3^st produces what is called ovarian dropsy, i. e., a distension of the belly with a very large quantity of fluid, which occasions much the same symptoms as peritoneal dropsy, viz., shortness of breath, inability to take exercise, cedema of the lower limbs ovary, a shows the sharp edge of the cyst, formed appar- ently by the round ligament of the uterus ; b, the os uteri ; c, the P'allopian tube, between which and the round liga- ment a bristle is stretched; d is placed on the ovary, which is not very distinctly seen in this view of the preparation, but Is quite separate from the cyst. — St. George's Hospital Museuin, Ser. xiv, No. 13L 854 SURGICAL DISEASES OF WOMEN. from pressure on the large veins, and sometimes pressure on tlie bladder, causing- irritation, or in rare cases difficulty in making water. Tcrniinalions of Orarian Dropsij. — If the disease is allowed to run its natural course it may i)rove fatal from the effects of its pressure, causing ditlicuUy in taking food, and wasting in consequence of the loss of albu- minous material into the cyst ; or it may burst into the pei-itoneal cavity, and then usually causes death, though a few instances have been recorded in which the tluid was absorbed again from the i)eritoneum ; and it is even possible that spontaneous cure may thus take place. In rarer cases the tumor may ulcerate into the bowel, bladder, or vagina, and this also is almost sure to produce death. In some rare cases, as it seems, the tumor may cease to secrete, and the fluid even may be to a certain extent re- absorbed. Tiie suppuration of the tumor will probably lead to its ulcera- tion, and this must almost necessarily be fatal. Tlius we see that the progress of ovarian dropsy is, speaking generally, to death, though its rate of progress varies greatly. Diagtiosis. — The diagnosis of ovarian droi)sy is not by any means easy in all cases, as is seen b}' the mistakes which are known to occur in the practice of even experienced ovariotomists. The first question is as to peritoneal dropsy. Peritoneal dropsy depends on disease of the kidneys, heart, or liver, so that it is necessary in first taking charge of a case of supposed ovarian tumor to ascertain that these viscera are healthy.^ Then the ph3'sical examination of the abdomen differs in peritoneal and ovarian dropsy. In the former tlie whole abdomen is uniformly dnll, unless the abdomen is so little distended that the transverse colon floats to the sur- face and its resonance is perceptible. In the latter the transverse colon is quite buried, but the flanks are resonant, and the line of the c^st can often be traced by making the patient turn from side to side, and ob- serving hovv the resonance to percussion advances or recedes. The tumor can also in many cases be felt in the pelvis by examination from the vagina or from the rectum; and very frequently the surrounding cysts can be felt as hard masses in the wall of the principal tumor. In cases of doubt de- cisive information may, very likely, be obtained by tapping, for the ap- pearance of the dense, sticky, gumlike, and often deeply colored fluid which is often found in ovarian cysts is quite different from the greenish serum of dropsy. Another source of error is mistaking a softened fibroid tumor of tlie uterus for an ovarian cyst. In a case of this kind which happened to myself as much as a gallon of fluid was contained in the softened fibroid, and the mobility and relations of the tumor exactly resembled one of the ovar}-. But if an accurate history can be obtained it will be found that there has been flooding, the uterine sound will probably discover that tlie cavity of the uterus is elongated, and the tumor is not fluid, but semi- fluid, so that, though a good deal of fluid can be obtained from it by taj)ping, it does not run out freely as from a cyst. Large cysts are also found in the kidney, and these have been operated upon by mistake for ovarian dropsy. Such tumors, however, generally present more towards one flank than ovarian tumors do, their contents are more or less urinous, and if the hand can be got into the rectum (page 616, footnote) the difference in tiieir relations may probably be perceived. 1 It is true thnt disease of the viscera does not necessarily preclude the occurrence of ovarian drupisy, but it would at any rate contraindicate any attempt at removal of the ovary. OVARIOTOMY. 855 Pregnancy has been mistaken for ovarian dropsy, but in most cases from haste or carelessness. Whenever the patient is of chihll»earing age tlie possil)ility of pregnancy siioukl not be overlooked, and careful examination should be made for its usual signs. It is more common and less discreditable to overlook pregnancy vviien it complicates ovarian dropsy, but even in cases of decided ovarian tumor, if tlie patient is married or likely to be pregnant — L e.^ if the menses have not appeared for some time — the breasts should be inspected, the abdomen carefull}'- auscultated, the os uteri examined, and " ballottement " searched for. Lastly, tumors of various kinds, chiefly those in the omentum, and even phantom tumors, have l)een mistaken for ovarian cysts; but a care- ful surgical examination will prevent any such error. Phantom tumors very commonly disai)pear under anaesthesia. Treatment. — When the diagnosis is settled the question of treatment occurs. There are, in the present day, for ordinary cases of ovarian tumor, only two methods of treatinent worth discussing, viz., tapping and excision. The injection of iodine has, I think, been satisfactorily proved to be more dangerous than ovariotomy, as well as being very uncertain ; and the establishment of a permanent opening into the tumor is reserved for cases in which, from extensive adhesions, the attempt to remove the tumor is unsuccessful. In selecting between these two plans of treatment a great considera- tion is the age of the patient. Ovarian cysts are sometimes detected in early life; the dermal tumors are probably always congenital, though they do not usually show till later in life ; and other cysts may be de- veloped in childhood. It would be impossible to expect prolonged life in such cases, except after ovariotomy. When, on the other hand, ovarian disease appears late in life, which is rare, the patient is probably better advised in avoiding ovariotomy if possible. But much will depend on the sequelae of a first tapping, and I am myself disposed to think that, as a general rule, ovariotomy ought not to be performed except after a preliminary and exneriraental paracentesis. This is useful in many ways, and hardly ever causes any bad symptoms. Afterwards, if the tumor refills only slowly, the patient may be better advised in having it tapped repeatedly rather than running the risk of the radical operation. But repeated tapping is by no means devoid of danger, and in cases of young healthy women ovariotomy is on the whole far preferable. Ovariotomy is thus performed. The patient should have been well purged, and should have her legs covered with a pair of warm drawers. The room should be warm— nearly 70°. A large band is to be passed round the belly, of waterproof cloth, with a hiatus for the incision. She should be in a semi-recurabent position at the edge of a firm table, with her feet supported by assistants. The bladder should l)e empty. Full anaesthesia liaving l)een produced by ether, ^ an incision is made in the linea alba from a little belovv the um'hilicus to a little above tlie pubes, and tiiis is deepened l\y successive strokes of the knife till the peritoneum is exposed. The peritoneum having been opened, some ascitic fluid very commonly escapes. The surgeon introduces liis fore and middle fingers. and sweeps them round over the cyst to ascertain in the first place that he is really in the peritoneal cavity, and secondly, to feel for adhesions.'' 1 Mr. Spencer Wells, I believe, uses the bicliloride of methylene; but ether seems to have all the necessary properties, being little liable to cause sickness and not pro- ducing depression, whilst it is undeniably safer than methylene. '^ I know of no way of determining the presence or absence of adhesions in most cases. Sometimes they may be detected by a certain crackling of fluid in them, and 856 SURGICAL DISEASES OF AV O M E X. These, if present, are gently separated from the wall of the cyst, until tlie wliole hand is introduced, and the cyst is freed from adhesions on all sides. Now the trocar is plunoed into the cyst. To tlie trocar a tube is fixed which goes into a pail on the floor. As the cyst is punctured the surgeon seizes it with a vulsellnni and draws it forward, so as to keep the trocar opening as much as possible outside of the vvound in the belly, and he and his assistants take care that the trocar does not slip. Mr. Spencer Wells has introduced a trocar the end of which is hollow and can be retracted within the canula, and which has a set of hooks on each side. As the cyst-wall collapses with the escape of the fluid it is drawn into the grasp of the hooks, and thus the caniila is firmly fixed. I have used tliis trocar with good results; but if the cyst-wall is thin the hooks are liable to tear it, and then it is better to trust to gentle traction with blunt for- ceps. As the fluid escapes and the cyst collapses the surgeon passes his hand gently round the sides and top of the tumor to ascertain that there are no adhesions behind, to divide them carefully if thei'e are, and to deliver tlie cyst. And at this stage of the operation the operator may find reason to extend his incision upwards even as liigh as the ensiform cartilage. At the same time the assistants (one on each side) keep up guarded pressure on either side of the abdomen, so that the intestines may not protrude. When the first cyst has been emptied it may be nec- essary to puncture others in the same way before the tumor can be de- livered, and in doing so the escape of cyst-fluid into the peritoneal cavity is still more probal)le. Or the tumor may be adherent to the liver or omentum above, to the intestines behind, or to the wall of the abdomen or pelvis. These posterior adhesions are the most formidable complica- tion in ovariotomy, especially those to the intestine. The omentum con- tains large vessels, and it may be necesary to tie it with catgut befoi-e freeing it from the tumor; otherwise there is little trouble in dealing with omental adhesions. Adhesions to solid viscera are not generally very formidable, but the intestine is sometimes almost imbedded in the wall of the tumor. In such a case the peritoneal lining of the tumor must be slowly and carefully peeled off along with the bowel. It is as well, perhaps, to have a clamp like that figured on p. 656 at hand, so that any broad hand of adhesion may be securely clamped while it is divided and its vessels tied with catgut. This appears preferable to searing the bleed- ing surface with the actual cautery, though this is a plan adopted with success. Finally, the tumor having been freed and its remains delivered through the wound, its pedicle must be secured. Three ways are in use for this purpose. The best, in my opinion, and the one which has re- ceived the approval of Mr. Spencer Wells, is to secure the pedicle with a clamp, whenever that is possible without much traction on the uterus. The clamp, which consists of two broad blades held together by a power- ful screw, liaving been fixed on the pedicle just outside of the abdominal wound, the whole tumor is cut away about two inches beyond it; and then the surgeon passes down his finger to the other ovary to assure him- self that it is healthy. If so, the wouiid is united, after any cyst-fluid whicli lias got into tlie pelvis has been gently removed witli a perfectly clean new sponge. In uniting tiie wound stout gilt harelip needles are used. These are passed from the left to the right lip of the wound, about may often be suspected from the history of previous psvin or other symptoms of peri- tonitis. But in all olr]-stiinding casns tliny may bo expected. Their existence to fi moderate extent floos not seem to prejudice the patient's prospect. The adhesions in front, between the cyst and the abdominal walls, are much tnoro easily dealt with when the cyst is full and tense than after it has been taj)pod. OVARIOTOMY. 857 an inch from its edge, and embrace the whole tissue down to the peri- toneum ; and it is well, I think, that the pin should take up a small piece of the peritoneum on either side (p. 235). Then any superfluous part of the tumor beyond the clamp may be cut awa\^, a broad flannel roller applied, and the patient cleaned from any stains of the operation, and put into a warmed bed. About one-quarter of a o-rain of morjihia should be injected subcutaneousl}', or double the quantity introduced as a sup- pository. When the clamp cannot be fixed on tlie pedicle of the tumor on ac- count of its proximity to the uterus, without injudicious traction on tliat oroan, the best plan is to perforate the pedicle with a needle tlireaded with stout wire, and tie it in halves, the ends of the ligature liaving been flattened down so as not to irritate the neighboring parts, and after cut- ting away the tumor down to within about half an inch from the ligature, drop the pedicle back into the belly. In a case treated successfully in this way, I searched some time afterwards carefidl}- for the wire V)y pal- pation from the abdominal wall and from the vagina, but could elicit no sensation of its presence. The other plan of treating the pedicle is with the clamp and cautery, returning the cauterized end into the belly; but this is, I think, more dangerous than the former, though it may be necessary to adopt it in some cases of very short pedicle. The after-treatment of the case should be simple. For about twelve hours notliing should be given by the mouth. The patient, if restless, should be quieted by subcutaneous injections or suppositories of morphia, some pieces of ice should be given to suck, and she may, if mucli ex- hausted, require stimulant enemata; but as a general rule the less that is given in an}' way at first the better. The room should be kept warm but fresh, and the pulse and temperature carefully watched ; and as soon as the tendency to vomiting has passed away, nourishment and stimu- lants should be given as the state of the i)ulse indicates. The urine must be evacuated with the catheter for several days at any rate after the operation. The superfluous part of the tumor left outside the pedicle (in order to insure that the clamp does not slip) may be trimmed off next day, and the clamp removed the day after. The harelip sutures should be faken away on the fourth or fifth day, the lips of the wound being kept together with broad strips of strapping and a flannel bandage. Acute and general peritonitis is almost always rapidly fatal. Its treat- ment must be the same as after herniotomy. Limited inflammation and suppuration sometimes occur around the pedicle, and by no means pre- chides the hope of a successful issue, though it will retard union. Besults. — The success of ovariotomy of late years has been very en- couraging, the operation in practiced hands having given a ratio of mor- tality not exceeding a quarter,' a wonderful triumph of surgery in an operation so extensive and so dreadful in appearance; and considering the recent introduction of the operation there is good reason to believe that even this ratio of deaths may be diminished. The improvement in the I'esults of the operation over those which attended it on its first in- troduction are due undoubtedly in the first place to ana;sthesia, saving the patient the horrible shock of the operation, and enabling the surgeon to carry on the necessarily protracted manipulations in quiet. In the next place they are due to the extended experience of the operation and to the simplification of operative measures and after-treatment. And no 1 Mr. Spencer Wells has published 500 cases, with a mortality of, as nearly as pos- sible, one-fourth. — Med.-Chir. Trans., vol. Ivi, p. 120. 858 DISEASES OF THE BREAST. doubt the results have heeu improved hy the fact that a large number of the cases have fiillen into the hands of individual operators, who have thus acquired a familiarity with the details of the operation and the manauenient of cases whicli can only be accjuired by frequent practice, and who also probably operate more freely — ?'. e., on a larger proportion of liopeful cases — tlian those do whose experience is more limited. Certain it is that the experience of ovariotomy in hospitals and by hospital surgeons has presented a deadly contrast to these results, and I believe I am not wrong in saying that the operation is not now practiced in the ordinary wards of our hospitals. Some have separate wards under the same roof, others separate buildings ; and under such conditions it is performed with more or less success. Several causes may be alleged to account for this want of success in hospital practice. It is always said b}' those who decry our hospitals that the ill success of ovariotom^^ in them proves the insalubrity of their at- mosphere. Yet the great success obtained by Mr. Spencer Wells in a hospital which differs from other hospital buildings only in being less aiipropriately constructed renders this conclusion very suspicious, espe- cially when we see the most delicate plastic operations, requiring the speediest and most healthy processes of union, going on successfully in the very atmosphere said to be so deadly. Yery probabl}^ cases of ovari- otomy involve a susceptibility of inflammation in the exposed peritoneum too great to be safely treated in the same ward with other suppurating wounds, and we see something analogous to this in healthy parturition. But why they should not be successfully treated in separate wards re- mains still unaccounted for. Possibly the fact that the attendants are in communication with other miscellaneous cases may liave a great deal to do with it. At any rate, for the present, we must recognize the fact; and if ovarian operations are to be undertaken at hospitals a separate depart- ment must be provided for them. I need hardly say that in such opera- tions the minutest precautions must be taken to insure the perfect clean- liness of every instrument, sponge, or other thing which touches tlie patient, and to see that no one takes part in tlie operation except the surgeon and his two immediate assistants, who must all have thorougldy washed and disinfected their hands just before commencing. The more strictl}^ obstetric operations, viz., the Caesarean section and those for extra-uterine pregnancy, are not treated of in this work. CHAPTER XLI. DISEASES OF THE BREAST. Hypertrophy. — The female breast is occasionally affected with simple hypertrophy. It is a rare disease which commences generally soon after puiierty, in single women as well as married. It is distinguished from tumor of the breast partly by its perfectl}' even and homogeneous feel, LACTEAL ABSCESS. 859 partly Ity the absence of all symptoms, and partly by the ft^et thatjt usu- ally affects both breasts, which tumors hardly ever do. The diagnosis is generally obvious if careful examination be made. In some cases large tumors of the breast have been carelessly classified as "hypertrophy;" but the error is one easily avoided. Nor should the genuine hypertrophy be confounded with the temporary enlargement which sometimes accom- panies amenorrhcDea. The differences are well described by Mr. Birkett. When the breasts are seen to be enlarging gradually, and to an incon- venient extent, the surgeon's first care is to inquire into the general health, and to attempt to stop the progress of the affection by correcting any- thing that may be amiss. Carefully applied i)ressure may also be tried. But it must be allowed that little good is usually done by any measure short of amputation, and to this no surgeon would willingly resort unless it is absolutely necessary in order to allow the patient to go about. It is said that sometimes after the removal of one breast, the other has become smaller. At7'ophy of the breast is natural in the later period of life, though usu- ally it is not much noticed, as the place of the gland tissue is occupied by fat; but atrophy' also takes place sometimes without any known cause, or in connection with tlie growth of a tumor in some part of the breast, or from excessive lactation. But it must be remembered that a good deal of wasting of the breast is quite consistent with the perfect integrity of the gland tissue, as evidenced by the secretion ; and it is noticed that women with breasts which are verj^ small, and have been supposed to be atrophied, often have a fuller supply of milk than others. Sometimes, however, there is genuine atrophy witli consequent want of milk. Nothing can be done to avert it. Injlammaiion of the rudimentary breast in infancy is not uncommon in both sexes, perhaps more so in boys than girls. It produces redness and tenderness, with a serous or even milky secretion from the nipple. Nurses are in the habit of aggravating the mischief by rubbing, to ''rub away the milk," as the}'^ phrase it. This ought never to be permitted ; the irritation will soon subside under soothing lotions and cataplasms, with attention to the state of the bowels. Chroyiic Abscfss. — Inflammation also occurs sometimes at pubert}', and here also in the male as well as the female ; though in boys it is usuall}'' insignificant and transient. In females it sometimes lays the foundation of chronic abscess, an affection often mistaken for tumor; and, in fact, not easy to distinguish from a solid tumor by palpation. But in all cases where a perfectly healthy young woman presents a rounded elastic lump in tlie breast, the idea of chronic abscess should occur to the surgeon's mind, and he should be cautious of giving an opinion without an explora- tory puncture. I have seen several such cases brought into operating theatres, a mistake which indeed involves no bad consequences, since the abscess is opened by the incision made to expose the supposed tumor; but which, at any rate, involves unnecessary alarm to the patient, and is as vvell avoided. I have heard of breasts having been removed for chronic abscess, a grave and a disgraceful mistake. Lacteal Abscess. — The common cause of inflammation of the breast is irritation in suckling, and usually in women who persist in doing so when in too weak a condition to bear it. Its cause is often to be found in an imperfect development of the nipple. The woman is generall}' a primi- para, and the abscess usually occurs within about a month after delivery. 860 DISEASES OF THE BREAST. But the inflammation sometimes commencos with the secretion of the milk or even before this, with tlie vascular excitement preliminary^ to the secre- tion, especially if the l)reast has been irritated or injured. Abscess soon forms, sometimes with much fever and constitutional disturbance. The abscess presents in one of three situations : over the breast, in it, or be- hind it. Superficial abscess produces generally oidy slight symptoms ; the pus lies near the surface, and a simple puncture suffices for its evacua- tion. The true mammary abscess is usually accompanied by more fever than superficial abscess, and by much tension, heat, and pain in the breast. As soon as fluctuation can be felt, or even before, if the symi)toms I)e decided, a free incision should be made into it, in a direction radiating from the nipple. The evacuation of the matter gives great relief, and prevents the abscess from burrowing about in the gland or behind it. Cases in which incisions have been neglected or refused are often seen, in which the breast is riddled with sinuses, indurated in various parts, and jn'obably permanently damaged as a secreting organ. In the deep or sulnnammary abscess the whole gland is raised from the surface of the chest, and tloats on the subjacent matter as on a water-bath. In this form, the patient sliould be brought under the influence of chloroform, and an incision made under the breast into the collection of matter so as to afford a depending opening which is to be kept patent with oiled lint. Or it is sometimes useful to pass a drainage-tube. It saves subsequent cutting to make a satisfactory opening at first, or even to open the abscess in several places. Patients with abscess after lactation should give up suckling entirely ; they require good diet; full doses of quinine are often very beneficial, and a moderate allowance of wine or porter; care being taken not to overload the digestive organs. Piecautionary measures may sometimes avert abscess in parturient or pregnant women whose breasts are much congested with milk or in whom the large milk-ducts are obstructed. These consist in free purging, sooth- ing warm applications to the breast, drawing off' the superfluous milk with a pump, and opening any ducts which are found to be obstructed with epithelium. Lobular Induration. — Hyperesthesia of the breast, with chronic indu- ration of various parts of it, is extremely common, and is very liable to be mistaken for tumor. In some cases the whole breast I'emains, after an acute attack of inflammation, hard, heavy, and somewhat tender. These cases are not so difficult of diagnosis, but when only a portion of the breast is indurated the hardened part much resembles a scirrhous or glandular tumor. The diagnosis can only be made by the fact that various separate lobules are usually affected and often in both breasts, and by tlie general aspect of the case, and of the patient, to which Mr. Birkett adds as diagnostic signs that in these cases the pain usually fol- lows the course and distribution of one or more nerves, and that if these nerves be sought for and pressed upon as they issue from tlie tliorax, the slightest pressure will induce acute pain, sometimes confined to a single branch distril)uted to the indurated part while the rest are unaffected. This induced i)ain is, he says, almost pathognomonic of the disease. Another diagnostic sign on which he also lays stress is, that "when the hand is pressed gently over the gland, nothing indicating the existence of a new growth is felt, which always happens when one exists — the indu- ration is very distinct if compressed between the fingers and thumb, but imperceptible with the hand placed flatly on the part." FUNCTIONAL DISORDERS. 861 In treating this affection the first point is to improve the general health, to insist on health}' habits ol" exercise, to cure any menstrual irregularities, and to dissipate the apprehensions of tumor and cancer whicli the patient probably entertains. Quinine, iron, and mineral acids often do good if the digestion be attended to, and iodine internally is highly tliouglit of by some surgeons. Local applications are always useful in removing the part from the patient's own constant inspection and handling, for which purpose a belladonna plaster may be used ; the breast if heavy and pendulous must be supported from the opposite shoulder. In some cases, where pressure can be tolerated, strapping, applied over a layer of mercurial ointment, removes the induration. Wliere the evidences of inflammation are more distinct, evaporating and soothing lotions must be employed. Neuralgia or Hysterical Fain. — In other cases, even without any swell- ing or induration, the breast is the seat of almost intolerable pain, some- times constant, sometimes [)eriodic, and usually accompanied by hyper- aesthesia of the skin of the breast, as well as by pain in the neighl)oring parts. The affection is more common in young girls than in elderly per- sons, and in the unmarried than the married. It is usually associated with deranged menstruation, and probably with other disorders of health and digestion ; and those who sulfer from it may sometimes be found to be addicted to depraved practices. The treatment consists in protecting the breast from all contact or examination. The organ will often be found to be hard, prominent, and congested ; and in this condition, I believe, relief will often be obtained by tolerably firm strapping, which ma}' be done under antx^sthesia if necessary. The bowels and the state of the menstrual secretion must lie carefully attended to, and the moral treatment recommended for other nervous disorders must be strictly en- forced, and it is unnecessary to say that any secret practices which may be detected must be put a stop to. Functional Disorders. — The secretion of milk may be disordered in various ways. It is said that in rare cases the breasts have been known to secrete milk quite independent of pregnane}', in old women, children, and virgins. Atrophy of the breast-tissue, causing absence in the secre- tion, has been referred to al)ove. The opposite state, in which the secre- tion is excessive (galactorrlia'a), or in which it does not cease on the ces- sation of suckling, is connected with derangement of the general health, and will subside as this is restored. The only derangement of secretion which constitutes a specific disease is congestion with milk, which some- times leads to so much solidity and brawniness of the organ as to be taken for cancer, especialh' as the raising of the gland causes the nipple to be buried. The diagnosis is settled by observing that there was no tumor before delivery, and that cancer hardly ever begins during suck- ling. Abscess is to be apprehended, yet cases occur, according to Mr. Birkett, in which the congestion subsides and the breast is again quite useful. Only one breast is usually affected. The improvement of general health, weaning the child, pressure with carefully applied strapping, or the application of tincture of iodine, or iodide of lead ointment, are the measures prescribed for the treatment of this condition. Tumors of the Breast. — The disease descriljed by Sir A. Cooper as "chronic mammary tumor," and formerly regarded as a fibrous growth, is now usually denominated by some name such as adenoma, adenoid tumor, or mammary glandular tumor, in order to mark the fact that in its structure tissue is found which bears considerable resemblance to that 862 DISEASES OF THE BREAST. of the gland itself. Simple adenoma forms a lii-ni, lobulated tnmor, sur- ronnded h\ a capsule of librous tissue, in vvliich, on microscopic examin- ation, rudimentary breast-tissue is found, ?'.(^., tlic ccecal pouches in which the ducts commence, and in some cases, according to Mr. Birkett, rudi- ments of the ducts themselves. He also describes tumors in which "the observer may detect ducts, sinuses, and even the secretion peculiar to this gland." Adenoma is more common at an early period of adidt life, the decade from twenty to thirty years of age forming the majority, and it com- mences more commonly in single than in married life. Scroeijsfic Tumor. — Closely connected with this disease is the form of new growth described bj' Sir B. Brodie as seroci/slic., and by Mr. Ctesar Hawkins as tuherocydic tumor. In this disease c^ysts are found into each of which a nevv growth projects. The cysts contain a tenacious viscid Huid, often more or less dark in color from the admixture of some of the elements of the blood. Ver}^ commonly there are many such cysts, and the growth of the solid matter into them gradually tills them up, until at length they are almost altogetlier obliterated; and then tlie growth projects through the c.yst, presses on the skin, bursts it, and fungates. Two views prevail of the origin of these growths. In Sir B. Brodie's view the cyst was the original formation, being produced either hy the obstruction of one of the ducts of the gland (which, however, seems to be ver}'^ rare), or in the connective tissue of the part, in the same way as cysts form in any other part of the body. The solid tumor then grows from the tissue which forms the wall of the cyst. But in Mr. Birkett's view the so-called cyst in these compound tumors is a secon- dary formation, and is reall^'only a space in the capsule of the tumor, the layers of which are separated I)}- fluid which has accumulated probabl}' in consequence of the pressure of the solid growth below it. Mr. Birkett, therefore, describes serocystic or tuberocystic tumor as merely a variety of the adenoid tumor; and he separates the cystoid cavities which form parts of such tumors entirely from the true cysts, likening them rather to "the arrangement of the capsular ligaments of joints attached around the articular ends of the long bones than to genuine cysts." The solid matter which forms the growing portion of such tumors consists in large proportion of cells, usually spindle- or awn-shaped, and rapidly growing into imperfect fibrous tissue, constituting the " libro-plastic tumor" of Lebert, or the "spindle celled sarcoma" of later i)athologists. Tlie im- perfect imitation of the gland-tissue characteristic of adenoma is also often met with in portions of these tumors, and this fact, together with the occasional coexistence of the firm adenoma (or chronic mammary tumor) with such seroc3stic growths, of which an excellent di-awiug will lie found in Mr. Birkett's essay (Syd. of Surg.., vol. v, p. 257), has led him to classify the sercKjstic tumor as a variety of adenoma. Opei-alionn. — At the same time, even if we allow that the two are varieties of the same form of tumor, the}' are vai'ieties which are char- acterized by the very important difference that in the (irm, hard, lobulated tumor which Sir A. Cooper described as chronic mammary, in which there are no cysts, in which the fibrous tissue forming the framework of the adenoid growtli is well developed, and the whole mass free from juice, I'ccurrence after removal hardly ever takes place ; nor is it necessary to lemove more tlian the tumor itself A free incision having been made tiirough tiie cajjsule of the new growtli, tlie latter should l)e enucleated, the l)reast being preserved, and especial care being taken not to interfere witii the nipple or the large ducts converging to it, particularly if the SIMPLE CYSTS. 863 jjatient is likely to have children. She may then he confidently assured that no recurrence is probable. But in the serocystic tumors, when the fibro-i)lastic or sarcomatous element prevails in the solid growth, the case must always be looked upon with apprehension ; for such tumors do unquestionably recur, and they are the more prone to do so the more succulent, loose, and imperfect their tissue is, and perhaps the older the patient is at the time of their forma- tion. This recurrence takes place g-enerally only in the scar itself, and I have seen several cases in wliich the patient has i)reserved her general health entirely unaffected after the disease has recurred many times. In one remarkable case in Mr. Cjesar Hawkins's i)ractice at St. George's Hospital it was not till after ten recurrences and eighteen 3'ears' dura- tion of the case that the patient finally succumbed to exhaustion pro- duced l)y the sloughing of tlie tumor, which at lengtli it became im- practicable to extirpate. But I have known one instance in which a serocystic tumor recurred in the other breast. These circumstances should teach caution in prognosis, and should incline the surgeon rather to remove the whole breast than merely extirpate the tumor whenever the growth is large and advancing rapidl}', and particularly if the patient be_somewhat advanced in years, or be from any cause unlikely to suckle. Diagno^U. — The diagnosis between simple adenoma and lobular in- duration has been given under the latter head. From cancer there is usuall}' no difficulty in distinguishing it, if the case l)e kept for some time under observation, looking to the age oH the patient, the non-im- plication of the gland or skin, the absence of the stabbing pain of cancer, the more lol»ulated feeling and less firm consistence of the tumor, and the almost imperceptible progress of the disease, though an incipient cancer is not uncommonly mistaken for adenoma on a single examination. The diagnosis between the seroc3'stic tumors and the softer forms of cancer is sometimes by no means easy ; for even if the presence of cysts has been ascertained, such cysts may exist in a mass of medullary cancer. But the rate of growth of the two diseases is very different — the skin is un- affected in the serocystic tumor, or if adherent is not infiltrated and brawny as in cancer ; nor are there the large superficial veins, and the great general vascularity which are found in cancer. However, if the growth be advancing rapidly, it is better to pronounce a very guarded diagnosis before removal, and to insist on the necessity of extirpating the whole breast; and when the skin has given way and the tumor is fungating out of a large opening, tiie diagnosis is the more diflicult, and the removal of the entire breast more obviously necessary. The condi- tion of tlie surrounding skin is the cliief element in diagnosis during this stage of a serocystic tumor. Tlie edges of the ulcer are sharp-cut, and the neighboring skin thinned ; while in the cancerous ulcer the edges are prominent and hard, and the cancerous matter is infiltrated for some distance around. Simple cyds also occur in the breast, in which no solid growth ever takes place. Some depend on obstruction of the ducts of the gland and contain a tenacious mucoid fluid. Such obstructed ducts forming small cysts will very often be found, on careful examination of the breasts of women who have borne children, and in whom the cysts have remained so small as never to occasion any symptoms. At other times, oftener in those who have borne children, one or more of them increase till they project under the skin and attract the patient's attention. Other cysts, also, sometimes form in the neighborhood of the nipple, usually earlier 864 DISEASES OF THE BREAST. in life than the duct-cysts, and in women who have not borne children, containing a simple watery serum, with only a slight proportion of albu- men. Tliese simple cysts require only a i)uncture, with pressure or stimulating lotion afterwards. The puncture may be repeated if the cyst fills ai>ain,"or it may ))e laid open and made to granulate. Sometimes the tumor bursts of itself, and then usually disappears. i)/i7A'-c!/s/.s, or " galactoceles," are tumors wliich form during lactation either from mere dilatation of an obstructed duct, or from its rupture and effusion of the milk into the neighboring tissue. They may subside on the cessation of suckling, to recur at each of the following pregnancies, of which Mr. Birkett gives a remarkable instance; and as the contents thicken they may present a considerable resemblance to a sold tumor. The cases are rare and the diagnosis will be difficult unless the patient has been under observation, and the sudden development of the tumor during suckling has been noticed. Generally they are not diagnosed till after a puncture has been made, wlicn the cyst must be emptied and made to heal by granulation. Rarer Forms. — There are other forms of innocent tumors which are met with, though very rarely, in the female breast. The expression "hydatid disease" in the older authors usually means cystic or serocystic tumor; but echinococci are sometimes found in laying open what have been taken for common cysts or abscesses. Common fibrous or fibro- cellular tumors are also found, but can hardly be diagnosed before re- moval. Fatty tumor may of course form in the adipose tissue over the breast, though I cannot remember to have seen a case ; and a few cases of enchondroma are on record. The main point in these cases is to distinguish them from cancer, in order to preserve the breast if possible. The precise anatomical form of the tumor is generally only ascertained after removal. Cancer. — Scirrhus is the form of cancer most commonly met with in the female breast, though medullary or soft cancer is not very uncommon. Isolated examples of colloid are to be found here and there, and have been known to run a definitely malignant course; but the nature of the disease can hardly be diagnosed before removal, nor is the prognosis by any means certain. As usually seen, cancer of the breast presents itself as a small, hard, stony lump situated in the thickness of the gland, and the size of tiie breast is noticed not to be much increased, even as the tumor enlarges, since the tissues around shrink as they become adherent to the tumoi-. This same shrinking of the tissues and the adhesion of the cellular tissue to the tumor produce the dimpling of the skin and the retraction of the nipi)le whicii are so often seen in cancer. The adhesion, however, may take place "in the other direction, causing the tumor to be- come attached to the i)ectoi-al muscle, or even to the ribs. Later on tiie cancer infiltrates the skin, and then ulcerates, fungating out of the ulcer in large bleeding masses if it be of the soft kind, or else producing the scirrhous ulcer. Cancer of the breast is accompanied by lancinating pain in the chest and neck and down the arn), by wasting and ultimately by cancerous cachexia. The axillary glands become enlarged, and some- times also the subclavian and other cervical, or even the mediastinal glands. The arm often becomes u?den)atous from the pressure of these enlarged glands on the veins; and in some cases the skin becomes ex- tensively infiltrated and matted to the deeper parts — "hidebound cancer." Cancer in the breast appears oillier in the form of a detined mass sepa- rated from the gland by a distinct capsule, or infiltrated throughout the CANCER. 865 glaiul-tissne, or containing cysts which may be formed by the softening of its texture, and according to Mr. Birlvctt by tlie etfiision of tiie juice of the cancer into tlie envelope of the tumor. It occurs usually between the ages of thirty and lifty. Out of 458 cases tabulated by Mv. Birkett, 100 occurred in the decade between thirt}' and forty, and 198 between forty and fifty. This shows that the occurrence of the disease is relativel}^ most common towards the period of the cessation of the catamenia; 3et in examining the particidars of 100 cases, Mr. Birkett failed to detect any connection between the two events, and he equally failed to prove the coi'rectness of the common opinion that cancer is more frequent in the single than the married, and in the sterile than in those who have borne children; or any connection between the growth of cancer and imperfec- tion in suckling. It is noticed that cancer liardly ever begins during pregnane}' or suckling, though it is not rare to see cancer in a suckling woman, the disease having begun before pregnancy. Diagiiosh. — The diagnosis of cancer from innocent tumor rests on the more advanced age of the patient, on the hardness of the tumor in scir- rhus, its rapid growth and great vascularity in the soft form of cancer, the early implication of the skin and cellular tissue around, leading to dimpling and retraction of the nipple,' the affection of the glands, the state of the general health, the characteristic pain (which, however, like pain of all other kinds, is liable to be simulated by mere nervous affec- tion), and lastly by the occasional deposit of cancer in remoter organs. Question of Operatioii . — When the diagnosis has been made the ques- tion of the removal of the disease has to be discussed. There is not, I think, any convincing evidence either way as to whether the operation prolongs life, or shortens it, on the average of a large number of cases, l)ut 1 do not see tliat this tells conclusively either for or against the o[)erati()n. The operation frees the patient for a time from the oppres- sion of a disease which is known to be gradually advancing to a fatal issue, it renders the interval (allowing that the cancer recurs) one of complete health for the greater part of the time instead of being a period of pain and anxiety, it gives the patient a chance, however slender, of immunity from- recurrence, and in many cases the cancer recurring in an internal organ, such as the liver, terminates life in a less painful manner than by the spread and ulceration of an external tumor. The operation, in these days of anaesthesia and of rapid healing of wounds, is not one of much danger or suffering. The ('ontraindications to the removal of the breast for cancer are either absolute or partial. The spreading of the cancer so far into the skin or neighboring parts that the surgeon cannot operate through healthy tissue, the implication of the glands beyond the axilla (in the subclavian trian- gle, or higher in the neck) the deposition of cancer in other ])arts, or an advanced condition of cancerous cachexia, are absolute contraindications. The infiltration of the skin to any extent, however small, the ulceration of the tumor, or an}' implication of the axillary glands, are very unfavor- able conditions, though under certain circumstances the surgeon may be justified in operating. It is true that all the visibly diseased skin may be removed with the breast ; that the removal of an ulcerated and bleed- ing mass ma}^ produce great temporary relief; and that all the visibly en- larged axillary glands may possibly be excised. The latter point, how- 1 Retraction of the nipple is met with occHsionally in non-cancerous tumors, from adhesion of the cellular tissue of the nipple to some portion of the tumor which bo- comes drawn in by the growth of neighboring portions, but it is far more common in scirrhus- 55 866 DISEASES OF THE BREAST. ever, is always doubtful, and the surgeon will often discover when lie opens the axilla, ex])ccting only to find one or two small scirrhous glands, that in reality the whole chain of glands is implicated, and that he is committed to a deep and dangerous dissection, which possibly has ulti- mately to be abandoned without the whole of the diseased glands having been removed. But however comi)lete the apparent removal may have been, a speedy return of the disease in the cicatrix may always be prog- nosticated under the conditions specified, so that the operation must at the best be regarded as only a palliative. Repetition of Operation. — With regard to the repetition of an operation, the same considerations exactly apply. Under circumstances which would have justified the original operation it may be repeated, and even more than once, in the cicatrix. t/'se of Caustics. — That cancerous breasts ma}' be successfully removed by caustics is amply proved by experience. The method is much in- ferior to removal by the knife, being slower, more painful, and less cer- tain to expose healthy tissue ; but the fear of a cutting operation renders the alternative acceptable to many, and the cancer-curing quacks make a livelihood chiefly V)y concealing some of the common potential caute- ries — generally chloride of zinc — with some inert nostrum. On the whole, the chloride of zinc is the best of these caustics, and is, I think, best used on the method of Maisonneuve, "cauterization en fleches," which will be found described in Chap. XLIY. The method introduced by Fell, of destroying the skin by means of some strong acid, then scoring the. exposed surface and stufhng the incisions with the chloride of zinc paste saves some time and pain. Treatment of Ulcerated Cancer. — It is, however, in the treatment of cancerous ulceration that the application of caustics is most frequently advisable. When the ulcer is of limited extent the caustic often gives little pain, and tiie separation of the eschar is sometimes followed by temporary cicatrization. Otherwise nothing can be done in ulcerated cancer, except to keep the part as free from odor as possible with some of the tarry solutions, and to soothe pain with morphia. I have found nothing better than tlie carbolic lotion covered with carded oakum. But the patient may get tired of the odor of this dressing, and then solution of chloride of zinc, or Condy's lotion, or solution of terchloride of carbon or chloride of potash may be used, mixed with laudanum or belladonna. The balsam of Gurjon, recently introduced, and the boracic acid lately recommended by Prof. Lister for its deodorizing qualities, have not an- swered in the trials I have made of them. Removal of the Mamma. — In amputating the mamma it is always advisable, whenever it can be done consistently with removing the whole disease, to leave sufficient skin to cover the wound without any tension. The nipple should be included lietween two curvilinear incisions, which are generally made to lie above and below it,^ though this is a matter almost of indilference. The angle of junction of the incisions outwards can easily be i}rolonged into tlie axilla, if any glands are to be removed from thence, and this better than to make a separate small incision over the glands themselves. The lower flap is to be first dissected back, down to tiie base of the tumor or of the breast, then the upper, these flaps being made as thick as is consistent with keeping well away from the disease. The breast being now fully exposed is to be forcibly drawn away from the pectoral muscle, and the cellular tissue which unites them divided by 1 See Fiir. 396. AFFECTIONS OF THE NIPPLE. 867 rapid strokes of the knife, the assistant putting his fingers on tlie bleed- ing vessels, whieh should then be rapidly secured with carbolized catgut ligatures. When all bleeding has been thus commanded, the wound is to be united by sutures, and dressed according to any plan which the surgeon prefers as likely to procure speedy union. Very often a large part, and in some rare cases the whole, of the wound unites by primary union. DiHea.Hes of the Mavimilla. — Malformations are common in the nipple. It is sometimes bifid, sometimes multi[)le, far more often deficient or ill- developed, and such ill-developed nipples are fruitful causes of trouble in suckling, as pointed out above. It may be possible, in some cases, where the nipple is merely short but otherwise natural, to draw it out by con- stant well-directed pressure l)y means of a breast-pump, and the attempt is worth making in a married woman before she becomes pregnant, or during pregnancy. Inflammation of the nipples and small ulcers or cracks on them are ver^^ common, especially during a first suckling. The ulcers should be carefully cleaned, covered with fine powder, as oxide of zinc, dusted on them through a muslin bag; or coated with collodion, and protected by a shield from direct contact with the infant's mouth. When abscess forms near the nipple it should be allowed to burst, or at least to come close to the surface, for fear that in opening it the milk sinus should be wounded. The nipple and areola are occasionally found to be the seat of epithe- lioma. I once treated a case of this kind in a married lad}', who from some malformation had (as I was informed) never been capable of com- plete sexual intercourse. Tlie nature of the disease was indubitable, and was proved afterwards by microscopic examination. There was a small hard gland in the axilla, which was not removed ; but the nipple and areola were fully excised. I saw her five years afterwards in perfect health, and the gland had quite disappeared. Such a case, however, should be carefully watched ; and on the appearance of any recurrence and extension of disease to the breast the whole organ should be removed. Sir J. Paget has lately called attention^ to the frequency with which an obstinate eruption of the nipple and areola, reseml)ling eczema or psoriasis, is the [jrecursor of cancer in the mammary gland. Tlie erup- tion is very rebellious to treatment, and usually persists till the period at which the cancer appears. He has noticed lifteen cases, in all of which the cancer showed itself within two, and in most within one year after the eruption. The cancer is not continuous with the diseased nipple, but grows in a remote part of the gland. In such cases, particularly when cancer is known to have existed in the patient's family, he believes the diseased skin ought to be removed or destroyed. The nipple is sometimes the seat of common sebaceous or cystic tumors and of naevi, but their treatment is the same as in other regions. Great care, however, must be taken not to induce deformity by an}' operative measure undertaken for their cure. Disease)^ of Male Breast. — Analogous affections sometimes though rarely attack the male breast. The irritation which in male infants sometimes leads to a secretion of milk has been spoken of. In later life tumors form in the male breast, which are usually of a scirrlious nature, sometimes fibrous, and I have once seen a case of serocystic tumor, precisely like 1 St. Bartholomew's Hosp. Keports, vol. x, p. 87- 868 DISEASES OF THE THYROID BODY. the same disease in the female/ The disease occurred in a man aged 54. The diagnosis of tliese artections is mucli the same in the male breast as in the female. Any growth which forms in this situation should be at once removed. CHAPTER XLII. DISEASES OF THE THYROID BODY. Endemic Goitre. — The tiiyroid gland is liable to an endemic enlarge- ment, which is called goitre, and which prevails extensively in the val- leys of many mountain regions in various parts of the globe, from some cause which is not completely understood. Cretinism also prevails usually in the same locality', either in the same or different persons. In this coun- try the endemic form of bronchocele is known as " Derbyshire neck," from the place where it chiefly prevails. This endemic disease seems sus- ceptible of little alleviation, either from prophylaxis or treatment, nor can it be till its cause has been discovered. Sporadic^ or Common Bronchocele. — More important in practical sur- gery-, though far less so in public hygiene, are the sporadic cases of bron- chocele which are seen prett}^ commonly in all parts of the country. Most of the patients are females, and usually unmarried. There is very com- monly some menstrual irregularity; yet the general health is often per- fectl}- good. The disease consists in an enlargement of one or both sides of the thyroid body along with its isthmus, the enlargement being gen- erally most marked on the right side. Sometimes it extends behind the sternum. It often causes distressing dyspnoea from pressure on the trachea, and has been know^i to produce death from this cause.^ Some- times, also, it seems to cause loss of voice from pressure on the recurrent laryngeal nerves, or even spasm of the glottis from irritation of the same nerve, and I have known a case wdiere the tumor burst, and suppuration threatened to prove fatal. The structure of the tumor usually consists of one or more large cysts, surrounded by the hypertrophied gland- structure, or it may be entireh' solid. The treatment of the disease which is most relied upon is by the ex- 'ternal and internal use of iodine, due attention being given to the gen- eral healtli, and especially the menstrual functions. Dr. Morell Mackenzie has lately'' called attention to the benefit which may be produced in cystic broncliocele by the injection of pefchloride of iron. His plan is to tap the cyst, then to inject 5j or 5ij (according to the size of the cyst) of a solution of percl)loride of iron (5ij : 5J) vvhich is left in the cyst for about three days, the canula being plugged and retained, when the iron is 1 St. George's Hospital Mugeum, Ser. xv, No. 50. 2 Sfte a case related by Dr. Dickinson, Path. Trans., vol. xii, p. 229. 3 Clin. Soc. Trans., vol. vii, p. 115. CANCER. 869 allowed to escape, and the part is poulticed, the plug being still retained until suppuration is fjiirly established, when it may be removed. In fibro- cystic bronchoceles after the cysts have been thus obliterated the solid part is treated b}- subcutaneous injection of iodine, but this is undeniably dangerous. These cysts are often treated by seton, a practice which, though it is sometimes very successful, is not witliout its dangers. Removal of Bronchocele. — In some cases it seems to me justifiable to remove sucli tumors, i. e., either where they threaten to prove fatal by great and increasing pressure on the windpipe or other structures in the neck, or when as in my case (recorded in the Am. Jour, of Med. Sci., Jan. 1873), the tumor has burst, and the suppuration is exhausting the patient. The operation is a formidable one, but has often been performed with success.' In cases where the tumor is so very large as it was in the one which I operated upon (where it hung down below the mamma) flaps must be carefully dissected off it, and its base must be commanded by an ecraseur, or some form of clamp, while tlie mass is removed. In smaller tumors, the best plan seems to be to lay open the capsule freely and enucleate the mass with the fingers as rapidly as possible, without paying any attention to the bleeding till the tumor is removed. Exophthalmic Goitre. — A singular malady affects the thyroid body amongst other parts, which is generally called exophthalmic bronchocele, from the protrusion of the eyes, which is one of the prominent symp- toms. There is palpitation of the heart, great I'apidity of the pulse, extreme prominence of the eyes, and a large soft pulsating swelling of the thyroid body, in which a musical brait can often be heard, and which varies greatly in size. Another prominent s^^mptom is the jerking pulse in the carotid arteries. In one unfortunate case I saw^ both cornene slough and the eyeballs wither away in consequence of their continued exposure. This form of bronchocele is sometimes accompanied by organic disease of the heart, otherwise it is not very dangerous to life, and under proper treatment there is a good chance of recovery. It often depends in some measure on mental causes, and is frequently associated with irregular menstruation. All concomitant circumstances of this kind being ascer- tained and treated as best may be, digitalis and iron seem to be the most promising internal remedies, and ice to the thyroid tumor the best local application. The reader is referred to works on Medicine for a fuller account of this affection, which falls more commonly under the physi- cian's care. Cancer occurs in the thyroid body; but it is very rare. Mr. Holmes Coote refers, however, to a few cases recorded by Mr. Caesar Hawkins and other authors ; but the disease is not within the range of surgical treatment. 1 See especially a paper by Dr. Greene, of Portland, Maine, in the Am. Jour. Med. Sci., Jan. 1871. 870 SKIN DISEASES. CHAPTER XLIII. DISEASES OF THE SKIN AND ITS APPENDAGES. It seems necessary to give in this work a general idea of the diseases of the skin, although the subject is so extensive, and the practical con- siderations connected with the treatment of skin diseases are so very numerous and complicated, that it is quite impossible for me to attempt anytliing here beyond the liarest outline, and this chiefly with the view of rendering what has been said in previous pages intelligible. But in order to acquire a useful knowledge of the matter and to be able readily to distinguish the various eruptions from eacli other, it is absolutely necessary to stud}^ these diseases in the living body, comparing the erup- tions seen in the out-patient rooms or in the wards with the drawings and descriptions which are given in approved authors, and with the models to be found in the Museum of the College of Suroeons and else- where. Affections of the cutaneous system are divided into those of the skin itself, and those of its appendages, the hair, nails, and cellular tissue. We will speak first of the eruptions of the skin itself. The anatomical classification of these eruptions is the most obvious and the most useful in practice — viz., into 1. Exanthemata or rashes; 2. Haemorrhages ; 3. Vesicles ; 4. Parasites : 5. Blebs ; 6. Pustules ; 1. Papules; 8. Scales; 9. Tubercles; and 10. Stains — to which certain conditions are to be added, named " Xerodermata," resulting from un- natural dryness of the skin. Exanthemata — or rashes — are eruptions characterized by the occur- rence of patches of skin which are injected and red, and thickened in consequence of being injected, but in which there is not necessarily any inflammator}^ effusion. The epidermis usually desquamates on the sub- sidence of an exanthematons eruption. The skin eruptions which are properly classed as exantliemata are roseola and erythema. Urticaria so closel}^ resembles some varieties of erythema, that it is usually described along with it, though it is not truly an exantliem. Many fevers are accompanied by exanthematons erup- tions ; but they are not spoken of here, since in them the eruption is only a subordinate symptom. I have enumerated and described the varieties of erythema in a pre- vious chapter f p. 67 ) in connection with erysipelas, so that the only trul}^ exanthematons disease left for description here is roseola. Boseola. — This arises from various causes, but is always of constitu- tional origin.' It is characterized by small rose-colored spots, or a roseate mottling of the skin. Some of its varieties (R. infantilis and R. testiva) approach very nearly in character to the eruption of measles, and are ac- companied by some fever and sore throat, but are not marked by the ' " The eruptions proper to tj'phus fevor, measles, typhoid fever, scarlet fever, and cholera are in reality roseola." — Jenner. •PURPURA SCORBUTUS. 871 coryza of measles. These varieties sometimes bear the name of " mor- billi nothi " — bastard measles. Another form of roseola is that wliicli sometimes precedes the small-pox ernption, and occasionally tliat of cow- pox. Roseola also is found in gout and rheumatism. Another form of roseola is found in definite rings — roseola annulata— hardly to be dis- tinguished from erythema marginatum. This is merely a symptom of deranged digestion. In fact, all these A'arieties of roseola are in them- selves insignificant, although the constitutional condition on whicli they depend may be of the gravest possil)le import. The varieties of roseola which constitute substantive diseases require only attention to the state of the digestive organs, and in infancy to that of the dentition, with mode- rate purging and free action of the skin. Syphilitic Roseola. — In 3'oung persons, especially girls, suflfering for the first time from S3'philis, an eruption is constantly' seen which is classed by many under the name of roseola, less red in color than the non-syphilitic varieties of the disease, and nearly allied to pityriasis. Like tlie latter eruption its favorite seat is the chest. It will rapidl^y disappear under the endermic use of mercury. /%.- Urticaria, or nettlerash, is usually described along with the exan- themata, though not properly belonging to that class ; since in urticaria there is not only redness fading on pressure, as in tlie exanthematous eruptions, but also elevated flat patches of skin called wheals or "pom- phi." These wheals are seated on the red patch of skin, and they testify to the effusion of serum into the tissue of the cutis, just as the wheals which occur in insect bites do, and as the wheals which follow a lash testify to effusion into the substance of the skin. These wheals tingle and burn like the stings of nettles. Urticaria is excited by all sorts of causes which disturb digestion; errors in diet, especially the eating of sliellfish, by those with whom it acts as a kind of poison, or from local irritation of the skin. These kinds of urticaria are acute and transitory, and can be cured by the witlidrawal of their causes, an emetic, if needful, and a mercurial purge. There are other varieties of urticaria which are chronic. In some of these .the individual wheals disappear while others come out — U. evanida; in others, on the con- trary, they are persistent — U. perstans ; other minuter differences in the arrangement and size of the wheals are expressed by the terms U. con- ferta, U. tuberosa; and a kind in which the causes and the symptoms of urticaria are present, the burning, tingling, etc., but no wheals are seen, is called U. subcutanea. In these more obstinate cases of urticaria the first care is to soothe the irritation of the skin by some wash. Lemon-juice or vinegar often succeeds. Mr. Erasmus Wilson prescribes Hydr. Per- chlor. gr. v-x, Sp. Roris marini, Sp. Vin. Tenuior., aa |j, Emuls. Amyg- dal. amar., ^vj. A dilute solution of prussic acid and almond emulsion is often very grateful. The next point is to discover and correct any error in diet or regimen, and to try the effect of copious diaphoresis, combined with change of air, strong exercise, and sea bathing. In other cases, arsenic, quinine, colchicum, or alkaline medicines have acted bene- ficially. Pii?'pura — Sco7-biitus. — The haemorrhagic diseases of the skin are pur- pura and scurv3\ Purpura is characterized by spots (petechifB) or large patches (vibices) of ecchymosis under the skin, which are easily distin- guished from every other form of spot by their persistence under pressure, and by their changing their color with time, as bruises do. Purpura hsemorrhagica is a severer form of the disease, in which blood exudes 872 SKIN DISEASES. from the mucous cavities, as in liremophilia (p. 105). Purpura is merely a symi)tom of some disorder of tlie healtli or tlie blood, and its treatment must depend on a thorough knowledge of its cause. Without this the ordinary astringents and hjumostatics will be prescribed in vain. Scurvy is a specific disease, and in no other sense a disease of the skin than that one of its symptoms is subcutaneous haemorrhage in the form of vibiees and petechia, just as the bleeding of the gums is another and still more prominent symptom. Vesiculse. — A vesicle is a small elevation of the epidermis, which is separated from the true skin by the effusion between them of a clear serum. This is usually the result of inflammation, and accordingly the neighboring skin is generally seen to be red and congested. The vesicular eruptions are sudaniina, miliaria, eczema, and herpes. Sudamina and Miliaria. — The two first fall within the province of the physician, sudamina being tlie small clear vesicles which appear in the course of certain fevers, apparently only as the result of obstruction of the sweat-ducts ; and vanish in a day or two. Miliaria are vesicles which are found in acute rheumatism, and in children or adults with very tender skin in the summer months, often mixed wath roseola, and dis- play more distinct traces of inflammation than sudamina do, being sur- rounded b}' a red halo, and easily passing on to suppuration. In some cases a fever accompanied b}' miliary vesicles (miliary fever) prevails as an epidemic. Eczema is the commonest of all skin diseases. It is characterized by the eruption on patches of inflamed skin of a thick crop of small vesicles, together with scattered vesicles each surrounded by its halo of vascular- ity, but unaccompanied by any diffused inflammation of the skin. The vesicles burst and tlie epidermis then may form scabs or scales on the surface, so that the erui)tion in this state may appear to be squamous; or, on the other hand, the fluid in the vesicles may become purulent, and then the eruption will resemble the pustular — impetigo. Successive crops of vesicles may make their appearance as the former die away. The fluid is strongly alkaline in reaction, and often as it oozes away it seems to scald or burn the skin, and a smarting sensation in the parts often accompanies the eruption, and justifies its appellation. It is a very common eruption on the leg, and is often accompanied by an ulcer — the eczematous ulcer aljove described (p. 413). Eczema is often nearly allied to gout, and the urine accordingly will be found to contain lithic acid or oxalate of lime. Varieties of eczema are described by Hebra without an}^ vesicular eruption — i.e., a diffused inflammation of the skin resembling eczema in its constitutional complications (or rather caus^es) and in its seat, but characterized by the separation of the epidermis from the skin in papules, scales, or pustules, instead of vesicles. The papular form would be classed V)y others as lichen eczematodes, the scaly as pityriasis rubra, the pustular as impetigo or eczema impetiginodes ; but the difi'erences are obviously immaterial. The recognized varieties of eczema are E. simplex, when the inflam- mation of tiie neighboring skin is not severe; E. rubrum, when the skin is much inflamed ; and E. impetiginodes, when the vesicles raj)idly sup- purate or are mixed with pustules. Hebra describes a form as E. margin- atum, wjiich is by many writers considered to be syphilitic, and there is no question tiiat eczema may appear as a secondary syphilitic eruption, though it is not a common sj'mptom of s^'philis. HERPES. 873 Eczema appears at all periods of life and in all parts of tlie body. "The face, the hairy scalp, and the skin beliind the ears are all common seats of eczema ; but there is no part of the trunk or extremities which it may not, nay does not, frequently affect. Befoie and during- the first dentition, eczema is by far the most common of the diseases of the scalp." — Jenner. It is never contagious. Its causes are constitutional and local; the latter being the n)ost easily cured, by withdrawing the irritation on which the disease depends. The kinds of eczema wliich depend on gouty, strumous, diabetic, and other constitutional conditions are often excessively obstinate. The treatment will consist in the first place in discovering and, if })os- sible, counteracting the causes on which the inflammation depends, tlien in diminisliing the inflammation of tlie skin by soothing and slightly astringent lotions or ointments, accompanied, of course, by suitable posi- tion of the parts, with moderate purgation and an antacid regimen if the condition of the urine indicates it; and in the more chronic condi- tion, when the disease api)roaches more to the scaly eruptions, by the application of some of the tarry substances (such as the ung. picis liquidae or the petroleum Barbadense) with a course of arsenic. If S3'philis be present or suspected, a mild and prolonged course of mercury or mercurial fumigation should be tried. When the scalp is affected, the hair must be most thoroughly and carefully removed with scissors, and the scales and scabs detached by a cap of gruel or a bread and milk poultice or linseed oil ; after which Sir W. Jenner recommends the ap- plication of liquid pitch if there is not much inflammation. While the eruption is in the ''weeping" stage the discharge must be absorbed by blotting-paper, or wet strapping, or soda lotion (soda snbcarbonat. 5iJ5 aquae Oiss.). Herpes is an eruption of vesicles situated in small groups on slightly inflamed skin. It diff"ers from eczema in many respects, chiefly in the fact that the vesicles form a far more prominent feature of the eruption than in eczema, and the inflammiition of the skin is far less marked. The vesicles also are usually larger than in eczema, and the fluid which they contain is less alkaline. There is also no such connection witli chronic constitutional disease, or with any abiding local irritation as is constantly found in eczema. The varieties of herpes are as follows : Herpes labialis is a very common affection which occurs sometimes from cold, but often with no affection of the health whatever. The ves- icles become more or less pustular, then crack, and the scabs fall off and leave the skin below a little irritable for a few days, tlie whole affair being generally over in about a week. The prepuce is another common seat of herpes, and these little cracks, occurring after suspicious connection, often cause the patient much alarm. Their numbei' and their perfectly superficial situation will disclose their nature, and the ai)i)lication of a little mild mercurial ointment will in a few days remove all cause for ap- prehension. No treatment is required for these simple forms of herpes beyond a purge, some care in diet, and the use of citrine ointment, or an ointment of gray oxide of mercury, gr. x-xv to the oz. Lemon-juice is a favorite application in herpes labialis, and there are a thousand do- mestic remedies for what is after all a spontaneously curable affection. Another form of herpes follows the distribution of one of the sensory nerves, and is often complicated by severe neuralgia of that nerve. The best known example is herpes zoster or shingles (cinguhim, a girdle) which follows the distribution of one of the intercostal nerves, extending 874 SKIN DISEASES. from the back to the sternum/ This is generally preceded b}'^ some fever and severe pain in the part, and often neuralgia persists in the part for some time afterwards. The eruption runs its course in about a fortnight, and is said seldom to affect the same individual twice. It requires in itself no treatment beyond a purge and some soothing application. The neuralgia which it leaves behind may require prolonged and careful man- agement. Other forms of neuralgic hei'pes occur in the face, following the distril)ution of the fifth nerve, and sometimes complicated with iritis, and iu other nerves also, but more rarely. Herpes jihlyctenodes is a variety found on the face, in which the vesicles are unusually large. H. iris is a rare variety in which there is a ring of vesicles arranged around a central one, and each surrounded by concentric circles of various shades of red. It is found usually on the back of the hand. H. circinnatus is when the eruption occurs in a red ring and spreads from the centre. Sometimes the vesicles are large, and it runs the ordi- nary course of herpes in other parts, disappearing in about a fortnight. But the form of the disease in which the vesicles are so minute that they often pass unnoticed, and the eruption appears to be of a furfuraceous character, is exceedingly obstinate, and is known in popular parlance as "the ringworm." It occurs on the face, trunk, and extremities, and is contagious; is often mixed with the parasitic disease — tinea tonsurans — on the scalp ; and its secretions seem to afford a nidus in which tlie para- site grows. The eruption spreads centrifu gaily ; the original ring disap- pearing and giving i)laee to a larger one, and so on. Its causes are local, and it is curable by local treatment — the ap[)lication of strong astringents, as sulphate of iron or gallic acid — of strong acetic acid, nitrate of silver, or blistering fluid. Parasitae. — The diseases excited on the skin by the growth of a vege- table parasite are tinea tonsurans, tinea decalvans (possibly), tinea favosa, tinea sycosis or simply sycosis (mentagra), and chloasma or pityriasis versicolor. Tinea tonsurans is exceedingl}' like herpes circinnatus ; so much so that by some they are classed as the same disease, and both are included in the popular term " ringworm." It is seated on the hairy scalp, and is only seen in children, seldom before two or after twelve. It appears in round patches covered with white scales, and here the hairs are so com- pletely I'emoved that the places seem to have been shaved; but on minute examination, short thick twisted hairs will be found among the scales, and the hair-follicles can be detected, and after its cure the hairs will always grow again. The disease is caused by the growth in the hair of a vegetable parasite — the trichophyton tonsurans.^ This imbeds itself in the secretion of the hair-follicles which is believed to be unhealthy, and as it grows into the hair it causes it to swell and become brittle, so that it breaks off and comes away. The spores of this plant may be found also in the epithelium of tiie patch, which is heaped up in opaque white scales. The treatment is directed to the destruction of the parasite. Strict * In some cases it is found in the course of the intercosto-hunieral branch as well as the intercostal trunk. ^ I must rct'or the reader to some of the special treatises — such as that of Mr. Nayler — for the microscopical appearances of these parasitic fungi. In the judgment of some dermatologists, as Dr. Tilbury Fox, they are all different stages of growth of the same plant. RINGWORM. 875 cleanliness must be enforced, the epithelium removed by a lotion of borax, and an ointment rubbed in twice a day to destroy all the spores of the fungus. Sir W. Jenner recommends 5 grains of the aminonio-chloride of mercury to tlie drachm of sn][)hur ointment for tliis purpose ; or 2 grains of the perchloride to the draclun of lard ; or 30 grains of nitrate of copper to 4 drachms of lard ; or 10 drops of creasote to the drachm of lard ; or strong blistering fluid or strong sulphuric acid, tlie part to be washed directly afterwards with cold water. Tinea Becalvans. — In so-called tinea decalvans the hairs are completely removed from the scalp, and sometimes from other hairy parts also, in large irregular patches, where the skin is perfectly bald with no trace of the truncated hairs which are found in tinea tonsurans. The skin ex- posed is smooth and paler than natural. This is said to be due also to the presence of a parasite — the microsporon Audouini — which, however, Sir W. Jenner says he has never been able to find either on or in the hairs about to fall from their follicles, nor has Mr. Nayler been more successful in his search foi- these sporules.' There is also no proof that the disease is contagious as parasitic diseases always are ; accordingly in this country the disease is more frequently classed as "Alopecia." The patches are bounded by definite margins, and as these areas fall into each other the whole scalp may become bald ; na}^ I have seen a case in which the whole body was so, no trace of a hair being recognizable on any part. Alopecia is also a common symptom of syphilis, especially common in the secondary syphilis of young girls and in congenital or acquired syphilis in infants. The remedies consist in the application of stimulants to the part. The bald patches should be painted about once a fortnight with blistering fluid, and left alone till the irritation has subsided, when a slightly stimu- lating ointment or lotion is to be applied till the time for the next blis- tering arrives. Liniments or lotions of ammonia seem well suited fortius purpose (see p. 403). Tn syphilitic cases a mercurial course is indis- pensable. Slight cases, especially at early periods of life, and syphilitic cases will probably get well ; in very extensive alopecia, and in older persons, there is much reason to fear that the baldness will be permanent. Tinea favom, or favus, is a very acute and formidable eruption of the scalp in childhood. It is due to the lodgment in the hair-follicles of the sporules of a fungus called the achorion Schonleinii. These give rise to an eruption consisting of brimstone-yellow crusts, cup-shaped, and each having a hair in its centre. These dry crusts are not uncommonly mixed with pustules of impetigo. As these crusts increase they kill the hair on which they form, and thus favus, unless soon cured, may induce perma- nent baldness of the aflTected part. In some cases a peculiar and unpleas- ant odor is perceived (compared to that of cat's urine) but not always. Sir W. Jenner has noted that children affected with herpes circinnatus are peculiarly exposed to the contagion of favus, and has given interesting examples of this fact. The cure of favus, as of other parasitic diseases, is procured by killing the parasite. For this purpose the hairs may be plucked out. The huile de cade is said to loosen their attachment, and the hairs have less than the normal tenacity of implantation in any case, so that when the disease is limited there is no great difficulty ; but it becomes almost impractica- ble when the scalp is extensively affected. No doubt drawing out the hairs facilitates the application of the parasiticide remedies, but Mr. Nayler saj^s that it is by no means necessary, and that after the usual 1 Diseases of the Skin, 2d ed., p. 21G. 876 SKIN DISEASES. preparatory cleansing, tar or the nng. picis liqniili\?, answers every pur- pose. In fact these applications as they separate bring away the hairs with them. Then a saturated solution of sulphurous acid applied on lint covered with oiled silk, or perchloride of mercury in the proportion of 8 grs to the ounce of lard, or acetate of copper, half a drachm to the ounce, are recommended for the destruction of the parasite. Favus affects the hairs of other parts of the body as well as the scalp. It is a rare disease, and only seen in the poorest and most neglected children. It is undoubtedly contagious, though not very activel}' so (see Nayler, op. cil., p. 245). Si/('ox/.-< is a disease of the beard and whiskers, very rarely of any other part, though Mr. Nayler refers to cases in which the eyebrows or the hair of the back of the neck have been att'ected, and I believe cases have been recorded in the female. It is due to the lodgment of a parasite — the mi- crosporon mentagrophytes — in the hair-follicle, the presence of which excites an inflammatory swelling of the follicle, like that of the sebaceous follicle in acne, followed bv suppuration. A hair is seen to traverse each pustule, which would sufliciently distinguish it from acne, to which other- wise it bears a considerable resemblance, as it does to impetigo ; but in sycosis there is much more thickening around the pustules than in impetigo. Sycosis is often very difficult to cure. The patients are frequently out of health, either from intemperance or starvation, so that tlie first thing is to correct either of these excesses, to bring the patient's digestion into good order, and supplj' him with a generous unstimulating diet. The scabs must be removed by poulticing, the hairs removed if possible, and some of tlie parasiticide ointments above prescribed applied. Iodide of sulpliur ointment and white precipitate ointment are the favorite applica- tions, but if the eruption does not yield to one, another must be tried. Chloasma. — Another uiidoubtedly parasitic disease is the one so often seen on the chest and loins,' especially in young people of delicate skin, and in others who neglect cleanliness, and especially who constantly wear the same unwashed flannel. The eruption, however, though favored by such dirty habits, does not arise exclusively from them, for in some cases, persons of scrupulous cleanliness are found to be affected. It never occurs in childhood. It is characterized by the presence of numerous cir- cular brownisii patches ("chloasma"), which, however, vary in shade from yellow to dark-brown, or even a reddish tinge, in different persons, and in the same person at different times, whence its synonym, "pityriasis A'ersicolor." The patches consist of epithelium which is branlike and desfpiamating, and if these scales be removed and examined in an alka- line fluid, or, as Mr. Nayler recommends, in acetic acid, abundant spores and mycelium of the fungus — microsporon furfurans — will be detected, The complaint is a very common one — and is consistent with the most perfect health — the only inconvenience the patient experiences being that his skin is irritable when he gets hot. It is to be diagnosed from "liver-spot" (lentigo hepatica), a very rare disease, which has no scaling of the epidermis and no parasitic origin, and wiiich occurs in childhood as well as in afterlife, — and also from the other kinds of pityriasis presently to be described. Its cure must be sought, as before, in the destruction of the parasite, for which purpose all dirty habits must be reformed, the skin well rubbed, ' Otlier parts of the body iiro occasionally though rarely atToctcd — the face very seldom. BULL^. 877 after thorough washing, with a flesh-brush daily, and then sulphur oint- ment or a lotion or ointment of bichloride of mercury will cure tlie dis- ease, though it is very liable to recur. Like other parasitic diseases it is contagious. Scabies. — The only parasitic animal which causes an eruption is the acarus ncahiei ov sarcopUs hominis, which burrows and hides itself in the deeper layers of the epidermis, and thus gives rise to an irritation which develops a definite erui)tiou — "the itch" — of either a vesicular or pus- tular nature. Tlie intolerable itching excites the i)atient to scratch iiim- self, and thus much aggravates tlie eruption. Scabies is seen first in the adult usually in the hands and wrists, espe- cially in the clefts between the fingers ; in children in arms on the but- tocks. It is known by the itcliing and scratching and by the vesicles or phl^'zacious pustules mixed with small cracks or burrows leading from the bases of some of the vesicles, and marking the spot where the animal may be found if the burrow l)e carefully opened with a needle and searched ■with a magnifying-glass. The remedy for scabies is sulphur, which never fails to kill the animal, if only the disease is not excited by fresh parasites from the clothes. If these are fumigated with sulphur or baked for a sufficient time, and all parts affected with the eruption smeared well over with the ung. sulphuris twice a day, the patient will be well in a few days. Sir W. Jenner says that at the St. Louis Hospital at Paris a cure is obtained in two hours by the patient being well rubbed over with soft soap for half an hour, then smeared with an ointment composed of eight parts of lard, two of sulphur, and one of carbonate of potash for half an hour, and then placed in an alkaline bath. If there is anj^ objection to the color or odor of the sulphur, the former may be concealed by the admixture of the bisulphuret of mercur}', and the latter by a few drops of essence of bergamot. BuUse. — A bulla or bleb diff'ers from a vesicle only in size. It is a cavity between the skin and epidermis filled with serous fluid. The bullous eruptions are two — pemphigus and rupia. Penfphigus^ otherwise called pompholyx, is an eruption of large bulLie, often in small numbers, sometimes even solitary, with little or no inflam- mation around them, attaining in some cases an enormous size, and con- taining pure serum, alkaline at first, which may turn acid and become puriform. The bullae Iturst and the epidermis dries down into a scab, while fresh bulhie probably form. Si/philific pemphigus is sometimes due in infancy no doubt to con- genital syphilis, and this is distinguished from the ordinary eruption by appearing on the feet and hands, and in some other cases it may be a tertiary symptom in later life. It occurs also as an acute disease attended with a febrile disturbance — febris bullosa. It also occurs in an acute form in old and cachectic persons ; but more commonly it is a chronic eruption, and depending on visceral disease. The treatment must be directed mainly to the constitutional condition. In the syphilitic variety iodide of potassium is indicated, with generous diet and opium. In cachectic persons the treatment must var}' with the nature of the cachexia. The blebs should be pricked ; the part pencilled with a strong solution of nitrate of silver (5J : sj), and after the cuticle has been tluis hardened into a scab, this should be detached b}' a poultice. If the cutis be ulcer- ated below, the ulcer should be stimulated with nitrate of silver. 878 SKIN DISEASES. JRiipia originates as a hullons eruption, tlie bulUe being comparatively small and seated on an inflamed base; bnt the contents of the bnllnesoon become purulent, and tlie jnis dries up into a rougli, coarse, prominent scab \vliich remains attaclied for some time, and when it falls off leaves a circular ulcer — the rupial ulcer. Sometimes the ulcer spreads without an}' falling otl' of tlie scab, and then a larger scab forms under the original one and raises it up, and so on until a projecting mass of scab is formed like a limi)et-shell. This variety is called R. prominens. Other varieties are R. escharotica, marked b}' a spreading or phagedenic condition of the rupial ulcer, and R. gangrsenosa, when the surface of the ulcer sloughs. Si/philitic rupia, particularly the R. prominens, is a frequent symptom of tertiary syphilis, especially in cachectic or dissipated persons, but it occurs also in other conditions of general cachexia. In its second stage, when the contents of the bullae have become purulent, it is hardly to be diagnosed from ecthyma, except by the more decided inflammation round the pustules in tlie latter disease. Later on, the prominence of the scab in rupia is plainly distinguished from the sunken adherent scab of ecthyma. The treatment of all forms of rupia must be by supports and stimulants; for the patients are always broken down in health. In the syphilitic variet}', rest, shelter, equable temperature, good diet, opium and sarsa- parilla, should precede an}' specific treatment. Then iodide of potassium ma}' be administered for a long time, followed b}' mild mercurial fumiga- tion. In other cases various tonics and stimulants will be found service- able. In the early stage of the eruption the bulljB should be punctured at once. When scabs are formed they should be removed, and the ex- posed surface dressed with some stimulant. Puipending on syphilis ; often preceded by burning pain in the part from which the pustules afterwards spring. The usual dura- tion of the disease when due simpl}^ to depression of the general health is onl}^ about a fortniglit ; but it is apt to recur or to propagate itself in the form of a constant succession of crops of pustules, and so becomes chronic. In the variety which is complicated with purpura (E. luridum), the pustules are surrounded with an areola of a purple color, in conse- quence of luBmorrhage. The eruptions which follow on the irritation of tartar emetic or sugar, applied to the skin, are variously classed as im- petigo or ecthyma, according as the affection of the hair-follicle is or is not regarded i)y the classifier as an essential character of impetigo. Little local treatment is required in ecthyma. The crusts should not be detached, as they protect the skin below. The part should be de- fended from friction or irritation by some simple ointment, and the same general treatment pursued as in rupia. Fapulse. — A papule, or pimple, is an elevation of the cutis covered by its cuticle ; the elevation being due to ef!"usion of inflammatory lymph into the substance of the true skin. The diseases classed as papular are strophulus, lichen, and prurigo. Stropliulus^ the common "red-gum," is a disease of inftmcy character- ized by the eruption of small pimples, usually red and close together, S. confertus — sometimes white and rather large, S. candidus' — sometimes -with red spots intermixed, S. intertinctus. The eruption is generally due to disorder of the bowels, or irritation about the gums, and is accompa- nied by slight itching in most cases; sometimes, in S. confertus, by a good deal of distress from irritation and cracking of the skin. It will in most cases subside in a few days with some aperient, and attention to the state of the gums and of the digestion. Care should be taken not to confound this fugacious affection with the permanent lichen of congeni- tal syphilis (see p. 407), and not to mistake fleabites or irritation of the skin from dirt, for strophulus. Lichen is characterized by the eruption of a large number of red, prom- inent, hard papules, which retain their shape, and to a great extent their color, under pressure. There is often some itching and tingling about the part, and occasionally' so much febrile disturbance that it is taken for an attack of measles. It is sometimes mixed with urticaria ( L. urti- catus), the papules becoming apparent as the wheals subside. It is a frequent syi)hilitic eruption, generally in the earlier stages of the consti- tutional ati'ection, often becoming tubercular in its progress. Syi)liilitic lichen is known by its coppery color, its appearance in curved figures (L. gyratus), its occasional presence on the soles of the feet, especially in infants, its tendency to crack at the base, and the history or concomi- tant symptoms of syphilis. Other forms of lichen are the L. tropicus or " prickly- heat," a familiar disease in hot countries, and often seen here in hot summers, though in 1 There is an eruption of larger white papules called S. alliidus, whicli, liowever, has been shown to be a form of acne, the elevation being really distended sebaceous follicles. PRURIGO. 881 a milder form ; L. circiimscriptus, where the pimples appear in defined patches ; L. pilaris, where each papule is found on a hair-follicle, and has a hair runnint; IhroutJjh it; L. agrius, characterized l\v the numerous hard rough pimples, generally on the face, where the skin feels like a nutmeg-grater, and by the excessive itching; L. lividns, a step between lichen and pnrpura, where the pimples are dusky-red or livid, and pur- puric spots may be interspersed, showing much cachexia and generally in old broken-down patients, and finally the L. ruber of Hebra, in which large portions of the skin become inflamed and thickened with copious eruption of dark-red papules on it, the thickening of the skin impeding motion, and the disease generally running onto a fatal termination. Sim])le cases of lichen will l»e cured by purgatives, the avoidance of all sources of heat, simple unstimulating diet, and tepid or cold bathing, mucilaginous baths Iteing most to be recommended. In the chronic forms arsenic (as in other dry erui)tions) is of the geatest service. The syphilitic variety is under the control of mercury, and Mr. Nayler regards mercury in small doses as being of service in all forms of lichen. The itching is allayed by sponging the parts with vinegar or lemon-juice, and anointing them with dilute citrine ointment, or by a prussic acid lotion — 3iss. or 5ij of the dilute acid to six ounces of almond emulsion, or of rose-water, to which a drachm of liq. potassa? may be added. Prurigo is an eruption char.'icterized by its itching and by the presence of flattened papules, so much the color of the skin as to be with difficulty perceived in some cases. The itching is increased by any stimulant or by heat, so that it often becomes intolerable in bed. It is often mixed with urticaria. Sometimes there is a sensation as of insects crawling over the skin. P. formicans. Old persons suffer from prurigo, which is then called P. senilis, and is often very obstinate. In younger subjects it usually disappears in a short time. There is no doubt that in many cases the complaint is caused by the presence of lice, and such cases may be cured at once by destroying or baking the clothes, and by free bathing and the application of the white precipitate ointment. There are other cases in which the prurigo is local, usualh' about the genitals or anus — P. podicis, pulvae, scroti, etc. In these cases the designation is usually a misnomer. The disease should be called pruritus, for there is intolerable itching, so that the patient is sometimes withdrawn from society by the impossibility of abstaining from scratching the part, but no pimples can l)e seen. Prurigo or pruritus is also sometimes a sequela of another eruption, i.e., intolerable itching is left in the part from which the previous eruption has disappeared. This is most common after eczema and scabies. The first principles of treatment in prurigo are precisely similar to those in lichen. The patient's bowels must be cleared, his digestion regulated, and all causes of heat and irritation avoided. In pruritus ani, vulvae, etc., any unnatural condition which can be detected must be remedied. The former sometimes depends on ascarides, or on fissure, the latter on the presence of a vascular tumor of the meatus, or on the habit of self- abuse. The most various local applications are in use and appear of ad- vantage ; of these the mercurial lotions and ointments, or lotions of sul- phuret of potassium, sulphur baths and ointments, and prussic acid lotions have the greatest reputation. Whatever is found best to allay the itching should be kept at hand for immediate application when the patient becomes warm in bed, and he should abstain as much as possible from scratching. 56 882 SKIN DISEASES. Sqttama' or scales are collections of dry epithelium, loosely connected to the subjacoiit skin, so that they may be easily rubbed off. Pifi/i'ia!arded as a parasitic animal, and which does often contain a microscopic parasite, the acarus folliculorum. In acne iiidurata tlie hardening and thickeninsf around the tubercles is greater, the tubercles coalesce, causing great deformity, and there is little tendency to suppuration. Acne rosacea is chiefly seen on the nose and parts adjacent, and has been spoken of on p. 594. Acne sebacea is a rare form of acne, characterized by a superabundance of the sebaceous secretion, which sometimes covers the skin, dries upon it, and turns hard and black, constituting what is called (not very ac- curately) spurious or sebaceous ichthyosis. The treatment of acne is in great measure local, consisting in opening the sebaceous follicles l)y bathing and friction, pressing out the secretion from them, and puncturing the tubercles which have suppurated. The tubercles may be lightly touched with acid nitrate of mercury, or strong nitric acid. Lotions of bismuth and mercury, or mercurial and sulphur ointments, may then be useful as permanent applications. At the same time much care must be used in regulating the diet, cor- recting any excesses in it, and forbidding the use altogether of anything which can promote acidity. Syphilitic Acne. — The term syphilitic acne used to be applied to the tubercular eruption so often seen on the face in the later stages of sec- ondary syphilis, but incorrectl}' if the word acne is restricted to an affec- tion of the sebaceous follicles. The color of the eruption, its dense ar- rangement over the face, and the presence of other syphilitic symptoms sufficiently mark its nature. There is not the tendency to suppuration which is seen in true acne, and a mercurial course is generally followed by its rapid subsidence. Molluscum is a singular disease, seen usually in children, in which there is a crop of large tubercles, frequently of a dead white or of the natural color of the skin, many of them presenting a dark point with a depression, and regarded as being obstructed sebaceous follicles, others having no such depression. Molluscum is regarded by many authors as contagious, and Hardy teaches that a cryptogamic plant is to be found in it, but others doubt that the eruption possesses any such property. The only treatment required is to lay the tubercles open and rub their interior with caustic, or to snip them off". There is no constitutional affection. Mr. Pollock has lately communicated to the profession two cases of a very peculiar aff'ection in women, bearing some resemblance to molluscum, in which large pendulous fibro-fatty masses occupied a great part of the neck, chest, and other portions of the body. In one of these cases much benefit followed on the removal of some of the largest of these pendulous masses, in the other case the patient died from the effects of the opera- tion.^ Lupus is a disease characterized by a tubercular eruption which in most forms of the disease perishes in a destructive ulceration, leading to the "lupous ulcer," spoken of on p. 415. Various forms of lupus are de- scribed, all of which are most frequent on the face, and chiefly on or near the alfie nasi, though all may occur on other parts of the body. Lupus is never contagious ; it shows little tendency to recovery except under 1 See Med.-Chir. Trans., vol. Ivi, and Path. Trans., vol. xxvi. 884 SKIN DISEASES. careful and often protracted treatment. The varieties described b.y Mr. Najler are as follows : 1. Tubercular (or lupus non-exedens), in wliich there is an eruption of pale tubercles, which become red under excitement, and which remain in much the same condition for _years, crusts like those of eczema forming on them, occasionally but very rarely ulcerating. " It is not infrequent to find the disease, after the lapse of twenty years and more, not exceed- ing in diameter that of a crown piece." This is essentially, as it seems, a strumous affection, and leads naturally to the mention of — 2. Strumous lupus, in which the tubercles rapidly give rise to a super- ficial painless ulceration, which slowly advances for an indefinite time, cicatrizing in parts, and often causing ectropium or other deformities. .3. Luinis exedens is a form in which the destruction of parts is much more active than in strumous lupus. It commences with a small hard tubercle ; and as other tubercles form, the original ones break down into a rapidly spreading ulcer, with a light-yellowish surface, which perforates all the tissues and sometimes destroys the nose altogether, at other times heals, or is brought to heal, and leaves a peculiarly sharp or pointed edge with a purplish color. 4. Syphilitic lupus is, in fact, syphilitic tubercle, complicated with ulceration, or syphilis attacking a person affected with one of the previous forms of ulcerating lupus, which generally adds to the severity' of the disease and the destructive nature of the ulceration. 5. Impetiginous or papulo-pustular lupus is a name given b}' Mr. Startin to a form of the strumous variety in which numerous pustules resembling those of impetigo are found on the part affected. The treatment of all these forms of lupus is by some powerful escha- rotic. For the tubercular and exedent forms nitric acid, the acid nitrate of mercury, or potassa fusa, are appropriate, any scabs being removed, the surface carefully dried, and the caustic thoroughly applied to a small portion of the tuberculated surface in the non-exedent form, and to the whole ulcer under chloroform in lupus exedens. For strumous and im- petiginous lupus Mr. Nayler recommends an arsenical and calomel caustic, acid, arseniosi gr. iij, hydr. bisulphuret. gr. ij, hydr. chlor. 5j, the powder to be made into a paste with water, and applied with a camel's-hair brush after the scab is removed. In most cases the anti-struraous regimen, or cod-liver oil with small doses of arsenic, proves serviceable; but active local treatment is in all cases urgently requisite. 6. To these forms Mr. Nayler adds another, for a complete account of which I must refer to his work on Diseases of the SHn^ or to the article in the System of Sui-gery ; the erythematous, commencing as a patch of erythema on the face, and this becoming covered with scales or crusts adhering to the surface, seldom ulcerating, but terminating either in complete recovery or in a white cicatrix on a level with the surrounding skin. The disease is usually seen after middle life, generally in women, and prevails more in tlie upper classes tlian in those who have been ex- posed to liardships. The remedies recommended are stiniulating appli- cations to tiie patch, as nitric acid lotion, if there is much redness, alternated with l)orax and hydrocyanic acid, if there is smarting pain at night, or blistering in the early stage of the eruption. The internal remedies are maiidy steel and arsenic. Elephantiasis is a name applied in common to two very different dis- eases, distinguislied from each other as E. Graecorum, the tubercular leprosy, and E. Aral>um, or Barbadoes leg. Leprosy. — The former is an endemic disease, which is at present ELEPHANTIASIS. 885 unknown, or nearly so, in these islands, lhon<>h it seems that it used to prevail here, and it is still prevalent in the Baltic; but its more favorite seat is in hot countries. It is more common in males than females, and is rarely seen till after puberty. It occurs in two forms, the amesthetic and the tubercular. In the former the skin loses its sensibility in })atches, the affected parts soon ulcerate, the fingers and toes shrivel and droj) off, and the patient usually dies from some exhausting disease, as diarrlujea or dysenter3% In the other form, after more or less pain in the part and disturbance of health, irregular discolored patches of skin are seen, which become covered with small tubercles, the face, palate, eyes, and larynx are af!ected, and ulcerate; and the patient usually sinks gradually, or dies suddenly from laryngeal symptoms. The cause of the malady is unknown ; nor does any treatment appear of use. The disease is plainly proved not to be contagious. Dr. Vandyke Carter has published (in the Trciusarfions of the Med. and Phtjs. Soc. of Boinba!/^ and in vols, xiii, xiv of those of the Path. Soc.) some very interesting researches showing the atrophied condition of the sensory nerves in leprosy. As the disease is not seen in this country, and is more a medical than a surgical affec- tion, it is unnecessary to dwell on it here. ElephaiitiamH A?'abum. — The elephantiasis, which we are called upon to treat surgically in this country, is that which is called P]. Arabum, or Barbadoes leg. It occurs in the lower extremity or in the genitals, and no doubt originates spontaneously in this country, though it is not prev- alent to any extent, in fact is rare, apart from some cause of obstructed circulation. In the leg the limb swells enormously, mainly from hyper- trophy of the cellular tissue ; the skin becomes hard, thick, and warty, and in some cases distinct tubercles are developed upon it. It cracks and ulcerate, and sometimes the toes drop oK In many cases (at least in the tropical disease) there are intermittent attacks of fever, and in the opinion of some experienced practitioners the disease owns a malarious origin. In other cases it seems to be venereal. In some cases it appears to be connected with lymphatic fistula. I have at present a patient under my care, laboring under elephantiasis of the labia and thigh, in whom during the febrile paroxysms clear fluid, displaying lymph-corpuscles under the microscope, exudes from minute openings in the groin and vulva. The treatment of elephantiasis, as far as I have seen, has not been very successful. The size of the limb may be much reduced, espe- cially in recent cases, by careful pressure and the application of mercurial lotions and ointments, or by iodine, with the administration of biniodide of mercury in small doses, but I believe that the disease generall}', if not always, reappears. The ligature of the main artery of the liml) was practiced b}^ Dr. Carnochan, of New York, and spoken of at first as universally successful; but since its more extended trial in this country it has been so clearly shown that the benefit which follows the operation is in most cases but temporary as to render it probable that it always is so, and that the operation ought only to be considered in the light of an experiment, which failing, amputation of the limb is indicated. Con- sidered in that light, it ma}' be justifiable to tie the femoral arter}^ Failing this, when the enlargement makes the patient's life intolerable, it must be removed, whether the leg. the scrotum, or the vulva and labia are the seat of the disease (see p. 841). Keloid tumoi'H, as usuall}' seen, are developed in scars ; and I have spoken of them on a former page (see p. 419). Dr. Addison has applied the same name to a condition which he calls " true keloid," but which is perfectly different from the flattened tumors (like gigantic tubercles) 886 SKIN DISEASES. which arise from tlie cicatrices of burns, floggings, and other extensive and slowly healing injuries. Addison's keloid is not a tumor at all, hut a patcli of hidebound skin, in which the skin, fascia, and muscles are ad- herent together, and the surface is yellowish and covered with scales. I am not aware that treatment has any efl'ect on this condition. Fra.mbccsia. — Of framboesia, or yaws, I will merely say that it is a highly contagious erui)tion of red tubercles, soon ulcerating, which affects chiefly the negroes in the West Indies, but has been seen in remote parts of Scotland and Ireland. Macxdde. — I need only enumerate the maculiTe, or permanent stainings of the skin. None of these affections come under the treatment of the surgeon ; and, in fact, the}' are hardly under the dominion of an}- treat- ment. They are the ^'■bronzing ^' of the skin connected witli the de- generation of the suprarenal capsules found in Addison's disease; the "mo/e.s," or congenital deposits of pigment, which are so often found covered with hair, and which are liable occasionally to degenerate into epithelioma; the silver-stain, or lividity of the surface which is found in persons who have taken nitrate of silver internally for a long time ; and the want of pigment which when universal is called "aZ6inzsw," and when localized in patches " uitiligo.'" Xeroderma Ichlhyoais. — The only other disease of the skin which I think it worth while to mention is the malformation which consists in the imperfect development or entire absence of the sweat-glands and ducts, which produces the condition named ichthyosis, a condition characterized by the collection of dry scales over a part or the whole body; congenital in the worst cases, in others occurring in later life, as after the cessation of the catamenia. I merely mention the subject here in order to caution the reader not to confound pityriasis or psoriasis with this affection, which is, as Mr. Nayler says, rather a malformation than a disease of the skin ; and which is sufficiently distinguished from those diseases by its history as well as by the appearance, for in ichthyosis it is not merely the scaly eruption, but also the thickening and dryness of the skin which constitute the morbid state. Plica Polonica. — I must now turn to the affections of the appendages of the skin. The only distinct disease which affects the hair is Plica po- lonica — a matted state of the hair of the scalp, and in rarer cases of other parts of the body, met with in Poland and tlie neigliboring countries. The matted hairs are stuck together by a glutinous material in which foreign substances are found, and in old-standing cases a fungus. The exact nature of the afliection is not known. Most authors now adopt Hebra's ex[)lanation that it is due to eczema or some other skin affection long neglected. Corns are elevations of tiic epidermis formed by intermittent pressure, which acts as an irritant and produces inflammatory effusion. Con- tinuous pressure, on tlie contrar} , causes absorption. Corns are, for ob- vious reasons, usually found on the feet, though they may grow on any part wiiich is irritated in a similar way, as on the fingers of tailors, musi- cians, or rowers ; but it will be sullicient to speak of the ordinary corns of the feet. They are cither hard or soft, the first being seated on the dorsum or more rarely the plantar aspect of the toes and feet, and con- WAKTS. 887 sisting of thickened and heaped-up epidermis; the corn sometimes when it has lasted long producing absorption of the true skin, and then often having a bursa below it. The}- are peculiarly liable to form on toes de- formed by the i)ressure of ill-fitting boots. They cause a good deal of pain in walking, and sometimes lead to more serious mischief, as to lateral curvature from the une(]ual use of the limbs. Or suppuration may occur in the bursa, or in the cellular tissue beneath the corn, and this may spread so deeply as to oi)en the articulation or expose the bone below, and then may spread to the other surface of the foot, constituting the " mal perfoi'ant du pied " of French authors. Soft corns form between the toes, and bear a greater resemblance to warts, consisting often of enlarged papilliie ensheathed by epidermis. They often grow to some size and then give rise to great annoyance, and they may inflame and suppurate as hard corns do. Another variety which also bears a certain resemblance to warts is the fibrous corn, sometimes seen on the sole oi the foot, and formed of the papillte of the skin covered with epidermis. These are often acutely painful, and from their position altogether hinder the patient from active exercise. Tlie treatment of corns in all their stages or forms must commence with correcting an3^ defect in the boots and withdrawing the parts from pressure, which can be managed if necessary with a "corn-plaster" — a piece of thick plaster with a hole in it to receive the corn. The hard- ened epidermis may be gradually rubbed down with glacial acetic acid or with nitrate of silver applied after the outer hard part of the corn has been pared, or with a corn-file ; or the cuticle ma}^ be softened by the ap- plication of strong alkalies. The chiropodists cure corns by cautiously digging round the thickened epidermis till it can be turned out of the hole which it has formed in the cutis, which they called extracting the root of the corn. When suppuration forms beneath a corn the littte abscess should be opened at once, and then the corn will often fall off altogether. When the corn forms on the back of a bent toe it cannot probably be cured till the toe is straightened. Soft corns mav generall}' be cured by keeping the toes apart with a plug of cotton-wool, and steeping the corns in acetic acid, or dusting them with oxide of zinc, pure or mixed with pnlv. a3ruginis. In the perforating disease I have seen such extensive denudntion of a metatarsal bone in both feet that I was compelled to excise the bones be- fore the patient could be restored to activit}-. Bunion has been spoken of on page 501. Wa,7-ts are collections of hyi)ertrophied papillae covered with epithe- lium, and someiimes hardened on the surface by friction and exposure. They are situated very commonly on children's hands, and occasionally on other parts of the body. 'Vhe verruca digitata or bi-anching wart, which forms sometimes on the scalp in women ; the sub-ungual warts, which foim below and at the side of the nails, and are ver}' painful; and the verruca contluens, in which a crop of small warts collects into a mass on the back of the hand or arm, or on the neck and thorax, so that the skin resembles coarse i)lush, are varieties which deserve special mention on account of the desirability of eradicating them at once. Venereal Warts and Condylomata. — The warts which occur from ven- ereal causes, and which are very common on the female genitals, and to a less extent on the male, are due to the irritation of discharge retained in contact with the skin or mucous membrane. The}' often spread over a large surface and attain a considerable size. Those which are truly AFFECTIONS OF THE CUTANEOUS SYSTEM. called wfirts consist of epitheliuiu and papilhy only. The condylomata are masses often of very large size, consisting of all the structures of the skin hypertrophied, sometimes to an enormous extent, ami covered with a copious warty growth. Verruca Necrogenica. — Other warts, which are due to the irritation of morbid fluids, are the dissection-warts or "verructe necrogenicae," which are found occasionally on the hands of dissectors and morbid anatomists. Sometimes this irritation produces not exactly a wart, but a condition of skin marked l)y a thickening of all its tissues, and especiall}' perceptible around the hair-follicles. Chimney-sweep's cancer is sometimes spoken of as a kind of wart pro- duced by the irritation of soot, and certainly it commences with a warty or papillomatous growth on the surface of the skin ; but at the time we generally see it the deposit of epithelioma extends far beyond the papil- lar}' structure. JNo cause is known for the common warts. 'They appearand disappear in the most capricious manner. The venereal warts are no doubt conta- gious, and this is popularly believed of the common warts, and especially of the blood from them, but without any proved foundation. In some rare cases warts may become the seat of epithelial cancer, and they may in others prove the starting-point of horns, but usually they are merely a disfigurement. They may be removed by thoroughl}' soaking them in nitric acid, or the acid nitrate of mercurj^, or glacial acetic acid, or perchlo- ride of iron, or b}- repeated applications of stick-caustic. I have personal experience of the efficacy of the acid nitrate of mercury' in the verruca necrogenica. The venereal warts must be treated by scrupulous cleanli- ness, by the application of the strong liquor plurabi, and by a mercurial course if other secondary symptoms are present, or they ma}- be removed. When large condylomatous masses exist it is necessary to remove them; and, as much haemorrhage may take place in such operations, it seems better to avoid the knife, if possible, and effect their removal with the ecraseur or the elastic ligature. Horns are occasionally' seen growing from the surface of the body in various parts. They originate either in accumulated sebaceous secretion, or from overgrowth of the epithelium, or from overgrowth of the nails, or from the hardened and continued growth of a wart." The vvhole horn must be removed, and if there is a sebaceous cyst at the bottom this is also to be cut out. Boils.— ^A common boil or furuncle is an inflammation of the skin and cellular tissue, limited to a very small extent, and containing in its inte- rior a small slough of cellular tissue called the '-ore of the boil. Another kind of boil, however, called a "blind boil," is less defined or limited, and contains little if any core. The common boil increases in size and pain- fulness for a da}- or two, forming a red angry lump in the skin, and then bursts, and the core or slough presents at the opening. This is drawn out, or gradually makes its own wa}', and then the infiamniation and swell- ing rajjidly sul)side and healing soon follows. In some cases the furun- cular inflammation gradually' subsides, and the patient recovers without any suppuration. IMiis, however, is not often seen in acutely painful boils. In blind boils, after some da3s of pain and inflammation, a vesicle or a ' See T. Smith, inSyst. of Surg., 2d ed., vol. v, p. 442. CARBUNCLE. 889 superficial pustule forms, and then the hardening gradually recedes and finally disappears. The causes of boils are very numerous. Locally they may be caused by dissecting-room poisons, and perhaps by otlier morbid matters applied to the skin ; but in the great majority of cases tlie cause is constitutional, and consists in some error of diet, some lovveriug influence, as parturi- tion, or some disturbance of health from climatic causes. The surgical importance of the boil is usually trifling, but the remote cause should be carefully investigated, for the constant recurrence of a crop of boils — -no infrequent event — is a very serious annoyance and sometimes even a source of danger. The presence of sugar in the urine is sometimes asso- ciated with tiie appearance of boils and carbuncles, often, as it seems, as a cause, and sometimes, as is said, as an effect of the boil, though this seems doubtful. The general treatment is therefore of more importance than the local, and this should as a general rule be tonic, due attention being paid to clearing out the bowels. Baric and quinine, with acid, are the tonics usually selected, with wine and good food. Surgically little should be done. In the early stage it is said tliat caustics, as strong liquor ainmo- niae, the acid nitrate of mercury, or pure liquor potassfB may prevent sup- puration ; but this (as Mr. T. Smith saj's) appears to be successful usually only in blind boils, which probably would never have suppurated in any case. In general the less the patient is teased with local applica- tions the better. A small poultice with a little laudanum in it is the best application, and when su|)puration has formed, a tolerably free incision. A thousand domestic remedies are in use, which probabl}' are all inert except so far as they relax tension by heat and moisture. Carbuncle is a name given to a spreading inflammation of the cellular tissue, involving also the skin which covers it, having a considerable re- senililance to boil, as it tends to rapid sloughing of the cellular membrane; but, unlike boil, not limited by any definite boundary, and often spread- ing to an enormous size. The disease commences with hardness anrl pain in the part, dusky redness of the skin covering the indurated tissue, and often some constitutional affection, low fever, and much depression. Soon the affected skin gives way in numerous places, and the slough is exposed. If the case runs a favorable course the inflammation stops, the skin between some of the openings sloughs to a greater or less extent, so as to permit the escape of the slough of the cellular tissue, and very commonly the skin perishes in the whole area of the disease. Thus a healthy ulcer is left, which granulates in the ordinary way. When the disease, on the other hand, tends to death, the carbuncle goes on spreading, the fever increases, the patient becomes delirious and comatose, and dies probably with symptoms of blood-poisoning and secondary abscesses. The chief cause of death in carbuncle are pysemia and asthenia. A very common situation for carbuncle is on the nape of the neck or between the shoulders. The disease is far more common in men than in women. The objects of treatment are to stop the spread of the inflammation, to allay fever, and to support the patient's strength. Carbuncle is a disease which (;ccurs chiefly in persons broken down either by high living, or by some constitutional affection, as gout, diabetes, or kidney disease. Hence few of the sufferers from it can bear anything like lowering treatment, nor do they bear well any shock or haiinorrhage. There are three main plans of local treatment: 1. To make a crucial incision, taking care to carry the knife into healthy tissues both at the borders and at the base 890 AFFECTIONS OF THE CUTANEOUS SYSTEM. of the carbuncle. Tliis is an eftectual, but a veiy severe, measure when the carbuncle is of y applying another band- age over the first. Many other substances have been introduced for making splints, such as parattin, silicate of [jotash, and glue. The par- affin seems to be in every way inferior to starch or gum ; the silicate of potash I have not tried. Glue makes a very good splint if the l)est French glue can be got; but lately this has seemed difficult. About one- fourth of its bulk of methylated spirit is added to the melted glue, and when the splint is hardened it is cut down the middle, and a series of eyelets let into holes which are punched in it, and it is then laced. The splint is not so solid as that of plaster of Paris or pasteboard, but it possesses the recommendation that it can be taken off and i)ut on as easily as a laced boot. The padelvjard splint is an excellent one, in fact, after trying all the modern substitutes for it, I see little advantage in any of them, for ordi- nary cases of fracture, over this old one. Pieces of pasteboard are cut to a pattern which shall embrace the limb, the pattern being generall}^ cutout of an old newspaper. They are then soaked in warm water tor a sufficient time. When quite flexible they are rapidly moulded to the 57 898 MIXOR SURGERY. limb, their edges trimmed off" with the fingers, and the_y fire bandaged on. After the pasteboard is quite dry tlie outer bandage is starched. Leather and OHtta-percha Splints. — A leather splint is still more secure than one of pasteboard, since it cannot crack; but.it is more costly, and a little more troublesome to make. A pattern is taken as before, the leather soaked in warm water till quite soft, moulded, trimmed with stout scissors, and finished as the pasteboard splint. Gutta-percha is more easily moulded, is much cheaper, and requires only dipping in nearly boiling water for a very short time to soften, but it has the great disad- vantage of being impermeable to the perspiration. Plaster of Paris Splint. — The great advantage over all these of the plaster of Paris splint for certain emergencies is the rapidity with which it hardens ; against which must be set the disadvantage that it is more ditlicult of removal, and cannot be reapplied or modified as the others can, if swelling occurs, or if for any cause it becomes desirable to examine the limb. The ordinary splint, therefore, appears better for most cases. On the other hand, it is easy to cut a hole in the plaster splint to expose the wound of a compound fracture or operation, and for such cases it is now in extensive use. It is thus made: One or two rollers of open ma- terial are charged with dr}' plaster of Paris by rubbing in as much as the bandage will hold.^ The surgeon has a bag of plaster and a basin of water read3^ The usual layer of wadding or cotton-wool being applied, the bandage is placed in the water for a very short time, and is then ap- plied, water being washed over each turn as it goes on, and fresh plaster being rul)bed over it, as much as required. Two la^'ers of bandage well plastered will make a good splint, the exterior of which can be smoothed and varnished with paraffin. In order to expose a wound its position should be marked with a thick wad of cotton-wool, and then the plaster can be dissolved with acid in that part and picked away till the wad is entirely' exposed. If the plaster is good the bandage will have set in a quarter of an hour, and the patient can then be removed— a great desid- eratum in military practice. Mr. Bryant speaks highly of the Bavarian splint, which is certainly easily applied, but is rough and fits far less well than the plaster splint made with the bandage as aforesaid. Two pieces of oblong flannel are sewn together down the middle. The upper (or inner) one is swathed round the limb, well charged with plaster of Paris paste, and crossed by the outer one, which is pressed into the jilaster, and secured with one or two straps or bandages. The splint is easily re- moved by tearing the edges of the flannel asunder, the stitching of the two pieces behind acting as a hinge. The most convenient of all these apparatus is that made of Ilides's patent felt. The splint is made of felt lined with soft leather, and is hardened by a preparation sold with the felt and put on with a brush, but it is too costly for general use. All these immovaltle aj)paratus should have a layer of cotton-wool be- tween the splint and the limb. They are removed with '• Seutin's scis- sors," or with a thick, strong pair of common scissors. Some place a piece of tai)e under the splint before it is made, which serves to pull it up and afford a space for the scissors. Those which are at all elastic may be allcrcMl in size by being cut up the middle and laced on again, or their halves jcMued together with a fresh piece of gummed l)andage. Sutures are made of silk, silver, catgut, hair, and occasionally of other ' In some parts of the body it may he. bett«r to miike the splint of pieces of muslin or any open tissue similarly charged with plaster and cut to the sliai)e of the part. SUTURES. 899 substances. Silver or wire sutures have the great advantaoe of causing the least possible irritation, since they do not imbibe moisture oi- putrefy; but they are not supple enough for the more comi)licate(l forms of suture. It is sometimes said tliat silver sutures do not cut. But that is true only when they have no tension upon them. If tied too tight at first, or if the parts swell afterwards, all sutures will and must cut the tissues, and silver, I think, cut faster than others as being more rigid. Catgut sutures are very little irritating, and they require no removal, since they melt away with the heat of the parts, leaving the knot to drop off in the course of about a week. For the same reason they are inappropriate for sutures which must be long retained. Horsehair is very pliant, makes very little mark, does not absorb moisture, and may be retained any length of time, but is difficult to tie, brittle, and too delicate to l)ear any strain. On the whole silk remains the most universally useful suture. The forms of suture are as follows : 1. Tlie interruptt'd^ in which each stitch is knotted as it is made. If silver is used the stitches are fixed b}' crossing each end perpendicularly across the other, and twisting them two or three times. The knot should lie on one side of the line of wound. 2. The continuous or glover's suture (Fig. 387) as used in the post- mortem room. In applying this to the intestine (which is the part gen- erally sewn up with this suture in the living body) the first knot is passed inside the bowel, and the suture is finished off with a knot as small and lying as close to the coat of the bowel as possible. 3. The twisted suture (Fig. 388; is made with a pin, around which the Fig. 388. The continuous suture. The twisted suture. suture is wound in the form of a figure of 8. It is chiefly used in harelip and in wounds made in removing cancer of the lip. When several pins are used the suture can be finished ofi' separately on each pin (as shown in the figure), or, as is more common, one long piece of silk is used, which is carried on from one pin to the next. The former plan has the recom- mendation that each pin can be separately withdrawn, but it takes longer to make the suture. 900 MINOR SURGERY. Clove-hitch. 4. The qailled suture is used almost exclusively iu the operatiou for rupture of the periueuui, aiul will be fouud desc'ril)ed ou page S48 with that operation. It maj' also be re- quired in some ver}' deep wounds, in order to prevent the bajigingof matter into their cavity, and keep- ing the dee}) parts together. Glooe-hitch. — For tying a string or towel securely on to anything wliich it is intended to fix so firmly that it shall resist traction (as the jaclc-towel or strap with wliich extension is made in dislo- cation, or the string by wliicli a catheter is tied in the bladder) tiie clove-liitch is useful. Here tiie string is made into two loops, and the ends of the second loop are passed through tlie first in the manner represented in the figure. If the hitch is properly made, traction on the ends only fixes tlie loops more firmly. Counter-irt'itauts and Cauteries. — Blisters are the commonest form of counter-irritation, and are most commonly made of the Spanish fly, either in the form of the common blister, the lilistering fluid, or the blistering- paper. For mere stimulation (rubefacients) mustard is almost univer- sally employed. Tlie method of employing these substances belongs more to treatises on Medicine. When instantaneous A'esication is re- quired it can be obtained by applying lint steeped in chloroform to the skin, covered with a watch-glass, or by liquor ammonire, or by the tran- sient application of a hot iron, but the latter is not a very safe form of vesicant, for if left on too long it might produce sloughing.^ There are few cases in which there is any real necessity for more rapid blistering than cantharides will produce, and in these chloroform can be employed. "When the blister has fully risen, the serum is to be let out by pricking it, and a little cooling ointment applied, unless it is desired to keep up the discharge, when the cuticle must be cut all round, left to cover the raw surface, and covered with ung. sabiime, or ceratum cantharidis, or blue ointment. More ))otent counter-irritation is procured by the croton oil liniment or the tartar emetic ointment, which bring out a crop of pustules over the whole part to which they ajiplied. Lssuen are now much moi'e rarely employed than was the case formerly, but their beneficial influence in some of the severer cases of joint disease seems to be indubitaiile. Tliey are now, I believe, always made with caustic potash, either pure or in the form of the Vienna paste, a mixture of 5 parts ol' caustic potash with (i pai'ts of quicklime. A piece of [»las- ter, with a hole corresponding to the size of the proposed issue is ap|»lied,''^ the hole filled with the caustic, and covered with cotton-wool or lint and strajiping. When the skin is thoroughly destroyed a poultice hastens its separation, and the ulcer is kept from liealing by occasionally touching ' A " tlicriiiiil hammer" was in use sume time (ii^d bearing the name of Dr. Coi'ri- gan. It was prc.«oiiI)ecl to be immersed in water at \2u" F. and held in contact with the .=lr i wo or three seconds as a rnbeCaeient and for 5 to 10 seconds as a vesicant. 2 Mr. T. Smith says the slough will always be about twice the size of the hole in the plaster. CAUTERIES. 901 its ed2;es with caustic potash. 'I'his is less painful and inconvenient than the old plan of bandaging peas on the sore. Ifo.ra. — Mr. T. Smith speaks of establishing issues by means of tlie moxa, but I have never seen this done, nor, indeed, liave I seen the moxa used for many years. It is a very painful application, which used to be employed either as a counter-irritant or a cautery. A piece of lighted German tinder was placed on a frame, and the flame directed on to the skin by means of a blowi)ipe. The use of the method is hardly so indubitable as to justify such a barbai'ous proceeding. I remember, how- ever, once seeing it work as instantaneous a cure in a case of hysterical paraplegia as "Duke Humphry's miracle" in Shakspeare's play. Seion.^ also, as counter-irritants, are becoming rapidly things of the past. They are made by pinching up a large fold of skin and passing a skein of silk threads underneath it through the cellular tissue above the deep fascia. For this i)urpose a needle of peculiar construction, with a very large eye, is convenient. If this is not at hand a straight knife must be passed in the track of the seton, and the silk conveyed along it by means of an eyed probe before the knife is withdrawn. The skein of silk is loosely knotted, and should be moved a little each day l)ackvvards and forwards as soon as suppuration has commenced. When used to empty abscesses or cysts one or two threads run through with a common needle will suffice. Actual Cauteries. — Cauteries are divided into actual and potential. The actual cautery is sometimes used as a counter-irritant, in which re- spect it is of the most signal service in painful affections of the joints, a white-hot iron, shaped like a hatchet, being drawn rapidly in cross lines over the skin of the part, so as just to scorch the epidermis and possibly produce very superficial sloughs. When used as a haemostatic the cau- tery should be broader and should be kept longer in contact with the tissues, but not so long as to stick to them and pull them off. Some surgeons prefer to use the iron at a dull-red heat for this pui'pose. In destroying morbid growths, for which purpose, however, it is generally inferior to the potential cauteries, it should be applied very lightly at first, and then others should be applied more deeply till the parts are as thoroughly charred as possible. Galvanic Cautery. — The galvanic cautery has the great advantage that its heat is renewed as fast as it is lost, but, of course, it can only be applied over a very small surface. Its chief use is in cutting through vascular parts, such as the tongue or the base of a pile, and it is used also for destroying the vvalls of sinuses and producing a healing surface. Many ingenious apparatus have been constructed for applying this form of cautery in various operations, based on the cautery of Middeldorpff, but it would be out of place to describe them here. Potential Cauterie><. — The potential cauteries are substances which enter into rapid chemical combination with the tissues of the skin or other parts, chiefly by withdrawing its fluid element from it, and so dis- integrating the part to which they are applied. The chief substances in use are as follows: Sulphate of copper, which is used chiefly in the form of blue lint — i.e., lint steeped in a saturated solution of the salt. This is a useful haemostatic, and produces a superficial slough of the exposed parts to which it is applied. Sulphate of zinc in the form of powder, or made into a paste with glycerin, is a useful caustic in warts, condylom- ata, and growths about the female urethra, according to Sir J. Simpson. I have seen these growths treated more frequently with the fluid caustics, of which acid nitrate of mercury and nitric acid are the most manageable 902 MINOR SURGERY. and the handiest. Sulphuric acid also made into a sort of paste with sawdust or asbestos is a very eHieacious and a very painless caustic. Arsenical paste, the formula for which is given on p. 884, is recommended by many writers on skin diseases as more eflicacious for stopping the spread of destructive ulceration than any other, but there is no question that its use is by no means free from danger, and that fatal results have occasionally followed.' The most universally serviceable of the potential cauteries are the chloride of zinc and the potassa fusa. The former is disguised in va- rious ways by quacks and sold as a nostrum. It may be used pure — rubbed on to the parts in stick, and mixed with flour or plaster of Paris into a paste, or made into sticks or pencils with flour, which are stuck like arrowheads into the substance of the growth to be destroyed. This is the i)lan of" Cauterisation en fleches" of M. Maisonneuve, and it is an admiiable method of removing morbid masses below the skin — e.g., en- larged glands. The patient being narcotized if it is thought necessary, a knife is passed deeply into the growth, and the arrow of caustic inserted. This is done in several places, the caustic arrows cut close to the skin and left in. A dose or a subcutaneous injection of morphia will dull to a certain extent the severe pain which follows for some hours. Then the skin turns a dead white. A poultice is applied, and in a few days a mass shells out something like a billiard ball, exposing a surface which if healthy will cicatrize, and if not may be treated with renewed applica- tions of the caustic. Another way of applying the chloride is by pro- ducing a superficial slough, and then scoring it, and stuffing the incision with the caustic. Potassa fusa is applied pure, or as Vienna paste, and is also a most excellent caustic. The pain of the cautery is somewhat dulled by the application imme- diately afterwards of some substance which will decompose it, as chalk for the mineral acids, and vinegar for caustic potash ; and their action is limited to the part which is to be destroyed b}^ smearing those in the neighborhood with oil or covering them with a ring plaster. Bloodlettivg is either general — venesection and arteriotomy — or local — leeching and cupping. Arteriotomij is now, I think, given up; at least, I never saw it prac- ticed but once. If any one should choose to open the anterior branch of the temporal artery no special directions would be necessary. The ves- sel lies close under the skin, and all that is required is to touch it with the point of a lancet. When the required quantity of blood is obtained, the puncture may be closed with compress and bandage or the artery cut across. Veneiicction. — But the only method of general bloodletting now in use is venesection at the bend of the elbow. A bandage is tied round the arm tight enough to make the veins of the forearm start out. Then the more prominent of the two veins at the bend of the elbow is selected. This is usually the median basilic, which has the further great recom- mendation that it is firmly supported by the bicipital fascia, and will not retract from the lancet. The surgeon should assure himself previously that there is no abnormal artery coursing l)elow the skin, and that he is away fi-om the position of the In-achial. He then steadies the vein with ' J' In the practice of M. Roux the application diirinn; a singlo nijfht of a paste con- taining 4 por cent, of arsenic to a surface of little more than an incli in diameter proved fatal."— Syst. of Surg., 2d ed., vol. v, p. 547. VACCINATIOX. 903 his left tliiunli wliile he dips the lancet into it, and lets the lancet cut it- self out l»y descrihino- a circle with it, thus niakinle. To this end the skin is stretched tight, the cnticle is gently raised by inserting the lancet point oI)liqnely through it, and the lymph is then introduced. Numerous contrivances have been devised for vac- cination. The lancet may have a groove in it which is filled with lymph before its introduction, or after the puncture is made may be charged hy dipping it into the lymph, then again inserted into the puncture, and the lymph squeezed off by pressing the edges of the puncture together, or an ivory or quill jioint may be used instead of the lancet for this latter purpose. Instead of the lancet [)uncture, scratches maybe made through the cuticle, into which the lymph is rulibed, or the cuticle may be raised by a minute blister, and when this is pi-icked it may be filled vvitli lymph, as Mr. Ellis recommends; or the cuticle maybe entirely scratched off .the part to which the vaccine is to be applied. The lymph also is pro- cured from the vaccinifer in many different ways. The one now most in use is to charge capillary glass tubes with it, seal them up, and preserve them for use, when the ends are broken off and the lymph blown out of them on to the lancet. It is more satisfactory, however, to take the lymph fresh from the arm of an infant who has been successfull}^ vaccinated and use it the moment it is drawn, and perhaps more satisfactory still to obtain it fresh from the cow. Another method, but a less secure one, is to charge ivory points with it and allow them to dry, moistening them in steam before using them, or to preserve it dry between two plates of glass. The result of primary'' successful vaccination is stated in the instruc- tions to public vaccinators to be as follows : "Tiie puncture may be felt slightly elevated on the second day; on the third it is surrounded by a sliglit halo of redness; by the fifth a dis- tinct vesicle will be formed, having a slightly elevated margin and a depressed centre ; on the eighth day the vesicle should have reached its perfect condition, when it is pearl-colored and distended with clear lymph, its margin being tinged, firm, and shining.^ From this period tiie redness around increases in extent and intensity until the tenth day, whe!i there is often well-marked swelling and induration of the subjacent cellular tissue. On the eleventh day the areola begins to subside, leav- ing as it fades two or three concentric rings of redness, the vesicle begins to dry up, assuming a brownish color, the remaining lymph becomes opaque, and generally concretes, forming by tiie fourteenth or fifteenth day a dry reddish-l)rown scab ; this contracts, dries, blackens, and finally falls off about the twenty-first day. Tiie resulting cicatrix is permanent, slightly de[)ressed, dotted, or minutely pitted." Hecondary vaccination, or the vaccination of persons who have been vaccinated before, sometimes gives results identical with these, or differ- ing only very slightly from them, showing that the subjects were in no respect protected by the previous vaccination, although probably if they had contracted small-pox the disease would have been milder. But it is more common for the results to be variously modified, and sometimes severe inflammation of tlie glands and absorbents is produced. It is always usual to vaccinate in three different si)ots, about an inch distant from eacli other, and some believe that the protection is more complete when this is done in botli arms — i. e., when the patient is vaccinated in six places at once. * It is at this period that the lymph should be taken from the vesicle for use in vaccination. ANiESTHETICH. 905 OPERATIVE SURGERY — AN/ESTHETICS. The subject of Operative Surgery, considered in itself apart from tlie questions of the diagnosis of the disease or lesion, the indications for the operation, and the [)revious and subsequent management of the patient, comprises the three following topics : (\) the administration of antes- thetics, (2) the arrangements for the prevention of h;emorriiage, and (3) the operative manipulations. The administration of anjiesthetics has now been developed almost into a special branch of practice in large cities; and the custom is a conve- nient one, as it permits the surgeon to attend to the details of the opera- tion exclusively, though it cannot be said to be necessary, since every surgeon who can trust himself to operate must be competent to super- intend, and if necessary to administer the ana?sthetic. Anaesthetics are divided into local, or those which merely benujnb the part to which they arc applied, and general, or tliose which abolish the sensation of the whole system. The latter are of universal, the former only of very limited utility. We will speak first of local amestliesia. Local AnseiitheticH. — The local anjesthetics at present in use are a freez- ing mixture of ice and salt and the pulverized vapor of ether, and in both of them the rapid action of extreme cold is the agency employed for abol- ishing the cutaneous sensation. This it does so rapidly that there is no necessity for continuing the action of the cold for any length of time. The skin turns of a dead-white color and becomes somewhat puffy, and may then be cut, cauterized, or otherwise treated without any sensation on the part of the patient. This insensibility lasts for a few minutes, after which the circulation and sensation return. No pain accompanies either the freezing or the thawing. The mixture of ice and salt is more convenient when the antiesthesia has to be distributed over a considerable surface, the ether-spray when it is to be limited to a small portion of skin or to the line of a single incision. In the former — introduced into practice by Dr. J. Arnott' — a quantity of rough ice is pounded into pieces, none of which should be larger than a nut, and rapidly mixed with as much salt. The pounded mixture is then put into a bag of rough muslin (so that the brine may run off as it is formed), and is laid closely round the skin which is to be frozen. After about four minutes the characteristic appearance of the skin will show that the desired effect has been produced. The application of the vapor of ether as an anaesthetic was first suggested by a Dr. Guerard,'^ and has been applied by Dr. Richardson by means of the spray-producer, which is modelled on the instrument recently invented for pulverizing the vapor of essences. The ether should be pure, or washed, and the direction of its vapor to the spot or the line cliosen for the incision during a ver}'- brief period will produce such intense cold as to render the skin quite insensible. The great objection to local anaesthesia is the very limited extent to which it reaches. It can only be applied to the very surface of the body, and only extends to the part which is actually frozen, the parts around being rather more sensitive than natural. It has been apprehended that the frozen parts would be liable to slough, but I never saw any founda- tion for this apprehension. 1 Lancet, Oct. 30, 1858. '■^ Trousseau et Pidoux, Th^rapeutique, vol. ii, p. 349, 8th ed. 90& AN.g^STHETICS. Ether and Chloroform. — The "feneral aniiesthetics wliich are in the most common use are ether and chloroform. After the first discovery of anaesthesia by the inhalation of ether, by the American dentists Morton or Wells, the details of tiie novel method were, of course, somewhat un- certain, and the administration was attended with some difficulty, which resulted chiefly from the surgeon not trustino- to the ether sufficiently and administering it too gradually. I do not know that I can do better than quote a recent letter from Mr. Warrington Haward {Brit. Med. Journ., Aug. 14, 1875), which gives in a short space all the precautions necessary for the administration of this aniijsthetic, to which 1 need only add that in this as in all other anjiesthetics it is very desirable to have the stomach empty — ^. c, to enforce abstinence for food for about four hours whenever it is possible. On an emergency, however, this is of no great importance, but the patient will probably be troubled with vomiting after the operation. Administration of Ether. — " For the safe and efficient administration of ether vapor for producing anaesthesia, several things are needful to be known and remembered, which are chiefly these: '' 1. That kind of ether should be used which is fittest for the purpose of inhalation, and this is the pure anhydrous washed ether, of specific gravity .720, free from alcohol and water. Robbins's 'ether for local anaesthesia' is a dangerous compound for inhalation. " 2. The ether siiould be given in such a way that the inhalation may be commenced vvitli a very weak vapor, which, after a few inspirations, can be rapidly increased in strength. If we begin with too powerful a vapor the air-passages are intolerant of it, and the patient resists the in- halation ; but after a few moments' inhalation of a weak vapor, its sti-ength can be increased without inconvenience and the patient rai)idly brought under its influence. I think a cone of felt, covered witli thin mackintosh, is the simplest and best apparatus for this purpose. "3. Stimulants should not be administered before the inhalation. Ether is itself a stimulant, and can be safely given iu cases where there is great depression ; liut^ as Mr. Clover has pointed out, it is very un- des^irable to have alcohol in the stomach when ether is being inhaled. " 4. Whatever danger may belong to ether has relation to the respi- ratory function ; the breathing should, therefore, be watched. And I ma}-- add, it is desirable so to place the head of the patient that the saliva (the secretion of which is increased by the ether) may run out at the corner of the mouth i-ather than into the trachea." Administration of Chloroform. — Chloroform is a more potent agent than ether, and takes less time to produce complete anaesthesia. The production of this state is marked by an absence of all voluntary motion and sensation and of reflex motion. As a test of this the e3^elid is usually taken, and when the eyel)all can be touched without any winking being induced, the patient is reported as being fit for operation. The danger of ansesthesia consists iu the risk that the poisonous effects thus manifested in tlie cerebro-spinal axis should extend to the central ganglia which pre- side over the functions of respiration and circulation, and so either the breathing cease or the heart become paralyzed. The methods of administering chloroform vary. Dr. Snow was led by tiie experiments he made to believe tliat 5 per cent, of chloroform in the inspired air is a proportion wliich could never produce danger, and he contrived an inhaler by means of which a certain surface of blotting- paper charged with chloroform is exposed to tiie contact of air at a definite temperature, so that the proportion of chloroform vapor could CHLOROFORM. 907 not, as he believed, rise above the limit of safet}'. Mr. Clover attains the same end more surely by mixing definite quantities of the vapor of chloroform and air in a lai'ge bag, carried over tlie shoulders and attached to the mask which covers the i)atient's mouth. But Mr. Lister has, I think, siiovvn satisfactorily that the evaporation from the usual quantity of chloroform poured on to a cloth never, even at high temperatures, rises above 4.5 per cent, (of which, of course, a great part is dissipated into tlie air),' and therefore that the method of administration witli the cloth or handkerchief is quite as safe as that by Dr. Snow's inlialer and a fortiori by other inhalers, which, in fact, are rather contrivances for economizing cliloroform tiian for regulating its dilution. Another ad- vantage in tliis simple method is tliat tiie quantity of chloroform poured on to the handkerchief is a matter of secondary importance, wliile in Dr. Snow's inhaler it is essential to the meclianism that not more than Jij should ever be in the instrument at tlie same time. About 5i''f^--5'j then of the cliloroform are to be poured on the handkerchief, and the patient is to be gradually accustomed to the taste and pungenc}' of the vapor by holding it rather far from his face, and giving him occasional l)reatlis of pure air, and when he is getting somewhat intoxicated pressing it rather more. A period of excitement, noise, and struggling usually, but not always, comes on, and then the patient hinks into a slumber, the limlis no longer I'esist when moved, he does not resent a pinch or prick with the knife, and the eye is insensible. Then the operation may be begun. Mr. Lister is a strong advocate of the theory that all that is necessary for safety in chloroform inhalation is to watch the breathing, and when any lividity of the face occurs, or any laryngeal stertor, to pull the tongue out of the mouth with a pair of forceps sufficiently far to open the larynx freely' and allow the patient to breathe naturally, withdrawing the cloth till the indications of returning sensibility necessitate the re- administration of the vapor. And doubtless these precautions would reduce the mortality after chloroform materially. Still there has been many deaths resulting, as far as we can judge, from sudden failure of the heart's action, under the hands of persons quite aware of the im- portance of watching the respiration, and whom we have no ground for charging with negligence ; and, in fact, Mr. Lister allovvs that there ma}'' be varying idiosyncrasies in respect of chloroform. The onl}' death from chloroform that I ever happened to witness was in a young man of perfectly healthy appearance, and in whom an experienced chloroformist certainly noticed no obstruction to the respiration before the failure of pulse which proved at once fatal. It seems, therefore, safest to watch both the pulse and the respiration, the latter most narrowly, as it is the side from which danger most commonly occurs. On the first symptom of the failure of the pulse the chloroform must be suspended, if the galvanic battery is at hand it should be applied, and the breast should be well slapped with cold towels, while hot affusion is practiced to the head. When the respiration is suspended, if forcible traction on the tongue fails to restore it, artificial respiration should be practiced, the tongue being still held forward. Relative Safety of Ether and Chloroform. — The question of the relative 1 See Syst. of Surg., 2d ed., vol. v, p. 48G, note. 2 I must refer the reader to Mr. Lister's article (p. 491) for his theory of the effect on the larynx of drawing forward the tongue and for his views of the nature and symptoms of laryngeal obstruction. The main point in practice is to recollect that defective breathing comes on very insidiously and suddenly, and may be relieved by forcible traction on the tongue. 908 ANAESTHETICS. safety of ether and (.■hloroform is being just now anxiously debated. I have no wish to dogmatize on the subject, but I have used ether with great comfort for many years, and have never seen any but the most trivial inconveniences from it, such as blistering of the lips from evapora- tion, and cough or irritation of the bronchial tul)es from its pungency. During the same time I have also employed chloroform perhaj^s as com- monly, and have been so fortunate as to escape any fatal accident from this in my own practice, and, as I have said above, never to see more than one death from it. But I tliiuk we can hardly resist the unanimous opinion of the American surgeons, founded ou nearly 30 years of exten- sive experience as to the relative safet}- of ether, and if so we should only employ chloroform in exceptional cases. There are some persons (chiefly old to[)ers) in whom ether pi'oduces such excitement, or whose bronchial membrane is so sensitive, tliat it has to be given up, and with them if any aujesthetic is used it should be chloroform. Chloroform seems also perfectly safe in childhood, but so is ether also. Anieslhetics in Heart Disease. — An idea seems still to prevail that anaesthesia is especially dangerous in disease of the heart, but I think this is an error. It is true that in extensive disease of the heart any ex- citement may prove fatal, and so may of course that of taking ether or chloroform. But then the shock of the operation without an anaesthetic is far more likely to cause death in that condition, so that if any opera- tion is required it seems safer to perform it under anaesthesia than with- out.^ In themselves both ether and chloroform are stimulants, especially the former.'^ Bichloride of methylene is an anaesthetic which possesses the advan- tages of producing insensibility very quickly, and of not causing any sub- sequent sickness or discomfort. The patient also recovers very rapidly from its eflfects. On account of the immunity from sickness it is much used for ovariotomy ; and on account of the rapidity with which persons can be brought under its influence, it is reported to be much used in some e3'e institutions where many operations are performed. But ether seems, with proper precautions, almost as free from after-vomiting, and the saving of time in producing anaesthesia is a poor reason for employ- ing an agent which seems to be more dangerous than the other anaes- thetics. Nitrous ocnide, or laughing gas, has now been made available for prac- tical purposes bj^ giving it freely and pure, i. p., unmixed with air. In this way it does not excite, but produces at once a condition of complete insensibilit3'. The patient becomes entirely comatose, the whole blood is unoxygenated, so that the surface is of^ a dark livid color, and the blood which exudes from an incision quite black. The condition of the patient appears most alarming, but in two or three minutes the color re- turns and he recovers, with no symptoms whatever, and no traces of the alarming state in which he has been. During those two or three minutes any operation can be performed with as complete absence of sensation as ' I have already alluded to a death which I saw from chloroform in a perfectly healthy person, in whom post-mortem examination detected no visceral disease of any kind. The next patient brought into the o|)erating theatre was one of my own — an old man, witii extensive disease of the heart. He was phiced under chloroform, and the operation com])leted without any bad sj'mptoms. A few days afterwards he fell down dead while walking across the wa7'd. Path. Trans., vol. xv, p. 69. 2 " An amputation jicrformcd under chloroform," says Mr. Lister, '' has often the effect of improving instead of lowering the pulse," and he gives a striking example of this. HEMORRHAGE. 909 under any other anfcsthotic. And as the administration can be repeated, long operations may be performed without any remembrance on the part of the patient. But it is doubtful whether tliis would not be as danger- ous as any other an.nesthetic, and it is certainly much less convenient, so that nitrous oxide is now reserved for very short operations, like tooth- drawing, or sometimes as a prelimimary to the administration of ether, though tills seems unnecessary. Tiie gas is stored under pressure in a liquid state, and on tlie removal of the stopper from the bottle a certain quantity resumes its gaseous condition and fills a bag which is screwed on to the bottle, and contains enough for one administration. The bag is then attached to the mouthpiece. MEANS OF RESTRAINING HEMORRHAGE. The Towniquet. — Hemorrhage is restrained in amputations, and other operations on the limbs, by the tourniquci, a contrivance wliereby pres- sure is made directly on the main artery, and also by means of a circular strap on the whole limb. The common tourniquet consists of a pad which is pressed down by a screw, and the screw is attached to a large stra[) whicli encircles the limb, and thus as tlie screw is pressed down, it tightens the strap and makes pressure equally on the limb all round. The pad is eitlier attached to the screw or is placed below it, secured also by a circular webbing strap, or is replaced by a piece of roller laid on the artery. Care should be taken so to direct the pressure as to compress tlie arterj' against the subjacent bone. This is a most efficient method of control- ling htx?morrhage, but it produces, of course, considerable venous engorge- ment, and cannot be tolerated for any lengtli of time. The Italian, Sig- norini's, or the horseshoe tourniquet, is an arch of metal larger than the limb, having an expanded piece to rest against tlie side opposite to the arttry, while a screw carrying a pad is directed against the artery from the opposite end of the arch. This makes no circular compression of tlie liinh, and does not produce venous congestion except by ths un- avoidable pressure on the main vein accompanying the artery. All the aneurism compressors are made on this principle, as well as the aortic toui'uiquet for amputation at the hip. Digital Presaiire. — Some surgeons are fond of using finger pressure on the artery instead of a tourniquet, and this is necessaiy in many situa- tions, as in amputations performed so high that there is no room for the tourniquet. Whenever the tourniquet can be applied I believe it is much better, as saving the loss of l)lood. In making digital com})ression, the assistant who takes charge of the artery should take a sufficient grasp of the limb to steady his tliumb, wiiich is to be firmly pressed on the artery in the proper direction, and supported by pressure with the thumb or fingers of tlie opposite hand. Wlieu tiiat tliumb gets quite tired the other is to be rapidly suiistituted for it and supported in the same way. Esmarch''i< Bandage. — The tourniquet does not render the parts blood- less ; in fact, it causes A'enous congestion ; but conqjlete absence of blood in the parts divided maj^ be secured by the application of an elastic ban- dage as recommended by Prof. Esmarch.^ A bandage consisting of stout india-rubber tissue is rolled round the limb exactly as a spiral roller 1 Esmarch's method of rendering a limb bloodless by the constant pressure of an elastic bandage is altogether different from the long-known method of applying a common bandage before putting on a tourniquet, which was so far from rendering the parts bloodless that it was found hardly worth the trouble of ajjplication, and fell out of use. 910 OPERATIVE SURGERY. is. No great force need be employed, but the constant resilience of the elastic tissue will squeeze the blood out. In order to hinder its return a stout piece of elastic tubing is i)assed twice round the limb just below the upi^er edge of the bandage and secured by hooks. Then the bandage is unwound from the limb, which is seen to be perfectly pale and bloodless, and, when out into, its tissues are as free from blood as in the dead sub- ject. Even the bones are sometimes entirely empty of blood. The bene- fits of this metliod are great during any operation in which the oozing from the parts is annoying, i.e., all dissecting oi)erations; and the}^ are also striking in excisions, since the precise limits of the disease can be seen as well as in tlie post-mortem room. In cases also of traumatic aneurism, of wound of tlie artery, and of the old operation for aneurism, the method seems applicable. I am not sure that blood is really saved by it, for in many cases the very free oozing whicli takes place as soon as the circular tube is removed pretty nearly balances what would have escaped if the operation liad been performed in the usual wa3^ I have not seen an3- prevalence of sloughing after operations so performed, nor have I realized the dangers of pressing the products of suppuration up the veins, or producing internal congestion by squeezing the blood back; in fact, I l)elieve them to be imaginary, but further experience is necessary to show us what is the real value of the metliod. The attempts to show that the mortality after operations so performed is lessened by the method are quite premature. After tlie constricting band is removed a few min- utes should be allowed for the bleeding to subside under the use of cold water after all the main vessels liave been tied, and with this precaution I have not met with any secondary or recurrent haemorrhage. We have now to treat of the strictly manipulative part of operative surgery. All the surgical operations, however, whicli are employed only in special parts of the body have been spoken of above in their appro- priate places, as lithotomy with diseases of the urinary organs, trache- otomy with those of the larynx, etc. It remains to speak of plastic sur- gery, amputations, and excisions. PLASTIC SURGERY. The operations of. plastic surgery are directed to filling up the gaps left by destruction of the nose, by the incisions made in dividing or ex- cising cicatrices, and in refreshing the edges of unnatui'al clefts. Some of tiiese operations, especially tiiose of the latter class, have been spoken of in previous pages. Such are the operations of harelip, fissured palate, and ruptured perineum. Tiie prin(!iple of this class of plastic operations is to lu'ing the edges of the cleft into ai)position by means of some form of suture and obviate tension, if necessary, by incisions. Incisions, however, are not always necessary. Thus, in harelip, no incisions are, as a general rule, required. If any are so they are made along the border of the nose. In fissure of the soft, palate the oliject of the incisions is chiefly to divide the muscles, while in that of the hard palate free lateral incisions are made through the muco-pcriosteal structures. In ruptured perineum and in recto-vnginal fistula incisions are usually superfluous, but sometimes the sphincter may require division. In vesico-vaginal fis- tula it is generally impossible to place incisions so as to give any assist- ance to the sutures, l)ut occasionally such incisions may be made through cicatrices in the wall of the vagina. TranaijlankUion of Hkiv. — The operations for restoring the nose and RHINOPLASTY. 911 for contracted cicatrix involve tlie process of transplantation of skin,' which is rarely required in the oi)erations for the closure of listulii'. Up to the present time I think it may he said with truth that nothing except the skin has been successfully transplanted ; but attempts are being made to transplant periosteum which may form the nidus of bone (osteo- plasty), and if such attempts succeed they might much extend the prac- tice of plastic surgery, and especially in the operation of nose-making. Two ways of transplanting skin are recognized, viz., b_y displacement or gliding, and by torsion. In tlie former tiie piece of skin is dissected up, left attaciied to the surrounding parts by a broad isthmus, and then its direction is so shifted that it can be fitted into the part where it is intended to lie. The neck, or isthmus, remains permanently, and tlie puckering or twisting caused by tlie displacement gradually disai>pears. In the method by torsion, the position of the flap of skin is entirely changed (for instance, it is brought down from the forehead to the nose) and for this purjjose it is left attaciied by a neck as slender as is consist- ent with the maintenance of vitality, which neck is twisted so as to per- mit of an entire change of position. Then the edges of the skin are stitched to those of the cleft, and after a sufficient time, when the trans- planted skin has fully received tlie elements of vitality from the neigh- boring parts into which it was transplanted, the neck is divideii and tliat part also of the transplanted flap inserted into the edge of the cleft, so that now the flap is permanently fixed in its novel position. Such trans- plantation can be effected from one part of the body to another, as from the arm to the nose, or from tlie thigh to the hand, the parts being kept in a[)position by some mechanism until the transplanted flap has grown into the cleft. It can even be effected from the body of one person into that of another, an o})eration of which we have heard a good deal in prose and verse, but which is not a part of practical surgery in the pres- ent day. lihhiopla^ty. — The operation of restoring a nose which 1ms been cut off, or lost by lupus or syphilis, is one which is little in favor with most surgeons of the present day, since it is found that the new nose, being formed only of skin, generally either withers away or remains flat on the face, and in either case the patient's appearance is not improved. Be- sides, in the usual method of operating, the flap being taken from the forehead, another scar is added to the previous deformity. Tlie common plan, or the Indian operation, is to take a piece of paper, gutta-i)ercha, or leather, and adapt it to the stump of the nose so as to form as shapely a feature as may be ; then lay this pattern on the fore- head, and cut a flap of skin accordingly, leaving it attached b}^ as broad a neck as possible to the bridge of the nose. In cutting this or any other flap, allowance must be made for the shrinking of the skin^ so tliat the flai) must always exceed the pattern a little in all directions. A little tongue is left on the middle of what was the upper border of the flap, and which when it is twisted becomes the lower, in order to form the colu- mella. The edges of the cleft should be refreshed before cutting the flap, and the latter brought down and attached as rapidly as possilile in its new position by several points of silver suture. The new nose must be ^ Tlicse flaps are always spoken of as being formed of skin, but in trutii as much as pos.-ible of the subcutaneous tissue also should always bo taken up along with the skin. The more fat and vessels can be raised with the skin, the less risk is there that the skin will slough. 912 OPERATIVE SURGERY. supported in position by a i^lug, or two plugs, of suitable size and shape, and of some non-absorbing material, and sui)ported on the plug by a pad and bandage loosely applied. When the union of the edges is complete and the transplanted flap perfectly warm and full, the neck may be di- vided, the rest of the cleft over the bridge of the nose pared, and the raw surface left by the division of the neck implanted there. The plug must be changed from time to tiuie, but great care is required in doing this, and it slionld be put otf as long as possible after the operation in order to leave the parts quiet till the edges have united firmly. Tlie same operation is also still, I believe, sometimes done after the method of Tagliacotius by transplanting the flap from the patient's arm. An apparatus must first be manufactured which will keep the arm in com- fortable apposition with the face ; and then the flap is to be marked out and raised, much as in the Indian operation ; but here the surgeon has the advantage that he can take a neck of any size that he wishes, so that possibly the'flap is less liable to slough. The restrained positio.u, how- ever, is"^ a great inconvenience, and necessitates the section of the neck as early as possible. Rhinoplasty is very liable to failure from sloughing of the flap, from want of union of the edge (especially when the tissues are cicatricial from old lupus), from erysipelas, and from secondary haemorrhage. It is, tliere- fore, not an operation which the surgeon should recommend.^ Mr. Skey, who had much experience in it, says, "Let it be the patient who urges the operation." And in the present day, when so many new materials are in use for masks, it will be found that a person who can command the necessary assistance will derive much more advantage from the services of the mechanician than the surgeon. I once met with a patient who managed to make for herself a far better nose, in some way which she would not explain, than any which rhinoplasty could have provided. Contracted Cicatrix. — The contraction of scars, especially those of burns, frequently leads to terrible distortion, particularly in the neck and at the flexures of the joints, as the axilla and the fingers. As I have said above (p. 135) much of this could be avoided by careful extension during the healing process, and by promoting rapid union ; but in many cases, especially in children, some amount of contraction is often inevitable. It is very diflicult to oi)ta'in ]iermanently satisfactory results by oj^era- tion in these cases. Consequently every attempt should be made to stretch the cicatrix by mechanical means before any plastic proceeding is undertaken. Wlieii, however, this becomes necessary, several dilferent measures present themselves for selection. The simplest is merely to divide the cicatrix, put the parts forcibly on the stretch, and let the gap fill up by granulation, keeping the apparatus constantly applied till the scar is completed, whicli may be hastened by skin-grafting. I have seen this method succeed in deformity from scarring in the limbs, but in the neck I believe it always fails. The gap left by the division of the cicatrix may be filled at once by a flap cut from the thorax or from the back of 1 Some novel attempts have recently been made to obviate the many causes of faiUiro in rhinoplasty and otlier operations by trnn>pl!intalion. Tlius Dr. Hardie, of MsinehestiT, has transplanted tlie distal phalanx of one of the fingers into the nose in order to provide a bony l)ase for the transplanted flaps (lirit. Med. Journal, Sept 25, 1875) and Dr. Wolf, of Glasgow, has even gone so far as to assert tliat no vascular connection with its original neighburhdod is necessary for the transplanted fhip, but that the skin nniv he simjiiyeut fnim the arm or other part and inserted into the face, and will adhere and grow there (ibid., Sept. 18, 1876), WEBBED FINGERS AND TOES. 913 the neck and made to glide on its base, so as to be attached to the edges of the divided scar, or rather to the line of division which is carried be- tween the scar and the integument supposed to be healthy.' But the olijection to this plan is that the edges of the cleft left by such divisions are always more or less cicatricial and the base of the cleft is also unnat- ural in structure, so that union cannot take place rapidly. Now, it is on the occurrence of rapid union that all prospect of success in plastic pro- ceedings depends, A somewhat more satisfactory result may be hoped for if all the cicatrix can be extirpated, but this is usually impracticable in the neck. The result of such operations, as far as I have seen (and 1 have performed and seen man}' such), has been that even in those which seemed most successful at first, where almost the whole flap united kindly and the deformit}' was at first greatly lessened, some part remained long unhealed, and at this point a band of cicatrix ultimately formed which subsequently, in spite of the best efforts of the surgeon, contracted slowly and to a great extent reproduced the deformity. Cheiloplody. — Again, the deformity of the lip is a very difficult feature in contractions of the neck. The lower lip gets drawn down, presenting its mucous surface externally, and causing great distress from dribbling of saliva as well as distorting the other features. This is l)est dealt with by freeing the reversed lip from the jawbone as well as possible with the knife, refreshing its upper edge, and drawing over it two pieces taken from the cheek and corners of the mouth. These pieces are cut by a line sloping away on either side from the centre of the lower lip to the base of the jaw, and continued along that bone as far as may be necessary, but so as not to wound the facial arter3^ These two pieces are movable enough to unite with each other in the middle line, while their bases are sewn into the refreshed edge of the lower lip. Similar operations may also be performed in cases where the upper or lower lip has been destroyed by cancer or injurj'. Webbed Fingers and Toes. — A somewhat rare deformity is that in which the fingers are united by a fold of skin either in their whole extent or for some distance in front of the natural cleft. The same deformity is found in the toes, but is of no consequence there. In the hand, hovv- ever, it so materially limits the movements that it is of great importance to remedy it if possible, but it is very difficult. The difficulty consists in the great tendency to cicatrization commencing at the posterior angle of the wound, in the situation of the natural cleft. If this does commence, it will surely though gradually extend forwards till the web is reproduced and tighter than before, because cicatricial. Of a great number of methods which have been employed in the treatment of webbed fingers, I will only mention two. One is to procure a permanent opening in the situation of the natural cleft b}' the insertion of a ring — much as the hole in a lady's ear is kept open — and when this opening is completely and permanently established to enlarge it by the insertion of tents or wedges increasing in size. A large separation being thus made at the cleft, the web in front can be divided gradually by elastic pressure ; or else, after the hole has been established, the web in front is divided close to one of the fingers, and the two flaps thus obtained are united together to cover the other finger, for which they are amply sufficient. Then a covering is obtained for the denuded finger out of some distant part of the body — say the outer side of the thigh. A flap is dissected up and left attached b^^ both its ' Mr. Butcher has shown how much assistance may sometimes be afforded in these cases by subcutaneous division of the cicatricial bands around the chief scar. 58 914 OPERATIVE SURGERY. ends, and the finger is thrust in below it — much as the hand is thrust into the pocket — and tlie edges of the flap united to those of the cleft. When union has taken place, the ends are divided, the hand released, and the cut ends implanted. AMPUTATIONS. The chief indications in amputation are — 1. To remove the whole of the parts whicli are diseased or injured beyond the prospect of recovery. 2. To avoid all unnecessary loss of blood. 3. To cut flaps of proper shape and long enougli to cover the bones without any tension. It might, per- haps, be added that the main nerves ought never to be left so long as to be exposed to pressure by the ends of the bones. The (;hief methods of amputation are as follows : The circular, in which a cut is made all round the limb through the skin and fat, which are thrown back from the muscles something like the cutf of a sleeve,' then the muscles are divided by one or more circular sweeps down to the bone, then all the soft parts are retracted from the bone or bones, and the latter are sawn about an inch above the part first exposed by the division of the muscles. Retractors are sometimes wanted in all amputations, but more gener- ality in the circular. They should never be required if the parts are health}'^, but may be indispensable when they are stiff" from oedema or inflamma- tion. For the tiiigh or arm the}' are usually made of two plates of metal, each having a handle at each end and a semicircular notch in the upper edge. One of these is placed above the bone, the other below. The two notches form a hole through which the bone passes, and the soft parts are then pulled forcibly upwards, the saw being applied just below the re- tractors. A split piece of stout cloth will answer the same purpose. When there are two bones, a tongue must be torn in the cloth and passed between the bones, the ends are then crossed and the cloth drawn upwards. Flap amputations are now more in use than circular. Tiie flaps are cut in two ways, b}' transfixion and by incision. In the former plan, when the flaps are made as is usual in front and behind the limb (antero-pos- terior flaps), tlie knife is passed as near as possible in front of the bone, or bones, just lielow the place where the saw is to be applied. Then the knife is carried downwards and outwards, cutting as long an anterior flap as necessary ; the same thing is done behind, the flaps are dr^iwn up, the bones cleaned a little higher up, and the saw applied. The same operation is sometimes done on either side of the bone (lateral flaps), chiefl}^ in the upper arm. In this way the flaps must be formed of all the tissues of the limb ; but if the operator wishes to take skin only, or in varying proportion to the muscles, he must make his flaps l)y incision, carrying the knife along any lines which he may find suitable, and then raising the parts from without inwards, and taking care to take an ample allowance of fat and other subcutaneous tissues along with the skin. The flaps formed by transfixion must be oval, those formed by incision may be of any shape. Tliey may also lie formed entirely of skin, the muscles being divided straight down to the bone; or the\' may include all the tissues of the limb (as in Teale's amputation), or, as is now very com- monly done, the flaps of skin having been thrown l)ack, the muscles may be divided as in the circular amputation — an operation usually spoken of as '• the modified flap amputation." I shall endeavor as well as my ^ This dis-oction is omiltHd by somi; opcM-iitor?, who morel}' divide all IIk^ parts down to tho bone by successive circular cuts, while an assistant retracts the parts as they are divided. AMPUTATION AT THE SHOULDER-JOINT. 915 space allows to illustrate each of these methods of oporatinp: in speaking of the amputations of different members, in doing which I shall describe tlie method whicli seems best adapted to each, though in all of them it is quite feasible, naj^ is necessary sometimes, to adopt a method the farthest possible from the one here recommended. J'or instance, in amputating at the hip or shoulder the flap amputation by transfixion is the best; but it is often necessary to cut tlie flaps by incision, and even the circular amputation may be performed. Instruments for Amputation. — The instruments required for amputa- tion are ver}' simple. In the present day many amputations are per- formed with a simple scalpel rather larger than a dissecting knife, but generally an amputating knife is employed. This should have a sharp point and a fine narrow blade,' and its length should be proportioned to the size of the limb. The shorter it is the easier is it to manage, but for transfixion operations its length must considerably exceed the tliickness of the limb. For cleaning the bones when there are two a small double- edged catlin is convenient. The back of this is pressed against the farther bone, dividing all the soft tissues and periosteum, then the point is thrust between the bones until their periosteum is also completely divided where their surfaces are opposed, then the point is disengaged by pressing the front of the blade on the nearer bone, and so its edge is drawn up the nearer bone till it comes to the point from which it started. A peculiar manipulation (called the figure of 8) is sometimes taught for doing this, but it requires really no special instruction. The amputating saw, a stout strong-backed saw, should be in readiness, and a pair of sharp bone-forceps to cut off" an}' splinter that may be left projecting, and if the bone is fractured the lion-forceps to hold it while it is sawed smooth above. A common scalpel, tenacula, ligatures, and the contents of the pocket case complete the armamentarium. Dressing the Stumjy. — After amputation the wound is to be dressed as prescribed in Chapter I, a piece of drainage-tube being passed through the deep part of the stump in order to drain off the abundant sero-san- guineous discharge which usuall}' collects in the cavity if it is tightly sewn up, and gives rise to suppuration. If the stump is long enough the patient will derive much comfort from its being placed on a splint and lightly bandaged, and the splint may be slung if recpiired. When the flaps are necessarily left somewhat deficient in length, or when they re- tract afterwards so as to threaten to leave a conical stump, much benefit may be obtained b}' careful bandaging, the parts being kept well drawn forward while the bandage is being applied ; and still more advantage is derived from the application of continuous traction by means of a weight acting on a stirrup of strapping, which has been secured to the stump by one or two circular strips, a few inches above the incision. Amputation at the shoulder-joint is best performed by transfixing, and cutting the flaps from within outwards. The situation of the joint having been already fixed in the surgeon's mind, he gets an assistant to compress the subclavian artery, while a second manages the arm for him, holding it at first at right angles to the patient's body. The operator, standing be- hind the patient, enters the knife just behind the posterior flap of tlie axilla, and brings its point out close to the coracoid process. It is quite easy to open tlie joint with the point of the knife as it passes across. Then a large flap is cut out of the deltoid muscle, which is retracted by the second assistant, who now brings the arm down to the side and pushes the 1 The old " cirouhir " knife with a round point is now very rarely used. S16 OPERATIVE SURGERY. head of the bone up out of the joint as the operator passes the lieel of the knife round it. The knife having now quite severed tlie articulation, the second assistant again hohts the arm perpendicular to the body, while the surgeon brings his knife parallel with the humerus, and cuts a short flap out of the parts internal to it in the axilla. One of the assistants or himself follows the knife with the fingers inside the flap to catch the axillar}' artery between the fingers and thumb in case the pressure on the subclavian is insufficient. On an emergency (such as sometimes occurs in war) the pressure on the subclavian may be dispensed with, and the operation can be and has been done without the aid of any trained as- FlG. 391. The stump of an amputation at the shoulder-joint, a, the glenoid cavity, the long tendon of tlie biceps seen at its upper part ; b, the coracoid process with the coraco-brachialis muscle and short head of the biceps; c, the posterior eiroumflex artery and circumflex nerve; d, the axillary vessels and brachial plexus. Above the letter a is seen the mass of the deltoid ; above the letter c the triceps muscle. In the depression between the deltoid and glenoid cavity are the tendons passing to the great tuberosity. That of the subscapularis is in the depression between the glenoid cavity and coracoid process. Above the coracoid process is seen the pectoralis major. sistant at all, the operator being aided only b}' a man who manages the arm for him and helps him to tie the vessels. If it is found more con- A'-enient, the surgeon in operating on the right arm may stand in front of the patient, and cut the anterior flap by entering the point of the knife by the side of the coracoid process, and bringing it out near the posterior flap of the axilla. The flaps are shown on Fig. 393, 1. There are many other ways in which this amputation can be performed, by cutting flaps from the skin inwards, by a modified circular method, or bj'^ using any tissue left uninjured to cover the glenoid cavity. I have seen cases in which the tissues were so far torn off the arm and scapula that even this was impossil)le, yet which healed well by granulation, and left really little to desire. Amputation at the shoulder-joint is by far the most successful of all the major operations; but it should not be performed except in cases of evident necessity, since any movable stump which can be formed out of the arm, however short, will be of some use to the patient. Amjmtalion of the Arm. — Amputation through the continuity of the humerus can be performed in any way that the operator fancies or that the nature of the disease or injury points out as advisable. One of the best methods, I think, is the combination of skin-flaps with a circular in- cision of the muscles. The lines of incision are shown on Fig. 393, 2. The tourniquet may be put on near the axilla, or Esmarch's bandage, or the axillary artery held by an assistant. The operation is now compara- tively rarei}' performed, being reserved mainly for cases of complicated AMPUTATION OF THE ARM. 917 injur}' in which it is impossibe to preserve the limb, creases of malignant disease. In the former case very few vessels will require ligature, proba- bly the brachial and superior profunda will be the only ones (Fig. 394). In cases of rapidly growing tumor, of course the smaller arteries will have become enlarged, and must be tied. Fig. 392. Fig. 393. 10 Fig. 392. — The front of the arm, showing the lines of incision for various operations. 1. One of the various incisions in use for the ligature of the axillary artery. 2. The incision for tying the brachial artery in the middle of the arm, in a line from the centre of the bend of the elbow below to the inter- val between the flaps of the axilla aliove. 3, 4. The lines for tying the radial and ulnar arteries high up. 5. Flap amputation of the forearm. 6, 7. Lines for tying the radial and ulnar arteries low down. 8. Anterior flap for amputation at the wrist. 9. Amputation of the thumb and metacarpal bone. 10. Amputation of a finger at the knuckle, the head of the metacarpal bone being removed. Fig. 393.— The back of the arm, showing the flaps for various amputations. 1. Amputation at the shoulder-joint, by an external flap cut from the deltoid, and a shorter internal flap from the axilla. 2. Amputation of the upper arm by a shorter skin-flap from the front, and a longer one from the back. The muscles may be divided in the same lines or circularly. 3. Teale's amputation in the forearm, the longer flap from the front, the shorter (here shown a little too long) from the back of the limb. 4. Am- putation at the radiocarpal joint. 918 OPERATIVE SURGERY. Through the Elbow. — In some rare cases amputation has been per- formed through the elbow-joint. I have never seen the operation done, thougli I liave seen the stumps of such operations, and very useful and good ones. There would be no difficulty in fashioning the flaps, but the opportunity for i)erforming the operation must be very rare, for any part of the forearm which can be preserved would be useful, and if the whole forearm is destroyed the humerus is also probably injured, and its end must be removed. Amputation of the forearm is a ver}' common operation, and is per- formed on account of laceration of the hand, or of caries of the wrist, or malignant tumor. I have placed on the diagram (Fig. 393, 3) a sketch of the rectangular or Teale's amputation in this part of the limb, and it is a ver}' good method, for the chief difficult}' in amputation of the forearm is caused by the numerous tendons (especiall}' near the wrist) which are liable to be cut irregularly, and so interfere with a perfect result. In the rec- tangular operation these are divided straight across, and the flaps formed are more regular. But many other plans are in use ; a modified flap — i. e., skin-flaps with circular incision of the muscles — or, on the other hand, a circular sleeve of skin turned back, and then short flaps cut out of the muscles by passing the catlin in front of the bones, below the two main arteries, and cutting outwards, and then making a similar small flap be- hind (as recommended by Mr. Hewett), or the common circular operation. Fig. 394. Fic;..395. Fig. 394. — Diagram of a section of tlic upper arm, showing the parts as they would be seen in a circu- lar amputation, a, The brachial vessels, having the median nerve in front of the artery, and the ulnar at some distance below it; h, The basiliac vein with the internal cutaneous nerve; c, The humerus, lying close to which are seen the inusculo-spiral nerve in the substance of the triceps muscle and the superior profunda vessels along with it. In front of the liumerus is seen the nuisculo-cutaneous nerve lying between the biceps and hrachialis anticus, and in the superficial cellular tissue the cephalic vein. Muscular vessels will probably require the ligature, lying in the substance of thethree muscles. Fig. 39.5. — Section of the forearm about thi; middle. R, Radius, with the radial vessels and nerve in front of it; m, Median nerve, which is sometimes acconipanied by a vessel requiring the ligature; u, Ulna overlapped by the fl. prof, digitorum and having the ulnar vessels and nerve in front of it. The interosseous membrane is seen between the bones, and, lying on it, the anterior interosseous vessels. The posterior interosseous vessels are seen between the deep and superficial layers of muscles at the back. AMPUTATION OF THE FINGERS. 919 will all give wood results when carefully executed. If any tendons project irregularly they must be trimmed off before the flaps are adjusted. The position of tlie vessels can be seen from the annexed diagram (Fig. 395). Amputation at the W7'ist. — In some rare cases the whole hand is re- moved at tiie wrist. This is best done, I think, by cutting two tolerably equal semicircular flaps back and front from the skin inwards. (Figs. 392, 8 ; and 393, 4.) If the pisiform or unciform process is incon- veniently prominent it may be cut off. Amputation of the Fingei-x. — The fingers are constantly amputated at any of their three joints, sometimes through the continuity of one of the phalanges, and more frequently through the metacarpal bone, the head of which is removed along with the finger. The two terminal phalanges are best amputated by cutting pretty straight into the articulation on its dorsal aspect, cor- responding to the cen- tral fold of the skin on this side of the joint, and then passing the knife through the joint and shaping a long flap out of the tissues on the palmar surface. In am- putating at the knuckle it is important in a labor- ing man to preserve the head of the metacarpal bone. Those who study appearances sometimes recommend its removal in persons who are not called upon for manual labor ; but this weakens the hand so much by the section of the trans- verse ligament and other structures, that it seems to me better always to preserve the iiead of the bone if possible, though the gap between the two fingers is no doubt an ugly deformity. In the T? ' ,. "^ , Showing the incisions for various operations, viz. : 1. The incision UlSSeCting-rOOm tlie am- ^^^ ty\u^ the carotid artery, at the edge of the sternomastoid mus- putatlOn (rig. 392, 10) cle, in a line from the sternoclavicular joint to the point between may be accomplished *''^ angle of the jaw and mastoid process. 2. That for tying the with a sinole sween of subclavian, lying just above the clavicle, in the space between the , 1 T '^ rpi 1 'e trapezius and sternoinastoid. 3. The incisions for the removal of LUe Kniie. lUe Kniie the breast. 4. The incision for ovariotomy, which is sometimes ex- should be long, thin, but tended up to the ensiform cartilage. The dot in the centre of this stout. The fino"er to be i'^clsion indicates the place for paracentesis. 5. The incision for the removed fsaV the mid- •'g'^*-'"''^"*'*'^^'^''''''"'^*^"''^- in tying the lower part of the externsl . . ^ *^ -^ iliac, only the lower part of this incision, lying somewhat parallel die) IS seized and drawn to Poupart's ligament, is required. 920 OPERATIVE SURGERY. to the ulnar sidts, the heel of the knife is laid on its radial side, at the an- terior end of the incision, and carried on with a sawing motion backwards till it arrives at the position of the joint. It is now turned transversely through the joint, and then forwards to cut out the flap on the ulnar side. The various exigencies of injur}- and disease often render this operation impracticable on the living subject, and tlie flaps must be shaped as the operator best can, but inclining to this model. If the head of the metacarpal bone is to l)e removed, the incision must be prolonged sufficiently l)ackwards to allow of the bone being cleaned and the cutting forceps applied. Amputalion of the Thumb. — The thumb is very rarely amputated, since its preservation, or that of any part of it, is so useful as a, j^oint d''appui to the fingers, even if it is itself immovable, that surgeons generally leave cases of injur_y of the thumb to nature ; and in cases of diseased joints or phalanges the expectant treatment is still more plainly imperative. The thumb may be amputated at its joint with the trapezium l)one by carry- ing an incision forward on the dorsal aspect of the metacarpal bone from the position of the joint, then making it include the metacarpo-phalangeal joint in an oval manner, as shown in Fig. 392, 9, and so returning to the point from which it started. Thus an ample covering is secured for the flap, and no incision made in the palm. The thumb being freely divided from tlie fold uniting it to the forefinger, is lifted up, the knife passed below its metacarpal bone, separating it from the palmar muscles, and then by dividing the ligaments which unite it to the trapezium the whole member is removed ; or palmar or dorsal flaps maj^ be formed by passing a long bistoury in front of the thumb from near the situation of the joint to the fold between the thumb and forefinger, and then cutting out a large flap from the mass of muscles of the thumb. The joint which is now ex- posed is divided, and a smaller flap made from the dorsum. The radial artery is sometimes divided in the operation, though by carefully keeping the knife close to the bone as the operator passes through the joint this may be avoided. Amjnitation at the HijyJoint. — The operation at the hip-joint is the most formidable of all the amputations. In performing it it is often essen- tial to get the operation over as rapidly as possible, and this is the case especially when a tourniquet cannot be applied. The surgeon will require at least four assistants: one to administer the anaesthetic; a second to attend to the tourniquet, and if needful, compress the artery in the groin ; a third to support the limb, and a fourth to manipulate it so as to facili- tate the movements of the knife. The tourniquet which is in use in this amputation is one invented by Professor Lister, and generall}'^ called after his name ; but he has pointed out that Professor Pancoast, of Philadel- phia, had previously designed a similar instrument.^ It is a large horse- shoe tourniquet, resting by a broad base on the loins and somewhat steadied by a strap which passes from its expanded end to its arm. The end of the arm carries a screw and pad. The pad is applied over the aorta, just above the umbilicus, and by screwing it home (if the tourni- quet is of the proper size) the pulse in both groins can be arrested, which shows that the aorta is commanded. This sometimes produces such dyspnfi'a that it cannot be tolerated even under anassthesia, in which case the second assistant must be charged to suppress the pulse in the groin b}' pressure with one hand, and to follow tiie surgeon's knife as it cuts out the anterior flap, and seize the femoral artery. Other assistants (or 1 Syst. of Surg., 2d ed., vol. v, p. 6'i2. DIAGRAMS. 921 Fig. 397. Fig. 897. — Diagram showing the incisions for various operations on the lower extremity. 1. Ampu- tation at the hip-joint by a short anterior and long posterior flap. 2. Amputation of the thish by short anterior and long posterior flap. 3. Teale's amputation of the log. 4. Syrae's amputation at the ankle. 5. Chopart's amputation. 6. Ligature of the femoral artery in Scarpa's triangle. 7. Ligature of the femoral artery in Hunter's canal. 8. Excision of the knee.' 9. Ligature of the posterior tibial artery. 10. Ligature of the anterior tibial artery. 11. Ligature of the posterior tibial artery lower down. 12. Lisfranc's amputation. 13. Amputation of the great toe. Fig. 398. — Lines of various amputations in the lower extremity, as shown on the back of the limb. 1. The posterior or short flap in amputation at the hip. 2. The posterior or long flap in amputation of the thigh, shown in Fig. 397, 2. 3. Teale's amputation in the leg, shown rather diagrammatically, the long anterior incisions being placed too far backwards, in order to render the position of the poste- rior flap intelligible. 4. The incision at the outer side of the lower flap of Syme's amputation. 922 OPERATIVE SURGERY. if there are onl^' four, tlie fourth) will press sponsjes on the vessels in the posterior flap as they are cut. Tiie easiest and quickest way of amputat- ing at the liip is by antero-posterior flaps. The knife is entered midway between the anterior superior si)ine and the great trociiauter, and its point is brought out in the middle of the fold between the nates and perineum, in doing which the operator, if lie knows accurately the posi- tion of the joint, will probal)ly open it. While this is being done the fourth assistant, who has gently flexed the limb in order to facilitate the opening of the joint, brings it quite straiglit, and the operator cuts out a long anterior flap, reaching about four or five inches from the groin if the tissues there are healthy. The second assistant draws this flap upwards, the operator cuts the joint freely open with the point of his knife, and the fourth assistant by strongly extending the thigh makes the bone start out of the socket. Then he flexes and adducts the limb so that the tro- chanter may become prominent, and the surgeon passes the heel of his knife round the trochanter, and gets its ]»lade altogether behind the femur. As he does this, the fourth assistant, following his movements, brings the limb straight again, and the posterior flap is cut out. The third and fourth assistants are now free to attend to the vessels and help the opera- tor in securing them. The long anterior flap has reached below the bifur- cation of the femoral, and the first care of the surgeon is to tie the femo- ral and profunda arteries (Fig. 399 a). When this has been done the Fig. 399. Amputation at the hip hy tlie long anterior and short posterior flap. a. The femoral and profunda vessels, with branchi s of tlie anterior crural nerve, b. The great sciatic nerve and its companion ar- tery. A large branch of the sciatic artery is seen in front, c. The muscular mass from the tuber ischii and tlie obturator externus muscle. Large branches are seen on either side from the profunda and gluteal. D. The psoas and other muscles immediately in front of tlie joint. The knife must be passed beneath this mass of muscle in the first transfixion, so as to avoid all danger of puncturing the femoral artery. second assistant's hands are at liberty, and then the large vessels in the posterior flap should be secured, while any smaller bleeding arteries in the anterior are compressed. The continuation of the sciatic artery and the comes nervi iscliiadici will be found near the sciatic nerve, large branches from the internal and external circumflex on either side, and some branches probably from the gluteal. When all the vessels are tied AMPUTATION OF THE THIGH. 023 Fig. 400. there is an ample covering for the stump. The posterior flap is shown in Pig. 398, 1, and the stump in Fig. 399. If from the grovvtli of a tumor, or any other cause, this method is impracticable, the flaps can he made either laterally or obliciuely, or one of the flaps may be lengthened at the expense of the other (Fig. 397, 1); or they may be made chiefly of skin, dissected and turned back before the deeper incisions are made. Ampula/ion of (he Thigh. — The thigh may be amputated in various ways, and at any level, the femur being divided as high as tlie trochanter, or as low as the condyles ; but surgeons are always anxious to go as low as is consistent with removing the disease, remembering Dietlcnbach's saying that "the danger rises with every inch." The old circular am- putation, or a combination in which the skin is cut in flaps, the longer anteriorly, and then a circular sweep is made through the muscles, seems to me the best method. For the amputa- tion close on the knee-joint Mr. Garden's method is now in great favor. Its principle is that of making the whole stump out of one long anterior flap of skin reaching below the patella, and cutting the posterior skin and muscles straight down to the bone ; then raising all the soft parts somewhat from the bone and dividing it horizontallj' show the flat face of the stump. A shows the femoral through the condyles, l)elow the medullary canal. This is sufficient in most cases of dis- ease of the knee, and leaves a very long and very useful stump. It is believed also to be less ex- posed to the danger of osteo- myelitis than the operations are in which the medullary canal is laid open. Flap operations can also be performed in any part of the thigh, either by antero-posterior (Fig. 397, 2) or lateral flaps. Mr. Teale's method by rectangular flaps is not appli- cable to the thigh, in consequence of the high level at which the bone must, on this method, be necessaril}' divided. Amjjutation through the knee-joint, leaving the whole cartilaginous surface of the femur and patella intact, is an operation of wliich I am myself rather fond, in cases where the whole of the leg is destroyed by accident, or where malignant disease attacks the tibia, yet there is i)lenty of sound skin below the knee.^ A long skin flap is cut out of the front of the leg by an incision, convex downwards, starting from the back of either condyle and reaching four or five inches down the leg. The skin and the patella having been raised from the bones and the lateral liga- ments completely divided, the surgeon changes the scalpel for an ampu- tating knife, which he passes behind the tibia and cuts a posterior flap ' The main advantages of amputation at the knee are the lenj^th and power of the stump, and the broad unirritabhs face for application of the artificial leg. Its disad- vantages are the tendency to sloughing of the long flap and to abscess extending up the thigh. Stump of circular amputation of tliigh bilow the mid- dle. The sleeve of skin has been quite turned back to artery, its vein behind it, and the profunda vein and artery behind them. The sartorius covers the vessels, b shows the great sciatic nerve audits companion aitery, the semi-membranosus muscle lying close to it and divid- ing the mass of adductors from the biceps and scmi-teu- dinosus. c shows the triceps extensor with the rectus aliovc it. Muscular arteries will have to be tied in all these masses, their number varying witli tlie nature and duration of the disease. 924 OPERATIVE SURGERY. outwards.' This flap need only extend a very short distance if the ante- rior flap is long enough, and it is better so, as the wound then falls com- pletely behind the femur. The popliteal and one or two articular branches are probably all that will require ligature. This operation is variously' modified. Mr. Butcher describes an ope- ration as "■ amputatiou at the knee-joiut," in which the end of the femur is cut through and the stump made chiefly from the skin and muscles of the calf, the latter being hollowed out as far, as is necessar}' to render the flap pliable and admit of its being attached to the skin in front of the femur. This is, as it were, Garden's method reversed, and the latter is generally preferred. Again, there is an operation which goes usually by the name of" Gritti's amputation," in which the flaps are formed as for the amputation through the knee-joint, but either in consequence of disease or injur^'^ in the lower end of the femur, or from not being able to get sufficient sound tissue to cover the condyles, the operator is obliged to saw through them. Then the patella is sawn perpendicularly, so that all its cartilage is removed. The anterior flaj) is brought over the sawn end of the femur, and the sawn surface of the patella applied to that of the femur. Or, in the amputatiou through the knee-joint, the chief flap can be made from behind, and the scar brought up in front of the femur, the patella being removed. Anipufation of the leg may be performed on the circular metliod, which secures a somewhat lower ^^°- '^^i- section of the bones than any of the flap operations, or by skin-flaps and circular section of the muscles ; or by flaps formed on the an- terior aspect 03^ section from the skin inwards, and on the posterior by trans- fixing the parts and cutting outwards. In transfixing from the tibial side the ope- rator must be careful not to pass his knifethrough the in- terosseous space in front of the fibula, instead of behind it. I have seen this twice done on the living subject. Mr. Teale's operation, by rectangular flaps, is, how- ever, a very good method in this amputation, when the operator has no objection to dividing the bones some- what higiier up ; and this seems a convenient place for describing it. No am- putating knife is required for this operation, which Diagram of Teale's amputation of the leg, performed a little below the centre of the lirab. The anterior long flap has been bent on itself, the better to show the position of the vessels. 1. The anterior tibial vessels and nerve. The artery is shown expo.sed throuybout the whole length of the tlap, where it has been peeled off the interosseous membrane. The tibialis anti- cus muscle is seen on its tibial side, the extensor proprius pollicis and extensor longus digilorum on its fibular side, ex- ternal to which is the mass formed by the peroneal muscles, here perhaps rather exaggerated in size. 2. The posterior tibial vessels and nerve lying near to the interosseous mem- brane, but separated from it by the tililalis posticus muscle, and from the tibia by tlie flexor longus digitoruui. 3. The peroneal vessels lying close to the fibula, in the substance of the flexor longus pollicis. In the cut face of the short and thick posterior flap are seen the section of the soleus, and superficial to this that of tbe gastrocnemius muscle, each con- taining the mouths of several muscular vessels. ' Or the posterior flap ma}' be cut from the skin inwards with the same knife as was used in cutting the anterior flaj), or the whole operation performed with a short amputating knife. teale's operation. 925 is performed with a rather large scalpel. Having made up his mind where he will divide the bones, the surgeon measures (with a tape or with his eye) the circumference of the limb, he talces a horizontal line the length of half this circumference with its extremities lying behind the tibia and fibula, and from the ends of this line he draws two incisions of the same lengtii as the base vertically downwards,' and unites their ends by an inci- sion })arallel to the base. He cuts through all the tendons and vessels straiglit down to the l)()nes and interosseous meml)rane, and then raises all the parts, inclnding tlie anterior tibial vessels, from the bones and inter- osseous membrane. Much care must be taken not to notch the artery in doing tliis, the edge of the knife being kept always on the membrane. Plav- ing raised the anterior flap completely, the operator cuts the posterior flap by a transverse incision running across the back of the leg down to the bones, the posterior flap being a quarter the length of the anterior (Fig. 397, 3). The interosseous membrane being divided and the bones per- fectly cleaned, the saw is api^lied. For this purpose the leg is turned outwards, so that the fibula is first presented to the operator, and the division of the fibula completed while the tibia is still only half sawn through. The vessels having been tied (see Fig. 401), the long anterior flap is bent over, its lower edge sewn to that of the posterior flap, and its doubled lateral edges stitched together. If the flaps have been cut truly the whole fits perfectly, and when it unites kindly it makes a most ex- cellent stump ; but it is not a suitable operation for weakly i)ersons on account of the probability of sloughing of part of the long flap, and if secondar3' haemorrhage comes on it is very troublesome. Mr. H. Lee has proposed to reverse Teale's proceeding, making the long flap from behind instead of in front, so as to obtain thicker tissue for the lung flap, which is therefore less liable to slough, and to avoid leaving a long piece of nerve (the anterior tibial), which has to be bent on itself in adjusting the flaps.' I have seen very good results from this operation in Mr. Lee's liands ; but it is somewhat diflficult to be certain of the position of the posterior tibial vessels in performing it, and the tendinous part of the gastrocnemius muscle in the lower part of the leg does not easily lend itself to the bending which the long flap has to undergo. Teale's method provides the bones with a thick cushion formed in great part of muscles. These muscles ultimately waste away, but while they are undei'going this process the stump becomes consolidated, and the skin does not adhere to the bones, so that the face of the stump will bear the wooden leg to press directly on it. Li performing amputation of the leg when the tissues are at all con- solidated by inflammation it is often dillicult to retract the parts from the bones. In such cases a linen retractor is required. This is made with a long piece of stout linen, in one end of which a tongue is cut or torn, leaving this end to consist of three strips, the central one the narrowest. This tongue is passed through the interosseous sjiace, the broader ends are crossed in front of the bones, and thus the parts can be forcibly pushed up and the bones exposed much higher than is otherwise possible. In amjjutating the leg the posterior tibial artery often retracts into the corner of the stump (especially when it is made b}' transfixion), and it is very troublesome to tie it, or any of its branches divided near the trunk. ^ As inn limb rapidly decreases in size, the lower end of the flap includes much more thnn half the circnmferonoe of the leg. 2 Med.-Chir. Trans., vol. xlviii, p. 195. 926 OrERATIVE SURGERY. Fig. 402. Sii/me's amputation through the ankle-joint is thus performed, if we follow the directions of its author : the anterior flap is formed b_v drawing the knife from the jxjint of tlie external malleolus to the corresponding point on the opposite aspect of the foot, /. «., below and behind the in- ternal malleolus (Fig. 897, 4). The anterior flap can be made to extend down tlie dorsum of the foot a short distance if the surgeon thinks fit. The i)()sterif)r flap is made by drawing the knife from one end of tlie anterior flaj) to the other across the lower surface of the os calcis, inclin- ing it rather towards the heel, so that the incision slopes backwards. The posterior flap is then dissected back and thrown round the end of the OS calcis until the tendo Achillis is separated from that bone and the knife turns round the upper aspect of the calcaneum. In doing this the operator must be careful to keep the edge of the knife directed towards the bone, so as not to score the skin and not to make a buttonhole. It is inipossil)le to do this satisfactorily if (as is often directed) the flaps extend from one malleolus to the other; for this makes the inner part of the flap so high and broad that it can hardly be dissected round the heel without great force. When the os calcis is denuded, the anterior flap is to be thrown up, the ankle-joint opened, the knife passed round the inner and then the outer malleolus, and the foot removed. Next the tibia and fibula are to be cleaned for about half an inch, taking care by keeping the knife close to the bone that the posterior tibial arterj' is not punctured, and a thin horizontal slice of the tibia with both malleoli sawn oflT. The arteries are then secured (Fig. 402), and the flaps sewn up. Man}^ surgeons think it best to pass a drainage-tube from one angle of the wound through an opening made at the back near the tendo Achillis, so as to avoid the bag- ging of matter in the posterior flap. Other- wise it is almost always necessary when suppuration sets in to make an opening in B. Tlie suction of tlictiliia. D. Tluit of the the flap.^ fibula, r. The posterior tiiiiai artery and The operation, howevev, is much morc its bifurcation Kxternai to this is seen ^^^jj performed in the reverse manner to threat extent liy liaving a foot-piece put on to it, and he can walk a short distance well enouyli without any ai)[)aratus at all. The opera- tion is available in most cases of disease of the ankle and tarsus, and in many cases of injury. Pir'ociojpx amputation is a modification of Syme's, in which the extrem- ity of the OS calcis is saved and is applied to the cut end of the til)ia, in order that it may unite with that bone and form a longer stump. The flaps being marked out in the same M'ay as in Syme's amputation, the- saw is applied to the incision across the under surface of the os calcis and that hone is savvn in a direction sloping upwards and backwards to its ni)per surface behind the ankle. Then the joint is opened and the malleoli and under surface of the tibia i-emoved just as in Syme's ampu- tation. The section of the os calcis is then i)laced in apposition with that of the tiiiia, and the wound united. When all goes well Pirogoff's amputation forms a very good stump ; but it is not very often available, for in cases of disease requiring ami)utation the os calcis is usually, or very often, involved, and in cases of injury either, on the one hand, more of the foot can be preserved, or, on the other, the surgeon finds himself obliged to amputate througii the leg. Syba.strar/alo'id Amjnitation. — In some cases it may be that the os calcis and the bones of the front of the tarsus are diseased or injured, but the astragalus is healthy ; and then a very good stump may be made by forming a heel and a dorsal flap long enough to meet beneatli the as- tragalus, severing that bone from its connection to the calcaneum and scaphoid, and leaving it in the ankle, while the rest of the foot is re- moved, but 1 have not had any opportunity of seeing this operation practiced. It does not seem of much importance by what precise inci- sions the flaps are formed, so that they are suflBciently ample, and that the lower flap is formed chiefl}' of the tissues of the heel, as in Syme's amputation. I must refer the reader for the details of the published eases of this rare operation to Mr. Hancock's Lecturei< on the Anatomy and Snrge7^ti of the Foot^ p. 191 et seq., where he will find described also a modification of the subastragaloid amputation devised and performed by Mr. Hancock himself, and bearing the same relation to the ordinary subastragaloid amputation as Pirogoff's does to Sj'me's amputation. Mr. Hancock preserves a portion of the back of the os calcis in the heel- flap, saws off' the head of the astragalus and its lower articulating sur- faces, and then adapts the cut surface of the os calcis to that of the as- tragalus. The result, as figured in Mr. Hancock's work, is an excellent stump, almost as long as the sound limb, and quite capable of bearing any amount of pressure. The distinguishing recommendation of the suliastragaloid amputation is the increased length of the stump, even as compared with Pirogoff"'s, and still more with Syme's amputation, and this advantage attaches still more strongly to Hancock's amputation. Chopart^s anvputation is performed througii the transverse tarsal joint (Fig. 403). The tuberosity of tlie scaphoid is easily felt, and the position of the calcaneo-cuboid joint halfway between the external malleolus and the point of the fifth metatarsal bone is known. An incision is di'awn across from one of these points to the other with a scalpel, and a short dorsal fiap is cut (Fig. 397, 5), the transverse tarsal joint opened, and the bones fairly separated from one another. Then I)y means of an am- putating knife a long plantar flap is cut outwards, or towartls the skin. 928 OPERATIVE SURGERY. Fui. 403. This flap can, of course, be cut with the scalpel by incision from the skin almost equally readily. One objection often made to Chopart's am- putation is that the tendo Achillis is liable to displace the bones upwards, being no longer antagonized by the tendons in front, so that the scar is brought downwards and the stump becomes too irritable to bear the pressure. This defect is not always noticed, nor is it eas}' to see exactly on what its occasional ab- sence depends. It may be avoided, according to some, by subcutaneous section of the tendo Achillis at tlie time of the operation, a com- plication which, however, it is desirable to avoid. The plan of passing the sutures through the tibial tendons, so as to attach them to the cicatrix (due, I believe, to the late Mr. Dela- garde, of p]xeter) is worth bearing in mind. Lixfranr/s operation consists in removing the whole metatarsus with the toes, and leav- ing the tarsus intact. Hey's amputation is the same, except that the second metatarsal bone is divided, and its head left in the articulation between the cuneiform bones. The projection of the second metatarsal bone backwards (Fig. 403) is the only ditliculty in this operation. The position of the articulation of the great toe with the internal cuneiform, and of the amputation is perronnrd at the little toe with the cuboid being fixed, a curved transverse tarsal joint, where the incision is drawn from the onc point to the bones are separated from each other ^+i,„„ /t?;„. oot i ci\ j \ a behind. Lisfranc's at the tarso- "^^''^l ^ ^^\ ^^^ ^ l^) and as much flap aS metatarsal articulations, where they pOSSlblc taken from the dorSUm. The flap are separated in front. being tlirown back, the joiut bctwecu the great toe and cuneiform bone is divided, then the point of the knife is carried directly backwards till it is slopijed by the middle cuneiform bone, when it is directed outwards, and then forwards again, so as to cut entirely round the head of the second metatarsal. Then by pulling the metatarsus forcibly downwards, while the knife is passed along the line of the articulations, which slope back- wards, the disarticulation is completed, and the plantar flap may be cut by transfixion or incision, as in Chopart's amputation. This operation is used almost exclusively in cases of injury, so that as much flap as pos- sible must lie taken on both sides to compensate for any possible sloughing. Finally, aMi[)utation may be performed through the tarsus in any situa- tion, by simply fashioning flaps and sawing through the bones; and this proceeding is, in the opinion of Mr. Hancock, the highest authority on these operations, superior to the amputations performed through the artic- ulations. The toes may be amputated exactly as the fingers arc, l)ut here it is still moi-e un(lesii'al)le than in the hand to remove the heads of any of the central metatarsal bones. If any of tlie smaller toes require removal the whole to(; sliould be amputated, since the portion left would be useless, and might lie in the way. 'V\h\ heads of the first and fifth metataisal bones should always be cut off in amputating those toes, the incision Skeleton of the foot. Chopart's EX(;i??ioNS. 929 througli the bones being sloped off if possible. The great toe with the head of its metatarsal bone can be removed by a V-shaped incision as shown in Fig. 897, 13. If the whole n)etatarsal bone is to be removed, the point of the Y must be extended backwards as far as the situation of the incision (12) on the same dingram, and the toe having been removed the metatarsal bone is dissected out from the incision, care being taken, in dividing its head from the cuneiform bone, to keep the knife so close to the bone as not to wound the plantar arch. EXCISIONS. Excisions of joints and bones are operations which are quite of modern date, and wliich, in I'act, could hardly be practiced freely before the inven- tion of aniifsthesia. They are performed chiefly on account of disease of the articular surfaces or of the tissue of the bone excised, sometimes (as in excision of the scapula and clavicle) on account of the grovvth of tu- mors from the bone, sometimes as primary or secondary operations after injury. The operations resemble to a certain extent the dissections by which tumors are removed. The diseased joint or bone may be regarded as a tumor to be exposed by appropriate incisions, tlie soft parts turned aside without injuring the main vessels and nerves, all its connections severed, and the whole of the morbid tissue removed. But there is this furtlier consideration in performing an operation of this kind, that the morbid structure removed is an important part of the skeleton, and that the operation must be so performed as to make provision for the subsequent stability or mobility of the limb as may be recpiired. Thus, in the ex- cision of the knee, it is im[)ortant that the bones should be firmly anchy- losed, a result which is especially to be deprecated in the elbow. The instruments required in excisions are, in addition to the usual dissecting instruments, saws of various sizes, from the amputatbig to the "key- hole" saw, retractors, the lion forceps, and the cutting bone forceps. In subperiosteal excisions the operator must have various raspatories, ?'. e., semi-blunt chisels or rasps, as well as the chain-saw, and a combination of a rasjjatory and director for the purpose of detaching the periosteum from the bone and carrying the chain around it. For some excisions a combination of a staff and a director is very useful — the "excision di- rector." This is shaped like a lithotomy statf, and mounted on a jointed handle. Its convex side is grooved. It is glided under the bone to be removed — say the neck of the femur — and then by reversing its position its grooved surface is turned towards the bone and lifts it out of tlie wound, while its concave part lies over and protects the soft parts. The use of Esmarch's bandage is, as I have said above (page 909), very advantageous in most of these operations. In late years, the advantages of preserving the periosteum ("subperi- osteal excision") have been much insisted on by Oilier and Langenbeck; and in some excisions they are incontestable, while in others ilie advan- tage of the new method is at any rate not as yet proved. I shall refer to the subject in speaking of each several excision. Excision of the ahoulder is perhaps as successful as any, even that of the elbow, considered merely as an operation, and is equally' applicable in cases of injur}' and disease ; but it differs from excision of the elbow in the inij)ortant particular that its results at their best are probably in- ferior — certainly not superior — to those of natural anchylosis, and there- 59 S80 OPERATIVE SURGERY. fore that it should never be practiced when there is any good prospect of ohtaiiiing a cure by natural ancliylosis. As tiiis cure is very often obtained in cases of disease of the slioulder, excision is but rarely practiced in civil life. In gunshot injuries, wiien the missile has not penetrated be- yond the bones of the joint, as in the cases figured on pages 344, 345, it is a very successful operation. In tumors springing from the head of the bone it might be justihaltle to excise the atlected portion of bone, if it could be clearly diagnosed that the tumor is not malignant, but this could very rarely be the case. Tiie operation, as usually jiracticed, consists merely in removing the head of tiie humerus. This may he done, if there is not much thicken- ing over tlie joint, by a single incision running downwards as far as may be judged necessary from the up|)er part of the acromion process, over the most prominent part of the liead, where it is most plainly felt beneath the skin. This line of incision corresponds pretty nearly to the direction of the long tendon of the biceps muscle. In some cases it is necessary to make a flap out of the deltoid muscle, of a somewhat triangular shape, with its base upwards. The precise position of the incisions which bound this flap is a matter c>f secondary imi)ortance, and is usually determined by that of the sinuses or wounds. The head of tlie bone, having thus been exposed, is to be rotated (when the shaft is entire) first outwards, in order to stretch the tendon of the subsca[)ularis, then inwards, to make tense those attnched to the gretiter tuberosity ; these tendons are to be divided, and the capsule thus freely opened, and then the head of the bone is to be tiirust out of tlie wound and sawn off. If the case is one of injury, and the head of the bone is severed from the shaft, it must be seized with the lion-forceps and dissected out. The bleeding is usuall}' free from the posterior circumflex artery or its branches. If the long tendon of the biceps can be distinguished it should be spared. In both disease and injury the glenoid cavity often escapes; but if it should be found affected, it may be thought necessary to remove it. This is best done with a large chisel or with hone-nippers of appropriate shape. The parts should l)e lightly put together by means of a few sutures, and the patient confined to bed for the first few days, until the consecutive fever has passed over. He may then be allowed to move about, the elbow being carefully su|)ported. The tendency of the muscles which form the flaps of the axilla to displace the bone may be counteracted by a pad in the arm])it. The ^iibperioilished in the Lancet for July 18, 1874, by Dr. Donovan, records a case in which the whole bone from the head to a point just above the condyles was excised subi)eriosteally, in a case of acute periostitis in a boy, with good results. The excision of the scapula on ai:;count of a tumor is a formidable operation, the advantages of which should be maturely weighed before its dangers are encountered. Oi)crations on this bone for necrosis are much more likely to be permanently successful, but they rather resemble the common operations for extraction of a sequestrum than formal excisions. The total excision of the scapula for a tumor should be thus performed. The patient being brought under the influence of chloroform, an assistant should be charged with the comi)ression of the subclavian artery, for which purpose, if the projection of the tumor makes compression dilii- cult, the incisions may be so managed as to enable him to put his flnger directly down upon it. This precaution much diminishes the h.iemor- rhage from the subscapular artery and its branches, which otherwise might be formidable. The surgeon then proceeds to denude the tumor of its outer coverings by turning dovvn appropriate skin flaps, taking great care, however, not to open the capsule of the tumor itself When the whole tumor is thus exposed tiie muscles inserted into the vertebral border of the bone should be rai)iilly divided, as also those whieh ai'e attached to the spine of the scapula. The tumor being now movable should be lifted well up, and freed from its other attachuients by rapid strokes of the knife, commencing from its lower angle. The subscapular artery is divided near the end of the operation, and can be caught hold of by the surgeon or his assistant, and held till the tuinor is removed, or can be at once tied. The ligaments of the shoulder are then easily divided and the mass removed. The acromion process, if not diseasccl, may be divided with bone-nippers, and left behind to preserve the shape of the parts and protect the head of the humerus. Excision of the Clavicle. — Excisions of any part of the clavicle should be undertaken with the greatest care on account of the close relations which the bone has to important structures, and on account of the risk of diffuse inflammation below the deep fascia of the neck ; and the total extirpation of the bone, for a tumor springing from its sultstance, is one of the gravest operations in surger}'. In Mott's case the operation lasted four hours^ and thirty vessels were tied. Mott says, "■ Tliis operation far sur|)assed, in tediousness, difticulty, and danger, anything whieh I have ever witnessed or perfcn'med." If it be decided to remove the whole claviele along with a tumor, the incisions should be made very free, one over the long axis of the bone, joined by otliers in appropriate 1 See Polluck, in St. George's Hospital Keports, vol. iv, p. 2'il. 932 OPERATIVE SURGERY. places for turning down such flai)s as may appear necessary, and the parts to be oi)erated on should be brought fairly into view before the bone is meddled with. After having freely divided all the superficial attachments of the bone and tumor, the next step is to divide the outer end of the clavicle from the scapula, either by cutting through the joint or by severing the bone with a small saw or ni[)pers. Then the part which is to be removed can be raised, and must be separated with great care from the imi)ortant parts whicii lie below it, so as to reach the sternal part, which is last divided, and which serves during the opera- tion as a pivot on which the bone can be moved and supported ; or, in other cases, it may be found more convenient to divide tiiis part of the bone also at an earlier period of the operation.' It ajipears that very useful motion ma}' be recovered after the removal of a large part, or even the whole, of the shaft of the clavicle. Excitiion of the elbow is a most useful and a most successful operation. It is practiced on account of injury and of disease with equal relative success, though the absolute success is, as in all operations, much greater in cases of disease tiian those of injury. Any disease which does not ex- tend far from the articulating surfaces, and wliich is otherwise incurable, is a clear indication for excision. As caries of the joint-ends of the elbow hardly ever involves any extensive intlainmalion of the shafts of the bones, this comprises most cases of serious disease of this joint. I'here are even cases in which the disease is not incurable, but where the cure would involve long disuse of the liml) and ultimate loss of motion from anchylosis, where it may be justifiable to resort to excision, if the patient be young and healthy, in the hope of cutting short the disease and pro- curing a more movable limb. And other cases are also met with, though rarely, in which the limb has been allowed to become anchylosed in an extended or otherwise useless position, and where the surgeon may be justified in excising the joint at the request of iiis patient after the risks and the probalile advantages of tlie operation have been explained to iiim. It must always be borne in mind in this operation that the oliject is to procure such union as shall be sutliciently firm, on the one hand, to atford a fixed centre of motion for the bones of the forearm, and thus give pre- cision and strength t(; the movements of the hand, and yet shall not be so close as to abolish any of the motions of tlie joint. In the most successful cases these indications are perfectly fulfilled, so that the motions of the hand are as extensive as on the sound side, and no case of excision of the elbow is to be reckoned as perfectly successful in which this is not the case. Such perfect success is n)ore probable in childhood than in mature life, though even tlien it is often obtained, and if it be not, an amount of motion ought at any rate to l)e insured which leaves the patient a very useful arm even in cases which do not quite come up to the ideal. The operation is now abnost always performed by means of a single straight incision running parallel to the course of the ulnar nerve, Imt a little (;xterilal to it — i. e.^ over tlie inner side of the olecranon and for about two inches above and itelovv it, This incision is made fairly down to tlie Ijone, dividing the triceps muscle and t!ie periosteum. The oper- ator prf)ceeds dilferently in tlie common and in the subperiosteal opera- tion. In tlie ordinaiy operation he opens the joint freely by cutting round the olecranon, er the nlnar nerve wliich lies amongst these parts.' Then the internal lateral ligament is cut away from the luimerus, and novv tlie joint is qnite destroyed. Tf the end of the lunnerns can he thrust out of the wound without interfei'ing with the bones of tlie foi-earm it is to be sawn across just above the condyles, or the olecranon may be cut away for this j)nrpose l)efore tlie rest of the disease is removed from tlie forearm. Tlien the bones of the forearm are to be thrust out of the wound and sawn off on the same level — i. «., just below the coroiioid pro- cess, the head and neck, but not the bicipital tubercle of the radius being removed. It is far. better to remove l)otli liones together by a clean cut with the saw than to divide the neck of the radius with bone nippers. And it is often convenient to reverse the usual order, by removing the bones of the forearm before dealing with the humerus. When tlie sur- geon is satisfied that all the disease is removed, the bandage is relaxed (if, as is generally advisable, Ksmarch's bandage has been employed), and the vessels tied with catgut ligature. Then a kw minutes are to be given for exposure and cold bathing to stay any residual oozing, the wound is to lie united with silver sutures, a drainage-tube being inserted into it, and the arm put on a splint and dressed. SubperioH/eal Method. — If the operator decide to proceed suliperioste- ally he must first take care that his incision has really divided the whole periosteum down to the bony structure, then by working with the raspa- tory on the back of the olecranon he will find it very easy to detach the periosteum there, and he must use all possible care to clean tlie back of the humerus completely of all soft structure — periosteum, capsule of joint, and tendons — and especially to detach as completely, and with as little injury as possible to their structure, all the tendons and other soft parts wliicli adhei'e to both condyles. The end of the olecranon may now be removed in order to obtain access to the front of the ulna, detach the tendon from the coronoid process, and tlius complete the denudation of the portion of ulna which is to be sawn off. If the attachments of the orbicular ligament can l)e recognized and i)reserved, it may be possible to remove the head of the radius without interfering with them. Now comes the most difficult i)art of the operation, viz., how to clean the fron*". of the humerus of its periosteum. M, Oilier attempts this by gliding a curved instrument between the bone and periosteum and conveying a chain saw in its course, but this curved raspatory is very apt, when act- ing in the dark, to pass through the periosteum. It seems better to divide the bone with the keyhole saw from behind incomiiletely, and then frac- ture it, as is done by some operators while removing the end of the femur in excising the knee. The periosteum will remain untorn, and the sur- geon can then proceed to detach it from either side, commencing from the part exposed in the wound. The advantages of the subperiosteal ex- cision of the elbow, which is far more lal»orious and involves more violence to the tissues than the common operation, are, I must say, as 3'et un- proved. After the operation, the limb should be placed lightly on a si)lint. The precise form of splint is of no importance ; in fact, the splint itself is not 1 Tho ulnar nerve is seen in operiitions on tlie dejid subject, but in flisease it is sel- dom visible, heinij hidden by the intliuiimutory products around the diseased joint. I have seen it in |)rirnnry excision for injury in the living, and in excisions in which Esmarch's bandage is used it may sometimes be seen. 934 OPERATIVE SURGERY. absolntel}' necessary, for some surgeons of much experience use only a bandaiie. But I think the support and confidence which the splint gives (especially if startings of the linili take place, as they are rather apt to do) are a great conil'oit to the patient. In about a week, when the parts are beginning to consolidate, the splint should be so arranged as to per- mit the hand to reacli tiie month, and when the wound has nearly' healed ))assive motion and then active motion is to be enforced. 'IMie precise time at which active motion is to begin cannot be fixed. If the quantity Fl(i.40t. The method of slinging the limb after excision of the elbow. of bone prescril)ed above has been removed, there will very likely never lie occasion for any passive motion at all, and in no case ought it to be used until all active inflammation has passed over and the wound is almost healed. While the ijatient is in bed it is a comfort to sling the arm from a pole over the bed, as shown in Fig. 404. The repair after exciHion is in rare cases b}'^ bony anchylosis. This is undoubtedly to be reckoned as a failure, and ought hardly ever to occur. It depends geneially on the I'emoval of too little bone, and on the neglect of passive motion afterwards. Commonly the repair is by means of filirous bands which tie the ends of the dilferent bones to each other. In rare EXCISION OF THE WRIST. 935 ¥[(-.. 4(15. cases there is considerable reproduction of bone and a complete joint is formed. Tiiis was the case in a remarkable instance described and figured by Mr. Syme, in which a considerable reproduction of bone had taken place from either side of tiie end of the lui- meriis, and these two newly produced condyles locked in the two bones of the forearm, forming- a complete hinge joint, in which tl>e radius played in a newly formed orbicular ligament 'The patient, who was a railway guard, had been able to use the excised elbow as well as the sound one for the purpose of swinging himself from one carriage to another of the train in motion. This rei)roduction is quite as perfect as any which has been proved to take place after subperiosteal resection. In fact the reproduced bone after the lat- ter operation is often exuberant and is detrimental to the motion of the joint.' Excision of the ivrist as a formal operation is not often practiced, since in cases of disease which are suffici- ently serious to justify so very severe a proceeding, the affection has gener- all}' extended too far ; while in slighter cases, tiie surgeon thinks that the pa- tient will ultimately do better if only "^ 'he lii.nieius locking in the bones of the the diseased portions of bone be dealt f:"'^''™ /" the n.w joint ,/ new orbicular , . ' liL;;nnent iiround the head of the radius ; (;, a With from time to time as may be nee- portion of the ligamentous union between the essary, and passive motion be kept ll[) ulna and humeras; A, tendon of the biceps; i, sedulously. In cases of injury I have a, n^w lateralligaments attached below to the . , , „ . . , . end of the ulna on Olio side, and to the orbicu- never as yet heard of excision being u,, ligament on the other. practiced. The two chief objects in the operation of excision of the wrist are not to divide any tendons which can be spared, and to remove the whole joint, i. e., the ends of the bones of the forearm, all the bones of the carpus (except perhaps the pisiform), and the ends of all the metacarpal bones. This is best done according to Professor Lister's method, which is thus effected. The patient is put under auiiesthesia, and then,tlie bandage or tourniquet being securely adapted, an incision is made commencing in front over the second metacarpal l)one internal to the tendon of the ex- tensor secundi internodii pollicis, and running along the back of the carpus, internal to the same tendon, as high as to the base of tiie styloid process of the radius. The soft parts, iiududing tlie extensor secundi internodii and the radial artery, being cautiously detached from the bones external to this incision, and the tendons of the radial exten.sors of the wrist being also severed from their attachments, the external Itones of the carpus will be exposed. When this has been done sutHciently, the next step is to sever the trapezium from the other bones with cutting pliers, Mr. Synic's case of reproduction of the joint after excision of the elbow. From the Lan- cet, vol. i, 1855. o. the humerus; 6, the ulna; c, the radius; d, e, projections from the shaft ' A very intere.sting account of the dissection of a Ciist! four years al'ter suhperios- teal resection will be found in Langenbeck's Archiv, vol. x, by Dr. Doutrelepont. 936 OPERATIVE SURGERY. in Older to facilitate the removal of the latter, which should be done as freely as is found convenient. The operator now turns to the ulnar side of the incision and cleans tlie carpal and metacarpal bones as mucli as can be done easily. The ulnar incision is now made. It should be very free, extending- from al)out two inches above the styloid process down to tlie middle of the (iftli metacarpal bone, and lying near the anterior edge of the ulna. The dorsal line of this incision is then raised along with the tendon of the extensor carpi ulnaris, which should not be isolated Fig. 40(). Diagram of the excision of the wrist (after Lister), a, the radial artery; b, tendon of the extensor sccundi internodii iiollicis; c, indicator ; d, Ext. conuu. digitornni ; k, Ext. niin. dig. ; K, Ext. prim. inl. pol. ; <;, Ext. oss. met. pol. ; il i, Ext. carp. rad. long, and brev. ; k, E.xt. carp. iiln. ; L l, line of ra- dial incision.— From the System of Surgery. from the skin and should be cut as near its insertion as possible. Then the common extensor tendons should be raised, and the whole of the ])osterior aspect of the carpus denuded, until the two wounds communi- cate quite freely together; but the radius is not as yet cleaned. The next stej) is to clean the anterior asi)e(;t of the ulna and carpus, in doing wliicli tlie pisiform bone and the hooked process of the unciform arc severed from the rest of the carpus, the former with the knife, the latter with the cutting pliers. In cleaning tlic anterior aspect of the carjius, care must be taken not to go so far forwards as to endanger the deep palmar arch. Now, the ligaments of the internal carpal bones being suf- liciently divided, they are to be removed with l)lunt bone forceps. Next the end of tlic ulna is made to protrude from the incision, and is sawn off, EXCISION OF THE HIP, 937 as low down ns is eoiiKistent with its condition, but in any case above its radial articulation. Tlie end of the radius is then cleaned sufficiently to allow of its beiiifj; protruded and removed. If this can he done without disturbing the tendons from their grooves, it is far better. If the level of the section is below the ui)])er part of the cartilaginous facet for the ulna, the remainder of the cartilage must be cut away with the pliers. The operator next attends to tlie metacarpal bones, wliieh are pushed out from one or the other incision and cut off with the pliers so as to remove the whole of their cartilage-covered portions. Tlie trapezium bone, which was left in the early stage of the operation, is now carefully dissected out, so as to avoid any injury to the tendon of the flexor carpi radialis or to the radial artery, and the articular surface of tlie first raetacar[)al bone is tlien exposed and removed. Lastly, the cartilaginous portion of the pisiform bone is taken avvay ; but the nonarticular part is left behind un- less it is diseased, in which case it should be removed entire. The same remark applies to the hooked process of the unciform. The operation is one of the most tedious and difficult in surgery, but it appears to me to give very satisfactory results, and therefore should, I think, always be ado[)ted in such cases as are favorable for any operation at all. It is advisable, if not necessary, to put on the tourniquet, so that the view of the parts should not be obscured by Idood. It is also very desirable to break down freely any adhesions which the tendons may have formed, while the patient is under chloroform previous to the oper- ation. No tendons are divided in this operation except the extensors of the wrist, for the flexor carpi radialis is inserted lower down than the point at which the metacarpal bone is usually divided. In order to insure motion, particularly in the fingers, passive move- ments should be performed from a very early period after the operation. For this purpose, Mr. liister places the limb on a splint with the palm of the hand raised by a large wedge of cork, fixed below it ; so that the joints of the fingers can be moved without taking the limb off the appa- ratus. S[)ecial arrangements are made for keeping the splint steady and for preventing displacement of the hand to either side. Careful and methodical passive motion should be used to each several joint — ^to those of the fingers and thumb almost from the day of operation, and to the wrist as soon as the parts have acquired some firmness, each movement, pronation and supination, flexion and extension, abduction and adduc- tion, being separately exercised ; and the patient should be encouraged to make attempts at voluntary motion as early as possible. In order to exercise the fingers, the portion of the splint which supports them may be removed while that on which the wrist is received, is stili left. Fin- ally, when the rigid splint is left ofl^ some flexible support is still to be worn for a long time. Excision of the hip is performed almost exclusively on account of strumous disease (so called) of the joint. The few cases in which this operation has been practiced for gunshot injuries have, I believe, all oc- curred in military practice, and they have been exceedingly fatal. I have spoken in the appropriate place (p. 480) of tlie indications for performing this operation in morbus coxarius, and have now only to deal with the operative details. Some operators content themselves with re- moving only so much of the femur us is diseased; others (as Dr. Sayre, of New York) consider it necessary to remove the whole of the trochanter major. The latter plan seems to me to involve an unnecessarily exten- dS8 OPERATIVE SURGERY. sive removal of bone ; but if it is preferred I have no doubt that the sub- periosteal method should be followed, as recommended by Dr. Sayre. The ordinary operation is thus performed. A free incision is made, of a semilunar shape with the convexity backwards, over the posterior part of the trochanter, which should go boldly down to the bone. Then by cuttino- along the neck of the femur the joint is reached,' and it should be freely opened ; the head of the bone twisted out of the joint, and the neck divided, with a keyhole saw, as low down as the surgeon thinks necessary. If the operation is performed for injury, and the neck of tlie bone is fractured^ the incisions must lie more extensive, the fi'actured jiart must be freely exposed, seized with the lion forceps and dissected out, and then search must be made for bullets, fragments of bone, and other foreign i)odies. Finally, the surgeon must carefully examine the acetabulum and remove by the gouge, trephine, chisel, and forceps all portions of diseased bone. In the subperiosteal resection, the periosteum is divided just below the great trochanter, and that process is denuded from all librous tissue (periosteum and tendons) inserted into it, and this l)roceeding is carried on upwards till the joint has been laid freely open. Tlien the common tendon of the psoas and iliacus is divided with a knife and the deep ix)rtions of the neck of the bone separated fi'om the fibrous strictures as well as it is possible. It is usual in Europe to dress the wound lightly, and either put up the liml) in a bracketed splint, or in a plasterof Paris case, or — which I have found easier and quite as satisfactory — with a weight and pulley. None of these plans aim at restoring the length of the limb. Dr. Sayre's plan consists in screwing the limb down by means of an extending apparatus to the same length as the other, and he asserts that in some cases after removing a great length of bone, the limb has regained its normal length, and all its natural movements. The operation is a dangerous one; at least a great many patients die after it ; many it is true, not from the operation l)ut from previous disease. Still the number who have died from the direct sequehe of the operation has not been small, in my experience. Nearly half of the published cases seem to have proved fatal^ from one cause or another. Union is almost ahvays b}^ ligament;'' in some rare cases, chiefly those which have been neglected, osseous anchylosis has taken place ; in others no union has cvccurred, or the femur has been so loosely connected to the j)elvis that tiie limb is useless, Ex(dtiion of the knee is an operation which has afforded excellent re- sults in the less severe cases of disease of the synovial membrane and articular surfaces of that joint, for which amputation used to be per- formed. B}'^ "the less severe cases" I mean such as occur in young persons of a tolerably healthy constitution, from chronic action, not spreading to any great extent into the bone, and not accompanied with very great distortion or atrophy of the limb. It is quite true that in many of these cases, if no operation be performed, tiie abscesses will dry uj) and the diseased bone exfoliate ultimately; l)ut it is also true that tliis action often takes many years to accomplish, during the whole 1 Thoiiy;Ii tlie joint in sidvanced stages of disease is iisuall}' spoken of as " dis- locatiid," it really hardly ever is so. Ibiving excised the lii(i-joint between twenty and thirty times 1 cannot remember to have come across a case in which the head ot the bone (or its remains) was not in the aeetabulum, and Dr. Sayre says that in fifty- two cases of excision he hjis only found one of dislocation. 2 Syst. of Surgery, vol. v, p. 694, 2d ed. EXCISION OF THE KNEE. 939 of which time the patient is unfit for any active employment, and that often at tiie end of it the limb is more an incnmbrance than anytliing else, and frequently requires amputation. However this may be it is certain that we used some years ago to see amputation practiced in many of the same class of cases as are now treated most successfully by ex- cision, and so far excision of the ie put into a plaster or other immovable apparatus, and the patient is to be allowed to walk about on a wooden leg. The use of the leg is often almost as good as ever. Two lads on whom I performed this operation, removing the astragalus wholly in one and partially in the other, were heard of some years afterwards doing the ordinary work of agricultural laborers, and able to walk all day ; but recovery is much slower than after amputation. Exciaion of the os calcia is an operation which may often be practiced with great advantage. Disease of the tarsus very commonly begins in the joint l)ctween the calcaneun) and astragalus, and frequently spreads into the former bone; the afliection of the latter being so superficial that the carious spot can be gouged away when the greater mass of disease has been removed, in these cases the central part of the calcaucum often perishes, leaving a large mass of necrosis inclosed in a thin-walled cavity of inflamed and sol'tened [)one. If now the whole bone, including this shell of softened bone, be removed, the patient makes a certain and speedy recovery with a useful foot ; while if the loose portion be re- ' Soe a paptM- by Mr. H. Lee, in Mi-d.-Cliir. Trans., vol. Ivii, p. 137. * See St. George's Hospital Keports, vol. iv. A Note on Excision of the Anide- ioint. EXCISION OF THE ASTRAGALUS. 945 moved, and the shell scooped, he may, it is true, recover, and the heel ma}' possibly be more firm, Ijut the recovery is at least doubtful, and in the course of a tedious convalescence the health may give wav, fresh disease be lighted up, and amputation become necessary. Excision of the os calcis is tiius peiformed. An incision is commenced at the inner edge of the tendo Achillis, and drawn horizontally forwards along the outer side of the foot, somewhat in front of the calcaneo-cuboid joint, which lies midway between the outer malleolus and the end of the fifth metatarsal bone. Tliis incision should go down at once upon the bone, so tiiat the tendon should be felt to snap as the incision is com- menced. It sliould be as nearly as possible on a level witli the upper bordei' of the os calcis; a point wliich the surgeon can determine, if the dorsum of the foot is in a natural state, by feeling tlie pit in which the extensor brevis digitorum arises. Another incision is then to be drawn vertically across the sole, commencing near the anterior end of the former incision, and terminating at the outer border of the grooved, or internal, surface of tlie os calcis, beyond which point it should not extend, for fear of wounding the posterior tibial vessels. If more room be required, this vertical incision may be prolonged a little upwards, so as to form a +.^ The bone being now denuded, by throwing back the flaps, the first point is to find, and lay open, the calcaneo-cuiioid joint; and then the joints with the astragalus. The close connections between these two bones con- stitute the principal difticulty in the operation on the dead suliji^ct ; but, as has been already stated, these joints will frequently be found to have been destroyed in cases of disease. The calcaneum having been sei)arated thus from its bony connections by the free use of the knife, aided, if necessary, by the lever, lion-forceps, etc., the soft parts are next to be cleaned otf its inner side with care, in order to avoid the vessels, and the bone will then come avvay. The flaps are to be closed lightly, with one or two points of wire suture, over the large gap left by the excision. Suhpei'iosteal Excision. — M. Oilier describes an operation by which the OS calcis can be removed sulijieriosteally without the division of any ten- dons, except the tendo Achillis. An angular flap is made by an incision running horizontally along the lower outer border of the bone, and ver- tically along the outer border of the tendo Achillis. Then the periosteum and the parts above it, including the peronei tondons, are peeled off the bone. Next the attachment of the tendo Achillis and the periosteum are detached from the tuberosity of the os calcis. Then the joints are opened, and the inside of the hone is cleaned, and so its removal is completed. I have only practiced this operation once, and then the result seemed to me less perfect than after the ordinary operation. ' After recover}', the only mark of deformity in the foot is an elevation of the heel proportionate to the size of the bone removed. Excision of the Astragalus. — The astragalus is easily removed by making a curved incision from one malleolus to the other, something like that made at tlie beginning of Syme's amputation. The ankle-joint is then to be laid freely open, and the whole upper part of the diseased bone tlius exposed. Then the ligaments connecting it to the scaphoid are to be severed, and the bone is to be levered up, when the interosseous 1 I have always divided the tendons of the peroneus longus and brevis. They can, of course, be dissected oat and held aside with a bhmt hook, but I have not observed any bad effects from their division. - See Clin. Soc. Trans., vol. viii. 60 946 OPERATIVE SURGERY. ligament connecting it witli the os calcis will, if entire, be felt, and can be readily divided. All that is then necessary to complete the operation is to clean the back part of the bone, which should be done with care, in order to avoid injury to the tendons and vessels which lie near it. I have had several cases in children, and have seen one in an adult in whom a very useful foot was left. The bone might also, no doubt, be removed by two lateral incisions similar to those used in excision of the ankle. This would avoid the injury to the tendons and vessels incidental to the above method, but vpould be more laborious. Other Excisions in the Foot. — No formal directions are required for excising the other tarsal bones. The soft parts are to be thrown aside by crucial incisions, radiating from the sinuses wliich lead to the diseased bone, and the latter removed ; care being taken, in all cases where it is possible, to excise the whole bone with the articulating surfaces. The metatarsal bone of the great toe is very often diseased ; and from its large size disease may go on in its substance for a long period without affecting any other bone. In such cases, after a sufficientl_y patient trial of the appropriate constitutional treatment, with rest, it is proper to ex- pose the disease ; and if this is found to include the greater part of the bone, then the best course is to remove the whole, with both its articular surfaces. This may be readily done by making an incision over the whole length of the bone, joined by shorter perpendicular cuts in front and behind, and thus turning back small rectangular flaps including the whole length of the bone. It is better to commence b}' severing it from the cuneiform bone, as in dividing it from the phalanx the plantar arch will most likely be wounded, and the bleeding may prove somewhat em- barrassing; wliereas if the artery be not divided till the bone is removed, there is no dilTiculty in tying it. No splint is required. The great toe sinks down somewhat towards the tarsus, but the foot is as useful in progression as lie fore. It seems hardl}- worth while to expend space on the description of such rare operations as the excision of the tarso-metatarsal joints,^ or of por- tions or the whole of the shaft of the long bones (see p. 425), or of the ribs or sternum. They are very rarely practiced, and in the latter case especially the indications for their performance should be narrowly scru- tinized, since they are by no means free from danger, nor at all certain to attain the end in view, which is to remove the whole disease and therein* take awa}' permanentlj^ what must always be a source of irritation to the subjacent viscera. ' See a case reported by me in the Clin. Soc. Trans., vol. v, p. 207. INDEX. Abdomen, gunshot wounds of, 342; injuries of, 2:^0; wounds of, 235 ; p.ariicentesis of, 617 Abdominiil iineurisiu, 616 Abscess, ,54; .alveolar, 685; cold, 55; intra- cr.iniiil, 160; ischiorectal, 658; lacunar, 388; lumbar, 487; periosteal, 425; post- ph.'irynfreal, 490; p.soas. 487; residual, 57; spinal, 484; subpectoral, 218 Abscess of bone, 429 ; breast, 859 ; joints, 461; labium, 393; prostate, 776; scrotum, 841 ; septum nasi, 599 ; tongue, 609 Abscess in perinseo, 785, 793 Abscess, bleeding from, 57 ; inflammation of, 57 Abscess knives, 56 Absorbents, inflammation of, 566 Acarus foUiculorum, 883 ; scabiei, 877 Accumulation of wax, 757 Acetabulum, fracture of, 243; impaction of femur in, 244, 292 Aehores, 878 Acne, 882 ; rosacea, 594 ; syphilitic, 883 Acquired hernia, 618 Acromial end of clavicle, fracture of. 254 Acromion, dislocation of, 271 ; fracture of, 257 Active congestion, 33 Actual cautery, 901 ; in haemorrhage, 126 Acupressure, 122 Acute laryngitis, 672 ; periostitis, 425 Additamentary bones, 472 Adenitis, 566 Adenoma, or adenoid tumor, 861 Adhesion, primary, 41 ; secondary, 45 Adhesions, peritoneal, producing strangula- tion. 612 Adhesions of iris. 712; of labia, 844; in ova- rian tumor, 856 Adhesive syphilitic inflammation, 396 Air, entrance of into veins. 111 Air-passages, foreign bodies in, 208 Albinism, 886 Allarton's operation for stone, 814 Alopecia, 875 ; syphilitic, 403 Alternating calculi, 805 Alveolar abscess, 685 ; cancer, 376 ; sarcoma, 366 Amaurosis, 730; from abscess of antrum, 589 Ametropia, 764 Amputation in burns, 136; destruction of joints, 469; fractures, 142; gunshot wounds, 345 ; osteomyelitis, 428 Amputation, 914; circular, 914; flap, 914; instruments for, 915 ; of arm, 916 ; at el- bow, 918 ; at shoulder, 917 ; of breast, 860; of fingers, 919 ; of forearm, 918 ; at wrist, 919 ; of foot. 925 ; partial, 926, 927 ; sub- astragaloid, 927; of leg, 924; of penis, 843; of thigh. 923; at hip, 921; at knee, 923; of thumb, 920 ; of toes, 928 ; Butcher's, 924; Garden's, 923; Chopart's. 927; Grit- ti's, 924 ; Hancock's, 927 ; Hey's, 928 ; Lis- franc's, 928 ; PirogofT's, 927 ; Syme's, 926 ; Teale's, 924 Amygdaloid glands, 396 Anassthetics, 905 Anastomosis, aneurism by, 357 Anatomical neck of humerus, fracture of, 268 Anchylosis, bony, 473 ; extra-articular, 472 j false or fibrous, 472 Anchylosis of spine, 494 Anel's operation for aneurism, 533 Aneurism, 623; arteriovenous, 627; cirsoid, 627 ; consecutive, 525 ; diffused, 625 ; dis- secting, 626 ; false, 52() ; fusiform, 526 ; true, 525 ; tubular, 526 ; varicose, 627. See also the names of individual arteries, as Popliteal. Recurrence of, 634 ; rupture of, 531 ; spontaneous cure of, 6.'51 Aneurism by anastomosis, 359 Aneurism of bone, 462 Aneurism needle, 114 Aneurismal sac, relations of, to artery, 530 Aneurismal varix, 627 Angeioleucitis. 566 Angular curvature, 485 Ankle, amputation at, 926 ; diseases of, 481 ; dislocation of, 328; compound, 329; exci- sion of, 943 Annular stricture, 784 Annular syphilitic ulceration of bone, 441 Ante-scrotal urinary fistula, 794 Antiseptic dressing, 50 Antrum, cysts and dropsy of, 588; tumors of, 591 Antyllus. operation of. for aneurism, 532 Anus, artificial, 638 ; imperforate, 665 ; fistula in, 657 ; prolapsus of, 657 ; pruritus of, 661 ; ulcer or fissure of, 660 Aorta, abdominal aneurism of, 550 ; ligature of, 551 ; compression of, 561 ; thoracic aneu- rism of, 639 Aphonia, nervous or hysterical, 678 ; paralytic, 679 Apparatus for fracture, 142 Arch, palmar, wound of, 251 Arm, amputation of, 916 ; aneurism in the, 648 Arsenic as cautery, 884 Arterial hsemorrhage, 112 Arterial varix, 527 Arteriovenous aneurism, 527 ; in orbit, 543 Arteries, aneurism of, 523 ; atheroma of, 521 ; calcification of, 621; division of. 110; em- bolism of, 522; inflammation of, 521; in- 948 INDEX, juries of, 107; laceration of, 109; licrnture of, 113; occlusion (if 522; partiiil lacer- ation, 107: subcutaneous rupture of, 108; wound of 1119 Arteriotomy. 902 Arteritis, 523 Artery. Sei- the individual names, as Femo- ral, Carotid. Arthritis, rheumatic, 471 Articular ends, diseases of 463 Artificial anus, 638 ; membrana tyn>pani, 759; pupil, 733 Aspintor, the, 229 ; puncture of the bladder by, 792 Assalini's fracture box, 314; tenaculum, 121 Astigmatism. 755 Astragalo-calcanean joint, diseases of, 481 Astragalus, dislocation of, 330 ; disease of, 481 ; excision of 945; fracture of, 315 Atheroma, 521 Atony friitn distension of bladder, 799 Atrophy of bone, 458; of breast, 859 Atropine in iritis, 712, 714 Aural polypi. 7ti3 Auricle, malformations of, 756 ; eruptsions of, 756 ; tumors of 756 Autoplastic par gli.'sement, 911 Aveling's apparatus for transfusion, 127 Avulsion of toenail. 893 Axilla, dislocation of shoulder into, 271 Axillary artery, aneurism of, 546 ; ligature of, 548 Back, sprains of the, 185 Bacteria, in blood-poisoning, 63; in erysipelas, 71 Baker Brown's needle, 848 Balanitis, 388 Ball-and-socket truss, 627 Bandages. 893 ; capelline, 895 ; compound, 895 ; four-tailed, 895 ; many-tailed, 896 ; T, 896 ; spica, 895 ; spiral, 894 ; starched, 898 ; suspensory, 896 Bandaging. 893 ; of wounds, 21 Barbadoes leg. 885 Base of skull, fracture of 170 ; union of 175 Bath, warm, in strangulated hernia, 622 Bedsores, SO ; from fractured spine, 191 Bellocq's sound for plugging the nose, 5&6 Bending of hones of forearm, 266. See also " Greenstick fracture.'' Bichloride of methylene, 908 Bilateral lithotomy. 815 Biliary fistula at umbilicus, 616 Bird's-nest cells in epithelioma, 373 Bistouri-cache. 665 Bladder, calculus in, 806; cancer of 771 ; contraction of, in cystitis, 775 ; dilatation of, in cystitis, 775 ; diseases of, 768 ; dis- tension of 786 ; foreign body in, 249 ; re- moval of from, 823; gunshot wound of, 343 hypertrophy of, 773 ; inflammation of 773 malformation of 768; paralysis of, 799, puncture of above the pubfs, 780 ; from the rectum, 791 : rupture of 244 ; from disten- sion, 786 ; wound of 249 Bleeding, 902 ; in wound of lung, 341 ; in head injuries. 182 Blepharitis, 685 Blind fistula. 657 Blisters, 900 ; in treatment of ulcers, 418 " Bloc, reduction en." 622, 636 Blood, organization of, 39 Blood-cysts, 350 ; within the skull, 165 RIood, state of, in inflammation, 48 Bodies, loose, in joints, 469; in tunica vagin- alis, 831 Boils, 888 Bone, diseases of, 422. See also its various affections, as Caries, Necrosis ; wounds of, 143 Bony anchylosis, 473 Bougies in stricture of oesophagus, 611 " Boutonniere, la," 792 Bowel, rupture of 231. See also Intestine. Brachial artery, ligature of, 549 Brain, compression of, 178; concussion of 177 ; traumatic lesion of, 176, 180 ; by gun- shot, 338; traumatic inflammation of 181 Brain, implicated in disease of the ear, 764 Brasdor's operation for aneurism, 540 Breast, diseases of, 858 ; abscess of 859 ; am- putation of, 866 ; cancer of, 864 ; functional disorders of, 861 ; inflammation of. 859 ; hypertrophy of, 858 ; lobular induration of, 860; neuralgia of 861; tumors of, 861 ; male, diseases of, 867 Bridle stricture, 784 Broad ligament, cysts of, 852 Brodie's lithotrite, 818 Bronchocele, endemic, 868 ; exophthalmic, 809; pulsating, 869; sporadic, 868; re moviil of 869 Bronchotomy, 680 Bronzed skin. 886 Bryant's test for displacement of femur, 291 ; tracheotomy canula, 682 Bubo, gonorrhoeal, 389 ; syphilitic, 395 Bubonocele, 643 Ballets, lodgment of, 335 Bullous eruptions, 877 Bunion, 501 Burns, 131 ; degrees of 132 ; of larynx, 214 Bursa of psoas enlarged, 478 ; patellae, en- largement of, 498 Burste, enlarged, 500 Bursal abscess, 499 ; tumors, 347 Busk's splint for fractured femur, 298 Butcher's amputation, 924 ; splint for excision of knee, 942 Buttock, wounds and contusions of, 240 Calcaneum, see Os Calcis. Calcification of arteries, 521 Calculus, 804 ; prost:itic, 824 ; salivary, 583 ; urethral, 824 ; vesical, 803 ; vesico-prostatic, 824 Calculi, tests for. 805 Calculous nephralgia, 766 ; pyelitis, 766 Callous ulcers, 1 16 Callus, 144; provisional, 145 Calomel vapor bath. 400 Canaliculi, obstruction of 750 Cancer, 368 ; colloid, 375; epithelioma, 374; medullary, 372; melanotic, 373; osteoid, 373; pulsatile, 452; scirrhous, 370; villous, 376 Cancer of bladder, 771 ; bone, 442 ; eyeball. 735 ; lip, 583 ; oesophagus, 613 ; ovary, 852 ; p-^nis, 842; prostate. 781; rectum, 663; scars, 420 ; scrotum, 842 ; spine, 494 ; testis, 837 ; thyroid, 869 ; tongue, 605 : uterus, 852; vulva, 847 Cancerous ulcers, 417 Cancroid tumors, 348 Cancrum oris, 85 INDEX. 949 Capelline bandage, 895 Capivi rash. ;^89 Carbdlic dressing for wounds, 51 Carbolizeil lijratures for arteries, 119 Carbonate of lime calculus, 805 j deposit in urine. 803 Carbuncle, 889 ; facial, 890 Carcinoma, MS; «(;« Cancer. Garden's amputation, 92.'^ C.-iries, -l-^l ; strumous, 481 ; of the spine, 551 Carotid artery, aneurism of, 540 ; compression, of, 541 ; ligature of common, 641 ; of ex- ternal, 54;! Carpus, dislocation of, 285 ; diseases of, 483 ; fracture of, 2ii9 Carte's compressor for aneurism, 636 Cartilages, degeneration of, 4(59; injuries of, 155 ; loose, 4fi9 ; ulceration of, 4(ifi Cartilages, costal, fracture of, 222 Cartilaginous stricture, 784 ; tumor, see En- chondrom:!. Castration, 837 Cataract, 717; congonital, 7 I 7 ; laminar, 718 ; pyramidal or punctated, 718; senile, 721 Cataract glasses, 727 Catarrh of the tympanum, 762 Catarrhal conjunctivitis, 689 Catgut, carbolized for ligature of arteries, 119 Catheter, tying in a, 790 Catheter, Eustachian, 760 Catheterization, 787; forced, 780, 791 Catheter-sound. 808 Caustic treatment of caries, 433; naevus, 361 ; rodent ulcer, 416 ; syphilis, 395 Cauterisat'on en fleches, 902 Cautery, actual, 866 ; in ovariotomy, 856 ; in hfemorrhage, 126 Cautt-rv. galvanic, 901 ; in fistula, 659 ; poten- tial, '90 I Cautery, operations for piles by, 656 Cerebral diseases spreading from the ear. 764 Cervix femoiis, fracture of, 289 Chancre, h.ird, 396 ; sloughing, 395 ; soft, 394, oflip, 409, 582 Charbon, 891 Charriere's guillotine, 585 Chassaignac's tubercle, 541 Cheiloplasty, 913 Chest, gunshot wounds of, 340; injuries of, 217 Chilblains, 891 Childcrowing. 674 Chimney-sweep's cancer, 842 Chloasma, 876 Chloroform, 871 Chopart's amputation, 927 Chordee. 387. 389 Choroiditis. 734 Chronic .'ibscess of bone, 429 ; mammary tu- mor, 861 ; rheumatic arthritis, 471 ; ulcers, 418 Cicatrices, 44, 419; contraction of, 420, 912; excess of, 4l9 ; keloid of. 419 ; neuralgia of. 419 ; tumors of, 420 ; ulceration of, 419 Cicatrices of cornea, 708 Cicatrization, 44 Cilia, m.'ilposition and redundancy of, 686 Cili;iry body, injuries of. 738 Circumcision. 843 Cirsoid aneurism, 527 Civiale's lithutrite, 817 ; urethrotome, 797 Clamp, Mr. Lee's, 606; for ovariotomy, 856 Clamp and cautery, operations for piles with, 666 Clavicle, dislocation of, 270 ; of both ends of, 271; excision of. 931; fr.icture of, 262; greenstick fracture of, 138 Clemot's operation for harelip. 572 Clergyman's sore throat, 675 Clitoris, hypertrophy of, 846 Cloacas in bon*, 435 Clots, "active and passive," in aneurism, 533 Clove-hitch, 900 Clover's crutch for lithotomy, 809; lithotrity syringe, 820 Clubfoot, 605; relapsed, 613; see (/hoTiiUnes. Clubhand, 514 Coagulating injections in aneurism, 538 Coccyx, fracture of. 244 Cold abscess, 65 ; ulcers, 412 Cold for arresting haeaiorrhage, 125; for local anajsthesia, 905 Coles's artery compressor, 557 Collapse, 128 Collar, treatment of fracture of thigh by, 302 Colles's fracture. 267 Colloid tumor, 375 Colotomy, 614, 665 Complications of fracture, 143 Compound cysts, 351 Compound fracture, 136 Compound di>location, 153; of elbow. 284 ; of shoulder. 279 Compression of the brain, 178 Compressi(m treatment of aneurism, 535 Concussion of the brain. 176; of the spine, 191 Condyles of femur, fracture near, 303 ; of hu- merus, fracture of, 261 Condylomata, 662. 887; of meatus of ear, 758 Congenital cataract. 7l7; cysts, 352; of blad- der. 769; dislocMtion of hip, 478; hernia, 618; hydrocele, 829 ; inguinal hernia, 640 ; syphilis, 407; tumors of the tongue, 609 Congestion, 33 Conical ooriieii, 710 Conjurieiiva. dise.ises of, 688 Cotijunclival tumois, 697 Coijun-etivitis, catiirrhal.686 ; contagious. 693 j diphtheritic. 696; EL'ypiian, 693 ; epidemic. 693; gonorrhoe:il, 690 ; inf.mtile. 689; phlvc- tenular. 696 ; purulent, 689, 690 ; simple, 689 Consecutive aneurism. 625 Contagious ophthalmia, 693 Continuous suture. 899 Contracted cicatrix, 420, 912; palmar fascia, 514 Contraction of bowel .ifter «trangulation, 637 Contre coup, fracture by, 169 Contusion, 39; of arteries, 107; of buttock, 240 ; of scrotum. 247 Copaiba, admini-^tTiiti(m of, 392 Goracoid process, fracture of, 257 Cord, scrotal, affections of 830 ; hsematocele of. 831 ; hydrocele of. 830 Cord, spinal, impli-eation of, in disease, 486 Corns, 886 Cornea, diseases of. 698 ; abscess of. 706 ; acute ulcers of. 707 ; cicatrices of, 708 ; conical, 710 ; flattening of, in ophthalmia. 693 ; im- plication of. in ophth.-ilmia, 690, 692 ; opacity of, 703; suppuration of 70.t; wound of, 740 Coronoid process of jaw, fracture of, 198 Coronoid process of ulna, fracture of, 266 ; in dislocation of elbow, 281 Coryza, chronic, 597 Costal cartilages, fracture of, 222 Coxeter's extractor, 337 950 INDEX. Cracks of lips, 6S1 Craiiiutu, tuinnrs of, 580 ; sec uho Skull. Crepitus of fracture, 140 Oripps's splint for fractured femur, 300 Croup, 6~-y Cruiie tubercle, '-^TS Crutch, Clover's, for lithotomy, 809 Cubebs in gonorrhoea, 392 Cupping, 903 Curvature, angular. 485 ; lateral, 491 Cutaneous cysts, 351 ; congenital, H52 Cut throat. 203 Cyanche tonsillaris, 584 ; trachealis, 673 Cyst, congenital, of bladder, 7fi9 Cystic disease of breast, 862, 863 ; testicle, 835 Cystic enchondroma. 35S Cystic tumors, 349 ; compound, 351 ; of bone, 4^0; of broad ligainent, 852 ; of jaws, 589; of labia, 846 ; of ovary, 852 Cystigerous cysts, 353; of ovary, 853 Cy.^tic oxide. 802, 804 Cystiti.s 773 Cystoeele, vaginal. 849 Deafness, diagnosis of its source, 761 ; syphil- itic, 764 Degeneration of muscles, 502 Delirium tremens, 91 Demarcation, line of, 76 Deposits, secondary, 61 ; urinary, 801 Depressed fracture of skull, 167; trephining for, 170 Dermal cysts, 353 Dermal tumors of ovarj', 853 ; testis, 838 Default's splint for fractured femur, 299 Diaiihragm, gunshot wound of, 342 Diaphragm.'itie hernia, 652 Diffuse inflammation, 70 Diffused iineurism, 526 ; bony tumor, 450 Digital compression in amputation, 909 ; of aneurism, 535 Dilataticm of stricture, 788; rapid, 788; for- cible, 796 Diphtheritic conjunctivitis, 696 Direct iriguinal lieinia, 646 Diieet ophth;ilmo.«copic examination, 727 Discission of the lens, 719 Dislocation, general pathology of, 154; of acromion, 271 ; of ankle, 328; of astragalus, 330 ; of carpus, 285 ; of clavicle, 270 ; of elbow, 280; of fingers. 287; of hip, 315; of humeru.s, 271 ; partial, 279 ; compound, 279 ; complicated wiih fracture, 276; of knee, 325; of lens, 740; of metatarsus, 333; of patella, 326 ; of pelvis, 243 ; of phalanges of foot, 333; of radius, upper end, 283; lower end. 284; of ribs. 292; of semilunar cartilages. 327 ; suhastragaloid, 331 ; of tar- sus, 333 ; of thumb, 286 ; of tibio-fibular joint, 327 ; of ulna, 283 ; of vertebrae, 188 ; of wri.st. 284 Dislocation, congenital, of hip, 478 Dislocation in hip di.sease, 477 Dislocation, partial, and osteoarthritis, 472 Displacement of fracture, 140 Dissecting aneurism, 527 Dissection warts, 8>S8 ; wounds, 93 Distal ligature in aneurism, 540 D>.g. hydrophobia in the, 102 Dolbeaii's perineal lilhutrity, 816 Dorsum ilii, dislocation in, 315 Double vision, 741 Double-headed roller, 895 Drilling ununited fracture, 151 Dropsy, ovarian, 854; of joint, 462 Dry gangrene, 76 Duchenne's disease, 504 Duodenum, ulceration of, in burns, 134 Dupuytren"s clas»ification of burns, 131 ; en- terotome, 639 Dura mater, fungous tumor of, 580 Durnam's tracheotomy canula, 682 Dysphagia, nervous, 611 Dysphonia clerinorum, 675 Dyspnoea in wound of lung, 341 Ear, diseases of the, 756 ; foreign bodies in, 196 Eir-ring, tumors in puncture of, 766 Earle's bed, 295 Eburnation of joint ends, 471 Ecraseur, the, 606 ; in fistula, 659 Echthyma, 879 Ectropium, 687 Eczema, 872: impetiginodes, 879; syphilitic, 872 Eczematous ulcer, 413 Elastic ligature in fistula, 659 Elbow, amputation at, 918 ; excision of, 932 ; subperiosteal, 933 ; diseases of, 483 ; disloc.i- tion of, 2«0 ; fractures near, 262 ; inflamma- tion of bursa of, 500 Electrolysis in ntevus, 361 Electro-puncture of aneurism, 538 Elephantiasis, Arabum, 885; Grajcorum, 884; of scrotum, 841 Elevated fracture of skull, 168 Elevator, 184 Embolism, 79, 522 Emigralion of leucocytes, 36 Emmetropia, 754 Emotional contractions, 516 Emphysema, 220 ; in wound of Umg, 341 Encephalitis, traumatic, 181 Eiicephalocele, 580 Eneephaloid cancer, 372 Enchondroma,, 357, 446 ; ossifying, 449; of jaw, 691; of septum nasi, 599 : of testicle, 836 Encysted hernia, 642 ; hydrocele, 830 Endoscope, the, 809 Enlarged prostate, 779 ; tonsils, 584 Enterocele, 617 Entero-epiplocele, 617 Enteiotome, the, 689 Entrance and exit wounds, gunshot, 333 Entropium, 686 Enucleation of eyeball, 739; of ncevus, 361 Enuresis, 800 Eperon, the, in artificial anus, 639 E|)ididymiiis. 83". Epigastric artery, wound of, in paracentesis, 616 Epiphyses, separation of, 139 Epiphysis, lower, of femur, sepiration of, 303 : upper, of femur, disjunction of, 295 ; lower of huinei us, separation of. 263 ; upper of hu- merus, separation of, 251 Epiplocele, 617 Epi.scleritis, 697 Epispadias, 781 Epi.-taxis, 596 Epithelioma, 374; of bone, 444 Epulis, 590 Eiininia mitis, 100 Erethism, mercurial, 399 Eruptions, bullous. 877; exanthematous, 870; bacmorrhugic, 871 ; papular, 880 ; parasitic, INDEX. 951 874 ; pustular, 878 ; secondary syphilitic, 401 ; siiuiiiiKius, 882; tertiary syphilitic, 405 ; tuhiTcular, 882 ; vesicular, 872 ; xero- derinatous, 88(5 Erysipelas, 67 ; phlegmonous, 70 ; of scalp, 159 Erythema. (57 ; laeve, (57 ; intertrigo, 67 ; fugax, 67 ; nodosuna, 68 Esmarch's bandage, 909 Ether, 906 ; as local anocsthetic, 905 Eust:ichian catheter, the, 760 Eustnchiiin tuhe, tx:imin;ition of, 760 Exanthematous eruptions, 870; jaw-necrosis, 687 Excisions, 929 ; subperiosteal, 930 ; of niilile, 943 ; of astragalus. 945 ; of clavicle, 9.31 ; elbow. 932; hip, 937; knee, 938; raelatar sal bones, 910; os calcis, 946; os uteri, 852; sciipula, 931 ; shoulder, 929 ; wrist. 935 Excision in osteoarthritis, 472 Exclusion of pupil, 713 Exfoliation, 435 Exostosis, 358, 447 ; ivory, 447 ; cancellous, 449; diffused, 451 ; of external meatus, 758; of j'lw, 591 External hfcmorrhoids, 654 ; urethrotomy, 795 Extra-capsular fracture of femur, 289 ; of hu- merus, 259 Extr.'iction of cataract, 722; haemorrhage after, 726 Extra-peritoneal operation for hernia, 631 Extraviisation in scalp, 157 ; below the skull, 162 ; in arachnoid cavity, 165 ; in the brain, 166 Extravasation of urine, 785 Extremity, lower, injuries of, 288 ; upper, in- juries of. 250 Extremities, gunshot wounds of, 343 Exuberant sciirs, 419; ulcers, 418 Eye, contusion of, 739 ; diseases of, 683 ; enu- cleation of, 739 ; injuries of, 737 ; paralysis of mu.-cles of, 748 ; tumors of, 735 Eyeball, rupture of, 740; tension of, 729 Eyeliishes, malposition and redundance of, 686 Eyelids, diseases of, 684 ; wounds of, 687 Face, gunshot injuries of, 339 ; injuries of, 195 Faci.il bones, fr^icture of, 196 Faecal flstuhi in herni.i, 635, 638 ; from imper- forate anus, 666 ; at umbilicus, 616 Fseees, impaction of 613 False iineuris-.u, 526 ; joint after fracture, 149; passage (urethral), 788 Farcy, 98 Fascia (if piilm, contraction of, 514 Fatty tumors, 354 Favus, 875 Female, lithotomy in the, 816 ; diseases of organs of gener.ition, 845 Femoral artery, aneurism of, 654 ; ligature, of common, 565; of supei ficial, 556, 556 Femoral hernia, 647 Femur, fracture of neck of, 289 ; of upper end of, 295 ; of lower end, 303 ; of shaft, 298 ; in childhood, 302 Femur, impaction of, in acetabulum, 244 Fenestrated lithoirite, 8 17 Fergusson's knot for strnn2;ulation of naevi, 362 Fever, hectic, 64; infl.inimatory, 35, 46; miliary, 872; urethral, 795 Fibrinous calculus, 806 Fibrocellular tumor, 356 Fibrocystic tumor, 356 ; of bone, 451 Fibroplastic tumor, 367; of breast, 863 Fibrous anchylosis, 472 Fibrous polypus of nose, 601 Fibrous tumor, 366 ; of uterus, 851 : diagnosis from ovarian tumor, 854 Fibula, dislocation of head of, 327 ; fracture of, 3 1 1 Figure of 8 bandage, 895 Fingers, amputation of, 919 ; dislocition of, 287 Fissure of anus, 660; of lip, 581 Fissured palate, 574 Fistula, 58 ; ante-scrotal, 794 ; in ano, 657 ; fee^'al, in hernia, 635, 638 ; fajcal, from im- perforate anus, 666 ; lachrymal. 750 ; lym- phatic, 566 ; in perinaso, 785, 794 ; recto- urethral, 814; recto-vaginal. 814; salivary, 195 ; umbilical. 616 ; urinary, 785, 794 ; vesico-intestinal, 776; vesicovaginal, 849 Fit, hysterical, 383 Flatfoot, 512 Flexion in aneurism, 537; in reduction of dis- location of hip, 316, 323, 325 Fluctuation. 65 Focal illumination for detection of cataract, 723 Foetal tumor of testis, 838 Follicular granulations in epidemic ophthal- mia, 693 Follicular Laryngitis, 675 Foot, amputation of, 926 ; dislocation of, from astragalus, 331 Forced catheterization. 780, 791 Forcible taxis, dangers of, 621 Forcipression, 125 Forearm, amputation of, 918; aneurism in the, 649 ; dislocation of, backwards at elbow, 281 ; fractures of 264 Foreign bodies in abdomen, 235 ; in air-paa- s;ige, 208 : in bladder, 249 ; removal of, 823 ; in ear, 196 ; in eyelids, 737 ; in hand, 251 ; in intestine, 23S ; in nose, 196 ; in oesopha- gus, 214 ; in rectum, 249 ; in stom.ach, 237 ; in thorax, 225; in urethra, 249 ; in vagina, 249 ; introduction of, for cure of aneurism, 538 Fourtailed bandage, 895 Fractures, general pathology of, 137 ; simple, 138; compound, 138; transverse, 138; ob- lique. 138; dentated, 138: greenstick, 138; impacted, 110 Fraciures of the astragalus, 316; carpus, 269; clavicle, 252 ; coccyx, 244 ; costal cartilages, 222; facial bones, 196; femur, 296; fibula, 311 ; foot, 3 '4 ; forearm. 264 ; humerus, 258; jaw, 196 ; larynx, 207 ; leg, 310 ; malar bone, 197; metacarpus, 269: met.itarsus, 315; neck of femur, 289; union of, 294; olecranon, 264 ; OS calcis, 314 ; ossa nasi, 196 ; p.itella, 306 ; pelvis. 241 ; phalanges of hand, 269: foot, 314; radius, 266; ribs, 218; .'^capula, 256 ; skull, 167; spine, 186; sternum. 222; tibia, 311 ; trochanter major, 295; ulna, 266; zygoma. 197 ; CoUes's, 267; Potfs, 325 Fracture-box. 314 Fr.icture of exostoses. 450 Fr.icture from necrosis, 438 Fracture, union of, 144; ununited, 148 Fracture, spontaneous, 459 Fr.igilitas ossium, 458 Fragments, impaction of, after lithotrity, 821 Framboesia, 886 Frontal sinus, fracture of, 168 Frostbite, 81 Fulminating glaucoma, 728 952 INDEX. Fundus of herniiil sac, 618 Fungous tumor of dura mater, 681 Fungus hscmatodes, 372 Funicular canal, patency of, 726 Fu.-ible calculus, 805 Fusiform aneurism, 526 Gag, Hutchinson's, 606 Galaetoeele. 864 Galactorrhcea, 861 Gallbladder, rupture of, 2:V.] Galvanic cautery, I'Ol ; in fistula, 659 Galviino-puncture of aneurism, 5;-;8 Ganglion, 501 ; compound palmar, 502 Gangrene, 75 ; dry, 76 ; moist, 76 ; traumatic, 75 : from embolism, 79 ; hospital, 81 ; senile. 84; of hernia, 619; treatment of, 6;H ; of penis, 844 ; after ligature of artery, 118 Garters, lithotomy, 809 Gastrotomy, 2;i8 ; for obstruction of bowel, 614 Gastrostomy, 239 Gelatinous polypus, 599 Genuflexion in popliteal aneurism, 558 Giant celled sarcoma, 365 Giraldes's operation for harelip, 573 Glands, inflammation of, 666 ; sympathetic afifections of, 567 ; strumous, 667 ; syphilitic, 404: cancerous, 568 ; inguinal, diagnosis of, from hernia. 649 Glanders, 98 Glaucoma, 728 Gleet, 388 ; treatment of, 384 Gliome, 735 Globus hystericus, 383 Glossitis, 610. Glue splint, 897 Gluteal aneurism, 55'! Goitre, Sfe Bronchocele. Gonori hoea, 387 ; in female, 392 ; treatment of, 391 Goaorrhoeal ophthalmia, 690; orchitis, 833; rheumatism, 389 Gordon's splints for fracture of radius, 268 Gout, rheumatic, 471 Gouty ulcer, 414 Grafting of skin, 421 Granuhitions, 44 Granubitions of conjunctiva, follicular, 693 ; papillary, 695 Graj' tubercle, 377 Greenstick fracture, 138 Griiti's ampul;ition, 924 Guillotine, tonsil, 585 Gum-and-chalk splint, 897 Gum boil, 586 Gumraata, 4(i6 ; of the tongue, 609 Gunshot wounds, 334 Gutta percha splints, 898 Hsematocele, 831 ; of the cord, 831 Htem;itoma. 39; auris, 756 Htematuria, 767; in gonorrhoea, 389 UaJinofihilia, 105 iliemopiy>is in wound of lung, 311 Hasinorrhage, 105 ; habitual, 107 ; arterial, 112; venous. 112; recurrent,, 118; prostatic, 778; secondary, after ligature rjf artery, 115, 534 Ha-'Miorrhage, means of restraining, 909 Hictnorrhiigi;i, 871 Hainonhagic diathesis, 105 Hie norihagic ulcers, 418 Hemorrhoids, 654; urethral, 846 Hemostatics. 126 Hemothorax, 221 , 341 Hainsby's harelip truss, 574 Hand, foreign bodies in, 261 Hani chancre, 396 Harelip, 669 ; double, 573 ; complicated, 573 Harelip suture, 899 Head, gunshot wounds of, 338 ; injuries of, 157 Healthy ulcer, 412 Heart, wounds of, 225 ; rupture of, 228 He.it. in inflammation, 34 Hectic fever, 66 Hernia, 617; gangrene of, 619; inflammation of, 619; incarcerated, 618; strangulated, 618; radical cure of. .629; sre also the various forms, as Inguinal, Femoral. Hernia cerebri, 182; of the lung, 224; testis, 836 Hernia knife, 631 Herni.il sac, hydrocele of, 830 Herniotomy, 630 Herpes. 873; zoster, 873; of lip, 581 llesselhach, triangle of, 646 Ht-terologous tumors, 348 Hey's saw, 184 Hide's felt splint, 898 Hilton's nasal snare, 600 Hip. amputation at. 922 ; disease of, 475 ; con- genital dislocation of, 478; dislocations of, 313 ; excision of, 937 ; subperiosteal, 938 Hddgkin's disease, 568 Holt's instrument for forcing a stricture, 796 Homologous tumors, 348 Horns, 888 Horsehair probang for oesophagus, 216 Hospital gangrene. 82 Housemaid's knee, 498 Hum"rns. disloc.ition of. 271 ; fracture of, 258 Hunierian chancre, 396 ; operation for an- eurism, 632 Hutchinson's gag, 606 Hydatids in bone, 452; breast, 864 ; liver, 617 Hydrencephalocele, 580 Hydrocele. 726 ; congenital, 829 ; infantile, 829 ; of the cord. 830 ; encysted, 830 Hydrocele of hernial sac, 830 Hydrocele of the neck, 349 Hydrophobi.i, 100 Hydrops aiticuli, 462 Hydrosarcocele, 830 Hymen, imperforate, 844 Hyoid bone, dislocation and fracture of, 206 Hyperiiietropia, 754 Hy |)ertro[)hy, congenital, of the tongue, 609 Hypertrophy of bone, 457 Hyp(ichondri:isis, sexual, 839 Hyponarthetic apparatus, 143 Hypospadias, 781 Hysteria,, 382 Hysterical aphonia, 678 ; contractions, 616 ; fit, 383 ; disease of joints, 474 Hysterotomy, 851 Ice. application of, in strangulated hernia, 622 I e and salt as an anesthetic, 905 Ichthyosis, 886; lingue, 608, 609 Iliac arteries. Iig;iture of, 551 Iliofemor.il aneuri,.'enital syphilis in, 409 Infiltrating cancer of bone, 442 Inflamed bowel in hernia, treatment of, 634 ; hernia. 619; ulcers, 418 Inflamm;ition, 33 Infl;imm.itory ulcer. 412 Inflition of tympanum, 760 Infra and supra-condyloid fractures of humerus, 263 Ingrowing toenail, 892 Inguinal aneurism, 554 ; hernia, congenital, 640; direct, 646; encysted, 642; infantile, 642 ; oblique, 640, 645 ; in the female 646 ; truss, 625 Injections, coagulating, in aneurism, 638 ; in naevus, 361; in gonorrhoea, 391; of hydio- cele, 828 ; of bone, their diagnosis, 443 Innoniin:ite artery, aneurism of, 539; ligature of, 546 Inoculation for pannus, 698 ; of secondary syi'hilis, 404 ; syphilitic, 410 Insufflition for polypi, 601 ; of invaginated bowel, 615 Intention, first, 41 ; second, 42 ; third, 45 Intercostil artery, wound of, 227 Internal ear, afiffctions of, 764 ; hasmorrhoids, 654; operations for, 655; mammary artery, wound of, 227 ; strangulation, 612 ; urethrot- omy, 797 Interrupted suture, 899 Intertrigo, 67 Interstitial cancer of bone, 443 ; keratitis, 704 Intestine, gangrene of, in hernia, 619 ; perfora- tion of, in hernia, 619; protrusion of, from wound, 236 ; internal strangulation of, 612; rupture of, 231, 622 ; suture of, 237 ; ulcera- tion of, in hernia, 6 19 Intracapsular fracture of feiuur, 289 ; of hu- merus, 258 Intracoracoid dislocation of shoulder, 273 Intnicranial suppuration, 160 Intussusception, 614 InvMgination of dead bone, 434 ; of intestine, 614 Iodide of potassium in syphilis. 400, 405 Iodine, injection of, in hydrocele, 829 Iridect..my. 701, 703, 709, 715, 725, 731 Iridectomy forceps, 725 Iridochor.iiditis, 716 Iris, adhesions of, 712 ; coloboma of, 711 ; cj-sts and tumors of, 711 ; inflammation of, 71 I ; wounds of. 740 Iritis, 711; serous, 716; from solution of catanct, 717 Irreducible hernia, 618, 622 Irrigation of wounds, 52 Ischiatic hernia, 653 Ischiorectal abscess, 658 Issues, 900 Itch, 877 Jaws, closure of, 593 ; necrosis of. 586 ; ex- antheinatous, 587 ; removal of, 592 ; tumors of, 588 J.iw, lower, dislocation of, 200 ; fracture of, 197 Jaw, upper, removal of, for nasoph.iryngeal polypus, 601 Joints, diseases of, 459 ; .tee also the names of the various joints and of special affections, as Synovitis, Arthritis, etc. ; wounds of, 289 Jugular vein, wounded in fracture of clavicle, Junks, 142 Juvenile incontinence of urine, 800 Keloid, 885 ; tumors of auricle, 756 ; of scars, 419 Kelotomy, 630 Keratitis, 701 ; interstitial, 704; suppurative, 705 ) Kidney, diseases of, 766; rupture of, 234; ' stone in, 766 ■ Knee, amputation at, 923 ; diseases of, 459- 474 ; dislocation of, 325 ; excision of. 938 ; fracture into, 305 ; gunshot wounds of, 346 ; wounds of, 289 Knock-knee, 457, 514 Kyphosis, 493 Labia, abscess in, 393 ; adhesion of, 845 ; cysts of, 846 ; hypertrophy of, 846 ; injuries of, 248 ; tumors of, 846 Laceration of the brain, 180 Lachrym.'il apparatus, diseases of, 750 ; fistula, 750 Licteal abscess, 859 Lacunar abscess, 388 Laminiir cat;iract, 718 L:ipis divinus, 693 Laryngismus stridulus, 674 Laiynj^itis, 671 , chronic, 674 ; follicular, 675 ; phthisical, 674 ; syphilitic, 675 Laryngoscopy, 669 Laryngotomy, 680 Laryngo-tracheotomy. 680 Larynx, burn of, 214 ; contusions of, 206 ; dis- eases of. 669 ; extirpation of, 678; fnctures, of. 207; scald of, 214; tumors of, 676 Lateral curvature, 491 Laughing gas. 908 Leather splints, 898 Lee's, Mr. H. , clamp, 605 ; amputation of leg, 925 Leg, amputation of, 924 ; fracture of, 311 ; compound, 312 Lens, diseases of, 717; dislocation of, 740; wounds of, 740 Lentigo hepatica, 876 Lepra, 882 Leprosy, 884 Leucocytes, emigration of, 36 Leucorrhoea infantum, 393 Lichen, 880; .syphilitic, 880 Ligature, for aneurism, causes of failure of, 534; of arteries, 114; repair after, 115; gangrene after, 118 ; elastic, in fistula, 659 ; of nsevus, 360 ; subcutaneous, 362 ; round penis, 248 ; of piles, 656. For ligature of special arteries, see their names. 954 INDEX. Lightning stroke, lofi Lime in eye, 741 Linear eM.iioiion of cataract, 724 Lineiir knife for ciitanict, 724 Lingual ;irtery, ligature of, 543 Lip, chiincre of, 410 ; diseases of, 58 1 Liponiii, ;i55 ; niisi, 594 Lister's method of dressing wounds, 49 Listen's tenaculum, 121 ; thigh splint, 300 Lithate of ainmonii calculus, 804 Lithates, deposit of in uiine, 801 Lithic acid deposit in urine, 801; calculus, 803 Lithotomy, lateral, 810; median, 8)4; peri- neal, 815; hypogastric, 816; causes of death after, 814 ; rectal, 815 ; in the fVmale, 816 Lithotomy and lilliotrity compared, SdO Lithotomy garters, 809 Lithotrites, 817 Lithotrity, 817; complications after, 821 ; re- moval of fragments in, 822; perineal, 816 Littre"s ojieration, 614 Liver, hydatid tumors of. 017 ; rupture of, 233 Liverspot, 876 Lobular induration of brea^t, 860 Local anaesthetics, 905 Locally malignant tumors, 348 Loose bodies in tunica vaginalis, 831 Loose cartilages, 459; operation for, 470 Lordosis, 494 Lower exfremitj', injuries of, 288 Lower jaw, removal of, 693 Lumbar abscess, 487 Lumbar hernia,, 653 Lung, gunshot wound of, 340 ; hernia of. 224 ; rupture of, 228; wound of in fractured ribs, 220 Lupous ulcers, 415 Lupus, 883 ; erythematous, 884 ; exedens, 884 ; im))etiginous, 884; non-exedens, 884; stru- mous, 884; syphilitic, 884 Lymjihadenoma, 568 Lymphatic fistula, 566 Lymphalies, inflammation of, 566 Lympho-sarcoma, 668 Lyssi in hydrophobia, 103 Maclntyre's splint, 314 M.icroglossia, 609 Macula, 886 Maisonneuve's instrument for urethrotomy, 798 Miilai'osteon, 453 Mahir bone, fracture of, 197 Male brr.i.vt, diseases of, 867 Malforu)atiiins. see the nauies of the organs affected, as Pharynx, Rectum, etc. Malgaigne's books lor fracture of patella, 308 Malignant pustule, 891 ; polypus of nose, 603; tumors, 348 Mammary abscess, 860; artery, internal, wound of, 227; tumor, chronic, 861 Mammilla, see Nipple. Manipulation of aneurism, 638 M.iny-laileil bandage, 896 ••Ma.«se, reduction en," 622, 636 Ma.-toid cells, disease of, 763 Maxilla, set; Jaw. Meatu.s, exieriuil, inflammation of, 757 Median lithotomy, 814 Mediastinum, wounds of, 225 Medullary cancer, 372 Medullary tissue of bone, inflammation of, 426 Meibomian glands, obstruction of, 684 Melancholic form of scrofula, 379 Melanosis, 366, 373 Membrana tympani, artificial, 759; examina- tion of, 767; incision of, 762; perforation of, 758 Meniere's disease, 765 Meningeal artery, middle, haemorrhage from, 163 ; ligature of, 163 Meningocele, 679 Mentagra, 876 Mercurial erethism, 399; inunction, 398; va- por bath, 400 Mercury in congenital ophthalmia, 690 ; iritis, 715; syphilis, 398 Mesenteric artery, superior, aneurism of. 550 Mesentery, rupture of, 621 Metacarpus, fracture of. 269 Metatarsal bones, excision of, 946 Metatarsus, dislocation of, 333 ; fractures of, 316 Microsporon Audouini, 875; furfurans, 876; mentagrophytes, 876 Miliaria, 872 Miliary tubercle, 377 Milk, irregularities of secretion of, 861 Milk cysts, 864 Minor surgery, 893 Mocmain lever truss, 626 Moles. 886 Mollities ossium, 453 ^^ Molluscum, 883 Monteggia's dislocation of hip, 325 Morbus coxarius, 475 Moxa, 901 Mucous cysts, 350 : polypus, 599 ; sarcoma, 366 ; tubercle, 366, 402. 662 ; of the tongue, 608 Mucus, accumulation of in tympanum, 762 ; ropy, in cystitis, 774 Mulberry calculus, 804 Mumps, oichitis after, 833 Muscles, atrophy of, 502 ; progressive, 502 ; in- flammation of, 497; rupture of, 218, 496; tumors of, 504 Myeloid tumor, 364 Myopia, 755 Myxoma, 366 Noevus, 360; degeneration of, 364; of lip, 581 i of the tongue, 609 Nails, ingrowing, 892 ; avulsion of, 893 ; pso- riasis of, 892 Nasal bones, fracture of, 197 Nas.il douche, 698; duct, obstruction of, 750 Nasopharyngeal polypus, 601 Navel, fee Umbilicus. Neck, gunshot wounds of, 340 ; injuries of, 203 Neck of femur, fracture of, 281 ; of hernial sac, 618; of humerus, fracture of, 268; of scapula, fracture of, 256 Necrosis, 433 ; acute, 436; operations for, 436; fracture from, 438 Needle, aneurism, 1 14 Needle, in hand, 251 Nelaton's operation for harelip. 512; probe, 336 ; test for dislocation of hip, 477 Nephralgi.i, calculous, 766 Nephritis, 766 Nephrotomy, 767 Nerves, wounds of, 617; cranial, injuries of, 183 INDEX, 955 Nervous uphoniii, 678; deafness, 764 ; diseases, 383; dysphagia, 611 Net-celled sarcoma, 366 Nettlerash, 871 Neuralgia, 518; of joints, 474; of scars, 419 Neuralgic ulcers. 418 Neuritis, optic, 733 Neurom.i, 620 Neuroiuiuiesis, 383 Neurotomy, 519 Nipple, epithelioma of. 867; eruptions of, 867; malformations of, 867; retraction of, 865 Nitric acid, treatment of piles by, 655 Nitrous oxide, 908 Nodes, 423 ; strumous, 440 Nodosity of joinis, 471 Noma, 85 Nose, absence of, 595; dise;isea of, 594; foreign bodies in, 196; malformations of 695; op- eration for restoration of, 911 ; plugging of, 596 Nystagmus, 717 Oblique inguinal hernia, 640 Obstruction of intestine, 613 ; operations for, 614 Obturator artery, irregular distribution and wound of, in femoral hernia, 648 ; foramen, dislocation of hip into, 322 ; hernia, 651 Occlusion of arteries, 523 Odontoid process, displacement of, in diseased s|iine, 49 I Odontomas, 588 ffidema of scrotum, 841 Q<]dematous ulcers, 418 (Esophagotomy, 216 Qisoph.igus, foreign bodies in, 215 ; pouch of. 610 ; stricture of, 610 Olecranon, fractures of, 264 Omental sac in hernia, 634, 660 Omentum, adhesions of in ovarian disease, 857; protrusion of from wound, 237; treat- ment of in strangulated hernia, 635 Onychia, 892; syphilitic, 892 Onyx, 706 Ophthalmia, see Conjunctivitis ; strumous, 699; sympathetic, 738 Ophthalmoscope, the, 727; use of for detecting cataract, 722 Optic nerve, injuries of, 183 Optic neuritis, 733 Orbit, pulsating tumors of, 544; wound of, 171 Orbital aneurism, 544 Orchitis, 832; chronic, 834; syphilitic, 834; scrofulous, ^34 Organization from inflammation, 38 ; of blood, 39 Os calcis, diseases of, 481 ; excision of, 945; subperiosteal, 945; fractuie of, 314 Os uteri, excision of, 862 Osteoaneurisin, 452 Osteoarthritis, 471 Osteomalacia, 463 Osteomyelitis, 126 ; chronic, 428 Osteoplastic staphyloraphy, 679 Osteoporosis, 468 Osteoid cancer. 373, 442 Ostitis, 422 Otoscope, the 760 Outer table of skull, fracture of, 168 Ovariotomy, 856 ; mortality of, 868 Ovary, tumor of, 852; suppuration in, 853 Oxalate of lime calculus, 804 ; deposit in urine, 802 Ozaena, 598 Pain, inflammatory, 34 Palate, fissure of, 574 Palmar arch, wound of, 251 ; fascia contracted, 514 ; g.anglion, 602 Pannus, 698 Pajiillary granulations of conjunctiva, 1)95 Papular eruptions, 880 Paracentesis abdominis, 616; pericardii, 226; thoracis. 228; of anterior chamber, 692; in ovarian dropsy, 865 Paraffin splints, 897 Paralysis of bladder, 799 ; of ocular muscles, 748; infantum, 603; pseudo-liypertrophin, 604 ; infantile, of hip, 479 Paraphimosis, 388 Partial dislocation of shoulder, 279 Passive congestion, 33 Pasteboanl splint, 897 Patella, dislocation of, 326 ; enlarged bursa of, 498 ; fracture of tninsverse. 3t)6 ; union of, 308; vertical or Y-shaped, 309 ; compound, 309 Pedicle, treatment of, in ovariotomy, 867 Pelvis, (leformily of in riekr-ts, 466 ; disloca- tions of, 243 ; fractures of, 241 ; injuries of the, 240 Pemphigus, 877; syphilitic, 877 Pendulous growths on synovial membrane, 463 Penetrating syphilitic ulceration of bone, 441 Penis, amputation of, 843 ; cincer of 842 ; gangrene of, 844; ligature of, 248; persist- ent priapism of 844 ; wounds of, 247 Perforation of bowel in hernia, 619; of mem- brana tympani, 768 Pericardium, wounds of, 225 ; paracentesis of, 226 Perinseal hernia, 663 ; lithotrity, 816 ; section, 792 Perinaeo, fistula in, 785, 794 ; abscess in, 785, 993 Perineum, injuries of, 247; rupture of female, 847 Periosteal abscess, 425 ; cancer, 442 Periosteum, transplantation of, 423 Periostitis, 423 ; acute, 426 Periostitis of meatus of ear, 767 Peritomy of conjunctiva in pannus, 698 Peritonitis after hernia, 729 Pert eve's instrument for forcing a stricture, 796 Petechiae. 872 Petit's tourniquet, 909 Phagedena. 82 Phagedenic chancre, 396; ulceration of bone, 433 ; ulcers, 83 Phalanges of hand, dislocation of, 287 ; frac- ture of, 269 ; of foot, dislocation of, 333 ; fractures of. 315 Pharynge.il abscess, 490 Pharyngitis, 610 Pharynx, tumors of 610 ; malformations of, 610 Phimosis, congenital, 843; gonorrhoeal, 388; syphilitic, 395 Phthisis laryngea, 675 Phlebitis, 560 Phlebolithes, 566 Phlegmatic form of scrofula, 379 Phlegmonoid chancre, 395 956 INDEX. Phlegmonous erysipelas, 70 Phlyctenuloe of corneii, IUI9 Phlycteniiliir coiijunctiviti-!, 696 Pblyziioious imstiiles, 878 Phosph:itic c.ilculi. 804; deposit in urine, 802 Phosphorus necrosis, 586 Photophobiii, 699 Phrenic herniii, ()52 Pigmentnrj' siircoiua, 366 Piles. fi.')4 Pirogoff s iimputntion, 927 Pituitiiry nieuibnine. thickening of, 597 Pityriiisis, 882 ; syphilitic, 871 ; versicolor, 876 Plaster of Piiris splints. 898 Plastic operations, 910 Plica polonica, 886 Plugging the nose, 596 Pneuinocele, 224 Pneuuiothoriix, 221 Poisoned wounds. 9;^ Politzer's method of inflating the tympanum, 760 Polypus of ear, 763 ; nasopharyngeal, 601 ; of nose. 599 ; malignant, 603 ; of rectum, 661 ; uteri, 850 P(.mph(.lyx, 877 PiiplitenI aneurism, 556 Porrigo, 879 Port-wine injection in hydrocele, 828 Potassa fusa. 902 Potassa cum calce, 900 Pott's fracture, 328; puffy tumor of, 161 Pouch of oesophagus, 610 Presbyopia. 754 Pressure, for arresting haemorrhage, 125 Priapism, persistent, 844 Primary union, 41 Probaiig, oesophagus. 215 Projectiles, modern, wounds caused by, 334 Polapsus ani. 6.')7 : uteri, 849 Proliferous cysts, 353 Propto.-is oculi, 544 Prostiite, affections of, 776 ; abscess of, 776 ; enlargement of, 779 : inflammation of, 776 ; cancer of, 781 ; division of, in lithotomy, 812 Prostatic calculi, 824 ; hasmorrhage, 778 Prostatitis, acute, 777 ; chronic, 777 Prostration with excitement, 129 Prurigo, 881 Pruritus ani, 661 ; scroti, .881 ; vulvae, 881 Pseudarthrosis, 149 Pseudoc.ilculi, 805 Pseudohviertrophic paralysis, 504 Psoriasis, 882 ; of nails, 892 ; syphilitic, 882 Psoas abscess, diagnosis of fiom hernia, 649 Psoas, enlarged bursa of, 478 Psydracious pustules, 878 Pterygium, 697 Ptosis. 687 Pubes. dislocation of hip on, 323; puncture of bladder above. 780 Pudendal hernia, 653 Puffy tumor of Pott. 161 Pulit-ys, use of, in di>location, 278 Pulpy (IfgHner.ilioii of synovial membrane, 462 Pulsatile cancer, 452 Pulsatinir tunioi of bone, 452 Puncta lacryiiiali.'i, obstruction of, 751 Puncture of bladder above the pubes, 780; from the rectum, 79 1 Pupil, iirlifi(!ij(l^ 733; exclusion of, 713 Purpura, 871 Pus, 42 ; kinds of, 64 Pustular eruption, 879 Pustule, malignant, 892 Puzz.letoy, use of. in reduction of dislocation of thumb, 286 Pycemia, 59 ; chronic, 64 Pyelitis, calculous, 766 Pyogenic membr.-ine, 54 Pyramidal or punctated cataract, 718 Quilled suture, 847 Quinsy, 583 Rabies, 100 R.idial artery, ligature of, 550 Radical cure of hernia, 629 ; of hydrocele, 828 Radius, dislocation of at elbow, 283 ; fracture of, 267 Railway injuries, 192 Ranula,, 583 '■ Rapid '' compression in aneurism, 537 Rapid dilatation of stricture, 788 Rashes, 870 Reiiction after collapse, 129 Rectal lithotomy. 815 Rectangular lithotomy staff, 812 Recto-urethral fistula, 814 Recto-vaginal iistula, 849 Recto-vesical fistula. 814 Rectum, diseases of, 654 ; foreign body in, 250 ; malfonnjition of, 265 ; puncture of bladder from, 791 ; wound of, 249; in lithotomy, 813; sfe. nlso the various affections, as Fis- tula, Polypus. Recurrent hsemorrhage, 118; vascular ulcer of cornea, 699 Red gum, 880 Reduction of dislocation, see Shoulder, Hip, etc.: of hernia, 621; " en masse, " 622, 636 Refracture of bone, 153 Relaxed uvula, 585 Renal hsematuria, 767 Resection, sve Excision. Residual abscess, 51 Resilieiit strictures. 795 Resolution of inflammation, 38 Rest, in treatment of aneurism, 531 Retained testis, 825 ; hernia with, 641 Retention of urine, 799; after lithotrity, 822; spasmodic, 798 Reticulated syphilitic ulcer of bone, 441 Retina affections of, 733 Retinitis, 733 Retraction of nipple, 865 Retractors in amputation, 914 Rheumatic arthritis, 471 Rheumatism gonorrhoeal, 390 Rhinolithes, 595 Rhinoplasty, 911 Rhinoscopy, 671 Ribs, fracture of, 218; dislocation of, 223 Richardson's S[n;iy producer, 905 Rickets, 455 ; operations for, 457 Rigors, 48 : urethral, 795 Ringworm, 874 Rodent ulcer, 4 16 Ropy Miucns, 774 Roseola, 870 ; syphilitic. 871 Round-celled sarcotna, 364 llupia. 878; syphilitic, 878 Rupture, sw Hernia. Rupture of aneurism, 531 ; of artery, 521 ; of bladder, 244 j from distension, 786; of dia- INDEX. 957 phragm, fi52: of eyeball, 740 ; ofhenrt, 228; of intestines, 2;j I ; bytiixis, (i21 ; of kidney, 284 ; of liver, 234 ; "of liinj,', 228; of mein- bi-nna tynn5ani, 758; of perineum. 847; of spleen, 234 ; of .stoiniich, 231 ; of .«trifitiire, 790; of tendons, 490 ; of ureter, 234; of urethra, 246 ; of vagina, 248 Sao. hernial, 617; hydrocele of, 829 ; lacera- tion of, 621 ; omental, 634, 660; operation for hernia, external to, 632 ; strangulation of hernia by, 633 Sacro-iliao disease, 48(1 Sago-griiin granulations in epidemic ophthal- mia, 693 Salivary calculus, 582; fistula, 195 Salter's swing for the leg, 313 Sanguine form of scrofula, 379 Sanguineous cysts, 350 Saphena vein, varix of, diagnosis of, from hernia. 649 Sarcoma, 348, 364 ; alveolar. 366 ; giant- celled, 365 ; net-celled, 366 ; pigmentary, 366 ; round-celled, 364 ; spindle-celled, 364 ; in bone ; 445 ; breast, 863 ; eyeball, 735 Sarcoptes hominis, 877 Scab, union under, 45 Scabies, 877 Scalding in gonorrhoea, 387 Scalds, 131 ; of larynx, 214 Scalp, anatomy of, 157; congenital cysts of, 362; c(^tusion of, 157; erysipelas of, 159; sebaceous tumors of, 251 ; wounds, 158 Scalp bandage, 896 Scales, see Squamous. Scapula, excision of, 931 , fracture of, 256 ; of neck of, 256 Scar, see. Cicatrix. Scarification in gonorrhoeal ophthalmia, 692 Scarlet fever, disease of the tympanum in, 763 Sciatic notch, dislocation of hip into, 318 Scirrhus, 370 ; operations for, 370: of breast, 864 Scissors for skin-grafiing, 421 Scoop, lithotomy. 813 Scorbutic ulcers, 414 Scorbutus, 871 Scott's bandage, 462 Scrofula, 377 ; in bone, 439 ; see also Struma, Strumous. Scrofulosis, 379 Scrofulous orchitis, 834 Scrotal truss, 625 ' Scrotum, cancer of, 842 ; elephantiasis of. 841 ; inflammation of, 841 ; injuries of, 247; in- dolent tumors of, 836 Scurvy, 872 Sebaceous tumors, 351 Secondary deposits, 61 ; htomnrrhage after ligature of artery. 116, 534; syphilis, 401; treatment of, 404 ; union, 42 Semilunar cartilages, dislocation of, 327 Semi-malignant tumors, 348 Senile cataract, 721; gangrene, 84; scrofula, 381 ; ulcer, 413 Separation of epiphyses, 139; lower epiphysis of femur, 302 ; upper epiphysis of femur, 296 ; lower epiphysis of humerus, 263 ; up- per epiphysis of humerus, 251 Septicaemia, 69 Septum nasi, diseases of, 599 Sequestrum, 434 Serocystic tumor of breast, 862 Serous cysts, 349 Serous iritis, 716 Serous form of scrofula, 379 Serpent bites, 96 Setons, 901 ; in hydrocele, 829; in strumous ophthaliniii, 7li0 ; in ununited fracture, 160 Setting fractures, 141 Seutin's scissors, 899 Sexual hypochondriasis, 839 Shackles for lithotomy, 809 Shingles, the, 873 Shortening in hip dise.ises, 476 Shoulder, amputation at, 915: diseases of, 482; dislocation of, 271; excision of, 929; subperiosteal, 930 Signorini's tourni(iuet, 537, 909 Silver-stain, 886 Silver sutures, 899 Simple ulcer, 412 Sinus, 58 Skin, eriijitiona of, 870 ; diseases of append- ages of. 886 Skin-grafting, 421 Skull, deformity of, in rickets, 456 ; fractures of, 167; of base of, 170 Sloughing, 76 Sloughing chancre, 395 Smith's, Mr. II., clamp for piles, 656 Smith's gag for staphyloraphy, 675 Snake-bites, 96 Snuflles, Ihe, 407 Solution of cataract, 717 Soot cancer, 842 Sore throat, .syphilitic, 403 Sounding for stone, 807 Sounds, forms of, for stone, 808 Spasmodic retention of urine, 798 Spasmodic stricture, 798 Spasms in gonorrhoei, 389 Spectacles, 727. 753 Speculum, laryngeal, 670 Spermatic canal, tumors of, 841 Spermatorrhoei, 838 Spica bandage. 894 Spina bifida, 495 Spinal abscess, 484 ; instruments, 489, 493 Spindle-celled sarcoma, 364 Spine, anchylosis of, 494 ; cancer of, 494 ; con- cussion of^ 191 ; curvature of, 489,491,494; from rickets, 455 ; disease of. 484 ; fracture of, 186 ; gunshot wounds of, 339 Spiral bandages, 894 Spiral spring-truss, 626 Spleen, rupture of, 234 Splints, 142, 897 Spontaneous cure of aneurism, 531 ; fracture, 459 Sprains of the back. 185; of lower extremity, 288 ; of upper. 260 Spray producer for local anassthesia, 905 Squamous eruptions, 882 Squint, 742 ; divergent, 748 ; operation for, 745; secondary. 744 Staff, lithotomy, 812 " Stammering," oesophageal. 61 I Staphyloma, 708 ; removal of, 709 Staphyloraphy, 576 ; osteoplastic, 579 Starch bandage, 897 Sternal end of clavicle, fracture of, 254 Sternoel.ivicular joint, dise.ises of, 482 Sternomastoid muscle, section of, 516 Sternum, fracture of, 222 Stilling's knife for lachrymal obstruction, 752 958 INDEX. Stoiunch. operation for opening the, 238; rup- ture ot', 2.S1 Stone, .sv« Calculus. Strahisinus, gff Squint. Strabismus hook, 747 Stranorulation of hernia. 618 ; internal, 612 Strappinji, .t3 Stricture of oesophagus, 610' of the rectum, 6.'i2 Stricture of urethra, 782 ; rupture of, 796 ; spasmodic, 708 Stricture, .^eat of. in hernia, 632 Strophulus. 880 Struma, 377 Strumous diseases of joints, 461; lip, 581 ; ophthalmia, 6il9 ; orchitis, 834 ; ulcers, 413 Strychnia poisoning and tetanus, 87 Stumps, dressing of, 915 Styes. 686 Styptics, 125 Subastragaloid amputation, 927 ; dislocation, 33 1 Subclavian artery, aneurism of, 545; ligature of first part of, 546 ; of second and third part, 547 Subclavicular dislocation of shoulder, 274 Subcoracoid dislocation of shoulder, 272 Subcu'aneous ligature of najvus. 362 ; method of removing loose cartilase, 471 Subcutaneous surgery, sre Tenotomy. Subglenoid dislocation of shoulder, 272 Submammary abscess, 860 Subpectoral abscess, 218 Subperiosteal excision, 426, 930 ; of fracture, 152 Subspinous dislocation of shoulder, 274 Suction, removal of cataract by, 719 Sudamina, 872 Sulphuric .acid treatment of disease of bone, 433 ; of joints, 465 Suppression of urine. 768 Suppuration, see Abscess, Pus ; beneath the skull, 160 Suppuration, visceral disease from, 66 Suppurative syphilitic inflammation, 396 Supracoracoid dislocation of shoulder, 275 Suprapubic lithotomy, 815 Suprastern.'il dislocation of clavicle, 271 Surgical neck of humerus, fracture of, 259 Suspensory b.and.ige, 896 Suture of bowel in herniotomy, 634 Sutures, 53. 899; continuous, 899; inter- rupted, 899; quilled, 847; twisted, 899 Swings for fracture, 143 Sycosis, 876 Symblepharon, 741 Syme's amputation, 926; operation for stric- ture, 795 Sympathetic irritation, 738 ; ophthalmia. 738 Synovial membrane, pulpy degeneration of, 462; pendulous growths from, 46.'i Synovitis, 460; abscess after, 461 ; chronic, 463 Syphilitic affections of bone, 440; of larynx, 675; of meatus of ear, 758; of retina. 733; of tongue, 604, 608 ; deafness, 764 ; erup- tions, 401, 406; see ah') the names of the various eruptions, as Lichen; fever, 401; iriti.a, 712: keratitis, 704; onychia, 892; orchiti.a, 834; sore throat, 403; stricture, 782; ulcers, 414 ; of the rectum, 664 Syphilis, 394 ; congenital, 457 ; constitutional, derived from the foetus, 409 ; infantile, 407 ; secondary, 401 ; tertiary, 405 Syphilization, 410 T bandage, 896 Tasriiacotian operation, 912 Talipes, calcaneus, 512 ; cavus, 513 ; equinus, 507 ; valgus, 512 ; varus, 509 Tapping the abdomen, 616 ; for ovarian drop- .sy, 855 ; of hydrocele, 827 Tarsal cartil.ige, incurvation of, 680; ophthal- mia, 685 ; tumors, 684 Tarsus, diseases of, 481 ; dislocation of, 333; friicttires of, 315 Taxis of hernia, 620 ; accidents in, 622 ; for- cible. 621 Te.ale's amputation. 924 Teeth, syphilitic, 408. 705 Temperature in erysipel.as, 69 ; hectic, 65 ; hysteria, 385 ; inflammation, 34, 48 ; inju- ries of head, 178 ; of spine, 187 ; disease of joints, 474 ; pyaemia, 60 ; tetanus, 90 ; trau- matic encephalitis, 181 ; fever, 49 Tenacula, 120; Liston's, 121 ; Assalini's, 121 Tendo Achillis, division of, 508 ; in fracture of the leg, 314; rupture of, 496 Tendons, inflammation of sheaths of, 497 ; rup- ture of, 496 " Tcnosinite crepitante,"' 497 Tenotomy, 505 ; in fracture of leg, 314 Tension of eyeball, 729 Tertiary syphilis, 405 Testicle, abnormal position of, 726 ; absence of, 825; affections of. 825; cancer of, 837; cystic disease of, 835 ; dermal tumor of, 838 ; enchondroma of, 836 ; foetal rera.ains in, 838; injuries of, 248; inversion of, 727; removal of, 837 ; retained, 825 ; hernia with, 641 Testis, hernia, 835 Tests for calculi, 805 Tetanus, 86 ; idiopathic, 87 Thickening of pituitary membrane, 597 Thigh, amputation of, 923 ; fracture of, see Femur. Thompson's lithotrite, 817; urethrotome, 798 Thoracentesis, 228 Thora.K, foreign bodies in, 225 Thro.it deafness. 760 Thrombosis, 560 ; connection with pyasmin, 64 Thudichuin's method of washing out the nose, 598 Thumb, amputation of, 920 ; dislocation of, 285 Thyroid arteries, ligature of, 543 Thyroid body, diseases of, 868 Thyroid dislocation of hip, 322; hernia, 651 Thyrotomy, 677 Tibia, fracture of, 311 Tibial arteries ligature of, 558 Tibial tendons, division of, 510 Tinea, 874; deealvans. 875; favosa, 875; sycosis, 876 ; tonsurans, 874 Tinea tarsi, 685 Tinnitus aurium, 764 Toe, amputation of, 928 Toenail, ingrowing, 892 Tongue, cancer of, 605 ; congenital hypertro- phy of, 609 ; diseases of, (iOl ; najvus of, 609 ; removal of the, 606 ; ulceration of, 604 Tongue-tie, 603 Tonsil, acute inflammation of, 583 ; chronic INDEX. 959 enlargement, 584 ; denfness with, 760; re- moval of, 5H5 ; wounds of, 585 Tooth cysts, 588 Tooth tumors, 587 Torsion of arteries, 123 Torsion forceps, 123 Tourni(|uets, 909 ; aortic, 921 ; Italian, 909 Trachea, rupture of, 208 ; foreign bodies in, 208 Tracheotomy, 680, 681 Transfusion, 126 Transplantation of bone, 152; of skin. 911 Transverse ligament of spine, ulceration of, 492 Traumatic fever, 40 ; gangrene, 75 Traumatopiioia, 341 Trepliine, 184 Trepiiinincr, 184; for abscess, 162; for blood beneath the skull. 163 ; for depressed frac- ture. 170. 179 ; in injuries of the bead, 338 Trephining in abscess of bone, 430 Trephining the spine. 1S9 Trichophyton tonsurans, 874 Trismus. 86 ; nascentiura, 87 Trocar for ovariotomy- 856 Trochanter, disease tif, 480 ; fracture of, 295 True aneurism. 526 Trusses, 624 ; measuring for, 626 Tubercle, 377 ; in bone, 439 Tubercle, mucous, 402. 662 Tubercular eruptions, 882; syphilitic ulcera- tion of bone, 441 Tuberculosis. 379 Tuberocystic tumor of breast. 862 Tuberosities of humerus, fracture of, 261 Tubular aneurism, 526 Tumors, 347 ; for special forms of tumor sre their names, as Fatty, Sarcoma, etc. Tunica vaginalis, hydrocele of, 726 ; loose bodies in, 831 Tuning-fork, diagnosis of diseases of the ear by, 761 Twisted suture, 809 Tying arteries, sei>- Ligature, also the names of the vessels, as Feuiorai. Carotid. Tying a catheter in the bladder, 790 Tympanum, affections of. 761 ; acute inflam- mation of, 761 ; catarrh of, 762; mucus in, 762 ; scarlatinal affections of, 763 : polypi of, 763 ; see also Membrana Tympani. Ulcers, 411; see also their various forms, as Eczematous, Cancerous ; of anus, 660 ; bone, 441; cornea, 707; recurrent vascular of cornea, 699 Ulcerated cancer, 866 Ulceration of cartilage, 466; cicatrices, 419 ; intestine in hernia, 619, 635 Ulna, dislocation of, at elbow, 280 ; fracture of, 266 Ulnar artery, ligature of, 549 Umbilical fistula, 616 ; hernia, 650 ; truss 629 Umbilicus, vascular protrusion from, 616 ; ul- ceration of, 616 Uncipression, 125 Union, see Wounds. Union of fracture, 144 ; by granulation, 146 ; irregular, 147; enlarged, 148; villous, 152; of neck of femur, 294 Ununited fracture, 148 Upper extremity, compound fracture of, 269 , injuries of. 250 Upper jaw, removal of, 592 Urates, see Lithates ; Uric acid, see Lithic acid. Urea, decomposition of, 774 Ureter, rupture of, 234 Urethra, affection of. 781 ; calculus in. 824 ; foreign body in, 249 ; malformation of, 781 ; rupture of. 246 ; stricture of, 782 ; vascular tumor of female, 845 Urethral fever, 795 ; hicmaturia, 767 ; hajmor- rhoids, 845 Urethrotomy, external, 795 ; internal. 797 Urinary abs'ce.'^s, 785, 793 ; deposits, 801 Urine, incontinence of. 799 ; retention of. 799 ; extravasation of, 785 ; suppression of, 768 Urticaria, 871 Uterus, cancer of, 862 ; fibroid tumor of, 851 ; softened, 854 ; injuries of, 249 ; polypus of, S50 ; prolapsus, 818 ; removal of, 851 Uvula, relaxed, 585 Vaccination, 903 ; secondary, 904 ; syphilis communicated by. 410; ofntevus, 361 Vagina, foreign body in, 249 ; imperforate, 844 ; injuries of. 248; obliteration of, 849 Vaginal cystocele, 653, 849; fistulso, 849; hernia, 653 Vanzetti, his method of uncipression, 125, 251 Vapor-bath, mercurial, 400 Varicocele, 839 Varicose aneurism, 528; ulcers, 417; veins, 563; operation on, 564 Varix. aneurismal, 528 ; arterial, 527 Vascular keratitis, 701 ; tumor, 359 ; of ure- thra, 845 Vault of the skull, fracture of, 167 Vegetations, gonorrhoeal, 393 Veins, diseases of, 560 ; entrance of air into, 111; injuries of. 110 ; wound of, I 13 Venereal disease, 394 ; warts, 887 ; see also Syphilis, Syphilitic. Venesection, 902 Venomous animals, bites of, 96 Venous hffiiuorrhage, 112 Ventral hernia, 235, 652 Verruca necrogenica, 888 Vertebrae, see Spine. Vesical haematuria, 767 Vesico-intestinal fistula, 776 Vesico-prostatic calculus, 824 Vesicovaginal fistula, 849 Vesicular eruptions, 167 Vibices, 871 Vicious union of fracture, 152 Vienna paste, 900 Villous tumor, 376 ; of bladder, 772 ; of rec- tum, 662 Viscera, abdominal, wounds of, 236 Visceral affections, syphilitic, 406 Vision, double, 741 Vitiligo, 886 Vitreous body, diseases of, 734 Vitreous humor, escape of, after extraction, 726 Vocal cords, paralysis of, 679 ; tumors of, 676 Volvulus, 612 Vulva, cancer of, 847 ; injuries of, 248 Wardrop's operation for aneurism, 540 Warm bath in strangulated hernia. 622 Warts, 887 ; di.ssection, 888 ; venereal, 887 W.'irty tumor of cicatrix, 420 Watery discharge in fractures of the skull, 173 Watson's splints for excisinn of the knee, 941 Wax, accumulation of, 757 Weak ulcers, 418 960 INDEX. Webbed fingers. 013 Weber's enntiliculus knife. 751 Weight, extension by. in fractured femur, 300 ; in diseiise of hip, 479 Wet-nurses, infection of infants with syphilis from, 409 Whitlow, 497 " Wind-contusions," gunshot, 335 Windpipe, foreisn bodies in, 209 ; sfe also Trache.i, Cut Throat Wire-treatment of aneurism, 538 Women, gonorrhoe i in. 392 ; stone in, 816 , surgical diseases of. 844 Wounds, 38 ; union of, adhesive or primary, 41 ; suppurative, or secondary, 42 ; under a scab, 45 ; dressing of, 49 ; poisoned, 93 ; of arteries, 109; of veins, 113; sf.e also the names of the various organs. Wrist, amputation at, 919 ; diseases of, 483 ; dislocation of, 284; excision of, 935 Wryneelt, 515 ; hysterical, 516 Xanthic oxide, 802, 804 Xeroderma, 886 Yaws, 886 Yellow tubercle, 378 Zoster, herpes, or zona, 873 Zygoma, fracture of, 197 HENRY C. LEA'S SON & CO.'S (late henry c. lea) OF MEDICAL AND SUKGICAL PUBLICATIONS. In asking the attention of the profession to the works advertised in the foUowinc pages, the publisliers woidd state that no 2)ains are spared to seeure a continuance of tlie confidence earned for the {jublications of the house by their careful selection and accuracy and finish of execution. The large number of inquiries received frnm the profession for a finer class of hind- i4igs than is usually placed on medical books has induced us to put certain of our standard publications in half Jiussia, and that the yrowing taste may be encouraged, the prices have been fxed at so small an advance over the cost of sheep, as to place it within the means of all to possess a library that shall have attractions as ivell for the eye as for the mind of the reading practitioner. The printed prices are those at which books can generally be supplied by book- sellers throughout the United States, who can readily procure for their customers any works not kept in stock. AVhere access to bookstores is not convenient, books will be sent by mail post-paid on receijjt of the price, and as the limit of mailable weight has been removed, no dilhculty will be experienced in obtaining through the post-oflice any work in this catalogue. No risks, however, are assumed either on tlie money or on the books, and no publications but our own are suj)plied, so that gentlemen will in most cases find it more convenient to deal with the nearest bookseller. HENRY C. LEA'S SON & CO. Nos. 706 and 708 Sansom St., Philadelphia, July, 1881. INCREASED INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAN JOURNAL_()F_ THE MEDICAL SCIENCES. TWO MEDICAL JOURNALS, containing nearly 2000 LAKGE PAGES, Free of Postage, for FIVE DOLLARS Per Annum. TERMS FOR 1881. The American Journal of the Medical Sciences, published ] Five Dollars quarterly (1150 pages per annum), with I per annum, The Medical News anl> Abstract, monthly (768 pp. per annum), ] in advance. SEPARATE SVHSCRIPTIOXS TO The American Journal of the Medical Sciences, when not paid for in advance, Five Dollars. The Medical News and Abstract, free of postage, in advance, Two Dollars and a Half. *^* Advance paying subscribers can obtain at the close of the year cloth covers, gilt-lettered, for each volume of the Journal (two annually), and of the News and Absti-act (one annually), free by mail, by remitting ten cents for each cover. It will thus be seen that for the moderate sum of Five Dollars in advance, the subscriber will receive, free of postage, the equivalent of four large octavo volumes, stored with the choicest matter, original and selected, that can be furnished by the medical literature of both hemispheres. Thus taken together, the "Journal" and the "News and Abstract" combine the advantages of the elaborate preparation that can be devoted to the Quarterly with the prompt conveyance of intelligence by the Monthly; while, the whole being under a single editorial supervision, the sub- scriber is secured against the duplication of matter inevitable when periodicals from ditferent sources are taken together. The periodicals thus otiered at this unprecedented rate are universally known for 2 Henry C. Lea's Son & Co.'s Publications — (Am. Joum. Med. Sci.). their high prolessionul standing. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by I. MINIS HAYS, M.D., for more than half a century has maintained its position in the front rank of the medical literature of the world. Cordially supported by the profession of America, it circulates wlierever the language is read, and is universally regarded as the national exponent of American medicine — a position to -which it is entitled by the distinguished names from every section of the Union which are to be found among its collaborators.* It is issued quarterly, in January, April, July, and October, each number containing about three hundred octavo pages, appropriately illustrated wherever necessary. A large portion of this space is devoted to Oi'iginal Communications, embracing papers from the most eminent members of the profession throughout the country. FoUoAving this is the Review Department, containing extended reviews by com- petent writers of prominent new works and topics of the day, together with numerous elaborate Analytical and Bibliographical Notices, giving a fairly complete survey of medical literature. Then follows the Quarterly Summary of Improvements and Discoveries IN THE Medical Sciences, classified and arranged under difierent heads, and furn- ishing a digest of medical progress, abroad and at home. Thus during the year 1880 the "Journal" contained 67 Original Communications, mostly elaborate in character, 170 Reviews and Bibliographical Notices, and 147 articles in the Quarterly Summaries, illustrated with 47 wood engravings. That the efforts thus made to maintain the high reputation of the "Journal" are successful, is shown by the position accorded to it in both America and Europe as the leading organ of medical progress : — This is universally acknowledged as the leading i The Philadelphia Medical and Physical Journal American Journal, and has been conducted Ijy Dr. issued its first number in 1820, and, after a brilliant Hays alone until 18t>9, when his sou was associated career, was succeeded in 1S27 by the Ameiican with him. We quite agree with the critic, that this Journal ol the Medical Sciences, a periodical of journal is second to none in the language, and cheer- world-wide reputation; the ablest and one of the fully accord to it the first place, for nowhere shall oldest periodii-alsin the world — ajournal which has we find more able and more impartial criticism, and nowhere such a repertory of able original articles. Indeed, now that the "British and Foreign Medico- Chirurgical Review" has terminated its career, the American Journal stands without a rival. — London Med. Times and Gazette, Nov. 24, 1877. The best medical journal on the continent. — Bos- ton Med. and Surg. Journal, April, 1879. The present number of the American Journal is an exceedingly good one, and gives every promise of maintaining the well-earned reputation of the review. Our venerable contemporary has our best wishes, and we can only express the hope that it may continue its work with as much vigor aud ex- cellence lor the next filty years as it has exhibited in the past. — London Lancet, Nov. 24, 1877. an unsullied record. — Gross's History of American Med? Lileraturv. 1876. The best medical journal ever published in Europe or America.— Ko. Med: Monthly, May, 1879. It is universally acknowledged to be the leading American medical journal, and, in our opinion, is second to none in the language. — Boston Med. and Surg. Journal, Oct.' 1877. This is the medical journalof our country to which thd American physician abroad will point with the greatest satisfaction, as reflecting the state of medi- cal culture in his country. For a great many yearB it has been the medium through which our ablest writers have made known their discoveries and observations.— .^ddrw* of L, P. Tandelt, M.D., be- fore International Med. Congress, Sept. 1876. And that it was specifically included in the award of a medal of merit to the Pub- lishers in the Vienna Exhibition in 1873. The subscription price of the "American Journal of the Medical Sciences" has never been raised during its long career. It is still Five Dollars per annum ; and when paid for in advance, the subscriber receives in addition the "Medical News and Abstract," making in all nearly 2000 large octavo pages per annum, free of postage. II. THE MEDICAL NEWS AND ABSTRACT. Thirty-eight years ago the "Medical News" was commenced as a monthly to convey to the subscribers of the "American Journal" the clinical instruction and * Communications are invited from gentlemen In all parts of the country. Articles Inserted by the Editor are liberally paid for by the publishers. Henry C. Lea's Son & Co.'s Publications*— (J m. Joum. Med. Sci.). 3 current information which could not be accommodated in the Quarterly. It consisted of sixteen pages of such matter, together with sixteen more known as the Library Department and devoted to the publishing of books. With the increased progress of science, however, this was found insuilicicnt, and some years since another periodical, known as the "Monthly Axjstuact," was started, and was furnished at a moderate price to subscribers to the "Amekican Journal." These two monthlies have been consolidated, under the title of "The Medical News and Abstract," and are furnished free of charge in connection with the "American Journal." The "News and Abstract" consists of 64 pages monthly, in a neat cover. It contains a Clinical Department in which will be continued the series of Ohkjinal American Clinical Lectures, by gentlemen of the highest reputation through- out the United States, together with a choice selection of foreign Lectures and Hospital Notd? and Gleanings. Then follows the Monthly Abstract, ajstemati- cally arranged and classified, and presenting five or six hundred articles yearly ; and each number concludes with an Editorial and a News Department, civintr cur- rent professional intelligence, domestic and foreign, the whole fully indexed at the close o^' each volume, rendering it of permanent value for reference. As stated above, the subscription price to the "News and Abstract" is Two Dollars and a Half per annum, invariably in advance, at which rate it ranks as one of the cheapest medical periodicals in the country. But it is also furnished, free of all charge, in commutation with the "American Journal of the Medical Sciences," to all who remit Five Dollars in advance, thus giving to the subscriber for that very moderate sum, a complete record of medical progress throughout the "world, in the compass of about two thousand large octavo pages. • In this effort to furnish so large an amount of practical information at a price so un- precedentedly low, and thus place it within the reach of every member of the profes- sion, the publishers confidently anticipate the friendly aid of all who feel an interest in the dissemination of sound medical literature. They trust, especially, that the sub- Bcribers to the "American Medical Journal," will call the attention of their acquaintances to the advantages thus offered, and that they will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheap- ness never heretofore attempted. PKEMIUM rOE OBTAINING NEW SUBSGEIBERS TO THE "JOUENAL." Any gentleman who will remit the amount for two subscriptions for 1881, one of which at least must be for a neiv subscriber, will receive as a pkemium, free by mail a copy of any one of the following recent works : — " Seiler on the Throat" (see p. 19), "Barnes's Manual of Midwifery" (see p. 24), "Tilbury Fox's Epitome of Diseases of the Skin," new edition (see p. 19), "Browne on the Use of the Ophthalmoscope" (see p. 29), "Flint's Essays on Conservative Medicine" (see p, 15), " Sturges's Clinical Medicine" (see p. 15), " Swayne's Obstetric Aphorisms," new edition (see p. 21), "Tanner's Clinical Manual" (see p. 5), "West on Nervous Disorders of Children" (see p. 21). %* Gentlemen desiring to avail themselves of the advantages thus offered will do ■well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1881. I^° The safest mode of remittance is by bank check or postal money order, drawn to tiie order of the undersigned. Where these are not accessible, remittances for the "Journal" may be made at the risk of the publishers, by forwarding in registered letters. Address, Henry C. Lea's Son & Co., Nos. 706 and 708 Sansom St., Phila. Pa. Henry C. Lea's Sou & Co.'s Publications — {Dictionaries). nUNOLISON {ROBLEF), M.D., Late Professor o/ Institutes of Medicine in Jefferson Medical ColUge, Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Con- taining a concise explanation of the various Subjectp and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence and Dentistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes ; so m* to constitute a French as well as English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- ified and Augmented. By Richaud J. Dunglison, M.D. In one very large and hand- someroyal octavo volume of over 1100 pages. Cloth, $6 60 ; leather, raised bands, $7 60 ; half Russia, *8. {Just Issued.) The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensedview of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view; the immense demand which has existed for the work has enabled him, in repeated re visions, io augment its completeness and usefulness, until at length it hasatta!inedthe position of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this en-- viable reputation During the ten years which have elapsed since the Inst revision, the additions to the no men slat ure oft he medical sciences have been greater than perhaps in any similar period of the past, and up to the time of his death the authorlabored assiduously to incorporate every- thing requiring the attention of the student or practitioner. Since then, the editor hiis been equally industrious, so that the additions to the vocabulary are more numerous than in any pre- vious revision. Especial attention has been bestowed on the accentuation, which will be found marked on every word. The typographical arrangement has been much improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The work has been printed on new type, small but exceedingly clear, with an enlarged page, so that the additions have been incorporated with an increase of but little over a hundred pages, and the volume now contains the matter of at least four ordinary octavos. A book well known to our readers, and of which every American ought to be proud. When the learned %uthor of the work pas.ied away, probably all of u.' feiired lest the book should not maintain its place in the advancing science whose terms it defines. For- tunately, Dr. Richard J. Dunglison, having assisted his father in the revi.«ion of several editions of the work, and having been, therefore, trained in the methods and imbued with the spirit of the book, has been able to edit it, not in the patchwork manner so dear to the heart of book editors, so repulsive to the taste of intel- ligent book readers, but to edit it as a work of the kind should be edited — to carry it on steadily, without jar or interruption, along the grooves of thought it has travelled during its lifetime. To show the magnitude of the task which Dr. Dunglison has assumed and car- ried through, it is only necessary to stale that more than six thousand new subjects have been added in the present edition. — Phila. Med. Times, Jan. 3, 1874. About the first book purchased by the medical stu- dent is the Medical Dictionary. The lexicon explana- tory of technical terms is simply a si7ie qua non. In a science so extensive, and with such collaterals as medi cine, it is as much a necessity also to the practising physician. To meet the wants of students and most physiiaans, the dictionary must be condensed while comprehensive, and practical while perspicacious. It was because Dunglison's met these indication.<^ that it became at once tlie dictionary of general use wherever medicine wag studied in the English language. In no former revision have thealterations and additions been 80 great. Morethan six thousand new subjects and terms have been added .The chief terms have been set in black letter, while ihe derivatives follow in small caps: an arrangement which greatly facilitates reference. AVe may safely confirm the hope ventured by the editor '• that the work, which possesses forhim a filial as well as an individual interest, will be found worthy a con- tinuunce of the position so long accorded to it as a st-indard authority." — Oincinnau Clique. Jan. 10, 1874 , It has the rare merit that it certainly has no rival in the English language for accaracyand extent of references. — London Medical ffoaette . As a standard work of reference, as one of the best, if not the very best, medical dictionary in the Eng- lish language, Dunglispn'a work has been well known for about forty years, and needs no words of praise on our part to recommend it to the members of the medical, and, likewise, of the pharmaceatical pro- fession. The latter especially are in need of such a work, which gives ready and reliable information on thousands of sabjects and terms which they are liable to encounter in pursuing their daily avoca- tions, but with which they cannot be expected to be familiar. The work before us fully supplies this want. — Am. Journ. of Pharm., Feb. 1874. A valuable dictionary of the terms employed in medicine and the allied sciences, and of the rela- tions of the subjects treated under each head. It re- flects great credit on its able American author, and well deserves the authority and popularity it has obtained. — British Med. Journ., Oct. 31, 1S74. Few works of this class exhibit a grander monu- ment of patient research and of scientific lore. The extent of the sale of this lexicon is sufflcient to tes- tify to its u .i'ulness, and to the great service con- ferred by Dr. K.jbley Dunglison on the profession, and indeed on others, by its issue. — London Lancet , May 13 V. As a detailed account of the development of medical .■science in America, by gentle- men of the highest authority in their respective departments, the profession will no doubt wel- come it in a form adapted for preservatiou and reference. ^EILL {JOHN), M.D., and aMITff {FRANCIS G.), M.D., Pro/, o/the rnstitute«o/ MeAicine inlheUniv o/Penna AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12njO. volume, of about one thousand pages, with 374 wood-cuts, cloth, $4 ; strongly bound in leather, with raised bands, $4 75. TIARTSHORNE {HENRY), M.D., Professor of ByyUine in the UnioKrsity of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Me.licii,, Practical Medicine' Surgery and Obstetrics. Second Edition, thoroughly revised and improved. In one large royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on wood. Cloth, $4 25 ; leather, $5 00. (Lately Issued.) We can say with the tstrictest truth that it is the best work ofthe kind with which we areacquainted. It embodie.s ina condensed form ail recent contribu- tions to practical medicine, and is therefore useful to every busy practitioner thronghout our country, besides being admirably adapted to the use of stu- dents of medicine. The book is faithfully and ably executed. — Charleston Med. Journ., April, 187.i The work is intended as an aid to the medical student, and as such appears to admirably fulfil its object by itsexcellent arrangement, the fnll compi- lation of facts, the perspicuity and terseness of lan- guage, and the clear and instructive illustrations in some parts of the work. — American Joxirn. of Pharmacy, Philadelphia, July, 1674. The volume will be found useful, not only to stu- dents, but to many o t he rswho may desire to refresh their memories with the smallest possible expendi- ture of time. — N. Y. Med. Journal, Sept. 1874. The student will find this the most convenient and useful book of the kind on which he can lay hie hand.^ — Pacific Med. and Surg. Journ., Aug. 1S74. Thisis the best book ofils kind that we have ever examined. It is an honest, accurate, and concise compend of medical sciences, as fairly as possible representing their present condition. The change? and the additions have been so Judicious and tlio- rough as to reader it, so far as it goes, entirely trust- worthy. If students must have a conspectus, they will be wise to procure that of Dr. Hartshorne.— Detroit Rev. of Med and Pkarm., Aug. 1874. The work before us has many redeeming features not possessed by others, and is the best we have seen. Dr. Hartshorne exhibits much skill in con- densation. It is well adapted to the physician in active practice, who can give but limited time to the familiarizing of himself with the important changes which have been made since he attended lectures. The manual of physiology has also been improved and gives the most comprehensive view ofthe late.st advances in the science possible in the space devoted to the subject. The mechanical execution of the book leaves nothing to be wished for. — Peninsular Journal of Medicine, Sept. 1S74. After carefully looking through this conspectus, we are constrained to say that it is the most com- plete work, especially in its illustrations, of its kind that we have seen. — tlncinnati Lancet, Sept. 1874. The favor with which the first edition of this Compendium was received, was an evidence of its varinus excellences. The present edition bears evi- dence of a careful and thorongh revision. Dr. Harts- horne possesses a happy faculty of seizing upon (he salient points of each subject, and of presenting them in a concise and yet perspicuous manner. — Leaven- worth Med. Herald, Oct. 1S7-1 l.D. rUDLOW {J.L.), A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations In one handsome royal 12mo. volume of 816 large pages. Cloth, $3 25 ; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the office examination of students, and for those preparing for graduation. rpANNER {THOMAS HA WKES), M.D., ^c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSIS. Third American from the Second London Edition. Revised and Enlarged by Tilbury Fox, M. D., Physician to the Skin Department in University Collei'e Hospital, London, &c. In one neat volume, small ]2mo., of about 375 pages, cloth, $1 50. *]ff* On page 3, it will be seen that this work is offered as a premium for procuring new subscribers to the "American Jouknal of the Msdioal Sciences.'' Henry C. Lea's Son & Co.'s Publications — (Anatomy). /IRAT {HENRY), F.R.S., Lecturer on Anatoviy at St. Oeorge's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M.D., and Dr. Westmacott. The Dissections jointly by the AuTHORand Dr. Cartku. With an Introduction on Qenenil Anatomy and Development by T. lloLMKS, MA., Surgeon to St. George's Honpiial. A new American, from the Eighth enlarged ^nd improved London edition. To which is added " Lamimarks, Medical and Surgical," by Lutukb Holdkn, F.R.C.S., author of" Human Osteology," " A Manual ol Dissections," etc. In one magnificent imperial octavo volume of 983 pages, with 522 large and elaborate engravings on wood. Cloth, $6; leather, raised bands, $7 ; half Russia, $7 50. {Now Rmdy.) The author has endeavored in this work to cover a more extended range of subjects than isous- ternary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those detailein the practice of medicine andsurgery, thusrendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- i gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, wtiich will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory ot those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of essential use to all physicians who receive students in their ofiBces, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Since the appearance of the last American Edition, the work has received three revisions at the hands ofits accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed requisite to maintain its reput.ition as acomplete and authoritative standard text-book and work of reference. Still further to increase its usefulness, there has been appended to it the recent work by the distinguished anatomist, Mr. Luther Holden — " Landmarks, Medical and Surgical" — which gives in a clear, condensed and systematic way, all the information by which the prac- titioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all the assistance that can be rendered by type and illustration in anatomical study. No pains have been spared in the typographical execution of the volume, which will be found in all respects superior to former issues. Notwithstanding the increase of size, amounting to over 10(i pages and 57 illustrations, it will be kept, as heretofore, at a price rendering it one of the cheapest works ever oiFered to the American profession. The recent work of Mr. Holden, which was no- ticed by UR on p. 53 of this volume, has been added as an appendix, so that, altogether, this is the mott prnetical and complete aaaiomical treatise available to American students and phy.iicianH. The former finds in it the necessary guide in making dissec- tions ; a very comprehenhire chapter on minute anatomy ; and about all that can be taught him on general and special anatomy; while the latter, in its treatment of each region from a surgical point of view, and in the valuable addition of Air. Holden, will find all that will be essential to him in his practice. — Ntw Remedies, Aug 1676. This work is as near perfection as one could pos- sibly or reasonably expect any book intended as a text-book or a general reference book on anatomy to be. The Aruericau publisher deserves the thanks of th« profession for appending the recent work of Mr. Holden, " Landmarkt, Medical and Hurgical," which has already been commended as a separate book. The latter work — treating of topographical anatomy — lias become an e.ssential to the library of every Intelligent practitioner. We know of no book that can take its place, written as it is by a most distinguished anatomist. It would be simply a waste of words to say anj^thlng further in praise of Gray's Anatomy, the text-book in almost every medical college In this country, and the daily refer- ence book of every practitioner who has occasion to consult his books on anatomy. The work is simply indi.^pensable, especially this present Amer- ican edition.— Fa. Med. Monthly, Sept. 1878. The addition of the recent work of Mr. Holden, as an appendix, renders this the most practical and complete tref Ohemisfry in Med Dept , Univ. of Penna. A MANUAL OF MEDICAL CHEMISTRY. For the Use of Students. Based upon Bowman's Medical Chemistrv. In one royal 12mo. volume of 312 pages. With illustrations. Cloth, $1 75. (Now Ready.) It is well written, and gives the latest views on i The little work before ns is one which we think vital chemistry, a subject with which most phy^i- ' will be studied with pleasure and profit. The de- cians are not sufficieolly familiar. To those who scriptions. though brief, are clear, and in most cases may wish to improve their knowledge in that diiec sufficisnt for the purpose This book will, in nearly tion, we can heartily recommend this work as being all cases, meet general approval. — Am.. Journ. of worthy of a careful perusal. — Phila. Med. and Surg. , Pharmacy, April, ISSO. Xeporfer, April 2i, 1880. nLASSEN [ALEXA^NDER], ^ Prnfenoor i a the Rayal Pr.lijtpchnic School, Aixla-ChapeVe. ELEMENTARY QUANTITATIVE ANALYSIS. Translated with notes and additions by Edg^r F Swith, Ph D.. Assistint Prof, of Chemi.'=try in the Towne Scientific School, Univ. of Penna. In one hand.some royal 12ino. volume, of ;-{24 pages, with illustrations ; cloth, $2 00. (Just Readi/.) It is proliablythe best minual of an elementary ad vancing to the analysis of minerals and such pro- nature extant, insomuch as its methods are the best, ducts as are met with in applied chemistry It is It teaches by examples, commencing with single an indispensable book for students in chemistry.—- determinations, followed by separations, and then : Bo.Hoii Journ. of Chemintry, Oct. 1878. ALLOWAT [ROBERT], F.C.S., Priif of Applied Chemintry in the Royal College of Science for Ireland, etc. A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- don Edition. In one neat royal 12ino. volume, with illustrations ; cloth, §2 75. (Lately Issued.) J?EMSEN[IRA), M.D., Ph.D., Prnfefisor of Cherai-it ry in the Johns Hopkins University, Baltimore. PRTNCIF'LESOF THEORETICAL CHHJ.MISTllY, wiih speoial reference to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 232 pages: cloth, $1 50. {Just Issued.) G BOWMAN'S INTRODUCTION TO PRACTICAL] CHEMISTRY, INCLUDING ANALYSIS. Sixih American, from the sixth and revised London edi- tion. With numerous illustrations. In one neat Tol., royal 12mo., cloth, $2 25. WOHLER AND FITTIG'S OUTLINES OF ORGANIC CHEMISTRY. Translated with additions from the Eighth German Edition. By Ika Remsek. M D., Ph D., Prof, of Chemistry and I'hysics in Williams College, Mass. la one volume, royal 12mo. of oo8 pp., cloth, $3. 10 Henry C. Lea's Son & Co.'s Publications — (Chemistry), JfpOWNES [GEORGE], Ph.D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. Revised and corrected by Henry Watts, B. A., F R.S., author of "A Diction- ary of Chemistry," etc. With a colored plnte, and one hundred and seventy-seven illus- trations. A new American, from tht Twelfth and enlarged London edition. Edited by Robert Bridges, M.D. In one large royal 12mo. volume, of over 1000 pages; cloth, $2 75 ; leather, $3 25. {Just Issued.) what formidable magnitude with its move than a thua~and page.-*, but with less thH,n this no fair rejire- senlation of chemistry as it now is can be given. The typo is .small but very clear, and the sections are very lucidly arrnnged to facilitate study and'reference. — Med. and Surg. Reporter, Aug 3, 1878. The work is too well known to American students to need any extended notice; saflice it to say that the revi^ion by the English editor has been faithfully done, and that Professor Bridges has added some fresh and valuable matter, especially in the inor- ganic chemistry. The book has always been a fa- vorite in tliis country, and in its new shape bids fair to retain all its former prestige. — Boston Jour. of Chemistry, Aug. 1878. It will be entirely unnecessary for us to make any remarks relating to the geueral characterof Fownes' Manual. For over twenty years it has held the fore- most place as a text-book, and the eUiborate and thorough revisions which have been made from time to time leave lit lie chantje for any wideawake rival to step before it. — Canadian Pharm. Joxi^r., Aug. 1878. As a manual of chemistry it is without a superior in the language. — Md. Med. Jour., Aug. 1878. This work, inorganic and organic, is complete in one convenient volume. In its earliest editions it was fully up to the latest advancements and theo- ries of that time. In its present form, it preseuts, in a remarkably conveuieut and satisfactory man- iifT, the principles and leadiug facts of the chemistry of to-day. Concerning the manner in which the various subjects are treated, much deserves to be said, and mostly, too, in praice of the book. A re- view of such a work af Fownes's Cheini-Hry within the limits of a book-notice for a meilical weekly is simply out of the question. — Cincinnati Lancet and Clinic, DfC. 14,1878. When we state that, in our opinion, the present edition sustains in every respect the high reputation which its predecessors have acquired and enjoyed, we express therewlih our full belief in its intrinsic value as a text-book and work of reference. — Am. Journ. of Pharm., Aug. 1878. The conscientious care which has been bestowed upon it by the American and English editors renders it still, perhaps, the best book for the student and the practitioner who would keep alive [he acquisitions of his student days. It has, indeed, reached a some- B LOXAMiC.L.), ^ Pro/exsor of Chemistry in King's College, London. CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illus- trations. Cloth, $4 00 ; leather, $5 00. {Lately Issued.) We have in this work a completeand most excel- lent text-book for the use of scliools, and can heart- ily recommend it as such. — Boston Med. and Surg. Journ., May 28, 1874. The above isthetitleofawork which we can most conscientiously recommend tostudeuts of chemis- try. It is as easy as a work on chemistry could be made, at thesa in e time that it presentsa full account of that science as it now stands. We have spoken of the work as admirably adapted to the wants of students; it is quite aswell suited to the require- ments of practitioners who wish to review their chemistry, or have occasion to refresh their memo- ries on any point relating to it. In a word, it is a book to be read by all who wish to know what i.'s thecbemistry of the presentday. — American Prae- titioner, Nov. 1873. It would be difficult for a practical chemist and teacher to find any material fault with this most ad- mirable treatise. The author has given us almost a c) clopsedia within the limits of aconvenient volume, and has done so without penning the useless para- graphs too commonly making up a great part of the bulk of many cumbrous works. The progressive scientist is not disappointed when he looks for the record of new and valuable processes and discover- ies, while the cautious conservati'^e does not find its pages monopolized by uncertain theories and specu- lations. A peculiar point of excellence is the crys- tallized form of expression in which great truths are expressed in very short paragraphs. One issurprised at the brief space allotted to an important topic, and yet, after reading it, he feels that little. If any more should have been said. Altogether, it is seldom yoa see a text-book so nearly faultless. — Cincinnati Lancet, Nov. 1873. o 'LOWES (FRANK), D.Sc, London. Senior Science-Waster at the High School, Newcastle-under-Lyme,etc. AN ELEMENTARY TREATISE ON PRACTICAL CHEMISTRY AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the Lalioratorie.s of Schools and Colleges and by Beginners. Second American from the Third and Revised English Edition. In one very handsome royal 12mo. volume of 372 pages, with 47 illustrations. Cloth, $2 50. {Just Ready.) fereace and instruction in his Horary. As a rnle. •such volumes are too techuicil and abstruse for study without some didactic aid, but the volume pieseoted is easy of comprehension, and will t)e of greit value to college students rind busy pr ictition- ers.— A^. r. Am.. Mi'd. Bi-We^Uly, Aprifg, 1881. The tables partlculnrly demand praise, for they are admirably formed, bi th for convenience of re- ference and liilness of information. In short, we do not remember lo have met with a book which could belter serve the stud' nt as a guide to the sys- ttiroatio study of inorganic cheiuistry. — LoxiisvMe Med. News, March 12, 1881. This is a valuable work for those about to com- mence chemistry, the more so as by its use they are simultaneously acquainted with the manipulation of chemical analysis, a method which is the most valuable to Impart a Ihor' ugh kn'iwlei'go of chemis- try. It is a very good little book, and will make for itself man* warm friends and snpnortirs It treats the snbjeci wel I and the t«bl's are very clear and valuable. — St. Louis Med. and Surg. Journ., Mar. 1881. This work Is not only well adapted for use as a text book I n medical colleges, but is aUo one of the best that a praciltlouer can have for coDvenient re- KX A PP'S TECHNOLOGY; or Chemistry Applied to the Arts and to .Manufactures. Wilh American additions by Prof. Wai.tek K.Johnson. In two very handsome octavo volumes, with 500 wood engravings, cloth, $6 00. Henry C. Lea's Son & Co.'s Publications— (P/mr., Mat. lied., etc.). 11 pARRISH [EDWARD), Late Profe.iKor of MrUeria Me.dica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Fourth Edition, thoroughly revised, by Thoma.s S. Wiegand. In one h.indsome octavo volume ot 977 pages, with 280 illustrations | cloth. $6 60; leather, $6 60; half Russia, $7. {Lately Issued.) Of Dr Pari-ish's great work ou (ilKirniacy It only remains to be said thai tlie editor has accomplished his work so well as to nuiiuiaiu, iu this fourth edi- tion, the high standard of excellence which it had attained in previous editions, under the editorship of Its aecomplished author. This has not heen accom plished with out much labor, an dm any additions and improremeiils, involving chauKes iu the arrange- ment of the several parts of the work, and the addi- tion of much new matter. With the modifications thus effected it constitutes, as now presented , a com- pendium of the science and art indispensable to the pharmacist, and of the utmost value to every practitioner of tnedlcine desirous of familiarizing himself with the pharmnreutical preparation of the articles which he pre-crihes forhispatieuts. — Chi- cago Med. ./'oitrji., July, 1S7-1. The work is eminently pra'ttcal, and has the rare merit of being readable und interesting, while it pre the work, not only to pharmacists, hut also to the multitude of medical practitioners wh-i are obliged to compound their own medicines It M 111 ever hold an honored place on our own bookshelves. — Dublin Med. Prennnnd Circular, Aug. 12, 1874. We expressed our opinion of a former edition in terms of umiualified praise, and we are in no mood to detract from that opinion in reference to the pre- sent edition, the preparation of which has fallen into competent hands. It isa book with which no pharma- cist can dispense, and from which no physician can fail to derive much Information of value to him in practice.— P«ct.A"c Med and Surg . Journ. , June, '74. Perhaps one, ifnot the most important book upon pharmacy which has appeared in the English lan- gUHge has emanated from the tra nsathi utic press. " Parrishs Pharmacy" is a well-known work on this side of the water, and the factshows us that a really serves a strictly •'cieniiliccharacter The whole work i useful work never becomes merely local in its fame, reflects the greatest credit on author, editor and pub | Thanks to the, j udicions editing of Mr. Wiegand, the Usher It will convey soineideji ofthe liberality which | posthumous edition of "Parrish" has been saved to has been bestowed upon its production when we men- the public with all the mature experience of its au- tion that there are no less than 2Sncarefully executed thor, am) perhaps none the worse for a dash of new Illustrations. In conclusion, we heartily recommend blood. — Lnnd. phar'm. Journal Oct. 17 1874. Q.RIFFITH [ROBERT E.), M.D. ^ A UNIVERSAL FORMULARY, Containing the Methods of Prepar- ing and Administering Officinal and other Medicines. The whole adapted to Physiciar s and Pharmaceutists. Third edition, thoroughly revised, with numerous additions, bj John M. MAiscH.ProfessorofMateriaMedicain the Philadelphia Collegeof Pharmacy. In one large and handsome octavo volume of about son pp., cl., $4 50; leather, $5 60. {Lately Issued.) To the druggist a good formulary is simply indis- pensable, and perhaps no formulary has been more extensively used than the well-known work before Many physicians have toofBciate, also, as drug gists. This is true especially of the country physi- cian, and a work which shall teach hirn the meMni- b.r which to administer or cotnhine his retnedies in the most efficacious and pleasant manner, will al- ways hold its place upon his shelf A formulary of this kind is ofbenefit also to the city nhysician in largest 'pr&cVic^.— Cincinnati Clinic, Feb. 21. 1874. A more complete formulary than itis in its pres- ent form the pharmacist or physician could hardly desire To the first some such work is indispensa- ble, and it is hardly les.< essential to the |iractitioner who compounds his own mpdirines. Much of what is contained in the introduction ought to be com- mitted to memory by every student of medicine. As a help to physicians it will be found invaluable, and doubtless will make its wav into libraries not already supplied with a standard work of the kind. — The American Practitioner, Louisville, July, '74. F ^ARQUHARSON [ROBERT), M.D. , Lenture.r on Materia Medina at fit. Mary's Hospital Medical School. A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Se- cond American edition, revised by the Author. Enlarged and adopted to the U. S. Pharmacopoeia. By Frank WoonsuRy, M.D. In one neat royal 12mo. volume of 498 pages: cloth, $2,25. (Jtist Ready.) copious notes have bean introduced, embodying the latest revision of the Pharmacopoeia, together with the antidotes to the more prominent poisons, and such of the newer remedial aceots as seemed neces- sary f,o the completeness of the work. Tables of weights and measures, and a good alphabetical in- dex end the vo\\.\m(i —Drtigyigts' Circular and Chemical Ome.tte, June, 1879. It isa pleasure to think that the rapidity with which a second edition is demanded may be taken as an indication that the sense of appreciation of the value of reliable information regarding the use of remedies i-^ notentlrelj overwhelmed in the cultiva- tion of pathological studies, characteristic of the pre- sent day. This work certainly merits the success it has 80 quickly achieved.— JVew Remedien, July, '79. The appearance of a new edition of this conve- nient and handy book in less than two years may certainly be taken as an indic^.tion of its useful- ness. Its convenient arrangement, and its terse- ness, and, at the same time, com ole'eness of the information given, make it a handy book of refer- ence. — Am. Jdiirn. of Pharmacy, June, 1879. This work contains in moderate compass snch well-digested facts concernirg the physiological and therapeutical action of renredies ai are reason- ably established up to the present time. By a con- venient arrangement the eorrespondi rg effects of each article in health and disease are presented in parallel c lumns, not only rendering reference easier but also impressing the facts more strongly tition the mind of the reader. The book has been adapted co the wants of the American student, and CHRTSTISON'S DISPENSATORY. With copiousad- ditions. and 213 large wood engravings By R. EnLF.sFiRiD Griffith, M.D. One vol. 8vo., pp. 1000, cloth, $4 00. CARPENTER'S PRIZE ESSAY ON THE USE OF Alcoholic Liquorb in Health and Disease. New edition, with a Preface by D. F Condib. M.D., and explanationsof scientiflowords. In oneueat]2mo. volume, pp. 178, cloth, 60 cents. 12 Henry C. Lea's Son & Co.'s Publications — (Jilat. Med. and TJierap.). SJTILLE [ALFRED). M. D., LL.D., and IfAJSCH [JOHN M.). Ph.D., A3 Pro/ of ThMry and Practicfof Medicine -^-'J- Pruf. ofMnt. JTed. and Hot in Phila. and of Clinical Med. in Univ. of Pa. Coll. ^hnrmncy. Sceytothe American Pharmaceutico.l A-i.tociatioii. THE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeia? of the United St^ites, Great Britain and Germany, wiih numer- ous references to the French Codex. Second edition, thorousrhly revised, with numerous additions. In one very handsome octavo volume of 1692 pages, with 239 illustrations. Extra cloth, $6 75 ; leather, raised bands, $7 50 ; half Russia, raised bands and open back, $8 25. {Now Ready.) Preface to the Second Edition. The demand which has exhausted in a few month? an unusually large edition of the National Dispensatory is doubly gratifying to the authors, as showing that they were correct in thinking that the want of such a work was felt by the medical and pharmaceutical profes.sions, and that their efforts to supply that want have been acceptable. This appreciation of their labors has stimulated them in the revision to render the volume more worthy of the very marked favor with which it has been received. The first edition of a work of .'■uch magnitude must necessarily be more or less imperfect ; and though but little that is new and important has been brought to light in the short interval since its publication, yet the length of time during which it was passing through the press rendered the earlier portions more in arrears than the la'er. The opportunity for a revision has enabled the authors to scrutinize the work as a whole, and t» introduce alterations and additions whereve: there has seemed to be occasion for improve- ment or greater completeness. The principal changes to be noted are the introduction of seve- ral drugs under separate headings, and of a large number of drugs, chemicals and pharma- ceutical preparations classified as allied drugs and preparations under the heading of more important or better known articles : these additions comprise in part nearly the entire German Pharmacopoeia and numerous articles from the French Codex. All new investigations which came to the authors' notice up to the time of publication have received due consideration. The series of illustrations has undergone a corresponding thorough revision. A number have been added, and still more have been substituted for such as were deemed less satisfactory. The new matter embraced in the text is equal to nearly one handred pages of the first edition. Considerable as are these changes as a whole, they have been accommodated by an enlargement of the page without increasing unduly the size of the volume. While numerous additions have been made to the sections which relate to the physiological action of medicines and their use in the treatment of disease, great care has been taken to make them as concise as was possible without rendering them incomplete or obscure. The doses have been expressed in the terms both of troy weight and of the metrical system, for the purpose of making those who employ the Dispensatory familiar with the latter, and paving the way for its introduction into general use. The Therapeutical Index has been extended by about 2250 new references, malang the total number in the present edition about 6000. The articles there enumerated as remedies for particular diseases are not only those which, in the authors' opinion, are curative, or even beneficial, but those also which have at any time been employed on the ground of popular belief or professional authority. It is often of as much consequence to be acquainted with the worthlessness of certain medicines or with the narrow limits of their power, as to know the well attested virtues of others and the conditions under which they are displayed. An additional value possessed by such an Index is, that it contains the elements of a natural classification of medicines, founded upon an analysis of the results of experience, which is the only safe guide in the treatment of disease. This evidence of saccess, seldom paralleled, keep the work up to the time. — Kew Remedies, Nov. ehowB clearly how well the authors have met the 1879. existing needs of the pharmaceatical aod medical This is a great work by two of the ablest writers on professions. Gratifying as it must be to tbem, ihey ^^i^^^ ^^^^^^ i^ America the authors h^ve pro- have embraced the opporuuuy offered for a thor- j^^^j ^ work which, for accuracy and comprehensive, ongh reviMoii of the whole work, striving to em- I nes'^. is un.=urpassed by any work on the subject. There brace withm it all that might have been omitted in j^ „„ ^.^^ ;„ the lin-li.h language ^hich contains so the f..rtner edition, and all that has newly appeared ^^^^^ valuable inf .rmation on the various articles of of safflcieat importance danng the time of Us col- j^e materia medica. The work has cost the authors laboration, and the short iQterval elap.sed since the y^^rs of laborious study, but thev have succeeded in previous publication. After hnving gone carefully producing a dispensatory which is not only national, through the volume we must admit th^t the authors but will be a lasting memorial of the learning and have labored faithfully, and with success, in main- ^bilitv of the author.^! who produced it.— Sdinburgh taming the high character of their work as a com- MediialJourna}, Nov. 1879. pendinm meeting the requirements of the day, to , . . , . . . , which one can safely turn in quest of the latest in- " '^ °y '*"■ ™°''^ international or universal than formation concerning everything worthy of Dotice in conaection with Pharmacy, Materia Medica, and Therapeutics. — Am. Jour, of Pkarmacy, A'ov. 1879. It is with great pleasure that we aanonnce to our readers the appearance of a second edition of the National Dispensatory. The total exhaustion of the any other book of the kind in onr language, and mure comprehensive in every sense. -Pacific Med. and Surg. .J own., Oct. 1879. The National Dispensatory is beyond dispute the very best authority. It is throughout complete in all the necessary details, clear and lucid in its ex- first edition in the short -pace of six months, is a P'anatioQs, and replete with references to the most safficieot testimony to the valne placed upon the recent writings^ where further particulars can be work bv the profession. It appears (hat the rapid ' obtained, if desired. Its value is greatly enhanced sale of the first edition most have induced both the i ^^ ^^^ extensive ludices— a general index of materia editors and the publisher to make preparations for | medica, etc., and also an index of therapeatics. It a new edition immediately after the first had been : would be a work of supererogation to say more about J-Hoed,for we find a large amount of new matter ' ""is well-known work. Mo practising physician can added and a good deal of the previous text alterpd i afford to he without the National Dispensatory.— ao'i improved, which proves that the authors do not Canada Med. and Surg. Journ., Feb. 1880. Intend to let the grass grow ander their feet, hat to ' Henry C. Lea's Son & Co.'s Publications — {Mat. 3Ted., Therap., etc.). 13 JUTAISCH {JOHN M.), Phar. />., Pro/, of Mnteria M'tliai nnrl Jintnnu in thf. PhUa. CnV. rf Phmrmnn) . A MANUAL OF ORGANIC MATERIA MEDICA. Being a Guide to Materia Medica of the Veffetable and Animal Kingdoms. For the use of Stadenta, Druggists, Pharmacists and Phy.<:ici:ins. In one handsome 12mo. ▼olume, with numer- ous illustrations on wood. (Preparing.) EXTRACT FROM THE AUTHOr'S PREFACE. When in 1866 the author wa." called to the chair of Materia Medica in the institution named (the Philadelphia College of Pharmacy), he seriously felt the need of a puitahle textbook which could be used in connection with his lectures, and made preparations for the publication of such a work at an early date. To elaborate a system of classification, which should be with- out diflBculty comprehended and readily applied by those for whom it was intended, was by no means an e.isy task, and the author found occasion, almost every year, to either remodel that previou.«ly selected, or to make whit in his opinion seemed to be desirable improvements. The publication of the " National Dispensatory'" in a measure supplied the want felt, at least a? far as a work of reference is con en ed. but owing to its local arrangement, it is not adapted to systematic instruction. However, its publication rendered a modification of the original plan for a treatise on Materia Medica desirable, and it is now presented in a form giving an outline of the substance of the lectures and embracing what are considered the essential physical, histo- logical, and chemical characters of the organic drug, so as to render the work also a useful and reliable guide in business transactions. Regarding the classification, the author is consciuua of its imperfection.', but he believes it to be convenient and capable of practical application. In reference to the scope of the work, the main aim has been to embrace all the drugs recog- nized by the U. S. Ph:irmacoprci;i, together with the old, but nnw unofficiLal ones, and such others, the use of which has been recently revived or suirgested, and which seem to deserve attention. The medical properti-^s and doses of the various drugs are merely briefly stated as subjects of general important information : ti.e present work is not intended for giving instruc- tion in the therapeutic application of drugs. C1TILLE {ALFRED), M.D., ProftuiHor of Theory and Practicf. of Jfedicint in the ITniversitp of Penna. THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Fourth edition, revised and enlarged. In twolarge and handsome 8vo . vols, of about 2000 pages. Cloth, $10; leather, $12: half Russia, $13. {L^tdy Issifd.) It is unnecessary to do much more than to an- of the pre^-ent edition, a whole cyclopsedia of thera- nonnce the appearance of the fourth edition of thi.s peutics. — Chicago Medical Journal, ¥eh. 187-5. well known and excqllen^ work.— Brtt. and For. The rapid exhaastion ofthreeeditiong and the nni- Med.-Chir. Review, Oct IfsT.o. versal favor with which the work has been received For all who desire a complete work on therapen- by the medical profession, are sufficient proof of its tics and materia medica for reference, in cases in- excellence as a repertory of practical and useful in- volving medico-legal questions, as well as for in- formation for the physician. The edition before us formation concerning remedial agents. Dr. St ilia's is fully sustains this verdict, as the work has been care- "par ex^ellence'^ the work. Being out of print, by fully revised and in some portions rewritten, bring- theexhanstionof formereditions, theanthorhaslaid ing it up to the present time by the admission of the profession under renewed obligations, by the chloral and croton-chloral. nitrite of amyl, bichlo- earefnl revision, importantadditions, and timely re- ride of methylene, methylic ether, lithium com- Issning a work not exactly supplemented by any pounds, gelseminum. and other remedies. — Am. other in the English language, if in any language. -Totirn. of Pharmacy, Feb. 1S75. The mechanical execution handsomely sustains the We can hardly admit that it has a rival in the well-known skill and good taste of the pnbliiher.— i multitude of its citations and the fulness of its re- St. LouiK Med. and Surg. Journal, Dec 1874. | gearch into clioical histories, and we must assign it From 'he publication of the first edition "Still^'s a place in the physician's library ; not, indeed, as Therapeutics" has been one of the classics; its ab- fully representing the present state of knowledge in sence from our libraries would create a vacuum pharmacodynamics, but as by farthe most complete which could be filled by no other work in the Ian- treatise upon the clinical and practical side of the guage.andits presence supplies, in the two volumes question. — BostonMed.and Surg. Journal, ^ov. o, . 1S74. (lORXIL (F.). AXD T>AXVIER (L.). ^ Pr'\f. inthe Fncnlty nf Med , '■ftrii. -ti Prof in the ColUgeof France. MANUAL OF PATHOLOGICAL HISTOLOGY. Translaterl. Tvith Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon to PhilaJa. Hospital, Lecturer on Refrsction and Operative Ophthalmic Surgery in Uni^i. of Penna., and by Henrv C. SrjrES. M D., Demonstrate r of Pathological Histology in the Univ. of Pa. In one very handsome octavo volume of over 700 pages, with over 350 illustrations. Cloth, $5 50; leather, $6 50; half Russia, $7. (Jiist Ready.) We have nohesit^tion in cordially recommending , the subject idmits of definition, and this one chap- the English transl ition of Cornil & Ranvier's " Pa- ter is worth the price of the book The illustra- thological Histology" as the best work of the kind tioos are copious and well chosen. Without the in any language, a^d as giving to its readers a ' slightest he-itation, the translators deserve honest trnsiworthy guide in obtaiaiog a broad and solid thanks for placing this indispensable work in the basis for the appreciation of the-practical bearings ! hands of American students. — Phila. Med. Tirneg, of pathological anatomy. — Am. Journ. of Med. i April 24, lS-0 Sciences, A.inl. ISSO. | This Tolnme we cordially commend to theprofes- This important work, in it» American dress, is a sion. It will prove a valuable, almost necessary, welcome offering to all studen's of the subjects I addition to the libraries of students who are to be which it treats. The great mass of material is ! physicians, and to the libraries of students who are arranged naturally and comprehensively. The ' physicians.— .Imerican Practitioner, June, ISSO. cUssificatiou of tumors is clear and full, so far as ' 14 Henry C. Lea's Son & Co.'s Publications — {Pathology^ etc.). JPEN WICK {SA MUEL), M.D., -*• A-iKi/itnnl Fht/sicimi to the Lnnilon Hospital, THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the Third Revised and Enl:irp;ed English Edition. With eighty-four illustrations on wood. In one very handsome volume, royal 12iuo., cloth, $2 25. {Just Issued.) (IREES {T. HENRY), M.D., v-^ L-'fturer on Palliologp a7i'i Morbid Aruxtomy nt Ohnring-CroxK Hospital Medical School, ete. PATHOLOGY AND MORBID ANATOMY. Fourth American. from the Fifth Enlarged and Revi.oed Engli.sh Edition. In one very handsome octavo volume of about 350 pages, with i;J8 tine engravings; cloth, $2 25. (Just Ready.) Extract from thr Author's Preface. In preparing the fifth edition of my Text-book on Pathology and Morbid Anatomy, T have ngain added much new matter, with the object of making the work a more complete puide for the student. All the ch;ipteps have been carefully revii.ed, some alterations have been made in the arrangement of the work, and an addition has been made to the number of wood-cuts. The new wood cuts, a* in previous editions, have been drawn by Mr. Ceilings from my own micro- scopical preparations. We have long cinside'ved this the b'^st guide yet presented to the "-tudent for I he identificH tion of va- rious morbid tissue''. We hive fonud it more satis- factory thaa any other. The present edition has been thoronurhly revised, and much new matter has been added. To the physician as a guide in diagnosis, we recommend this volume. — Physician and Surgeon, Miy, ISSl. B RISTOWE {JOHN SFBR), M.D., FR.C.P., j Pliy.iici'in and Joint Lecturer on Medicine, St Thoman^g B^oapital. A TREATISE ON THE PRACTICE OF MEDICINE. Second American edition, revised by the Author. Edited, with Additions, by James H. Hutch- inson, MD., Physicitin to the Penna. Hospital. In one handsome octavo volume of nearly 1200 pages. With illustrations. Cloth, $5 00; leather, $6 00; half Russia, $6 50. (Notv Rejdy.) The second edition of this excellent work, libe the first, has received the benefit of Or. Hiitchiu.''on's annotntions, by which the phases of disease which are peculiar to this country are indicntod. and thus a treatise which was intended for British practi- tioners and .-Indents is made more practically nsf ful en this side of the water. We see no rfason to modify the high opinion previously expressed with regard to Dr. Bristowe's work, except hy adding our appreciation of the careful lab ts of ilie author in following the lateral growth of medical science. — Boston Medical andSurgiculJournal, February, ISRO. What we said of the first edition, we can, with Increased emphasis, repeat conceroiug this; "Every page is chi( rMCtei'ized by ihe otterauce> of a thonght- fnl man. W lal has been said, has been well said, and the book is » fair reflex of all ihat is nertaifly kn'wn on the sub ects considered." — Ohio Med Recorder, Jan. 7, 18S0. The views of the author are expressed with preci- sion and sufficient promptness to impress the student with the weight of his authority ; and should the iiipdical professor differ on any subject from his doc- trine he will need to find strong arguments to carry his class to ttiecpposite conclusion. — N. 0. Mtd. and Surg.Journ, Ftb. ISSO. The reader will find every conceivable subioct connected with the practice of medicine ably pre-' sented, iu a styl" at once clear, interesting, and con- cise. The additions m ide by Dr. Hitchiuson are appropiiate and practical, and greatly add to its usefulness to American re-iders. — Buffalo Med. and Surg. Journ , March, 18S0. We regaid it as an excellent work for students and for practitioners. It is clearly written, the author's ^tyle is attraclive, and it is especially to be com- mended for its excellent expositiou of the patbol jgy and clinical phenomena of disease. — St. Louis Glin. Record, Feb. ISSO. H ABERSHON {S. 0.) M.D. Senior Phyxicinn to, and late Lecturer on the Principles and Practice of Medicine at, Ouy'g H'ispitaL, etc. ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE of the Stomach, and other parts of the Alimentary Canal, CEsophagus, Caecum, Intes- tines and Peritoneum. Second American, from the Third enlarged and revised Eng- lish edition. With illustrations. In one handsome octavo volume of over 500 pages. Cloth, $3 50. {Now Ready.) amended by Ihe author. Several new chapters have been add^d, bringing the work fully up to tt.e timea, and making it a volume of interest to the practi- tioner in evry field of medicine and suraery. Per- verted nutrition is in some form associated with nil dixea-ies we have to combat, and we need all the light that ctn "e obtained on a subject so broad and generil. Dr Haberslion's work is one that every practitloQ'^r sh 'Uld read and study for himself.^ N. Y. Med. Journ , April, 1879. This valuable treatise on dlsea'ies of th.< stomach and iibdomen has been o"t of print for several years, and is theref «re not bo well known to the profession as it dpserven to be. It will be found a cyclofajdia of Information. systematlcHlly arranseil, on all dis- »aseii of the alim-'ntary I ract, from the mo 'th to the rectum A fair proportion of each chapter is devoted to symptoms palholo^iy, and therapeutics. The preHent edition Is fuller than former mesiu many particulars, and hag been thoruughly revised and ULDGE'R ATLAS op PATHOLOGICAL HISTOLOGY. Translated, wilh Notes and Additions, by Joseph Lbidt, M. D. In one volume, very large imperial quarto, with .320 copper-plate figures, plain and colorpd. eloth %4 00 LA ROCHE ON YELLOW FEVER. considered in Us Historical, Pathological, Etiological and Thera peutlcal Relations. In two large and handsome •rtavo rolnmesofnearly 1.100 pp .cloth $7 00. BTOKES' LECTtTRES ON FEVER Fdlied by JoHS WiM.iAM MooRK, M. !>.. A-sistant Physician to the Cork Sireft Ke^or Hoapttal. In one neat 8vo ▼Oiuue. cloth, 4)2 00. PAVY's TREATISE ON THE FUNCTION OF DI- GESTION: Us Disorders and Iheir Treatment. From the Second London edition In one band- some volume, small octavo, cloth, %'2 00. HOLLAND'S MEDICAL NOTES AND REFLEC- TIO.XS. 1 vol 8vo.. pp. lOO, cloth. *.S -lO BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Conbik, M n 1 vol Rvo., pp. Hon. cloth. «2 .50. TODD'SCLINICAL LECTURE.'Jon CERTAIN ACUTE DiMRASEH. In one neat octavo volnme, of 320 pp. cloth. $2 60. Henry C. Lea's Son & Co.'s Publications — (Practice of Medicine). 15 WLINT (A USTIN), M.D., ^ Professor of the Principles and Practice of Medicine in Bellevue Med . College, N. T. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fifth edition, entirely rewritten and much improved. In one large and closely printed octavo volume of 1163 pp. Cloth, $5 50; leather, $6 50; very handsome half Russia, raised bands, $7. {Just Ready.) ■practically, this edition is a new work; for so tnany additions and clianges have been made that one well ncquainteil wiih previous editions would hardly recognize this as an oid friend The size of the volume is somewhat iucre*hed. An enlire new sertiou and several new chapters have been added. It Ik universally conceded tliat no text Ijook upon this 8ul)ject •va-( ever pttl>listied in this country that can at all compare with it It has long been at the very head of American text-book literature, and til ere cin be no doubt bu. that it will be many years before it yields the place to others. — Naa'i- ville. Journ. of Med. and Surg , Feb. 1881. " Flint's Practice'' is recogniziid to be a standard treatise of high rank upon the principles and tlie practice of medicine wherever the English language is read. The opinions eveiywliere reveil the man of extensive experience, diliirent study, calm judg- ment, and unbiassed criticism. The work ^hould be in the hands of every practitioner. — New Yurk Med. Record, Feb. 2H, 1881. This edition differs so much from all previous editions, on account of the revisions eliminations, amplifications, and additions, so conf-piciously ma nlfest, that no one can be sa'd to possess tne actual views of the author on the practi'^e of medicine, un- less he becomes the p sse<*or of this volume It is certainly the only American work on this subject which can be unreservedly recommended, and the only one which does luslice to American authors, observers, and pracUtioaers. — G'auiard'* Medical Journal, Feb. ISSl. >Y THE SAME AUTHOn. The htylo and character of this work are too well known to the profession to require an introduction. For a number of years this volume has ocrupied a leading p >sition as a lextb tok in the majority of medical schools, and tbe high position accorded to it in the past is a guarantee of a hearty welcome in this now edition I' be hook may be said to represent the present state of the science of medicine as now understood and taught. It is a safe guide to students and practitioners of medicine. — Miiryland Medical Journal. March 1, 1881. A marked feature of value In the new edition of Flint is the condensed fection r)n morbid anatomy prefacing each subject disciv^sed, and the very go"d prefix on general pathology, chapters all of them written, as the author states in hi- preface, by Dr. Wm *i. Welch, lecturer on patli.)logical bist^dogy ill Bellevue Hospital Medical College. Dr Welch has done his part of the work to ail acceptatiiin. — Cincinnati Lancet and Clinic March 12 1881. The author has, in this edition, revised and re- written a great oart and rntde it accord with the more advanced idea" which have been developed within the past few years. He is he more liiteJ to do so, as he is actively engaged in his profession, and can mike deductions, not from the work of others, but from his own labors. It is a treatise wuich every American physician should ha»e upou his table, and which he should consult on occasions when his leisure permits him to do so. — St. Louis Med. and Surg. Journal, March, 1881. B' CLINICAL MEDICINE; a Systematic Treatise on the Diagnosis and Treatment of Di.seases. De.signed for Students and Practitioners of Medicine. In one large and handsome octavo volume of 795 pages; cloth, $4 50; leather, $5 50; half Russia, $6. (Now Ready.) in this country as that of the author of two works of g'eat merit on special subjects, and of numerous papers, exhib'ting much originality and extensive restarch. — The Dublin Journal, Dec. 1879. There is every reason to believe that this book will be well received. The active practitioner is frequently in need of some work that will enable him to obtain information in the diagnosis and treatment of cases with comparatively little labor. Dr. Flint has the faculty of expressing himtelf clearly, and at the same time so concisely as to enable the searcher to traverse the entire ground of his search, and at the same time obtain all that isesKentiil, without plodding through an intermi- nab'e space. — N. ¥. Med. Jour., Nov. 1879 The great object is to place before the reader the latest observations and experience in dingiiosis and treat nent. .Such a w >rk is especially valuahle to students. Ills complete in its special design, and yet so condensed, that he can by its aid, kei'p up with the lectures on practice without neglecting oiher branches. It will not esc reut subjects and their several parts receiving the atten- tion which, relatively to their importance, medical opinion claims for them, is still more ditflcult. This t-isk we feel bound to say has been executed wi'h more than partial success by Dr Flint, whose name is already familiar to students of advanced medicine DF THE SAME AUTHOR. ESSAYS ON CONSERVATIVE MRDICTNE AND KINDRED TOPICS. In one very handsome royal 12rao. volume. Cloth, $1 38. (Just Issued.) DAVIS'S CLINICAL LECTURES ON VARIonS IMPORTAN r DISEASES ; being a collection of the Clinical Lctures delivered in the Medical Wards of Mercy H )spial, Chicago. Edited by Fra.nk H D.ivis, M.l). Second edition, enlarge!. In one handsome royal 12no volume. Cloth, $1 75. THE CYCLOPEDIA OF PRACTICAL MEOICINE: comprising Treatises on the Nature and Treatment ot Diseases, Materia Medica and Therapeutics, Dis- eases of Women and Children. Medical Jurispru- dence, etc etc By Dunoi.ison, FoRBiiS, Twef.die, and <^0N0i,i,r. In four large super royal octavo volumes, of :t254 double columned p iges, strongly and handsomely bound in leather. *l.'i: cloth, til . STURGES'S INTRODUCTION TO THE STUDY OF CLINICAL MEttlClNE. Beinga Ouide to the lu- vesligation of Disease. In one handsome 12mi'. volume, cloth, $1 25. (Lately Issued.) 16 Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). piCHABDSON (BEXJ. W.), M.D., F.R.S., M.A., LL.D., F.S.A., -L*^ Fellow ii/th'' Roi/al O'll/ege of Php.iicians, London. TREYENTIVE MEDICINE. In one octavo volume of about 500 pages. (/;/ Press.) The immerse strides taken by medical science during the l.'ist quarter of a century huive had no more conspicuous field of progress than the causation of disease. Not only has this led to marked advance in therapeutics, but it has given rise to a virtually new department of medi- cine — the prevention of disease — more important, perhaps, in its ultimate re^uIts than even the* investigation of curative processes Yet there has been no attempt to gather into a systematic and intelligible shape the accumulation of knowledge thus far acquired on this most interesting subject. Fortunately, the task h'S been at last undertaken by a writer who of all others is, perhaps, best qualified for its performance, and the result of his labors can hardly fail to mark nn epoch in the history of medical science. The plan adopted for the execution of this novel design can best be explained in his own words : — "With the object here expressed I write this volume. I have nothing to say in it that has any relation to the cure of disease, but I base it nevertheless on the curative side of medical learning In other words, I trace the diseases from their actual representation as they exist before us, in their natural progress after their birth, as far as I am able, back to their origins, and try to seek the ^onditions out of which they spring. Thereupon I endeavor further to analyze those conditions, to see how far they are removable and/bow far they are avoidable." liroODBrRY {FRANK), M.D., ' ' Phi/fiiHnn to the. German Hospital, Philadelphia, late Ohie/\ Assist, to Med. Clinic, Jeff. College Hiixpitnl, etc. \ A HAiNDBOOK OF THE PRINCIPLES AND PRACTICE OF Medicine ; for the use of Students and Practitioners. Based upon Husband's Handbook of Practice. In one neat volume, royal 12mo. (In Press.) JPOTHERGILL [J. MILNER), M.U. Ediv., M.R.C.P. Lond., J- A.tst. Phyfi. to the Went Lond Ho.sp. : A.'^s-t. Phy.s-. tn the City of Lo7id. Ho.tism by Alfred Baring Gab- rod, Constitutionsil Syphilis by, Jonathan Hutchinson, Diseases of the Stomach by Wilson Fox, Diseases of the Skin by Balmanno Squirk, Affections of the Laryn.x by Morell Mac- KBNKiK, Diseases of the Reotnra by Blizard Curling, Diabetes by Lauder ISrunton, Intes- tinal Diseases by John Syer Bristowe, Catalepsy and Soinnambuli.sm by Thomas King Cham- bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- sema of the Lungs by Sir William Jenner, etc. etc. All the leading schools in Great Britain have contributed their best men in generous rivalry, to build up this monument of medical sci- ence. St. Bartholomew's, Guy's, St Thomas's, University College, St. Mary's, in London, while the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical School at Netley, the military and naval services, and the public health boards. That a work conceived in such a spiri', .and carried out under such auspices should prove an indispensable treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and the success which it has enjoyed in England, and the reputation which it has acquired on this side of the Atlantic, have se.-iled it with the approbation of the two pre-eminently practical nations. Its large size and high price having kept it beyond the reach of many practitioners in this country who desire to possess it, a demand has arisen for an edition at a price which shall ren- der it accessible to all. To meet this demand the present edition has been undertaken. The five vtduraes and five thousar d pages of the original have by tne use of a smaller type and double ccdumns, been comprest store- , which he hassubjected it. — Am. Jour. Mtd. Sciences, huase of information, in regard to so many of the [ Jan. ISSO. 18 Henry C. Lea's Son & Co.'s Publications — (New. Dis , d;c.). T>ARTHOLOW {ROBERTS), A.M., M.D.. LL.D. *-* Prnf. nf Materia MtiUca and Oeneral Therapeutics in the Jeff. Me.d. Coll. of Phila., eta. A PRACTICAL TREATISE OX ELECTRICITY IN ITS APPLI- CATION TO MEDICINE. In one very handsome 8vo. volume of about 270 pages, with 98 illuEtrations. (Just rendy.) EXTRACT FROM THE AUTHOH's PUEFACB. I have attempted in the preparation of this work to avoid these errors; to prepare on9 so simple in stntement that a student without previous ncquaintnnce with the subject, may read- ily master the essentials; so complete as to embrace the whole subject of medical electricity, and so condensed as to be complete in a moderate compass. I have endeavored to keep con- stantly in view the needs of the two classes for whom the work is prepared — students and prac- titioners. I hiive as-uraed an entire unaoquaintance with the elements of the subject as the point of departure — for I am !uldre'!epartment nf the New Y'irk Honpitnl. NERVOUS DISEASES; THEIR DESCRIPTION AND TREATMENT. Pei^ond edition, thoroughly revis'd and rewritten. In one handsome octavo volume of about OUO pages, with numerous illustrations. (lit. Press.) Henry C. Lea's Son & Co.'s Publications — (Dis.of the Skin, dtc). 19 MORRIS (MALCOLM). M.D., ^'-*- Joint Lecturfr on Dertuntnlnffp, St. Mary's Hnnpttnl Med. Srhnol. SKIN DFSEASES, Incliidinf? their Definitions, Symptoms, Diasrnosis, ProT THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, cloth, $4. ■jDY THE SAME AUTHOR. ' A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 696 pages, cloth, $4 60. ROWN [LENNOX), F.R.C. S. Ed., Senior Surgeon to the Ci-ntml Condon Throat nnd Ear Hospital, etc. , THE THROAT AND ITS DISEASES. Second American, from the Second English Edition, thoroughly revised. With one hundred Typical Illustr.itions in colors, and fifty wood engravings, designed and executed by the author. In one very handsome imperial octavo volume of over 350 pages. (^Preparing.) aEJLER (CARL), M.D., AJ Lecturer on Laryni.'(tscopy at the Univ. of Penna., Chief of the Throat Dispensary at the Univ. Hospital, Philn., etc. HANDBOOK OF DIAGNOSIS AND TREATMENT OP DISEASES OF THE THROAT AND NAS\L CAVITIES. In one handsome royal 12mo. volume, of 166 p.ages, with 35 illustrations; cloth, $1. (Jii.'st Ready.) We most heartily ooramoud this book a« showing , A convenient little handbook, cloar. concise, and B sound judgment i n practice, and peifect fainiliari'y with the literature of tlje spec alty it so ably epi- tomizes. — Philada. Med. Times, July 5, 1879, accurate in iis method, and admiral)ly fulfil ling its purpose of brincing the subject of which it treats within the comprehension i)f the general practi- tioner. — if C. Med. Jour., June. 1879 OLrNIOAt OBSERVATIONS ON PHNOTIONAL NERVOnS DISORDERS BvC. H.^ndpieldJonf.:? M.D.. Physician to St. Mary's Hospital, .Sic. Sec ond America p Edition, in onehdadsomeoctavt Tolaineor348 pages.clotb, iil3 26. HILLIER'S HANDBOOK OF SKIN DISEASES, for Students and Craciltioners. Second Am Ed. In one roval 12mo.TOl. of 338 pp. With illustrations. Cluth, $2 26. 20 Henry C. Lea's Son & Co.'s Publications — ( Venereal Disemes^ &c.). 'DUMSTEAD {FREEMAN J.), M.D.,LL.D., ~-' Late Pro/e/mor of Venereal Dixeaxen at the Ool. o/ Phy.i. and Surg.. New York. &c. THE PATHOLOGY AND TREATMEXT OF VENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Fourth Edition, revised and largt>iy rewritten with the co-operation of R. W. Taylor, M.D., of New York, Prof, of Derniatologj' in the Univ. of Vt. In one large and handsome octavo volume of 835 pages, with I3S illustrations. Cloth, $4 75 j leather, $5 75; half Russia, $6 25. (Now Ready.) "We have to congnitulate our countrymen upon the truly valuable addition which they have made to American literature. The careful esiimate of the value of the volume, which we have made, jufitifieH OS in declaring that this is the best treatise on venereal diseases in the English langaagi^. and we might add, if there is a better in any other tougiie we cannot name It ; there are certainly no books in which the student or the general practitioner can find snch an excellent rinumi of the literature of any topic, and such practical suggestions regarding the treatment of the various coraplicaiions of every venereal disease. We take pleasure in repeating that we believe this to be the best treatise on vene- real disease in the English languiigtj, and we con- gratulate the authors upon their brilliant addition to American medical literature. — Chicago Med. Jour- nal and Examiner, February, ISSO. It is, without exception, the most valuable single work on all branches of the subject of which it treats In any language. The pathology is sound, the work is, at the same time, in the highest degree practical, and the hints that he will get from it for the man- agement of any one case, at all obscure or obstinate, will more than repay him for the outlay. — Archives of Mfdicine, April, IS'^O. This now classical work on venereal disease comes to us in its fourth edition rewritten, enlarged, and materially improved in every way. Dr. Taylor, as we had every reason to expect, has performed this part of his work with unu.sual excellence. We feel that what has been written has dono but scanty jus- tice to the merits of this truly great treatise. — St. Louis Courier of Medicine, Feb. 18S0 We find that we have here practically a new book — that the etateraeut of the title ppge, as to the fact that it has been largely rewritten, is a sufficiently modest announcement for the imporlaut changes in the text. After a thorough examination of the pre- sent edition, we can assert confidently that the enor- mous labor wfl have described has been here most faithfully and conscientiously performed. — Amer. Journ. Med. Sci., Jan, ISSO. It is one of the best general treatises on venereal diseases with which we are acquainted, and is espe- cially to be recommended as a guide to the treatment of syphilis. — London Practitioner, March, ISSO. G ROSS {SAMUEL W.), A.3I., M.D., Lecturer on Genito- Urinary and Venereal Di.fera.sfi.* in the Jeffer-ion Medical College, Phila. A PR.lCTfCAL TREATISE ON IMPOTENCE, STERILITY, AND ALLIED DISORDERS OF THE MALE SEXUAL OKG.XNS. In one ver;? hand- some octavo volume of 174 pages, with 16 illustrations. Cloth, $1 50. {Just Ready.) flULLERIER {A.), '^ Surgeon to the Hdpital du Midi. and Z> UMSTEA D ( FR EEMA N J.), i. -*-' Pro/es-.'ior of Venereal Di.ifia.ie.9 in Hie Collegeof , Pky.fic.ian.t and Surgeon.^. N. Y AN ATLAS OF VENEREAL DISEASES. Tran.slatetl and Edited by Freeman J. BuMSTEAD. In one large imperial 4to. volume of 328 pages, double-columns, with 2fi plates, containing about 150 figures, beautifully colored, many of them the .size of life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. Anticipating a very large sale for this work, it is offered at the very low price of Three Dol - LARS a Part, thus placing it within the reach of all who are interested in this department of practice. GJentleiuen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. LEE'S LECTURES ON SYPHILIS AND SOME FORMS OF LO(;aL disease AFFECTING I'RIN- CIPALLV THE ORGANS OF GENERATION. lu one handsome octavo volume; cloth, $2 2"). COM DIE'S PRACTICAL TREATISE ON THE DIS- EASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume oi nearly 8^0 closely-printed pages, cloth, $6 25 ; leather kd 26. WILLIAMS'S PULMONARY CONSUMPTION; its Nature, Varieties, and Treatment. With an An- alysis of One Thousand Cases to exemplify its duration. In one neat octavo volume of about Sf>i^kA'rk,etr.. THE PRINCIPLES AND PRACTICE OF GYN.^=:COLOaY, for the use of Students and Practitioners of Medicine. Second Edition. Thorouglv Revised. In one large and very band.vome octavo volume of 875 pageH, with 133 illustrations. Cloth, $6; leather, $fi ; half Russia, raised bands, $6 50. (Just Ready.) Preface to the Second Edition. The unusually rapid exhau.stion of a large edition of this work, while flattering to the author as an evidence that his labors have proved acceptable, has in a great measure heightened his sense of responsibility. lie has therefore endeavored to take full advantage of the opportunity afforded to him for its revision. Every page has received his earnest scrutiny; the critici.sms of his reviewers have been carefully weighed ; and while no marked increase has been made in the size of the volume, several portions have been rewritten, and much new matter has been added. In this minute and thorough revision, the labor involved has been much greater than is perhaps apparent in the results, but it has been cheerfully expended in the hope of rendering the work more worthy of the favor which has been accorded to it by the profession. In no country of the world hnn gyuwculogy re- ceived more attention tb»n in America. Iti.s, tlien, with a feeling of pleasure that we welcome a woit on diKeasei* of women from ko e"iluenl a gyiueeolo gist as Dr. Emmet, and the work i« eswentially clini- cal, and leaves a strong impi-«.-» of the author's in- dividnality. To criticiz»>, with ilie care it merits, the book throughout, would dem;< ud far more spacp than is at our command. In parting, we can nay that the work teems with original ideas, fresh and valuable methods of practice, and is written in a dear and elegant style, worthy of the literary repu- tation of the country of Loni; fellow and Oliver Wen- dall Holmes. — Brit. Med. Journ. Feb. 21, 1880. No gynecological treatise has appeared which contains an equal amount of original and uselul matter; nor does the medical and surgical history of America include a hook mor» novel and useful. The tabular and st.atiKtical information which it contains is marvellous, both in quaniity and accu- racy, and cannot be otherwise than invaluable to future investigators. It is a work which dem.nnds not careless reading' but profound study. Its value as a contribution lo gyua;cology is, perhaps, greater than that of all previous literature on the subject combined. — Chicago Me.d Gaz., April f, ISSO The wide reputation of the author makes its pub- lication an event in the gynjccological world ; and a glnnce through its pages shows that it is a work to be studied with care. . . . It must always be a work to be carefully Htudied and frequently con- sulied by those who practise this branch of our pro- fession. — bond. Med. Timeti and Gaz , Jan. 10, 18sO. The character of the work is too well known to require extended notice — suflice it to say that no recent work upon any subject has attained such great popularity so rapidly. Asa work of general reference upon the subjoct of Diseases of Women it is invaluable. As a record of the largest clinical experience and observation it has no equal. No phyfician who pretends to keep up with the ad- vances of this department of medicine can afford to be without it. — NashvUle Journ. of Mtdiciue and Surgery, May, 1880. D UNCAN [J. MATTHEWS), M.D., LL.D., F.R.S.E., etc. CLINICAL LECTURES ON THE DISEASES OF WOMEN, Delivered in Saint Bartholomew's Hospital. In one very neat octavo volume of 173 pages. Cloth, $1 50. {Just Ready.) They are in every way worthy of their author ; indeed, we look upon them as among the most valu- able of his contribu'.ions They are all up m mat- ters of great interest to the general practitioner. Some of them deal wih subjects that are not, as a rule, adequately handled in the text-books ; others of them, while bearing upon topics that are usually treated of at length in such works, yet bear such a stamp of individuality that, if widely read, as they certflinly deserve to ba, they cannot fail to exert a wholesome restraint upon the undue eagerness with which many young physicims seem" bent upon fol- lowing tho wild teachings which so infest the gyn«8- cology of the present day. — N. T. Mud. Journ., March, 1880. The author is a remarkably clear lecturer, and his discussion of symptoms and treatment is full and suggestive. It will be a work which will not fail to be read with benefit by practitioners as well as by students.— P/iiia. Mtd. and Surg. Reporter, Feb. 7, 1880. We have read this book with a great deal of pleasure. It is full of good things. The hints on pathology and treat meal scattered through the book are sound, trustworthy, and of great value. A healthy scepticism, a large expeiience, and a clear judgment are everywhere manifest. Instead of bristling with advice of doubtful value and un- sound character, the book is in every respect a safe guide. — The London Lancet, Jan. 21, 1880. M A MSB THA M ( FRA NCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one 1 irge and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised bands ; with sixty-four beautiful plates, and numerous wood-outs in the text, containing in all nearly 200 large and beautiful figures. $7 00 pARRY {JOHN S.), M.D., Ob.ttetrieian to the Philadelphin Hoiftitnl, Vioe-Prest. of the Ohetet. Siciety of Philadelphia. EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREATMENT. In one handsome octavo volume. Cloth, $2 50. (Late/y Issued.) mANNER {THOMAS H.), M.D. ON THE SIGNS AND DISKASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates and illustra- tions on wood. In one handsome octavo volume of about 500 pages, oloth, $4 26. y 24 Henry C. Lea's Son & Co.'s Publications — (Midwifery). TEISHMAN {WILLIAM), M.D., ^^ RtgiuK Prnftsnor of itidwifery in the. Univergify of GlaKgow, Ac. A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF PREGNANCY AND THE PUERPERAL STATE. Third American edition, revised by the Author, with addition? by John S. Parry, M.D., Obstetrician to the Pliiiadelphia Hospital, itc. In one large and very handsome octavo volume, of TA'6 pages, with over two hundred illuBtrations. Cloth, $4 50; leather, $5 50 ; half Russia, $6. {Just Ready.) Few works on this en^jecl have met withas great j seems to require, aad we cannot bat adrnire the a demand ao this one appears to liave. To judge ability with wliict the task hag been performed, by the frequency wUh which its anther's views are i We consider it an admirable text-book for sta'Jeuts qaoted, and Us staiements referred to in obstetrical I during tbeir attendance npou lectures, and have literainre, one would judge thai there are few phy- great pleasure in recommending it. As an exponent Bicians devoting rnuch attention to obnetrics who , uf the midwifery of the present day It has no sups- are withoutit. The author is evidently a man of rior in the English language. — Canada Lancet, Jan. ripe experience and coneervative views, and in no 1680. branch of medicine are these more valuable than in | to the American student the work before us must this.— Aew liemediea, Jan. 18!rO. | p^^^g admirably adapted, complete in all its parts, We gladly welcome the new edition of this excel- i ei'sentially modern in its teachings and with dem- lent textbook of midwifery. The former editions I onntratlous noted for clearness and precision, it will have been most favorably received by the proles- gain in favor and be recognized as a work of stand- sion on both sides of the Atlantic In the prepara- ' ard merit. The work cannot fail to be popular, and tionof the present edition the author has made such . is cordially recommended. — N. 0. Med. and Surg. alterations as the progress of obstetricil science ' /oMrn.., March, 1S80. PLAYFAIR ( W. S.), M.D., F.R.C.P., Profe.ysor of ObKteirlc Medicine, in King's College, etc. etc. A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. Third American edition, revised by the author. Edited, with additions, by Robktit P. Harris, M.D. In one handsome octavo volume of about 700 pages, with nearly 2C0 illustrations. Cloth, $4; leather, $5 j half Russia, $5 50. iJust Ready.) The medical profession has now the opportunity i a very intelligent idea of them, yet all details not of adding to their stock of standard medical works ., nece-sary for i full understanding of the subject ace one of the best volumes on midwifery ever published, omitted. — Cincinnati Med. Newn, Jan. 1880. The subject is taken up with a master hand. The The rapidity with whicl^oue edition of this work part devoted to labonn all Its various preientations, ; foUows another is proof alike of its excellence and the management and results, ..^ admirably arranged, , ^f the estimate that the profession has formed of it. and the views entertamed will be found e.sseutially ^ ,[ jg jn^eed so well known and so highly valued modern, and the opinions expressed trustworthy ■ 11,^1 nothing need be said of it as a whole. All The work aboands with plates, illustra ing various i^^ considered, we regard this treatise as the very ob!.te>rical positions; they are admirably wrought, | ^e^t on Midwifery in the English language. -i\r. Y. and afford great assistance to the student.— i\r. 0. [ ^fcdical -JoHrnal May 1880 Med. and iSurg. Journ., March, \SSO. t^ , . , .',.,, ... , ,, ,, . . , " , J. , J , . , I' certainly is an admirable exposition of the If inquired of by a medical student what work on Science and Practice of Midwifery. Of course the obstetrics we should recommend for him, as par additions made by the American editor. Dr. R. P. excellence, we would ULdoubtedly advise him to Harris, who never utters an idle word, and whose choose Playfair «. It is of convenient size, but what | studious researches in fome special dei.artinenis of is of chief importance, its treatment of the various | obstetrics are so well known to the profession, are subjects IS concise and plain. While the discussions | „( ^ value.— r/ie American Praetiiioner, April, and descriptions are suiQciently elaborate to render J artment of Obstetrics; It is something more than an >rdinarytreatiseon midwifery; it is, in fact, a cyclopedia of midwifery. He has aimed to em- body in a lingle volume the whole science and art of Obstetrics. An elaborate text is combined with ac- curate and varied pictorial illustrations, so that no fact or principle Is left unstated or unexplained. —Arn,. Med. Timeit, Sept. .S, 1864. ^ *jff Specimens of the plates and letter-presB will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. ^ QfTAD WICK (JAMES /?.), A.M., M.D. A MANUAL OF THK I)ISK\SKS PENULT .AR TO WOMEN. In one neat volume, royal 12mo., with illuistrations. {Preparing.) Henry C. Lea's Son & Co.'s Publications— (Suryery). 25 TJAMILTON {FRANK H.) M.D., LL.D., J-J- Surgeon to the Btllcvue Hos/>ital. AVjo York. A PrvACTICAL TREATISE OX FRACTURES AND DISLOCA- TIONS Sixth Edition, thoroughly revised, and nm^'h improved. In one very hand.^ome oetnvo volume of over 000 im-res, with 352 illustrntious. Clolh, $5 50; leather, $0 50; half Russia, raised bands, $7 00. So many kind expiessioun nl welcome hare lieen showered upou e.ith ancceasive edl iou of ihts val- uable tre.-iii^e, that ^ca^cely (nyihiug leniHius for n.s to lio but toex.eud the cuBloui;iry cordial greet- Dr Hamilton bac devoted great labor :o thestiidy of these m bjects. His large experience, extended reseHrtb. i^pd p.ttieu. investiitation have made him one 01° the hiKtie^t aulhurliii » among living writers ing. It 18 the only complete wiirk ou the subject i In this br.< neb of smg.ry This work is systematic of Fractures iu the Eugiisb luugutige We cou grainlate the accoiiipli;-hed author on the deser'ed success of his work, and hope tlia; he may live to have many succeeding editions pas- under his skill- ed supervision. — Phila. Coll. and Clin. JSecord. Nov 15. ISSO. Universal verdict has pronounced it, hninanly speaking,,! perfect treatise upon l his siibjei't. As it is the only complet and ilUi.olrated work in any language tre.itiug of fracture- and dislocations, it ii safe to : tilrm that every wide-awake surgeon aad geueral practitioner will regard it as iodispeu.-able to the safe and pleasant conduct of their profes- sional work.— i)efroi< Lancet, Nov. IS, ISSO. and prai teal iu its arrargement ana presents its subject matter ele.nrly and f. rcibly to the reader or student. — MarylanU Mtdical Journal, Nov. 15, li^SO. The ouly complete work on its subject In the Euk" lish tongue, .ind, indeed, may now I'S said lo be the ouly work of its kind iu any lengue. It would require an exceedingly critical examiuallou to de- tecc in It any panlcnlars iu which it mii;ht be im- proved. The work is a monumenl to American sHr»;ery, and will long si rve to keep green ibe memory of its venerable author.— Jfic/it^an Med. News, Nov. 10, ISjI. A SHHURST {JOHN, Jr.), M.D., ^-*- Prof .of Clinical Surfifrxi. Vniv of Pa.. Surgeon to the EpUicopal Hospital, Philadelphia. THE PRINCIRLES AND PRACTICE OF SURGERY. Second Edition, enlarged and revised. In one very large and handsome octavo volume of over 1000 pages, with 542 illuetrations. Cloth, $6; leather, $7; half Russia, $7 50. {Just Ready.) langna»:e all that is necessary to be learned by the student of surgery whilst iu attendance upon lec- tures, or ibe geueral practitioner in hi!" daily routine practice. — Mil. Mud Journal, Jan. 1879. Conscientiousness and thoroughness are two very marked traits of character iu the author of this book. Out of these traits largely has grown the success of his mental fruit in the past, and the pre- sent offer seems in nowise au exception to what has gone before. The geueral arrangeiueut of the vol- ume is the same as In the first eilUiou, but every part has been carefully revised, and much new matter added.— P/ii7a. Med. Times, Feb. I, 1S79. The favorable reception of the first edition is a guarantee of the popularity of this f dilion, which is fresh from the editor's tjands with mauy euinrge- ments and improvements. The author of this work is deservedly popular as an editor and writer, aud his contributions to the literature of surgery have guiued for him wide reputation. The volume now offered the profefsiou will add new laurels to those already won by previous contributions. We cau only add that the work is well arrang< d, filled Tith practical matter, and contains in brief and clear The fact that this work has reached a second edi- tion so very soon after the publication of the first one, speaks more highly of its merits than anything we might say in the way of commendation. It seems to have immediately gained the favor of stu- dents aud physicians, — Cincin. Mfd. News,Jau. '19. We have previously spoken of Dr. Ashhur.'^fs work iu terms of i)rrtise We wish to reiterate those terms here, and to add that no more satisfactory representation of modern surgery has yet fallen from the press. In point of judicial fairness, of power of condensation, of accuracy aud conciseness of expression aud thoroughly good English, Prof Ashhurst has no superior ;tmoug the surgical writers in America. — Am. Practitioner, Jau. 1S79. s TIMSON [LE WIS A.), A.M., M.D., Surgeon to the Presbytt-rian Hospital. A MANUAL OF OPERATIVE SURGERY. In one veiy hantlsome royall2mo. volume of about 500pages, with 332 illustrntions ; cloth, $2 50. {Just Iss/n'd.) The work before us is a well printed, profusely performing them. Tht work is handsomely illus- 11 lustra ted manual of over four huudred and seventy t rated, auil the de- criptious are cle.i r and well drawn, pages. The novice, by a perusal of the work, will It Is a clever aud useful volume; every student gain a good idea of the geueral domain of operative should possess one. The preparation of this work surgery, while the practical surgeon has presented ; does away with the necessity of pondering over to him within a very concise aud intelligible form larger works on surgery for descriptions of opeia- the latest aud most approved selections of operative tions, asit presents in a nut-shell just what is wanted procedure. Thepreoision and conciseness with which by the surgeon without au elaborate search to liud the diflerent operations are described enable the it. — Md. Med Jmirnnl, Aug. 1S78. author to compress an immense amount of practical j The authors conciseness and the repleteness of Information in a vejy small compass.— iV. l.JileiHcal I t^e work with valuable illustrations entitle it to be Becord, Aug. 3, 187S. 1 cia,sged with the text-books for students of operative This volume is devoted entirely to operative sur- ' surgery, and as one of reference lo the practitioner, gery, and is iuteuded to tamiliarize the student with —Oincinnati Lancet and Clinic, July 27, ISVS. the details of operations and the different modes of SKKT'S OPERATIVE SURGERY. In 1 vol. 8vo. ol., of660 pages ; withabont lOOwood-onts $.S 36 COOPER'S LECTURES ON THE PRINCIPLES AND PracticeofSuruert. Inlvol.Svo crh.7()0p. I|(2. GIBSON'S INSTITUTES AND PRACTICE OF 8UK- HERT. Eighth edit'n, improved and altered. With thirty-four plates. In two handsome octavo vol- umes', about 1000 pp.. leather, raised bandf *6 50. THE PRINCIPLES AND PRACTICE OF SURGEKT. By Wn,Li.\M PiRRiK,F.R S E., I'rofes'rof Surgery in'the University of Aberdeen. Edited by John NBTI.L, M.D., Professorof Surgery In the Pe una. Medical College, Surg' n to the Pennsylvania Hos- pital. &c. In oue very handsome octavo vol. of 780 pages, with .Slti illustrations, cloth, $3 75. MILLKK'SI'KINCU'LK.-;!.*!' SUKGKRV FourthAme- rican, from the Third Kdiiiburtth Edition. In one larste Svo. vol. of 700 pages, with 340 illustrations, cloth. $:i 76. MILLKK'S PRACTICE OF SURGERY. Fourth A me- rican, from the last Edinburgh Kdition Revised by the Anierioau editor In ouelarge 8vo. vol. of nearly 700 pages, with 304 illustrations: cloth, $S 76. 26 Henry C. Lea's Son & Co.'s Publications— (/Swrgrery). /^ROSS {SAMUEL D.), M.D., v^ Professor of Surgerp in the Jefferson Medical College of Philadelphia. A SYSTEM OF SURGERY : Pathological, Diagnostic, Therapeutic and Operative. Illustrated by upwards of Fourteen Hundred Engravings, Fifth editioB, carefully revised and improved. In two large and beautifully printed imperial octavo vol- umes of about 2.S00 pp., strongly bound in leather, with raised bands, $16 ; half Russia, raised bands, $16. We have solilom rend a work with the practical value ol which we have beeu uioreimpressed. Every chiipter is ^o concisely put tugellier. that the busy priiclitioner, when in difficulty, can nt once find the inforuiation he requires. Ilis work ip cosmopolitan, the surgery of the world beinj; fully represented in it. The work, in fact, is so historically unprejudiced, and so puiiiiently practical, that it is almost a false compli- ment to say thatwe believe it to be destined to occupy a foremost place as a work of reference, while a system of surgery like the present system of surgery is the practice of surgeons. The prinlingand binding of the work is unexceptionable; indeed, it contrasts, in the latter respect, remarkably with English medical and surgical cloth-bound publications, which are generally 80 wretchedly stitched as to require re- binding before they are any time in \xi&.—Dub. Journ. of Med. Sci., March, 1874, Dr, Gross's Surgery, a great work, has become still greater, both in size and merit, in its most recent form. Tlie difference in actual number of pages is not more than 130, but. the size of the page having been in- creased to what we believe is technically termed "ele- phant. "there has been roomforconsiderabloadditions, which, together with the alterations, are improve- ments. — Lotid. Lancet, 'Nov. 16,1872, It combines, as perfectly as possible, the qualities of a text-book and work of reference. We think this last edition of Gross's "Surgery," will confirm his title ol " PHmus inter Pares." It is learned, scholar-like, me- thodical, precise, and exhaustive. We scarcely think any living man could write socompleteand faultless a treatise, or comprehend more solid, instructive matter in the given number of pages. The labor must have been immense, and the work gives evidence of great powers of mind, and the highest order of intellectual discipline and me'hodical disposition and arrangement of acquired knowledge ai^d personal experience. — JS.T. Med. Journ.. Feb. 1873. As a whole, we regard the work as the representative "System of Surgery" in the English language, — St. Louis .Medical and Surg. Journ., Oct. ISli, The two magnificent volumes before us afford a very complete view of the surgical knowledge of the day. Some .years ago we had the pleasure of presenting- the first edition of Gross's .Surgery to the profession as a work of unrivalled excellence; and now we have the result of years of experience, labor, and study, all con- densed upon Ihegreat work before us. And to students or practitioners desirousof enriching theirlibrary with a treasure of reference, we can simply commend the purchase of these two volumes of immenseresearch. — Qincinnati Lancet and Observer, Sept. 1872. A complete system of surgery — not a mere text-book of operations, but asoientific accountof surgical theory and practicein all its departments. — Brit, and For. Med. Chir. ifew., Jan. 1873. 7?r THE SAME AUTBOi.. A PRACTICAL TREATISE ON THE DISEASES, INJURIES and Malformations of the Urinary Bladder, the Piostate Gland and the Urethra. Third Edition, thoroughly Revised and Condensed, by Samqel W. Gross, M.D., Surgeon to the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- trations: oloth, $4 50. {Just Issued.) Por referenceandgeneralinformation, the physician orsuri;eoncan find nowork that meets theirnecessities more Thoroughly than this, a revised edition of an ex- cellent treatise, and no medical library should be with- out it. Replete with handsome illustrations and good ideas, it has the unusual advantage of being easily comprehended,by the reasonable and practical manner in which the various subjects are syBtematized and arranged We heartily recommend it to the profession as avaluableadditiontotheimportantliteratureofdis- eases of the urinary organs. — Atlanta Med. Journ., Got. 1876. It is with pleasure we now again take up this old work in a decidedly new dress. Indeed, it must be re- garded as a new book in very many of its parts. The chapters on "Diseases of the Bladder," "Prostate Body," and "Lithotomy," are splendid specimens of descriptive writing; while the chapter on "Stricture" is one of the most concise and clear that we have ever read. — New York Med. iTourn., Nov. 1876. TtT THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 76. D RUITT [ROBERT), M.R.G.S.,Src. THE PRINCIPLES AND PRACTICE OP MODERN SURGERY. A new and revised American, from the Bighkh enlarged and improved London edition. Illus- trated with four hundred and thirty -two wood engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. All that the aurgical student or practitionercould desire. — Dublin Quarterly Journal. It is a moBladmirable book. We do not know when we have examined one with more pleasure. — Boston Med. and Surg. Journal. In Mr. Draltt's book, though containing only some seven hundred pages, both the principles and the practice of surgery are treated, and so clearly and perspicuously, as to elacidateevery important topic. We ttave examined thebook most thoroughly, and caniay that this success is well merited. His hook, moreover, possesses the Inestimable advantages of having the subjects perfectly well arranged and classified and of being written In a style at once clear and succinct. — Am. Journal of Med. Sciences. ASHTON ONTHE DISEASES, INJURIES, and MAL- FORMATIONS OF THE RECTUM AND ANUS: with remarks on Habitual ConHtlpation. Second American, from the Fonrthand enlarged London Edition. With lllnHtratlonB. In one 8vo. vol. of 287 pages, cloth, $3 2&. SARGENT ON BANDAGING ANDOTHER OPERA- TIONS OF MINOR SURGERY. New edition, with an additional chapter on Military Surgery. One 12mo. vol. ol383pag3B withl84 wood-cuts Cloth, $170, Henry C. Lea's Son & Co.'s Publications — (Surgery). 27 JJOLMES [TIMOTHY), M.A., -*—*- Siirfff.on find Lecturer on Siirgni-y at St. Oe.nrge.'n Honpital, Lonrfon. A SYSTEM OF SURJERY; THEORETICAL AND PRACTICAL. In Treatises by various authors. American Edition, Thoroughly hkvised and KKWHITTEN bv JoHN 11 I'ackaui), M.D., SiirgeoD to the Episcopal and .St. Joseph's Hospi- tals, Philadelphia, as.sisted by a large corpse of the most eminent American surpeoiis. In three large and very handsome imperial octavo volumes of about 1000 pages each, with over 1000 illustrations on wood and thirteen lithographic plates, beautifully colored. (Sold only hy subscription.) Price per volume, in cloth, $000; in leather, $700; in half Ku'hsia, $7 50. Per set, in cloth, $18 00 ; in leather, $21 00 ; in half Hussia, $22 50. Volume I. (nearly ready) contains General Pathology, Morbid Processes, Injuries in Genhral, C0MPLICAT10N.S OF Injuries and Injuuieh of Regions. Volume II. (shortly) contains Diseases of Organs of Special Sense, Circulatouy Sts- TEM, Digestive Tract and Genito-urinaby Organs. Volume III. (shortly) contains Diseases op tub Respiratory Organs, Joints, Bones, and Muscles, Operative and Minor Surgery, Gunshot Wounds, Hospitals and Miscel- laneous Subjects. This gr-at work, issued some j'ears since in England, has won such universal confidence wherever the language is spoken, that its republication here, in a form more tlioroughly adapted to the wants of the American practitioner, has seemed to be a duty owing to the pro- fession. To accomplish this, the aid has been invited of over thirty of the most distinguished gentle- men, in every part of the country, and tor more than a year they have been assiduously engaged upon the tatk. Though the original work presents the combined labor of the most eminent members of all the most proinirent schools of England, yet the lapse of time since the appear- ance of the last edition, the progress of science, and the peculiariliea of American practice, have rendered necessary a most careful, thorough, and searching revision. Each article has been placed in the hands of a gentleman specially competent to treat its subject, and no labor has been spared to bring each one up to the foremost level of the times, and to adapt it thor oughly to the practice of the country. In certain cases, this has rendered necessary the sub- stitution of an entirely new essay for the original, as in the case of the articles on Skin Di.'^eases, and on Diseases of the Absorbent System, where the views of the authors have been superseded by the advance of medical science, and new articles have therefore been prepared by Drs. Arthur VAN Harlingen and S. C. Busey, respectively. So also in the case of Anaesthetics, in the use of which American practice diflers from that of England, the original has been supplemented with a new essay by J. C. Reeve, M.D., treating not only of the employment of ether and chloroform, but of the other anaesthetic agents of more recent discovery. The same careful and conscienti ms revision has been pursued throughout, leading to an increase of nearly one- fourth in matter, while the series of illustrations has been more than doubled, and the whole is presented as a complete exponent of British and American Surgery, adapted to the daily needs of the working practitioner. In order to bring it within the reach of every member of the profession, the five volumes of the original have been compressed into three, by employing a douole-columned imperi.il octavo page, and in this improved form it is offered at less than one half the price of the original. It is beautifully printed on handsome laid paper and forms a worthy companion to Reynolds's " System of Medicine," which has met with so much favor in every section of the country. The work will be sold by subscription only, and in due time every member of the profession will be called upon and offered an opportunity to subscribe. The few notices appended will serve to indicate the hearty approval accorded to the unrevised edition on its appearaice some years since : — There is fo much that is Instruciive, even to the experienced practitioner, in their practical and dis- crlminatiug manner of dealing with mooted ques- tions, none tf which seem to be neglected; their abundant illui^tratioiis, drawn at once from an nn limited lield of hospital experience, and their candid and sen.'iible mode of handling the whole snbject, that these particular portions of the work possess a value which places them far above any publication oa the same topics yet Issued in the language. — .il?(i. ^ourn. Mtd. Sciences. The enumeralion of the treatises, and the names of the surgical writers from whuse pens they pro- ceed, sutlice to show that this is no ordinary book, and that in the thousand pages of this goodly volume lies a store of information such a.s no other surgical \ work in the language can pretend to offer. Those wlo are acquainted with the special researches aud pub- lications of the respective authors will not fail to notice that by a judicious exerci.se of editorial dis- cretion, each subject ha« been entrusted, a.i far as possible, to a surgeon of the hospitals who is known to have given especial attention to it, and to possess facilities for summiugup witli authority theaccepted opittimus ot the day, and adding original matter to »be stock. — London Lanctt. The work must be considered a very complete ac- count of everything connected with the science and practice of snrgery. In conclusion we can cordially leeommeud thlH work as a valuable addition to the library of the surgeon. — Edinhxirgh M edical Jour- nal. It is a cyclopaedia of surgery of the most complete and extensive charatler ; and we may justly state that its design and execution do great honor to those concerned, and that the large number and high standing of the authors selectfd for the various monographs render ihis "System" what it no doubt was iuteudtd to be, representative of the actual state of surgical science and art in the country. — London Lancet. In conclusion, we will add that we can most con- scienciously recommend the book to every medical praciitiouer. In recommending the " Sy/tttm <>/ Sur- ffery" to our friends who have to deal in surgical cases, we by no means wish to confine our recom- mendation to them alone. Every practitiouei of medicine may cull something worthy of uoie from a perusal of this volume.— T/ie British Mtd. Journal. The four volumes remain a monument to the sur- gical genius of our day. The great majority of me- tropolitan surgeous of eminence and proved ability are represented in them ; and lor many yeara to come, whoever wishes to know the most author!, tative words of English Surgical science on most subjects in the domaiu of surgery must turn to these pages 10 read what there is het forth. But tHken as a whole it is the most important surgical work which has ever issued from the English press.— iowdon Lancet. 28 Henry C. Lea's Son & Co.'s Publications — (Surgery). T>RYANT (THOMAS), F.R.C.S., J-^ Surgeon to Guy's Hospital. THE PRACTICE OF SUEGERY. Tliird American, from the Sec- ond and Revised English Edition. Tlioroughly revised and luucli improved, bj' Jolin B. Roberts, M.D. In one large and very handsome imperial octavo volume of over 1(100 pages, with 672 illustrntions. Cloth, $6 60; leather, $7 60 ; very handsome half Russia, raised bands, $8 00. (Just Ready.) Mr. Bryant's work has long lieen a favorite one with suvgoouR. As its uauie indicate", it is of a tho- roughly practical character. It is distinctly indi- vidual ia that it gives the results of the author's large and varied experience as an operator and cli- nical teacher, and is on tliat account prized deserv- edly high as an orij^inal work. Tlie style is neces- sarily condensed, the descriptions of surgical dis- eases brief and to the point. The lllustratious are well chosen, and the typical ca.-es of the author's experience are full of Interest, and are of more than ordinary value to the working surgeon. — N. 1. Medical Record, March 5, 18S1. It is a work especially adapted to the wants of Btudeuts and practitioners. Vhile not prolix, it affords instruction in sufficient detail for a full un- derstanding of surgical principles and the treat- ment of surgical diseases. It embraces in its scope all the diseases that are recognized as belonging to surgery, and all traumatic injuries. In discussing these it has seemed to be tlie aim of the author rather to present the student with practical infor- mation, acd that alone, than to burden his memory with the views of different writers, however dis tiuguished they might have been. In this edition (he whole work has been carefully revised, much of it has been rewritten, important additions ha- e lieen made to aim ist every chapter. — Giuoinnati Med. A^cwA-, Jan. ISSl. The English edition, from which this is printed, lias V)een carefully revised anil rewritten; almost every chapter h-is received additions, and nearly one hundred new cots int odnced. The labors of the American editor, Dr. John B. Roberts, have veiy much iucreas.d the value of the book. He lias introduced many new illustrations and iiuich new niMtfrial not found in the English eilitioa. He has written too with great conciseness, wliich is a rare virtue in an American editor of au English work. If one could procure or wished only ouo surgery, ihis volume would certainly be selected. If he desired two, Erichten's Surgery would be lidded, and if he wished a third, (jross's Surgery would ju.stly be the work selected. As the great work of Gross is amply sufficii-nt for the waits of any surgeon, the priority given to Erichsen, and above all others, to this work of Bryant, is no labored eulogy of the last volume, but a simple and Just statement of its demonstrable and pre-eminent merits.— ^7/i. Med. Bi- Weekly, Feb. 26, 1881. fiRICHSEN [JOHN E.), -LJ Professor of Surgery in University College, London, etc. THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- gical Injuries, diseases and Operations. Carefully revised by the Autlior from the Seventh and enla.ged English Edition. Illustrated by eight hundred and sixty two en- gravings on wood. In two large and beautiful octavo volumes of nearly 2000 pages: cloth, $8 60 ; leather, $10 50; half Russia, $11 50. {Now Ready.) Of the many treatises on Surgery which it has been The seventh edition is before the world as the last our task to study, or our pleasure to read, there is none which in all points has sati.'sfied us so well as the classic treatise of Erichsen. His polished, clear style, his free- dom from prejudice and hobbies, his unsurpassed grasj of his subject, and vast clinical experience, qualify him admirably to write a model text-book. When we wish. at the least cost of time, to learn the most of a topic ir surgery, we turn, by preference, to his work. It is v pleasure, therefore, to see that the appreciation of it if general, and has led to the appearance of another edi tion. — Med. and Surg. Reiiortn-, Feb. 2, 1878. Notwithstanding the increase in size, we observe thai much old matter has been omitted. The entire work has been thoroughly written up, and not merely amend ed by a few extra chapters A great improvement ba^ been made in the illustrations. One hundred and tiftj new ones have been added, and many of the old ones have been redrawn. The author highly appreciates tht favor with which his work has been received by Ameri- can surgeons, and has endeavored to reniier his latest edition more than ever worthy of their ajiproval. That he has succeeded admirably, must, we tliink, be the general opinion. We heartily recommend the book tt both student and practitioner. — N.Y.Med. Journal. Feb. 1878. word of surgical science. There may be monographs which excel it upon certain points, but as a con- spectus upon surgical principles and practice it is unrivalled. It will well reward practitioners to read it, for it has been a peculiar province of Mr. Eiichsen to demonstrate the absolute interdepend- ence of medical and surgical science We need scarcely add, in conclusion, that we heartily com- mend the work to students that they may be grounded in a sound faith, and to practitioners as in invaluable guide at the bedside. — Am. Practi- tioner, April, 1878. For the past twenty years Erichsen's Surgery has maintained itspiace as the leading text-book, not only in this country, but in Great Britain. That it is able CO hold its ground, is abundantly proven by the tho- roughness with which the present edition has been revised, and by the large amount of valuable mate- rial that has been added. Aside from this, one hun- dred and fifty new illustraiions have been inserted, including quite a number of microscopical appear- ances of pathul igical processes. So marked is this change for the i>etter, that the work almost appears asanentirely new one. — Med. Record, Feb. 23,1878. H LMES ( TIM OTHF), M.D., Surgeon to St. George's Ho-ijntal, London. SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- some octavo volume of nearly lOOO pages, with 411 illustrations. Cloth, $6; leather, $7 ; half Russia, $7 60. (Just Issued.) This is a work which has been lookedfor on both Bldeo ofihe Atlantic with much intdrest. Mr. Holipes Is a surgeon of large and varied experience, and one of the best known, and perhaps the most brilliant writer upon surgical subjects in England. It is a book for students — and an admirable one — and for the busy general practitioner. It will give a student all the knowledge needed to pass a rigid examina- tion. The book fairly jnsllflesthe high expectations that were formed oflt. Its style is clear and forcible, even brilliant at times, and the ciinciseness needed to bring it within its proper limits has not Impairea its force and distinctness. — N. T. Med. Record, April 14, 1876. It will be found a most excellent epitome of sur- gery by the general priictiiioner who has not the timelogiveattentionio more minute and extendt-d works, and tothe medical student. In fact, we know, of no one we can more cordially recommend. The author has succeeded well in giving a plain and practical acconnt of each surgical injury and dis- ease, and of the treatment which is most com- monly advisable. It will no doubt become a popu- lar work in the profession, and especially as a text- book.— C'inci'iwaii Med. News, April, 1S76. Henry C. Lea's Son & Co.'s Publications — {Ophthalmology). 29 WELLS {J.SOELBEKG), ' ' Prafe.ssor of Ophthalmology in King's College Hospital, Ac. A TREATISE ON DISEASES OF THE EYE. Third American, from the Third London Edition. Thoroughly revised, with copious addili. in?, by Ch.-is. S. Bull, M 1)., Surgeon nml Pathologist to the New York Eye and Ear Infirinjiry. Illus- trated with about 260 engravings on wood, and six colored plates Together with seleo- tions from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume of 900 pages. Cloth, $5 ; leather, $C ; half Rusbia, raised bands, $6 60. {J/tst Rr.adij. ) The long-conliuued illness of the author, with its fatal termination, has kept this work for some time out of print, and has deprived it of the advantage of the revision which he sought to give it during the la,st years of hi- life. This edition has therefore been placed uuder the editorial supervision of Dr. Bull, who has labored earnestly to introduce in it all the advances which observation and experience have acquirrd for the theory and practice of ophthalmology since the appearance of the last revision. To accomplish thi?, considerable additions have been required, and the work is now presented in the confidence that it will fully deserve a continu- ance of the very marked favor with which tt has hitherto been greeted us a complete, but con- oif-e, exposition of the principles and facts of its important department of medical science. The additions made in the previous American editions by Dr. Hays have been retained, including the very full series of illustrations and the test-types of Jaeger and Snellen. This uew editioo of Dr. Wells's great Work ou the guage. In the tecond edition, the author showed eye will be welcomed by tiie profession at large a well as by the oculist. It coiitain s much new m.i tter relating to treatmeLtand pathology, and is brought thoroughly up with the i>re^enl hiatus of ophtbal- mjlogy. Its chtipter on retraction and accommo- dation — a subject much discussed of late years, and of great importance — is exceedingly complete. — Louibville Med. Ntws, Nov. l.S, 18S0. The merits of Wells's treatise on diseases of the eye have been so universally acknowledged, and are 60 familiar to all who profess to have given any at- tention to ophthalmic surgery, that any discussion of them at this lale day will be a work of superero- gation. Very little that is practically useful in re- cent ophthalmic literature has escaped the editor, and the third American edition is well up to the times. As a text-book on oph Jialmic surgery for tlie English-speaking practitioner, it is without a rival. — Ain.Journ. of Med. Set., Jan. 1881. The work has justly held a high place in English ophthalmic literature, and at the time of ils first ap- pearance was the best treatise of its kind in the lan- indnstrious research in adding new material from every quarter, and hi."! spirit was eminently candid. A work thus built up by honest eifort should not be sufl'ered to die, and we are pleased to receive this third edition from the hands of L)r. Bull. His labor h IB been arduous, as the very great number of addi- tions bracketed with his initial testify. Under the editorship which the third edition has enjoyed, the work is sure to sustain its good reputation, and to maintain its usefulness. — N. Y. Med.Journ., Jan. 18S1. There is really no work which approaches it in adaptation to the wants of the general practitioner, while the most advanced specialist cannot rise fr(un a perusal of its ample pages without having added to his knowledge. The American editor, Ur. Bull, won his spurs in ophthalmology some time back. His additions to the work of the lamented Wells are many, judicious, and timely, and in just so much have added to its value. — Am. Practitioner, Jan. 1881. XFETTLESHIP (EDWARD), F.R.C.S., •*- • Oijhtholmic Snrg. and Led. on Ophth. Surg, at St. Thomas'' Hospital, London. MANUAL OF OPHTHALMIC MEDICINE. In one royal 12mo volume of over .350 pages, with 89 illustrations. Cloth, $2. (Just Ready.) The author is to be ci^ngratulated upon the very information they contain. We do not hesitate to successful manner- in which he has accomplished hia task; he has succeeded in being concise without sacriticing clearness, and, including the whole ground covered by more voluminous text-books, has givttu an excellent risumi of all the practical pronounce Mr. Nettleship's book the best manual on ophthalmic surgery for the use of students and " busy practitioners" with which we are acquain- ted.— .kwi. Jour. Med. Sciences, April, 1880. c lARTER (R. BRUDENELL), F.R.C.S., Ophthalmic Surgeon to St. George s Boxpiial, etc. A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. (Just Issued. ) It Is with great pleasure that we can endorse the work (chapter is devoted to adi.^cussion of the uses and selec- as a most valuable contribution to practical ophthal- 1 tion ofspectaoles, and is admirably compact, plain, and mology. Mr. Carter neverdeviates from the end he has j useful, especially the paragraphs on the treatment of in view, and presents the subjectin a clear and coucist I presbyopia and myopia. In conclusion, our thanks are manner, easy of comprehension, and hence the morf j due the author for many useful hintsin the ftreat sub- valuable. We would es)ieciiilly commend, however, as worthy of high praise, the manner in which the thera- peutics of disease of the eje is elaborated^ for here the author is particularly clear and practicftl. where other writers are unfortunately too often deticient. The final jeot of ophthalmic snrjrery and therapeutics, a field whereof late years we glean but a few grains of sound wheat from a mass of chaff. — Aeto York Medical Record, Oct. 23,1875. B ROWNE (EDGAR A.), Hurgeon co the Livrpool Eyeand Barlnfirma.rj/, andtotheDispensary for Skin Di.seasea. HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- struct ions in Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- tions. In one small volume royal 12mo. of 120 pages : cloth, $1. (Now Ready.) LAURENCE'S HAND? BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. Second edition, revised and enlarged With numerous iUnsiraiions. In one very handsome octavo vol- ume, cloth, $2 75. LAWSON'S INJURIES TO THE EYE, ORBIT AND EYELIDS: their Immediate and Remote Effects. With about one hundred iilustrations. In one very handsome octavo volume, cloth, $3 60. 30 Henry C. Lea's Son & Co.'s Publications — (Med. Jurisprudence). 'DURNETT (CHARLES H.), M.A, M.D., J-^ Aura! Surg t« the Prtsb. Honp., Surgeon-in-tharge ofthelnfir.forDis. of the Ear, Phila. TIIK EAR, ITS ANATOxMY. PHYSIOLOGY AND DISEASES. A Priictical Treatise for the Use of Medical Students and Practitioners. In one hand- some octiivo volume of fi 1 5 pnges, with eighty-seven illustrations : oloth, $4 60 ; leather, $5 60; half Russia, l!i6 OU. (Now Ready.) Foremott Hinoug the nameroun receut coutrilm- tions to Bural lUeratur* will b." ranked tliis work of Dr. Buroelt. It Is impossible to do justic» to this volume of over 600 pages in a neces-arily bri«f notice. It must sufflce to add that the book is pro- fusely and accurately llluBiraled, the relereuces are coDiicieati' usiy acknowledged, while the result has been to produce a treatise which wiil henceforth rank with the classic writings of Wilde and Von Tr61tsch. — r/i« Land. I'mct dinner, May, 1S79. On account of the great advances which have been made of late years in otology, aud of the increased inttrest manifested lu it, the medical profesNion will welcome this new work, which presents clearly and concisely its present aspect whilst clearly indi- cating the direction in which farther researches can be most profi(ably carried on. Dr. Barn tt from his own matured experience, aud availing him.->elf of the observations and discoverie.? of others, has pro- duced a work which, as a text-book, stands /rjcite firirici'ji.v \a our language. We had marked several pa-sages as well worthy of quotation aud the atten- tion of the general practitioner, but their number and the space at on r com m And forbid. Perhaps il is bet- ter, a.s the book ought to be in the hands of every medical student, and its study will well repay the busy practitioner in the pleasure he will derive from the agreeable style in which many otherwise dry and mosily unknown subjects are treated. To the specialist the work is of the highest value, and his sense of graiitude to Dr. Burnett will we hope, he proportionate to ihe amount of benefit he can obtain from the carelnl study of the book, and a constant reference to its trustworthy pages.' — Edinburgh Med. Jour., Aug. 1878. rfAYLOR [ALFRED S.),M.D., J- Lecturer on Med. Jurisp. and Chemistry in Ouy'a Hospital. A MANUAL OF MEDICAL JURISPRUDENCE. Eighth Ameri- ciin edition. Thoroughly revised and rewritten. Edited by John J. Reese, M.D.,Prof. of Med. Jurisp. and To.xicology in the Univ. of Penn. In one large octavo volume of ■933 pages, with 70 illtjstralions. Cloth, $6; leather, $6; half Russia, raised bands, $6 50. (Just Ready.) The American editions of this standard manual have for a Ion.' time laid claim to the attention of the prol'ession in this country ; and i hat the profes- sion has recognized this clai i with favor is proven by the call for frequent new millions of the work. This one, the eighth, coraes belore us as embodying the latest thoughts and emendations of Dr. Tayl ir, upon the subject to which he devo ed hi.^ life, with an assiduity aud success which made him facxh. prinr^ps among English writers on medical juris- prudence. Both the author and the book have made a mark too deep to be affected by criticism, wliether it I e censure or praise. In this case, how- CTer we shoi^ld only have to seek for laudatory teims. — Am. Ji'urn. of Med. Sot., Jan. ISSl. It is not very often that a medical book reaches its tenth edition, or that the last eartlily labor is per- formed by the author in retouching the work that first came from his hand thirty-five years before. All this, however, has h.T THE SAME AUTHOR. ' 'the PRINCIPLES and PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo volumes, cloth, $10 00; leather, $12 00. This great work is now recognized in England as the fullest and luost authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Amer- ican profeision, the publishers trust that it will assume the same position in this country. >r THE SAME AUTHOR. is to announce, not criticize the completed task. The value of the gem is too weil kuowu to requiie more than the telling vhat the mtster-hand has rebright- ened its tacets and polished its angles before leaving it as his legacv to hs brethren in the profession. — Phiia M'-.d. Tiifids, Dec. 4, 1880. It will Buffiie to remark that this new edition shows the signs of juili.'ious revision A great num- ber of il.usliaiive medico- legal cases which have occurred since the last edition was pu^'lished are cited in heir proper connection, and add much to the interest aud value of the work; they comprise the bulk of the additions to the text. As an iadicik- tionofthe re^hnesof the work, we notice numei"- ous references to medic '-legal experience that has transpired during the year just ended ; among tbes-e is a cumment by the American editof upon that midsummer madness, theTitnner fasting exploit of last Aug'ist. In these features aud in others there is ample evidence that this admirable book will maintain its hi^h place as a standard authority eoa- cerning th« matters of which it tTea,is.— Boston Med. and Surg. Journal, Jan. 13, 1881. Bl B POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Third American, from the Third and Revised English Edition. In one large octavo volume of 850 pages ; cloth, $6 60 ; leather, $6 50. (Just Issued.) The present Is based upon the two previous edi- tlons;"'butlhe complete re vision rendered necessary by tim" has converted it into a new work." This ■ tatement from the preface contains all that it is de- sired to know In reference to the new edition. The works uf this author are already in Ihe library of every pbyi-lcian who is liable to be called upon for medkco-lega I testimony |andwhBt'>Del»noti').sothat all that IH required to be known about the present book is mat the aatbor has kept It abreast with the being describod which give rise to legal investiga- tions. — r/ie Olinio, Nov. 6, 1876. Dr. Taylor hai- brought to bear on the compilation of this volume, stores of l«arning, experience, and practical acquaintance with his subject, probably far beyond what any other living authority on toxicol- ogy could have amassed or utilized. He has fully sustained his reputation by the consummate ekill and legal acumen be has displayed in the arrange- ment of in« subject-matter, aud the result is a work times. What makes It now, a» always, especially „„ Poisons which will be indispensable to every stn- Taloable to the practitioner Is i ts coaci8«ue»s and .jem^r practitioner in lawaud medicine.— r/»« i>M6 pr*clical character, only those poisonoas subslances 1 n^^ Journ . uf Med Set. , Oct. 1875.